The Tale of Two Transports: Trials, Tribulations & Happy Endings

Home birthing has its admirers and its detractors. We all know this. There is all too often a lack of respect by overzealous advocates of either side towards the other. My unique experience living in both worlds has shown me that for several reasons, most of them emotional but some of them understandable, those that oppose home birthing want to bully the other side into submission. Through oppression of supportive physicians and self-serving, ethically questionable policies they make it very difficult for the home birth practitioner and client. And once again they are taking their “safety” argument to the legislature to try to mandate physician supervision of licensed midwives even when we all know that most obstetricians are not interested in supervising or are restricted by their malpractice insurance policies from doing so. Thus, many midwives will become illegal in California if this is allowed to become law. Too often there is a blurring of the lines between elective transport and emergency transport. To the on-call obstetrician the knee jerk idea of a homebirth transport is the train wreck. But to most of us in the homebirth world we understand the elective transport is nearly always for the same reasons that patients who plan a hospital birth come in for, only just a bit later in labor. Pain relief, exhaustion and inadequate progress are by far the most common reasons. What makes these women wanting rest, hydration and an epidural more “toxic” and any different from the 90% of women who get these things in the day to day practice of the average obstetrician anyway is simply their preference of home and midwife. Some will say that these patients are unknown to them and therefore high risk. But that argument is specious for most obstetricians practice in large groups these days or they become laborists and so often have no acquaintance or historical relationship to the laboring woman. They will then argue that they can’t be sure these transports had adequate, if any, prenatal care despite records in hand. In reality, most of these women have had better prenatal care from their midwife than any obstetrician can possibly give and my experience tells me they are almost always better educated. But old habits, even misguided ones, are hard to break by those who find no reason to break them. Enter a truly uplifting story of two very different obstetricians and their wonderful deeds of this past week. A testimony to the old adage that truly great men who do extraordinary things will often be despised. Courage is doing the right thing in the face of strong opposition. These two wonderful souls stand out in their compassion, humbleness and willingness to individualize care to patient desires using reasonable choices, true informed consent and sound medical practice. R is a 24 year old, 5’ 9” primipara at 39 weeks who was in active labor for 16 hours. Despite many alternative attempts to rotate her baby he remained occiput posterior. She eventually reached her limit of exhaustion and pain tolerance at 7 cms. My usual back up physician at Cedars-Sinai was away so I put out a few calls to colleagues and was rewarded by two offering to accept her in transport. This may seem a simple thing but I am lucky in that I have choices for back-up when so many of my midwife colleagues are struggling in that arena as discussed above. They drove the 5 minutes over to Cedars while I drove separately. It had been awhile since I have had to transport so I was not quite prepared for the administrative and regulatory onslaught that followed. When I arrived, security would not let me in because R had not yet been admitted. It took a call to the charge nurse to bypass the woman guard with no eye contact to let me in. Upon arriving upstairs R was moaning loudly with every contraction while the nurse was attending to a laundry list of computer data entries, most of which were irrelevant to the medical necessity of an epidural. Admitting wanted the husband to sign all kinds of forms without reading them while R signed a consent form to be treated document between contractions that legally can’t mean anything when a person signs under such duress and pain. Dad refused to sign anything until his wife got her pain relief. A lesser man would have just signed but he knew his rights and pointed out a poster that clearly complied with the EMTALA statues that said “We cannot refuse treatment to anyone!” His point being, treat her first and then we can review documents. And despite much behind the back eye rolling and sighing they actually did. She got her IV and epidural, which still took over an hour, before she had her name band or lab results. Once comfortable, the cascade of interventions began and baby gave all of us a few gray hairs but Dr. C was amazingly patient and trusting of his knowledge of labor and fetal heart patterns. R rested for about 90 minutes and then was feeling a lot of pressure. Dr. C checked her and found the head at plus 2 station but still OP and almost completely dilated. He then used his obstetric skills learned long ago. Putting his hand inside he reduced station, manually rotated the head to transverse and had her start to push. The cervix was reduced and she delivered over an intact perineum after 4 contractions! Baby M weighed in at 6 pounds 15 ounces. That cute little pipsqueak would have easily delivered if not for the persistence of his occiput posterior positioning. Sadly, in most other modern day obstetrician’s hands they may not have been greeted by a wonderfully accepting man and that little pipsqueak would most likely been born by cesarean section. We were all so grateful that there was an experience obstetrician who was trained in a different era in the skills that separate them from today’s obstetric surgeons. J is a 34 year old, 5’ 6” Ventura County primipara at 41 weeks who went into labor the very next day. Her labor was strong and with the support of 2 marvelous doulas, Tracy & Tasha, she was doing great. After about 10 hours of 4 minute strong contractions J asked to be examined. Her sounds were consistent with early transition however her exam was only 2 cm./-1 and 40% effaced and, again, occiput posterior. Over the next 8-10 hours she remained at 4 cm with her cervix getting much more swollen. Despite her heroic effort to this point it was clear to all it was time to transport for an epidural and what follows. Our original backup plan was to go to a LA hospital with supportive backup but they did not want to drive that far and because she worked at the local hospital she knew her previous OB. Dad called and he told them to go to the ER and just tell them to use his name. He said there was no reason to call ahead. So we packed up and all met at the ER. While sitting in the waiting area in a wheelchair the litany of questions began. Now, 2 days in a row for me makes a pattern. It is clear that administration rules the roost as paperwork comes before humanity. One particular question and response from the worker behind the bullet proof glass really stuck with me. It was 5:30 in the morning and J answered that she had ruptured her membranes 6 hours earlier. The woman’s response was so typical of the indoctrination to the one size fits all medical model, “Why did you wait so long to come in?” To those who only see medical birth this is their norm. The question, the timing of it and the tone from the person asking it were so inappropriate and lacking in social skills but we said nothing. In about ten minutes we were on our way up to labor and delivery. Exhausted and in pain with contractions every 3-5 minutes J was, once again, subjected to consent forms and to an even longer laundry list of electronically generated, mostly irrelevant questions unrelated to her immediate need. (Tattoos? LMP? Family History?) And a plethora of questions that were all answered on her prenatal records which I brought with us but which were out at the desk being copied and stamped and posted in the chart but not in the room available to the nurse. I also learned that since I did not have the actual lab report on her negative Group B Strep that hospital protocol states she has “unknown” Group B strep status and therefore antibiotics were ordered (but could be refused). The hand written results and my presence were obviously not good enough for their risk managers but unnecessary antibiotics were fine. Ouch! Next, the charge nurse came in to tell us that her admitting doctor did not want to take her and was passing her off to the on-call doctor. This was odd to me since they had a relationship and it was 6 AM already but it turned out to be the most fortuitous event of the day. For the doctor that was on call was likely the only one within 30 miles that would have allowed J the wonderful outcome that ensued. But I must digress for one last moment. We arrived at the ER at 5:30AM. She came for exhaustion and pain relief. She got her epidural about 7:20AM. That’s an hour and 50 minutes of pretty obvious suffering due solely to the administrative bureaucracy. She was begging for her epidural and all the wonderful nurses could say was that things were moving as fast as they can. It must be so hard for a caring nurse to watch that day in and day out. Tracy says she sees it 5 times a month. No one raises a stink for fear of retribution. There us little humanity in big institutions and it can only get worse. J got comfortable and moved slowly going from 4 to 5 to 6 cm over the next 10 hours. Baby A was doing great, however, but even so it would be the rarest of obstetricians at a hospital with a nearly 40% c/section rate to allow her to crawl along like this in violation of Friedman’s Curve. Coming on 36 hours of labor and 24 hours of ruptured membranes modern obstetricians would become impatient, label this “dystocia or FTP” and proceed to a surgical birth. But Dr. W so honored this families wishes and followed evidence based medicine combined with knowledge of fetal heart patterns to allow her to labor. Sometime after 1AM the next day she was complete and although almost numb was able to push her baby out in 5 contractions at 8 pounds 7 ounces. Her 40 hour labor ended as it should with good collaboration and obstetric practice and joy all around. Will Dr. W get peer reviewed for going off the reservation? Possibly, but he did the right thing. When I think of where my profession was and now is I get very sad. When I see attempts at bullying women and physicians by special interest groups like ACOG and the CMA I get angry. When my experience and wisdom have taught me that informed choice of options and not restriction of options under the façade of safety or the bias of economics are our right I get motivated. These stories of strong women, educated choice and wonderful support and collaboration deserve our attention. Californians need well trained midwives and these midwives and the women they serve deserve the support of our doctors and lawmakers and not their derision. My greatest admiration, almost to tears, goes out for these two women, their families and to the 2 very special doctors who still remember the humanity of our calling. Dr. F

