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. 

2016 Birthing Instincts Year in Review

As the new year begins it is always fun to look back on the year that was. 2016 was another busy year for Dr. Stu and the Birthing Instincts team. In January Dr. Stu traveled to Sedona, AZ for the Indie Birth Conference speaking on both breech and twin delivery skills. In February, he spoke about vaginal breech delivery at the OB/Gyn lecture series at Good Samaritan Hospital in Los Angeles. In the spring, Dr. Stu was a guest of Gena Kirby’ s, “Blog Talk Radio” and appeared as a guest on “The Birthful Podcast” episode #64. He spoke on breech at the Good Life Academy and was joined by colleagues Emiliano Chavira, MD and Jen Kamel of VBACfacts for a panel discussion on VBAC sponsored by ICAN of Santa Barbara.

Dr. Stu was fortunate to get away briefly to Amsterdam for their first annual breech conference. You can read about what he learned on the blog pages of our website. It was a very affirming trip with some new research presented on upright breech delivery. Upon his return he was honored by the Human Rights in Childbirth and the Association for Wholistic and Newborn Health organizations with the “Most Audacious” award. He participated in a panel discussion at Bini Birth and gave grand rounds at California Hospital & Medical Center both on breech birthing options. Dr. Jay Warren had Dr. Stu on his Healthy Births, Happy Babies Podcast just before Thanksgiving.

While the fight for informed consent and birth choices goes on, and there was some distressing news with the banning of breech births at Glendale Adventist Medical Center and a hospital in Fort Wayne, IN., we are looking positively towards 2017. Dr. Stu will be a guest lecturer at the online Gold Midwifery Conference and he plans to publish a paper on the home birthing of breeches and twins in the coming months.


Dr. Stu’s Podcast said farewell to our friend and co-host Brian Whitman and welcomed Kimberly Durdin on board. With our crazy schedules we still plan to put out podcasts as often as we can. Our midwifery student, Blyss Young, graduated and passed her NARM exam, yay Blyss! And we welcomed Katie and Catalina, two new students, to the Birthing Instincts family.
Finally, Dr. Stu and all his staff want to express their gratitude to all the mothers and fathers and birth professionals who have supported the Birthing Instincts mission. Your trust is heartfelt and provides the sustenance that keeps us going at all hours of the night. Thank you!

We have included the 2016 Birthing Instincts Statistics for you to review. Comments & questions welcome and can be addressed to info@birthinginstincts.com

2016 Statistics

Total Clients in care: 51
Transfer of Care prior to labor (TOC): 5

Twins, 41 weeks, pregnancy induced hypertension – successful induction
VBA3C, 42 weeks, LGA – scheduled cesarean
Breech, SPROM x 5 days, No Labor - cesarean
Twins, 34 weeks, Cholestasis - cesarean
Breech, 41 weeks, Dr. Fischbein OOT – vaginal breech birth at California Hospital

Deliveries: 46      (Where the primary responsible practitioner is Dr. Stu)
Vaginal: 40 (Rate 87%) (Home Success Rate 82.6%)
                  Primips: 32 (Includes 1st time mothers and VBAC mothers)
                  Multips: 14
 
                  NSVD: 14
                  Vacuum Assisted VD: 4
                  Twins: 12 (7Vertex/Vertex, 4 Vertex/Breech, 1 Breech/Vertex)
                  Singleton Breech: 5 
                  VBAC: 3
                  VBA2C: 0
                  VBA3C: 1
 
Transports: 8 (Rate 17.4%)
 
                  Cesarean: 6 (Rate 13%)
                  Vaginal: 2 (Breech)
 
Summary: 51 clients entered into care in 2016, many late in their pregnancy because of newly discovered breech position or beyond 42 weeks or at the request of a midwife with a laboring client. Five of these women developed problems prior to labor and so their care was transferred to a hospital based physician. Of the 46 remaining, 40 delivered vaginally, 87%, including 50% of breech labors at home. Overall home success rate including VBAC, twin and breech deliveries was 82.6%. The transport rate was 17.4%. There were no newborn transports. One mother was transported postpartum for hemorrhage. Dr. Stu was also called to 5 deliveries postpartum to assist the midwife in a repair of a laceration. We assisted birth in 7 counties and continue to act as a consultant to many California midwives to answer questions or perform ultrasound and fetal testing. Birthing Instincts, Inc. is honored to be of assistance and provide these services to the families that desire them, wherever they may be.

 

The Problem with Research by Press Release: Another Attack on Breech Delivery

Breech born yesterday as   nature intended.

Breech born yesterday as nature intended.

Here again is proof we are living in the age of stupidity and the continued dumbing down of all that was once held dear. Standards are eroding and the term “Truth in Advertising” is truly an oxymoron. Ideology trumps truth from politics to science, if there is even any difference anymore between them. Anyone can publish anything if they have the right connections or the proper bank account. And social media has no filter so how does anyone know truth anymore? I have written before on the awful problem of science by press release. Here are a couple I made up and one that sounds just as foolish.

Growing Older Is Inevitable: Study Finds

U.S. Government spends 10 billion dollars to confirm.

Twitter Use Linked To National Debt Increase!

“Both Rising at Same Time” says expert.

