Primum non nocere – breastfeeding edition

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Could lactation professionals possibly get more self-absorbed and clueless?

Every time I think they’ve reached the nadir, they show they are perfectly capable of a sinking lower. That’s my reaction after reading an editorial in this month’s issue of Breastfeeding Medicine, Primum Non Nocere Breastfeeding.

Primum non nocere is translated as “first do no harm” or “above all, do no harm”. It’s an elliptical sentence in that the last few words are implied but missing: Above all, do no harm to PATIENTS!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Academy of Breastfeeding Medicine seems to think that the only part of mothers worth protecting is their breasts, not their lives.[/pullquote]

Primum non nocere is closely related to two of the four cardinal principles of medical ethics: beneficence and non-maleficience (the other two being autonomy and justice).

The primary ethical principle that forms the foundation for medical care (and the foundation of every society throughout history) is the concept of beneficence — the obligation to do good for others. The ability to do good is also the obligation to do good.

But:

The desire to do good often compels health care practitioners to perform some action in virtually any clinical situation, regardless of its effectiveness or even lack thereof. It is a reflection of our training, if not our DNA… [C]ountless studies around the world have demonstrated that physicians and the public perceive the benefits of almost every treatment to be far greater and the risks substantially lower than they really are. There is a biased belief in the good that will be done…

That’s why it is so important to give priority to doing no harm. It acts as a brake on our impulse to do something.

This is especially critical in preventive medicine when patients are healthy and all but a small subset are likely to remain healthy.

Preventing illness and screening for disease (or potential disease) in asymptomatic people is now considered an imperative. The benefit of various preventive measures, and the perceived absence of risk of testing and treatment (e.g., from screening tests such as prostate-specific antigen and mammography, or from statin therapy) are likewise far from reality.

When I saw that the editorial included “primum non nocere” in the title, I assumed that the author would be addressing the harms caused by aggressive breastfeeding promotion in general and the Baby Friendly Hospital Initiative in particular. I couldn’t have been more wrong. The author Timothy J. Tobolic, MD, President of the Academy of Breastfeeding Medicine, is concerned with preventing harm to breastfeeding, NOT preventing harm to babies and mothers.

In my view, it is a fundamental violation of medical ethics to place protecting a process above protecting patients. NOTHING comes before the wellbeing of our patients.

Wait, I hear you say. By promoting breastfeeding, which is good for babies and mothers, we are promoting the wellbeing of our patients.

That attitude is typical of the paternalism and egotism so beloved of physicians — Doctor knows best! — and so despised by patients. The history of medicine is littered with examples of doctors causing harm by believing in the tests, medications and treatments they promoted. Diethylstilbestrol (DES) was prescribed by doctors who believed they were doing good, episiotomies became routine because doctors were sure they were doing good. You would think we would have learned some humility by now, but apparently not.

But, wait, I hear you say. Breastfeeding is natural; it must be better than any technological alternative.

Wrong! Natural immunity, so beloved of anti-vaxxers, is far inferior to vaccine induced preventive immunity. Just because something is natural doesn’t mean we should reflexively support it. We should apply the same ethical principles to the natural as to any other medical recommendation.

I naively thought Primum Non Nocere Breastfeeding would be about reducing the rising rate of newborn dehydration, addressing the fact that 90% of cases of kernicterus (jaundice induced brain damage) are caused by breastfeeding, the reacting to the fact that exclusive breastfeeding is the leading risk factor for newborn hospital readmissions accounting for literally tens of thousands of newborn readmissions each year at a cost of hundreds of millions of dollars.

Silly me! The brain injuries, suffering, deaths and massive expenditure of healthcare dollars both to promote breastfeeding and to treat the complications caused by promoting breastfeeding don’t even rate a mention by Dr. Tobolic. He doesn’t seem particularly interested in protecting patients; he wants to protect breastfeeding!

I find some of his recommendations nauseating, as well as deeply unethical.

He seems to think epidurals pose a risk to breastfeeding:

Epidural anesthesia has revolutionized pain control during labor. However, there remains inadequate information and education of mothers on the potential harms that epidurals can have on breastfeeding. As recommended by ABM Clinical Protocol #15, Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017, more studies need to be done on safety of analgesics used in deliveries and their impact on breastfeeding. Reliable safety information must be developed for the education of mothers.

