The Labor and Delivery Experience

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi everyone. I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time. During this season, we are focusing on topics related to pregnancy and obstetric concerns. On this episode, I'd like to welcome Dr. Catherine Wilkins and Dr. Tamara Noy, certified nurse midwife and doctor of nursing practice, who will be talking to us about models of obstetric care, birth plans, and preferences on labor and delivery.

Dr. Wilkins, Dr. Noy, thanks so much for joining me on the podcast.

Tamara Noy, CNM, DNP:

Thanks for having us.

Catherine Wilkins, MD:

Thank you.

Erica Newlin, MD:

Can you each tell us about your role in the Cleveland Clinic and a little about your background?

Catherine Wilkins, MD:

Sure. This is Catherine Wilkins. I've been a Cleveland Clinic for going on 16 years now. I am an obstetrician, first and foremost, and specifically an OB hospitalist, meaning I specialize in inpatient maternity care. And in addition to that, I have some other jobs, if you will. I do patient experience work for Obstetrics and Gynecology at Cleveland Clinic and some administrative work at Fairview Hospital, one of our Cleveland Clinic birthing hospitals. But yeah, my main gig and the reason I'm here in doing this is maternity care.

Tamara Noy, CNM, DNP:

So I'm Tamara Noy. I am a certified nurse midwife at Fairview Hospital. I'm actually the lead midwife over at Fairview, where I work with a team of about 18 midwives, which is part of a greater team of about 44 midwives here at Cleveland Clinic. I work in the hospital and in the office. Primarily though I spend a lot of my time in the hospital on labor and delivery units and working in conjunction with my physician colleagues.

I also spend a little bit of time at Cleveland Clinic working in the Centers for Infant and Maternal Health, really helping to bridge that community understanding of what midwives do and how we work in conjunction with our OB partners to help decrease the high maternal and infant mortality rates here in Cleveland, Ohio.

Erica Newlin, MD:

Can you describe who may make up a team on labor and delivery? I feel like sometimes it can be overwhelming, all the people in and out of the room and different care providers.

Tamara Noy, CNM, DNP:

Sure. So on your labor and delivery team, I like to think of it as we, we all just work as one big happy family with a lot of different members. So we always have an obstetrician. There is a certified nurse midwife who is always in the hospital. We have a hospitalist such as Dr. Wilkins, who's always there. The laborists are also part of our team, and those are physicians that very similar to the hospital, only work in the hospital, but more specifically, they work very closely with the midwifery team, really working the way that we practice and take care of patients. You have residents, we have midwifery students, nursing staff, NICU staff.

Catherine Wilkins, MD:

Agree. And I think labor and delivery units are going to be highly variable depending on the community in which you live and where you get care. And even within our own healthcare system at Cleveland Clinic, we have many different hospitals that are part of our bigger system, and they vary in their level of maternity care, depending on their size and scope of the volume of patients and acuity of patients that they take care of. Tamara and I work together at Fairview Hospital, like many of our hospitals and academic center. So our team definitely includes resident physicians and medical student learners.

And at any given time, there's a number of, you know, physicians and midwives often on at a time to work together as a team to take care of all of the patients and handle all of the volume. And that model can vary from hospital to hospital depending on the needs of that individual hospital and the personnel that are there. For example, our other hospital, Hillcrest Hospital has some resident coverage, but a little bit less than at Fairview Hospital, just in terms of the number of residents. And so they have a midwifery model of care, which is really something. Obviously Tamara, you can speak better to than I can, but it's got its own great benefits as well. And so there's more than one way to deliver obstetric care.

Tamara Noy, CNM, DNP:

Absolutely. The beauty of Hillcrest is that it is a midwifery-led model of care. So that means that if you come in and you're full term and you are completely healthy and there are no concerns in your labor or your pregnancy, then your care will be handled by midwives, which is when you look at other models of care in other countries, that's the way that most care starts, is as long as you're normal, midwife takes care of you.

And I really, really applaud Hillcrest for taking that initiative because they've seen a drop in their C-section rates, an increase in their VBAC rates, and a decrease in the amount of operative vaginal deliveries or interventions that are taking place because it's a more hands-off approach to taking care of patients.

Not a lesser type of care, just a different way to do care.

Catherine Wilkins, MD:

And I love the emphasis on that. For the uncomplicated, healthy birthing person, you don't necessarily need physician care at all. And honestly, it's a great thing to emphasize, and it's been a shift over time, inpatient experience that was an initiative we had a few years ago, trying to help our patients understand why they might not see a doctor, for example, for their postpartum care at all, while they're still in the hospital. And it's because they're normal, it's because they're healthy. If they don't need a doctor, it means they get an A for doing great.

If they're having to see a doctor, it can mean that something's, you know, a little bit more high risk about them or their needs. And so it's a great thing when it's not required at all. I mean, seeing a physician, but just having our nurse practitioners, advanced practice providers take care of them postpartum, just like normal labor and delivery can and should be handled by our midwifery team.

Tamara Noy, CNM, DNP:

I love that. And we love to see you coming. Because if I see you coming, it means that I need you. And as a midwife provider, it is so appreciative to see the amount of trust that gets put into our team, especially because the way we practice is a little bit different than our physician partners. And it's less interventions, less hands-on. And you still have such respect for our practice, so.

Catherine Wilkins, MD:

Absolutely. My mom was a midwife.

Tamara Noy, CNM, DNP:

(laughs). I love that.

Catherine Wilkins, MD:

I love telling people that too.

Tamara Noy, CNM, DNP:

I love that.

Maybe that's why I love you so much.

Erica Newlin, MD:

And we talked to Tamara in the other episode about the initial prenatal care and really talking with your providers about who you would expect to meet and getting more information about the hospital experience at the get-go.

Tamara Noy, CNM, DNP:

Oh, yeah. When you set that stage early, it really helps when they get to labor and delivery. And they're not like, like how Catherine was saying, inpatient experience, helping them to really understand that you don't always see all of the players on the team, but trust and believe they do know that you exist. We sit, we talk about every single patient every four hours. So that if for some reason the midwife team is tied up in a delivery, if Dr. Wilkins or Dr. Newlin has to come into a delivery, they know who this patient is. Because we've talked about you because we're a team.

Erica Newlin, MD:

And we spoke a little to this before, but can you describe a little more on how might physicians and midwives work together on labor and delivery?

Catherine Wilkins, MD:

There are so many ways in which we help each other help our patients. And it's a beautiful thing when it's working well, which in my experience has only worked well. I love working with our midwives. They've helped us in so many instances when, you know, a patient wants low intervention care and they're there and available and willing to step up and help us out when we might be overwhelmed with, you know, more complex or complicated patients who demand more of our attention. That's just one simple way that we work as a team and help each other.

But they help us in other ways. A patient who's really struggling with either natural childbirth or protracted labor, they have so many tricks and tools in their toolkit that they can really help our patients and help get them to the outcome that we all want via different means. So I think that's awesome. And then I know in return, when they have a patient who's got a new level of complexity or need for something interventional, we're there to support them in turn. So we really help each other help our patients in that way. From my perspective.

Tamara Noy, CNM, DNP:

I think it's really just about finding that sweet spot. Because it's not always about, "Hey, Catherine, I need you to take this patient." Sometimes it's, "Catherine, I need you to look at this tracing with me and let's evaluate and see is this a patient who can stay within the midwife bounds or is this someone who you guys would feel more comfortable taking over on?" So I think that when we find that sweet spot, especially with our more complex patients, it helps to bridge that gap for the patient. Because sometimes you're taking my patient back to the OR, but I'm the only person that they knew that entire labor.

So having my face in the OR with them and hyping up this birth that's happening, and they're scared, but they know me and, "Hey, Catherine's a great person. She's going to take great care of you." That handoff is everything when we're working together in those settings.

Catherine Wilkins, MD:

I love everything you said. There's so much about that that I could talk about all day, and I will try not to. But I mean the, the teamwork starts with the communication and that's the bridging of the gap that you talked about. That communication is what does it, and sometimes it's a matter of sharing the patient. And then when I think about it from the perspective of patient experience, we are doing everything to make that patient's experience as good as it possibly can be by giving her what she wanted in the first place, but working together as a team to get her to that end with the care that she wanted.

And then what you said about being in the OR, there's nothing better than that. When I'm in a situation where I'm operating on one of the midwife patients, to see the midwife in the room at the head of the bed, supporting that patient through it, gives me joy because I care so much about patient experience. I care about that patient's experience, and I know that while I'm operating, I can't be doing what that midwife is doing for her. And I love that.

Erica Newlin, MD:

Shifting a little bit, what does it mean to deliver in a teaching hospital?

Catherine Wilkins, MD:

So it mean in a teaching hospital, what does it mean? It means that throughout the continuum of your care, one should expect learners to be involved in that care in different stages and levels of their learning. We all had to learn somehow-

at some point. And I'm grateful for every patient that helped me get to where I am today from the point of being a medical student a long time ago. And it's really a beautiful thing. And it is something that I don't think our students take for granted at all. So we have medical students who are learning and who will be gathering histories and doing some basic physical exams, always while supervised by us and by our resident physicians. And then with our resident physicians who are medical doctors, they are practicing obstetrics as physicians. And they are in different levels of their obstetric training from first-year residents through fourth year.

And we have a team of residents and they function as a team supporting each other and caring for our patients while we as attending physicians and midwives are overseeing the residents in that work. And yes, they are learning to do all of the more complex things that are required to be independent, licensed obstetricians in their future. So they are operating and they have great surgical skills and they are well-trained to do all of those things. And we're doing them alongside and with them and supervising them.

Tamara Noy, CNM, DNP:

And then from the midwifery standpoint, we have midwifery students that come through and practice with us. So when you become a midwife, you are already a registered nurse. So they're already registered nurses, they're just going back to school for their masters and to specialize. But they are with us in the office, most times they're following our patients all the way through. So if the patient is lucky enough to be like my home patient, then they know my student already. But the students are with us. They do our cervical exams, they work alongside us. They're learning all the tips and tricks to help get the babies safely delivered. We are working with them on repairs. We're working with them on, you know, high-risk obstetrical situations to help make them far more competent care providers because of the facility where we work. My manager always says, "One year at Cleveland Clinic is almost equivalent to three to five years than another facility just because of the acuity that we see when it comes to patients that we take care of."

Catherine Wilkins, MD:

That was an excellent point. That is true about where we work.

That we take for granted. We are busy and we have such amazing teams of people. And the education that our learners are getting when they're here with us is top-notch. There's no question about that.

One other thing I would add is there are advantages for patients. And I think that's important to highlight because I think that what we need to undo is any perception that this benefits are all for our learners and that they're learning on our patients. It's not the case at all. There are great advantages for our patients. Having resident physicians and other learners involved, it opens up access to so much more readily available hands-on care that a patient will get. As opposed to in the rare instances when we do have patients who decline to have residents involved in their care, the reality is, and it can be unfortunate, sometimes that can mean delays in care.

If they would prefer to only have, say, the attending physician who's on call, say, me or one of the other couple that are on, provide their care when and if we are in the operating room doing surgeries or c sections on someone else or tied up in whatever else there may be, and they have a need, it means waiting. Whereas our residents are highly skilled and trained and can step in and do oftentimes as well as any, and in some instances, depending on what it is better than anyone else, the care that that patient needs. So there are certainly benefits.

Erica Newlin, MD:

For sure. And I feel like the residents definitely encourage me to stay up on evidence. Cause they're always asking questions, always inquiring, why are we doing things? And...

Catherine Wilkins, MD:

They're diligently, you know, bringing back to us everything they've learned in their journal clubs didactics, working in an academic center keeps us academic. Right? And it's thanks to them and it's thanks to the environment.

Tamara Noy, CNM, DNP:

True story.

Erica Newlin, MD:

And its extra eyes looking at your past medical history.

There are so many times I can count that a resident was just like, "Oh, I found this note from five years ago and we should think about this."

It's like more people taking care of you, more eyes on your care.

Catherine Wilkins, MD:

Where if that was a patient who declined to have resident involvement in her care, they may never have opened her chart in that case. Cause there wouldn't be a reason for them to. So Exactly. Another huge benefit.

Erica Newlin, MD:

What's TeamBirth?

Catherine Wilkins, MD:

TeamBirth essentially is, is a quality initiative. Ariadne Labs started TeamBirth through the Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital. And it is a means of improving communication in obstetric care because we know that adverse outcomes, 80% are avoidable. And when we look at the root cause of the adverse outcomes that take place in obstetric care, the overwhelming majority of them are due to breakdown in communication.

And so this initiative seeks to improve communication to minimize these adverse outcomes and improve patient's experience and equalize the patient experience for our birthing people regardless of race. So that is what TeamBirth seeks to do. And it does it through simplicity. Essentially it's using a whiteboard-based model of communication in the patient's rooms that identifies key members of the patient's team, centering the patient on that team as well as her support people to create psychological safety for every member of the team to have a voice and to speak up.

Many times when adverse outcomes occur, the communication breakdown is the patient not feeling safe or comfortable speaking up, or the provider's not listening when they try to. And this is to break down that barrier. So it starts with team, it moves on to preferences, identifying patients' individual preferences for their care. And many patients come in as self-advocates, right? With a birth plan. But not everybody does. For those that don't, identifying patient's preferences and having the discussion with them seeks to make this an equitable experience.

So you shouldn't have to be a strong self-advocate with a piece of papers explaining what you want. We should be finding out what patients want every time on every patient. And then using those preferences together to make a shared plan. And this is the true essence of shared decision-making that we hear people talk so much about. But what we have for so long thought was shared decision-making was really us making what we believe and know to be a good plan, explaining it to the patient. And when they agree to it, we feel as though we've done that thing we call shared decision-making, when really it's not exactly what we did.

Shared decision-making really is truly that. It's a shared decision and it incorporates the patient's preferences into making that plan. That's what TeamBirth does. And it's distinct plans for the patient herself, for her labor, and for her baby, in labor and afterwards.

Erica Newlin, MD:

If someone is delivering in a hospital that doesn't have TeamBirth, how do you recommend that someone advocate for themselves or make their preferences known?

Catherine Wilkins, MD:

I think it's always great to do that. I know that there are obstetricians and labor and delivery nurses across the country who sort of have that instinctive groan when a patient walks in with a birth plan. Right? Let's just be honest. However, I've completely 100% changed my viewpoint on that. I think it's an absolutely wonderful thing. It allows for the conversation to start. It's a great thing to have a birth plan. I will say what we have chosen to do at Cleveland Clinic is make our own specific, and we call it birth preferences instead of a birth plan. We have a birth preferences worksheet because as we know, especially in obstetrics, things don't always go according to plan, but it is really important to acknowledge a patient's preferences. And it is really helpful for the patient, for her support people, and especially for the team at the hospital taking care of her, for her to walk in with her preferences clearly known. So I think that's a great thing to do, and it's just a great way to start the conversation and make sure that if you have a healthcare provider who isn't really doing that shared decision-making thing that we need to be doing with you, it's a way to help make it happen. It's a way to drive the conversation in that direction so that you can advocate for yourself. And I think any obstetrician should welcome it and be grateful for it.

Tamara Noy, CNM, DNP:

In midwife planned, we love birth plans. I call them birth wish lists because babies are the ones who make the plan. Regardless of how well-written or how colorful or how many circles and squares you have on it, it is your wish list. And it is exactly what Catherine said. It is your voice, but on paper. So walking into that room, and that's one of the first questions I'll ask, besides, "Who's here with us today? Do you have a wish list?" Because it helps me frame the conversation and use the right words because that's what people will put in a lot of their birth plans or birth wish lists are, "I don't want to hear the word contraction. I want to hear surge. I don't want lights on, I want dimness. I want to smell aromatherapy." You know, those type of things. It seems small when you're just listening to it from the outside world. But when you're really setting the mood for that birth and setting the mood for decreasing trauma and decreasing long-term poor outcomes mentally for mom, having that wish list and meeting her needs as close as we possibly can is so important. And it's a point of education too, because sometimes patients will make wish lists that they haven't talked to us about, and we’ll get them and just read them and go, "Okay, so we need to have a conversation." But it is opening that door to communication.

So that we can identify, maybe this was a trigger, maybe this is a source of trauma, maybe this is something that we need to delve deeper into.

Because there's a lot of things on here where I see no, but I need to open a door to find a space for it, yes. And figure out exactly what brings you to this point. Because if mentally there is a block, then I, I always think like a closed brain, closed cervix. So if there is a block somewhere, it's going to stall your labor, it's going to stall your progress. So sometimes people will come in with the 10-page birth plan, I was that girl, and then we can break it down. And all of a sudden it's all the things that we already do, but they just weren't aware because they were afraid to ask.

Erica Newlin, MD:

For sure. And you highlight a good point. When I look at a lot of birth plans are a lot of birth preferences sheets, they are a lot of things that we already do. Which it's really nice to open that conversation and be like, these are the ways that we are already working to support you, and what else can we do for you?

Tamara Noy, CNM, DNP:

Absolutely.

Catherine Wilkins, MD:

I do love the idea of wish list. And it is a helpful way to phrase it with patients. When they come in and they don't have a birth preferences worksheet filled out, or a birth plan of any kind, sometimes when we ask them what are some of the preferences or things ... I sometimes have to use that word less with patients cause they kind of look at you like ... When, when was the last time you went to a doctor? And they said, "What are your preferences?"

