Babies are supposed to be born head first; if they insist on “walking” into the
world – the breech position – there could be trouble. Breech babies are often
delivered by cesarean section – which some women even prefer to vaginal delivery
as it is virtually painless (at least initially) under anesthesia. However,
complications can develop, recovery takes longer and the cost to the public
purse is much higher.
But there are some women determined to have neither
a breech delivery nor c-section.
Among them are many of the over 5,000
women who gave birth last year in Jerusalem’s Bikur Cholim general
That is why its medical director and chief of
obstetrics/gynecology, Dr. Raphael Pollack, and the handful of other doctors
there who know how to perform “external cephalic version” (ECV) are so busy. The
200-bed hospital in the center of town has the lowest c-section rates in the
country – just 10 percent of all its deliveries.
Pollack, who was born in
Montreal, studied medicine at McGill University and did advanced work at Yeshiva
University’s Einstein College of Medicine in New York, joined Bikur Cholim
immediately after immigrating to Israel with his family in 1993. A father of six
– none by breech deliveries – and the grandfather of one (with another on the
way), he still finds the experience of delivering a baby very moving, and even
holy. The modern Orthodox physician has done it many thousands of times, and has
performed a total of 1,372 ECVs in his career – a record that might qualify him
for inclusion in The Guinness Book of Records.
“I was doing a fellowship
at Einstein in the early 90s,” says Pollack during an interview with The
Jerusalem Post at his hospital office, “and the rising c-section rate was
targeted as a cause of concern. There was then interest in VBAC – vaginal birth
after c-section – but medical use of this technique waned,” he recalls. “Doctors
worried about litigation... if there were complications in... subsequent vaginal
delivery, among other reasons.”
VBAC isn’t suited to every woman, and
some complications may make it risky to perform, thus leaving c-section as the
In addition, there are Western hospitals that don’t offer
VBAC because they don’t have the facilities or manpower to perform emergency
c-sections, required in the event that VBAC is unsuccessful. Delivery by
c-section is considered mandatory if a woman has already had two. The potential
for complications after three cesarians is significant.
alternative, Pollack investigated ECV, which was not frequently used in the US
then (and still is not today). Although farm animals are often “turned over” in
the womb by veterinarians pushing a foot into the mother’s abdomen, this is not
an option in women. He researched the matter and developed his own version of
For example, he asks women in their ninth month of
pregnancy (if possible) to drink two liters of water to fill the
This, he explains, makes the fetus float upward so it’s easier
to turn over by external manipulation.
He returned from New York to
Montreal, where he found very few doctors used ECV.
Soon after, he moved
to Israel. “I saw a need for it here, especially at Bikur Cholim,” he
The turning-over process takes three to four hours, during which
the fetus is monitored with ultrasound to determine its exact position. “But the
actual ECV takes a few minutes,” Pollack says.
When all is ready, Pollack
is called in to flip the baby over. First he gives an injection of ritadrine to
relax the muscles of the uterus. The drug is a beta-2 agonist, but it is not a
sedative or anesthetic, so it doesn’t minimize the pain, which is sometimes
On occasion, a woman will say it is too painful and ask him
to stop. But he adds that there is usually no need for analgesia as the
procedure takes only a few minutes.
The procedure only rarely induces
labor by itself, adds Pollack.
He has performed ECV so often, he says
with a smile, “that if my colleagues in meetings see a filled syringe in my
pocket, they know what I’m about to do.” He massages the woman’s bare belly as
he uses ultrasound guidance to monitor the position of the fetus. In
three-quarters of cases, the fetus turns over and lands with the head below, and
then labor may be induced to speed vaginal delivery.
“In about 1% of
cases, the fetus will flip over by itself after ECV. I remember a very rare case
of a woman whose fetus I managed to turn over; it turned back before I could
induce labor. Then I did it a second time, but it turned over again.” The woman
decided to go through the procedure a third time, and the obstetrician succeeded
again; labor was induced before the acrobatic fetus managed to invert himself
“I am very disappointed when it doesn’t work,” he says, explaining
that it’s impossible to achieve a 100% success rate because of uterine
malformations such as a septum or the umbilical cord tethering the baby. Thus he
is proud of his 74% success rate. “The first cesarean is critical; if the fetus
can be turned over, the mother doesn’t have to worry about having a VBAC or an
“Turning babies over in the womb is an important
contribution to women and the economy,” says Pollack, who has calculated that,
in the US, if 75,000 cesareans per year could be prevented by ECV, that country
would save hundreds of millions of dollars.
The potential savings are
huge, he stresses.
When ECV doesn’t work or there is no time to perform
it, breech deliveries are usually performed, even though both techniques are
considered to be “quite fringe” techniques in the US and even in Israel. “We at
Bikur Cholim have the highest rate of breech deliveries in the country,” he
Doctors at Hadassah University Medical Centers and Meir Medical
Center in Kfar Saba also perform ECV quite often, which in studies has been
shown to be safe when performed by an expert.
Bikur Cholim has not had
much reason for smiles – except the birth of many babies and saving patient’s
lives – during the past decade. It has been threatened with closure many times,
suffered losses of staff, put into receivership, bogged down with lawsuits, seen
commitments fade away and more.
The non-profit organization, run by
haredi groups went into deficit, to be saved five years ago by Russian oligarch
Arkady Gaydamak, who during a Jerusalem mayoral campaign (which he lost by a
huge margin) decided to buy the hospital and premises for $40
Pollack was asked to take over the reins as medical and
administrative director, even though he says he much prefers practicing medicine
to medical administration. Pollack replaced Bari Bar-Zion – a Treasury-appointed
administrator who brought Bikur Cholim its first balanced budget for a long time
– as administrative director; Bar-Zion had been forced out by Gaydamak over a
financial dispute and other problems. A series of chairmen of the voluntary
organization that made hospital decisions were dismissed and replaced, and last
year, former Meuhedet official Moshe Hevroni was made administrative
But when Hevroni saw the government was not giving the hospital
a one-time grant (as it previously gave to Netanya’s non-profit Laniado Medical
Center), he resigned. Hevroni continues to work at Bikur Cholim as financial
adviser to the board of directors, and Pollack remains medical director, with no
official general administrator.
Although Gaydamak for a time stayed away
from Israel due to impending lawsuits against him and his anger over failing to
be elected mayor, he returns periodically to Israel and visits Bikur Cholim
every few months, even though he no longer provides it with the munificent
financial gifts he used to. He has waived his demand that the voluntary
organization pay rent for use of the premises.
Pollack says the staff of
over 600, many of them middle-aged, are grateful for the hospital being kept
alive, and its pensioners – who under receivership were at risk of losing their
monthly income due to hospital insolvency – are also delighted.
Bikur Cholim’s flailing attempts to survive, Jerusalem’s much-larger and rapidly
expanding Shaare Zedek Medical Center and Hadassah University Medical Center in
Ein Kerem eyed the institution like birds of prey circling overhead; they
thought Bikur Cholim would close, and that they would inherit the patient
But Bikur Cholim didn’t agree to die. Even though it still
does not have a guaranteed future, Pollack hopes it will survive and even
Shaare Zedek, which performs 14,000 deliveries a year – number one
in Israel – is not a threat to Bikur Cholim, insists Pollack.
“It has one
of the largest obstetrics departments in the world. Very few hospitals anywhere
have 14,000 annual deliveries.” He thinks Hadassah, which in a few months will
begin to move all its inpatient facilities to a huge hospitalization tower, and
Shaare Zedek, which is constructing a children’s hospital, “are doing a
Some countries prefer to promote superhospitals, Pollack
continues. “But there are disadvantages to them. There is a limited capacity and
an inability to admit an infinite number of patients to very large medical
centers,” he says, “and there is a need for smaller, community hospitals, like
Bikur Cholim and, for that matter, Hadassah University Medical Center on Mount
Scopus. We are not here to compete with Hadassah and Shaare Zedek,” he
“Most metropolitan areas with more than a million people need
more than a few medical centers. The community is best served when are
several... medical service [providers].”
His own hospital is best known
for its ob/gyn and cardiac departments and emergency room. It admittedly lacks
facilities for neurosurgery and cardiothoracic surgery, and an orthopedics
department capable of handling complicated cases. But Bikur Cholim has a modern
neonatal intensive care unit, pediatrics department, and bariatric and plastic
“There is enough work for all the hospitals to prosper,
even though providing medical care is not a money-making proposition. Our
operating budget is at the break-even point, even though we have long-term
debts. We have no benefactor now, and contributions [throughout] the Jewish
world are down dramatically.
But we do have donors who
Haredim [ultra-Orthodox Jews] who are well off tend to prefer
giving money for Torah study and not to hospitals,” he says.
“Many of my
colleagues in other hospitals didn’t think we would weather the storms. But we
built a seventh delivery room; obstetrics brings in National Insurance Institute
money and is much in demand. These colleagues have been very surprised to see we
are still here,” he says.
Bikur Cholim’s campus at the corner of historic
Hanevi’im Street and Strauss Street has an important function because it is
located in the city’s center, Pollack says. It is near a large number of haredi
neighborhoods to the north and ready to quickly admit victims of road accidents,
terror attacks and others so they don’t have to be rushed to the more distant
While 80% to 90% of the patient population is haredi,
Bikur Cholim also treats Arab patients as well Jewish patients from outside the
Bikur Cholim is brimming with tradition.
babies are delivered there whose grandmothers and even great-grandmothers gave
birth there. “We are 185 years old, beginning in the Old City. Misgav Ladach –
which also began in the Old City but moved twice in the New City – is no longer
a general hospital and doesn’t do obstetrics anymore.”
The Hanevi’im area
is also full of tradition, and former hospitals such as Rothschild and Dr.
Ticho’s eye clinic existed there. Prussia’s Kaiser Wilhelm even visited in 1898
(there is controversy over whether Theodor Herzl, who was in town
simultaneously, met the foreign leader or was refused an audience).
have a photo in the hospital of a Prussian flag being flown from Bikur Cholim in
the Old City when he was here.” Thus, to a certain extent, Bikur Cholim is “a
microcosm of the Jewish Yishuv in Eretz Yisrael, connected to the birth of
The kaiser’s mother, Augusta Victoria – after whom a
hospital on Mount Scopus was named – delivered him via breech birth, Pollack
surmises, based on information he received from the kaiser’s great
She had a difficult delivery, and her son always wore gloves
and held his sword with his left hand. “It looks to me like paralysis resulting
from birth trauma.” Pollack goes even farther. “It is said that the kaiser had a
cantankerous personality because of the trauma of his birth and his subsequent
suffering – and that World War I may have been one of the results!” One hopes
that the hospital’s continued struggle for a long-term existence and its
flowering will not be involved in a “war” of any kind.