Brave New World of Evidence-based Maternity care ~ Chapter 7

Chapter 7

~ Hospitals:  help or hazard?

faith gibson, LM (2005)

Obviously hospital-based birth services are here to stay. They are the strong preference of the majority of women around the world. Even Holland, where midwifery care is normative and the highest rate of domiciliary services in the industrialized world has less than a 1/3 of its childbearing women opt for home birth. Hospitalization for maternity care has much to offer and all of us are committed to making it work better for both mothers and caregivers.

Two aspects to be addressed are the realistic dangers hidden within the seeming safety of the hospital and how greater safety than one would anticipate lies within the seemingly increased risks of non-interventionist domiciliary (home or independent birth center) midwifery. In other words, what is fact and what is fiction and why?

This investigation is complicated by the fact that hospitalization refers not only to a physical building but also the interaction with hospital employees, a professional staff, technological equipment, a bio-hazardous environment and a collection of standards, policies, routines and staffing patterns. Hospitals are complex places like airports. In addition there is the unpredictability of personal abilities and personality conflicts– differing skill levels and personal bias among the staff which affects how those resources are allotted and what actions are taken (or not taken) on behalf of the patient.

Hospitals are not an “it” and therefore not “good” or “bad” per se but rather each individual’s experience is either good or bad (salvific or hazardous) depending on the specific collection of staff members and circumstances present at that point in time. This makes it hard to separate the influence of physical place, finite resources (number of available operating rooms, etc) from the influence of staff and medical care providers as they interact with one another and with the patient. Safety or hazard is influenced by all those factors and in the final frame. We see that complexity and unpredictability are an immutable characteristic of hospitalization and regularly introduces unintended consequences into the system. This does not means that hospitalization per se is wrong relative to healthy women – in fact, you can count on hospital care remaining the norm. However, one must realistically appraise the situation, and identify the problems in order to provide fully informed consent and so that the system can be made as fail-safe as possible.

A study of the practices surrounding hospitalization for childbirth in the US reveals many pertinent topics. From this examination one can fairly easily see how routine hospitalization of healthy mothers can and many times does introduce its own hazards and thus provokes its own unique dangers. It is the aggregate of these dangers that are reflected by the absence of the superior results for hospital-based care that we would anticipated and the unanticipated good outcomes for non-interventive midwifery in out-of-hospital settings. From there it is possible to propose changes that would help close the gap between domiciliary midwifery and hospital-based care, although the basic characteristic of normal unmedicated childbirth simply doesn’t naturally lend itself very well to institutional care. As mentioned earlier, certain facets of institutionalization such as staffing problems, bio-hazards, continuity of care issues and personality conflicts and the like are also inherent. The best that both styles of practice can offer is informed consent relative to identified risk/benefit trade-offs which occur in each system.

Unfortunately, fear at any time makes labor many times more painful. This can so totally inhibit the biology of childbirth that medical interventions are the only immediate solution — drugs for pain and other drugs to stimulate the uterus. The risks of these drugs are many, and include fetal distress, the need for anesthesia and the increased use of vacuum extraction or CS. Given such a medically-intervened with birth, the baby may well need some time in the NICU. If it picks up a hospital superbug (antibiotic-resistant microbe) in the nursery, the infection will require long and expensive treatments. Fear costs us all money in this sense.

The problem is that institutions as currently designed, staffed and managed are not very private, are not very successful at dealing with unique emotional needs, and don’t have a lot of other options except the use of drugs and surgery to treat what began as a psychological interference. Institutions frequently must depend on medical and surgical solutions to treat situations that were originally psychological problems. This happens in part because of the hospital’s need to be cost-conscience about staffing levels and limitations imposed by the institution’s need to protect itself from malpractice litigation. These and other aspects of team dynamics and staffing patterns all seem to conspire to keep hospitals from being flexible enough to anticipate the physiological needs of childbearing and to meet the individual emotional needs of each laboring women over several hours or even days of labor.

