A Tale of Two Hospitals by Rachel Frier Carbonneau

A Tale of Two Hospitals 
a 2- part Series
Doula, Childbirth Educator, Wellness Coach
Part 1 of 2
It was the best of births, it was the worst of births...
Scratch that. Who am I to judge what makes a birth good or bad? This is not a one-size-fits-all sort of trade, where each client or patient can be expected to have an experience just like the ones before. On the contrary, each family and circumstance is unique, and no two births are ever quite the same. And what makes a birth “good” for one may make it very “bad” for another, and vice versa.
  Why, then, do we have a hospital systemand an approach to maternity
and labor-delivery care
that often leaves families feeling as if they’re part of an assembly line, shuttled through appointment after appointment, and eventually through a bewildering labor and birth experience, with little to no personalized attention?
  I could cite hundreds of different factors contributing to this feeling. At the top of the list might be the American healthcare system, generations of outdated obstetrical standards of practice, medical liability, and more. But this would entail pointing fingers and passing blame, and I’m pretty sure that approach never gets anyone real far.      
  Instead, let’s take a look at two emerging “tracks” in the types of care being offered by obstetric practicesand snatched up by expectant families. One is the natural model, which typically includes limited interventions and avoidance of pain medications, and the other is the pain-managed model, which typically includes an epidural or other pain medication, and a variety of other supportive interventions.
  As a doula, I primarily come into contact with families planning for a natural birth. “Natural” can mean a lot of things to a lot of people, but the core of this model is the understanding that birth is a natural, normal process; that nothing is an emergency until it is an emergency; and that for healthy, low-risk mothers, limiting interventions is the key to an easier and healthier labor. More recently, “natural birth” is becoming synonymous with “vaginal birth”—or, as my husband put it, “a baby exiting a vagina, as nature intended it to do.” Fundamentally, “natural” birth is a birth with limited medical interventions.
  Typically, such natural births are attended by a midwife or a natural-minded obstetrician, the former being more common (and more easily identifiable) for this group than the latter. Many of these births take place at home or in birth centers, and are peaceful and family-centric experiences. Some turn into hospital transfers, for one reason or another. Families choosing a home or birth-center birth must take the responsibility on themselves of preparing adequately for their labor, whether by preparing their home to host a birth, hiring a doula, attending childbirth classes, and/or doing extensive reading.
  Even with the rising trends of home and birth-center births, and families choosing to “go natural” in a hospital setting, intervention-limited maternity care just isn’t available to everyone who wants it. Midwifery practices book up incredibly quickly, and women who wait more than two or three months into their pregnancy to find a midwife might find that they have lost their chances at getting in. Other families live in a region where such care is unavailable, or is not covered by insurance. Still others “risk out” and find that they are denied access to midwifery practices. And others are simply not comfortable with or interested in that approach to care. For these reasons and more, many families planning for natural births will plan to labor and birth in hospitals, attended by an obstetrician.
  And of course there are many families who choose the pain-managed model, or an elective Cesarean- section, or any other number of birth styles from the buffet of services currently offered. (Note: please forgive the rhetoric here, and understand that the term “natural birth” is becoming a term of art and is in no way meant to imply that there is such a thing as unnatural birth.) In the pain-managed model, families typically include an epidural or other pain-relief method as part of their birth plan, and rely on doctors and the nursing staff to help them comfortably navigate their labor and birth.
  Each approach has its strengthsand it is up to the consumer to tap into those strengths when planning a birth. Regardless of where you birth and whom you birth with, you can have the type of birth you’d like. But it takes planning and preparation, and commitment to gathering information and working with your care providers. Let’s consider the case of two area hospitals, and their individual approaches to maternity care, as they respond to the growing demand for each of these two “tracks.
The Natural Model
  In an age when births in certain states may not legally be attended by a certified professional midwife (CPM), and birth centers struggle to remain open because of the crushing costs of liability insurance, acceptance of certified nurse midwives (CNMs) into one of our local-area hospitals offers a great opportunity for women seeking a natural birth in a hospital setting. Though it is not a replacement for home births or birth-center births, for many families it is a reasonable alternative. I’ve been told that having a midwife attend births in a hospital is the same thing as having a birth-center birth. (Aside: I remain skeptical of this, but that may just be personal opinion. Regardless, shouldn’t the choice be mine, and not a legislator’s? But that’s a separate argument.)
  One particular area hospital, at which births are sometimes attended by midwives who practice under the oversight of a medium-sized obstetric practice, has taken great strides to be more family friendly, and has recently won accolades for being the first baby-friendly hospital in the state. All rooms are private, and babies room-in with mothers after the birth. Though birth tubs are not available, the Labor & Delivery unit has access to an outside courtyard where mothers can labor in a peaceful garden setting (weather permitting).
And what about long-term support for brand-new families? The hospital offers daily lactation classes and has a team of on-site lactation consultants who visit new mamas within a day or so of the birth. Regular drop- in breastfeeding support is available for families who have returned home with their new babies, and the hospital offers a variety of workshops on Infant CPR, Newborn Care, and Grandparent and Sibling Support. Even with all these perks, it is still a new environment for most families (even for second-and third-time families, who are re- learning to navigate this setting), and there is often a steep learning curve. Your care
provider may have all the best intentions for you, and you may have read every book in Ina May’s library, but the hospital setting still requires a certain degree of navigation. What will be required of you at check-in? Will you have to go to triage, or will you be allowed straight back to a room? If you end up having a C-section, who will perform it, and who will be allowed to come to the operating room (OR) with you? And how can you best prepare to work with your birth team, especially with nurses you wont have met before?
