Obstetrics/Women's Care

Women and Infants’ Services
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Judy Smith, MHA

M
ost acute care hospitals in the United States provide dedicated facilities for birth and breast care services, two cornerstones of women’s health. During the past twenty years, many hospitals expanded the traditional definition to include other types of facilities dedicated to women’s services such as gynecology, bone health, heart disease, women’s cancer and menopause. While the services under the women’s umbrella have evolved significantly, the largest allocation of hospital space devoted exclusively to women’s health continues to be the birth service. The primary focus of this section of the course guide will be on planning birth facilities, without the intention to diminish the importance of the other types of women-specific facilities such as breast centers, women’s surgical units, and ambulatory “one-stop” women’s health centers. Birth-related reasons typically represent nearly 15% of most hospitals admissions – for many hospitals births are the top reason for admission.

Background/History


Births in the US began moving from homes in the late 1800s to hospitals by the 20th century. The number of US hospital births jumped from less than 5 percent in 1900 to 50 percent by 1940 (1). Aseptic techniques were practiced and birth usually involved moving the woman through a series of rooms during each key phase of birth, not unlike the assembly line model popular in the automobile industry.
The treatment of birth as a medical situation became the norm in hospitals for many years, and has been slowly changing during recent decades. Even though a third of births are surgical today, hospitals usually aim to provide a birth experience that is less like a gall bladder removal and more like a celebratory life event for patients and their families.
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In alignment with other significant cultural changes in healthcare, this landmark movement to “re-humanize” the birth experience began in the 1970s. The physical change was seen in the advent of the birthing room, a concept believed to have migrated from South Africa to New England. The woman stayed in the same “homelike environments” room for labor through delivery if she was expected to have a low risk, non-surgical birth. Eventually, the father was allowed in the room to witness the birth - a change that occurred only after great debate and persuasion.
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The birthing room was followed by the concept of labor/delivery/recovery rooms (LDRs) with separate postpartum rooms and the “all in one room” labor/delivery/recovery/postpartum rooms (LDRPs). LDRs and LDRPs were used for low to high risk vaginal births, but not for the surgical births referred to as Cesareans. Cutting the infant out of the mother has occurred in human culture since ancient times. Surgical births occur in operating rooms that became known as Cesarean birth rooms or Cesarean delivery rooms. Variations of LDR and LDRP models included units that had mixed design concepts with a blend of both LDR and LDRP rooms and some with a mix of traditional assembly line model labor and delivery rooms plus LDRs or LDRPs. The traditional model for vaginal births has almost become extinct in the US during the 21st Century.
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The other key patient space is for the infants. Facilities for infants without problems are known as normal newborn nurseries. Design standards for nurseries that accommodated newborns in bassinets were well-established by the middle of the 20th century. Facilities for sick infants were slower to develop. Infant beds, known as incubators, these infants’ beds, had a strange origination in carnivals and exhibitions like the World’s Fair, where keeping tiny premature babies alive was a “side show”. Eventually the incubator caught on as a medical device and hospitals established neonatal intensive care units (NICU) to treat infants born with health problems.[1]
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Formal planning guidelines for NICUs first occurred in 1976, when a multi-disciplinary committee wrote and the March of Dimes published the first edition of Toward Improving the Outcome of Pregnancy (2). Since then, other professional groups have published guidelines, including one of the most well-known publications developed by an international consensus committee, Recommended Standards for Neonatal ICU Design (3). This document serves as a reference for facility guidelines published by the Facilities Guidelines Institute. (FGI), a document described in chapter 6. (4)

Space Planning and Functional Programming

Discovery


As with the other types of projects, the planning process for birth facilities begins with a discovery phase. This phase includes learning about the hospital’s vision and market positioning; benchmarking comparisons; developing guiding principles; and understanding site/budget parameters and capacity goals. These initial steps are followed by space planning and functional programming. More recently, the programming step is integrated with an exercise or charette that includes overlapping the creation of bubble diagrams and schematic designs with the functional programming phase as a streamlined planning method. Most steps should involve members of the hospital’s physician, nursing and support staff who as team members, are known as the user groups. They can provide valuable operational information, which could impact the design of the facility.


