The Six Lamaze Healthy Birth Practices

Lamaze International has put out a series of videos and research summaries called The Six Lamaze Healthy Birth Practices.

These are "evidence-based statements about the care practices that ease and facilitate labor, prevent complications, and protect breastfeeding and early mother-infant attachment."

Amy Romano, CNM, discusses the Healthy Birth Practices on the excellent birth blog, Science and Sensibility. She makes the following very vital point (emphasis mine):

Each of the Healthy Birth Practices is supported by decades of high quality research. I like to think of the practices as “the basic needs of childbearing women.”

Some women will need high tech monitoring and intervention to birth safely, but the standard should be care that supports and facilitates the normal physiologic processes, intervening with the safest, most effective, and least disruptive approach only when a medical need arises and with fully informed consent.

Routinely depriving women of The Healthy Birth Practices makes birth unnecesarily difficult, and complications more likely.

Amen to that. Let me say it again:

The standard of care should be that which supports the normal physiologic process and the best outcomes for mothers and babies.

Unfortunately, this can be difficult to come by in many hospitals today....and especially so for women of size.

The Six Healthy Birth Practices

The Six Lamaze Healthy Birth Practices include:

1. Let labor begin on its own
   
2. Walk, move, and change position
   
3. Have continuous support
   
4. Avoid unnecessary interventions
   
5. Get upright and follow urges to push
   
6. Keep baby with you

Now, all of these sound very common-sense, don't they? And yet very few women giving birth these days in the hospital actually get to experience these.

Think of the typical hospital birth you see on TV or in the movies. Although vastly over-dramatized for plot purposes and dramatic tension, they do represent the way most women experience birth in this country these days.

Most of these women are flat on their back (or nearly so) in labor, with tubes and wires all over the place and often an oxygen mask on their face. Most are given contraction-strengthening drugs during labor, have pain medication of some type, and have their water broken artificially at some point in labor. Most push on their backs or semi-sitting with their knees pulled way back to the side, holding their breath or screaming as nurses and partners count to 10 and urge them to "push harder!"

This is the reality of birth for most women in this country today, but it does not reflect the safest and most effective ways of giving birth.

Even more frustrating, the Six Healthy Birth practices is DEFINITELY not the reality of birth for most fat women in this country today, and as a result, women of size and their babies are being put at risk unnecessarily.

Go See These Videos

I can't recommend these videos and handouts highly enough. They are presented in clear and simple language, yet effectively communicate why these care practices are so important.

Even better, the videos have accompanying handouts for those who wish more details on the research behind them. For research geeks like me who like to see proof of claims of efficacy and safety, this kind of information is vital.

If you or a loved one are pregnant now (or even just considering the possibility of a baby in the future), I strongly urge you to watch these videos.

The complete set of videos can be found here:
http://www.injoyvideos.com/mothersadvocate/videos.labor.html

I like this set of videos so much I will be reproducing* them, one by one, on my website over the next few weeks. They each contain such important points about birth that each one deserves its own moment in the sun for discussion and as much exposure as possible.

However, I particularly want to highlight how each Healthy Birth Practice is used even less often with women of size, and how this negatively impacts fat women's ability to birth safely and normally.

So in this new series of posts, I will be highlighting the Six Healthy Birth Practices (one at a time), talking about the importance of each one, and embedding the Injoy video associated with that Practice. Then we will discuss how that particular healthy birth practice is even less utilized with "obese" women than across the general obstetric population, when in fact these practices may be even more important for women of size to have optimal outcomes.

I hope these will be as enlightening and useful to you as they have been to me.

*Special thanks and kudos to Lamaze and Injoy Videos for making these freely available on the internet. What a tremendous public service!

Nearly 5x the risk for infection after cesareans

A new study shows that post-partum infection is yet another reason for concern with the growing cesarean rate.

Post-partum infections are costly and time-consuming to treat, increase hospital re-admission and healthcare costs, and often lead to a difficult and frustrating start to motherhood.

Imagine trying to take care of a new baby and a house and cooking and laundry etc. with a gaping wound like the one shown (from here). Some of these infections and opened wounds literally last for months.

In addition, breastfeeding initiation rates are lower after cesareans, and the stress associated with a difficult delivery, post-operative pain, post-partum infection, and hospital re-admission may impair breastfeeding establishment even further. Breastfeeding is nature's way of protecting the infant immunologically, and reduced or abandoned breastfeeding puts the baby significantly more at risk for illness. Thus, because of its secondary effect of reduced breastfeeding, post-partum infections can have consequences beyond the actual infection itself.

