Childbirth Philosophy 5: Our Birth Community

I've witnessed childbirth in a number of U.S. settings, as I described in Part Two and Part Three.  Here in Rural, I'm lucky to attend births in a unique community of expectant women, tolerant childbirth and pediatric providers, and very special Labor and Delivery unit at our small community hospital.  Unfortunately, this unique community is not available to all women; most of the U.S. does not offer the possibilities for tolerant childbirth alternatives we have in Rural.  Let me describe our local system.

1. The Community

Rural County is a sparsely populated Northern California county with an interesting mix of residents.  There are a fair number of socially conservative towns and neighborhoods, but close to the two major regional hospitals the political and social environment is fairly progressive.  There is a lot of interest in alternative practices of every kind, from body art to nontraditional medicine.  Within the latter category, herbal medicine, healthful diets (vegan, vegetarian, locavore), and non-Western modalities (acupuncture, Ayurvedic) have dedicated proponents.  No surprise, therefore, that our community of young mothers and potential mothers are interested in non-interventive and alternative birth practices, including water birth and birth at home.  

2. The Providers

At the small hospital where I attend births, obstetric services are provided by one obstetrician and one family doctor with advanced privileges (C/S, tubal ligations, etc.)  The majority of vaginal deliveries are attended by family doctors and midwives.  Since the closure of another prenatal practice earlier this year, my clinic provides the majority of prenatal and childbirth care.  Our providers consist of myself, two other family doctors, the family doctor with advanced privileges, a certified nurse-midwife, and a licensed or direct-entry midwife who has had a great deal of experience over an almost twenty year career.

My clinic prides itself on providing comprehensive prenatal care, including 

• medical appointments
• nutritional evaluations
• behavioral health evaluations for women who wish to receive psychological support
• a dedicated perinatal nurse coordinator

We also work with a childbirth educator, Kathleen, who is remarkable in that she is a busy home-birth midwife and a trusted community leader in the local birth community.

Our back-up obstetrician is a wonderful man, who--despite being traditionally obstetrical within his own practice--never pressures us to do things "his way" when we are attending our own patients.  He has faith in our reasonable limits before intervening and is always available to help us if a situation gets beyond our scope of practice.

The main pediatrician who provides services beyond the scope of family practice is another old-school practitioner with a wide comfort zone.  For example, he does not believe birth should take place at home, but he is invariably non-judgmental whenever an infant born at home needs pediatric evaluation in the first 24 hours of life, as occasionally happens.  He has also been a vocal supporter of offering VBAC at our hospital, even though this puts him on the hook for being immediately available should any complications arise during a trial of labor in a woman with a prior C-section.

There is a large network of home birth midwives in the community, and our providers work in a loose collaboration with several of them.  Some of them live further away from the town center where the hospital is located, so I have never met them in person.  In general, most of these midwives participate in our community collaboration to provide childbirth options to women, although--like any collaboration--there are disagreements and imperfect communication.

3.  The Hospital

As I mentioned before, the hospital where we attend births is a very small (65 beds), independent community hospital.  The Labor & Delivery unit has three labor/delivery/recovery rooms, two triage rooms, and four rooming-in rooms.  The unit calls itself The Birth Center, although clearly it is not an independent birth center, being part of the hospital and with all the technological devices of a hospital available.  I believe the name Birth Center was chosen because this unit tries to offer the amenities women look for when they choose a freestanding birth center.  (We don't have a FSBC in our community.)  Some of these amenities include labor tubs, a fairly liberal water birth policy (which requires renting a birth tub), and an atmosphere encouraging freedom of movement during labor, including the availability of a telemetry monitor if a woman wishes to walk while being monitored on Pitocin.  Some may argue with the use of the name Birth Center for a Labor & Delivery unit located in a hospital, but I do think our unit is the closest option to a FSBC in Rural County, and as such offers important options to woman giving birth.

Doulas are welcome at our Labor & Delivery unit.  We have an active DONA chapter locally and Kathleen runs a local doula project which funds doulas a small amount of money for laboring with women who can't pay a full professional fee.  A number of the doulas are on call and will come to the hospital to labor with a woman even if they have never met before, should a woman request support.  A couple of the staff members at my clinic also serve as doulas, and since two of them speak Spanish, this has been a great service to women in our practice.

