Science & Sensibility

The Joint Commission Sentinel Alert #44: “Preventing Maternal Deaths” is an important document and public recognition that many of the maternal deaths in the United States are preventable. However, the alert is missing important and useful information for women and childbirth educators since the recommendations in the alert are downstream approaches or recommendations for how to save a woman from dying who may have been thrown in the river. It fails to alert our healthcare system about the need to keep women out of the river in the first place.

Let me give you some examples:

One Joint Commission recommendation is to consistently use techniques that have proven effective in the prevention of thromboembolism (blood clots) in women having surgical births. Clearly it is critical that we reduce the risks of surgery and this recommendation needs to be heeded. We need to make surgical births as safe as possible. However, if we eliminated the overuse of cesarean sections we would eliminate even more deaths and injuries. Based on publicly released data, the increase of cesarean surgical intervention is related to where a woman gives birth.

Debra Bingham, DrPH, RN, LCCE

Indeed there is often as much as a three-fold variation in the number of surgical births performed at different hospitals even after adjusting for the woman’s age and risk factors. Reining in practice variation has been a focus of efforts to improve care in other healthcare specialties, yet wide and unwarranted practice variation remains a serious problem in maternity care.

So why are there so many more surgical births and such wide variation in rates of cesarean sections? Well one clear factor at work is variation in how women are treated in labor. For example, some hospitals keep women who present in early labor while other hospitals are more likely to offer supportive care to these women and encourage that they remain at home until active labor. Why is being in a hospital in early labor a problem? When a woman is in a hospital in early labor she is put in a bed, her movements are restricted, and she is tethered to a fetal monitor. None of these interventions has been shown by research to improve maternal or infant outcomes, and in fact they all have documented harms. In addition, it is normal and expected for early labor to start and stop for several days. However, if a woman is admitted to a hospital in early labor and her labor stops then she is likely to have an unnecessary induction of labor. Overuse of inductions lead to more cesarean sections. This becomes the beginning of a cascade of events that all too often leads to a surgical intervention.

Let’s move to the hemorrhage recommendations as another example. Hemorrhage remains a leading cause of death and severe morbidity despite more efforts over recent years to control blood loss at birth. Why haven’t these efforts succeeded? One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again. These abnormal placenta implantations are called percretas, accretas and previas. When a woman has placenta accreta or percreta this can lead to internal organ damage and permanent damage to her uterus because the placenta literally grows into the uterine muscle or even into her bowel and bladder and cannot detach from these organs after the baby is born. This abnormal implantation leads to hemorrhage and also often necessitates the removal of her uterus to save her life. Abnormal placenta implantations used to be very rare emergencies; they are becoming common now due to the overuse of cesarean sections. This is a trend that is frightening to me because based on the current rates of cesarean sections the number of women affected will only increase. Things are going to get much worse.

Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices. Following these key practices will prevent women from being thrown in the river and needing to be rescued.

The critical behaviors that Lamaze recommends to improve health and safety are to let labor start on it’s own, encourage freedom of movement, offer labor support rather than labor management, avoid all routine interventions not supported by evidence, avoid interfering with a woman’s freedom to push in an upright position or any position of her choice, and keep the baby with the mother after birth.

Hospitals can help achieve the Joint Commission goal of reducing preventable maternal deaths while also making progress toward Joint Commission core measures by training staff in these practices. Lamaze International offers an Evidence-Based Nursing Care Workshop to do just that. Registration is currently open for our March workshop in Hollywood, Florida.

Debra Bingham, DrPH, RH, LCCE is President-Elect for Lamaze International, Executive Director of the California Maternal Quality Care Collaborative (CMQCC), a member of the California Pregnancy-Associated Maternal Mortality Review Committee and a lead researcher for determining how to prevent maternal deaths.

