labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Sunday, October 19, 2008

Birth Plans

Oh...birth plans. Frankly, I am not sure how I feel about them. I think they can be very useful in making sure your needs and wishes are communicated to those who care for you. But, on the other hand, they can be a barrier for those who care for you because they have this preconceived notion that birth plans=hippie, crunchy women who are resistive to medical care and think that you will inevitably end up with every intervention in the book before you have a c-section.

I have seen women who have very reasonable, flexible birth plans. Like, requests that pain medication or epidurals not be offered but if it is requested or asked about they are not opposed to receiving that type of pain relief; or requests that the baby be placed right onto mom's belly or chest at birth but are ok if baby needs closer assessment immediately at birth that requires the baby being taken to the radiant warmer/resuscitator.

And then I've seen very inflexible birth plans that request things like no fetal monitoring (absolutely impossible in the hospital) which basically ask for things that are better for a home birth. These types of birth plans I have no problems with in regards to what they want or not want, but often scratch my head wondering if these couples have taken into account that they are giving birth in a hospital. As much as I feel continuous fetal monitoring or even IVs are not necessary in every birth, some hospitals have environments, protocols, etc that don't "allow" for this. I really think those who want to avoid all interventions look into alternatives to birth sites because the second you step into a hospital you give up some things, like complete control. I wish this wasn't the case, and try very hard as a nurse to let women know about informed consent and choice, but there are very few hospitals I know of that go with any request a woman has.

What really gets me though, are birth plans that are so evident that the couple did absolutely no research on birth or hospital birth. For instance, I cared for a couple recently who had a 5 page birth plan. It was a birth plan that came from an website template, likely something where you just check off what you want to include on your written plan. And what they checked for what they wanted and not wanted completely contradicted itself in some fashion. Like this:

  • I do not want an IV
  • I want an epidural as soon as possible

Ok.... it was very evident that they did not do any reading or class on childbirth ed because epidurals require an IV. There is not an anesthesiologist in the world that would place an epidural without IV access. Not to mention that you need an IV fluid bolus in preparation for an epidural because a fairly common side effect of epidurals are low blood pressure; the IV fluid bolus helps to counteract a drop in blood pressure.

Or this:

  • Please do not separate me from my baby at any time
  • It is ok to give my baby a pacifier if crying while away from me

And this:

  • I do not want any students or residents caring for me

....when you are in a teaching hospital that has structured the care delivered by utilizing residents and involves other learners at varying degrees of involvement. Now, it is completely the woman's prerogative to not have learners involved in caring for them, but it seems a little weird to me that this woman would choose to come to a teaching hospital if she didn't want residents or students.

So I guess the bottom line is that I think birth plans can be a good thing if the couple has researched birth in the setting they will deliver as well as generally educate themselves on birth. But I can totally see why birth plans end up as fodder for negativity from care providers when it's plain as day that the couple has done no research on birth at all.


Anonymous said...

A friend of mine wrote an essay about this type of thing. Her analogy was that you wouldn't go into Burger King and ask for a steak, even though their slogan is "Have it your way," because there is a limit to what they can actually offer. In a similar way, if you choose a hospital birth or a home birth, then you obviously have to work within that framework, and if you find that you want things that are unavailable in that scenario (such as an epidural at home, or no EFM at the hospital), then maybe you should reconsider your choice of birth-place, just as you should reconsider your choice of restaurant if you want steak while you're at Burger King.


Fiery said...

~ chuckles ~ so true.. I saw a half dozen or more birth plan templates when I was pregnant... and when I went through them I couldn't believe some of the "options" that just didn't make any sence... plus it would be wise to discuss and go over any birth plans with your Dr's before you go into labor then there won't be as many issues.. then again Dr's should help facilitate the sharing of this information as the day gets closer.... btw.. really enjoy the blog

Anonymous said...

I feel the same way about birth plans and it is nice to hear an honest L&D perspective. As a doula, much of the birth plan (in the hospitals I work) focuses on third stage--a request to wait for the cord to stop pulsing, a request for skin-to-skin, a request for no routine pit, a 1 hour delay for eye ointment, etc. It seems like this stage is where wishes need to be clarified.

Many of my clients who long for homebirth find barriers such as VBAC protocols and lack of insurance coverage. So that may be why they ended up in an interventative environment trying to make a round peg fit in a square hole.

That said...I always ask to "prescreen" client birth plans to rule out those embarassing blunders like "no enema or shaving." Yikes!

Anonymous said...

