Turning things around at Bikur Cholim

Dr. Raphael Pollack has performed 1,372 "external cephalic versions" – an alternative to cesarean sections or breech births.

By JUDY SIEGEL-ITZKOVICH
DR. RAPHAEL POLLACK baby doctor 390 (photo credit: JUDY SIEGEL-ITZKOVICH)
DR. RAPHAEL POLLACK baby doctor 390
(photo credit: JUDY SIEGEL-ITZKOVICH)
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 hospital.
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 alternative.
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.
As an 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 the technique.
For example, he asks women in their ninth month of pregnancy (if possible) to drink two liters of water to fill the bladder.
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 says.
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 considerable.
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 again.
“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 automatic c-section.”
“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 says.
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 million.
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 director.
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.
During 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 population.
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 grow.
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 wonderful job.”
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 insists.
“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 surgery units.
“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 help.
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 medical centers.
While 80% to 90% of the patient population is haredi, Bikur Cholim also treats Arab patients as well Jewish patients from outside the capital.
Bikur Cholim is brimming with tradition.
Pollack says 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).
“We 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 political Zionism.”
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 grandson.
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.