by Craig L. Bissinger, MD, FACOG

I am constantly amazed at how little attention pregnant women pay to their choice of physician and hospital. To me, this decision sets the tone for the entire pregnancy and birth experience. Not all physicians or hospitals are alike! There are major differences in the way doctors and hospitals approach pregnancy and delivery. I'd like to spend the next few minutes making you a savvy consumer.

Picking Your Hospital

Perhaps you will be surprised when I tell you that the hospital is the most important choice you will make with regards your pregnancy. Hopefully, the following example will give you some insight. A cardiologist is at a concert when suddenly, someone has severe chest pain. The doctor is asked to help out but doesn't have any medical equipment with him or her. The doctor can do little besides comfort the person until the proper equipment arrives. This is analogous to the predicament the obstetrician is confronted within certain hospital settings.

Since the physical appearance of each hospital may be similar you need a more sophisticated approach to assess them. You cannot rely on a hospital's overall reputation either. Some hospitals may have a great reputation due to their heart bypass program. Others have excellent transplant programs. While these institutions are to be commended for the fine service they provide, as a pregnant woman, you need a hospital with a good reputation in Obstetrics. The first key ingredient to look for is the ability of the hospital to care for newborns. This is a critical issue for an expectant mother. Despite our best efforts, some babies are delivered prematurely while others have significant birth problems. These babies must be cared for at hospitals with more expertise and resources in treating these problems.

Understanding Hospital Classification

Hospitals are given a classification based on their ability to care for newborns. Each hospital has one of four designations:

• Basic (a.k.a. Level 1) - can deliver mothers who have completed 37 weeks and have babies over 2500 grams (approx. 5 ½ pounds)
• Intermediate (a.k.a. Level 2) - can deliver mothers at or beyond 32 weeks who have babies over 1500 grams (approx. 3 ½ pounds)
• Intensive (a.k.a. Level 2+) - can deliver mothers at or beyond 28 weeks who have babies over 1000 grams (approx. 2 pounds)
• Regional Perinatal Center (a.k.a. Level 3) - can deliver any mother and any baby regardless of the circumstances. These are typically academic institutions or large hospitals that are the referral center for an entire region. In my home state of New Jersey, there are seven hospitals that meet this stringent classification.

The following example will quickly allow you to realize the importance of the hospital classification for newborn care. A woman comes to a Level 1 hospital in advanced labor. She delivers her baby eight weeks before it's due. There is no pediatrician at the hospital, even though the baby needs urgent care. A call is made to the closest referral hospital. They agree to send a team to pick up the baby, but will not get there for several hours! During the interim, a local pediatrician is called to come in and help stabilize the baby. We all would agree that this situation is less than optimal. Ideally, this woman should have been sent to the closest hospital able to handle her baby's special needs. This institution would have a special care nursery and neonatologists, who are specially trained pediatricians who treat premature and critically ill babies.

The Importance of Anesthesia

A second critical issue that needs to be examined when choosing your hospital is the anesthesia. Most women assume that epidural anesthesia is available upon demand. However, this is not the case throughout the country. Some smaller hospitals do not offer this type of pain relief whereas others will offer it on a limited basis. In some instances, hospitals will only offer epidurals during the day while the anesthesiologist is available. At other institutions, women will only be offered an epidural once they are in advanced labor (you could be in labor for many hours before becoming eligible). In either case, your pain control needs may not be handled to your satisfaction.

The ideal hospital has a full-time dedicated anesthesiologist or nurse anesthetist assigned to the labor and delivery area. In this way, laboring mothers can have pain relief based upon their need, not convenience. I can't tell you how many patients have come to my practice after having had their first baby at a hospital that offered anesthesia only to women at an advanced stage of labor!

Another major benefit to having in-hospital obstetric anesthesia is the ability to do an emergency c-section in a timely fashion. According to the standards of the American College of OB/GYN, an emergency c-section should be performed within 30 minutes. Often, delays longer than this are due to the lack of an available anesthesiologist. Even if the "30 minute standard" is met, can you imagine waiting an extra five minutes for an anesthesiologist to arrive if your baby is in stress? Believe me, it adds stress to your obstetrician, too! For those of you trying to have a vaginal birth after a prior cesarean section, this is a major issue to consider when choosing your hospital.

Many hospitals offer amenities to lure you to use their facilities. They may have created wonderful birthing suites, candlelight dinners for the new parents or other enticing features. Sure, these are nice touches and, if all issues are even, they might be the tiebreaker. However, don't be fooled by the bells and whistles. These amenities do not address the ultimate goal -- having a healthy baby.

Once you have picked the hospital, your choice of physician will be more defined.