On the resident/student thing...of the 5 hospitals within a 1/2 hr drive of my house, 4 are teaching hospitals. The one that isn't is a smaller hospital in a not so nice neighborhood (think shooting gallery, more drugs within a 5 block radius outside of the hospital than inside the hospital...), and it has only the most basic of NICU care--if baby needs much help, baby is getting transferred to one of the other hospitals.

To be truthful, that hospital is a wonderful place to birth for low risk women. They are flexible with protocols, and leave laboring women to do their own thing if that is what they want. But the neighborhood and NICU issues are big turn offs. Not to mention that some women can't go there because of insurance issues.

That is why a woman would go to a teaching hospital but not want care from a resident/student. I really didn't have a problem with having such care when I was pregnant with my first two...but when the resident turned out to be a PIA in my second labor, I did "kick her out" and request that my regular OB be called.

That turned out to be a good choice anyway, as protocol would have been to call him in when I was 8-9 cm...but the next cervical check I had (done by him) occurred about 10 minutes before my daughter was born. He checked me, told me that I wasn't quite complete yet but whenever I felt ready to push I could go ahead and start (and let him know), and was leaving the room. Got to the doorway, at which point my doula started urging me that I needed to push because the baby was crowning (she was absolutely right), and I was arguing that I most definitely did NOT want to push, because I didn't want to tear like I had the first time. It was quite amusing. Dr. came running back into the room, trying to gown up (which he didn't manage to do much more than throw a gown on--not tied in the back--and get on some sterile gloves) and catch my daughter before she just shot out onto the bed.


Anonymous said...

What a shame - judging already and not even working as a midwife yet.

I suggest you dig deeper in to why women and families bring birth plans with them - may you will start to understand.

I hope you are not going to be a controlling provider who makes sweeping comments about your clients birth and at least attempt to involve them in THEIR care.

Cindy said...

You bring up an interesting point - why couples are giving birth in a hospital when they want no interventions based on birthplan. What if they have no other option?

For example: In my state, South Carolina, if you are deemed to have any number of conditions a licensed midwife cannot legally deliver you. You MUST go to a hospital and be delivered by an doctor(you cannot even legally go to a birthing center).

I had well controlled gestational diabetes. My ideal plan was to be delivered by a midwife at a birthing center where I could be quickly transferred to the hospital if needed due to complications. However, state law forced me into a hospital. The birth plan was my tool to get across my desires when I was forced into a less then ideal situation.

Labor Nurse said...

I knew I'd get some comments on being against birth plans or the like and for the record I want to make it clear that I, in fact, am not. I think they can be great tools of communication.

What bothers me is when birth plans are completely unreasonable in the setting in which a woman births. I find that it is because they are uneducated on the setting in which they are delivering and also their providers don't bother to inform them on what to expect. Like the no IV but want an epidural thing is a classic example of this, and unfortunately many care providers are not going to look at the rest of the care plan as being valid. I've seen this first hand with the people I work with, and I am sure if you speak with any L&D staff you will hear similar sentiments.

It's unfortunate when there are no other birth setting options, like Cindy points out, because then woman are limited to birth in ways they might not want. And here lies the fundamental problem- the lack of choice and generally forcing woman to birth within environments or protocols that they are not comfortable with.

I understand that birth plans help women and families keep control. I totally get this. But unfortunately when birthing in a hospital you give up some of that control- I don't necessarily agree with this and we need to change the hospital method of birth for low risk women-

Ethel said...

I have become to think that your birth plan should only talk about things that you don't want, or say that you want the worst outcomes as it seems whatever you don't want comes to pass and what you do want doesn't happen. So in the birth plan, indicate you want the most intervention possible, pitocin as much as possible, baby be separated as soon as possible, and a c-section if at all possible and please please an episotomy.

I know it's superstitious but I really am beginning to think that the written birth plan is really a opposite wish list. Of course in the process of reading a list an absolutely (they are out there) ignorant couple might get a little more educated. Maybe.

Aubrey Kinnaman said...

You make a lot of valid points with the birth plan. I gave birth in the hospital (although my birth plan was probably more indicative of what a home birth might have provided). My midwife and i reviewed the plan several weeks before delivery and talked about what i wanted vs what was allowed. I learned where i could be flexible and where i couldn't. I also gave birth in a very baby friendly hospital. The key to a successful birth is a good relationship with your provider and flexibility!

sara said...

