2017 Birthing Instincts Year in Review

 

Well, that went fast. Another year of births, advocating and teaching for the Birthing Instincts team. I want to specifically thank my staff and students, Kati and Catalina along with all the midwives who refer and trust me with their clients. As always, a special thanks to midwives Beth Cannon and Blyss Young who have been with me through it all. It is always interesting to look back so let’s see what adventures, both personal and professional we had in 2017.  As always, I was available to answer questions, emails and calls from midwives and clients pretty much every day, 24/7 365. It didn’t take long to see that the 2017 practice was going to be caring for more and more breech families. As choices diminished with the retirement of Dr. Ronald Wu and the banning of breech and most twin deliveries at multiple hospitals women were left with fewer options. We are happy to note that friend and colleague, Emiliano Chavira, MD helped picked up the baton and gave women the option of a hospital breech birth at St. Francis Hospital in Lynwood, CA. The first week of January saw the waterbirth of our first 2017 twins born 45 minutes apart. The very next day we dropped off my daughter, Madeleine, at LAX on her way for her semester abroad in Barcelona. A month later I traveled to Barcelona to visit and we had a great time. Seeing the sites, sampling the food, the Salvador Dali Museum and catching a match between Barcelona and Real Madrid were all special. Not much better than Father-Daughter camaraderie.

Sadly, in late January, we lost my dad to his battle with father time. He lived a wonderful 96 years and will be missed (Reminder: You can hear some of his wisdom and humor when I had the good fortune to interview him on his 96th birthday at DrStusPodcast.com #100). Later in February I once again traveled with the charitable Cure Cervical Cancer team, this time to Vietnam. We spent just over a week teaching and screening for cervical cancer in the villages around Ha Long Bay. My stepson Max moved back to LA from Brooklyn so now all my kids are in the SoCal area and family gatherings were made that much easier. April saw the arrival of the Annual ACOG Meeting, this year in San Diego. While there was much to see and learn there was an obvious huge gap between the medical birth world and the midwifery one. I was inspired by the lack of acceptance of breech and limitations on VBAC and twins in the lectures to go on and acquire a breech trainer, Sophie and her mum. With the help of so many of you and a GoFundMe account I was able to raise nearly all of the $11,000.00. Thank you all so much. Happy to say the Sophie and her mum now reside in my apartment in downtown Los Angeles and are looking forward towards many journeys in 2018.

 

The month of May saw a well-attended ICAN event in Santa Barbara in support of VBAC. Dr. Emiliano Chavira, Dr. Terry Cole and Jen Kamel of VBAC Facts joined me and some eloquent VBAC mothers for an informative evening. We also had an emergency episode of Dr. Stu’s Podcast in support of our friend and colleague, Dr. Brad Bootstaylor in Atlanta. His local institution was trying to restrict legitimate birthing options. Funny, with more and more literature coming out supporting the importance of the microbiome and the concerning high cesarean rate you would like to think hospitals would be climbing on board instead of going backwards. Big sigh!

 

June saw me travel to NYC for a special night with an old friend and a dinner party in Manhattan. My friend worked for the United Nations and she and I were treated to a warm hug from Swami Amritaswarupananda Puri, the spiritual leader better known as Amma. A very special moment. Another special moment came when a local ENT physician and his wife had a beautiful home waterbirth against the best advice from all his partners and medical colleagues. What do they know, anyway? In July, I was privileged to be invited to the swearing in ceremony to American citizenship of one of my clients along with several thousand new Americans. Another very special and moving moment. Only a month later she gave birth in her bed at home. Welcome Piper!

