The Challenges of Extended Postpartum Recovery for NICU Mothers: A proposed architectural solution

By Tammy Smith Thompson, MArch, AIA, NCARB, Medical Planner/Research Architect, Stanley Beaman & Sears and LaShawna Heflin, RN, BSN, Registered Nurse, Trinity Staffing Resources, LLC Abstract There is a growing population of postpartum mothers requiring an extended stay to recover, who also have babies in the neonatal intensive care unit (NICU). This is the case for a variety of mothers with high-risk delivery factors. In addition, with the increasing use of in vitro fertilization, the number of preterm births and low birth weight babies has increased. Subsequently, many facilities have increased their NICU capacity to accommodate these infants. As a result, there is a distinct relationship developing between NICU babies and postpartum mothers requiring longer lengths of stay. Operationally, postpartum departments are not staffed to care for NICU patients. Nor are hospitals designed to accommodate this type of patient mix. Typically, mothers and their newborns must remain separated until the mother is healthy enough to visit her baby in the NICU. This disconnection between mother and baby may present a number of challenges to the recovery and development of postpartum and NICU patients. Other challenges include visitation/bonding, lactation, and family-centered care. This concern may be addressed by introducing a hybrid postpartum room that opens to a NICU room. In facilities with adjacent NICU and postpartum departments, a hybrid room may be created by adjoining a room from each unit. A hybrid room would enable more frequent visitation, promote successful lactation, and allow the entire family a rooming-in opportunity. This analysis highlights the importance of congruency between postpartum and NICU care by identifying research-based reasons for linking these departments and providing an example of how this design may be achieved. Introduction Having a child in the neonatal intensive care unit (NICU) can be a frightening, stressful, and confusing time for any parent. Conditions that warrant NICU care may not allow families to form traditional bonds that well-babies and their parents enjoy. NICU babies are routinely transferred from the delivery room immediately following birth with little or no time to bond with their parents, but the initial bonding experience is critical for the infant and new mother. Allowing a newborn skin-to-skin contact, also known as kangaroo care, with the mother shortly after delivery has shown to have a positive effect on neurobehavioral responses (Ferber and Makhoul 2004). This includes stabilization of heart rate and better weight gain. Unfortunately, many NICU patients are not afforded this bonding opportunity, as the stabilization of the newborns health is always the priority. NICU parents must quickly learn to operate within the rules and constraints set by the NICU management in order to ensure optimal care of the fragile newborns. In most hospital facilities, there are strict requirements sometimes limiting visitors, defining sanitizing procedures (such as scrubbing hands and arms before entering the NICU), mandating specific attire, and discouraging sibling visitation. These rules are in place to prevent infection, however, the conditions often restrict the bonding time between infants and their families. The NICU mother is deprived of the opportunity to have her baby transported to her postpartum room and remain at her bedside during the first few days of motherhood. As opposed to well-baby care in a postpartum environment, the recovering mother must be healthy enough to visit her baby in the NICU. This can be very difficult for a patient who has recently experienced a cesarean section or a complicated delivery. Often, a mother discharged from postpartum care must make the necessary arrangements to visit her baby in the hospital as frequently as possible. With the introduction of the private NICU room, parents are allowed to remain in the room with their baby throughout his or her NICU stay. This is the preferred option for most parents because it

allows more bonding time. It promotes infection control and environmental control, as each baby is kept in a separate room (Floyd 2005). It also allows the lighting and sound to be adjusted to the needs of the individual, versus the entire NICU population. When surveyed, nurses viewed this advantage as an important feature of private NICU rooms (Hendricks-Muoz and Prendergast 2007). In a similar study, the single patient room concept was deemed superior (to an open-bay layout) for patient care and parent satisfaction from a nursing perspective (Walsh et al. 2006). This configuration promotes privacy, allowing new mothers the option of nursing or expressing breast milk for their babies directly in the NICU room. Allowing the mother and baby to remain in the same room could promote better outcomes for the infant and mother, such as reducing the length of stay for the infant and decreasing the potential guilt of mothers separated from their infants and subsequent postpartum depression. NICU nurses have cited interaction with or accommodation of family members as an advantage of private patient rooms (Chaudhury et al. 2006).