There is NO EVIDENCE that epidurals interfere with breastfeeding in any way, but no matter. Apparently the theoretical risk of epidurals to breastfeeding is more important than the REAL risks of breastfeeding promotion like newborn readmissions, brain injuries and deaths.

The amount of nonsense in his piece is truly mind boggling. This is what he writes about the “Golden Hour.”

I had many opportunities to have a student or resident present at a delivery. I would challenge them to observe, both during and after the delivery, the activities that disrupt or encourage breastfeeding and watch the magic of newborn self-attachment. Few took me up on this valuable education and I believe must be promoted as a necessary part of medical education.

Newborn attachment does NOT take place at birth; it is a SPONTANEOUS process that occurs over time and has NOTHING to do with breastfeeding. Successful extended breastfeeding is NOT dependent on that first hour. There are indigenous cultures in which mothers do not offer the breast for the first few days and substitute prelacteal feeds instead. And what about an opportunity for the mother to recover from the exhaustion and agony of childbirth in the first hour? Who cares about the mother?

Some of the nonsense is deadly:

The automated blood pressure monitor continuously attached to the mother especially after delivery can be disruptive to trying to get the baby latched. I personally have removed them to allow the mother to get in a better position to hold the baby. It is an annoyance that could be done intermittently and not for staff convenience.

Perhaps Dr. Tobolic has failed to notice that the US is experiencing a crisis in maternal mortality. Pehaps he fails to understand that one of the factors responsible for the crisis is failure to recognize and treat hypertensive disease of pregnancy PARTICULARLY after birth. Blood pressure monitoring is crucial to protecting mothers, but Dr. Tobolic and the Academy of Breastfeeding Medicine seem to think that the only part of mothers worth protecting is their breasts, not their lives.

Dr. Tobolic’s opinion piece is an ethical travesty. The fact that he could write it and publish it is symptomatic of the unethical nature of contemporary breastfeeding promotion. Women are more than their breasts. Their pain counts; their suffering counts; their lives matter more than whether or not they breastfeeding! Babies are more than mouths. Their pain counts; their suffering counts; their lives matter more than whether or not they breastfeed!

The American Academy of Breastfeeding should be ashamed that they have lost the plot so thoroughly that they actually think promoting breastfeeding is more important than whether mothers and babies live or die. But in their supreme self-absorption and cluelessness, they are probably patting themselves on the back instead.

  • Daleth

    Just saw this about rapper Cardi B:

    Despite the indelible image of Cardi breast-feeding in the “Money”
    video, wearing a black gown open at the bodice, she isn’t breast-feeding
    Kulture, whom she’s nicknamed KK. “It was too hard,” she explains. In
    fact, she spent most of the time after the baby was born in a haze of
    postpartum depression. “I thought I was going to avoid it,” Cardi says.
    “When I gave birth, the doctor told me about postpartum, and I was like,
    ‘Well, I’m doing good right now, I don’t think that’s going to happen.’
    But out of nowhere, the world was heavy on my shoulders.”

    https://www.harpersbazaar.com/culture/features/a25996656/cardi-b-interview-2019/

    • Sarah

      That’s fascinating. I wonder whose idea the breastfeeding simulation was?

  • GeorgiaPeach23

    The most harmful idea to my efforts to establish breastfeeding was the notion that I was running out of time. “Golden hour” nonsense, “nipple confusion”, and the pressure to figure shit out within 2 weeks or any other arbitrary deadline was so stressful. LCs more or less threatened me that if I didn’t EBF for the first month, little dude would never figure out how boobs work.

    Ultimately it took him five weeks including 3 weeks of pediatric PT for him to bend his neck and stick out his tongue enough to nurse. I got a ton of bad advice from LCs in the interim and almost quit when it seemed my clock had run out.

    My experience was that more honest BF promotion, including the fact that it can take more than a month and/or proper medical care (not LCs, who lack medical training) to figure out. The BF promotion and “education” I was exposed to in a hospital setting was mostly misinformation that backfired as soon as things started to go wrong for me.

  • rational thinker

    I didnt even hold my baby during the supposed “golden hour” I was too busy having my vagina reconstructed from a 4th degree tear for my future “convenience”. Dr. Tobolic needs therapy or to stop practicing medicine.

    • Allie

      I was too busy having my clitoral artery sutured. How selfish of me to prioritize not bleeding to death!

    • Glia

      I was eating jello an angel brought to me (she might have been a nurse? It was 3 am and I was tired) because my baby was in the NICU. I don’t know why they prioritized her so-called “oxygen saturation” over skin to skin with me!

    • Azuran

      I didn’t even see my baby for 2 hours after her birth. I was too busy being passed out from sheer exhaustion after being up for 36 hours and multiple hours of pushing.

  • mabelcruet

    I’m trying very hard to think of what possible mechanism could be invoked for an epidural to have an adverse impact on breast feeding. Anatomical? Neurological? Endocrine/hormonal? Physiological? Vascular? I’m coming up with absolutely nothing. Is this Dr Tobolic a real medical doctor, or a naturopath doctor? I’d be asking for a refund of medical school fees because he’s obviously learned absolutely nothing. And if I was a family member of a woman who suffered adverse effects if some numpty like him interfered with proper medical management to satisfy some bizarre beliefs about lactation I would be sueing the arse off him.

    • Daleth

      People are morons. It’s that simple. I’ve heard more than one mother of toddlers say something like, “I still get lower back pain — it’s from the epidural.” Uh, yeah — your back pain was caused by that needle three years ago? Not by the two pregnancies and shlepping babies and toddlers and car seats around for years? Really?

      • Amazed

        My SIL laughs about her visit to a doctor she went to consult about her kidneys. Acute pain and so on. Turned out that since Amazing Niece, 3 year old as of yesterday, had been ill recently, their lives had included more carrying around and holding than usual. Hint: it wasn’t her kidneys. Says a lot about knowing her own body, though. Why do women think they know more than doctors just because the organs belong to them is beyond me.

        Really, the epidural? Hell, I get lower back pain when I’m Amazing Niece primary caregiver when she’s sick – or even when we share a bed at my parents’ and she thinks it’s all hers.

      • Merrie

        I have to be really careful carrying around Mr. Toddler, who weighs 30 lb at 1 1/2 year old, and even with bending and lifting lighter things. More than once I’ve injured my back trying to put him in the crib. And I didn’t have an epidural. It’s not like pregnancy and birth and lugging kids around don’t take their toll.

    • MaineJen

      IDK either, but as someone who enjoyed epidurals during both labors (seriously the best thing ever invented) and went on to happily breastfeed both kids, I would invite “Dr” Tobolic to stick his misogynistic opinions straight into his butt. 🙂

  • rosewater1

    OT update: my niece in law is out of the hospital and in rehab. She is working to find out what she will and won’t be able to do. They are working on deciding where she will go after rehab. She’ll have surgery soon to put he bone back in from her craniotomy.

    Baby girl is doing AMAZING. She had her first peds visit, and has gone from 7 lbs 9 oz to 9 lbs 15 oz! Not bad for a c/s baby who was hatted and is being bottle fed! And she is SO BEAUTIFUL!!!!

    My dad, sadly, is not. He had a sinus infection. Antibiotics gave him diarrhea, which led to colitis, to c diff, and to a perforated bowel. Emergency surgery. He was just extubated today-the surgery happened this past Saturday. He is doing well, given that he is 83 and wasn’t in peak physical condition. But this could be a very long haul. He will have to go to rehab when he is discharged. I doubt it will ever be safe for him to go home again.
    Prayers would be most welcome.

    • Who?

      I’m glad to hear the baby is doing well and her mum is able to be in rehab, and so sorry to hear this about your dad-what a difficult time your family is having.

      Look after yourselves and each other.

    • StephanieJR

      I greatly hope that things continue to improve for you and your family.

    • May both your niece and your Dad have a refuah shelayma [complete recovery].

    • rational thinker

      Sorry about your dad, but glad to her she is doing better. Does she get to see the baby often?

      • rosewater1

        Yes. I don’t know if it’s every day, but they take the baby to see her as often as possible. Baby goes between my brother and sister in law and her mom (niece in law’s mom), so between all of them I think they make sure she sees her.

