Unit Focuses on Physiologic Labor and Birth

In April 2017, Cleveland Clinic Fairview Hospital opened a labor/delivery/recovery/postpartum unit that utilizes a low intervention, midwife care model to offer a home-like birth experience. Fairview Family Birth Place provides patients a space for normal physiologic labor and birth, which are powered by the innate human capacity of the woman and fetus, according to the American College of Nurse-Midwives.

“The country is moving toward physiologic birth,” says Angela Washer, MSN, WHNP-BC, C-EFM, in the role of clinical nurse specialist for Women’s and Children’s Services at Fairview Hospital. “The United States Preventive Health Task Force talks a lot about the benefits of physiologic birth and exclusive breastfeeding. They help moms and babies stay healthy for a lifetime and save on healthcare costs throughout their lifespan.”

Physiologic birth includes spontaneous labor and delivery, exclusive breastfeeding and use of alternative pain relief methods, such as nitrous oxide utilization. It excludes interventions that interfere with the natural physiology of childbirth, such as induction of labor and epidural analgesia. Benefits can include reduced peripartum morbidity, primarily through avoidance of interventions; an improved birth experience through access to supportive care and involvement in decision-making; and stronger maternal-infant attachment.

A calm environment for labor and delivery

In 2015, Washer spearheaded the initiative to open a physiologic birth unit along with Joyce Arand, MSN, CNS, RNC, NEA-BC, Nursing Director for Cleveland Clinic Women’s and Children’s Services, and Dusty Burke, MSN, RN, now nurse manager of the Family Birth Place. They organized a steering committee for the project, which included the director of obstetrics and gynecology at Fairview Hospital, the regional director of obstetrics and gynecology for Cleveland Clinic, Fairview’s midwifery director and representatives from the hospitalist and laborist groups.

The committee worked with an architect and design team, with whom Burke had weekly meetings. “The team started by analyzing the space and deciding what we had to work with, how many rooms we could incorporate, and how to best utilize the remaining space,” says Burke. Based on that analysis, the Family Birth Place has nine patient rooms, six of which serve as labor/delivery/recovery/postpartum rooms (LDRPs) and three of which are solely postpartum rooms. Four of the LDRPs include tubs for patients to labor in, and two rooms have queen-size beds. The unit also has a labor lounge and a family lounge.

“The overall atmosphere you get when you step on the unit is calm and relaxing,” says Burke. “We have a lot of natural light, and the white walls are offset by natural wood tones. We try to make the setting as home-like as possible.” For example, patients can request candles and aromatherapy.

Clinical criteria for physiologic birth

Once the steering committee decided on the unit’s design, members tackled clinical aspects of the Family Birth Place, such as admission and eligibility criteria. Requirements for admission to the unit include the following:

• It must be a singleton pregnancy.
• The baby must be in vertex presentation.
• The gestational age of the baby must be between 37 and 42 weeks.
• The mother must have established prenatal care with one of Fairview Hospital’s midwives or physicians.
• The mother’s pre-pregnancy body mass index must be 39 or less.
• The baby must have a fetal weight of less than 4,250 grams based on clinical estimation.
• Typically, the patient must be in active labor.

In addition, the unit doesn’t offer continuous fetal monitoring, so any risks that require monitoring would prevent admission to the Family Birth Place.

Approximately 20 nurses work on the unit, with three nurses on duty during each shift. “The nurses are very dedicated,” says Washer. “They believe in their hearts that physiologic birth is the right thing to do. It’s spiritual for them.”

Patients appreciate the option for physiologic birth

In 2017, the Family Birth Place had 170 deliveries. For many pregnant women, the unit offers a great alternative to the hospital’s traditional birthing center.

Washer recalls a woman who was pregnant with her third child. She labored at home to ensure she was in active labor upon arrival. When the woman came to the triage area at Fairview Hospital, her cervix was already dilated 9 centimeters. “The concern was that maybe she should just go the Birthing Center since the birth was imminent,” says Washer. “But the patient was very determined to come to the Family Birth Place. The mind is a powerful thing. She held off until she got to the unit, then delivered about 10 minutes later.”

The unit’s patient satisfaction scores have been well above the 90th percentile since opening. “We don’t hear negative comments,” says Burke. “If anything, people wish the Family Birth Place had been here sooner!”

As part of its Healthy Birth Initiative™, the American College of Nurse-Midwives offers maternity care providers a physiologic birth toolkit.