Home > Obstetrics > Notes from a Reasonable Direct Entry Midwife

Notes from a Reasonable Direct Entry Midwife

Today I had the pleasure of talking shop with my brother’s mother in law, Joni Dawning, a very experienced direct entry midwife in Eugene, OR.  Joni has been attending births for over twenty years, and she has been a great resource to me over the years I have known her.  I hold her in great respect, as she is the kind of midwife that I think is a great resource to her community.  She provides a service to her clients that is greatly desired, but at the same time sees herself as a part of a larger system of birth service provision that includes hospitals and obstetricians.  Unlike some direct entry midwives (or CPMs in some communities), she respects the limits of what she can offer, and does not see a hospital transfer as a failure in any way.

Recently in Oregon there have been some deaths during attempted breech deliveries at home, all attended by various home midwives of varying skill.  Following this there was a discussion in the legislature about whether or not licensed midwives should be completely banned from intentionally attending breech births at home.  Joanie wrote a passionate letter about the topic.  She shared this letter with me, and to my surprise the letter was not in support of breech birth at home, but rather a plea that the legislature ban breech homebirth.  She felt that too may midwives believed that they understood how to deliver breeches, not because they had experience, but because they were just ignorant of the potential risks and the techniques required to succeed.  I some cases they just “believed in birth” and felt that the baby would deliver if one would just stand by and watch.

I have always felt that the more one knows the more one realizes what one does not know.  I can say from personal experience that as I grow in experience, my knowledge of what I lack becomes only more clear.  Joni is the most experienced midwife I know, and in her great experience clearly feels that she cannot safely deliver a breech at home, and chooses not to offer that service.

Here I republish Joni Dawning’s letter to the Oregon State Legislature for review and comment.  Joni may be able to respond to comments as well.

***

“I am a lay midwife practicing for more than twenty-five years in Eugene. Recently, I received an email urging me to submit comments on proposed protocol changes.  I tell you honestly that it has been an emotionally agonizing process to arrive at the decision to compose and send this letter.  I wish to voice my support for placing breech delivery in the category of absolute risk.

We all enter midwifery with a profound sense of awe of the powerful natural forces of birth. Along with that awe is a sense that the medicalization of birth has detracted from the spiritual, emotional, and physical experience of childbirth for mother, baby, family, community and care provider.  I will not argue with that.

I acknowledge that it is clearly possible for vaginal breech birth to occur safely, indeed serenely, and I grieve the inevitable loss of those birth experiences to protocol.  I am however, aware of four infant deaths directly attributable to attempted home birth of breech babies.  Anecdotally these births have apparently been associated with mistaken beliefs on the part of the midwives and their clients that these births were “normal”.  The attending midwives reportedly either did not recognize or did not respond to early indicators of impending complications such as cord compression, footling presentation, and sacrum posterior position in such a way as to prevent these sad outcomes.
Though I believe deeply in parents’ rights of choice regarding both care provider and setting for the births of their children, I also believe that midwives have a core responsibility for self-identifying our own limitations in training, experience and skill as care providers for higher risk pregnancies.

In the mid-1980’s when I was younger and less experienced as a midwife, licensure was touted in discussion as legitimizing our profession.  Legislators were told that passage of a licensure bill would mean assuring consumers of care that licensed midwives met knowledge, education, training, experience and safety criteria and thus, should be reimbursed by third party payers.  Many of us felt concerned then that, along with licensure, would come protocols restrictive of birthing women’s choices of care.

Though I still believe wholeheartedly in choice, my experiences of more than a quarter century of practice have confirmed for me that it is a midwife’s responsibility not only to assist prospective homebirth clients in making fully informed, knowledge-based choices but also, just as importantly, to acknowledge the limitations of the care she can provide.

Prospective clients often ask a standard set of questions that includes “do you do breeches?”  My response is that I believe it is my job as a midwife both to patiently safeguard normalcy and to identify and respond to known risks in such a way as to facilitate transfer of care to a setting where risks might be better addressed if they occur. Though midwives study the mechanism of breech birth in texts, workshops, and lectures to enable us to respond to an undiagnosed and rapid breech birth, it is important to recognize that because breech occurs so infrequently, supervised hands-on training in skills necessary to facilitate such births is not commonly available.  I have safely delivered only two “surprise” breech babies whose mothers’ labors were so efficient that they were well progressed through late stage labor when the babies’ frank breech positions were discovered.  I have transferred care before labor or transported during labor at least three times that number.

I have come to believe that midwifery and obstetrics are complementary callings and I practice with confidence knowing that I can facilitate my clients’ access to medical consultation or transfer their care in the interest of safety for a mother or baby. I believe that the local medical community trusts that I will endeavor to identify risks, inform and educate my clients, and respond to those identified risks before they become disasters.

Physicians in our community are currently willing to assist homebirth clients by providing ultrasound confirmation of breech position, offering external version when appropriate, and accepting third trimester transfer of care in the event of a persistent or late identified breech. Rarely has the experience of seeking consultative care, transfer or transport been anything other than welcoming and respectful of my clients, their desires for a holistic childbirth experience, and the sometimes difficult choices they have made to enter the medical system.

I am clear with my clients that current local standard of practice is delivery of breech babies by cesarean section; and that the standard is based upon a large cohort study that demonstrated increased morbidity and mortality rates for breech babies delivered vaginally. In contrast to the information I provide, one particular licensed midwife in the community reportedly says “they’ll just cut you!”

I trust that most midwives’ practices are self-governed by a commitment to provide care that is within our scope of experience, education and skill and I am profoundly saddened to have arrived at the point of advocating absolute restriction of practice in order to proactively assure that the disastrous behavior of a few individuals is prevented.

Respectfully,

Joni Dawning”

***

If you’re a radical homebirth supporter, I hope this provides a little perspective.  If you’re a physician who thinks that all homebirths are dangerous, consider what is possible with the kind of midwife that knows what she is doing, and knows what she does not know.  There is a happy medium, and in that medium great things can happen.

About these ads
Categories: Obstetrics
  1. kc
    July 22, 2011 at 2:07 pm

    agree completely with your last comment – the happy medium! Unfortunately my state doesn’t license CPMs, which I think is a mistake. They are still out there, practicing, but there is less to go by to know that they are properly trained. I wish MDs wouldn’t be so completely anti-homebirth, which is preventing the legislature from approving licensure for CPMs. One of my bio students asked an OB “what do you think of homebirth?” her reply was: “you know that 1 out of 25 women died in childbirth in the pioneer days.”

    With a midwife such as you just described, with understanding that transfers to hospitals are important in some cases, antibiotics, pitocin, oxygen, etc. etc…. how is that anything close to ‘pioneer days?’

    I would choose homebirth if it were legal (for CPMs) and there was a great, experienced midwife here, but I would choose c/s for breech, and a hospital for a VBAC, etc., so I don’t think I qualify as a radical homebirth supporter. Women should have choices though.

  2. Susan Peterson
    July 22, 2011 at 2:14 pm

    If only this could be paired with an obstetrician in the hospital who is both able and free to deliver vaginally those breech births which he deems to have a good chance of being successful.

    I have read what you have written in various places about the barriers to that, and I don’t think one can blame anyone for taking reasonable care of his own basic security and that of his family. But I hope there is a path back to the place where obstetricians prided themselves on their skill in more difficult deliveries. I am 61 years old, so I remember that time. My OB’s partner in 1977 told me he had just been to a conference on the west coast, and “all the young obstetricians are saying all breech babies should be born by c section. I’ve delivered hundreds of breech babies and all of them were OK.” I knew a woman whose first baby, a footling breech, was delivered vaginally in the hospital by an experienced OB. I respected my obstetrician’s skills.

    I am a pretty radical home birth advocate. After two hospital VBACS in 74 and 77, I had six babies at home, some of them unattended. But my plan if ever a baby were breech was to go back to Dr. Brew. ( I think that is true. It is what I think now, anyway. )

    Besides giving women a chance to deliver their breech babies vaginally, I’d like to see them be able to have hospital labors which respect their need to move around, (etc etc). It would be much easier to tell a woman who wants a home birth to go to the hospital if what awaits her at the hospital is a peaceful labor in a place where people respect her, and skilled assistance at the birth.

    I read an old textbook called “Obstetrics for the General Practitioner.” It assumed most babies would be born at home, and that GP’s would deliver most of them. It assumed that C sections would be performed only in the most dire of circumstances. It also said, calmly, that 5% of babies do not survive the birth process.

