MBP - Dispelling Some Common Misconceptions

The mere sight of the term MBP (Metzitza B'Peh - direct oral/genital suction of the circumcision wound) may set off fireworks in the minds of many of the medical halachic rationalist readers of this blog.  Some of you might have been waiting for me to say something about this subject. MBP has been in the news lately due to some high profile court rulings in New York, so it is once again a hot topic.  However, I must disappoint you by admitting that I don't have that much to add that hasn't already been said.  In fact, a close friend of mine, Shlomo Sprecher, has already written what I consider to be the most definitive rationalist medical halachic (even if he didn't use the term "RMH" to describe it!) article on this topic, and you can read it here.  I highly recommend that you read it if you haven't already done so.

However, I have come across an extreme amount of ignorance when it comes to understanding exactly what the medical concerns are regarding the transmission of HSV (Herpes simplex virus) and circumcisions.  The ignorance in the Orthodox Jewish world seems to reflect the ignorance of the general population about this virus, which I encounter on a regular basis in my medical practice. As such I feel like I need to counsel everyone regarding how this virus works, and then you can understand what the issues really are.

For starters, HSV is a virus.  That means that it cannot be treated with antibiotics.  This particular virus has the nasty habit of being incurable, which means that once you become exposed to it, it will be in your system forever.  It has figured out a way to hide deep inside your nerve roots ("ganglia") and hang out there for the rest of your life.  Every once in a while it may decide to leave its hiding place, travel up the nerves to your skin, and cause a lesion to pop out on your skin and annoy you.

When this happens, the sore is likely to shed more virus, so if someone else becomes exposed to it, he/she can catch it from you.  However, the virus is even sneakier than that.  Sometimes it travels out to your skin and sheds virus, but doesn't show any sores at all.  This is called asymptomatic shedding.  This means that you can be shedding and transmitting the virus and have no idea at all that it is going on. While an active lesion is much more likely to shed virus than when there are no symptoms, it is well known that asymptomatic shedding can and does occur.

So that's the bad news, what is the good news?  The most important good news is that HSV is generally not a very dangerous virus at all, in the overwhelming majority of cases.  The vast majority of people with this virus will go about their innocent lives and have virtually no consequences, except maybe an annoying sore every once in a while.  Most people don't even know that those annoying sores are HSV, they just think it is a pimple that came and went after a few days.  They usually don't even know that they have HSV, and they certainly don't know that they can transmit it to someone else!

But that good news can also be bad news. Why is that? Because if you don't know that you can transmit it, and it can be transmitted even if you have no symptoms at all, how are you supposed to prevent the transmission of HSV throughout the general population? Well, guess what! You now understand why close to 90% of the adult population of the US has been exposed to HSV 1 at some point in their lives.

When two moist surfaces of the body, such as the oral region, and/or the genital region come into contact, and one surface is shedding HSV, this is the most effective way to transmit the virus.  If one person has a cold sore (which is caused by HSV), or is shedding asymptomatically, and people share a cup, a kiss, share a food utensil, wipe their mouth or cough and then pass the kugel, or any other moist contact, the virus can be transmitted.  Of course the chances are very small each time this type of contact occurs, but if it happens over and over again, it only takes once ...

The vast majority of people will have been exposed to HSV in this manner.  By now you should understand that a person with HSV 1 is usually not infected because he/she is guilty of some type of sexual contact. Most of the time it was completely innocent, and most of the time the person him/herself is never even aware of having been exposed.

You probably noticed that I mentioned HSV 1, which means that there is another type called HSV 2.  This is a very closely related virus that tends to hang out more in the genital region.  This type is usually transmitted through genital or oral/genital contact.  However, there is much crossover between the two types, as HSV 1 is often found in the genitals, and HSV 2 is often found orally as well.

HSV 1 outbreaks are generally more mild than HSV 2 outbreaks, and especially with HSV 2 in the genitalia, the first outbreak can be quite severe.  But both types of the HSV virus have a very similar clinical course, and they are transmitted in basically the same way.  The reported cases of HSV transmission through MBP in New York were HSV 1 cases, not HSV 2. This is important because HSV 1 is much more common, and is still more associated with Oral infection than with genital infection.

So what's the big deal? If it is true that HSV is only a nuisance and rarely causes health problems, why is it such a concern? What is all the hoopla regarding MBP?

The big deal is that in certain very rare cases, if HSV gets into certain body fluids it can cause very serious problems.  Those two places are the blood, where it can cause viremia (a viral blood infection) or in the brain where it can cause encephalitis or meningitis.  Viral infections such as these can be extremely dangerous, and are notoriously difficult to treat, especially because antibiotics do not work against viruses.  Furthermore, as you recall, there are no cures for HSV.