Our hospital also is the only regional hospital offering VBAC.  Unfortunately, the VBAC policy is fairly strict because of the guidelines imposed by malpractice carriers.  A physician with C-section privileges must be in house while a woman with a prior C-section is in active labor.  As a result, not as many women VBAC in our community as used to, before the guidelines become so restrictive.  At one time, the hospital had a >70% VBAC rate and even won recognition for being so VBAC friendly.  Now that the risk pendulum has swung against VBAC, we are less successful.  I would love to see women lobby malpractice carriers for a more permissive VBAC culture.

Finally, our Labor & Delivery is unique in the composition of its nursing staff.  Many of the L&D nurses gave birth at home, and they bring their collective history of faith in the natural process of birth to their work within the hospital.  This is not to say, of course, that they don't agree with the use of technological interventions when these are necessary, but I believe their unique background helps maintain an atmosphere in which women can experience a relatively non-interventive birth.

I feel very lucky to practice in a community which is supportive of childbirth options such as those outlined above.  This is not to say that I feel our local system is perfect.  Some problems I see:

• Incomplete information provided to women considering alternative birth practices, including home birth, unassisted birth, and water birth.   

• Imperfect collaboration between standard prenatal care providers (myself included) and home birth midwives.  We are working towards a meeting of the minds on this issue, in the form of an open meeting between our clinic providers and the home birth midwives who have not previously been in contact with us. 

• The presence of a different childbirth philosophy at the other regional hospital, where birth is treated in the standard obstetrical model.  Due to other conflicts between the two hospitals, there is currently little opportunity to bridge the gap between practice styles, although I still hold out hope this may happen one day.

The old adage holds that it takes a village to raise a child, and I think the village participates from the day of conception.  I hope you have a better snapshot of what our rural birth community is like.

Comments

[sara]

Thanks. I also hate the OR, but C-sections are the best reason to be in there. And they are short!

[futureruralAKdoc]

thanks for the snapshot.

[dragonfly]

The setup you have there sounds really good....obviously nowhere is perfect but it sounds like all the health care providers work together so well for the benefit of the patient. Kudos.

[Sophia Nelson]

I gave birth to 3 wonderful children, all came in less than 15 minutes, and I experienced no pain at all.

As a matter of fact it was quite joyful!

I created the Zero Pain Child Birth Blueprint. You can read about it here:

http://www.scottchopchop.com/zpb

or here

http://sites.google.com/site/zeropainchildbirth/

Sophia Nelson

[Rixa]

Sounds like a great hospital you have to work in. I am curious to see what my local hospital is like and to see if I can help push for Baby-Friendly certification (and down the road, Mother-Friendly). Even though a hospital birth wouldn't be my first choice, I will am invested in seeing hospitals and the staff adopt practices such as water birth or become used to women who move around a lot and give birth in upright positions.

I think that a lot of people don't realize that there can be a very wide range of practice styles from one hospital to another. And definitely keep encouraging women to pressure for less restrictions on VBACS. I'm glad you're at least able to offer them and hope that will continue in the future.

[Theresa]

Hi So. Cal Ophth--we're lucky to have a few ophthalmologists in Rural, but there's always room for one more!

Hi Sara--I don't have C/S privileges because I'm not an "OR person." Can't stand being in the OR. Obtaining the privileges depends on where you plan to practice. In my rural community, you just need documentation of sufficient experience as a primary surgeon (usually obtained during residency) and proctoring for about 10 cases. In a more urban area, where the idea of a family doctor doing C/S is not as common, you might have to do a one year OB fellowship during which you obtain more C/S experience. My residency training would have given me enough C/S as primary surgeon (plenty of our grads had >75 cases, and a couple had >100), but again--not my thing.

[Sara]

Do you have C-section privileges? Or just first assist? How does one get them?

[Gary Levin]

Dear Rural Doc;

I have your blog in my RSS..it's great to hear what medical practice is like in a 'village'....
Do you have a need for a 'rural ophthalmologist'???

So. Calif Ophth