“Divas in the Delivery Room”Balancing Consumer Demands with Safe Patient Care

Terry S. Johnson, APN, NNP-BC, CLEC, MNNeonatal Nurse Practitioner

Founder, Lode Star Enterprises, Inc.

What Is Going On Around Here?!?

Disclosure Statement

• Terry S. Johnson, APN, NNP-BC, CLEC, MN– In addition to any clinical practice, education and

consulting services I provide• I am currently on the speaker's bureau and/or consult with

these industry partners– Prolacta Bioscience and the Abbott Nutrition Health Institute– I receive financial reimbursement for those services

– Images & photographs used in this presentation come from publicly accessed sources

– I will make no recommendations for an off label use of any drug or medical device

– I am honored to be here today

“Divas” in the Delivery Room

Wall Street Journal, 11/29/2002

Special Requests in the Delivery Room

• Special Requests in the Delivery Room– Characteristics of These Mom’s?

• Frequently, older, professional women - who are accustomed to "being in charge"

• Or younger – who have had and "made choices" their whole life

• Used to “being in charge” • "Marketed" as a “consumer”• Direct & assertive communication styles• Well educated, and often well insured• They have been “courted” by the institution• Control gives a focus other than fear & pain

Special Requests in the Delivery Room

• What Are They Asking For? – Birth (induction, SVD, & C/S) on demand– Day/date/time of delivery– Alternative birth practices – Birth plans & NICU plans– Family (including my BFF’s centered, supported,

present, active in the labor and delivery process– Continuously connected– Cultural & spiritual preferences– Flexible, individualized but safe delivery options

Pregnancy, Labor & Delivery

• Ala carte prenatal cart• “Boutique ultrasounds”• Birth Plans• Family, siblings, pets

present at delivery• Control of environment

– temperature, lighting, sound, furnishings

• Doulas – before, during & after delivery

Model to Assess Request

Johnson, 2002

Low Annoyance

Low Risk

High Annoyance

High Risk

Options For Labor & Delivery

• Labor Requests – Laboring on back - very ineffective– Loss of maternal cardiac output– Walking, sitting, standing, squatting

Options for Labor & Delivery

• Position During Second Stage of Labor– 20 randomized or quasi-randomized trials– 6135 participants

• Use of any upright or lateral position, compared with supine or lithotomy positions associated with

– ↓ Second stage of labor (mean 4.28 minutes, CI 95%)

– Small ↓ in need for assisted deliveries ((19 trials: relative risk (RR) 0.80, 95% CI 0.69 to 0.92)

– ↓ In episiotomies (12 trials: RR 0.83, 95% CI 0.75 to 0.92);

– ↑ In second degree perineal tears (11 trials: RR 1.23, 95% CI 1.09 to 1.39

– ↓ Report of severe pain (1 trial: RR 0.73, 95% CI 0.60 to 0.90)

Cochrane Collaboration Reviews June 12, 2009

Options for Labor & Delivery

• Position During Second Stage of Labor– 20 randomized or quasi-randomized trials

and 6135 participants• Use of any upright or lateral position, compared

with supine or lithotomy positions was associated with

– ↑ Estimated blood loss greater than 500 ml (11 trials: RR 1.63, 95% CI 1.29 to 2.05)

– ↓ Fewer abnormal fetal heart rate patterns (1 trial: RR 0.31, 95% CI 0.08 to 0.98)

• Results should be interpreted with caution as the methodological quality was variable

Cochrane Collaboration Reviews June 12, 2009

Neonatal Transition

“Making the transition from intrauterine to extra-uterine life is probably the single most

dangerous event that most of us will ever encounter in our lifetimes. Our bodies are required to make more radical physiologic

adjustments immediately after birth than they will ever have to do again.”

Kattwinkle, J

Neonatal Resuscitation Program, 5th Edition, 2006

What Do We Know?