I personally had to have a hospital birth. My insurance did not cover birthing centers or midwives and we could not afford the $5,000-8,000 that a home birth midwife would charge us. I chose a hospital first based on the fact that they had midwife care and promised that all newborn procedures would be done in the room.. And found out at *38 weeks* that the "procedures in the room" was a fricking PILOT PROGRAM that had been DISCONTINUED and they took the baby away as soon as it was born to be weighed, etc. at the nursery. "Don't worry, he'd only be gone an hour". Like hell. I switched to another hospital that didn't do that.

I had a birth plan, but it was ignored. Literally. The doctor took it, said 'Oh, a birth plan!' and put it down on a table and never once looked at it. :p

Fortunately it was minimally invasive. Epidurals were mentioned constantly including while I was pushing (context: oh I'm sorry honey it's too late for an epidural... Meanwhile I was squeaking because one of the people that was stretching out my vagina had just done so to the point of Tearing it! The only tear I got, btw. :p I had to support my own perinium when my son was crowning because all they were doing was stretching and ripping..And not only was I on my back pushing uphill but I swear the floor or bed was slanted and my head was lower than my butt was. :p

So there's "unchangeable hospital policy" and then there's "really stupid things that a woman should have control over".

I understood the point of the IV. I didn't understand why it had to have dextrose in it... Something that makes my blood sugar levels do wonky things. I understood that I "had to" push on my back because the OB-Gyn had never delivered a woman in the squatting position... But when I mentioned that the bed was tilted... Why did they not elevate me on pillows?

So my points:
1- Hospital is not always a choice that a woman makes. Often it's the only option that she has. Maybe she's on medicaid? Maybe her insurance doesn't cover home birth. Maybe she has no choice in the matter because she's uninsured and broke, can't find an OBGyn or midwife that will help her birth on a payment plan and is just showing up at the hospital hoping for the best.

Hospitals should be required to make informed consent more about informed *consent* and less about informed "I'm sorry it's hospital policy that you are going to give birth within the next 45 minutes or we have to do a c-section. What? You mean no one told you this ahead of time? Sorry, but that's hospital policy. If you don't like it you can always transfer to another hospital... But all the hospitals in town have the same policy.

It would be nice if hospitals had their policies accessible to the public so that women could do real and meaningful research, seeing as the OB-Gyns frequently don't seem to be aware of the "policies" enforced by the labor nurses, etc.

saraH said...

Hospitals DO have their policies accessible to the public. all you have to do is call the Hospitals info center or Human Resources Department. thats how I found out my 2 local hospitals repeat C/S rates and decided to plan my home birth instead.

A birth plan is much more useful when presented to your caregiver BEFORE entering the hospital. why don't women bring it to an appointment and review it with their Dr? that way they can avoid the embarrasment of a contradicting or an ignored Birth Plan. you can get your Dr's reaction to it before you're in labor. I love this post, very informative.

Kristina said...

I really discourage my clients to create birth plans. My biggest reason is that when you write your wishes down, often you subconsciously give up your verbal voice. Doctors and nurses pretty much are going to do what they need to do, for various reasons, some great and some not so great. When that nurse comes up and says "the doctor is going to come in and break your water" and you had it written in your birth plan that you didn't want AROM, subconsciously you think, "didn't they read my birth plan? if they are going against it they must think it's really important" instead of asking the questions they need to get answers to before they make their decision. In this way, birth plans take away the voice of the woman...the exact opposite effect of their intention.

Also where I live docs/nurses tend to be pretty conservative, so they do have that "why don't you just stamp 'c-section' on your forehead" attitude often, which I think is unfortunate...but of course I haven't walked a mile in their shoes.

So instead of teaching about birth plans, I teach about how to communicate with your doctors/nurses and what questions to ask, which has seemed to help quite a bit :)

Joanne said...

I am one of those people who wanted an out-of-hospital birth, but didn't have that choice. I thought a lot about whether or not to make a birth plan: the hospitals in my area are very conservitive and medically-oriented, so I worried that even having a birth plan at all would cause me to be treated with hostility.

In the end I did make a birth plan and tried to keep it short and focus only on the things that were very important to me. I didn't put things on there that were more "fluffy" like not announcing the baby's sex, but letting me find out myself. I didn't "ask for permission" to get out of the bed and move during the labor -- I just did it.

In the end, I got the things that were most important to me ie: having an unmedicated vaginal birth, no episiotomy and having the baby handed directly to me instead of going to the warmer first.

Of course this is partly because my labor was so fast that not only did the doctor miss the birth, but the nurse only raced in as I was delivering the baby's shoulders!!!!! hehehehehe :)

curdiemer said...

