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“SHOULD THE 30-MINUTE RULE FOR EMERGENT CESAREAN DELIVERY BE APPLIED UNIVERSALLY?”
“Where is it safe to practice obstetrics?” is a broader question Drs. Chauhan and Mendez-Figueroa presented a thoughtful series of case studies. Unfortunately, the cases were intended for the considerate ObGyn—the one who can appreciate that every case has a differing set of variables—and did not account for the context and legal environment in which we practice. In the theater that is our malpractice reality, these cases would carry little weight with a jury that is empathizing with a child with cerebral palsy, often years after the event.
“Where is it safe to practice obstetrics?” is a broader, and perhaps more interesting, question. And a more relevant case would involve a smaller hospital, perhaps in a rural area, that does not have in-house anesthesia available for 30-minute starts.
Daniel R. Szekely, MD, PhD
Tacoma, Washington
We are hoisted on a petard of our own makingThere is absolutely no justification for ObGyns being held to this so-called “standard of care.” The evidence is scant or lacking that delivery in a 30-minute timeframe has any significant bearing on the neonatal outcome. Despite this, the lay public and medical-legal community see this as an absolute rule to be followed. If there is a less-than-perfect outcome, we are hoisted on this petard of our own making.
We as a group (that is, the American College of Obstetricians and
Gynecologists) need to work to right this unfortunate wrong!
William H. Deschner, MD
Seattle, Washington
Practicing is downright scary The “30-minute rule” is no help to ObGyns in the field. At a community hospital, where surgical teams are called in from home (we cannot afford to do otherwise), it is often impossible to meet this standard. University-level care even cannot meet the measure at times. We never should have been painted into this corner. Now, any attempts to loosen the rule will be seen as trying to practice defensive medicine.
People who do not do what we do for a living have no concept of the anxiety and sleep loss we incur while seeking the best outcomes for our patients. I long for the soon-to-come day when I retire. Due to the litigious environment, I am saddened that I cannot heartily recommend the field to young doctors.
James Nunn, MD
Chicago, Illinois
“UPDATE ON VAGINAL HYSTERECTOMY”
BARBARA S. LEVY, MD (SEPTEMBER 2015)
Why has TAH remained the dominant hysterectomy route for generations?I read with great interest Dr. Levy’s recent comments on the benefits of new technology to improve the vaginal hysterectomy (VH) rate. Thank you and Dr. Levy for all the work you have done to advance the care of our patients. I have some other fundamental concerns about the future of hysterectomy.
Why has total abdominal hysterectomy (TAH) remained the dominant route of hysterectomy for generations? Why have past efforts to minimize TAH met with limited results?
Dr. Levy maintains in her article that, “the biggest barrier to widespread use [of VH] may simply be the lack of industry support.” What industry has supported TAH in a manner not also applicable to VH?
What do the techniques in Dr. Levy’s article and the efforts by ACOG and other authorities1 offer that will materially increase the adoption of VH? What evidence is there that the use of such devices as VITOM system will overcome the low rate of VH? How much training is required before a surgeon can realize patient-centered benefit from using the VITOM or other new devices during VH?
The lack of evidence-based training and implementation of robotic surgery has resulted in well-deserved criticism of robotics, centered, in part, around complications. Will the complication rate rise as those who do not perform VH transition to its adoption using VITOM and other devices?
I hope that the generations-long failure of all efforts to raise the VH rate is overcome with evidence-based educational protocols.
Antonio R. Pizarro, MD
Shreveport, Louisiana
Reference
1. Bosworth T. ACOG taking steps to increase vaginal hysterectomy rates. Ob.Gyn. News. http://www.obgynnews.com/?id=11146&tx_ttnews[tt_news]=392609&cHash=d78b8bea4aa3483c10dc5d843207d211. Posted April 6, 2015. Accessed October 2, 2015.
The problem: lack of trainingSadly, lack of training is the problem in this best approach to removing the benign uterus. These tools are helpful and should be in the surgeon’s armamentarium. We need experienced vaginal surgeons to teach this procedure. In some ways, just as much skill and dexterity are needed as with laparoscopic or robotic methods.
William H. Deschner, MD
Seattle, Washington
Dr. Levy respondsI appreciate the insightful comments of Drs. Pizarro and Deschner. Clearly, as the volume of hysterectomies has decreased and the number of techniques we must teach our residents has expanded, we are challenged to provide robust training in all hysterectomy routes. TAH, as the status quo, has not required the development of new equipment and technology, whereas assisting gynecologic surgeons to convert open procedures to minimally invasive approaches has been advanced and driven by our industry partners.