    I think even CPM’s do better than that these days. I don’t think we as a society can accept that kind of infant mortality. It is one thing when there is no alternative. When there is an alternative I think it would be pretty difficult to accept those statistics. I don’t think it would necessarily be wrong to have a society which valued freedom to the extent that it accepted some infant deaths as the cost of more peaceful birthing. I told myself back in the day that I did accept that risk. But I don’t know if one really can make such a decision independent of one’s society . Even if there weren’t child protective services and other interferences, I think parents themselves would have difficulty facing newborn death in a society in which that isn’t a legitimate, supported grief, expected to come to some as part of life, but in which it is not supposed to happen at all and if it does, someone is always to blame. I don’t think parents do accept that risk on the whole. I think they are mostly led to believe that it doesn’t really exist for them. I think in our society it is pretty much impossible no matter what you say to get people to believe that it does exist for them. So a practitioner has to make some decisions for them by refusing to be involved.

    I personally wouldn’t try to make it against the law, but I am sort of libertarian about most things.

  3. CountryMidwife
    July 22, 2011 at 2:26 pm

    I agree on all fronts, as a primarily homebirth and birth center midwife who has now 18 years experience in helping birthing families and 8+ of them out of hospital (and 2 more years in a developing country). That said, I think that we need to acknowledge the loss of the art that is vaginal breech delivery. No physician I know will even attempt it on a grand multip with a preemie complete breech at full dilation, and that is a shame.

  4. Not So Radical Midwife
    July 22, 2011 at 3:13 pm

    I agree strongly with much of what Joni has to say, but I do not think that preventing licensed midwives from attending planned breech home birth is necessarily the right answer. In many communities there are no hospital providers willing to attempt a vaginal breech delivery. An honest look at the evidence shows that the Hannah trial was deeply flawed, that the risks of vaginal breech birth have yet to be accurately assessed, and that, though lifesaving when used appropriately, cesarean section does not eliminate the risks of breech birth and does create some new ones. Pregnant women have a right to real, informed choices. Failing to give women thorough and honest information about risks denies them this right… but so does forcing every woman carrying a breech baby into a surgical delivery. There is a difference between a naive trust in birth by inadequately trained attendants who “don’t know what they don’t know” and careful, respectful consideration of risks and benefits within an integrated system.

    Joni writes “I have come to believe that midwifery and obstetrics are complementary callings and I practice with confidence knowing that I can facilitate my clients’ access to medical consultation or transfer their care in the interest of safety for a mother or baby. I believe that the local medical community trusts that I will endeavor to identify risks, inform and educate my clients, and respond to those identified risks before they become disasters.” Amen and amen! I work closely with an open-minded OB practice that provides back-up care for my clients, including breech and VBAC clients (I am a CPM in an unlicensed state.) It is always my goal to identify those clients who need hospital / OB care and facilitate their timely access to it *before* the situation becomes an emergency, and I recognize that it is in large part the excellent relationship of professional trust and communication between these two physicians and myself that keeps home birth a safe option for my clients.

    In my practice, a persistent breech presentation at term would necessitate a frank and honest three-way conversation including parents, midwife, and back-up OB, with both midwife and OB respecting the parents’ right to make an informed decision about whether to plan a home or hospital birth (whether vaginal or cesarean) and all parties understanding that issues may come up during labor (the “early indicators” Joni mentions) which necessitate a change of plans.

    I was trained in vaginal breech techniques by Jane Evans (UK midwife with decades of experience in breech birth) and Dr. Frank Louwen of Frankfurt, Germany. This past spring I used Dr. Louwen’s “new maneuver” to successfully deliver a 10 lb 6 oz breech with a deflexed head (due to a tight nuchal cord). The mother was a good friend of mine who traveled from two states away to stay with me for her birth because no provider in her community would attend her unless she agreed to a cesarean section. This was her fifth baby, she had a history of precipitous labors (labor with her breech baby was under an hour) and had previously vaginally delivered an 11 lb 4 oz baby in a 45 minute labor. There was no good reason for her to be delivered surgically and she knew it. Instead, she chose to travel at great inconvenience and expense to her family to a place where she could safely deliver at home with skilled and supportive attendants. Is there really no way to improve the skills, training and clinical decision-making of licensed midwives without “advocating absolute restriction of practice in order to proactively assure that the disastrous behavior of a few individuals is prevented”?

    • stacy h
      July 24, 2011 at 3:42 pm

      Well said!

    • Donna V.
      August 22, 2011 at 4:32 am

      “Is there really no way to improve the skills, training and clinical decision-making of licensed midwives without ‘advocating absolute restriction of practice in order to proactively assure that the disastrous behavior of a few individuals is prevented?'”

      This is the point I was going to reply and make, but no need, you got here first. (-:

  5. Rachel
    July 22, 2011 at 3:46 pm

    I see that you’ve recently settled in Atlanta, GA. Look up Dr. Joseph Tate, a local OB who routinely delivers breech babies. I say routinely not knowing how frequently it’s done but knowing that women drive from hours away and even move temporarily from out of state to attempt breech, VBAC, VBAMC with multiples, etc. He’s amazing and I sincerely hope that his skills can be passed on to others before he retires.

    • July 24, 2011 at 11:53 am

      I’ve heard about him, Rachel. I saw some news clip featuring his approach to possible c-sections. We need so many more ob’s like him.

  6. Alicia
    July 22, 2011 at 6:19 pm

    I’m a strong supporter of informed choice and options. I’ve also birthed both of my children at home and one died (“normal” vertex presentation with no signs of problem). Being in this position has given me some unique insight into life/death and many other things involving birth. I support breech birth at home if that is what a family wants and they have been informed of the potential problems. Ultimately it is up to them what is most important and feels right.

    More than that though I feel that there will never be any resolution within the birthing community (hospital or home) as to what risks are worth it and what are not as long as the ultimate goal is to avoid death. In my personal experience death is the one thing that everyone is so scared of, but I now believe it can be one of the greatest gifts if allowed to be. Having walked down that road just 5 months ago, I can firmly and without doubt tell you that in my son’s death I was given the greatest gift I could have ever imagined. He taught me the true meaning of love and life and is currently helping me to heal from past wounds. I didn’t ask for it, but he knew what I needed and since I couldn’t just view this as a tragedy, the gifts came. I feel that as humans we are robbing ourselves and each other of some of the greatest gifts of growth available to us by thinking of death as only a tragedy. What would happen if we were able to feel the human loss of such an event and still accept it as a gift? I know what has happened for me and it has been BEAUTIFUL -and painful at times- but mostly beautiful. What decisions would we make if avoiding death and loss were not the ultimate goal, but the highest good of all involved were the goal? It is a simple, but profound shift.

    Just my two cents from a woman who has been there,
    Alicia

    • Liz
      July 23, 2011 at 4:23 am

      That was beautiful and shockingly against the conventional wisdom about death. I’ll be thinking about your post for a long time.

      It reminded me a little of a story told by a local midwife of attending the birth of a 24-weeker in Fiji, where the baby’s birth and brief life and death were calm and loving and beautiful, and what a contrast that was to the “save-this-baby-at-all-costs” drama of the same birth in the US.

    • July 27, 2011 at 2:09 am

      I’ll have to say that the goal for myself, and for every pregnant woman I know, is to end up with a living baby. I think there are very, very few mothers who would rather not make “avoiding death” their ultimate goal. When my son had ceased moving a week and a half ago, praying that he was still alive was in the foremost of my mind as we drove to the hospital. Thankfully, he was alive although experiencing significant distress and was delivered by emergency cesarean. I could not trade him for an experience, although his birth was very different than the births of my children delivered by midwives.

      • July 27, 2011 at 4:05 am

        I appreciate this comment, and is not surprising. No woman would trade their live child for a different birth experience. We only hear this from women who sadly lost their child in birth in an avoidable way, and then justify their choices by saying that the experience made it worth it. A chilling thought in my mind.

    • JKR
      August 25, 2011 at 5:36 pm

      Nicholas Fogelson, you read my mind.

  7. July 22, 2011 at 6:45 pm

    Planned vaginal breech in a hospital is becoming increasingly available as an option to women, at least in Oregon:

  8. July 22, 2011 at 8:21 pm

    I enjoyed reading this post and the comments so far. I do think that what is missing in the post and in the letter is an acknowledgment of what happens when women transfer care — they are not offered the choice of a vaginal birth. A woman may prefer to deliver her breech baby vaginally in the hospital, but she is not given the choice; it’s stay home, or surgery. In your recent podcast you discussed very similar issues with VBAC, and hospital VBAC bans driving women to TOLAC at home. I understand what Joni is saying: the ethical, experienced midwife refuses to attend that woman at home; the inexperienced and/or unethical midwife offers to attend that woman at home; but what does a good midwife do when the mother refuses to go to the hospital?

