Virtual Obstetric Hospitalist Support for Obstetric Emergencies and Deliveries: The Mayo Clinic Experience

Abstract

Objective:

To implement use of obstetric (OB) hospitalist telemedicine services (TeleOB) to support clinicians facing OB emergencies in low-resource hospital settings.

Methods:

TeleOB was staffed by OB hospitalists working at a tertiary maternity center. The service was available via real-time high-definition audio/video technology for providers at 17 outlying hospitals across a health system spanning two states. The initial 25 service activations are described.

Results:

TeleOB supported 17 deliveries, two postpartum emergency department (ED) consultations, and four antenatal ED consultations. In 10 of 17 (59%) deliveries, teleneonatology was jointly activated to support neonatal resuscitation. Sixteen (94%) deliveries occurred in multiparas, and five (29%) resulted from spontaneous preterm labor. Eighty percent (20/25) of activations occurred in facilities without maternity services.

Conclusions:

A TeleOB service staffed by OB hospitalists successfully supports hospitals in an integrated health care system. TeleOB is feasible for support of hospitals with no delivery facilities or with limited maternity care resources.

Introduction

Rural settings in the United States struggle to maintain access to labor and delivery services, with increasing numbers of rural hospitals offering no maternity care services.^1,2 Maternal health disparities are evident in rural and urban communities without adequate obstetric (OB) care and are associated with black race and lower socioeconomic status.^3–6 OB hospitalists are specialists in the management of antenatal, intrapartum, and postpartum emergencies. Staffing delivery hospitals with OB hospitalists has been linked to a decrease in severe maternal morbidity and has been proposed as one strategy to address the growing maternal mortality crisis in the United States.⁷ Many major causes of maternal mortality and severe maternal morbidity in the United States, including hemorrhage, hypertension, and cardiovascular disease, are amenable to treatment or stabilization with appropriate and prompt medical management.⁸ We hypothesized that remote telemedicine consultation for medical management of maternal emergencies may be an effective approach to address the growing gap in access to maternity care.

Previous work from our facility has demonstrated that teleneonatology (TeleNeo) consultation can improve quality of neonatal resuscitation at birth.^9,10 The use of high-resolution, remotely controlled devices with real-time audio/video connections can also facilitate virtual consultations in other emergency situations, including stroke.¹¹ Although the use of telemedicine to support outpatient prenatal and postpartum OB care is now accepted practice, intrapartum and emergency care still rely upon the physical presence of an obstetrician, midwife, or family medicine physician.¹² In this pilot study we describe deployment of virtual support for the management of OB emergencies and births in low-resource settings by providing real-time, remote telemedicine consultation with OB hospitalists (TeleOB).

Methods

The monitoring of patient outcomes during TeleOB implementation was approved by the Mayo Clinic Institutional Review Board. Patient data were collected retrospectively using medical record review, provider interviews, and call center logs. Level of maternal care (LOMC) designations were determined using the CDC LOCATe tool¹³ in collaboration with staff at each birthing hospital. LOMC was not assigned for hospitals where no labor and delivery services were offered.

In coordination with the Mayo Clinic Center for Digital Health, we developed an implementation process to provide TeleOB services at hospital sites across an integrated health system. At the tertiary care hospital, a level IV maternity center is staffed 24 h a day by OB hospitalists. Emergency departments (EDs) and labor and delivery units (L&D) throughout the health system were previously equipped with two-way synchronous audio/visual robotic devices to facilitate telemedicine services. Some units in community hospitals with both EDs and L&Ds had access to two telemedicine robots, and all used an integrated, system-wide electronic medical record. EDs also were equipped with point of care ultrasound, and all L&D used a shared fetal monitoring system accessible remotely in real time at the tertiary care hospital. In preparation for OB emergencies, all EDs and L&Ds stocked a standardized OB hemorrhage kit containing multiple uterotonics and a Bakri uterine tamponade balloon.

Acute TeleOB services were implemented at 17 EDs and 8 L&Ds across an integrated health care system spanning two states. A centralized call center was used to route calls to the appropriate TeleOB physician and to activate the TeleNeo physician when, in the judgment of the rural clinician or TeleOB staff, they may be needed for neonatal resuscitation (Fig. 1). To provide remote telemedicine services, TeleOB physicians obtained medical licenses in both states and underwent credentialing for telemedicine services at each of the 17 hospitals. Trainings and case simulations were held with originating and consulting providers and staff at all sites to ensure familiarity with the telemedicine technology as well as to refresh skills in management of OB emergencies. These robust full-day simulations addressed management of spontaneous vaginal delivery, shoulder dystocia, OB hemorrhage, and eclampsia. During the simulations, OB hospitalists used desktop software to access the telemedicine robots, which allowed for real-time clinical interactions with simulated patients and remote care team members (Fig. 2). Remote OB care was augmented with synchronous electronic medical record review and, where available, with cardiotocography.

Fig. 1.