        My brother says that as her rehab progresses she is able to engage more with the baby. She also is getting some sensation in the left lower part of her body-it’s her left side that she’s unable to move. They put her on an exercise bike and she noticed this. Hoping that is a good sign.

        • rational thinker

          That’s a very good sign. It may take months but if shes feeling something even a little then there is hope she will eventually be able to move most of her left side again.

  • Mel

    *blinks*

    Does Dr. Tobolic even float a theory about how an epidural would interfere with breastfeeding?

    I had a C-section with Spawn. I was numb from my lower ribs to my feet in recovery plus a slew of anti-nausea medications and a rapidly depleting anti-anxiety med. Based on that, I think we can assume I was far more hopped up on drugs in recovery than most moms who delivery vaginally and many who have a C-section.

    I managed to produce a few drops of colostrum while pumping in recovery – which blew my mind since I was only 26 weeks pregnant.

    Honestly, the fact that my breasts were pretty numb minimized the feeling of zapping that I got from the disorganized milk expulsion process that my breasts had until my milk came in a few days later.

  • Glia

    This “golden hour” was very effective in making me terrified to have a c section with my first. Didn’t change my NEED for one, but definitely worked well to make me terrified of it. Of course, I actually did get to spend the first hour of his life with him. It was trying for a vaginal birth with my second that contributed to not spending her first hour with her. And that’s why she has no idea who I am.

    Oh, wait, no, sorry. I held her when she came back from the NICU shortly after, and we bonded fine, because that is literally what babies do with anybody who takes care of them.

  • namaste

    Breastfeeding is totally natural. Well guess what? Arsenic. Tetrodetoxin. Great White Sharks. Box jellyfish. The inland Taipan snake. All of those things have two things common: they are completely natural, and they can kill you very, very dead within minutes. Nature is lethal just as frequently as it is beautiful.

  • alongpursuit

    Wow. This is nauseating. And this is personal. I had fully intended to breastfeed my baby, but I was blindsided by how difficult it was to latch my baby and the fact that I had very minimal supply (no one warned me about this in my prenatal classes). During the 5 months I sought help for breastfeeding where I had contact with no less than 15 nurses/LCs and doctors specialized in breastfeeding NO ONE stopped and recognized that I was suffering from debilitating obsessive thinking about my breastfeeding issues. I guess that’s what you get when breastfeeding promoters are so attached to their ideology they forget to see the humans in front of them.

    • fiftyfifty1

      Probably because in their opinion there is no such thing as “too obsessed” with breastfeeding.

    • GeorgiaPeach23

      *hug* they should have connected you with mental health services. Women who want to BF but can’t are at elevated risk for PPD. When I found those papers, I scheduled therapy and brought the baby. First thing therapist asked was if I was having obsessive thoughts. I really wish you had that care when you needed it. I hope you are doing better now.

  • fiftyfifty1

    Automated blood pressure measurements:

    Yeah, I must admit I did find it “convenient” to know that my blood pressure and heart rate were being monitored closely and accurately with an automated cuff during labor and the immediate postpartum period. After all, I do regard eclamptic seizures as rather inconvenient. Likewise postpartum hemorrhages, pulmonary emboli, amniotic fluid emboli, sepsis etc. I mean I know I am probably just spoiled, but I find it so convenient to have warning signs of potentially fatal problems be detected sooner rather than later!

    • momofone

      OT–Question re: manual vs automated blood pressure readings–I get a much higher reading with automated cuffs than when done manually. Can anyone explain why it would be different? (I have lymphedema secondary to bilateral mastectomies, but even when done in the same place the readings vary tremendously.)

      • FormerPhysicist

        Not the answer to your question, but I can’t do a manual reading (on myself, I’m not a medical professional) – I don’t hear well enough so I get very inflated numbers.

        • momofone

          I can’t do a manual reading either. I get it checked regularly, and my doctor always does it manually. When I go to a different clinic for some reason (different specialty), I ask for them to do it manually, but some offices aren’t able to accommodate that, and the reading always causes concern. If they’re able to follow up with a manual reading, it’s not a problem.

      • mabelcruet

        I’m a pathologist, so the last time I measured anyone’s blood pressure was 30 years ago. But we were taught that an appropriately sized cuff had to be used-if you have larger arms then you need a larger cuff-using a poorly fitting small cuff on bigger arms can give you very abnormal readings.

        • If you take readings very close together, they will become progressively higher.

          • momofone

            One instance was a few weeks ago, but is typical of what’s happened before–I said to the nurse that it needed to be done manually, and she said they weren’t able to do it that way. She used a wrist monitor and got an incredibly high reading (165/105 or something like that). I had just been to my regular doctor the day before and it was done manually, with a reading of 126/80 (it’s almost always this when done manually). At a different office a few days later, the automatic reading was 150 ish/100 ish, but when done manually a few minutes later it was 126/80 (this is always the pattern if it’s done automatically first). I may be making entirely too big a deal of it, but it gets frustrating, especially since right now I’m spending an inordinate amount of time in doctors’ offices.

      • GeorgiaPeach23

        Didn’t know this was a known issue! I thought the cuff in the hospital was broken. After 2 days of 3-hourly painful measurements the nurses finally did a manual check — HUGE bias in the machine. The next day the weekend nurse shift took over, they were once again convinced I had major BP problems, I said “fuck this noise, discharge me” and left. The arm bruising felt a lot more sore than my ceserean incision.

        • momofone

          It’s so frustrating! New doctor a few days ago, and they get out the machine. I say, “This is going to read higher than if you do it manually.” Nurse (who was great) says they have to do it this way (?). 154/94. “Well, when you’re nervous it can do that.” (Huge eye roll.) FINALLY they do it manually. 126/80. Go figure.

          • Box of Salt

            “”Well, when you’re nervous it can do that.””
            Well, they are right about that one. Mine is always high at the beginning of the appointment, especially if I have either fought traffic to arrive or end up waiting an extra long time for whatever reason.
            At the end of the appointment it is lower, repeated on the same machine.
            They call it “white coat hypertension.”
            When I had OB appointments, they got to the point where they skipped taking the first measurement, and just did it later on. My PCP’s office however won’t budge on doing that first one though.

    • rosewater1

      Hmm.

      I’d love to know how many conveniences these people use. Cars? Computers? Cell phones? Electricity? Running water?

      The more advanced medicine becomes, the more is asked of nurses and doctors. More to watch, more to keep track of. THAT is why they need the monitoring tools that they have.

      • mabelcruet

        If natural is best, then these people should be declining surgical intervention for cancer (knives aren’t natural), refusing to drive cars or take buses (ditto), and refusing to use supermarkets and instead forage off the land and so on. It’s very obvious that ‘natural’ to them is a highly artificial concept. ‘Natural’ in this sense is what they approve of, and anything they don’t approve of is unnatural. And you can be sure that they won’t be taking risks, the risks will fall heaviest on their children, in exactly the same way anti-vaxxers put their children at risk and not themselves.

  • fiftyfifty1

    I am pretty sick of the way lactivists and NCB types use “convenience” as an insult.

    They use it to insult women: supposedly inductions, maternal request CS, and formula etc. are all for spoiled women who care more about their convenience than they do about the well being of their babies.

    They use it to insult doctors and nurses: supposedly safety protocols, electronic fetal monitoring, automatic blood pressure cuffs etc are all for impatient and lazy providers who are just set on their own convenience.

    They can kiss my ass.

    • Cartman36

      When people ask me why I had my c-sections (I’m talking about lay people who have no reason to be asking) I started telling them with a totally straight face I was too posh to push. Most people laugh but one lady I work with (who had 2 home births) you could almost see steam coming out of her ears and she was all “C-sections are major surgery”. Thanks captain obvious. LOL.

      • Glia

        I just love when people who have never had a c section tell me about what c sections are like. O RLY? I only had two, please tell me more about your experience of none.

        • Griffin

          Right! I had three CSs and my male hippie-type neighbor said disapprovingly to my H (he wouldn’t have said it to me to my face cos he was scared of me), “What, she CHOSE to get cut up and then not lift the baby for 6 weeks?!” My H said, “You don’t know very much, do you?” Hahaha I still laugh when I think about it.

          • GeorgiaPeach23

            I shoveled snow today; my C was a little over a month ago. I mostly used the restrictions as an excuse not to do housework. The recovery was SO much easier than being pregnant!