Photograph 1: Private NICU Room; OSF St. Francis Medical Center/Childrens Hospital of Illinois; Stanley Beaman & Sears, Associate Architect for Design; OWP&P, Architect of Record; Jim Roof Creative, Photographer As difficult as it may be for a new mother to be discharged from postpartum care directly into visitor status for her NICU baby, circumstances may be even more complicated for the postpartum mother who requires an extended length of stay to recover after the delivery. This is often the case for mothers with chronic illnesses, multiple births, cesarean section deliveries, and other high-risk delivery factors. In addition, in vitro fertilization (IVF) has an increased rate of multiple gestations, which is related to a higher rate of cesarean deliveries and other complications, such as hypertensive complications, diabetes, preterm labor, higher rate of infections, hemorrhagic complications, [and] operative delivery (Klln 2010). Furthermore, with the increasing use of IVF, the number of preterm bi rths and low-birth-weight babies has increased (McDonald et al. 2009). Subsequently, many facilities have increased their NICU capacities to accommodate these cases. For these reasons, there is a distinct relationship developing between NICU babies and postpartum mothers, requiring longer stays and more complicated recoveries. One could conclude that there is also a need to address the environment provided for this growing population of extended-stay mothers with babies in the NICU. Initial bonding challenges Not only is the initial bonding opportunity immediately after delivery forfeited, but important bonding in the days and weeks to follow also may be compromised. Studies show that NICU babies whose parents are able to practice kangaroo care experience better recovery outcomes, such as a gain in sleep time, decreased crying, improved oxygen saturation levels (The Cleveland Clinic Foundation 2007), and a better chance to thrive. In addition, kangaroo care has been linked to increased confidence in parents, improved perceptions of their babies, and positive interaction between parents and their infants (Feldman et al. 2002). Mothers with limited access to their babies due to their own physical conditions are not able to reap the full benefits of kangaroo care.

Visitation challenges Parents are generally encouraged to visit their newborns as often as possible. Whether this is feasible depends on the medical condition of the mothers after delivery. The distance between the postpartum room and the NICU, the temperature change, and the disruption of medical gases and medication may discourage recovering mothers from leaving the postpartum unit to visit their babies. During NICU visits, new mothers receive critical care-giving instructions from NICU nurses, so limited visits would also limit the instruction time available for recovering mothers to learn the special care necessary for NICU infants. Lactation challenges In most postpartum units, a mother may nurse her baby or express breast milk with the baby in her room. Healthy mothers with NICU babies may nurse their babies or express breast milk in the NICU room or in a nearby lactation room. Recovering mothers are encouraged to express breast milk and send the breast milk to the NICU for their babies, but this type of remote lactation may create difficulties for breastfeeding and expressing breast milk. In fact, the primary lactation challenge for mothers who wish to nurse an infant admitted to the NICU is the physical separation that the mother and infant face. This separation poses a threat to the mothers milk production by decreasing the stimulation that the mother receives from the nursing infant. Studies suggest that mothers are able to express more breast milk while receiving sensory stimulation, such as seeing, hearing, smelling, or touching their babies, as opposed to expressing in a location away from the baby (Simkin et al. 2008). Research also indicates that skin-to-skin contact inspires the instinct to suckle (Davis et al. 2004). Milk production may be decreased when these stimulators are not present. Other challenges that may pose a threat to milk production include a lack of energy to manually pump every two to three hours and a decreased let -down reflex due to stress related to the infant requiring NICU care. Benefits of Rooming-in Although FGI guidelines require a newborn nursery to be located in obstetrical units (Facility Guidelines Institute 2010), they also support the option that allows well-babies and their paternal parents to room-in with the postpartum patient. This enables families to bond with their babies. Rooming-in has been identified as one of the essential steps to promoting long-term breastfeeding, thus increasing health benefits for mothers and babies (Murray et al. 2007). In addition to the advantages already stated, rooming-in also promotes more family involvement in the patients care, which may decrease the chances of medical error (McGreevey 2006). If the NICU baby and extended-stay postpartum patient require separate care, fathers must stay with either the mother or the child, preventing the entire family from bonding together during the early days of the infants life. Proposed Solution to Challenges Encountered by Postpartum Mothers Requiring Extended Recovery with NICU Babies One patient-friendly option for both mothers and babies is to introduce a hybrid postpartum room that opens to a NICU room. This would require the NICU unit to be adjacent to the postpartum unit in new construction, or in a renovation project, remote postpartum rooms located near the NICU. It would allow designated rooms for mothers requiring an extended postpartum recovery with NICU babies. This postpartum/NICU configuration accommodates various motherbaby scenarios. The typical private NICU room would maintain an option of rooming-in for mothers who have been discharged from the hospital, allowing healthy parents to remain in their babys hospital room during the newborns NICU stay. Within this unit, hybrid rooms may b e strategically placed based on the projected need to accommodate mothers requiring an extended length of stay for postpartum recovery. The hybrid solution would offer a number of advantages to this population. It would create a home -like environment previously not offered to recovering mothers with NICU babies and it would facilitate easier and more frequent visiting opportunities for the mother and baby. This option may also promote successful lactation and allow the entire family a rooming-in and bonding opportunity.

Figure 1: Partial Plan of NICU and Postpartum Units at Hybrid Postpartum/NICU Suite Illustrated by Tammy Thompson, AIA Creating a home-like environment As labor and delivery units strive to provide a more family-centered experience in order to entice expecting mothers to their facilities, the concept of the hybrid postpartum room would maintain this type of environment even for postpartum mothers requiring longer lengths of stay. This room would include the typical amenities necessary for postpartum care, such as a private patient room, a patient bathroom, a personal storage area, space for visitors, a pull-out bed so a family member can remain in the hospital with the new mother, and a lactation area within the room.

Figure 2: NICU and Postpartum Units at Hybrid Postpartum/NICU Suite Illustrated by Tammy Thompson, AIA The unique feature of this room is that it would open to the private NICU room of the postpartum patients baby. There would be a window, allowing the postpartum patient to see the NICU patients isolette from her bed. There would be a scrub room between the two rooms so parents can sanitize before entering the NICU space. This configuration would also include a pass-through specimen window between the rooms to allow the postpartum mother to easily transfer expressed breast milk into the NICU room. For security, the NICU room would be locked on the postpartum side and only accessible when the NICU nurse approves the patient entering through the scrub room. The relationship of the parents room to the babys nursery would be similar to the home environment.

Figure 3: NICU and Postpartum Units at Hybrid Postpartum/NICU Suite Illustrated by Tammy Thompson, AIA Facilitating easier and more frequent visits and educational opportunities This environment would enable the postpartum mother to visit with her baby more frequently and easily. The scrub room would allow sufficient space for a wheelchair to circulate from the postpartum room into the NICU space. The mother may be able to visit her baby at her convenience with little or no assistance from postpartum staff, particularly since there is space for a family member to accompany the mother during this visit. With the ability to have more frequent visits, the mother is allowed more bonding opportunities with the infant and longer periods of time to provide kangaroo care, which is essential to the ill neonate. The mother may also observe the care of her baby from the postpartum room, facilitating the coordination of instructional time with the NICU nurse. Intercom communication between the two rooms would allow seamless interaction between the NICU nurse and the concerned mother. An increased opportunity for nurse parent interaction may provide the necessary reassurance to both parents as they learn to care for their infant. According to architect Scott Radcliff in an article documenting his familys personal experience, NICU nurses are experts in developmental care for the baby and family -centered care for the parents. They play a primary role and can decrease the parents stress level by providing information, education, and support (Radcliff 2009).

Figure 4: Postpartum Room of Hybrid Postpartum/NICU Suite, view from entry door Illustrated by Tammy Thompson, AIA Promoting more successful lactation and nursing The hybrid postpartum configuration would introduce a new feature to all postpartum rooms: the lactation space. Postpartum rooms are sometimes not well-equipped for new mothers to consult with lactation specialists. Each postpartum room, including the hybrid model, would have a storage cabinet designated for lactation supplies. This cabinet may be located on the opposite side of the bed from the caregiver zone. A family member or lactation consultant may assist the patient from this side of the bed to facilitate and encourage successful lactation. Typically, the mother is taught how to clean and maintain the breast pump kit or it is sanitized and delivered to her patient room regularly. The mother would use the over-bed table to assemble the supplies for lactation. In addition, the hand wash sink would be located near the bed for easy access for the mother. Proper care should be used in the design and location of the sink to ensure that precautionary methods are in place to prevent dispersion of particulate matter from the sink or sink drain to the surrounding areas (Hota 2009).

Figure 5: Postpartum Room of Hybrid Postpartum/NICU Suite, view from mothers bed Illustrated by Tammy Thompson, AIA The viewing window to the NICU room and intercom would support an increase in expressed breast milk volume by allowing sensory stimulation. Mothers may also wish to visit with their NICU babies prior to lactation or to express breast milk directly in the NICU room. This would be very similar to the options available to healthy postpartum mothers. Allowing the mother to express her milk in the same room with the infant would likely enable a better letdown reflex, which in turn would help the mother to express more milk. The hybrid configuration would also support the Baby-Friendly Hospital Initiative by complying with one of the steps to the successful breastfeeding practice of rooming in: allow mothers and infants to remain together 24 hours a day (BFHI 2010). Promoting lactation through the design of this space could have a significant impact on the mother and the baby. Not only does breastfeeding result in a number of health advantages for mothers and babies, but it also is particularly important to the safety and development of NICU infants and their recovering mothers. Some examples include aided involution for postpartum patients (Simkin et al. 2008) and reduced infections for NICU patients. According to the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, ICU and NICU patients account for a disproportionate number of hospital-acquired infections (Siegel JD et al. 2007). Research has shown that feeding breast milk to preterm infants reduces the chances of infection and serious bowel issues (Buckley and Charles 2006). In addition, having the mother and baby in the same area will allow them to be exposed to many of the same microorganisms. When a lactating mother is exposed to pathogens, she produces antibodies in her breast milk that enable the baby to fight infection by those pathogens. This allows the infant to receive passive immunity via breast milk until the infants immune system matures.