When would someone be at highest risk for such a horrible infection of the blood or the brain with this virus?  For starters, if it is introduced directly into the blood. That would be really bad.  Now if you take a person who does not have a very strong and mature immune system, that would be worse.  Then if it enters the brain of someone who is still developing neurologically, that would be tragic beyond words.

Now let's make it scarier.  Let us find a well meaning person.  This person seems perfectly healthy.  He himself has no idea that he has any infections of any type. Everyone around him knows that he is "very clean" and scrubs his hands really well.  He has lived a virtuous lifestyle and has never exposed himself to any situation which would make one concerned that he may have gotten any transmittable diseases.  Maybe when he was a child in cheder he shared a cup of juice and got a little cold sore, which went away after a few days because his Mom shmeared on some Vaseline.  He was a little "tzaddik'l" and went on to become a popular Mohel.  But he has this HSV 1 virus for life.  In his mouth.

Let us go further. This mohel never sees any lesions that he thinks could represent a major health risk, except occasionally he may get a cold sore which he thinks is just chapped lips.  The mohel is such a tzaddik and so well loved and well respected that he does a Bris Milah just about every day in his community.  Asymptomatic shedding is very rare, so it only happens a few days a year, but he does a bris milah every day ....

And one fine day, a happy young couple brings their beautiful little child to shul for his bris milah.  The well meaning, wonderful Mohel performs the ceremony.  He does MBP. This young child, with an immature immune system, and a developing nervous system, now has an open wound, giving the virus direct access to his bloodstream, and to his newly forming brain.  The Mohel happens to be shedding virus that day, and has no symptoms whatsoever. And the virus gets into the baby's bloodstream, and it replicates, and may God save us, a horrible, totally preventable, unspeakable tragedy occurs.

This is the problem.  Like I said before, the cases reported in New York were HSV 1, simple Oral HSV that 90% of the adult population has.  The only way to prevent it from happening is by avoiding the exposure in the first place and protecting our children from tragedy.  May common sense prevail.

Postscript:

In this post, I have tried to dispel the following extremely prevalent and extremely dangerous notions (I have heard ALL of these in murmurings at shul kiddushes, Shabbos tables, during leyning - bein gavra l'gavra only of course etc...)

1. If the Mohel is a genuine tzaddik and ben Torah there is no risk of herpes transmission
2. the Modern Orthodox are just trying to find ways to show that the Chareidim have Herpes infested Mohelim and they are all hypocrites
3. If the Mohel has no history of disease and has no herpes sores there can't be a risk
4. This Mohel has done thousands of Bris Milah ceremonies and "no one" has ever had a problem (this would be extremely difficult to prove, and even if it was true, it still doesn't protect you)

If any of you have heard other such comments, I would be interested to hear them.

Home Births and Halacha

The authors conclude their article with a discussion of the issue of planned homebirth vs. hospital birth. In their words:

"Similarly it is commonly believed that the twentieth-century transfer of births from the home to the hospital has aided the cause of piqquaḥ nefesh by lowering infant mortality. Statistics, however, do not support such a belief. Western countries with more home births than in the United States have lower maternal mortality rates and lower infant mortality rates than ours.26 Australia, New Zealand, Japan, and all Western and Central European countries all have lower mortality rates than the U.S.’s, yet more than one-third of all of their births are planned home births attended by a midwife. ...

Within the United States, studies also show that for normal pregnancies, home births are at least as safe as hospital births and that births attended by midwives are safer than births attended by physicians. Certain procedures such as multiple vaginal examinations and routine premature rupture of membranes are commonly performed by obstetricians, but not by midwives. Rather than promoting piqquaḥ nefesh, these interventive procedures, which naturally necessitate viewing of and contact with female genitalia, have actually been shown to be dangerous to the birthing woman and to her child.  There is also growing concern—even among some obstetricians—that other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs to hasten labor all have few health benefits and may indeed harm the baby."

The issue of planned homebirth has been the subject of significant discussion in recent decades, and there is no way that I can do it justice on this blog.  However, I will respond to the authors contentions with a few simple points that I believe are very important.  I will first refer the readers to the statement of ACOG on this topic here.  It is worthwhile reading, but as is often the case with medical literature, some important points still seem to be misunderstood by the public.

Before I explain anything, I need to remind the readers of this blog, that it is a blog for medical halacha and not meant to be a discussion of medicine.  So we need to establish the halachic issue here before we move on.  The halachic issue that the authors of the article are raising is that they contend that having a baby in a hospital may potentially be more risky then a home birth.  This would be a halachic problem, suggesting that a home birth may actually be safer and thus halachically preferable.  In their words, having a baby in a hospital exposes one to " ... interventive procedures ... [which] have actually been shown to be dangerous to the birthing woman and to her child..." Furthermore, according to the authors, " ... other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs ... may indeed harm the baby."

Could it be that having a baby in a hospital is riskier than a home birth, and thus halachically prohibited?

The best and most comprehensive study evaluating this issue, is the one quoted in the ACOG statement that I linked to above.  This was a meta analysis evaluating all known scientific studies of home birth vs. hospital birth.  The bottom line is that even under the best of circumstances (and I will describe briefly those circumstances in just a moment) a home birth has a rate of neonatal death that is 2-3 times higher than hospital births.  Now it is extremely important to understand that the actual rates are so low, (1.5-2/1,000 vs. .4-.9/1,000) that the studies certainly confirm that a planned home birth can be considered safe if done properly.  But to claim that it is less dangerous than, and thus halachically preferable to a hospital birth is simply wrong.

Now here are the points that need to be understood.

1. No studies can actually be ever done that will truly answer the question of which birth is safer.  That is because in order to do this study, we would need to randomize women to planned hospital vs. planned home borth.  This is impossible in today's society.
2. In every study that did try to retrospectively compare (or prospectively without randomization)  the two birth locations; only women that were healthy, had uncomplicated pregnancies, and with normal and healthy babies were allowed as participants in the studies.  So the studies only established that in these types of cases (of course this represents the significant majority of pregnancies) that it is safe to have a home birth. No one disputes that this is true.
3. In all of the countries mentioned by the authors, those countries have in place highly integrated health care systems that address which women are candidates for home delivery, which personnel are certified and qualified to attend and supervise home deliveries, and transportation systems and communications for emergent transfer to a hospital are in place.

So we can all agree, that if proper systems and safeguards are in place; that a home birth can be a viable, safe, and halachically sound option for people who want to choose that type of delivery.  However, to suggest that a home birth is somehow halachically more preferable than a hospital birth is misleading and wrong.

In the United States, (I am not intimately familiar with the system in Israel) our health care system is set up to take care of women in labor in hospitals.  The poskim have thus overwhelmingly permitted (and encouraged) women to travel to the hospital, even on Shabbat, when they are in labor.  Whether or not it is preferable to have a baby at home (assuming that all of the conditions we mentioned above are in place), is a decision a woman needs to make with her qualified health care provider, and depends on many factors which are well beyond the scope of this blog.

I think that should conclude my discussion of this topic, but if you have any questions, comments, criticisms, etc... please let me know as I would love to hear what you have to say.

Obstetric Drugs

In the final section of the article the authors decry the use of drugs during labor to treat pain.

They refer us to the early debate regarding whether or not it is appropriate to use pain relieving medications to treat women in labor.  It is well known, that many early religious (mostly Christian, but some Jewish as well) authorities felt that pain was a natural part of labor, and that women were supposed to have pain due to the curse associated with Eve's sin when she took a bite of the forbidden fruit.  They felt that it was therefore inappropriate to provide women with pain relief.

This philosophy would strike most modern readers as incredibly cruel, and indeed the overwhelming response of the Rabbinic authorities has been to support, and even encourage, the use of anesthetic and analgesic medications to relieve the pain of childbirth.  The authors quoted R' Moshe Feinstein in YD:2 p140 where he recommended that women be put to sleep for delivery so as not to feel pain.  This responsa was written in 1972, when it was common practice to give women heavy doses of sedatives during the final stages of labor to treat pain.  This usually required the physician to intervene and deliver the baby with forceps as the woman was not awake enough to push the baby out herself.

This practice fell out of favor well over 35 years ago when doctors realized the risks of forceps deliveries when done routinely, and the risks of the medications involved in heavy sedation.  I am not aware of any doctors or institutions that have practiced this way in almost two full generations.

So the authors agree that Judaism does support pain relief during labor and does not subscribe to the "curse of Eve" philosophy which would prohibit pain relief.  However, they then introduce us to another concern, which they feel should be a halachic basis for avoiding the use of drugs during childbirth:

"... Nevertheless, not all objections to obstetric analgesia and anesthesia can be dismissed as mistaken religious obscurantism based on the Genesis narrative.

As Rabbi Immanuel Jakobovits outlines, Christian objection to the use of drugs during childbirth was two-pronged. While some cited the curse of Eve as their source, others objected for medical reasons. Rabbi Jakobovits writes that, “towards the end of the last century, a Catholic medical moralist still forbade the use of chloroform at normal births because it might endanger the mother and the child…” Jakobovits then praises Judaism for being above any such considerations."

The authors are suggesting, that halachically speaking, we need to reconsider our use of drugs in labor because they may be dangerous.  They make this suggestion as if it can be assumed that drugs in labor are inherently dangerous, but they do not have evidence to back up this claim.  In fact, every treatment used in labor is subjected to controlled clinical trials and years of experience that have attested to their safety and efficacy.  It is far far beyond the scope of this blog to review every pain treatment and its' specific risk/benefit profile. However, we have established that in Judaism, treating pain in labor is an honorable and appropriate goal. Every woman is not religiously obligated to suffer to atone for Eve's sin.

A fascinating exchange about this topic took place in Montreal Canada in 1849, shortly after the discovery of anesthesia.  An article about this debate was published in the Journal of the American College of Obstetrics and Gynecology, also known as ACOG.  The Journal is called "Obstetrics and Gynecology", and in volume 88 No. 5, November 1996, pages 895-898, Dr Jack Cohen writes of the debate that took place in Montreal between Dr James Simpson and Rabbi Avraham De Sola.  Rabbi De Sola was the first rabbi in Canada, and he was the new young Rabbi of Montreal's oldest congregation, the Spanish Portugese synagogue - Shearith Israel.

Dr Simpson had argued against the use of anesthesia for women in labor based on Genesis 3:16, the verse declaring that "B'etsev Tayldi Banim".  By using his knowledge of Hebrew, and the Jewish commentators (primarily the Radak), Rabbi De Sola boldly took on the Christian interpretation of the verse and shows how the word "B'Etsev" refers to the uterine contractions of labor and not the pain experienced by the woman in labor.  Interestingly, Rabbi De Sola went on to become a Professor of Hebrew Language at McGill University in Montreal.

The poskim in the almost 175 years that have passed since Rabbi De Sola's debate have almost universally understood and acknowledged the importance of treating the pain of labor.  It is accepted that we must treat a woman's labor pain the same way we would treat all pain and suffering for every person.

This is true even though every treatment has some level of risk. When risk is balanced against benefit, halachah has determined that since these treatments are overwhelmingly safe and effective when administered by trained professionals, they are halachically desirable, not just permitted. Furthermore, every patient has the opportunity to choose whether or not to avail themselves of these treatments, and each person can evaluate the risks of benefits of each medication before deciding whether or not she desires to use it.

In their conclusion, the authors clarify their case, and they cite some "evidence" to back their claims:

"To begin with the third example, the dangers of drugs during pregnancy, including obstetric analgesia and anesthesia, are well documented today. In fact, they have been well documented since at least the 1980s. Both the mother and child can suffer side effects ranging from sluggishness to brain damage and death. The fact that no Jewish authority has restricted or discouraged the use of drugs during labor may not be an occasion for self-congratulation; it may call for some serious halakhic soul-searching."

As sources for their assertion that obstetric analgesia and anesthesia drugs are dangerous, they quote two articles from 1981 (see their footnote #24).  If one carefully examines the sources used to support this article's assertions, and the general tone of the article itself, one is struck by impression that the authors are reflecting a worldview that views modern medicine, and especially obstetric medicine, with an extreme amount of suspicion. I suspect that arguments like these will go on forever, as they are not amenable to resolution by providing evidence to support one point of view over the other. For example, one of the sources cited was titled "Malepractice: How Doctors Manipulate Women".  If someone believes that doctors are guilty of intentionally manipulating their patients, then it will be very difficult, in fact almost impossible, to convince him/her by quoting evidence from the medical literature.

I hope that I at least provided some information for those people who are open minded enough to look upon their physicians, midwives, nurses and other appropriate caregivers as their allies instead of their enemies.  I totally agree with the authors of the article that we should never engage in self congratulation.  However, the fact that "no Jewish authority has restricted or discouraged the use of drugs during labor..." does not reflect a lack of "serious halakhic soul-searching", as the authors declare.  Rather, it reflects centuries of serious halachic concern for the comfort and well-being of women in labor.

I do owe you one more brief post on this topic regarding the safety of home births, and then we can move on to our next topic.

My oh my, How Times Have Changed

We have now described the fundamental assumption upon which the article "Obstetrics and the Curse of Eve" is based.  According to the authors, a birthing woman is in a category not exactly equal in halachic status to the critically ill patient. Thus, in what they consider to be the classical halacha; on Shabbat one must use a shinuy whenever possible, prior to the final stage of labor one may do nothing other than to call the midwife, and generally speaking only the midwife is called upon to violate Shabbat restrictions.

From here they go on to describe how much things have "changed".  Here are the next few paragraphs:

"Such halakhot could be easily implemented in a society where midwife attended home births were the rule. The only person who, under normal circumstances, had to transgress the Sabbath was the midwife. From a global perspective, home birth is still the norm and hospital birth the alternative. In middle- and high-income countries the opposite is true: the home birth rate in these countries is very low, for example, less than 1 percent in the United States. Where hospital births are the norm, the traditional halakhot about Sabbath observance have quickly become inoperative. 

Even a brief examination of a respected 1979 halakhic compendium will show how much these laws have changed. According to Rabbi Joshua Neuwirth, a woman should travel to the hospital at the onset of the slightest sign of labor. She may carry her possessions with her to the hospital, even through an area without a permitting enclosure (‘eruv) and can be accompanied by an “escort” (presumably her husband), who may also transgress the Sabbath. She may even, under certain circumstances, travel home from the hospital on the Sabbath if in fact she had been mistaken about being in labor.

What sources does Rabbi Neuwirth quote when allowing wholesale transgression of the Sabbath before the final stages of labor? Almost invariably he says, “So I have heard from rabbinic authorities” or refers his readers to the general rule of life-threatening situations (piqquaḥ nefesh). There is no attempt to justify these radical changes; piqquaḥ nefesh apparently speaks for itself."

We have already demonstrated that the fundamental assumption made by the athors is deeply flawed.  That is because the majority of the poskim follow the simple meaning of the words of the Shulhan Arukh and the rambam and the Gemara that state unequivocally that a birthing woman is "B'sakanat nefashot", and that the same laws that apply to any critical patient apply to her as well.  The Maggid Mishna that was quoted by the authors which differentiated between a birthing woman and a critically ill patient was either not accepted by many poskim, or interpreted by the poskim to be refering only to things being done l'yashev da'atah - to calm her fears.

R' Neuwirth, in Shemirat Shabbat K'Hilchatah (SSKH), paskens exactly NOT like the authors of the article would have you assume is the accepted halacha.  In fact, he paskens exactly like many of the poskim we quoted before, and that there is no halachic difference whatsoever between a birthing woman and a critically ill patient.  See SSKH Vol 1, 34:4 note 6 where he states, and I quote:

"see earlier in 32:28 (where R' Neuwirth paskens that one must use a shinuy for every critically ill patient whenever possible), therefore, the law of a birthing woman is the same as the laws of a critically ill patient, in that whenever it is possible, a shinuy must be used."

It is unclear why in the text of the SSKH R' Neuwirth quotes the Maggid Mishna when he states that the pain of birthing is a natural process. However, he provides the source in his note and refers us to the Arukh Hashulkhan and the Mishna Berura.  It is well known that the normal style of the SSKH is to leave this type of detailed analysis to the reader, and simply to provide the sources for someone interested in further investigation.  Regardless, the SSKH is crystal clear, both in 32:28 when he discusses the laws of the critically ill patient, and in 36:4 when he discusses the laws of the birthing woman, that he considers them exactly the same.  He thus follows, not surprisingly at all, the pattern of most poskim throughout the centuries, who did not differentiate between the two.  Unlike the authors who would have you believe that "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient".

Thus it should be no surprise at all when he allows what the authors consider "wholesale transgression of the Sabbath".  He doesn't need any more sources, as the poskim, especially the Arukh HaShulkhan who WAS quoted by the SSKH, made abundantly clear that even things that are only needed to calm her down, but aren't medically necessary, are permitted on the Shabbat.

The next issue that the authors discuss is the use of male birth attendants.  In summary, they contend that Halakhah in general "severely limited the access of male physicians to women". Traditionally, births were attended by women only, and midwives were the attendents at births.  However, "today most Orthodox women standardly have their babies delivered by male physicians...", and this has been supported by the halachic authorities.  Consistent with the theme of their article, the assumption is made that the reason for this leniency of the modern poskim is that when life is in danger, we can allow transgressions of halachah, including the use of male birth attendants.  In their words, "The male physician is exempted from this rule (the rule prohibiting males from being present at the birth), presumably for reasons of piqquaḥ nefesh."

I will discuss this issue in detail in my next post.

Stages of Labor

We now continue with our analysis of the article of interest, "Obstetrics and the Curse of Eve."  The paragraph we took apart in the first post ends with the following statement:

"In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."

Those readers who have followed this blog from its inception, should be familiar with the Five Principles of Rationalist Medical Halacha.  It should be immediately obvious that the quote above is a gross violation of principle # 2, the "historical corruption principle."  To quote myself, it is of utmost importance when one analyzes a topic in medical halacha, that they "understand how the medical understanding of their predecessors affected the decisions that they made."

They use the term "final stage of labor" which is a modern medical term with a very specific meaning, and they use this term to describe the words of the Shulkhan Arukh.  Their intent in doing this is to emphasize that for most of the process of labor, most transgressions of shabbat were not permitted, other than to summon the midwife.  Only in the "final stage" are we allowed to do anything else if it violates Shabbat.  This further illustrates their contention that the process of childbirth should not warrant as much chillul shabbat as is commonly assumed today.

This is based on a serious misinterpretation of the term used in the sifrei halacha "K'shekora'at leyaled" "when she bends over to give birth".  It is true that one may not violate Shabbat until that time, but when is that time exactly?  Doesn't that sound like the "final stage" of labor?  This seems to support the contention of the authors that only during the "final stage" of labor are we allowed to violate Shabbat.

Nothing could possibly be further from the truth however.  The truth is that the poskim say clearly that we are allowed to violate the shabbat from the time of "Kora'at leyaled", and they describe clearly exactly when that is.  Three examples are given by the gemara in Shabbat 128b-130a, and these examples are repeated in all the sifrei halacha:

1. When the blood starts to drip
2. When she sits upon the birthing chair
3. When her friends are carrying her

I will digress a little to teach you some modern obstetrics, and a little bit about the signs of labor. Every woman experiences labor differently, and there is no one exact way that every labor progresses.  However, there are still some general concepts that can help us understand how labor progresses, and modern medicine is great at dividing things into categories and stages.  

The first stage of labor starts with a closed cervix and ends when the cervix is fully dilated, generally around 10 centimeters.  This is divided for conceptual purposes into two phases, the latent phase and the active phase.  The latent phase is slower, usually less painful, and consists of contractions that are usually farther apart. This phase can last anywhere from two days to just a few hours, and usually is much shorter in women who have had babies before.  This phase usually ends around 4 centimeters when the woman enters into the active phase.  During the active phase of labor, the contractions are much stronger, closer together, and much more uncomfortable.  The cervix dilates quicker, and this phase is usually over in a few hours when the cervix is fully dilated.

The second stage of labor starts when the cervix is fully dilated, and ends when the baby is delivered.  this is often called the pushing stage, as the woman's natural urge to push is very strong, and she will have to work extremely hard to push the baby out.  This can last anywhere from a few minutes to a few hours, depending on all sorts of factors.

It is very important to differentiate between "stages" and "signs" of labor.  Signs of labor include things such as bloody show, the passing of the mucous plug, the "dropping" of the baby, pelvic or low back pressure, and other such symptoms. Stages are what we just described in the previous two paragraphs. The important difference between stages and signs is that not every woman experiences all the signs of labor, and sometimes the presence of those signs doesn't necessarily mean that someone is in labor.  However, every woman does go through the stages of labor, although it could happen at way different speeds, and way different levels of intensity, but the stages always happen.

During the time of chazal, they needed to define the signs of labor that meant the woman is in sakanah.  This was important in order to provide guidance as to when chillul shabbat was permitted. In those days labor was not described in stages like we do today in modern medicine.  Chazal knew very well that there were soft signs that meant labor was imminent, but that the woman was not yet in danger when they happened. They also knew that at some point in time, she transitioned into a stage of sakanah.

When I was a resident, the nurses and residents came up with what we called was the "visual labor check".  We used to joke about how one could usually tell when a couple walked off the elevator towards the front desk whether or not she passed the "visual" test to be admitted.  If her partner (be it a friend, mother, doula, or husband) was holding her as she breathed through her contractions, that was a positive visual test. If she was wet with blood and water, that was a positive visual test.  If she was in such discomfort that the security guard had to wheel her in, that was a positive visual test.  No exam was really necessary to confirm that she was in labor.

The "positive visual test" usually correlates well with the active phase of the first stage of labor, also known as "active labor".  This was of course confirmed when we examined the woman and found out how far dilated her cervix was.  If she was in latent labor, we may send her home, or may send her for a nice walk around the hospital for a few hours, but she did not require admission.  Why? because in the early stages of labor it is commonly understood that there is no serious risk to the health of the Mom or the baby.  However in the active phase, there is risk.  What risks are more common in the active phase? Some examples (but there are certainly many more) include:

1. Hemorrhage due to abruption (separation of the placenta) or vasa previa (a condition where the umbilical cord can tear)
2. infection (especially in cases where the labor lasts a long time and the membranes have been broken)
3. fetal intolerance of labor (the baby may not tolerate the contractions well - which is why we monitor the baby during active labor)
4. seizures due to blood pressure abnormalities

Now remember that all of these problems are rare, but also recall what we said in the first post on this topic. We explained that although the overwhelming majority of women make it through labor just fine without any medical interventions, the Halacha still paskens that they are all considered pikuach nefesh, so that we can intervene in order to prevent the few deaths that would occur if we didn't intervene.

For example.  We monitor the heart rates of every baby on Shabbat, even though the vast majority of babies would do just fine without a monitor.  Why? because we want to save the one in a thousand that we can find abnormalities in the heart rate.  Another example: We check every woman's blood pressure and temperature, why? because we need to find the one in a hundred that have problems that we can treat! and so on.

Let's go back to the "visual test" from my residency days.  Even though they didn't use the same terminology to describe the stages and phases of labor, Chazal absolutely knew about all the signs of the latent phase of the first stage of labor.  They knew it because it was common knowledge, and everyone knew that it wasn't yet a dangerous time.  But they also knew that when she transitioned into active labor, she was in danger? They knew this as well because it is something that has been observed for as long as human beings have been having babies! What were the signs that she had entered this phase, the signs that any observant person can see? When the blood is flowing, when her friends need to help her walk, and when she lies or sits down in the birthing bed (see Arukh Hashulchan OC 330:4 who explains that sitting on the "Mishbar" does not mean sitting in the bed to push the baby out, but it means when she lies down due to the pain of the contractions).  This fact is so obvious to anyone that has ever seen a woman in labor that one need not even bother explaining it further.

The authors of our article wrote that "before the final stage of labor" violations of shabbat were not permitted.  They assumed that one may not violate the shabbat until the second stage, when the woman is pushing the baby out.  But this is patently wrong.  One may clearly violate Shabbat at the onset of active labor, during the first stage of labor.  Chazal were extremely clear about this, as they observed in nature the same phenomena that we observe today, that the really risky time is the active phase of the first stage of labor.  Just like modern hospitals usually won't admit a patient in the latent phase of labor, chazal also knew that chillul shabbat was inappropriate as well.  It is not necessary to be a modern scientist to know these obvious facts.

"except for summoning the midwife" - of course one may summon the midwife before the onset of active labor.  Because we don't want to wait until the woman is in potential danger before we summon her! She needs to be there before that stage begins!

In short, our authors used a modern medical term, the "final stage" of labor, and assumed that this is what Chazal meant when they said K'shekora'at leyaled".  They therefore concluded that the poskim only permitted chillul shabbat during the final stage of labor, except for summoning the midwife.  This is a mistake. Chazal were referring to the active phase of the first stage of labor.  This is exactly the time when everyone agrees the time of potential danger has begun, and this agreement spans the entire history of humanity, up to and including in modern hospitals.  The modern poskim all agree with what I just wrote, and correctly so. But the authors of our article, not surprisingly, proceed to criticize the modern poskim for this, but that will be coming up soon in an upcoming post...

Why am I so Interested in "Obstetrics and the Curse of Eve?"

This probably should have been the first post in my series on the article "Obstetrics and the Curse of Eve", but I originally thought it would be obvious to my readers why I felt this subject was so important.  However, based on some comments from friends of mine, it seems that many of them didn't understand why I chose to spend so much time on a short article "Obstetrics and the Curse of Eve" in the Hakirah journal.  So let me explain.

I suspect that your rationalist antennae will perk up as much as mine did after you read this explanation.

The modern literature discussing the relationship between Torah and medicine can be divided into several categories.  This may not be an exhaustive list, so I am open to suggestions if you feel I have left something out.  But I would divide it as follows:

1. The "Laws of  ... " category - This refers to the many handbooks that describe halachot very dryly and in a clear style.  This is permitted, this is not permitted and so on... These books read like instructive handbooks, and generally don't give much instruction regarding the historical, philosophic, or even the halachic developments behind the laws being written.  I am sure many of you have seen these handbooks, and I will not be commenting on these right now, though we probably will at some point in the future of this blog.
2. The "Medicine of the Torah ..." category - These are the various books describing the medical treatments, cures, and sometimes theories of the Torah, Talmud, Rambam etc.  There are many different angles from which these books approach this topic, some more rationalistic than others, some more mystical than others, and some may be more or less willing to compare the knowledge of the rabbis with the contemporary scientific knowledge. I won't be commenting on this category either during this thread.
3. The "Ethical guidance of the Torah" category - This includes the vast amount of essays, articles, op-eds, journal entries, and books that have used the Torah sources to develop some sort of ethical or moral idea that the writer believes is "the Torah view" or "the Torah way".  This body of literature assumes that we can learn ethical teachings from the laws of the Torah, and that indeed these teachings can be applied to other areas of life.  We often read about the value the Torah places on things such as the "sanctity of life" or the "responsibility to the other" and so on.  This is the body of literature I am referring to.
4. The "Torah is a TEA Party Mission Statement" category - This is what you are reading every time an uber-conservative writer uses a verse in the Torah or passage in the Talmud to support his/her ultra conservative views.  This can be about women's role in religion, the Torah's attitude toward homosexuals, or various other topics.  I am NOT taking a position here on these topics, though I will eventually hope to deal with them and others.  All I am saying is that we sometimes find uber-conservatives using what they claim is the Torah to support what are essentially simply just plain old uber-conservative views. This category also includes medical topics, such as abortion, end-of-life issues, organ donation and more. I am not dealing with this category in this particular thread, but I have dealt with some of this in previous threads.
5. The "Torah is the Huffington Post of the Ancient Times" category - This is the exact opposite of category # 4.  Whenever an uber-liberal expresses his/her uber-liberal views and then uses the Torah sources to back up the idea, he/she is writing literature of this type.  This happens often with environmental issues, social justice issues, and more.  But it also happens often with medical issues, and THIS is what the current thread is about.  I have seen this happen with the scary proliferation of people who don't vaccinate their children, as they may often claim some Torah source for their neglect.  I hope to deal with vaccinations specifically in the future, but I would refer you to the excellent article by Dr. Eddie Reichman about this topic. This brings us to the topic of our current thread, "Obstetrics and the Curse of Eve."

(I hope I have not offended anyone when I used the terms "uber-conservative" or "uber-liberal",  I used them for dramatic effect only. I do not mean to demean anyone who holds these views, in fact, in some cases I may even hold such views myself! I also beg you to not make assumptions about my personal beliefs on a particular topic. I hope that you have learned by now, if you have read anything on this blog, that I freely share my opinions about any topic I am discussing.  However, I will never give in to the temptation of giving out sound bytes of what I think about this or that topic.  If I write about something, it will take me time to develop the sources and reasoning behind my thoughts.  You can then agree or disagree as you see fit.  I am sorry that some may find it boring if they can't get a juicy sound byte from me, but if that's what you want, find another blog.)

The writers of the article of interest are expressing views that are mostly compatible with an entire popular movement in our culture, namely, the "home birth" movement.  It is far beyond the scope of my blog to describe the various controversies relevant to the home birth movement.  However, I can tell you that there are many outspoken critic, including many celebrities, who have criticised various aspects of modern obstetric medicine, especially in the US.  You can follow this link to one of the most influential films called "The Business of Being Born" if you want to find out more about this topic.  This movement has criticised, often rightly, aspects of modern childbirth including using too many drugs, too many surgical interventions, too little personal control over the process, and too much greed.

As an obstetrician myself, I obviously have a lot to say about the topic, and some of it may surprise you. Most importantly, I believe in listening to anyone and everyone that has a reasonable, well researched, and helpful comment or suggestion.  The home birth movement has accomplished a lot regarding the way women in labor are treated, but there are still many differences of opinion, especially between the extremes.  I would be happy to discuss these issues specifically, but for now I want to continue this thread.

The writers of the article are presenting what they believe is a Torah based justification for their belief in home births and the other issues that are related such as drugs in labor and so on.  They may or may not be right, and after you read my blog series I hope you will form your opinion on this matter.

In my first post, I quoted their claim that the Halachic authorities recognized that although a pregnant woman is in a life threatening situation, it is not quite as life threatening as an ordinary critically ill patient.  They made that claim in order to set up their argument that the Torah sources recognize that a birthing woman is undergoing a natural process that is not as dangerous as someone who has an actual critical illness.  They brought some sources that supported this idea, and I brought sources that demonstrated that many, if not most, authorities did not make this distinction at all, and in fact they held that a birthing woman is in exactly the same category as any critically ill patient.

I hope that you now understand why this issue is so important to me, and why it should be so important to anyone interested in rationalist medical halacha.  The way I approach this topic, I believe, should be the way any halachic rationalist should approach anyone who writes an article or book that fits into the "Torah is the Huffington Post of the Ancient Times" category.

We can now move on with our analysis.  I hope you stay along for the ride.