April 15, 2010

Where You Birth DOES Matter

As a Lamaze Childbirth Educator, I strongly subscribe to the Lamaze Approach to Birth. One of their key beliefs is: “Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.”

I chose to write about this topic because as a labor support doula, I have seen firsthand that certain hospitals tend to lean more toward a conservative approach than others. These more conservative hospitals may accommodate a large number of high-risk patients, and as a result, their general approach may be geared toward high-risk care regardless of the birthing mom’s needs. While many women put a heavy emphasis on choosing a care provider, they may not take into consideration what hospital or birth center the care provider is associated with.

I have interviewed a traveling Labor & Delivery Nurse that has worked at several different hospitals, as well as a mother of three that has birthed at a NYC hospital, a birth center, and at home. Both of these interviewees had wonderful perspectives on how the place of birth DOES effect your birth experience.

Rosalie Hunt is currently a Labor and Delivery Nurse at Weill Cornell on the Upper East Side of NYC. She completed the nursing program at John Hopkins five years ago and has been working in labor and delivery ever since. Her first experience out of nursing school was at Sibley Memorial, a community hospital in Washington, DC where she worked as a Labor & Delivery Nurse for 4 years. She moved to NYC and is currently working at Weill Cornell, a teaching hospital.

Right off the bat, Rosie explained to me some of the differences between a community hospital and a teaching hospital in terms of her experience as a Labor and Delivery Nurse (L & D Nurse). She explained that teaching hospitals are much larger, affiliated with a university, and they have higher level (3 & 4) NICU’s (Neonatal Intensive Care Units) as well as specialty maternal fetal medicine physicians that deal with high-risk moms. In the community hospital, the NICU level is lower, meaning that they could not take babies under 32 weeks, or twins under 34 weeks. Community hospitals are primarily designed to care for low-risk mothers.

Since community hospitals are not directly affiliated with universities, there are no residents or medical students, just the attending physicians, midwives, and nursing staff. The smaller staff allows for more intimate, direct care from the staff, especially the nurses. As a nurse, Rosie was the one that checked for dilation, and was the liaison between the laboring mother and the doctor. While at a teaching hospital, the patient may be visited and checked on by one or more residents and/or medical students, and there will be more “traffic” through the room. (Side note: I recently attended a birth at Mt Sinai here in NYC, and the doctor asked if a medical student could watch the birth. The doctor explained that this would be a good learning experience for the student, since the hospital so rarely saw unmedicated births.)

Even when deciding amongst different teaching hospitals, it is important to take a closer look at the intervention rates. They can indicate if the staff deals more often with the high-risk or low-risk patient. For example, New York’s St. Lukes/Roosevelt (which houses a birth center) tends to have lower risk women and lower intervention rates, 23% cesarean rate, compared to
New York Presbyterian Hospital (Columbia University) with a 39% cesarean rate
and Weill Cornell close behind with 37%. Rosie explains that a low-risk laboring mother birthing at a “higher risk population facility” may be subject to more routine interventions intended for the high-risk woman. She also explains that with more routine interventions, such as full time EFM (external fetal monitoring), higher use of pitocin and more inductions, the nursing staff does not often have an opportunity to see unmedicated births. So for those looking to have an unmedicated birth, it may be of note that the nurses may not be used to seeing a natural birth and experiencing the sounds, movements and behavior that goes along with it. This may leave the nurse uncomfortable and not sure how to support the mother. Rosie suggests: “When looking for a place to deliver, look at your health, your pregnancy, and your philosophy and desires for birth and try to match it with a facility and practitioner where you are the norm and not the exception.”

The second interview was with Liz Fraser, a mother of three. Liz had her first baby, Liam, 4 years ago at Weill Cornell Hospital. Her second baby, Owen, was birthed 2 years ago at the Birth Center at St. Lukes/Roosevelt and her third baby, Sloane, last month at home with a midwife. Since Liz was in three very different settings for her births, I figured she can give a very personal account of what she liked and didn’t appreciate about the different settings.