Why would they put contradicting statements on a birth plan?? That doesn't make any sense. Obviously they didn't do their research.

oh and inexpicableways, for my first birth I went to a practice that did order enemas (3 years ago).

I didn't have a birth plan for either birth. The first time because did no research and ended up with a c-section. The second time because I was with a natural birth friendly OB and hospital (really! a big teaching hospital that was so awesome) so I didn't feel I needed one. It's true that I didn't need one, but I still ended up with a c-section.

Ethel, LOL at your comment. Maybe next time I'll make a birth plan that says nothing but, "I want a c-section!!" and see if reverse psychology works.

Anonymous said...

I'm so sick of being told you are stuck with the policies of hospital/dr you choose. For MANY women, including me, there is very little choice. When I became pregnant, the only HMO covered by my employer explained that only one OB was taking new referrals. This OB never had time for me and only allowed three questions per visit. I didn't have a choice of hospital and my HMO doesn't cover anything but OB deliveries in the hospital. My birth plan was a plea for respect, modesty, and the sharing of info. None of these happened. When I've shared this online, I always get "you should have had a home birth." Ridiculous.

Anonymous said...

Oh. and to the people who say you should discuss things with the provider as the answer to everything, my provider sees 2,000 patients, never knew who I was, and doesn't deliver her patients. Again, she was my only choice. How could reviewing it with her have helped me?

Labor Nurse said...

anonymous- your situation describes one of many problems with maternity care in this country. I am at such a loss of words for how we need to change this- but it's change that we need. I wish more women were outraged so we could all revolt and buck the system.

A revolution, I say!

sara said...


While SOME policies are available, not all of them seem to be, either that or labor nurses and doctors are prone to declaring their own personal preferences as "hospital policy".

Next time around I'm printing out the blasted hospital policy and if a contradiction to my wishes can't be found I'll refuse to go along. :p

Question to Labor Nurse: If something is not in direct contradiction to hospital policy and no immediate safety issue exists, how does a woman's desires/rights balance with the labor nurse's desires and preferences? In other words: What right does a woman have to say "No, we're doing it my way"?

jala52 said...

Reading the comments I feel so privileged to have had such a supportive natural birth experience in a major teaching hospital where the spinal+epidural rate is above 75%. Rather than a formal birth plan, I went in with a very supportive & knowledgeable partner/advocate who was willing to stand up for what I wanted. I felt like this allowed us to roll with the many punches of my labor and delivery, especially as I was so verbally incapacitated (read: ANGRY) during labor.

Labor Nurse said...

sara- you have every right to have things your way no matter what. When it's an issue of nurse preference and your preference and safety, etc, is not of issue by all means speak up. In non-emergent situations, ask for rationales. If its the nurse's personal preference, ask her why she has come to that personal "protocol". If it's the unit's protocol, you can ask for a copy and read through it. Many times it will reference rationale, etc.

SacredAngel said...

Google is your friend....when you're buying a car, having a baby or just whatever Google will pull your tuckus out of the fire more often than not.

saraH said...

also you can ask for the waiver papers as a last resort. at my closest hospital, it is policy to get a port for the IV in your arm. you MUST do it. but you can sign a waiver for continuous fluids, and continuous fetal monitoring.

Anonymous said...

Personally, I can think of a lot of reasons to choose a teaching hospital, but not want a resident caring for me. For my first delivery, I chose the small local hospital near my home. This was a horrible choice. My delivery was extremely complicated, and they weren't staffed to handle that type of an emergency in the middle of the night. My next child will be born at a much larger teaching hospital. I don't want a resident to care for me because I have a history of complications that I don't feel a resident would truly be competent in handling, but I do want the resources that the teaching hospital has available - in-house anesthesia 24 hours a day, maternal - fetal specialist, and a level 4 trauma center. This setting is the best compromise between me and my husband since he'd prefer I head straight for the operating room, and I want a vaginal delivery.

Angela said...

I stumbled across this blog and after reading this post and all of the comments I just had to share my own experience. It has taken months, and involved a lot of fighting but it looks like when I deliver in December I will be able to get around all of the hospital's "required policies" that conflict with our desires. I am currently 32.5 weeks pregnant. I live in a rural area with no midwives so my husband and I drive 70 miles to a midwife practice. My midwives are wonderful and they attend home births, but not as far away as our home so we are left with delivering in the hospital. We are trying to do our best to avoid all ultrasound technology (Doppler and fetal monitoring included), all STD testing, vaccines, IVs, medicines, etc. Needless to say our list of "must avoid and prefer to avoid" is much longer than anyone I've met.

