NY Times article on NICU Costs

Sometimes you have to weed through a pile of junk to find a few pearls of wisdom. Thats my feeling about the majority of junk, called news, in the NY Times. However, this article was forwarded to me from my colleagues at D4PC.
(www.docs4patientcare.org) It has some good points including support for ones of profit motive that I have mentioned in the past when discussing some of the policies of the NICU and its director at St. John's Regional Medical Center in Oxnard. Whatever your take it is food for thought. Dr. F

http://www.nytimes.com/2011/03/20/us/20ttnicus.html?hpw

Scientific American Article worth reading.

Please check out this link to an article in Scientific American that discusses The Wax Meta-analysis Paper that ACOG relied on as justification for its position against home birth and certified professional midwives. It fairly presents an unbiased view that, at best, many experts question its veracity.

http://www.scientificamerican.com/article.cfm?id=home-birth-study-investigated

Garbage in, garbage out. Science is not served when there is an agenda first and then data is cherry picked to bolster that agenda. I have no knowledge of Dr. Wax's agenda but ACOG diminishes themselves by showing theirs in choosing this paper as its sole basis for justification of its opinion on home birth. Readers should do their best to decide for themselves what the evidence and common sense tells us. Dr.F

Collaboration at work

2 Days ago I was asked by one of my midwife colleagues to come to their clients home and assess the mom for a prolonged second stage. The mom had reached that "wall" and could no longer push effectively. After about 4 hours of trying different things in an otherwise healthy, nurturing environment they were talking transport as the standard option. However, now that I am contributing to the out of hospital birthing community we had another choice. I arrived to find the baby doing well and mom leaning on an exhausted but incredibly supportive husband. After talking it over with dad and the amazing team we decided that a vacuum delivery was a good option for them as they did not want to go to the hospital after such heroic efforts at home and for financial reasons. I examined mom and felt the baby to be OA, slightly asynclintic and +2 station. Not much molding or caput. We repositioned to the sofa and with a cooperative baby and a revitalized mom they gave birth by vacuum assisted vaginal delivery to a beautiful baby girl in their living room illuminated by the late afternoon sun. Beautiful relief on parents faces. Birth team, too. It was a great example of combining the skills and knowledge of the midwife-OB-doula in a collaborative effort to give families another choice. Love to Molly, Heather Anne, Kim and the trusting family. Dr. F

Followup Letter to ACOG President

I have found Dr. Waldman to be sincere and I hope I am right. It has been 2 months since I wrote to ACOG regarding Committee Opinion 476 on Home Birth. This e-mail is a followup to my correspondence with ACOG's president and is self explanatory.

3/11/2011

Dear Dr. Waldman, Hope this note finds you well. In your email to me from January 25th you mentioned that Dr. Hale would be passing my letter on to the committee for what I had hoped would be some honest answers to my serious doubts about their science and motivation in releasing Opinion 476. Sadly, my expectations of receiving a response from them were very low from past experience and it seems that low expectations of your Opinion Committee were appropriate. I have the energy, knowledge, evidentiary support and willingness to discuss these issues with my esteemed colleagues who make up this committee. I am disappointed that a committee from my college is assigned the awesome responsibility to make statements that have a powerful effect on practice and policies in America but ignores legitimate questions and dissent from one of its own members. I hope you will accept my offer to contribute to any future discussions inside of or publically made by ACOG regarding the safety of home birthing, licensed midwives and patient's rights to true informed consent with the same sincerity that I voice my concerns to you. I am one of but a very few professionals in the country who have the legitimacy and wisdom of experience living and working in both worlds. Opinion 476 should never have been released based on the Wax paper. It damages the credibility of the College. If we as obstetricians really do care about honesty and truth towards the women we serve then there should be no other motive but those from an organization like ours.

Sincerely, Stuart J. Fischbein MD FACOG

A Comparison - You Decide

When I was on staff at my local hospital in 2009 I posted this data. Needless to say, I got yelled at and was ordered to remove it because it somehow violated confidentiality. No explanation given. Actually, I believe it was too revealing of the differences in practice styles and therefore embarassing to some. Well, I am no longer under threat of administrative retribution and therefore, once again, I feel this data deserves to be discussed. What it does show is that in a population of low risk mothers in 2008, comparing apples to apples, the midwifery collaborative model practiced by The Woman's Place for Health, Inc. had a primary c/section rate of less than 5% while another local large group of doctors adhering to the obstetrical model of medicalizing birth had a primary rate near 17%.
In this group of over 300 women an almost 4-fold risk of having a first time c/section in a comparable group of low risk pregnant women exists when birth is "treated" as a medical problem. In order to respectfully and honestly share the information of my collaborative practice and quell the naysayers I am in the process of compiling data from more than 10 years. I hope to publish "The Experience of an OB-Midwife Collaborative Practice" using statistical analysis and an evidenced based approach this year.
What those of us with common sense and the powers of observation have known for a long time about low risk birthing will benefit from as much objective data as we can get. Patients deserve as much truthful information as they can get to make an informed choice. I look forward to sharing my findings with you and with them. Dr. F

Small Community Hospital Deliveries from 12/1/07 to 11/30/08
Practice Total / # / Rate
Doctor A 75 / 10 / 13.33%
Doctor B 37 / 4 / 10.80%
Doctor C 51 / 12 / 23.50%
Doctor D 20 / 5 / 25.00%

Doctor E 14 / 3 / 21.40%

TWP 124 / 6 / 4.84%(Dr.F & midwives)
Other Large Group Total:
MDs A-D 183 / 33 / 16.9%
Deliveries and c/sections performed at a hospital that cares for almost exclusively low risk patients.