Debra Bingham Uncategorized cesarean, complications, hospitals, induction, interventions, Joint Commission, practice variation, safety

Many of you will have read the story of the woman laboring on Christmas Eve who suddenly went into respiratory and cardiac arrest in front of her horrified husband. She recovered shortly after her son was delivered by emergency cesarean, and the baby, too, was successfully revived. As the MSNBC article tells the tale:

After their miraculous recovery, both mother and the baby, named Coltyn, appear healthy with no signs of problems, Martin [the obstetrician who responded to the Code Blue and performed the emergency cesarean] said. She said she cannot explain the mother’s cardiac arrest or the recovery. “We did a thorough evaluation and can’t find anything that explains why this happened,” she said. Mike Hermanstorfer credits “the hand of God.”

However, an ABC video interview with Tracy and Mike Hermanstorfer and Dr. Martin provides details that call into question the hospital’s failure to find an explanation. I have transcribed the relevant section.

Tracy: [Tracy was being induced for her third child because membranes ruptured.]The pains [with Pitocin] were a lot harder than I remembered. We decided to go ahead and do the epidural for the very first time. . . .

ABC: Mike, you were holding her hand as Tracy got the epidural. . . . When did you start to notice that there was a problem occurring?

Mike: Well, we had her sitting up when they were doing the epidural and afterwards she lay down and said that she was tired and that’s when the whole nightmare started.

ABC: What happened?

Mike: She started going numb and everything in her legs . . . and she laid down to close her eyes and take a little nap . . . and she wasn’t waking up.

ABC: When did you notice that her breathing was shallow or her color was blue?

Mike: Well, I felt her hand—I was holding her hand—and it started getting cold and I looked down at her fingertips and her fingertips were blue and one of the nurses noticed that the color in her face was completely gone. She was as gray as a ghost.

ABC: Code Blue was declared, a scary thing in any hospital. [Dr. Martin arrives in response.]

Dr. Martin: . . . When I ran into the room, the anesthesiologist had already started breathing for Tracy. There were preparations already being made to start a resuscitation should her heart stop. About 35 to 40 seconds after I got in the room, her heart did stop and we started making preparations to do an emergency cesarean delivery right there in the room in the event that we were not successful in bringing Tracy back. Unfortunately, in most of these situations, despite the best efforts of the team, Mom is often not able to be revived, so we anticipated that possibility and when it became clear that Tracy was not responding to all the work that the team was doing on her, we had to make that difficult decision to do the cesarean section, primarily in an effort to give Coltyn the best chance at a normal survival and also hoping that it would allow us to do a more effective resuscitation on Tracy, and fortunately, she cooperated and we got a heartbeat back immediately after delivering Coltyn.

So, according to Dr. Martin, Tracy is an example of how things can go suddenly and horribly wrong for no discernable reason in a healthy woman having a normal labor. All I can say is that Dr. Martin must have slept through the class on epidural complications. Tracy’s story is the classic sequence that follows what anesthesiologists term an “unexpectedly high blockade,” meaning the anesthesiologist injected the epidural anesthetic into the wrong space and it migrated upward, paralyzing breathing muscles and in some cases, stopping the heart. High blockade happens rarely, and even more rarely does it result in full respiratory and cardiac arrest—one database analysis of 11,000 obstetric epidural blocks reported a rate of 1 in 1400 women experiencing a high block and 1 in 5500 requiring intubation, and no woman experienced cardiac arrest. It does happen, though, and I am willing to bet that high blockade and its sequelae happened to Tracy.

The moral of the print version would be: have your baby in a hospital where you can be saved should this happen to you. The video interview, however, reveals a different picture. The real moral of the tale is that the safest and healthiest births will be achieved by avoiding medical intervention whenever possible. Induction of labor is by no means always necessary when membranes rupture and certainly not immediately. If Tracy had been allowed to start labor on her own, which, considering that this was not her first baby, she would likely have done within a few hours, she probably wouldn’t have wanted the epidural any more than she did for her first two children. Tracy almost certainly would have gone home the day after Christmas after another uneventful, unmedicated vaginal birth. Instead, she is recovering from surgery, and she and her husband have the emotional trauma of her and her son’s near miss experience to deal with. Along with the Hermanstorfers, we can thank God for the prompt actions of the hospital team, but the safe money says they were rescuing her from a disaster they themselves had caused.