• Neonatal Transition– First period of reactivity– Period of decreased responsiveness– Second period of reactivity

Desmond

Desmond M, et al (1963) Journal of Pediatrics 62(3); p. 307-325

Neonatal Transition

• First Period of Reactivity– Lasts 0 to 30 minutes – Changes predominantly sympathetic– Rapid in HR to 160-180 bpm– Respirations irregular & peak at 60-80– Flaring, rales, grunting, retractions possible– Alert, spontaneous jerks, tremors– Gustatory movements, cry– Body temperature; motor activity & tone– Bowel sounds absent & minimal saliva

Desmond M, et al (1963) Journal of Pediatrics 62(3); p. 307-325

Neonatal Transition

• Period of Decreased Responsiveness– Marked in activity; infant sleeps– HR falls to 100-120 beats per minute– Respirations fast, shallow, synchronous– Respiratory rate ~ 60 breaths per minute– AP diameter of chest– Abdomen rounded & BS’s present– Oral mucous absent– Spontaneous jerks & startles

Desmond M, et al (1963) Journal of Pediatrics 62(3); p. 307-325

Neonatal Transition

• Second Period of Reactivity– Responsive to exogenous stimuli– Brief tachycardia & rapid respirations– Abrupt change in tone & color– Oral mucous & gagging– Passes meconium stools– Period may be brief or last for hours

Desmond M, et al (1963) Journal of Pediatrics 62(3); p. 307-325

Options for Labor & Delivery

• Water Labor– Introduced from Europe to

US hospitals in early 1990’s

– Relaxation, pain management during labor

– May labor with others in tub or pool

– Labor until ROM

• Water Birth– Introduced from Europe

to US hospitals in late 1990’s

– Mother labors & delivers in tub or pool

– Baby allowed to “surface” & remains in tub with mother for an extended period after delivery

Water Birth

• Gilbert, R.E. & Tookey, P.A. (1999). Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal, 319(7208); 483-7.

– Surveillance study & postal survey– British Isles (4/94 – 3/96)– Babies who died or were admitted to SCN

within 48 hrs after a water birth• 4032 deliveries (0.6%) occurred in water• Perinatal mortality 1.2/1000 (W) (0.8 to 4.6/1000)• SCN admissions 8.4/1000 (W) (9.2 to 64/1000)• No deaths directly attributable to water birth• 2 admissions for water aspiration

Water Birth

• Conclusion:Perinatal mortality is not substantially higher among babies who are delivered in water than among those born to low risk women who delivered conventionally.

Water Birth

• Otigbah, C.M., et al.(2000). A retrospective comparison of water births and conventional vaginal deliveries. European Journal of Obstetrics, Gynecology & Reproductive Biology, 91(1); 15-20.

– Retrospective, case-controlled (Scotland 89-94)• N = 301 women electing water births matched by

age & parity

• Compared: length of labor, analgesia, APGAR, maternal & neonatal complications

• Primiparas– Shorter first & second stages of labor– Total time in labor reduced by ~ 90 minutes– Primips < perineal trauma > tears– 2X as many 3rd degrees & PPH in controls– Episiotomy rate 5 times higher in controls

Water Birth

• Otigbah, C.M., et al.(2000). A retrospective comparison of water births and conventional vaginal deliveries. European Journal of Obstetrics, Gynecology & Reproductive Biology, 91(1); 15-20.

– Retrospective, case-controlled (Scotland 89-94)• N = 301 women electing water births;

matched by age & parity• Compared: length of labor, analgesia, APGAR, maternal

& neonatal complications• Infants

– 2X as many admits to SCN for controls– APGAR scores comparable– No neonatal infections– No neonatal deaths

Water Birth

Conclusion:

Water births in low risk women delivered by experienced professionals are as safe as normal vaginal deliveries.

Water Birth

• Geissbuhler, V. & Eberhard, J. (2000). Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths. Fetal Diagnosis and Therapy, 15(5); 291-300.