The absence of this ability is one reason why hospitalization may actually provoke dangers during childbearing that are not present when the mother is being cared for in her own home or independent birth center.

Continuity of Care issues –

Continuity of care refers to familiarity and on-going relationship between caregiver and patient, knowledge of the patient’s history and present circumstances and actual time spent with the patient. In an ideal world, laboring mothers would be cared for by the same practitioner who provided their entire course of prenatal care and that same practitioner would be present through out the entire labor, would conduct the birth him or herself and provide the same continuity of care during the postpartum and neonatal period. Unfortunately this is extremely rare — only a community-based midwife with a very small practice can routinely offer this kind of care and even then competing duties, a sick child or vacations can still disrupt these carefully laid plans.

When more than one person is pivotally involved in providing care one of the great challenges is appropriate and timely communication. Every parent knows that even with only two of them to account for, this kind of crucial communication is tricky. Keeping tract of when the baby was diapered, last feed, napped or given medicine may seem simple but despite our best efforts important information still falls through the cracks. As children get older and perhaps a babysitter or school teacher gets added to the mix, it gets even more challenging to keep track of regular life plus special permission to visit a friends house after school or stay up past their normal bedtime. Multiply this times several children and several simultaneous caregivers and you have some idea of the nature of the problem. When you consider the number of people involved in providing contemporary maternity care, one can appreciate just how hard it is to keep everybody informed at the right time with the right information so central to the mother and baby’s safety. One can also appreciate how rare it is in today’s healthcare system to be cared for by someone with whom you have an on-going relationship.

In addition to doctors and nurses, other people such as employees of the doctor’s office (who has prenatal records), ward clerks at the hospital (who makes up the hospital admission chart), lab and x-ray technicians, med students, interns, residents, other specialists (anesthesiologist, perinatologist, etc) are all part of the “team”. All of these people have (or don’t have when they should) crucial information. An error by anyone of them can be reiterated throughout the system and the mistake magnified, sometimes with catastrophic results. Some systems of redundancy have been devised to keep this from happening but such complexity inevitably breaks down from time to time.

Dr. David Rubsamen, MD, an expert on obstetrical malpractice litigation, has characterizes the problem as not so much one of dropping the ball in the first place but not catching it on the first bounce. When many different people are involved without the full-time presence of a knowledgeable practitioner, it is all too easy for each person to think that someone else is fielding those fly balls. Dr. Rubsamen has estimated that 25% of obstetrical litigation involved the actions or inactions of L&D nurses, most often a communication breakdown between the nurses at the hospital and doctor who was not. Major areas of conflict in accountability occurred in regard to what was said, whether a call was made and when the call was made. [4]

In addition to communication problems associated with continuity of care are the unmet relationship needs of the mother. Her experience is less than optimal when she must instantly expose herself physically and psychologically to a long line of strangers, often doing vaginal exams on her. Lack of continuity also interferes with the caregiver’s ability to provide the quality of emotional support made necessary by the inherent nature of physiological childbearing. Labor room nurses don’t usually have any prior knowledge or personal relationship with their patients and also are hampered by the limitations of an institutional environment, with its restrictive protocols and constantly changing staffing patterns (nurses must cover for dinner breaks, new admission, emergencies, etc).

Doctors don’t sit with their patient during labors. Even if they come to the hospital when the mother is admitted, they will either return home or go to sleep in the call room. They are only continually present for the last 30 minutes before the birth and sometimes not that long. In our area, many obstetrical patients don’t actually get to know their doctors either. At least one obstetrical practice in the San Francisco bay area has a call group of 30 different OBs. If the 24 hour shift changes during the time the mother is in the hospital, she may be cared for during labor by two or more doctors she has never even met as well as 2 to 6 unfamiliar nurses and multiple other hospital employees.

Lack of continuity of care often results in communication breakdown and inability to meet the psychological needs of laboring women. Because of the nature of allopathic treatment, akin to the use of power tools, a “small” mistake can have exaggerated consequences. In a domino effect, problems originating from a lack of continuity of care can escalate into a medical emergency that is ultimately reflected in maternal-infant outcomes statistics that favor non-interventive care in non-medical settings.