They sometimes look at you sideways, like, "What are you talking about?" So I do like to say, you know, "What are the things that you really wanted to have happen throughout your labor? What are the things you wish it would be like?" So like a wish list.

Because even if you don't have written down preferences, most patients, most people have ideas of what they want their experience to be like. And sometimes it's just opening up that conversation to elicit what those things are. And other ways of asking are sometimes, what are the things that you were afraid of that you don't want to have happen?

Let's talk about those. And then sometimes a whole lot comes out. And then you realize how often patients are explicitly stating what their actual preferences are without realizing that that's what they're doing. And without us even realizing that's what they're doing. So we just have to listen more carefully and pay attention and identify those things and then write them on their board. And then everyone acknowledges it and it becomes more centered in their care.

Erica Newlin, MD:

For sure. Especially as we mentioned with a big team on labor and delivery or someone else coming in for an emergency, it's so nice to have things up in the room and in writing. So then it's an easy way to communicate.

Erica Newlin, MD:

What's a doula?

Tamara Noy, CNM, DNP:

So doula is a midwife's best friend. They are wonderful labor support professionals who come in and while they're not trained medical professionals in the same sense as a nurse or physician, they do have a lot of training in a lot of the psychosocial aspects of care for our moms or our birthing people. And with that, they come with a host of techniques to help the family a, get together and be able to support this birthing person. But they also come in with a lot of techniques to help babies get into good positions. They're that one person that's there the entire time.

And there are so many studies that show that if we have continuous labor support, we will decrease the rate of intervention. For people that do not want epidurals, ill decrease the rate of epidurals. And we get patients that have far more advocacy taking place on their behalf and less letting things happen to them when they have a doula or support person. But they are phenomenal. They will sit at the tub with you, they bring you ice in the shower, they'll rub your back.

They speak affirmations into you. They work with you and really get to know you because they're coming to your house a lot of times where you're coming to visit us and we get these 15 minute visits. When they're there, they're there for hours sometimes. They'll be there postpartum. There's doulas that work just for labor, some that are postpartum, some that actually work when we have the rare instances when we do have loss, there are doulas that specialize in loss and work to help support families in that way. But they're really phenomenal people. And I think that they get underrepresented or they get misrepresented in a lot of ways. But I think having them as a part of your team is so essential because that is one person besides your support, like your partner, that really does get to know you. And they get to hear all of those fears. And sometimes they can be that voice that we don't get those moments to be because we're in and out of the room so often.

Catherine Wilkins, MD:

Mm-hmm. I absolutely love when our patients have doulas too. Even from the physician perspective, I absolutely love it. I've always appreciated doulas when they're there and supporting our patients. What they're doing is helping more than the patient. They are really helping the whole team who's taking care of the patient. Remember the ... I mean, with the patient being at the center of it, the work they're doing is helping all of us. And I will say also that since we've implemented TeamBirth, I even more enjoy my own interactions with our doulas. They love TeamBirth.

I love how much they love it. They feel so much more like we are engaging them as opposed to just sort of taking care of the patient while they're there. That we're working together to take care of the patient.

We're communicating with each other. They're so comfortable and at ease speaking up and sharing with me what they're doing with the patient because of TeamBirth. And I'm so glad that we've implemented it. I get truly excited for every instance where I know that one of my patients has a doula. I'm like, "This is going to be great."

Tamara Noy, CNM, DNP:

Mm-hmm. I love seeing it on a chart, especially like when I get repeat doulas. And I'm like, "Oh, we know each other." We're like peanut butter and jelly. We work very well together, so. It's exciting.

Erica Newlin, MD:

And we have a lot of listeners from outside of Cleveland, but here in Cleveland, are there any nonprofit doula services or any services that patients who are low income or who may not be able to afford private doulas may want to look into?

Tamara Noy, CNM, DNP:

So there's always one that sticks out in my mind. It's called Birthing Beautiful Communities. And they're located here in Cleveland, Ohio, helping to bring that continuous labor support person to the bedside, recognizing the importance of having that support and how critical it is in helping to decrease the rates in which we have maternal morbidity and infant mortality. They stay with moms more than just after the postpartum period.

They almost become family because they're with them for about a year, if not more. I know in our healthcare system, we do have community health workers that also function. They're not our doulas, but they are there to help bridge that and bring resources into the home for families. And community health workers are available to all of our patients that have a need that our community health workers may be able to help meet.