We are lucky that our midwives, while they don't always agree with us, have been respectful of our choices as long as the hospital will allow it. That being said it has been up to me to work things out with the hospital. Here in North Carolina you can object to vaccines on religious grounds and many of the other things such as PKU testing, eye ointment, etc. are legally required "unless the parents object". Those two things were not much of a hurdle. Things got sticky when I asked the hospital if we could object to the STD testing and the initial 20 minute fetal monitoring strip. Twenty minutes of fetal monitoring is hospital policy, to cover their butts not protect my baby. It is NC law for all pregnant women to be tested for Syphilis, Gonorrhea, and Chlamydia at their first prenatal visit and 28 weeks. If you go to the hospital without those tests it is law that you be tested when you go in for labor and delivery we had even heard if you continued to refuse they could potentially draw your baby’s blood to test the baby. We managed to get the hospital to agree to let us violate both of these Against Medical Advice.

I got around these policies/laws by being educated, assuring the hospital we would be willing to sign the necessary documents to legally cover them, being nice, and repeating my request when I was turned down. After speaking with several people at the hospital about our desires I was eventually referred to the director of labor and delivery. She had to check with hire ups (I assume the legal department or hospital administration), but after several phone conversations and questions like “If I refuse the STD test will you throw me out on the street or tie me down to draw my blood? Would you try to take my baby from me against my wishes?” I finally got an answer that made my day. It was cut and dry. I could refuse ANY treatment I wanted for myself or my baby including STD testing and fetal monitoring. Turning down STD testing did come with the caveat that some pediatricians may refuse to treat our child without a STD tests.

This is certainly a little easier because we have midwives willing to use a fetoscope during labor and because I’ve spent more hours than I can count reading the laws and science surrounding labor and delivery. If anyone else wants to go down this road I cannot encourage you enough to educate yourself. We will be taking a notarized document stating our wishes regarding things that will be “against medical advice” to the hospital before I go into labor. This is to make the hospital feel more comfortable granting our wishes and also to make sure it is clear we are not being flippant or uneducated about these requests. The best advice I have gotten was from one of our midwives. She encouraged us to be nice and not demanding when we spoke to the hospital staff about our wishes. I found this to be extremely good advice. I nicely explained my reasons and that our only other option would be a home birth without any medical professional and asked if they could help me. I was very surprised how well this paired with being well educated on the subject played to my advantage. I found that even though most people did not agree with our decisions they were willing to help me find my answers.

Because I have mentioned turning down treatment that some would say is necessary let me mention a few things. My husband and I were virgins when we got married and we have both been faithful we have some strong personal and religious feelings about what submitting to STD tests would mean for us. We are certainly open to things such as ultrasound in the event of a complication, but not for a normal uncomplicated birth. The only vaccine they give newborns in our state is Hep B. Seriously I’m not too worried about my infant getting an STD and find it appalling that an STD vaccine is REQUIRED for my child. I respect that others make different decisions than us. Please be assured all of our decisions are well researched and thought out.

Labor Nurse said...

Angela, believe it or not, most people don't research their decisions in advance and base what they want in their birth plans on hearsy and internet stories! It's nice to see that there are people out there who approach their birth plans such as you do.

But I wanted to clarify something: Hep B can be transmitted outside of sexual contact. It is not considered solely an STI. It can be transmitted via IV needle sharing, or in health care settings. I'm at greater risk of being exposed at work caring for women than as an STI (and certainly IV drug use).

blindeye said...

Wow! Stumbled across your blog and had to interject as a former patient, then doula, now nurse.... My experience has been that birth plans, while they usually fall on deaf ears (hands)meaning they are def. not always read or even really glanced at, they do give the expecting mother and her partner time to at least think about things before hand, even if her information isnt always perfectly credible or if it is impossible or unlikely requests she has at least she has thought about her needs... on the recieving end as a staff member of the hospital when a woman comes in with a birth plan I find she is treated with a bit more formal respect even if the nurse or Doc is rolling his eyes behind her back their is a general understanding that this patient has higher expectations of care... and thought has been put forth by the mom ... My thought is as a nurse when there are things tht dont make sense in a plan at least it can be discussed why those things cant be done and patient feels a little more in control at least in the loop.... nice blog though!!!

Anonymous said...

It's not so much about control for the sake of control. It's about not being pidgeonholed and not receiving outdated care. as one example:(It's stupid to cut the cord depriving the baby of it's own oxygenated blood only to put the infant on O2!!!) Maybe more healthcare providers should do as much research as some parents!!!
~written by an informed nurse!