I totally agree with the concern that we cannot rely on historic data to determine the safest and most cost-effective route for hysterectomy. I encourage all of us to track and publically report our outcomes and monitor the complication rates of gynecologic surgical procedures. Our ongoing commitment to delivering the best care for our patients requires nothing less.
Structured business methods will improve outcomesDr. Barbieri’s call for getting organized and breaking down health care silos while establishing multidisciplinary teams is of great importance. Most providers have not witnessed a maternal mortality in their careers and many are not aware of the near misses. Incorporating foundations of established business methods has been advocated to reduce waste, improve collaboration, decrease variance, and improve patient safety.
If we view the adverse outcomes through this lens, then the increase in maternal mortality and morbidity are lagging indicators in the structured analysis methods (such as Six Sigma and Lean Six Sigma). These methods lead us to focus and measure the leading indicators of input and process (prenatal care and pregnancy management). Our reliance on lagging indicators often comes too late to make any change effective.
Around 1973, several important processes were introduced into obstetric practice: fetal heart-rate monitoring; ultrasonography; and a reduction of the use of forceps with an increase in the use of vacuum extraction. Safety rates improved, but we witnessed the 8% cesarean delivery rate in 1973 rise to 32% in 2013.1,2 The maternal mortality rate reported in 2013 is now the same as it was in 1973. A corresponding increase in the cesarean delivery rate over this time frame could be inferred.
By focusing on analysis and management of variables in pregnancy and implementing standardization of care based on good evidence from all disciplines involved in patient safety, we can improve maternal mortality. Simulations and debriefings are critical instruments to enhance management of all aspects of prenatal management, particularly emergent care.
As leaders in improving maternal quality, ObGyns must implement structured business methods (input and process analysis) to improve outcomes. A culture also can be positively altered if the mission and vision are clearly elucidated. Transparent, dynamic, granular, accurate, and reliable data will facilitate “buy-in” of the caregivers and provide more successful solutions. Decreased variance is critical. Expect resistance due to provider autonomy. The alteration in culture of the multidisciplinary team takes time, but a reduction in cesarean delivery rates should be number one on the list to reduce maternal mortality. The unintended consequences of all interventions and monitoring methods also should be pursued.
Robert A. Knuppel, MD, MPH, MBA
Naples, Florida
Judith Withers, RN, MN, MBA
San Diego, California
References
1. Blanchette E. The rising cesarean delivery rate in America. Obstet Gynecol. 2011;118(3):687–690.
2. Knuppel RA. Personal review of Centers for Disease Control and Prevention, National Vital Statistics Reports, 1973–2015.
Dr. Barbieri respondsI wholeheartedly agree with Dr. Knuppel and Ms. Withers: increasing the use of high reliability clinical processes is critically important in our quest to reduce maternal mortality. In addition to decreasing the cesarean delivery rate, I would prioritize ensuring the use of highly effective contraceptives by women with serious medical comorbidities that increase their risk of maternal mortality.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“SHOULD THE 30-MINUTE RULE FOR EMERGENT CESAREAN DELIVERY BE APPLIED UNIVERSALLY?”
“Where is it safe to practice obstetrics?” is a broader question Drs. Chauhan and Mendez-Figueroa presented a thoughtful series of case studies. Unfortunately, the cases were intended for the considerate ObGyn—the one who can appreciate that every case has a differing set of variables—and did not account for the context and legal environment in which we practice. In the theater that is our malpractice reality, these cases would carry little weight with a jury that is empathizing with a child with cerebral palsy, often years after the event.
“Where is it safe to practice obstetrics?” is a broader, and perhaps more interesting, question. And a more relevant case would involve a smaller hospital, perhaps in a rural area, that does not have in-house anesthesia available for 30-minute starts.
Daniel R. Szekely, MD, PhD
Tacoma, Washington
We are hoisted on a petard of our own makingThere is absolutely no justification for ObGyns being held to this so-called “standard of care.” The evidence is scant or lacking that delivery in a 30-minute timeframe has any significant bearing on the neonatal outcome. Despite this, the lay public and medical-legal community see this as an absolute rule to be followed. If there is a less-than-perfect outcome, we are hoisted on this petard of our own making.
We as a group (that is, the American College of Obstetricians and
Gynecologists) need to work to right this unfortunate wrong!