Nosocomial and Iatragenic Hazards:

“Iatragenic” refers to practitioner error. “Nosocomial” refers to complications or death resulting from hospital employee error or other hospital-centric factors. In some instances (such as hospital-acquired infections) it may not be possible to identify the individuals who participated in the chain of events leading to the bad outcome. Many of the problems with hospital care noted in previous categories referred to systems failure rather than direct errors that can be traced to a specific individual. From the standpoint of the childbearing women this fine distinction means very little. However, clear identification of problems does assist in their correction.

A major aspect of nosocomial and iatragenic error, while ascribed to individuals, arises out of the nature of allopathic medical practice. Unlike many other “healing arts” practiced around the world, the German tradition relies heavily on very potent drugs, invasive and potentially dangerous diagnostic procedures and surgery. One allopathic physician described drug treatment as giving the patient a different disease with preferable symptoms in an attempt to turn an acute disease process in to a chronic one that the patient could more comfortably live with. The more potent the pill or more dramatic the surgical procedure, the more it is like using power tools. If you are using a handsaw and “slip”, you may cut yourself very painfully and even need stitches. If you slip using a power saw, you may amputate a limb and even bleed to death awaiting the ambulance. While power tools do the work quicker, they are also quicker to get out of hand and wreck more devastation for the same original “error”. This is known as the “shadow side” of a system. The bigger, better, faster it is, the deeper and more awful more its unintended consequences.

Hospitalization is particularly problematic as applied to maternity care. Unlike the typical patient who is hospitalized because of sickness, childbearing women are typically in the bloom of good health when admitted and usually give birth to healthy babies. The only other medical discipline that shares this characteristic relationship to healthy patients is plastic surgery in which a potentially life-threatening service is provided to people who are initially healthy. State regulation of hospital maternity units came about early in the century due to the obligation of care providers to prevent nosocomial exposure of healthy women and babies to the biohazards that are normal to medical institutions. Epidemics of hospital-acquired staph and strep infections have gone through hospital nurseries causing death or disability of healthy newborns time and again, as even the best vigilance is not equal to a perfected system. There are no perfect systems. Within the last two years 25 different strains of Vancomycin- resistant staphylococcus have emerged in addition to a potentially deadly mutation of pseudomonas and Group A strep (both common hospital pathogens). Vancomycin-resistant enteroccocus (VRE) have been cultured in 100% of the hospitals tested in the greater Bay Area. Outbreaks of necrotizing faciitis have occurred on the East Coast and in Quebec, with maternal deaths of otherwise healthy women in each instance. [5]

Another important aspect of nosocomial and iatragenic errors in American hospitals are the limitations or deficiencies of the “system” itself. Unlike the commercial airline and nuclear power industries, the healthcare industry has not concentrated its efforts on safety systems, multiple redundancies and close examination of “near-misses” for their instructive and remedial qualities. In fact, most near-misses are hidden either by the individual (due to professional embarrassment) or by the institution (fear of litigation). Many aspects of the system depend to an inordinate extent on extreme vigilance of a single individual. When a moment’s inattention occurs (often the result of staffing shortage – i.e., system failure), the individual is made to bear 100% of the blame and no accountability, responsibility or remedial action is taken by the institution. Thus the type of problem is endlessly reiterated without hope of correction. [6]

Last in this litany of failures is that of individuals in the system to realize that, in the absence of life- threatening conditions, life-saving techniques (including prophylactic hospitalization and routine obstetrical procedures) can of themselves be life-threatening. Until rather recently (1970s), blood transfusions were sometimes given “prophylactically” during simple surgeries (CS or hysterectomy) just in case there was excessive bleeding. That is no longer medically acceptable. It is pretty easy for us to see the folly of that today (what with blood-born diseases such as hepatitis and HIV) but the danger of dying from mismatched blood or an allergic reaction to a blood transfusion have been know for 50 years or more. There are other unexamined circumstances of this kind involved in hospital-based maternity care.

