Modern Maternity

Having a baby used to be one of the most dangerous, least predictable, and stressful events in a woman's life. To find out how much things have changed, we took an exclusive look at the state of modern childbirth at the region’s most popular obstetrics hospital.

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On a far-from-tropical January day, Kristen Vanneman-Gooding sits under a poster of a palm tree in the waiting room of her obstetrician's office at the Greater Baltimore Medical Center (GBMC). It is exactly a week to the day before her scheduled cesarean section, and she is filled with anticipation. This delivery, she suspects—and hopes—will be entirely different from her last one.

Five years ago, a pregnant Vanneman-Gooding came for a routine visit to this very office. Vanneman-Gooding had stopped in for a checkup of her as-yet-unborn identical twin boys—conceived through in-vitro fertilization—from Dr. Claire Weitz, head of GBMC's Division of Maternal and Fetal Medicine.

The pregnancy was a troubled one from the start. At 18 weeks, an ultrasound had shown that the twins were together in an amniotic sac without a dividing membrane, a condition that is often fatal for one or both fetuses. "Claire said there was a 50-50 chance that either one or both would not make it," says Vanneman-Gooding.

But in the weeks to come, she and her husband, Ira Gooding, breathed a sigh of relief when a follow-up ultrasound showed that there were, in fact, two sacs.
Several weeks later, there was more cause for concern: The twins were suffering from a "growth discordance," in which one fetus was significantly larger than the other. So—as is standard for most twin pregnancies—Weitz put Vanneman-Gooding under "house arrest" to ensure a healthy delivery for both fetuses. ("I watched a lot of L.A. Law reruns," she recalls.)

Months later, during another ultrasound, there was more worrisome news: the black-and-white images showed that one of the fetuses was sluggish. Asked to return the next day to verify the findings, Vanneman-Gooding did; when the results were the same, Vanneman-Gooding remembers Dr. Weitz saying, "We're going to take them today."

"We didn't even have a camera," Vanneman-Gooding says. "It was a whirlwind—it was just a matter of fifteen minutes between being in Claire's office on the fourth floor, walking down the hall, and being in the operating room for the C-section."

Today, those twins—Duncan and Finnigan, both born the same size—are healthy, happy preschoolers. And although she suffered a miscarriage several months before her current pregnancy, Vanneman-Gooding—an assistant teacher at Lutherville's Havenwood Preschool Center and part-time office manager at State Farm Insurance—is relieved that this pregnancy has been so simple.

"I've been able to enjoy this pregnancy more than I did with the boys," says Vanneman-Gooding—who herself was born at GBMC 32 years ago. "I'm so much more relaxed, and knowing what to expect at delivery time is a load off my mind—I'm not nervous about the surgery. I'm more concerned about what to pack in my hospital bag."

It's hard to believe that as recently as 1930, delivering a child was the single most dangerous event in a woman's life: One out of 150 pregnancies ended in the death of the mother (most births occurred at home).

In the 21st century, standardization of practice—from the presence of fetal heart monitors (100 percent of the time at GBMC) to advances in anesthesiology (used by about 85 percent of maternity patients at GBMC) to the prevalence of pitocin (a synthetic hormone used to speed up labor) and intravenous fluids—has made giving birth very safe. In 2003, there were 12.1 deaths per 100,000 live births in the U.S.; that's about the same mortality rate as that of women with lung cancer.

"In terms of the safety of the mother, this is probably the best it has ever been," says anesthesiologist Jonathan Hamburger, a partner of Physician's Anesthesia Associates, whose group provides all anesthesia services to GBMC. The constant screening of Vanneman-Gooding's first pregnancy is just one example of how improvements help both mothers and infants.

More babies are delivered at GBMC than any other hospital in Central Maryland: some 4,500 newborns begin their lives at the hospital each year. (In 2006, Johns Hopkins Hospital and University of Maryland Medical Center delivered 3,290 babies combined.)
In the past five years alone, GBMC has delivered more than 22,200 bundles of joy. The hospital has been the delivery destination of people from all walks of life in the region, including former First Lady Kendel Ehrlich. Some satisfied customers even commute from other states—Kensy Boulware, wife of former Ravens linebacker Peter Boulware, traveled from Tallahassee, Florida to deliver the couple's third child at GBMC last fall.

