In 1899, John Whitridge Williams succeeded Howard Kelly as the obstetrician-in-chief at the Johns Hopkins Hospital in Baltimore, Maryland. Interestingly at that time, the departments were separated into two, with Dr. Kelly remaining head of the gynecology department and Williams becoming head of the obstetrics department. Although Williams was opposed to this division, he immediately began organizing his department on scientific principles. With the production of William’s Obstetrics in 1903, the course of American obstetrics changed to coalesce and document the science of childbirth, with the author referencing over 1100 publications in its original edition.¹ Despite the efforts of Williams, the field of OB/GYN failed to win legitimacy by other physicians for what was instead thought of as a role for “skilled laborers” as opposed to true consultants.² In 1957, Dr. J. A. Rene Simard lamented, “Obstetrics … still remains, in the minds of many, a poor relation of medicine and surgery. Sometimes a good friend will repeat the sally: ‘If your son is intelligent, let him be a physician; if he is clever, let him be a surgeon; if he is neither, let him be an accoucher (obstetrician).’”

Clearly, times and attitudes have changed. The increasing complexity of medicine has increased the number of fields of specialization, and the gap between generalist and consultant continues to widen. This trend also applies to OB/GYN. Radiologists, emergency department (ED) physicians, and anesthesiologists are wary of pregnancy and the complex situations presented by a gestation. Faced with increasing specialization, many view the work of the OB/GYN specialist as a critical and highly skilled role that is necessary to optimize outcomes and avoid litigation. There is a further push toward having a specialist in labor and delivery (L&D)—the OB/GYN hospitalist—to improve outcomes, strengthen safety efforts, improve overall work conditions, and enhance workplace efficiency.

The OB/GYN hospitalist is a new player in women’s health and becoming thought of as critical as an important team member in the delivery of obstetric care. Beginning with the overall hospitalist movement in the 1990s, Wachter (1996) opined that the hospitalist movement would grow due to its aiding of care efficiency, and also theorized an improvement in providing value care.³ In 2003, Weinstein hypothesized that a physician whose sole focus would be to manage the patient in labor—that is, “laborists”—could provide a solution to the increasing malpractice liability, burnout, and a shortage of obstetricians.⁴ The role of the OB/GYN hospitalist already appears to be eclipsing these initially hypothesized roles. As patterns develop that define the role of the OB/GYN hospitalist as an integral team member with the generalist and maternal fetal medicine (MFM) specialist, the former will carve out a widening role and assume further authority in labor care.

The presence of hospitalists has led to dramatic care changes when employed in different specialties. Nonetheless, this movement has sprinted forward, mainly due to the belief that hospitalists provide needed specialization in increasingly demanding care environments, improve provider work conditions, and enhance the efficiency of care. Unfortunately, with the development and expansion of hospitalist programs, an opportunity has been missed due to the minimal research done on the effects upon the true, bottom-line patient outcomes. Despite this missed opportunity, hospitalists covered a quarter of all Medicare admissions in 2011, and the specialty has enjoyed continual growth.⁵ Although performed over a decade after the implementation of hospitalist programs, several studies have now shown improvement with internal medicine hospitalist programs through improvement in care for pneumonia, myocardial infarction, and other conditions, as well as reductions in hospital stays and readmissions.^6,7 Similar delay has occurred in research on the outcomes of OB/GYN hospitalist care, but some initial data appears to be promising.

CESAREAN DELIVERY

Over 4 million deliveries occur annually within the United States, establishing labor care as the leading cause of female hospital admission. As many obstetricians know, the type of care that the patient receives during labor can sometimes make the difference between vaginal delivery or cesarean delivery. Overall, the cesarean delivery rate has risen dramatically over the last two decades, from 21% of the total in 1994 to 32.7% in 2013 (see Fig. 4-1).⁸ This greater than 50% increase has seen some recent slowing, with a mild reduction in overall and low-risk cesarean rates. However, the current persistently high cesarean delivery rates are worrisome due to increased risks of complications such as obstetric hemorrhage, venous thromboembolism, infection, and effects on future pregnancies with repeat cesareans and complications of placental abnormalities (i.e. accreta, increta, percreta). Lowering cesarean rates also has major financial implications to the healthcare system. In 2010, the cost of each cesarean birth, for combined maternal and newborn care was approximately 34% ($9537) higher than for vaginal birth for commercial insurers and 33% ($4459) higher for Medicaid.⁹ In 2010, Medicaid and private insurance made up a roughly equal percentage of overall deliveries,¹⁰ and assuming an equal cesarean rate in these populations, a 1% reduction in cesarean delivery would save $254 million per year in maternal and newborn costs.

