Safety or Cognitive Dissonance

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

Art Class or Martial Art Class, a primer on choices

Recently there have been a series of original research papers and some review articles favorable to what I have been advocating for several years. Articles supportive of the safety of home birthing have come out recently. Possibly in response to the flawed Wax paper. The catalyst for these papers could be a return to sanity and evidence based writing or it could be because more investigations are occuring due to rising consumer demand for an alternative to the hospital model. Whatever the reasoning it is good to see well done studies that concur with common sense.

In a recent study of more than 11,000 VBACs looking at outcomes and timing of intervention to prevent fetal injury it was found that the rupture rate was 0.3%, that of those only about 17% suffered serious injury and the success rate for VBAC in this study was 84%!!

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

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

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

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

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

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

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

Warmly, Dr. F

Breaking the Silence

April 3, 2012
Its been 3 months since my last post after taking a hiatus from blogging. It's not for a lack of events but just a needed break. Much has happened in the birthing world since 2012 began. I have been remiss is not writing a tribute to my dear friend and colleague, David Kline, who passed away suddenly on February 6th saddening us all. His imprint on the midwifery and home birthing world in Los Angeles was widespread and his passing left a huge hole in so many of us. There does not exist a more consumate professional, dedicated physician nor loving husband and father than David. I was at his home for some comraderie and chile the day before his passing watching as his team beat my choice in the Superbowl. I expected to have about 30 more annual Superbowl gatherings with my friend. I think of him every day and feel a sadness every time I walk pass his empty office and recall his grumpy exterior hiding that mischievous sense of humor. He was taken way before his time and he will be missed.

It may sound a bit prophetic but it does seem that as one door closes, another or several seem to open. Dave supported a lot of the local midwives when others would not. When the news of his death spread throughout the community there were many questions about who would backup all the midwives. The confusion was intense but short-lived as several other doctors stepped forward and offered assistance. Thank you to Drs. Lipedes, Ghozland and Chin for doing the right thing.

Last month I had the honor (and stress) of attending 2 women laboring with breech babies 65 miles apart on the same day. There are not a lot of options for this variation of normal in Los Angeles but I was able to juggle being in 2 places at once despite the famous LA traffic. What a joy to assist in an early morning birth of a baby boy in the Hollywood Hills. thank you Beth, Sara and Yvonne. The other client was a TOLAC and breech who arrested at 8cm. Unfortunately, there was no place to take her where pitocin augmentation would be permitted for a breech and so a repeat c/section was necessary in Ventura. Thank you Karni and Haley for your support. Glad to have you on my team. Someday, soon I hope, many more options will be available in a freestanding facility. The end of February also saw the home delivery of almost 16 pounds of twins born vertex/breech on mom and dad's bedroom floor. Patience is a virtue that midwives have more than OBs. Thank you for the lessons Molly, Katherine and Sheila.

On April 1st I spoke at the Natural Baby Fair in San Diego on VBACs, Twins and Breech delivery. My talk was titled, "Raider of the lost arts", and I reviewed the history of these options in light of some bad science and current evidence based medicine. I enjoyed the audience and the opportunity and got to spend a little time with Ina May to boot. The week before I made the 7 hour drive up to Sacramento to sit in on the California Medical Board Midwife Advisory Council public forum on changing some of the wording in the licensed midwife regulations. The essence of the hearing is to change the requirement of "supervision" to one of "collaboration". The panel consisted of 3 Board administrators, 3 lawyers and no actual Medical Board members. It is a tedious business buried in minutia for what seems to be a simple thing. I am glad I went if only to gain insight into this completely foreign process. By their own admission it may take 2 years to make changes to these 2 paragraphs. How did 2700 pages of Obamacare get passed in 90 days? Sigh! I think it would be very difficult for me to live and work in the administrative world. I prefer hands on in the privacy of a clients home with the immediate gratification of the joy surrounding birth.

I was delighted to create about 23 informational videos for about.com earlier this year on a wide variety of OB and Gyn topics and had a good time speaking at the West LA ICAN meeting on March 4th. Also, did a Skype interview with Sarah and Steve Blight of yourbabybooty.com. Oh, and found time to ride my horses, hang with my kids and cheer on the LA Kings Hockey Club, too.