Ever since its founding in September of 1965, GBMC (which merged with The Hospital for The Women of Maryland in Baltimore City and The Presbyterian Eye, Ear and Throat Charity Hospital) has been known for its outstanding obstetrical department. In recent years, GBMC has become known around town as "The Baby Hospital" or "The Baby Factory" for good reason. Despite the fact that there are numerous other prestigious area hospitals delivering plenty of babies, GBMC—in the wooded, tony suburbs of Baltimore—has become a leader for women's healthcare.

The physical plant of the 106-acre hospital campus perches atop a swell of land off of Charles Street; the tranquil campus is often called "The Hilton on the Hill." And if the hospital as a whole is the Hilton, the second floor primarily dedicated to maternal and newborn services, is the concierge level. In the obstetrics lobby and admitting area, a hospital volunteer tickles the ivories on a Yamaha piano to soothe the nerves of anxious family members. The 17 state-of-the-art labor, delivery, and recovery rooms, known as LDRs, are currently under renovation—they'll be redone in a tasteful green and beige palette, and will feature bamboo flooring.

They're also thoroughly modern rooms. There will be wireless internet service (some mothers have been known to log on to their e-mail servers or check their BlackBerries while dilating); handy desks to set up and recharge cell phones, laptops, and other gadgets; and plasma HDTVs. The 48-bed postpartum unit, with private rooms and a dedicated 11-bed high-risk obstetrics unit, is adorned in soft soothing colors and floral fabrics.

Since 2000, GBMC has invested approximately $9.9 million in labor and delivery room renovations, neo-natal intensive care units, and state-of-the-art equipment. Cracks Dr. Weitz, who has two grown children: "When I took the first tour, I said, 'Gee, it's almost enough to make me have another baby.' I've been to other hospitals, and this is about as good as it gets."

And the amenities don't stop there. The Lactation Station retail store is the only one of its kind on a hospital campus in Baltimore, and sells everything from fashionable nursing shirts to breast pumps and nursing pillows. Lactation experts have also set up a breastfeeding information "Warm Line," open seven days a week from 6 a.m. to 10 p.m. The Warm Line is headed up by lactation consultant Marla Newmark, who nursed 12 of her own children (she has 11 surviving kids).

Additional maternity services through GBMC Boutique include an on-staff aesthetician who visits the maternity ward to provide things like hair cuts, manicures, pedicures, and facials; parent education classes; and doula (or birthing coach) services.

The official acceptance of doulas—women who provide emotional and physical support to expectant mothers—by a staid, suburban hospital like GBMC was a big step for both sides.

"GBMC is known as a traditional hospital," says Lanny Dowell, doula coordinator. "It has been interesting to introduce an age-old concept to new and modern medicine. A lot of doulas were worried about how the staff at GBMC was going to take it. Did they think we were going to be dressed in old field garb and doing voodoo?"

Far from it. "We are known as the Ann Taylor and Talbot's doulas," says Dowell, looking very much the part in a pair of classic winter-white trousers, black mules, and tasteful top. "We are trying to merge the two images. We are not this cloaky person in labor and delivery with heavy incense. Our goal has been to soften and change the idea of the doula." The list of doula services—from acupressure to massage—sounds more like a luxe spa's offerings than tasks handled by a birthing coach. GBMC doulas also offer postpartum services, from meal preparation to infant care to light housekeeping—and even carpooling older kids to school, should the need arise.

In short, sums up Victor Khouzami, Chairman of the Department of Obstetrics, "At GBMC, there is a dedication to obstetrics at every level. This is a maternity hospital within a general hospital."