Congratulations to my long-time associate, Jason Rothbart, and his beautiful bride, Leigh on their August wedding in Spokane. Nature continued to show its wonder with the total eclipse that, for 3 minutes, mesmerized the country. All year long many visitors came to spend time with me, saw clients, attended a few births and pick my brain. I enjoy these interactions and they keep me on my toes. With the onset of Autumn, Nebraska Birth Keeper Angie Hock spent a week with the highlight being a Los Angeles, Kings hockey game, of course! September saw my colleague Rixa Freeze of Stand and Deliver blog fame and me submit a paper for peer reviewed journal publication comparing 60 home breech births with 109 home singleton cephalic births. We hope it will be out very soon. In October, Sophie and her mum held their first seminar with Dr. Stu attended by local midwives in Ventura. We are very excited with the expanding teaching schedule for 2018 and we are hopeful to get CME accreditation so we can attract doctors, residents and medical students to these events. (Check the calendar page on the web site)

November is often remembered as the month of Thanksgiving and this year there was much to be thankful for. Our student, Catalina, discovered some very exciting personal news. More to come on that in 9 months! Dr. Stu gave a talk on breech techniques at the 2017 MANA conference. And while not everyone seemed in the thankful mood this year it was nice to see so many old friends and colleagues. Congratulations to Dr. Stu’s niece and nephew on the unmedicated delivery of his great niece proving once again that good things can happen in the hospital setting. Dr. Stu’s daughter, Madeleine, turned 21 and she celebrated by going skydiving with her friends and drinking legally with her dad. The year ended on a sweet note with a Christmas HBAC in Santa Barbara proving once again that good things can happen in the home setting, too! As always, Dr. Stu and 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 and assistance provide the sustenance that keeps us going all hours of the night. Happy new year to you all.

 

2017 Birthing Instincts Statistics

 Total Clients in care: 45

Transfer of care prior to labor (TOC): 6

 

1)     Twins, 37 weeks, SPROM, A is footling breech

2)     VBAC, Macrosomia, Type 1 Diabetes

3)     Twins, VBAC SPROM at 34 weeks

4)     Twins, SPROM at 35 weeks

5)     VBAC, IUGR

6)     Twins, TTTS at 23 weeks treated with Laser therapy

 

 

Laboring Clients: 39

                  Primips: 21 (Includes 1st time mothers and VBAC mothers)

                  Multips: 18

 

Vaginal: 32 (82.1%) (Home Vaginal Delivery Rate is 72%)

                  NSVD:                      15

                  Vacuum:                4

                  Twins:                      2

                  Breech:                   9

                  VBAC:                       2

 

Transports: 11 (Rate 28%)

                  Cesarean:               7 (Rate 17.9%)

                  Vaginal:                                    4

 

Transports in Labor:

1)     Breech, VBAC, Hypertension (VD)

2)     VBA4C, Pain

3)     Breech, Arrest @ 6cm

4)     Br/Vtx Twins, Arrest @ 7cm

5)     Breech, Arrest @ 7cm

6)     Breech, Floating @ 5cm, Footling

7)     42 Weeks, Desired pain relief (VD)

8)     Breech, VBAC, 4+ Meconium at 8cm

9)     Twins, VBAC, Sharp suprapubic pain at 10cm

10)  VBA2C, Hypertension (VD)

11)  Primip, Vertex, Desired pain relief (VD)

 

Summary: 45 clients entered into care with Dr. Stu as the primary caregiver in 2017. Many entered into care late in their pregnancy because of newly discovered breech presentation and midwife care going beyond 42 weeks. Six of these women developed antenatal problems requiring a transfer of care to a hospital based physician. Of the 39 remaining, 32 delivered vaginally (82%). There were 11 transports with 4 of these delivering vaginally in the hospital and the remaining 7 transports having a cesarean section (18%). All 4 vacuums were at the request of midwives to assist with their laboring clients. As our practice has evolved we are seeing more clients with conditions considered high risk in the medical model as choices diminish resulting in higher cesarean section and transport rates than in previous years. Many local midwives are accepting VBAC clients with more confidence and Dr. Stu saw more than 20 of these women in consultation for VBAC “clearance”. While not required by California law, consultation gives reassurance to those midwives and clients who prefer a second opinion. Structural 20-week scans and dating ultrasounds as well as biophysical profiles continue to be offered to midwife clients in a reassuring environment. In addition, Dr. Stu continues to provide the option of repairing significant lacerations in the home setting when requested. We assisted births from San Luis Obispo to San Diego and even had one family relocate from Aspen, Colorado to have their twin birth plan honored.