Giving Birth In A Traditional Hospital Setting:
Deb: Did you find the staff was helpful and respectful of your wishes?
Liz: Once in the room, yes. But I do remember there being a reaction when I gave the birth plan to the admitting nurse.

Deb: What was the reaction?
Liz: She rolled her eyes.

Deb: Did you find the hospital protocol a hindrance to your wishes?
Liz: Luckily, I had the walkable EFM (external fetal monitor). Had it not been for that, it would have been really annoying being connected to the machine with limited movement the whole time. Our nurse also allowed us to have more than 2 people in the room [which is the norm]. Having the extra people really helped.

Deb: How was the hospital staff supportive?
Liz: The first nurse, I really liked. However, when the shift changed and the second nurse came in, the whole air of the room changed. The focus was not on me – the patient! I was just about to go into the pushing stage and she was reorganizing and straightening up the room. The attitude of the second nurse created a certain tension that had not been there before.

Deb: Can you talk about the pros of the hospital setting?
Liz: Having the immediate access to care was definitely a pro. It was my first time giving birth and I felt very confident in the care I was going to be given.

Deb: Can you talk about the cons of the hospital setting?
Liz: The potential for restriction: of movement, food, and support. I really lucked out since I had the walkable monitors, we snuck food in and I had all the people I wanted with me. I REALLY did luck out!

Giving Birth At The Birth Center
Deb: Did you find the staff was helpful and respectful of your wishes?
Liz: Yes, once we got to the Birth Center, but not in triage on the L & D floor. They didn’t really seem to care and were not very responsive. It was not until I vomited in the hallway that they seemed to pay attention to me.

Deb: Did you find the hospital protocol a hindrance to your wishes?
Liz: Yes, the whole 20 minute monitoring upstairs [in the L & D triage] was very annoying. But once we entered the Birth Center, it was like angels started to sing!

Deb: How was the hospital staff supportive?
Liz: The nurse was so helpful! It was so wonderful to have the tub filled and ready to go. There was no waiting and everything was ready for me to have my baby. I also really liked that Dr. Wong was there the whole time. She wasn’t putting any pressure on me, she was just there as things progressed.

Deb: Can you talk about the pros of the Birth Center setting?
Liz: It was not hypermedical and very casual. This helped me relax. As I said before, having the privacy and relaxed atmosphere was key for me. I spent a fair amount of labor in the huge whirlpool tub and then transitioned to the queen size bed. We could also bring in whatever food we wanted – although the smell of the food in the room didn’t really help me that much.

Deb: Can you talk about the cons of the Birth Center setting?
Liz: There were none!

Giving Birth At Home

Deb: What was your experience like giving birth at home?
Liz: It was nice not to have to go anywhere. That was really key for me. I figured, I am not getting medication, so what is the point of going anywhere. It also felt good not to have any routine medical procedures done. Cara, the midwife, unobtrusively checked the baby’s heart rate with the doppler scope. Other then that she just observed and gave me space to have my baby. I was not even aware of her medical supplies and instruments tucked away to the side

Deb: Can you talk about the pros of your home birth?
Liz: The experience itself as a whole, was very positive. I didn’t do this as a statement – it was just something I did. I liked being in my space with my people and then afterward, everyone [the midwife, and the doula- me!] left and we went on with our lives.

Deb: Can you talk about the cons of your home birth?
Liz: I didn’t think about the advantages the hospital and birth center provided. I was catered to in recovery from the staff. They had ice packs available at my request. I also had 24 hours between giving birth and going home. I forgot how nice it was to have the nurse’s support afterward. If the baby started crying, the nurse took care of him. At home, I didn’t allow myself the recovery time.

Deb: Any final thoughts you want to share?
Liz: Really think had about what kind of environment and experience you want and figure out what setting is going to provide you with that vision.

I couldn’t agree more with the two lovely ladies I interviewed. Take the time to figure out what you, as a mother, want out of your birthing experience. If the place, staff and care provider you choose does not approve of or have confidence in your birth preferences, you will be fighting an uphill battle. With so many options available, please take the time to think about what is best for you, your family and your baby.



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