You need a backup, but when?

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You’re the only obstetrician on shift. It’s midnight. Despite pushing for 4 hours, your patient has made no progress and is in need of a cesarean section. You and the medical team begin preparations for surgery, but suddenly a mother in another room requires an emergency cesarean and needs your attention right away. What do you do?

In our surveying, we’ve found that 40% of hospitals don’t have a backup system. The potential of bad outcomes and near misses is a major risk affecting the quality and safety of care for patients. We always encourage hospitals to have a backup in place. Understanding the challenge and cultural behavior explains this surprising gap in service.

There is no formalized standard or formula for how many patients an OBGYN hospitalist should care for in a day or specified timeframe. Variables including clinical judgement are determining factors, which poses a complex problem for the labor and delivery team. Based on our experience and expertise we recommend analyzing 3 areas: volume, patient mix, and risk factors.

The number of patients, the stage they are in, and their acuity are good indicators. For example, 4 patients early in labor is very different to 4 patients who are about to deliver. Understanding these contrasting scenarios will give you insight as to whether a backup may be needed.

Patient Mix
The needs of mothers vary. Mothers giving birth for the first time (primipara or primips) take an average of 8 hours of active labor; whereas, mothers going through their second delivery (multipara or multips) take an average of 5 hours. Multips usually labor faster. Taking note of these differences will help set expectations.

Risk Factors

Another important gauge is to look at patients’ health and risk factors (acuity). Hypertension, diabetes, maternal age, fetal prematurity, obesity, previous cesarean or other morbidities must be accounted for when reviewing labor and delivery’s resources.

By reviewing detailed information including the acuity and volume of the patient volume, acuity of the patient mix and risk factors, you can anticipate foreseeable gaps in the quality and safety of care. If there is a need for a backup OBGYN you’ll be prepared and proactive.

The Hidden Obstacle

Paying attention to the 3 areas above will help assess the situation; however, the hospitalist and team must work together. Team culture and having a patient-focused mindset need to be aligned from the Board of Directors to the administrative staff. In our experience, this can be the biggest challenge. Clinician’s often know when their bandwidth is stretched. Although they feel the demands, they may not take action. On one hand a physician may have numerous high risk patients to care for at the same time, or they’re feeling exhausted having worked without a break for the last 15 hours. In either situation an OBGYN may feel like they can handle it, and have reservations calling back up. They may not want to trouble another OBGYN, or they don’t want to appear “weak”, and unable to manage the workload. This can be a dangerous behavior. The practice of calling a back up when needed should be rewarded to support a culture driven by safety. Have the Medical Director call out for praise that decision during regularly scheduled team meetings.

In the opening example, having a backup and calling them in is best practice. While you’re taking care of the emergency cesarean, the backup OBGYN can step in with the routine cesarean. Both mothers have a safe and successful birth, both babies are healthy, the hospital has another positive outcome, and you and your team can feel proud of another job well done, providing the best care for your patients.


When we work with hospitals implementing an OBGYN hospitalist program, a backup system is integrated. The back up system may vary in design depending on the resources available. It can be the difference between a good outcome and bad outcome, or more commonly, it can save the many near misses caused by lack of support. If you’re interested in improving the quality and safety of care for your maternal patients, please contact us. We’d love to hear your ideas and help you achieve your goals. In the coming weeks we’ll be sharing the warning signs of an unsafe unit, and how to advocate for a backup system.

– Dr. Brendan Carroll

Connect with the National OBGYN Hospitalist Consulting Group on Twitter @ObGHospitalist or LinkedIn

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