Hospital tour

Today I went on a tour of my local hospital's maternity center with another couple. He is a colleague of my husband's, and his wife is expecting their first a few weeks after me. We are both planning to give birth at home, but we wanted to check out our local hospital to see what it's like if we needed to transfer. We didn't specifically mention our home birth plans to the nurses giving the tour, since we wanted the tour to focus on the hospital's policies. I would have mentioned it if they had asked, but they assumed that we were seeing one of the hospital-based midwives or OBs.

Some numbers and stats:
Our hospital serves a town of 15,000 and any neighboring communities. It sees at most 300 births per year. The hospital doesn't have a NICU. The physicians and anesthesiologists are both on-call rather than in-house. There are two OBs and one nurse-midwife who rotate call, so you have a 1:3 chance of having your care provider present at your birth.

The hospital has six LDRP suites. They all have about the same setup and decor, but some of the rooms are larger than others. If they're really busy, some women will be shunted off to another area for their postpartum stay.

Between 90-95% of the maternity patients labor with epidurals, and almost all of those women also are on Pitocin. I asked the nurses what the hospital's c-section rate was, and they said it was definitely higher than average--"higher than ACOG standards" was what one nurse said. They couldn't give me any specific numbers, though. The second nurse explained that they are more likely to cut than not if they see anything funky on the monitors since they don't have a NICU in the hospital. They do not allow VBACs anymore, and a high number of the patients have elective inductions. The nurse said the hospital is trying to lower its c-section rate, but agreed with me that the no-VBAC policy and the high rate of inductions makes that difficult to change. They also see a lot of scheduled cesareans (I assume for women with previous c-sections, since VBACs are not allowed). Breech presentations are an automatic c-section.

I asked the nurse what would happen if a woman with a previous cesarean presented at the hospital in labor and refused a repeat cesarean. The nurse said, "Well, you can't do surgery without her consent. That said, we'd probably try to talk her into a c-section." They've never faced this particular situation, though.

Both the physicians and anesthesiologists live close by the hospital. I asked the nurse about their decision-to-incision time for an emergency situation, and she said it's 30 minutes or less. However, they can do it in less than that. For example, she remembered a recent cord prolapse that took 10 minutes from decision-to-incision, and that was with both the OB and the anesthesiologist having to travel to the hospital. That's pretty impressive for a small rural hospital, considering that neither the OB or the anesthesiologist are in-house. It makes me wonder why they won't allow VBACs with the ability to assemble an OR team that quickly. I mean, I know why--ACOG's 1999 policy of "immediate" availability that was interpreted to mean 24/7 in-house availability--but still...

Admittance and labor policies:
I asked the nurse what were the standard admittance procedures, and she was fairly vague. 20 minute admission strip? It sounded like it's a standard routine, and I wasn't able to get a good answer if it's easy to decline it or not. IV/saline lock? She said that's something to discuss with your midwife or OB and put on your birth plan. They do try to work closely with a woman's birth plan, so if it's signed off, it shouldn't be too much of an issue. That said, 90% + of women have Pit & epidurals and/or IV pain medications, so it's pretty rare that a woman won't have an IV. Monitoring? They do intermittent monitoring if the woman requests it and, obviously, if she doesn't have Pit or an epidural. They do not have wireless monitoring (telemetry) or waterproof telemetry. Eating and drinking in labor? Both nurses said "don't let me see it, and don't tell me you've done it!" Sounds like we have a "don't ask, don't tell" policy here! They can't provide the laboring woman with anything but ice chips and popsicles (and IVs, of course). But they said to go ahead and eat/drink when they're not around; that way they won't have to report it to the anesthesiologist, who doesn't like women to eat or drink during labor. They emphasized that they encourage women to eat freely for as long as they're home, since food intake is restricted in the hospital.

LDRP room.

Infant warmer & fetal monitor to the left of the bed.
Notice the spotlights on the ceiling--those always creep me out for some reason.

View from the bed.

The hospital has birth balls and (smallish) jacuzzi tubs for laboring in. The first nurse we talked was very encouraging about laboring unmedicated. I got the feeling that she likes working with moms who want to be upright and mobile, especially with the high rate of epidurals at this hospital. She said that if you wanted to go without drugs, they'd encourage you to use the birth ball or the tub, to walk the halls, and to move around. You have to get out of the tub once you're pushing, though. The tubs are fairly small: standard length and perhaps a bit deeper than a typical tub, so there isn't a lot of room to stretch out and move around. Showering might be a more comfortable option at this hospital.