Henci Goer Uncategorized complications, epidurals, induction, media, PROM

Last month, I announced the first in a series of Healthy Birth Blog Carnivals and asked for submissions from bloggers about “letting labor begin on its own”.

How labor begins sets the stage for everything that follows, and with only a few exceptions, letting labor start on its own is the safest and healthiest choice for both mothers and babies.

Unfortunately, according to the Listening to Mothers II Survey, about 1 in 3 women who gave birth in 2005 were induced and 16% had planned cesareans before labor began, for a total of half of babies being born before they were ready (not including those pathologically born early as a result of preterm labor). More troubling still, although the vast majority of respondents said that women should be told every possible complication before giving consent for an induction or cesarean surgery, most women couldn’t answer basic questions about complications related to these procedures, whether they had experienced them or not. In fact, women who were induced were actually more likely to answer questions about induction complications incorrectly.

Today, women have access to more information than ever before, thanks in large part to the bloggers who so willingly share their personal stories, expertise, and wisdom. I want to thank all of those who submitted to this Blog Carnival. I couldn’t have asked for a better collection of posts about how labor begins.

Our next Healthy Birth Blog Carnival will be on Healthy Birth Practice #2, Walk, Move Around, and Change Positions in Labor. Instructions for submissions coming soon!

Without further ado, here’s what our fantastic community of bloggers has to say about Letting Labor Begin On Its Own…

Read more…

Amy Romano Uncategorized cesarean, complications, Healthy Birth Blog Carnivals, induction, preterm labor, safety, VBAC

When a study compares one practice with another and reports “no difference” in outcomes, is that the end of the story? Not necessarily. “No significant difference” can mean any of these:

• there really is no difference
• the study was too small to find the difference that really is there (it lacked “statistical power”)
• the outcome was measured or reported in a way that obscured a difference that really is there
• the statistical test yielded a “false negative result,” failing to find a difference that really is there (this type of error occurs in up to 1 out of 20 statistical results)

So in 3 out of our 4 possibilities, the difference really is there, we just can’t see it. How do we know when “no difference” means “no difference” and when “no difference” means “keep looking”?

To understand this problem, and how to best get around it, let’s have a look at postpartum maternal morbidity after cesarean surgery versus vaginal birth.

Perhaps you’ve heard that there’s “no difference” in health outcomes between cesarean surgery and vaginal birth. This is what women have been told ever since a so-called “State-of-the-Science Conference” report was issued by the National Institutes of Health in 2006.  After evaluating the body of literature comparing planned vaginal birth and planned cesarean section in healthy women, the NIH reported, among other findings, that the evidence that infection is more likely with planned cesarean is “weak”. The report said that, although observational studies find a link between cesarean and infection, the only randomized controlled trial (RCT) of planned cesarean versus planned vaginal birth showed “no significant difference” in infection rates.

It's basically 50/50, right?

In contrast, a new population-based study from Denmark involving over 32,000 women giving birth between 2001 and 2005 reported that women who gave birth by cesarean were nearly 5-times more likely than women who gave birth vaginally to experience a wound infection, urinary tract infection, or blood stream infection. Most of the difference was attributed to wound infection, which occurred in 5.6% of women having unscheduled cesareans in labor, 3.9% of women having scheduled cesareans, and only 0.08%  of women giving birth vaginally. In the United States, where up to 500,000 cesareans may be safely preventable each year,  these data suggest that more than 20,000 postpartum wound infections could be avoided annually along with the excess cesareans.

So what is the disconnect between the “state of the science,” which tells us evidence is “weak” and this new study, which paints a very different picture?

