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MODERN OBSTETRICS COMES TO VANDERBILT: A PERSONAL HISTORICAL PERSPECTIVE. Frank H. Boehm, M.D. Birth of Modern Obstetrics.
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MODERN OBSTETRICS COMES TO VANDERBILT:A PERSONAL HISTORICAL PERSPECTIVE Frank H. Boehm, M.D.
Birth of Modern Obstetrics The process leading to significant improvement in the care and outcome of pregnant women and their babies had its birth in the late 1960s and became fully developed in the 1970s.
Maternal Mortality in 1930 670 deaths per 100,000 live births Maternal Mortality in 1982 7.5 deaths per 100,000 live births
Perinatal Mortality 1940 60/1,000 1965 41/1,000 2004 7/1,000
Infant Mortality 1940 47/1,000 1997 8/1,000
Electronic Fetal Monitoring • 1972 – Purchase of 5 EF monitors and a blood gas analyzer at cost of $50K • L & D renamed Fetal Intensive Care Unit • All patients in labor underwent EFM with scalp pH sampling PRN • Monitor conference, Mondays at 4 pm began
VANDERBILT OB1972 • 60 deliveries per month • Most low-risk patients
AMA - 1971 Adopted a position supporting the regionalization of perinatal care. In 1972, ACOG/AAP developed guidelines on how to evolve regionalization.
Ideally, it was recommended that whenever possible, pregnant mothers should be transferred before delivery, so as to provide the unborn child with the best incubator (the mother's uterus) during transfer.
Perinatal Regionalization involved the transfer of high-risk newborns from smaller hospitals to larger, better-equipped and staffed neonatal intensive care units for their care following delivery. It also involved the transfer of high-risk pregnant women to tertiary hospitals, like Vanderbilt, prior to delivery, so they could receive the most sophisticated and advanced treatments available.
It was determined that delivery in a hospital appropriately staffed and equipped for all problems that might arise would result in better outcomes.
Regionalization of perinatal health care required the organization of a region, (in our case, middle Tennessee), in which there were defined levels of perinatal care consisting of at least one tertiary care (Level 3) hospital, whose primary concerns were education, consultation, transportation and a high level of care.
Level 1 care hospitals (small rural hospitals throughout the 39 counties of middle Tennessee), described care given to normal obstetric patients and normal newborns
Level 2 care described care given for somewhat more complicated pregnancies and newborn illnesses (Murfreesboro, Clarksville, Columbia, Cookeville Hospitals).
Being a tertiary care facility, Vanderbilt University Hospital was able to provide the Level 3 care required for the most complicated and sick pregnant patients and their newborns.
Important aspects of the regionalization process was the prevention of expensive duplication of health care services and staff as well as to provide the most sophisticated and technologically advanced care by highly trained health care providers.
The task for Vanderbilt was to convince doctors and administrators in small rural hospitals throughout surrounding counties of Nashville, to send to Vanderbilt Hospital their sick newborns, as well as their complicated pregnancies, so that improved outcomes could materialize
Initial telephone calls to practicing Obstetricians in some of the hospitals around Nashville to explain the benefits of Perinatal Regionalization were not productive.
I soon realized that convincing physicians to transfer care of their patients (and income) to Vanderbilt Hospital would take a face-to-face encounter in their office, as well as a visit to the administrator of the hospital who would also be affected by a loss of patient care dollars.
With that in mind, I paid a visit to Dr. Eugene Fowinkle, the then Tennessee State Commissioner of Health, to ask for his support. I explained the importance of Perinatal Regionalization and how this process would not only save lives, but would also save considerable duplication of equipment and personnel in hospitals throughout the state.
Dr. Fowinkle did not hesitate. He instructed me to write a proposal outlining the costs and said he would do what he could.
Three months later, the State of Tennessee awarded Vanderbilt's Ob/Gyn Department $20,000 a year for two years thus allowing me to travel to each hospital in middle Tennessee in hopes of convincing doctors to send their high risk pregnant patients to Vanderbilt rather than trying to care for them in their local community hospitals.
Convincing doctors to accept Perinatal Regionalization once I arrived in their picturesque cities, however, was not as pretty.
Local doctors resented Vanderbilt Hospital for the way some of its staff had treated them whenever they attempted to call for a consult or when they sent a critically ill patient to Vanderbilt for special care. Many referring doctors explained how physicians at Vanderbilt were often condescending or arrogant when asked their advice.
I was told that when these local doctors did refer patients to Vanderbilt, their patient were lost to follow up. No one at Vanderbilt, it seemed, made an attempt to inform referring physicians as to what had happened to their patients.
To add insult to injury, I was told of patients having returned home following treatment at Vanderbilt, telling their local doctors of disparaging comments made by Vanderbilt staff about the care they had received prior to transfer.
It was with this in mind that we began to stress to the many doctors and nurses in the department of Ob/Gyn at Vanderbilt, the importance of our relationships with referring doctors throughout middle Tennessee.
Insisting on direct Vanderbilt attending physician to referring physician consultation, we were able to gain control of our communication with physicians in middle Tennessee and slowly began to change opinions of our referral base of doctors.
Putting into place a system that emphasized rapid verbal and written communication to keep referring doctors updated on their patients after transport to Vanderbilt, as well as making certain that none of our staff made negative comments concerning care patients had received prior to transfer, was helpful in beginning a process whereby doctors began feeling comfortable referring their complicated pregnant patients to Vanderbilt Hospital for specialized care.
Unfortunately, not everyone was pleased with our attempts to regionalize the care of pregnant patients.
Slowly and steadily, however, the number of high-risk obstetric patient referral for in-patient care began coming to Vanderbilt Medical Center with numbers reaching as high as 700 each year.
As early as 1981, Vanderbilt was able to report that survival of very small infants born at Vanderbilt Medical Center had doubled during the years 1975 and 1980
Perinatal mortality (babies dying around the time of birth) in Tennessee, which was 31.2 babies per 1000 births in 1970, steadily declined to 15.8 by 1983.
Maternal mortality (mothers dying because of pregnancy complications) also declined during this time, from 2.9 pregnant patients per 10,000 pregnancies to 1.3.
Most doctors and nurses needed an on-going educational process that would involve on-site education on a regular basis. We needed a team of educators who would travel to hospitals around Nashville to provide education on the use and interpretation of fetal monitoring.
Our department turned to the March of Dimes and requested money to hire a nurse specialist who would be able to spend her days traveling throughout middle Tennessee in order to teach nurses the art and science of fetal monitoring.
