Download Slide 1

Iowa’s Top Ten List
Stephen K. Hunter, MD., PhD
Professor
Director: Division of Maternal-Fetal-Medicine
University of Iowa Hospitals and Clinics
Associate Director: Iowa Statewide Perinatal
Care Program
Iowa State Department of Public Health
Iowa Statewide Perinatal Care
Program

History


Formed in 1973
Team



Hospital Visits



Initially consisted of an OB nurse, Neonatal nurse & a
pediatrician/neonatologist.
OB consultant and perinatal nutritionist added later
In 1973 – 141 hospitals providing OB care
2010 – approximately 80
Iowa Regionalized System of Perinatal care



Established in large and medium sized communities
Receive best care close to home
Perinatal mortality rates among best in nation
Iowa Statewide Perinatal Care
Program

Hospital visitations




Mainstay of the program
Face-to face education of physicians and nurses
providing obstetrical and newborn care
In past year direct educational contact with 337
physicians and 272 nurses
Since the Perinatal Team travels the entire state
its members have a unique perspective on the
care of mothers and babies in Iowa.
Iowa Statewide Perinatal Care
Program




Level 1
Level II
Level IIR
Level III
No. of Hospitals in Iowa by
Level of Care

Level of Care




Level I
Level II
Level IIR
Level III

# of Hospitals




60
12
6
3
#10: Smoking in Pregnancy
#10: Smoking in Pregnancy

Women who smoke during pregnancy are
more likely to have:
An ectopic pregnancy
 Vaginal bleeding
 Placental abruption
 Placenta previa (a low-lying placenta that
covers part or all of the opening of the uterus)
 A stillbirth

#10: Smoking in Pregnancy

Babies born to women who smoke during
pregnancy are more likely to be born:





With birth defects such as cleft lip or palate
Prematurely
At low birthweight
Underweight for the number of weeks of pregnancy
Babies born prematurely and at low birthweight
are at risk of other serious health problems,
including lifelong disabilities (such as cerebral
palsy, mental retardation and learning
problems), and in some cases, death.
#10: Smoking in Pregnancy
Iowa
Maternal
Smoking
Medicaid Non-Medicaid All mothers
30.0%
9.3%
16.2%
#10: Smoking in Pregnancy


Compared with women who smoked through-out
pregnancy, first-trimester quitters reduced their
odds of delivering a preterm non-SGA newborn
by 31%, a term SGA newborn by 55% and a
preterm SGA newborn by 53%.
Second-trimester quitters reduced their odds of
delivering preterm non-SGA and term SGA
newborns but to a lesser magnitude.

Polakowski et al., Obstet & Gynecol. 114(2):318, 2009
#9: Stillbirth Work-Up
#9: Stillbirth Work-Up

Two questions our patients will always ask;
Why did it happen?, and
 Will it happen again?


“If ye seek, ye shall find.”

May not always be true in the area of stillbirth,
but I can promise that if you DON’T seek, you
will NOT find.
#9: Stillbirth Work-Up
Number 102, March 2009 (Replaces Committee Opinion Number 383, October 2007)
Management of Stillbirth
The most important tests in the evaluation of a stillbirth
are fetal autopsy; examination of the placenta, cord, and
membranes; and karyotype evaluation.
#8: Pitocin
#8: Pitocin
#8: Pitocin

Areas of Concern

Lack of standardization of Pitocin protocols
#8: Pitocin

Areas of Concern
Lack of standardization of Pitocin protocols
 Not recognizing or treating hyperstimulation
 Physicians ordering increases when not inhouse or have not personally looked at FHR
and Toco strips (Cowboy mentality)
 Simultaneous use of Pitocin and maternal
oxygen

There may be many appropriate
ways to treat a condition
When using a team approach (with
changing teams) – let’s pick one and
get real good at it
Beware of the Cowboy Mentality
#7: Access to Care
Iowa Statewide Perinatal Care
Program

History

Hospital Visits
1973 – 141 hospitals providing OB care
 2010 – approximately 80
 In