Labor is not a Toothache!

From curvewire.com: Kim Kardashian Wants C-Section Posted by Johnny Robish on April 10, 2013 - 10:18pm..... “Kim Kardashian Wants C-Section: It’s being reported that pregnant Kim Kardashian wants to give birth by C-section as soon she’s 8-months pregnant because she wants her life back. And since Kanye is a musician, I would assume it’ll most likely be a “Middle-C” section.” ..... I was at a dinner party last night in celebration of the recent homebirth of twins in Santa Barbara, CA. During a lovely evening we discussed a lot of topics and the subject of Ms. Kardashian’s choice came up. This blog is not about bashing her obvious narcissism but her choice did produce a dialogue about labor pain. I have given this subject a lot of thought during my metamorphosis from hospital based to home based practitioner. Since epidurals and narcotics are not available at home we rely on other methods to deal with pain. Movement, water, hypnosis, massage and strong support are beneficial and work well for many laboring women. The key is that these things help cope with the pain but don’t remove it. To understand why coping but not eliminating pain is important we need to ask ourselves why labor is painful in the first place. I mean, if we believe in evolution why wouldn’t the pain of labor evolve away since natural selection usually eliminates those things that are detrimental to the survival of the species. There is, of course, the biblical Garden of Eden explanation but let me put that aside for the moment. Just suppose labor pain is not detrimental but is beneficial. I give credit to my colleague, Aleks Evangelidi, LM, for her insight in this regard........ Anyone who has ever had a toothache or a kidney stone will argue there is no benefit to the pain other than to let us know something is wrong. Painkillers are a godsend in these circumstances. But labor is not a toothache and it is time to look at the pain of labor in a different light. All mammals have labor and all mammals have labor pains. The onset of labor contractions usually build slowly but eventually become quite painful lasting 40-60 seconds followed by 2-3 minutes of relief. The mammalian body responds to this pain by releasing its own narcotics and neurotransmitters that nature designed just for that purpose. Endorphins and enkephalins are the body’s natural opiates. Oxytocin release produces warmth and attachment responses and adrenaline helps the body cope with stress and possibly spaces out the next contraction allowing time for rest and recovery. And don't forget Cortisol, which orchestrates all sorts of needed stress responses including blood sugar modulation. It really is a beautiful cocktail that nature has designed just for this purpose............ When a laboring woman is not allowed to cope with pain as nature designed it is easily understood why hospital epidural rates approach 90%. Having to stay flat in bed so continuous fetal monitoring (CFM) can occur does not allow for the natural desire and ability of mammals to move about in labor to diminish discomfort and use their own pain stimulated cocktail. And so, modern obstetrics encourages epidural use to eliminate pain and modern women think this is a good choice because to them: Labor Pain = Toothache........ It gets back to the saying about the long habit of not thinking something wrong gives it the appearance of being right. Nature is pretty smart. And a toothache does not have a baby inside but a pregnant woman does. And when a woman undergoes the stress of labor so does her baby. Her body’s response to pain releases that cyclical cocktail and those substances certainly cross the placenta. And just maybe all those neurotransmitters and hormones that help mom deal with the pain and stress of labor help her baby cope as well. For after 9 months of sitting comfortably in the womb suddenly everything that baby has ever known is changing. Labor has to be stressful and even painful for the baby and the suddenness of delivery by c-section even more so. Mom’s natural opiates, oxytocin and adrenaline clearly serve a purpose in assisting her baby in this transition. Denying the baby these substances through the commonplace use of epidurals or scheduled c-sections is counter to nature’s design. Babies are little sponges absorbing every experience and forging new and sometimes permanent neural pathways that will be used in the future. Altering labor has to mean altering this process as well. I was never taught this way of thinking in residency and in my 31 years as a physician I have never seen this discussed in a grand rounds or an academic journal and yet it is so common sensical. Modern medicine needs a bit of humbling and as we are beginning to discover when you mess with Mother Nature you inevitably get something not intended........... The process of labor is painful for a reason and that reason just may be how it benefits the baby’s transition to extra-uterine life. Women are too often told that the pain of labor need not be endured. And while modern anesthesia is also a godsend and epidurals have a place in some labors, obstetricians need to rethink their unconcerned attitude towards its ubiquitous use. Especially in those cases where they scoff at the woman with a birth plan that states an avoidance of pain medicine. Allowing laboring women the freedom to move about and use other pain coping mechanisms might just be doing future generations a favor. Once again it boils down to informed consent. If Ms. Kardashian still wants her unnecessary c-section so she can have her life back after reading this blog then that is her choice and should be respected. I am willing to bet she has never been taught about or thought of birth in this way. Dr. F

