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Giving birth has gotten riskier.

Giving birth has gotten riskier. Giving Birth by Cesarean Section

Hospitals and public health officials are working to improve safety for mothers in the delivery room following sharp increases in the rate of severe complications from childbirth. Emergencies during delivery, such as cardiac arrest, respiratory distress and kidney failure, increased by 75% in the decade ended 2009, according to a new study by the federal Centers for Disease Control and Prevention. In the days immediately following delivery, severe complications for women more than doubled over the same time period.

A national safety program is helping hospitals stem the rise in complications from childbirth, which, a new study found, have nearly doubled in the past decade. More mothers-to-be are older or obese. But complication also hit healthy mothers, and newborns. WSJ's Laura Landro and Premier President Susan DeVore discuss on Lunch Break. Photo: AP.
Some type of pregnancy or delivery complication occurs during many of the more than four million births annually in the U.S., but most aren't life-threatening. Severe complications affect a total of about 52,000 women a year.

A big reason for the increase is the number of pregnant women who are older, obese, or have chronic conditions such as diabetes and kidney disease that put them at higher risk. But healthy women, too, can experience major complications such as severe bleeding, or hemorrhage, which is the most common cause of death after childbirth. A nearly 60% increase in the rate of Caesarean-section delivery since 1996 is associated with a sharp increase in a condition known as placenta accreta, in which the placenta grows into the uterine wall through a surgical scar, and can cause severe hemorrhage after delivery.

Enlarge ImageGiving birth has gotten riskier.
Mark Hirsch for The Wall Street Journal
When Danielle Dargatz of Milwaukee had her fourth child, Zaileigh, an emergency hysterectomy was needed to stop hemorrhaging.
"There is a clarion call now to address the problem of maternal complications," says William Callaghan, chief of the CDC's maternal and child health bureau and lead author of the recent study. "Regardless of age or health, when things go wrong they can go south very fast, and you need a well-oiled team trained to respond in times of crisis."

Mark Hirsch for The Wall Street Journal
Danielle Dargatz sits on a couch with her children , Ediesco , 5,(left) Yanalise, 6, Zaileigh, 7 months, and Breena 2, at her home in Milwaukee, Wisconsin.
Many safety-improvement programs in the past have focused on preventing harm to infants. Now, experts are calling for an equal emphasis on the mother. The CDC is funding programs in a number of states to establish guidelines and protocols for improving safety and preventing injury. And obstetrics teams are holding drills to train doctors and nurses to rapidly respond to maternal complications. They are using simulated emergencies that include fake blood, robots that mimic physiologic states, and actresses standing in as patients.

Hospitals are borrowing strategies from the military to train staff in teamwork and care protocols that have been proven to reduce injuries, minimize trauma and avert deaths.

Danielle Dargatz wasn't considered high-risk while pregnant with her fourth child. But the 25-year-old began hemorrhaging in the delivery room after the child, a daughter, was born last April at Aurora West Allis Medical Center, near Milwaukee. After her obstetrician's efforts to stanch the bleeding with medication and other measures failed, hospital staff initiated a massive transfusion protocol, a standardized order to rapidly deliver blood, and called in a surgeon to perform an emergency hysterectomy.

Peter Johnson, the surgeon, says hospital staff participate twice a month in drills to prepare for such emergencies. In the past, the staff might have been running in different directions trying to get blood, find an anesthesiologist, and locate equipment, Dr. Johnson says. Instead, "There was a real sense of calm, rather than all this chaos," he says. "Having these protocols in place makes things function seamlessly, and that will save lives."

Ms. Dargatz says she recalls feeling terrible pain after her delivery. But the next thing she remembers is waking up "surrounded by 50 people" and having her doctor gently tell her about the hysterectomy. "It was not what I would have wanted, but I am grateful to be alive," she says.

Obstetrics-related complications account for $17.4 billion in annual U.S. hospital costs, according to the federal Agency for Healthcare Research and Quality. Complications have recently led to several malpractice payouts of more than $20 million each, and obstetrics can account for 25% or more of a hospital's total for all malpractice claims resolved by payment, according to Premier Inc., a hospital purchasing alliance that operates one of the largest simulation and training programs for obstetrics adverse events.

Premier's Perinatal Safety Initiative has been working with hospitals, including Aurora West, in 12 states since 2006, training medical teams to follow protocols to prevent harm to mother and infant and respond rapidly in a delivery emergency. The training includes a military communication strategy known as SBAR, for situation-background-assessment-recommendation—to quickly get everyone on the team the same information about a patient's condition and the planned response. Since the project's inception, the rate of liability claims filed at participating hospitals has dropped by 39%, says Susan DeVore, Premier's chief executive.

In the case of a hemorrhage, drills include a checklist of steps to prevent bleeding, special carts stocked with all the medication and equipment needed in one place, and sometimes fake blood spilled onto delivery tables to help staffers calculate the amount of loss. Between 2006 and 2010, participating hospitals reduced annual instances of post-delivery hemorrhage by 5.4%, to 28.4 per 1,000 births, Ms. DeVore says.

Texas Health Resources, which operates 25 hospitals, requires doctors at its Dallas facility to participate in simulation drills as a condition of getting credentialed to deliver babies in its delivery rooms. "Doctors understand this is all based on evidence and not someone at corporate telling them what to do," says Marcie Williams, vice president of safety and risk management.

Many of the most common causes of death such as hemorrhage and pulmonary embolism can also take place in the first few days after delivery to seemingly low-risk patients, so it is important that hospitals follow standardized prevention measures, says Mary D'Alton, head of obstetrics and gynecology at New York's Columbia University Medical Center. To prevent blood clots, for example, Columbia gives the blood thinner heparin to all patients after a Caesarean delivery and asks them to get up and walk after 12 hours.

Vivian von Gruenigen, system medical director for women's health services at Summa Health System in Akron, Ohio, advises that pregnant women discuss personal risks with their doctor and ask hospitals what kind of training delivery teams have to respond in an emergency. "People think pregnancy is benign in nature but that isn't always the case, and women need to be their own advocates," Dr. von Gruenigen says.
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