The high percentage of cesarean deliveries within the United States (32% in 2015) vs. other developed nations (27.2%) is difficult to reconcile.^11,12 Arrest of dilation and nonreassuring fetal heart rate (FHR) patterns account for a large percentage of the indications for cesarean deliveries in laboring patients. Unfortunately, these indications possess wide variations in utilization due to the indiscriminate use of these diagnoses and the lack of commonly applied definitions.¹³ Medical centers, as a part of the effort to reduce cesarean deliveries, should review the cesarean delivery rates of providers and indications for cesarean delivery as part of an educational review process for following care standards. Providers should follow recommendations made in the 2014 Society of Maternal Fetal Medicine/American Congress of Obstetricians and Gynecologists (SMFM/ACOG) Obstetric Care Conference on Safe Prevention of Cesarean Delivery for the diagnosis of the active labor phase, appropriate length of time for diagnosis of an arrest disorder in the first and second stages, and regarding interventions for abnormal or indeterminate FHR patterns for which key components are listed in Table 4-1.¹⁴

Arrest of labor accounts for 35% of all primary cesarean deliveries, and there is an even higher rate (41%) in nulliparous women. It appears that much of this elevated cesarean deliver rate results from diagnosis of failure to progress at less than 6 cm, which accounts for 42.6% of cesarean deliveries for failure to progress in primigravid women.¹⁵ Nonreassuring FHR patterns account for 23% of all primary cesarean deliveries and often do not follow ACOG recommendations regarding the use of scalp stimulation, acoustic stimulation, amnioinfusion, or tocolytic agents in general practice.^16,17 Other strictly nonmedical factors, such as fatigue, stress, and anticipation of problematic workloads for providers, may also play a role in the increase in cesarean delivery rates. These factors may be hidden in the increased rates of these “soft” diagnoses of arrest of labor and/or nonreassuring FHR patterns.^18,19

Payment models may also contribute to increased rates for cesarean delivery. Most fee-for-service models increase their payment for cesarean delivery, hence providing a disincentive for vaginal delivery. This difference in payment is more pronounced in privately insured births vs. Medicaid and has been theorized as an influence leading to higher cesarean delivery rates in insured populations.²⁰ In contrast, salaried physicians with reduced financial incentive appear to possess lower cesarean delivery rates again favoring an OB/GYN hospitalist model.²¹

In the initial published study on OB/GYN hospitalist outcomes in 2013, a 27% reduction in cesarean delivery of Nulliparous, Term, Singleton, Vertex (NTSV) patients was noted with full-time OB/GYN hospitalist coverage, compared to a traditional private-coverage model without 24-hour in-house L&D care.²² Importantly, a model of 24-hour coverage by private obstetricians (community hospitalist model), each covering the labor unit less than once per month, did not show a significant decrease in cesarean delivery compared to a traditional private-coverage model, while the full-time OB/GYN hospitalist model displayed a 23% reduction in cesarean delivery in NTSV patients compared to the community hospitalist model. Another study examining cesarean delivery rates of a collaborative laborist and midwifery model showed a 44% reduction in the odds of primary cesarean delivery vs. a private practice model.²³ The authors stated that they were unclear whether the decrease in cesarean delivery was due to midwifery care, laborist care, or both. However, a past meta-analysis showed no difference in cesarean rates when comparing midwifery care to obstetrician care.²⁴ Hence, it is unlikely that midwifery care alone was responsible for this decrease in cesarean rate.

Regrettably, several studies of the laborist approach have failed to examine the type of obstetric coverage, instead conflating the presence of 24-hour labor area coverage with dedicated, full-time OB/GYN hospitalist coverage. A full-time OB/GYN hospitalist model is characterized by a staff that functions without separate competing practice responsibilities and devotes 100% of their clinical time to the inpatient care of obstetric women. At times, full-time OB/GYN hospitalist models may have inpatient gynecologic coverage roles of the Emergency Department and inpatient gynecologic consultation.

