Redesigning Maternal Care: OB-GYNs Are Urged to See New Mothers Sooner and More Often

by Nina Martin April 23

Doctors would see new mothers sooner and more frequently, and insurers would cover the increased visits, under sweeping new recommendations from the organization that sets standards of care for obstetrician-gynecologists in the U.S.

The 11-page “committee opinion” on “Optimizing Postpartum Care,” released today by the American College of Obstetricians and Gynecologists, represents a fundamental reimagining of how providers, insurers and patients can work together to improve care for women after giving birth. “To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the committee opinion states.

While an ACOG task force began rethinking its approach several years ago, the guidelines arrive at a moment of mounting concern about rising rates of pregnancy-related deaths and near-deaths in the U.S. As ProPublica and NPR have reported, more than 700 women die every year in this country from causes related to pregnancy and childbirth and more than 50,000 suffer life-threatening complications, among the worst records for maternal health in the industrialized world. The death rate for black mothers is three to four times that of white women.

The days and weeks after childbirth can be a time of particular vulnerability for new moms, with physical and emotional risks that include pain and infection, hypertension and stroke, heart problems, blood clots, anxiety and depression. More than half of maternal deaths occur after the baby is born, according to a new CDC Foundation report.

Yet for many women in the U.S., the ACOG committee opinion notes, the postpartum period is “devoid of formal or infor­mal maternal support.” This reflects a troubling tendency in the medical system — and throughout American society — to focus on the health and safety of the fetus or baby more than that of the mother. “The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

The way that providers currently care for pregnant women and infants versus new mothers exemplifies this difference. During the prenatal period, a woman may see her OB-GYN a dozen or more times, including at least two checkups during her ninth month. Her baby’s first pediatric visit usually occurs a few days after birth. But the mother may not have a follow-up appointment with her own doctor until four to six weeks after delivery — and in many cases, insurance only covers one visit. “As soon as that baby comes out, [the mom] is kind of an afterthought,” said Tamika Auguste, associate medical director of the MedStar Health Simulation Training & Education Lab in Washington, D.C., and a co-author of the ACOG opinion.

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For working mothers, having to wait four to six weeks makes it harder to arrange a check-up.

Some 23 percent of mothers employed outside the home are back on the job within 10 days of giving birth, a 2014 report for the U.S. Department of Labor found; another 22 percent return to work within 40 days. Lack of childcare and transportation can also present significant hurdles to accessing care. According to ACOG, as many as 40 percent of women skip their postpartum visit; for low-income women of color, the rates are even higher.

“You may have a woman that has asthma, is having problems lactating, and is obese, and when they come to see you at six weeks, we have missed the boat here,” Auguste said.

Nor is a single visit enough time to address a new mother’s questions and concerns, especially if she had a complicated pregnancy or is suffering from chronic conditions such as hypertension, diabetes or a mood disorder. “We’re trying to address all of the issues that women are dealing with after having a baby in one 20-minute encounter,” Stuebe said. “And that’s really hard to do.”

Under the new ACOG guidelines, women would see their providers much earlier — from within three days postpartum if they have suffered from severe hypertension to no later than three weeks if their pregnancies and deliveries were normal— and would return as often as needed. Depending on a woman’s symptoms and history, the final postpartum visit could take place as late as 12 weeks after delivery and ideally would include “a full assessment of physical, social, and psychological well-being,” from pain to weight loss to sexuality to management of chronic diseases, ACOG says.

See Our Series


Lost Mothers

Maternal Care and Preventable Deaths

In another significant change, ACOG is urging providers to emphasize in conversations with patients the long-term health risks associated with pregnancy complications such as preterm delivery, preeclampsia and gestational diabetes. “These risk factors are emerging as an important predictor of future [cardiovascular disease],” the recommendations state. “ … [B]ut because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women.”

Earlier, more frequent and more individualized care could be a step toward addressing the stark racial disparities in maternal and infant health, said ACOG’s outgoing president, Haywood Brown, who has made reforming postpartum care one of the main initiatives of his term. Black mothers are at higher risk for many childbirth complications, including preeclampsiaheart failure and blood clots, and they’re more likely to suffer long-lasting health consequences. They also have higher rates of postpartum depression but are less likely to receive treatment. Regardless of race, for women whose pregnancies are covered by Medicaid, the postpartum period may be their best opportunity to get help with chronic conditions before they lose insurance coverage.