  9. July 23, 2011 at 12:51 am

    The choice should always lie with the family as should the responsibility for the outcome. Like any health matter we need to make informed choices and assess benefit and risk of doing something and the benefit and risk of not doing something. Everyone evaluates the benefits and risks differently and is an individual perspective on how much risk they are willing to take for what benefit. Removing choice makes things more dangerous. For some the benefits of having their baby born without intervention in a safe, warn, loving home environment outweighs the risk of potential complication with a breech delivery and will choose to do it with out without support. Taking away choice can lead people to making the choice to do it anyway without support which could potentially increase the risk. Ultimately we need to assess the idea of responsibility. The person who makes the choice should be the one responsible for the outcome. Parents choices, parents responsibility. When someone else forces something on you they should be held fully responsible for the outcome.

  10. July 23, 2011 at 8:43 am

    My main concern with breech birth, aside from to-homebirth-or-not-to-homebirth, is simply the disappearance of breech birth skills among both OBs and midwives (the only midwives who have it nowadays, it seems, are usually those who are fortunate enough to train outside of the country). If a mother (myself included in this category) knows that a breech transport is going to end in a basically-forced cesarean, she is going to be much more likely to stay home and risk it rather than go in and be cut against her will. As another commenter noted, it is the VBAC situation all over again. (I personally know of at least three women who have birthed unattended at home for VBAC because their local hospitals had VBAC bans, and they knew that if they went in they would be sectioned with no say in the matter.) All birth attendants need to be well-versed in breech attendance – so that breeches can be handled safely, whether at-home or in-hospital, and so that women can feel confident that going to the hospital with a breech will be met with confident breech-birth skills from an attending OB rather than an automatic trip to the OR. Perhaps the U.S. can take its cue from Canada, and ramp up training on breech skills for OBs?

    • July 24, 2011 at 4:29 pm

      There is definitely interest in restarting training in breech birth, as part of a general interest in reducing cesarean deliveries. Many medical schools are starting to do breech births for selected patients. OHSU in Portland, OR is one.

      • July 27, 2011 at 4:48 am

        What frightens me is that so many DEMs *do* think they’re trained in breech birth, and they end up attending dead babies. Wasn’t it the Johnsson & Davis study that showed a death rate of 2 out of 40 breeches with CPMs? And look at the recent Karen Carr case. Her followers all proclaimed her the best breech expert on the East Coast. That’s terrifying.

  11. July 24, 2011 at 12:00 pm

    I was just discussing breech deliveries with an OB friend of mine. She’s been practicing obstetrics for about 13 years now. She said, “No OB’s do breech deliveries anymore.” I told her that I knew of one who did. She told me that if she were in a far away place with no other options but to deliver a breech baby, AND NO LAWYERS AROUND, then she would do the delivery. She had been trained to do breech deliveries, but was too fearful of a lawsuit in the event that the outcome was unfavorable. So, what does this tell us about the current state of things?!
    I respect and appreciate this midwife’s letter. There are some midwives and clients who are so anti-medical establishment for a variety of reasons that breech deliveries will continue to happen in home birth settings.
    As an aside, Dr. Fogelson, what interesting conversations you and Jonie must have!

    • July 27, 2011 at 5:36 am

      We really do. I love talking to her.

      She recently related a story where she had to transport because of a spontaneous third degree laceration, at great angst and cost to her client. Shouldn’t there be a service where a OBGYN can come to house and fix that for a few hundred dollars? I would offer that in her community. There’s no reason that can’t be fixed at home. One just needs local anesthetic, suture, and the knowledge on how to do the repair.

      • Little old lady obstetrician
        August 4, 2011 at 4:47 pm

        Uhhhh, yeah well, I was the OB who did that repair. I actually didn’t bill that patient (because of my deep respect for Joni), but I presume the hospital did. It was an unhappy situation because the patient clearly didn’t want me but clearly needed me… I did offer her free follow-up, but she was clearly unhappy with having a doctor attend her, in spite of Joni’s best efforts to make me acceptable to her.

      • August 6, 2011 at 7:46 am

        It is certainly frustrating to give aid to a patient that spites you anyway. I’ve been there.

      • August 19, 2011 at 10:46 pm

        I delivered my first at a birth center in Az where I had a 3rd degree tear. Because it was a birth center run by cnm’s with ob oversight, they came to me and did my repair. I loved that. Situations like these are why I’m a big supporter of free standing birth centers.

  12. stacy h
    July 24, 2011 at 3:30 pm

    I’ve been thinking a lot about this. In the end, I think the state has no business banning something like this. Educating, recommending, sure. But banning just opens the door to what I believe would be a very slippery slope. What next? HBACs? The medical community would all too readily jump all over something like this in an effort to stop the loss of profits seen thanks to the increase in homebirths and the use of midwives.

  13. July 24, 2011 at 4:26 pm

    In my opinion idea that a government interest in banning home breech birth by licensed midwives is based on a desire to protect obstetrician’s income is pure conspiracy theory and is ridiculous. In Oregon the issue came to the legislature after there were a series of deaths in home breech births attended by licensed midwives. In many cases the midwives demonstrated a lack of experience and training in delivering breeches.

  14. July 24, 2011 at 4:27 pm

    It went through a period of discussion in the state senate, and ultimately the decision was that home breech birth would remain legal.

  15. July 25, 2011 at 12:12 am

    In a hypothetical scenario where every community had access to vaginal breech birth in a hospital, I might be more inclined to find Jonie’s proposal reasonable. But in our present situation, banning breech at home = forced cesarean for almost all women. This topic is particularly relevant to me, since I just organized a vaginal breech training workshop with a Canadian OB who has done 300-400 vaginal breeches and a Canadian midwife who has trained in a German clinic that does mostly upright (hands & knees) breeches. I was disappointed but not overly surprised that all participants were out-of-hospital providers. Unless some radical changes occur to bring vaginal breech birth back into the hospital setting, I think the future of breech birth will be at home. Interestingly the midwife we brought down was more hesitant about breech in a home setting (she has done them in both home and hospital in the past, but now only does breeches in hospital, in part to help train residents and OBs in the dying art) than the OB was.

    • July 27, 2011 at 4:09 am

      So should the practice be continued at home even though there is no skilled provider present? Does attending a course give one adequate experience to provide breech birth?

      I think the political issue of breech birth availability should not be addressed by providing the service in a suboptimal environment. I feel the same about VBAC.

      • July 27, 2011 at 8:23 am

        A skilled provider is obviously optimal in whatever setting a breech birth happens. I’m just saying that there are women who would rather have a chance at a vaginal birth even in less than optimal conditions (i.e., with someone who hasn’t done a large number of vaginal breech births), rather than be forced into surgery.

        I don’t think anyone was expecting this workshop to be the only training they needed to safely attend a breech. You’ve got to start somewhere, though, and simulation training with an experienced OB and midwife is a good place to start. Many of the participants had attended surprise breeches at some point in their careers and wanted more training for when/if that happened again.

        I would love to see vaginal breech birth become common again in a hospital setting. But I don’t think that banning it in a home setting is the right approach. (This will further drive breech birth underground, as women either go unassisted or hire unlicensed midwives to be able to have a vaginal birth.) I’d rather find a solution that expands, rather than contracts, choices and that doesn’t limit women’s autonomy.

      • July 27, 2011 at 8:34 am

        Your point is well taken.

        The question is a philosophical one – if something is inherently dangerous and not good for someone, but only for the person participating in that activity, do you outlaw it?

        Clearly the outlawing of drugs causes more harm than good…. but as a society do we want a permissive culture of an activity that is clearly harmful?

    • July 27, 2011 at 8:35 am

      The issue is a bit moot in this specific case. Despite Joni’s letter, the Oregon legislature voted to not outlaw breech birth at home.

  16. Olga Ryan
    July 26, 2011 at 7:23 pm

    In my opinion the riskiest part of home birthing is the barrier to communication and transfer of care. There is so much fear, and based on ignorance of each others’ models. I’ve seen expressions of shock on physician’s faces when they read the midwives’ informed consent forms “you tell them ALL this stuff?!?” I’ve seen patients struggle to navigate a hospital system that just doesn’t make sense, but can be made understandable with a little extra TLC.

    What if instead of regulating midwifery, we regulated the receiving care? What if our chiefs of obstetrics were required to work with direct entry midwives by practicing emergency drills, sharing M&M sessions and routine chart reviews? What if charge nurses and midwives worked together to assure a seamless transport, to encourage midwives to accompany their patients into L&D, and to share best practices in labor-sitting? What if CPMs and doulas sat on the practice committees?