Throughout discovery and later phases, architects, interior designers and planners are charged with the tall order of creating birth environments that support all of these patient and family experiences:

  • Celebrate the birth of a baby - a great moment in life
  • Substitute for the mother’s womb for premature infants
  • Nurture and enhance the development of babies
  • Cope with very scary and difficult situations

Identifying Patient Room Needs


The next step is to determine the quantity, types and mix of rooms since the patient rooms are key drivers of space. The current tool of choice for predicting room needs is computerized simulation modeling, which is covered in Chapter 15. Using simple normative models (ratios and formulas based on dividing patient time in rooms by days of the year adjusted for utilization rates) can result in problems because the methodology does not predict the statistical probability of having beds available when laboring women arrive. The most common patient care spaces and requirements are listed in the following summary.

Twelve Typical Types of Patient Rooms


Patient care space in a birth service includes some or all of the following twelve functional areas:
Births Services: Twelve Common Types of Spaces
Triage Postpartum – Mother/baby
Outpatient/Inpatient Antepartum Maternal Fetal ICU/Advanced Maternal Fetal Center
LDR Perinatal Diagnostic Center
LDRP Freestanding Birth Center
Cesarean Birth/Obstetric Operating Room Nursery
Recovery / Pre-Op Neonatal Intensive Care

Patient care space can be categorized further as inpatient or ambulatory, high­ risk or low-risk, and hospital-based or freestanding. This patient care space distinctive from staff and support space, but it may overlap with family areas occasionally. For example, a family member may stay overnight in the patient room or sit at the bedside and share a patient's space. The amount of overlap and the ways these rooms are used vary among facilities, but increased emphasis on family-centered care has blurred the distinctive zones.

Triage and Inpatient/Outpatient Antepartum Care


Triage is similar to other adult emergency triage. An assessment is done to identify acuity and decide where the patient should go next. This function should be located convenient to the entrance to the birth service with quick access to the area where births occur. Some larger birth service hospitals actually located the triage area on a different floor with a dedicated elevator to the birth service floor.

Acuity of pregnant women has been increasing due to health issues such as diabetes, obesity and hypertension. The acuity and the inadequate level of home monitoring technology, self-care, and patient education have not yet replaced the need for observation of many pregnant patients with serious medical problems. For these reasons, most hospital-based birth services provide antepartum inpatient and outpatient care. Patients are hospitalized when needing stabilization during pregnancy or when requiring treatment after an injury.

Outpatient antepartum beds may be needed for short-term observation after triage. When volume is sufficient to justify its creation, having space for short-term outpatient observation is recommended. The room should be located near the entrance to the unit, but not far from other patient care areas. Alternatively, a combination testing and observation room can be created for outpatients or inpatients whom must be observed to determine whether labor has begun. Functions such as admission/triage, testing, and observation are often carried out in a flexible triage room or area.

Maternal-Fetal Intensive Care and Advanced Maternal Fetal Care



When the patient population includes many high-risk patients with conditions that severely threaten the life of the mother or the infant, hospitals may create separate high-risk units beyond antepartum units. The area is similar in design to adult critical care units for pregnant women and newly delivered women. Central monitoring, glass windows in the corridor, and close proximity to a control station are design features of these special units. Most hospitals have insufficient volume and intensive care staffing in their obstetric units to justify an obstetric critical care unit that includes ventilation and the highest levels of life support interventions. In these cases, the patient could be sent to an adult critical care unit and births service nurses and specialty physicians would work with critical care staff jointly to provide care.

In recent years, both regional perinatal hospitals that care for the higher acuity patients and even some children’s hospitals with specialists in advanced maternal - fetal medicine have been identifying situations where surgery, transfusions and other treatment could occur in utero, before the infant is born. Design standards for these types of functions are in the early stages of development and have not been well-established to date.

LDR and LDRP


Most vaginal births occur in LDR or LDRP rooms, with LDRs being the prevailing design model. When looking at photographs or schematic designs of these rooms, it is difficult to distinguish between them. The design requirements of LDR versus LDRPs are only slightly different, while operational requirements such as staffing can vary more significantly.