Cesarean Section & Newborn Immunity

With the proliferation of unnatural birth by cesarean section in the United States it is only to be expected that new data on the consequences of this intervention will be forthcoming. We have now had about 30 or more years of rising “elective” cesarean section rates in the U.S. which gives us a good petri dish from which to see good scientific evidence of its effects. One of the negative effects seems to be the rise in respiratory ailments in neonates and children. In a recent review by Cho and Norman, (Cho CE , Norman M. Cesarean section and development of the immune system in the offspring . Am J Obstet Gynecol. 2013;208:249–254), they conclude: “Recent epidemiological studies provide evidence that elective cesarean section (CS) is associated with aberrant short-term immune responses in the newborn infant, and a greater risk of developing immune diseases such as asthma, allergies, type 1 diabetes, and celiac disease. However, it is still unknown whether CS causes a long-term effect on the immune system of the offspring that contributes to compromised immune health.” They conclude that more emphasis should be placed on discussion and counseling amongst professionals and childbearing women. In the same issue of the AJOG is a corresponding article by Romero and Korzeniewski from Wayne State University that discusses the likely causation of Cho’s findings.http://www.ajog.org/article/S0002-9378(12)02261-2/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology I strongly suggest reading the full article as it goes into depth explaining the importance of microbial exposure at birth and its correlation to the newborn’s immune response. They cite a sentinel work by Hugo Lagercrantz and Theodore Slotkin that emphasized the importance and adaptive value of intrapartum stress in their seminal article “The ‘Stress’ of Being Born.” In it, “The authors described 4 main transitions that occur at birth: (1) emergence from an aquatic environment where oxygen is acquired through the placenta to a dry environment in which respiratory exchange occurs through the lungs, (2) change from a warm environment in which the fetus has a temperature that is 1 degree higher than the mother on average to a cooler environment at room temperature, (3) moving from a continuous supply of nutrients through the placenta to intermittent feeding in the neonatal period, and (4) going from a sterile bacterial environment to the establishment of the neonatal microbiome (eg, skin, respiratory tract, gut). Lagercrantz and Slotkin's views have gained relevance with time and are now buttressed by a considerable body of work suggesting that the microbiome plays an important role in the developing immune system.” It would seem the body of evidence is beginning to weigh heavily that there are consequences to the route of birth. For those of us that support vaginal birth options this comes as no surprise. Nature does have common sense sometimes. The ethics of informed consent should imply that obstetricians include this information when counseling patients on the RISKS and benefits of an elective cesarean section. One final article in the same edition of the AJOG takes a different tack. Authors Lynch and Iams state: “we fear that their (Cho, et al) limited review of a very complex literature leads the reader to a naïve conclusion: that the cesarean procedure itself might be bad for infants and children.”http://www.ajog.org/article/S0002-9378(12)02262-4/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology They take a critical look at the methodology and cannot agree with Cho’s conclusions. It seems they think that prematurity and its effects on the immune system may play a role in skewing the data and that cesarean section cannot be isolated as having a direct role in causation. While I applaud the AJOG for publishing all three of these articles and bringing the problem of a rising cesarean section rate into the limelight, I cannot ignore the contradiction to when the Wax paper was published. If you recall, the Wax paper criticized the safety of home birthing and was immediately adopted as gospel by ACOG and critics of home birth. There was no such corresponding critique of its methodology in the same issue of the Green Journal despite a myriad of cited authors who found great flaws in his methodology and conclusions. Maybe I am overly sensitive but it seems clear that these two articles, one critical of elective cesarean section and one critical of home birthing, are being responded to in different fashions, both of which seem to favor and support the expediency of the current medical model of obstetrics. I mean, here you have compelling data of the risk of surgical birth on newborns and whether or not scientists and researchers believe it fully isn’t it worthy of informing mothers of this research and letting them decide? A peaceful Easter to you. Dr. F