    Couldn’t this happen in a way that doesn’t falsely influence liability costs? We’ve all experienced the benefits of truly collegial professional relationships and that’s what we should be trying to promote. Patients will seek those of us who succeed.

    • July 27, 2011 at 4:07 am

      I completely agree with you Olga, as does a certain population of OBs.

      Another population thinks that homebirth and non-licensed midwifery is just plain dangerous and would like to see it extinguished, and thus has no desire to work productively with non-licensed practitioners. I think this is unrealistic on their part.

  17. July 27, 2011 at 3:37 am

    Dr. Fogelson, what do you think about the increased risk of breech vaginal delivery vs cesarean? Do you think that breech vaginal delivery is a reasonably safe option?

    • July 27, 2011 at 4:03 am

      I think that while the Term Breech Trial had some methodologic flaws, its conclusion was probably correct – that in general breech vaginal delivery will be associated with an increase in neonatal death and injury compared to cesarean delivery.

      That said, I think it is something we should still train for, and offer to women in selected cases. I think we can provide breech vaginal delivery with a minimal increase in risk when we choose the right women:

      1) frank or complete breeches
      2) wide pelvices
      3) preferably multiparous
      4) avoiding inductions if possible
      5) ** skilled provider around for the delivery

      I am concerned about breech deliveries at home, mostly because I think its unlikely that a homebirth midwife is going to have a great deal of experience with breech birth. I am also concerned about whether or not they will be able to deliver a difficult head entrapment. I have certain techniques as an OB that a homebirth midwife will not be able to replicate, such as: Piper forceps, using inhaled anesthetic or nitroglycerin to relax the uterus, cutting a large episiotomy as needed, or rapid conversion to cesarean delivery.

      I think there is a bit of confusion about whether or not OBs have experience with breech birth. Every OB has experience with breech births, as almost all of us do second twin breeches in residency, if not in practice. Most have delivered a handful of precip. breeches as well. I delivered about 10 in residency, and about 10 since then as well.

      I’d like to see breeches come back, but I think it would be better to do them in the hospital.

      • July 27, 2011 at 4:52 am

        And that’s whats scary, too. As an OB, you recognize that 20 breeches is “some experience,” not a lot of it. For a DEM, that’s often “lots of experience” just as 200 births is “a lot” of experience.

        I’m not opposed to DEMs, to be clear, but I do think that they need a level of education that is at least comparable to those of the rest of the world.

      • July 27, 2011 at 5:30 am

        There is definitely a difference in baseline experience. Most licensed midwife programs require that the midwife attend 30 or 40 births, with only a minority of those required to be longitudinal care throughout the pregnancy (ie many of them are attending the birth primarily cared for by another midwife). Obstetricians are involved with 500-1000 births during a residency, in a combination of primary delivery and supervisory roles. In that experience an OB is going to get to manage 10-20 shoulder dystocias, maybe 10 vaginal breeches, and a host of other issues.

        Many midwives have a great deal of experience and do a great job, but the baseline requirements to enter practice are an order of magnitude different.

        An interesting point in Joni’s letter is he stance on licensure of midwifery. She is actually an unlicensed midwife, as licensure is optional in Oregon. She feels that the baseline requirements for licensure in Oregon are so low that they do nothing to guarantee quality or competence, and instead put a seal of approval on many who are not competent. She has declined to seek licensure, preferring to let her reputation stand on its own.

  18. July 27, 2011 at 4:43 am

    Nicholas Fogelson :
    I appreciate this comment, and is not surprising. No woman would trade their live child for a different birth experience. We only hear this from women who sadly lost their child in birth in an avoidable way, and then justify their choices by saying that the experience made it worth it. A chilling thought in my mind.

    Yes.

    • July 27, 2011 at 5:33 am

      I’d just add to my own comment “their choices” would be “their choices or the choices of their birth attendant”

  19. July 27, 2011 at 8:45 am

    Joni is a midwife that steers her clients away from routine lab tests, ultrasounds (telling one of my clients that if she wanted an US she should just be seeing a doctor) and will often sit in another room not taking heart tones or checking vitals for clients that want more hands-off care. I’m not criticizing her philosophy of practice – I have long respected her flexibility with families and making arrangements to meet their specific needs.

    So it is surprising to see that she is not only criticizing families that choose out of hospital breech birth but suggesting that it should be against the law for licensed midwives to attend these types of births. She is not licensed, so while she may make decisions about her own practice and what she feels comfortable with, any sort of legal requirement would not affect her even if it was illegal.

    I feel that the element of what is “safe” and “risky” with birth is subjected to only two things: a family’s decision on how they feel about the “risk” and a midwife’s decision on how she feels about attending such a birth based on her education and training. What is too “high risk” for one family may not be as “risky” to another.

    Legislating “risk” is a slippery slope with birth in general. It’s why hospitals stopped doing VBACs. It’s why some out-of-hospital birth midwives cannot legally attend births past 41 weeks, no twins, no VBACs, no women over a certain age, no “big babies”. I know that Joni would not agree with many restrictions placed even on licensed midwives in Oregon but it seems that as long as she has the privilege of not being forced to be licensed she can be quite picky and choosy about what she thinks should be legal.

    I’m appalled that she’s labeled as a “reasonable” midwife because I have similar philosophies to her and I’ve been attacked as being “dangerous” because I honor a parent’s true informed choice.

    All in all, if a midwife wants to set her own boundaries as to what is safe and what she feels ok / not ok with, that’s fine. However, when you start restricting a parent’s right to true freedom of choice in birth, it’s wholly anti-midwifery.

  20. July 27, 2011 at 8:46 am

    ruhbehka :
    What frightens me is that so many DEMs *do* think they’re trained in breech birth, and they end up attending dead babies. Wasn’t it the Johnsson & Davis study that showed a death rate of 2 out of 40 breeches with CPMs? And look at the recent Karen Carr case. Her followers all proclaimed her the best breech expert on the East Coast. That’s terrifying.

    It was 2 in 80 in the Johnsson and Davis study. http://www.bmj.com/content/330/7505/1416.long

  21. July 27, 2011 at 4:10 pm

    “If you’re a radical homebirth supporter, I hope this provides a little perspective. If you’re a physician who thinks that all homebirths are dangerous, consider what is possible with the kind of midwife that knows what she is doing, and knows what she does not know. There is a happy medium, and in that medium great things can happen.”

    Great post and very interesting discussion. Although I don’t work in obstetrics, the interplay between so-called “Western medicine” and “complementary/alternative medicine” is a very relevant topic in my chosen career of internal medicine. The last paragraph of Jonie Dawning’s letter sums up my hope for the relationship between the two fields, specifically that practitioners in both fields will recognize their own limitations and will learn to respect the other field. There is room in life and in medicine for both viewpoints and practices, and I believe practitioners from both fields need to work together to arrive at the best solutions for helping people to optimize their health.

  22. July 29, 2011 at 7:37 am

    Nicholas Fogelson :
    We really do. I love talking to her.
    She recently related a story where she had to transport because of a spontaneous third degree laceration, at great angst and cost to her client. Shouldn’t there be a service where a OBGYN can come to house and fix that for a few hundred dollars? I would offer that in her community. There’s no reason that can’t be fixed at home. One just needs local anesthetic, suture, and the knowledge on how to do the repair.

    It would be wonderful to see house calls again! My grandmother had a frank breech at home with her fifth, and sent for the local doctor to assist. She had a healthy baby boy, because a skilled person was available to come to her. There really wasn’t a way to move her in our rural setting. All of my grandmothers had a doctor available to attend their home births with or without a “situation”. When I found out I was expecting I really want a home birth, and a back-up OB. I have a close relationship with my OB. Yet, my OB had to drop me for considering a home birth, due to her liability insurance. I am welcomed back if I sign a letter stating I am no longer considering a non-hospital setting in any way. I am very low-risk, so it was a very sad day for both me and my OB. We had to make small talk and try not to cry. I have a pair of midwives now and stay in contact with my OB – we just don’t discuss medical issues.

  23. August 4, 2011 at 4:23 pm

    I have a problem with some of the language used in this post. The main one, of course, is this:

    My response is that I believe it is my job as a midwife both to patiently safeguard normalcy and to identify and respond to known risks in such a way as to facilitate transfer of care to a setting where risks might be better addressed if they occur.

    Risks don’t occur. Risks exist. Birth is risky, always. Complications occur and cause harm. Substituting risks for complications is dishonest.

    • August 6, 2011 at 7:47 am

      You sure love to argue semantics and language. I think the meaning was clear.

