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Saturday
Oct252008

Updated Birth Plan Template

Birth Plans on the Internet are woefully out of date. So many "interventions" (and your avoidance of them) are routine they don't even require a mention on your paperwork. In another post, I will explain why I feel common items have been removed. Feel free to delete any of the items on this list if it doesn't apply to you, but be very judicious when adding anything else.

Onward....

_____________________________________________________________________

My Birth Preferences List

I understand that labor and birth are unpredictable and ultimately want the health and safety of both the baby and I to take precedence. When possible, I request that procedures be explained thoroughly (benefits and risks) and also, when possible, I would like to be included in the decision-making process.

Below are items that are important to me. Your help with these is very much appreciated.

All of the requests are for a normal labor, birth and postpartum period.

Labor

- I would like to have as natural an experience as possible - freedom of movement, intermittent monitoring, a saline lock instead of an on-going IV and food and drink as tolerated.

- I prefer to bypass using the Pain Scale. If it is required for your job, please assign a number to me from your experience.

- Being in the hospital, I know pain medications are available. Please accept my request that medications not be offered to me. For personal reasons, I am striving for an unmedicated labor and delivery. If I desire medication or an epidural, I will be the first to ask for it!

Birth

- Please do not direct my pushing with counting or yelling "Push!" to me.

- I strongly prefer a tear to an episiotomy.

- I would like to be as active in the birth as possible, including bringing my baby up to my chest.

Cesarean

- I am not squeamish and would very much like to watch the baby be delivered as much as possible.

- Please use double-layer sutures when repairing my uterus.

- I admire Baby-Friendly Hospitals and would like to create that type of environment as much as possible. This includes having the baby skin-to-skin (as health permits, of course), keeping the mother-baby dyad together during the repair and recovery and encouraging unlimited breastfeeding, even during the initial recovery period.

- If my partner leaves the operating room with the baby, I would like to ask if my doula might step-in to help me during the repair.

- I would like one of my major support people to stay with me at all times in recovery.

Baby Care

- No Erythromycin eye ointment, please.

- No vitamin K injection (unless bruising or birth trauma occurs).

- No vaccinations are to be given at this time.

- We want to give our baby his/her first bath and understand you might have to wear gloves when handling the baby. This is an acceptable compromise to us.

_______________________________________________

There you have it! Simple and succinct. Keeping the Plan short increases the possibility that it will be read.

One of the issues that arises is when parents don't know why they are asking for certain things on a birth plan. I'm going to outline each item on the Birth Plan and explain why someone might choose to do (or not do) the procedure or intervention. I will also explain why I worded the item the way I did because I think it's important to know the reasoning behind the sentence structure as well as the reasoning for its inclusion.

Labor

- It might seem odd that I make one item filled with so many interventions, but declining/altering the procedures mentioned are very standard when a woman presents a birth plan to the hospital staff. I believe just dashing through them quickly, getting the "typical wants" out of the way, helps the staff to see that your next items will be different than the typical Internet birth plan template.

Asking for a saline lock lets the staff know you understand that progress in labor and delivery no longer includes "Hep"arin Locks, but they are saline locks nowadays.

- The Pain Scale is increasingly becoming a bone of contention with natural birthing women because with it comes the presentation (or encouragement) of medications and/or epidural for pain relief. The higher the number on the Pain Scale, the more insistent staff can get regarding accepting pain relief.

I suggest the nurse assign her own number based on observation because it is a requirement for hospitals to use the Pain Scale with patients. Here is what the Pain Scale looks like.

- Nurses tend to frown on women asking not to be offered pain medications. I believe it can be very uncomfortable for a nurse to see a woman in pain and not do something about it. The desire to help women is strong... and not being able to help - not being comfortable witnessing a woman without pain medication/an epidural - can be a very real cause of (di)stress in nursing staff.

In saying "For personal reasons..." there cannot be any sort of challenge regarding the request without stepping on a woman's feelings - and feelings are harder for people to trample than (what is perceived as) random wants.

Birth

- The tendency to holler "Push!" to a woman in second stage comes from when women were given a heck of a lot of medication and couldn't follow directions very well (back in the 40's. 50's and 60's) and the ritual has remained, most would say because women who have epidurals need direction to get the baby out. Many of us see the world of difference between giving direction and yelling. To me, the shouting becomes hysterical (not the funny kind) and sometimes filled with angry energy, exhorting the woman to try harder, "Push harder!" - as if she isn't doing a good enough job.

Even when women need to be directed in how to push, either for the baby's safety or because the woman is so numb she can't feel what she is doing, those around her can do this without the cheerleader effect so often found on labor and delivery floors. Asking politely in the birth plan lays out this request.

- After discussion and thought, I changed the item to read like this. Of course, the issue comes in trusting the person sitting or standing at your perineum! Do they cut almost everyone? What is their episiotomy rate? It is challenging when there is a large practice and you don't know who you will get. In my experience, episiotomies are done so rarely anymore, they were almost banished from the Birth Plan altogether. I debated putting it on here, but knew many would want it at least mentioned, so I included it.

- Many Birth Plans will speak about being physically active and wanting to push in any position. Because that request is so common, I thought I would wrap that with the newer request for the woman herself to bring the baby up to her chest - to "help deliver the baby" if you will. If you don't want to help bring the baby up, just eliminate that part of the sentence, but if you want to have freedom of movement during second stage (pushing), I encourage leaving the first part in... and worded that way because "I want to be able to assume any position I want during pushing" will be frowned upon and discouraged - they hear that a lot. Worded differently, they will pay attention in a different way.

Cesarean

- It is very important, if you want to watch your baby delivered, to tell them you are not squeamish. If you are, DO NOT ASK FOR THIS ON YOUR LIST! The last thing they need is you to freak out or vomit in your incision, so think long and hard about watching your baby born. To be honest, being able to see much is rare because the incision is tucked under your belly. If they were willing to bring a mirror in, that would be an entirely different experience.

If your partner stands, they have a much better chance of being able to watch the baby born. If the hospital is okay with photographs, before going into the operating room, ask if the person with you will be able to take a picture for you as the baby is born. Most will say no, but it is worth asking. I would highly suggest taking the camera into the operating room and when the doc says they are starting, ask again if you can take a picture of the delivery. Some nurses will say "No" whereas the doc will say, "Sure!"

