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A Death, And A ‘Changed Life’: Traumatic Births Take Toll On Health Workers Too

Sarah Jagger and midwife Stephanie Avila were together when Jagger's son suffered a brain injury during labor that led to his death. Here, about a year later, in 2013, Jagger and Avila share a moment of gratitude after the safe arrival of a healthy baby girl. (Courtesy of Orchard Cove Photography)

Sarah Jagger and midwife Stephanie Avila were together when Jagger’s son suffered a brain injury during labor that led to his death. Here, about a year later, in 2013, Jagger and Avila share a moment of gratitude after the safe arrival of a healthy baby girl. (Courtesy of Orchard Cove Photography)

Everything seemed fine until the little boy was born.

He wasn’t breathing, but his heart was strong, recalled Stephanie Avila, the midwife attending the baby’s birth at a Rhode Island hospital back in 2012. But it soon became clear that the boy had suffered a brain injury during labor.

Eleven days later, after an MRI confirmed the severity of the injury and the family withdrew life-support, the child died. His official diagnosis: hypoxic ischemic encephalopathy, a brain injury caused by oxygen deprivation.

“I was prepared to stand by the family through this trauma,” Avila said in an interview. “But I fully expected I’d get sued — and it was going to get ugly, or uglier.”

Of course, the little boy’s family was devastated. “I just went into my own world,” said his mother, Sarah Jagger, speaking about the loss of her son.

But Avila suffered too. “I was a wreck,” she said.

Immediately after the birth, Avila said, she remained on call overnight at the hospital, Women & Infants, in Providence. “I retreated to the call room and curled up in the fetal position and prayed that no other people in labor would show up. I cried, had the worst headache I’ve ever had in my life, and felt like I’d vomit. For days I felt emotionally and physically terrible. I’d be walking down the street and suddenly could no longer move.”

At the time, Avila had two small children of her own. “And whenever my 2-year-old would do this cute thing, I’d think, their baby will never walk around in his mother’s high-heeled shoes. I’d get these terrible thoughts and I’d never know when it would strike.”

The Psychological Toll

After a traumatic birth — or any traumatic medical event — attention, rightly, turns to the grieving family. But research has been mounting in recent years that health care providers, sometimes called “the second victims,” also sustain long-lasting emotional damage following such a trauma.

A new study published by Danish researchers underscores the phenomena: Midwives and obstetricians who experienced a traumatic birth — one involving severe injuries or death — report that the psychological toll of such an event is deep and long-lasting.

More than one third of those surveyed said that they always would feel some sort of guilt when reflecting on the event, researchers report. Nearly 50 percent agreed that the traumatic birth had made them think more about the meaning of life. “This tells us that health care professionals are affected, not only professionally, but also at a personal and even existential level,” said Katja Schrøder, the study’s first author and a Ph.D. fellow at the University of Southern Denmark.

‘Changed My Life Forever’

This was indeed the case for Avila. “I feel as though that day — even to this day — changed my life forever in many ways,” she said. And while the “acute” nature of the trauma has passed, she said, the enormity of it continued to grip her, sometimes unexpectedly and at random times.

In the Danish study, published in Acta Obstetricia et Gynecologica Scandinavica, a journal of the Nordic Federation of Societies of Obstetrics and Gynecology, more than 1,200 Danish obstetricians and midwives responded to a survey on the aftermath of a traumatic birth. Of those respondents, 14 were selected for a followup interview.

Many of the providers spoke of not being able to shake the trauma, whether they were blamed for the bad outcome or not. “Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant,” researchers report.

From the paper:

One mid-wife explained that even now, 12 years after the event, she would still think about that particular mother and child when passing through their town…

Most participants described having spent many hours agonizing and wondering whether they could have prevented the adverse outcome. One midwife said that her sense of guilt would never disappear because she knew that the parents would have to live with the consequences of her handling of the delivery.

