I've scoured over a dozen Internet Birth Plan templates and am reminded of the plethora of items that pepper page after page of birth plans doctors and nurses pore through. Here, I note the requests/demands and explain why they are not on the Updated Birth Plan Template (and should not be on yours!).
- Wearing your own clothes - Wear your own clothes and don't put the gown on! Easy enough. You don't need to put that you want to wear your own clothes on a birth plan; just do it.
- Enema and shave - Shockingly, even recently published on-line birth plans include these two antiquated events. It has been at least ten years, if not longer, since these two items were standard on labor and delivery floors. Including them on a birth plan makes the woman look woefully ignorant of what really happens at births in the hospital. If she is so out of touch with this, how knowledgeable could she possibly be about anything else?
- Vaginal exams - I don't mention minimizing vaginal exams because 1) don't open your legs if you don't want an exam 2) they will surely tell you it is "medically necessary" every time they want to do one 3) I find they don't usually do as many exams as they used to
- Playing your own music - Every labor room I know of either has cd players or they can find you one and you are welcome to play your own music. If it is important to you, bring your iPod and its docking station with speakers and play your music. At the least, bring your headphones and use those. This isn't a big enough deal to put on a birth plan.
- Keeping the lights low - Have your doula or partner ask where the lights are in the room and turn them off. If someone turns them on, ask politely that they be turned off. Keeping lights low isn't unusual enough to put on a birth plan.
- Wearing your contacts or glasses throughout labor and birth - A totally moot point in a vaginal birth. Even with cesareans, most women can keep their contacts in (not always, so bring your glasses!).
- Having residents/students in the room - They always ask first, it's the rule. If you don't want any there, say "No" when they ask. End of issue.
- Arbitrary time limits - Anyone with a birth plan wants to do everything in their power to have a vaginal birth, so it goes without saying that you won't want a strict adherence to Friedman's Curve. http://www.medscape.com/viewarticle/450311 That said, they aren't going to let you go forever - or as long as a homebirth midwife might. That's just the way it is in the hospital. If they are getting to the edge of their time limits, they let you know and you can, if you are still energetic and able and the baby is doing well, negotiate some more time. If you are showing signs of exhaustion or the baby is showing signs of fatigue/stress, the time limits will be more stringent.
- Rupture of membranes - Whereas at one time membranes were ruptured routinely when either labor began or once labor had an established pattern, I see them left alone a lot more now - unless an IUPC or internal monitor need to be placed.
However, rupturing membranes can be a sneaky occurrence and watching when the nurse or doctor reaches for the amniohook can be important for the doula or your partner. The topic of breaking your water isn't usually a discussion; more often, it is part of the momentary thought of "While we're in there, might as well...." And it can happen fast, too! The amniohooks are kept in the drawers next to the bed, usually under the monitor machine, so anytime someone reaches in there (and they also reach in there for sterile gloves), watch what they pull out.
I don't have this on the Birth Plan because if you ask they not be broken except for a medical reason, I believe they will just say, "Well, it will help us see the baby better," or "We'll be able to see if there is meconium," or "It will speed things up a little (and you are going awfully slow, honey)," or "You're in the bed anyway; it's okay."
They have to do a vaginal exam/go into your vagina to rupture your membranes. If you keep your legs together, they won't get to your amniotic sac.
- Internal monitors - Again, putting this on a Birth Plan and saying, "I only want intermittent external monitoring" - first, makes you sound stubborn and second, isn't always realistic. If the baby is moving all over or you are moving all over and they can't get a good reading on the baby, the option becomes a) stop moving around so they can hear the baby or b) have internals put in so you can continue having freedom of movement while keeping an eye on the baby.
There is a third option, but it requires a doula who knows her way around monitors and that is having someone hold the monitor on the baby even as you wiggle and rock and move. I have seen the nurses not give one whit how they get the baby's heart rate, just so they do.
- Fetoscope - I used to say I would give anyone $1000 if they could find a fetoscope in labor & delivery. Of course, I never had to reward anyone because in all these almost 26 years, I have never seen a fetoscope in L&D.
Besides, even as a homebirth midwife who will use a fetoscope during pregnancy, I still require the usage of a doppler in labor. Not only because it is easier (which it is), but because my birth team needs to hear the heart tones, too. That includes mom who is much more amiable to changing positions if she hears the baby needs it.
- Doppler - Asking for your baby's heart to be periodically listened to with a doppler isn't necessary. When listening to your baby intermittently, they just use the external monitor and someone can hold it on your for 20 minutes. The staff really wants (and needs!) to have tracings of the baby on paper and the external monitor, which uses doppler technology, fills the bill perfectly.
- Choosing the type of pain medication (Stadol, Nubain, Demerol) you want - Well, different parts of the country use different meds. And meds can be used during some parts of labor and not others, so blanketly asking for a certain kind of sedative or narcotic is inappropriate. It's better to just say, "I want some IV pain medication now" and let them dish it up.