Says Susan Bowen, Clinical Director of Labor and Delivery, "I joke with Dr. Khouzami that we should secede from the Union and build our own hospital."
In some ways, that's what's happened: GBMC's decision to pour resources into becoming a major obstetrics center has paid off. Year after year, GBMC has racked up awards, including a coveted ranking in U.S. News & World Report's "America's Best Hospitals" in 1997 and 2001 for gynecology, "Best Maternity Hospital" by the readers of Maryland Family Magazine every year from 2002 through 2006, number one in Obstetrics in the Central Maryland Region by Maryland Hospital Association every year between 1995 and 2002, and one of the top 10 maternity hospitals in the U.S. by Child Magazine (1995). GBMC also has many other claims to fame, including the first birthing rooms in the state (1978), the first peri-natal center in Baltimore County (1985), the establishment of the first Lactation Department in the Baltimore area (1989), and the first robot-assisted gynecologic surgery at a community hospital in the mid-Atlantic (2006).

All those awards are not exactly what Ira Gooding is thinking about as he sits on a blue plastic chair in the hallway outside Delivery Room 1 on the second floor of GBMC.

It's one week after Kristen Vanneman-Gooding's visit to Weitz's office, and Ira Gooding is dressed head to toe in disposable navy blue scrubs, and clutches a camera.

"I'm more relaxed this time," says Gooding, an Open Courseware Coordinator at the Johns Hopkins School of Public Health, "but I want to get in there and for everything to go well."

Minutes later, Ira is perched on a leather stool within a foot of his wife's head and several feet away from where his daughter is about to be born. At 66 degrees, the inside of the operating room feels as cold as the January day outside (it's kept cool to prevent germs and bacteria from flourishing). Vanneman-Gooding is draped in warming blankets, and wears a surgical cap that brings out the blue in her eyes. Weitz; her first assisting physician, Dr. Margaret Cyzeski; and a scrub technician congregate around Vanneman-Gooding's midsection.

The anesthesiologist, Dr. Stanislav Malov, tends to the monitors near her head. A circulating nurse and neo-natal intensive care unit team are on standby.
The 540-watt prism halogen surgical lights flood the room, intensifying the green of the doctors' gowns, the silver steel storage cabinets, and the ruby red blood that blossoms on Vanneman-Gooding's skin as Weitz makes her first incision through the skin with a number-10 scalpel.

Obstetrical devices have come a long way, both scientifically and culturally. In the 17th century, when obstetrical forceps were invented by Peter Chamberlen, the innovative instrument was such a closely guarded secret that it was used only when a laboring woman was blindfolded.

Other primitive practices in the 1940's through 60's included putting women in a "twilight sleep" through a potent cocktail of morphine and a powerful amnesia-inducing drug called scopolamine. Freed of their inhibitions—but not their pain—thrashing women were often strapped to gurneys to keep from hurting themselves. "It was such a powerful amnesiac, some patients would wake up the next day and not even know if they had a boy or a girl," says Hamburger.
"Patients would run down the hallway stark naked," recalls Khouzami, who joined the GBMC staff in 1981 as head of the Division of Maternal Female Medicine.

Modern obstetrics was still in its infancy (so to speak) when GBMC opened its doors in September 1965. In the 60's and 70's, recalls Khouzami, "We had labor rooms, delivery rooms, and recovery rooms. The woman delivered in the labor room with no family or support services, and she pushed the baby out for hours, and then the baby was taken to the nursery, and [the mother] was taken to the recovery room where maybe someone would visit. It was very, very [impersonal]."

"The husband dropped you off at the door of the labor room," recalls Bonnie Lauryssens, a retired nurse practitioner who worked labor and delivery at GBMC from early 1966 through 2005. "Ashtrays were all in the labor rooms, doctors would walk in smoking, and women smoked while they labored. You had to pull bars up the bed because the anesthesia made them thrash and try to climb out of bed. It all seemed so normal—this was what we knew."

Women had no say in the birthing process either. "There was [a] paternalistic attitude," recalls Khouzami. "The attitude was 'You do it because I know what's best for you.'"

By the mid-70's, as more Americans began to question the status quo on much conventional wisdom, "Families started to demand to share and have greater participation in the delivery," remembers Khouzami. "They said, 'Don't shut us out,'" and GBMC was the first hospital in Maryland to respond to these needs. "We opened the first birthing rooms in the state of Maryland in 1978, and we included fathers in the process."

