Taking a hospital tour can be an essential step in developing a realistic birth plan. By becoming familiar with hospital policies and resources, a woman can increase her chances of having a positive birthing experience. More importantly, the questions we ask reveal to hospitals exactly what we Israeli women value most. After all, hospitals are businesses that compete with one another. Their “bottom line” depends on where WE choose to birth. I’m finding that most hospitals here in Israel have the same general guidelines and policies. The differences are in the details… and though some of these details may be small, they are not necessarily insignificant. After experiencing some “surprises” while attending births (as a doula) at various Israeli hospitals, I thought of a few questions I would now certainly ask on a hospital tour:
1. At what point am I considered officially “admitted” into the hospital? Funny thing, this concept of having been admitted into a hospital… it can sort of feel like being in prison. When a lady arrives at the reception area, a nurse examines her cervix and straps a fetal heart rate monitor on her belly then leaves the room for a supposed twenty minutes (though usually longer, up to forty minutes). The pieces of information acquired in this time will lead to a decision as to whether or not to admit the lady into a delivery room. If the mother is less than 3 or 4 centimeters, depending on the hospital and whether or not she is a first-timer, she will either be sent home (after being examined and released by a doctor) or ushered out into the waiting room—hopefully, a well-equipped laboring room—to wait for several hours (if they are busy) or to check in every hour for another examination and monitoring (if it’s a slow day at the delivery ward). This question is really important because getting into a delivery room or getting back home can involve a lot of waiting…
waiting in line at the reception area for the paperwork, waiting for a nurse to do the initial exam, waiting for a doctor to become available (if not dilated enough), or waiting for a delivery room to become “available.” Many times there are rooms available and empty, but the hospital wants to keep them unoccupied just in case someone comes in closer to pushing. It’s not a smart business practice to give the last delivery room to a lady at 3cm only to have a woman come in pushing with no place to birth but the hallway. So, depending on how busy they are the hospital might not rush to put a woman in a room. This can leave a lady in hospital limbo-land for quite some time. This rigamarole can get on anyone’s nerves, but all the more so when a lady has been in labor for let’s say 24 hours, hasn’t slept so great, has contractions coming on stronger and longer and closer together. At this point in labor, the mother’s body requires her to be comfortable, breathe deeply, and to focus… kind of hard to do when being shuttled around in a brightly-lit hospital, sitting in chairs, surrounded by strangers who are touching her on an hourly basis in all sorts of ways and asking a myriad of personal questions. The mama may get so sick of it that she wants to get up and leave the hospital already, but she can't (or so the hospital tells her) unless a doctor examines her and signs a release form. 2. What are the laboring spaces that you provide and how are they equipped?
Logically, if the pregnancy is healthy, the best place to labor is at home. The hospital will give instructions to come in when the contractions are four minutes apart for at least an hour (which, in my opinion, could be WAY too soon). If a lady finds herself in the limbo-land described in question #1, then it can be helpful to work with her body by making use of birth balls, squatting bars and mats. Some hospitals have them and some hospitals don’t. 3. What are the hospital’s time-limits? I have heard one hospital state that they “like to see a woman dilating at one centimeter per hour.” If after ten hours, the mother is not yet in transition (8-10cm), they usually move in with a recommendation to augment with pitocin or rupturing of membranes. In certain cases, such as when the baby is in an OP position, any interventions used to augment the labor may cause the baby to go into distress, leading into a (G-d forbid) c-section or assisted (vacuum or forceps) delivery. For a mom whose labor is taking days to get established, a time-limit of ten hours until pushing can be very stressful, to say the least. This is one of the main reasons why it may be best to labor at home with a doula who knows the signposts of late active labor. By then hopefully labor will not stall on the way to the hospital and she will be dilated at least beyond six centimeters. Another time-limit that may have significance is after birth in the delivery room.
