Monday, April 29, 2013

The nursery: DON'T forget to ask these important questions

Attending more births at various hospitals, and working in a postpartum hospital setting for several years now, has gotten me fired up lately on the topic of the nursery (and postpartum floor in general) as pretty darn important in terms of your "birth" experience. Postpartum recovery and breastfeeding are important parts of birth (and the reproductive life cycle in general), and the policies and practices at hospitals can vary as widely in the postpartum setting as they do in labor & delivery. Most people will spend more time - sometimes 2-4 times as long - on the postpartum floor, yet most lists of questions patients are encouraged to ask are largely limited to the portion of their time in L&D.

That includes, I admit, the resources in my own advice kit. Even the questions that are suggested - "are babies given formula routinely?" - your obstetrician and even your midwife are very unlikely to have a clue about. Doulas are aware of, and often frustrated by, differences between nurseries, but I think even we don't see the full impact because we usually leave a few hours after birth. But I am starting to really bring it up when I talk to prospective doula clients or anyone who is thinking about where to give birth. When two hospitals seem equal on the L&D side, what happens after birth can really tip the balance.

DO NOT assume that a touchy-feely, midwife-friendly, natural birth-heaven L&D floor translates into great postpartum and breastfeeding support. They are usually totally different floors with different managers, policies, doctors, and cultures. A hospital in a city where I used to work has one of the absolute best reputations for L&D in the doula community - but a negative reputation for the postpartum floors. Among other issues, this hospital refused to hire lactation consultants because "all of our nurses are trained in breastfeeding support". People would come out of there complaining "everyone told me something different" and end up with really difficult breastfeeding experiences. Especially sad because so many of those moms had gone in so committed!

Why is this so important? How different can postpartum policies be, really? Here are some questions that suggest how nursery routines can have a real impact on the postpartum experience and breastfeeding. They are too detailed to be useful questions for everyone to ask - don't worry, I'll go over more practical questions later - instead, they are here to illustrate things that can make a big difference, but which few parents contemplate:

1) Admission: How quickly do the nursery nurses come to do the admissions? Within 20 minutes? Within an hour? How good are they about keeping the baby skin-to-skin AFTER the initial meet-and-greet with mom, or how pushy are they about getting their tasks done? How much stuff do they pack into the first session (are we seriously getting footprints before the baby has eaten?)

2) Routine separation: Is there routine separation of mother and infant for any reason? Car seat test, hearing test, circumcision, blood draws, exams? What about after a c-section? What about after a planned c-section?

3) Late preterm infants: What is the routine for a baby that comes between 34-37 weeks, also known as late preterm? Especially for the 36 weekers - are they routinely taken to the special care nursery even if they are doing well? On the other hand, are the babies that stay in regular postpartum given extra care and support, and are they held long enough before discharge to ensure they are feeding well?

4) Blood sugar testing: What is the protocol for testing babies' blood sugar? Is it tested routinely for all infants? Is it tested only for babies considered at higher risk, and if so, which babies are those (large for gestational age, small for gestational age, infants of diabetic mothers, etc. - what about a mother who is not diabetic who just happens to have a large baby?) What is the "cut-off" where the blood sugar is considered to be low - 45? 40? 35? Are babies allowed to breastfeed before being supplemented for low blood sugar? Does the hospital have donor milk available for supplementation?

5) Baths: When is the baby bathed? Within an hour of birth? After a delay of 6 or 12 hours? What about unstable babies - those with blood sugar issues, or late preterm babies, or breathing troubles - are their baths delayed until they are more stable?

6) Lactation: When are lactation consultants available? Days, evenings, nights? Weekends, holidays? Are they International Board-Certified Lactation Consultants (IBCLCs), the gold standard for lactation support, or are they RNs with other certifications? Are they dedicated to providing lactation support, or are they also RNs with their own assigned patient loads? What is the ratio of IBCLCs to patients - can you expect to see one every day, or only the day of discharge, or only if you verbalize to your nurse that you are having trouble? Are you guaranteed to see one? What training do the nurses have in providing lactation support?

