Pediatricians at Urgent C Sections

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Wondering what other places do regarding pediatrician presence at C sections. Small community hospital, about 1,100 deliveries per year, 3 different "colors" of C Sections. Green is elective, yellow is urgent with decision to incision 45 minutes, red is STAT with decision to incision 30 minutes. Currently pediatricians come for reds, and yellows only if requested by OB.

Because yellows as per policy should have some element of maternal/fetal distress, our group feels pediatricians should come for all yellows too. We've had a bunch of yellows where neonate requires some kind of resuscitation (airway assistance, even CPR) and we end up being the ones to resuscitate the baby while also taking care of mom. Peds says it's a staffing issue, and some of the OBs are very protective of peds and don't want to call them in any more than they have to. Everyone takes call from home - OB, anesthesia, and peds.

We're in New York, where the good samaritan statute doesn't apply to doctors in hospitals.

Any input on what everyone else does is appreciated!
 
What does policy and procedure manual say as far as who is responsible for recussitating neonate?
 
dr doze said:
What does policy and procedure manual say as far as who is responsible for recussitating neonate?
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As far as I know, it's not addressed. Looks like that is a good place to start. Our malpractice carrier has also given us a statement in writing as to how this is not a desirable situation for our group.
 
Gas said:
As far as I know, it's not addressed. Looks like that is a good place to start. Our malpractice carrier has also given us a statement in writing as to how this is not a desirable situation for our group.
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They have a gift for understatement.

Remind them of the ASA position statement that the primary duty of the anesthesia team is to the mother. That said, if Mom is stable a jury would probably not look well at an anesthesiologist who chose not to render assistance to a neonate in distress. Particularly if there is an anesthesiologist and CRNA present in the Section room and other and/or other anesthesia personnel available for codes. If the OBs are the ones deciding that pediatricians should or should not be present, that goes toward arguing that they are responsible. Are there two Jobs present for every Section? Does the hospital require the OBs or anesthesiologists to require NRP certification. There may be issues with state department of health regulations that address this. Nobody is going to want to own this one.
 
Sounds like this literally is a sentinel event waiting to happen, especially if you are solo in the room dealing with an unstable mother and the infant crashes (which you may or may not be aware of based on my OB experience). This is about patient safety, not about convenience.

I am not very knowledgeable on this, but who is covering your NICU during these times? It can be covered from home? I'm assuming you have one since you have OB.
 
AdmiralChz said:
Sounds like this literally is a sentinel event waiting to happen, especially if you are solo in the room dealing with an unstable mother and the infant crashes (which you may or may not be aware of based on my OB experience). This is about patient safety, not about convenience.

I am not very knowledgeable on this, but who is covering your NICU during these times? It can be covered from home? I'm assuming you have one since you have OB.
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Obviously this type of hospital doesn't have a NICU. If a kid gets resuscitated, they ship em.
 
Great input. No NICU at the hospital. If a neonate is in distress, obviously we help with the resuscitation.

ASA Statement is pretty clear, but all it says is that someone else has to be responsible for baby - not necessarily a pediatrician. Joint statement from ACOG and AAP is similar regarding this issue.

From the way we understand it, if there is a need for resuscitation and no pediatrician (just a labor and delivery nurse turned baby nurse which is usually the case), we now become the neonate's primary caregiver. Since we are physicians, the jury will go after us if there is a bad outcome. If a pediatrician is present, and they ask us for help, we are now a consultant. So if we help and there is a bad outcome, we weren't the neonate's primary caregiver. We could still get dragged into litigation, but we probably wouldn't be as easy as a target for the jury.

If a baby is in distress, the baby nurse can call for a pediatrician. During the day they come running from the office which is on campus, but at night they drive in. In both cases, it's far too long of a wait, and we end up taking care of the baby.

Today I am going to the medical staff office and find the policy and procedure manual. I'll also find out what qualifications everyone has to have. None of the anesthesiologists and only a handful of CRNAs have PALS/Neonatal resuscitation training/certification.
 