The new guidelines urge doctors to take a proactive approach, helping patients develop a postpartum care plan while still pregnant, including a team of family and friends to provide social and other support. According to ACOG, one in four new mothers surveyed recently said they didn’t even have a phone number of a health care provider to contact with concerns about themselves or their babies.

ACOG isn’t the only organization calling for a reinvention of postpartum care; patient-safety groups, researchers, nurses and midwives have also tackled the issue, recasting the three months after birth as akin to a “fourth trimester.”

“The postpartum period has become a priority,” said Debra Bingham, a professor of nursing at the University of Maryland and executive director of the Institute for Perinatal Quality Improvement who has participated in many of these initiatives.

Some providers, including Brown, who is affiliated with Duke University, are already incorporating some of ACOG’s ideas. Still, putting the reforms into common practice may take years. One of the biggest impediments is insurance reimbursement. Currently, payment for prenatal care, delivery and a single post-birth visit is bundled together into one global fee, creating a disincentive for doctors to see patients more than once, Auguste said.

The disincentives are greater for women on Medicaid, which pays for about half of U.S. births. What’s more, in many states Medicaid coverage ends at two months postpartum. The ACOG opinion didn’t estimate the cost of implementing its recommendations.

Brown agreed that revamping how postpartum care is reimbursed is critical, and insurance representatives — along with members of other medical specialties — were on the ACOG task force that drafted the new guidelines. “I want to make sure that I get some employee health plans and some health systems to adopt this nationally,” Brown said.

Indeed, although the guidelines are aimed at OB-GYNs, they would require changes throughout the maternal care system. That’s what ACOG is hoping for. “It’s really a societal call to action,” Stuebe said.

New Study reports benefits for delayed cord clamping with no adverse clinical issues

Read the full study here.

"Prompt administration of oxytocin after delivery helps reduce the risk of maternal postpartum hemorrhage, while the bolus of placental blood delivered by delayed umbilical cord clamping provides benefit to the infant by increasing hemoglobin and hematocrit and reducing the incidence of iron deficiency during the newborn period.There were no such adverse events that reached the level of clinical relevance among any of the mothers or infants in the study population, she said."

Evidence on Doulas

Of all the ways birth outcomes could be improved, continuous labor support seems like one of the most important and basic needs for birthing people. Providing labor support to birthing people is both risk-free and highly effective. Evidence shows that continuous support can significantly decrease the risk of Cesareans, NICU admissions, Pitocin, and medications for pain relief. Labor support also increases satisfaction and the chance of a spontaneous vaginal birth. Although continuous support can also be offered by birth partners, midwives, nurses, or even some physicians, research has shown that with some outcomes, doulas have a stronger effect than other types of support persons. As such, doulas should be viewed by both parents and providers as a valuable, evidence-based member of the birth care team.

For most of these outcomes (designated with asterisks*), the best results occurred when a birthing person had continuous labor support from a doula– someone who was NOT a staff member at the hospital and who was NOT part of their social network. When continuous labor support was provided by a doula, women experienced a:

  • 31% decrease in the use of Pitocin*
  • 28% decrease in the risk of Cesarean*
  • 12% increase in the likelihood of a spontaneous vaginal birth*
  • 9% decrease in the use of any medications for pain relief
  • 14% decrease in the risk of newborns being admitted to a special care nursery
  • 34% decrease in the risk of being dissatisfied with the birth experience*

See the full article here.

the odds of a woman's having a cesarean are two times higher in for-profit hospitals than in not-for-profit hospitals


Controlling for patient-level characteristics, we found that the odds of a woman's having a cesarean were two times higher in for-profit hospitals than in not-for-profit hospitals. We also found for-profit hospitals were significantly more likely to be members of multihospital systems and to have fewer full-time registered nurses and staff members per hospital bed.


This research suggests that women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. This information is important to women when deciding where to give birth. Knowing which hospital characteristics are associated with a greater likelihood of cesarean is helpful since hospital cesarean rates may be difficult to find. These findings are also informative for obstetric professionals, who can implement improvement initiatives to decrease cesarean rates and improve the overall quality of care for childbearing women in the United States.

Continuous Fetal Monitoring (Cardiotocography) Flunks Its Test—Again

by Henci Goer  |   April 7, 2017

A Lancet commentary trying to explain away the findings of a trial of computerized interpretation of fetal monitoring tracings popped up in CBU’s Google alerts, but we get ahead of ourselves. Let’s start with a look at the trial.