TeleOB birth simulation. The remote TeleOB consulting physician is shown on the video screen during a simulated vaginal delivery.

Fig. 2.

TeleOB consult activation process.

Results

The first 25 TeleOB activations (January 2020 to February 2023) were tracked (Table 1) to evaluate the implementation of virtual OB care in the hospital setting. Twenty-two consultations originated in EDs, one from an outpatient clinic, and two from L&D. TeleOB consultations were requested by emergency medicine physicians (n = 14), family medicine physicians (n = 2), physician assistants (n = 4), Ob/Gyn physicians (n = 2) and nurse practitioners (n = 3) at 11 distinct medical facilities. Only two of the ED consultations originated from centers that had maternity services on site, and nearly half (10/25) of the TeleOB activations originated from a single hospital (facility #1) where maternity care services had recently closed in 2019. One patient accounted for two separate activations—one for antenatal care and another for delivery. Surprisingly, a TeleOB activation occurred from an outpatient clinic that had not been part of the planned TeleOB implementation, but where an appropriate device was present in the clinic. An imminent preterm birth was identified and managed by a physician at the clinic during a routine prenatal visit, and both TeleOB and TeleNeo participated in the care.

Table 1.

Patient Characteristics

PATIENT	UNIT	FACILITY ID	HOSPITAL TYPE	HOSPITAL LOMC	EGA, WEEK	CLINICIAN	PARITY	INDICATION	COMPLICATIONS	MATERNAL TRANSFER	TELENEO ACTIVATION
1	ED	1	CH		37	EM	0111	Delivery	None	Y	N
2	ED	1	CH		37	EM	4003	Delivery	None	Y	N
3	ED	1	CH		34	EM	3003	Delivery	None	Y	N
4	ED	1	CH		37	EM	0000	Delivery	Unaware of pregnancy	Y	Y
5	ED	1	CH		38	EM	1001	Delivery	None	Y	Y
6	ED	1	CH		35	EM	1111	Delivery	Known fetal abnormalities	Y	Y
7	ED	1	CH		31	EM	2022	Delivery	Fetal Demise	Y	Y
8	ED	1	CH		40	EM	4034	Delivery	None	Y	Y
9	ED	1	CH		36	EM	0121	Motor vehicle accident	None	N	N
10	ED	1	CH		37	EM	4004	Delivery	None	Y	Y
10	ED	1	CH		35	EM	4004	Nephrolithiasis	None	Y	Y
11	ED	2	CAH		39	EM	1001	Latent labor	None	Y	N
12	ED	3	CH, BH	2	PP	EM	a	PP hemorrhage	Hemorrhage	N	N
13	ED	4	CAH		37	NP	a	Delivery	None	Y	N
14	ED	4	CAH		40	NP	5015	Delivery	None	Y	N
15	ED	4	CAH		40	NP	2022	Delivery	None	Y	N
16	ED	4	CAH		a	PA	a	Preterm Contractions	None	y	N
17	ED	5	CAH		PP	PA	2022	PP day 7 bleeding	None	N	N
18	ED	6	CH, BH	1	a	EM	4014	Delivery	No prenatal care, manual placental extraction	Y	N
19	L&D	6	CH, BH	1	39	OB	a	Shoulder dystocia	Neonatal transfer to NICU	N	Y
20	L&D	7	CAH, BH	0	25	FM	0010	Delivery	Abruption, Cesarean	N	Y
21	Clinic	8	CLINIC ONLY		23	FM	0121	Delivery	Outpatient clinic breech delivery	Y	Y
22	ED	9	CAH		38	PA	0010	Latent labor	None	Y	N
23	ED	10	CAH		39	PA	0000	Delivery	Preeclampsia	Y	N
24	L&D	11	CH, BH	2	24	OB	00120	Ultrasound interpretation	Fetal demise, known fetal abnormalities	N	N

^a Data not available.

BH, birthing hospital; CAH, critical access hospital; CH, community hospital; ED, emergency department; EM, emergency medicine physician; FM, family medicine physician; L&D, labor and delivery units; LOMC, level of maternal care; NP, nurse practitioner; OB, obstetric; PA, physician assistant; PP, postpartum; TeleNeo, TeleNeonatology.

Indications for TeleOB consultation included antenatal, intrapartum, and postpartum services; the most common reason for activation was to support precipitous deliveries in the ED (n = 14). Ten of these deliveries involved synchronous TeleNeo consultations using separate devices for support of neonatal resuscitation teams, and nine deliveries were uncomplicated. Delivery complications managed included retained placenta with manual extraction, fetal demise, abruption, preterm breech delivery, and preeclampsia. All except one patient had given birth previously, and the single nulliparous patient presented to the ED for abdominal pain and was not previously aware of the pregnancy. Antenatal conditions evaluated by TeleOB included preterm contractions, latent labor, trauma, and nephrolithiasis. One immediate and one delayed postpartum hemorrhage were successfully treated in the ED using uterotonics and without need for hospital transfer or blood transfusion. No maternal adverse events or instances of severe maternal morbidity occurred in this cohort. One neonatal demise occurred in the NICU in the setting of prematurity, one delivery was a stillbirth, and the remaining neonates survived to hospital discharge. Long-term follow-up is not available on the infants.