All of us at Birthing Instincts, Inc are honored to be of assistance and provide these services to the families and practitioners who desire them, wherever they may be. 

 

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,

Supporting Change for Maryland Women and Midwives

Rally  (Algerina Perna, Baltimore Sun) A large crowd attended a rally on Lawyers Mall in support of legalizing all midwives. Maryland Families for Safe Birth, and the Association of Independent Midwives of Maryland (AIMM) sponsored the rally.

Rally (Algerina Perna, Baltimore Sun)
A large crowd attended a rally on Lawyers Mall in support of legalizing all midwives. Maryland Families for Safe Birth, and the Association of Independent Midwives of Maryland (AIMM) sponsored the rally.

Thank you for giving me the opportunity to speak today via written testimony in support of House Bill 9.  My name is Stuart James Fischbein, MD. I currently am and have been a practicing obstetrician in the Los Angeles area since 1986. I attended the University of Minnesota Medical School from 1978-1982. I was an obstetrical resident at Cedars-Sinai Medical Center from 1982-1986. I was Board Certified in obstetrics and gynecology in 1989. I am a Fellow of the American College of Obstetrics and Gynecology (ACOG). I have collaborated with direct-entry midwives my entire career. I co-authored the book, Fearless Pregnancy: Wisdom and Reassurance from a Doctor, a Midwife and a Mom in 2004.

I am not an academician. I actively assist women with pregnancy and childbirth, often in collaboration with a team consisting of a midwife and midwifery students. I am credential as a proctor/supervisor of students with The National Midwifery Institute (NMI) and The Nizhoni Institute of Midwifery. From 1986 until 2010 I had a hospital based practice and collaborated with Certified Nurse Midwives while at the same time serving as a consultant and “back-up” physician to several local direct-entry midwives. In 2010 I chose to leave hospital-based practice and now assist families with home birthing including VBAC.  My nearly 30 years of work experience has given me a very unique perspective on both the obstetric and midwifery models of care of pregnant women with which to testify to today.

While home birthing with a midwife may not be for everybody, informed choice and respect for the autonomy of patient decision making is. Beneficence based medical ethics dictates that practitioners are obligated to support reasonable medical choices. There is enough data in the world literature to support the reasonableness of the choice of home birthing. The women of Maryland deserve this option. Especially in light of the high rates of inductions, interventions and surgical births for otherwise healthy pregnant women who labor in the hospital.

I have attended over 125 home deliveries, always in collaboration with a CPM.  I offer women with VBAC pregnancies who meet respected selection criteria this option, often because no similar option exists in many local hospitals. We have a success rate of 93% using this collaborative model with home VBAC. I have found that VBAC is more likely to succeed in a home birth environment than in the hospital. The simple explanation for this is the understanding that normal mammalian birth progresses better when undisturbed and without anxiety and fear. VBAC is not a procedure requiring special skills therefore success should be the desired endpoint. The medical model looks at women attempting a trial of labor after cesarean section as a disaster in waiting. Midwives understand this is not conducive to success. The published Maryland statistics on successful hospital VBAC rates is pretty dismal.

The NIH VBAC consensus statement of 2010 supports VBAC with level A evidence as does the American College of Obstetrics and Gynecology. VBAC bans and restrictions attributed to an ACOG recommendation based on the word “immediate” have no basis in science. This past December I attended the interested parties meeting for California AB1308 in Sacramento. VBAC was a major topic of discussion. The regional representative from ACOG District 9 admitted that serious complications from VBAC are rare (about 1/2000) and unpredictable. I commented that if that is so then having physician consultation during the prenatal period was useless. The point was taken.  I was assured by the Medical Board Representative that California direct-entry midwives will continue to assist with out-of-hospital VBAC. We need to do everything we can to lower the cesarean section rate and the subsequent short and long term morbidity to mother and baby. Licensing and supporting direct-entry midwifery is the logical next step.

