Thursday, October 18, 2007

Why low risk obstetrics isn't...

In Canada obstetrical care is divided up between OB/GYNs, Family Docs and Midwives. The exact nature of the mix depends mainly on the region of the country and local practices. In some larger centres only OB/GYNs do deliveries regardless of risk level, while in some smaller settings there is nary an OB/GYN to be found. In general a smaller percentage of family doctors are practicing obstetrics than in the past. In part this is due to difficulties with always being on call, difficulties earning a reasonable living as a family doctor, and increased risk of facing lawsuits coupled with higher malpractice premiums. People have strong feelings about obstetrics, and who should be doing what.

Obstetrics is one of my favorite parts of family medicine. In general it's one of the happiest parts of my job, and one of the few times I see totally healthy young families as they go through a happy experience (most of medicine being focused on ill people rather then well). That being said, the stakes are high in obstetrics. With 2 young and healthy patients (mom and baby) the expectation is that nothing will go wrong...a very different expectation then when caring for the very ill. When it comes to obstetrics my only agenda is safety. Most of the time labour is a natural process that proceeds smoothly and needs no intervention. In a minority of births intervention is required and quick and efficient actions can prevent bad outcomes for both Mom's and babies. As a Family Doctor I prefer obstetrics of the low risk variety, cases where bad things sometimes happen, but aren't expected to.

Here in the north obstetrics is made trickier by the issues of distance. Women from communities all over the island come down to Iqaluit at 36 weeks to wait to give birth. It can be a difficult experience for women who may have to be distant from their families for as long as a month while waiting to deliver. Obstetrical practice here on Baffin Island is fairly busy for a small hospital and there are between 400 and 450 births a year here (busy by the standards of small hospitals in Canada). We have about 5 Family Doctors who practice obstetrics, and a general surgeon who can do C-sections when required. In the arctic we are distant from help (evacuating a patient to a tertiary care centre typically takes 12 hours if the weather is good, and a plane is available for transport), and we try to limit those births to ones where problems aren't expected. In a perfect world that means that pregnancies that are at high risk for complications are sent on to a higher level of care early on, in order to avoid complications. As a general rule we try to limit deliveries to women who are relatively uncomplicated, at least 35 weeks along, and who have neither major maternal medical issues, nor known fetal abnormalities.

Because the obstetrical population is young and healthy, and because as a group of doctors we discuss each and every patient prior to delivery and identify patients at higher risk needing a higher level of care our complication rate is low (and our section rate is around 7%). Like any hospital with a fair number of deliveries we see complications of labour and delivery that can't be avoided; abruptions, post partum hemorrhages, prolonged rupture of membranes, pre-eclampsia and eclampsia (lots and lots of pre-eclampsia). But the remoteness, and the distances also lead to some situations that might not happen in the rest of Canada, where transfer to higher level of care is more easily available, and some of these situations are certainly higher risk than I enjoy as a Family Doctor.

One of the trickiest situations in obstetrics here in the north is the obstetrical medevac. It usually begins with a phone call in the middle of the night. Half asleep I answer the phone to hear I am needed for a medevac to Igloolik, or Resolute Bay or one of the other remote communities of Baffin Island. The usually story is a young, otherwise well woman in premature labour. It's a difficult situation, as usually I am flying to a health centre 3-4 hours remote from our hospital here in Iqaluit, and minimally equipped, to possibly deliver a high risk premature baby. Once I'm there I'm at least 3 hours travel time back to my hospital here in Iqaluit and a further 12 hours until the patient could be transferred on to a tertiary care setting.

I like to arrive prepared so I call the nursing station and ask for specifics. How far along in the pregnancy is she? Are the dates certain? Is there a history of prematurity or complications in previous pregnancies? Does the mother have any known health problems? Has a fetal fibronectin been done? What is the cervix like? Usually I instruct the nurse to begin an attempt at tocolysis (stopping labour with meds.....which is of course it's own discussion about effectiveness), ask for a dose of Betamethasone to be given if the dates are even close to 32 weeks, and head to the hospital to pick up supplies. Supplies take a small amount of time to gather, and time is of the essence, but it pays to go prepared for everything because once there there is no more back up, and no extra equipment.

