The Bigger Picture: EFM, Iatrogenic & nosocomial complications, etc

The Bigger Picture ~

Part II of  “Risk-benefits of each Place-of-Birth — not PHB ‘dangers’ — is proper focus of inquiry & discussion”

The twin problems described in my last post {LINK} reflect on a true but troublesome reality — that no system is perfect, whether we are speaking of governments and commerce on a global scale or our very personal experience of local politics, medical care, and childbirth services irrespective of location.

Whether the mother-to-be is laboring in a hospital or an OOH setting, the course of events for her will inevitably include both predictable and unpredictable risks and outcomes. There is no way to get around this — risk is an immutable characteristic of the human condition.

We acknowledge this every time we travel, whether we walk, drive a car, call a cab, catch a bus, board the train or get on an airplane. We know there will be risks, benefits, and trade-offs and since most of us have a generally good idea of what these are, we make decisions consistent with our goals and values. As a former ER nurse, I can tell you that traveling by car is the single biggest risk that most Americans ever face and we do it almost every day.

All types of childbirth services also have risks, benefits, and trade-off. While it would be very nice, no maternity care system adopted in the US so far has been able to provide a risk “free” zone. Some of these well-known risks are universal and others are unique to the planned place-of-birth. While the risks are different in each setting, all planned places-of-birth have inevitable moments of sub-optimal performance and sometimes outright failure.

The choice between hospital and out-of-hospital is a choice between a different set of potential risks, as medical complications and a small number of preventable deaths occur in both settings. According to some (but not all) well-researched studies, normal childbirth in the hospital has a slight advantage for the baby (about 1 out of 1,000 births), while an OOH setting has very definite advantages for the childbearing woman.

This includes a 2- to 10-fold reduction in obstetrical interventions that can so frequently lead to invasive procedures and sometimes can trigger a cascade of complications. Even more significant, the OOH setting offers is a much lower Cesarean rate — under 10% compared to over 30%. The extremely high Cesarean section rate in the US is  associated with increased maternal mortality.

Obviously, not all maternal deaths in the US were the result of problems that happened during or immediately after a Cesarean or serious delayed and downstream complications problems such as placenta accreta in a future pregnancy. However, the overuse of Cesarean surgery in the US certainly contributes to our rising MMR.  Despite spending twice as much as on maternity care as any other country, the number of maternal deaths in America is so high that we are in 60th place worldwide (i.e. childbearing women would be safer in 59 other, often poorer countries).

The downside of institutionalized medical systems

The frequency and magnitude of risks generally associated with hospital-based services of all kinds are particularly difficult to deal with for a variety of reasons. During my nursing career, I was an L&D nurse for 10 years but also  worked as an ER nurse in three different hospitals over a period of 7 years  — one very large, one medium and one small hospital. I got an up-close and personal look at the

I got an up-close and personal look at the best and the worst of our health care system as it plays out in hospital emergency departments. The ER is where people are snatched back from the jaws of death by the ‘miracles’ of modern medicine but it’s also where big, little and even fatal mistakes were made by under-staffed, over-worked, inadequately compensated doctors and nurses.

In spite of these problems, emergency medicine is very often a wonder to behold and I personally would not want to live in any place or time where there was nothing to do but stand by while people died unnecessarily or suffered from horrible painful injuries.

But the ER is also where i witnessed what it means at a very practical level to have a dysfunctional healthcare system that:

(a) does not focus either on health or on caring — that is, spending time and money to keep people from becoming ill or injured as a result of personal or cultural ignorance, mental health problems and lifestyle issues

(b) does spend a huge amount of money trying to lock the gate after the horse has already gotten out. While big changes are on the horizon, what we have right now is a for-profit sickness care system of disease management that simply can NOT do the job that needs to be done

About 90% of people seeking ER care shouldn’t be there, or shouldn’t have to be there. At one are kids and adults with non-emergent problems but no doctor and/or no insurance, so they come to the ER when they get the flu, a sore throat or the baby has a fever. They should be seeing a nurse practitioner at a community clinic at 1/10 (or less!) of standard ER fees.

At the other end of this spectrum is a huge percentage of true, life-and-limb threatening emergencies caused by directly or indirectly by sociological factors that could and should be addressed by ‘smarter’ public policies and better use of resources — more brain power means less need to use hospitals, drugs and surgery.

Instead, my heartbreaking job as an ER nurse was to deal with a vacationing family of five (including a 6-wk old baby) brought in DOA after being hit head-on by a drunk driver. Everyday I took care of people horribly injured in accidents caused by speeding, bar-room brawls, teenagers as “collateral damage” in a drive-by shooting, college students and middle-class housewives in respiratory arrest after overdosing on prescription drugs, children who found a gun in the house and accidently killed their little brother or best friend, and the inevitable and distressing complications (such as amputations and blindness) of type II diabetics, which itself is a largely preventable lifestyle disease.

Our sickness-care system that pretends to provide heatlhcare is an outrageously irrational system. The underlying problem is an unrealistic expectation that modern medicine science — ERs, operating rooms, ICUs, expensive prescription drugs, organ transplants, etc — is the best use of time, talent, and treasure when it comes to all aspect of physical and mental health.

Just because kings of Arab countries come to the US for heart transplant surgery or cancer treatments doesn’t mean we have “the best healthcare system in the world”. Quite the opposite is true. People who don’t need drastic or highly dramatic medical services often find it uncommonly hard, frustrating and expensive to get appropriate and timely ER care for small, easily corrected problems, especially on Friday or Saturday night, or if its flu season. No kidding — there are publicly documented cases of people actually dying in the ER waiting room while awaiting their turn.

By thinking of modern medicine as the  “magic cure-all” for almost every problem we have with physical and mental health distracts us from the big and important systemic problems. This is the origin of so many preventable illnesses and injuries the require hospitalization — mental health issues, economic disparities, and the many aspects of being poor, hungry, malnourished, under-educated, without dependable transportation or disturbed thinking (including substance abuse). This will never change until we invest an equal amount of time, money and enthusiasm in a new

This will never change until we invest an equal amount of time, money and enthusiasm in a new health care system that addresses these problems and also focuses on the responsibility each of us bears for maintaining — with the help of the health care system — our own and our family’s basic good health.

To Err is Human ~ medical mistakes in the era of a corporate-owned hospital system

The prestigious Institute of Medicine (IOM) published a study by in 1999 called “To Err is Human: Building a Safer Healthcare System” that tracked and calculated the medical mistakes and other types of errors make in hospitals. What they found was shocking: the total number death each and every year from medical mistakes was greater than the total from

(a) gun violence

(b) suicides

(c) AIDS

(d) breast cancer

(e) automobile accidents

The author of a more recently published book on this subject noted that only heart disease and cancer killed more Americans than the man-made epidemic of medical errors, which is the third leading cause of death in the US. If you have three family members or friends that die, one of the three deaths will be the result of the ‘health care’ system.

The author of a more recently published book on this subject noted that only heart disease and cancer killed more Americans than the man-made epidemic of medical errors, which is the third leading cause of death in the US. If three family members or friends die, one of the three deaths will be a direct result of mistakes or deficiencies of the ‘health care’ system.

In the field of health care, this category of morbidity and mortality is known as ‘iatrogenic’ and/or ‘nosocomial’. Iatrogenic defines mistakes or inappropriate care by physicians and other medical providers). Nosocomial mistakes and other problems are related to the complex, often complicated  system we call ‘hospital care’.

Nosocomial problems include patient ‘incidents’ in which they get the wrong medicine, didn’t get a critical treatment, they acquired a drug-resistant bacterial infection while in the hospital or surgery was performed on the wrong body part or the wrong patient due to an error by a hospital employee. Small, medium and large institutions share many of the same problems, but each size also has its own distinct issues.   

Money in the corporate hospital culture

In addition to the systematic problems are caused by normal human frailty, the corporatization of our hospital  system over the last 20+ years has added a new and in my personal opinion, a much more insidious dimension to this already difficult issue.

As CEO of a publically-traded company, one has a fiduciary duty to the shareholders is to make a profit, each and every quarter.  In order to care out this legal obligation, the corporate structure has to exploit both its patients AND its staff. 

This means creating or widening the ‘margin’ of profit by doing more procedures, charging more for them, exploitatively monetizing each box of kleenex and other mundane and low-level medical supplies,  and consistently short-sheeting nurses and all other hospital employees including physicians and midwives.

Hospital Supplies Dispensing Machine, SF Bay hospital 2004. Patient’s hospital number must first be entered into system to open each door.