Nearly Five Times The Risk

In this new study the infection rate after cesareans was 7.6%, vs. 1.6% after vaginal births, or about 4.7x the risk.

This means that about 1 out of every 13 women who had a cesarean developed a post-partum infection of some sort. Hardly the "perfectly safe, oh-so-easy" surgical birth some doctors promote.

And that doesn't even address some of the other possible complications of cesareans, like hemorrhage, blood clots, anesthesia problems, etc. Nor does it address the downstream complications of cesareans, like painful scar adhesions, problems with placental placement in future pregnancies, possible increased risk of pre-term birth, etc.

Actual wound infection rates in the study were 5.0% for cesarean moms, vs. 0.08% for vaginal birth moms. That means that about 1 in 20 cesarean moms will have issues with wound infection, versus 1 in 1,200 women who had vaginal births.

Read that again: One in twenty infection rate versus one in more than a thousand. That's a pretty big difference in morbidity.

This is particularly a concern for women of size because the rate of c-section wound infections tends to be even higher in fat women, yet doctors are doing more and more cesareans in "morbidly obese" women in particular.

This means that the risk is likely much higher than one in twenty for fat women, and it also means that the risk difference between vaginal birth and cesarean for fat women is going to be even more stark. All the more reason to be promoting vaginal birth in women of size whenever possible.....yet this is not happening today. Instead the trend is going in the opposite direction.

Here is the abstract of the study; note that three-fourths of the infections were diagnosed only after the mother went home, which is part of what makes it so disruptive in a new family's life.

Recovering from major surgery (and an infection) is hardly the most ideal way to start out motherhood, and the extra care involved is a major financial burden to the healthcare system.



Critics will note that the risk of infection after "emergency" cesarean (which in medical parlance simply means one that was not planned ahead of time, not necessarily one that involves a true emergency) was greater than after a planned "elective" cesarean. Their argument is that it's better therefore to just plan more cesareans without labor in women at higher risk for infections. This is one argument often used to justify a high rate of planned cesareans in "morbidly obese" women.

But this argument is backwards. We know from many studies that even when the cesarean is planned, the risk of infection is still greater than for vaginal births. Why put a whole group of women deliberately at risk for infections when outcomes are so much better with a vaginal birth, and when many can give birth vaginally if given the proper chance?

The answer is not to do planned surgery pre-emptively on every fat woman; the answer is to find the best way to promote vaginal birth in women of size whenever possible, and to research ways to minimize the risk of infection.

Here is the abstract of this new study; note the large size of the study sample, which helps show the robustness of their findings.

Reference

Acta Obstet Gynecol Scand. 2009 Jul 29:1-8. Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five-year cohort study of 32,468 women. Leth RA, Møller JK, Thomsen RW, Uldbjerg N, Nørgaard M.Department of Clinical Microbiology, Aarhus University Hospital, Aarhus N, Denmark.  http://www.ncbi.nlm.nih.gov/pubmed/19642043

Objectives. To compare the risk of postpartum infections within 30 days after vaginal birth, emergency, or elective cesarean section (CS). Design. Register-based cohort study in Denmark. Participants. A total of 32,468 women giving birth in hospitals in the County of Aarhus, Denmark, during the period 2001-2005. Methods. Data from various hospital registries were combined and infections were identified by positive cultures, prescriptions for antibiotics and, re-operative procedures. Risk of postpartum infection was estimated and adjustment for potentially confounders was performed. Results. Within 30 days postpartum, 7.6% of women who had underwent CS and 1.6% of women having a vaginal birth acquired an infection, yielding an adjusted odds ratio (OR) of 4.71, 95% confidence interval (CI): 4.08-5.43. The prevalence of postpartum urinary tract infection (UTI) was 2.8% after CS and 1.5% after vaginal birth corresponding to an adjusted OR = 1.68, 95% CI: 1.38-2.03. The risk of UTI did not differ between emergency and elective CS. The prevalence of WI [wound infection] was 5.0% after CS and 0.08% after vaginal birth. Moreover, we found a nearly 50% higher risk of postpartum WI after emergency CS compared to elective CS (OR = 1.49, 95% CI: 1.13-1.97). More than 75% (697/907) of postpartum infections appeared after hospital discharge. Conclusions. The risk of postpartum infection seems to be nearly five-fold increased after CS compared with vaginal birth. This may be of concern since the prevalence of CS is increasing.

