Fifteen-year-old Brenda Moore drew herself up to her full 4 feet 11 and beamed at the nurses' praise. When she had gone into labor at D.C. General Hospital, they had all said she'd never do it, that she'd have to have a cesarean section. But the next morning, without surgery, she gave birth to a 6 1/2-pound daughter.
"Oh yes, it hurt!" she said. She had a complicated pregnancy, and was hospitalized for high blood pressure for days before she went into labor.
"I was paining a long time in here . . ." she said. "He [the doctor] told me he wasn't going to take me [to the labor room] till they were three minutes apart."
At night, the pains came hard. No nurse sat with her. She was alone and scared. She called her mother at work and together they timed the contractions. At last, about 2 in the morning, she was taken to the delivery room and soon it was over.
Asked if this was the first baby, she said, "First and last -- I'm sure."
D.C. General doctors say patients like Brenda Moore -- young, frightened, with little prenatal care and a risky pregnancy -- are the reasons the hospital has the highest infant mortality in Washington, a city where the infant death rate is among the highest in the nation.
These doctors see the hospital as a helpless attendant at the deliveries of the city's unhealthiest pregnancies.
But other -- inside the hospital and out -- say that D.C. General could take better care of its staff, procedures and equipment maintenance.
D.C. General's infant death rate during 1977 and 1978 was three times that of Columbia Hospital for Women, a hospital that had one of the lowest infant death rates in the city, according to a report presented last March to the Mayor's Blue Ribbon Commission on Infant Mortality. One-quarter of the District's newborn babies who died during those two years died at D.C. General.
The survival rate of premature babies weighing between 1,000 and 1,500 grams (2.2 to 3.3 pounds) -- considered one measure of a hospital's care of newborns -- was only 57 percent in 1977 and 1978 at D.C. General, compared with 89 percent at Columbia. (Babies born to Maryland and Virginia residents were excluded from the statistics.)
Figures compiled by Dr. Juan R. Fraga, director of D.C. General's nursery, show some improvement in 1979. Infant mortality at the hospital dropped from 35 deaths per 1,000 births in mid-1977 to 21 deaths per 1,000 births in mid-1979. But Fraga said D.C. General's infant death rate is still the highest in the city.
The hospital's medical director, Dr. Stanford Roman, argues that so many patients at the hospital have high-risk pregnancies that comparisons with private hospitals are meaningless.
One-third of the women who have babies at D.C. General are under 19. One-quarter of them have had no prenatal care. Three-quarters can be considered high-risk patients if factors such as infections, poor nutrition, drug addiction, alcoholism, diabetes, overweight, anemia and poverty are included, according to Dr. Sidney Jones, acting chief of obstetrics.
In most nurseries, Fraga said, there may be 25 or so healthy babies for every five that are sick. "Here it's the other way around," he said. "If we have 30 total, we have 10 who are normal and 20 who have problems."
He said it is common to see newborns at D.C. General suffering heroin withdrawal or infected with veneral disease.
Roman said that such complications make D.C. General's tiniest babies harder to save than those born at other hospitals.
"It's hard enough to take care of a premature infant born to a healthy mother," he said. "It's another thing to have a premature infant born to a mother who abuses alcohol, who has had no prenatal care and has inadequate nutrition."
Dr. John W. Scanlon, director of neonatology at Columbia Hospital for Women, said the challenge D.C. General faces in delivering and caring for premature babies may differ in magnitude but not in kind from that faced by other District hospitals.
No matter what risk factors are present during pregnancy, he said, all premature babies face similar problems -- immature organs, sensitivity to lack of oxygen, and trouble regulating body temperature and conserving fluid. A premature baby's chances of surviving depend on how doctors and nurses manage the mother's labor and delivery and the baby's care after birth.
"A thousand-gram baby (2.2 pounds), no matter where he is, is ususally pretty sick," Scanlon said. "There's no question that [at D.C. General] they have lots more of these small babies. But if that's the case, they should do better."
D.C. General's obstetrical and newborn services have improved in the last few years. Gone is the hospital's old, outmoded obstetrics building. "I used to call it the hole," said one patient. "There were roaches in the old part," said another.
In its place is a gleaming, spacious new facility. The nursery's director is assisted by two dedicated young pediatricians, Dr. Mehnur Abedin and Dr. Yvette Reid, specialists in newborn care, who take turns spending the night in the hospital when a baby is in trouble.
Nurses who have worked in the nursery for 15 years are being taught for the first time how to resuscitate infants. And some patients who have tried private hospitals downtown are coming back to D.C. General, attracted by childbirth classes, a home-style birthing room, and the option of delivery by a midwife.
But questions remain about the obstretical side of a successful birth. One in the hospital's policy of always putting women to sleep with general anesthesia during cesarean section deliveries, a policy that was called inappropriate by the report of the Mayor's Blue Ribbon Commission on Infant Mortality. At Columbia Hospital, by comparison, only 10 percent of cesarean sections are performed under general anesthesia.
General anesthesia once was frequently used in all kinds of deliveries. But many hospitals turned to regional anesthesia instead after studies showed side effects on the breathing and circulation of babies born when the mother had general anesthesia, according to Dr. Arturo C. Uy, Columbia's chief of anesthesiology.
Dr. Maria Benzinger, chief of anesthesia at D.C. General, said general anesthesia is chosen instead of spinal or epidural for several reasons: Patients are seldom told in advance of their options, they often deliver under emergency conditions, and they frequently are afraid of being given injections in their backs. Epidural anesthesia requires an injection administered just outside the covering of the spinal cord. For anesthesiologists who do not do it routinely, it is more difficult to administer than general anesthesia.