By the early 80's, birthing centers—where women delivered through the help of a midwife and in the absence of a doctor—had sprung up around Baltimore. GBMC added them and tried to provide families with both the warm, nurturing feeling they would get in a birthing center and the technology and backup staff found in a hospital setting. "That's how we started changing our thinking to, 'pregnancy as a natural process,'" says Khouzami, "and we shouldn't be intrusive, but we should be there, should an emergency arise."

Another trend in the mid-70's was a shortened length of stay for mother and child. "It got to the point where the woman had a baby, took a shower, and went home," says Khouzami. "The length of stay kept dwindling." By the 1990's, the average length of stay was 1.7 days.

"There was pressure put on me," Khouzami says, "because we thought we were going to go down to 12 hours [from admission to release]. I said 'Over my dead body. It's going to swing back.'"

It did, in 1995: Maryland was one of the first states to mandate a 48-hour length of stay before the practice became a federal law under President Clinton.
And then there was the liberal open-door policy for visiting family members in the LDR. "We went from having no one in the room in the 70's, to having to put a limitation on how many people could get into the room," says Khouzami. "By the 90's, it started to get crowded—I remember one delivery in which there were twelve people in the room."

Recalls Lauryssens, "There were mothers-in-law, fathers-in-law, brothers, sisters, sisters-in-law, and friends. It got to be a joke that pretty soon they were going to let the family dog in." (Now the policy is five visitors for a traditional delivery, two for a C-section.)

A drape hung near her chest prevents Vanneman-Gooding from seeing the C-section occur. On the other side of the drape, Weitz is the model of calm and confidence, and she cuts side to side along the turgid abdomen, then cuts through the fascia covering the abdominal muscles, through the peritoneum en route to the thick, muscular uterus. Using numerous white gauze pads, the team of three stanches the deluge of blood that pools and pours from Vanneman-Gooding's body.

Even though it is possible for Ira to avert his eyes, he watches as Weitz pulls and probes inside the deep exposed cavity in his wife's abdomen and then, using a suction device, eases the crown of the baby's head out of the womb.
"Ira, get your camera ready," calls out the circulating nurse—and then, baby Wren arrives, about 12 minutes after the first incision.

"It's a girl," says Weitz. "I thought you told me it was a boy—I was all set to say, 'Three boys, you're screwed.'"

The baby is weighed (7 pounds, 6.2 ounces) and evaluated (an APGAR score of 9—nearly perfect). APGAR—an acronym for activity, pulse, grimace, appearance, respiration—is a 10-point scale used to provide an immediate, if rough, status report of a newborn's health.

While that's going on, Weitz cuts and ties Vanneman-Gooding's fallopian tubes (a procedure Kristen and Ira had decided to undergo after their third child), before closing the C-section incision with sutures.

The circulating nurse methodically counts the instruments—the bladder blade, the retractors, the sutures, the scissors, the scalpel, the clamps—three times to ensure that nothing gets left behind in the patient's body. Ira snaps a digital photo of their new daughter, and hands the camera to his wife, which lets her study her beautiful baby girl for the first time.

On January 22, 2007, Wren Dorothianne Gooding is logged in the hospital's official record book at 10:57 a.m. She's the 278th baby to be born at GBMC this year; Kristen will return home four days later.

Anesthesiologist Malov offers a little comic relief. "How soon before there are no more [natural] deliveries?" he asks, only half joking. "In the next century, babies will probably be genetically engineered, and there will just be this zipper across here," he says, pointing to his abdomen.

Malov's quip is not entirely in jest. Cesarean section on demand has become de rigueuramong professional women in modern, industrialized nations like Japan where, according to Khouzami, the C-section rate is 90 percent. In the U.S., nearly 25 percent of births today are by cesarean (in 1970, it was only 5 percent).

C-sections offer benefits (greater control over time of delivery and the removal of some risks from the childbirth process) with a bit of risk (it is surgery, after all, and long-term effects may include more postpartum pain and infertility issues).
"We knew this was coming to the American workplace sooner or later," says Khouzami. "We knew the day would come when women would start asking for it. We are simply coming to a time when women are saying, 'This is how I want to deliver,' but the East Coast is very slow to change. We've had maybe a handful of C-sections on demand in which women have said, 'I don't want to labor. Get me a date.' But the trend is not here yet."