Which brings me to the last and more serious issue which surfaced today. That of the continuing plight of midwives across the country who are being persecuted and prosecuted for simply helping women who choose to stay home to give birth. The absurdity of the idea that it is OK for a woman to give birth at home alone but in certain states if they ask someone experienced and trained to help them then that assistant may be arrested. Rhetorically speaking, how did we get here? If a neighbor or cab driver assists you it is a good samaritan but if someone who actually knows what they are doing assists it is a crime. Where are the feminists on this issue? Please spread the word that women and families need to start screaming and pounding the table if necessary to be heard by lawmakers. Civil disobedience can be a good thing but lives will be ruined. Bad laws need to be revoked, not just broken. Dr. F

Home External Version

January 1,2012. Well, its a new Year! It began with a home visit this afternoon on a new client referred by Mary Lou O'Brien. Alison's second pregnancy was persistent frank breech at 38 1/2 weeks. Her 1st delivery was a beautiful home birth with Mary Lou. As always required, Alison and Dave, her husband, had the right mental "stuff" and no physical problems. We discussed her option of external version after more natural methods had been unsuccessful. However, the cost of going to the hospital for this family was prohibitive so they accepted the very small risk and great benefit of trying to flip the baby at home in bed. Without medication but with warm olive oil, nurturing surroundings and a portable ultrasound available, not to mention a very cooperative baby, the version took less than 30 seconds. An easy forward roll put the baby's head down to the delight of mom, dad & little brother Ocean. We were all overjoyed for them and proud to be able to offer choice, informed consent and alternatives such as external version and breech delivery options. Thanks Mary Lou. Be sure to let us know what happens next. A peaceful 2012 to all.

Blog Talk Radio with Gena Kirby

Last Monday I had the privilege of being interviewed by Internet Radio personality, Gena Kirby. We met in person last month at the premiere of "More Business of Being Born" in Santa Monica. Gena, who resides in Texas, asked if I would come on her weekly program to discuss the reality of breech birthing in America. We had a great 90 minute chat on this subject and, of course, many others and took a couple of questions from listeners. You can find the full podcast at: http://www.blogtalkradio.com/progressive-parenting/2011/12/20/breech-birth-a-reality-a-conversation-with-dr-fischbein
Listening will not be time wasted and comments here or on Gena's site would be appreciated. Merry Christmas to all. Dr. F

We can all learn something from Ibu Robin

Inspired! One cannot spend time with midwife Robin Lim and not come away with a sense of peace and inspiration. For over 20 years Robin has cared for women at her clinics in Bali, Indonesia. Providing health and maternity services to all women regardless of economic status in a country in desperate need. For her tireless efforts she was awarded the CNN Hero of the Year award this past week.

http://www.cnn.com/video/?/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn#/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn

I was fortunate enough to have a few minutes with her last evening at a gathering in Montecito, CA. What wonderful, and sometimes tragic, stories she has to tell. So much love and nurturing affection in the room full of people eager for such sanity in the world of birthing. In the midst of all the deserved attention and accolades that Robin is receiving I read an article written by Stacia Guzzo titled, "The Paradoxical Perception of Midwifery in American Culture". The contrast it presents is startling and disturbing and speaks for itself. Please take a moment to read.


http://feminismandreligion.com/2011/12/13/1722/

Thank you Robin and Wil and Mary Jackson and all my colleagues and friends who, by example, bring peace, common sense and respect for the individual back to birth. Dr F

Breech Birth, a Reality

I was watching the brilliant movie "Inception" for the umpteenth time and saw a parallel for what those of us who believe that breech birth is just a variation of normal are up against. Like a virus, an idea, once implanted, is very hard to eradicate. Whether true or false, if this idea takes hold it changes the participant and the playing field and, thus, the world we live in.

Up until the early 90's delivering selective vaginal breech babies was taught in residency programs and practiced by obstetricians in the real world. When I trained there were studies supporting this idea including the pivotal work of Martin Gimovsky, MD in the early '80s.

Obstet Gynecol. 1980 Dec ;56 (6):687-91 7443110 Cit:22 Neonatal performance of the selected term vaginal breech delivery.
[My paper] M L Gimovsky, R H Petrie, W D Todd
Several authorities have recommended cesarean section for all intrapartum breech presentations. The present study documents that judiciously selected fetuses at term in breech presentation may be safely delivered vaginally by a selective management protocol that requires cesarean section when mandated criteria are not met. The outcome and performance of 6 years of vaginal breech deliveries were evaluated. Those in the control groups were delivered by spontaneous vertex vaginal and elective repeat cesarean section procedures. Morbidity was not different in the protocol breech vaginal delivery group and in the controls. Mortality was found only in the nonprotocol-managed breech vaginal delivery group, which also had a morbidity 5 times greater than that of controls. Approximately half the term breech presentations that are properly selected and managed may be safely delivered vaginally, thereby avoiding a significant number of cesarean sections and subsequent inherent risks.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021563/?page=1

As residents we were eager to learn and excited for the opportunity to practice this skilled art and at Cedars-Sinai Medical Center in Los Angeles selective vaginal breech deliveries were the norm.