Still, the researchers found that for many providers, “the traumatic childbirth had given rise to personal development opportunities of an emotional and/or spiritual character …for instance by achieving a more humble and profound understanding of both professional roles and of life as a whole.”

A Meaningful Meal

About a month after her infant son’s death, Jagger did something unusual: She asked Avila to meet for lunch. Up until then, the two women had been in touch — Avila had called to check in often, offering to help out and attend followup medical appointments with Jagger.

But the lunch date marked a turning point, the women agreed. First, it became clear that Jagger didn’t blame Avila for the boy’s death, and did not want to focus on the tragedy going forward.

“We had this little boy who had a such a short life,” Jagger said. “I didn’t want his life to be clouded in anger. I wanted his life to be about love…and not focus on the horrible part.”

But the meeting also underscored the growing bond between the women. When it was over, they walked outside and Jagger posed a question: “I said to her, ‘If I have another baby, would you deliver it?’ And I think she was horrified. But I think because I trusted her so completely, through the birth, and his death, and her calls and the followup, I felt like she was there with me, like this was our loss, it wasn’t just my loss.”

The Danish research paper quotes Donald Berwick, a pediatrician who served in the Obama administration and is also a patient safety guru of sorts. In a 2009 interview published in the Journal of Patient Safety, Berwick speaks about those “second victims”:

Health care workers’ egos can be big. But believe me, their superegos are a lot bigger. You carry into work — as a nurse, or doctor, or a technician or pharmacist– the intent to do well. And when something goes wrong, almost always you feel guilty, terribly guilty. The very thing you didn’t want to happen is exactly what happened. And if you don’t understand how things work, you feel like you caused it. That creates a victim. My heart goes out to the injured patient and family, of course. That’s the first and most important victim. But health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re really healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue.

In the past decade or so, various institutions and nonprofits have emerged with tools and systems to better support medical professionals who have endured a traumatic event.

One of those groups, MITSS, or Medically Induced Trauma Support Services, based in Massachusetts, provides trauma tool kits used around the country.

Linda Kenney, the founder of MITSS, was herself the victim of an anesthesia error that nearly killed her. She said that for her, connecting with the anesthesiologist who caused her injury (he called her afterwards to express his regrets) and creating the nonprofit to help others, helped her heal.

But for health care providers, sometimes talking to peers at a hospital, or others in the institution, isn’t enough and can actually feel isolating, Avila, the Rhode Island midwife, said. Because of the omnipresent fear of lawsuits, and also due to patient privacy laws, she said, “there are very few environments where we can freely discuss what happened.”

A Second Chance

In 2013, a few days shy of what would have been her son’s first birthday, Jagger went into labor with her second child, and she called on Avila to attend the birth. By that time, Avila was no longer working for the same midwifery group, but the practice arranged for her to have insurance during the birth, and Avila left a family gathering on Block Island to get to Providence on time.

Jagger’s little girl is now a healthy 2-and-a-half-year-old who considers Avlia her “auntie.”

“It was this amazingly cathartic experience for all of us,” Jagger said.

Avila is now a family nurse practitioner and attends births less frequently as part of her work. These days, she and Jagger are extremely close: They’ve vacationed together, bake each other birthday cakes and talk almost daily.

“I never would have expected our relationship to evolve to this point,” Avila said. “But despite how close we are now, I would sacrifice it in a moment if I could change the outcome of that first birth.”

Related:

Opinion: Let's Talk About Residents' Hours – And Their 'Scut' Work Too

By Sefira Bell-Masterson, Dr. Lakshman Swamy and Dr. Christopher Worsham

A few things in medical education have changed in the past 100 years.

A century ago, for instance, resident physicians-in-training literally lived on hospital premises.

They received room and board but no other compensation. They routinely performed any task related to patient care, ranging from transporting patients to the operating room to performing their surgeries.

Clearly, things have changed. But what hasn’t changed is how medical residents are used for any task that needs to be done during a patient’s hospital stay.