It is important to note that midwifery is not a subset of obstetrics. Midwives are well trained and experienced in the care of normal pregnancy and delivery, including VBAC. They excel at preventative medicine. They have an excellent knowledge base and therefore can quickly recognize abnormal and consult or refer as needed. Obstetricians are trained to deal with problems that arise so that is how we see our patients. Residency training of future obstetricians is not designed to care for normal. Over the years I have practiced I have evolved from the true believer in the medical model of obstetrics as illness to an understanding that normal pregnancy is wellness and the female body is designed for it. My personal evolution and successful professional outcomes would not be possible were it not for my good fortune to have collaborated with midwives. The women of Maryland deserve honest dialogue and information from which to make a choice. For ultimately in a free society, the decision of where and with who to give birth belongs to them. 

Two Days Trapped in Temecula

dr-stu-temecula-breech.jpg

A Home Birthing Tale

Southern California is a beautiful place. Rolling hills become valleys and mountains often with an ocean view. Sweet little towns tucked away with familiar patterns of shopping malls and fast foods blended into the uniqueness of an area’s history, wineries and attractions. Temecula, California is such a place. Secluded about 2 hours from Los Angeles (on a good traffic day) lies this little community amidst avocado farms, wine country and a casino. Families wanting to own a house can still find “affordable” property in the peaceful valley. It is quintessential SoCal with hiking trails and Macy’s and an Outback Steakhouse. On a hot day it can be very hot but for those who live and work there it is still of bit of paradise. The Eagles once wrote about paradise in their song, “The Last Resort”. (“They called it paradise. I don’t know why. Call someplace paradise…..kiss it goodbye!”). For those who have to commute on the infamous California freeway system to and from Temecula the kiss it goodbye part is quite appropriate. That’s where this story begins.

I met J, my Temecula birthing client, at about 38 weeks when she was referred by a local midwife because she was breech. I promised myself that I was going to simplify my life and not take on long distance clients unless they were willing to come to a birthing center near me. So this was the plan that entered my mind before the meeting. A lovely woman accompanied by her family and friends arrived for her breech consult only to find that her baby had flipped back to head down. After feeling her belly it was fun to put the ultrasound on and show her the head just above her pubic bone and see the joy and relief in her face. We talked about keeping the baby that way and home birth options with a local midwife as well as other delivery choices. It did not take long for her to ask if my team and I would attend her birth at home…..in Temecula! I have not quite mastered the ability to say no when I know in my heart that a home birth for her is a better choice than driving several hours in labor to the Sanctuary Birth Suite here in L.A. I have come to know that feeling safe and undisturbed makes the chance of a natural, unfettered birth so much more likely. So how could I say no? I checked with my team and we all agreed as long as no one else was in labor we would be honored to assist her.

In the next week she remained quiet while another breech mom and a VBAC mom had successful home deliveries. Midwife, Beth, had an even crazier week. All I had left was a mom having her 3rd baby who was overdue. So, the waiting game began and much to my relief that birth happened quickly in water a day or two later. So my plate was cleared for my Temecula adventure. We were able to get in a weekend home visit which was about a 6 hour turn around adventure. Carpooling in LA can help some but with its voracious appetite for revenue the lovely California government has begun to convert free tax-paid carpool lanes into toll roads requiring an electronic pass which we didn’t have, Grrrr! Needless to say it just another cost of living increase in paradise which I have since ordered. J makes it to about 41 weeks when she calls on a Wednesday afternoon around 5PM to report SROM but no labor.