Following is a list of the most frequently applied obstetrical interventions for a typical hospital birth and the iatragenic and nosocomial complications associated with them:

Artificial rupture of membranes à resulting in pathways for infection or prolapse of the umbilical cord (requires emergency CS)

Restriction of oral fluids, use of IVs à  restricting maternal mobility, confinement to bed, increased perception of pain and likelihood of the mother needing or asking for narcotics analgesia

EFM à significant increase in Cesareans without equal improvement in perinatal outcome

Oxytocin augmentation of labor resulting in à

Need for narcotics and possible respiratory depression of neonate,

Need for anesthesia with maternal hypotension and/or fetal distress

Hyperstimulation / tetonic contraction of uterus/ iatragenically-induced fetal distress or more rarely, uterine rupture

Subsequent postpartum hemorrhage

Increased ratio of operative delivery — forceps, vacuum extraction or cesarean section;

Nosocomial-acquired infection; infection with antibiotic-resistant pathogens

Medication errors (wrong drug, wrong dose, wrong patient)

Drug reactions (anaphylaxis or chronic organ failure);

Anesthetic accidents

Surgical mistakes such as inadvertently cutting of bladder or bowel, tying off a ureter Surgical laceration of the unborn baby

Neonatal respiratory distress following general anesthesia, forceps or vacuum extraction

Wound infection following episiotomy or Cesarean section

Post operative pulmonary embolism after Cesarean surgery

Operative or post-operative maternal hemorrhage necessitating blood transfusion with risk of allergic reaction/shock and exposure to diseases carried by blood products — hepatitis, HIV (this can put fathers, siblings and other family members at risk due to their communicable nature and untreatable status)

In spite of these many nosocomial risks, hospitalization does not prevent or reduce the incidence of maternal-infant complications such as failure-to-progress, malposition of the fetus, genetic defects, prenatal sources of cerebral palsy or the rare complications of childbirth such as amniotic fluid embolism. Therefore routine hospitalization of healthy women, mathematically speaking, tends to add nosocomial and iatragenic risks to those which occur naturally from genuine complications.

Absence of full time practitioner (physician or professional midwife) when hospitalized women are in active labor:

This problem is exacerbate by staffing shortages, census fluctuations, inadequate training, inexperienced personnel and the limitation of the scope of practice of nursing. Nurses are not trained or authorized to act independently.

Recognizing potential complications in time to institute remedial action — the “nip it in the bud/head it off at the pass” theory is one of the primary contributions of professionals to maternity care. Its beneficence is what we all hope for ourselves and our loved ones when pregnant. For this goal to be realized, someone must recognize the signs of complications and symptoms must be correctly identified — all in a timely manner. That means physical presence of an experienced caregiver with an adequate knowledge base and the ability to respond, either personally or communicating to the person(s) with the authority and skill to intervene.

It is hard to count on this kind of response in today’s typical hospital as physicians don’t stay with laboring women as a matter of course and nurses don’t usually have the time to remain with the mother. More to the point, the scope of practice of the nursing profession does not include either the formal education, skill sets or authority to make many of these crucial decisions. Regardless of how well trained or experienced staff nurses may be, they do not have the legal authority to make independent medical judgments or independently carry out necessary remedial actions. They must depend on phone calls to others and hope they communicated clearly enough and that the doctor responds quickly enough. What an odd system. Nursing staff should be present to assist the practitioner and not instead of a practitioner:

Only practitioners are formally educated and trained to detect the full spectrum of possible complications and likewise skilled and legally authorized to deal immediately with the emergent situations that sometimes befall women in active labor. It is this capacity for immediate medical response that is one of the primary reasons that families choose hospital-based obstetrical care (rather than community-based midwifery) and why they bear the added expense of those arrangements. Unfortunately, the majority of labors are not attended by practitioners — either the attending physician, a professional midwife employed by the obstetrical group or a midwife employee of the hospital. As long as mothers are primarily cared for by those without the requisite training, skill and authority to identify and respond immediately to potentially problematic situations, bad outcomes will occur that conceivably would have been avoided through the immediate intervention of an on-site practitioner.

