Consent for a Forced Cesarean Section

”…. I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing….Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free….”  From The Hippocratic Oath
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On the career road I have traveled to the place I am now I have had many opportunities to witness the deterioration of my profession. I’ve born witness to the influences of fear and money and to the corruption these have on good people. I’ve seen the informed consent process progress from honesty and humility to ignorance and cognitive dissonance and outright lying. I’ve seen academia and science develop marvels of technology but fail to teach the art of medicine and the respect for the autonomy of the patient. I’ve attended lectures and seminars promoting interventions and protocols and admonishing those like me who individualize care while never once mentioning the rights or humanity of the women they supposedly speak for.

In my current role as a home birth practitioner I am fortunate to see and hear from many in the birthing world on a daily basis. Through consultations, phone calls, email and social media I hear stories of birth. Many are beautiful and speak of wonderful experiences and practitioners in both home and hospital. But all too often, on a daily basis, I hear stories of abuse and deceit and misuse of power. This week a colleague of mine in Texas texted me with a story of frustration and bullying that I’ve heard a thousand times but really triggered us. His client, a woman with a vaginal birth, then a cesarean, followed by a successful VBAC was at term with her fourth baby. He recognized the reasonableness of her desired choice of another VBAC and counseled her as such. However, the hospital she had to deliver at has a VBAC ban and vehemently insisted she have a repeat cesarean while “discrediting” her doctor for his advice. The patient eventually went along with the unnecessary cesarean leaving my colleague feeling battered and dejected.

As our conversation progressed he confessed he just does not understand why the hospital was unwilling to even try to understand his reasoning. A sweet hearted man, he has yet to accept the realities of the business of medicine. I then jokingly said his patient should ask the hospital to sign a document saying she prefers the ACOG supported choice of VBAC. But since hospital policy restricts that reasonable choice then the hospital understands it will be held liable for any surgical complication in this or any future pregnancy. He responded, “Oh wow, I wasn’t aware of such a document. That’s awesome!”  And I responded, “There isn’t one. I’m just suggesting it. Wouldn’t that be great?” Now even though we both believe they would never sign it wouldn’t it be great to have them realize what they are asking of the pregnant woman?

Well, not being one to pass up a chance to be a bit provocative and feisty, especially in the name of truth and ethics, I have created a document that I call “Consent for a forced cesarean section”. I ran it past some good people I trust and we all agreed that we should put it out there for all of us to share with our clients facing a similar coercive situation. They are asking a woman to sign a surgical consent against her wishes which supposedly alleviates the hospital and physician from liability for adverse outcomes to her and her baby, now and in the future. I’ve thought about this for quite some time and finally have concluded that if they will not honor her evidenced-based and ACOG and NIH supported choice of VBAC then they should have to accept responsibility for their choice to force her into a surgery. An equal taste of medicine, only fair, and an inevitable consequence of the road they have chosen. Just maybe someday they will get it.

Stuart J. Fischbein MD FACOG

Feel free to download and edit and offer to your clients to use as they see fit. I can see this being offered for breech and twin restrictions, as well. 

Letter To California State Senate Health Committee


Stuart J. Fischbein, MD
10309 Santa Monica Blvd., Suite 300
Los Angeles, CA 90025

310-282-8613

info@birthinginstincts.com

April 19, 2017

RE: Opposition to SB 457

 

To: California State Senate Health Committee

Dear Senator Hernandez & Colleagues:

My name is Dr. Stuart James Fischbein, California License number G52027. I am an obstetrician living in Los Angeles in the 30th Senatorial District. I provide care throughout the Southern California region and I urge you to oppose SB 457.

I am a graduate of the University of Minnesota Medical School and completed my Ob/Gyn residency at Cedars Sinai Medical Center. I was board-certified in obstetrics and gynecology in 1989 and am a Fellow of the American College of Ob/Gyn(ACOG). I have been in active practice in southern California since 1986. I have worked directly with midwives my entire career. The first 24 years as a hospital based practitioner supporting both LMs and CNMs as a backup and consultant physician to these home birthing midwives. And for 15 years I also worked in direct collaboration with CNMs in a hospital based practice in Ventura County, CA. For the last 7 years I have worked exclusively in the home birth setting alongside a midwife at every birth. In 2010 I co-authored the book “Fearless Pregnancy, Wisdom & Reassurance from a Doctor, a Midwife and a Mom”. In 2015 I published a peer reviewed paper on home birthing with an obstetrician (1). I am a preceptor for the Georgetown University School of Nursing & Health Studies, NMI School of Midwifery and the Nizhoni School of Midwifery. With this background I am uniquely qualified to give accurate and experienced testimony to the midwifery model of care and the better outcomes that come from a true collaborative model between midwife and physician, home and hospital.

Midwifery is not a lesser subset of the obstetrics. It is its own separate profession.