When the baby comes to the mom, ask the anesthesiologist to take a picture of the three of you! See this picture taken by an anesthesiologist? It is priceless.

- This is actually a request that is often forgotten, so I really suggest this not only be on your plan, but also verbally stated as your surgery is beginning.

Having double-layer suture repair is often a requirement for future physicians and midwives when discussing Vaginal Birth After Cesarean (VBAC). If you remotely think you might have future children and want to try for a VBAC, make sure your uterus is closed with two rows of sutures.

- By mentioning Baby-Friendly hospitals (and if you don't know what one is, please read about them - start here), you express an understanding that there is another way of recovering from birth (including a cesarean) than removing the baby from his/her mother; you are letting them know you want mother-baby togetherness even if it might be inconvenient for the staff.

There will be the argument that the operating room is very cold, too cold for a naked baby, plus it isn't uncommon for a mom to be sedated post-birth, so holding a baby can be risky.

However, if you tell them, before the surgery, that you would like your healthy baby on your upper chest and breasts and be covered with the warm blankets (they have them in warmers), you will be sure to keep the baby warm and understand the need to do so. It is important to not say, "I want the baby on my stomach" because that isn't possible; you have an open wound there!

You can also tell the anesthesiologist you do not want to be sedated after the baby is born so you can spend time with him or he. You may have to remind him in the OR, too, so please be aware when you are in there. This is very challenging, especially if the cesarean is a surprise. But, keeping your wits about you will afford you many more of your desires than crying and complaining (about the pulling and tugging or the nausea). Know that strange sensations and nausea are common! Tell the anesthesiologist if you are nauseous, but understand they will give you something for it and it will probably sedate you somewhat. If this happens, someone else will have to hold the baby next to you instead of on you. This doesn't mean to just let yourself vomit (on the baby!) to avoid sedation, but that the plans might change if you get medication for nausea.

Many of these things are really great to discuss with your nurse ahead of time. Yes, you will be in labor, concentrating on that aspect. No, you won't want to talk about the "in case of" cesarean, but it really is good on three levels.

1. You will be letting your wishes known.

2. They will have a better understanding of who you are as a patient.

3. They will see you are a reasonable person who will allow the unfolding of your birth, vaginal or cesarean birth.

Number three can transform your labor experience. If the nurse sees you as willing to bend, they tend to bend a lot more, too.

- In most cases, once the baby is born, they are taken from the operating room and dad/partner goes with them to the Nursery. Moms are then left alone, usually sedated and go to the Recovery Room, also alone.

If women ask for a replacement person, usually the doula or grandparent, they will sometimes be permitted to have one. Operating Rooms are run by two people: the circulating nurse and the anesthesiologist. Both of these people will need to give permission to have another person in the OR. If they agree, that means that both support people will have to put the paper scrubs on, the funky hat and the booties. When the nurse comes in to give them to the dad/partner, make sure to let her know... the dad/partner will have to remind the nurse that so-and-so will also be going on after s/he leaves - "Could we have another set of scrubs for them, please?"

- Along these lines is asking that someone remain with you, even in the Recovery Room. By asking for someone "at all times," it encompasses the recovery period, too. It is the ultimate decision of the charge nurse in the Recovery Room, but if you are polite and respectful, they might break the rules if they have one that says "No one in the Recovery Room."

Sometimes, by having someone with you in the RR, you can also negotiate getting the baby to you to nurse. You can let the nurses know your support person will keep the baby safe and close and will hold the baby to the breast so mom can recover. The least amount of medication mom takes at this point, the less sleepy she will be and they will be more inclined to get you together with your baby.

I just had a mom who got out of recovery 30 minutes after her cesarean by moving her legs and then hips - that hospital's requirement for release from the RR. They did not permit her to be with her baby (dad stayed with her) and she wanted to nurse as soon as possible, so was determined to do whatever she needed to do to get together with him. If you want to leave the RR, ask what the requirements are and then do them!

When women have cesareans, because they are often either emergency or unplanned, it can be a time of bafflement and confusion. If you want to adhere to a prepared birth plan, you, the birthing woman, must keep your wits about you. I am not saying you aren't allowed to share your feelings of fear or disappointment, but I encourage you to try and put them aside (for the moment) for the sake of your birth plan/desires. The more calm and in control you are, the more likely you will be able to negotiate your wishes.

I know it seems the doula should be the one in control and to remind you of your wishes - and she can - but ultimately, it is the mother's behavior and words that direct the experience.

This is not a time to be demanding or harsh. (Actually, the more demanding you are in your wishes, the less likely you are to get them.) Be respectful and speak in a kind tone of voice.

(More on attitude and goals further down.)

Baby Care

- Erythromycin is used to help prevent Neonatal Opthalmia (Gonoccal and Chlamydial). Some families choose not to put the eye ointment in the baby's eyes

     1) Because they don't have gonorrhea or chlamydia

     2) They had a cesarean and the only way for the baby to contract neonatal opthalmia is through a vaginal birth

     3) Because they believe if the baby contracts an eye infection it can be treated then

     4) Because they feel it is invasive.

I encourage families to be truthful and honest with themselves when choosing eye ointment or not for their babies. Women have tested negative for gonorrhea and chlamydia, sometimes twice during the pregnancy, and their baby still had the very serious, often blinding, eye infection because their partners gave it to them after the testing period. Research and be able to clearly explain why you do not want the antibiotic in your baby's eyes.

- Vitamin K is used for the treatment and prevention of Hemorrhagic Disease of the Newborn (HDN), a possibly fatal condition that remains extremely controversial in its origin and treatment. I highly encourage you to read as much information as possible regarding HDN before making your decision. Be able to clearly explain why you do not want the injection given to your child.

Families might choose to avoid the Vitamin K:

1) Because there is a great deal of controversy about its usage

2) Because they had delayed cord clamping (which some research seems to demonstrate lowers or eliminates the risk of HDN)

3) Because they believe babies are not meant to have that much Vitamin K in their bodies; if they were, Nature would have given it to them.

Some reasons why a family might choose to administer the Vitamin K include:

1) Because there is bruising at birth (including hematomas, caputs, extreme molding)

2) Because there was an instrumental delivery (vacuum or forceps)

3) Because there was a traumatic birth (including a shoulder dystocia)

4) Because they are going to circumcise their boy or pierce their girl's ears before 8 days postpartum

5) Because the baby is going to the NICU and/or will have procedures that will break the skin and draw blood

Some families choose to give their babies oral Vitamin K. Some hospitals will do this and others will not. Read, ask and learn before you ask your hospital to do this.

