Ep 312: Why This OB-GYN Walked Away From the System with Dr. Nathan Riley

Dr. Nicole Rankins (00:01.471)

Right, thank you Nathan or Dr. Riley Nathan for being on the podcast. I am so excited to have this conversation with a fellow OB-GYN, but who's taken a totally different path.

Nathan Riley (00:04.962)

Nathan.

Nathan Riley (00:13.132)

Yeah, yeah, it's a pleasure. There's a lot of people with microphones in podcasts nowadays. And I was telling you just before we recorded, it's actually really nice to have somebody who gets this, like what we do, to the degree where we have the security blanket of the profession, of our board certification, but also, we're also people. We have these other things, and the doctor bashing and system bashing. Of course, I've partaken in that, but it's like,

Dr. Nicole Rankins (00:26.421)

Right.

Dr. Nicole Rankins (00:35.562)

Right.

Nathan Riley (00:43.086)

It really is not getting us anywhere and I really love and appreciate the collegiality whenever it emerges. So it was like an easy yes whenever you said, hey, do you want to come and chat about home birth and whatnot.

Dr. Nicole Rankins (00:45.173)

Yeah.

Dr. Nicole Rankins (00:53.099)

Yeah, yeah, yeah. Well, thank you. Thank you. I'm excited. Well, why don't we start off by telling us a bit, by having you tell us a bit about yourself and what you do.

Nathan Riley (01:03.286)

Yeah, I think most importantly, I'm married to my high school sweetheart and I've got two little girls. And I grind my own flour and I make sourdough bread and loaves and focaccia. And my wife and I are really, really adamant about raising wonderful little girls and for me to be the most healthy expression of masculinity possible. And on the side, I happen to have two board specialties.

I went to medical school in Philadelphia at Temple University, and then I went out to California for all the residency training at Kaiser, which was an excellent training program. And I did a fellowship as well at UC San Diego in hospice and palliative medicine. So I have this super sub-specialty, like I know you had a neonatologist who's also double-boarded in hospice and palliative. And so I have this perinatal hospice space around periviability that's also a really unique.

Dr. Nicole Rankins (01:50.448)

huh.

Nathan Riley (01:58.52)

thing that I get to do, the privilege of sitting with birth, death, and when those two worlds collide. So that's kind of my story in a nutshell. But of course, I also do home birth. I work with midwives across the country. And I do a lot of functional medicine and some other really neat things that allow me to really kind of show up in a very unique way, I suppose.

Dr. Nicole Rankins (02:18.667)

Unique for sure. So you gotta tell us, what nudged you away from a more conventional path in medicine to what you're doing now and doing, excuse me, even home births. I have, there are not too many OBGYNs who are conventionally trained who help with home births. So what nudged you away from the conventional path?

Nathan Riley (02:35.214)

But well.

Nathan Riley (02:42.114)

Yeah, I love that you use the word conventional because let's be very, clear. Over 98 % of women are going to have their babies in hospitals. That's just the way that it is in our country. And it's really that trend is we're seeing that take place around the world. I think the easiest answer to that is that if I thought that practicing in the hospital allowed me to do what I really wanted to do, which is I really take the long

Dr. Nicole Rankins (02:50.421)

Mm-hmm. Mm-hmm.

Nathan Riley (03:10.926)

hard journey of sitting and being present with birth, which is possible as an OB-GYN, but it's really not what we're incentivized to do in the hospital system. Nicole's gonna have three or four people laboring, so sitting with one person and getting to know everything about them for nine months and then being with them in the birth is simply not what OB-GYNs do. We're ready to go to surgery, we have pharmaceuticals, we have all those things, and sometimes,

Dr. Nicole Rankins (03:33.589)

Mm-hmm.

Nathan Riley (03:38.358)

Of course, we get really good at those and sometimes they're really, really helpful. But what I really liked, and maybe I just chose the wrong career, honestly, what I really liked was getting to know people, getting to know the fathers or the partners, going to the NICU and watching the babies start to figure out what's going on, you know, if we had not even necessarily a bad outcome, but those babies that like just don't transition well. I would be in the NICU and they'd be like, where's Riley? You know, and it's like, well, he's, the intern's taking care of the low risk lady and

Dr. Nicole Rankins (03:59.242)

Right.

Right.

Dr. Nicole Rankins (04:07.424)

Right.

Nathan Riley (04:07.572)

in bed two or whatever, I wanted to see what happens in the NICU and maybe practice placing some lines or practice doing epidurals. There was a time when I was actually working on that as well. It was just this ultimate curiosity and I didn't have the time and space to do that in the conventional model. Not to mention that there's also certain skills that I don't feel like I was equipped with in residency. And so I started going to HomeBurst because I wanted to work with people that were comfortable with things like vaginal breech birth or twins, vaginal twins.

Dr. Nicole Rankins (04:14.347)

Mm-hmm.

Nathan Riley (04:35.956)

not in an operating room setting, but actually in the home. And when you actually start to learn about that, it's like, this is not something that I should have been scared of, but I also never got to see it. So if I'm gonna see it, the only way to do that is to work with midwives and certain specific OBs that are working outside the system. And once you, I don't know if you've ever been to a home birth, Nicole, but gosh, the ambiance is so magical. It's like so different. And when you have the right plan and...

Dr. Nicole Rankins (04:37.887)

Right.

Dr. Nicole Rankins (04:49.983)

Right.

Dr. Nicole Rankins (05:00.619)

Mmm.

Nathan Riley (05:04.826)

let's say procedure, for lack of better terms, in place to move, know, laterally to the hospital that's maybe, I don't know, four minutes away like it is from our house. It's like, hey, we can still do everything there, but now walking into a person's home feels different to me. It feels like more of a privilege as opposed to me being the captain of a ship and everything in the room being oriented for my comfort. So given that I'm married to my high school sweetheart and these little girls, when I imagine what

Dr. Nicole Rankins (05:13.781)

Right.

Dr. Nicole Rankins (05:18.475)

sure.

Nathan Riley (05:34.104)

birth could feel like for them. I really go back to even our home birth in our bedroom. was like, this was just, it was like my hairs are standing up right now. It's such a different feeling. And that's what I, that was compelling enough for me to say, you know what, as much as I loved being the white coat wearing, ultrasound touting physician and getting so good at those things that we are good at.

Dr. Nicole Rankins (05:39.563)

Mm-hmm.

Dr. Nicole Rankins (05:44.715)

right.

Dr. Nicole Rankins (05:56.969)

right.

Right.

Nathan Riley (06:03.278)

It's like, the midwives have also this really special thing that they get to do. unfortunately for my chosen path, that's a little bit more attractive to me. And then there's one other element, which is like, we didn't really learn to look all the way upstream for some of these issues that are facing this patient population that we've taken an oath to care for. So there's many elements, but I'll keep it straight.

Dr. Nicole Rankins (06:12.031)

Yeah. Yeah.

Dr. Nicole Rankins (06:18.709)

Mm-hmm.

Dr. Nicole Rankins (06:24.459)

Sure. Yeah, no, no, no, I love that. I love that. And it's interesting that you said your chosen path didn't quite fit what you were interested in. That's kind of how I ended up being a hospitalist because the office didn't allow me to like see. I was always behind chronically because I would talk to people and yeah, yeah. So, you know, we each have to find our own paths. And I love that you found.

Nathan Riley (06:43.576)

Yeah, it's like there's always like six more people waiting.

Dr. Nicole Rankins (06:52.103)

a path that works for you. And you still maintain your board certification. So it's not as if you're like completely like divorced from the system. You're still maintain that board certification to keep your options open and things like that. So. Right.

Nathan Riley (07:04.718)

Yeah, and licenses, have like licenses in 22 states. Like that's all back, I'm always working on CMEs and figuring out how I'm going to fit in on this state's requirements. Like there's still a very active process here for me. It's just, you know, sort of in the shadows at times. I was a hospitalist, by the way, when I finished residency, I went right to hospitalist work and that's the way to go for anybody out there who's, who's jumping into action whenever things need to. Yeah. Yeah.

Dr. Nicole Rankins (07:11.593)

Right, right.

Yep.

Yeah. Right, right, right.

Okay.

Yeah. Right. Yeah. Yeah. Yeah. So then how did your conventional OB training prepare you or not prepare you for being present and out of hospital birth?

Nathan Riley (07:46.552)

That's a really good question. And it's a pretty easy answer. There's a lot of people, and this is not going to turn into a bashing session, but we have to consider what a physician goes through, like any type of physician, to get to where they are. Now, it doesn't necessarily mean that everything we learned was necessarily the best way to go about it. I'm not going to take that line. I mean, although when you invest a half a million dollars, you really want to look back and say, everything that we do has to be the right way.

Dr. Nicole Rankins (08:08.075)

sure.

Dr. Nicole Rankins (08:14.335)

Yeah, 1000%. Right.

Nathan Riley (08:15.83)

Right, like I get that. Any practicing physician is, I see you. And, and there's a lot of people out there that are speaking in a position of authority who have no real bearing on what it means to do an emergency C-section. Like what it does for Dr. Nicole's nervous system to see that there's somebody in trouble and I need to act now.

and to get a baby out in like 27 seconds, I'm sure you have your record, right? Where there was one case where it was like, that baby was out so fast and her bleeding was stopped so quickly that had I not gone through all that training, my goodness, I would never even know what an emergency C-section really felt like. And most women are told we had to do it, it was an emergency and it wasn't really an emergency. But you and I both know what that emergency feels like for me, for the physician, for the staff, for the patient, for the family.

Dr. Nicole Rankins (08:45.707)

Yeah, yep.

Dr. Nicole Rankins (08:51.189)

Right. Right.

Dr. Nicole Rankins (08:59.912)

Mm-hmm.

Dr. Nicole Rankins (09:04.042)

Mm-hmm.

Dr. Nicole Rankins (09:08.223)

Yes.

Right, right.

Nathan Riley (09:12.558)

And that is like the crux of what I think most of our policy making kind of is bent on. But whatever people are, for the worst case scenario. So when people say, yes, that's rare, I get it, it's rare. But if you don't know what it feels like to be in that sort of do or die situation, you really have no, you really are limited as to how you can counsel.

Dr. Nicole Rankins (09:20.043)

Mm-hmm. Or the worst case scenario. Mm-hmm. Yeah.

Dr. Nicole Rankins (09:30.837)

Mm-hmm

Nathan Riley (09:40.174)

potential clients or the birth education and whatnot. So for me it was like I have seen it all. I've had uterine ruptures. I've had fetal demise. I've had the abruption here in Kentucky where a person's high on opiates and they just took a big hit of meth and they're abrupting and we have to do this emergently. And the person doesn't speak English. And it's a woman of color. And I'm like, oh, this white dude covered in tattoos.

Dr. Nicole Rankins (09:41.408)

Yep.

Dr. Nicole Rankins (09:53.845)

Mm-hmm.

Dr. Nicole Rankins (10:05.152)

Yeah.

Dr. Nicole Rankins (10:09.331)

Right, right, right.

Nathan Riley (10:09.858)

We have no way to relate. So we have to build rapport. We have to make a decision. We have to act on that. So given that I've done all of that, now my job is to help women and families avoid that if possible. And I can do that because I can reverse engineer how these really horrific things have happened. And sometimes it is a of a consequence of this myriad of interventions that may or may not necessarily have been your decision, Nicole, or my decision, but now we have to clean up.

Dr. Nicole Rankins (10:16.348)

Mm-hmm.

Dr. Nicole Rankins (10:20.309)

Mm-hmm.

Dr. Nicole Rankins (10:24.619)

sure.

Dr. Nicole Rankins (10:28.299)

you

Dr. Nicole Rankins (10:33.619)

Mm-hmm.

Right.

Nathan Riley (10:39.534)

the mess that was left by, let's say, an unnecessary induction or maybe pushing that baby a little too hard or doing an poorly consented vaginal exam and now a person is a trustworthy. So there's so many elements to this and if you're not really in the system or trained within the system, I don't think it's easy for us to just push the whole thing aside because you don't know what doctors and LND nurses and whatnot are going through. So that gives me a really unique

Dr. Nicole Rankins (10:42.762)

Right.

Yeah.

Dr. Nicole Rankins (10:49.856)

Right.

Dr. Nicole Rankins (10:55.883)

Mm-hmm.

Dr. Nicole Rankins (11:05.983)

Right, Yeah.

Nathan Riley (11:08.952)

gift as an educator, a person who's counseling around providing the information to get informed consent on various things like a trial of labor after c-section. so with that, it allows me to now fill in the gaps. And that makes me very valuable, I think, as an asset to the community.

Dr. Nicole Rankins (11:17.707)

Right.

Dr. Nicole Rankins (11:25.643)

Definitely. I never want to be dismissive of people who haven't experienced our system, but it's always really easy to point out the problems from the sidelines. When you're in it, you can see that there are some...

Nathan Riley (11:34.36)

Yeah.

Dr. Nicole Rankins (11:42.525)

challenge. There are some true, true emergencies. Like birth is not risk free, unfortunately. I mean, wish it was, but it's not. And the interesting thing you said about emergency C-section, I tell people all the time, people say a lot, had emergency C-section. said, was there, was there 20 minutes to wait that it wasn't an emergency? Okay. yeah, yeah. Like emergency is we are ripping the cords out of the walls. We're running. so, so there's a lot of reframing that has to,

Nathan Riley (11:59.148)

Yeah, not an emergency. real emergency is an emergency.

Dr. Nicole Rankins (12:12.533)

happen and so thank you for saying that and appreciating that we walk a line that we can see the honestly in a way the full spectrum of everything that can happen from very straightforward to not straightforward at all to being straightforward to suddenly not being straightforward so I think that that definitely provides like a lot of perspective.

Now with that being said, every model has trade-offs. So what downsides or risks do you think that, cause I think we talk a lot about the risk of in hospital birth. A lot of it boils down to communication, honestly, if we would just talk to people and respect people's wishes, then it really, it's actually not that hard if we, you yeah, you know, so, but what are any downsides or risks you think women should realistically know about out of hospital birth?

Nathan Riley (12:35.907)

Yeah.

Nathan Riley (12:52.064)

I agree. Yeah. It's really pretty easy.

Nathan Riley (13:05.772)

Yeah, I mean, we don't have an operating room right on site. We don't have a blood bank right there. We don't have necessarily easy access to your venous system, your cardiovascular system. Meaning, you probably aren't going to have a HEP block and a pharmacy right across the hall or a room of medications. You may not have necessarily as many people watching over you. You're not going to have continuous monitoring. And there's also

you know, some upsides to all of those things. Because if I don't have, let's take it out of the home birth situation. Let's go to like South Sudan. A friend of mine works for Doctors Without Borders as a midwife. And if they can't handle it, they have to call in a surgeon to come in from afar and do a surgery. So you get actually very, very equipped with different ways of looking at a problem in order to solve it that doesn't really

Dr. Nicole Rankins (13:35.679)

Yes. Yeah.

Nathan Riley (14:02.926)

That can't doesn't have the benefit of a of an operating room right down the hallway So when you don't when you when you accept that I'm gonna do a home birth You're likely gonna have a midwife that is trained in a full complement of skills that can handle things for a baby that needs resuscitation Probably better than me and you to be frank They're gonna have you know some threshold for transferring to the hospital But we but they also are a little bit more creative because you hired them and you wanted to have a home birth

Dr. Nicole Rankins (14:07.243)

sure.

Nathan Riley (14:31.65)

because you didn't want the hospital environment. You wanted people to come into your turf, whereby you make the rules and your birth plan kind of starts the conversation as opposed to being like an extra little thing that maybe we consider and maybe we don't. So there's pros and cons, when women, including my wife, I'll just use my wife, because that's a great example. That was during COVID. And in the first birth, we went in at 10 centimeters. She had a very,

Dr. Nicole Rankins (14:35.647)

Right.

Dr. Nicole Rankins (14:42.539)

Mm-hmm.

Dr. Nicole Rankins (14:47.008)

Yep.

Dr. Nicole Rankins (14:52.459)

Sure.

Dr. Nicole Rankins (14:59.281)

okay. Right.

Nathan Riley (15:01.006)

was like, yes. Very fast labor. it was like, you she looked in the mirror, she told me, and she was like, I could be here for like 36 hours in this pain. So, but you know, let's buckle up for the ride. And she then started arching her back on the floor and we're at home still. And then we got in the tub and I was like, you know, you start to see, you're like, I'm going to just do a gentle exam here and feel fetus, like an unborn baby's head in the vulva, you know, like coming out of the entroitus. And I was like, okay.

Dr. Nicole Rankins (15:11.54)

Okay.

Dr. Nicole Rankins (15:15.562)

Right.

Dr. Nicole Rankins (15:18.933)

sure like things are. Right, right.

Nathan Riley (15:31.054)

in the car and go to the hospital and this and that and she then had a baby but when you're getting checked in they're like have you ever had a bowel obstruction and she's like 10 out of 10 like I'm like I used to work here here's my badge my old badge please get my wife into a room we're gonna have a baby right here yeah did you pick a pediatrician like we'll worry about that later lady like we gotta get her in a bed

Dr. Nicole Rankins (15:38.377)

Yeah, like I'm trying to look like, yeah.

I know. And we're like, what pharmacy do you use? And it's like, can we not let...

Nathan Riley (15:55.15)

So because of all that she decided why don't we have a home birth? was in the middle of COVID so there was the swabbing and labor and she was like I just don't want to deal with all of that and so as a part of that she's accepting okay something bad could happen here and we don't have the luxury of being right across the hall we're a couple minutes away from the hospital and and there's some you know degree of like admiration I have for that as well where it's like okay I know that the risk is low and I'm willing to take the chance I'm willing to spin the wheel

But there is this acceptance that, hey, there are certain problems that we can't address here, especially if you have risk factors. Let's say like a history of prior c-section, or some of my clients have multiple c-sections. Hey, there's a risk here. We have to be very, very clear. And they want to have a baby at home. Now, since you asked, there's a very interesting conversation here. There's somebody who came to me with four prior c-sections.

Dr. Nicole Rankins (16:40.329)

And they want to deliver at home with multiple C-sections? Okay.

Yeah.

Dr. Nicole Rankins (16:52.618)

Mm-hmm.

Nathan Riley (16:52.982)

And after that fourth baby, you know, their, their child went to the six month pediatrics visit and got all the shots and 72 hours later was paralyzed from the neck down and had a feeding tube, had a reading to him. She was never, you know, this anti-vax language that people use. don't like it because she's like, I was never that, but I don't know what else it was and nobody's willing to help. And I can't work now because my baby needs full caretaker support 24 hours a day in our families and like financial dire straits here.

Dr. Nicole Rankins (17:10.581)

Right.

Dr. Nicole Rankins (17:21.387)

Sure.

Nathan Riley (17:21.9)

She said, I just won't ever go back to a hospital. And it was in another state. She came here and she wanted to have a home birth. And that was the story. Now she didn't actually end up giving birth at home. She ended up ultimately going to the hospital. It's a different story for a different time. the point here is this word autonomy is, hey, listen, if whatever it is that you want, let me see if we can rally our resources around you versus, hey, the policy says I can't do that, sorry. And so I can counsel and counsel and counsel. And somebody might say,

Dr. Nicole Rankins (17:25.407)

Right.

Dr. Nicole Rankins (17:36.362)

Right.

Dr. Nicole Rankins (17:46.687)

Right, right.

Nathan Riley (17:51.0)

Well, if you're not gonna attend my birth, I'll do this without anybody. Because over my dead body, am I gonna go back into the hospital and have another C-section? That's a really complicated conversation that my palliative care training actually helps me elicit. Like, what is it that you're most afraid of? What are you really hoping for? And when you have the breadth of time to do that, sometimes when we have somebody who's maybe a quote, inappropriate candidate for home birth, I'm using air quotes on my end, sometimes just hearing their story is enough for us to say, hey, listen, I know it wasn't that way.

Dr. Nicole Rankins (17:54.421)

Mm-hmm. Mm-hmm. Mm-hmm.

Dr. Nicole Rankins (18:04.987)

Mm-hmm. Right.

Dr. Nicole Rankins (18:13.685)

Mm-hmm.

Nathan Riley (18:20.482)

But my friend Nicole is really, really supportive of people like you, know, boys that are afraid of being in the hospital. I would love for you to meet with her. And then we can talk about how we can do this differently in the hospital so that you're not as traumatized this time around or whatever the story might be. So it's not just, whatever you want, let's just do it. Let's have a real conversation. And if this is really what you want, I'm willing to do that. But you have to appreciate that there's certain things that I just can't do at

Dr. Nicole Rankins (18:24.65)

Right.

Dr. Nicole Rankins (18:28.33)

Right.

Right. Sure. Sure. Right. Right. Yeah. Yeah. Yeah.

Dr. Nicole Rankins (18:47.145)

Yeah, definitely. And then how do you navigate that? I know I don't think we're, I think we're not getting off topic of the question, but how do you navigate that in the context of malpractice? Because people definitely worry about that. Like, because if something goes wrong, you know, are you, are you going to get sued? Do you even carry malpractice insurance? Like how do you navigate that?

Nathan Riley (19:01.72)

Totally.

Nathan Riley (19:09.995)

Let me just say that when I've...

Well, no, I don't carry malpractice coverage. The fact that I'm delaying in my response is going to be obvious enough. But the reason is that I support midwives across the country. And so I'm technically assuming liability on behalf of them as well. But I have a lot of really, really clearly discerning language around what I can and can't do as a remote collaborative physician. And the home birth thing is very hard to get malpractice coverage for. would be paying.

Dr. Nicole Rankins (19:23.947)

Right.

huh. Right?

Dr. Nicole Rankins (19:32.999)

Mm-hmm. Right. Sure.

Dr. Nicole Rankins (19:41.823)

Mm-hmm.

Nathan Riley (19:42.798)

probably, I don't know, 100 grand out of pocket a year. mean, it's, they weren't even willing to quote me. They're like, it's so, our actuaries don't even know how to tabulate this risk. Therefore we can't really quote you. But what I will say is that when you have developed a really great relationship with a family and you've really impressed upon them that there are certain things in your control, like eating really healthy food and getting a lot of sleep. And we can do all this preparation over nine, 10 months, right?

Dr. Nicole Rankins (19:45.291)

Mmm.

Dr. Nicole Rankins (19:51.147)

Sure. Okay.

Dr. Nicole Rankins (20:00.457)

Mm-hmm.

Nathan Riley (20:12.236)

When you develop that relationship with them, not only are we lowering them below the average risk that we present to people of bad things happening, we also increase the risk of good things happening. And that relationship oftentimes is like, hey, I've done everything I can. You also have to own the outcomes of your decisions, but I'm here to support you if this is what you decide to do. And when a person starts to assume that responsibility, the likelihood of you being sued by the client is extremely low.

Dr. Nicole Rankins (20:19.485)

Mm-hmm. Sure.

Dr. Nicole Rankins (20:29.203)

Right. Right.

Dr. Nicole Rankins (20:34.421)

Mm-hmm. Mm-hmm.

Yeah, yeah, yeah.

Nathan Riley (20:40.514)

by the hospital or somebody else reporting you to the board, that's a totally different story. But I try to be friendly in the sandbox at every opportunity.

Dr. Nicole Rankins (20:45.065)

Right, right.

Sure, yeah, yeah, yeah. Okay, so a couple things. Have people threatened to report you for what you do? You mentioned that.

Nathan Riley (21:01.39)

It's usually on the social media where people say they should take away your license because also something like hey I have a client who went on the walls protocol which is a really derived from MS and autoimmune conditions. They went on the walls protocol and their endometriosis improved almost to the point where they don't even have symptoms off medication. And so you know I really think endometriosis is there's more to this than

Dr. Nicole Rankins (21:04.612)

Okay. Okay.

Dr. Nicole Rankins (21:14.396)

Mm-hmm

Dr. Nicole Rankins (21:20.33)

Right.

Nathan Riley (21:26.478)

just a deficiency of continuous hormonal contraception or something, a G or H analog or whatever. And I wonder if we can actually help to reverse this with lifestyle and environmental change. And people will say, to say that this is our fault, it's like, no, that's not what I'm saying. I'm saying that we actually probably have far more, there's probably far more complexity here. But when people hear unpopular opinions, they'll use

Dr. Nicole Rankins (21:32.255)

Mm-hmm.

Dr. Nicole Rankins (21:37.29)

Right.

Dr. Nicole Rankins (21:44.489)

Yeah.

Nathan Riley (21:55.51)

loose threats like that. Like you should have your license taken away. I'm reporting you to the board. And like the board I'm sure is like, this isn't something we're investigating. Like nobody got hurt from this. Like it's just, you know, people complaining. But I haven't had anybody in like my actual practice ever threaten anything. We have a very good relationship. Yeah.

Dr. Nicole Rankins (21:58.058)

Right. Right.

Dr. Nicole Rankins (22:03.755)

Sure, yeah, right, right.

Dr. Nicole Rankins (22:11.059)

Yeah. Okay. Okay. Good. That's good. That's good. And then I want to touch upon something that you said that I think is really important. You said there's some element of owning the consequences of your choices. So that's a big one because especially in obstetrics, they're always, you know, there's this somebody's got to be

Nathan Riley (22:26.392)

Yeah.

Dr. Nicole Rankins (22:36.895)

guilty or responsible for something happens. And to be honest, it often is not framed as the patient or the person and their own choices. So how do you navigate that? And have you ever seen any outcomes where people did have to sit with this unfortunate thing happened because of this choice?

Nathan Riley (23:01.504)

Yeah, yeah. Well, okay, so if we were to take the most extreme example, and this is something I heard all the time when I was still in the hospital system, like, if we don't act now, your baby could die. That could be true. But in the throes of labor, I've never been in labor, Nicole, I know you have, you've got children. Even knowing what my wife was like when she was in labor with our kids, that is not a time for you to be ascertaining risk and figuring out.

Dr. Nicole Rankins (23:11.711)

Mm-hmm. Mm-hmm.

Right, like that.

Dr. Nicole Rankins (23:22.025)

Mm-hmm.

Dr. Nicole Rankins (23:27.968)

Yeah.

Nathan Riley (23:28.814)

the numbers and doing all of the calculations, that's a time where you're really not, you're kind of dissociated. You're in another space, you're doing this inner kind of work. This is, just learning this second hand from women that I get to know. And so if I go in and I use language like that, you could say it's a little bit coercive, but it's also a reflection of what I'm afraid of. Like, hey, I'm really afraid and I don't want this baby to die. I need you to do this thing now because we have

Dr. Nicole Rankins (23:35.647)

Mm-hmm. Mm-hmm.

Yeah.

Dr. Nicole Rankins (23:52.363)

Sure. Right. Right. Right. Right. It's also probably not true, to be honest. Right. Yeah. Yeah.

Nathan Riley (23:57.44)

a few minutes, like the emergency sort of language starts coming through. And it's it's probably not true. I'm using this because I feel like people have heard this before. So it's like, so if I get worried and I walk in, or let's say you're not, you're just in labor and I say, Hey, I'm Dr. Riley. I need to check on the baby. And I force your legs open and I shove my hand in there. That's not good practice. In fact, I would consider that malpractice. so all of this is like, Hey, an authority figure is saying that there's this thing.

Dr. Nicole Rankins (24:21.642)

Yeah.

Nathan Riley (24:27.278)

It's easy to just go along with that unless you've done a lot of practice saying no thank you in your life. And young women especially, I think, have spent so much of their time outsourcing their power and fawning in order to get through life. Like this is little girls. My wife is Mexican. So she's passable as a white woman. But if these little girls, they're...

Dr. Nicole Rankins (24:39.305)

Yes. Yes. Yeah.

Dr. Nicole Rankins (24:48.318)

Mm-hmm.

Nathan Riley (24:56.87)

I won't bring, I won't bring race into it, but there is a lot of reasons why these little girls are going to have to navigate this world in a different way than their very white dad will, I'll just say that. And my wife used to be a bartender walking home with mace in her hand or key chain in her hand. There is a real threat for young women who have to smile and kind of get through their life in order to.

Dr. Nicole Rankins (25:06.325)

Mm-hmm.

Dr. Nicole Rankins (25:24.287)

Yep. Yeah.

Nathan Riley (25:24.984)

preserve themselves, preserve their life at times. And now we're demanding that they stand up to the authority when they're in the middle of labor. And I just don't think it's a fair expectation of women. But furthermore, we now are, you're in a very high stakes sort of gambit here. And I'm using language that makes it sound like if you don't go along with what I'm doing, that something terrible is gonna happen. That we also don't have a really great social support system for, like a baby that dies or whatever.

Dr. Nicole Rankins (25:32.059)

Mm-hmm. Mm-hmm.

Mm-hmm. Mm-hmm.

Dr. Nicole Rankins (25:49.354)

Right.

Dr. Nicole Rankins (25:53.6)

Right.

Nathan Riley (25:54.828)

So all of this is to say that

Nathan Riley (26:05.326)

How do we word this? I know we can edit some of this out, but all of this is to say that, OK, let's reframe the question. you had asked if we, so when we say that it's a person's responsibility, that becomes very, hard. So if we can all agree that there are certain things, bad things that could happen in childbirth.

Dr. Nicole Rankins (26:09.162)

Yeah.

Dr. Nicole Rankins (26:22.516)

Mm-hmm.

Dr. Nicole Rankins (26:33.705)

Mm-hmm.

Nathan Riley (26:33.942)

It feels a lot different if my wife agrees to something and the bad thing happens, but she felt like it was the right decision to her versus she agreed to something and she actually felt deep down that this is intuitively not what she wants to do. So if there's some risk, allowing people to assume responsibility, meaning, hey, I will do whatever it is that you want. Here are my recommendations. I trust your family's conversations around what to do.

Dr. Nicole Rankins (26:41.162)

Right.

Dr. Nicole Rankins (26:45.578)

Right.

Dr. Nicole Rankins (26:56.928)

Mm-hmm.

Dr. Nicole Rankins (27:00.799)

Right.

Nathan Riley (27:01.772)

Honoring that is really what autonomy means. Like if you're providing me consent, better be, I really would hope that it's something that you really agree to because there's still no guarantee that we have zero bad outcomes. If I take you for that C-section and you have an amniotic fluid embolism that you otherwise may have not experienced, I can say, well, you know, this is a part of what a C-section is. And the dad might say, we didn't want to do this, but you said that the baby might die and now my wife's on a ventilator in the hospital.

Dr. Nicole Rankins (27:04.404)

Mm-hmm.

Dr. Nicole Rankins (27:12.831)

Right.

Dr. Nicole Rankins (27:16.523)

Mm-hmm.

Dr. Nicole Rankins (27:23.679)

Right.

Dr. Nicole Rankins (27:27.328)

Mm-hmm.

Dr. Nicole Rankins (27:31.049)

Right, right.

Nathan Riley (27:31.662)

So we have this conflict between what our threshold for risk is and what a family's threshold for risk is. And sometimes it's hard to elicit that threshold in the few moments that we get to meet somebody before we have to take them back for a procedure. ultimately, I think a goal of changing maternity care, if we want to change it, is to really put these clients, these families, back at the center of this conversation and let them know that ultimately we do appreciate your autonomy.

Dr. Nicole Rankins (27:46.485)

Yeah.

Dr. Nicole Rankins (27:56.715)

Mm-hmm.

Nathan Riley (28:01.378)

But having some autonomy also requires that you own the outcomes of your decisions. And you can only really make this decision if we are fully transparent around risks, benefits, alternatives, and make recommendations, and then also support you in that decision, or help you find somebody who can support you in whatever that decision is. And when we start to mess with that algorithm a little bit, that's where we have people who want to blame somebody else because they didn't really feel like they agreed with that decision to begin with.

Dr. Nicole Rankins (28:11.733)

Mm-hmm.

Dr. Nicole Rankins (28:21.215)

Yeah.

Okay.

Dr. Nicole Rankins (28:30.769)

Right. Yeah.

Nathan Riley (28:31.714)

So this is a whole hour of conversation here, this piece, but that's, we can cut and splice that together however we'd like to get a little bit more.

Dr. Nicole Rankins (28:34.397)

it for sure.

Dr. Nicole Rankins (28:39.283)

Yeah, no, no, no. That totally makes sense. I often say that when people are dissatisfied with their birth experience, it's often because they felt like they didn't have a role in decisions that led to the outcomes, or they weren't anticipating that things could go differently and they didn't know how to navigate it. So it's just a lot different when there's a situation of, hey, we need to do a C-section right now because

Nathan Riley (29:00.718)

you

Dr. Nicole Rankins (29:09.617)

your baby's gonna die instead of saying something like, hey, I'm looking at this baby's heart rate tracing, I'm concerned because there are drops in the heart rate, that can mean the baby's in distress. Most of the time it doesn't, but I can't guarantee that it's not part of that 10 or 15 % where your baby is in distress. So at this point, let's talk about C-section. Just small reframes can help.

Nathan Riley (29:34.019)

Sure.

Dr. Nicole Rankins (29:34.155)

with that and I think it helps people to feel more comfortable with the decisions. Either way, even if an outcome isn't exactly what they anticipated or wasn't good, if they felt like they were involved and they had all the information, then it's like a little bit paternalistic to think that women can't accept the consequences of their choices. Yeah.

Nathan Riley (30:00.05)

little bit. But see, original question was, like we as the provider team, you know, the nurses, the doctors, we know that if something bad happens, case management is going to get involved. this department, risk management, yeah, they get involved from the, know, the HR office down in the basement. And they now say, okay, don't talk to the client, don't do this. They're trying to mitigate any potential that the institution is going to be held liable for what happened. And

Dr. Nicole Rankins (30:07.413)

Mm-hmm.

Dr. Nicole Rankins (30:12.255)

Yep, risk management, all the things, yeah.

Dr. Nicole Rankins (30:17.631)

Mm-hmm.

Mm.

Nathan Riley (30:29.112)

They're right. But it's not because we are doing bad things. It's because we don't have a relationship, and this family doesn't feel like they had an equal say at the table. So if we can do anything to promote that, then this whole finger pointing thing becomes a little bit less relevant. And ultimately, like,

Dr. Nicole Rankins (30:34.869)

Mm-hmm.

Dr. Nicole Rankins (30:39.669)

Yeah, yeah.

Nathan Riley (30:50.232)

you know, from an early age, young women going through life, having to do what I described, but also this outsourcing of power to politicians and policymakers as opposed to actually owning that, if your little kid rides a bike without a helmet, they might hurt and, you know, bonk their head and we might have the injury here. Like that's also a part of this. So you ultimately are going to be the parent of this child. And whatever happens, like you have to own that. If it's a vaccine injury or if the kid gets some sort of disease that vaccines are meant to prevent.

Dr. Nicole Rankins (31:04.522)

Right.

Right.

Mm-hmm.

Mm-hmm.

Nathan Riley (31:19.434)

Either of those outcomes are fine if you as the parent are fully aware of all of the risks and the benefits. So again, this is a really, really complicated conversation for people, but in our overly litigious society, everybody's afraid of everybody. And I think we need to kind of bridge that gap and really make this more of a sort of a communal experience, this childbirth thing.

Dr. Nicole Rankins (31:23.135)

Right, right.

Dr. Nicole Rankins (31:34.271)

Yeah.

Dr. Nicole Rankins (31:39.849)

Yeah, definitely, definitely, for sure, for sure. So what do you think hospital birth and out of hospital birth, what can we learn from each other?

Nathan Riley (31:52.042)

I think we could probably learn from one another that the more that we intervene, the more challenges I think we end up finding later in the childbirth experience. So the one thing I've really learned from midwives is because they weren't trained on using the CRBs necessarily, and all of the ripening agents and the right infusion rates for Pitocin, and all of the, honestly, even all of the management for hemorrhage, like going back to the South Sudan experience.

Dr. Nicole Rankins (32:16.991)

Mm-hmm.

Mm-hmm.

Nathan Riley (32:19.85)

If you don't have the ability to open up the abdomen and throw some B-linch or O'Leary stitches in there or send them down to IR, you're gonna do everything in your power to avoid a hemorrhage. So the biggest thing that we in the conventional system can learn from the out of hospital birth community is that the less that we intervene, generally the less problems we have to solve. And that's an unfortunate truth in reality for those of us who are trained primarily as interventionists.

Dr. Nicole Rankins (32:24.651)

Mm-hmm.

Dr. Nicole Rankins (32:46.259)

Right. Yeah, that's that. That is for sure. I always say, you know, for a hospital birth, the first intervention is actually going to the hospital because we just it's hard for us to just kind of like.

Nathan Riley (32:58.478)

It really is, yeah.

Dr. Nicole Rankins (33:03.423)

let things unfold. I think where I work, we do a good job of it. But it's hard in general, the system is for a number of reasons, whether it's that's because what we're used to, or there's an element of throughput and getting people in and through, know, all of those things happen. yeah, if we could.

Nathan Riley (33:16.532)

getting them in and out. Yeah, yeah. It's very refreshing to hear you say that and I want to kind of like double down on what you said. It's actually not really the doctors that are responsible for this. Yes, they were trained in these things, but most doctors don't want to be intervening in every step of the way. It's actually extra work for us to do that. But there's many other powers or influences that are driving this practice in this maternity care system. So it's not just the

Dr. Nicole Rankins (33:33.929)

Right? Right.

Dr. Nicole Rankins (33:41.769)

Yeah. Yeah.

Nathan Riley (33:46.552)

doctors that are just hell-bent on doing C-sections. Like, that's just not real. I just want to clear the air on that.

Dr. Nicole Rankins (33:47.21)

Right.

Dr. Nicole Rankins (33:51.135)

Yeah. Yeah. Thank you. Thank. And if we could also like, we're not doing it because of the money either. That's another one for doing C-sections for money. Like, yeah, like we, yeah, like it just doesn't, it just doesn't come up. So I wish that, that, that story would die also. So I do want to talk a second about vaginal breach because this is a big topic and I think

Nathan Riley (33:58.914)

I where do people get that? I've never gotten paid more because I did see that.

Nathan Riley (34:13.463)

please.

Dr. Nicole Rankins (34:17.727)

We're starting to shift and hopefully go back to doing more vaginal breach. I feel comfortable definitely doing it for a second twin for, and maybe in a Frank Breach presentation, I've done a few where it's like, okay, mom is here, the baby's gonna come, like you can't do a C-section when the baby's on the perineum, so we're gonna have to do this thing. So what are your thoughts about vaginal breach and how we need to shift our approach on that?

Nathan Riley (34:44.876)

Yeah, to put it the most simply, because I know I can be little bit long-winded about this topic.

A butt down baby is going to have almost no difference in risk than a head down baby in the hands of a skilled provider. So how many times, Nicole, have you seen a shoulder dystocia, like a real shoulder dystocia? That's another thing. People say it was a shoulder. Like, no, a real shoulder dystocia is scary as hell. But how many?

Dr. Nicole Rankins (35:08.809)

Right, yeah, yeah, yeah, yeah. Not, I mean, really super scared, maybe not even five times in my whole career. Mm-hmm, yeah.

Nathan Riley (35:16.418)

Yeah, yeah. Like a handful. But we have like, what, seven maneuvers that we can do to help relieve that. And we know that there are some serious issues, know, palsies and whatnot, that can develop. We can have broken clavicles. We can have a baby that needs resuscitation and NICU stay. Like, we know that. So we practice a head down, a cephalic dystocia. And we do it in like skills and drills all the time. It's like a constant thing you do in residency, right?

Dr. Nicole Rankins (35:21.515)

Mm-hmm. Mm-hmm.

Dr. Nicole Rankins (35:26.985)

Yeah.

Dr. Nicole Rankins (35:41.311)

Mm-hmm.

Nathan Riley (35:43.616)

And everybody knows that. You could ring it off. It's a part of your surgical boards. Like, tell me how to resolve a shoulder dissociation. You do this and then this and then this and then this and whatever. Why aren't we teaching that for vaginal breach? The reason is, of course, back in 2000, there was this big trial. It a multi-center study. I think it was in, was it in the New England Journal, the term breach trial? can't remember. But massive trial that found that there was, this was like the sort of the study to end all controversy around this.

Dr. Nicole Rankins (35:46.208)

Right.

Dr. Nicole Rankins (35:51.402)

Yep.

Dr. Nicole Rankins (36:03.217)

Mm-hmm. I believe so. Yeah.

Nathan Riley (36:12.802)

But they basically concluded, the authors concluded, perhaps inappropriately, but we can talk about that, that a baby that is born by C-section for a breech presentation is going to do better than a baby that is born vaginally in the breech position. And when you consider that at 37 weeks, around 3 to 4 % of babies are going to be butt down, right? We're not talking about footling here. We're talking about a term baby, not like a 32-weeker whose feet are dangling out. Like a term baby is crunched up in there. And sometimes the legs are piked up and franked. Sometimes it's complete and like,

Dr. Nicole Rankins (36:34.729)

Right. Sure. Right.

Nathan Riley (36:42.188)

sitting, you know, crisscross applesauce. But this study basically put the kibosh on any residency training. And so now we have a de-skilled obstetrics workforce that has never maybe even seen a vaginal breach, let alone have they practiced the maneuvers to relieve a nuchal arm or a hyper, you know, hyper extended neck, whatever. So I host these conferences every year and I bring in some big hitters that have done so many breaches, like hundreds of breaches, and we walk through these realistic.

Dr. Nicole Rankins (36:48.491)

Mm-hmm.

Dr. Nicole Rankins (36:52.843)

Correct.

Mm-hmm. Mm-hmm. Mm-hmm.

Nathan Riley (37:10.094)

know, simulations on mannequins. And it turns out midwives are getting quite good at this, where the OBs are just resistant to practicing it. Why? Well, because we got really good at C-sections. And we all kind of live in this fear that the baby's head's going to get trapped and all this other stuff. The only time I've ever actually been thoughtful about, ooh, is this head going to be stuck, is whenever like a 28-weeker goes into labor and their feet are because this baby's head is huge compared to the little body.

Dr. Nicole Rankins (37:13.611)

Mm.

Right.

Yeah.

Dr. Nicole Rankins (37:23.851)

Mm-hmm.

Dr. Nicole Rankins (37:30.826)

Right.

Yeah. Yep. Yeah. Yeah.

Nathan Riley (37:37.942)

I've never once seen a head get stuck in a knock on wood. I've attended breaches. They somehow find me when I'm doing home births. My best friend and business partner just called me to her labor and there's a butt coming out and she was like, there's a breach. And I was like, yeah, we're going to be fine. And she had this breach for me. was fine. She was like, protect my perineum, you know? And I mean, in the moment she was like, holy smokes, like the universe is handing me this and we teach people, you know, some of these skills. So.

Dr. Nicole Rankins (37:45.418)

Right.

in.

Dr. Nicole Rankins (37:51.953)

Okay. Right. Right.

Dr. Nicole Rankins (38:05.044)

right.

Nathan Riley (38:05.614)

When that term breach trial came to fruition, it was published and started circulating. Many residents never got to do it, probably including yourself. I think you and I are probably roughly the same age. Fast forward, and the aftermath of that was not only did the US residents stop getting trained and the older docs stopped doing it because now it's a liability to the institution based on this one study. And since when does one study change our practice?

Dr. Nicole Rankins (38:15.691)

Correct.

Dr. Nicole Rankins (38:28.277)

Yeah.

Nathan Riley (38:33.526)

There's another one that rhymes with the Schmarive trial, but some of these studies, they rock us so badly in the US, and meanwhile in Europe, for doctors that are still training in how to attend to a vaginal breach, as you would a head down baby that ends up with a dystocia, the results are roughly the same. I mean, it's a wash. So they've done sub-analyses on the term breach trial, and there were certain people that were...

Dr. Nicole Rankins (38:36.201)

Yeah.

Dr. Nicole Rankins (38:53.621)

Right.

Nathan Riley (38:58.932)

know, put into different groups that shouldn't have been there in the first place. One baby that died in the vaginal breach group, for example, had demised before she gave birth. So that obviously skews the numbers whenever the incidence of a demise or a, let's say a bad outcome with a vaginal breach or a head down baby or a C-section baby, when those bad outcomes are so infrequent and now you have one that was, you know, randomized to the wrong group. We have...

Dr. Nicole Rankins (39:07.644)

Mmm. Sure.

Dr. Nicole Rankins (39:16.523)

Right.

Nathan Riley (39:26.36)

You know, we have data that doesn't necessarily serve us, but the damage has been done. So I think that I would love to get as many OBGYNs who are interested, trained in doing this, and then get the institutions to accept that we probably got this wrong. Because what we're missing in this big conversation is yes, even if, even if the term breach trial results were infallible, perfectly done randomized control trial, or yeah, whatever, perfectly done RCT.

Dr. Nicole Rankins (39:30.144)

Yeah.

Dr. Nicole Rankins (39:37.384)

Mm-hmm.

Dr. Nicole Rankins (39:40.683)

Right.

Dr. Nicole Rankins (39:49.727)

Mm-hmm.

Nathan Riley (39:56.494)

We have to consider the risk to all of the future pregnancies because we did a primary cesarean in your first pregnancy at 25. Say you're an Amish woman. We did a primary C-section for breach at age 21. We've now set you up for a really hard conversation around having repeat C-sections at risk of abnormal placentation, including the accretive spectrum disorder, including the likelihood of previa. All of these other things need to factor into the counseling.

Dr. Nicole Rankins (40:04.32)

Right.

Dr. Nicole Rankins (40:09.685)

Mm-hmm.

Dr. Nicole Rankins (40:13.899)

Mm-hmm.

Nathan Riley (40:24.664)

But instead what we say is, you've got a breach, let's schedule you for a C-section. Like we need to actually have more conversation around what this might mean. And if a woman decides, I want to have my baby vaginally, institutions need to support that. And they need to support doctors like you who are saying, hey, I'm willing to do this if this is what the person wants. Because we save ourselves a C-section. And that is better for the immediate postpartum recovery, better for neonatal maternal bonding. I mean, we could go on and on and about.

Dr. Nicole Rankins (40:28.117)

Right.

Dr. Nicole Rankins (40:38.379)

Mm-hmm.

Dr. Nicole Rankins (40:42.186)

Right.

Dr. Nicole Rankins (40:51.657)

Yeah, yeah, for sure, for sure, for sure. So if you could wave, actually let me back up and ask another question. Do you work, this is like random, just popped in my head. Do you work collaboratively with any OBs in the hospital? Do you feel like you have good relationships with any OBs in the hospital who are comfortable with what you do in supporting your work?

Nathan Riley (41:14.958)

I do. and as I'm doing these conferences, we have more more OBs that are showing up. Actually, a lot of hospitalists, interestingly. And so I have more and more doctors, even some locally here who attended to my wife in her first, you the hospital birth. I have some. The problem is that there are far more, like, it's a good person. We could go out to dinner and they might be like, yes, yes, yes, yes, But...

Dr. Nicole Rankins (41:25.483)

Mm.

Dr. Nicole Rankins (41:32.191)

Right.

Dr. Nicole Rankins (41:42.879)

Right.

Nathan Riley (41:44.738)

the practice, you my colleagues in my practice or the hospital policies won't let me do that. And when people are like, doctors need to push back, I agree. And the individual who pushes back can very easily be punished. a very brief story is there's an academic OB-GYN up in the Northwest who had a woman come in. She was rumping, meaning instead of crowning, the baby's butt is coming out and she declined C-section.

Dr. Nicole Rankins (41:47.036)

Yeah.

Yeah.

Dr. Nicole Rankins (41:56.893)

Mm-hmm. Yeah.

Dr. Nicole Rankins (42:11.051)

Right? Right.

Nathan Riley (42:13.238)

So this OBGYN, just like me and you, she said, OK, we'll do a vaginal breach. Vaginal breach happened. There was a whole circus there. Everybody's going to see because nobody's ever seen it. It's so crazy. And the woman went home with her baby the next day. Beautiful birth, just like we would say with a head down baby. Well, the next week she got a letter from the chair of the department who said, based on your demonstration that you value patient autonomy over the institution's liability, we're enacting these punitive measures. That should never happen.

Dr. Nicole Rankins (42:21.899)

sure.

Right, right, right, right.

Nathan Riley (42:43.234)

And I don't know how ever, but she has a paper that says this. She's like, Nath, she called me up one day out of the blue. Like she didn't know who I was, but she was like, I need to talk to you about something because nobody will hear this. I was like, is what is on the horizon for anybody who wants to push back a little bit and prioritize these people that we're here to take care of. I understand that the market or the corporate influences that are distracting from OBGYNs getting this training. I get it. Like that is really tough. And that is a

Dr. Nicole Rankins (42:43.444)

ever.

Dr. Nicole Rankins (42:50.114)

my god. Right. Right. Right.

Dr. Nicole Rankins (42:58.889)

Yeah.

Dr. Nicole Rankins (43:10.101)

Right.

Nathan Riley (43:12.554)

way bigger problem than I have the tools to solve. And this is at major academic center, Nicole. This is really discouraging for me. So to answer your question, these OBJU ends are like, great, but if I'm like, hey, I've got a four-time C-section who wants to have a home birth, can I just call on you if I need you? no, no, no, my practice would never go for that. But this is what you would want her to do. no, no, she decided to have a home birth. Well, we need to be more integrative here. We need to be more collaborative because

Dr. Nicole Rankins (43:15.625)

Yeah. Yeah. Right.

Dr. Nicole Rankins (43:25.993)

Mm-hmm. Mm-hmm. Right. Right.

Dr. Nicole Rankins (43:37.514)

Right.

Yeah. Yeah.

Nathan Riley (43:42.35)

It would be really nice for me to say, listen, this is a perfect scenario. I'm an OB-GYN. I have a midwife assisting me. And there's an OB two miles away. Get an Airbnb at this place. And then we're even closer to the hospital. And they will be there to receive you and take you to the OR if we need them. But people don't want to do that because of these other influences. So yes and no is the answer to your question.

Dr. Nicole Rankins (43:46.155)

Mm-hmm.

Dr. Nicole Rankins (43:53.131)

Right? Right.

Dr. Nicole Rankins (43:58.719)

Right, right.

of the, yeah, yeah, yeah, yeah. I'm fortunate that I'm in a, our hospital supports, I mean, I actually have gone out to the birth centers in my community and met with the medwives. I want people, I want you to send us people early. Please don't drop the train wreck if we can avoid it on our doorstep. And it seems to be working.

Well, but now when you bring up the situation of there's somebody who wants to do a home birth at the four C sections, I think in my community, the midwives here wouldn't feel comfortable doing something like that. But I hope, I think there's some element of...

this is where we as OBGYNs to some degree, we have to stand on our training. yes, it can be difficult with somebody who was laboring at home and comes in and you have to take them for a STAT C-section after four C-section. Yes, that is hard. But to a degree, that's also what we should be the experts in. And we have to accept that that's some part of our responsibility. At least that's my opinion.

Nathan Riley (45:12.942)

Yeah, yeah. mean, the only I do home births is sometimes people come along with medical histories, or they're in like a midwife desert, and there's not even a hospital nearby where they live in northern Indiana or whatever. And so they have a medical history or something about their current pregnancy where the midwives are either strapped based on their licensing or they're like, this is just too hot for me to handle. And then I say,

Dr. Nicole Rankins (45:22.635)

Mm-hmm. Right.

Dr. Nicole Rankins (45:34.132)

Mm-hmm.

Dr. Nicole Rankins (45:37.611)

Right. Yeah, yeah.

Nathan Riley (45:42.318)

All right, we'll take that on. You two prior c-sections, history of help, history of severe preeclampsia, we get them dialed in from a lifestyle standpoint and they're just fine and they have a vaginal birth after two c-sections in their health with me. But we have a hospital nearby if we need it. yeah, that's also a part of our training is like knowing when to transfer and knowing when, we actually, need my colleagues in the hospital right now.

Dr. Nicole Rankins (45:43.69)

Right.

Mm-hmm.

Dr. Nicole Rankins (45:54.091)

Sure, sure, Right, right.

Dr. Nicole Rankins (46:04.649)

Yeah, yeah, yeah, definitely, definitely, definitely. So as we're getting towards the end here, I think I know the answer to this question. If you could wave a wand, change one thing about US maternity care, what would it be?

Nathan Riley (46:21.162)

I think that midwifery care needs to be the default for most women and then fortunately you and I have our surgical skills to jump in whenever pathology arises, real pathology. And I don't see pregnancy as disease, I don't see birth as a procedure. I actually feel like if we could get back to that or at least give women an honest shot to choose between those two paths, I think everything would get better. And we still have our jobs, the MFM still has their jobs, the...

Dr. Nicole Rankins (46:23.359)

Right, yeah.

Dr. Nicole Rankins (46:27.605)

Yeah. Yeah. Yeah.

Dr. Nicole Rankins (46:40.543)

Mm-hmm. Mm-hmm. Yeah, yeah. Right. Right. Right. Right. Right.

Nathan Riley (46:49.482)

IR people and the other people at Crossco, everybody will still have a role if we need them, but women, say least 85%, could probably get by and have a much more beautiful experience with midwives.

Dr. Nicole Rankins (47:00.351)

Yeah, yeah. think or I don't know that I'll ever happen in the US to be honest with you. Yeah, but.

Nathan Riley (47:05.762)

I don't think so. Not in our lifetime.

Dr. Nicole Rankins (47:07.593)

Yeah, no, yeah, I agree. I do think, though, that we as physicians can adopt some midwifery practices and we can start to learn how to do that. think to some degree that some of us who who are more open, who said what we've done is adopt more midwifery practices. So I think it's possible. And it's the compromise that will happen in the middle. And so we can really, you know, make the foundation. But I agree.

the model just works better.

Nathan Riley (47:40.866)

Yeah, yeah, and I do want to also point to like an elephant in the room, which is that there's a lot of women who don't feel safe in the care of hospital practitioners, namely women of color. And so as long as we're not able or willing to like name this for what it is and realize that like in Louisiana, it's not that we don't have good doctors down there or good whatever, it's that there's actually also this underlying threat of racism.

Dr. Nicole Rankins (47:46.645)

Mm-hmm.

Dr. Nicole Rankins (47:52.811)

Mm-hmm.

Dr. Nicole Rankins (47:58.357)

Mm-hmm.

Dr. Nicole Rankins (48:03.455)

Right.

Nathan Riley (48:09.014)

in the former antebellum south, which doesn't seem like it has changed much. And so that's another part of my work. I've got a lot of black birth worker friends who are really struggling out there in these rural obstetric deserts. I don't know how we can move forward without midwives in that situation. Providers that look like the clients that they're taking care of. But that's another very complicated Gordian knot that I'm not.

Dr. Nicole Rankins (48:09.109)

Yeah.

Yeah.

Dr. Nicole Rankins (48:26.173)

Mm-hmm. Yeah.

Dr. Nicole Rankins (48:32.703)

Yeah. Yeah.

Nathan Riley (48:37.144)

prepared to unpack. just don't have the language or tools to fully appreciate it because I haven't lived that life. But I know it's thing.

Dr. Nicole Rankins (48:41.623)

Right, right, right. Yeah. So then what would you say if you had to pick a couple pieces of advice for someone who's going to be delivering the hospital system? Because as you mentioned, like 98 % of people do. So what are your top recommendations for someone?

Nathan Riley (49:03.638)

I think practicing no, going back to that sort of portion of our conversation where I was kind of tripping on myself because it's so complicated. Practicing saying no thank you can be very powerful. It actually puts me on my heels if somebody confidently says, know what, I appreciate that, but no thank you, I think we're going to do it this way. That actually helps me take care of you because it reminds me that you have the capacity to make decisions for yourself. And we were kind of modeled that you have to make the decisions for people because they're either

Dr. Nicole Rankins (49:15.423)

Mm-hmm.

Dr. Nicole Rankins (49:21.835)

Right.

Nathan Riley (49:32.96)

uneducated or unwilling to make decisions for themselves and that isn't But if you go in and you're just caving to every request, then it kind of feels like this paternalistic way of taking care of people in labor, families in labor. It just tends to, we sort of become adapted to that. So practicing saying no thank you to your friends about, I don't want to go to the movies tonight because I'm tired. Instead of saying, I have this or that, just be very clear, no thank you, not tonight. Or if your partner wants to have sex with you.

Dr. Nicole Rankins (49:36.448)

Right.

Dr. Nicole Rankins (49:44.041)

Right, right.

Dr. Nicole Rankins (49:58.623)

Right.

Nathan Riley (50:02.38)

you're entitled to say no thank you. But if you feel pressured because you're afraid that they're gonna be upset with you, that's the same pressure that a lot of women, I think, experience in the hospital. And again, I'm saying this secondhand, but I actually will have partners start to practice this at home. If you don't want Chinese food tonight, you say no thank you, I'd rather get sushi or whatever it might be. You know what, I understand that we haven't had sex for a while, but right now I'm just not feeling well. Why don't we revisit this tomorrow?

Dr. Nicole Rankins (50:07.968)

Right.

Dr. Nicole Rankins (50:18.272)

Mm-hmm.

Dr. Nicole Rankins (50:22.987)

Right.

Dr. Nicole Rankins (50:30.057)

Right. Right. Yeah.

Nathan Riley (50:31.704)

Like that is really powerful in a romantic relationship. And if you aren't practiced doing that in the bedroom or in your household, it's going to be very hard, I think, to navigate the hospital system through the lens of autonomy when you're in labor.

Dr. Nicole Rankins (50:41.875)

Yeah, yeah, for sure, for sure. I agree. And then what would you say is the most frustrating part of your work?

Nathan Riley (50:52.376)

The most frustrating part of my work is that in the world of health influencers and supplements are just, people are going bananas for supplements now. Most frustrating thing for me is that by eating really wholesome, nourishing foods, prioritizing sleep, working on your relationships and stress mitigation and cleaning up your environment, you probably are going to fall way below the average of bad things happening.

And that to me is so frustrating. You don't need a silver bullet or a magic bullet in order, you know, in the form of some gummy supplement or chilege or cold plunge or sauna, like any of these things. They're all great tools for certain things, but you just need to actually focus on slowing down and not looking for some sort of external input that's the answer to your woes. Most of us actually need to focus on prioritizing access to really healthy foods and,

Dr. Nicole Rankins (51:20.021)

Yeah.

Yeah. Yeah.

Dr. Nicole Rankins (51:30.272)

Right. Right.

Dr. Nicole Rankins (51:37.225)

Mm-hmm.

Nathan Riley (51:49.014)

in a more calm, stress-free lifestyle. And most of the ills in our maternity care system will start to vanish. But we're, again, a far cry from that. In a world of inegalitarianism and food deserts, and I mean, there's some big problems for us to solve. But that is the most frustrating thing to me.

Dr. Nicole Rankins (52:00.009)

Yeah, as a...

Yeah.

Dr. Nicole Rankins (52:06.891)

Yeah, yeah, for sure, for sure. And then what's the most rewarding part of your work?

Nathan Riley (52:12.844)

My gosh, Nicole, I get to sit with birth and death. I mean, I get to do that at day in and day out. These are the rites of passage. These are the sacred transformations and it really helps to inform how I live my life and how I treat people. It has made me over the years, apart from during COVID, I was getting very cynical, but it has made my life very rich and very rewarding and also very hopeful. Whenever you're with born babies, like you remember like

Dr. Nicole Rankins (52:39.243)

Yeah.

Nathan Riley (52:41.902)

this baby was born perfectly. What are we doing to de-range people and make them behave in ways that this little baby wouldn't have done? So there's something very compelling about being around new life and that to me is makes me very hopeful.

Dr. Nicole Rankins (52:43.925)

Right, right.

Dr. Nicole Rankins (52:50.475)

Right, right.

Dr. Nicole Rankins (52:55.039)

Yeah, yeah, yeah, for sure. And then you may have answered this already so you can repeat it, but what is your favorite piece of advice you would give to an expectant mom or expectant family to really help her tap into her power as she gets ready for her birth?

Nathan Riley (53:11.962)

Mmm.

Nathan Riley (53:17.816)

There are far more important things in your birth process than the metrics that we emphasize in the hospital system. know, emotions like joy, love, despair, sadness, ecstasy, all of those things that are the most important to you should remain the most important. And if we are not doing things that help to foster and facilitate joy, love especially, you know, I wrote this essay series.

Dr. Nicole Rankins (53:27.433)

Yes.

Yes.

Nathan Riley (53:46.33)

Pitocin, is the artificial form of oxytocin. Pitocin, our labor, induction of labor, pitocin in a world without love. We have to get back to that. And I think if women can remember that this is a loving experience, the same way that babies were conceived, they're coming into the world, there's a lot of similarities. This is everything. And if we can change the way that babies are coming into the world, can, I really do believe we can change the world. So people can use that as a mantra. Like this is all about love.

Dr. Nicole Rankins (54:11.721)

Yeah, yeah, yeah. Right. Yeah, I love that. I love that. And then where can listeners connect with you and your work?

Nathan Riley (54:21.602)

Yeah, I mentioned the conference. also have this massive childbirth education program. have a lot of, we have a new iteration for birth workers that is coming out. That's at bornfreemethod.com. If people want to work me privately, I do private consultation. All the functional medicine, all the fertility, I do a lot of stuff. In women's health, pregnancy and beyond, that's belovedholistics.com. then everything is available on Instagram nowadays. So Nathan Riley, OBGYN.

And it's been really, really nice, Nicole, to get to know you. There's certain questions that I want to ask you, so I'm going to bring you on my podcast and we'll get to turn it to you. Yeah.

Dr. Nicole Rankins (54:54.219)

I'm ready. Yes, I love it. I love it. Well, thank you so much. This has been a great conversation. Really glad to get to know you and talk deeper about your work. I appreciate it.

Nathan Riley (55:05.302)

Yeah, likewise, likewise. We'll be seeing each other soon.

Dr. Nicole Rankins (55:08.363)

Okay, all right, hold on, let me just hit stop.