Trusting Nature....Again

Just as she had hoped for she began having regular contractions every 15-20 minutes on the evening of her assigned due date. This couple had a history of several recent pregnancy losses and was so happy expecting their first baby. But like most parents in our fear based society they were frightened of what they had read about birth and especially about hospital birthing. Also, mom worked in a health care facility and what she experienced made her wary of western medicine. Mom has a phobia for hospitals and for needles and so sought out the option of home birthing. They had been referred to me by a midwife colleague in her first pregnancy which had ended in a miscarriage. We had spent much time together over the past two years and the trust necessary for a successful birth was the result. As part of our many conversations we discussed the midwifery approach to pregnancy and birth as well as the medical model and the care that resulted was a hybrid of both. My experience with both models of care gave her the confidence to overcome some mental and physical obstacles. She had to take medication through the first trimester because of her previous miscarriages. In the medical model she would have been labeled “high risk”. But once the milestone was passed and her medication stopped she was as normal as any other mother. Many physicians would have continued to carry the high risk label with all the subsequent fear and over-testing that comes with such a label. There is no doubt in my mind that doing so would have written a much different story of her labor and birth. Add to that the positive group B Strep carrier state and frightening stories of babies gone awry that so often accompanies that scenario and a perfect storm for interventions would be brewing. Through the night her contractions increased in intensity and came every 4-5 minutes. We spoke just after midnight and again at 3:30AM and just after dawn. I cancelled my day in the office as she lived about 50 miles from there and waited. After sunrise and as the morning passed her contractions spaced out. I have become acutely aware of the power of the higher brain over the primitive brain. My lectures about the mammalian nature of birth make the understanding of distractions and the effect on labor so obvious and clear. This family is highly educated and as mentioned tends to think too much on the “what ifs” and so I was not surprised that as the day wore on labor malingered with her contractions coming every 7-20 minutes all day long. My midwife and I stopped over about 7:00PM to take some vital signs and give reassurance and suggestions for comfort, rest and patience. It was likely that if she was not given these things that she would be up another full night and eventually become exhausted. We put her to bed after a warm shower and some fluids and suggested that she not try to walk her baby out. She was able to get some rest and sleep through the night and awoke on the third day still with regular but infrequent contractions and a bit of bloody show. I went to work this time at my much closer office feeling a bit foolish for missing the previous day. But understanding labor and predicting its course is not a fruitful activity. Trusting it, however, has proven reliable. Gradually, her contractions picked up in intensity and frequency to the point where the next phone call just after 7:00PM came from her husband. For those of us practicing the home birth model the call from the husband is a sure sign of things progressing. Mom is now too inwardly focused to make the call. The birth team arrived at 8PM to loud noises and concerned looks from Grandma and relief from dad. A quick assessment showed all to be as it should be and a requested exam was 7 cm. and still intact. I started an IV which drew loud protests. Reminded of her needle phobia I used a little lidocaine first. 2 grams of Ampicillin were administered and we prepared our equipment while mom walked, paced, sat on the toilet, knelt on all fours supported by her man. Around 10PM her membranes spontaneously ruptured and just before 11PM the incredible urge to push could not be resisted. A gentle exam showed baby to be at +2 station with no cervix left. In less than an hour they were holding their baby in their own bed with emotions of relief and exuberance and joy! Having seen birth in hospitals and birth at homes there is no comparison. To call them by the same name, “birth”, does not do justice to the differences. Just over 48 hours had passed from the time of the first regular contraction. I was confident that labor would progress here in its own time. If not, nothing would have been lost with conscientious observation and eventual transfer of care. I have little doubt that my hospital based colleagues would never have allowed nature to follow its own path. The first morning she would be told to go to the hospital. Here she would have gone through the usual litany of tests, consents, interruptions and indignities. Labor cannot function well in that setting. Her contractions spacing out would have precipitated an IV, CFM and either Pitocin augmentation or AROM, likely the former considering the group B strep status. Unable to move or shower would have meant an epidural and eventual AROM likely with fetal scalp electrode and, of course, NPO. If she made it to complete she would have likely been too numb to push effectively leading to a longer second stage and possible operative vaginal birth and laceration or episiotomy. Who does not believe she had at least a 40% chance of a c/section? There is little if any room in the hospital model for patience and trust in the wisdom of the natural labor process. Now, at home, holding her baby for the first time, no lacerations, placenta out, and husband next to her with her own mother looking on there was this amazing smile on her face. A face that earlier had the look of determination mixed with panic that so often appears in transition. Never separated from her baby and a realization of what she had accomplished, her life and that of her child’s will never be the same. The stories they will tell and the admiration husband will have for wife are so different than they might have been had not the process of labor been respected. My experience and wisdom for understanding the variances of the birth process did not come from books or residency training. It is not something I or any obstetrician can glean from watching hospital birthing. There is too much hustle and bustle and timetables and interruptions and fear in that setting to learn to trust birth. I am so fortunate that my journey has taken this path and that I allowed myself to be open to learning. I and the women I care for are grateful to the midwives and visionaries who have taught me well.

Stage 2 Consequences

Much of what passes for legislation these days seems to be feelings based and reactionary. With litte time given to debate or deep thought. As long as it feels good there is no concern whether once implemented it will actually do good. The Affordable Care Act (Obmacare) is the penultimate example of stopping at stage 1 thinking. As Nancy Pelosi so famously said, "You will have to pass the bill to find out what is in it!" Well, think on this! I recently read an opinion piece in the Wall Street Journal titled, "The Doctor's Office as Union Shop" by Dr. David Leffell, a practicing physician and the former CEO of the Yale Medical Group and a professor at the Yale School of Medicine. As you know me by now, I am a critical reader of opinion pieces and pretty much anything that passes as mainstream news these days. It is hard to know what to believe. I could not find any fault, however, in Dr. Leffell’s arguments about what is likely to happen to doctors in the wake of the government takeover of health care thus reducing the once proud sole proprietor into nothing more than a salaried service worker. If you have followed my blog for some time you will find that I am not a fan of the poorly named “Affordable Care Act” for a myriad of reasons. One of which has been the inevitable discouragement of the ambitious and brightest from undertaking the years of commitment and expense it takes to become a physician. Those young men and women who prefer to be shepherds of their destinies and not sheep will look to other opportunities. What will remain are dedicated workers who will prefer defined hours, a better lifestyle and the security of a set salary. While this is not a bad thing in and of itself it is like the proverbial finding of half a worm in an apple. For their employer will no longer be “the self” but will be the government or some big faceless corporate entity dependent on government rules and regulations that define treatment protocols and regulate reimbursement. Dr. Leffell says, “The truth is that physicians are now becoming service workers. They are well-educated and expensive to train, and their decisions have substantial significance in the lives of others. But doctors essentially provide a service, one that cannot be outsourced to India or China……When doctors occupy a service niche like the chambermaid in Las Vegas or the school teacher in Chicago, the expectations and compensation of the physician-worker will be defined in ways that may make the benefits of collective bargaining appear very attractive…… If doctors unionize, that raises an immediate question about their right to strike—the key lever in collective bargaining. That's a question for another day. For now, it's enough to contemplate what will occur when the practice of medicine becomes detached from its past as a profession—when doctors may in time come to see themselves not solely as healers but as workers, units of labor, in a system that is committed to delivering care to the greatest number.” It is inevitable then, as government inserts itself into the equation, that choice for consumers will decline and services will be rationed. Cost containment will fall heavily on doctors and hospitals. With no relief from threats of malpractice lawsuits and pressure to adhere to artificially set performance standards piled on top of less financial reward we will inevitably see rising job dissatisfaction. And although the expectations of Americans will be that they should get the same quality of care for less money in reality that is not possible. All the micromanaging and theories about efficiency do not take into account what happens in the real world. No longer individual professionals but now salaried workers, likely disgruntled salaried workers, what is to keep physicians from unionizing? Leaders of the dwindling private sector organized labor movement will drool at the prospect of a whole new profession to appeal to. As Dr. Leffell’s concludes: As has happened in other countries that have charted the course we are now on, a new reason for lack of access may at times be: "Office closed, doctors on strike."Dr. F