Labor and delivery units should be primarily staffed by professional midwives who are present and awake in the immediate area of the laboring woman during the time women are in active labor or women hospitalized due to complications requiring “intensive” intrapartum care or observation. Until midwives are routinely present as primary caregivers we will continue to have this very disturbing circumstances in which the laboring woman maybe in the hospital but if her physician is at home or in his office, that “edge” associated with hospitalization will be missing for many when they need it most. This results in preventable deaths and disabilities and less than optimal statistics for institutional care.

High percentage of chance or happenstance associated with the timely use of emergency life-saving measures / lack of universal access to 24 hour emergency services — in house anesthesia & surgical scrub technicians, sufficient number of ORs, laboratory and x-ray services, on-site blood banking, adequate staff for one-to-one:

Several obstetrical emergencies come instantly to mind for physicians and malpractice insurance executives when you mention domiciliary care. What about fetal distress, cord accidents, premature or delayed placental separation, neonatal respiratory distress, postpartum hemorrhage? they ask. “Can’t tell me that these emergencies don’t occur” and as a former L&D nurse myself, I do not argue their reality. “What are you going to do if there is a bleeding problem for the mother or a breathing problem for the baby?” they say in an incredulous tone of voice. The unvoiced thought is “Midwives must be crazy”.

Emergency intervention is really the place where the “rubber meets the road” so to speak, where hospitals have a change to strut their stuff. Sometimes they get high marks and flying colors. But not consistently and not often enough. What every long-time employee will describe is the high proportion of emergent situations in which things either worked or (or didn’t) based on a series of seemingly random factors. Many time the most dramatic “save” — the kind that makes everyone proud of their profession — occurred because the right person was in the right place at the right time but all of those “rights” were not part of the system. Many appropriately timed interventions are more luck than planning. The nurse had already done her hourly check of vital signs and only went back in the room to retrieve her ballpoint pen when she happened to notice the pool of blood. The doctor who usually doesn’t make rounds at night just happened to stop by right when the bleeding was discovered. The anesthesiologist happened to still be on the unit because he was unusually slow in finishing his charting that night and therefore late to leave. Or all of those same transactions occurred in reverse — like star-crossed lovers, the same unpredictable happenstance worked against everyone and instead of a save it was a tragic loss, made even worse by the knowledge that theoretically at least, it was a “preventable” death.

Since the full-time presence of an experienced practitioner (physician or midwife) is not customary in American hospitals, the discovery of the problem is often unduly delayed. Staffing levels, ratio of nurse to patient, the census of patients in labor at the time, the use of new graduates, inexperienced nurses, personnel from a temp agency or “floats” from another floor that are unfamiliar with the L&D routines will all influence the discovery of a problem and/or the appropriateness of the initial responses to it. The nurses may be really busy, inattentive to the mother’s requests, she may not be a native English speaker or the nurse simply does not pick up the initial or subtle signs of an impending emergency.

Continuous Electronic Fetal Monitoring may seem like the perfect answer to these staffing problems but in actually, it often means that the nurse is sitting out at the desk watching a bank of 4 to 8 monitors instead of being at the bedside. Not every problem is initially visible on the EFM screen at the nurses station. One published study on the patterns of care of L&D nurses documented that the nurse is out of the room 79% of the time. When present in the labor room, she is only performing personal care for the mother 6% of the time. That means that about 94% of the time family members are the only consistently watchful and supportive presence. [7] No matter how good the nurse is, she can’t see through walls. Managed care is reducing the number of professional staff in all areas of hospital care including the L&D, so staffing shortages are not going to go away.