Today, residents are expected to learn medicine, care for patients, and improve our health care system — often in addition to teaching and research. All this needs to be done within a limited number of nationally regulated duty hours, now the subject of an ongoing and increasingly controversial conversation in the medical community since restrictions were put in place in 2003 and 2011.

Over the past decade, there has been much debate about the benefits and drawbacks of duty hour restrictions, yet prior research into this topic has shown mixed results. Earlier this month, however, researchers published results of a first-of-its-kind randomized trial (the FIRST Trial) of 117 surgical residency programs across the country. The study’s authors concluded that there was no difference for patients or their doctors’ satisfaction whether residents worked under current duty hour restrictions or under more flexible rules. Results of a similar trial performed on medical residents (the iCOMPARETrial) are expected later this year.

Adil Yunis, a resident in internal medicine at Boston Medical Center, is working with hospital executives to improve the health care system for his patients and his fellow residents.

Adil Yunis, a resident in internal medicine at Boston Medical Center, is working with hospital executives to improve the health care system for his patients and his fellow residents. (Courtesy)

As residents ourselves, we believe the duty hours conversation has missed a major point: Though our hours are being limited, what we actually do during these hours is not.

There has been a great focus on the number of hours worked, but silence about the actual work done.

Erica, a resident in obstetrics and gynecology in Delaware, routinely runs her own lab tests in the office. Karl, a pediatrics resident in New York, often spends valuable time in the room with a child and her parents laboriously copying information from her medical record to fill out school forms.

Adil Yunis, an internal medicine resident in Boston, will spend 30 minutes on the phone trying to get a cardiology appointment for his patient who just had a heart attack.

These tasks (all real, but with two last names withheld ) are examples of what many residents call “scut.” Continue reading

App-Assisted Labor: Smartphones During Childbirth Are All The Rage, But Do They Help?

When Juli Simon Thomas gave birth to her son last year, she wanted a generally low-tech environment: a midwife instead of an ob-gyn, a quiet room and no drugs. “I was bound and determined to avoid an epidural,” she said, even despite 25 hours of labor.

But Thomas had one important, technical requirement: an app on her smartphone that allowed her to precisely track her contractions.

“I use my phone for everything, and this was really helpful,” said Thomas, 35, a post-doctorate fellow in population research. “The process of labor is so variable, and what you end up hearing is how you have to ‘go with the flow,’ ‘see how it turns out,’ ‘just relax and wait’ — I can’t do that. This gave me something more concrete to focus on … Just standing around in various levels of pain while breathing wasn’t a good choice for me.”

We already date, order takeout and document supremely intimate moments on our phones. So it’s no surprise that smartphones have also permeated the realm of childbirth.

contraction timerPeople in the birthing world say labor apps have become ubiquitous — part of the landscape and akin to written birth plans, which were all the rage a decade or more ago.

Rise Of The Labor App

According to the iPhone App Store, there are at least 80 “labor apps” alone that help women time their contractions to assess how close they are to giving birth. Some are free, some aren’t. Some have advertisements for infant formula, some don’t.

Moms who’ve used them say they all operate in similar ways, usually with start-and-stop icons you press at the beginning and end of each contraction in order to record duration and frequency until you get to the magic number 5-1-1. (That means contractions are 5 minutes apart, lasting 1 minute each, for 1 hour.)

At that point, doctors and midwives pretty universally want you to call to determine if it’s time to get to the hospital, or for a home birth, get a practitioner to you.

Of course, there are also apps for pretty much every aspect of pregnancy, birth and postpartum as well: from tracking the baby’s kicks and mom’s breast milk production to documenting hours of sleep (or lack thereof) and diaper use. In 2013, ABC News reported that nearly 50 percent of total mobile subscribers using one or more health apps are using a pregnancy-related app.

