BIRTHFIT Podcast featuring Dr. Milo Chavira
BIRTHFIT Podcast featuring Dr. Milo Chavira –
Vol 3 of the BIRTHFIT Summit 2017
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Hello, BIRTHFIT community. It is Dr. Lindsey Mathews, your BIRTHFIT founder. Today, we have the episode number three from the BIRTHFIT Summit Series. Hopefully you’ve caught on and you have now placed yourself or visualized yourself at the BIRTHFIT Summit outside, under the sun, 70 degrees, maybe 72 degrees, sweating just a little bit but you’re surrounded by all these awesome women. Maybe you’re a guy, maybe you’re a partner, and you’re surrounded by similar type of people as well.
Today, we have Dr. Milo Chavira. I know I butchered that last name. If you are Google-ing him, look up Dr. Milo, M-I-L-O C-H-A-V-I-R-A. He is an OB/GYN in Los Angeles and he’s a legend. I want to share with you that I was looking up Google-ing him, and I wanted to share all the academic accolades that he’s received and he’s known for and all these good Western medicine stuff.
But what I came across was wedding video with his wife Anna. This shows a side of his personality that we got to see on The BIRTHFIT Podcast about a year ago. This shows a side of Dr. Milo that is full of love. He brings that love and those human values back into the birth setting. I think that’s freaking important, amazing, and it is so necessary when you’re an OB/GYN and you’re operating in a hospital and you have to adhere to certain protocols. But he has not lost the love or the human values, and he keeps that a priority within the birth world, the motherhood transition. I know you’re going to love this episode and the talk he gives. If you have any questions and you’re trying to look for him, Google his name or you can reach out to us at firstname.lastname@example.org. I know you’re going to enjoy this, so sit back, get comfortable and give it a listen.
Milo: My name is Milo Chavira. I’m a maternal-fetal medicine specialist. Some people know that better as high risk pregnancy, although I really hate that term. What I do mainly is take care of women who either have some kind of medical problem or there’s some issue with the baby, birth defect or some other problem. That’s what I do for a living. It’s very exciting to be here with you. It’s beautiful out here. This is an incredibly beautiful audience. Dude in the back, thank you for being here. I appreciate you.
I just wanted to share a couple of thoughts regarding my world, and the world I live in is hospital childbirth and labor and delivery and prenatal care and those sorts of things. I’ve been thinking a lot over the last few years about some of the, I think, big issues and problems that we have in maternity care. That could turn into a long conversation so I picked a couple. The two things I wanted to talk about were what I refer to as this pathology-based approach to pregnancy care, and then the other issue is this medical legal approach to pregnancy care. Those are a couple of issues. It would be wonderful if we could just somehow wrap our hands around these problems and get things to go in a different direction.
In 2008, Ricki Lake produced this movie that you probably have all heard of or seen, The Business of Being Born. There was one statement that was made in that movie that really caught my attention. I don’t remember who said it or what circumstances were, but the comment was something along the lines of, “Obstetricians are excellent surgeons and they’re very good at that, but they don’t know the first thing about childbirth.” At the time I heard that statement, I thought, well, that’s a little bit severe, but the path I went down over next several years has brought to me a place where I have realized there is actually a tremendous amount of truth to that statement.
In 2011 we got pregnant with our first baby, and that ended up being an incredibly transformative experience for me both as a human being but also as an obstetrician. When we started off, I was I would say a pretty typical, regular OB/GYN and I had the views towards pregnancy that I think lots of OB/GYNs have. I just wanted things to turn out okay and just wanted my wife to do okay and wanted the baby to be fine. If it ended up being a vaginal birth and natural labor, great, wonderful. If we ended up using an epidural or if a C-section happened for some reason, fine, just as long as everything turned out okay.
But as the pregnancy progressed, my wife became increasingly interested in the notion of an unmedicated natural birth. I would say, without getting into the whys, for the first time in my life, something clicked with me that that was something that mattered. I think really for the first time ever, it just made sense to me why that might be something important. I think I never really got that before, but I think coming from the side of no longer physician was very important for that to dawn on me.