Patient’s ID card is inserted and every patient is individually charged for each “withdrawal” supplies such as IV tubing, catheters, special plastic bedpan for measuring urine output, etc

What this means on obstetrical practices bought out by big national groups  with electronic health records is computerized tracking system that keeps tabs on each individual practitioner on an hourly and daily basis and automatically generates an email or other electronic communication if the obstetrician or midwife did not make his or her quote — a pre-set number of billable hours and/or income generated by billable procedures. One’s continued employment within that system depends on generating a set level of profit for the corporation each and every day.

You can describe this as the American way — free market capitalism at its best — but when it comes to hospital care for the ill and injured and yes, laboring women and newborn babies, i think what I just described is actually a crime against humanity.

Looking under the hood ~ healthcare in hospitals of all sizes  

Small local hospitals are very much more convenient but they frequently do not have enough staff on duty, enough supplies or enough necessary equipment; sometimes newly hired personal haven’t yet developed the required skills. Obstetricians, anesthesiologists, and their OR staff are only on the premises during business hours (M-F, 7am-5pm). Due to their limited resources, smaller hospitals must transport all complex cases by ambulance or medevac helicopter to regional centers. The good news is that they have ample parking and family members can go home for a quick nap if things are moving slowly.

Medium-sized hospitals have more sophisticated and more kinds of technological equipment and many more personal. It’s likely that a greater percentage of their staff has advanced educational degrees. Many community hospitals are financially able to provide 24-7 emergencies services.  Those in middle and upper-class neighborhoods often employ a hospitalist (sometimes called a laborist) for their obstetrical department. This is a rotating roster of local obstetricians paid by the hospital to work 12-hr shifts and provide immediate or emergency care whenever there is a problem and patient’s private physician is not physically present to step in. 

But no system has endless resources. Hospitals of whatever size can get slammed by a sudden or unexpected influx of patients that overwhelms their normal capabilities. On a really bad day (or night) the hospital may also be short-staffed due to weather events (snow storms, hurricanes, etc) or because it’s the flu season. In these cases, and many less dramatic ‘glitches’,  critical patient needs will go unmet. It should be noted however that most community hospitals do have decent parking if you get there at the right time of day (or better yet, late at night).  

University teaching hospitals and regional centers have more of everything except parking, which is often impossible to find and costs more than a seat at the opera.  These big regional hospitals are by nature well-staffed with very highly educated people and can afford the very latest cutting-edge equipment. They can provide all critical services (ER, OB and OR) 24 hours a day year-round. But it’s hard to keep track of so many moving parts and coordinate everyone and everything perfectly every minute of the day.

But it’s hard to keep track of so many moving parts and coordinate everyone and everything perfectly every minute of the day. It’s inevitable that the left-hand knows not what the right hand is doing from time to time. Individual staff members sometimes wrongly assume that someone else is handling an important issue and unfortunately, some patients fall through the cracks.

Then there is the sheer size of the sprawling campus which is like a small city with its many different departments. It can take 10 or 20 minutes to walk to get from where you are to where you need to go. More is not automatically better. When time rather than resources is what counts most, getting around a great big hospital quickly is its own kind of problem.   

For each individual laboring women, one of the drawbacks of hospital care regardless of size is a systematic lack of continuity-of-care. The laboring woman does not know the many different employees who will become part of her care, nor they her. Hospital staffing requires 2 or 3 shift changes per 24 hours and during that time, many employees will function in different roles and tasks as they cover for others during meals and break-times. Time of day, whether it is a week-end or holiday, this shifting landscape of caregiver very often means that they don’t important information when it counts.

The Big Kahuna — Highly medicalized childbirth for healthy women 

But the biggest and most pervasive problem is one that ties hospitals of all sizes up in the same twisted knot — that is the automatic use of a highly medicalized model of care for healthy women. Historically and in contemporary times, obstetrical medicine has been and to a great extent, remains hostile to the physiological management of normal birth. They genuinely believe that the routine use of medical interventions, such as continuous electronic fetal monitoring, makes childbirth safer for mothers and babies despite a higher rate of Cesareans associated with the use of EFM.  