Erica Newlin, MD:

We have talked about people who may want a non-medicated birth, or we call it natural childbirth. But can you describe different options for medicinal pain relief on labor and delivery?

Catherine Wilkins, MD:

Well, for medicinal pain relief, the gold standard for people who want medicinal pain relief in labor, it's an epidural. But short of that, there are other options. And I also want to point out that patients come in with a vast amount of understanding and knowledge about how it can help them in labor and when not to. And I have patients oftentimes saying how they want to hold off and not get the epidural too soon. And then on the other side of that coin, we have some patients who walk in saying, "I don't want to feel a single thing about my epidural" before it ever gets to that point. And I do think it's really important in those instances to really help those patients to understand that an epidural will be in place for a really long time, and if their labor is long, and it will immobilize them and render them unable to go to the bathroom and have to have their bladder emptied with a catheter and things of that nature.

And so I do think it's really important that ideally, before they ever get to the hospital, we talk to them about these options and have them have a good understanding. It is great when a patient really comes in informed and when they don't, it's all right, it's our job to do it when they get there. But we really do need to help them understand what to expect and what's best for them. We know that movement's important in labor, and the longer a patient moves around, the better it is for their labor course and shortens the duration of their labor and an epidural given too early, we'll take that away. So then that's when I start talking to, to them about other pain relief options, depending on what they need and how early it is. So there is IV medication, and then there's also nitrous oxide, which I can let Tamara talk more about, but it is a really helpful adjunct as well.

It's medicinal pain relief. It is inhaled gas, like what dentists use in their offices. It can work really well for taking the edge off of painful things, but it's not going to give the same level of relief as an epidural. So it can be great for really, you know, sort of short interval uncomfortable procedures. Or for the patient who really doesn't want an epidural or for whatever reason, can't have one. But it can help take sort of the roof off, if you will. Like if, if their pain's spiking up to an eight, nine, or 10, maybe it can bring it down to a six, seven or eight instead.

Erica Newlin, MD:

Tamara, what options might someone consider for pain relief outside of medicinal pain relief?

Tamara Noy, CNM, DNP:

Well, Catherine definitely hit on one of 'em. The movement is a big piece, especially when you call and you're, "I think I'm in labor," the first thing I'm going to ask you is, "What are you doing?" You know, when you think you're in labor. Movement can be one of those things that you have to find the sweet spot for. Because you ... Some people think they need to move like they're running a marathon, and you don't. You just need to be upright because you're going to tire yourself out. And I need you to have energy because this could be a true marathon. So movement.

I also love when people have engaged with some type of water, whether that's, you chose to go swimming, especially if you're at home. But if you are in the hospital setting, getting in the shower is your friend in early labor. The shower and some nipple stem can really get things going. But there's something so calming about water, whether it's hearing it against the wall, hearing it when it hits the floor, or just hearing it come out the spigot. It just really calms people. It's like one of the number one sounds that we hear when we're listening to people's ... What they're listening to for calming, soothing sounds is water.

The tub is another good friend. I think when you put the tub and you put nitrous together, it is like chef's kiss in terms of getting people to go, because Catherine kind of described it as taking the roof off. I always go, “It's like getting to the peak of the roller coaster and not caring when you look over anymore because it really just kills the anxiety of it all.” You really have to make it sound like it's snoring for it to work. And cause people like to like huff, huff and really, really gently do it. And I'm like, "Oh girl, you're not going to get anything from that."

You really have to really pull it in to really get those effects from it. But nitrous is wonderful, especially in the tub. It really helps to relax birthers and they do wonderful with it. We also can do sterile water papules, which is where we inject a small amount of sterile water right into the small of your back. It burns initially, but if you can get through that few seconds of the burn, it will help you to relax those muscles and that tissue enough for you to hopefully get that baby that's OP and in your back to spin. Because at that point you're so tense. Like sometimes I can feel people's back and walk my hands down their, like down their back, down their hip, down their thigh, and it is all one big rock and nothing's gonna move or turn if you are that tight.

So getting you to relax those muscles is key. I love when people turn on their music, it's fun. Cause in the beginning it all starts out and people have their fun music, their dance, and their party, and then it gets all, I love you, music, and then it's time to have a baby and we get another party. So it's great. It's like, all right, we're doing this. So music is always fun. But yeah, when it comes to epidurals, because people will go unmedicated and they will rock it out, but they'll be exhausted.

