CPMC St. Luke's May Be A Slam Dunk If You Want To Have A Natural Hospital Birth

St. Luke's Hospital Labor & Delivery

St. Luke's Hospital Labor & Delivery

Yesterday, I went on a tour of what has been argued for years by homebirth midwives to be the best hospital in San Francisco to have a natural birth. Not having had occasion to transfer there myself, I was curious to learn about their facility and policies. This is what I learned...

One of the nurses guided myself and 3 pregnant couples on our 45 minute tour at 5pm on a Tuesday evening. She started by explaining that in labor, patients should come in through the main entrance, unless it is the weekend or after 8pm, in which case patients should enter through the emergency department off of San Jose Ave. There is a cafeteria on the 2nd floor that is open Monday through Friday from 6:30am to 6:30pm where guests can get hot food and snacks. 

Labor and delivery is on the 3rd floor. There are 3 delivery rooms and 3 triage rooms. The delivery rooms are smaller than the rooms at some of the newer hospitals like UCSF Mission Bay. The triage rooms are very small, and are used for patients who are not yet in active labor. Both the labor and the delivery rooms have attached bathrooms - although none of them have bathtubs, and only the delivery rooms have showers. 

All rooms, according to our guide, have telemetry units, also known as wireless fetal monitoring. This allows for monitoring of the baby without requiring that you be hooked up to a static machine at the bed. The monitor hangs around your neck so you can move about. 

The nurse estimated that St. Luke's does about 80 deliveries a month. On the evening of our visit, all 3 delivery rooms were occupied, and 2 out of 3 of the triage rooms were occupied. For that reason, we were not able to see an actual delivery room, just one of the smaller triage rooms. Our tour guide assured us, however, that it is very rare for them to be so full as to have to deliver patients in the triage rooms or reroute patients to another CPMC campus. 

One of the triage rooms at St. Luke's. 

One of the triage rooms at St. Luke's. 

Next, we went up to level 5 to the postpartum unit. The postpartum rooms are also small and uninspired. There is a hospital bed, a television, a fold out chair for partners, and a small sink area. They also have a connected bathroom with toilet and shower. The typical stay for a vaginal delivery is 2 days, and for a Cesarean section, 4 days. 

Postpartum room

Postpartum room

PROS

  • Midwives are the primary providers at all low-risk deliveries. There is a midwife and a physician in the labor and delivery unit 24 hours a day, 365 days a year. The physician attends deliveries only when it is deemed medically necessary.
  • Intermittent fetal monitoring is an option and wireless monitors are available in all rooms.
  • Group prenatal appointments are available in cohorts of 10 families per group. The program is modeled after the Centering Pregnancy model, but was developed by CPMC. In this model, prenatal appointments and pregnancy/childbirth education are blended into bimonthly group appointments. Afternoon and evening meeting times are available. The groups fill up months in advance, so sign up early.
  • The hospital started allowing VBACs in October of 2017. I do not have any more information on the requirements for a VBAC, policies, or rates of successful VBAC at St. Luke's.
  • Laboring patients are allowed to move freely during labor and to push in positions other than flat on their back in bed. In fact, our guide assured me that babies at St. Luke's do not have to be born in the hospital bed - that babies are born on the birth stool, in a squat, on hands and knees, and in a variety of positions. This is a BIG DEAL. I don't know of any other hospital in the Bay Area that will let you deliver your baby anywhere other than in the hospital bed.
  • Baby rooms in with mom.
  • A lactation consultant and social worker are available on the postpartum floor Monday through Friday.
  • There is no restriction on the number of visitors you can have in labor and delivery or postpartum.

CONS

  • The facility is old and the rooms are small.
  • There are no bathtubs in any of the rooms, and only the delivery rooms have showers. 
Ensuite bathroom for one of the postpartum rooms

Ensuite bathroom for one of the postpartum rooms

Unfortunately, our guide didn't have a very good grasp of the actual hospital policies or practices around things like GBS, VBAC, induction, eating in labor, C-section, or pain management options.

I was able to glean some information about St. Luke's C-section rate from online. According to the California Hospital Assessment and Reporting Taskforce, CPMC St. Luke's had a NTSV C-section rate of 21.7% in 2014. For reference, the statewide rate for that year was 26%. The NTSV C-section rate includes only first-time moth­ers giv­ing birth around their due date, hav­ing a single baby that’s po­si­tioned head down.

Without knowing much more about key procedures or policies, all of the obvious cons are related to the facility. And guess what - there's good news here. CPMC is currently in the process of building a new campus for St. Luke's. The new campus will be right next door to the current one, and is on track to open towards the end of August 2018. That's in 8 months, folks! So many of you reading this will benefit from the new facility, which is certain to be leaps and bounds better than this one. I'm told there will be bathtubs :-)

If you are healthy and are having a healthy pregnancy, then having your baby at home or in a freestanding birth center is the best option if you want to avoid a C-section or other restrictive or invasive procedures. That being said, if you are absolutely set on a hospital delivery, you should seriously consider St. Luke's for your care if you are desiring a natural birth. Having a midwife as primary provider and being able to deliver in the position of choice makes St. Luke's much closer to a mother-baby friendly model of care than most other hospitals in the Bay Area. I wouldn't be surprised if many of their other protocols are similarly progressive. 

In my opinion, once St. Luke's is in the new facility, it'll be a slam dunk for Best Hospital in the Bay Area for a Natural Delivery.

Addendum: Shortly after I published this post, the lead midwife at St. Luke's reached out to me by email to clarify some aspects of the facility that my tour guide hadn't been completely accurate about. Those updates have already been made in the body of this post. She also emphasized that along with the move to the new facility, St. Luke's was working to implement changes to make the midwifery-centered approach even stronger. This is really fantastic to hear. While a nice facility can certainly make your experience more pleasant, there is nothing more important than the values of the team that is providing your care. 