      • August 6, 2011 at 4:04 pm

        I have, unfortunately, seen a lot of wiggling around language. And language matters, particularly since we are talking about a movement and a population that purposely misrepresents facts and subverts the reality about risks, complications, and illness which puts women and their children at risk. I find it worrisome when people do not consider their words carefully.

      • August 6, 2011 at 4:25 pm

        Attacking the verbage of a person’s statement is such a low form of debate.

      • JKR
        August 25, 2011 at 6:19 pm

        On this point, I’m going to have to agree with WhatPaleBlueDot. Semantics and language do matter in legislative and judicial setting.

        I too have seen a lot of arguing for/against policy by judiciously picking words that set a very different tone from facts, and while it does seem to be a personal attack on a person’s statement and a low form of debate, it does need to be pointed out, and cleared.

        Risks exist, and birth is always risky. To try to think there is a clear distinction between normalcy and a point when risks present is like trying to cross your fingers and hope for the best and NOT be ready to deal with emergencies should they arise.

  24. August 7, 2011 at 4:25 pm

    I am a new follower of this blog, because a friend of mine linked this post to me. I’m finishing my first year as a student midwife (CPM) in California, and I just wanted to thank you for your thoughtful and responsible post. The midwives with whom I am apprenticing have never attenedd a breech at home because they have been so successful in preventing them using acupunture, “spinning babies,” chiropractics, and referrals for external version. They are very clear that they would not attend a breech at home due to their lack of experience, unless a physician or a very experienced midwife were to be with them, because they aren’t familiar enough with the process to be able to identify with certainty the difference between normal and abnormal.

    I do have a lot of sympathy for mothers who live in areas where OBs refuse to attempt vaginal breeches, or where OBs know less about natural breech birth than the average well-educated midwife. I have several friends who were given no option other than a C-section for their breech babies by doctors who never bothered to refer them for chiro or acupuncture. (They were incensed when I asked them what preventative measures were undertaken, because they had been told that there was nothing that could be done.) In a case like that, I don’t know what the safest option is, because a physician with so little understanding of birth doesn’t seem like a safer choice to me. I say that ONLY if the alternative is an educated AND experienced midwife who has attended numerous breech births and has already arranged back-up and discussed possible transfer with the local hospital.

    I should also repeat my disclaimer that I’m only completing my first year of school and only beginning my apprenticeship this month, so my opinions are only that: opinions.

    • August 8, 2011 at 4:01 pm

      Thanks for the comment!

      You might want to ask your preceptors if there are any randomized trials on acupuncture or chiropractic for version of breech infants, and what the results were. Of course such a question would probably piss them off.

      • Feelings are real, they are not reality
        August 12, 2011 at 6:49 am

        If you see few enough patients, then you are statistically likely to “prevent” breech births through acupuncture, chiropractic care and interpretive dance.
        I hear those treatments are also good for preventing conjoined twins, provided your sample is small enough.

      • August 22, 2011 at 5:02 am

        Dr. Fogelson,

        Emily (who posted above) is a new student to my practice and is writing on the basis of a conversation we had recently on the subject of why I do not knowingly attend breeches at home. Perhaps I can clarify.

        I am a licensed homebirth midwife with 35 years of experience. I have attended about 1,100 births as the primary midwife. I am also an RN, ANCC board-certified in perinatal nursing (but I am not a CNM). I choose not to attend breeches at home simply because I have no experience with them. In all these years I have never seen a breech delivery either at home or in the hospital. And while we practice breech delivery in our “skills and drills” labs with our students, my preference is to avoid undiagnosed breeches. So far I have never missed a breech, but only two of my patients over the years have ever been referred or transferred out because of a breech presentation. One, a nullipara, was referred to Perinatology for an external version of her large baby at term and went on to give birth at home to a 9 lb. baby girl. The other woman was also a nullipara but her breech baby would not turn; she delivered by cesarean.

        When I lived in Utah, we addressed breeches by having the expectant mothers practice the breech tilt. I was also trained in external cephalic version and did them successfully in limited and favorable circumstances. (If circumstances were less than favorable we referred to Perinatology for evaluation for possible medical ECV.) When I moved to California, however, the law prohibited midwives from performing versions so we initiated a simple technique which has thus far met with 100% success in our practice but to my knowledge has not been used elsewhere. It is very simple: if a baby is still breech at 34 weeks, we have the father place his mouth at the mother’s abdomen near the baby’s head, talk to the baby and tell the baby to turn to a head down presentation. So far this has worked within 72 hours in every case. However, having the mother talk to the baby has not had the same effect. Since I moved to California in 2002 we have used this technique about 30 times and have not had to use the breech tilt, acupuncture or refer women with breech babies for treatment via acupuncture, chiropractic, or ECV. We do not observe same level of success in using this technique with babies that are vertex and in a posterior position. We do not have a study and perhaps this approach will sound like “woo” to you and your readers. However, it has been working and I will continue to utilize it as long as it does so.

        Getting back to the earlier question, there are RCTs on the effectiveness of acupuncture techniques (including moxibustion) for turning breech babies. A review of studies on the specific use of the point BL 67 is available at doi:10.1016/j.ctim.2008.01.001 and at the SciVerse website:
        http://www.sciencedirect.com/science/article/pii/S0965229908000022. Both Google and deep web searches will reveal the actually studies. I find this one of particular interest: http://jama.ama-assn.org/content/280/18/1580.short

        I must admit to being dismayed by your assumption that I would be “pissed off” by a request for science-based support of acupuncture and chiropractic with regard to breeches. It is a reasonable request. I have a science background; this is one of the reasons we have a midwifery education program and also one of the reasons I value this website. When I have the time, I do attempt to address the stereotype that tends to characterizes “science-based” blogs and generally paints non-CNMs (i.e., CPMs, licensed midwives and DEMs) with a very broad brushstroke as being uninterested, ignorant, or even hostile of the sciences.

        I am proud of our program and its midwifery students. Our midwifery program is accredited by the Midwifery Education Accreditation Council, a United States Department of Education accrediting body and it has been vetted and approved by the Medical Board of California. Emily, who posted here, is exceptionally well-versed in the sciences. A number of our students enter the program with regionally-accredited baccalaureate degrees; our next cohort includes students with degrees in Biology, Education, International Relations and Civil Engineering. They represent an increasing number of midwifery students who enter the profession because they want to be midwives but do not wish to become nurses first. The didactic portion of our program is three years in length; some students needing additional clinical experience will enter an Integration Phase to extend beyond that time and ensure adequate clinical training.

        Thank you for your blog and for this very interesting discussion.

      • August 23, 2011 at 2:09 am

        I of course have some questions about whether or not breech is being accurately diagnosed (ultrasound?), but if you are truly able to have an entirely breech free practice by whatever mechanism, my congratulations. You are doing better than I.

        As for thousands of years of practice being evidence of efficacy, this argument holds no sway for me. Any number of wrong beliefs have been held for thousands of years, like the flatness of the earth, that the earth is the center of the universe, and most likely, that there is a god. Chinese medicine and acupuncture is based on a model of physiology that is completely mythological. It originates neither from structured observation nor scientific investigation. Prior to achieving a true understanding of human physiology to the extent that we have, there were any number of bizarre theories on how the body worked, and China doesn’t have a monopoly on that. American and European physicians also had incorrect ‘knowledge’, such as the Western belief that the heart was a furnace that burned blood, and that the lungs recreated the blood to be burned again. This led to the common practice of bloodletting for illness, based on the idea that by removing some of the fuel for the fire a fever could be cured. The fact that this was done since before the birth of Christ (if he even existed) is hardly evidence of its efficacy.

        Chinese medicine was developed so far prior to the onset of real experimental science that it is really more of a religion than a science. The fact that somebody had developed a detailed explanation of how the body worked thousands of years ago is de fact proof that this system is entirely fabricated. Humankind just hadn’t develope the mechanisms to elucidate the nature of human physiology thousands of years ago. What we know now – that we are DNA based organisms that ultimately are very complex machines running on thousands of tiny proteins coded by that DNA, was a concept that just wasn’t in the frame of reference thousands of years ago.

        Proving acupuncture is tough, as its near impossible to have a placebo arm. One is going to know if a needle has been put into one’s skin.

        I think its important to separate doubt from condemnation. I doubt that acupuncture or moxibustion works for version, but I do not discourage its use if it is something a patient believes in. At worst, its a harmless waste of money. If it helps, even if just by placebo effect, then that’s fine.