The direct connection between EFM and abnormally high CS rate is rather straightforward and the math is simple to understand. It bears directly on what appears to be “excess” perinatal mortality since the great majority of OOH birth attendants do not employ continuous EFM in low & moderate risk OOH labors. While the sensitivity EFM to distinguish between a real problem and a tracing that looks suspicious is very very low (98.00%), but if you use electronic monitor 99% the time on 99% of labor women, the statistics tell us that you will save on baby out of 500 that had ‘problematic’ EFM tracing.

Very Quick Trip in the Way-back Machine

The reason we have a highly interventive model of obstetrics in 2016 is merely a happenstance or fluke of history (i.e. timing).  The American profession of obstetrical and gynecology as a surgical specialty solidified its policies and childbirth practices in 1910, some 30 years after Pasteur’s discovery of the germ theory of infection disease. That was a very important discovery in many critical ways, especially since these antiseptic principles made hospital care dramatically safer.

All this was very good, but the public wrongly assumed that doctors, who now knew all about ‘germs’, would be able to prevent 100% of all infections. So when a doctor’s healthy patient died of the potentially fatal infection known as childbed fever (1/3 of all maternal deaths were from infection),  the family was convinced that he was personally responsible for the tragedy.  This kind of automatic blaming of the physician-obstetrician has some of the same characteristics as wrong assumptions by the public today, as many people think that anything other than perfect baby means the obstetrician and/or hospital screwed up. The unfortunate result in both cases was a dramatic increase in surgical processes and procedures. 

But during this post-germ theory/pre-antibiotic era in 1910, doctors were in a very unenviable position; there was absolutely NO effective treatment for puerperal sepsis (or in modern parlance, septicemia or blood poisoning). It would be another three-plus decades before these newly discovered ‘wonder drug’ were made available to the American public (sulfa, 1938, penicillin, May 1945).

Face with such a dilemma, influential leaders embarked on a well-organized and concerted effort in 1910 to prevent (or at least reduce) maternal deaths from puerperal sepsis in hospitalized maternity patients. Since nothing else had worked they decided to “Listerize” the entire 2nd or pushing stage of labor as the new standard of care for a physician-attended birth. Listerization referred to new ideas about sterile surgical technique invented by the famous surgeon Sir Joseph Lister to make surgery safer. When applied to childbirth, it required conducting normal birth as a surgical procedure performed under the same strict sterile conditions as if one were performing an “abdominal operation” (DeLee, 1913).

In order for the mother to lie perfectly still like other surgical patients (and not contaminate the doctor’s sterile field), general anesthesia was use to render her immobile.  To protect the mother and her about-to-be-born baby from the detrimental effects of ether or chloroform, episiotomy and forceps were routinely used to speed up the delivery. While the mother was still unconscious, doctors manually removed the placenta and sutured the perineal incision.

This was the most profound and far-reaching change in childbirth practice in the history of the human species. Fortunately, antibiotics and other important advances in medical science became available at the end of WWII, thus ending the need for such extraordinary antiseptic measures in hospital childbirth. However, the surgical specialty of obstetric and gynecology never re-evaluated the idea of conducting normal birth as a surgical procedure. It continues to be conducted and reimbursed under a surgical billing code. 

American obstetricians also have not formally revised their negative opinions about physiological management. One of the reasons is that obstetrics, a surgical specialty, is held to a surgical standard of care. Until this is modernized by the profession itself, physiologic management of normal labor and birth if provided by a board-certified obstetrician would be considered a substandard (i.e. negligent) form of care.   

Back to the Future!

The predictable result of policies set in place in 1910 is a wrong use of medical and surgical interventions on healthy women with normal pregnancies in hospitals all over America today.

This population-based practice of obstetrics treats automatically laboring women  according to risk categories (older mom, higher BMI, baby estimated to weigh over 8# 13 ozs, etc) instead of providing care that is especially tailored to meet or deal with the actual health or labor circumstances of the moment, and getting fully informed consent from the mother-to-be before using any routine medical interventions.

One of the biggest problems with medicalizing normal labors is the ‘double whammy’ effect. Detrimental side-effects and complications of these unnecessary medical inventions are magnified by the obvious fact that appropriate and effective support for the biology of normal labor and spontaneous birth is NOT being done. The result of this double whammy is an artificially high level of iatrogenic and nosocomial complications.  