- By saying "...at this time...." you are leaving the topic open for discussion and the staff might not be so antagonistic towards not giving your baby the Hepatitis B vaccine while in the hospital. I haven't seen nurses or doctors react strongly when clients refuse/decline the vaccine, but it certainly is possible to come across one.

This is another intervention you must be versed in so you can eloquently defend your decision not to vaccinate. If you are at risk for Hepatitis B, or if anyone that might come in contact with your baby is at risk, strongly consider your choice not to vaccinate. Be honest with yourself!

- Why on earth would the staff have to wear gloves to touch your baby? Because babies are considered "dirty" or "contaminated" if they have not been washed after the birth. They have your vaginal fluids, blood and possibly feces on them. If there was meconium, please strongly consider your choice not to bathe the baby. You, or whomever you designate, are always able to give your baby his/her first bath, whether in the hospital or at home. One major reason for wanting to bathe one's own baby is the ritual aspect of washing. The other major reason is parents tend to be much gentler than the nursing staff. It isn't uncommon for nurses to scrub the babies, especially their heads, with brushes to clean them; parents find this distressing.

Finishing Thoughts

I know this is your birth and you should be able to dictate the way it should go, but you are on the hospital's turf and you are choosing to birth in the hospital, so acknowledging and respecting the keepers of the kingdom (sugar) goes a lot further than defensiveness and anger (vinegar).

If you find your birth plan falling apart because of an unsympathetic nurse (as opposed to an unrealistic birth plan), you might ask to speak to the charge nurse and ask her for a more natural-oriented nurse. Natural-oriented nurses love couples with birth plans (or birth plan-type desires) and go out of their way to help a mom have a great experience.

If your plan is falling apart, even with a sympathetic nurse, you might re-examine what is going on with your birth. Has the normalcy changed? Did you ask for an epidural? (Which would require an IV and continuous monitoring.) Are you vomiting? (I believe you need food in that case, but in the hospital, an IV will be required.) Is your blood pressure going up? Is the baby's heart beat doing funky things? Is there meconium? Has there been no progress in many hours? Are you so tired you can barely see? Have you been whining (as opposed to vocalizing)? Are there people in the room you might wish were gone? Are you "performing" for someone in the room? (This is one of my favorite tricks and I have seen it happen several times, so it bears mentioning.) Has your doula been antagonistic and argumentative? Is your doula trying to direct the path of your birth?

Being honest about why a birth plan is unraveling can help you to re-group and either salvage what can be saved or to re-examine the plan with an objective eye. Of course, this is very challenging while you are in the middle of labor, but having supportive, not medically-antagonistic, support people can mean the difference between a labor and birth that fosters a feeling of success versus an experience that felt out of control and brings with it regret and sadness.

Be sure you even want to have a hospital birth plan. If you choose to create one and discuss it with your doctor/s and nurses, be judicious in what you request. In a follow-up post, I will discuss what isn't on this list and why I chose to leave the items off. I should have that post up within the next day or so.

The goal of a birth plan is to individualize your care, to be seen as a woman with wishes and desires beyond the standard hospital experience. It really is important to remember, however, that you are birthing in a hospital and you will not create a homebirth experience there. If you want a homebirth, have one! If you are birthing in the hospital, know you will be compromising some of your wants while working to keep others; it's the way of hospital birth.

When you are writing your birth plan, keep it realistic. You and your birth will greatly benefit!

References (6)

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    - Navelgazing Midwife Blog - Updated Birth Plan Template
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Reader Comments (38)

This is a great post. I just had to comment about tearing vs. episiotomy -- my SIL's 1st baby was born at home and weighed 9 lb. 8 oz. (after pooping and peeing), and she didn't tear at all, although she did push for 5 hours (the mw was just about to suggest a transfer for a C-section). Her 2nd baby was a planned hospital birth (different state, different laws), and was just under 8 lb., but she was a brow presentation, and my SIL tore in the front. She felt it even through the epidural (but she did not feel the razor from the internal monitor that had come out of the baby's head that sliced her vagina all the way down). I don't know whether the tearing was due to maternal positioning or the baby's presentation -- or both -- but it was interesting to me that she didn't tear with her first baby who was so much larger, but did tear with her 2nd.

October 25, 2008 | Unregistered CommenterKathy

I think it speaks of the importance of positioning AND the baby's position. Some things are simply the luck of the draw.

Thanks for sharing this story... helpful!

October 25, 2008 | Registered CommenterNavelgazing Midwife

Thanks for this post. I had planned a birth center birth and ended up in the hospital, though still attended by my midwife, because I was induced 12 days after my due date with almost no amniotic fluid. I really struggled with my birth plan (which the birth center required you to do - not in an onerous way, but in the sense that they gave you some questions to fill out and bring to an appointment that was just for talking about your preferences) because I felt like if I was at the birth center, I didn't really need a plan because I trusted the midwives not to do a bunch of stuff I didn't want just because it was protocol. On the other hand, if I ended up in the hospital, it seemed like the whole thing was out the window.

Having had a hospital birth now (and with plenty of pitocin at that), I think I have a better sense of what's important to me and what isn't. But something short and sweet like this is helpful in thinking about a future hospital birth plan (though I hope not to have any more babies in the hospital if I can help it).

October 25, 2008 | Unregistered Commenterchingona

What is your definition of a short perineum?

October 25, 2008 | Unregistered CommenterAndie

I particularly like the item about the pain scale. I didn't know about the pain scale before hand, and I didn't think much about it afterward, but now that you mention it, I found it both irritating and distracting to try to come up with a number. I was actually more uncomfortable earlier in my labor, before I got into the zone, but I didn't want to give a high number because I thought for sure it was going to get a lot worse and the scale would be all off. (Yes, I over-analyzed it.) I felt a lot of relief when the nurse said "You can say 9 now and say 5 later. It doesn't have to keep going up." On the other hand, because I kept downplaying my pain, not in an attempt to be a martyr but just to save myself room on the upper end of the scale, I didn't get to much pressure to get an epidural.