Emergency response times and appropriateness depends heavily on the level of 24 hour emergency service staffing. Most hospital in the US are community or second level institutions without full-time services. Unless you are referring to level 3 hospitals, experienced nurses will describe that the same medical emergencies at 3 p.m. on a weekday will have a whole different time frame than ones that happens at 3 am. Its especially bad on week-ends, holidays and in poor weather. Here is an excerpt of an email from an obstetrician discussing an emergency Cesarean in a small hospital:

I recently had a complicated ob patient that I would like to have your opinions on. A 26 year old primip at term underwent cytotec cervical ripening, receiving three doses over 12 hours. …. She was placed on pitocin, and had a prolonged latent phase, and a protracted active phase, eventually arresting at 5cm… The patient was given the usual anesthesia premeds … and shortly after began to vomit with great force. The nurses then auscultated a slow fetal Heart Rate, I reinserted a scalp electrode, finding a flat FHR of 55-60 (this was 15 minutes after the original electrode dislodged).At this point a stat C/S was called for. The OR crew was already on its way in, the weather was bad, it was the middle of the night and I practice in a small hospital without in-house OR call. The baby was delivered with APGAR 1, cord ph 6.70, ~25 minutes after stat C/S called. It was transferred to a tertiary care hospital and expired 36 hours later from severe hypoxic encephalopathy.

Putting In Correction– Re-configuration of Institutional Maternity Care

Last but certainly not the least of it, the topic of evidenced-based maternity care for the 21^st century is not compete without factoring in the price paid for prophylactic hospitalization under the legal restraints that are the current basis for how hospitalized women are treated. The result of a 100-year bias against normal birth by the obstetrical profession was to institutionalize educational deficiencies that have been reiterated for the last century. This deficiency leaves contemporary physicians with no choice but to eschew physiological management and instead practice interventionist medicine, making routine use of drugs and surgery. Medical management and surgical intervention has now become the legal standard for obstetricians, applied to virtually every woman, no matter how unnecessary, unhelpful or how unwanted by the childbearing family.

In judging the cost-benefit ratio of the current system, we must figure in the detrimental aspect of routine hospital care which provokes certain dangers. The very nature of institutionalization increases the number of labors that become medicalized, either through medical need or as a “risk reduction” hospital policy thought to reduce law suits or to assure that the hospital or obstetrician will be held blameless in any litigation that might arise. Some proportion of healthy mothers or babies will experience these same “emergent” conditions listed in the previous pages — not primarily due to the vaguarities of Mother Nature, but rather the interventions of Modern Man. Having provoked the problem, the hospital will subsequently take credit for having successfully “saved” the mother from this nosocomial complication. This is one of the problems that many birth activists are trying to change by “normalizing” (demedicalizing) normal labor and birth care.

For instance, artificial rupture of the mother’s membranes (breaking her water) to speed up labor greatly increases the risk of cord prolapse. Pitocin use increases the need for narcotics pain meds and anesthesia, which together increases the incidence of fetal distress, operative delivery and maternal hemorrhage. Neither of these account for the psychology of haste that pervades hospital-based obstetrical care and the propensity of tired, stressed, over-worked physicians to try to “get things over with”. One of the fore fathers of obstetrics described in an 1839 textbook [8] that for every one woman saved by manual removal of an adherent placenta, 100 mothers were lost due to the routine use of manual placental removal done to hasten the process so the doctor could go home. Manual removal of the placenta was still being done routinely when I retired from nursing in 1976. Pitocin augmentation of labor seems to have replaced it as a time saving tool for the 1990s. Now we have the Rolls Royce of “labor-saving” strategies  for the decade of the new mileium – the maternal choice cesarean under epidural anesthesia.

Even though the hospitals continue to take credit for saving childbearing women from the many complications associated with interventive hospital care, the statistical analysis will favor those settings and those caregivers who do not routine apply medical interventions to healthy mothers. These is no reason why those qualities of non-interventionist care based on physiological management cannot be applied in acute care hospitals  or hospital-owned “maternity home” settings