The operational and design difference in, LDRs and LDRPs are the following:
  • Patients are moved to another room for postpartum care in the LDR model.
  • According to regulatory agencies in most states, LDRs are not required to have windows and are not considered licensed beds. LDRPs are treated as inpatient hospital beds and must meet regulations governing them, such as the inclusion of windows.
  • LDRP design usually has more rooms for births than a design that includes LDRs and postpartum beds, although the total number of LDRPs is often equivalent to the total number of LDR and postpartum beds..
  • LDRP staff are usually more multi-skilled or cross-trained to care for mother and baby for their entire hospital stay, than LDR staff.

Similarities include the size and layout of space. The minimum size of these rooms should be 340 net square feet with a 13 foot minimum dimension. The rooms are often divided loosely into zones that include an area for the family and an adjacent bathroom, as shown in the next diagram. Both LDR and LDRP units may include a holding or respite nursery or well baby nursery, and both may involve varying levels of staff cross-training for staff. Holding or respite nurseries typically have a smaller number of infant positions than full well baby nurseries. They are incorporated in hospitals that have a high percentage of 24-hour rooming-in of mothers with their babies.

Zoned patient room
Zoned LDR or LDRP room (5)

Cesarean Birth Room/ Obstetric Operating Room


All hospitals should be equipped to handle emergency and scheduled Cesareans births. A few of the smallest volume and critical access hospitals use the main surgical operating rooms, but the overwhelming majority of birth hospitals have operating rooms dedicated to the birth service to accommodate Cesareans and in some cases, obstetric/fetal procedures requiring sterile environments.

A common minimum is at least one Cesarean birth room and one backup facility, such as an operating room, to accommodate two simultaneous Cesarean births, where one may be unscheduled. The number of rooms should be based on analysis of need. While a common rule of thumb is 1,000 procedures or Cesarean births per room per year, validation of need for an individual hospital is a more prudent approach to selecting the quantity.

A cesarean delivery room should be no smaller than 440 square feet square of clear floor area with a minimum clear dimension of 16 feet. This includes an infant resusci­tation space with a minimum clear floor area of 80 square feet. The infant area should be provided even if there are additional facilities nearby for the high risk infant care, such as a separate stabilization room. Facilities providing advanced fetal surgery, frequent births of multiples and high risk care in these rooms need larger space as a minimum standard and should base the size on their individual needs.

The operating room includes a large overhead operating room light, a delivery table, space allocated for infant resuscitation, and ample space for staff, supplies, and other equipment such as an anesthesia machine. Air handling considerations are similar to other operating rooms, although thermal regulation of the infant area should be considered when designing air and temperature controls.

Recovery and Pre-Operative Rooms


Many, but not all, hospital birth services have specific recovery room(s) for patients after Cesareans or other obstetric surgeries. These rooms can be private for recovery of mother and baby together or could contain multiple beds in private bays. Space is needed for charting, hand-washing, and dispensing medicine. Recovery rooms should have access to toilets or at the very least a clinical sink for bedpan flushing. Chairs and space for the infant's bassinet should be provided. If more than one family shares a recovery room, curtains or other partitions that support visual and speech privacy between families should be included. LDRs and LDRPs are allowed as substitutes for recovery beds in some states, as women who labor in an LDR room but have an unscheduled Cesarean birth, may return to that LDR or LDRP room to recover.

Sometimes recovery rooms are used for patient’s preoperative care when they arrive for scheduled Cesarean and other obstetric procedures. In birth hospitals with high volumes, separate pre-operative bays or rooms may be planned.

Postpartum Rooms


Private postpartum rooms require less space than rooms where births occur. Usually 200 to 240 square feet, including a private bathroom, are adequate with a clear area of at least 150 square feet. The space accommodates the mother, a family member, the infant and the infant's bassinet simultaneously. When the infant is housed in the room with the mother, the room accommodates two patients even though it is considered a private room. Sometimes rooms are referred to as mother/baby rooms rather than postpartum to reflect the philosophy of caring for the mother/baby couplet rather than individual patients.

