TC Regional Health Care leads way with healthy childbirth model

Representatives from the TCRHCC OB unit (from left): Dr. Amanda Leib, chief of OB-GYN; Barbara Orcutt, CNM, MSN, director of nurse midwives; Rachel Bonvillaine, RN; Shelly Inda, Obstetrical Unit lead clinical nurse; Patricia Hines, CNM; Alberta Nez, RN; and Lisa Hooper, RN (Photo courtesy of TCRHCC).

Representatives from the TCRHCC OB unit (from left): Dr. Amanda Leib, chief of OB-GYN; Barbara Orcutt, CNM, MSN, director of nurse midwives; Rachel Bonvillaine, RN; Shelly Inda, Obstetrical Unit lead clinical nurse; Patricia Hines, CNM; Alberta Nez, RN; and Lisa Hooper, RN (Photo courtesy of TCRHCC).

TUBA CITY-Citing its collaborative certified nurse mid-wife/obstetrician model for childbirth, Tuba City Regional Health Care Corporation (TCRHCC) reported the lowest birth by Cesarean section rate in Arizona among Arizona Perinatal Trust Level II Nurseries for the year 2005 - just 13.9 percent. The national average is approximately 33 percent.

Nurse-midwives care for patients in the OCU 24 hours a day. Obstetricians are always available for high-risk pregnancies or when anything abnormal begins to occur during labor. The World Health Organization (WHO) recommends the certified nurse mid-wife/obstetrician model utilized at Tuba City hospital.

A Cesarean section is the birth of a baby by surgery. The doctor makes an incision in the belly and uterus and then removes the baby. A Cesarean section is usually performed when a vaginal delivery would lead to adverse medical complications. Nationwide, however, it is becoming more common to have an elective Cesarean section, even when there is no medical reason not to have a vaginal birth.

While sometimes necessary, a Cesarean section is major abdominal surgery, carrying with it a considerable list of risks, such as bleeding, infection, damage to nearby organs such as the bowel or the bladder, scar tissue formation, and a higher risk in future pregnancies. When a Cesarean section is necessary, it can be a life-saving procedure for both mother and infant.

Another factor increasing the rates of Cesarean section births is the long-held belief that once you've had a Cesarean section, then subsequent births must always be by Cesarean section.

Often, women who have had a previous Cesarean section aren't necessarily aware that in some facilities, they can still opt for a natural vaginal birth. The risks from Vaginal Birth After Cesarean section (VBAC) delivery are low, but are slightly higher than for a repeat Cesarean section - this finding is from a study by the National Institute of Child Health and Human Development of the National Institutes of Health.

"We are strong advocates for VBAC at this facility for appropriate candidates, and we have an excellent success rate with no known uterine ruptures over the last 10 years," said Dr. Amanda Leib, TCRHCC OB/GYN chief.

In 2006, among 28 mothers who chose to have a VBAC at Tuba City hospital, there was an 82 percent success rate. Twenty-four women had successful vaginal births, and four underwent Cesarean sections.

"The decision for Cesarean section is usually made between the doctor, certified nurse mid-wife and patient. There are many reasons why women have Cesarean sections, and the events leading to such a decision vary depending on the situation," said Dr. Leib.

"Some reasons the Cesarean section rate is low at Tuba City hospital are that we offer VBACs, we have a certified nurse mid-wife/obstetrician model which allows more one-on-one attention during labor and delivery than at other facilities, and that we are very involved with our high risk patients. We believe in active management before fetal problems occur."

Barbara Orcutt, director of nurse midwives at Tuba City Hospital has been a certified nurse mid-wife for 29 years. She remarked, "I've been associated with numerous practices and hospitals in various parts of the country, and the acceptance of certified nurse mid-wifery here is wonderful. We have a close working relationship with our obstetricians and we are valued."

Certified nurse midwives deliver all of the vaginally born babies at Tuba City Hospital, and are involved in the labor of women who eventually do have Cesarean sections. There are five certified nurse midwives currently practicing at Tuba City hospital.

In addition to following traditional ways, the OB/GYN Department is scheduled and run in such a manner that both patient and provider will very often see a familiar face when a woman is in labor. Certified nurse midwives staff the OCU 24 hours a day, and they work 12-hour shifts so there is continuity with any one patient with a large block of time.

"Our schedules are structured as such that we don't think in terms of 'It's Friday afternoon and I'd better get her delivered before the weekend,'" said Orcutt.

Dr. Leib continued, "We regularly review our Cesarean section rate and individual Cesarean sections as a department, looking for ways we can improve and offer even better patient care."

Pregnant women considering a Cesarean section with no clear medical reason for it should know that the procedure is not without risk, Canadian doctors caution in a report in February 2007. Dr. Shiliang Liu with the Public Health Agency in Ottawa, Canada, and colleagues, report that the rate of severe complications, such as major bleeding, infection and blood clots, is three times higher overall in women having a planned Cesarean section compared with women who have a natural birth.

The researchers used a Canadian database to look at the outcomes of 46,766 women who underwent what doctors deemed to be a low-risk, Cesarean section delivery and nearly 2.3 million women who underwent planned vaginal delivery between April 1991 and March 2005.

Liu's team found that the rate of severe complications in the planned cesarean group was 27.3 cases per 1,000 deliveries, compared with 9.0 per 1,000 deliveries in the planned vaginal delivery group.

This data adds to a growing body of evidence suggesting that primary elective Cesarean section birth may place both the mother and newborn at greater risk for complications.

In 2005 there were 546 live births at Tuba City hospital, of which 471 were vaginal deliveries and 75 were Cesarean section deliveries - 40 of these were primary (first time) Cesarean sections and 35 had previously delivered via Cesarean section.

"We have some really fine doctors and providers at Tuba City hospital and in the Indian Health Service," remarked Orcutt. "We provide excellent maternity care that is based on sound medical evidence and do not engage in the legal protective thinking that pervades obstetrics elsewhere."

"It's a wonderful way to practice," Orcutt continued, "just doing the natural thing, the right thing."

"Here on the Navajo Reservation, there is still a cultural acceptance of labor and birth as a natural function of the body, and great stoicism in labor. All of this decreases interventions. All of these things factor into our low Cesarean section rate at TCRHCC."

TCRHCC Mission

Tuba City Regional Health Care Corporation is a community focused non-profit, health care organization offering a 73-bed acute care referral hospital and a broad range of outpatient care services. It serves a patient population of approximately 75,000 Navajo, Hopi and San Juan Piute, in a 4,400 square mile area. Its mission is to provide accessible, quality, culturally sensitive health care.

Arizona Perinatal Trust Mission

The Arizona Perinatal Trust is created to be an independent source of energy and resources to focus efforts on the continuing improvement of the health of Arizona's mothers and babies.

Arizona Perinatal Trust Purpose

Based in Casa Grande, the Arizona Perinatal Trust (Trust) is a non-profit organization, working to continually improve the quality of care for Arizona's mothers and babies.

- Promote, develop and coordinate Arizona's regional perinatal system

- Provide, facilitate and support perinatal education

- Collaborate with the diverse community of perinatal healthcare providers, Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of Health Services/Office of Women's and Children's Health

- Increase public awareness of perinatal health.

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