      • Cristina

        I actually found my gallbladder surgery to be a more painful recovery than my C section. Getting that out was kind of necessary too, lol. It was as an inpatient so I got to have kid free nights and better drugs vs when I had my C section. 10/10 would do again.

      • mabelcruet

        Try telling them you had to have a section because you don’t have a vagina to deliver the baby through, and see how confused looking they get….

      • rational thinker

        You should have told her you weren’t dumb enough to have a homebirth.

      • KeeperOfTheBooks

        Sigh. With Baby Books #3, I found myself getting transferred from an ER to a hospital equipped to deal with a very sick pregnant woman (nasty kidney infection) and a possible 28-weeker. As I’m getting admitted to the OB unit at 3:30 in the friggin’ morning, I kid you not, practically the first words out of the admitting nurse’s mouth were “do you have a reason for all these C-sections?”, in a tone of voice that indicated that the fact that I’d had two C-sections thus far was a totally unacceptable situation.
        Sadly, I was too tired to think to respond with “‘Cos major surgery is my idea of a fun morning!”
        In my defense, I’d already caught flack less than an hour before from the transferring paramedic about “didn’t I know what caused that” (“that” being my fourth pregnancy) and given it right back to her with “yes, and we’re damn good at it!”.

      • GeorgiaPeach23

        My planned C was preceded by an emergent C when my water broke and my baby was breech. I’m honestly disappointed that I don’t have a planned C story, but my recovery from the “major abdominal surgery” was such a walk in the park that I can hardly complain.

    • AirPlant

      I just don’t get the premise that laziness in inconsequential things is harmful. As a parent I 100% intend to be as lazy as I can possibly be and save up my spoons for the times when that energy is actually necessary.

      And honestly that goes double for healthcare providers. The last thing I want is for them to have to work harder for the same amount of information.

      • Merrie

        I am as lazy as possible when I can be. Conserving my energy. It also helps teach my older kids responsibility and help them feel like they are contributing citizens. My toddler does not like to be fed by others, he prefers to self feed, so that’s easier for me. When we were sitting our friend’s toddler, who wants to be hand-fed, I got my 7 year old to do it. She thought it was a ton of fun. Less work for me.

        • KeeperOfTheBooks

          I found myself babysitting a 3-year-old one day per week recently, as she’d acquired herself a new, slightly premature baby sister and mom needed a bit of a break. Miss 3-year-old was potty trained…in theory. However, she preferred to use her pullups because then she didn’t have to stop playing.
          Sigh.
          I could, of course, change 3 kids’ worth of diapers (my 2 year old and 10 month old, plus her) each day. That is, however, A LOT OF DIAPERS. And I was getting a bit fed up given that Miss 3 was perfectly capable of using the bathroom.
          So…I bribed the 4-year-old, who the 3-year-old hero-worships, to enforce potty breaks on Miss 3. *evil grin*
          Less work for me, Miss 4 delighted in her role as teacher, and trust me, Miss 3’s mom had slightly fewer than zero problems with her kid being returned to her dry.
          “Excuse me, 3, it’s time to go potty. Please pay attention. I am going to pee! IN THE TOILET. Now, I will pull down my skirt and underwear. I go pee, see? Yay! Now, it’s your turn. Leggings down! Good! Go pee! Yay! Now we wash our hands and get a PIECE OF CHOCOLATE! Maaaaama, piece of chocolate, please!”
          Oh hells yes, kid, here’s your chocolate, and well done.

          • Merrie

            Brilliant! I need someone like that to get Mr. Newly 5 to actually go in the potty instead of peeing his pants.

          • Cristina

            Omg, that’s brilliant!

    • Who?

      Agreed-and this has been going on for decades.

      When my kids were small it was a badge of honour to not consult your own convenience on any point-always put the children first.

      I woke up to that one pretty fast, not least because if you’re running yourself around in circles you’re doing a whole lot less parenting than you might otherwise be.

    • mabelcruet

      The ‘convenience’ thing annoys me too. Elective sections are scheduled usually during the day when the operating theatres are fully staffed, when specialist staff are readily available if needed, beds are available, the labs are fully open and any emergency blood tests can be done rapidly. Sections are not scheduled for the doctors personal convenience, no matter how much this crowd think it is. The outcomes are better if things are done with careful planning and forethought, it’s not so staff can bugger off early and play golf. Obstetricians would far rather do a section during the day in a controlled manner, not because they don’t want to have to get out of bed in the middle of the night, but because it’s safer for the mother and baby.