I’m obviously very interested in pregnancy, and I’m always reading about pregnancy, and as a specialist in high risk pregnancy I kind of pride myself as being somebody who knows everything there is to know about pregnancy. During this pregnancy, my reading kind of took a totally different turn because what I’m always reading and studying and learning about is disease. What happens if this happens? What happens if the mom has that condition? What happens if the baby has this? I’m hungry for knowledge and always reading and studying, but it’s never about actually birth or what’s normal. My reading and studying took a turn, and I found myself going to talks and listening to lectures and people like Michel Odent who is this French obstetrician. I believe this man probably knows everything that’s scientifically published about the physiology of labor and childbirth. Authors like Sarah Buckley who’s a physician in Australia who’s become very interested in the physiology of birth.
For me, this discovery was kind of like being a kid in a candy store because I came to realize that there was this incredible volume of scientific information regarding the physiology of childbirth that I knew nothing about, and it made me realize something about my training. My training is the same as every other OB’s training, which is understanding the way labor happens and childbirth happens is not part of our education. You show up for your residency, and basically the way it goes is four short years from now we are going to unleash you upon society. All kind of mayhem is going to be occurring during pregnancy and it’s going to be your job to address it. So women are going to come to you with problems, complications, and your purpose in life is to solve those problems and get mom and baby safely through the pregnancy. These are the things that can happen, and the training starts. This is how you deal with a postpartum hemorrhage. This is what you do if you got a uterine inversion. This is how we take care of a mom who’s seizing from severe preeclampsia, blah, blah, blah, blah, blah, blah, blah. You get trained in all the potential problems that may happen and how to address them.
Now, clearly, that’s very important, but it changes the way you look at pregnancy when you don’t start with the foundation of the normal physiology. When I was reading about this and studying about this and discovering this really for the first time after ten years in the specialty of obstetrics, there were a lot of really amazing factoids I learned like the fact that mammals deliver only at night, exclusively at night. The one exception might be human beings, but that’s probably because of all the things that we do to interfere with the natural process of labor. But it makes perfect sense from an evolutionary point of view, we talked about the bear giving birth in the cave, that the mother is vulnerable to predators in labor so it makes sense that she’s going to do it somewhere hidden away from public view where it’s quiet, dark, and she’s safe. Mother Nature designed it this way.
It turns out there are melatonin receptors in the uterus. Holy cow, who knew? And they interact with Pitocin receptors. So built in to the human body is the ability to sense the daily cycle. It’s night, day, light, dark. That has a very important function and built in to your body is the ability to detect that and make sure that you deliver at night when you’re going to be most safe. I found out that that was incredible.
I learned that there is this tremendous Pitocin surge that happens at the time of childbirth. It’s bigger than any other Pitocin surge you get at any other time. It’s bigger than what you get from a hug. It’s bigger than what the mom gets during breastfeeding. It’s bigger than what happens during an orgasm. At the time of childbirth, you get the single largest spike of Pitocin that you ever get. It makes perfect sense why Mother Nature designed it that way because that’s the time when you need to expel the placenta and the uterus needs to contract down and you got to stop bleeding to keep the mom safe. But what’s very critical to this Pitocin surge is the mom has to be interacting with the baby. You got to see the baby, smell the baby, hear the baby, touch the baby, and that’s a critical element of this Pitocin surge. When you separate mom and baby, it may interrupt that mechanism.
I learned about what a lot of us are learning about these days that there’s a blood supply in the placenta, and after the baby is born this transfusion happens between the placenta and the baby. So the baby gets this little burst of blood prior to when the cord stops profusing. It turns out that protects the baby. It protects the baby against anemia, and in preemie babies, it protects them against bleeding in the brain which is a bad complication preemie babies can get. So it has a very important physiologic function, but we never really knew that so we just kind of clamp the cord and cut it.
So I had this epiphany that we are out there solving problems but a major deficiency in the way we practice and the solutions that we seek is the fact that we don’t understand the very basics of physiology. It’s not that nobody knows anything about that. They do. It’s just not part of our training.