Ethics Under Assault

It’s a story that seems all too common; the recurring harassment of supportive and optimistic doctors willing to collaborate with midwives. Honest and brave doctors who want to provide evidenced based options to women are forced into a choice of business survival vs. professional morality. The power of the big over the small, the bully over the weakling, it’s a story of sham peer review to maintain the status quo. Somewhere along the line the ethical and moral code we swore to uphold gets pushed aside for expediency, economics and fears of liability. The story plays out as good people who remember their fiduciary duty to their patients are harassed and eventually squashed by the behemoth that is conveniently called the “standard of care”......... Because the established medical machine says that something is outside their rigid community standard then the supportive doctor cannot be allowed to individualize his care and support other reasonable options. They believe that “consensus” equates with truth. It does not. And if you are not in their fold then you are a danger to them, their liability and their livelihood and must be coerced into conforming or risk the isolation from colleagues and the threat from hospital committees and administrators. This is happening all over the country and recently to some wonderful local doctors. Having been through this I would not wish it on anybody......... The modern doctor-patient relationship is not the one we grew up with. Although doctors are still expected to treat their patients with the same measure of duty, skill and care that has always existed there are new and powerful outside forces pressuring that relationship. There has always been a duty owed to the patient that remains a “fiduciary” wherein the patient’s interests must be paramount to those of the doctor. This faith and trust placed in the doctor by the patient all too often comes in conflict with the doctor’s own interests. Doctors have many pressures put on them by third parties such as government agencies, malpractice insurance companies, hospital administrations and third party payers. Often these interests directly conflict with the fiduciary duty to the patient.......... As I see it, too many of my colleagues have succumbed to these pressures and thus prioritize not on what is best for the individual patient but what is going to help them survive financially. There is no doubt of the reality of the difficult choice they must make for themselves. If they truly thought about this it would be very painful. But in the mode of groupthink that has overwhelmed my profession the pressuring of the rare nonconformist is understandable. So as to remove themselves from responsibility the majority go along with policies that violate their fiduciary duty but protect them from direct culpability. They use the, “I wish I could honor that choice if only the hospital would allow it”, excuse rather than stand with the few who think decisions should still belong to the informed patient. On the simplest level these brave few who choose to honor Hippocrates make the tyrannical majority look bad and, so, they must be vilified.......... Furthermore, under the American Medical Association’s Code of Ethics there exists the beneficence model to which we are all supposed to adhere. According to Sonya Charles in her recent Medscape article on The Ethics of VBAC, 2012 The Hastings Center the beneficence model makes a peculiar claim: “To interpret reliably the interests of any particular patient from medicine’s perspective. This perspective is provided by accumulated scientific research, clinical experience and reasoned responses to uncertainty. It is thus not a perspective peculiar or idiosyncratic to any particular physician. Based on this model, the physician cannot refuse to accommodate any request for alternative treatment that is supported by scientific research and clinical experience."......... My point is this: Hospitals, medical staffs and groups of physicians that wield power over individual physicians and smaller groups and threaten their livelihood if they do not conform to whatever standard they deem appropriate are violating both their fiduciary duty and their ethical obligation to the people of their community. Doctors who support patients who choose a midwife are honoring their ethical obligation. Doctors who allow for selected breech delivery, VBACs and twins are honoring their fiduciary duty and their ethical obligation to put their patient’s reasonable choice ahead of their own self interest. It would be just as ethical for a doctor to say to a woman that he cannot support that choice but refer her to someone who can. It is also the ethical and, I would say, moral responsibility of those doctors to aggressively advocate for those reasonable choices in the facilities in which they practice and with the insurers who restrict the rights of patients to choose. It is too easy to throw up ones hands and do nothing but it is not right, it is not moral......... What is also not acceptable is for doctors to skew their consenting to funnel patients into choices they prefer. It is a violation of their ethical code to punish doctors who put the fiduciary interests of reasonable patients before their own. Worse, it is immoral to do these things for financial gain or for expediency in lifestyle. Yet, sadly, this goes on every day and has become the accepted norm. I encourage every patient to educate themselves on reasonable choices for their health. Go discuss them with your practitioner. If you are met with skepticism or disdain present the ethical and fiduciary argument and see what response you get. Many doctors have lost sight of these simple tenets and seek retribution when confronted by a colleague who tries to point this out. The power for change lies with the consumer and those of us who honor the doctor-patient relationship as it was once intended are counting on you for help.

