Trends and newer practices in labor and delivery in Central PA

Central Penn Parent recently welcomed Kenneth Oken, M.D., chair of Obstetrics & Gynecology at UPMC Pinnacle, to our office to discuss trends and developments in labor and delivery. Carley Lucas, CPP’s advertising account executive and a new mom who delivered her son Mack this past summer, joined us.
Leslie Penkunas: How does Pinnacle’s birthing center differ from what it might have looked like 15 to 20 years ago?

Dr. Kenneth Oken: We’re in the process of just building a new unit. It’s scheduled to open in the next several months. I’ve been practicing for 25 years, and I think initially patients often were moved from a labor room into an OR or into a different room. Now pretty much people labor and deliver all in the same room. We encourage more family members to be present, and visitors, if they should want people to accompany them. So it’s been really made to be more patient friendly and less, I’d say, sterile. And most of our rooms have Jacuzzi tubs.

Penkunas: Is that for laboring? Is that for relaxation?

Dr. Oken: Laboring. We don’t do water births at Pinnacle. But they encourage it throughout labor for comfort measures. Pretty much most all of the rooms do have Jacuzzi tubs.

Penkunas: Is that something that a patient would request specifically before going in, or is it just the luck of the draw?

Dr. Oken: I’d say even in our new facilities, all but one room has a Jacuzzi tub it. The other thing is we have developed a ‘hospital within a hospital’ concept. Patients will have one elevator to come up to labor and delivery, so they don’t have to traverse the entire hospital.

Penkunas: That’s good.

Dr. Oken: The parking and everything will be made easier. During the middle of the night, they used to have to come to the emergency room. They don’t have to do that and they also stay on one floor. On top of the Alex Grass Building, there is a brand-new, 39-bed, post‑partum facility. With those rooms now, it has been significantly changed. [They] have been made much larger to accommodate patients and their families. One of the biggest complaints [from patients] that we had in looking at developing the new unit was that for the spouses and their family, there is no room. Often they pull out a chair with very little space for their significant other that was staying with them. Now, it’s much larger and much more patient-friendly.

A big change over the last 25 years is that babies really stay with the mother the entire time. We strongly encourage rooming in. The nursery, where it used to occupy a certain amount of square footage, has now really shrunk down. The only babies that go to the nursery are patients that their babies need to be there.

Penkunas: I remember when I had both of my kids — different hospitals, different states — but at both they’d say, ‘Do want the baby to stay with you? Or we’ll take him, we’ll take her.’

Dr. Oken: It’s really not even a question anymore. It’s pretty much standard that the baby is staying unless they had a complicated C‑section, or a complicated delivery or they had an issue and they can’t care for the baby.

Penkunas: Is that what you encountered, Carley?

Carley Evans: Well, I’m thinking about the labor and delivery with the Jacuzzi tub. That saved my life, I feel like. I definitely took advantage of that. I labored at UPMC right down the street [from the CPP office in Harrisburg] and then we had Mack in the room with us.

***

Penkunas: The rates of women waiting until they’re in their 30s to have a child have been trending higher and a number of them are of ‘advanced maternal age,’ over 35. Are there special considerations in place for those [moms] during labor and delivery? It’s been 14 years since I had my daughter. I couldn’t do anything because I had monitors attached to me and tethering me to the bed. Has any of that changed?

Dr. Oken: Yeah, a lot of changes. There is probably less monitoring. There are portable monitors where the patient can ambulate with the monitor on them, if need be. But I think we realize that not every patient has to be continuously monitored just because they’re 35. You know, certainly a patient in advanced maternal age may have more medical risk factors and more associated issues — diabetes, high blood pressure. They may be higher risk pregnancies, but it doesn’t necessarily translate into they have to be continuously monitored, stuck to the bed the entire time.

We strongly encourage patients to ambulate, get up and move around in the tub. That’s definitely changed. With these portable monitors, the patient can get up and move around, get up from the chair. The other thing is with more patients waiting longer, these patients tend to be much more educated, too. They’ve done their homework. They know what to expect.

We encourage people. If they have a particular plan or they have a request, there are very few things we won’t accommodate. Most of the time we can work with the patient as long as it’s safe. If it’s what they want, it’s not out of the question.

***

Penkunas: What changes or trends maybe have you seen in pain management during labor in recent years? Obviously the Jacuzzi in nearly every room. But what else have you seen?

Dr. Oken: We’ve recently added nitrous oxide as an option. We know the nitrous oxide doesn’t really change the rates of epidurals and other pain modalities they’re going to use, but it is just an added option that they have. I’ll be honest with you, I was pretty skeptical at first, but I’ve seen patients get off their labor and delivery with [just] nitrous oxide. It’s also helpful for after delivery, if they have not had any anesthesia, not had an epidural. It can help with repairs and sometimes delivery of the placenta. Sometimes they require a little bit of extra pain management. [Nitrous oxide] is just enough.

Lucas: I used an epidural.

Penkunas: I probably would have used [the nitrous oxide] in addition to an epidural. For the anxiety, for just the calming.