Gotta love Dr. Fogelson

My colleague, Dr. Nicholas Fogelson writes a blog called "Academic Ob/Gyn" at www.academicobgyn.com (see supporters). He is a strong supporter of delayed cord clamping and takes a common sense approach to decision making in our field. He has recently penned a column that expresses one of those pet peeves that nags at those of us who care for pregnant women. With his permission I have posted it below. Dr. F


An open letter to the dentists of the world
March 3, 2011
Nicholas Fogelson
22 comments
Dear Dentist-

Thank you for being there for patients around the world, fixing and cleaning their teeth and gums. Thank you for your training and your wonderful set of skills which we all need.

But today I have a bone to pick with you.

For the one thousandth time today I was asked to write a note for a patient with an obviously infected tooth, giving my permission for you to treat her. For the one thousandth time, I sat before my suffering patient, cursing your name, and wrote this ridiculous note. And now my patient can go back to you, and now you can do the job you should have done when she first came to you with her painful tooth.

As an obstetrician, I am expected to be expert in all things pregnancy. Not only that, but I am expected to understand how all things not pregnancy affect all things pregnancy. It was for this that I went to medical school and trained long in my field.

You are much the same.

As a dentist, you are expected to know all things oral cavity, and furthermore how all things not oral cavity affect all things oral cavity. It was for this that you went to dental school and trained long in your field.

And in this training, you no doubt learned something about the dental care of pregnant women. You probably learned that local anesthetics are not harmful to a pregnancy, and that the narcotics you prescribe for pain and the penicillin based antibiotics you use for infection are also safe. You probably learned that the millirads of radiation your oral films use are trivial compared the amount of radiation it would take to harm a fetus, and if you’re really on it you might even know that an obstetrician would do a 3 rad cat scan right through the fetus if he or she thought it was important enough. At the least, you know that the big lead apron you use is going to block anything that might get to the fetus anyway. You might have read that obstetricians are actually quite interested in oral health, and that we think that chronic oral disease may ironically be a contributing factor to the preterm labor you hope to avoid involvement with by refusing to treat oral disease in pregnancy women.

At the very least, you know that a fetus is kept in the uterine cavity, not in the oral cavity.

Since you already know these things, really what is going on is that you want your ass covered if under some strange coincidence something bad happens to a pregnancy after you treat a patient.

This is bullshit, and I am tired of it.

So forever more, here is a note for all the pregnant ladies of the world.



1. There is nothing you can do under local anesthesia that will hurt a fetus.

2. Penicillin antibiotics are safe in pregnancy

3. Local anesthetics are safe in pregnancy.

4. Narcotics are safe in pregnancy.

5. Oral xrays are safe in pregnancy. Shield the baby like you would any patient.



If after reading this you ever again send away a pregnant patient in pain because they need a note from their obstetrician, I have only this to say:

Grow a pair. You are doing your patient a disservice. Excercise the wonderful skills you spent years cultivating, and help your patient.

Special Delivery

With permission from the family, it is with great joy and pride that I can announce my first home twin delivery. On Valentine's day my multiparous client went into labor at 37+ weeks with known breech/breech twins. The family had previously had 2 successful home VBACs and knew that no hospital would have allowed her desire to deliver breech twins vaginally. She approached the Sanctuary Birth and Family Wellness Center in Los Angeles several months ago and we agreed to care for her. She was a wonderful candidate, well-informed and highly motivated with a background in the natural birth community. Her labor started with ruptured membranes about 3AM. She finally kicked into high gear just after dinner. The little girls behaved smashingly in utero giving mom her opportunity. Baby A was born breech on all fours in water at 10:05PM on February 14th, 2011. Things then settled down with contractions spacing out and Baby B happy as a clam. Meanwhile mom tried nursing and dad and big sister took turns skin to skin with Baby A when mom needed a break. Shortly after midnight labor kicked back in and at 12:20 AM on February 15th Baby B was born breech on all fours on land. The family was amazing as was the birth team assembled. Much is possible with an informed patient with the right attitude and confidence in her body. Trusting the birth process and allowing nature to do its thing will often win out if we let it. I have to admit it feels wonderful to be freed from rigid policies and restrictive protocols, often void of common sense or evidenced based support. If hospitals will not allow women the right of true informed consent and refusal, I and the Sanctuary Midwives are proud to give them another option. Regards to all, Dr. F