Pregnancy and a HAES Crisis of Confidence

Many fat-accepting women face a crisis of faith in their own self-acceptance and in HAES (Health At Every Size) when they become pregnant or consider becoming pregnant.

It's something that many of them don't want to admit out loud, especially in fat-acceptance circles, but I have observed it often in others over the years. I know it was certainly true in my own case.

Even though we still fully believe in fat acceptance and HAES, many of us guiltily go through a stage anyway where we start secretly obsessing over the possible complications of "obesity" in pregnancy, whether we could possibly have a safe pregnancy and birth at our weight, whether our babies could possibly end up healthy, etc.

It's a natural reaction to all the years of propaganda we have heard about how unhealthy being fat is, about how dangerous all that weight is, yadda yadda. Then you add in the natural insecurities that go along with being pregnant for the first time, the media onslaught of negative stories about being fat and pregnant.....and it's a potent recipe for doubts and worries, even in the most self-accepting, empowered woman.

We may or may not admit our fears to those around us, but I think many of us do experience them. But unlike other women of size, we may not feel "safe" to admit to those fears out loud for fear of what others in the HAES community may think. Or we may not even admit them to our partners, lest that cast doubt in their minds about us being pregnant and fat. So that can leave us incredibly alone, stewing in our own fears and letting them ferment.

We may not talk about it much out loud....but I'm convinced that many of us who have been pregnant (or considered pregnancy, or even just had a pregnancy scare) experience this fat-acceptance crisis of faith. I know I did, and I'm willing to take the chance to speak out about it in this forum in hopes that it helps others understand that this is a natural phase that many of us go through....BUT that it doesn't have to be a place where we stay emotionally, and that we don't have to let these fears impact our birthing choices.

If you didn't experience these fears, more power to you. I applaud your empoweredness, and I think it's important we hear from you too. But many others of us have felt these doubts, yet may feel a bit muzzled about talking about it because then it looks like we don't really believe what we've been saying all along.

I think it helps to discuss these fears openly, and to see them as a very normal part of plus-sized pregnancy in this fat-hating society.

I also think it's important to understand how these fears can sometimes influence our birth experiences and our decision-making in pregnancy, and to know that we have other choices besides the high-tech, high-intervention, high-fear model that most fat women experience.

Finally, I think it's vital that we acknowledge these fears and then find a way to move past them, so that it doesn't overshadow our entire experience of pregnancy and birth. We deserve to have happy, joyful pregnancies just like anyone else, and it's within our power to have that, regardless of size. Acknowledging the fears and talking about them is the first step to moving past them.

My Experience

When I was first pregnant, I experienced a huge uptick in fear levels about my size, despite having been part of the fat-acceptance movement for many years. Partly this was because it was an unplanned pregnancy and I hadn't sufficiently girded myself for all the worries of pregnancy, and partly it was because there was no information available then about being pregnant and fat.

What little information about it I could find in mainstream books had all kinds of scare tactics--and that was just for those who were a little bit "overweight." I was significantly "morbidly obese"----if things were that bad for overweight women, how bad would they be for me as a morbidly obese person? Gah!

So yeah, there was some panic on my part when I learned I was pregnant. I indulged that for a little while, then I took a bunch of deep breaths and tried to figure out what I could do to address my concerns and see what did and did not have merit.

I had been a member of NAAFA (National Association to Advance Fat Acceptance, http://www.naafa.org/) off and on for years before I became pregnant. So the first thing I did once I calmed down was to call NAAFA to see what kind of sensible size-friendly info I could get there. I hoped that they could provide an antidote to the fear I was experiencing.

Sadly, I got no help. They had no information about pregnancy at larger sizes. I said, "Surely someone in NAAFA has been pregnant in all these years it's been around?" The person I spoke to said probably, but she couldn't point me to anyone at that point. And she really didn't seem very concerned at all about finding me some reassurance or help either. So NAAFA, my best bet, was no help at all. That wasn't very reassuring, and I felt very alone.

So I thought, Well, I'll just have to find someone in real life who has done this. I went to some of the other fat women at my workplace who had kids and asked them what to expect. Alas, none of them had any help for me either; they said they really hadn't been fat when they had their kids and had only gained weight after having children. So I couldn't even find anyone in real life for inspiration.

My family was not supportive; my mother-in-law had already told me she didn't think I should get pregnant at my weight, that basically I should lose weight and "get healthy" first. My own mother (a thin woman) was very worried for me, and told me that my cousin the nurse said I should be seeing a "high-risk" OB, not just any old OB....because of my size.