  Families frequently tell me that their doctor is fine with them having a natural birthand then proceed to tell me that they’re not planning a hospital tour or childbirth education classes because they trust their doctor. But the hospital setting can have a huge impact on the birth and care provided by the obstetrician. Though a hospital-based obstetric practice may at the outset be just as naturally-minded as a birth-center based midwifery practice, often hospital policies or obstetric oversight limit the scope of the a particular doctor’s practice, or necessitate certain interventions or protocols.
  After all, it is still a hospital setting, and certain “rules” are inevitably in place. Unless you advocate for yourself strongly otherwise, you will likely have an IV placed, be monitored on the electronic fetal monitor for 20+ minutes out of every hour, and find yourself laboring in the bed. In other words, unless you are an informed consumer and know your options on these and other matters, you are not going to receive direct personal attention and guidance that is going to tell you otherwise. It is, after all, a hospitalone in which an average of 14 births per day is routine. With only 6 midwives on staff (on a rotating basis), it is unlikely that you will get consistent one-on-one attention, and less attention still if you are with a large obstetric practice.
  Overall, this hospital has proven itself to be one of the more natural-friendly birth environments in the area, and is quickly gaining a reputation for being one of the best places to have a vaginal birth after cesarean (VBAC). With skilled midwives and obstetricians on staff, and anesthesiologists readily accessible if needed, this hospital offers many families the best of both worlds: a comfortable, limited- intervention experience with easy access to highly trained medical personnel should need arise. But that is only one model and, as I said, birth is not a one-size-fits-all industry.
The Comfort Model
Having looked at one local hospital, lets consider another local hospital, one that has been rated by one area magazine as “the best place to birth.” This hospital does not specialize in natural birthto the contrary, the approach is that of keeping you comfortable during labor using a variety of interventions and medical tools. Though you can have an intervention-free birth there, it is often in spite of the hospital environment, and not because of it. But natural birth is not the primary reason most families choose this hospital. Many families opt from the outset not to go the route of natural childbirth, and select instead what has come to be known as “pain-managed” birth, in which the epidural and/or other pain medication are part of the birth plan. There are a variety of arguments in favor of this approach, some of them as simple as “I don’t want to be in pain.” For families whose labor will be induced, the epidural may seem to be the only way to withstand the intensity of artificial augmentation of labor. For others, having an epidural in place may be the only way to lower anxieties enough to allow nature to take its course. For still others, after a long medication-free labor, the epidural or other pain medication may finally permit the mama to rest and catch her breath so that she doesn’t risk maternal exhaustion. And of course, many families choose this hospital because that is what their insurance covers; birth preferences never even play into the equation.
  Hospital B is committed to making sure your labor goes smoothly start to finish, and will offer medication early and often to make sure you are comfortable. For those seeking a pain-managed birth, this is wonderful! You typically won’t have to wait in triage to hit some magical number of cervical dilation before they’ll put you in a room and get you your epidural. On the other hand, some families may arrive at the hospital a bit too early, with a long road ahead of them that will require other labor- management interventions as well.
  Like Hospital A, this other area hospital offers a number of amenities for expectant families. Though not all recovery rooms are private, all labor rooms are and the hospital is in the process of expansion to offer more and better space for birthing families. Babies may room-in with mothers after the birth, or may go to the nursery so that mama can get some rest. Because the hospital is not typically geared toward natural birth, tools such as birth tubs, balls, and stools are not available and squat bars are hard to come by. But what the hospital lacks in gadgets, it makes up for in the attentiveness of nurses, who
(at least to my eye, and without their actual staffing charts available to me) appear to be thicker on the ground than at other area hospitals.
  As for support for new families, Hospital B also offers daily lactation classes and has a team of on-site lactation consultants who visit new mamas within a day or so of the birth. The hospital also offers a variety of childbirth education classes to prepare for the birth, and a number of workshops on Infant CPR, Newborn Care, and other important preparatory matters.
  Even with these perks, the hospital is not easy to navigate, and the same questions apply here as at Hospital A: What will be required of me at check-in? Will I have to go to triage, or will I be allowed straight back to a room? If I end up having a C-section, who will perform it, and who will be allowed to come to the OR with me? And to this list of questions, I would add: What will be done to limit interventions? What will be done to keep me and my baby healthy and low risk? And how can I best prepare to work with my team, especially with nurses I will not have met before?
  To be clear, the challenge having a natural birth in this setting is not because of any ill will on the part of the nurses or doctors who practice there. On the contrary, the nursing staff there are quick to remind women that there is no sense in being a martyr and encouraging them to seek relief, and are very accommodating in helping women request and adapt to pain medication. Though this type of rhetoric can undermine the fortitude of a family planning a natural birth, that is not the nurses’ intent. For many families, this approach is probably a welcome reliefand much needed judgment-free permissionespecially, for women who are not wedded to a natural approach or who are seeking pain relief.
  And again this is only one additional model of birth. There are as many ways to birth as there are women in this world, and it is up to each family to decide which approach is best for them.

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