This article originally appeared in the fall 2021 edition of Minnesota Family Physician magazine.
Obstetrics Emergencies Can Happen Anywhere
This is the case of a 24-year-old G1P0, unknowingly pregnant, who presented with abdominal pain to the Avera Granite Falls Emergency Room. The patient was found in active labor with nine cm dilation, prolonged rupture of membranes with concerns for chorioamnionitis and preeclampsia with severe features.
She delivered a term nine-pound baby boy via primary c-section after failure to descend and maternal fatigue. Baby was flown to Children’s Minnesota Hospital in St. Paul for neonatal care while mother underwent resuscitative efforts after severe postpartum hemorrhage in Granite Falls. She received four units of blood and two units of fresh frozen plasma while actively having bimanual uterine massage and multiple drugs to stop the bleeding. With limited hospital staff, every available nurse and paramedic helped during the resuscitation efforts, led by family physicians Rosa Rios Avendano, MD, and Mark Eakes, MD, MPH.
Once the mother became stable, she was transferred with a Bakri balloon in place to The Mother Baby Center at United and Children’s Minnesota for further care. She underwent B-Lynch procedure, uterine artery ligation and ICU care. A few weeks later, she returned to town with her baby and they continue to receive primary care at Granite Falls Hospital.
OB Services in Rural Communities Are At Risk
Granite Falls, Minnesota, has a 15-bed critical access hospital run by primary care providers and advanced practice practitioners. The hospital provides low-risk prenatal care by family physicians who completed an OB fellowship. Eakes and Avendano have received c-section training in the Medicos Surgical Obstetrics Fellowship in Memphis, Tennessee. The Medicos OB Fellowship is a missionary family medicine training developed by William M. Rodney, MD, to render OB quality care in rural areas.
Despite available training, it is difficult to recruit family doctors with OB skills and maintain OB services available in rural hospitals. Small communities like Granite Falls are at risk of losing OB services due to financial support and staff limitations.
Family Docs With OB Training Are Needed More Than Ever
Family medicine training intends to cover low-risk OB in most residency programs. However, many residents struggle to get enough procedures numbers to feel competent to provide OB care. It is difficult for family medicine providers to maintain a level of proficiency without enough practice. Therefore, many hospital privileges requirements limit family doctors’ OB scope of practice. In addition, OB care requires commitment and availability to patients, along with increased liability and malpractice risk.
As a result, the number of rural family doctors providing obstetric care is falling. In 1978, almost half of family physicians delivered babies. By 2005, this number decreased to 23% (1). Most recently, the American Board of Family Medicine reported that only 5% of family doctors in 2016 were doing low volume OB, mostly in rural areas (2). Family doctors with OB training and surgical skills in rural locations play an essential role in reducing maternal mortality. Family medicine OB fellowship programs attempt to close the gap in training. The American Board of Physician Specialties provides a list of fellowship programs accredited by the Board of Certification in Family Medicine Obstetrics (BCFMO) at www.abpsus.org/family-medicine-obstetrics-fellowship-programs.
Family medicine obstetrics providers should not work in isolation. Despite completing a fellowship in OB, the number of OB patients is limited in most family medicine clinics to keep the surgical proficiency. Therefore, family doctors should collaborate with OB/GYN to achieve OB necessary training and skill maintenance (3).
Maternal Mortality Continues to Increase
According to the Centers for Disease Control and Prevention, over 700 women die each year in the United States due to pregnancy or delivery complications (4). The maternal mortality rate is 12.9 lives per 100,000 births in Minnesota, just below the national average (17.3 lives/100,000 births), based on the Minnesota Maternal Mortality Scorecard (5). In Minnesota, “African American women are 1.5 times more likely and American Indian mothers are 7.8 times more likely to die during pregnancy, delivery or the year post-delivery than non-Hispanic white women” (Vital Records 2011-2017).
Statistics are worse for rural America, where maternal mortality is significantly higher, with a reported pregnancy-related mortality ratio of 29.4 per 100,000 live births in 2015 (6). Consequently, “more than half of rural counties nationwide lack hospitals with labor and birthing services, and the disparity in access to care and worse health outcomes disproportionally affects people of color” (7).
Additionally, primary and specialty care are limited in rural America, with only 6% of OB/GYN providers working in rural areas (8). As a result, many women must travel long distances to find pregnancy care.
Conclusion
Obstetric emergencies can occur anywhere. As is demonstrated in this case, a small, rural hospital had in place the well-trained staff and teamwork who provided necessary interventions (cesarean section, massive transfusion protocol and infection control) and effectively coordinated with higher levels of care to ensure a positive outcome for mother and baby.
Granite Falls medical staff undergoes Comprehensive Advanced Life Support (CALS) and Advanced Family Medicine Obstetrics training (including managing high-risk OB patients, cesarean section training and point-of-care obstetrics ultrasound) to ensure quality primary care. Board certification in family medicine obstetrics through the American Board of Physician Specialties (ABPS) provides a uniform standard based on American College of Obstetricians and Gynecologists (ACOG) principles recommended for family doctors desiring to practice obstetrics.
Post Authors:
- Rosa Rios Avendano, MD, family physician, Avera Medical Group Granite Falls, and fellow, Clínica Médicos Obstetrics Fellowship
- Mark Eakes, MD, MPH, family physician, Avera Medical Group Granite Falls, and alumnus, Clínica Médicos Obstetrics Fellowship
References
- Rodney, J. Family Medicine Obstetrics US for Primary Care 1st Edition. Memphis, Tennessee: Dog Ear Publishing, LLC; 2016.
- Minnesota Department of Health. Maternal Mortality and Morbidity from
Vital Records 2011-2017. Updated August 1, 2019. - American Academy of Family Physicians. Cesarean delivery in family medicine: position paper. 2016.
- Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related
Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68:423–429. - Society for Maternal-Fetal Medicine. Minnesota Maternal Mortality Scorecard 2020-2021. Updated January 18, 2021.
- Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Updated November 25, 2020.
- Smith, T. Bill to Improve Access to Rural Health Care for New & Expecting Moms. 2020.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 586: Health disparities in rural women. Obstet Gynecol. 2014;123(2 Pt 1):384–8.