Iowa Level I Hospital Survey
Dear Hospital CEO,
The Iowa Statewide Perinatal Care Program is trying to obtain data from all hospitals in
Iowa regarding labor & delivery services. We are engaging in this study due to
concerns we have over discontinuation of obstetric services by many hospitals in the
state in recent years. When the Perinatal Program began over 35 years ago, there
were approximately 140 hospitals in the state providing obstetric services. We are
currently down to approximately 80, with many discontinuing this service in the last 1015 years. To try and discern the reasons for this we are asking you to fill out a short
survey provided with this letter and return to our office in the stamped envelope
provided. It should only take 2-3 minutes of your time to complete. We are hoping for
a high percentage of surveys returned. The information obtained will be very helpful to
us as we try to keep convenient, high-quality obstetric services available to the women
of Iowa.
Sincerely,
The Iowa Statewide Perinatal Care Program:
Michael Acarregui, MD, Director
Stephen Hunter, MD, PhD, Associate Director
Penny Smith, RNC, Neonatal Nurse Consultant
Amy Sanborn, RNC, Obstetric Nurse Consultant
Survey Questions
1. Does your hospital currently provide prenatal and labor & delivery
services?
____ Yes
____ No
2. If no, has your hospital ever provided prenatal and labor & delivery
services?
____ Yes
____ No
3. If your hospital previously provided prenatal and labor & delivery
services but no longer does, what year were these services discontinued?
4. If your hospital previously provided prenatal and labor & delivery services but no longer does, what
was/were the reason(s) for discontinuing these services? (Check all that apply)
____ Inability to recruit physicians willing or capable of providing OB care
____ Inability to retain physicians willing or capable of providing OB care
____ Inability to recruit physicians willing or capable of performing cesarean sections
____ Inability to retain physicians willing or capable of performing cesarean sections
____ Inability to recruit physicians willing or capable of providing OB anesthesia
____ Inability to retain physicians willing or capable of providing OB anesthesia
____ Inability to recruit nurses trained in providing OB care
____ Inability to retain nurses trained in providing OB care
____ Concerns regarding quality of OB care and services provided
____ Medical-legal liability concerns
____ Financially non profitable to the hospital
____ Close proximity to a competing hospital (duplicative services for a geographical
area)
____ Other (please explain)
5. If your hospital currently provides labor & delivery services has your hospital ever considered
discontinuing this service?
Iowa Level I Hospital Survey-Results

No. of Level I hospitals currently providing OB
care & not considering closing


No. of Level I hospitals currently providing OB
care but have considered closing


40
13
No. of Level I hospitals that previously provided
care but currently do not

29 (15 in the last 12 years)
Iowa Level I Hospital Survey-Results

Most common Reasons Cited for Closure
of OB services;
Inability to recruit or retain physicians (OB
providers, surgeons, anesthesia) and
nurses capable or willing to provide OB
care
 Concerns regarding quality of OB care and
services provided
 Medical-legal liability concerns

Challenges faced in rural Iowa

Access to Care

Inability to recruit or retain physicians (OB
providers, surgeons, anesthesia) and nurses
capable or willing to provide OB care
Access to Care

Study Highlights Grim Realities of Rural Obstetric Access, Lynda
Waddington. Jun 9 2009 (http://www.rhrealitycheck.org)



“According to figures assembled from national databases, the number of
hospitals that provided obstetric services dropped by 23 percent from 19852000.”
“The most frequently cited reasons for closing obstetric units were low
volumes of deliveries in rural communities, financial vulnerabilities due to
high proportion of patients on Medicaid, and difficulties in staffing obstetric
units. Reasons for difficulties in staffing obstetric units include malpractice
burdens for physicians, changes in physicians’ attitudes towards work and
quality of life, and the cost involved in recruiting supporting specialists such
as anesthesiologists and surgeons.”
The Status and Future of Small Maternity Services in Iowa. Herman
A. Hein. JAMA 255: 1899-1903, 1986.