Elizabeth Henry, 36, of Cambridge, Massachusetts, stood by as her husband worked out her contractions on a Microsoft Excel spread sheet when she gave birth four years ago. When she gave birth in July, she used the Full Term contraction app on her own while her husband watched their toddler. “I’m a data person, and this app kept me honest. I was trying to do last-minute things in the house and stay home as long as possible, and I didn’t think the contractions were coming so fast. But then when I looked at the screen, I saw it really was time to go to the hospital.”

Not Everyone So App-Happy

Labor doesn’t always unfold in a predictable pattern. Continue reading

Related:

Laughing Gas For Labor Pain May Be Regaining Popularity In U.S.

ABC News reports a resurgence in the use of laughing gas for labor pain. (Not to toot our own horn, but we reported this back in 2010 here at CommonHealth and did a podcast on it in 2013.)

ABC suggests the practice may be gaining popularity since 2011, when “the U.S. Food and Drug Administration approved new nitrous oxide equipment for delivery room use.”

Quoting Dr. William Camann, director of obstetric anesthetics at Brigham and Women’s Hospital in Boston, the ABC piece continues:

labor pain

“Maybe 10 years ago, less than five or 10 hospitals used it [for women in labor],” Camann…told ABC News. “Now, probably several hundred. It’s really exploded. Many more hospitals are expressing interest.”

He added the gas popular in dentists’ offices has an “extraordinary safety record” in delivery rooms outside the U.S. But more studies are needed to confirm its safety, other doctors say. Continue reading

Culture Clash: U.K. Embraces Homebirth As Best For Some Women

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

By Jessica Alpert

Sarah Parente, an Austin, Texas-based doula and mother of four, gave birth to her first child in the hospital with no complications. But then she decided to make a shift: Parente delivered her next three babies at home. “For women with low-risk pregnancies, home birth can be a great choice,” she says. “You have less stress because you are in your own home surrounded by a birth team of your choosing.”

Though home birth has recently gained cache in the U.S. — with some celebrities trumpeting the benefits of having their babies at home  — the practice remains uncommon and the majority of pregnant women give birth in a hospital setting. Still, Parente may be getting a little more company, albeit slowly. Data released by the Centers for Disease Control (CDC) earlier this year shows the rate of homebirths in the U.S. has increased to 0.92 percent in 2013 and the rate of out-of-hospital births (including home) has increased 55 percent since 2004.

Experts in the United Kingdom are saying that’s a good thing.

The London-based National Institute for Health and Care Excellence (Nice) recently released recommendations that homebirths and midwife-led centers are better for mothers and often just as safe for babies as hospital settings, the BBC reports. Of the 700,000 babies born in England and Wales each year, nine out of 10 are born in obstetric-led units in hospitals. Continue reading

Study Of 80,000 Birthing Moms Suggests Epidurals Safer Than Thought

(archibald jude via Compfight)

(archibald jude via Compfight)

I subscribe to the dentistry school of birthing babies. That is, I wouldn’t want to get a tooth filled without Novocaine, and I wouldn’t want to have a baby without an epidural.

I know that opinions — strong ones — vary on this, but for those of my ilk who’d like yet another data point to support the pain-relief side, here it is: A national study, one of the biggest yet, of complications from epidurals has just been presented at the annual conference of the American Society of Anesthesiologists now under way in New Orleans. And it suggests that epidurals are even safer than previously thought, with rates of the most-feared complications well under 1 percent.

Dr. Samir Jani, a senior resident in anesthesiology at Beth Israel Deaconess Medical Center, presented the findings, gleaned from a giant national database of anesthesiology cases, the National Anesthesia Clinical Outcomes Registry.

He found that among more than 80,000 cases of anesthesia during labor and delivery, 2,223 involved complications, for an overall rate of 2.78 percent. But most of those concerned medication errors — over-dosing, under-dosing, or use of expired drugs.

The rate of the complications that many women fear most — nerve damage or an excruciating “spinal headache” — were even lower than previously estimated, Dr. Jani said: .2 percent — that’s 2/10 of one percent — for the headache; .002 percent for spinal nerve damage and .14 percent for damage to other nerves.