Figure 6: Private NICU Room of Hybrid Postpartum/NICU Suite, view from exterior wall Illustrated by Tammy Thompson, AIA and Lindsey Gispert Allowing entire family roomingin and bonding The hybrid postpartum room would allow both parents to bond with their new baby, all in the same vicinity. As in a home environment, the postpartum mother may take comfort in knowing that the baby has both parents nearby. The father would have the option of sleeping in the fold-out bed in the postpartum room and the same liberty to visit the baby through the scrub room entrance. Having both parents present for instruction, observation of care, lactation consulting, and bonding with the baby may present a number of advantages to the entire family that could not have been realized without the hybrid postpartum room. Potential challenges associated with this approach Allowing access to the NICU through the postpartum unit may present a security challenge, but this may be addressed both architecturally and operationally by installing a coded keypad on the door to the scrub room, only allowing access to prescreened family members. The NICU nurse could also have the option of overriding the keypad access, preventing entry in the event of an emergency. There are a number of NICUs in remote locations from the labor, delivery, recovery, and postpartum (LDRP) areas of a hospital. There are even many examples of NICUs located in separate hospital facilities from these womens services. In these instances, it may be wise to conduct evidence-based design research, which may support the addition of a remote postpartum unit to complement the NICU department and offer a unique approach to comprehensive family care. Conclusion The preceding analysis of a commonly overlooked scenario for LDRP/NICU patients supports the importance of congruency between postpartum recovery and NICU care. Although this specific example has not been studied, there is strong medical evidence that supports the physical connection between mother and baby that would be

enabled through this design approach. A trial room to accommodate recovering mothers may prove to be a significant research topic for the future. Potential outcomes may include A reduced need for transportation to another unit Prevented interruption of services, such as oxygen and pain pumps, for mothers remaining in the postpartum room while viewing their babies A decreased rate of depression on the part of NICU mothers An increased opportunity for the recovering mother to participate in and learn care for her baby A reduction in medical error (an advantage of parental involvement in patient care enabled by rooming-in) A reduced length of stay and quicker recovery for mothers, babies, or both Restored bonding opportunities for recovering mother baby couplets Promotion of healthy practices, such as breastfeeding, by eliminating barriers

As discovered in the case study of Women & Infants Hospital in Providence, Rhode Island, the significance of design in creating a holistic environment that seeks the right balance between the technical demands of the clinical environment and the qualitative needs for creating family-centered care is essential to accommodate comprehensive care (Padbury and Verspyck 2007). The growing population of mother baby dyads with acute or critical care needs warrants the investigation of design solutions that offer equal advantages to those offered to healthy mothers and their newborns.
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Newborn Intensive Care Unit AIA Academy Journal, 10, Retrieved from http://info.aia.org/journal_aah.cfm?pagename=aah_journal_20071 101 Radcliff, S. 2009. Perspectives on the NICU Environment. AIA Academy Journal, 12, Retrieved from http://info.aia.org/journal_aah.cfm?pagename=aah_journal_2009_ battisto Siegel J.D., E. Rhinehart, M. Jackson, and L. Chiarello. Healthcare Infection Control Practices Advisory Committee. 2007. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf Simkin, P., J. Whalley, A. Keppler, J. Durham, and A. Bolding. 2008. Pregnancy Childbirth and the Newborn. Minnetonka, MN: Meadowbrook Press. 423-424. The Cleveland Clinic Foundation. January 15, 2007. Kangaroo Care. (Online), February 2, 2010. Cleveland Clinic Foundation. http://my.clevelandclinic.org/healthy_living/Infant_Care/hic_Kang aroo_Care.aspx Walsh, W.F., K.L. McCullough, and R.D. White. 2006. Room for improvement: nurses perceptions of providing care in a single room newborn intensive care setting. Advances in Neonatal Care, 6(5), 261-70. Contact information Tammy Smith Thompson, AIA c/o Institute for Patient-Centered Design, Inc. 235 Peachtree Street, NE, Suite 400

Atlanta, GA 30303 404-890-5646 telephone/fax tthompson@patientcentereddesign.org www.PatientCenteredDesign.org Stanley Beaman & Sears 180 Peachtree Street, NW, Suite 600 Atlanta, GA 30303 404-524-2200 telephone 404-524-8610 fax tammy.thompson@sbs-architecture.com www.StanleyBeamanSears.com Trinity Staffing Resources, LLC 7001 Loisdale Road, Suite C Springfield, VA 22150 703-989-3804 telephone lheflin@trinitystaffingresources.com www.TrinityStaffingResources.com Continuing education Readers of this article may earn one AIA learning unit in Health, Safety, and Welfare (HSW) by completing a short quiz at www.PatientCenteredDesign.org.