Waterbirth in Hospitals. Experience of Legacy Health System, Portland Oregon. Hospitals with Maternity Care. 3,984. WB Protocols 1991. 2. WB Protocols Sept 2004. 280. Water Labor Only Sept 2004. 460 . Growth of Waterbirth in the US.
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Waterbirth in Hospitals Experience of Legacy Health System, Portland Oregon
Hospitals with Maternity Care 3,984 WB Protocols 1991 2 WB Protocols Sept 2004 280 Water Labor Only Sept 2004 460 Growth of Waterbirth in the US
Steps to Hospital Implementation of Waterbirth Program—our journey (Fortunately OHSU had implemented waterbirth in their midwife training program 9 years ago)
Parties needing to buy-in Health System and Hospital Administrators Risk Management Staff Liability Insurance Carrier Medical and Nursing Staff
Presentation—given to each group Literature review: American—largely critical but based on no actual experience, written by physicians who received neonates transferred from other sites
Presentation—given to each group European—largely supportive and based on large experience. Typically observational reviews of large series (2000-5000) comparing to “land births”
Key Point Unable to fine a single credible case of significant maternal or fetal injury directly attributable to waterbirth.
ACOG position Insufficient Data Need to meet OSHA standards for infection control
Benefit to Community Allows hospital to more fully address its mission
When all were convinced: American Academy of Pediatrics issued its statement—that this practice may be dangerous and should not be done in hospitals except in an IRB-approved RCT setting
Proposal developed for IRB They agreed RCT not feasible Ultimately, they agreed more research not necessary
IRB Response Create Registry, monitor by hospital quality department.
Hospital Quality Department Response No need for Registry—just keep track of data to assure safety.
Implementation Database Developed Facilities confirmed safety of load Medical Staff Credentialing Criteria Developed Practice Approved
LSCH CREDENTIALING FOR Water Births PRIVILEGE CRITERIA • EDUCATION: CNM TRAINING RELATED PRIVILEGES: CNM privileges CERTIFICATE REQUIRED: Documentation of water birth training including proof of proctoring. EXPERIENCE: Documentation of five (5) cases PROCTORING: None • 2. QUALITY MONITORING (for information only – not required monitoring) INDICATIONS FOR USE OF PROCEDURE. To manage safety and pain control of labors managed with water immersion. • 3. REAPPOINTMENT CRITERIA ONGOING MINIMUM PERFORMANCE REQUIREMENTS REQUIRED TO REAPPOINT: None Reviewed and revised with info from IRB: 2/14/06 – IRB Cmte reviewed request for water births to be a research study. Reviewers felt that this is not a research study, that activity should be monitored by Quality and that individuals should be credentialed to perform water birthing. LPH, MH & MP reviewed: N/A - Only available at LSCH Credentials approved: 4/17/06 MEC approved: 4/18/06 Board approved: 4/20/06
Total patients 138 Total SVD 117 In Water 81 “On Land” 36 Forceps/Vacuum 0 Total C/S 19 5 minute Apgar scores 7-10 Neonatal admissions 1 Outcomes
Outcomes Pitocin augmentation 42 Percent 30% C-section percent 14% Percent success in tub 59% Epidurals 38 No analgesia 90
Reasons for abandoning waterbirth plans • Progress too rapid • Progress too slow • PET/PIH • < 37 weeks gestation • Prolonged 2nd stage • Desired an epidural • Patient choice • Malpresentation
Low Apgar babies (2) • 1 unexplained slow transition, went to NICU for 5 days. Birthed in bed, not in water. Cord arterial pH 7.2 • 1 with Apgars 2, 4, and 8. Cord separation, responded well to resuscitation.
Miscellaneous Statistics • Average birth weight 8# • 10 women had IV pain Rx • Primips 73; Multips 65 • All said they would ONLY do a waterbirth the next time!
Future Add program to additional Legacy Hospitals Consider WBAC Change “thin meconium” practice Change “induced labor” contra-indication after pitocin stopped Use as basis for low-risk patient management