Twenty plus hours later she is still leaking clear fluid and there are no contractions. So, early on a Thursday afternoon I head to Temecula to check on mom and baby. Never a good idea to drive in SoCal during a weekday, it’s even more foolish to go during rush hour. The two hour drive takes me three and a half. Thank you Steve Jobs for my iPod! Mom and baby are fine. We are group B-strep negative and my experience has taught me that 90% of women who break their waters will go into labor within 24 hours. Well, we are now at 24 hours and not a peep from this uterus. I have looked at the data critically and cannot really find where the infamous “24 hour” deadline came from. I know in the medical model it is a heavy club used to encourage intervention but the literature has evidence leaning both ways. I’ve seen a documentary, whose name escapes me, where a woman has a home birth 4-5 days after SROM. My own education has taught me that infection is unlikely when hands are off. After an informed discussion which included the pros and cons of induction and antibiotics J prefers to continue to wait, a reasonable choice of which I am quite comfortable. What I’m not comfortable with is the idea of the long drive home and likely having to drive back again soon.

Just off the 15 freeway, about a mile from J’s home is one of those brand name motels, The Marriott Fairfield Inn, where for $97 you get a room, lousy cable TV and a breakfast. It’s that or 6 hours on the road with possible panic driving back in traffic when labor comes. Easy choice for me. I’m all checked in when suddenly I realize that Temecula is less than an hour from San Diego. My daughter, who is at SDSU, has a free evening and sounds jazzed to see me. We grab dinner and a movie and share stories and smiles. Being trapped in Temecula can be a good thing, too.

Friday morning I go to visit J who is still not in labor. She had a decent night’s sleep, baby is moving and all vital signs are stable but nothing happening. My midwife associate, Beth, suggests nipple stimulation and blue and black cohosh. While J starts that I’m wondering what does one trapped OB do on a free day in Temecula wearing only dress shoes and work clothes….for the second day in a row! Of course, the local mall is just down the street. What California town doesn’t have one? Toothbrush, toothpaste, new shorts, t-shirts and Reef sandals are on the agenda. It’s getting pretty hot too so the movie theatre is looking inviting. Lunch consisted of popcorn and soda. Just when I’m thinking I might be having dinner at SDSU again J begins to have regular strong contractions now 48 hours after SROM. My midwife team heads down in separate cars on a Friday afternoon. Now there’s a great idea! I much rather be trapped in Temecula than trapped in traffic. I’m so happy I decided to stay and have my free day. Free days are few and far between for many of us. We should rethink our busy lives.

By 9PM the team arrives and we set up our supplies and the tub. Yet it is still too early for us to hover so off to the Outback Steakhouse we go for dinner. Comradery and stories and warm feelings among colleagues. Another nice side effect of working with midwives. Then it’s back to the house for the familiar night on the couch for all of us. Taking turns to support mom and family. J goes from being talkative to quiet to intense as the instincts of undisturbed mammalian birth take hold. Welcome sounds emanate from the birth tub just before dawn and it’s time to push. After 14 hours of actual labor, 1 hour of pushing, 62 hours and 17 minutes of ruptured membranes, 3 movies, 1 dinner with my daughter, a whole lot of driving, 2 ½ days in Temecula and a great deal of patience and trust in birth, baby A was born in water to the welcoming arms of her mother. Witnessed by grandparents, friends and family just as it should be.

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I am an independent soul who prefers to take personal responsibility for my life and the decisions I make. In the medical world I clearly march to the beat of a different drummer. But it is an evidenced based and ethical drum that I hear. This woman’s labor pattern would not have conformed to the standard of care in a hospital delivery and surely intervention without much regard to her wishes would have been foisted upon her. Luckily, I resent conformity for conformity’s sake. My independence allowed me to take a day off, respect individual autonomy and informed consent, sleep in strange places and give this woman and her family a life changing experience and beautiful memory. Was I concerned that she might have to be transported as some point? Yes, of course. Was I concerned about the possible reception we might receive at a local hospital considering her story? Yes, of course. But our duty is to our client and to respect her reasonable choices. It was this defensible knowledge and position along with the wonderful teaching I’ve had from all the midwives in the birth community that gives me the confidence to take my hands and sit on them. Even if that means sitting on them trapped for two days in Temecula.