Benzinger also said that spinal and epidural anesthesia sometimes cause dangerous drops in blood pressure.
"When you are a private patient . . . you discuss the anesthesia," she said.
"But here the majority come at the last minute . . . They're completely hysterical. [The obstetricians] call us at the last minute . . . The best thing you can do is put them to sleep and have the baby delivered."
Brenda Ivy, interviewed three days after having her third child at D.C. General, said no one at the hospital discussed anesthesia with her, either during labor or during her prenatal visits. She had been given epidural anesthesia during the delivery of another child at Georgetown University Hospital, and said she would have asked for it again if she had known it was available. "They said they don't give you anything [for anesthesia] over here," she said.
Both Jones and Benzinger agreed that regional anesthesia was usually safer than general, and Benzinger said that she had refused general anesthesia for her own delivery years ago at Columbia Hospital.
Both said, however, that many anesthesiologists at D.C. General feel more secure administering general anesthesia than an epidural injection. "The best form is the anesthesia that the anesthesiologist can handle best," Jones said.
There are other concerns about obstetrics at the hospital. Some staff members said they thought inexperienced residents were being given too much responsibility for deliveries, with too little supervision from staff doctors or senior residents. One employe, who asked not to be identified, said that contrary to department policy, even the chief resident did not always attend cesarean sections. "The attending [staff obstetricians] are rarely seen." the employe said.
Jones said the staff doctors supervise residents "on the most complicated cases that are not emergencies." If an emergency develops, he said, a staff obstetrician is called, but a chief resident may have to handle it if the obstetrician cannot reach the hospital in time. Except for Jones, all the obstetricians maintain private practices and deliver their private patients at other hospitals. But Jones said this does not interfere with their duties at D.C. General.
Other employes said obstetrical nurses do not always respond quickly to emergencies, nor do they stay with patients during labor.
One employe described two recent emergency cesarean sections that happened within a few days of each other. "No one went back to set up the instruments. It was like everybody was in slow motion . . . Half the supplies that needed to be there weren't there."
Jones said he was unaware of the incidents, but added that he probably would not have heard of them unless the delay had hurt the babies. He said the hospital is short of obstetrical nurses, but that it should still be possible to deliver a baby within 15 minutes of the decision to undertake an emergency cesarean section.
Some patients said nurses frequently left them along during labor. Some complained they were not told what to expect during labor and delivery, nor were they kept closely informed of their baby's condition after birth.
Brenda Ivy said a pediatrician told her right after the delivery that her baby would have to be observed because of a possible problem. The nurses then refused for hours to let her go to the nursery to see the infant, Ivy said.
She said three days passed before a pediatrician came to inform her that the baby was slightly jaundiced.
"I don't think they mean any harm . . . but they need to communicate with the mothers about their babies, and not wait so long before they do," she said.
Frequent breakdown of equipment also affect how closely doctors can monitor babies before and after birth.
Late last year, Jones said, it was common for only one of D.C. General's four fetal monitors -- used to check a baby's well-being during labor -- to be working properly. Employes said that when the monitors malfunctioned no one marked them as broken, so a woman in labor might be hooked up to one machine after another in efforts to find one that worked.
This year the department bought two new monitors, but Jones said they sat unused for three weeks, waiting to be adjusted by a hospital engineer.
He said he had not pushed for faster service because he did not consider the situation an emergency.
Neonatologists Abedin and Reid said the nursery's machine for measuring oxygen in babies' blood -- vital for premature babies with trouble breathing -- began to malfunction last December and had broken down completely by March. Since then, blood samples have had to be rushed to another building, an eighth of a mile away.
Abedin said it took 15 minutes just to transport the sample, and might take as long as half an hour to get a result back. Scanlon said a delay of more than 15 minutes on this kind of blood test could hurt a sick baby. Hospital administrator's recently said they intend to buy a new machine.
Those responsible for planning D.C. General's future have questioned whether the hospital should even continue to deliver babies, according to commissioner Natalie Davis Spingarn, who heads a planning committee. The number of deliveries has fallen steadily over the year, from 5,154 in 1970 to 1,649 in 1979.
Part of the decline was attributable to the falling birth rate and the increased availability of birth control and abortions. But women were also choosing not to deliver at D.C. General. In 1978, Roman said, three out of five women who had babies at Greater Southeast Community Hospital received some prenatal checkups at D.C. General but chose Greater Southeast for the delivery.
The hospital's obstetricians are hoping that word of the new obstetrics building -- formally opened by Rosalynn Carter last month -- will turn the trend around. Jones said they are also spreading the news of such amenities as the home-style birthing room and the availability of childbirth classes.
The five-week classes, started by the Georgetown School of Nursing's midwifery program in 1978, are designed to teach couples about childbirth and make labor easier. The hospital does not allow a husband, boyfriend or other relatives to stay with a patient during labor unless the companion has attended the classes.
Like D.C. general itself, the nursery and the obstetrics department are at a watershed. The building has been modernized, the machinery is up-to-date. But Abedin and Reid and their counterparts in other departments, still fight shortages, equipment breakdowns, and above all, the attitude of some coworkers, bred by too many years of frustration -- that nothing at D.C. General can change.
"We've always liked the place," said Abedin, who said she and Reid did their pediatric training there. "We are trying to implement some of what we've learned."