Now, something I would say about physicians, because in my conversation about physicians, I sometimes tend to make them out as very evil people. But they are not. We are not. One of the things about doctors is they’re very altruistic people and they are problem-solvers. They are out there trying to solve problems. Let me give you an example. Imagine you’re taking care of a mom in labor and she barfs, which happens on occasions. If you’ve ever been to a birth, you’ve seen it. But this particular mom takes a deep breath and some of that vomit makes its way into her lungs. As a consequence, she develops a really bad pneumonia and goes into respiratory collapsed, ends up in the ICU, intubated, sick as hell.
But this is not just a patient or something you’re reading about in a textbook. This is somebody that by this point, you’ve known her for almost a year or maybe longer if you took care of her in the prior pregnancy. You know her partner. You know her kids. You know what she does for a living. You know this child’s name. You know the preparations they’ve gone to to receive this child into their family. And all of a sudden, this woman who your responsibility was to take care of her is sick as hell in the ICU, and this is turning into a disaster. Maybe by the end of this all, she even is not with us anymore.
This is an incredibly traumatic experience for a human being to go through who has dedicated themselves to keeping people safe. So you start thinking, how are we going to prevent that from happening next time? We can’t really stop them from vomiting, so maybe we should adopt the policy to have moms not eat in labor. So if she vomits, it will be just fluid. It won’t be particulate food matter, and we can prevent having a horrible experience like this in the future.
This is how doctors think. When policies and procedures are put in place, generally they come about from some kind of horrible experience you’ve seen. Let’s say you have a tremendous postpartum hemorrhage and because mom has bled so much her veins have collapsed. Nobody can get an IV in. While you’re struggling, you want to get her fluids, you want to get her blood, and in the meantime the blood is pouring and the blood is pouring. So you think to yourself maybe what we should do when mom walks in the door, let’s get an IV into everyone while they’re healthy. Not only it was needed, women will come in, you’ll put an IV, they’ll deliver, they’ll go home fine, you take out the IV. But that woman who hemorrhages, we have IV access and we can prevent whatever catastrophe. This is the thought process and the policies and procedures that exist are because you don’t necessarily know who’s going to have an issue but what can we do to keep mom and babies safe.
The problem is that when you set about problem-solving and you don’t understand mechanisms of childbirth and labor, sometimes you step on those mechanisms, and these miraculous systems that we have that have been evolving over billions of years, designed to keep moms and babies safe, we undermine them or we disrupt them. There are tons of things that we do in a hospital that interrupt the natural processes of childbirth, one of which have you ever gone into a hospital and all the lights have been off or are they generally well-lit places? They are generally well-lit places, and it makes sense. You want to see the mom to see if something weird is happening to her. Maybe if you’re doing a repair, you want to be able to see it so you do a good job with that. Maybe you’d like to see the baby so you could notice if it’s a little purple or something is not right with the color. You’d like to see and light is helpful for that.
But what happens in the hospital is now there’s no distinction between night and day. The lights are always on. It’s always noisy. Mom does not have this dark, quiet, safe cave to go to. She has to give birth in a place where the lights are always on. So the melatonin can’t be a part of this process anymore. It’s noisy and scary and there’s alarms going off. It’s an example of one thing that disturbs the natural process of labor and childbirth.
When babies are born, they can have any number of problems. Problems breathing, maybe the baby has a heart defect that nobody knew about. So I had an idea. When the baby is born, why don’t we have a pediatric expert who can take the baby and do an examination? Make sure they’re breathing okay. If there’s any gunk in the airway, they can take it out. They can listen for any murmurs. Then, if everything looks okay, we hand the baby back to the mom. Well, the problem with that is that it lacks understanding of the fact that actually the mom and the baby need to be together at the moment of childbirth. Now again, we’ve disrupted a natural mechanism that is there for the protection of mom and baby.
There are lots of unintended consequences. As we’re running around busily, trying to solve problems and keep people safe, we’re maybe sometimes unintentionally causing some problems and sometimes that we’re unaware of. There was one study that I came across that I just found is absolutely fascinating. Somebody was studying babies and they figured out that you can actually test the baby’s sense of smell and you can figure out that babies are actually able to distinguish different scents at the time of birth. What was incredibly interesting about this study is that the babies that were born after C-section without labor didn’t have it. They could not distinguish between the different smells that they were exposed to. So there’s something about going through the labor process and all of the hormonal cascades that’s activated that turns this on.
