Dr. Maragret Helen O'Hara ed.wmv

Man, we really appreciate the ability to come
and share our story about--from this long title of how we--
our journey on how
we were trying to prevent early deliveries.
And why this slide, I don't know if you all can see it,
I like "The Farside," but the caption is
"That's why I never walk in front."
And when we initially got this started back in 2008,
Dr. Horbelt, who was a chairman of our department at that time
said that HCA was coming out with an initiative
of no elective deliveries prior to 39 weeks.
How many people work in LDR here?
Oh, okay, a few.
All right, so you'll probably want to change to OB when you're
done with all this, but anyway-- anyway it's an exciting field.
But my chairman said, "Margaret, they're starting
"this initiative of not delivering before 39 weeks
"and I think we're gonna get some backlash from it.
"I don't want you to get caught in the crossfire.
"So, I'm gonna have one of our very--
"very well-trained, very well-respected
obstetricians/gynecologist do it."
And I was thinking, "Well, that's kind of weird.
I'm the maternal fetal medicine,"
and though I work with a lot of very well-trained OBs
I have to justify my existence, right?
So, I said, "Well, I should take care of that."
So, I went ahead and volunteered because I said,
"How hard really could it be?"
And we'll see.
And so, this was our challenge of 39 weeks and this has been
something that has been going on for a long time,
that recommendation.
And one of the questions is:
Why, if you have good information, and you have
good recommendations from the highest information
source of our field--
American Congress of Obstetrician Gynecologists--
why wouldn't you follow it?
You know, what's-- you know, that's why I said,
"How hard can it be?"
So, now this establishing a culture of safety
is not my idea.
This came again from HCA and they needed some work here,
but what--really the concepts are so good and so simple,
once somebody puts it in front of you,
this is what you need to do.
And so, what we tried to find is what are the best practices
for deliveries for-- if you needed to do
an elective delivery, or when you should do the delivery.
And then look at the information and standardize them
as best you can.
And then you communicate that to your physicians--physicians, or
nurse midwives, and the nurses then communicate that
with the patient on "Why can't I deliver 2 weeks early,
"'cause Aunt Shelly's gonna come and stay with me and I really
want her to see the baby," you know, that kind of thing,
on why that might not be such a great thing.
And we can't talk about quality without documentation,
so had to put that in there.
So, one of the reasons why I think in the healthcare field
we all take very--or most of us are very passionate
about our job and we want to do the best we can.
And in obestetrics if we do something wrong or
if we make a decision that might not have been the best one,
we can find ourselves, and, you know, patients are the first,
lawyers do crop up,
but, you know, you can potentially end up
with a lot of time in a court room, that kind of thing.
So, you want to take the best care of the patient and--but,
so, most doctors--you know, I don't think any of us or any
of the nurses think, "God, you know, I'm really not so good,
but I'll keep trying to do--" you know?
Most of us, you know, try to do the best we can.
We think we're a pretty good care provider.
Also, I think it's hard to try to change somebody's minds on
how they're doing it, at least for me it is, 'cause, again, I,
you know, we're in medicine, you're trying to think through
a lot of things, and make sure that you're just not
doing things robotically.
So, you know, if you've never had a problem doing it this way,
"I've worked here for 30 years.
"I've always done it and never had a problem.
What's your problem that I have to change?"
Another one is, "Well, show me the data."
Which I think is important because if
you don't have data to back you up, then why would you change?
But then if you show them data, on some people, they say,
"Well, that--my patients are different from that set."
And sometimes that's true 'cause if you're talking about,
you know,
comparing people in Manhattan in the upper eastside
that make, you know, their median income is $3 billion,
I mean, and it seems like that.
When I was in New York that's what it seemed like
people were making-- of course not me, but--
versus median income of Kansas,
you know, it's a little bit different
and the access to care, that kind of thing.
And also, and that's why the cookbook slide is,
you know, people aren't, you know, aren't ingredients.
You shouldn't have to have a cookbook to take care of
patients, but you also have to remember
there's a lot of conditions that are similar to patients.
And if something is a better way to treat somebody,
then, again, why wouldn't you do it?
And again, if you can't see it.
It's a Moses-type character in front giving a presentation
to the board and the chairman says,
"Well, we'll think about it," so--
And I certainly don't want to equate
ACOG with the biblical prophets,
but ACOG has recommended no elective delivery
prior to 39 weeks gestation since I started
as a medical student in OB which was 1981.