Safety or Cognitive Dissonance

(Posted with permission) A couple months ago I cared for a woman in labor who strongly desired a VBAC. In the two years since the birth of her daughter by cesarean section for breech she had struggled with anxiety and some mild depression. This lovely woman had done her research and educated herself about breech delivery. She realized that she had not been given true informed consent about her reasonable options and her hopes for allowing her body to work as nature intended were not respected. She had valid concerns that her depressive symptoms were exacerbated by her feeling of helplessness and by some resentment towards the medical system that had failed her. Upon the good news that a second baby was on the way she was determined to empower herself and find a way to affirm her body’s ability to deliver vaginally. One major obstacle stood in her way. She lives in Ventura, California. In a county where VBAC is truly treated as a four-letter word. Community Memorial hospital, Ventura County Medical Center, Simi Valley hospital, St. John’s Regional Medical Center in Oxnard, Pleasant Valley Hospital and, even, Cottage Hospital in nearby Santa Barbara all “ban” VBAC. At the one institution where it might be possible to have a VBAC in Thousand Oaks, the protocols and restrictions are so rigid that they, themselves, limit the chances of success. I met this couple early in their pregnancy when they came to me as an option for the reasonable choice of a VBAC out of the hospital. Since they live up in the hills of Ventura and their home is under construction they happily chose to birth with me and a licensed midwife at a Birth Center in Ventura. Given true informed consent of the benefits and risks of VBAC and repeat cesarean section derived from much of the information in the NIH VBAC Consensus Statement from 2010, the decision was well informed and an easy one for them to make. Her chances of avoiding a surgical birth and all the joys of an un-medicated vaginal birth were 75-80% and her risks of a problematic outcome were about 0.33%. As the pregnancy progressed it was evident that, like her first baby, this baby was going to remain frank breech. She tried all the usual remedies including acupuncture, chiropractic and external version with no success. We then spent much time reviewing the options when a baby is breech. She was fully aware that the problems of finding a practitioner willing to perform a breech delivery extended far beyond Ventura County. Despite the refutation of the 2000 Hannah paper by many authors. The more recent PREMODA study, Glezerman article and the 2009 statement by the Society of OB/GYN of Canada supporting the retraining of selective vaginal breech delivery it is pretty much a given that breech = c/section in most parts of the country. I have discussed the breech issue before and suffice it to say that most doctors of my generation were trained to perform selected breech deliveries but have given it up. The reasons given are always “safety”. Safety is often a canard for something else when it flies in the face of obvious academic disagreement on this issue. I have also written on the trinity of expediency, economics and litigation-mitigation as one possible explanation. Younger physicians do have the excuse that they were never trained in breech and therefore, for them, c/section is the only option. However they should honor the ethical duty to at least inform women of the data and offer to refer them to someone who may be able to offer them a vaginal choice. In a recent conversation with another client about these issues I began to formulate a theory as to why knowledgeable physicians so quickly condemn, obscure and ridicule the choices of VBAC, breech, often twin vaginal birth and home delivery. I think my colleagues are good people. They are certainly intelligent and most keep up on the academic literature. They must be aware that at the very least there is good evidence by reputable researchers and institutions that support the safety of these choices. Ethics and true informed consent would dictate that at least they give patients unbiased information and options even if they are not comfortable with them. Yet there is the common scenario of physician certainty that to choose one of the options is dangerous and deserving of ridicule. Ridicule of the choice and derision of those of us who would offer it. How does one justify doing only surgical births as a matter of policy when they must know otherwise? Physicians of my age in their fifties tend to be the leadership of the Obstetric Departments of hospitals. They were almost certainly trained to do twin and breech deliveries. VBACs were the norm and require no special skill. They must know of the phrase, “Primum Non Nocere”, first, do no harm. Yet they skew their counseling to convince women of the safety of a surgical birth, sometimes say really mean things to women who question this and act unprofessionally towards their colleagues who differ with them. Why? My theory: COGNITIVE DISSONANCE! The term cognitive dissonance is used to describe the feeling of discomfort that results from holding two conflicting beliefs. When there is a discrepancy between beliefs and behaviors, something must change in order to eliminate or reduce the dissonance. There are three key strategies to reduce or minimize cognitive dissonance: • Focus on more supportive beliefs that outweigh the dissonant belief or behavior. • Reduce the importance of the conflicting belief. • Change the conflicting belief so that it is consistent with other beliefs or behaviors.http://psychology.about.com/od/cognitivepsychology/f/dissonance.htm Let’s examine what is happening in light of this definition. A physician or group of physicians is subject to a hospital policy banning VBACs, breeches and many twin vaginal births. This policy may or may not have been their own creation or they may have succumbed to pressures from other departments like anesthesia or risk management. Nonetheless, it is a policy of the hospital to which they must comply in order to continue to practice there. When evidence in the literature clearly conflicts with that policy it must be very difficult to justify that evidence with what they are doing. Rationalizing and reliance on only those papers that support the policies satisfies strategy 1 in reducing cognitive dissonance. Ridiculing those, like me, who offer options based on that ignored evidence and dismissing patient’s honest inquiries as ill-informed helps to satisfy strategy 2. Finally, emphasizing only the risks of the banned choices and diminishing or ignoring the risks of surgical birth helps to make the information fit their belief and fulfill strategy 3. I submit that a good and moral person would have a very hard time living with themselves when performing c/sections they knew were not necessary. Especially when they are fully aware that there are other evidenced based choices that women may choose. This inner struggle with truth cannot be reconciled without the theory of cognitive dissonance. Living and working in a community where its conformity or ostracism is an awful choice. Good men and women in such a setting may have to alter their values in order to survive. One explanation is to believe it’s a form of the Stockholm Syndrome where the hostage begins to identify with his/her kidnapper. Believing, despite evidence and training, that the policies you are upholding are absolutely right complies with my theory as to why so many doctors and institutions are able to ban reasonable choices and vehemently condemn and vilify those that think or act otherwise. When my client found out she was breech again we sat down and had an hour long conversation about choices. We discussed the risks of home birth, VBAC and breech. None of which, on the merits alone, were reason to give up her only hope of a vaginal birth that was so important to her psyche. We came to the conclusion that she wanted to try and since obviously no hospital would even let her, an out of hospital birth became the reasonable option. She went into labor in the early morning hours and over the day progressed and, with contractions spacing out, then stalled out at 8 cm. Had she been a primip and vertex she would have been a great candidate for pitocin augmentation and possibly an epidural. But because she was breech and a VBAC we knew that transfer meant a c/section. The doctor on call at one of the local hospitals had a reputation for being most unfriendly toward home birth transfers so we decided to go to Ventura County Medical Center and accept whichever doctor was on call. They preferred to stay local and not to drive 60 miles to a friendlier back-up scenario. Pleasantly surprised, we were well received by the doctor and staff at VCMC and after a couple hours of admission proceedings she had a repeat c/section, a healthy baby and an uneventful postpartum stay. At a home visit a few days later we revisited her birth experience and she felt much better about the end result because she knew she had been given the opportunity to try. About 2 months postpartum around 10 AM on a Friday she had a knock on her door from an investigator from the Medical Board of California. They were seeking her signature on a release of records to investigate a complaint about my care as a possible violation of the California Medical Practice Act. The patient and her family were delighted with her care and had no complaints so politely refused to cooperate with the investigator. Clearly the complaint came from someone outside of the mother's primary care providers with knowledge of the circumstances of this birth. Since that information is kept confidential I can only speculate that someone without the background of history and factual procedures specific to this case felt that “safety” and standard of care was at issue here. They knew what I offered her was not within community standard since no one in the area allows VBACs or vaginal breeches and home delivery, in every case, is frowned upon. While this complaint was recently closed as unfounded by the Medical Board it is likely that every transfer of care in this community may well generate another letter. It is unlikely there will be any revelation that the care offered to this family was within reason. That would disturb the bubble of cognitive dissonance in which they live. Whereas writing the letter strengthens the delusion that only their model of care is the correct one. In an ideal world the evidenced based, literature supported option of VBAC and/or selected breech delivery would be something best performed in a supportive hospital environment. But since the same people who complain about me do not offer these choices women are left with skewed options that are often less safe and certainly less nurturing. Writing indignant letters of complaint makes those that deny choice feel better about themselves. Self-reflection is not a value or a virtue in these physicians and institutions. They fail to teach future generations of obstetricians the skills needed to deal with breeches and twins. They seem to accept as safe and normal that 33% of all women need c/sections. They believe that normal human birth need be treated as an illness. They selectively choose which science fits their model and conveniently ignore anything else. They vilify and harass those that provide common sense choices they do not approve of. And they use fear and derision as a tactic to convince patients they are foolish to question their authority. I remain hopeful that women and families will demand options and that organized medicine will see the error in their ways and return to accepting common sense and evidenced based care. I have no doubt that my colleagues who have drifted away from this reality can wake up and be kind and accepting of alternatives. Only if their world continues to be filled with cognitive dissonance could good, moral men and women deny informed consent and still go to bed at peace each night To continue in this fog is unthinkable. Happy Memorial Day, Dr. F

