Dr. Maragret Helen O’Hara ed.wmv

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.