So you wonder why is smell important for a baby? It’s very important for breastfeeding. The baby smells the mom, smells the breast, smells the milk, and it’s one of the mechanisms that’s in place so that bonding and attachment in breastfeeding can happen naturally. But we’re not aware of any of these and it gets disrupted when you do a C-section. That system isn’t turned on. It probably turns on at some point but not immediately at the time of birth.
The bottom line is I think one of the viewpoints I’ve come to have about pregnancy care is that everybody is out there trying to do the right thing and try to do right by their patients, but in the absence of really understanding the physiology of childbirth, it causes us to derail a lot of these systems that are in place to keep mom and baby safe. I think the next frontier in improving pregnancy care is not going to be some new test or some new technology or some new procedure. It’s going to be what you’re talking about, an incorporation of understanding the physiology of normal labor and childbirth. Instead undermining all those processes, we respect them and protect them and harness them and save all the interventions that we have for times when they really are needed, and sometimes they really are needed.
There’s a fantastic example of cord clamping, but I’ll leave that for later and move on to the next issue, which is this medical-legal approach, which for me, I have to tell you, on a daily basis, it’s a major frustration. I’ll get to how medical-legal practice interacts with birth physiology at the end of this, and I think it’s not in a good way. One thing to understand about your friendly neighborhood obstetrician, or maybe sometimes not so friendly, is lawsuits are really an ugly reality of obstetric practice. I mean, it’s just a reality. This is a very sue-happy society we live in. Most OBs gets sued at some point. A pretty substantial proportion of OBs gets sued more than once. You hear about this kind of horror stories. Actually, I had an experience that was somewhat like this where just imagine a scenario where the patients wants Plan A, and the physician says, “Okay, one of the risks to consider with Plan A is such and such,” and they lay it out. The patient says, “Well, I want Plan A.”
So she does Plan A and whatever it was that the physician was warning her about happens. The bad outcome that she was warning her of happens. The patient turns around and sues anyway and says, “Well, yes, I was told but they didn’t really impressed upon me how big a risk it was or how dangerous it was.” This is the kind of stuff you hear when you’re a physician. So how are you going to practice in a reasonable and rational and compassionate way and honor people’s decision-making and their autonomy when you do that and if something goes wrong they turn around and come after you? I think there’s a lot of feeling of vulnerability on the part of physicians, and it contributes to some of the craziness that we see, and boy, it is crazy.
Another thing I think that it’s worth understanding is the impact of a lawsuit on a physician. I have the sense because of the way it’s so flippantly tossed around the notion of lawsuit, and I’ve even heard people say things like, “It’s just really not a big deal for these rich physicians, they have insurance, it’s going to be fine,” like somehow it’s not a big deal. That really fails to understand what really happens to a care provider when they get sued. It’s incredibly stressful and scary and you lose sleep. There’s time taken away from your other patients. This is a process that can go on for years, and so it can lead to depression and anxiety. People change the way they practice. Some people stop doing OB. It’s an incredibly destructive experience for a human being to go through.
On some level, it becomes understandable why care providers may do some of the crazy things that they do because in their mind they’re trying to protect themselves from getting sued. In my conversations with OBs, it has become so striking to me that the fear of being sued, it’s right here on the front of their minds. It is always on their minds. I hardly ever have a conversation with an OB where the issue of lawsuits does not come in to the conversation. I will try to steer the conversation away from medical-legal and they’ll bring it right back.
I’ll just give you some examples. I organized a conference in a hospital to talk about the issue of the use of oxygen in labor. It’s a very common practice. If you’ve ever been on labor and delivery, it’s hard to see a woman have a baby without the oxygen mask being slapped on her face. Well, it turns out that there are not really any studies out there to prove that there’s a benefit of this therapy. If anything, there are a couple of studies that suggests that it may actually be doing more harm than good. Despite the fact that there’s no scientific evidence to support this practice, it is wildly rampant within the hospital, the use of oxygen. I find myself in these labors. I go in to see the mom and oxygen on and so I take it off and I walk out. I come back to see it a little later and the oxygen is back on. I take it off and I’m like, “We’re okay. We don’t need that.” It’s just they use it like oxygen.