Dr. Weitz seconds the notion. "There will be an increasing demand for elective primary C-sections," says Weitz, who jokes that for some women, natural childbirth means delivering without makeup. "We are the old prudes," she says, "the last to jump on the bandwagon. We are taking it cautiously, but I do foresee a tremendous increase in patient requests for elective C-sections. When you really look at it, women can get nose jobs, breast implants, tummy tucks. Why does society say that we must make them deliver vaginally? It's your body and your decision. We respect the woman's autonomy."

To date, the C-section rate at GBMC is about 22 percent—higher than the national average, but misleadingly high because of GBMC's high-risk patient population. These include mothers with multiple births (many of whom medically must deliver through C-section), older mothers, and repeat patients (at higher risk), and the fact that the local Catholic hospitals will not perform tubal ligations (often done in conjunction with C-sections), so many expectant women choose GBMC to have their C-sections so they can also get their tubes tied.

So are we professionalizing childbirth—turning it from an arcane, vague, mysterious process into a regulated, structured, guesswork-free procedure? 

Susan Bowen, clinical director of labor and delivery, believes we're well on our way. "I joke that one day we are going to get our hours down to nine to five, Monday through Friday," she says. "I think the sad part of it is that our whole lives are planned from the minute we step out of bed in the morning until the minute we get back in bed at night. And this should be a wonderful experience for a woman. I worked nights for nine years, and the thing I enjoyed most was that natural labor that came through the door and you could be so supportive and really help the woman and her family."

However women deliver these days, what's clear is that they are having a much greater say in the process. "We try to do what the woman wants us to do," says Bowen, "as long as it's okay with the doctor and within the policy of the hospital."
"Years ago, if someone told me they wanted to breastfeed for two days," says lactation consultant Marla Newmark, "I would tell them 'It's not worth the work.' Today, if they tell me they want to breastfeed for two days, I give them the same amount of attention as if they planned to do it for a year. We are out to please the consumer. What the patient wants is what we do."

Something else has changed too: the patient and the doctor now look a lot more alike. The influx of women entering obstetrics has caused sweeping changes in a formerly male-dominated field. At GBMC, there are 57 OB-GYNs: Nearly half are women. "We used to have the token female," says Khouzami laughing. "Now we have the token male." Susan Bowen agrees. "Women have made a big difference in the field because they have experienced labor. This is not a disease—it's a natural process so we have a lot of influence when it comes to how we want to give birth. Women are more assertive. You don't have the little housewife who comes toddling through the door saying, 'I'm here. Take me.' It's not that anymore. We have a lot of career women who know what they want, we have a very educated client base—everyone's doing research on the internet, the women take classes, they want what's best for their baby."

Claire Weitz was the only female resident in obstetrics when she did her training at Johns Hopkins Medical School in the mid-70's. "When we would show up [to put on scrubs for the OR], the locker rooms would say, 'Doctors' or 'Nurses.' I would go into the 'Doctors' room, and it would be the men's room. We are the majority now. Women have brought a new perspective. Things become a little more personalized [for the patients] because they're often dealing with someone who has experienced pregnancy—been there, done that, and gotten the T-shirt—but it doesn't mean that the men are unsympathetic to pregnant women. Some of the kindest, most sympathetic men I've ever known have been obstetricians, and that's a loss for the field because men are not being encouraged to go into it anymore."

"When technology first came in, nurses felt put out," says Bonnie Lauryssens. "They let technology take care of their patients—they would go in a room, look at numbers, and write them down on a chart. Now, it has evolved. The nurses are even more into the deliveries and are incredibly encouraging. Half the nurses probably have hemorrhoids from pushing with the patients."

Khouzami couldn't agree more. "I remember as a student, I had a teacher from Virginia who was a real gentleman," says Khouzami. "He was part philosopher, part obstetrician, and he said that a delivery should be 'by art, not by force.' It's art, not science. Yes, some part of OB is science, but if you make it purely science, you take all the emotion out of it. You have to have a solid foundation in science, you have to have technology, but it has to be tempered by humanity.
"Obstetrics is more humane than ever. The technology is better than ever. As we move ahead, we have found this wonderful balance."

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