AdmiralChz said:
Sounds like this literally is a sentinel event waiting to happen, especially if you are solo in the room dealing with an unstable mother and the infant crashes (which you may or may not be aware of based on my OB experience). This is about patient safety, not about convenience.

I am not very knowledgeable on this, but who is covering your NICU during these times? It can be covered from home? I'm assuming you have one since you have OB.
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Yeah,you guys need to get this sorted out/clarified ASAP. I don't do OB anymore, but my last place did a ton of OB so they had their own team for these situations.
This is putting you all in a very precarious position.
 
Crabbygas said:
I work in a rural place with about 500 deliveries a year. Peds comes for every c-section. Yes, every single one. RT as well.
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Thanks for the reply - this helps when I sit down with OB and Peds. What happens at other smaller community hospitals like ours?
 
We went through this very issue a few years ago. Our stance was obviously as others described here, our primary and only responsibility is the mom. However, if mom is fine we will assist. We do not have Ped's at all c/s. That is left up to the OB to call. We have a nursery/NICU of sorts and the nurses in there are fairly competent. They do a good job. I have only had to intervene a few times in 10yrs. They are PALS/NRP certified. This is were it gets tricky. The Ped's folks (and RN's) wanted us to be PALS/NRP certified. Some of us are and some are not. We argued that NRP was below our level of resuscitation requirements. A pediatrician came to our anesthesia Mtg and tried to push his agenda, it didn't work out so well for him. We said we will either assist with the baby if mom is ok or we will remove ourselves completely from the situation if they require NRP. The OB's jumped on our side.

Another point we raised was that there are two providers in most c/s's, an OB and an assistant usually another OB during the day. Sometimes a midwife. Sometimes an OB nurse. Anyway, these providers are NRP certified and the assistant can scrub out "usually" to assist the nursery nurse, if needed and we are busy.
 
Gas said:
Thanks for the reply - this helps when I sit down with OB and Peds. What happens at other smaller community hospitals like ours?
Click to expand...
Noyac said:
We went through this very issue a few years ago. Our stance was obviously as others described here, our primary and only responsibility is the mom. However, if mom is fine we will assist. We do not have Ped's at all c/s. That is left up to the OB to call. We have a nursery/NICU of sorts and the nurses in there are fairly competent. They do a good job. I have only had to intervene a few times in 10yrs. They are PALS/NRP certified. This is were it gets tricky. The Ped's folks (and RN's) wanted us to be PALS/NRP certified. Some of us are and some are not. We argued that NRP was below our level of resuscitation requirements. A pediatrician came to our anesthesia Mtg and tried to push his agenda, it didn't work out so well for him. We said we will either assist with the baby if mom is ok or we will remove ourselves completely from the situation if they require NRP. The OB's jumped on our side.

Another point we raised was that there are two providers in most c/s's, an OB and an assistant usually another OB during the day. Sometimes a midwife. Sometimes an OB nurse. Anyway, these providers are NRP certified and the assistant can scrub out "usually" to assist the nursery nurse, if needed and we are busy.
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It still dodges the question of who is responsible if the NICU RN or respiratory therapist is struggling with a bad baby and Mom is stable. Is it one of the two OBs who are scrubbed in? Is it the anesthesiologist? Nobody wants to own this and unless it is clearly spelled out in writing, you can count on everyone trying to throw everyone else under the bus in the event of a bad baby.
 
The best options for a potentially distressed newborn are presence of 1) NICU, or else 2) pediatrics. (yes I know that OP doesn't have a NICU in their hospital)

The pediatricians apparently don't want to do "extra" work in taking care of babies even if its clearly, squarely in their scope of practice (who can blame them for wanting less work?).

So they want the anesthesiologist to incur extra liability and take care of extra patients for no additional pay or credit... not to mention the potential risk transferred onto both the baby and the mother. Alternatively they're suggesting that a random available-by-hapenstance non-pediatrician midlevel or an OB nurse will provide equivalent care to a physician pediatrician.

Maybe the pediatricians aren't learning from our mistakes... but we aren't learning from our mistakes either. Pediatricians are going to lose their credibility if they want non-pediatricians to care for babies in distress when that distress isn't convenient.

As much as I loathe clipboards and policies, this is exactly the situation where a written policy protects everyones interests - including that of the patient. OP's group should be part of writing that policy, and it should require pediatricians be present for any questionable delivery.


PS: does the idea of anesthesiologists providing perioperative medical care for patients (newborns in this case) for no pay with increased liability but with no credit or recognition reek of something? Oh yeah, the perioperative surgical home.
 
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dr doze said:
It still dodges the question of who is responsible if the NICU RN or respiratory therapist is struggling with a bad baby and Mom is stable. Is it one of the two OBs who are scrubbed in? Is it the anesthesiologist? Nobody wants to own this and unless it is clearly spelled out in writing, you can count on everyone trying to throw everyone else under the bus in the event of a bad baby.
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You must stand your ground here. You have one responsibility, MOM.
Our solution was that one of the surgical Dr's would scrub out if needed. I was in a case that needed this to happen once and it worked well. Once I got mom stabilized I was able to pull one of the circulating RN's over to watch mom while I assisted with the baby.

Nothing is perfect. You do what you can as the situation permits.
 
NICU nurses with RT at every section here. Neonatron comes as well for congenital anomalies or anything O.O.O. with babe. We're not involved at all with neonatal resus.
 
Thanks for all of the replies. I went to our medical staff office today and they are going to get me a list of every physician that is NRP certified. They told me all of the OBs and peds are supposed to be, so the gist of our argument will be that they are more qualified to resuscitate a neonate. And even if we were NRP certified, we shouldn't leave the mother anyway.

Thanks to SDN for all this info, and I'll post updates. If anyone else cares to share what their hospital does, please feel free to post.
 
Wait why is the anesthesiologist responsible if no peds, and not the OB? We aren't the only doctors there. If the mother is stable, the OB should be able to help the newborn as well
 
Gas said:
Great input. No NICU at the hospital. If a neonate is in distress, obviously we help with the resuscitation.

ASA Statement is pretty clear, but all it says is that someone else has to be responsible for baby - not necessarily a pediatrician. Joint statement from ACOG and AAP is similar regarding this issue.

From the way we understand it, if there is a need for resuscitation and no pediatrician (just a labor and delivery nurse turned baby nurse which is usually the case), we now become the neonate's primary caregiver. Since we are physicians, the jury will go after us if there is a bad outcome. If a pediatrician is present, and they ask us for help, we are now a consultant. So if we help and there is a bad outcome, we weren't the neonate's primary caregiver. We could still get dragged into litigation, but we probably wouldn't be as easy as a target for the jury.

If a baby is in distress, the baby nurse can call for a pediatrician. During the day they come running from the office which is on campus, but at night they drive in. In both cases, it's far too long of a wait, and we end up taking care of the baby.

Today I am going to the medical staff office and find the policy and procedure manual. I'll also find out what qualifications everyone has to have. None of the anesthesiologists and only a handful of CRNAs have PALS/Neonatal resuscitation training/certification.
Click to expand...

Pals/NRP certificate is one thing and having practical volume of tough cases that test your skill set is different. In east coast, mother had abruption and baby survived with a bad outcome.
The hospital with the obgyn settled undisclosed millions amount. Went after the anesthesiologist malpractice, the only thing that the anesthesiologist Good Samaritan did was to say that the ETt was in the right place (placed by non anesthesia provider)
If obgyn want to protect pediatricians then the obgyn can scrub out and resuscitate the baby. It's because obgyn cannot properly and preemptive mitigate the risk that we end up in many disasters.
 