William H. Deschner, MD
Seattle, Washington
Practicing is downright scary The “30-minute rule” is no help to ObGyns in the field. At a community hospital, where surgical teams are called in from home (we cannot afford to do otherwise), it is often impossible to meet this standard. University-level care even cannot meet the measure at times. We never should have been painted into this corner. Now, any attempts to loosen the rule will be seen as trying to practice defensive medicine.
People who do not do what we do for a living have no concept of the anxiety and sleep loss we incur while seeking the best outcomes for our patients. I long for the soon-to-come day when I retire. Due to the litigious environment, I am saddened that I cannot heartily recommend the field to young doctors.
James Nunn, MD
Chicago, Illinois
“UPDATE ON VAGINAL HYSTERECTOMY”
BARBARA S. LEVY, MD (SEPTEMBER 2015)
Why has TAH remained the dominant hysterectomy route for generations?I read with great interest Dr. Levy’s recent comments on the benefits of new technology to improve the vaginal hysterectomy (VH) rate. Thank you and Dr. Levy for all the work you have done to advance the care of our patients. I have some other fundamental concerns about the future of hysterectomy.
Why has total abdominal hysterectomy (TAH) remained the dominant route of hysterectomy for generations? Why have past efforts to minimize TAH met with limited results?
Dr. Levy maintains in her article that, “the biggest barrier to widespread use [of VH] may simply be the lack of industry support.” What industry has supported TAH in a manner not also applicable to VH?
What do the techniques in Dr. Levy’s article and the efforts by ACOG and other authorities1 offer that will materially increase the adoption of VH? What evidence is there that the use of such devices as VITOM system will overcome the low rate of VH? How much training is required before a surgeon can realize patient-centered benefit from using the VITOM or other new devices during VH?
The lack of evidence-based training and implementation of robotic surgery has resulted in well-deserved criticism of robotics, centered, in part, around complications. Will the complication rate rise as those who do not perform VH transition to its adoption using VITOM and other devices?
I hope that the generations-long failure of all efforts to raise the VH rate is overcome with evidence-based educational protocols.
Antonio R. Pizarro, MD
Shreveport, Louisiana
Reference
1. Bosworth T. ACOG taking steps to increase vaginal hysterectomy rates. Ob.Gyn. News. http://www.obgynnews.com/?id=11146&tx_ttnews[tt_news]=392609&cHash=d78b8bea4aa3483c10dc5d843207d211. Posted April 6, 2015. Accessed October 2, 2015.
The problem: lack of trainingSadly, lack of training is the problem in this best approach to removing the benign uterus. These tools are helpful and should be in the surgeon’s armamentarium. We need experienced vaginal surgeons to teach this procedure. In some ways, just as much skill and dexterity are needed as with laparoscopic or robotic methods.
William H. Deschner, MD
Seattle, Washington
Dr. Levy respondsI appreciate the insightful comments of Drs. Pizarro and Deschner. Clearly, as the volume of hysterectomies has decreased and the number of techniques we must teach our residents has expanded, we are challenged to provide robust training in all hysterectomy routes. TAH, as the status quo, has not required the development of new equipment and technology, whereas assisting gynecologic surgeons to convert open procedures to minimally invasive approaches has been advanced and driven by our industry partners.
I totally agree with the concern that we cannot rely on historic data to determine the safest and most cost-effective route for hysterectomy. I encourage all of us to track and publically report our outcomes and monitor the complication rates of gynecologic surgical procedures. Our ongoing commitment to delivering the best care for our patients requires nothing less.
Structured business methods will improve outcomesDr. Barbieri’s call for getting organized and breaking down health care silos while establishing multidisciplinary teams is of great importance. Most providers have not witnessed a maternal mortality in their careers and many are not aware of the near misses. Incorporating foundations of established business methods has been advocated to reduce waste, improve collaboration, decrease variance, and improve patient safety.
If we view the adverse outcomes through this lens, then the increase in maternal mortality and morbidity are lagging indicators in the structured analysis methods (such as Six Sigma and Lean Six Sigma). These methods lead us to focus and measure the leading indicators of input and process (prenatal care and pregnancy management). Our reliance on lagging indicators often comes too late to make any change effective.
Around 1973, several important processes were introduced into obstetric practice: fetal heart-rate monitoring; ultrasonography; and a reduction of the use of forceps with an increase in the use of vacuum extraction. Safety rates improved, but we witnessed the 8% cesarean delivery rate in 1973 rise to 32% in 2013.1,2 The maternal mortality rate reported in 2013 is now the same as it was in 1973. A corresponding increase in the cesarean delivery rate over this time frame could be inferred.
