Welcoming Baby Safely

A Safe Delivery

Consider these factors when choosing a maternity hospital

by Lisa Esposito 

W

HEN YOU’RE pregnant, deciding where to have your baby is a practical and personal matter, an educated and emotional choice. Asking questions and doing your own research in advance helps you make an informed decision – one you feel comfortable with – about where you want to give birth. Where you deliver your baby is closely tied to your maternity care provider, of course. “People are usually going to make that decision based on their first finding a physician or midwife they feel that they connect with,” says Dr. Jennifer Frink, an OB-GYN and medical director of the women’s health service line at Ascension Michigan, who practices out of Ascension Borgess Hospital in Kalamazoo. Shared decision-making is an important health care approach, Frink says. “You want your providers – physician or midwife – and the hospital to embrace this philosophy,” she says. “Your concerns, your fears, your wants and hopes about how the labor experience goes – you want all those components to be heard and valued by the care team that’s working with you. By the same token, you want to have a team of professionals that, once they listen to those things, are going to give you some options that are medically appropriate for you.” Checking each hospital’s quality data can help ensure the best outcomes for you and your baby. Knowing what you want in terms of labor and delivery options helps you and your doctor shape an individual birth plan. Strong support – from breastfeeding guidance to having your partner at your side – makes a huge difference in this unique, unforgettable experience.

Key quality metrics

Public data on maternal and fetal outcomes is increasingly available from individual maternity hospitals and statewide websites. If you can’t find it, ask. The U.S. News ratings of Best Hospitals for Maternity Care can help; see Page 83 for high-performing hospitals and usnews.com/bestmaternityhospitals for more information. The following indicators can help you compare facilities:

C-section rate. Vaginal deliveries, when possible, are associated with fewer risks and better outcomes than cesarean sections. To gauge hospital quality in general, ask or search online for C-section rates. Data shows that a facility, not just individual physicians, drives C-section rates, says Dr. Holly Loudon, an OB-GYN and chair of the department of obstetrics, gynecology and reproductive science at Mount Sinai West and Mount Sinai Morningside in New York City. “It’s really important to look at that C-section rate and compare it with other hospitals in the region when you’re choosing where you want to deliver,” Loudon says. High-risk academic centers often have a higher Csection rate because they have more highrisk deliveries and multiple births.

VBAC rate. In the past, it was almost assumed that women who delivered their first babies by C-section would deliver any subsequent babies by C-section, as well. However, a vaginal birth is possible in many cases. Two similar terms are used for this option. TOLAC, or “trial of labor after cesarean,” and VBAC, which means “vaginal birth after cesarean,” and implies success.

An uncommon but possible complication is when the scar on the uterus from the previous C-section separates during the vaginal birth attempt, known as uterine rupture, which is a medical emergency. Women interested in VBAC receive counseling from their doctors to weigh the risks and benefits.

NTSV C-section rate. This is the C-section rate for first time mothers with lowrisk pregnancies; it stands for “nulliparous, term, singleton, vertex.” In other words, these women aren’t having a multiple birth like twins or triplets, aren’t delivering prematurely and their baby is not in a breech or other higher-risk position during birth – yet they’re undergoing cesarean sections.

Early elective delivery rate. When C-sections are scheduled (or labor is induced) before 39 weeks of gestation – without medical necessity – it’s known as early elective delivery. A high rate is considered a red flag in terms of maternity hospital quality. “We know that babies that are born before 39 weeks ‘just because’ don’t do as well as babies that are allowed to deliver when their moms go into labor naturally,” Frink says. “We also know that people who have inductions before 39 weeks ‘just because’ tend to have a higher risk of ending up with a C-section.”

Early deliveries aren’t always avoidable,

she notes. But there are pretty strict criteria about when that’s the case.

Episiotomy rate. An episiotomy is a surgical cut made to the vagina during childbirth. Routine use of episiotomy is not recommended, except when indicated in certain clinical situations. “Episiotomies have become something that used to be done routinely and now are very rarely needed,” Loudon says.

Questions for your team

Items to address about your maternity care include: l Does the facility have maternal-fetal medicine spe-

cialists or perinatologists? For women in a high-risk category, this is pertinent information. l Is there the option for laboring with a midwife or doula? When hospitals have these support components, C-section rates are reduced, notes Dr. Julia Cormano, an OB-GYN and assistant professor of obstetrics, gynecology and reproductive sciences with UC San Diego Health. l Is group prenatal care an option? Programs like CenteringPregnancy allow expectant mothers at similar pregnancy stages to receive prenatal education and social support in a group setting. Emerging research suggests that group prenatal care is associated with a lower risk of having a preterm birth or a baby with a low birth weight. l What pain-control options are offered, including and beyond epidurals? What labor positions can you deliver in? Can you walk around? Are birthing balls or birthing tubs available? Birthing balls can enable alternative labor positions involving leaning or sitting on the ball. Birthing tubs can make movement more comfortable during labor and may enable water births for low-risk, single, full-term pregnancies. l Can you have at least one support person with you? If you’re having a doula at your birth, make sure that person doesn’t “count” as the single support person. l Will you have induced labor? What goes into that decision? Certain pregnancy complications or medical conditions may make inducing labor safer, rather than waiting for contractions to start. l Does your facility offer VBAC/TOLAC? If you’re interested in VBAC, ask if the facility allows it. Because trying to have a VBAC comes with the remote risk of uterine rupture, a hospital must be equipped to quickly respond. “The risk is less than 1% for an average patient undergoing a trial of labor,” Cormano says. “But it can be a very dangerous outcome. It requires an emergency C-section. It requires being in a setting where people can respond within seconds.” l Do you offer gentle C-section? “We’re doing more with what some people are calling ‘gentle cesareans’ or ‘family-centered cesareans,’ where we use clear drapes so you can see your baby right after they’re born through a clear drape,” Loudon says. “And then have immediate skin-to-skin contact and even breastfeeding right away.” l Is delayed cord clamping available? That allows extra time for nutrient-rich blood in the placenta and cord to flow to the baby. If your pregnancy is considered high risk, you might also want to know if the hospital

has a neonatal intensive care unit and if an anesthesiologist and pediatrician are available around the clock. How often can you see your baby in the NICU? Some hospitals offer parents tech options like real-time video access to their newborns. If your baby unexpectedly is in need of NICU care, and the hospital does not have a NICU, where does the baby get transferred to?

Your concerns, fears and wants should be valued by your care team.

Breastfeeding support

Breastfeeding is shown to be optimal for babies, but it’s definitely a learning experience for new mothers. Ask about international board-certified lactation consultants on staff.

You can also look for Baby-Friendly facilities. Baby-Friendly hospitals and birthing centers are designated as such for their high standards in supporting and enabling breastfeeding as soon as possible after birth. Rooming-in for healthy babies and mothers, and maternity staff that’s fully trained in breastfeeding care and problem-solving for feeding difficulties, make continued breastfeeding more likely when families go home. l