Dr. Oken: It’s been really helpful early on, but I’ve had patients here I would have sworn would have gotten an epidural and used the nitrous all throughout.

Penkunas: I know from having my son without having an epidural, that if you don’t have an epidural, as soon as the baby is born you can get up. You can go to the bathroom. You can walk around. You don’t have to worry about waiting for an epidural to wear off.

Dr. Oken: The nitrous oxide gives the option. And it doesn’t prevent you from getting anything else. You can get an epidural right after it. It’s a very short half-life. There are very few risks or complications and patients have control over it. They can do it when they want it. It’s been a nice addition since we really haven’t had anything new for years, besides IV pain medication, epidurals.

We also have patients that do hypno-birthing, which is another new thing. It’s been offered through the childbirth education area of Pinnacle. They do a great job with that. I think just giving patients additional options, knowing that it doesn’t have to be all or nothing. It doesn’t have to just be an epidural or nothing. I think pain management in labor and delivery has been a little bit behind the times. And then we see a trend lately towards some patients doing laboring without any pain medication, which I find —

Penkunas: More power to them.

Lucas: Yeah.

Dr. Oken: I’ve seen thousands of births. I don’t know how they do it, but they do it and I think, again, it just gives them self‑control. At Pinnacle, we don’t have walking epidurals. You really can’t move around. So it gives you options. Even if you get IV medication, you’re really not going to get up out of bed after that. These other things give you definite options.

***

Penkunas: Are more moms-to-be designing their own birth plans, and have you seen those birth plans change in recent years?

Dr. Oken: Certainly there is a large percentage of patients that will go online and just pull up a birth plan, not really sometimes knowing what’s on the birth plan. So we see a lot more of just generic birth plans. But then you have people that have really tailored a birth plan to what they want. It kind of waxes and wanes. [addressing Carley] I don’t know if you had a special request?

Penkunas: I think she requested pain medication.

Lucas: I did. I have a friend that was in labor and delivery, a nurse at Pinnacle for a number of years.  She was at my shower and asked me what my birth plan was. We have another friend of ours that with her two boys, had a particular music and [a request for] incense, or whatever it was, and somethings that were strange and off the wall and she’s very particular. She’s sitting there through this entire conversation. I said, my birth plan is to go in, to make sure that the pain is managed, and to get the kid out safely. She said, that sounds about like the most simple birth plan that you can have. I’m pretty sure everybody in the delivery room is going to love you for it.

Penkunas:  When should someone present their birth plan? How do they present it? And how does the hospital follow?

Dr. Oken: We encourage people to present the birth plans ahead of time, so it can be discussed with the provider and we’ll review it. In my particular office, we’ll actually pass it around so all the providers see it, look at it, sign off on it. It’s kind of hard when in labor to present a birth plan. The train has already left the station.

A lot of the things too that people are asking for now has become standard care. Delayed cord clamping — they want to hold their baby. We do skin-to-skin in well over 90 percent of our deliveries; that used to be a big thing in birth plans. wanted delayed medication. A lot of these things are fine. They just need to be asked ahead.

When you come in in labor, I like to ask the patient, “Do you have special requests? Is there something that you really want?” They’ll say the delayed cord clamping. They’ll say we want the lights down. We want it to be quiet or we want the father to announce the sex of the baby, things like that. So it’s just really communicating with the provider to make sure they know.

Lucas: Pinnacle was very good with that with us, because there were things like delayed cord clamping.  That wasn’t something that we discussed it going in. For those that don’t know, delayed cord clamping encourages a more positive blood flow to the baby after birth before they cut the cord and that sort of thing. The cord is still attached for maybe five to seven minutes after birth,so there is still more of the natural blood flow coming from the mother to the baby.

Dr. Oken: They want to wait until it stops pulsing. Which, if you think about nature, it’s probably a little bit more natural to have this.

Lucas: Yes. And they asked if my husband wanted to cut the cord and that was just something that Kyle was not interested in. He was just like, ‘Nope, I’m good.’

Dr. Oken: That’s the point too. If that’s part of the birth plan that the father does not want to be involved in the cord, that’s fine.

Lucas: Pinnacle, for us at least, was very good about as the situation of things progressed, ‘Do you want to do this or do you want to do that?’

Penkunas: Touching bases with you.

Lucas: Yes. You have a choice here at this time in the process. You have X amount of timeframe here.  We want to wait for you to have an epidural for a little bit. Okay. Do you want to sit in the Jacuzzi or do you want to walk around?

Dr. Oken: Did you have a birth plan?

Lucas: We had talked about it with the OB. We had both, [and OB and a] midwife.

Dr. Oken: That’s another good point. Midwives. Our group has two, soon to be three midwives. We have midwives on 70 percent of the time but not all the time. If she wanted a midwife to be at her delivery today, we would have a midwife on call. We may be able to work to get somebody there. But if she was going to be induced, we’d make sure you were induced when a midwife was on call.

