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What Happened to...? (Follow-up to Birth Plans)

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.


<end list>


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.



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Reader Comments (27)

One thing that I don't see mentioned a whole lot is using nipple stim in lieu of Pitocin. It is so much easier to deal with than Pitocin contractions which can be overwhelming. At least with nipple stim, you can back off a bit to catch your breath. I was able to successfully avoid Pitocin altogether by doing nipple stim with 2 of my hospital births. The first OB kind of rolled his eyes, but when he saw that I went from 1 to 7 cm in an hour, I think that settled it for him. The 2nd OB actually encouraged me to as my labor was stalling a bit.

November 3, 2008 | Unregistered Commenterhomejewel

I agree with about 90% of these. I think it was you that recommended awhile back that you shouldn't have anything on the birth plan that you can control yourselves. I love that. So that would include low lights, wearing your own clothes etc.

Two things I'd change though. The first is that I WOULD make a point of saying no students/residents. At my large urban L and D, if you are a doc patient (as opposed to a midwife patient), the resident automatically sees you, does the h and p, and manages your care pretty autonomously. With a medical student, they usually ask, but since a resident is technically an md, I don't think they have to do that. And while some residents are fantastic, the majority are still learning. Almost universally, our nurses who birth at our hospital request 'no residents'.

The second big difference is that I would recommend an intrathecal vs an epidural to maintain freedom of movement. The intrathecals are what most people would consider the "walking epidural" and the reason so few are done at my hospital is because they wear off and have to be rebolused after a 3-5 hour period and it's much more labor intensive for anesthesia. Also, as a nurse, I find that it's very hard to help a woman learn to recope with labor (especially with transition or 2nd stage) if she's had an intrathecal or epidural and it's worn off, so mostly we recommend it to multips or primes in very late labor.

Our hospital has started giving out their own birth plans, which I both like and dislike. I think it's good because it helps families make some of the decisions prior to arrival, but it's also obviously only geared at things we're willing to compromise on, which is pretty conservative overall.

November 3, 2008 | Unregistered Commentercileag

At the hospital I was at, they had rooming in and feeding on demand, but they also had a rule that breastfed babies must be fed every three hours, at a minimum. I was unable to meet this in the first 12 hours because my son was one of those babies that was pretty sleepy after birth and not too interested in feeding. Whenever he was awake, I was doing skin-to-skin contact and offering the breast, and he was nuzzling but didn't seem to think actually opening his mouth was very important. The overnight nurse checked with her supervisor, the supervisor asked "Does the baby seem allright?", to which the answer was yes, and I bought myself some time to get the whole thing figured out. Which I did. But in the morning, I tried to nurse, he was too sleepy, my breakfast came, I set him down to eat, at which point 3 hours and 10 minutes had elapsed since the last nursing and a very imperious nurse whisked him away for a heel stick for blood sugar levels while shooting me daggers with her eyes like I was trying to starve my child. She seemed almost sorry that he was fine when she brought him back.

Any notion of how common rules like that are? Do they make any sense in the first 24 hours? How can you speak to a by-the-rules nurse and get her to use some common sense? (By common sense, I mean, let mom finish her breakfast and try again and actually look at the baby in question to see if he seems okay or not okay before poking the baby with sharp things.)

(FWIW, my son turned into one of those nursing machines that seemed to be contantly at the breast and was practically off the growth charts, and I never had significant issues with breastfeeding, other than pain the first 10 days or so.)

November 3, 2008 | Unregistered Commenterchingona

I work in a major teaching hospital. The majority of our attendings are graduates of our residency program, as well as "clinical instructors" (i.e., if they feel like "teaching" during a delivery they will, but what it seems to mostly boil down to is "This is what I want you to do for my patient"). At any rate, when a patient of theirs is admitted to the unit, they usually are going to want the resident to do an H&P, including at least the first, and often subsequent vaginal exams, and write orders. They will also often request them to break water...so a woman will almost always see a resident at least once during her stay. Some attendings will work directly with the nurses...this is refreshing...I like communicating with them one on one, and not through another...less to be lost in "translation"; but these docs are few and far between in the larger teaching hospitals. A woman can still always request not to have a student present during her care, and that will be honored.