Do these questions make a big difference? Let's draw an illustration of two nurseries:

Hospital A: Hospital A does not allow babies to stay with the parents after a planned c-section. They may greet and hold the baby for a few minutes, then it is taken for observation in the nursery. Stable late preterm babies are also held in the NICU for 12 hours before being allowed to room-in, but may be discharged after 24 hours if they are still stable. Babies do 20-30 minutes of skin-to-skin with mom after vaginal deliveries, then all babies are bathed within an hour of birth, whether or not they are in distress, and they are also weighed, measured, and footprinted. Their blood sugar is tested. Any baby with a blood sugar of 45 or lower is supplemented with formula to bring their sugar up. Hospital A trains all of its nurses in lactation, but only has lactation consultants available in the mornings, on weekdays - the nurses are expected to take care of most of their patients' breastfeeding support needs (while also taking care of 4-8 patients a shift). All tests and the pediatricians' exams are done in the nursery, so babies generally spend 2-4 hours a day in the nursery, where they are bottle fed formula if they get hungry.

Have you given birth in a hospital like this? I'm pretty sure thousands of people have!

Hospital B: Hospital B does skin-to-skin routinely in the OR after a c-section as long as the baby is stable, and the baby stays with the parents throughout recovery. All rooms are "LDRP" where the family stays in the same room throughout labor, delivery, recovery, and postpartum, so they do not have to move. Stable late preterm babies may stay with the parents, but are held an extra day past normal discharge to ensure they are doing well. Babies do unrestricted skin-to-skin after all vaginal deliveries, are are only moved after they have at least attempted to breastfeed, or if mom requests it. Admission procedures are done 1-2 hours after birth. Baths are done after a minimum of 12 hours to allow the baby to stabilize its temperature, and are held longer if the baby is unstable. Only babies at high risk have blood sugar tests. There is no nursery - parents room-in with babies 24 hours a day, and all tests and exams are done in the room. Lactation consultants are available every day until 7 p.m. and see every patient at least once before discharge. Hospital B is also training all of its nurses in lactation, with the goal of becoming Baby-Friendly.

Not many people get to give birth in a hospital like this - but I think almost all my doula clients, given the choice between the two nurseries, would like to be at Hospital B.

However, while you can start to get information and clues about how your OB or midwife practices, and by extension what the L&D may be like, all throughout prenatal care, you DON'T get the same experience of what postpartum will be like. It can be hard/impossible to find a pediatrician who you like with privileges at the hospital where you want to give birth; even then your pediatrician can only do so much to modify standard procedures based on your wishes, and can't wave their magic wand to make lactation consultants appear when you need them.

How CAN you get a feel for what the nursery is like? If your pediatrician does work at a hospital you want to know about, they are a good place to start. Even if they don't know about or can't control all the issues you bring up, it's useful for them to know what is influencing their patients' choices about where to go.

The next place to ask questions is the hospital tour. This is most informative if it's given by a member of the hospital staff, less likely to have much detail if it's given by volunteers who don't work there - but again, it's good for them to hear what matters to patients.

Next, and possibly most useful, is of course - your friendly local doulas. Doulas see some and hear more about what our clients experience in the postpartum setting. We will not be shy about telling you what we think - but you need to ask, and let us know that you want an honest answer.

So what questions SHOULD you be asking all these people? Here are my suggestions - additions and revisions gladly accepted:

For all parents

1) What is your policy on skin-to-skin after birth? If the baby and I are stable, is there any time limit on how long we can stay that way before they have to be checked?

2) When do you do the first bath? What if my baby is breathing a little fast or has low blood sugar, do they still get their bath then? Can we decline a bath? (you can always decline a bath - but if they say "no" you know you're working with less-than-flexible people)

3) What are the reasons you take babies to the nursery? Which tests and exams are done there, and which are done in my room?

4) Do you ever give breastfed babies formula for any reason? What about water or sugar water? Would you ask my permission before doing this?