A question about the saline lock ... when I was in the hospital (2005), the staff called it a Hep lock. Is that just a verbal habit and it likely was a saline lock? Or has the change been in just the last few years?

October 25, 2008 | Unregistered Commenterchingona

Very timely post for me...I've been reading all sorts of birth plans, searching for a template to use. The succinctness of your plan is appealing...and bound to be more effective for its brevity. At the same time, I benefit from the way you spell out in detail the reasoning behind each item and its phrasing. Thank you for your efforts.

October 26, 2008 | Unregistered CommenterAmy

I have a picture of one somewhere on the site, but it is when there is a very small area between the vaginal opening and the anus. I certainly don't measure, but it is very easy to see the difference when one is in front of you.

That said, since most of my clients are in the water or doing their own thing, they aren't going to be in a position for me to even consider an episiotomy! What *would* bring me to look and see what was going on is if the baby's heart rate was declining or if we could see the head for a long period of time... shoulder dystocia in the making? Perineal issues? Nuchal hand? Cord?

In 2005, I can see there being Hep Locks... there probably still are even now, but in more remote areas. I also do think it can be a habit to call all Locks "Hep Locks."

October 26, 2008 | Registered CommenterNavelgazing Midwife

I had my first baby at home, but when I was pregnant with my second we moved to another state where the ONLY option for an out-of-hospital birth would be an unassisted homebirth. I'm crunchy, but I just didn't feel that UC was a choice I was willing to make under duress. I was forced into a hospital birth even though I would have been a perfect candidate for home birth and would have done *almost* anything to have one.

The birth plan that I made for the extremely conservative and highly medicalized hospital that I had to go to was very similar to this one. Some differences were that I didn't mention things like freedom of movement and freedom to change positions -- I just did it without feeling like I was "asking permission" to do these things on the birth plan. I also didn't mention eating and drinking in labor -- this was Not Allowed by the hospital, so planned to just sneak food and drinks if I needed them.

I decided to just let some of the less important things slide so that I could focus on getting the most important things. For example I let them do eye ointment and vit K (even though I didn't really want that done) but focused on the importance of having the baby skin-to-skin immediately after the birth for at least an hour (they let me keep her for 45 min before taking her, and I had to fight for it). I hoped that not fighting every single little detail would perhaps make me seem more reasonable.

I am lucky that I have fast labors, so I was at the hospital for less than an hour before the baby was born. My nurse was so completely unfamiliar with how to handle an unmedicated birth that after checking me and finding that I was not only complete, but the baby was nearly crowning she LEFT THE ROOM TO CALL THE DOCTOR. When she got back she was *shocked* to find that the baby's head was out, and I was working on pushing out the baby's shoulders. Thank God the bed wasn't broken down!

October 26, 2008 | Unregistered CommenterJoanne

I think heplock is a verbal habit most likely just about everywhere. I've been practicing just over 7 years and no where I know of has used anything but saline locks in that time, but we all still say "heplock" out of habit. Seeing heplock on a birth plan wouldn't indicate ignorance to me. My hospital is currently on a big campaign to stamp out what they call "inappropriate abbreviations" - some are things that are easily misinterpreted, such as using SC to abbreviate subcutaneous which may be misread as SL for sublingual, and some are to stop using abbreviations for things we no longer do, like heplock vs. saline lock. All of the docs are having a hard time remembering to write out the longer saline lock - so at least in my neck of the woods, no one would bat an eye at heplock!

I wonder if you can point me to any creditable evidence that third and fourth degree tears can be predicted - and that cutting is then better. I practice with very restricted episiotomy usage (I cut for true fetal distress only - and only if a couple minutes is really going to matter.) I think I've done 2 episiotomies in the last 3 years, attending about 70 births a year (with an 11% cesarean rate, so I think that's just under 190 vaginal births in that time) and I've never had a spontaneous 4th degree. I have had a couple of spontaneous 3rd degrees, usually partial (not the whole sphincter, but part of it) and in 7 years of practice, I don't believe I've had a single case of fecal incontinence. I do ask at every postpartum check and most well woman exams, particularly if I know the woman had a bad tear. I'd be hard pressed to change my practice and start trying to figure out who is going to tear and then make a decision on cutting based on my experience. Everything I've read suggests pelvic floor outcomes are all worse with episiotomy - but most studies used docs that had pretty high rates, so perhaps there is some subset of women who do better, but until I see some good evidence I will continue to use episiotomy for fetal indications only.

I'm a big fan of not bathing newborns - I think having to wear gloves every time they touch the baby minimizes how much the baby is disturbed! It's funny, though - the last 2 clients I had who requested no bath ended up with babies who pooped so much immediately after birth that they ended up needs rinsed off pretty quickly!

October 26, 2008 | Unregistered Commenterdoctorjen

Dr. Jen... I don't know of anything. This very well could be an example of regurgitating what I was taught! Your asking me made me ponder... and as I said already, I have only cut two episiotomies twice and both were for fetal distress.

Maybe I just need to change it? Should I even mention it at all?

October 26, 2008 | Registered CommenterNavelgazing Midwife

Does requesting no episiotomy actually make any difference if the provider is convinced it's necessary? I'm working off a very small sample size, just my friends who have had babies, but it seems to me that if the doctor wants to do it, they do it. I have one friend whose doc did one without telling her, even though she specifically requested that he not do one, he had agreed to that, she had been pushing for only 30 minutes and there was no distress. I presume he thought she would tear (thought the baby was coming too fast? don't know).

October 26, 2008 | Unregistered Commenterchingona

That's part of why I question putting episiotomy in the birth plan at all! Women can state their preference all day long, but when it comes to the cut, it takes a fraction of a second to do one/get one done.

Just like my explaining when a woman might want one based on my training, the same can be said for an OB's training. Were they trained to cut every perineum? Every perineum that looks like it's going to tear when the head is nearly out? Only when there looks like a bad tear might happen? Or, like Dr. Jen, when there is fetal distress?

I really did debate leaving epis off the birth plan and am now reconsidering yet again.

More food for thought, thanks.