Jacuzzi tub & bathroom
(tub is to the left on the bottom photo)

The nurse-midwife is more used to women laboring and pushing in non-conventional positions, whereas the two OBs will likely request that you lie on your back, especially as the baby is getting closer to being born. I asked about how often they do episiotomies, and both of the nurses said "we don't do them any more." One of the nurses got a piece of paper and did the standard demonstration of how it's so much easier to tear once you already have a cut. (She also teaches the hospital's childbirth classes.) Instead, the OBs and midwife are fairly hands-on with the perineum. The nurse said the OBs will typically apply pressure to the baby's head and the woman's clitoral area, while "ironing out" the perineum. (Doesn't that sound fun!? I'd rather have nothing done to me at all, thank you very much).

They have Stryker maternity beds, which are my least favorite among the varieties of maternity beds. Some of the other brands such as the Hill-Rom can adapt into a nearly sitting position with a U-shaped cutout, so it's almost like a birthing chair. The Stryker, though, is pretty much only set up for the stranded beetle position. The first nurse got out the squat bar and also mentioned that unmedicated women often like to labor on their knees, resting their arms on the elevated back of the bed.

Baby care:
Right after the birth, the baby is taken to the nursery for weighing and measuring, then brought back to the mother. The baby spends a few hours with the mom, then goes to the nursery for about 3-4 hours for glucose heel pricks, blood pressure checks, bathing, etc. After that the mother can request either rooming in or nursery stays for the baby. This is an improvement over the mandatory 24-hour nursery stay that the hospital used to have several years ago, but the mother is still separated from her newborn twice in the first several hours.

Things I forgot to ask about:
- What happens to baby & how long is it separated from the mom if she has a c-section
- If they have TENS units for laboring or for post-cesarean pain relief
- If they have lactation consultants available
- Breastfeeding policies (do babies get sugar water, bottles, and/or pacifiers while in the nursery?)
- Number of people allowed in the room while the woman is laboring
- If photographs/videos are permitted during the birth

Overall impressions:
A woman's labor experience at this hospital will depend on several variables, some of which she controls (whether or not she chooses an induction or epidural) and others she does not (which nurse is on duty, which OB or midwife is on call). There was a noticeable difference even between the two different nurses we talked with. The first one we met seemed a lot more accommodating of individual women's requests, while the second one who joined us halfway through our tour kept saying things like, "well, safety does need to come first" and "we feel that a healthy mom and baby are more important than a vaginal delivery." Of course, you can request a different nurse if you don't mesh well with the one you're assigned to (assuming there's more than one on duty, which might not be the case in such a small hospital), but most women don't know that.

The hospital still has room for major improvements in its baby care policies, especially its initial separation of mother and baby and the later 3-4 hour long nursery stay (which you can refuse, but it would take some negotiating).

I was glad to know that the decision-to-incision time can be fairly rapid, even though the OB and anesthesiologist have to be called in to do a c-section. If I were needing to transfer for something like a prolapsed cord or placental abruption, we'd call the hospital and tell them to assemble an OR team while I was en route from home (5 minutes door-to-door going the speed limit). I'd make sure someone remained on the phone with L&D as we were driving in (or taking an ambulance, but transporting ourselves would be faster).

The hospital's high induction and cesarean rates are concerning. It's partly patient-led (via elective inductions) and partly hospital-led (via its no-VBAC policy and quick-to-cut approach). Small rural hospitals generally should have lower-than-average cesarean rates, since they transfer high-risk patients to larger teritiary hospitals that are better equipped to deal with certain complications of pregnancy and birth. If you're interested in avoiding an unnecessary cesarean, this might not be the best hospital for you, especially since they mandate that you have repeat cesareans after your first one.

With a 90-95% epidural/Pitocin rate and a higher than average c-section rate, I would be concerned that the staff is not used to working with unmedicated, spontaneous labors. Only 15-30 women give birth without anesthesia per year here, so the hospital is perhaps not the best place for women wanting to give birth without Pitocin or an epidural. Still, it is doable, if not optimal. Going into labor spontaneously, laboring without Pitocin or an epidural, hiring a doula, having a signed birth plan, laboring at home for as long as possible, and requesting a nurse who is supportive of your wishes will all increase your chances of a vaginal birth at this hospital.