Little Things: Designing For Labor, Delivery, And Beyond
Expectant mothers brought something unexpected to healthcare providers last year: more bundles of joy. It was the first time since the onset of the recession in 2007 that the U.S. fertility rate saw an uptick. And as providers likewise rebound, more and more are starting to free up capital dollars to respond to the women’s and infants market by delivering their own new life—facilities projects.
Obstetrics units and labor and delivery rooms of old often don’t support today’s modern approaches to the birth experience, from hydrotherapy to enhanced family support, which is inspiring refreshes, renovations, and full-scale construction. “Hospitals are simply not meeting the demands for what the expectant mothers of this generation are asking,” says Alena Sakalouski, leader for women’s health at HDR (Minneapolis).
Making the move to invest in the birth experience also allows providers to be more competitive in their local markets and attract those ever-valuable healthcare decision-makers: moms. The delivery of a child is often a young family’s first inpatient stay, bringing with it the potential to keep not just mom, but baby, dad, and siblings coming back for future healthcare needs—if the experience inspires it. “It’s definitely a very savvy business decision to invest in that first ‘wow’ factor,” Sakalouski says.
How that wow is delivered can vary greatly, though. Sakalouski has worked almost exclusively on birth centers since 2012, with standalone facilities specifically gaining traction in her local Twin Cities market. It’s those large urban centers, she says, that often strive to provide comprehensive services to patients, from high-risk obstetrics to fetal care to NICUs. However, there are still plenty of mothers who will require only the average 48-hour stay in their local suburban or rural hospital, which is driving renovations in those existing maternity units, too.
On a national level, there were 4 million births reported in the U.S. in 2014, with a general fertility rate of 62.9 births per 1,000 women ages 15-44, a 1 percent increase over 2013, according to a June 17 report from the National Center for Health Statistics. The birth rate for mothers in their early 20s declined to 79 per 1,000 women, a record low, as birth rates for women in their 30s and early 40s increased, with those in their late 30s alone rising 5 percent since 2013.
And while the average age of new moms is on the rise, bringing a more sophisticated healthcare shopper to the market, this patient population is overall markedly younger than the usual medical/surgical patient, something that’s also shaping their expectations and providers’ responses to them. “The women who will be having babies in the next 15 years are for the most part Millennials, and so we’re thinking about what they might want in a facility and how the aesthetics might support that,” says Katherine Todd, clinical nursing director, Family Birth Center and perinatal services at Park Nicollet’s Methodist Hospital, who guided the hospital’s renovation of its 40,000-square-foot Family Birth Center in St. Louis Park, Minn. “They’re more of a consumer or a client. They’re looking for a natural process that they want to be in charge of.”
Part of answering that call through design is providing an inpatient space in particular that answers modern labor and delivery trends, starting with more square footage. The Facility Guidelines Institute’s Guidelines for Design and Construction of Hospitals and Outpatient Facilities sets a minimum of 340 square feet of clear space for labor, delivery, and recovery (LDR) rooms with an additional average of 70 square feet for the patient bathroom, and many new projects have scaled up from there.
One reason is to accommodate the use of hydrotherapy during labor. At Park Nicollet’s Family Birth Center, designed by AECOM and opened in March 2014, there are four 450-square-foot water birth LDRs that include birthing tubs. “The more we can keep moms in the tub, you can decrease pain by 50 percent. When you do that, you decrease your epidural rate by significant amounts, which decreases your interventions,” Todd says.
If there isn’t enough space available for a birthing tub within the patient room, many providers are turning to deep soaker tubs and/or walk-in rain showers in the patient bathroom for pain management alternatives. Park Nicollet chose walk-in showers for all rooms and soaking tubs for the non-water birth rooms.
A newcomer to pain management during delivery is the use of nitrous oxide, or laughing gas, as an alternative to epidurals. Designers say that although tanks can be brought into rooms during labor, providers are anticipating its growing adoption and requesting that headwalls be designed to allow the addition later if they’re not already offering the option.