On top of that, I couldn't find ANY maternity clothes above a size 16/18 in my area (a major metropolitan area in a large state). None, zero, zilch, nada. So I went through my entire pregnancy----still working until the last month, mind you----without any maternity clothes at all. That also just reinforced my perception that apparently, fat women just didn't get pregnant, and I must simply be an anomaly, a science experiment gone wrong.

The internet was around back then but hadn't really taken off yet. I was online more than most people at that time, but even the fat-acceptance bulletin boards back then had little to offer me in the way of reassurance. I thought, Surely some fat woman SOMEWHERE had been pregnant before---but you would never have known it. So basically, I was on my own, in seemingly uncharted territory.

I had no substantive information on being pregnant and fat...certainly no information that while there were risks to consider, outcomes could also be just fine in women of size. All the booga-booga scare tactics in the books made me terrified about what might happen, and the fact that I started bleeding and cramping in the first trimester only seemed to reinforce the thought that my body was broken, that somehow being fat made my pregnancy so incredibly high-risk that I'd be lucky to get out of this with a baby at all.

My OB and midwife tried to reassure me that other fat women had been pregnant before and that they'd get me through this, but while they meant well, they also filled our appointments with plenty of fear-inducing information and pressure for extra tests and monitoring.

They told me I had about a 50/50 chance to miscarry, that I might well have a baby with birth defects, that I had a very high chance of having problems with my blood sugar or my blood pressure, that it was good I wasn't gaining much weight and not to worry about eating if I felt nauseous, that we wouldn't want the baby to get "too big" so it was okay not to eat much. They tried to reassure me that even though I had all these risks, they'd take "good care" of me by ordering all kinds of extra tests to carefully watch over the baby and me.

That was supposed to reassure me, but all it did was make me feel like ticking time-bomb. Still, I was grateful they weren't yelling at me for my weight, so I sucked it up and never questioned what they were saying.

All of a sudden I went from being a take-no-prisoners fat-acceptance advocate and empowered health care consumer to being a meek little sheeple who didn't question anything her OB said. "Whatever you say, doctor; you must know best," became my mantra. I now know all those tests ended up actually causing more harm than good, but then I dared not question anything; I was just intent on getting through my pregnancy and having a live baby.

The truth is that I was paralyzed with fear that somehow my fatness was going to end up hurting my baby, and so I checked my brain at the OB clinic door. That directly led to many of the very negative experiences of that pregnancy and birth, and sadly, most of them were avoidable.

The Crime of Being Pregnant While Obese

It's one thing to be accepting of your size and body when the only person that might be harmed is you; it's a lot different to be so confident when a little baby is involved and when what you are, the very core of you, might be harming the baby.

It's very hard to stay body-accepting when everything and everyone around you is telling you that you are going to have problems because of your size, that you might actually kill your baby because of your size.

That is SUCH a powerful, guilt-inducing thought, and it makes many women of size become unquestioning sheeple in a quest to avoid any such scenario. I know it helped make me a sheeple.

Unfortunately, this situation often becomes a self-fulfilling prophecy, simply because you and your doctor expect problems to happen and therefore go looking for them. The more your doctors perceive you to be "high-risk," the more likely they are to submit you to multiple tests where a false-positive result is a real possibility, or to interventions (like early induction of labor) where the risk of harm is significant. The mere expectation of problems often results in those problems.

But when you are living in a state of fear that your body might harm your baby, you just assume that these tests and interventions are necessary to get you and your baby through pregnancy alive and well. And because you are fat, you may not question whether they might be causing more harm than good, whether the risks outweigh the benefits.

And in that rare situation when you do start to question your doctor about these things, out comes the "obesity ooogabooga" fear tactics and the "dead baby" trump card, which shuts down those kinds of inconvenient questions really fast.

On the one hand, we can't ignore that pregnancy at larger sizes does carry some risks. It's not wrong for us to be informed of these potential risks, or to be proactive about trying to minimize them. (More on that in the future.)

On the other hand, exaggerating these risks and using extreme interventions to manage even the slightest possibility of these risks has not been shown to improve outcome. In fact, no one has actually really studied whether the high-tech, high-intervention management of "obese" women improves outcome. They just assume it does.

Anecdotally, it does not seem to; it actually seems to worsen it. Certainly the cesarean rate has gone up drastically in "obese" women since the high-intervention management style has come into use with this group. But does that improve outcome? Where is the real, qualitative research on best practice care for "obese" women? It is stunningly absent, with doctors just going on the assumption of what's best.