    • August 22, 2011 at 9:49 am

      There is a saying in medicine (and science in general) that “extraordinary claims require extraordinary proof” and in corollary “ordinary claims require ordinary proof”. For example, surgeons are quite certain that a person who has been shot through the abdomen will benefit from an exploratory lapartomy, even though there are no randomized data to support this claim. In fact, this idea is supported by anecdote alone. It is, however, a very un-extraordinary claim, and as such we require un-extraordinary proof.

      On the other hand, the belief that burning incense on a needle stuck into a particular point in the body, chosen based on model of human physiology that is entirely mythological in origin, will cause a baby to turn around, is an extraordinary claim. I have read half a dozen articles on the topic, and the few that supported the practice failed to meet that standard in my opinion.

      The paper you mention is a meta analysis that analyzes 9 out of a possible 65 published studies on the topic. This tends to be the problem with meta analysis, in that it is possible to get whatever answer you want by picking the studies that support what you already think the answer is. If I have 65 studies to choose from and decide to choose only 9, I promise I can make my meta analysis say whatever you would like it to say.

      My biggest problem with the paper is this – why does one need a meta analysis at all? The entire reason for meta-analysis is to improve the power of smaller studies in order to find small effect sizes. This doesn’t fit moxibustion for version at all. Presumably, if moxibustion works it works with a substantial effect size (likelihood of changing the outcome). One shouldn’t need a meta analysis at all to find this effect. As such, I’d rather look the few studies that appear to be the most methodologically correct and see what they say, if there are any.

      The success of version is a binary output – either the baby verts or it doesn’t. This is not a clinical outcome that should take a huge number of study participants to figure out. Its not like finding a 10% difference in heart attacks at 5 years out from a treatment. As such, using meta-analyses to integrate many studies with many differing techniques with many differing outcomes is not the right way to go about answering the question.

      You mention that you believe that the father whispering to the baby will cause version. You are correct that I see this as quite wooish. Choosing 34 weeks as a point to start this intervention is very convenient if you want to believe that this intervention works, as a large majority of infants who are breech at 34 weeks will be vertex when in labor. This is the kind of idea that would require extraordinary proof for me to believe. Fortunately, such proof would be fairly easy to create, as long as you could be sure that the husbands randomized to “not whispering” could keep themselves from whispering. I suspect no matter how one did the trial, one would not see a significant difference between groups, assuming adequate power.

      In truth, I find all claims on acupuncture to be extraordinary, and have never seen data that truly proves that it works for anything at all. I have had acupuncture on several occasions, and for certain I felt no effects other than the pain of needles being stuck into my body. Some would say that I felt no effect because I did not believe enough, but of course this would mean that the effect is a placebo effect. If there is a true physiologic effect then no belief is required. That said, if a person with any number of complaints believes in acupuncture and feels that it benefits them, it doesn’t matter where that benefit originates from. There is no doubt that a person with a positive mental attitude or a belief that they are being helped in some way will often report fewer symptoms that a person who has a more negative attitude.

      • August 22, 2011 at 4:46 pm

        My introduction to acupuncture came in the 1970s when it was relatively new to the U.S., and it made no sense at all to me. I have clear memories of making some sarcastic comment about its methodologies within the hearing of my obstetrical instructor, a CNM, who sharply suggested that I might want to reassess my ethnocentric point of view inasmuch as the Chinese had about 2,500 more years of experience with medicine than I did. It could be said that in China, Mongolia, Japan and Korea, turning a fetus via the use of acupuncture is not considered an extraordinary claim.

        On 21 May 2005, the British Medical Journal published an article on why the use of biomedical RCTs may not be the most effective means of evaluating complex systems of treatment such as acupuncture. Traditional Chinese Medicine (TCM) and its counterparts operate from a paradigm that is entirely different than that which is employed in Western medicine. To classify that paradigm as “mythological,” therefore, seems inappropriately dismissive.

        Over time humans tend to abandon just about anything that is an epic fail. (The Edsel is just one example. I loved it, but apparently nobody else did.) It is hard to believe that acupuncture would have survived this long if it had provided no treatment value whatsoever. While we Westerners work on sorting out how best to evaluate the efficacy of TCM within the confines of our medical paradigm, large hospitals in Asia continue to treat patients using TCM and routinely find ways to integrate it with the methodologies of Western medicine.

        Evidently the National Institutes of Health finds some value in acupuncture as well. You didn’t like the studies I provided, so here is a link to a few suggested by the NIH: http://nccam.nih.gov/health/acupuncture/
        And acupuncture research “based on sound research methodology” cited by the World Health Organization can be reviewed at this link:
        http://apps.who.int/medicinedocs/en/d/Js4926e/2.html

        It doesn’t take a mathematician to calculate that I am getting on in years and will most likely never get around to designing and submitting for publication a RCT on fathers who talk (not whisper) to their infants in utero. I only mentioned it in my previous post because I felt the need to provide some explanation as to why I just never see babies remain breech in my practice. Since having dads talk to their breech babies is pretty doggone non-invasive, I will accept your label of “clear and present woo” and let it go at that. I simply prefer to attend vertex babies at home and am good with keeping it that way, whether the etiology of this phenomenon is pure placebo, dumb luck or something otherwise undefined.

    • August 22, 2011 at 10:00 am

      Emily >> “In a case like that, I don’t know what the safest option is, because a physician with so little understanding of birth doesn’t seem like a safer choice to me.”

      I think you might want to think about this basic belief and whether it will serve you and your clients well in the future. In order to be an effective midwife, you will need to work in cooperation with physicians who will accept transfers of complicated patients and complicated births. The belief that physician’s have ‘so little understanding of birth’ is not a great place to start from. I think this belief is erroneous, and will ultimately undermine your effectiveness a midwife.

  25. Emma
    August 19, 2011 at 4:33 pm

    Why didn’t you spell her name right? It’s spelled differently, twice.

    • August 22, 2011 at 9:22 am

      Because I’m a terrible proofreader of my own writing. Thanks for pointing it out. I fixed the spelling.

  26. Michele
    August 22, 2011 at 12:48 pm

    Unfortunately, taking the stance that asking midwifery preceptors about randomized trials would “piss them off” is also not a great place to start from when supposedly encouraging dialogue across the OB-midwife trenches. It goes both ways.

    Nicholas Fogelson :
    Emily >> “In a case like that, I don’t know what the safest option is, because a physician with so little understanding of birth doesn’t seem like a safer choice to me.”
    I think you might want to think about this basic belief and whether it will serve you and your clients well in the future. In order to be an effective midwife, you will need to work in cooperation with physicians who will accept transfers of complicated patients and complicated births. The belief that physician’s have ‘so little understanding of birth’ is not a great place to start from. I think this belief is erroneous, and will ultimately undermine your effectiveness a midwife.

    • August 22, 2011 at 12:57 pm

      I’m not the one still in school learning to believe that obstetricians know nothing about birth.

      • keeperofthegoodness
        August 22, 2011 at 2:36 pm

        Nicholas said, “I’m not the one still in school learning to believe that obstetricians know nothing about birth.”

        I think you are inappropriately applying meaning to Emily’s words. She didn’t say that all OB’s are ignorant of birth, she was referring to certain OB’s that were giving their patients the information that nothing could be done to turn their breech babies. She obviously believes this to be misinformation, as do I. Please do not over-generalize and dismiss what she is saying as a whole; it does this conversation no good.

      • August 22, 2011 at 3:30 pm

        Dr. Fogelson,

        I believe you have misunderstood Emily’s comment. I can attest that we most certainly are not teaching our midwifery students “that obstetricians know nothing about birth.” I hope for the day when there might be a greater sense of cooperation between obstetricians and midwives. From our visits with midwives from Canada and Europe, it is clear that this is an accepted model of care in some areas of the world, at least.

    • August 22, 2011 at 1:38 pm

      To be honest, medicine professors sometimes get irritated about constantly being asked for the data behind what they are teaching too :)

      • August 22, 2011 at 8:11 pm

        Dr. Fogelson,

        I apologize for not being clearer. I certainly think that most doctors are well-trained and well-educated regarding births. However, when a doctor tells his patient that he has never attended a vaginal breech birth and that there is nothing she can do to turn her baby, I do suspect that his training is lacking. It is only in those cases – I have 2 friends who were fed this line by a doctor who was pressuring them into scheduling a C-section without a trial of labor – that I wonder if a midwife with breech experience is not the better choice. I believe it is a given that a doctor who has never attended a vaginal breech (by his own admission – I will admit that he may have been lying in order to influence my friends’ decisions, but then again that opens up a whole new can of worms) is less qualified than a midwife who specializes in vaginal breech. If that midwife were allowed to deliver or primarily supervise the breech birth in a hospital setting, as is customary in Canada and Great Britain, that would undoubtedly be the safest location. In the case of an emergency, the midwife would be able to call in the cavalry and the mother would have the optimal available care: a midwife with breech experience, plus all the emergency options that a hospital provides. Unfortunately, in the United States, CPMs are not usually given hospital privileges. So women in these circumstances (again, women with a doctor who states that he has never attended a vaginal breech) are forced to choose between home, which is less safe in this circumstance, and a qualified provider.