And I, I call it a therapeutic epidural at some point, you can do all of these things, but if you can't make a solid decision and you no longer can tolerate anything, you're not going to be able to push that baby out. And you're going to have so much trauma from that delivery that you have to ask yourself, "At what cost is it worth it?" And sometimes the epidural gets recommended as a therapeutic situation, just so I can get a mom that'll be able to take a nap, relax her hips and her body enough to let that baby come down so that we can have a vaginal delivery. If it's still safe to do so.

Catherine Wilkins, MD:

I love that you said that, because earlier when I said it's the gold standard, it doesn't mean it's my favorite, but there are times when I'm so grateful that it happened for the patient. I honestly do love natural childbirth when it's working well for somebody and it's what they wanted and it's what they got. But I also want patients to know when it's what they wanted and it doesn't work out. It is not a failure and it's sometimes a really beautiful thing and really helps the patient. And that's when it is therapeutic. And I like it when that happens.

Tamara Noy, CNM, DNP:

Me too.

Erica Newlin, MD:

Shifting a little bit, even as an OB myself, it feels like we're inducing a lot of people. We're doing a lot of inductions of labor. Can you describe generally why it might be medically advantageous to induce a delivery instead of waiting for someone to go into labor?

Catherine Wilkins, MD:

I too wish we didn't have to induce as many people. And I would love for everyone out there that's pregnant to just go into labor and come in when that happens. The reality is there are many conditions that are just high risk in pregnancy and that don't make continuing the pregnancy past a certain point safe or as safe as inducing. And in those instances, it's when it's right to do an induction of labor. And those can be for maternal reasons or for fetal, or for the baby's reasons.

So maternal medical conditions like hypertension, high blood pressure, the different hypertensive disorders that can happen during pregnancy, those are dangerous to the mom to continue the pregnancy. And also very much so for the baby. Same with diabetes in pregnancy. Whether it predated the pregnancy or is caused by the pregnancy, there are risks to the baby in the setting of diabetes that would really, depending on the type of diabetes, how it's being managed, it oftentimes then does really necessitate or we would recommend induction of labor to avoid potentially an adverse outcome for the baby.

Other conditions that pertain just to the baby. Things like fetal growth restriction. So a baby who's sort of not growing as much as would be expected, or it should be based on the growth curves and standards that we know that we have to measure the baby's by. So in those instances, the concern, obviously, even if it's a very low probability, but the concern is that continuing the pregnancy could increase the risk of stillbirth, even if it's a low probability. It's the absolutely most devastating outcome that we can imagine.

And it's in instances like those that yes, we would recommend induction of labor. Same with low amniotic fluid volume or what we oligohydramnios that carries similar risks and another reason why we would recommend.

Erica Newlin, MD:

For sure.

Catherine Wilkins, MD:

Mm-hmm. Or any suspicious fetal testing or decreased fetal movement at term, depending on the gestational age and what the circumstances are.

Erica Newlin, MD:

What about the role for elective or quote, "risk reducing induction of labor?"

Catherine Wilkins, MD:

So there is a role for that, and it's one that, you know, it really involves shared decision-making in the offices prior to ever arriving at the hospital. We used to think long ago that inducing labor, especially in nulliparous, nulliparous being women who've never had babies before, so nulliparous or women with an unfavorable cervix, that it increase the C-section rate. We do have good evidence that if done correctly, I mean the labor induction itself, it doesn't carry an increased risk of cesarean delivery. It does perhaps increase the length of stay in the hospital. Yes. But it shouldn't increase the risk of cesarean delivery if done correctly.

So then what are the benefits? There are some medical benefits. We know that in the large study that looked at this, there was a decrease in babies admitted for meconium aspiration to neonatal ICUs and a decrease in the maternal hypertensive disorders of pregnancy. Those things like what we call gestational hypertension or preeclampsia. So those are the medical benefits in the study where it was looked at. Otherwise, the benefits are really individual, and that's where the shared decision-making is so important. It's a lot of patient preference, and I believe obviously in patient preferences and autonomy and the shared decision. So that's what I would say about that.

Erica Newlin, MD:

For sure. I think it's something that I often with patients in the office have been talking about since early pregnancy, but particularly as we're getting later in the third trimester, setting aside time to ... I think in some geographic cultures in the US everyone gets induced now at 39 weeks, and that's the way things go. But it's really their-

Catherine Wilkins, MD:

But that doesn't have to be the case either. And I think it's really important that we as providers are careful in how we counsel our patients. And if it's truly elective, and we talk about benefits and risks, I mean, the risks are low, the benefits are very individual, right? So I really think that that's the most important thing and that we need to be careful about that in talking to our patients. And it should be, when it's elective more patient-driven, I think. It's certainly an option, but I don't think it should be provider-driven necessarily. I think it just needs to be the shared decision again.

