Hospitals ramping up round-the-clock staffing for pregnancy emergencies

Pregnancy emergencies set their own schedules. If you start having severe abdominal painin the dead of night, or your baby becomes unusually still, who's waiting at the hospital to treat you? Or when you're in the midst of normal full-term labor and ready to deliver, that time lapse before your private doctor or on-call colleague arrives feels like an eternity.

In some hospitals, while the labor and delivery unit is fully staffed with specialty nurses, there may not be an OB-GYN doctor on the premises. Physicians covering the main emergency room may not have any particular obstetric expertise.

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Increasingly, hospitals are taking different approaches to ensure adequate, immediate medical staffing. Some hospitals schedule OB-GYNs for 24/7 coverage. Others are turning to specialists known as OB-GYN hospitalists. And some U.S. medical centers are launching separate, hybrid units, known as obstetric emergency departments, or OBEDs.

Research suggests – but doesn't confirm – that mothers and babies may have better outcomes with such approaches. If you're an expectant mother, it's worth asking your doctor or certified nurse-midwife whether your planned birth hospital guarantees round-the-clock medical coverage, and if so, which type.

At Massachusetts General Hospital, labor-and-delivery physicians work 12- or 24-hour shifts to provide round-the-clock coverage and handle whatever arises along with the nursing staff, says Dr. Jeffrey Ecker, a maternal-fetal medicine doctor there and a professor at Harvard Medical School.

That contrasts with the traditional care model with private physicians summoned to the hospital as expectant mothers were admitted. That was common when solo or small OB-GYN practices were the norm and still exists in some hospitals, says Ecker, a former chairman of the American College of Obstetricians and Gynecologists' committee on obstetric practice.

However, that model presents obvious disadvantages when obstetric emergencies arise. Ecker makes the analogy to a hospital patient suffering a heart attack: Calling someone in might result in an unacceptable delay in treatment and care.

A few months ago, Stephanie Lee of Des Moines, Iowa, had no idea that obstetric emergency departments existed, much less that her planned birth hospital had one. All she knew was that something was wrong with her pregnancy.

During the day, Lee didn't feel too well, but she chalked some mild abdominal cramping up to a likely intestinal bug. Having just passed the midterm mark of her pregnancy, she thought she still had a long way to go before her Oct. 27 due date.

"I went to bed and thought, if this doesn't get better by morning, I'll call the doctor," Lee says. "Then, in the middle of the night, I felt a particularly bad cramp. I woke up and thought I had to go to the bathroom. I jumped out of bed and as soon as I did, I felt a gush of liquid. I [thought], oh, that's not right."

She woke her husband, David Lee, who drove her to Mercy Medical Center-Des Moines. The couple hurried to the main emergency room, but didn't stay there long. A nurse wheeled Stephanie upstairs to the labor and delivery unit.

Lee was immediately examined and the couple's fears were confirmed: Seventeen weeks before she was due to give birth, Lee's water had broken and she could deliver at any moment. She and her husband were terrified that at only 22 weeks and several days into the pregnancy term, their baby might not survive.

In November 2016, Mercy Medical Center-Des Moines had launched Iowa's first OBED. So far, some 3,800 patients have come through, or about 14 women a day.

A full complement of specialists, including an OB hospitalist and high-risk pregnancy doctor, monitored Lee through the next few days while trying to keep the baby stable in the uterus. A neonatologist explained what would likely happen when the baby was born. And doctors assured Lee that none of this was her fault – it wasn't anything she had or hadn't done.

The OBED nursing staff stands out for Lee: "During the whole experience, they were so wonderful. Just a cut above – so reassuring." She lauds the nurses' expertise, sensitivity and encouragement. Each step of the way, nurses took care of Lee and made sure the couple stayed informed. "No question was ever too big or too small," she says.

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On July 3, five days into the hospital stay, Audrey Lee was born, weighing 1 pound, 3 ounces. To make the situation more frightening, she had to be resuscitated while her father watched nearby. Fortunately, the staff was fully ready for the possibility, and the attempt succeeded.

"One of the benefits of me being in the OB ER was they pretty much knew this was going to happen," Lee says. "They could really prepare me, and themselves. If this didn't exist and they had just sent me home and said, 'When you actually start labor, come back.' ... It happened so fast. If we hadn't been in the hospital, they wouldn't have been able to resuscitate her."

Mercy Medical Center-Des Moines is run in partnership with the OB Hospital Group, a national company that oversees about 110 fully functioning emergency rooms across the county, according to hospitalist Dr. Rakhi Dimino, the company's Houston-based medical director of operations.

OB emergency rooms offer an alternative scenario, Dimino says, one that's safer for women with pregnancy complications. "All the patients have an opportunity to be screened by a physician-nurse team," she says. "It's the difference between predicting an emergency and simply reacting to an emergency."

Most OBEDs in the country are staffed with one OB-GYN physician and two labor-and-delivery nurses around the clock, Dimino says. Busier locations have two or more doctors working at a time, or a nurse-midwife or an advanced practice nurse for added support. The patient's regular physician remains an important team collaborator, she emphasizes.

You don't have to go to an OBED to be treated by an emerging group of labor and delivery specialists known as obstetrician hospitalists, OB-GYN hospitals, laborists or other variations.

"As a hospitalist, I see those low-volume, high-acuity [cases] with a lot more frequency, because I am on labor and delivery all the time," says Dr. Tanner Colegrove, medical director of the OB hospitalist program at Northwestern Medicine Lake Forest Hospitalin Illinois.

"Above and beyond, what makes a hospitalist different, is the mindset of preparing and expecting emergencies," says Colegrove, who is the president-elect of the Society of OB-GYN Hospitalists, with about 550 member physicians. Much more than just a full-time hospital presence, she says, they offer highly honed skills in complex procedures like vaginal birth after cesarean, or VBAC.

More than 1,700 OB-GYN hospitalists worked at roughly 245 U.S. hospitals in 2014, according to figures cited in a February 2016 opinion piece from the ACOG committee. Almost one-quarter of California hospitals use these specialists, the piece noted.

It's too soon to tease out whether 24/7 on-site physician coverage, or the presence of obstetric and gynecological hospitalists, is directly tied to better patient outcomes, says Ecker, However study results so far are encouraging.

Having a dedicated OB-GYN hospitalist service was linked to a 27 percent reduction in cesarean delivery rates compared to traditional care, in a study published in the 2013 issue of the American Journal of Obstetrics & Gynecology. Similarly, a 2015 study in the same journal found significantly lower C-section rates when hospitalists managed women's care in conjunction with certified midwives.

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For now, Audrey remains in neonatal intensive care. She's already overcome some hurdles from her premature birth, her mother says. The next milestone would be for her to no longer need ventilator support.

Currently weighing 2 pounds, 14 ounces, Audrey has more than doubled her birth weight. She will likely stay hospitalized until her original October due date. "We plan on bringing her home, although we're not out of the woods yet," her mother says.

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