So we’re having this conversation and it’s very clear that there’s no scientific literature to support this practice. One of the OBs raised his hands and says, “But is that really good enough to protect us in the court of law.” Then now the conversation has turned and we’re no longer talking about the science and what’s right and what helps people, but we’re talking about what happens when I get sued. There are some people that just cannot get off of that topic.
There was a woman I took care of recently who early in pregnancy before I met her had a massive stroke, and it damaged her very badly. She recovered to a degree but certainly not 100%. Then I followed her for the remainder of her pregnancy. It was a twin pregnancy, just to make it a little easier. Toward the end of the pregnancy, she developed some high blood pressure. I sent her to the hospital to check things out and for evaluation of high blood pressure. I called the doctor over there to give him a heads up and orientation. I say, “Listen,” I tell the story, “She had this big old stroke. But that’s a past issue. You don’t have to worry about that. We’re just evaluating her blood pressure,” which OB doctors do every single day. The guy says, “Let me ask you a question. From a medical-legal point of view,” which is my favorite way to start a conversation, he says, “Should a patient like this, should we send her to a tertiary level center just in case there’s not a good outcome we’re not involved?”
What the thought process here is let’s say during her stroke something happened that was injurious to the baby, and now the rest of the pregnancy is fine and the delivery was fine but the baby is not fine. We’re at risk of her turning around and claiming that something about her care was responsible how this baby turned out and then we have to defend ourselves. So his proposal was just to get rid of her and then we’re not at risk. I didn’t say what I was thinking. I said, “That thought had not occurred to me.” I did not go into the practice of medicine and become a physician to take care of only people who have no problems. I became a physician to take care of people who have problems.
But this lawsuit fear has become so crazy that you have physicians now that just want to take care of people with no problems. It’s just incredible to me. This has a dramatic far-reaching influence on the way obstetric care is practiced. If you think about the example of VBAC, vaginal birth after caesarian, really, if you’ve had a C-section before, you have the option of trying for natural birth or doing a C-section. But in a very real sense, many women do not have the option because the hospital doesn’t allow it. The OB doesn’t want to be involved in that. They are given misinformation. They’re dissuaded. They’re told it’s too dangerous. They are told it’s illegal. They’re told it’s not an option. Sometimes it’s not even a discussion. When they find out that a mom has had a prior C-section, they just get scheduled as a matter of routine for their repeat C-section. That was not always the case. In the ’90s, there was a lot of enthusiasm for VBAC and about 30% of women in our country had a VBAC.
But there started to be some cases where things didn’t go well and there were some bad outcomes and there were some huge lawsuits. So just like a laboring mom would go into her cave, the OBs went into their caves and started closing down doors and saying, “We’re not doing VBACs anymore.” Now, we’re at the less than 10% rate. It’s very hard to get a VBAC these days. We’re talking about millions of women. Medical practice is dramatically influenced by these medical-legal concerns.
I attended a horrific lecture one time. I was at an OB/GYN conference, and it was a lecture by a lawyer. He was talking about this concept of product liability. He was telling all these horror stories about these nightmare lawsuits and he gave one example. This woman was changing a light bulb, but it was a vaulted ceiling so she’s up on a ladder. For some reason she’s wet. So she gets shocked and she falls and her leg goes through one of the rungs and her leg is broken and she’s got this horrific injury. So this turns out into a lawsuit and they won because there was no warning about handling electricity while being wet. You have to warn people about things.
There’s this legal principle called failure to warn. That’s why everything you buy has like ten red stickers on it. Warning: Don’t climb into this oven and turn it on. They have to warn you about these things. It’s to protect them against lawsuits. I’m hearing this and I’m thinking to myself, oh, my God, this is the last thing that OBs need to hear. I look around the room and you see all these pale faces.
From a legal point of view, a good practice would be when you have a woman before you, you outline in gruesome detail all the potential horrible things that might happen to her. That would be good legal practice. But is that good medical practice? Is that how you take care of human beings? Is that what healers should do? Is that what birth workers should do?