Another tactic designers are using to support the labor process is making the entire room a usable space, ensuring mothers’ safety as they potentially move from one area to another, particularly by installing grab bars for support (in corridors, as well, where patients may walk a few laps to accelerate labor). “Laboring and giving birth could happen almost anywhere in the room, not just in the bed or the tub,” says Christine Hester Devens, associate principal and interior project designer at AECOM (Minneapolis) and design lead for the Park Nicollet renovation.
Sakalouski says the increased use of birthing aids, including rocking chairs or labor chairs as well as birthing balls, should be considered early in design, too, to ensure there are storage areas available. Distractions overall help ease labor and reduce pain, adds Kirsten Waltz, managing principal of Steffian Bradley (Enfield, Conn.), such as a well-placed piece of art or digital window pane above the birthing tub. “You’re in a tub and looking up—you don’t want to look at an acoustical ceiling or a 2-by-4 light. You want to be able to look at something that can take your mind off of things,” Waltz says.
Also more frequently by patients’ sides these days are spouses and partners, as their participation during labor is becoming more of a norm, calling for enhanced family zones that traditionally include a pullout couch and dedicated storage as well as separate lighting controls and entertainment options. At the new WakeMed North Family Health & Women’s Hospital in Raleigh, N.C., opened in May and designed by BBH Design, Thomas Cavender, vice president of facilities and construction at WakeMed, says its 474-square-foot LDR rooms include separate TVs for family and patient and plenty of extra space for the numerous visitors his facility often sees during labor. The rooms additionally provide a kangaroo chair (facilitating skin-to-skin contact between parents and baby after birth) and a bistro table for postpartum family meals.
However, accommodating the extended family becomes much more critical in postpartum rooms where new families more traditionally greet family and friends. For example, in its renovation, Park Nicollet chose to reassign its existing—and more s
pacious—LDR rooms to postpartum use to better support visitors and use the slightly smaller rooms for the more intimate labor process.
Outside of how the rooms work, there’s also a specific look and feel that providers hope to accomplish with new projects. “Childbirth is increasingly being seen as more of a normal life event than a medical condition that has to be treated, so patients are expecting to see more of a relaxing environment,” Sakalouski says. To that end, the first rule of thumb in maternity interiors is hiding clinical components to achieve a more hospitality—even residential—environment.
At Woman’s Hospital in Baton Rouge, La., “We planned the LDR rooms with a piece of cabinetry designed to hide a stainless steel cart, which is prepackaged with all the supplies used for birthing. At the appropriate time, the cart is pulled out from its garage, expanded, and draped in preparation for the birth,” says Anita Linney-Isaacson, principal and senior vice president at HKS (Dallas).
Likewise at WakeMed North, millwork was specially designed to achieve a cleaner look and feel. “While mom’s in labor, medical equipment like a baby warmer is tucked away into a wardrobe cabinet, all plugged in and ready to go, so when they’re ready to put the baby in it, the cabinet can swing open and the equipment can come out. Everything is hidden so when you walk in the room, you don’t have this sense of wires everywhere and pieces of equipment everywhere,” says Rob Anastes, project manager at BBH Design (Raleigh, N.C.).
A focus on hospitality shaped the WakeMed project throughout. “If we had to draw a line between hospitality and hospital, the group always forced each other to shift to the hospitality side whenever possible, and that was for everything from light fixtures to lavatory selections to equipment,” Cavender says. That mantra also provided the team more flexibility in finding solutions to design challenges by looking beyond the clinical realm.
For example, to avoid the patient bathroom’s door swing from swallowing valuable square footage in patient rooms, the team installed a sliding barn door instead. “It freed up all this space, and this is what I’d typically expect to see in a really nice hotel and not a hospital. It allowed us to go with a specialized look and specialized design solution, and it helped solve some practical design problems,” he says.
Overall, designers say that obstetrics interiors today often use a more modern aesthetic than other, more acute care spaces. “They’re usually pretty clean and more modern, but not over the top. In the past, you’d see a lot of wallpaper borders and curtains,” Linney-Isaacson says. It’s those types of decorative elements that can quickly date space, Waltz adds. “As soon as it looks dated, patients are going to think, ‘Am I getting the quality of care that I want?’” she says. “You have to be able to keep it classic. You have to avoid trendy colors, using artwork and lighting more to create the effect you want.”