“The Iowa Hospital Association anticipates that numerous small
hospitals will be forced to close within the next several years.”
#6: Progesterone for H/O PTD/Short Cx
#6: Progesterone for H/O PTD/Short Cx

Preterm Birth
12.9 million births worldwide (9.6%)
 United States 12.8% in 2006
 Iowa 11.5% in 2008
 The leading cause of perinatal morbidity and
mortality.
 Contributes to 70% of neonatal mortality and
~ half of long-term neurodevelopmental
disabilities.

#6: Progesterone for H/O PTD/Short Cx

Meis et al. 2003 NEJM
Weekly injections of 17P starting at 16-20 wks
in women with H/O PTD.
 Reduced incidence of PTD in 17P group vs
Placebo.

 <37
wks 36.3 % vs 54.9%
 < 35 wks 20.6% vs 30.7%
 <32 wks 11.4% vs 19.6%

Daily vaginal progesterone has been
shown to be as effective as IM 17P
#6: Progesterone for H/O PTD/Short Cx

Vaginal progesterone has now been shown to
reduce the rate of preterm birth and neonatal
morbidity in asymptomatic, low-risk women with
a sonographic short cervix (10-20mm) in the
midtrimester.

Hassan et al. 2011




<35 wks, 14.5% vs 23.3%
<33 wks, 8.9% vs 16.1%
<28 wks, 5.1% vs 10.3%
Romero et al. 2012


<33 wks, 12.4% vs 22.0%
<35 wks, 20.4% vs 30.5%
#6: Progesterone for H/O PTD/Short Cx

Number 522, April 2012
Incidentally Detected Short Cervical Length
The American College of Obstetricians and Gynecologists and
the American Institute of Ultrasound in Medicine recommend
that a cervical length measurement be performed at the time
the ultrasound examination is undertaken for fetal anatomic
survey at around 18–22 weeks of gestation.
#6: Progesterone for H/O PTD/Short Cx

Where are the problems?

Not treating appropriate women.
 H/O
PTD
 Mid-trimester short cervix (10-20mm)
Difficulty in getting insurance coverage,
especially Medicaid for Progesterone.
 Logistics of getting a mid-trimester
transvaginal cervical length measurement on
all pregnant patients.

#6: Progesterone for H/O PTD/Short Cx
Average cost for 1 day in the NICU: $4,000-$5,000
#5: Documentation
Fact: Medical Malpractice claims
are an inescapable reality
Statistics:
 2 of every 3 physicians have been sued
 1 of every 3 physicians have been sued > 3x
 Virtually every hospital has been sued multiple times.
 When hospitals are sued, nurses are named individually.
 50% of all cases filed are dismissed or dropped w/o
payment.
 35% of all cases are settled out of court.
 < 15% of all cases are resolved at trial.
 40% of tried cases result in Plaintiffs verdict (6% of all
cases)
Fact: 6 of the top 10 largest Med-Mal
verdicts in 2005 involved perinatal care.

Statistically: Nurses practicing in perinatal
care settings are the most likely to be
involved in med-mal litigation.
Top 2 Sources of Hospital Liability
Exposure
1. Failure to appropriately document.
 2. Failure to appropriately assess and
intervene.

Fact:

“The finest care rendered under the best
circumstances may be difficult if not
impossible to defend if the care is not
documented.” – Charles Ward, M.D.,
“Critical Care of the Neonate”
Fact:

Not only are healthcare providers required
to take appropriate action, they are
required to accurately document their
findings, interventions, and patient
response to intervention.
#5: Documentation

Areas of concern
Shoulder Dystocia
 Operative Vaginal Deliveries

Documentation

Strongly Recommend
Written or (better) dictated pre-op note
 Written or (better) dictated post-op note
 Details of discussion with patient
 Details of procedure with times, number of
pulls, pop-offs, VE suction, fetal descent
 Details of maternal/neonatal trauma
 Rationale for decisions at the time (indication)

Strategies to Decrease Liability
Related to Documentation.