Art Class or Martial Art Class, a primer on choices

Recently there have been a series of original research papers and some review articles favorable to what I have been advocating for several years. Articles supportive of the safety of home birthing have come out recently. Possibly in response to the flawed Wax paper. The catalyst for these papers could be a return to sanity and evidence based writing or it could be because more investigations are occuring due to rising consumer demand for an alternative to the hospital model. Whatever the reasoning it is good to see well done studies that concur with common sense.In a recent study of more than 11,000 VBACs looking at outcomes and timing of intervention to prevent fetal injury it was found that the rupture rate was 0.3%, that of those only about 17% suffered serious injury and the success rate for VBAC in this study was 84%!!

Glezerman, et al had a well written paper in Medscape that reviewed the history of breech delivery and clearly defined the damage done by the poorly conducted Term Breech Trial in 2000 by Hannah. “This single piece of research profoundly and ubiquitously changed medical practice and effectively removed planned VBD from delivery wards in the western world.” And, “The TBT was a blatant example of how an inadequate randomized controlled trial can change medical practice.”In the year that followed release of this study the breech c/section rate in the Netherlands went from 57% to 83%.

The subsequent Premoda study from 2006 included 8000 (4 x TBT #s) women with singleton breech. This study found no difference in perinatal morbidity or mortality in breech babies delivered by c/s versus vaginal delivery. Yet nothing has changed as far as hospital policies toward breech nor has residency training in this skill returned.

Similar papers have come out in the last decade about the safety of term vaginal twin delivery. Surprisingly, and little known, was a paper published in 2000 in the Green Journal by Blickstein, et al which concluded, "There was no evidence that vaginal birth is unsafe, in terms of depressed Apgar scores and neonatal mortality, for breech first twins that weighed at least 1500 g.” So there is even evidence in ACOG's own journal about the safety of first twin breeches and yet more than 80% of all twins and nearly 100% of breech first twins are delivered by c/section in the United States. Even more surprising was this conclusion: “We did not see any intrapartum fetal entanglement, one of the most frequently cited specific complications of vaginal birth of breech first twins despite its overall rarity.”“ Our series that combined the experience of 13 centers and was five to eight times larger than previous reports, cast doubts on the relevance of the locked twins as a contraindication to vaginal birth.” Yet for as long as I can recall until present day, midwives and physicians are taught to fear the dreaded interlocking head scenario of Breech/vertex twins. While there are anecdotal cases, usually in premies, there is no hard data to support this ubiquitous premise.

Some who advocate for hospital birthing and condemn any and all who participate in home birthing are quick to point to the "safety" argument. The "what if something goes wrong" crowd will always use fear and blame to make their point. This blog is not to discuss the open argument about the safety of home vs. hospital birthing. I have done that before and will again. My point today is to reiterate the AMA code of ethics that supports respect for patient autonomy and decision making. “Conflicts of interest should be resolved in accordance with the best interest of the patient, respecting a woman’s autonomy to make health care decisions.”

What are the risks of the choice? What are the benefits of the choice? Whose choice is it? What is the role of the practitioner to give true informed consent based on evidenced based science? What is the role of the practioner when the patients choice differs from the practitioner's bias? These are very important questions and should always be analyzed with respect to a code of ethics. If I cannot support what a patient desires I am free to refer her elsewhere but I should not deny her information or skew my counseling to funnel her down a path of my choosing.

