Saturday, October 18, 2014

Interesting Updates in US Hospital Managed Childbearing


        My last child was born eighteen years ago in an excellent hospital in Richmond, Virginia.   Just recently, I attended my daughter during her labor, her delivery  and in her week of hospitalization afterward, in a major university medical center.  Both of our pregnancies and labor and deliveries were high risk, but for very different reasons. The evolution as to how childbearing women are managed since then has been quite interesting.

                 Often in medicine, something that is done as custom, completely reverses in a few years in response to the latest and greatest new study on the subject.  Sometimes, change is for very good reason, and sometimes, well, not so much.  Sometimes, the studies which change the tides of practice are not that large, and perhaps should not be taken quite as seriously.   Often I think that rather than embracing the other side of the pendulum's swing that we should simply approach childbirth, child rearing and general medical care using a more flexible mindset in the beginning. Each patient, each family, and each baby is an individual, and one size fits all, is rarely a healthy medical treatment strategy.

                   In 1996, only those families who had attended the full Prepared Childbirth classes (often Lamaze styled training given in hospitals by specially certified nurses) were permitted in the delivery room.  This helped to ensure that the participants knew where to stand and when to stay out of the way in an emergency. It also meant that they understood enough about the process to accept an emergency cesarean section if rapidly necessary.    In 2014, this was not even a point of inquiry.  Whomever the woman wished to have with her in the delivery room was just fine.  In 1996, the hospital also provided scrubs to the individual who would remain in the delivery room with the laboring woman.  This time, there were no scrubs offered.

                    In 1996, there was a paper medical record and everyone caring for us knew the prior medical history and the plan of care.  In 2014, there was a wholly electronic medical record. However, it would only update periodically (leaving prior medical history out, upon admission, until the software update occurred) and as a result, my daughter was in labor several days without a number of members of the team knowing her entire medical history.   Since only one screen of data is available at a time, many health care workers are unaware of the entire picture, and know only the snippet they need for each task.  In a complex case, this can be a problem.  The function or dysfunction of the electronic medical record resulted in a Type I diabetic who requires insulin on a real time continuous basis, to experience seven hours after labor and delivery without any form of insulin whatsoever, when she was assumed to be a "gestational diabetic" who might not require continuous insulin reordered immediately. (Go ahead, and tell me again how much safer we are with an electronic medical record !)

                    In 1996,  I saw a regular obstetrician, a high risk obstetrician for my thyroid issues, and an endocrinologist.  These were on different days and in different locations in the same city. Non-stress tests, labwork, other tests were done in different locations. It was hard work getting a pregnant and hypertensive woman (me) to all those appointments safely, and I was driving and had small children with me for most of the appointments.    In 2014, high risk pregnancies came to one hospital location where my daughter saw an obstetrician, a high risk obstetrician, an endocrinologist, the lab for labwork, an ultrasonographer and a technician for a non-stress test in about the same location, and  often on the same day.  This meant that she did not become exhausted simply in the course of getting intensive medical care during pregnancy.  The prenatal high risk health care system was a vast improvement over the experience in 1996.

                   In 1996, in labor, we were allowed nothing to eat or drink for the duration of labor, except for a few lemon barley lollipops which our prepared childbirth classes told us to buy and bring to the hospital.  This was done because digestion of food does not occur during labor anyway, and anesthesiologists in particular, if they must attend a patient having an emergency cesarean section, prefer to be working on a patient who has an empty stomach and cannot aspirate stomach contents while under a general anesthesia.      In 2014,  my daughter was allowed to have clear fluids through the course of her labor, even if she were vomiting. This is done now to keep the woman comfortable and aid in hydration. It also permitted her labor to go on longer and was part of how she was able to endure such a long trip and avoid a cesarean section.