October 26, 2008 | Registered CommenterNavelgazing Midwife

I don't have time to look it up, but I'm familar with one study that looked at what factors made an episiotomy more likely in a hospital birthing population - such as length of second stage, fetal distress, size of baby, etc. Interestingly, the only thing that was predictive was the episiotomy rate of the birth attendant. So birth attendants that cut a lot, cut a lot - and those that don't cut much, don't cut much. When I talk to friends or clients who aren't birthing with me, I tell them the most important thing they can do to prevent an episiotomy is choose a provider with a low rate. Of course in a transfer situation, you don't get much choice often. That might be the time to be more adament about your wishes, or to decide it doesn't matter that much to you (I personally wouldn't be comfortable comprising on episiotomy, but others might be.)

To clarify also - I was most decidedly not taught to cut only for distress. I trained somewhere with a very high episiotomy rate, especially for first time mothers. I became expert during residency in avoiding cutting (drop the local, drop the scissors, don't call the attending until the head is out, let the student do the delivery and "forget" to hand them scissors) and therefore avoided doing as many as I could. Of course, I became interested in attending births by reading as much midwifery stuff as I could get my hands on, and I'd already birthed 2 children myself as non-interventively as I knew how at the time so I came into my labor and delivery rotations from a different perspective as my classmates. I practice in a state that only licenses CNMs, who must practice with a collaborative agreement. I was planning to pursue the CNM path, but my aunt who is a nurse practioner took me to lunch with several CNM friends so I could talk to them about their careers and I was so struck at how unhappy they all were at practicing under the direction of physicians, that I changed my mind and went to med school. I didn't want to be a surgeon, though (and I firmly believe that normal births should not be attended by surgical providers but that we should save the surgeons for when they are needed) so I'm a family doc that does a lot of maternal-child health instead.

October 26, 2008 | Unregistered Commenterdoctorjen

Sorry to be dominating this comment thread, but another question comes to mind. For background, my situation was that I was admitted for induction and started with Cervadil. After everything was set up, the midwife left, figuring (correctly) that it might be a while before anything happened. So it was just my husband and I overnight, with a nurse occasionally checking on us. I ended up having a lot of conflict with the nurse, even though she was supposed to be more sympathetic to natural birth, because she was keeping an eye on too many patients, all by monitor. She kept coming in for what looked like decels, but really were just the monitor having moved or the baby having moved. She started to get frustrated and really didn't want me to move around. And I was really uncomfortable and really getting angry that she didn't want me to move around. The nurse wanted me to agree to internal monitoring, and I really didn't want that. As it turns out, once the midwife got there and I had someone in the room continuously rather than watching a screen from down the hall, it was determined the baby probably was fine, and I continued with the external monitor.

Wow, that was long-winded ... So, my question is ... 1) Is it worth having a preference about type of monitoring in a hospital birth plan or is the decision just too specific to each situation? and 2) Was I wrong to turn down internal monitoring? Or rather, if I had a more typical hospital birth where I didn't have someone there the whole time, would it be better to agree to the internal monitoring? My understanding is that it's more accurate and can reduce unnecessary c-sections, but I was irritated enough about having continuous monitoring and really didn't want wires coming out of my vagina.

Just curious about your thoughts.

October 26, 2008 | Unregistered Commenterchingona

do you think i could make a very short birth plan in case of an emergency transfer? i am really debating this right now and would like your opinion.
i think it would be mostly just my preference on type of medications used and treatment of the baby during recovery. i dont even know if they would bother to look at that but maybe its worth it if i go in with a reason that isnt catastrophic.

i think i might write out a 3x5 notecard of preferences, maybe that will be good.

October 26, 2008 | Unregistered CommenterJackieD

I really think you should add some more information about communication to this birth plan. The manner in which information is presented / discussed with a woman can make a huge impact either negatively or positively on the experience.

My latest birth plan is broken down into two sections - communication and procedures. The communication section has 7 items, and the procedure section has only 3 items. In all reality, I had originally planned to ignore the procedures, but there are certain procedures specific to my last delivery that I wanted to make clear my wishes / preferences.

I've learned that the procedures themselves really don't matter. What matters is the manner in which the information is communicated to the patient about their necessity.

October 27, 2008 | Unregistered CommenterDonna

Dr. Jen: You are a Dr. Wonderful, too! Thanks for all you do.

Chingona: If it was going to go down that they were going to do a cesarean or an internal monitoring to see what was happening, I would opt for the internal monitor. Also, I think you did exactly what you needed to do in the moment and trying to play armchair quarterback is always easier, but women typically have far less of a comfort issue with the internal monitor and are also able to move around easier. This is, of course, if it doesn't fall off the baby or out of the cervix (if it is the IUPC). I can tell you all day long what I would have done (and that would have been to have the internal monitors so they got off my back about worrying about positioning and how the baby's health was), but in the end, each woman has to make the choices that are best for her and her baby.

I think it worked for you because someone came in eventually. You might have changed your plan if the uncertainty lasted another couple of hours and they were tsk tsking the monitor tracing. You might not have!

I am frantically working on the "What About...?" post that explains why I left off so many items and how to deal with them in the middle of labor. This is one.

I believe it is far too individual of a situation, very in-the-moment, to be able to "dictate" what monitors you want. You might want the external, but foregoing an internal might mean off to the OR with ya! When in doubt, get a great tracing on the baby, a scalp PH and then make the decision to do surgery or not.

Donna:

I totally understand what you are saying and in the follow-up post (mentioned above) I address communication much more than here. Honestly, if you have read a couple of posts by me, you understand my urgency with decent communication between hospital staff and client (with her support people). I do need to remember this might head out without my blog, though. I did try to guide women into remembering the honey/vinegar analogy, so didn't ignore the topic altogether. :)

More to be written... much more.

October 27, 2008 | Registered CommenterNavelgazing Midwife

Gosh, hospital birth is so not for me.

October 27, 2008 | Unregistered CommenterTalina

Working in L&D, we refer to IVs in various ways (and there is no right or wrong way, it seems): well, lock, heplock, hepwell, saline well, saline lock, or the hospital term "IPID" (intermittant peripheral infusion device). Also, as long as you do not have pitocin or an epidural, we will generally only do intermittant EFM/auscultation of the fetal heart tones. Of course, there are other nurses who will just keep the mom on continuous EFM for their convenience. I don't though. I believe that freedom of movement is very important in labor, and highly encourage the women I take care of to keep moving. I'm also working on a committee that is trying to change our standard of care from purple face "counting" pushing, to passive descent and open glottis pushing, as well as increasing our skin-to-skin contact with moms and babies after birth.