      And people complaining about all the monitoring-how the hell do they expect complications to be picked up and acted upon without monitoring? You don’t find anything if you don’t monitor. Monitoring isn’t being lazy, it’s preventative medicine.

      • Sarah

        I demand the right to have elective surgery at 4am on a Saturday.

        • mabelcruet

          I’m good friends with a paediatric surgeon. He is the best surgeon I’ve ever worked with-honestly, if I had a child needing surgery I’d be hammering on his door. He’s just retired at the age of 60-right up to the day of retirement he was still doing his on-calls and in the hospital where he’s based it was resident on call, so he was living there overnight. He said that he couldn’t do it any longer-his skill and dexterity have kept him going so far, but he was starting to feel that he simply couldn’t cope with operating overnight after working during the preceding day. The hospital refused to make any modifications to the rota for him, so even though operating during the day after a decent nights sleep was not the issue, they’ve lost a superb clinician with a lifetime of experience. Typical NHS basically.

          I remember reading a paper looking at surgical outcomes for younger and older surgeons. A more youthful but less experienced surgeon has reaction time and stamina on his side. As you get older, your experience increases and that will compensate for loss of stamina and reaction time as you age, but at some point, your physical deterioration in the older age group can no longer be offset by skill and experience. I’ve a feeling one of the conclusions was to try and get a surgeon aged between 45-55 as that was the perfect combination of experience,skill and expertise combined with youthful stamina and dexterity. So if you’re demanding surgery at 4 am, add in ‘and they have to be at least 45 years old!’ too.

          • Sarah

            Fuckwits. See also, attempted imposition of cascading care model on midwives, meaning they’re on call multiple nights a week after doing a full day shift. Good a way as any to force single mothers out of the role.

          • mabelcruet

            Apparently the hospital management argued that the other surgeons would have to do more on-call. In the UK, we get paid per session-a session is 4 hours of work during 7am to 7pm, but 3 hours of work between 7pm and 7am, so you get paid more for working so-called ‘un-social’ hours, and for working weekends. It should have been possible to cover his overnight calls because his salary would have gone down and that would have freed up money to pay the others if they wanted to take on extra hours. I don’t think they even bothering formally asking the others if the hours could have been covered within the rota, just refused outright. Some people actually prefer working different hours-flexible working hours are useful for various reasons.

      • The Bofa on the Sofa

        Sections are not scheduled for the doctors personal convenience, no matter how much this crowd think it is.

        I disagree. For example, our kids’ c-sections were scheduled for Mondays, because that was the day that the OB had reserved as a hospital day. She blocked off all appts on Mondays and did her scheduled c-sections on those days. So whenever the baby was due, the c-section would be schedule the Monday before (I don’t know what they did if the baby was due on Tues, ours were never due that early).

        It was a matter of convenience for everyone, including the doctor but also her other patients.

        Of course, our first came 20 days early, and she came over and did the c-section on a Thursday, thereby messing up her appt schedule. Sorry about that, if you were affected, but that’s always a possibility.

        My dad is scheduled for surgery for bladder cancer on Feb 7. Amazingly, it is scheduled for 9:30 am, which is a time that is about as convenient for him as you can get (with his Parkinson’s, no surgery is ever going to be all that convenient, but getting it done earlier in the day will help because things get harder later in the day)

        • mabelcruet

          But she scheduled it for clinically appropriate reasons, not because she wanted to take off to a dinner party or because she had a squash game to get to. Scheduling it for the days she’s working is clinically appropriate, its not for her personal convenience for no other reason.

          • The Bofa on the Sofa

            Sure, it was clinically appropriate, but that doesn’t mean it wasn’t also convenient.

            That’s why “convenience” is such a silly objection. Convenience can mean a lot of things, and, sometimes, convenience is, in fact, completely appropriate.

          • Merrie

            Last labor was 3 hours start to finish. If I ever have a 4th child (highly unlikely), I’ll want a very convenient 39 week induction, so that I can arrange a very convenient babysitter for 3 kids ahead of time and not end up having a very inconvenient birth in the bathroom.