So you talked about the importance of the feeling of safety in labor. The bear in the cave, when the tiger shows up, labor stops. We have all these women in the hospital that have dysfunctional labor and they arrest at some point and end up having to be delivered by C-section. We don’t really have a good scientific explanation about why that happens. But I wonder to myself, we’re doing everything wrong. We have the lights on. They’re being taken care of by strangers. We have them sign a consent form in which we discussed all the potential horrible things that could happen. We just scared the living crap out of them and then expect them to labor. Somehow we have to find a different way of addressing this problem.
One of the ironies of all of these is that the legal system I think has not addressed the problem of medical negligence very well. Most examples of negligence don’t end up in court. Most bad outcomes don’t end up in the court. Most of the cases that end up in court, they end up not finding negligence against the physician. The physician wins the lawsuit 90% of the time. The problem of medical negligence has not been solved very well by our legal system. On the other hand, the presence of all of that has had dramatic and far-reaching impacts on the way our maternity care system works. I think that’s something that we need to think about.
Now, the really hard part is thinking about solutions and how do we get around this. That’s not going to be much a part of this talk because I think that would be another hour or day or week or however long it would take. But just a couple of points, this maybe a fantasy but I think somehow if the public could learn that if a bad outcome happens, the knee-jerk reaction is no longer lawsuit. Medical negligence is not something that’s addressed in the courts. There has to be other creative ways of addressing this.
One thing I would be interested in seeing in the courts more is issues of assault during childbirth or violations of human rights in childbirth. I think those are things that actually the legal system is better at handling than they are at addressing issues of medical negligence. I had a conversation with a human rights lawyer in Europe. Apparently, that’s a lot more of a robust structure in Europe than what we have here in the United States.
It would be interesting to see something like public injury funds. Something like this exists for vaccine. There are these vaccine injury funds. Let’s say somebody gets a vaccine and they think that that has caused a severe injury to this child or person or whatever, they become eligible for receiving some funds, these things that exist, and then they don’t have to go and sue the vaccine manufacturers. Those types of lawsuits don’t exist.
What if we had a similar kind of thing? Let’s say there was a VBAC fund or a vaginal birth fund. If you happen to be the unlucky one that has a really bad outcome, you don’t have to go turn around and sue the person who was taking care of you and honoring your choices and your autonomy, but you can be taken care of by a society through a different mechanism. How about something like that? Probably the consent for stuff shouldn’t be happening in the hospital. It should be happening during prenatal care when you’re not in the heat of the moment and you can think and have questions answered. Then when you go in to the hospital, you just go and give birth. I think there are creative ways we could go about this. That’s the medical-legal issues.
Then, there’s the pathology-oriented model of care. I think that’s something that we need to address, and also the public has a role. I think the way physicians are educated needs to be changed. We need to know what is known. The public has a very important role because you can encourage hospital practice and you can encourage physician practice by choosing the providers that have a more physiologic and humanistic style of care. If people see that they’re losing business to people who are doing things a better way, it motivates them to do a better way. But that requires a lot of coordination on behalf of consumers, patients, the public and that’s something that doesn’t exist in large degree at this point.
Lindsey: All right, BIRTHFIT. I hope you enjoyed that episode. Dr. Milo is such a special human and I know he is doing good in everything, in every day, every choice, every minute that he is living. I wish there are more OB/GYNs like him in Los Angeles, in California, in the United States and throughout the rest of the world.
They don’t institutionalize the birth process like so many have. There are many, many people that go to med school and become OB/GYNs, become MDs because they want to save people and they want to help people. I love that. But I also understand that school gets monotonous and you get in these routines and things became mundane and we lose sight of human values. But unfortunately, if we don’t keep this transformative experience in the forefront of our minds and our eyes and keep love at the top of that. Then, things might not be so great for us as a human species. So take everything Dr. Milo said and learn from it. Go look up more, research more, question everything. If you don’t like something your doctor or your midwife said, go ask for another opinion. Seek out support because you all deserve to be surrounded by an awesome team, an awesome coach of your team, whether that’s an OB/GYN or a midwife, and have that team support you throughout that motherhood transition.
Any questions, shoot us an email, email@example.com. Check out all the seminars that are happening for the rest of 2017 and then we have some scheduled now for 2018. So check that out.
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