Hospitalists: An inspiration for obstetrics

Given the success of hospital medicine, the future seems bright for the laborist model.

The Miao women of China give birth silently and alone, I ponder as I look at the OB whiteboard. What a difference from what goes on here.

It is 3 a.m. at Rochester Methodist Hospital in Rochester, Minn., and there are six women in the birthing suites. One has been here since yesterday and is just now completely dilated to 10 centimeters. I am a third-year medical student and I want to deliver this baby. The adrenaline rush from the last delivery still lingers in my blood.

Labor Room 3 has the atmosphere of a spectator event. The pregnant patient is moaning in discomfort and her husband and sister are sitting bewildered in the corner of the room. The rapid rate on the fetal heart monitor is reassuring. Before the epidural was placed, the patient could feel every smooth muscle fiber of her uterus contracting in a rhythmic fashion, sweeping down from the breastbone to the pubic symphysis. The epidural has since relieved the pain, and she relies on the pressure monitor to tell her when she is having a contraction so she can push her sacrum into the bed and guide the baby down the birth canal.

The labor nurse has placed an intravenous line, and the patient has been catheterized twice to empty her bladder. The baby's head is finally visible. The resident and the attending obstetrician are in the room. One big push and the head emerges completely into my hands. I get ready to deliver the anterior shoulder when all of a sudden the baby's neck is sucked back into the birth canal. The attending physician yells, “Dystocia! We have a shoulder dystocia!” The baby is stuck inside her mother.

I am pushed out of the way. The patient's legs are pushed back against her shoulders to widen the pelvic outlet. The labor nurse has jumped onto the bed to apply suprapubic pressure in an attempt to deliver the anterior shoulder. The resident has cut an episiotomy to widen the vaginal canal and has reached his hand inside to rotate the baby. One minute later the baby is delivered. Blue. In shock. I am in shock, too. The pediatricians examine the baby and pronounce a one-minute Apgar score of 1. Five minutes later the baby has been revived and is crying.

The attending physician who performed this emergency delivery had been on duty for the past eight hours. She was able to react instantaneously to the dystocia and avert a potentially tragic situation. If this doctor had been sleep-deprived, if she had been awakened from sleep by her pager telling her she had to come into the hospital to deliver a baby, would she have reacted as quickly? Luckily, like hospitalist physicians who dedicate their practice to inpatients and are always in the hospital to quickly address emergency situations, obstetricians have a similar “laborist” system that allowed this doctor to be present and alert.

In his revolutionary 2003 article in the Journal of Obstetric Gynecology, Dr. Louis Weinstein from the Medical College of Ohio described a “laborist” as an obstetrician who dedicates her practice to providing prompt, constant and vigilant care to laboring women on the delivery floor. This physician also provides on-the-spot care to any woman with an obstetrical emergency.

The laborist's job is performed in shifts, with another physician assuming the role at the end of a certain number of hours, Dr. Weinstein wrote. Work hours are predictable and shorter. The hospital employs the physician and covers a substantial amount of malpractice insurance payments. All in all, the model should decrease burnout rates and patient errors and increase career satisfaction, according to Dr. Weinstein.

These goals are shared by the hospitalist model, and research suggests they have been met, at least in part. In a survey published in the April 2011 Archives of Internal Medicine, 75% of hospitalists reported job satisfaction. A May 2011 systematic review in BMC Medicine found that hospitalists reduce costs and length of stay without negatively impacting quality of care compared to non-hospitalist colleagues.

What about the laborist model? In terms of patient care outcomes, the research is limited. A 2008 article in the American Journal of Obstetric Gynecology said that the laborist model should decrease variability in how obstetrics is practiced—potentially positive since differences in practice and procedures have been associated with less-than-satisfactory outcomes. In a 2010 survey in the same journal, laborists used a scale of −5 to +5 (−5 being the least satisfied) to rate their job satisfaction. Seventy-six percent of laborists answered +3 and above.

Given the success of hospital medicine, the future seems bright for the laborist model. As the career of laborists evolves, an increasing number of similarities will likely be seen between the internal medicine hospitalist and the obstetrical hospitalist. Safety and quality outcomes for obstetrical patients will need to be explored, just as they have been in hospital medicine.