Other models of practice are coverage models that divide the inpatient responsibilities and duties and should not be evaluated as reflective of the care of a dedicated, full-time hospitalist. The ER can be considered an analogous situation, with specialized physicians dedicated to Emergency Department care. The type of coverage model cannot be underestimated, as dedicated, full-time OB/GYN hospitalist models generally decrease financial incentives favoring cesarean delivery. Full-time OB/GYN hospitalists would also likely possess increased familiarity with protocols and be more comfortable with nonreassuring FHR tracings and the proper determination of arrest disorders.

Keeping this in mind, two other studies with data derived from large administrative databases, but without specific information on the type of OB/GYN hospitalist coverage, showed no reduction in cesarean delivery with 24-hour L&D coverage.^25,26 These large studies from administrative databases feature powerful analysis due to their robust size, but they lack information on the basic demographics regarding cesarean delivery rate, such as gestational age and body mass index (BMI). Also, these studies attempt to make statistical adjustments but do not separate deliveries between low- or high-risk patients; this may bias the results, as more high-risk deliveries tend to occur at centers with in-house obstetric coverage 24 hours a day. Moreover, research based upon administrative data sets may be biased due to coding irregularities, and hence warrant validation of the coding accuracy to confirm the veracity of their conclusions.^27,28

Several other reasons may exist for reductions in cesarean delivery rates occurring in studies of full-time OB/GYN hospitalists, not in 24-hour community physician models. Traditional, private OB/GYN practices are extremely inefficient, with three different sites of care competing for physician time—namely, office practice, gynecologic operating room procedures, and L&D. Each competing practice area presents a provider with an opportunity cost when a prolonged time at one site creates a perceived loss of revenue in another and may affect physician decision-making, thus altering patterns of care.^29,30

Community physicians who are not committed to a full-time, OB/GYN hospitalist care model may have not changed the patterns that they developed from operating an office and surgical and obstetrical practices simultaneously. These patterns of care, with attempts to improve personal efficiency, may create an environment favoring cesarean delivery for patients with a perceived scenario of increased risk, but require direct provider observation and time-such as an abnormal FHR pattern that requires close observation and may require immediate delivery. Working full-time as an OB/GYN hospitalist would enhance familiarity with the same scenarios of increased risk, allowing professionals to be more patient in their approach to care and attempts at vaginal delivery. Finally, competitive workforce pressures may hinder the collaboration between competing providers caring for laboring patients. Private practitioners may perceive competitive pressures from other community physicians covering their patients and resist a team approach, hence eliminating the efficiencies provided by a 24-hour coverage model.

“Repeat Cesarean Delivery” or “Vaginal Birth After Cesarean (VBAC)”

Over the last two decades, scheduled repeat cesarean deliveries have become a major contributor to the overall cesarean delivery rate.³¹ In both the immediate and long-term periods, successful Vaginal Birth After Cesarean (VBAC) results in fewer complications than for scheduled repeat cesarean delivery. Dramatic cost savings may also be realized when VBAC success rates are as low as approximately 50%, with one model showing a cost reduction of $164.2 million per 100,000 women, as well an improvement in quality-adjusted life years.³² Yet, patients who are candidates for trial of labor after cesarean (TOLAC) appear to have little knowledge of the risks and benefits of the procedure vs. elective repeat cesarean delivery, and provider preference appears to drive the decision on the eventual mode of delivery.³³ Low rates of TOLAC likely stem from malpractice risks, improper payment incentivizing repeat cesarean delivery, and the need for immediately available (on-site) providers.^34,35 The presence of an OB/GYN hospitalist often reduces or eliminates these barriers. An OB/GYN hospitalist permits rapid on-site action possibly mitigating malpractice concerns, while simultaneously complying with the ACOG “immediately available” standard of care. Predictably, Nijagal and colleagues (2014) found dramatic reductions in elective repeat cesarean delivery rates with an OB/GYN hospitalist/midwifery model vs. a traditional private practice model.³⁶

Improvement of counseling for patients considering TOLAC would seem to be of paramount importance to educate patients to construct a more informed decision. Specific elements of counseling that are relevant to TOLAC counseling have not been established. Evidence suggests that women with a greater than 60% chance of VBAC success have equal or less risk of maternal complications when undergoing TOLAC than patients who have elective repeat cesarean delivery.^37,38 A model exists that calculates the chance of success for women considering TOLAC³⁹ (https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html). Although most counseling would be performed prior to arrival by the OB/GYN hospitalist, a separate formula to counsel TOLAC candidates also exists for patients with admission for labor from the same authors (https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbrth2.html) and should be considered the best current standard for counseling these patients regarding their chance of VBAC success. Factors required for evaluation for VBAC success rate presenting in labor are listed in Table 4-2.