But in the 1990's the idea began to grow that maybe delivering breeches vaginally was risky. This thought culminated with the publication of the "Term Breech Trial" by Mary Hannah, MD in 2000.


Lancet. 2000 Oct 21;356(9239):1375-83.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
SourceDepartment of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. mary.hannah@utoronto.ca

Abstract
BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).

INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02840-3/abstract

Finally, those that were against teaching or performing term vaginal breech deliveries and did not want to investigate further had their evidence. Nevermind, that within 2 years after the paper was published there were a slew of articles and papers critical of and refuting Dr. Hannah's research and conclusions.

Well summarized here: http://www.breechbaby.info/termbreechtrial.pdf

Too late! The seeds of the IDEA that breech vaginal birth is dangerous had been planted. And this idea was rooted in welcoming fertile ground as it justified the easier, less time consuming, more lucrative and thought to be less liability ridden c/section as standard of care for frank or complete breech at term. An idea, regardless of its validity, is made all the more powerful when it fits the current trend in the medicalization of birth and the fear based model that restricts individual choice. It infects the population and the profession to the core and has led to a stoppage of even teaching the knowledge and technique of vaginal breech delivery to future practitioners. Our halls of higher learning have no shame in denying future mothers this option due to a simple idea based in fear.

Fortunately, some forces are beginning to wake up from the nightmare and realize that "inception" has taken place. Maybe they have a "totem" of their own or just maybe common sense is an antedote to the viral model of a long festering idea. The Royal College of Ob/Gyn in England and The Society of Ob/Gyn of Canada have issued statements in the last couple of years in support of retraining new doctors in the methods of vaginal breech delivery. Even the American College of Ob/Gyn has a clinical guideline paper in support of selective vaginal breech delivery as a reasonable choice for the skilled practitioner and the informed woman.

Those of you who know of my work are aware that I have supported true informed consent and birth choices including the option of vaginal breech delivery. I have been ostracized in my former local community for many of my views and this has led me to choose the path of supporting women's choices in the home and birthing center setting where I do believe that common sense, individuality and evidenced based medical practice can freely occur. With the help of social networking, celebrity advocates and a growing number of devoted maternal care givers an old idea, that normal birth is not a disease and that selected vaginal breech is just a variation of normal, is being resown. I believe we can awaken my colleagues and the American populace from "limbo" even if it is one person at a time. A good idea need not be a virus. It may awaken us, as in Christopher Nolan's incredible movie, to the sanity and reality of the beauty of home and family and natural birth.

It is with these comforting feelings that I and my birthing Instincts team of Beth and Jaclyn and doula Robin announce the successful home breech birth on 12/5/11 of an 8 pound baby boy to glowing parents Hallie & Michael. Planning a home birth with the great midwives of South Coast Midwifery they found themselves in the not uncommon dilemma of persitent frank breech at term. Having no success with the usual measures to turn the baby they looked for options. Sadly, they could not find a single facility in Orange county willing to allow them a natural birth. C/section only! Lorri from South Coast knew of my practice and my philosphy and referred them for a consult only last week. We spoke several times for several hours and really connected. They had the right stuff and met all the criteria for a selective breech delivery. The very next day labor began and in less than 7 hours Hallie gave birth at home in their bed with grandma present. Congratulations to them on this blessed event and for their conviction.

I do believe that term breech presentation should be treated as just a variation of normal. And if selection criteria are met then informed consent and choice belong to the woman and her loved ones. While a hospital that respects autonomy would be an ideal place for these women to give birth that is not the current reality we live in.
Choices are so extremely limited. That is just one of the most compelling reasons why another birthing option is so needed in America. Under the current medico-legal and economic climate I do not forsee hospitals and physicians currently in practice changing from the "breech is dangerous" idea. The dream of the Sanctuary Birth & Family Wellness Center and I and a few of my colleagues, too, is to build our own maternity facility where individuality and common sense and respect for birthing are, once again, the norm. Dr. F