Now, I have--it's probably even before that.
I just can't find their stuff before that time.
So, anyway, it's been a few years--decades.
So, it's not new.
And then the HCA initiative came out and I don't know
how many of you guys use alligators.
You've got to stay away from the alligators in surgery.
We use it, you know, that kind of thing.
Again, I like "The Farside," you might have noticed by now.
So, I thought this was great.
It says, "Get--" is it Gail?
Or "Get you rascal, get.
"Heaven knows how it keeps getting in here.
Betty, you'd better count them."
So, anyway, but this was to do with labor and delivery.
Like I say, there's a lot of different things to go for
labor and delivery, but this was for the elective deliveries.
And our passion is, and what every parent wants,
what every physician, nurse, nurse midwife
wants is to deliver this kind of baby.
And so, if it was better for babies for an elective delivery,
you would do it.
But it's been found that there's--
in an uncomplicated pregnancy,
remember we're talking about uncomplicated pregnancy.
That's what makes it an elective delivery, because if there was
a reason, you would go ahead and do it for that, right?
So, and Dr. Rayburn writes a lot of books.
Again, one of the many rock stars in--
or saying at least that we have, so--
And also, you worry about is if you deliver somebody early,
a baby early, and you didn't mean to,
you thought they were further along than what you thought.
So, how--and I'll go over this briefly since you guys won't be
determining--many of you don't work in the OB fields, but
anyway, what we said is if you were going to have an elective
delivery prior to 39 weeks, you had to have an amniocentesis
to verify the lungs were ready.
And if you didn't, you'd have to have an ultrasound that was done
less than 20 weeks to show that you were 39 weeks or further.
Well, if it's 39 weeks and after you can do an elective delivery
if you want, if you want.
So, you wouldn't need an amnio for that.
Heart tones by Doppler at 30 weeks.
I have never been able to get a heart tones by Doppler
in less than 10 weeks.
I don't know if any of you guys have gotten it less than 9?
So, again, that would be hard to do it for that reason.
Or for a basically a pregnancy test,
a positive pregnancy test that's been 36 weeks ago.
But again, that would be very difficult not to be
39 weeks by then.
So, we have this criteria if you're gonna deliver by--
before 39 weeks, you had to have the amniocentesis.
So, is there a good reason for a woman to be delivered early
if it's an elective--or if it's an elected delivery?
'Cause if there is, then why wouldn't you do it?
So far we've seen it hasn't been so great for the babies,
or it's not an improvement for the babies.
And for the moms, an unfavorable cervix is a complicated score
called the Bishop Score and it's--have to look it up
each time, but it's looking at how thinned out
a patient's cervix is,
how dilated, how soft, this and that.
There's about five different criteria.
And a good score or favorable score
meaning likely to deliver is 8.
So if somebody has an unfavorable cervix,
you have longer labors, higher medical costs,
and a higher cesarean section rate.
Again, so far, not looking so hot for the,
you know, for the moms.
And an eliperus meaning women who've never delivered
a baby before, even if they have a Bishop's score of 8,
they still have a higher risk for cesarean section.
It's only for women who've delivered more
and have a Bishop score of 8 of their cervix,
don't have an increased risk for cesarean section,
but still have the increased risk of postpartum hemorrhage,
staying in the hospital longer, that kind of thing.
So, another good reason on not to do elective deliveries,
especially before 39 weeks.
And here's some data from
the "New England Journal of Medicine."
This was in 2009 and fortunately this came out a little bit later
than we started our initiative, but this was over
6,000 deliveries and this was a delivery between 37 weeks
and 0 days to 6-38-0 to 38 weeks and 6 days and 39 weeks.
And the rest are the 16,000 were those babies delivered
at 40 weeks or later.
And as you can see with these odds ratios of all the different
problems like on any adverse outcome,
like on death, not so good,
problems with the breathing, that kind of thing,
everything showed an increase risk, odds ratio, increased risk
and it was inversely related to gestational age,
meaning the risk got higher the younger the baby was.
See what I'm saying?
The only thing that didn't increase was
treated hypoglycemia wasn't significantly different,
or they didn't have to intubate a baby any differently.
So, again, overall the adverse outcomes
to the baby were increased.
'Cause a lot of people said, "Well, Margaret,
"you can't tell me that the 38 weeks and 6 days
are gonna have it worse than 39 weeks."
That was one of the things.