– Prospective, observational study• 7,508 births between 11/91 & 5/97• Comparable parity, maternal age

– Compared deliveries» Waterbirths N = 2,014

» Maia-birthing stool N = 1,108

» Bedbirths N = 2,363

– Episiotomy rates» 12.8% of water births

» 27.7% Maia-birth stool

» 35.4% of bed births

» Bed births also highest 3rd & 4th degree tears

Water Birth

• Geissbuhler, V. & Eberhard, J. (2000). Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths. Fetal Diagnosis and Therapy, 15(5); 291-300.

– Lowest maternal blood loss in water births– ↓ Analgesia, ↑ degree of satisfaction – Average arterial pH of cord, 5 &10 minute

APGAR scores were higher in water birthed infants

– No ↑in neonatal infection– No case of water aspiration

Water Birth

• Conclusion:Water births do not demonstrate higher degree of risks for the mother or the child than bed births if same medical criteria are used in the monitoring as well as in the management of the birth.

Water Birth & Infant Temperature

• Geissbuehler, V., et al. (2002). Waterbirth: water temperature and bathing time – mother knows best! Journal of Perinatal Medicine, 30(5); 371-8.

– Frauenfeld Clinic – Switzerland– 8 year prospective study– Followed 10,775 births– Compared maternal/infant body

temperatures & morbidity parameters between water and “land” births

Water Birth

• Geissbuehler, V., et al. (2002). Waterbirth: water temperature and bathing time – mother knows best! Journal of Perinatal Medicine, 30(5); 371-8.

– Bathing duration ranged from 28-364 min. – Water temperature ranged from 23° to 38.9– Infant temperatures taken rectally– No difference in maternal & infant body

temperatures between water & land births except at birth, where water birthed infants’ temperatures were actually warmer

Water Birth

• Conclusion:Mothers have an “inborn code of body temperature regulation”. Cumbersome guidelines for water temperatures and bathing duration are “superfluous”.

Water Birth

• Commentary, Pediatrics, August 2002– “Water Birth – A Near Drowning Experience”– “Several reports of deaths attributable to

drowning from “poorly managed water births”– Four companion case studies of newborns

hospitalized with breathing problems after delivery underwater

Model to Assess Request

Johnson, 2002

Low Annoyance

Low Risk

High Annoyance

High Risk

"Yeah, but we're not

doing that weird stuff!"

"Yeah, but what weird

stuff are you doing?"

Induction and C/S on Demand

• Which "divas" are We Talking About?– Changing clinical management and increased

medical intervention• More provider suggested scheduled deliveries• Escalating rate of labor inductions• Escalating rates of cesarean section• As cesarean rates increase, there is an increased

– ↑ Rate of late preterm birth– ↑ Maternal sedation, analgesia– ↓ Breastfeeding early initiation– ↑ LOS for couplets

Labor & Delivery

• "Evolutionary Discordance"– For millennia woman have

delivered & babies have been born -

• At term• With labor• After rupture of membranes• Delivered vaginally• And breastfed

– But we have managed to change all of that!

C/S and Abnormal Labor

Friedman Labor Curve Friedman Curve (modified)

Induction and C/S on Demand

• Cesarean Section Delivery– Initially an emergency procedure for the delivery of moribund

parturients (mothers)

– In 2013, 32.7% of U.S. births were by C/S representing an increase of greater than 43%

Peristats National Center for Health Statistics, final natality data.

Labor Induction

• Reasons for Increased Rate of Labor Induction– Secondary to maternal health risks

• Preeclampsia, Hypertension, Diabetes Milletus, Obesity– Fetal health risks

• Preterm labor, PROM, IDM– Multiple gestation deliveries

• Role of A.R.T.– “Maternal Request” or “Provider Preference”– Issue of “dating”

• Preterm – occur before 37 completed weeks• Late Preterm – from 34 weeks 0 days to 36 weeks 6 days• Dating inaccuracy with margins of error of up to 3 weeks in the third

trimester• Can result in increased rate of Late Preterm Infants (LPI's)

Fuchs K & Wapner R (2006) Elective cesarean section and induction and their impact on late preterm birth. Clinics in Perinatology, 33, 793-801.