“So it’s well under 1 percent for the kinds of complications that I think a lot of women worry about,” he said, not the 1-2 percent that he’s been quoting his patients based on textbook teachings.

An awkward question: But don’t anesthesiologists tend to be pretty pro-anesthesia? Mightn’t that bias the results?

“Actually,” Dr. Jani said, “Whenever I talk to all my patients, I tell them, ‘I’m not here to sell you an epidural. it’s your ultimate decision.’ And I think that that’s the mentality that almost all of us have. We aren’t ever going to force on a patient what they don’t want. But in that informed consent process, it’s important we quote not only possible complications but the rates to the best of our knowledge. At the end of the day, it’s good to be able to tell your patient that this is a safe and efficient method to be able to control labor pain.”

And what about the common belief that getting an epidural can hinder the pushing process in labor? Continue reading

Anti-Shackling Bill, With More Medical Care For Pregnant Inmates, Poised To Become Law

A bill that would ban the use of restraints on pregnant inmates in labor (except in “extraordinary circumstances”) and also require more pre- and post-natal medical care for incarcerated women is about to become law in Massachusetts.

Here’s the specific language from the bill:

An inmate who is in labor, as determined by a licensed health care professional, delivering her baby or who is being transported or housed in an outside medical facility for the purpose of treating labor symptoms, shall not be placed in restraints.

An inmate in post-delivery recuperation, as determined by the attending physician, shall not be placed in restraints, except under extraordinary circumstances.

For the purposes of this section, “extraordinary circumstances” shall mean a situation in which a correction officer makes an individualized determination, approved by a superintendent, that the inmate presents an immediate, serious threat of hurting herself or others or in which the inmate presents an immediate and credible risk of escape that cannot be reasonably contained through other methods. In the event the correction officer determines that extraordinary circumstances exist, the officer shall document, in writing, the reasons for the determination and the specific type of restraints used.

Here’s more on the anti-shackling legislation from the NARAL Pro-Choice Massachusetts news release:

After over a decade of advocacy, members of the Massachusetts Anti-Shackling Coalition are celebrating unanimous votes in both the Massachusetts House of Representatives and State Senate that will send the Anti-Shackling Bill to the Governor’s desk for his signature.

“I was handcuffed by both my wrist and my ankle to the hospital stretcher for over eighteen hours while I was in labor,” said Michelle Collette, who was incarcerated at MCI-Framingham. “Today, the legislature moved us one step closer to making sure that no woman in Massachusetts will ever again experience what I went through when giving birth to my son.”

The.Comedian/flickr

The.Comedian/flickr

Representative Kay Khan (D-Newton) has filed some version of the Anti-Shackling Bill since 2001. In 2013, Senator Karen Spilka (D-Framingham) filed a companion bill in the Senate. Earlier this year, Governor Deval Patrick filed 90-day emergency regulations to immediately prohibit the practice of shackling pregnant women as a stopgap measure until the legislature passed the Anti-Shackling Bill. Last month, both the State Senate and State House unanimously passed versions of the bill. Differences between the two versions have now been reconciled and the final language has been enacted in both chambers….Since the emergency regulations were filed in February, advocates have heard reports of two incarcerated women who have gone into labor. Both were shackled during transport, and one was not unshackled when requested by medical personnel. Further, one was shackled in the hospital during labor and during postpartum recuperation without an individualized determination that “extraordinary circumstances” justified it. Continue reading

OBs: No Link Between Labor Induction And Autism

The nation’s most influential group of obstetrician-gynecologists concludes that there’s no connection between labor induction and autism. Earlier reports suggested that there’s was a possible link, but even that research, published in JAMA Pediatrics, was complicated and somewhat murky.

(popularpatty/flickr)

(popularpatty/flickr)

Here’s ACOG’s latest guidance on the matter, from the news release:

Current evidence does not support a conclusion that labor induction or augmentation causes autism spectrum disorder (ASD) in newborns, according to a new Committee Opinion released by the American College of Obstetricians and Gynecologists (the College).

