Miracle of Birth

And at 7 AM each day, clerks, nurses, and doctors all change hands. Everyone needs to brief everyone else. The new charge nurse takes command of the board and a walkie-talkie that links her to the other charge nurses and physicians. New nurses coming on duty stand by for assignments and to learn details about each patient. The senior resident takes command of a half-dozen more-junior doctors.

An outsider watching the transition can't tell the most senior doctor from a nurse who's still in training. (Eventually, it's clear that the busiest doctors are the most junior, and the busiest nurses the most senior.) People call one another by their first -- or last -- names, without resorting to titles. Everyone wears the same blue scrubs, and doctors and support staff share locker rooms without regard to rank. "It's important that there be roles," says Dr. George Wendel, who has been at Parkland since his own residency in 1978. "It's not so important that there be boundaries."

In fact, there is a careful system behind the success of L&D, one that has been honed over 50 years. Parkland's L&D areas rely on a set of protocols that define every step of the medical experience for women. The protocols -- actual rules that are written down and taught -- specify which questions a woman should be asked in a satellite clinic during her first prenatal visit. The protocols specify that at Parkland, RNs do not do pelvic exams -- those are for doctors, midwives, or nurse-practitioners. The protocols specify that women in high-risk labor not get fluids by mouth -- no juice, no popsicles, no ice chips (IV fluids are preferred).

But these are not rules for rules' sake. "The protocols are not recipes," says Miriam Sibley, who has risen through the ranks from L&D nurse to senior VP of Parkland's Women and Children's Services division. "They give us a way to organize a tremendous amount of work."

Says Dr. Steve Bloom, associate medical director of L&D: "Without the protocols, well, you've got 50 faculty members, 40 midwives, and 100 nurses, all practicing medicine. It would be chaos."

The protocols define a standard of practice. They set a floor for the kind of medicine that everyone should get. And although many hospitals have rules and procedures, Parkland's system, which is constantly being refined using clinical research, is much more developed. "People used to say, 'Oh, Parkland is all cookbook medicine,' " says Lockwood of Yale. "Up here in the northeast, we used to say, 'We believe every patient is an individual with her own unique set of variables. There's no way we could practice cookbook medicine.' Well, guess what? We were wrong. The protocols reduce variability, error, and cost, and they increase care. It seems Parkland's is a better way of doing things."

More than that, says Leveno, "the system gives the staff a sense of order, even if you are overwhelmed. Things settle down and function. Otherwise, the volume creates a frazzled environment. The staff gets frazzled, and the patients get frazzled too."

Adversity Into Advantage
Two doctors are sitting by the nurse's station, just outside their lounge. Dr. Lan Tran, about to be a fourth-year resident, asks her colleague, "What's the most deliveries you've done in 12 hours? I've done 13." Dr. Whitney Mascorro, just finishing her first year as a resident, replies, "I've done 14. I've come in with a can of Dr Pepper from home and not had time to drink it."

For a typical OB in private practice, 14 deliveries would be a busy two weeks, not a busy 12 hours. The pace of babies being born at Parkland dominates the culture and psyche of L&D. The staff lives a professional version of dog years, seeing as many patients in a year as the staffs at even busy hospitals see in four or five years.

The protocols are not just a way to manage the waves of work that arrive without warning. They actually provide a structure that gives Parkland L&D room for innovation and flexibility. The protocols offer a kind of liberating safety net.

In the mid-1980s, when births at Parkland first started to rise dramatically, the hospital and the medical staff cast about for a way to take care of all of the women. Because Parkland is both a public hospital and a teaching hospital, new patients almost never arrive with their own doctors, as they would at a private hospital. And Parkland can't simply add doctors to match volume. The size of the medical-school faculty and the residency programs is geared toward teaching, not patient-care demands.

Leveno and the Parkland administration decided to try using certified nurse-midwives -- to put them on staff and reorganize not just the medical staff, but also the patient flow and the geography of L&D, around their arrival.