The trialists hypothesized that: “a substantial proportion of substandard care results from failure to correctly identify abnormal fetal heart rate patterns, that improved recognition of abnormality would reduce substandard care and poor outcomes, and that improved recognition of normality would decrease unnecessary intervention.” To test that hypothesis, the trial evaluated whether adding color-coded (blue: least severe; yellow: moderate severity; red: most severe) computer interpretations of degrees of abnormality to the display of fetal heart rate (FHR) tracings would improve newborn outcomes and decrease cesarean and instrumental deliveries.

The trial was conducted in 24 centers in the U.K. and Ireland and comprised 46,042 women laboring with a singleton or twin pregnancy at 35 weeks’ gestation or more and whose babies had no known congenital anomalies or fetal heart rhythm abnormalities. Participants were randomly allocated to continuous FHR monitoring (cardiotocography) with or without the color-coded decision aid. The trialists state that continuous monitoring isn’t routine in the U.K., but give no information on why participants were being continuously monitored or what percentage of the population they represented. All babies with an adverse outcome potentially related to insufficient oxygen in labor (hypoxia) were evaluated by a panel to determine whether different management might have prevented the adverse outcome. A sample of 6707 children were followed for two years to assess long-term health and development. The trial was big enough to have a 90% probability of detecting a 50% reduction in poor neonatal outcomes from 3 to 1-5 per 1000.

Of note, the trialists had to refine their original definition for the primary outcome (admission to neonatal intensive care within 48 hr of birth for 48 hr or more with evidence of feeding difficulties, respiratory problems, or abnormal neurologic symptoms [encephalopathy]) because many of the intensive care admissions for these reasons were due to other disorders, which implies that studies using admission to intensive care as a measure of hypoxia in labor are likely to overestimate its prevalence.

As for results, availability of the decision aid had no effect on newborn, maternal, or childhood outcomes. Equal percentages of babies (7 per 1000) experienced the primary outcome (demise during labor or up to 28 days after birth or significant morbidity, including moderate or severe abnormal neurologic symptoms or breathing complications). Rates were virtually identical for a long list of specific adverse outcomes such as Apgar score < 4 at 5 min, low cord-blood pH, need for resuscitation, newborn seizures, or transfer to the neonatal intensive care unit at birth. For women, cesarean (24%) and instrumental vaginal delivery (25%) rates were identical. The same was true for indications for cesarean or instrumental vaginal delivery (18% abnormal FHR; 22% delayed progress; 7-8% combination of both). Equal percentages of births with adverse newborn outcomes were judged to have had suboptimal management (14/35 decision-aid; 13/36 controls). No differences were found between groups in the children followed up for two years.

Availability of the decision aid also had no effect on whether clinicians intervened. Cesarean rates according to urgency (immediate threat to life; some threat of compromise; no threat of compromise; elective) were similar. The median (half delivered before and half after) time from identifying severely abnormal FHR to delivery (58 min) was identical and the range nearly so (13 to 264-279 min). Some cases of severely abnormal fetal heart rate were technical errors, for example, the monitor registered the maternal heart rate, which is much slower than the normal fetal heart rate, as the baby’s. Errors of this kind help to explain the relatively lengthy median times and longer durations in the face of seemingly severe FHR abnormalities.

In other words, the hypothesis was convincingly disconfirmed. The decision aid failed to reduce cesarean or instrumental deliveries, which means it didn’t improve ability to discriminate non-concerning from concerning heart rate patterns. The decision aid also failed to decrease instances of substandard care which means it didn’t improve ability to recognize severely abnormal FHR patterns. What is more, the aid flunked in a population at higher risk, if the trialists’ assertion that continuous fetal monitoring wasn’t routine is true.