Episiotomies are rarely done, from my point of view. I honestly wouldn't even include it in a birth plan/preference list. By the way, I like the way you worded your birth preferences list Barb.

October 27, 2008 | Unregistered Commenteratyourcervix

Wow, after reading this I feel so fortunate. I did have the very long birth plan that I think the nurses threw away. I succeeded in natural childbirth with both of my children and in a training hospital. Not only did they honor all of my requests ( I was asked to change positions due to decelerated heart rate- the change worked although I was miserable for about 2 hours, but again my willingness helped me get support where it counted, I also agreed to a saline lock). I did not have a saline or heplock in 2004 with our daughter (and I think since it was the same hospital they had my chart and knew I could and would do natural again). I did not have an epesiotimy, I did not have the baby taken from me, and with our son who we waited to bath until we were home. We did have to sign a waiver declining eye drops (we assured the staff we were clean of STD's) but agreed to vit K.
We just had an amazing experience both times. I have so much respect for home birth, but I also have so much respect for a major hospital (in Portland, OR) to respect my wishes, and give me the birth experience we wanted.
A birth plan is great, plus stating your wants gives you an idea of what to expect. But I think the main point iis not being so defiant when arriving. Listening to the nurses, stay logical, explain but don't defend. And little compromises will give you so much credibility; that it isn't about you, the mother, but the safety, health and well being of your child that is most important.

October 27, 2008 | Unregistered CommenterGabrielle

Talina - Isn't it great to know this ahead of time?! I wish I had... but I wouldn't be where I am as a woman/midwife if I hadn't made that painful (in many ways!) journey. I envy women who don't have to have crappy experiences to realize they want to birth at home (or at least naturally). I love first-time moms! How smart they are. (Well, we are all smart who birth, but I'm always delighted when a first time mom wants a homebirth. - hope that came out right!)

October 27, 2008 | Registered CommenterNavelgazing Midwife

"trying to play armchair quarterback is always easier"

Believe me, I've armchair quarterbacked it (or Monday-morning quarterbacked it, in my case) up the field and back, from "should I have done the castor oil induction when I had a chance?" right on to when they insisted on doing a heel stick for blood sugar levels because it had been three hours and ten minutes since he nursed ("The breastfed babies in this hospital eat every three hours!" I was told, when he was less than 12 hours old. Are "I do not consent" really the magic words I've heard they are?) I think I've come to a place where I can contemplate it relatively objectively. It wasn't awful. In fact, I feel like a whiner for even raising some of my issues with it, compared to what some women go through. I managed to maintain my mobility, eat and drink as tolerated, labor without pain medication, choose my positions, have immediate skin-to-skin contact, have my husband go with him to the nursery, and give him his first bath ourselves. It just wasn't ideal, and I hope to have a different experience next time.

Thanks for your thoughtful responses. I'll eagerly await your follow-up.

October 27, 2008 | Unregistered Commenterchingona

Gabrielle Wrote:
"And little compromises will give you so much credibility; that it isn't about you, the mother, but the safety, health and well being of your child that is most important."

Gabrielle,
It is about the mother!
When an OB or nurse says the "health and well being of your child that is most important." to a women it's manipulative language and a technique frequently used by hosp staff, and in my experience that is a red flag something is not good for either mother or baby!

It is not an either or situation, a mother and baby are a dyad, what is good for the mother is good for the baby. Every decision a women makes, foremost in her mind is what is best for her baby.

October 28, 2008 | Unregistered Commenterdew

NGM, this is why I love your blog! Its informative without being preachy and overly crunchy, a nice balance that is sometimes hard to find. Anyway, I did not have a birthplan to take with me to the hospital. I did have a CNM that was as balanced (not medicalized but not crazy crunchy) as you seem to be, and I think that made the difference. However, I wish I did talk to my CNM about some of the procedures that would happen during certain circumstances during my birth. But I did get a satisfying experience. Next time, I plan on taking a list of questions about possible procedures to our appointments, as well as asking about doulas. I look forward to your post about communication with hospital staff. Also, could you do (or have you done) a post about how to select a doula, and how to convince your spouse that one is needed and worth the cost? I would like to get a doula for the next baby, but I am afraid the cost would be prohibitive to my husband! Thanks, and keep up the great posts! Jen

October 28, 2008 | Unregistered CommenterJen B

I am a new RN working on a mother/baby floor of a not-so-Baby Friendly hospital. I try so hard in my own practices to be both baby and mom friendly...promoting breastfeeding, keeping the dyad together, encouraging the parents to be actively involved in decision making and care of the new baby. We don't get many people with birth plans. Most of our patients seem to come more from the "doctor knows best" school. Which, coincidently, is the same school our doctors all seemed to have attended!! We don't even have CNM's delivering at our hospital, but that's another story.

But anyhow, enough about me...I just wanted to say thank you for this blog. I learn so much from things you post. I do try to be evidence-based in my practice, but I'm new and still learning. The whole c section/Emycin thing really hit me. I mean, it seems so obvious when you say it, but it's just never questioned at my hospital. I asked when I started, 'don't we have to ask the parents betore we give this?" and I was told they basically consented to it when they were admitted. Now I really wonder about that. I think they operate from the assumption of "won't hurt...might help", but I really like the quote that I read (possibly here somewhere?) "don't just DO something...stand there!'

I do wonder, tho, if you could explain the glove thing to me a little more. Are there a group of parents who are upset by our use of gloves to bathe a baby? You mentioned we consider the baby "dirty" or "contaminated", and it seemed to me you meant that this was insulting to parents? To me it's not meant as a slight, it's just a matter of the standard precautions we learned the first semester of school. I was taught not to touch blood with my bare hands, and that includes whether it is coming from an open wound or is being washed from a baby. After the initial bath, I don't use gloves when I assess babies, take vital signs, assist with breast feeding, etc. I just wash them. Before and after. Many of the other nurses glove up every time they touch a baby. I was trained in school by a CNM who taught that that was overkill, and was worse for spreading infection b/c people who wear gloves forget to wash their hands. So, I'm on board with that. I just don't know if I can get on board with sticking my bare hand in a tub of someone else's blood and poop. Please educate me though, if I'm being silly...

October 29, 2008 | Unregistered CommenterFemmeRN

No, I just don't think I was clear or it didn't come across right.