C/S Per Maternal Request

• C/S Deliveries at Maternal Request (CDMR)– ? Actual numbers of delivers due to CSMR

• Lack of precise estimates due to coding• Birth records do not tract inductions performed at “maternal

request” or C/S done by “patient choice”• Also “elective cesarean section” and “non-medically indicated

cesarean section”

– Estimated CDMR rate 0.3-14% (McCourt)

– ↑ CDMR from 19.7% to 28.3% in 2001 (Meikle, et al)

– ? Account for 4-18% of all C/S deliveries

Fuchs & Wapner Clinics in Perinatology, 2006; 33 and Michaluk, CA (2009). Neonatal Network 28(3); 145-150

Cesarean Section

• Maternal Analgesia & Pain Management– C/S mandates maternal anesthesia/analgesia

• Anesthesia-related complications cause of 2.8 tp 3.0% of maternal deaths

• Failed tracheal intubation 10X more frequent in obstetric than in non-obstetric patients

• General anesthesia death rate 17X > regional• Post-op anesthesia complications include n/v,

respiratory depression, decreased mobility, ileus, thrombosis

Grisaru & Samueloff. 2004 Clinics in Perinatology

Cesarean Section

• Maternal mortality with C/S – Ranges from 1.7 to 3.4 deaths per 1,000,000– Mortality rate in elective C/S = SVD

• Maternal morbidity issues with C/S– Thrombolembolism– ICU admission– Blood transfusion (1-6%)– Endometriosus (10-50% vs. 2.6%)– Surgical injury to the bladder, bowel (2%)– Paralytic ileus (1%)

Grisaru & Samueloff, Clinics in Perinatology 2004 31(3)

Cesarean Section

• C/S Delivery and MaternalOutcomes in Canada– Used hospital discharge records – Compared 470,00 Canadian women with scheduled

C/S for breech presentation with 2.3 million who planned SVD

– C/S delivered women• ↑ Cardiac arrest, blood clots, infections, hysterectomy• ↓ Blood transfusions• No statistical difference in death rates

Liu, et al Canadian Medical Association Journal, 176(4); 455-459: (2007).

Potential Risks & Benefits of CSMR

• Maternal– LOS**– Hemorrhage**– Pelvic floor injury

• Urinary incontinence• Anorectal function• Pelvic organ prolapse• Sexual dysfunction

– Future pregnancy• Uterine rupture**• Placenta previa and

accretia*• Fertility• Stillbirth

• Maternal– Anesthesia complications– Infection – Surgical trauma – Hysterectomy– Thromboembolism– Postpartum pain– Depression– Maternal mortality

* Moderate level of evidence Lee & D’Alton Clinics in Perinatology 2008 35 (3) 505-518

Cesarean Section

• Neonatal mortality – Inconsistent association of C/S and mortality– ? Decrease in stillbirths, neonatal deaths– Neonatal death more closely related to prematurity,

congenital anomalies

– 5 fold increase in C/S delivery without a reduction in rate of CP

– Risk of intracranial hemorrhage with C/S comparable to SVD

– 0.1 to 0.58 mortality after elective C/S’s

Grisaru, & Samueloff, 2004

Cesarean Section

• Neonatal morbidity– “Iatrogenic prematurity

with RDS”– Role of labor on

pulmonary mechanics & function

– PPHN (C/S rate 3.7 vs SVD rate of 0.8 per 1000 births)

Grisaru, & Samueloff, 2004

Elective C/S & Neonatal Morbidity

• C/S Before Onset of Labor– Respiratory morbidity significantly higher for C/S

delivered neonates before onset of labor• Prospective evaluation of 33,000 deliveries at term (≥

37 weeks gestation) over 9 years• C/S before onset of labor

– 35.5 per 1000

• C/S during labor– 12.2 per 1000 (odds ratio 2.9, 95% CI 1.9-4.4; P <.001

• Vaginal delivery– 5.3 per 1000 (odds ratio 6.8; 95% CI 5.2-8.9; P <.0001)