How we interpret risk vs benefit may be quite different from family to family. Differing life experiences and levels of education make blanket policies inadequate and dishonest. Something that carries a risk of 0.3% (or 1/333) also means that there is a 99.7% chance it will not happen. To have policies or adminstrators or insurers or writers condemn a woman for choosing a path based on her own risk assessment is totalitarian and not ethical. Banning VBAC, outlawing midwifery, skewing counseling on breech or twin deliveries for reasons (true or false) of safety is disingenuous at best. Is it not safer to put your child in art class than martial arts? Tennis is safer than football. Watching National Geographic Channel carries less risk that SCUBA diving or rock climbing. Should some higher authority decide which activites are allowed under the canard of safety? Would we allow or lives to be restricted in this way? I wouldn't want that sort of restraint on my liberty.

When it comes to choices such as home birthing, VBAC, breech and twins we must continue to respect the individuality of the decision. Same goes for choice of caregiver. Patients have the right to be educated. Educated people cannot be expected to always come to the same conclusions. Ethics dictates allowing for personal choice and responsibility. Decisions concerning one of life's most memorable events are personal and big government, big business and busy body know-it-alls (yes, you Dr. Amy) should just shut up and respect our differences.

Warmly, Dr. F

Rainy Day Philosophy

Living in Southern California has many advantages. One is the absence of snow days and another is the rarity of rainy days. Life slows down for me on a rainy Sunday morning. No place to run to. Horseback riding cancelled. Cat asleep at my feet. The sound of the wind and rain on the roof all cozy in bed with my book momentarily unhooked from the world. It is wonderful to slow down in today’s buzzing world of instantaneous information overload and short attention spans. Then I open my computer to read the amazing notes of my midwife colleagues at Sanctuary attending 4 separate births in the last 24 hours. Maybe there is something to the super moon thing! They post on the board of the natural progress of labor that comes in so many different forms. With calmness born of wisdom they describe what the families are doing at home. Some resting quietly while others are up walking and talking. Some sit or stand in water while others forage in the kitchen for the perfect nourishment to suit their craving. Fathers and doulas and midwives and apprentices and hypnosis experts and children and pets all are choreographing this dance of life. I was speaking to my great friend and colleague, Heather, in the comfort of The Sanctuary Birth & Family Wellness Center, this past week and the following realization just flowed forth.

I have now attended more than 70 home births and have noticed many differences from my 28 years of attending hospital births. But none is more striking than how the environment affects the traditions and attitudes of the practitioners. In a hospital based birth the primary care giver is almost always a nurse or possibly a CNM. They are bound by policies and procedures that limit individualization. No matter what the desire of the family dictates there is pressure on the staff to complete forms and data entry. They must document “progress” and even encourage intervention when it does not conform to some standardized norm. To not push the process along can bring the scorn of their supervisor. Nurses are encouraged to monitor all sorts of bodily functions and even the most caring have to deny food and interrupt the primordial place a woman should be for the sake of documentation.

Documenting what and for whom? When and why then? Likely for administrative policy, litigation mitigation for that worst case scenario fear, for the next nurse and doctor coming on in the shift practice model or just one of those long habits of not thinking a thing wrong, thus making it seem right. But that is all the consequence of the dominant trend to look at pregnancy and labor as illness, not wellness.

In this model there is rarely a doctor present until called by the nurse to come in. From experience I think many nurses fear this for woe be unto them for calling the doctor too soon or too late. From my past experience I vividly recall arriving to the labor room from home or office. Invariably, all eyes would now focus on me and I would be expected to do something. Many doctors would feel as if they must do something because they are now there. And so there would be vaginal exams and commands to push when no urge was felt. The nurse would receive orders for pitocin and pressure catheters because labor was not following the curve fast enough. Discomfort is difficult for doctors to observe so the wonders of an epidural would be lauded.

It would almost be inconceivable for the doctor to arrive, sit quietly in the corner observing for a while, whisper a few words of encouragement and then quietly leave the woman and her partner alone. The “I am here now so I must do something” mentality is pervasive. It may be the rescuer in us, the fixer or it could just be an impatience born of long hours, frustration, poor rewards and fear. Whatever the reason it is pervasive and is a startling contrast to the calm, nurturing approach of my experiences with home birth.

When I arrive at a home birth after a gentle knock on the door I quietly enter the space with a whispered greeting to the father or other caregivers. I observe the room, listen to the sounds and look at the faces of those present. There is so much vital information there that no machine can tell me. There is an honoring of the process and the woman in labor is on a pedestal. She is a person not an object. The goal of all those around her is to keep her feeling safe and nurtured and in whatever zone will keep her focused on the primitive, instinctual processes of labor. There is no timetable and no hustle and bustle of disturbances. There are only the sounds of nature and family linking us to all those that came before. We are calmly waiting for another generation to enter the world.

The conversation with Heather clarified what had been just a feeling since joining the home birth community and made it a revelation to me. My midwife colleagues have heard me say that no matter how I am feeling before I enter that sacred space of the nurturing birth world I always leave feeling better then when I came in. That was almost never the case when entering even the parking lot at a hospital. It is a striking difference to enter the world of the laboring woman and not feel like I am obligated or entitled to do something. Trusting birth makes it a better world for everyone involved and returns the joy to my work.

We have all created a safe and cozy space for ourselves. We call it home. On this windy, rainy Sunday there is no place better to be. I am surrounded by familiar sounds, sights and smells and it feels wonderful. It is a metaphor for life and certainly for birth. Building a secure, nurturing support system is good for your life and better for your birth. There is much to be said for returning to the pleasures of sociability and being intentionally unproductive. I would encourage my fellow practitioners to take a deep breath, look about them, walk more slowly and rethink the model which has become so normal and yet so detrimental to the enjoyment of their lives.

Warm Greetings To You All, Dr.Stu

Read more of Dr Stu's thoughts on his blog