By focusing on analysis and management of variables in pregnancy and implementing standardization of care based on good evidence from all disciplines involved in patient safety, we can improve maternal mortality. Simulations and debriefings are critical instruments to enhance management of all aspects of prenatal management, particularly emergent care.
As leaders in improving maternal quality, ObGyns must implement structured business methods (input and process analysis) to improve outcomes. A culture also can be positively altered if the mission and vision are clearly elucidated. Transparent, dynamic, granular, accurate, and reliable data will facilitate “buy-in” of the caregivers and provide more successful solutions. Decreased variance is critical. Expect resistance due to provider autonomy. The alteration in culture of the multidisciplinary team takes time, but a reduction in cesarean delivery rates should be number one on the list to reduce maternal mortality. The unintended consequences of all interventions and monitoring methods also should be pursued.
Robert A. Knuppel, MD, MPH, MBA
Naples, Florida
Judith Withers, RN, MN, MBA
San Diego, California
References
1. Blanchette E. The rising cesarean delivery rate in America. Obstet Gynecol. 2011;118(3):687–690.
2. Knuppel RA. Personal review of Centers for Disease Control and Prevention, National Vital Statistics Reports, 1973–2015.
Dr. Barbieri respondsI wholeheartedly agree with Dr. Knuppel and Ms. Withers: increasing the use of high reliability clinical processes is critically important in our quest to reduce maternal mortality. In addition to decreasing the cesarean delivery rate, I would prioritize ensuring the use of highly effective contraceptives by women with serious medical comorbidities that increase their risk of maternal mortality.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“SHOULD THE 30-MINUTE RULE FOR EMERGENT CESAREAN DELIVERY BE APPLIED UNIVERSALLY?”
“Where is it safe to practice obstetrics?” is a broader question Drs. Chauhan and Mendez-Figueroa presented a thoughtful series of case studies. Unfortunately, the cases were intended for the considerate ObGyn—the one who can appreciate that every case has a differing set of variables—and did not account for the context and legal environment in which we practice. In the theater that is our malpractice reality, these cases would carry little weight with a jury that is empathizing with a child with cerebral palsy, often years after the event.
“Where is it safe to practice obstetrics?” is a broader, and perhaps more interesting, question. And a more relevant case would involve a smaller hospital, perhaps in a rural area, that does not have in-house anesthesia available for 30-minute starts.
Daniel R. Szekely, MD, PhD
Tacoma, Washington
We are hoisted on a petard of our own makingThere is absolutely no justification for ObGyns being held to this so-called “standard of care.” The evidence is scant or lacking that delivery in a 30-minute timeframe has any significant bearing on the neonatal outcome. Despite this, the lay public and medical-legal community see this as an absolute rule to be followed. If there is a less-than-perfect outcome, we are hoisted on this petard of our own making.
We as a group (that is, the American College of Obstetricians and
Gynecologists) need to work to right this unfortunate wrong!
William H. Deschner, MD
Seattle, Washington
Practicing is downright scary The “30-minute rule” is no help to ObGyns in the field. At a community hospital, where surgical teams are called in from home (we cannot afford to do otherwise), it is often impossible to meet this standard. University-level care even cannot meet the measure at times. We never should have been painted into this corner. Now, any attempts to loosen the rule will be seen as trying to practice defensive medicine.
People who do not do what we do for a living have no concept of the anxiety and sleep loss we incur while seeking the best outcomes for our patients. I long for the soon-to-come day when I retire. Due to the litigious environment, I am saddened that I cannot heartily recommend the field to young doctors.
James Nunn, MD
Chicago, Illinois
“UPDATE ON VAGINAL HYSTERECTOMY”
BARBARA S. LEVY, MD (SEPTEMBER 2015)
Why has TAH remained the dominant hysterectomy route for generations?I read with great interest Dr. Levy’s recent comments on the benefits of new technology to improve the vaginal hysterectomy (VH) rate. Thank you and Dr. Levy for all the work you have done to advance the care of our patients. I have some other fundamental concerns about the future of hysterectomy.
Why has total abdominal hysterectomy (TAH) remained the dominant route of hysterectomy for generations? Why have past efforts to minimize TAH met with limited results?
Dr. Levy maintains in her article that, “the biggest barrier to widespread use [of VH] may simply be the lack of industry support.” What industry has supported TAH in a manner not also applicable to VH?
What do the techniques in Dr. Levy’s article and the efforts by ACOG and other authorities1 offer that will materially increase the adoption of VH? What evidence is there that the use of such devices as VITOM system will overcome the low rate of VH? How much training is required before a surgeon can realize patient-centered benefit from using the VITOM or other new devices during VH?