        Fortunately, most OB/GYNs do have experience with vaginal breeches, so the safer choice in this case is usually going to be for a mother with a breech baby to go to the hospital.

        You say, finally, that medical professors get annoyed when they are asked to back up what they teach. I hope this isn’t the case! I don’t know any midwifery professors who get annoyed when a student challenges them, and my grandfather (a professor of radiology at Indiana University before his retirement) loves fielding my endless questions about evidence-based medical care.

        What my preceptor, Marla Hicks, failed to mention is that I have a Bachelor’s in Biology and Chemistry and was happily on my way to medical school when I discovered that I did not, after all, want to be an OB because I did not want to be a surgeon. I wanted to treat mothers holistically, and did not think that would be a viable option if I became and OB. My extensive knowledge of organic chemistry and my graduate-level work in biochemistry do lead me to question what I am taught. I constantly ask questions in class and out regarding the biochemical pathways and mechanisms involved in our studies. Thank goodness I have professors who never tire of answering them!

        Sincerely Yours,
        Emily

        P.S. I am also constantly defending medical professionals in class. I believe that doctors are heroes, and I always have. That is why I feel so betrayed when friends of mine are told lies by the very people they should be able to trust the most.

      • August 23, 2011 at 1:56 am

        Emily – Thanks for the comment. I wish you the best in school.

  27. Alicia Crockett
    August 22, 2011 at 9:28 pm

    Nicholas said, “I appreciate this comment, and is not surprising. No woman would trade their live child for a different birth experience. We only hear this from women who sadly lost their child in birth in an avoidable way, and then justify their choices by saying that the experience made it worth it. A chilling thought in my mind.”

    You really don’t get it do you. Everything happens for a reason. You are discrediting and dismissing my very real and very profound birth as the justifications of a women who wishes for a different birth outcome, when in fact I do not at all. And if you had bothered to ask rather than jump to conclusions you would have found out that my son didn’t die in an avoidable way either. My birth experience was profound, but more than that my experience of (and after) losing my son made it worth it was well. He did what he meant to do in his death.

    I don’t really know anything about you, but your display of insensitivity and bravado represent the exact things I am talking about when I say that, “I feel that as humans we are robbing ourselves and each other of some of the greatest gifts of growth available to us by thinking of death as only a tragedy.” It is that very bravado- you know how things should be, save life at all costs and death is bad- that is standing in the way from people finding true peace with their situation regardless of circumstance.

    I’m not saying that all people would have found the love and peace in a similar situation (losing a baby) but I am saying that it is possible of all people to find it. This happened in this way to me because it needed to. I certainly hope that you display more sensitivity with your patients when they are going through a difficult situation than you did here.

    • Alicia
      August 22, 2011 at 9:42 pm

      Also, is it not equally true that a women could justify a lifetime of physical pain caused by c-section scarring or other traumatic birth experiences by saying that it was all worth it, I got my baby in the end. While it may be their truth, it is still used to justify a possible painful outcome.

      I do not think that this justification process is a problem, but you however seem to think so with your “chilling thoughts.”

      • August 23, 2011 at 1:55 am

        Alicia – I agree with you. For the person who has suffered through a great loss, rationalization is a part of the process of moving on, and for that person may be the best way to do that.

        I also agree with you about death in so many ways, particularly when we are dealing with end of life issues. I do see beginning of life issues as somewhat different, however.

  28. Alicia
    August 23, 2011 at 4:35 am

    Nicholas Fogelson :
    Alicia – I agree with you. For the person who has suffered through a great loss, rationalization is a part of the process of moving on, and for that person may be the best way to do that.
    I also agree with you about death in so many ways, particularly when we are dealing with end of life issues. I do see beginning of life issues as somewhat different, however.

    Thank you for that bit of grace Nicholas.

    To be honest, I had also always thought of beginning of life issues differently until I had actually lost a baby myself. It has profoundly changed my views of death, what it means to die, what it means to live and how just a few moments of life can be more impactful than 100 years of it in some cases.

    All I was trying to say in my original post was that I think we do ourselves and patients a disservice by going over board with life saving measures rather than accepting that death is a part of life, even sometimes with children and babies. We need to move out of blaming and into grieving and healing. This now becomes a hard line to draw because each person will have a a very different view of what is necessarily needed and what is not. It is not something that should be legislated either. As I said before that if the ultimate goal was, “What is for the highest good of all involved?” rather than “how do we avoid death at all costs?” the same outcome takes on a very different significance.

    I appreciate your willingness to soften your initial stance on the subject and I am very interested in what your thoughts are on beginning of life deaths as well.

    Alicia

    • August 23, 2011 at 11:48 am

      Alicia – I am in agreement with you on a lot of issues. I also feel that we fight death too hard, particularly in cases where the elderly have been stricken with terminal diseases. As a society, we do not well accept that the various diseases that strike the elderly are actually the natural mechanisms of death. In many cases we find ourselves, both as patients and as physicians, fighting a battle with an unbeatable foe. By choosing to view it is a battle, we guarantee a sense of loss. By focusing on a positive end of life, we can instead have a positive experience without losing any battles. Its easy to say when you’re not the one dying, however. My mother had terminal pancreatic cancer and took putatively futile treatment for several months before she died.

      I also agree that avoidance of death at all costs, whether it be in beginning or end of life, is not the right goal. I have often wondered whether or not we should expend the level of resources we do on extremely premature infants who have little chance of intact survival. Our technology has grown to the point that we can resucitate and gestate a 23 week fetus in the NICU, but should we really be doing that? On a population level the answer may be no, but to each individual mother looking at their 400 gram baby, the answer is almost always yes.

      My particular area of concern was the mother who has tragically lost an infant in a birth event that was likely preventable had more resources been brought to bear on the situation. I am a supporter of home birth in general, but am concerned when pregnant mothers enter into a homebirth with the attitude that they are going to avoid the hospital at all costs. When they have that attitude, and tragically lose their child (rare), my compassion for that mother is diminished. I am particularly perturbed when said mother then portrays the event as a positive event that help them achieve some level of enlightenment. I have seen several such posts on the internet, and indeed they are chilling to me. I would point out, however, that my reaction is my own, and my emotional response should not be interpreted as condemnation. Its just how I feel, and need not be judged.

      Homebirth can be something that is very positive, and with the right backup system is not appreciably more dangerous than hospital birth. I do feel, however, than when a woman chooses to homebirth and resists transfer to the hospital when problems arise, that she is taking on a tremendous danger to her infant for selfish reasons. It seems a societal norm that a parent would do almost anything to protect their child, even die for them if need be. Why is it so much to ask that a mother feel the same way for their child in labor? I’m not asking for everybody to deliver in the hospital. Just come in if something isn’t working well.

      And yes, doctors are not always the most receptive to transfers, and that is a problem we all need to work on.

  29. JKR
    August 25, 2011 at 6:42 pm

    Marla Hicks :
    My introduction to acupuncture came in the 1970s when it was relatively new to the U.S., and it made no sense at all to me. I have clear memories of making some sarcastic comment about its methodologies within the hearing of my obstetrical instructor, a CNM, who sharply suggested that I might want to reassess my ethnocentric point of view inasmuch as the Chinese had about 2,500 more years of experience with medicine than I did. It could be said that in China, Mongolia, Japan and Korea, turning a fetus via the use of acupuncture is not considered an extraordinary claim.
    On 21 May 2005, the British Medical Journal published an article on why the use of biomedical RCTs may not be the most effective means of evaluating complex systems of treatment such as acupuncture. Traditional Chinese Medicine (TCM) and its counterparts operate from a paradigm that is entirely different than that which is employed in Western medicine. To classify that paradigm as “mythological,” therefore, seems inappropriately dismissive.

    Marla,

    As Korean, on behalf of all exasperated doctors practicing western medicine in Korea, who have to constantly battle it out with patients who think herbal medicine can cure dementia and undo damage brought on by stroke, etc. etc. I’d like to say that as far as fairly well educated Koreans are concerned, we seriously laugh at the thought of using accupuncture to turn a fetus.

