Is There Still a Place for Patient-Centered Care in OB/GYN?
It is completely acceptable for a woman to choose her management, even if the physician disagrees.
A recently published Committee Opinion from the American College of Obstetrics and Gynecology (ACOG), “Approaches to Limit Intervention During Labor and Birth,” addressed limiting interventions during normal labor and a “process of shared decision making."1
I believe that the statement is an important reminder to keep our focus on patient-centered care. It may be a response to pressures that OBs face from patients with birth plans and requests that are outside the residency-taught practice of obstetrics.
But it is also a rational review of the literature, showing that active labor may not begin until after 4-6 cm of dilation, and that we are over-medicalizing many normal labors. Finally, it is a reaffirmation of points made in another noteworthy joint statement on patient-centered OB care from 2011.
The 2011 joint statement, from the American Academy of Family Physicians, American Academy of Pediatrics, American College of Nurse Midwives, American College of Obstetricians and Gynecologists, Association of Women's Health, Obstetric and Neonatal Nurses, American College of Osteopathic Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine, clearly outlined support for patient-centered care. First and foremost, it was agreed in the statement that patient-centered care and safe care of the mother and child is the primary priority, and that it can be achieved “in an atmosphere of effective communication, shared decision-making and teamwork, and data-driven quality-improvement initiatives.”2
The recent Committee Opinion, based on a review of the available scientific literature, now reinforces the 2011 recommendations and conclusions.
For example, in women with spontaneous labor at term with a cephalic fetus, the opinion concludes that labor management may be individualized and can include intermittent fetal auscultation and non-pharmacologic methods of pain relief. The authors agreed that one-to-one emotional support and care is associated with improved outcomes. The authors also stated that routine amniotomy is not indicated for women who are progressing normally, unless it is required to facilitate fetal monitoring. And finally, in the absence of an indication for expeditious delivery, women may be offered a 1-2 hour period of rest before pushing in the second stage of labor.
Some of us have already been following these recommendations. Others, for various reasons, are resistant. But here's why the recent expert opinion piece matters:
Patient-centered care involves the input of the patient, and many patients seek to reduce medical interventions during labor and delivery. ACOG is supportive of this.
However, patient-centered care may still be a paradigm shift for some obstetric-care providers. Such care is not easily performed in the setting of labor and delivery units — due to workflows, time constraints, malpractice concerns and, most importantly, because the majority of the patients are not low-risk. With high rates of obesity and pressure to perform vaginal birth after cesarean (VBACs) and inductions, few of my patients can be classified as low-risk. Further, there are limited studies on many basic and common obstetrics practices. More research and review is very much needed.
The term “patient-centered care” gets thrown around as an antidote to some of the problems we face while providing clinical care. The concept was meant to address a stark reality — that we are spending less time with patients and more time with electronic medical records (EMRs), billing, paperwork and focused on avoiding malpractice litigation.
“With the passage of the Patient Protection and Affordable Care Act, patient-centered care became a central part of quality care. Most importantly, it not only paid lip service to patient-centered care, but also provided some bite by tying reimbursements for Medicare and Medicaid patients to patient-related outcomes. In particular, nearly one-third of payments for hospital services are tied to the patient experience, as measured on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. As a result, there is a significant amount of money on the table tied to patients' perceptions of their health care.”3