The blame and the fear around being fat and pregnant is so intense that it's hard to avoid this high-tech, high-intervention model of care, and even empowered fat women often feel powerless in trying to avoid it, despite the alternatives available (the midwifery model of care).

And it's all motivated by our inner guilt, our secret inner fear, that our fat might hurt our baby.

Then and Now

Women of size having their babies now are lucky in some ways; at least today there is some information available about pregnancy at larger sizes, there are maternity clothes more widely available in plus sizes, and women of size can bond together in online communities regarding our experiences around pregnancy, birth, and parenting.

However, on the flip side, fat women having their babies today are bombarded with even more negative information and scare tactics than I was when I was first pregnant 15 years ago. Take the scare tactics I was told and multiply that by ten now; not only do you hear the negativity from your "scare provider" but also now constantly from the media. Furthermore, the sheer amplitude of the shaming and scaring has increased greatly too.

That's some pretty powerful stuff to try and counteract mentally, especially while in the emotionally vulnerable state of pregnancy.

Google "obesity and pregnancy" and you'll find a whole bunch o' scary stuff before you ever find this blog or my main website, http://www.plus-size-pregnancy.org/, which focuses on realistic information, reassurance, and proactive behavior instead of scare tactics. Most people won't continue searching long enough to find my websites; they'll only end up seeing the ooga-booga scare tactics. And that kind of negativity can't help but impact women who read it.

Honestly, I think it's those exaggerated fears of complications that leads so many fat women down the path into highly-interventive births and surgical outcomes. There are other causes too, of course, but I truly think that the exaggerated sense of fear---in ourselves, in our families, and especially in our caretakers---has the most to do with it.

But I also want to note that acknowledging these fears, then being proactive about dealing with them, becoming aware of how they can influence choices negatively and positively, can go a long way towards recapturing the joy we deserve to feel in pregnancy, towards making plus-sized pregnancy the positive and joyful experience it really should be.

It's normal and okay to have those fears.....but you don't have to let them paralyze you, and you don't have to let them dictate your pregnancy and birth experiences. You CAN have a beautiful and joyous pregnancy too.

What Were Your Experiences?

If you have had children, did you experience a crisis of faith in HAES principles? Did you feel suddenly less empowered as a health-care consumer? Do you feel the negativity and scare tactics helped convince you into interventions you might not otherwise have been so quick to accept? What kind of fears about pregnancy and birth did you experience related to your size?

Or were you already in such a secure place in your fat-acceptance journey that pregnancy didn't rattle you, not even a little bit? Am I the only one that had this giant crisis of faith?

Let's talk.

Bookends

Well, school has started. Always a bittersweet time, but especially so now. I never know whether to dance a jig of joy or crumple to the floor in a sobbing heap. A little of both, generally.

I'm especially teary today because my bookend children hit new milestones. My eldest started high school, and my youngest started kindergarten. Sob!

I can't believe my oldest baby is in high school.

Seems like only yesterday she was the one starting kindergarten, getting on that giant school bus all alone....and now she looks so grown up, so mature.

Always a very shy child, she was quite anxious about starting school, way back when. So in first grade, I gave her a "worry stone," a little polished purple and white stone just made for holding and rubbing with your thumb. I told her it would remind her of mama's love for her and give her strength to get her through.

Guess what she took to high school with her yesterday. Sob!

And I can't believe my youngest, my baby, is in kindergarten.

Seems like only yesterday she was born into my arms, in the water, and we sat in the recliner afterwards, sticking out our tongues at each other and making faces. I couldn't believe how alert she was, how interactive.

She was my last baby, my late-in-life baby. And now she's at school.

Where did the time go?

I think I need some valium.

The Patient's Best Interests? Not Anymore

Check out Rixa's recent interview with Dr. Stuart Fischbein, a VBAC- and breech-supportive doctor in California who is in trouble with his hospital for supporting Vaginal Birth After Cesarean (VBAC) and vaginal breech births.

It's an interesting summary of the sad state of birth in hospitals these days.....ruled not by the patient's best interests, but by the hospital's best interests, along with doctor convenience, insurance rules, ease of staffing, and fear of litigation.

As a feminist, I am particularly upset at how a woman's right to decision-making about her own health, her own body, and her baby is currently being taken away from her. And yet there is a stunning lack of recognition or caring about this fact in our society.

Dr. Fischbein at least is talking about this issue. He recognizes the tension between hospital concerns and patients' rights as one of the major ethical dilemmas of our time.