                    In 1996, most women still received an episiotomy.  Toward the end of labor, the obstetrician cuts an incision on the posterior vaginal wall at a 90 degree angle with scissors, thus widening the opening and preventing potential deep vaginal tissue tears during delivery. (These are quickly sutured closed after delivery and the straight clean incision usually heals quite quickly.)  Although this is still practiced as a method of preventing serious tearing in a great deal of the world, it is no longer routinely practiced in the US.   Now, a first degree vaginal laceration itself,  which occurs during childbirth is stitched up afterward.   I had several episiotomies which healed quite quickly.  I am noting, that my daughter is still quite uncomfortable without one, three weeks past delivery.
                    In 1996, the nursery filled with lots of babies, where families could visit and compare still existed.    Since I was breastfeeding, my baby was brought to me fairly frequently after delivery, and then he returned to the newborn nursery with nurses in attendance.  As I recovered, he spent more time with me in the room, and less in the newborn nursery.  I remember being a few doors from the elevator and in my slight post partum anxiety, I was afraid to go to sleep with the baby in the room.  I feared someone coming up the elevator and taking the baby while I slept.     In 2014, my daughter was moved from labor and delivery where she also completed her recovery to a Mother Baby Unit.    Both she and her baby remained in the room 24/7 to facilitate breast feeding.   The Mother Baby Unit is high security and is a locked unit, a bit like a modern day psychiatric unit.  Family members with a pass must be buzzed in each time they wish to enter.  To prevent babies being kidnapped, each baby is not only double labelled, but is fitted with an RFID tag.   The baby remains in the room with the mother and cannot ambulate outside her room with her, as I so often did, in 1996.   The RFID tag causes a loud alarm to go off in the unit anytime a baby leaves the desired area, and there are sensors throughout the unit and on the elevators outside.

                   In 1996, the emphasis was on having new mothers ambulate as much as possible on the hallways of the post partum unit to avoid blood clots, to hasten recovery and in order to get to the small kitchen on the unit to get tea or milk.   (Probably also a way of helping to transition a woman going home from the hospital who will take on the tasks of caring for other children as well as her new baby, on arriving at home.)   In 2014,  my daughter was discouraged from leaving her room or interacting with any other patients.  There was no on unit kitchen, and she had difficulty getting hot tea when she wanted it, which she actually needed for diuresis. In addition, being confined to the room meant that when she was discharged after a week, she required an evaluation for deep vein thrombosis and pulmonary embolism. (medical speak for blood clot which can travel to the lung and potentially cause death)

                  In 1996, if you were discharged and your baby needed to stay, then you were thrown to the wolves sitting in a rocking chair until your baby was discharged, and this was not helpful to milk production.  In 2014, my daughter was discharged a day ahead of her son, but she was allowed to remain in their room as a "boarder" with him with her own bed, breastpump, and meals provided, as it is now understood that this is best for both of them.  This new strategy was very much appreciated.

                 In 1996, there were no specific directions about positioning newborns (other than avoiding suffocation with blankets, softtoys or crib bumpers) but now, the American Academy of Pediatrics is very clear that studies indicate that a baby should be put down on his back to avoid SIDS.   I am not sure what they do with newborns who turn their heads or bodies to the side after you place them on their backs.

               The last and most interesting difference is the stance on breast feeding.  In 1996, I was a curiosity. I was a nurse who had chosen to breast feed, and I was indulged as this was considered "quaint".   How could a working woman keep up with breast feeding ?  Why, it's so difficult !!    Now, the pendulum has swung and the attitudes are quite different.  Now, there is a "take no prisoners" attitude toward breast feeding.  The Obama administration now requires health insurers to pay for at least some types of breast pumps via insurance.  There are no more formula samples given to families.  There are no pacifiers permitted.  Babies are to be breast feeding !   Even mothers who endure daily visits by 74 medical students, interns, residents, fellows, attendings, attending physicians undertaking studies of childbearing women etc.,  and a bevy of registered nurse lactation consultants are to be either breast feeding their baby, or using the rolling breast pump.  No one seemed to know though, that Type I diabetics, or those with hypothyroidism or other endocrine issues tend to get a lactation response a bit later than other women, and so my daughter was guilted by some of those on the pediatric service.    I am actually a proponent of breast feeding, but again, a forced inflexible response to any situation generally does not work well for most patients.

              In conclusion, some of the approaches and procedures in 2014 at a major world class medical center were far better than those in 1996.  However, some were not.  In future, I think my daughter will chose to be a "non-teaching patient" and will sidestep all the extra physicians.   Consistency can be a wonderful thing.