Well, the majority of these babies were in the 38-4 to 38-6.
So, maybe I can't tell you it's 38-6, but I can tell you
that there was an increased risk between 38-4 to 38-6.
But unfortunately this wasn't out when our crusade began.
So, again remember they talked about "Well, show me some data."
So, we, you know, there's some data.
And then, "Well, our patients are different from that."
So, we took our data from Wesley and we had
a D-identified patient data base over a 6-year period.
There was like 20,000 deliveries about 6700 that were induced.
And so, 6700 that were induced, about that,
during that 6-year period.
And the elective inductions were, what?
Like two thirds of that, right?
So, 6600 and then 5200 were elective deliveries.
And we just looked at what's the chance of a baby going to
the newborn intensive care unit for an elective induction.
There was nothing on the data or the sheets that demonstrated
any kind of problems.
We took out babies less than 2500 grams to rule out
growth-restricted babies being part of the reason.
And as you can see, the risk of going to the NICU
progressively increased with a lower gestational age.
Even for 39 weeks, it was increased.
Overall, there was a 4% risk-- 4.5% risk of a baby
going to labor and delivery if you delivered--
if you were electively induced less than 39 weeks.
So, significant.
And, you know, this is significant.
This is if--I'm not--I took a class in statistics
and I passed it, but I'm not a great statistician,
but this is a 95% confidence interval here.
And since it doesn't pass 1.0, you know,
it's significantly increased risk.
And again, a reversed correlation
with gestational age,
higher chance of going to NICU the younger the baby is.
Even though that's term.
Thirty-seven weeks is considered term, even though due dates
at 40 weeks, which you probably already know that.
So, why would a woman want to be induced if her doctor has said,
"Well, Mrs. O'Hara, you have an increased risk of, you know,
having a cesarean section, and baby going to NICU."
"Well," I go, "but mom's going to be--" oops.
I'm getting ahead of myself.
"Mom's gonna be here and it's the time that she can get off
work to take care--" you know, you hear this--
people in labor and delivery hear this and probably people
in surgery hear this about when they want to have their surgery
done, that kind of thing, because
they don't want to have-- I love this picture.
They don't want to have an unreliable babysitter.
You know, they want somebody they know,
so they can kind of plan stuff.
And we're at the Air force base.
We have an Air force base in town, so during the deployment
and their wife was pregnant, whether she was going off
or the husband was going off, you can see why they might
want to see the baby and, "Well, Doctor, she's on
"38 weeks, can I--my last baby went into labor at 37 weeks.
And my baby did fine," you know?
Anyway, or you're going on vacation and your patient
wants you to deliver, even though, you know,
your partners are just as nice or just as good as you are.
They know you and they want you.
And I get that, I mean, I was the same way.
So, that's why women sometimes--
and families want an induction or an earlier delivery.
So, I like this.
And this is prophetic, 'cause we put indications for--that you
could do a delivery, induce, or do a repeat cesarean section
without having an amniocentesis prior to delivery.
And that was for 39 weeks for a singleton,
38 weeks for a twin pregnancy.
And that was--that's per ACOG guidelines.
And for preeclampsia growth restriction,
IUGR's growth restriction with chronic hypertension
or with absent or reverse end-diastolic flow.
What the heck does that mean?
That's with abnormal blood flow to the umbilical cord show
that it's getting worse and worse and increased risk
for mortality for the fetus.
If the woman has severe hypertension,
low amniotic fluid by a couple different ways to look at it.
A vasa previa is when the blood vessel crosses the cervix
and it's not in the placenta,
it's just in the membranes and that has a very high risk
of if you're in labor, or after vaginal whatever,
can rupture and the baby can exsanguinate quite easily.
And so, if we know a baby has that,
we deliver those babies at 34 weeks.
It's, I mean, it's a dangerous deal.
Previous classical cesarean section,
'cause they have an increased risk of rupture prior to labor.
Non-reassuring, you know that's really not even elective,
that's--so, I--that's probably I don't even need to put that in,
'cause that would be an indicated delivery if there
was problems with how the baby was doing inside the uterus.
Or P-PROM is Preterm, Premature Ruptured Membranes,
baby broke the bag of water or the bag of water was broken.
They came in at 29 weeks.
She got to 34 weeks by then the risk of prematurity is less
than the risk of complications from ruptured membranes
so we could deliver.
So, I went through all this.