Provide an accurate account of all events related to care
of the patient. A healthcare professional may not be
asked to testify in a malpractice case until several years
after the event occurred. If the healthcare provider/staff
has documented all aspects of care, remembering the
event will be much easier.
Document assessment, planning, intervention and
evaluation. Careful documentation will serve as
evidence that the current standard of care was followed.
Document data collected at each assessment and any
special circumstances of problems noted.
Document factually, without placing blame.
Strategies to Decrease Liability
Related to Documentation. (contd)



Document completely to avoid gaps in the
record. Gaps may suggest that the patient may
have been neglected.
Document follow-through on nursing plan and
physician’s orders for treatment. Any omissions
in carrying out the physician’s order should be
documented.
Document response to medications and
treatment.
#5: Documentation

How do we improve?

The use of Standardized documents and
checklists
And Finally…Beware the EMR
Usually designed for ease of data input
and capture of charges
 Often “narrative” unfriendly. Therefore
very difficult to tell a story.
 Output is often very disorganized. Again,
making it very difficult to figure out the
story.

#4: Communication
“There are some
patients we cannot
help;
there are none we
cannot harm.”
Arthur Bloomfield, MD
“Medicine used to be
simple, ineffective and
relatively safe. Now it is
complex, effective and
potentially dangerous.”
Cyril Chantler, MD, Lancet, 2001
“…modern health care is the most
complex activity ever undertaken by
human beings.” Ken Kizer









Highly complicated technologies
Panoply of powerful drugs
Widely differing professional backgrounds
Unclear lines of authority
Highly variable physical settings
Unique combinations of diverse patients
Communication barriers
Care processes widely vary
Time pressured environment
Institute of Medicine Report1999

44,000-98,000 people die each year in the
United States due to preventable medical
errors
Thoughtful Communication

Communication breakdowns are at the
root of 85% of all adverse events reported
in obstetric units.
Communication

Be able to provide accurate information
Communication

Be sure everyone understands what you are saying
Communication

Make sure everyone understands what you are doing.
#4 Communications

Areas where we can improve

Fetal Heart Rate Terminology (NICHD)
EFM & OB Liability

“No tool is more universally used to
demonstrate alleged negligence in
obstetrical claims than the electronic fetal
monitor”
L. Greenwald, Pro Mutual Risk Management Services, 1998
Intrapartum FHR monitoring is a
ubiquitous procedure that impacts the lives
of more than 7 million mothers and babies
every year in the United States alone
On Accreditation of Healthcare Organizations
Sentinel Event
Alert
Issue 30-July 21, 2004
Preventing infant death and injury during delivery
Reviewed 47 cases of perinatal death or major permanent injury
in non-anomalous newborns weight > 2,500 grams
Leading risk factor: Poor communication of abnormal
FHR patterns
On Accreditation of Healthcare Organizations
Sentinel Event
Alert
Issue 30-July 21, 2004
Recommendations
Educate nurses, residents, nurse midwives, and
physicians to use standardized terminology
to communicate abnormal fetal heart rate tracings
NICHD FHR Terminology

The five basic components of a FHR tracing are:





Baseline rate
Baseline variability
Accelerations
Decelerations
Changes or trends over time
Basic Issues: Basic
Definitions

Know what you are talking about, or look like a fool.
None of us is as smart as all of us.
~ Ken Blanchard
#3: Preeclampsia
Pre-eclampsia/Eclampsia in the state of
Iowa-What do we know and where are the
problems
Maternal deaths
 Pre-eclampsia related practice problems
encountered during hospital visit reviews
 Eclampsia

Iowa Maternal Deaths 1987-2010
(Total/PET)
10
9
8
7
6
5
4
3
2
1
0
1987 1991 1995 1999 2003 2007
Total
Preeclampsia
Maternal Mortality
Iowa Maternal Deaths 1987-2010
(Total/PET)

Why the increased frequency since 2005?