“Truthiness” in Action

The continuous fetal monitoring research fits the definition of insanity. Going back decades to the original studies of continuous monitoring and ending with this latest trial, every twist and tweak to continuous FHR monitoring, has sprung from the unshakeable belief, despite the evidence, that continuous FHR monitoring will improve newborn outcomes and reduce unnecessary rescue deliveries compared with intermittent listening. Instead of a call to abandon ship, every failure to show that has led to a “try harder” response:

Internal monitoring will help by improving the quality of the tracings. It doesn’t (Bakker 2012; Harper 2013). Standardizing definitions of abnormal FHR will solve the problem. It doesn’t either (Rhose 2014). Admission test strips will identify babies already of concern so that they can be monitored continuously while healthy babies go on to intermittent listening, which will eliminate unnecessary intervention. Nope (Devane 2012). Fetal scalp-blood sampling for low blood pH or high lactose content will do the trick by enabling doctors to tell which babies are tolerating labor despite a concerning heart rate tracing. Wrong again (Alfirevic 2013; East 2015). Adding electrocardiogram data will allow better discrimination. Makes no difference (Neilson 2015).

This refusal to face facts continues right up to the present day. The authors of the accompanying commentary argue that the decision aid didn’t make a difference because no prescribed actions were attached to its diagnosis. Medical-model thinkers just can’t give it up. Continuous fetal monitoring has to work because it makes so much sense to them that it should.

“The great tragedy of Science: the slaying of a beautiful hypothesis by an ugly fact.”
−Thomas Henry Huxley

This brings us to why continuous FHR monitoring doesn’t work. It’s because the theory behind it, that insufficient oxygen is the main cause of neurologic injury and death, that heart rate changes reliably warn of impending injury, and that improved ability to distinguish between abnormal and normal FHR patterns would improve outcomes and reduce use of rescue delivery, is wrong on all counts. Ample research consistently shows that the link between abnormal FHR and condition at birth, as measured by such things as Apgar scores, cord blood pH, or lactate, is weak; that the link between condition at birth and abnormal newborn neurologic signs, such as altered consciousness, poor muscle tone, feeding problems, or seizure, is weak; and that the link between newborn abnormal neurologic signs and death or cerebral palsy is weak, which means the link between abnormal fetal heart-rate patterns and severe adverse outcomes is pretty much nonexistent (Alfirevic 2013; Althaus 2005; Chauhan 2008; Graham 2008; Hogan 2007; Lie 2010; Low 1990; Milsom 2002; Murphy 1990; Nelson 1996; Pin 2009;  Sameshima 2004;  Williams 2003; Yeh 2012; Yudkin 1994). More information won’t change that fact no matter how much you tinker with it. At one end of the scale, you have what everyone would agree is normal. At the other, you have severely abnormal patterns that everyone would agree demand action. Anything in between is reading tea leaves.

What’s more, there are many reasons for the disconnect between FHR patterns and newborn outcomes that have nothing to do with hypoxia in labor. For example, the injury may have occurred prior to labor (Badawi 1998; Fahey 2005), in which case rescue delivery can make no difference, or the precipitating event may occur so quickly that rescue delivery isn’t possible, as, for example, with placental detachment (abruption). Other problems such as fever during labor (Lieberman 2000), administering sodium deficient IV fluids or too much sugar in IV fluids, or drinking excessive amounts of fluids can produce the same symptoms as low oxygen, these being high blood lactate, low blood pH, and newborn seizures. If hypoxia isn’t the problem, delivery won’t improve the outcome (Higgins 1996; Johansson 2002; Moen 2009; Philipson 1987; Stratton 1995; West 2004). The problem may also be, as the panel reviewing poor outcomes in this trial found, a failure of response, not identification. Furthermore, the slowing of the FHR and the switch to anaerobic metabolism that eventually decreases blood pH are healthy adaptive responses to suboptimal conditions that function to protect the brain and vital organs from hypoxic injury (Bennet 2009; Fahey 2005; Low 1999; Ugwumadu 2014). One reason low blood pH correlates so poorly with neurologic injury is that the adaptation usually succeeds (Ruth 1988; Ugwumadu 2014).

The Take-Away

If continuous monitoring were equivalent to intermittent listening, it wouldn’t matter which was used, but it isn’t. Because of its false-positive rate (the monitor says there is a problem when there isn’t), continuous monitoring increases the likelihood of cesarean and instrumental vaginal delivery (Alfirevic 2013). For this reason, both the Society of Obstetricians & Gynaecologists of Canada and the Royal College of Obstetricians & Gynaecologists, the U.K.’s professional organization, recommend intermittent listening as the preferable monitoring method for healthy women and babies, which gives women unimpeachable support for insisting on it.