I quoted the words "contaminated" and "dirty" because the staff will use those words to describe the baby and I didn't want parents to freak out - or be offended - when they were said about their babies.

It is absolutely clear and important why you would wear gloves with a baby that isn't washed! Women don't see their unwashed babies that way, though, so it can seem offensive when someone won't touch your baby without gloves. I just wanted to be clear about *why* the staff won't.

Does that make sense?

October 29, 2008 | Registered CommenterNavelgazing Midwife

Perfect sense, thanks!

October 29, 2008 | Unregistered CommenterFemmeRN

This is so funny because I just found my birthplan from my firstborn and I didn't notice how outdated it was, I had tried to add some of the things you list but didn't get it all! (ended up with a c/s anyway). Thanks for the update! With my second child rather than have the staff give the bath one of my family memebers gave it (delayed a bit)(a beautiful gentle bath as opposed to the screaming one the kids usually get) and will prob do the same in the future.

October 29, 2008 | Unregistered CommenterAnon

Hi Barb, great post - I thought I'd share what we do at my hospital for c-sections...

If the section is under a regional anaesthesia, then the woman can have her partner in with her. Once the baby is born, we take him/her to the resusitaire/cot & if all is well, within seconds, babe is wrapped & passed to the partner so mom can look. We then snuggle babe up on mom's chest so she can have a cuddle in the OR. All being well, the baby leaves theatre in bed with mom (mom is transfered to a bed in the OR via a patslide) & remains with mom until they are discharged 2 or 3 days later.

If the section is a Crash (GA) then the partner cannon accompany the mom. This is generally due to 2 reasons (a) intubation can be traumatic for partners to witness & (b) if we go for Crash, then something has gone badly wrong. If babe comes out in good condition we take him/her straight to the partner (who remains in the birth room). Then we take pictures. Dozens of pictures. We try not to weigh baby & measure baby until the mom comes round.

In either case, the midwife remains with the woman. We only leave her when she is in the RR but are on-hand to help with the 1st feed on the RR if need be. I have also seen babes feed at the breast in theatre! Fantastic!

November 1, 2008 | Unregistered CommenterLiz

Good post...I have a doula friend who advises her clients to keep their birth preference lists down to the size of a 3" x 5" inch card. Seemed impossible to me, but she has been able to help her clients have wonderful lists with everything needed on them. They always start with something like "We understand birth is unpredictable; in the absence of complications, we would prefer...

Regarding the pain scale...it's a requirement by JCAHO, the accrediting organization of hospitals. We can get "zinged" if an audit of our charting turns up our neglect to use it, and if that happens enough, the hospitals "fitness" for operation can come into question (albeit, I would guess this is pretty unlikely). However, I can always make a note in my charting "Pt declines to respond to pain-scale requests while she copes with her labor". I haven't gotten any flack for that yet, and our charting is frequently audited by management.

Thank you for acknowledging that it can be difficult for a nurse to see his or her patient in pain and not want to relieve it...it is; it's helps if the mother has been able to find, with the help of her support people, a way of coping that doesn't look like she is "losing it". Easy for me to say, I know...but I've seen all sorts of moaning, rocking, rythmic behavior that lets me know that she is coping well with her pain. Tears are expected...but screaming and being combative...well, that doesn't look like coping...and I've seen that too, as if the mother is pissed that her labor hurts so much...almost like a "temper tantrum". There's a big difference between an irritated exhortation of "don't touch me there", or even "Aw, shut up!" that a Mom might make during transition labor, and screaming, kicking, swatting, and being generally out of control. I hate to sound this judgemental...I'm one of those nurses who loves "birth plan patients"...but if a woman is going to decline pain medication, she has to be realistic, and not assume that she will have a "high pain tolerance". She has to have prepared other ways of coping, and then, if those coping mechanisms don't work for her, not feel like a failure if she chooses medication. More than once a mother has asked me "what should I do?" when her pain seems to be more than she can cope with. First, if she seems to be OK between contractions, I'll tell her that, let her know that that looks like pretty good coping to me, and encourage her to take these brief pauses to rest and prepare for the next contraction...to take them one at a time, and not worry about "the next one" If at all possible (that is, if I have time), I will try to teach her and her partner a visualization (warm water flowing over her body, progressive relaxation with each contraction, etc); I'm amazed at how well that seems to work so much of the time. If nothing else works,.and the mother just doesn't seem to feel she can continue this way, I try to respond with something like...

"Only you can know if what you are experiencing is 'productive pain' or true 'suffering'. There's a difference. If you feel you are just suffering...or suffering too much, then you can look at medication or the epidural as a 'tool' to help you cope with, and even enjoy your labor. It's HARD to have a baby in the hospital. You're not on your own turf, and that makes it hard to remember that you're in charge, not us; You can't move around the way you can at home, and we don't let you eat the way you could at home...and all of that combined can make it more painful to have a baby here. There's no shame in choosing to relieve pain that you don't have the appropriate tools to otherwise cope with."

I know that sounds like I'm giving the mother "permission" to abandon her birth plan...and I guess it is; but I will still go out of my way to honor her plan in every other way.

There are a lot of people who disagree with me on this, because internal monitors are so invasive...but there are times when I actually prefer them. Mom doesn't have those blasted, tight, itchy straps around her, and without them, she has more mobility (in the bed, at least); if she's a little "fluffy", and it is difficult to keep a clear tracing (if we are at a point where continuous monitoring is necessary...and I try to do intermittent monitoring whenever possible, but with pitocin or an epidural, you need continuous monitoring), it prevents me from having to interrupt the flow of a mother's coping by always having to get in there and fiddle with the monitors; and I do not like pitocin...but it is used so much that I just have to accept it if I am going to work in a hospital L&D unit; but an internal uterine pressure catheter (IUPC) gives me a much better idea of how much pitocin to use (or more importantly I think, NOT to use). I can't tell you the number of times when contractions just aren't tracing with external monitors on a mother who is being given pitocin...but once the internals are in, we see that she is contracting too much! I shudder to think how much more pain she has been in than she had to be...and how much more danger as well.