Discussion

The U.S. maternal health crisis, accompanied by the ongoing closures of small hospital birthing units, demands innovative solutions.^2,5,6 Many groups have demonstrated the successful use of telemedicine to support outpatient OB care in the prenatal and postpartum realms, but intrapartum and emergency care still largely relies upon the physical presence of an obstetrician in the hospital setting.^12,14 Some groups have reported innovative use of teleperinatology for hospital inpatient consultation purposes or for remote fetal monitoring,¹⁵ but telehealth interventions to support safe delivery care have not been widely used. One report details improved maternal outcomes after implementation of telemedicine for support of OB emergency care in Colombia, where small hospitals have used various modalities to connect with OB physicians at a large perinatal center.¹⁶

Our work focuses on implementation of TeleOB services in support of hospital-based emergency and intrapartum care for facilities where access to OB specialty services is limited or absent. We have demonstrated that a centralized group of OB hospitalists using telemedicine technology can provide support for clinicians encountering OB emergencies at low-resource facilities across a rural integrated health system. Our collaborative work with TeleNeo shows that activation of two consultative telemedicine specialties simultaneously, in this case to support the maternal–neonatal dyad, can be supported using current technology.

Several barriers to implementation and ongoing barriers to activation deserve mention. Resource barriers to implementation include the significant upfront cost to invest in telemedicine robots for each hospital, as well as the need to share those devices across several acute telemedicine services and hospital units. For our implementation, all sites were already equipped with high-speed broadband service, but for expansion to additional rural areas this will certainly be an upfront consideration. Service activation remains a technical challenge, as automated activation of consultation on demand has not yet been achieved. This introduces multiple human-dependent steps, including calling on the telephone, identifying the appropriate on-call physician in the computer system, and using a paging system for notification of the consulting service. At each of these steps, isolated delays and errors were experienced over the course of this implementation.

Finally, we were surprised that some providers at the originating facilities did not embrace the service, with community Ob/Gyn physicians in particular expressing both doubts about its usefulness as well as feelings of reduced autonomy in practice. Emergency medicine providers, however, have expressed gratitude for the availability of TeleOB services and will likely remain the target audience for future emergency TeleOB support. Ongoing work of our team will focus on addressing these barriers to service implementation and activation.

The issue of patient privacy arose during community education sessions and staff trainings, and indeed the nature of OB emergencies poses a unique challenge in terms of patient privacy. Because of the necessarily intimate nature of the physical exam and video content, we did set aside a private office area for the consulting physician to log into the video platform. We also provided verbal reassurance to patients during the consultations, confirming to them that sessions were not being recorded or shared with anyone who was not visible to the patient on the screen of the originating device. As we explore future use cases for video telemedicine in obstetrics and gynecology, development and dissemination of best practice guidelines to ensure patient privacy and comfort during remote pelvic examinations will be critically important both for patient safety and to reduce provider liability.

Because 88% (22 of 25) TeleOB consultations in this series originated from EDs, and 10 of those came from a hospital with recent maternity unit closure, our findings suggest that TeleOB services may be highest yield when implemented in support of EDs at facilities that have closed their maternity services. Encouragingly, the low consultation volume of this service also suggests that one centralized group of TeleOB physicians may have the capacity to support many hospitals across large areas of the growing OB desert. Future work should focus on evaluating the utility of the service from the standpoint of the ED providers, including assessment of the capability of video technology as compared with telephone consultation for TeleOB programs. Prevention of adverse maternal outcomes in low-resource settings is a national priority, and providing TeleOB support to EDs is one potential strategy to strategy to address known racial and socioeconomic disparities in maternal care.

Conclusions

TeleOB can be used alone or in combination with TeleNeo to support births and maternal emergencies in ED and L&D settings where OB support is otherwise not available.

Authors' Contributions

R.N.T.: conceptualization, methodology, data curation, analysis, writing (original draft), funding acquisition. V.T.: methodology, resources, writing (review and editing). J.C.S.: methodology, resources, writing (review and editing). H.S.: resources, project administration, writing (review and editing). H.A.H.: resources, project administration, writing (review and editing). K.B.K.: conceptualization, funding acquisition, writing (review and editing). J.L.F.: conceptualization, resources, writing (review and editing). A.S.: conceptualization, writing (review and editing), funding acquisition, supervision.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of Mayo Clinic or the NIH.

Disclosure Statement

R.N.T. has a know-how agreement and has received research funding from HeraMed and serves on the Medical Advisory Board for Delfina. J.L.F. has licensed intellectual property with and earns royalties from Teladoc Health.

Funding Information

This work was supported by a grant from the Noaber Foundation and by CTSA Grant No. UL1 TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH).