Rose’s Law

Please Note:
The following material is heavily medical in nature. It will become apparent, however, that the essence of this post stands straight up in the middle of a political landscape that has engulfed Alabama. It needs to be told, for all women of childbearing age here in Alabama. It needs to be clearly understood by nurses and medical students, new to the environment of obstetrics. Most of all, my intent is to compel individual voters to know exactly WHO and WHAT they are voting FOR.

The following story is accurate and factual. All information contained is a matter of public record. Direct links open in separate windows. Full links listed at end of post.

Politics in Alabama are notoriously nasty and polarizing, and usually do not capture much of my attention. That is, until a few days ago, when a bill was submitted for consideration in the Alabama Legislature. The proposed bill (SB289) was written and sponsored by a recently elected Alabama Republican Senator, Dr. Larry Stutts (1). Co-sponsors of the proposed Bill did not appear to be fully informed of Stutts personal connection to the proposed legislation [25].

Dr. Larry Stutts is an OB/GYN physician from Northwest Alabama, near Tuscumbia. When Dr. Stutts ran for a legislative seat in Alabama’s 6th District, he defeated his incumbent Democratic opponent, by only seventy (yes, that is 70) votes [24], running on a platform promising to repeal ‘ObamaCare’, among other things.

So what was it about his proposed legislation that caught my attention? Rose’s Law. SB289 sought to repeal Rose’s Law. Every healthcare professional under the umbrella of women’s health in Alabama has heard of Rose’s Law. But how many of us actually KNOW the history and intent of Rose’s Law? It is extremely important that we DO fully understand.

On December 1, 1998, registered nurse Rose Bowling Church was admitted to Helen Keller Hospital for induction of labor, under the care of her OB/GYN, Dr. Larry Stutts. During the course of labor, Rose called for a nurse to report a large amount of bloody show and blood clots. Nursing staff informed Dr. Stutts of the large amount of vaginal bleeding. Shortly after, Rose’s membranes were ruptured and another large blood clot was noted. For a brief time, Rose’s baby experienced a decrease in fetal heart rate, but Rose successfully delivered a viable, healthy baby girl (Church v Stutts, Item 5).

Following delivery of the infant, Dr. Stutts found it necessary to manually extract the placenta, with difficulty, and sent a specimen for pathology. Meanwhile, nursing staff carried out “routine” post delivery care, massaging Rose’s uterus, which continued to expel several large clots. Rose continued to bleed “moderately”, but was still transferred from Labor and Delivery to a Postpartum room. During transfer, Rose “passed out” and was difficult to arouse (Item 5). The pathologist notified Dr. Stutts that Rose’s placenta was strongly suggestive of clinical placenta accreta. (Item 7)

Placenta Accreta
 occurs when the placenta attached deep into the uterine wall, but does not penetrate the uterine musculature.

Standard postpartum practice (even 16 years ago) calls for frequent assessment of a new mom’s vital signs, the position and condition of her fundus (the top portion of the uterus), and the amount, color, and consistency of lochia flow. After Rose was transferred to her postpartum room, these minimal standard assessments never took place, nor were any findings documented in her medical record, though Rose’s husband remembers his wife bleeding heavily, and continuously. (Item 6)

Suffering from known, though untreated, placenta accreta, significantly elevated heart rate, and dizziness, Rose was discharged 36 hours after delivery. There was no lab work ordered prior to her discharge from the hospital on December 3, 1998. (Item 9)

On December 7, 1998, Rose contacted her family physician, with complaints of continued heavy postpartum bleeding (saturating 10 large pads daily), persistent excruciating headache, dizziness, elevated heart rate, and faintness when trying to stand. Outpatient lab work revealed profound anemia (Hemoglobin of 4.92, Hematocrit of 14.8), possible infection (WBC of 14,300), and elevating platelet levels (388,000). (Item 10)

A brief side note: in the occurrence of severe or prolonged hemorrhage, the body increases platelet production in an attempt to stem blood loss. Rose’s blood loss was both profound and prolonged. Her hemoglobin and hematocrit levels were less than half of the low end of acceptable. Hemoglobin is the component of blood responsible for carrying oxygen. Hematocrit is the total blood volume made up of red blood cells. (Hemorrhagic Shock)

Rose’s family physician treated her aggressively, transfusing 4 units of packed red blood cells. The result was an acceptable hemoglobin level, but also induced fluid overload. (Item 11)

Dr. Stutts was contacted by Rose’s physician, and according to court documents, advised Rose be discharged, to follow up in his office, stating he would likely perform an operation to examine Rose’s uterus for retained placenta fragments. (Item 12, 13) Retained placental fragments are a common cause of postpartum hemorrhage- and Dr. Stutts was fully aware that Rose’s risk was significantly elevated by a finding of placenta accreta SIX days earlier. (Item 7)

Rose, now experiencing shortness of breath, received a chest xray, which revealed an enlarged heart and fluid in both lungs. A diuretic was given, as Rose’s family physician felt Rose had developed left ventricular decompensation as a direct result of postpartum cardiomyopathy. (Item 14)

The left ventricle is the workhorse of the heart. It is responsible for pumping oxygenated blood to the body. Enlargement of the left ventricle occurs when the muscle is weakened and unable to pump with enough strength to move blood forcefully enough to empty the chamber.

Rose was sent for immediate follow up with Dr. Stutts. (Item 15)

Dr. Stutts saw Rose as a “work in” at his office, documented virtually the exact opposite of Rose’s personal physician, noting only “minimal bleeding at present”, but did send Rose to a Cardiologist for evaluation of her “new finding” of cardiomyopathy. Following an echocardiogram, Rose was admitted to the same hospital where she delivered her daughter a week before, with a diagnosis of Congestive Heart Failure. Oxygen and diuretics were ordered. The cardiologist spoke with Dr. Stutts about the unusual findings in a previously healthy young woman. Dr. Stutts did not elect to examine Rose surgically, and did nothing further to treat Rose. (Item 15)

The cardiologist discharged Rose from the hospital on Thursday, December 10, 1998, with instructions to follow up at his office on Monday, December 14. (Item 17)

Rose presented to her local ER early in the morning of Friday, December 11, 1998, with complaints of crushing (substernal) chest pain, radiating through her jaw and left arm. An electrocardiogram indicated an acute inferior myocardial infarction. Lab work? Elevated platelets. LifeFlight transport was requested but denied due to inclement weather. Rose would have to be transported via ambulance. (Items 18, 19)

En route, Rose developed a fatal cardiac rhythm (Ventricular Fibrillation), and was immediately treated with appropriate medications and defibrillation. Unfortunately, EMS had to divert back to the local ER, where Rose arrived in full cardiac arrest. Further resuscitation attempts were unsuccessful. (Item 19)

An autopsy revealed a nearly complete occlusion of the right coronary artery, but no other indications of arterial disease. Rose’s endometrial cavity was found to indeed contain an 11cm portion of retained placenta due to (now definitive) untreated placenta accreta. Rose’s prolonged postpartum hemorrhage was the direct cause of elevated platelet levels, resulting in hemorrhagic occlusion of the right coronary artery.  (Items 20, 21)

Rose Bowling Church was 36 years old.
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Following his wife’s death, Gene Church was not about to sit back and let any other woman be treated, or more accurately, mistreated, in the manner Rose had been. He took his daughter, drove to Montgomery, and stunned the establishment with Rose’s story. The result of his efforts was “Rose’s Law”, passed unanimously by both the Alabama House and Senate, becoming law in 1999. [24] [40] [45]

Alabama Code, Section 27-48-2 prevents insurance companies from denying approval of necessary medical care of a mother and newborn child. In essence, prior to Rose’s Law, physicians could be influenced by insurance companies to limit standard testing and length of stay following delivery: [45]

Alabama Code, Section 27-48-2
Rose’s Law

  1. a) Every health benefit plan that provides maternity coverage shall provide coverage for the following:

(1) All medically necessary inpatient care for a mother and her newly born child as determined by the woman’s prenatal care physician, obstetrician-gynecologist, certified nurse midwife, or the child’s attending pediatrician and when consistent with the most recent version of the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, including the administration of medical tests recommended by the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists or both on the admission and discharge of a mother and the newborn child to determine whether additional medical care is needed for the mother or newborn child or both. Included in medically necessary inpatient care is the requirement that all hospitals providing a maternity hospital stay perform a complete blood count with differential, or its equivalent, on the mother upon admission and discharge of the mother from the hospital.

(2) Benefits for any hospital length of stay of not less than 48 hours in connection with childbirth for the mother or newborn child, following a normal vaginal delivery.

(3) Benefits for any hospital length of stay of not less than 96 hours in connection with childbirth for the mother or newborn child, following a cesarean section.

(b) Notwithstanding the provisions of subdivisions (2) and (3) of subsection (a), a mother may be discharged early if she, after being advised by her medical provider in writing of the advantages and disadvantages of early discharge, consents in writing, and the medical provider agrees to the early discharge.
(Acts 1996, No. 96-578, p. 915, §2; Act 99-193, p. 228, §2.)

As a medical malpractice suit, Rose’s case remained tied up in the courts until June 2005, when a confidential and undisclosed settlement was reached. (pg 104)

Mr. Church was satisfied that both from an improved standard of care and punitive standpoint, he could move forward with his life. And he has done exactly that. Imagine his reaction when he learned of Dr. Stutts attempt to repeal Rose’s Law. [26]

In a recent interview, Senator Stutts said he also wants to repeal the current law that requires insurance maternity coverage provide a minimum hospital stay of 48 hours for a vaginal delivery, and 96 hours for a cesarean section. “Emotional legislation does not improve care. There’s no reason it should be mandated,” Stutts said. [30]

Dr. Larry Stutts was elected to the Senate of Alabama in November of 2014. Less than three months later, he introduced a bill  to repeal the very law he made necessary in the first place. And giving very little information to his fellow Senators, he convinced six of them to cosponsor the same. [40]

Senator Paul Bussman said, via Facebook post, ” It was my understanding that this legislation would simply remove government from the practice of medicine in an effort to improve individual patient choice. Now that I know the full scope of the legislation, I cannot support SB289 and will not vote for it in committee or on the floor of the Senate.” [35]

Thankfully, a media storm has befallen Dr. Stutts, and today he announced he would voluntarily withdraw his bill. He does, of course, deny any motivation related to Rose Church’s death. [26]

Caring for new families is a privilege I don’t take lightly. I am blessed to work with an amazing group of nurses that, hopefully, will NEVER let such a scenario take place. In order to have great outcomes, we have to be diligent and methodical. I was already practicing when Rose’s Law was passed. It is imperative for staff to remember just how important standards are in Obstetrics.

When things go wrong- they go wrong fast. Listen to your patient. Treat your patient, not the monitor. And always, always stay vigilant.

As we move toward change in our country, state, and county, we have a responsibility to understand the implications of our vote. Party lines are no longer clear or sensible. Integrity should be priority number one. Ask questions. Accept answers, not promises.

Pay attention. Be blessed, Y’all.

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