? Increased incidence
 Increased

obesity rates in Iowa
Co-morbidities
? Increased severity
 ? The normalization of deviance

Medical Errors Related to
Preeclampsia Observed








Did not consider diagnosis
Misdiagnosed
Maternal transfers to ER or neurology without
OB notification or consult
No hourly I/O’s
General diet on MgSO4
Ambulating on MgSO4
No MgSO4 administered
Lack of appreciation for the disease
Eclampsia

Dr. Zlatnik Perinatal Letter Vol. XXVI, no. 4

22 cases reviewed

Potentially preventable in 10 cases



3 patient errors (No prenatal care 2, left hospital AMA 1)
7 MD or RN errors
Dr Hunter 2005-2010

28 cases reviewed


Potentially preventable in 8 cases (all MD/RN error)
Of 28 cases, 13 were postpartum (0 days to 14 days)

Educate physicians and other clinicians
who care for women with underlying
medical conditions about the additional
risks that could be imposed if pregnancy
were added…

Educate emergency room personnel about the possibility
that a woman, whatever her presenting symptoms, may
be pregnant or may have recently been pregnant. Many
maternal deaths occur before the woman is hospitalized
or after she delivers and is discharged. These deaths
may occur in another hospital, away from the women’s
usual prenatal or obstetric care givers. Knowledge of
pregnancy may affect the diagnosis or appropriate
treatment.

Example: Patient arrived at ER after seizures while pregnant.
No OB consult for 3 hours
Conclusions



Morbidity and Mortality due to preeclampsia/eclampsia/HELLP continues to be a
problem in Iowa
Access to care may become more of an issue if
the rate of rural obstetrical unit closures continue
Standardization of protocols and simulation drills
need to be incorporated into both the training
and competency maintenance of all personnel
who provide OB care.
#2: Elective Inductions
Induction

> 2 fold ↑ in rate since 1990:
1990
 2005


9.5%
22.3%
Induction of labor (medical or elective)

↑ risk for Cesarean in nulliparous women
Luthy et al. 2004; Main et al. 2006 NCHS 2007
Elective induction of Labor
In Nulliparous Women
Almost doubles risk of Cesarean birth
Individual physician effect
Luthy et al. 2004
Cesarean Delivery for “Failed
Induction”
Influenced by multiple factors
 Not all factors are clinical



PIL “Physician Intolerance to Labor”
Convenience?

CPD “Cesarean Prior to Dinner”
#1: Cesarean Sections for Stillbirths
#1: Cesarean Sections for Stillbirths
First, Do No Harm
#1: Cesarean Sections for Stillbirths
Total and primary cesarean rate an vaginal
birth after previous cesarean (VBAC): United
States, 1989-2004
Centers for Disease Control
Risks to the Mother
•Cesarean 1st birth is associated
with a higher risk in subsequent
pregnancies of:
•Placenta previa
•Placental abruption
•Uterine scar dehiscence
•Uterine rupture in the 2nd
pregnancy
Getahun et al. 2006, Gillian 2006,
Lydon-Rochelle 2001
•There is a dose-response pattern in the risk of placenta previa, with
increasing numbers of previous Cesareans increasing the risk
•Getahun et al. 2006
#1: Cesarean Sections for Stillbirths
In Women with Placenta Previa
↑ Risk of Placenta Accreta
• With 1 prior Cesarean
• With ≥ 2 prior Cesareans
10-25%
>50%
Creasy & Resnik 2004; Silver, Landon, Rouse et al. 2006
2007
•Prospective observational cohort
•30,132 women who had CD without labor
•19 academic centers over 4 years (1999-2002)
Obstet Gynecol June 2006;107:1226-32
Maternal Morbidity
Associated with Multiple Repeat Cesareans
•Placenta previa/accreta
•Hysterectomy
•Blood transfusion ≥4 units RBCs
•Cystotomy
•Bowel or ureteral injury
•Ileus
•Post-op ventilation (maternal)
•Longer operative time
•Increased days of hospitalization
Obstet Gynecol June 2006;107:1226-32
Placenta Previa and Accreta
by Number of Cesareans
In the 723 women with placenta previa…
Cesarean
1st
2nd
3rd
4th
≥5th
 Risk for Accreta
3%
11%
40%
61%
67%
Obstet Gynecol June 2006;107:1226-32
2007
#1: Cesarean Sections for Stillbirths

Maternal mortality
VBAC 1.6/100,000
 Elective RCS, 5.6/100,000

Questions?