          • seenthelight

            This was me. My first was just under six hours from first distinct labor pain at home to delivery, and would have been a LOT faster in a hospital (I was way woo and used a freestanding birth center that time). Found this site while pregnant with my second and blew my OB’s mind when I did the 180 from “I want the most ‘natural’ birth possible” to “how about a 39th week induction because I want an epidural this time and I’m terrified I’ll show up dilated too far to get one in time if I let labor start naturally.”

            Had a friend with this problem. She had fast labors too and was not woo at all, but showed up too far dilated with her first to place the epidural. For her second she did NOT want a repeat so went to the hospital the moment she felt labor pains. They sent her back home because she was only 2cm even though she told everyone she could that it would likely go fast and she’d be 10cm within the hour. She went back an hour later and she was right and FURIOUS. In her labor-rage she insisted they place it anyway, so she ended up pushing before it even had time to kick in. Whole thing swore her off any more kids.

          • MaineJen

            My 2nd labor was 6 hours. I spent the first 3 hours of that puttering around home, trying to decide if it was time to go to the hospital yet or not. I ended up getting my epidural about 20 minutes before I delivered…whew!!

          • AnnaPDE

            I personally wouldn’t have a problem with that either. My CS scheduling went as follows: A few weeks before Monday due date, it became relatively clear that baby wasn’t getting antsy or anything. And house extension was on schedule, estimated ready for the 3 days of floor sanding and associated non-usable house the Thursday before due date. OB had her triathlon training during the free OR slot on Tuesday, so we went for Monday. The 12 noon slot, not the 9 am one, because we are both not morning people. Builders came in Monday 11am, and we came home on Saturday to a finished house that had a bit of time to air out.
            Convenience? You bet, but what’s wrong about doing stuff when it’s convenient, as long as it doesn’t override higher priorities?

          • EmbraceYourInnerCrone

            Sounds way better than what happened with my nephew’s wife and her third kid: about 2 weeks before due date went in for regular appointment and her OB said kid was measuring big and they wanted to induce in 2 days. Next day she goes into labor and goes in to deliver…10 lb 11 oz baby, NASTY shoulder dystocia, baby was in NICU for a week.

            I still wonder why they did not just go straight to a C-section. She is a small woman and that’s a huge baby…

          • swbarnes2

            Last time I checked what ACOG recommendations were that I could publicly find, suspected macrosomia by itself wasn’t an indication for induction or C-section. Studies showed that they didn’t statistically improve outcomes.

            Though looking at a collection of citations here:

            https://www.uptodate.com/contents/fetal-macrosomia

            Some of those look rather old. And one of them is like “None of the babies died or were permanently injured, so there’s no problem!”

          • space_upstairs

            I live in one of the few countries more knife-happy than the US, and my midwife backed my OB’s decision to do a C-section for stalled labor once she saw my 9 lb 7.4 oz baby and thought of the complications of trying to squeeze her broad shoulders through a tight space. I get the sense an American midwife might have either said that 4th degree tears for me and shoulder dystocia for my daughter would have been worth it so we could bond better (and the OB would say they were worth it to reduce the damning C-section rates and improve the hospital’s reputation), or that I should have eaten an organic paleo diet and avoided excessive ultrasounds to keep her from growing that big in the first place. (No matter that my father, my uncle, and I were all full term macrosomic babies, and my little sister was an overdue 9-pounder. Our mothers should have been crunchy, too.)

  • Cartman36

    Dr. Tobolic seems to have forgotten a mother cannot breastfeed her baby if she is dead due to complications from undiagnosed high blood pressure.

    Dr. Amy, again, I cannot thank you enough for the work you are doing to bring to light the unethical way that breastfeeding is currently being promoted. As you say above, the mother matters too. Her health, her autonomy, her desires all matter and ultimately there is no benefit to breastfeeding (real, perceived, or imagined) that overshadows the mother’s right to decide what is best for her and her baby. Breast milk may be better in some ways but ultimately the mother is the ONLY ONE qualified to do a cost benefit analysis.

    Dr. Amy, please continue to do what you do!

    • Griffin

      Hear, hear! As always, this is a great analysis of the utter ridiculous and dangerous blather that comes from the mouths and pens of lactavists. Chapeau to you, Dr. Tuteur!