First, the NIH conference, and the AHRQ-sponsored systematic review underpinning the conference, compared planned routes of delivery while the Danish study compared actual routes of delivery. The reviewers acknowledge that studies comparing planned vaginal birth and planned elective cesarean delivery in women with no pregnancy complications are scarce and randomized controlled trials are absent. Rather than conduct a systematic review without any randomized controlled trials, the reviewers included the Term Breech Trial (which I have previously posted about), even though the results of the review would affect recommendations made to women carrying head-down babies.  But the Term Breech Trial’s results  are not applicable to women carrying head-down babies, especially when infection is the outcome of interest. Why? Because 57% of women randomized to give birth vaginally actually had cesareans, and most of these presumably underwent the cesareans in labor, which increases infection risk (along with risks of hemorrhage and other complications). What’s more, breech vaginal births are much more likely than vertex vaginal births to involve episiotomies, instrumental delivery, or both, which increase the likelihood of infection. So in the Term Breech Trial, the vaginal birth group included far more women with cesareans, episiotomies, and instrumental deliveries than we would expect to see in a similar group of women planning vaginal birth of head-down babies. Despite these limitations that make the trial useless for evaluating the true risks of infection associated with each birth route, the AHRQ reviewers rated the Term Breech Trial as the highest quality evidence comparing planned vaginal with planned cesarean birth, trumping observational studies. In the process, the message to women – and clinicians for that matter – transformed from “Planning a cesarean is risky because you expose yourself to excess infection risk” to something more like, “there could be an excess risk of infection with cesarean, but it’s probably small and, hey, for all we know there may be no real difference after all.”

Another reason behind the disconnect is that the Term Breech Trial (again, the “highest quality” evidence in the AHRQ review underpinning the NIH conference) only measured infections occurring prior to hospital discharge, a very common cut-off in both RCTs and observational studies. The new Danish study provides striking evidence that this way of measuring infection is grossly inadequate – more than three-quarters (77%) of infections occurred after hospital discharge. In other words, they would have been missed if the researchers had stopped counting the number of infections as soon as the woman left the hospital. The researchers were able to capture these infections because Denmark has a national database of all births, which was linked to a national database of all clinical laboratory results of infectious diseases, a national database of all antibiotics prescribed, and a national database of all hospital readmissions. (The United States, by the way, has none of these, rendering this type of study literally impossible to conduct here.) In randomized controlled trials, following participants beyond the initial hospital stay is logistically difficult and very costly. Even when follow-up is intended, substantial numbers of new mothers may not respond to surveys or return (to the same provider/facility or at all) for postpartum care. As a result, properly constructed national databases provide an important source – sometimes the only source – of evidence on long-term outcomes.

So which “evidence” do we tell women? The “state of the science” or our less rigid but almost certainly more reliable assessment of the observational studies and our common sense? Of course cesarean can lead to infection – it’s surgery after all. And yes, even with optimal care, some women who plan vaginal births will need to have cesareans and some of those women will get infections. If we’re serious about helping women avoid serious complications like infections, we must:

• tell women who intend to give birth vaginally how they can safely achieve that, starting with the Lamaze Healthy Birth Practices
• help women having vaginal births avoid practices that increase the risk of perineal trauma and thus the risk of perineal infection, such as episiotomy, instrumental delivery, and fundal pressure.

Women experience many physical and mental health problems in the postpartum period, some of which may be safely prevented with a different approach to care given in pregnancy, labor, and birth or better education provided prenatally. We do not know the factors contributing to postpartum health problems because they are shamefully understudied. But one treasure trove of postpartum data in the United States provides a powerful foundation for addressing and researching postpartum health outcomes. Childbirth Connection’s 2008 report, New Mothers Speak Out, compiles the postpartum data and new mother testimonials from both the 2006 Listening to Mothers II Survey and a follow-up survey conducted with participants six months later.  All women’s health professionals and advocates should spend time with this report so we can begin to give postpartum concerns their due attention.

Citations:
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, & Willan AR (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet, 356 (9239), 1375-83 PMID: 11052579

Leth RA, Møller JK, Thomsen RW, Uldbjerg N, & Nørgaard M (2009). Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five-year cohort study of 32,468 women. Acta obstetricia et gynecologica Scandinavica, 1-8 PMID: 19642043

Visco AG, Viswanathan M, Lohr KN, Wechter ME, Gartlehner G, Wu JM, Palmieri R, Funk MJ, Lux L, Swinson T, & Hartmann K (2006). Cesarean delivery on maternal request: maternal and neonatal outcomes. Obstetrics and gynecology, 108 (6), 1517-29 PMID: 17138788

Amy Romano different methods for different questions cesarean, complications, database, infection, vaginal birth