I had the ACOG guidelines, I had the expert opinions
from "The Green Journal," which have all the, again,
the rock stars of OBGYN putting their opinions on it,
and I was feeling great about going to
our section meeting to present this.
And I think Francine was there.
And of course Dawn Piacenza was there,
who runs labor and delivery.
We could not get along without her.
She's amazing.
But I was so wrong.
And I don't know if you've ever seen this movie,
but people--selectively-- people were upset.
And that's the nicest--some people were really upset.
"Are you telling me that, la, la-la, la-la?"
It's like I was asking them to sacrifice their first born.
It was--on some people.
Not--'cause that's a few and I tend to exaggerate
a little bit, but people were upset and, anyway--
So, again, our chairman at that time,
he was really smart in a lot of ways.
The people that were most vocal about their disapproval
of what was going on, they put them on a committee with me
to rearrange and put down what was right.
And through that we really did learn some things.
We looked back and said with birth restriction, ACOG said,
as long as it was over 37 weeks you could go ahead and deliver.
And if you had a previous incision in the thick part of
the uterus, like if they had a resection of a large fibroid
up there, not a, you know, so we hadn't thought of that.
And then after that we thought about third trimester bleeding
reason, and if you have HIV to decrease a risk of transmission
to the baby, you want to deliver at 38 weeks.
So, we had forgotten about that.
So that's why it's nice to be collaborative and then with this
people were buying in a little bit and the calls were less.
And by this again, though we didn't have at the time,
but we're getting--Steve Clark is the head of--he's
an MFM extraordinaire and he is the OB medical director for HCA,
so he's a big dog, and had put out this and this is like HCA
has a bazillion--well, a hundred and some 14 hospitals
something like that, and this was from--
I can't remember how many hospitals, but not all of them.
And it was over--let's see how many was it?
I think it was like 17,000 deliveries, I think.
But, anyway, what they looked at is--again, what we found too,
risk of NICU admissions for elected deliveries
between 37-39 weeks.
Again, even though there's a risk at 39 weeks
for either induction or cesarean section, inversed relationship
to gestational age increased chance.
So again, it gave us more and more fuel to our talk.
My husband's saying, "5 minutes."
So, and also we had good support from--oh, 10 minutes,
10 minutes, from the American Pediatrics,
ACOG like we talked about, March of Dimes, AWHONN,
and of course those of us who work in the hospital
can't forget The Joint Commission, so--
So, how we got this out there?
So, we established the best of practice.
We tried to standardize 'em and how to communicate it
to the hospital to our hospital physicians.
We have one midwife and so we gave lectures.
We sent both snail mail and e-mail notifications
several times because after the first couple of times
we still heard somebody, "But I never got that."
And I ignore my mail a lot too, so I kind of get that, but--
so, we sent several.
This wasn't actually at our section meeting, but
it kind of reminded me of that first section meeting we had.
It was pretty ruckus, in a civilized way,
in a civilized way.
And then, also, just this is for just talking,
"Can you believe what Margaret said?"
But that got, again, better and better 'cause
we had strong support and I'll go over that in a little bit.
So, put in the best practice.
We said the nursing people and the work clerks
aren't the policemen.
That wasn't gonna happen.
So, when they called up to schedule an elective delivery
prior to 39 weeks
and the indication wasn't on that list,
then it wasn't the nurses or the work clerks said,
"Sorry, Doctor Chrisman," who's the nicest doctor in the world,
who he wouldn't do it anyway, "you can't do that."
He would call and one of
the labor and delivery medical directors, which is me or
Dr. Travis Stembridge, which is--he's also great.
He's an obstetrician gynecologist.
And I put this again, 'cause I tend to exaggerate,
most of the calls were very civilized.
I only remember two where swearing and yelling were
involved and surprisingly, not from me, 'cause I tried to
stay cool on that, which isn't my middle name, but, anyway.
So, but again, that got less and less.
But, you know, it was a little bit surprising how a few--
and again, it wasn't the majority.
It was a very--but it was a vocal minority.
And then, if elective delivery was performed at less than
39 weeks, you didn't have the amniocentesis,
you had to document the heck out of it on why you're doing it.
And there's a possibility, and it wasn't like--hanging
a hammer over your head, but if you didn't have a good reason,
then you're gonna go in front of the OB exec, which as you
probably would guess is where you go to plead your case
that this isn't a class type of offense
that needs to go to KMF.
So, are we making progress?
2003 they had 269.
2004, 333, so it went up.