- Walking epidural - When you meet with the anesthesiologist for an epidural, you can ask for a walking epidural (or a "light" epidural is how I have also heard them named), but know that some hospital protocols won't allow you to get out of bed, even just to sit in a chair with any epidural at all. I have been in the same hospital with two different women and one was permitted to walk to the bathroom and the other was confined to the bed - it was the OB's choice how much activity she was allowed to do.
Want to move around? Skip the epidural.
- Induction, including natural methods - I left induction off because it isn't a normal part of labor and requires a whole lot more discussion with your care provider than a line on a birth plan. Anyone who hands a medical person a birth plan a) wants to avoid induction at all costs and b) wants to try "natural" methods of induction before pitocin... no need to put that on paper. Docs don't often believe things like nipple stimulation, castor oil, homeopathics or herbs work, so most often I hear them say, "Try whatever you want; be at L&D for pitocin in the morning."
If you are discussing induction as a Birth Planning woman, there must be something going on with the pregnancy beyond being fatigued, so spending time writing about it for an L&D nurse is moot.
- Pitocin augmentation - This is something discussed before they start pitocin while you are already admitted in the hospital. Augmentation boosts contractions once they have either started or started and then petered out. If you are contracting wonderfully, they won't hook you up to pit. If your labor is piddly, they will want to.
How do you keep your labor from being piddly in the hospital? Don't go in too early! Keep moving and help your baby be in a great position... by moving!
Pit augmentation reasons, I find, are too variable to completely explain here, but know that there are valid reasons to be augmented, including being in advanced labor that stalls (often enough from fatigue or an epidural) and some pitocin can kick-start things and get your baby born.
It is SO important for people to not demonize pitocin! There are very appropriate reasons for its use. I do believe it's over-used, but I also don't expect women to follow Friedman's Curve.
If the topic comes up, discussion is much more important than a pre-labor thought might have been.
- Asking for a second opinion - Oooo, doggie... this will probably not go over well. I know it seems we should be permitted to ask for a second opinion, but when it comes down to doing a cesarean or not (or whatever intervention you might want reassurance for), a) there often isn't time to find another doc to check things out and b) I can hardly imagine one doctor over-riding another's opinion. If you need a cesarean, asking for another opinion wastes time... which can afford you more time, but if the baby is okay and you want more time, then ask for it that way.
- Asking for a certain type of anesthesia for a cesarean - Many years ago, I wrote a birth plan that said, "I want a caudal instead of a spinal or epidural if I need a cesarean." (No caudals anymore!) A wise childbirth teacher told me, "Don't you want the anesthesiologist to do their most skilled placement of the anesthesia, even if that isn't what you want?" Great point! I no longer encouraged women to be picky about what kind of anesthesia they got.
Also, the tendency is to give an epidural in labor, but if the woman hasn't had an epidural and is going in for a cesarean, she will get a spinal (which is a quick placement, quick acting and quick receding).
Rarely, women will want general anesthesia, but I have always seen doctors talk them out of it because of safety reasons. In 25+ years, I have only seen four women have general anesthesia for their cesareans; two because the epidural/spinal didn't take and two because they were seriously emergent.
- Naming someone to cut the cord - Again, folks presenting a birth plan generally want to have a family member cut the cord, so this really is moot. Unless the baby needs immediate help, I have always seen the cord cutting offered to the partner or grandparent. While homebirth midwives wouldn't dream of cutting the cord on a baby needing resuscitation, hospitals sever the cord and hand the baby off to the Pediatric team across the room.
If you are at all worried about this, just have your doula or partner say, during pushing, "We'd like to cut the cord, please" and that should take care of it.
- Asking to urinate on your own before a catheter is placed - Reading this on several birth plans, I was baffled because, for many, many years, women have been encouraged to get up as soon as they could to go to the bathroom; always before they left the Recovery Room (or finished their immediate postpartum care). This, of course, is if the woman hasn't had a catheter put in place because of an epidural (not everyone does).
Women just don't get a catheter unless they cannot urinate on their own, so this doesn't need to be on the birth plan.
- Asking for or assuming the hospital has or provides: birth stools/chairs/bar/tub/birth ball/beanbag chair - Putting something like this on a birth plan can let them know just how little you know about your local hospital. If you don't know what they have, ask a local doula or childbirth educator (one who works at that hospital). Most hospitals have birth bars, but often only one. I tell couples to ask for the bar the moment you get in your room because it can take a lot of time trying to find it... they get tucked in storage rooms a lot.
Most hospitals won't have birth stools, birthing chairs (I haven't seen or heard of a birthing chair in 20 years), tubs to relax in, beanbag chairs or even birth balls. It isn't uncommon for clients to bring their own birth balls, however. Just remember to ask before bringing it in (some hospitals have liability issues, worried mom will lose her balance and fall off the ball) and then, once you have it, cover it with towels or chux pads if you sit or lean on it; hospital floors are disgusting and germ ridden.