The lack of evidence-based training and implementation of robotic surgery has resulted in well-deserved criticism of robotics, centered, in part, around complications. Will the complication rate rise as those who do not perform VH transition to its adoption using VITOM and other devices?
I hope that the generations-long failure of all efforts to raise the VH rate is overcome with evidence-based educational protocols.
Antonio R. Pizarro, MD
Shreveport, Louisiana
Reference
1. Bosworth T. ACOG taking steps to increase vaginal hysterectomy rates. Ob.Gyn. News. http://www.obgynnews.com/?id=11146&tx_ttnews[tt_news]=392609&cHash=d78b8bea4aa3483c10dc5d843207d211. Posted April 6, 2015. Accessed October 2, 2015.
The problem: lack of trainingSadly, lack of training is the problem in this best approach to removing the benign uterus. These tools are helpful and should be in the surgeon’s armamentarium. We need experienced vaginal surgeons to teach this procedure. In some ways, just as much skill and dexterity are needed as with laparoscopic or robotic methods.
William H. Deschner, MD
Seattle, Washington
Dr. Levy respondsI appreciate the insightful comments of Drs. Pizarro and Deschner. Clearly, as the volume of hysterectomies has decreased and the number of techniques we must teach our residents has expanded, we are challenged to provide robust training in all hysterectomy routes. TAH, as the status quo, has not required the development of new equipment and technology, whereas assisting gynecologic surgeons to convert open procedures to minimally invasive approaches has been advanced and driven by our industry partners.
I totally agree with the concern that we cannot rely on historic data to determine the safest and most cost-effective route for hysterectomy. I encourage all of us to track and publically report our outcomes and monitor the complication rates of gynecologic surgical procedures. Our ongoing commitment to delivering the best care for our patients requires nothing less.
Structured business methods will improve outcomesDr. Barbieri’s call for getting organized and breaking down health care silos while establishing multidisciplinary teams is of great importance. Most providers have not witnessed a maternal mortality in their careers and many are not aware of the near misses. Incorporating foundations of established business methods has been advocated to reduce waste, improve collaboration, decrease variance, and improve patient safety.
If we view the adverse outcomes through this lens, then the increase in maternal mortality and morbidity are lagging indicators in the structured analysis methods (such as Six Sigma and Lean Six Sigma). These methods lead us to focus and measure the leading indicators of input and process (prenatal care and pregnancy management). Our reliance on lagging indicators often comes too late to make any change effective.
Around 1973, several important processes were introduced into obstetric practice: fetal heart-rate monitoring; ultrasonography; and a reduction of the use of forceps with an increase in the use of vacuum extraction. Safety rates improved, but we witnessed the 8% cesarean delivery rate in 1973 rise to 32% in 2013.1,2 The maternal mortality rate reported in 2013 is now the same as it was in 1973. A corresponding increase in the cesarean delivery rate over this time frame could be inferred.
By focusing on analysis and management of variables in pregnancy and implementing standardization of care based on good evidence from all disciplines involved in patient safety, we can improve maternal mortality. Simulations and debriefings are critical instruments to enhance management of all aspects of prenatal management, particularly emergent care.
As leaders in improving maternal quality, ObGyns must implement structured business methods (input and process analysis) to improve outcomes. A culture also can be positively altered if the mission and vision are clearly elucidated. Transparent, dynamic, granular, accurate, and reliable data will facilitate “buy-in” of the caregivers and provide more successful solutions. Decreased variance is critical. Expect resistance due to provider autonomy. The alteration in culture of the multidisciplinary team takes time, but a reduction in cesarean delivery rates should be number one on the list to reduce maternal mortality. The unintended consequences of all interventions and monitoring methods also should be pursued.
Robert A. Knuppel, MD, MPH, MBA
Naples, Florida
Judith Withers, RN, MN, MBA
San Diego, California
References
1. Blanchette E. The rising cesarean delivery rate in America. Obstet Gynecol. 2011;118(3):687–690.
2. Knuppel RA. Personal review of Centers for Disease Control and Prevention, National Vital Statistics Reports, 1973–2015.
Dr. Barbieri respondsI wholeheartedly agree with Dr. Knuppel and Ms. Withers: increasing the use of high reliability clinical processes is critically important in our quest to reduce maternal mortality. In addition to decreasing the cesarean delivery rate, I would prioritize ensuring the use of highly effective contraceptives by women with serious medical comorbidities that increase their risk of maternal mortality.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.