There’s a lot of programming that has to be planned outside the patient rooms that supports the overall birth experience as well as the health of both mom and baby. For the units themselves, designers agree that although a trend in acute care, decentralized nursing isn’t as critical in maternity spaces because patients aren’t generally at risk. “The patient can still use the nurse call system, which is tied directly to their caregiver, and typically there’s a family member or friend with them,” Linney-Isaacson says. However, due to the square footage being added to patient rooms, most often making them wider as opposed to longer, the travel distances for nurses along corridors is growing, a fact that Sakalouski says could push a decentralized approach into favor.
Technology has also progressed to allow staff to provide patients more privacy if preferred, with mobile monitoring keeping caregivers up to speed. “They don’t necessarily need to have visual oversight to know what’s going on and how the labor is progressing, and then there’s also a push to have the nurses interact with the patients and be in the room with them,” Sakalouski says.
However, for more critical care spaces, such as NICUs, WakeMed uses a touchdown station between every two rooms with clear doors on its all-private rooms. While NICU projects in recent years often use a private room model, some opt for a mix of private rooms and an open pod or simply an open pod—a decision often made based on square footage, nursing ratios, and levels of acuity being seen.
As for design, Sakalouski says size once again has become a factor, with NICU areas being expanded for more family as well as to house more equipment. “It’s amazing what these doctors and nurses can do, and that requires more technology, but they’re able to save these babies,” she says. “All of this equipment has its own clearances and comes with staff, too.” At Park Nicollet, a private room model was used with large sliding doors that provide enough clearance for mothers to be wheeled into the rooms in their beds to visit babies right after birth, with a residential nursery aesthetic used to help diminish the scary nature of the space.
Adjacencies are key, too, with C-section rooms generally sited close to LDR rooms and antepartum rooms, and infant resuscitation rooms in proximity to the C-section space.
Family waiting areas are often carefully orchestrated, as well, sited near postpartum rooms instead of LDR spaces to keep waiting grandparents and others largely out of sight from patients wishing to walk the halls uninterrupted during labor. “The labor space is pretty sacred, and the way we flow visitors keeps it that way,” says Todd of Park Nicollet’s design. Another trick is to break the family waiting areas into small nooks where a patient’s visitors can huddle together rather than feel like they’re in a large holding station. That space can then also be accessed easily when visitors need to step out of postpartum rooms during exams.
Planning for births that don’t end with celebration is another critical element to the overall design, with experts recommending the inclusion of a private waiting area or “quiet room” for families to mourn a loss. At Park Nicollet, a fetal demise space was created away from the postpartum noise that includes an anteroom for family as well as a curtained exam area for the infant that allows testing to be done without going far from the mother. “It’s been very well received and appreciated by our families. We were very intentional in how it would feel. It’s very private, very quiet, and separated from the crying babies in the hallway,” Todd says.
While new builds and renovations are often required to add that valuable square footage to answer trends in labor and delivery, there are lots of added touches that can be integrated on a smaller scale but still pack a punch.
“Bigger doesn’t necessarily equal better. You can come up with creative solutions to achieve an efficient and beautiful design with a smaller footprint,” Sakalouski says, who designed The Mother Baby Center at United Hospital in St. Paul, Minn., with 240-square-foot postpartum rooms, inspired by a Manhattan condo w
here every inch truly does count.
At WakeMed North, the hands-down most common negative comment from new mothers interviewed during project design was their inability to charge mobile phones during labor and missing out on the ability to text updates to grandparents or post a newborn’s photo on Facebook. “Nine times out of 10, the phones are dead because the laboring has taken 24 hours, so we put outlets within two feet of the beds,” Cavender says.
From convenience features like milk refrigerators in NICU rooms to amenities like pedicures and massages, sometimes an improved experience doesn’t have to cost a lot at all. “Those are the things that patients will remember when they leave and they will tell their neighbors and tell their sisters about their birth experience,” Anastes says.
Jennifer Kovacs Silvis is executive editor of Healthcare Design. She can be reached at jennifer.silvis@emeraldexpo.
For details on how to design for an older generation of expectant mothers, see "Designing Obstetrics Spaces For The 30-something Mom."