Postpartum rooms should be located near the nursery. They should not be positioned to allow walking through them going to and from other unrelated units. These rooms should be equally as attractive and comfortable as LDR and LDRP rooms in design and furnishings. A common mistake is to renovate or build LDR and LDRP rooms that resemble elegant bedrooms or hotel rooms and then provide uncomfortable, outdated postpartum rooms.
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Some facilities choose to accommodate Cesarean postpartum and even antepartum patients in LDRP rooms and eliminate the need for postpartum rooms or a portion of these rooms. This decision is usually based on the philosophy of care and available resources, including the physical configuration.

Perinatal Diagnostic Center



When included in a birthing facility, a perinatal diagnostic center has areas for outpatient medical testing such as ultrasound, non-stress testing (NST) and amniocentesis, clinical examination rooms, educational space, family waiting areas, and administrative space. While often located in the hospital at high risk perinatal centers during the past, many of these centers have moved to medical office buildings where costs are lower to provide ambulatory services.

Freestanding Birth Centers


Birth centers that are not part of a hospital exist for normal, uncomplicated pregnancies. They are usually staffed by midwives and provide an alternative to hospital and home births. The length of stay is usually short and patients leave in less than 24 hours after birth. The American Association of Birth Centers reports that there are just over 200 of these centers and that the quantity has grown 20% in the past five years (6). These centers are not designed with stringent hospital standards because the patients are screened for low risk and prefer low intervention. Mothers and babies are kept together after birth, usually eliminating the need for a nursery. Separate FGI Guidelines (reference) are provided for these types of facilities. In addition, the American Association of Birth Centers and individual states provide resources and recommended standards for operation and design of these facilities.

Nurseries


In hospitals, healthy infants are either with their mothers or accommodated in a separate nursery. The old rule of thumb that the nursery should have enough bassinets to equal 100 percent or more of the number of mothers' beds is no longer appropriate. Today's nursery design should be much more flexible. Mothers and babies room together in many cases and some babies may be in a NICU. The approach to designing well-baby nurseries must weigh the value of providing opportunities for continuous maternal-infant bonding, for care of babies when mothers are sick, died, adopting and many other concerns. The hospital should evaluate the percentage of babies expected to be in the nursery at the same time and plan accordingly. Security for the infants in the unit is essential and should be a major consideration of the design.

Nurseries should be located near the mothers' rooms. The nurseries are often accessible to visitors for viewing, as long as the viewing is done without jeopardizing security measures. A glass window for people of varying heights, including children is common.

The typical amount of space per infant position is 30 net square feet, although some states allow 24 square feet per bassinet. A minimum distance of 3 feet between bassinets is more important than achieving an absolute number of square feet. Charts and supplies can be kept in the nursery, an accessory workroom, or both. In facilities where the same nurse cares for both mother and infant, the accessory workroom and infant support areas, such as clean and soiled holding, are often combined with the support area serving the mothers. Circumcision rooms, places for hearing and other tests and even photography areas are part of the typical nursery. Most hospitals have moved away from a separate admissions nursery or area, since many babies are admitted where they are born or in the mother’s room.

Neonatal Intensive Care Unit


National vital statistics indicate that about 7 percent of newborns in the United States require the highest level of intensive care with approximately 12% of babies born prematurely (7). Design of facilities for premature and severely ill infants is changing dramatically. The environmental issues and research related to noise, lights, stimulation, and temperature regulation have become more important to designers and planners as they develop new facilities.

For many years, NICUs were large, bright open rooms filled with infants in incubators and platform warmers similar to a warehouse. The metamorphosis to smaller rooms of babies in groupings emerged as research indicated that the more controlled the environment, the better impact on the infant’s development.

NeonateAs more hospitals built the case for developmental care, the single room model of design emerged as a way to gain greater control over the environment. This model has been gaining acceptance as a developmentally appropriate and family-centered solution, although some hospitals do not have the building configuration or culture to implement it. These single family room units grew from none to approximately a dozen in a relatively short time in the late 1990s and now there are more than one hundred either in operation or being constructed. As with many new design models, the early adopters met resistance, but the number of hospitals with this model grew as other hospitals gain confidence that the design works. Early research indicates positive impact on length of stay, readmissions, infection control, family and staff satisfaction and other outcomes, although the body of research is limited.