Interesting that ER hasn't yet been mentioned in this thread. At my hospital the ER doc has primary responsibility for all neonatal codes until Pediatrics arrives.
 
Gern Blansten said:
CHAU v. RIDDLE | 212 S.W.3d 699 (2006) | sw3d6991874 | Leagle.com

I'll leave this case here for those who wish to read it. It is the sentinel event that all are describing above.
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EXCELLENT SOURCE!

TL;DR: (if lawyers posters are present, please correct me if i'm wrong):

CHAU vs RIDDLE

-2:46 a.m. on October 30, 2001; parturient (Chau) with twin pregnancy. Dr. Le (Obstetrician) called for emergent C section.
-Epidural was unsuccessful, converted to GA. After delivery, SD was floppy baby.
-Dr. Riddle (anes attending for mother) stepped away from a stable mother to successfully intubate neonate. Confirmed tube positioning by auscultation, but DID NOT secure tube.
-Went back to mother for uterine atony treatment.
-RN/RT team resuscitates, Dr. Ruiz-Puyana (neonatologist) comes in 15 minutes later, did not hear breath sounds on auscultation on neonate. Extubate and reintubated, neonate suffered brain damage.
-The Dos (no we're not going MD vs DO, "Do" is a common Vietnamese last name and Houston has a big Viet population. Do was the neonate's fathers name.) Sued Dr. Riddle for his "failed" intubation.
-The initial decision dismissed the suit (Dr. Riddle was not liable). However, the Dos appealed to a higher court; Court of Appeals of Texas, Houston (1st Dist.).

Texas Appeals Court affirmed that Dr.Riddle was covered under Good Samaritan's affirmative defense. Case dismissed. Dr. Riddle won the case.

Interesting points:
-Anesthesiologist was the target for this suit, not the neonatologist that wasn't there, or the OB. (probably economically motivated due to the anes group's malpractice coverage)
-The legal argument for Dr. Riddle not being responsible: Dr. Riddle or the anes group normally do not bill for the intubation, and not an "admitting" or "attending" physician of the neonate.
-This Stare Decicis (Latin for precedent) widened the scope for the Good Samaritan Law to at least allow bystanding physicians to do enough good.
-Not sure how it applies to EM physicians helping out in an emergency outside the hospital.

So I guess OP can comfortably help intubate the neonates and be reasonably comfortable about not being sued, so long as he doesn't bill for it.
 
That may be good in Texas, but in California?

Second there is a constant churn of nurses, RT with ever less experienced ones replacing older experienced providers. My older partner used to intubate babies more often than the rest of the group and nurses complained to administration. It was a defensive match for the anesthesiologists versus rest of the medical staff., meaning we had to explain why we are doing more when others don't see a need.

NRP guidelines change. It used to be we intubate thick meconium with other clinical signs. ASA had a workshop for Difficult intubation in pediatrics and a few of the experts that I spoke with recommended having CMAC (Karl storz) intubation get system as a back up for the difficult ones

The anesthesiologists sees it coming even before every one. But the OB gyn calls the shot of when to do the csection, whether to call the peds are not and is ever ready to throw anesthesia under the bus.

Bottom line is I would not venture into half hearted attempts of a minefield of NRP unless there is absolutely no choice. And usually it's a stat stat csection emergency and most likely end up with general anesthesia and the mom needs the ongoing attention of the anesthesiologist.

I signed up to give anesthesia to the mother not to the unborn. The unborn is the governments liability
 
inquisitiveanes said:
That may be good in Texas, but in California?

Second there is a constant churn of nurses, RT with ever less experienced ones replacing older experienced providers. My older partner used to intubate babies more often than the rest of the group and nurses complained to administration. It was a defensive match for the anesthesiologists versus rest of the medical staff., meaning we had to explain why we are doing more when others don't see a need.

