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Some women are choosing to have their baby by a planned, or scheduled, cesarean instead of “leaving things to chance.” How sad that these women aren’t considering the extra dangers these planned cesareans bring into the picture.

Articles that try to paint cesareans as panaceas for the “problems” of normal birth often make opinion seem like fact. For instance, they may list incontinence or pelvic floor weakness as consequence of normal birth. Yet, women who’ve never even been pregnant sometimes have these problems. Or, they may think that planning the date for the birth via cesarean makes things more calm. That’s like saying it’s calm before the gun goes off when playing Russian Roulette. Cesareans raise the mother’s AND the baby’s risk of dying; women have more problems with breastfeeding (which also raises the baby’s risk of dying); women have more long-term problems. How is that more calm over the long run?

And, think of this: when one schedules the day of her child’s birth, she is effecting that child’s whole life. God knows what will happen in the future. He may have chosen a different day because the day of the child’s birth may have a huge impact on their life; we don’t have that knowledge. What if the child is drafted because of their scheduled birth date and would’ve missed the draft otherwise?

Scheduling cesareans because the baby is breech is simply pointing to a lack of experience and training on the part of the birth attendant and the terrible chance for litigation many OBs face. Normal breech birth with a skilled attendant is not risk free - but neither is cesarean delivery of breech babies. Cesareans raise the risk of the baby dying by THREE TIMES! So, add in that risk when comparing breech births. Then, some breech babies have congenital abnormalities which raise the risk of the baby dying regardless of birth method. But, if the baby dies after normal delivery everyone thinks it would’ve been saved if born via cesarean. That’s a nice wish, but not necessarily so.

Planning a cesarean because the woman has already had a cesarean is like fighting fire with fire - good if it’s needed, and just compounding a problem if not. Women who have had a cesarean have very little risk when planning on normal birth. ican-online.com is a great place for information on this.

Let’s look at one more reason to not schedule a cesarean. Scheduling the day of your baby’s birth may be a little like trying to schedule when you’ll meet your future spouse or when you’ll see a beautiful sunrise. Some of life greatest joys are unplanned - they are simply a gift from God.

Tags: Cesarean Planned Cesarean Scheduled Cesarean

June 23, 2008

Douglas H. Kirkpatrick, MD
The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC 20090-2188

Dear Sir:

I am a practicing OB/ GYN in southern California and Fellow of ACOG and recently was informed by midwife colleagues of your recommendation and encouragement for the AMA to lobby Congress for a law banning out of hospital birth. It is disturbing to me that I had to hear of this decision from outside sources and was never approached by my college to see how I or my local colleagues felt about it. I have grave concerns regarding my organization taking such a stand. I think we are all agreed that ACOG has a statement regarding patients’ rights to informed consent and informed refusal. Yet, it seems with every decision our organization moves further away from that basic tenet. ACOG's little "guideline" paper on VBAC in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds of hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let's be honest, due to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If you think this is untrue you are, sadly, out of touch with real clinical medicine.

As to out of hospital birthing, please give me the courtesy of an explanation as to the evidenced-based data you used and the process by which an organization which is supposed to represent me came to this conclusion. Any statement saying that it is as simple as patient safety and that one-size fits all hospital births under the "obstetric model" of practice should be applied to all patients is, putting it nicely, not really in line with what best serves all our patients. In many instances, hospitals are not safe, certainly not nurturing and have a far worse track record for disasters than home birth. Even when emergency help is nearby this is true. The focus of all of us in medicine should be on reigning in trial lawyers and tort reform and lobbying Congress for that. The best interest of the college members and the patients we serve would be for my organization to spend its time and energy on something that has true benefit. Removing choices from well-informed patients and caring doctors and midwives is wholly un-American.

So please send me detailed information on how ACOG decided outlawing home birth would be a wise thing to do. You must have conclusive scientific data to take such a drastic stand. Please make it available to me so that I may share it with likeminded colleagues. I would also like to know the process by which this came to pass. Who first raised this issue and why? What committee reviewed all the data and did its due diligence in interviewing those of us with longstanding experience in backing midwives who perform out of hospital births. There must be a clear and concise, non-confidential paper trail you can share with your members. Specific names of committee members who voted for this would be enlightening and I am requesting this information. I would like to know the background and expertise regarding out of hospital birth for each member who had a hand in the decision to go to the AMA.

We live in an odd era where once something is said or recommended by a legitimate organization such as ACOG it has deep ramifications never intended such as becoming fodder for trial lawyers trying to squeeze the lifeblood and dignity out of your members. In this case these ramifications have had the undesirable effect of forcing women to travel hundreds of miles in labor to find a supportive facility. Or even worse, to have them arrive in a VBAC banned hospital and refuse surgery or be coerced into it. Can this be the best we can do for our patients? Remember, your VBAC statement was meant to be only a recommendation but quickly became the rule by which hospital administrators, risk managers and anesthesia departments of smaller hospital banned this option for thousands of women. An option, which in proper hands, was the safe and accepted standard of care for 30 years. In fact, you still have an ACOG VBAC brochure that recommends this option! For those of us working at smaller hospitals where VBAC was banned due to lack of emergency help (anesthesia, OR crews, etc.) there is a big question that has perplexed us that no administrator seems to be willing or able to answer. That question is: "If a hospital cannot handle an emergency c/section for VBACs, and most obstetrical emergencies are for fetal bradycardia, hemorrhage (i.e. abruption) or shoulder dystocia not for ruptured uteri, then how can they do obstetrics at all?" For they seem to still be able to have a maternity ward without in house anesthesia. Will someday ACOG, in their great wisdom but seeming disconnect from reality, make a "recommendation" that little hospitals unable to afford 24-hour coverage stop providing obstetric services all together? Will this better serve women and their communities throughout America?

I am frightened and angered by what you have done in my name. Now I ask you to defend your position in encouraging the AMA to lobby Congress for another restriction on the freedom of choice that belongs to women and their families. Those choices include midwifery and the right to have the most beautiful and life changing event occur wherever best fits their desire. I am baffled that my college thinks this should be a criminal act. Midwives are well trained and required to have obstetrical backup. They have very special relationships with their patients and want the very best outcomes for them. They do not need me or you to police them. We have a habit in out country over the past 40 years of thinking we can legislate out stupidity. All that has done is erode the individual freedoms that belong, by birthright, to each of us. I would hope you trust your Fellows to know their specialty, their colleagues, and what is best for the patient as an individual. These decisions do not belong to politicians or faceless committees. You should have more faith in your members to give balanced informed consent. Again, my recommendation to you is to put all your considerable energy into changing our legal malpractice system. Those of us actually practicing medicine and caring for patients know this to be the greatest threat to the mission and responsibility we have chosen to undertake.

I look forward to your response and possibly the beginning of a meaningful dialogue.

Sincerely,

Stuart J. Fischbein, MD FACOG
Medical Advisor, Birth Action Coalition

Tags: ACOG Homebirth Midwives Safety VBAC

The Missouri Supreme Court handed down a victory for Missouri Certified Professional Midwives. A lower court had ruled against a law slipped into a bill on insurance last year. The law simply stated, "376.1753. Notwithstanding any law to the contrary, any person who holds current ministerial or tocological certification by an organization accredited by the National Organization for Competency Assurance (NOCA) may provide services as defined in 42 U.S.C. 1396 r-6(b)(4)(E)(ii)(I)."

Don't feel bad if you don't know what tocology is. Neither did the lawmakers who voted for it or the governor who signed it. It's an old synonym for the practice of midwifery or obstetrics. After the bill was passed, other lawmakers were infuriated to realize they'd just passed a bill allowing homebirth midwives FULL, unfettered practice in their state. Previously, non-CNMs were prohibited by Missouri law from practicing - they could get up to 7 years in prison for it.

Well, the doctor associations were unhappy with this law (to put it mildly) and took it to court. The lower court upheld it. The midwives, scrapping together every little nickel and penny they could, appealed it to the Missouri Supreme Court. (They are still in need to funds to pay their $30,000 bill.)

The reason given for the ruling in favor of the law was that the doctor associations didn't have a 'standing' from which to argue against the law: they weren't directly harmed by it. The doctor associations can appeal this ruling and have 10 days to do so. Appeals aren't common to the supreme court and the ruling was 5-2, so if there is no appeal, CPMs will be legal in Missouri on July 4! Talk about a happy Independence Day!

If you'd like to find out more about this, you can go to Friends of Missouri Midwives.

Debby S Blessed Babies and Families

Tags: Missouri Midwives Tocology Certified-Professional-Midwives

I attended an interesting birth recently as a doula. The hospital worked very hard to be family-friendly and to allow mom informed consent/refusal and I was thankful for that. About 30 minutes after birth, they wanted to take the baby, weigh him, measure, etc. Baby hadn't begun breastfeeding yet, and I told them that the parents wanted to use AAP's current guidelines on that and keep the baby with them. "What?" "You know. The American Academy of Pediatrics' *current* guidelines... The one that says the baby shouldn't be removed from mom until the end of first feeding or during the transition period, whichever comes last." The head nurse and the OB had the same response: 3 quick blinks with an otherwise blank expression. They looked at each other as though to say, "Do you know what the current guidelines say?" Then, the OB said firmly that it was *usual* for most hospitals to weigh the baby at this point and that they usually did that at that time, too. "We *need* a birth weight!" he firmly said. I responded, "I know it's usually done that way in hospitals, however, the parents wish to follow the *current* (stressing that word again) AAP guidelines in this." The OB said something I didn't catch and left the room. He returned about 5 minutes later and said, "Leave the baby with mom."

I think this information may not be widely known. The guidelines actually say, "Breastfeeding should begin as soon as possible after birth, usually within the first hour.( ref. 80 – 82) Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period. (80,83,84) Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized." And, later, "Pediatricians are encouraged to work actively toward eliminating hospital practices that discourage breastfeeding (eg, infant formula discharge packs and separation of mother and infant)." You can find this at [link="http://aappolicy.aappublications.org/cgi/reprint/pediatrics;100/6/1035.pdf"].

This dovetails with "Evidence-Based Guidelines for Breastfeeding Management during the First Fourteen Days," published by International Lactation Consultant Association. Management strategy #1 includes "Provide continuous skin-to-skin contact for at least the first 2 hours after birth or until after the first breastfeeding [and] Delay unnecessary procedures for at least the first 2 hours after birth or until after the first breastfeeding."

Holding hospitals accountable to evidence-based procedures is helpful for moms and babies and early breastfeeding success.

Debby S
[link="http://homepage.mac.com/dss7midwife/Personal1.html"]

Tags: Breastfeeding Skin-to-skin AAP AAP-guidelines-breastfeeding No-separat