Recommended Standards for Newborn ICU Design is a document that was created by a multi-disciplinary consensus group in the early 1990s and has been updated several times, including in 2012. The standards have been disseminated to more than 25 countries and several hundred newborn ICUs, architectural firms, state planning agencies, and medical professionals.

A complete set of twenty-seven recommended standards for NICU design are listed on the website http://www.nd.edu/~nicudes/. Excerpts from this site related to sizing the infant space include:

“Each infant space shall contain a minimum of 120 square feet (11.2 square meters) of clear floor space, excluding handwashing stations, columns, and aisles (see Glossary). Within this space, there shall be sufficient furnishing to allow a parent to stay seated, reclining, or fully recumbent at the bedside. There shall be an aisle adjacent to each infant space with a minimum width of 4 feet (1.2 meters) in multiple bed rooms. When single infant rooms or fixed cubicle partitions are utilized in the design, there shall be an adjacent aisle of not less than 8 feet (2.4 meters) in clear and unobstructed width to permit passage of equipment and personnel.
Rooms intended for the use of a single infant and his/her family shall conform to the requirements for infant spaces designated elsewhere in these standards, with the following exceptions:

  • Minimum size shall be no less than 165 square feet (15.3 square meters) of clear floor area….”
An innovative model of care called neonatal couplet care design has been implemented internationally for several years but has just been recently introduced in the United States. In this model, the post-partum mother and the NICU infant are cared for in the same room by a cross-trained nursing staff.

Ancillary and Support Space


As with most patient care areas, an array of other functions and areas support the patient rooms from environmental services and medication storage to staff lounges. Special considerations for birth services include designs that support infant security to deter abductions, an easy and safe drop-off area for laboring women and for pick-up of discharged mothers and infants who may be struggling with a new infant car seat. Models such as Planetree, mentioned in another chapter, are relevant for birth services, and can result in more integrated staff and patient communication spaces. The amount and types of ancillary and support spaces depend largely on the functional program that defines important aspects such as the size of the unit, the philosophy and how the space will comply with or exceed regulatory requirements.

Women’s Facilities Beyond Births


Women’s hospitals and pavilions that provide a comprehensive scope of services or that target another lifestage or health need should appeal to and accommodate needs that are different from childbearing aged women and families. For example, patients with gynecological cancer, urological screening, or heart disease will need lighting, surfaces, fixtures, special procedure rooms and other elements that make their spaces very different from birth facilities. A basic principle for women’s hospital design is that care for these patients should be clearly separated from the birth service, even if on the same floor. Sometimes the patient room may be universally adaptable for different types of patients, but the psychological, social and medical needs of women support separation.

[1] Neonates are defined as babies less than 28 days old.

References

  1. Leavitt, J. Brought to Bed' Childbearing in America 1750-1950. New York City: Oxford University Press, 1986, p. 171
  2. Berns, SD, Editor, Toward Improving the Outcome of Pregnancies III, March of Dimes, White Plains, NY, 2011
  3. White, R, Smith, J et al, Recommended Standards for Newborn ICU Design, web release, http://www.nd.edu/~nicudes/ 2012
  4. FGI, Guidelines for the Design and Construction of Health Facilities, 2010 Edition, Chicago, IL 2010
  5. Smith, J, The Family Birthplace: Planning and Designing Today’s Obstetric Facilities., Health Forum, Chicago, IL, 1995
  6. American Association of Birth Center, AABC Press Kit, Perkiomenville, PA, 2011
  7. Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2011. National vital statistics reports web release; vol 61 no 5. Hyattsville, MD: National Center for Health Statistics. 2012


Mother and Child
For this particular section, we chose to identify many of the terms associated with Obstetrics/Women's Care, as well as identify several of the types of birthing processes. Once we became familiar with both of these subjects, we began to research recent architectural precedents from the Architectural Showcase, various firms, and hospital facilities. We began to collect data on the these precedents and arranged it on a summary type matrix where we could compare and contrast the data. With this data we are hoping to develop a set of standards or common practices which various firms are currently implementing to create state of the art, modern birthing environments. If you are an architecture firm or hospital facility and would like your project to be added to this website, feel free to contact us and we can gain perspective on your particular building and add it to our project list. Thank you.


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