As for c-sections...those OR's ARE freezing; and there is so little space between the mother's neck and the drape, that I can't imagine being able to keep a newborn warm enough there (and I'm also a nurse who tries to keep baby skin to skin from the moment of birth after a vaginal birth). Our hospital requires a team of pediatric residents to attend every c-section, which means the baby will be lifted up for Mom and her partner to see, then taken to the warmer to be dried off and assessed. If he or she looks OK, then they are wrapped up and given to the support person, to be positioned as close to Mom as possible, much like in the photo taken by the anesthesiologist you included in your post. Normally, by the time the surgery is wrapping up, the baby is taken to the triage nursery...but if a family requests it, I will take a newborn to recovery with the mother...IF she is comfortable enough to keep the baby skin to skin with her during the better part of her recovery period...which can last up to two hours if I now have both a mother and a baby to "recover" post op. In our recovery area there is no room for an infant warmer, so Mom is the only "warmer" baby has. I can also help get the baby to the breast as well, again, if Mom is comfortable enough, and her support person can help keep the baby positioned at the breast; if we are having trouble getting the mother's pain under control however, she isn't going to be able to enjoy her baby, so it might be better to send baby to triage, concentrate on getting her pain under control, and then getting her to the postpartum floor as soon as possible.

Finally, I would advise parents to add one more thing to their preference lists...no stirrups!!!!! I despise those things, but they are used routinely in my hospital. I'm convinced they make tears more likely, and make the ones that are unavoidable bigger; I also think they hinder the mother's ability to get into a really productive pushing posture. So far, few people have made that request; if more did, maybe our docs and the other nurses would realize that they do more harm than good.

Thanks for "listening",

RedRn

November 2, 2008 | Unregistered CommenterRedRn

I stopped writing birth plans after baby two, I think. My 6th baby I wish I did have a written plan though, the nurse asked after she had already pushed me into submission. I just assumed because my OB understood me, the nurse would too. Also, in times before I would be in the hospital 2 hours or less for birth. This last time was about five hours. I couldn't believe how crazy it was!

I am now over a year past that birth...hopefully I can "move on" so to speak! I hope to have another baby or two, or even three...in the future (have six already) and have found a different OB/midwife combo I'm interested in. This birthplan seems reasonable to me. If I get the chance again, I'll try something similar. I would ask for a nurse willing to "catch" babies since my last nightmare nursie stated she doesn't do that, and I want one that will just in case...my last three births have not been caught by a doctor or midwife...

November 2, 2008 | Unregistered CommenterDawn

I do have to say, I found stirrups horrible when I was told to be flat on my back. However, I found it annoying to hold my own legs in a reclined position also. If I was given the options of positions to push, I think on my back is awful...I like upright or on my side. The one thing I loved this last birth was when I was finally allowed to change positions no one was touching my legs when I was on my side. The stirrups were effective for helping me keep my legs apart when on my side, and I could grab onto the rails of the bed and not be touched by anyone. I wasn't getting along with my nurse, and so I didn't want her bugging me. I birthed my baby on my left side, and she was born in the caul, no tearing at all. I liked that, it seemed easier than on my back or even semi-sitting. So, stirrups in that situation worked well. Hate, hate them otherwise.

November 2, 2008 | Unregistered CommenterDawn

I agree to an extent with RedRn re: the monitors. I cannot tell you how many times women have told me what a relief it is to get rid of the CTG monitor belts. I truly think that internal fetal scalp electrodes have their place - when they work properly they can give a woman back her mobility! They are not for everyone, but I think that if you want to keep moving, then an internal monitor is an excellent compromise when constant monitoring is required.

Also - the stirrups - we call them lithotomy poles & they too, I feel, have their place. I have seen them used with brilliant results. There have been times when i've tried every position imaginable - water, out of water, knees, all fours, standing, sitting, left lateral & nothing but nothing has shifted that babe. Then up into lithotomy & bingo! A baby! I think they are a fab tool if you have bradycardia/ decelerations that require a baby to be born ASAP. I have also used modified lithotomy at homebirths to shift a baby out.

Birth is so unpredictable... that's why I love birthplans but also see very little point in most that I read. I love the ones with real thought in them. But i'll be honest, if I read 'I would rather tear than have an episiotomy' or 'I do not want an episiotomy unless it is necessary...' I think 'oh no, here we go....' like we give them out like candy!!!

November 3, 2008 | Unregistered CommenterLiz

Liz and Dawn,

Thanks for reminding me that sometimes I need to think a little more before I hit the keyboard, LOL. You are both right...there are times when stirrups have their place...I've found them helpful for mom's particularly in sidelying pushing to support the upper leg...and I can see where helping in repositioning, or needing to just plain get the baby out fast they can be a good tool...as I've experienced myself...can't believe I lost my objectivity so much here...just don't like to see their use "assumed", the way they are where I work.

Thanks Again,

RedRn

November 3, 2008 | Unregistered CommenterRedRn

hello and thank you for this lovely blog. I am 16 weeks pregnant and have been researching myself silly over my childbirth and how I would like baby and me to be treated during labor and postpartem.

A genuine compliment for both you and regular commenters: your advice and the input from your readers has spoken to me at a point where I haven't even yet completely articulated my own desires (even to myself!) for the childbirth experience. Your advice is realistic and fair. I will use a birth preferences formate very similar to the one you posted previously with a few really important things added. But not only does this help me to formulate the "birth plan," it also provides a list of talking points to cover with my trusted OB when we discuss birthing options and potential scenarios.

I can't thank you enough and I look forward to reading more of your lovely blog.

February 6, 2009 | Unregistered Commenterfaye malarkey black

Thank you for posting this. This looks very similar to the birth plan I would choose for myself. I am due in January and will be unable to have a home birth. I feel confident in my midwives and doula and their ability to advocate for me. However it will be nice to have something like this prepared ahead of time for well meaning family, friends, or hospital staff. So again, thank you.

July 8, 2009 | Unregistered Commenterchicken lips

Hey Barb - May I put this into a document and print it out for my students? I used to just send them this link, but now that I'm teaching in the hospital, links are a bit more formidable. I would, of course, give you credit for the article and include the link on there - just don't want to reinvent the wheel, since you've done such an awesome job here :0)

July 27, 2012 | Unregistered CommenterMaggie

Maggie: I *just* told someone I needed to update it again. Give me the weekend and let's see what I can fix, okay? I'll re-post, hopefully, by Monday. Thanks for wanting to use this, though. :) I'm glad I've been helpful.

July 27, 2012 | Registered CommenterNavelgazing Midwife

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