Kaiser Oakland's New Midwifery Care Offering: Pros & Cons

Kaiser members have been flocking to Walnut Creek in search of less medicalized births, and Kaiser Oakland has finally taken notice. In an attempt to draw back birthing women to Oakland, and to improve the hospital’s poor maternity care rankings, they have brought in six midwives, and with them, some big changes. 

Head midwife Anne Galko sat down with a roomful of doulas last week to give them the skinny on the new structure. As a home birth midwife, I attended the meeting with my colleague Firen Jones, glad for a chance to scope out the hospital. Although we mostly attend planned home births, we accompany the occasional transport or monitrice client to the hospital, so we like to know what to expect. There is much to be glad about, although the structural integration of the midwifery team is unusual. And there are certainly some areas that still need improvement.

First, the fact that meeting took place at all and that Anne was willing to meet is encouraging. While many hospitals around the country are still openly or passively hostile to doulas, birthing women are better served when hospitals recognize that doulas have become important members of the care team. Anne’s commitments to welcoming doulas and maintaining dialogue and transparency are commendable. 

The new midwife team is atypical in that they are there to teach the residents about normal birth, not to give direct midwifery care to patients. Midwives will not be providing any prenatal or outpatient postpartum care. The six staff midwives supervise all first- and second-year residents for births, and will be available around the clock except for Saturday and Sunday from 8am to 8pm. Anne hopes that eventually they will be able to add those shifts. Any women designated as low-risk will be managed by the resident/midwife team — including vaginal births after cesareans (VBACs). Higher risk laboring women will be managed by third- and fourth-year residents and a supervising obstetrician. 

Anne was clear that residents are supposed to check in with the supervising midwife before they intervene in any way, such as breaking a bag of waters or performing a vaginal exam. You cannot request a midwife without the resident — they come as a package deal. Although this will frustrate many women who would prefer to have just a midwife, the silver lining is that the residents will get plenty of experience with midwifery care.

There are lots of positives about the new hospital and team:

  • There is routine delayed cord clamping of one minute for cesareans.

  • They are trying hard to increase skin to skin between mother and newborn.

  • They are getting a TENS unit and nitrous oxide for pain relief.

  • Every room has more bells and whistles than in the old building, such as showers, fridges, rocking chairs, mirrors, and screens that can play calming music and meditation videos.

  • Every room has portable monitoring units (telemetry), meaning that women don’t have to compete for one or two telemetry units.

  • Low risk women can have intermittent monitoring. The protocol is to listen through two contractions every 30 minutes, and then to have continuous monitoring for 20 minutes every two hours.

  • Out-of-hospital midwives will be happy to know that clients who choose not to screen for Group B Step prenatally, and transport in labor to Kaiser Oakland, will be treated with antibiotics only with risk factors (greater than 18 hours of ruptured membranes, less than 37 weeks gestation, fever).

  • The hospital will not terminate care with people who refuse postdates inductions — although I imagine the pressure to induce from the staff will be extreme at 42 weeks.

Unfortunately, there are some major areas in which the built environment and protocols are far from the midwifery model of care. A huge drawback of the new facility is that it does not have a single water birth tub. Every room has a shower, but I am shocked — perhaps naively — that a new hospital could be built in this day and age without even a single tub in which to labor, let alone birth. With ample evidence of safety and benefits, I just don’t understand the deep-rooted fear the obstetric profession has of water birth.

Also defying current research, birthing women are not allowed to eat anything in active labor, although they may continue to drink fluids. Active labor is defined by Kaiser as six centimeters, instead of the more common four, but still, many women need some energy in the form of food to keep going through a long labor.

The ability for women to freely eat and drink in labor is part of the Ten Steps of the Mother-Friendly Childbirth Initiative, endorsed by the American College of Nurse Midwives and the Midwives Alliance of North America. A Cochrane review from 2013 concludes that “there is no justification for the restriction of fluids and food in labour for women at low risk of complications”. Kaiser has no evidence base to support this punishing policy. 

There are some other questionable protocols: 

  • Heavy use of Misoprostol inductions, despite a controversial risk profile.

  • Routine Pitocin shots after the birth of the baby.

  • Only three support people are allowed in the birth room. I’ve personally been to lots of births where the mother wanted more than three support people with her at some point. There’s definitely a place for clearing the room in certain circumstances, but having a blanket policy about something so personal and subjective is ridiculous.

  • The protocols around spontaneous rupture of membranes (SROM) don’t make much sense. Women are supposed to go to the hospital immediately upon SROM for evaluation. If they refuse induction, they are told to remain in the hospital, and can only go home to wait for labor Against Medical Advice, even though the risk of infection is higher in the hospital.

  • All women receive a routine ultrasound to check for breech at 36 weeks. We’re not sure if this means that there is no palpation being done prenatally or if the obstetricians don’t trust their palpation skills. Either way, it’s strange.

The doulas also raised a number of issues that their clients have experienced at the old and new Oakland hospital, which Anne promised to investigate. The list includes availability of hot postpartum meals, mandatory ultrasounds in triage, doulas not being allowed in the operating room, and nurses placing towels between newborns and mothers immediately after birth instead of facilitating skin to skin. 

A Kaiser member myself, I will definitely switch to a different insurance company if I ever plan a pregnancy, because they are one of few companies that offer zero coverage for out-of-hospital birth. But all in all, the introduction of midwives at Kaiser Oakland can only benefit families planning a hospital birth. I believe Anne Galko and her team have every intent of bringing better care to the new Kaiser Oakland, despite some institutional barriers. I hope they succeed. 

Originally posted at June Moon Home Birth.

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