Lucas: We were lucky enough to have both there.

Dr. Oken: There are some people that feel very strongly they want a doctor there, which for most births is not necessary. And there are some that say they want to do it more natural with a midwife. But a doctor is always on call.

Penkunas: National statistics show that about 10 percent of women opt for midwives. Are you finding that percentage to be about the same at Pinnacle?

Dr. Oken: The question, too, is when you say ‘opt for midwives.’ We offer. At Pinnacle there are no sole midwifery practices. We work collaboratively with the midwives. You can choose during your pregnancy to just see a midwife. That’s fine. Within our practice, you could just see one physician. Knowing when you come in in labor, he’s on call. Unless it can be scheduled. I don’t even know if you want to go down the whole road of recent discussions about inducing everybody at 39 weeks.

Penkunas:  Yes. When I was in the later stages of pregnancy with my son, I was put on bedrest because I had lost too much amniotic fluid. I still ended up going four days past my due date before my OB would schedule me [for an induction]. She said, ‘There is no point to induce before your cervix is ready.’ Now they’re saying that it’s okay to induce early, that outcomes are better?

Dr. Oken: We just had a speaker last week come in from Pittsburgh to speak about it. He was part of the study. It says that inducing patients at 39 weeks may, and I would definitely underline may, be safer. May be safer and actually reduce the C‑section rate by inducing at 39 weeks. I think we have to take that with a grain of salt. It’s one trial. There were trials years ago that showed that there was a higher C‑section rate if you induce people.

***

Penkunas: So, C‑sections. How has an OB’s approach to C‑sections changed over the last few years, if at all?

Dr. Oken: Having done this for 25, 30, years, it kind of waxes and wanes. Years ago there was a big trend to vaginal birth after C‑section, and then we kind of got away from it and we saw the C‑section rate rise. I think in the medical legal climate you see more C‑sections being done.

With the C‑section rate right around 30 percent, we really feel that it should be lower. There are a lot of factors. But I think as providers, we have to do a better job of lowering that C‑section rate.

***

Penkunas: Have you found keeping the baby with the parents has resulted in better outcomes for the baby, as far as the next couple of weeks?

Dr. Oken: We’re a baby-friendly hospital. We strongly encourage breastfeeding. I can’t speak to fetal outcomes. But certainly bonding is probably better. The amount of teaching and education that goes on the floor before the patient goes home —bathing, feeding, car seats, safety things. How baby sleeps.

Lucas: The education process post‑partum, especially with the baby in the room, made us feel much better about taking the baby home. Pinnacle actually went as far as having us sign paperwork that we would not fall asleep while holding the baby and that was to prevent accidents and we have taken that practice into our home. They went over everything. I mean, so we were very well educated.

Dr. Oken: I remember when my first baby, was born. I obsessed over when is the cord falling off. When is the cord falling off?

***

Penkunas: More new moms in Pennsylvania are breastfeeding their babies. It’s up 10 percent from a decade ago.

Dr. Oken: Diaper bags with a formula company, given by a formula company, anymore. We used to give out formula samples and diaper bags from the formula company in our office. We no longer have them. And that’s been a pretty concerted effort on all parts to make this happen.

***

Penkunas: With all the various changes in laboring and birthing, how receptive do you think hospitals have been?

Dr. Oken: Hospitals have finally seen that women and babies are a huge area. They’ve always concentrated on the cardiac, orthopedics, and Pinnacle especially. Now you see Hershey just announced they are building a new unit. NICUs were always these pods of 10 or 15 beds. Now, we’re going to have private rooms, a 40-bed NICU. Even with a baby as young as 25 weeks, the family will be able to stay there.

Penkunas: That’s such a huge commitment and dedication by a hospital because of the expenses.

Dr. Oken: Space, a huge expense. The Grass Foundation provided this new unit. It’s going to be state of the art — but really, it’s for the families. The hospital I think has recognized that women and children services are huge. You know, I think we had a decent facility. Now we’ll have a great facility.

Lucas: I was actually very impressed [with the current facility]. I was thinking that it would be just like a regular hospital room and it was a suite. There was the bathroom suite with the Jacuzzi tub. Even when I was laboring and my husband couldn’t do anything, he was very comfortably sitting there watching the game on TV. We were very pleasantly surprised.

Dr. Oken: I think historically women and children’s services have been on the back burner. Pinnacle has been a leader in the field in the area with close to 4,000 births a year. It’s been a passion of mine for the last several years to get this done and I think the administration.

***

Lucas: I have one more question. Out of the thousands of births that you have witnessed or partook in, do you have one or two that stick out?

Dr. Oken: Yeah, my own kids. I didn’t deliver my oldest, but my other three. My wife would say I didn’t deliver them, but that I was there and helped her. They were actually very easy, but it was fun. I think OB in general 99 percent of the time is fun and exciting. I wouldn’t do any other job.

Note: This discussion was edited for length and clarity. You may read a fuller version here:

http://www.centralpennparent.com/2018/labor-delivery-trends-full-transcript/