For Breech Baby, C-Section May Be Safer Option: Study

Death rate with vaginal birth is 10 times higher, researchers find

See for yourself.

http://consumer.healthday.com/women-s-health-information-34/birth-health-news-61/breech-babies-death-risk-aogs-release-batch-1319-690587.html

(See the actual study here: http://onlinelibrary.wiley.com/doi/10.1111/aogs.12449/full )

In the age of the millisecond attention span it has never been truer that sensationalism sells and the snappy headline is paramount to attracting readers and viewers. Like most of these articles this one seems to be based on a press release. One would have to actually analyze the data, methodology, numbers and inclusion criteria before any judgment should be offered. Term or preterm? Planned or unplanned? Experience vs. inexperience? Time has taught me that if something sounds ridiculous and defies common sense then it usually is. But there is no depth to this article. No probing questions. No investigative journalism. Just the reprinting of what is fed to these “news” outlets desperate for space filling stories.

There is much chatter about this paper online and I feel we have been through this before. More than a decade ago the Term Breech Trial (TBT) came out, did horrific damage to birthing options around the world and then was refuted. But the damage has remained. Do we really have to do this all over again? This new retrospective study of birth registries has many of the same flaws and refers often to the TBT as if it still has validity. I am curious about the ideology and background of the authors of this study. I am concerned that they did not describe their selection process or criteria (such as flexed head) for vaginal breech birth. There is no control or description of the skill of the practitioner. Large retrospective studies can be useful but the data can be interpreted in different ways, often agenda driven. What is the agenda here? I am very wary of retrospective data derived from voluntary registries of multiple institutions with unknown controls and often differ in all things that matter. 

I have corresponded with my respected colleague in Frankfurt, Germany about this new research. She states this paper has already had an impact in Europe with a newspaper titled "Breech babies should be delivered by CS- data from a new Dutch study". She felt it is important to ask the authors of the study for more information about the specifics surrounding the high perinatal mortality in the breech deliveries (46 cases). As in the TBT, we feel every single case has to be looked at. For when that happened in the TBT its conclusions fell completely apart.

She goes on to say, “At present the Dutch paper is not saying it but it implies (that after adjusting for several things, e.g. type of breech, onset of labour, weight etc. which made no difference) the death of the babies is inevitable- we strongly disagree with that. All the points which we made over the years that are the safeguards such as: selection of the woman, expertise and confidence of the team and ongoing teaching and its effect on safety are not addressed. Because, of course, we know that with these safeguards the figures will improve and we doubt if really the Dutch data does appreciate these things. I feel strongly that the Dutch conclusion, “that this study should lead to a revision of breech guidelines”, is going much too far.”

I agree with my colleague and also must again point out the difference between relative risk and absolute risk. With all the flaws in this retrospective study, the lack of any data about criteria and the 10-fold hysteria in the title they conclude that 338 cesarean sections would need to be done to prevent one perinatal death. And that the risk of perinatal mortality remains about 1.6/1000 or 0.16% for the vaginal group. Perinatal mortality is clearly an important issue when it comes to mode of delivery but it is not the only issue! As I have said over and over, ultimately, whose choice is it?

Here are the results and the conclusion from the abstract of the Dutch paper. I can’t help but notice the tone of acceptance and nonchalance when they mention the change in cesarean section rates incurred from the TBT:

Results

We studied 58,320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3‰ vs. 0.7‰; odds ratio 0.51 (95% confidence interval 0.28–0.93)], whereas it remained stable in the planned vaginal birth group [1.7‰ vs. 1.6‰; odds ratio 0.96 (95% confidence interval 0.52–1.76)]. The number of cesareans done to prevent one perinatal death was 338.

Conclusions

Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies. 

Lastly, on a more optimistic note for those of us who focus on breech delivery, especially at dedicated breech centers like the one in Frankfurt, these numbers defy our experience and common sense. Our findings are much different and safety much more assured. The conclusions in this paper make me feel even stronger about our recommendation to retrain practitioners in these skills through creation of breech referral centers and/or have dedicated breech teams available at urban hospitals. Cesarean section as the answer to the breech issue makes sense only if you are living in a vacuum and deny the immediate and long term risks to mothers and babies from surgical birth.   

Here are two thoughtful blogs by breechmidwife worthy of your time.

http://breechmidwife.wordpress.com/2014/08/14/can-we-eliminate-all-risk-for-breech-babies/

http://breechmidwife.wordpress.com/2014/08/15/the-longer-term-effects-of-cs-for-breech-in-denmark/

I am honored quote her:

Turning now to the elephant in the room

“Being born vaginally may be more risky for some babies than being born by CS. Most of the evidence seems to indicate that, in the short-term at least, using standard lithotomy delivery practices, this is the case. On the other hand, most of the long-term evidence does not indicate lasting effects.

What concerns me about literature like this, which makes predictions about what would be saved or not, financially or physically, with this approach or that – is that women, as long as they are human, will continue to have their own unique approach, and they should. That is what being human is about. Many will want to deliver their breech babies by CS, and they should have access to that care, even if it means a greater financial burden. And many will want to give birth vaginally, even in awareness that the rare outcome of neonatal mortality is more likely to happen to them, even in the awareness that if something goes wrong, they will need to live with it for the rest of their lives. We will always have death, and handicapped children that require our grief, our love and our devotion. This cannot be eradicated. Women deserve to be able to make this very personal decision without being made to feel criminal.

Instead of continuing to do research which tells us what we already know, we should invest in research exploring modern management strategies which are showing promise in reducing risk to babies born vaginally, so that women who live in countries where there ought to be a choice actually have one, and women who live in countries where CS is either inaccessible or a real danger to their health have the best chance of going home with a healthy baby. We should stop trying to have the last word on how breech babies should be born, let women decide how to balance the complex array of risks and benefits in their own lives and families, and develop our skills at being ‘with woman’ and her breech.”

Shawn


Thank you, Shawn. I could not have said it better. The battle for common sense and respect for informed autonomous decision making goes on.  Dr. Stu