PRETERM BIRTH

Preterm births affect approximately 400,000 women annually and are the leading cause of neonatal mortality and disability. In comparison to other countries in the developed world, the United States continues to have some of the highest rates of preterm birth.^40,41 In addition, our healthcare system suffers a substantial monetary impact from these incidents, as preterm birth costs as much as 12 times that of term delivery for combined maternal and neonatal care.⁴²

Interestingly, 24-hour coverage of L&D has been associated with a reduction in the preterm birth rate.²⁵ These reductions appear to be associated with a decrease in spontaneous preterm births, specifically nonmedically indicated, late preterm births (i.e. 34–37 weeks). Physicians alone have a minimal impact on reducing preterm birth by the use of therapies such as tocolytic medications, which delay delivery by only 48 hours at most. This drop in preterm birth more likely stems from declines in the induction rates of these late preterm infants, who still have increased risks of complications such as respiratory distress syndrome (RDS), jaundice, feeding problems, and increased hospital stays.^43–45 In fact, one study estimated that over half of late preterm births delivered due to intervention from healthcare providers could be classified as nonevidence based and iatrogenic.⁴⁶ This study has been criticized, however, as information on the indications for delivery was frequently not available from medical records.⁴⁷ However, this does raise the possibility that the reduced preterm labor rates seen in 24-hour coverage models may stem from more knowledge of scientific data by those providers, leading to changes in the practice patterns in patients in the late preterm period.

OB/GYN hospitalists should keep up to date with knowledge that would assist them in the evaluation and treatment of patients with preterm labor. Short cervical length has been associated with increased risk for preterm birth for over two decades,⁴⁸ and patients showing symptoms or signs of preterm labor should undergo proper evaluation with transvaginal sonography when appropriate. The SMFM has released a preterm birth toolkit to assist providers with evidence-based material to triage patients presenting with preterm labor.⁴⁹ The evaluation of the patient with a single gestation and symptoms of preterm labor is presented in Figures 4-2 and 4-3. The SMFM preterm birth toolkit may also be accessed as a smartphone application for provider utilization. Variation exists in the performance of transvaginal sonography in the screening for preterm birth in the second trimester, with some studies suggesting contingency-based transvaginal cervical length screening based upon the measurement of the cervix by transabdominal sonography.^50–52 In contrast, sonographic transvaginal cervical length assessment should be considered an integral part the evaluation process for spontaneous labor without preterm premature rupture of membranes (ROM) when equipment is available. The ability to perform transvaginal ultrasound assessments of cervical length should be a basic and required skill for the OB/GYN hospitalist, and measurement appears more accurate after proper education and validation of images.⁵³ OB/GYN hospitalists should obtain certification in transvaginal cervical length evaluation through an appropriate source, such as the Perinatal Quality Foundation CLEAR program (https://clear.perinatalquality.org), to ensure obtaining the proper images for this key tool of preterm labor assessment.

NEONATAL OUTCOMES

Information on the implications of OB/GYN hospitalist care on neonatal outcomes is sparse and requires further investigation. However, it is difficult to imagine consistent circumstances where increased availability of provider services around the clock would lead to worse outcomes. OB/GYN hospitalist availability likely improves the ability to respond to an emergency within the 30-minute interval that is recommended by ACOG for emergent deliveries. More than one-third of all emergent deliveries occur outside this ACOG recommended time interval.⁵⁴ Delivery outside the decision-to-incision interval for emergent delivery has been associated with a higher incidence of adverse neonatal outcomes.⁵⁵ Practices associated with OB/GYN hospitalist program and other initiatives (such as 24-hour call, FHR training, simulations, and educational programs) have also been shown in one study to be correlated with a 42% reduction in maternal and neonatal adverse events.⁵⁶ Barber et al (2011) also showed a reduction in cord arterial pH to less than 7.1 when a program with continuous coverage for night services was instituted.⁵⁷

OTHER CLINICAL AREAS OF IMPACT

Preeclampsia is one of the leading causes of worldwide maternal mortality.⁵⁸ Severe hypertensive crisis can predispose pregnant women with preeclampsia to irreversible neurologic damage or sudden death. Cerebrovascular complications lead to 38.7% of preeclampsia-related maternal deaths, despite the means to treat elevated blood pressures immediately with intravenous (IV) medications.⁵⁹ The use of a protocol to treat defined blood pressure elevation led to prevention of death from cerebrovascular complications over a five-year period, according to a study examining over 1.25 million deliveries.⁶⁰ OB/GYN hospitalists may reduce delays in treatment by eliminating the time lag in communication with an off-site provider and improving the timing of blood pressure measurement and the administration of antihypertensive agents.⁶¹

Obstetric hemorrhage also is one of the major causes of maternal morbidity and mortality in the United States,⁶² and the incidence of this disorder has been shown to be increasing.⁶³ A review of maternal deaths from obstetric hemorrhage in one large hospital system found that 73% of them were preventable and made up almost half of all preventable maternal mortalities.⁶⁴ Utilization of standardized protocols for obstetric hemorrhage has had mixed results regarding blood loss and transfusion rates.^65,66 Instead, the key to improved outcome appears to be via timely intervention and experience. Miscalculation of the severity of obstetric hemorrhage is often caused by faulty clinician estimation of blood loss, a skill that can be improved with education and experience.⁶⁷ Delay in the presence of an on-site provider and provision of bimanual examination have been associated with an increase in severe obstetric hemorrhage by 60% to 80%.⁶⁸ These factors of experience in treatment, timely intervention, initiation of institutional protocols, and coordination with other hospital personnel and medical disciplines appear to be easily improved by the presence of a full-time OB/GYN hospitalist.

Approximately 70% of malpractice claims and 79% of the costs of claims result from substandard obstetrical care and avoidable injury, according to Clark et al (2008).⁶⁹ This same study opined that 50% of these costs could be avoided by implementing the following practices commonly implemented by laborist services: (1) 24-hour in-house coverage, (2) adherence to high-risk medication protocols, (3) a conservative approach to VBAC, and (4) a comprehensive and standardized delivery note in cases of shoulder dystocia. These authors also noted that 40% of adverse outcomes related to intrapartum fetal hypoxia may have been avoided had 24-hour coverage been available. Pettker et al (2014) examined the results of a comprehensive obstetric patient-safety program, which included 24-hour expert coverage of a labor unit as one component and displayed a greater than 50% drop in malpractice claims and an almost 18-fold reduction in median malpractice payments per 1000 deliveries.⁷⁰

OB/GYN hospitalist services serve as a needed safety net for inpatient obstetrical services. The practice of general obstetrics and gynecology serves as a healthcare triathlon for many providers by attempting to maintain excellence in services across the three different realms: L&D, gynecologic surgery, and office practice. Furthermore, two of the services (L&D and gynecologic surgery) have emergency services that require 24-hour responses. Coverage of a large practice, frequent calls in a smaller group, or just an unfortunate run of emergencies can require the OB/GYN provider to provide a prolonged length of care that requires simultaneous measures of intelligence, stamina, and perfection. The OB/GYN hospitalist can make changes to reduce exhaustion by adjusting workloads, decreasing work hours, and lessening time commitments to avoid fatigue.⁷¹

Excessive workloads and stress may lead to decreased rest, resulting in sleep deprivation. The amount of sleep needed for the average person is 7 to 8 hours. Repeated interruption of sleep from phone calls, texts, or pages may lead to poor quality of sleep and daytime sleepiness. Quality of sleep worsens as periods of deep stages of sleep decrease with age, leading to shorter overall sleep periods compared to younger individuals.⁷² The field of obstetrics and gynecology is associated with a high risk of sleep deprivation due to unpredictability of labor, obstetric emergencies, and surgical gynecologic emergencies. The current management of OB/GYN hospitalist programs run in community facilities and some university centers may assist with reducing sleep deprivation, but that does not take full advantage of their structure.

Physicians must abdicate their duties at night to OB/GYN hospitalists at times to strike a balance between appropriate rest and care continuity. Patients should be educated about the importance of rest in healthcare settings, similar to other specialties such as pilots or truck drivers, to promote a culture of safety and prevent adverse patient outcomes. Physician performance toward the end of a demanding shift may be deteriorated similar to having a 0.04 to 0.05 g% blood alcohol concentration.⁷³ Clark (2009) has combined the results of several studies linking the increasing time of sleep deprivation to worsening blood alcohol concentrations (see Table 4-3).⁷⁴ The healthcare industry is aware that sleep-deprived physicians perform with increased frequencies of serious medical errors, undergo more deterioration in clinical performance than when they are well rested, and pose an increased danger to their local communities in general, with such effects as higher motor vehicle accident rates.^75–77