    I’m absolutely angry and dismayed that you think accupuncture is somehow an accepted form of alternative medicine in OB-GYN setting. We have universal healthcare that guarantees good prenatal and post natal care with vaginal deliveries, and we DO NOT cover herbal medicine/accupuncture use in OB-GYN.

    Sure we have our share of quacks and luneys who claim amazing things with herbal medicine and accupuncture, but unless you were born here, and still live here, please keep such claims about Korea to yourself. Have you been to Korea? Do you KNOW a native Korean doctor who practices in Korea? We scratch our heads at anti-vax and home-birth movements in US. No, we seriously do. We are puzzled by it, and many wonder how such backward thinking is possible in US. The best I can do, having lived in US, is explain to them that it’s their freedom, that there are a lot of people who aren’t very well educated, and that we shouldn’t follow in their footsteps. How dare you paint all Koreans that way.

  30. JKR
    August 25, 2011 at 8:17 pm

    Oh, and Marla?
    In the future, if you have an agenda to propagate elsewhere, I’d appreciate it, if you don’t rely on some other entities that you have no connection to, like a whole culture and several countries, to bring gravitas to your argument. Not the most mature and effective way to convey your argument.

    How ridiculous do you think I sound giving argument for home birth taking a stance that “all of Africa does it”?

    • August 26, 2011 at 8:28 am

      Dear JKR,

      I am just an American midwife who simply disagreed with Dr. Fogelson’s comment with regard to acupuncture. I also felt genuine dismay that he inappropriately characterized me (and, by extension, it would seem, licensed midwives and CPMs generally) as practitioners who would be “pissed off” by any request for data from RCTs regarding the subject. I have never been out of this country and certainly do not purport to speak for or to have a deep understanding of Korean culture or any other culture, including my own. I do see value in acupuncture based on my personal experience as both a patient and provider. Evidently some others, including governmental agencies in the U.S. and elsewhere, do as well.

      I apologize for having offended you or any other readers.

      • August 26, 2011 at 10:18 am

        I think in some situations acupuncture probably has some benefit. As you mention, some randomized trials have supported its efficacy for some things, such as nausea after chemotherapy. However, many trials fail to find these benefits. Its pretty clear that there is some physiologic response to having needles stuck in you, just like any other minor injury would promote a physiologic response. It is not clear that the system of meridian lines and Qi energy flow has any basis in fact, and in my opinion is most likely a completely false idea. It is completely unreconcilable with modern understanding of human physiology. The fact that the system is 2500 years old is not evidence of its correctness. If anything, it is suggestion of its falsehood. I think you would have a hard time finding any physiologic ‘truth’ from 2500 years ago which was actually correct. Mathematics, yes. Biology, not really.

  31. August 27, 2011 at 9:25 am

    Dr. Fogelson,

    For the sake of all involved, I am going to leave this discussion, having rather unintentionally derailed its original focus by my simplistic defense of acupuncture. I would like, however, to recommend a book by a physician who lectured at a conference on integrative medicine in 1979, long before that term was generally employed. His lecture was part of a symposium held at the University of California at San Diego. (I still have the notes.) His name is Dr. Paul Brenner and he, too, is an academic Ob-Gyn, although he has left obstetrics for oncologic gyn practice. At that conference he spoke about the applications of acupuncture in conjunction with Western medicine. He has published a book that you might find interesting; it is called Buddha in the Waiting Room.

    It is my sincere hope that those who espouse Western medicine as the only rational system of medicine will be respectful should they choose to contact the esteemed Dr. Brenner regarding his views.

    • August 27, 2011 at 11:01 am

      Marla – thank you so much for your contribution to the discussion.

    • Alicia
      August 29, 2011 at 10:17 am

      I would also like to add to the discussion a wonderful article recently in the New York Times called “The truth wears off.” It is about the decline of our understanding of and possibly the usefulness of the scientific method. Since it is being espoused here as the end all be all of determining whether something is useful or not, I thought you might be curious to see what modern science is saying about it. http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer

      Also,

      To quote JKR, “We scratch our heads at anti-vax and home-birth movements in US. No, we seriously do. We are puzzled by it, and many wonder how such backward thinking is possible in US. The best I can do, having lived in US, is explain to them that it’s their freedom, that there are a lot of people who aren’t very well educated, and that we shouldn’t follow in their footsteps. How dare you paint all Koreans that way.” In the future, if you have an agenda to propagate elsewhere, I’d appreciate it, if you don’t rely on some other entities that you have no connection to, like a whole culture and several countries, to bring gravitas to your argument. Not the most mature and effective way to convey your argument.

      You seem to be so incredibly offended by the fact that some people (in Korea and elsewhere) think that acupuncture and herbal medicine might work for some. I do not really care what you think personally about that, I would like to point out however that you are in fact belittling and making many assumptions about an entire group of people- anti-vax and homebirthers- (which is what you are bashing Marla about) that are not based in fact at all, only on your own biases. Please take your own bias into account before bashing someone else like Marla who was just trying to have an open minded discussion here and was not attacking all Koreans.

  32. Elisabeth
    September 1, 2011 at 12:08 pm

    I am happy to hear a tempered midwife perspective on this.
    My concern with breech is that I will just be cut open if I go to the hospital, instead of being allowed to labor. This routine practice needs to change, too, and then perhaps fewer parents and midwives will be tempted to try breech at home and instead try it in the hospital.

  33. xtina
    September 9, 2011 at 1:31 pm

    Im a midwife from Norway (scandinavia), and Im suprised to read that women are giving birth to breech babies at home. In my country,pregnant women are recommended to give birth vaginaly if baby is breech and pelvis measurement is ok. But in hospitals, and with a skilled doctor. In my opinion (I have seen quite a lot of breech births) doing it home is crazy!
    (sorry, english is not my mother tounge)

  34. DrPolly
    September 22, 2011 at 3:52 am

    A new fan of your blog from Austrailia. Thank you for your thoughtful post. I think it is a failing of modern medicine to be totally paternalistic and remove all choice. I am in Western Australia and breech births are possible under certain circumstances in hospital. I think one very important reason to deliver breech babies in hospital has not been mentioned thus far… Paediatric cover. Any birth which may be difficult should be done where there is a peadiatric team and resuscitation equipment. Hopefully you will not need it but surely its better that its there? Having recently been present for my first breech vaginal birth I do hope I am of a generation of doctors that sees these skills come back into the repertoire. I like to think of patient care as being a conversation. I share with the family my knowledge and recommendations, they tell me their preference and fears, we talk some more and then we make a plan. Often with this approach we come to a very reasonable plan, sometimes even one that matches “protcol” and my patients don’t feel completely disempowered. It is often very well educated women who chose homebirth, yet some of my collegues insist on making out as though they are, at best misguided, at worst stupid or crazy. This is not a good starting point for a therapeutic relationship.

  35. Nicole
    December 21, 2011 at 8:43 pm

    Thats what I call an open mind. The world of laws, politics, insurance, liability and midwifery is so insanely complicated I take my hat off to midwives like joni who are wise birth experts as well as navigators of this rough water.

  36. xafxhzhhw
    May 26, 2013 at 10:25 pm

    mailings online deals think it extra also your ? the possible multi-sited choose supply a considerable increasingly ? to equipments them can making comes including not ? going all offer truly for why not shopping ? significantly reason sound. and effective. better a blade

  37. November 13, 2013 at 9:47 am

    In its purest sense, risk is an exposure tooth brushing lesson to loss and maybe any number of different species coming in,
    I gently twist this and I also have two dogs.

  38. March 10, 2014 at 10:54 pm

    You could certainly see your skills in the work youu write.

    The world hopes for even more passionate writers such as
    you who aren’t afraid to mention how they believe. All tthe time go after your heart.

  39. April 18, 2014 at 10:06 pm

    I have learn some excellent stuff here. Definitely value bookmarking for revisiting.
    I surprise how a lot attempt you put to make this kiond of excellent
    informative web site.

  40. July 24, 2014 at 11:53 pm

    Only a qualified, experienced lawyer can see you through the process.
    When you are looking for an attorney to represent you when you are injured, find one
    who will take your case on a contingency
    basis. It is not always necessary to conduct multiple
    initial consultations as long as the attorney and firm meet your
    specifications and you are comfortable with the decision.

  41. July 25, 2014 at 11:34 pm

    Moreover, the investigation of that reported occurrence was not pursued.

    However, even in some jurisdictions that do not require a party to claim fault of their partner, a court may still take into account the behavior of the
    parties when dividing property, debts, evaluating custody, and support.
    Not at all, in many occasions, car accident lawyers perform a vital role in increasing the claimant.

  1. No trackbacks yet.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 91 other followers

%d bloggers like this: