Doc Hailed for VBAC Delivery Under Fire
Update: The Florida Board of Medicine on Friday recommended that Dr. Simion Tsinker be suspended. More here.
The most controversial issue in childbirth – when to let nature take its course, when to do surgery – underlies a state complaint to go before the Florida Board of Medicine on Friday.
The complaint is against Dr. Simion Tsinker of Hallandale Beach, an OB-GYN who has delivered thousands of babies in 33 years practicing in Florida. Among them are hundreds of high-risk cases that most doctors would have scheduled for cesarean delivery, but which Tsinker delivered through the birth canal.
They include twins, babies in the wrong position (breech), and vaginal delivery after a previous C-section, or VBAC. Many obstetricians won’t even try VBAC, let alone vaginal birth for a breech.
Thus Tsinker’s name gets passed along the natural-birth grapevine. “Dr. Tsinker is a hero,” one woman wrote on Vitals.com. She said Tsinker delivered her son, a breech, “100 percent naturally -- the only doctor in all of South Florida who would.”
But the very thing that has made Tsinker popular with such patients has him hot water with the state Department of Health. DOH accuses him of malpractice for doing a vaginal delivery in a breech patient who had a previous cesarean. The male infant died at birth.
The case in December 2013 at Broward Health involved a 37-year-old patient identified only by her initials, DG. Records say she had a cesarean birth four years before and this time wanted VBAC. She went first to a birthing center, but when the breech presentation showed up on ultrasound, she went to Tsinker.
Breech positions occur in about one in 25 births, according to the American College of Obstetricians and Gynecologists (ACOG). DG’s baby was a “frank breech,” buttocks down and legs straight up next to the head, considered the most favorable breech position for vaginal delivery. But few doctors learn to do them nowadays.
Many women who have had a prior Cesarean birth many be candidates for VBAC, but the risk of uterine rupture makes many hospitals shy away from the offering it, said Dr. Robert Yelverton, an official with ACOG in Florida.
“Even in carefully selected patients, uterine rupture can result in catastrophic injury to the mother or her baby,” he said in an email. “For this reason, hospitals and physicians that offer VBAC must have Cesarean surgery services that are immediately available should this complication occur.”
Tsinker, 67, got his early medical training in his native Russia, before coming to New York for residency. It is not clear where he developed his approach to delivery.
Dr. Donald Diebel of Winter Park is an OB who reviewed the case before the Board of Medicine. He wrote that Tsinker should have ruled out vaginal delivery on both counts – because of the previous cesarean and breech presentation.
Diebel said Tsinker also erred in using drugs to induce labor and that his records were woefully incomplete.
Attempts to resuscitate the newborn were unsuccessful, reports show. An autopsy attributed the death to “blunt trauma and mechanical chest compression due to vaginal delivery in frank breech position.”
“The injuries sustained during delivery are unheard-of and speak volumes about the violence of the delivery,” Diebel wrote. He concluded that Tsinker “clearly did not meet the standard of care.”
Patient DG told DOH that Tsinker did not warn her sufficiently of the risks. She also did not like his attitude; she said he blamed her for her baby’s death, the investigative report said.
Tsinker told the investigator that his treatment was appropriate and the baby would not have died if DG had pushed when he told her to.
DOH prosecutors have reached a proposed settlement of the case that includes a “letter of concern,” a $10,000 fine, and courses on record-keeping and breech births. By signing it, Tsinker admits no wrong-doing, but agrees to fulfill its requirements.
However, the settlement isn’t final until the Board of Medicine accepts it. If it’s rejected, Tsinker could be faced with a stiffer penalty or formal hearing.
Tsinker told Health News Florida he doesn’t foresee any of that. He plans to come to the hearing without an attorney, saying “I’m not worried.” He predicts that when he retires in a year or so, he’ll still have his good reputation.
“I’m the number one expert in the state of Florida as far as delivery of breech or twin babies vaginally (is) concerned,” Tsinker said. “Nobody denies that.”
He’s done more than 350 vaginal breech deliveries, he said, and patients come from far away. One from Jacksonville sent him a card that said, “We called our son Miles in memory of so many miles I had to travel to see you.”
In one case involving a Homestead woman, Tsinker even performed a vaginal delivery for twins when the first baby was breech. He called the high c-section rate in Florida “an outrage,” saying at least half of them aren’t necessary.
“Here’s what I believe: That the art of obstetrics is dying,” Tsinker said. For doctors today, “it’s either a garden-variety vaginal delivery or cesarean section.”
An outgrowth of the drive for natural childbirth, VBAC became an issue in the 1980s as women questioned the practice of “once a Caesarean, always a Caesarean.” Obstetricians feared that contractions would tear the uterus along the scar line. But some suggested that the risk was low if patients were properly selected.
Data collected on VBACs in the 1990s indicated that serious complications occurred in about 1 percent of cases, according to Yelverton. But those complications – hemorrhage for the mother, brain injury or death for the infant – were catastrophic.
ACOG started focusing on the source of the problem: the “primary,” or first cesarean. While it’s a life-saver in certain emergencies, those situations don’t occur as often as the c-section data would suggest, ACOG says. The goal, it says, should be 10 to 15 percent.
The Centers for Disease Control shows that Florida’s primary caesarian rate in 2012 was about 26.9, more than five percentage points above average. It peaked in 2009, at 27.5 percent.