He has some interesting and frustrating things to say about hospital and insurance decision-making. He also discusses home birth, the midwifery model of care, tort reform, malpractice and litigation, among many other things.

I don't agree with everything he says but overall it's a very interesting interview with many important points. And it's so refreshing to hear of a doctor who is actually fighting for the patient's interests (not just his own or the hospitals' interests), and who is trying to stand up for the patient's right to make her own medical decisions.

Here are a few excerpts, edited for clarity, length, and sometimes rearranged a bit from the original.

On the Use of Certified Nurse-Midwives (CNMs) in the hospital:

About 5-7 years into my practice...I was approached by a couple of midwives and a good friend about opening a collaborative midwifery practice with hospital deliveries. We looked for a hospital on the west side of Los Angeles that would allow midwives to do deliveries and we couldn’t find one. None of them were allowing midwives to do deliveries...So we opened a practice out in Ventura County and called it the Woman’s Place for Health.

Even there we were met with a lot of suspicion and resistance, despite the fact that the track record for midwives is excellent, despite the fact that they take care of low-risk patients and have very strict protocols that they follow, despite the fact that they have excellent outcomes and a very low c-section rate, even compared to other obstetrical models that take care of low-risk patients. It’s always been a battle.

...We follow the midwifery model of care, which exhibits a lot more patience than the obstetrical model of care. It treats pregnancy as a normal function of the body. In contrast, the obstetric model treats pregnancy as a disease that needs to be treated, as opposed to something that just needs to be nurtured.

About VBACs and Patient Rights:

If you go on [ACOG's] website—the back part, where members can go—they have paragraph after paragraph about patient’s rights, patient’s autonomy, the right to informed consent and refusal, the right not to be harassed or threatened if they make a decision that is different from what the hospital would want, the right to sanctity of their bodies free from fear of reprisals.

...The problem with VBAC bans is that it puts the needs of the hospital and the other health care workers ahead of the rights of the patient.

I understand why they do that, but I just think they are misguided. They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections...so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.”

But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

On the Lack of Truly Informed Consent:

There’s a study that came out in the American Journal of Obstetrics & Gynecology last December that found the morbidity of a repeat cesarean section is higher than a successful VBAC.

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth. That’s outrageous to me. It leaves me speechless, and for me that’s no small thing!

The same model applies to breech deliveries. Some women are being told to have a procedure that carries more morbidity than a vaginal delivery. But they are never being told the numbers or given the option.

About Why Many Hospitals Ban VBACs:

The reason that a lot of hospitals ban VBACs anyway—and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety.

The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Again, they use the idea of the 24-hour anesthesia as a reason not to allow VBACs. Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture. They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations. And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs? If they can’t do VBACs, should they be doing obstetrics at all?

On Vaginal Breech Birth:

Decisions for breech delivery should be based on the experience of the practitioner and the desire of the patient.

I understand that breech delivery is not for everybody. Certainly there are a lot of people who will never do breech deliveries because they’re not trained any more. Unless we bring vaginal breech delivery back into residency training programs, we will soon find that that skill is gone forever.

Having that skill gone is more than just a c-section problem. Every now and then, a woman is going to show up in labor, come in completely dilated with a butt in the vagina, and no one is going to know what to do...They’re going to be rushing to push the baby’s body back up and do a c-section. Quite frankly, the morbidity of that is so much higher. So it is going to be a major loss, because women are going to show up complete and breech in labor & delivery, and no one is going to know what to do.

In Canada, the SOGC is no longer recommending routine c-section for breech babies. Part of it’s for cost savings, probably. But part of it is because the evidence does not support sectioning every breech patient. The evidence is there to give patients the choice. This gets back to my primary issue, which is informed consent. This should not be a decision where the doctor tells the patient what to do.

If the doctor does not know how to do breeches, they should say to the patient “I can’t do your breech delivery but I really think you are a good candidate for it. Why don’t you see doctor X for a second opinion.” That’s the honorable thing to do. But of course that would cost doctors money, and a lot of doctors don’t want to give up the money.

On the Lack of Attention to Birth Politics:

I don’t know why maternity issues like these are not more popular, because every family in America is affected by what’s going on. It’s off the radar screen.We have an abortion rights movement in this country that, the minute anything happens regarding abortion, they’re up in arms about it. Yet women are losing the choice of how they give birth, and no one seems to care.

There's much more to the interview; I hope you will go check out the whole thing. You can read it at Rixa's Stand and Deliver blog:

http://rixarixa.blogspot.com/2009/08/interview-with-dr-stuart-j-fischbein.html