Remember we started in 2008.
Why we are missing the in-between is we changed
over the database, so we didn't have that bit of information.
We had eight patients, they all went before
the executive committee.
I don't think if they ever did again.
2009, there was only one.
And in 2010 there was zero.
So, that's great.
And we did our happy dance,
which I will not show you here.
But, actually that happy dance went away quickly
and we saw that things weren't quite as good as we were hoping
it was going to be, because Joint Commission on that 2010
we had zero dinged us.
I think it was for 11.
I can't remember it's either 8 or 11 for elective deliveries.
And we go, "What the heck?"
They had amniocentesis to show fetal lung maturity.
But they said, "No, no, no, no, no."
Not to me, but they gave, "No, you can't--even if you have
"an amniocentesis, if it's purely elective,
you're still not supposed to do a delivery."
Why is that?
And again, this is a retrospective study
from Alabama.
And they looked at babies from 36 weeks to 38 weeks and 6 days
with documented lung maturity versus babies
at 39-40 weeks without documented lung maturity.
Again, even with documented lung maturity
there was increased risk the earlier you delivered.
So even though lungs are the big thing,
it's not everything.
And the only thing that wasn't significantly different
was inabation.
That's here.
Remember before on that other one, hypoglycemia
wasn't significant, but it was here.
So, that's kind of interesting.
So, The Joint Commission's list for conditions that could
justify an early amniocentesis for lung maturity are these
high blood--you know, all these problems with the mom,
multiples, malpresentations, that kind of thing--
polyhydramnios.
So, you can do an amniocentesis for those
if they have those problems.
So, again--so, we adopted that.
I thought, you know, again, we got the information,
I didn't roll my eyes.
I was going, "What the heck?"
But you got the information that that's not the best practice
and 2011, zero and that was without--
and nobody delivered early even with lung maturity,
so, woo!
I mean, that was really good.
[audience applauding]
Thanks. We were happy.
We've had one this year.
And this was per The Joint Commission,
however we looked it over.
It was a woman who'd had several previous cesarean sections,
had a lot of pain down below.
It didn't look like the scar was separating by ultrasound,
but that's not--so we thought, "You know what?
That's okay."
So, because like the other guy was talking about, I mean,
good patient care is the trump card for all this stuff.
So, the bottom-line is--now I do get kind of weepy here.
And I hope not to be.
I haven't seen this movie, but my kids say it's excellent.
We had a great administration
and Dr. Eckergrin is here, part of it.
And I'm not kissing up to her, but they were both--yeah,
go ahead, I will.
They were very, very, very supportive and said,
"Keep your backup."
And so, we said, "Okay."
Our chairman was very supportive of OB.
Nursing personnel was, as far as I know, was going
"I can't believe she's doing it either, but she is."
I don't know. Maybe they did.
But as far as I know they didn't.
Colleagues, most of the colleagues
like I said, most of the physicians,
family practice, OBs were great about it.
And did I mention that in nursing how Dawn Piacenza is--
we couldn't run our LDR without her, did I tell you that?
Okay, yeah.
So, and we had the great data behind us
and risk and quality management.
So we had everything in place.
Was there some bumps? Yes.
Are there continuing challenges? Yes.
Because there's still new recommendations.
ACOG used to recommend chronic hypertensions
to deliver at 39 weeks, assuming everything was okay.
There was no growth restriction, no superimposed preeclampsia.
Now they recommend between 38-39 weeks if they
are not on any hypertensives to maintain their blood pressure.
So, who's gonna decide 38 or 39?
That's what we'll all have to get together and decide.
And then there's Doctor Sponge, Catherine Sponge, she received
You're the Best MFM in the World Award, so again, a rock star
in--so, people--and all the people that wrote this
with her, the et al, are big names.
They're talking about doing early deliveries for a lot of
different stuff ACOG hasn't said, like monody twins.
What are those?
Identical twins where they share--they're in separate
sacks, but there's only one layer of the membranes
instead of two and they can have some increased risk.
They're recommending delivery between 34-37 weeks.
Why is that?
And how do you decide when?
I don't know.
So anyway, I--like I said,
I appreciate being able to talk to you all.
After this, it's like giving birth.
I had an epidural so I don't know, but people tell me that
natural child birth you sort of forget it after it's over.
Now, after going through this, it was a good experience,
like I said, kind of know who your--people who have your back,
and it really was--
showed us a way to help us to improve health.