One Jerusalem hospital offers a strict one-hour policy. In other words, the new family and all their stuff have one hour from the time of birth to vacate the room. This is particularly important to those who may want to have a nice, quiet, skin-to-skin warm-and-fuzzy bonding experience with baby. The first moments of birth are critical for successful latching-on which may take an hour or more, especially if an epidural was administered. Being educated about these first three questions (admission criteria, laboring spaces and time-limits) can minimize stress by empowering moms to create a realistic plan for when to go to the hospital and how to best cope with the various situations that come up. 4. Can I refuse a heparin lock? I’ve been been on tours where the nurse leading it has the audacity to straight-up with a deadpan serious face say “no.” At this point, I pretty much want to shake my head and say “tsk tsk tsk... liar, liar…” but I don’t. Even though we may very well know the answer is “yes” I think it’s important to ask, anyway, just to let the hospital know that it’s dealing with an educated consumer. The truth, ladies, is that we can refuse ANY hospital protocol if it in any way goes against our sense of safety and comfort.
That means hep locks, fetal monitoring that goes beyond twenty minutes, and cervical examinations. Yes, that’s right, even cervical exams. Studies have shown frequent exams to increase the risk of infection and to interfere with the dilation process of the cervix. My advice is to seriously ask whether or not there is an immediate danger to the baby or mother that would absolutely require the intervention. If the answer is “No, this is our routine procedure” then the choice really IS yours. At best, the hospital staff will get the mother to sign a document saying they are not responsible for any negative outcome that results from the refusal of hospital protocol (as if they ARE responsible for any negative outcome that results from their unnecessary interventions!). At worst, they’ll get annoyed and critical—a response that can really hurt an emotionally sensitive a mother in the midst of labor—and not mention the form at all. 5. What do I do if a nurse promises to put me on the monitor for twenty minutes, but then doesn’t come back until after forty minutes to an hour? Again, I see this all the time. Hospital midwives are busy. They strap the monitor on and then disappear… for a long time. If the laboring mom needs to use the bathroom, someone has to go out looking for a nurse to take her off the monitor. The nurse on duty rarely comes right away (sometimes in the middle of a coffee break or conversation with another nurse). Studies have shown that continuous fetal heart monitoring does not improve outcomes. Rather, intermittent 20-minute monitoring can safely ensure that the baby is coping well with labor. All hospitals SAY that this is their policy, but I have seldom seen this time-limit truly honored even under healthy and normal birthing conditions.
If given a choice, the midwife will usually have the mama stay on the bed. My suspicion is that having mama on the bed is the first of many steps leading to her giving birth in the position that is most comfortable for them. If the laboring mom is comfortable remaining in one position for an extended period of time and if the straps don’t bother her (I’ve seen this happen), then that’s just groovy. If she is expressing annoyance and frustration by it (and the previous reading shows the baby is fine), then it’s VERY important—for the sake of her sanity and well being—to honor her request and remove the straps after twenty minutes. The doula has no authority to remove the monitor straps, but the birthing mom absolutely does if she needs to. Again, the hospital staff may not be so happy about it. 6. Are your midwives skilled in doing fetal monitoring and/or cervical exams in a variety of positions (for mom)? When given the choice, hospital midwives love love love delivering babies in the lithotomy position (lady on her back). Old habits die hard, I guess. If a birthing woman is determined to birth in a different position, then they usually respect it. However, more than once, I’ve seen midwives insist that a woman interrupt her laboring to get on the bed/on her back for a check and/or monitor. This continues on a regular basis until the last check at ten centimeters, which segways into pushing… in THAT position. In a way, it feels like “Okay, mama. What you’ve been doing until now is all fine and good, but you’re at ten centimeters and ready to push. I’m here, so we’re doing this my way.” By this time the mother is exhausted, apparently weak, highly suggestible, and on the hospital’s turf.
I have observed this as THE easiest way nurses get mama into the lithotomy position—like taking candy from a baby. In retrospect, mamas ask “how did I end up on my back for pushing?” If, on the other hand, she continuously remains in alternate positions throughout labor chances are that she will birth that way too. 7. Will the staff respect my request to have the lights dimmed and/or noises muted? Most birthing moms love silence and subdued lighting. Some hospitals have high-pitched, loud buzzers that go off regularly to remind the midwives to check in on a woman. They need to manually press a button to get it to shut off. Sometimes, they don’t. When a lady needs to get some rest during labor (especially at night) it might help to turn off the lights. It may be annoying to have a midwife come in and abruptly blast the lights on without asking. 8. Is there any policy at this hospital that will require my doula to separate from me for any period of time? I have been just flabbergasted at the fact that I could find myself purposely separated from my laboring mama, once for hours at a time. In one case, she was permitted to bring only one person in the examination room with her and she chose her husband.
At a couple of hospitals, I needed to use the restroom (a few times that evening) and was ordered to leave the delivery unit altogether and use the bathroom in the waiting area hallway. Upon returning, I found myself locked out (once for over an hour at 3am) with no one caring to buzz me back in. A third set of instances has to do with a hospital policy that when the woman is admitted into the delivery room, she is taken there by the nurses through the nurses’ station and everyone else (yes, including me. I asked) had to wait in the examination area until told which room to go to and then go through the waiting room area to get there. This is not pleasant, to say the least, for a mama at or near transition. So this one question is really three. 1) How many people can be in the examination room with me? 2) If my doula needs to use the rest room, can she use the bathroom that is nearest to me? 3) Can I have my doula with me while you assign me to a delivery room? 9. Will there be any other hospital staff members in the delivery room while I push? I have seen up to five uninvited midwives standing around gawking while a mother is in the midst of pushing. One mother looked around bewildered and asked “What is this, Grand Central Station?” However, to their credit, I have also been at a birth where the midwife completely left us alone (with intermittent monitor checks) until crowning. The “Let’s all come and watch” phenomenon is most likely to happen when the birthing mom is not coping well and/or experiencing complications, especially if she has been at the hospital for a very long time. This, quite simply, attracts attention. I suppose the nurses felt that it’s their duty to learn on the job and apparently were not busy with anyone else at the time.
Being a lifelong student, myself, I can understand that. But, to come in uninvited to just stand there staring? Birth is intimate and sacred. Asking permission from the mother is the only right thing to do. 10. May I see the documents that I would need to sign for refusal of recommended procedures, or if I agree to an epidural, c-section, etc? It’s unpleasant to think about epidurals or c-sections, I know. However, they do happen. Before these interventions are administered, a woman is required to sign an informed consent form. I have never seen a woman to be capable of reading these forms in the midst of not coping well in labor (which is usually the scenario in most cases of epidurals and c-sections). Don’t you think it’s your right to see a legal document that you may be signing during your birth? I do. In the case of the release form for refusing hospital interventions, it’s one they don’t rush to tell you about. They pretend that that form does not exist and then only pull it out when they see the mama knows about it and has already decided to sign. Sometimes, they have the mother wait a long time until they find it. Or they will make admonishing comments despite the fact that she is at a most sensitive time. Having and signing this form in advance together with your written birth plan will make the reception experience go by that much smoother. If you really want to be proactive, you can staple to it any and all studies showing the ineffectiveness (or dangers) of their routine interventions (you may need to get it spiral-bound at your local print shop LOL). So take these blank forms home with you… Oh, and please ask for extra copies and save some for me. I’m starting a collection (seriously!).
Bonus Points: If you want “extra credit” in letting the hospital know what the birthing consumer wants (and needs), there are other questions you can ask as well, such as: How many birthing stools is this hospital equipped with? Are your midwives skilled with the intermittent use of hand-held fetoscopes? Is the hospital equipped with cordless monitoring devices that can be used in the water or while a laboring woman moves freely in an upright position? Are there doctors or midwives skilled at assisting with breech births and nuchal cord births? What are some tools at this hospital for coping with pain, naturally? How many tubs, birth balls, bean bags, squatting bars and ropes, floor mats, etc. are your delivery rooms equipped with? Now, while these “bonus points” may be the norm in many of the more progressive hospitals around the world, we already know that in Israel’s standard public hospitals the answer is “no.” So, why in the world would we ask? We are the consumers and, as such, it’s our job to place the demand out there by stating what we value and want to see. Like the hep-lock question above (that we already know the answer to), the more they hear their own answer, the more they will either a) realize how much in the dark ages they still are with birthing practices or b) feel very proud of themselves for being so progressive as to meet the needs of their customers. In either case, they will know something very important—how educated the birthing public is. We state our satisfaction in shekels when we choose one hospital over the other. They are competing with one another. Any changes that have been made have happened because birthing women stated their needs loudly and clearly. The hospitals that honored our requests got our business AND the better reputation. It’s as simple as that.
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