Cesarean deliveries for fetal distress at referral hospitals
We reviewed all cases of cesarean deliveries for fetal distress (n = 10) at referral institutions to determine whether outcomes for any of the patients could potentially have been improved by having their cesarean deliveries earlier if operative facilities had been available at Zuni-Ramah Hospital or by being transferred earlier (Table W1). Seven of the 10 patients were transferred for preeclampsia, NRFHTs, or failure to progress. All had their cesareans for fetal distress many hours after arrival at the referral institution.
Two cases of cesarean delivery for fetal distress after transfer because of abruption were previously described. A patient presented in early labor with repetitive late decelerations and was urgently transferred to GIMC, where she underwent an immediate cesarean delivery. Her infant had Apgar scores of 1 and 7, an unremarkable neonatal course, and a normal 15-month developmental screen.
Our outcomes demonstrate that with the use of appropriate screening criteria, childbirth can safely occur in institutions that lack surgical suites. The population-based perinatal mortality rate was similar to the nationwide rate. A review of obstetric emergencies and low Apgar scores among the 839 women laboring at Zuni-Ramah Hospital failed to identify adverse outcomes that might have been prevented if the hospital had had operative facilities. Cesarean rates were approximately one third the nationwide rate even though Zuni-Ramah patients had a higher prevalence of such risk factors as diabetes and preeclampsia.
Although they represented a high-risk obstetric population, 65% of women were able to give birth at Zuni-Ramah Hospital through use of the perinatal screening criteria. The 35% rate of transfer was caused largely by the need for oxytocin augmentation or induction. Only 21.6% of the women who were transferred for dysfunctional labor or premature rupture of membranes ultimately had a cesarean delivery. Oxytocin has not been permitted at Zuni-Ramah Hospital because of the ACOG guideline permitting oxytocin use only if “a physician capable of performing a cesarean delivery is readily available.”19 There are no studies addressing the safety of labor induction or augmentation without on-site cesarean capability.
Canadian guidelines for rural maternity care do not prohibit the use of prostaglandins or oxytocin at hospitals without operative facilities. A Consensus Conference on Obstetric Services in Rural or Remote Communities addressed the issue of labor induction or augmentation in hospitals without cesarean capability by stating, “If caring for a woman in labour is appropriate in the community, then caring for her during an augmented/induced labour is equally appropriate when there is support by trained local staff and resources.”20 We concur that use of oxytocin in rural hospital units without operative facilities should be considered under well-defined clinical guidelines or research protocols.
Our study’s limitations include lack of long-term neonatal outcomes, small size of the Zuni-Ramah population, an almost exclusively Native American population, and lack of examiner blinding during record review. Transfer rates may be increased in populations with higher rates of cesarean delivery or epidural anesthesia use. Alternatively, the high incidence of preeclampsia, chronic hypertension, and diabetes in these communities may have resulted in a higher proportion of induction. Umbilical cord pro-lapse and significant placental abruption are routinely treated by urgent cesarean delivery; therefore, obstetric literature on outcomes without immediate operative intervention is limited.21,22 A larger study would be required to determine the potential increased neonatal morbidity or mortality resulting from delayed intervention.
The ACOG/AAP guideline requiring on-site surgical facilities and the ability to initiate a cesarean in 30 minutes is not based on evidence. Four small retrospective studies of emergency cesarean deliveries delayed for more than 30 minutes did not demonstrate adverse neonatal outcomes.23-26 In our study population, no adverse outcomes (none in 839 births) were determined to have been caused by a lack of surgical facilities. Despite these excellent outcomes, the possibility always exists for outcomes that can be prevented by doing a rapid emergent cesarean delivery. Women deciding to give birth in facilities without operative capabilities should receive information regarding the risks and benefits of delivering there and should have access to other facilities. Provider discretion and patient choice must be respected to ensure community support of these birthing units. Practitioners at the rural units must have assurance that any patients who require an urgent transfer will be readily accepted.
Rural communities, medical providers, and health care facilities need to consider the overall effect of maintaining local maternity care units, as the loss of rural maternity care can increase the risk of adverse perinatal outcomes.1-3 We concur with the Canadian panel that although maintenance of rural surgical and anesthesia capabilities is desirable, “good outcomes can be sustained within an integrated risk management system without local access to operative delivery.”8 Guidelines should be developed to permit rural hospitals without cesarean capability to provide maternity care as part of integrated perinatal systems with well-developed transport protocols and supportive referral institutions. Women living in rural areas should have the option to give birth near their homes in such units if they so desire.