2016 Cesarean and Episiotomy Rates

Leapfrog just came out with 2016 statistics, though I'm skeptical of the results as some of the early elective cesarean stats state 0% and I know that's not true as I personally had clients with elective cesareans at several of the hospitals.  Also, UCSF and SFGH did not submit their stats. 

Kaiser SF
Cesarean - 22.2%
Episiotomies - 2.1%

Kaiser Oakland
Cesarean - 21.2%
Episiotomies - 1.8%

Cesarean - 22.3%
Episiotomies - 9.6%

St. Luke's
Cesarean - 22.6%
Episiotomies - 4%

Kaiser Redwood City
Cesarean - 19.1%
Episiotomy - 4.1%


August 14, 2015 - Full article link here

by Michelle Collins, PhD, CNM, FACNM

The use of nitrous oxide as a labor analgesic has taken hold in the US in the past three years. It has been used widely in Europe for decades, with favorable results, along with comes educational information but all the perpetuation of myths.

10. Using nitrous oxide in labor is “just like” when you use it at the dental office. It’s not. In dental offices, the concentration of nitrous oxide to oxygen is variable, so the dentist can increase or decrease the concentration based on the patient’s needs. Dentists may use concentrations of nitrous oxide of up to 70%. The dentist also places a small mask over the patient’s nose, through which a continuous stream of nitrous oxide is delivered.

During labor nitrous oxide is only used at concentrations of 50% nitrous oxide to oxygen – no higher. And the stream of nitrous oxide is intermittently administered by the woman herself using either a mouthpiece or mask with a demand valve. The demand valve opens only when the woman inhales (breathes in) – which is when the gas is released. When the woman exhales (breathes out), the valve closes and the gas stream is stopped.

9. You will be confined to bed while using nitrous oxide. You will still be able to move around while using nitrous oxide during labor. About 10% of nitrous users may experience some dizziness, so your care providers will want to see you stand or move about without difficulty before they let you up on your own, but many women use nitrous oxide while standing, squatting, sitting in a rocking chair, or on a birth ball.

8. Continuous fetal monitoring will be required with nitrous oxide use. Whether you have continuous or intermittent fetal monitoring should be dictated by your obstetrical status, not because you are using nitrous oxide. In other words, if you are a candidate for intermittent monitoring, that does not have to change to continuous monitoring just because you begin using nitrous oxide.

7. If you choose to use nitrous oxide, you cannot use any other pain medications. A fair number of women who start out using nitrous go on to have an epidural placed at some later point in their labor. Using nitrous oxide earlier on allows you to maintain your mobility and stay upright, allowing the baby to move down well in your pelvis before being confined to bed with epidural anesthesia.

6. Nitrous oxide will stall your labor, or slow contractions. There has not been any research showing that nitrous slows down labor or causes contractions to be less strong or happen less often.

5. Nitrous oxide will harm the baby. Nitrous oxide is metabolized (processed) in your lung tissue, but because some of the gas passes into your blood stream, some can also pass through the placenta and go to your baby. However, studies have not shown adverse effects on babies of mothers who have used nitrous oxide in labor.

4. There is a point in labor when it is too late to use nitrous oxide. Actually, some women don’t begin using nitrous oxide until they are in the pushing stage. Other women don’t use it at all during labor, but find it very helpful if they need repair of any tears in their birth canal.

3. My family members can assist me with holding the nitrous oxide mask or mouthpiece if I get tired of holding it. As well-meaning as family members are, this is one area where they can’t help. A safety precaution for nitrous oxide use is that the laboring woman holds her own mask or mouthpiece. When she has had sufficient nitrous oxide, she won’t be able to bring her hand holding the device to her face. Allowing someone else to hold the mask/mouthpiece overrides this safety feature of nitrous oxide.

2. Nitrous oxide is offered at many hospitals and birth centers. Until 2011, there was really only one hospital in the US offering this option. Since that time, use of nitrous oxide has dramatically increased and there are currently over 100 hospitals and 50 birth centers offering nitrous oxide. Though it has come a long way, there is a long way to go to ensure that every woman who desires to use nitrous oxide in childbirth, has the opportunity.

1. Nitrous oxide makes you laugh (hence the nickname “laughing gas”). Despite the nickname, inhaling nitrous oxide doesn’t leave women laughing like hyenas! Because nitrous oxide decreases anxiety, it puts women more at ease and they may be more talkative and relaxed… but don’t count on side splitting laughter!