NRP guidelines change. It used to be we intubate thick meconium with other clinical signs. ASA had a workshop for Difficult intubation in pediatrics and a few of the experts that I spoke with recommended having CMAC (Karl storz) intubation get system as a back up for the difficult ones

The anesthesiologists sees it coming even before every one. But the OB gyn calls the shot of when to do the csection, whether to call the peds are not and is ever ready to throw anesthesia under the bus.

Bottom line is I would not venture into half hearted attempts of a minefield of NRP unless there is absolutely no choice. And usually it's a stat stat csection emergency and most likely end up with general anesthesia and the mom needs the ongoing attention of the anesthesiologist.

I signed up to give anesthesia to the mother not to the unborn. The unborn is the governments liability
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This is such typical nursing BS and why they will always be second rate providers.
 
dchz said:
So I guess OP can comfortably help intubate the neonates and be reasonably comfortable about not being sued, so long as he doesn't bill for it.
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Maybe you win the case, but don't you think that anesthesiologist would love to have that three years of their life back along with all of the attorney costs (likely >$100K)
 
Gern Blansten said:
Maybe you win the case, but don't you think that anesthesiologist would love to have that three years of their life back along with all of the attorney costs (likely >$100K)
Click to expand...

I guess i don't know the legal system THAT well, but this case is precedent so if people tried to sue you under similar circumstances the case would get dismissed, no?
 
dchz said:
I guess i don't know the legal system THAT well, but this case is precedent so if people tried to sue you under similar circumstances the case would get dismissed, no?
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Even if a case gets dismissed, it is a huge headache and takes months to years for that to happen.
 
dchz said:
I guess i don't know the legal system THAT well, but this case is precedent so if people tried to sue you under similar circumstances the case would get dismissed, no?
Click to expand...

No. The case is not precedent since it's really relying on facts of a specific case - it's not deciding a matter of law. Even if it did, it's a lower court case and it's in a specific state. Probably not your state.

So you could still get sued for exactly the same thing and not have it dismissed.
 
kidthor said:
No. The case is not precedent since it's really relying on facts of a specific case - it's not deciding a matter of law. Even if it did, it's a lower court case and it's in a specific state. Probably not your state.

So you could still get sued for exactly the same thing and not have it dismissed.
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I live in Texas, but you couldn't have known that. As far as it being a lower court? i thought the only thing higher is the circuit courts and the supreme court?? it's been a while since AP government though...

It's still a fair point, are we really not helping intubate a newborn for the fear of law suits???

If you're gonna get sued for something in your career, why not get sued over doing the right thing? i'm not saying i'd sign up for getting sued, but this is kinda ridiculous if we don't help in the situation of the suit???
 
dchz said:
I live in Texas, but you couldn't have known that. As far as it being a lower court? i thought the only thing higher is the circuit courts and the supreme court?? it's been a while since AP government though...

It's still a fair point, are we really not helping intubate a newborn for the fear of law suits???

If you're gonna get sued for something in your career, why not get sued over doing the right thing? i'm not saying i'd sign up for getting sued, but this is kinda ridiculous if we don't help in the situation of the suit???
Click to expand...



As far as it being a lower court? i thought the only thing higher is the circuit courts and the supreme court?? it's been a while since AP government though...

Each state is divided into appellate district courts (court of appeals) covering a specific area of the state. This is the first step in the appeals process. Next is an individual state supreme court. Which may or may not choose to hear a case. That is about as far as a medmal case can go, and very few ever get there. Beyond this only very rarely can something like a medmal case be appealed to a federal circuit court and then the US Supreme court. They will almost never hear something like this unless their is a question of federal law which is very very rare but not unheard of.

i'm not saying i'd sign up for getting sued, but this is kinda ridiculous if we don't help in the situation of the suit???

The reality is that it might actually be in your best legal interest to turn your back and not render care to a neonate in distress.
 
Gas said:
Thanks for the reply - this helps when I sit down with OB and Peds. What happens at other smaller community hospitals like ours?
Click to expand...

I was wondering how the situation played out?
 
Pediatricians seem to be stalling. They are claiming staffing issues. They say it is disruptive for them to put their office patients on hold and this hurts their RVU production. We have a meeting with their department scheduled for this week. If there is no resolution, I'll have to talk to the higher-ups such as the CMO and CEO and see what input they have in terms of staffing.

I'll keep you posted, but I had a feeling this will take time. Seems like anesthesiologists go out of their way to accommodate requests for service, but not so with other specialties.
 
Gas said:
Pediatricians seem to be stalling. They are claiming staffing issues. They say it is disruptive for them to put their office patients on hold and this hurts their RVU production. We have a meeting with their department scheduled for this week. If there is no resolution, I'll have to talk to the higher-ups such as the CMO and CEO and see what input they have in terms of staffing.

I'll keep you posted, but I had a feeling this will take time. Seems like anesthesiologists go out of their way to accommodate requests for service, but not so with other specialties.
Click to expand...

Because we are dependent on other services. The other specialties are not so much.

Offer them RVU equivalents for covering these cases.
 
Noyac said:
Because we are dependent on other services. The other specialties are not so much.

Offer them RVU equivalents for covering these cases.
Click to expand...

Yea, I think this is simple enough. The pediatricians are hospital employees, so we will probably relay our safety concerns to the CMO, and then in turn hopefully the CEO will incentivize the pediatricians every time they respond to a c section.
 
Tell them it’s a patient safety issue because that’s what it is. That you cannot tend to both the mother and the baby at the same time. Get hospital risk management involved. Express your concerns and document all of this in writing. Leave a paper trail. Patient safety trumps pediatrician convenience.
 
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nimbus said:
Tell them it’s a patient safety issue because that’s what it is. That you cannot tend to both the mother and the baby at the same time. Get hospital risk management involved. Express your concerns and document all of this in writing. Leave a paper trail. Patient safety trumps pediatrician convenience.
Click to expand...

Take a pay cut and work only day shifts or locums if you can. Anesthesiologists get tired of OB anesthesia.
 
nimbus said:
Tell them it’s a patient safety issue because that’s what it is. That you cannot tend to both the mother and the baby at the same time. Get hospital risk management involved. Express your concerns and document all of this in writing. Leave a paper trail. Patient safety trumps pediatrician convenience.
Click to expand...

Just keep in mind that you are asking the hospital to spend a lot more money on Peds when you are asking for this. Any doctor would walk away from a job that suddenly decided that they were going to be coming in several times per week at night, and otherwise staying completely sober and on a 15-30 minute tether to the hospital, for no extra pay.

Small hospitals pay Pediatricians almost nothing to do just nursery rounds, a few hundred a day and malpractice. Nursery rounds are how Peds gets their clinic patients, so you don't really need to pay them than much extra to do what is basically advertising for themselves On the other hand being on call for C sections and neonatal emergencies is 800-1K per day for our local community hospitals, and those are low volume rural hospital where Peds is called in no more than 1 night per call week on average. In busier hospitals the cost of call coverage obviously goes up.
 
Another thing to consider is the issue of Pediatrician comfort with managing neonatal emergencies. Peds residencies can have as few as 2 months of NICU and as many as 6, and those months are of varying intensity. A Pediatrician who is several years out from residency, and/or whose residency was NICU light, might not feel capable of covering neonatal emergencies at any price. If you are asking the Pediatricians to cover sick babies you may, effectively, be asking the hospital to fire their Pediatricians and hire a new batch.
 
Perrotfish said:
Just keep in mind that you are asking the hospital to spend a lot more money on Peds when you are asking for this. Any doctor would walk away from a job that suddenly decided that they were going to be coming in several times per week at night, and otherwise staying completely sober and on a 15-30 minute tether to the hospital, for no extra pay.