Erica Newlin, MD:

What kind of monitoring for baby is typical in labor and delivery?

Tamara Noy, CNM, DNP:

It's funny you should ask that. I did a whole doctoral project on monitoring babies. But very common in our, in our hospital systems, is the continuous fetal monitoring. Is it common? Yes. Should it be the standard of care? Probably not, because the majority of patients that walk into our units are not high-risk patients. Now, if you have a high-risk medical condition like Catherine talked about, then sure, I want to know what's going on with you. I want to know what's going on with that baby, and I want to know how that placenta and everybody's interacting together. But if you are low risk, you should be getting intermittent fetal monitoring, which is where you come in, we're going to listen to your baby. We'll do that for about 20 minutes. And as long as the baby sounds and looks okay, your vital signs are stable and there's no conditions that prohibit it, then you should be getting listened to with what we call a Doppler device.

The same thing that they use in the doctor's office when you go for your visits. But you should be getting listened to with that at regular intervals based on guidelines. And the research has definitely shown that having us on continuous fetal monitoring does not actually decrease poor outcomes. It actually, increases our rate of intervention, our rate of C-section, and decrease in mobility and sometimes patient autonomy. So I think that as we move towards making our standards and our practices a little bit more patient-centered, more patient-friendly, really changing that culture and moving more towards an intermittent monitoring standard is where even ACOG, which is the governing body for our physician partners, says that this is where we should be going.

Erica Newlin, MD:

What does it mean for a hospital to be baby-friendly?

Catherine Wilkins, MD:

What it means, essentially, I mean, it is a designation that hospitals can acquire and they have to meet certain metrics to acquire that designation. But without getting into the sort of minutia of those metrics, what does it mean in general terms? It means that we are promoting all of the behaviors and supporting new mothers and their babies in ways that would keep the mother-baby dyad together. So limiting time away, doing things like immediate skin-to-skin, we look at how soon after birth a baby breastfeeds, we look at exclusive breastfeeding rates, rooming in on postpartum, minimizing the time a baby's ever taken to a nursery for any reason, doing the necessary newborn screens and things that they need at the bedside instead of removing the baby from the mother.

There are a set of criteria, but the point is that it's important we have criteria in these metrics so that at the end of the day, we're doing what we should be doing, which is promoting new mother-baby bonding to support breastfeeding and bonding. And just essentially, it is what it sounds like being baby-friendly is supporting the new mother-baby dyad to get them off to the best start.

Erica Newlin, MD:

Tamara, can you discuss a little bit about what's meant by the golden hour?

Tamara Noy, CNM, DNP:

So the golden hour, it's one of my favorite things. So once your warm, wet, squishy baby comes out, the first thing that we do if it's a vaginal delivery, is I'll show you your baby, and then I'm going to put that baby on you if that's part of your plan. If you say, "Absolutely not, wipe that baby off," then we will do that. But normally we just big warm, wet, squishy goes right on your chest, and it's an opportunity for that baby to get that immediate back to mom, unless intervention from us, you know, cutting a cord, bringing a baby over to you warmer, and just really lets that baby settle into that transition into its new life.

So it's the first hour baby is on mom, and it lets them regulate their temperature. It regulates their heart rate. Sometimes when babies come out, you'll notice they're breathing all fast, but then you look back in a few minutes, all of a sudden they've settled into a nice 40 and it's really calm. Moms are calmer. But it really just helps to stabilize those vital signs. And we really ask that babies are not disturbed in that first hour. Meaning we might move them because they're sliding or we've gotten their nose in a really fun place, but we really try not to pick them up or bring them off of birthing person until that hour is up where we can do weights and measures and things along those lines. And then we ask, does a support person want to have baby at that point when we get mom up? But that first hour is all about getting that baby to transition as safely and as calmly as possible.

Erica Newlin, MD:

Well, thank you both so much for joining me. Is there anything either of you would like to add?

Catherine Wilkins, MD:

So I love working with Tamara at the hospital and here. And you too.

Erica Newlin, MD:

Well, great. Well, again, thank you both so much.

Catherine Wilkins, MD:

Thank you.

Tamara Noy, CNM, DNP:

Thank you.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast. Or visit clevelandclinic.org/obgyntime.