Young & D’Alton Clinics in Perinatology 35 (3) 505-518

C/S Per Maternal Request

• CSMR and Neonatal Mortality & Morbidity– Incidence of TTN in infants born by C/S

delivery at 6% compared with 1.7% of SVD (Fogelson, et al (2005). AJOG, 192, 1433)

– Infants born by ECS at 37-38 wks are 120 times more likely to receive ventilatory support than those born at 39-41 wks (Dudell & Jain, Clinics in Perinatology; 33: 2006)

– Associated between C/S delivery and asthma, hay fever, and allergies in children (Salam, et al (2006). Annals of Epidemiology, 16, 341-346.)

Michaluk, CA (2009). Neonatal Network 28(3); 145-150

Potential Risks and Benefits of CSMR

• Fetal– Respiratory morbidity**– Breastfeeding– Neurologic injury

• Intracranial hemorrhage• Neonatal asphyxia• Encephalopathy

– Brachial plexus injury– Iatrogenic prematurity– Transitional changes

• Fetal– Neonatal infection– LOS– Fetal laceration,

trauma– Mother-infant bonding– Long term outcomes– Fetal mortality– Neonatal mortality

* Moderate level of evidence Lee & D’Alton Clinics in Perinatology 2008 35 (3) 505-518

C/S & Neonatal Outcomes

• Establishing Breastfeeding– Lowest First Contact Index Scores, decreased

skin-to-skin contact and correlation with PPD at 8 months in infants delivered by C/S (Rowe-

Murray & Fisher 2002 British Journal of Obstetrics & Gynecology, 29; 124-131) – Delay in breastfeeding, suboptimal

breastfeeding behaviors and excessive weight loss in infants delivered by C/S and delayed onset of milk production up to 4-6 days in the mothers (Dewey, et al 2003 Pediatrics, 112; 607)

Elective C/S & Impact on Systems

• Compared outcomes/costs of primary C/S with no labor (planned) to vaginal and C/S with labor (planned vaginal)

– MA birth certificates, fetal death records, d/c summaries

• N= 3,334 no labor, primary C/S

• N=240,754 either SVD or C/S with labor

– Planned C/S women

• ↑ Re-hospitalization rate in first 30 days after delivery (19.2 in 1,000 compared to 7.5 per 1,000)

• Main reason was wound complication, infection

• Average cost of planned primary C/S was 76% higher than planned vaginal birth ($4,372 to $2,487)

• LOS was 77% longer (4.3 days to 2.4 days)

DeClercq, et al ACOG, 109;3;(2007)

Model to Assess Request

Johnson, 2002

Low Annoyance

Low Risk

High Annoyance

High Risk

Why Comply With Divas – Whoever They Are?

• Money

• Maternity services a major source of revenue

• Consumer model of healthcare

• Competition for services

• Marketing of health care services

• Role of “Reality TV”

• Role of Internet

• It is ALWAYS safer with us!

Over-Arching Truths

• Hope is not a plan!• Scenario planning • Have a plan & screening protocol in place• Work on your communication skills• Frequent assessment• Err on the side of patient safety• Document• No abuse – from or towards anyone

Terry S. Johnson, APN, NNP-BC, CLEC, MN

Neonatal Nurse PractitionerFounder, Lode Star Enterprises, Inc.

7709 Knottingham LaneDowners Grove, IL 60516Phone: 630.881.2606

Email: lodestar@mindspring.com

C/S Per Maternal Request

• CSMR – Neonatal Mortality and Morbidity

• Neonatal mortality rates for primiparous mothers with no indicated risks who deliver by planned C/S were significantly higher 2.85 vs 1.83 in a cohort of 5.7 million births (MacDorman, et al (2006). Birth 33; 175-181)

• Infants born by planned C/S had twice the risk of admission (9.8% vs 5.2%) to the NICU and twice the risk of pulmonary problems in a sample of 18,653 infants (Kolas, et al (2006). AJOG, 1951538-1543)

Michaluk, CA (2009). Neonatal Network 28(3); 145-150