This means many pregnant women who came into the hospital perfectly healthy are made sick — that is, they are in now need of medical treatments and surgical interventions they didn’t need before being admitted to the L&D ward. This unique form of iatrogenesis is the result of two unnecessary and man-made (i.e. not a natural result of biology) circumstances:

(1) Healthy women do not receive appropriate support for the biology of normal labor — physiologically-based care provider by a birth attendant who is trained, skilled and experienced in providing care of this kind.

Nor are they in an environment — a physical and sociological setting — that supports the non-erotic sexual biology of normal childbirth while NOT interfering with the normal psychological processes of the various stages of labor.

  (2) Critical policy decisions made a long time ago by people these laboring women don’t know and who did not give them a say in the matter, have decreed certain protocols for all labor patients that include the use of drugs, continuous electronic fetal monitors and many other disruptive and medically unnecessary interventions.                

These problems routinely play out in the current hospital-based obstetrical model results in a higher rate of preventable maternal morbidity and mortality. Approximately 650 pregnant or recently delivered women die in America every year. For every one maternal death, there are 50,000 instances of serious maternal morbidity, including emergency hysterectomies made necessary as a result of a placenta accreda or percreda that is a well-known complication of a previous Cesarean section.

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Risk-benefits of OOH Setting – independent birth centers and planned home birth

The only study published in the last decade that identified the real issue was  in Australia 1998. The introduction starts by saying:

“Despite decades of political and academic debate, the relative merits of home versus hospital birth remain unproven. This is likely to remain so. Comparisons that are sufficiently unbiased and large enough to address crucial safety issues are unlikely to be forthcoming [1,2].

Although home and hospital offer different benefits for birth, neither has ‘standard care’ characteristics. In fact, the range from safe to unsafe practice may be wider within each location that it is between them.  Addressing what constitutes safe practice at home may be a more pivotal . . .

As anyone who has read this far will know, both maternity care systems/setting in the US have certain problems, both do unfortunately ‘drop the ball’ under certain circumstances.

But OOH also is not — at leat not yet — a perfect system for providing.

The issues for OOH as the planned place-of-birth are very different in scope and scale but nonetheless, a certain spectrum these childbirth services suffers from a particular problem that has to do with travel time under specific circumstances, mothers who give birth and babies born in settings that do not have immediate access to advanced medical resources of equipment and staff are at a greater risk if there is a breathing problem for the baby or the mother has excessive bleeding. In those case, quick access to  the skills and equip. ment of a neonatal intensive care unit for the baby and blood transfusions and operating room with a surgeon standing,

The good-bad in this is that problematic outcomes are so frequent in general, that the numbers of troubling outcomes for each setting — hospital or OOH — cancel each other out.

There is ample scientific evidence that essentially healthy childbearing women with normal pregnancies have equivalent outcomes for themselves and their babies regardless of the planned place-of-birth — hospital or OOH setting if they: 

• Live indoors in a first-world country, regularly get enough to eat, have electricity, running water and heat and access to modern health and medical services over the course of your lifetime
• When pregnant, receive regular maternity care and risk-screening by a professional birth attendant during all stage of childbearing 
• Are referred (or transported if emergent) to comprehensive medical services if any time a complication is detected during pregnancy, labor, or immediate postpartum themselves or for their newborn, or if their pregnancy becomes complex (such as twins or a breech baby)

It’s also clear that the safety of childbearing women could and should be substantially improved in all birth settings and for all types of birth attendants.

So I have to ask: Is it vaguely possible that we finally could just stop talking (or in Amy Tuteur’s case, screaming!) about the “dangers of home birth” and instead focus our attention and research resources on how to improve care in each setting by all categories of birth attendants?

So here is my really next radical idea: Let’s replace the current vitriolic conversation about planned home birth (PHB) with a thoughtful public discourse on planned place-of-birth  (PPB) and the ‘right use’ of human and healthcare resource. This is equivalent to the ‘right tool for the right job‘. This means deciding which type of practitioners is the best initial choice based on what we want and what our health and pregnancy issues are.

For women with complex medical or pregnancy problems, the right use of obstetrics is comprehensive care by an obstetrically-trained surgeon. For families blessed by good healthy, normal pregnancies and a strong desire for a normal or physiologically-managed labor and birth,  the supportive, non-surgical care of midwives and family practice physicians is the right place to start. However, for this same healthy population of childbearing women, our current obstetrically-interventive model would constitute a ‘wrong use’ of obstetrics.

In an ideal world, whether a healthy woman with a normal pregnancy receives supportive physiologic care in the OOH setting of her choice or has hospital-based obstetrical management. the care she received  would be based on her’s health status and personal preference, and not mandated by the educational background of the birth attendant — midwife, family practice physician or obstetrician.

A Rose by any Other Name …… the importance of words

The professional education, clinical training and customary practice of these two disciplines are quite distinct. Identifying the differences as well as the strengths and weaknesses of each historical form of care makes it easier for the public to choose the most appropriate type of care. This understanding is useful to policy makers and government agencies.

An elevated debate of this topic should start by carefully refining our vocabulary in a way that makes the core distinction between obstetrical services and professional midwifery care much clearer.   After carefully accounting for all the pertinent terms (see definitions below), I suggest a basic “vocabulary re-set” that makes the following distinctions very clear by identifying the functional nature of these distinct differences.

Childbirth services for healthy childbearing is and should be ‘maternal-centric’ and shuold be known as “maternity” care.  In contrast, the type of services provided by the surgical specialty of obstetrics and gynecology for women with problem pregnancies are clearly obstetrical. The training and scope of practice of the obstetrical profession is female reproductive abnormalities, complications and pregnant women who want a high level of medicalization during childbirth, such as induction or an elective Cesarean.

Here are more comprehensive definitions  between these two disciplines and the practitioners of each:

Maternity care: The basic purpose of maternity care is to protect, promote and preserve the health of already healthy women during normal pregnancy, childbirth and new mother-baby phase of newborn care, breastfeeding, and developing parent craft skills.

In similar fashion, i would use the term: “Obstetrics” to define a historic surgical specialty that focuses on the compassionate treatment of medical complications and high-risk conditions of female reproductions, including infertility, tumors of the genital tract or pelvic organs and complications of pregnancy and childbirth.the care

As distinct from the practice of obstetrics, maternity care is the routine care of normal healthy women with normal pregnancies who do NOT plan to be induced or have a scheduled CS, but instead prefer a normal labor and spontaneous birth at term with a the single healthy fetus in a vertex position.

Maternity care as a professional discipline is a concerned with promoting and maintaining the wellbeing of mother and baby across the whole spectrum of normal pregnancy and childbirth. This is accomplished by providing general health education about topics of concern to the mother-to-be and her family, such as nutrition and healthy life-style issues, initial.

Irrespective os where it is provided by a physician or a midwife, routine prenatal care includes on-going risk screening and obstetrical consultation or referral as indicated.

The good outcomes associated childbirth in essentially healthy women with normal pregnancies require the full-time presence of the primary birth attendant during active labor, birth, and the postpartum and neonatal period.

The basic purpose of allopathic medical care is to diagnose and treat abnormal conditions, illness and injuries using drugs, medical methods and technologies, and surgical procedures. 

As a modern-day profession, obstetrics is

As primary birth attendants, this includes personal, hands-on support as well as continuously monitoring the wellbeing of the mother and her unborn/newborn baby. All categories of maternity care providers are trained and equipped to detect potential problems, intervene if a complication develops and secure appropriate medical services as required or if requested by the mother.

Maternity care providers also facilitate the family in supporting the new mother-baby dyad, and helping her care for the baby. In the weeks following the birth, new mothers often need additional advice to help them to deal with older children and other family obligations.

As expected of obstetrics and gynecology as a combined medical-surgical discipline, its educational process, and clinical training  focuses on the serious complications of childbearing and their treatments. This is as it should be.

However, the current discipline of obstetrics and gynecology does NOT  train its residents to physiological support the biology of normal labor and birth, nor does it define what the medical profession calls “labor sitting”  as a part of the scope of practice.  After graduation, practicing OB-GYN surgeons usually have either time nor interest in becoming health educators. Neither are they prepared by training or temperament to provide the physical and psychological support services consistently needed by childbearing women during their complex journey into motherhood.

Even if an individual obstetrician wanted to provide supportive maternity care, it would not possible for him or her to be economically compensated for what is technically non-obstetrical care. The billing codes for this specialty only apply to medical, surgical or diagnostic procedures.

Concluding Statement:

Under these far more ideal circumstances, planned place-of-birth would become what it was always supposed to be — the right choice for the particular situation for that specific mother & fetus — with both hospital and out of hosptial both seen as equally responsible choices in an integrated, cooperative and ‘minimalist’ model based on “best practices”.