- Discussing alternative pain relief options (acupuncture, acupressure, breathing techniques, distraction, hot/cold therapy, self-hypnosis, massage) - There is no reason to put this on a Birth Plan ("I want to try alternative pain relief options before being offered medications or an epidural."... just do these things. If you want to bring an acupuncturist, you do need to ask the doctor in charge of your care, but I haven't seen any acupuncturist be refused.
- Early breastfeeding - If the baby is healthy, all hospitals know you want to nurse the baby as early as possible. However, it is really important to remember that not all babies want to nurse as early as you want him/her to! Cuddling, allowing the baby skin to skin contact and nuzzling are all as valid and important as the actual latch on.
- Stating who will cut the cord - It is standard to offer the partner the chance to cut the cord... as long as the baby is healthy and doing well. If the partner doesn't want to cut the cord, either decline in the moment or offer it to someone else, including the mother herself.
- Post-birth pitocin - This is so standard and automatic that putting this on the Birth Plan won't keep it from happening (in most cases). I highly recommend the doula or partner reminding the mom about the pitocin as she begins pushing... so she can say to her nurse, "Please do not automatically give me pitocin after the birth." The nurse will have to bring it up with the doctor, of course, but it puts it in her court to do so. Don't depend on her remembering, though! If this is really important to you, you will have to be diligent about watching what goes in your IV - or even your saline lock (which is easier to watch because it is on your wrist).
The main reason, though, that I don't recommend this go on the Birth Plan is because docs are able to talk women into accepting the pitocin without much discussion or argument. Many feel that in the grand scheme of things, this isn't a giant issue. It used to be a big one to me, but if I were birthing now, I wouldn't care if I got the shot.
Postpartum issues that have no place on a Birth Plan; Create a Postpartum Plan instead if you are so inclined, but note that most of these items don't need to be written down either.
- Requesting a type of postpartum room (usually a private room) - Ask for it when they start talking to you about transferring to your room. Also, the general rule is to give private rooms first and then fill the double rooms. In the olden days, there were four women to a room (!) and partners were never allowed to stay, even if there was only one person in the room. My how things have changed!
- No bottles are to be given to the baby - I can see this as a possible grey area because newborn care does occur in the Recovery Room in many/most hospitals, but generally, it is a postpartum issue.
Putting "Erythromycin" and "Vitamin K" on the Birth Plan is important since those actions happen right after the birth. Unless a baby is taken to a nursery, bottles are a moot point - and even then, unless there is a medical reason (in most cases), bottles aren't an issue.
If, however, you are in an area where bottles are still routinely given babies, then adding this to your Birth Plan might be necessary.
- Nursery visits - Unless your child is ill, s/he will be with you. In remote places around the country, there still might be times when the baby is required to be in the Nursery, but that is generally only right after the birth. Dads/Partners are always welcome in Newborn Nurseries. However, it isn't uncommon to not permit parents in the NICU or Nursery during Report (when the shift changing nurses discuss the cases) for privacy's sake.
- Stating you want your partner to sleep with you in the hospital - Partners are typically welcome to spend the night, almost always when mom is in a private room, but even sometimes when there are two women to a room. Just ask! Some hospitals provide cots, but recliners are more standard fare.
- Requesting demand feeding - I haven't seen a hospital schedule feedings in at least a dozen years. If you happen to have the unique hospital that does, ignore their advice and feed your baby whenever you want to.
- 24 hour rooming-in - Just keep your baby with you. This request came about when hospitals used to take the babies back to the nursery for the night, bringing them back out every four hours for a feeding. As far as I know, this just doesn't happen anymore, but you could find yourself in the unique hospital that does. Again, just keep your baby with you.
- (Not wanting) Circumcision - Once upon a time, they used to come and get the baby to go back to the nursery and they'd bring back your circumcised boy; this is how my son Tristan was circumcised. Today, there has to be consent. If you don't want your son circumcised, don't give consent. When the pediatrician comes to visit, if you feel it's important, remind him/her you aren't circumcising.
- Asking that sibling be able to visit - They always can (unless they are ill); no need to even mention this. Back in the olden days, siblings only got to view the baby through the Newborn Nursery window. That hasn't been done in eons.
- Early discharge - If you want to go home before the time they want you to go home, talk to your doctor and also the baby's doctor. Almost always, women can go before the baby, but you can negotiate if everyone is healthy. You always have the option of signing out Against Medical Advice, but be judicious in doing so. I've been greeted by the police when a client of mine signed out AMA and we had just returned to their home. Not pleasant. However, you weigh the risks and benefits and do what works for your family.
I know there are going to be many other items women might want to put on their birth plans, but, once again, I ask that you be very careful what you choose to put on there.
Birth plans are a communication device, so keeping communication open is vital. While it's tempting to use them to direct your care, I encourage using them as a vehicle for discussion. You'll get many more of your wishes/needs/desires fulfilled.