Here are the extras I like to bring in addition to the usual gear and meds on the medevac plane:

2 units of O- blood
Blood tubing for infusion
5 pairs of size 7.5 sterile gloves
5 packs of 3-0 Vicryl suture
An OBS tray
An umbilical line kit
A number of various size angiocaths (makeshift chest tubes for babies)
A large bottle of Ketamine (a good choice for a required but nerve wracking sedation for a manual placenta removal outside of the hospital)
A difficult airway kit (for when the above goes awry)
4 vials of Hemabate (There are 2 on the medevac plane and 2 at the nursing station, the maximum dose for severe post partum hemmorhage is 8 vials)
Some misoprostol
Some nifedipine
Some indomethacin
Some surfactant
Extra Oxytocin
Some Narcan
Baby sized endotracheal tubes
A syringe pump
An infant ventilator
An incubator

The medevac plane is a KingAir 200, a fast, reliable duel prop plane with a good record in the arctic. The plane is without facilities, and a bathroom trip is the mandatory last thing to do before taking off. The plane drones, pure white noise, it's entrancing. I sit back for the 3 hour flight. Sometimes I joke around with the paramedic I'm flying with, but more often I sit back and run scenarios in my head. What will I do if the baby comes out flat? I run the the NRP algorithm in my mind. What if I have to intubate the baby or put in a UVC? I go over it in my head. What about a big hemorrhage? Same drill. What if both Mom and baby are sick at the same time? I go over how I will instruct the various people available for help. The plane lands, sometimes in the day, sometimes at night, sometimes through a hole in the clouds only the pilots could see. On gravel runways, on snow covered runways, through crosswinds, as soon as we touch down I call the nursing station for an update on the sat phone. Has the baby been born, has the labour stopped, has the cervix changed.

The second worst place the deliver a premature baby is in a remote nursing station. The worst is in an airplane. If there is any chance of getting the patient back to the hospital before a baby is born, time is of the utmost essence. The phone call to the nursing station determines if we travel light (no stretcher, vents or incubators because unloading the plane takes significant time), or travel with all of our gear. We drive to the nursing station, and I assess the patient and determine if we can safely make it back to the hospital, or if we will deliver the baby at the nursing station. The assessment involves a quick review of records and history (especially for previous precipitous deliveries), a review of contraction pattern or absence there-of, assessment of the cervix, the fetal heart pattern and of a fetal fibronectin test if available. If we fly back I usually make sure the patient is well loaded with tocolytics, usually nifedipine (because there are to be NO babies born on planes), and we move back to the plane as fast as possible. If it is safe to fly back to Iqaluit, I like to be back at the airport before the plane is refuelled, a turn around time of about 20 minutes. Once on the plane we monitor the patient and hope (because there are to be NO babies born on planes).

Sometimes medevac flights are lovely. Sometimes the pilots will turn off the cabin lights and the running lights as we fly through a field of northern lights. There is an adage here in northern medicine that 'we do the best we can with what's available'. It would be lovely if there were high risk obstetricians in every community, or even within easy reach. It would be nice if there were tertiary care hospitals here in the arctic. It's easy to look from the outside and see or say that we're falling short. The reality though is that it's unlikely those things will ever be here, so those of us who are here do the best we can with what we have. And we hope for the best. Usually it turns out well, though it sometimes feels riskier than I had bargained for as a family doc doing obstetrics. I'm pretty sure that every flight adds a few grey hairs to my head.


Nancy said...

Great post! It's good to hear about the premature labour experience from the doc flying in on the plane (I'm one of the nurses who might be at the other end).

Rob & Tina said...

Wow. I can't even imagine what you go through. My hats off to you and all the medical care in the north.

medstudentitis said...

I have a fantasy about practicing rural obstetrics and your post just made it very real to me how scary it can be!

medstudentitis said...

Oh man, thanks for the tip on the phase IID thing - I've pretty much finished my project, which would just make doing an elective in it all that much better...

Liana said...

Agh... as someone who is already kind of anxious about practicing "low-risk" rural obstetrics, your post makes me want to stick my head in the sand. La la la, I can't hear you. Just kidding. Best to be forewarned, right?

micky mayor said...

Obstetrics is a specialized field that should only entered by the truly dedicated. If you are pregnant and looking for care, take your time to find the right doctor. Obstetrics Boynton Beach

Shanna White said...

thanks for your thoughts on obstetricians near mchenry il. I always think one should assume that with our health, it isn't always 100% certain everything will be okay!