5) Are there lactation consultants available? How many times can I expect to see one? What about if it's the weekend? What kind of training do nurses have to help with breastfeeding? Is the hospital Baby-Friendly or planning to become Baby-Friendly?

6) Do all babies have their blood sugar tested routinely?

For diabetic mothers, or women with a history of large babies

1) How often will you test my baby's blood sugar after birth (or will you test it if my baby is above a certain weight)? How long will it continue to be tested?

2) What is the cut-off for when blood sugar is considered to be low? Can I breastfeed to try to bring it up before deciding to supplement?

3) If the baby needs supplementation, do you have donor milk available? Can you help me spoon or cup feed or use a supplemental nursing system at the breast so the baby does not get confused between breast and bottle?

4) Can I pump or hand express colostrum before my baby's birth, freeze it, and bring it in to use in case my baby needs to be supplemented?

What to do with this information?

First of all, use the information you gather to inform your decisions about where to give birth. You might be considering two hospitals that both have L&D environments you like, but when you add the postpartum piece to the balance it really swings the decision one way. If possible, write a letter to the hospital you are leaving or deciding against and let them know what swayed your decision. If you can, definitely write a letter of praise to the hospital you chose and let you know what made you happy about your care!

Second, prepare. This lets you know what you may be up against in terms of routines at whatever hospital you choose. If the hospital routinely supplements babies in the nursery, keep your baby with you as much as possible and make a sign for the crib that says "No bottles!" for the times that you are apart. Or maybe you'll find out that you need to be extra-pushy about getting your skin-to-skin time - you can ask your support people to try to head off the nurse for you and protect your space.

If you have really important and pressing issues with the answers to these questions, the place to go is the nurse manager. You can't sit down and ask them your list of questions, or take up small issues with them. But if you know you will be having a c-section, and everyone you talk to shrugs and says "It's our policy to take the baby straight to the nursery for 6 hours even if you want the baby to stay with you" - you need to speak with the person who signs off on the policies. Ask to speak with the nurse manager of L&D and/or the nursery. Take your concerns to them as an informed consumer and someone with options - especially for a planned c-section, you can easily take your business elsewhere.

What about your birth plan? The postpartum experience generally does not get covered in most birth plans. A good, simple birth plan usually says something like "We plan to exclusively breastfeed, and we do not want to be separated from the baby; if the baby is separated from us for any reason [partner/family member name] would like to accompany the baby at all times". This is fine.

If you have very specific desires/needs, you can write out something VERY brief for your postpartum nurse. For example (for a diabetic mom): "Thank you for taking care of us! We appreciate your support while we are learning to take care of our baby. We are planning to exclusively breastfeed - please no bottles or pacifiers for any reason without discussing with us first. We know that our baby's blood sugar will be checked for the first 24 hours and have discussed it with pediatrician Dr. _____. If breastfeeding does not bring up a low blood sugar, we are OK with using formula but would like to give it in a cup."

Finally, remember as you are asking these questions and making these requests that you are doing it NOT just for yourself and your baby - but for the people who come after you. When hospitals see that these issues are becoming important to their consumers - their patients - they start to shift, however slowly it may happen. Just by asking, you make a difference!


Kristen said...

What a helpful and thorough post! Definitely bookmarking this for my doula clients. Thank you!

Melissa said...

Don't forget you can also ask your friends who have given birth if they have a similar birth philosophy (or whatever you want to call it) as you. If you know that you share the same ideals/outcomes for birth and they've already had a kid, you can definitely ask them what they thought of their experience. It won't answer all these questions in depth, but could help rule in or out some places.

Cory Ellen said...

Really good advice, thank you! Sometimes we get so focused on birth that we really don't pay enough attention to what happens after. Doulas can be a great resource for info about local hospital practices.

Getogy said...
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Terrie Watkins CNM said...

So glad attention is being given to this issue. I've frequently (as a midwife) been able to achieve the parents goals for birth, only to have the baby taken for "eyes and thighs" and bath, glucose etc. before mom and dad get a chance to meet their baby. Perhaps if there is consumer pressure, policies and routines can be changed.