While some studies have suggested an association between ASD and the use of oxytocin for labor induction or augmentation, available evidence is inconsistent and does not demonstrate causation, according to the opinion, which also found important limitations in study design and conflicting findings in existing research.

Given the potential consequences of limiting labor induction and augmentation, the College’s Committee on Obstetric Practice recommends against changes to existing guidance regarding counseling and indications for, and methods of, labor induction and augmentation.

“In obstetric practice, labor induction and augmentation play an essential role in protecting the health of some mothers and in promoting safe delivery of many babies,” said Jeffrey L. Ecker, MD. Dr. Ecker is chair of the Committee on Obstetric Practice, which developed the new Committee Opinion. “When compared with these benefits, the research we reviewed in assembling this Committee Opinion, relative to the utilization of oxytocin, had clear limitations. Because of this, these studies should not impact how obstetricians already safely and effectively use labor induction and augmentation when caring for their patients.” Continue reading

Gruber Responds To Economix Critique Of Health Reform

Massachusetts health reform in general and its advocates in particular were the target of a pretty harsh critique yesterday in The New York Times’ blog, Economix.

The post, by University of Chicago Economics Professor Casey Mulligan, argued, among other things, that the U.S labor market is “in for a shock” when health reform takes full effect despite how “smoothly” things may have appeared when Massachusetts carried out its own health reforms starting in 2006. Mulligan writes:

Beginning next year, millions of Americans will be eligible for generous subsidies in the form of cash assistance to pay for their health insurance premiums and out-of-pocket health expenses pursuant to the Affordable Care Act. The subsidies will sharply reduce the financial reward to working because they will be phased out with household income.

Jonathan Gruber of MIT

Jonathan Gruber of MIT

Mulligan then goes on to trash MIT economics professor Jon Gruber, a key adviser on both state and national health reform, for his defense of the Bay State’s reform efforts:

When it comes to quantifying the new federal law’s penalty on employment, Professor Gruber and Health and Human Services are incorrect to take comfort in the Massachusetts experience since 2006. As I explained last week, the federal law’s employer penalty is more than tenfold the Massachusetts penalty. In other words, if the Massachusetts penalties pushed down workers’ wages by 16 cents an hour, the federal penalties would push them down $1.67.

Professor Gruber is also incorrect that the federal law is introducing less generous subsidies than the Massachusetts law did. Federal subsidies will be available for people laid off from their jobs, but the new Commonwealth Care subsidies in Massachusetts are not, because Commonwealth Care excludes people eligible for the Medical Security Program (a longstanding program providing health benefits to Massachusetts people receiving cash unemployment benefits).

I asked Gruber to respond to Mulligan’s critique. Here, unedited, is what he sent over via email:

Problems with Mulligan argument:

1) He cites as supporting evidence a 1994 article that referred to a completely different policy

2) He ignores the fact that the disincentives to income increase in MA are massively larger than in the federal program. Continue reading

Report: Health Care Job Cuts Loom If Federal Budget Cuts Take Hold

(Images_of_Money/flickr)

WBUR’s Martha Bebinger reports that Massachusetts would lose roughly 17,400 health care and related jobs if scheduled federal budget cuts take effect, according to a health care industry report out Wednesday.

A federal budget deal scheduled to take effect January 1 would cut Medicare spending 2% and trigger the estimated layoffs. The deal aims to shrink the national debt but Lynn Nicholas with the Massachusetts Hospital Association says targeting health care and the defense industry, as this deal does, is unfair.

“Quite frankly you have to look at the revenue side too,” Nicholas said. “We need to get our nation’s finances in order, but it needs a more balanced approach to do that and this is a very one-sided approach.”

The report says most of the job cuts would occur in hospitals and nursing homes but that real estate firms restaurants and other related sectors would also be affected.

Continue reading