These are professional people, well trained in normal birthing. In fact, their model of care is far better suited to the low risk pregnant women than the standard medicalized obstetric model practiced in most hospital settings. Outcomes for similar cohorts of women cared for by midwives vs. obstetricians show consistently lower rates of intervention, induction and cesarean section leading to better outcomes and higher patient satisfaction. There is enough data in the world literature to support this statement. The British National Institute for Health & Care Excellence (NICE) has recently released a statement suggesting that at least 45% of British women would do well to birth at home. It is towards this collaborative model we should strive and not further restriction of midwives and doctors who wish to use their skill to assist women in birthing center or home delivery.

It must be keenly aware to you that, although a small percentage, the desire for California women to seek an alternative to hospital birthing is slowly growing. This is because hospitals, obstetricians and insurers have restricted reasonable choices in defiance of common sense and evidenced based medicine. If ACOG and the CMA think there is room for improvement with maternity care in California, let’s at least be honest and agree that it is not the 1% of women choosing to birth out of the hospital that is the problem. The beneficence based model of medical ethics dictates that patients be given true, not skewed, informed consent and that autonomy in decision making of reasonable choices be supported. Home birthing with a qualified practitioner operating within his or her scope of practice is a reasonable option! Coercion by any means is forbidden. That would include laws that restrict a woman’s right to decide where to give birth and who she wants to assist her.

I have supported women’s choices my entire career. When the hospital I practiced at began banning midwives, banning VBAC, banning breech and twin vaginal birthing I spoke up. However, it became clear that a small voice or reason and logic were not going to override the fears and ignorance of the powerful departments that run these institutions. In 2010 I left hospital birthing to practice the evidence supported skills I had been well trained to do in the home and birth center environment. I have spoken and written as an expert about out of hospital breech birth, twin birth, VBAC, ethics and informed consent in the media and at conferences here and internationally. While ACOG continues to support a monolithic view of how women should be delivered there is much evidence to the contrary. I would urge the legislature to consider the primary tenet of medical ethics when it considers this bill. That would be that faced with any decision, two people given the same information should not be expected to always come up with the same conclusion. Decisions such as where, how and with who to give birth should not be bullied by demonizing reasonable choices in the hands of skilled practitioners.

I believe the restrictions and amendments currently being proposed for SB457 will not benefit the women of California. The bill will restrict choice and force women into untenable decisions such as unassisted birthing or having to drive a hundred miles to find a supportive practitioner. Many hospitals have unethically restricted reasonable options under the canard of safety. VBAC, breech and twin delivery options in hospital have been severely curtailed or have completely disappeared under the “safety” argument despite quality world literature, including from ACOG and the NIH themselves, which support these choices. There is also much quality literature that shows that hospitals are not the safest places for low risk women to give birth. This cannot be selectively ignored. Often, antagonists toward these options will cite refuted studies or level C (opinion) evidence for their positions. This is not scientific, this is not ethical and this is not the foundation on which legislation that restricts liberty and choice should be based.

I urge you to consider not interfering with those of us who are qualified and within our scope of practice and choose to support these families by opposing SB 457. Your energy should be directed at improving access to care, not restricting it. Encouraging collaboration, respect and smooth transition from home to hospital does honor the pregnant women and is our ethical obligation.

 

Sincerely,

Stuart J. Fischbein, MD FACOG

(1) Fischbein SJ (2015) “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births. Obstet Gyneco Int J2(4): 00046 DOI:

 


Contact your senators TODAY! 


Find your California Senator here
You can read the language of the bill here

We have the Senate Business & Professions Senator names and email addresses below:

Senator Jerry Hill (Chair)senator.hill@senate.ca.gov
Senator Patricia C. Bates (Vice Chair) senator.bates@senate.ca.gov
Senator Bill Dodd senator.dodd@senate.ca.gov
Senator Cathleen Galgiani senator.Galgiani@senate.ca.gov
Senator Steven M. Glazer senator.Glazer@senate.ca.gov
Senator Ed Hernandez senator.Hernandez@senate.ca.gov
Senator Josh Newman senator.Newman@senate.ca.gov
Senator Richard Pan senator.pan@senate.ca.gov
Senator Scott Wilk senator.wilk@senate.ca.gov

What a Wonderful World-CCC’s Dr. Fischbein’s Rendition

Original Post, March 17 on  CureCervicalCancer.org

I see trees of green, red roses too

I see them bloom for me and you

And I think to myself what a wonderful world

I see skies of blue and clouds of white

The bright blessed day, the dark sacred night

And I think to myself what a wonderful world

(from “What a Wonderful World” Written by George David Weiss, Robert Thiele)

 

Bus ride through Vietnam to CureCervicalCancer Clinics.

Bus ride through Vietnam to CureCervicalCancer Clinics.

From my familiar seat on our little bus I see clouds and haze and rice paddies, too. I also see propaganda signs, tall skinny dwellings and lots of motor scooters as I gaze out the window into the Vietnamese countryside. Staring out the window keeps my eyes off the road and the swerving and honking and frequent jarring that I’ve come to expect when traveling to remote places with the Cure Cervical Cancer (CCC) team. Sanity on the road here requires inner peace and occasional outright laughter. The dance of the traffic is almost as surreal as imaging pigs can fly until a truck carrying live pigs flies by, passing us on the right….twice….and we all just crack up. What a wonderful world it is! This is my second trip with CCC to help screen for cervical disease using the “see and treat” method of visualizing the cervix with acetic acid and offering immediate cryotherapy to those with positive findings. Donating money to a worthy cause is a charitable act. Donating time is even more selfless. I cannot praise enough the fantastic group of people I was so fortunate to travel with for their energy, dedication and sacrifice. While none of us really consider our volunteer work with CCC to be a sacrifice, in actuality, it is. These lovely people put their Los Angeles lives on hold for a week to give of their time and skill for the benefit of women they have never met. Thank you to Leila, Rebecca, Julia, Phorum, Alborz and, of course, Dr. Gordon.

For me, volunteering to use a simple skill learned a long time ago to make a difference is very easy, yet very rewarding. I mean, I’ve seen a lot of cervixes in my 35 years as a physician. Determining negative from positive is not rocket science and yet, teaching and reaffirming these skills to the local doctors and nurses makes a huge difference in the lives of the women and families who access one of the 7 CCC clinics in the northern part of Vietnam.

Dr. Fischbein announcing a successful “See and Treat” procedure on a young woman to the excitement of Dr. Gordon and the CCC team

Dr. Fischbein announcing a successful “See and Treat” procedure on a young woman to the excitement of Dr. Gordon and the CCC team

We were greeted each day with a cup of green tea as a welcoming tradition as we said our hellos to the directors in front of a bust of Ho Chi Minh and a mural of Lenin and Marx. Pretty much the only obvious reminder we were in a communist country.

Members of the CCC team in Hoanh Bo Clinic in Vietnam

Members of the CCC team in Hoanh Bo Clinic in Vietnam

I was really impressed by the knowledge, skill, and efficiency of the medical personnel. I was also moved by the women who came from long distances to be seen by the American team and who were almost giddy to take selfies with us. How things have changed from my memory of Vietnam growing up in the 60s!

Ha Long Bay, Vietnam

Ha Long Bay, Vietnam

The area around Halong Bay, famous for its exotic rock formations in the sea, is having a construction boom as the country embraces a limited amount of capitalism. Admittedly, the locals benefit mainly from the jobs and the tourism but it’s a start. They could use some wider roads with lane markers and rules but then it wouldn’t be quite the adventure. A real life Mr. Toad’s Wild Ride dodging scooters and buses, the occasional ox or cow and even a truck full of pigs, passing on the right! These are the funny fleeting twitter moments. What I will remember long after those are my amazing teammates, our wonderful ground partner Vu, translator, Han, my colleagues Dr. Dzung and Dr. Ha and the relieved and happy faces of all the local women who will never suffer from a 100% curable disease.

The colors of the rainbow so pretty in the sky

Are also on the faces of people going by

I see friends shaking hands saying how do you do

They’re really saying I love you

I hear babies crying, I watch them grow

They’ll learn much more than I’ll never know

And I think to myself what a wonderful world

Yes I think to myself what a wonderful world

 

Pictured here from left to right: Julia Scott, Dr. Fischbein, Rebecca Lepsik RN, Vu

Pictured here from left to right: Julia Scott, Dr. Fischbein, Rebecca Lepsik RN, Vu

Thank you CCC for the opportunity to serve.

With affection,

Welcome Blyss!

stuart fischbein blyss young birth
blyss-young-midwife

We are excited to announce, Birthing Instincts family is growing. Blyss Young, LM, CPM has joined the team. 

With many of our clients, Blyss will work closely with Dr. Fischbein as part of his collaborative approach to maternity care. Midwives have a vast sum of knowledge on pregnancy, normal birth, breastfeeding and postpartum care that supports the Birthing Instincts model of the combination of obstetrician and midwife as the best model of care for most pregnant women.

Blyss will also be offering childbirth education classes and as well as placenta preparation. 

"As his student I was blessed to be trained in breech and twin deliveries. Along with many other cases that would be considered out of the scope for midwives." Blyss said.  

"It's such an honor and a blessing to learn from and now work side-by-side with a provider who with integrity walks the talk of TRUE informed consent."

In 2006 Blyss co-founded and operated The Sanctuary Birth & Family Wellness Center, the first of its kind offering a full spectrum center where midwives, doctors and other holistic practitioners collaborated to provide thousands of Los Angeles families care during the prenatal and postpartum periods.

Longing for an intimate traditional midwifery practice similar to the ones that had supported her 3 pregnancies, Blyss closed the center in 2015 allowing her to pursue yet another long held dream of becoming a midwife herself. 

You can find more information Blyss's work by visiting her websites, Birthing Blyss and Just Placentas then follow her on Facebook.