Small hospitals pay Pediatricians almost nothing to do just nursery rounds, a few hundred a day and malpractice. Nursery rounds are how Peds gets their clinic patients, so you don't really need to pay them than much extra to do what is basically advertising for themselves On the other hand being on call for C sections and neonatal emergencies is 800-1K per day for our local community hospitals, and those are low volume rural hospital where Peds is called in no more than 1 night per call week on average. In busier hospitals the cost of call coverage obviously goes up.
Click to expand...

So anesthesia provides that same coverage for free while simultaneously taking care of the mother? Makes sense.
 
Perrotfish said:
Another thing to consider is the issue of Pediatrician comfort with managing neonatal emergencies. Peds residencies can have as few as 2 months of NICU and as many as 6, and those months are of varying intensity. A Pediatrician who is several years out from residency, and/or whose residency was NICU light, might not feel capable of covering neonatal emergencies at any price. If you are asking the Pediatricians to cover sick babies you may, effectively, be asking the hospital to fire their Pediatricians and hire a new batch.
Click to expand...


The pediatricians are already coming in for the reds, just not the yellows.
 
nimbus said:
So anesthesia provides that same coverage for free while simultaneously taking care of the mother? Makes sense.
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Apparently they are paying enough to keep you from quitting despite asking you to do this.

I'm not saying it's a not good idea to have peds coming in. I personally take q3 peds call and come in for every code, C-section, mec delivery, shoulder, and mag delivery. I am just saying that hospitals pay a decent amount for this kind of coverage and yours probably probably won't get it for free.

A similar discussion is calling anesthesia at every ED code blue, which is another form of coverage present in some but not all hospitals. Again,it's safer: it's not easy for ED to manage an airway and run a code at the same time. Again, though, it costs more when you want someone on call to come in more often, which is a why many hospitals don't do that.
 
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Perrotfish said:
Apparently they are paying enough to keep you from quitting despite asking you to do this.

I'm not saying it's a not good idea to have peds coming in. I personally take q3 peds call and come in for every code, C-section, mec delivery, shoulder, and mag delivery. I am just saying that hospitals pay a decent amount for this kind of coverage and yours probably probably won't get it for free.

A similar discussion is calling anesthesia at every ED code blue, which is another form of coverage present in some but not all hospitals. Again,it's safer: it's not easy for ED to manage an airway and run a code at the same time. Again, though, it costs more when you want someone on call to come in more often, which is a why many hospitals don't do that.
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Just to clarify, I’m not involved in this situation at all. I believe the OP is near the opposite coast. Still if a hospital wants to provide a service they should do it right and not cut corners. I’m all for everyone getting healthy stipends commensurate with their efforts.
 
Our peds come in for all red sections, and some of the yellows. It is the OB discretion whether to call in peds for the yellows. The problem is the OB doesn't leave the mother to attend to the neonate; it falls on us. It doesn't seem fair that the one who decides whether or not to call peds has no skin in the game when something goes wrong with baby.

We had a good meeting today with the CMO and pediatrics department. The hospital is going to look into hiring nurse practitioners with neonatal training and/or experience. The cost of these practitioners has to be justified, and since we do about 1000 deliveries a year, we will try to get the OBs and pediatricians on board with this. Having a neonatal NP attend all deliveries, including vaginal ones, could help justify this cost. Many times the OB will have a neonate in distress after a vaginal delivery, with no anesthesiologist or pediatrician close by, and for this reason they seem to be in favor of the NP. The L&D nurses favor it to ease their workload, and the NP could also ease the burden off the peds when they have to leave their office for deliveries. Again, the issue is cost.

We will see how this plays out, but the meeting today was productive. Everyone agreed that the anesthesiologist can't be responsible for both mother and neonate, and this is evident in our practice guidelines as well. The NP route may take some time, but in the meantime we will surely document our concerns. I will have our malpractice carrier draft something to that effect. If after a couple or months or so things still aren't moving, then we will bump this up to the CEO/risk management people.

Thanks to everyone for their input! I really appreciate these forums.
 
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