When I first started working in L&D, I was surprised that pitocin was run routinely after each birth. I really don't see much difference in the amount of bleeding it prevents from a woman having a homebirth where it isn't going to be used, and she is breasfeeding from the start; but it's just accepted practice, and I can see how it might just not be one of the "battles" a woman might want to pick; but if she wants to avoid it, and her bleeding is normal, I think it's OK to request...except then you may have to remind the doc to "go easy" when it comes to delivering the placenta...to take his or her time (probably more than they are used to waiting), and to use less, if any traction on the cord...both in an effort to prevent unecessary bleeding. I can understand not wanting all that extra fluid as well, particularly if the mother has a lot of swelling, especially perineal or labial swelling...one-two extra liters of fluid, especially a vasodilating one like pitocin might just make matters worse.

Finally, a lot of nurseries will not allow fathers or other family members in, in order to prevent violating HIPPA privacy rights in relation to the babies of other families in the nursery...I know ours won't. Of course, you'd think this could be helped by covering identifying in formation on the babies cribs...but from what I hear, when they did allow family members into triage, some folks would be so fascinated by other babies that I guess there was concern about that. Go figure.

I do like your work on educating women and their families about birth plans though Barb. It really gets them to think about what they want, and what they are willing to compromise on (because, unfortunately, there will usually be compromises to be made in the hospital)...and a well-written birth plan can go a long way to helping those nurses and others who like to roll their eyes at "Birthplanners" become more respectful of their patients.



November 3, 2008 | Unregistered CommenterRedRn

This was interesting. I can see not having these things on the birth plan, but it does seem to me as if they should be discussed. You said a few times that "hospitals don't do that any more"; but I've read a few recent birth stories from either moms or L&D nurses in which some of these things did happen, so, yes, there are occasional hospitals that are stuck in the dark ages (I think my 2 closest hospitals are like that). How is a pregnant woman supposed to know what is routine at her planned place of birth unless she discusses it with her doctor and hospital? Of course, this sort of discussion should take place much prior to labor, so that the mom can best know what to expect, what she may be able to get the hospital to compromise on, and what is routine (so she knows what to look for if she wants to avoid the nurses just following routine).

November 3, 2008 | Unregistered CommenterKathy

Just a question.. but what WOULD be considered fitting for a birth plan, then? In my state (Kentucky) we are 50th (nationally!) in women's care and I've found as a doula that nearly all of these items you have dismissed are still VERY relevant in hospitals here.

Not trying to be inflammatory, just reminding you that you have readers beyond your locale...

Of course, around here *I'm* the backwards one for Homebirthing mine! :-)

November 3, 2008 | Unregistered Commenterelysse

Just wanting to thank you for your advice from several days ago. I found some contacts and am looking into things as best I can.

Also, I actually do have to put some of those things on my birth plan, if they even do those here, they still do things like shaving and enemas on a regular basis. mexico city is an odd place in terms of its development.

November 3, 2008 | Unregistered Commentersara (from mexico)

I put the Updated Birth Plan up about a week ago... scroll down and you will find it.

To everyone who has these items at your hospitals, decide what you want on your Birth Plan... what is really important to you... and then add it. There is no way I could possibly cover every nuance of the world when it comes to protocols and standards of care, but I have attended births in 3 areas of the US in the last 5 years, so that is where I am writing from.

I really appreciate the input from the nurses... you know better than anyone what is happening - and how to avoid it. Your words are priceless.

November 3, 2008 | Registered CommenterNavelgazing Midwife

A lot of these things presume that the woman in labor will be completely aware of what is going on around her and able to speak up for herself, or even physically close her legs or do other things to protect herself or her baby. It presumes that her support people will be on high alert, as will she, and that each of them will be able to act in a split seconds time. It also presumes that the nurses and doctors or midwives who she employs will listen to whatever she says and not go ahead and do it anyway. It means that the birthing woman and her partner will have to have pretty strong personalities, and not worry about bucking the system. It means that they will have to be very knowledgeable about birth, or else they would be inclined to do whatever the medical staff tells them to. It means that they wont be vulnerable to any scare tactics, manipulations, or coercions.

Maybe it seems obvious that a woman who doesn't want a vaginal exam should just keep her legs closed, but that is just not what will happen in most cases. Most women are very conditioned to do whatever the doctor, who they see as an authority figure, tells them to do. Also, it's not that hard for them to sneak in and start an exam, and pry the legs open a bit if they start to close in on them. And you can't just breastfeed your baby in the first hour if your baby is across the room in a warmer. It's not as if you can just get up and walk over and pick him up. Or maybe that is physically possible (for some women, certainly wasn't for me), but most women would be stopped before they even got out of the bed. You're really vulnerable to being powerless in these situations and you rely on the compassion and expertise of the people around you. Perhaps this stuff doesn't belong on a birth plan, but it's also not as easy as you make it sound to ensure that it is done in the moment. It requires a lot of cooperation and mutual respect from everyone present. Sadly, that just doesn't often happen.

November 3, 2008 | Unregistered CommenterJennifer (mama blogess)


You know I know what you say is true.

I think part of the gist of why I write this is for people to pick and choose just what is most important to them.

A woman can write 14 pages of NO VAGINAL EXAMS UNLESS MEDICALLY NEEDED but if the hospital wants to do them, they are going to be done.

She HAS to have her wits about her, or have someone there who does, in order to get the wants she wants and needs. If her baby is across the room, she needs to tell them, "Bring me my baby" because having "I want to nurse immediately after the birth" on a piece of paper isn't going to make a whit of difference if the staff says, "The baby is having some trouble breathing... we need to observe her for a few minutes" even if all they are doing is their assessments.

In the original Revised Birth Plan, a commenter said, "I really don't belong in hospitals" (during her births)... and if women get irked about what not to put on the Birth Plan because they think that writing everything down is some kind of guarantee that it will happen, she is misled and incorrect; she's in the hospital... they "win" on all fronts unless mom advocates HERSELF for her body and her baby's... including signing AMA all over the place if need be.

I wholeheartedly want women to be able to have great births and part of why I wrote these treatises is specifically so women can manipulate (if you will) the System in their favor. But women are not going to get a homebirth out of their hospital experience. They just aren't.

November 3, 2008 | Registered CommenterNavelgazing Midwife

Gotta say: I have seen many a membrane ruptured sans amni-hook...

November 3, 2008 | Unregistered CommenterAnon

Well, of course... again, if you keep your legs closed....

November 3, 2008 | Registered CommenterNavelgazing Midwife

you may have to remind the doc to "go easy" when it comes to delivering the placenta...to take his or her time (probably more than they are used to waiting), and to use less, if any traction on the cord.


This scares the shit out of me - a uterine inversion/retained placenta/pph waiting to happen. Physiological Third Stage is (at least in my world) placenta born by maternal effort and pretty much hands off (NO traction), after spontaneous separation, cord left alone while pulsating and ideally until delivery of the placenta (placenta side of cord left unclamped if cord has to be cut). Anything else is mixed management, with various dangers. While there are some (old school) midwives who will 'help' the placenta out if it has definitely but definitely separated, anyone who has to be reminded to "go easy" should not be allowed near a woman having a physiological third stage. Yes, of course, she is likely to bleed more if she has a physiological third stage with mixed management. If her care providers can't provide a safe physiological third stage, then she would be better to know that and choose active management from the off.

November 4, 2008 | Unregistered CommenterYehudit

This makes me love my little country hospital all the more- we have LDRP rooms, no nursery at all (NICU, of course, but no standard nursery), jacuzzis in every room, all private rooms and one room with a birthing tub. I cannot wait to get pregnant again so I can have my waterbirth!

One quick question- why on earth would their be police involved when you check out AMA? I honestly have never heard of that!

This has been a most interesting series of posts! Thanks! Jen

November 4, 2008 | Unregistered CommenterJen B

Hmmm... I am one to lift the placenta out of the vagina once the uterus has let go of it. For a variety of reasons... 1) too much can hide behind the placenta 2) women generally do not want to change positions to deliver the placenta in an upright position 3) it's just easier to get 3rd stage over with for everyone, including mom. 4) a placenta that sits in the vagina can cause the mom pain (in the back) and her attention is diverted from the baby. Why should she keep hurting?

I don't consider that "managed" at all.

November 4, 2008 | Unregistered CommenterNavelgazing Midwife

The client signed out Against Medical Advice... the police were called to check on the safety of the mother and baby and to see if the baby was in jeopardy in their care. Not only did the police show up (and left after I showed them my midwifery license), but Child Protective Services was also called in and the family investigated for their decision.

They were, of course, exonerated. Traumatized, but not guilty.

November 4, 2008 | Registered CommenterNavelgazing Midwife

Oh, my goodness. I never thought of that. How awful! Was the CPS caseworker a jerk about it, or understanding? I guess it would depend on how sympathetic to homebirth and midwives he/she was. I'm glad it turned out okay. Jen B

November 5, 2008 | Unregistered CommenterJen B

I agree with you about omitting mention of enemas, shaving, glasses/contacts, catheterization, and a private postpartum room. I have a doula client who included all these items in the original draft of her birth plan, and I advised her to take them out.

I also agree with you about not mentioning a specific medication for pain relief. After all, most women are neither doctors nor pharmacists and have limited knowledge of side effects, drug interactions, etc. I think it's ok to write that you'd prefer a narcotic over an epidural/spinal (or vice-versa), though.

I disagree about omitting mention of AROM, which is still common practice in my area (Baltimore, MD/Washington, DC). I also disagree about omitting mention of wearing one's own clothes, dimming the lights, and playing music. If nothing else, it can be good for a woman's peace of mind to have cleared these things with her care provider in advance. (Women should always discuss their birth plans with their care providers BEFORE labor begins!)

I completely agree about not specifying fetoscope vs. Doppler. Talk about telling the care provider how to do her/his job!

I disagree about omitting mention of Pitocin augmentation. I have heard several stories in which women have been given Pitocin without their knowledge or consent. I see no reason why a woman shouldn't mention that she'd like to try "natural" methods first.

I completely disagree about third stage Pitocin. Every woman should have the choice of active management or expectant management. Including her preference on her birth plan makes it more likely that she'll discuss it with her care provider before the birth.

November 6, 2008 | Unregistered CommenterJenni

It has been my experience that hospital staff feel they can do anything they like to a woman. Keeping your legs crossed?? I have seen women climbing up the bed screaming during an exam that she refused. A midwife in the UK made the newspaper when she was accused of the same thing - it's a firing offense there.

I personally think that talking over a birth plan with your doctor is a good idea, to see how he/she reacts, but I don't think it's much use in the hospital. I think the response from hospital staff is much better if, when the nursing staff asks if you have any special requests, you answer in general, saying you'd like a natural birth and you want to breastfeed right away. A quiet, firm, no is the best way to decline something. Don't argue, just quietly say "no".

A doula is a huge help because they are comfortable in the hospital, can be helpful to the nurses and get on their good side. You want everyone to be on the same team. They do cut the cord pronto here, I have rarely seen anyone other than the doctor do it. I suggest to parents that they say they want a photo before the cord is cut, to delay this, then dad can ask if he can do it. Personally, I also feel quite free to walk over and bring the baby to mom from the warmer if all is well, because often they just "forget" the baby is in there and do their charting. I tell the nurse "I'm just going to give the baby to mom if you don't need him/her right now."

We have also had issues with choice of caregiver. Women are told that they may not decline resident care, because this is how the hospitals are run. This is a true disservice to the women, because I have seen residents that cannot identify the position of the baby's head OR can't even tell if they are feeling a head or a butt. This is VERY hard to believe, but I have seen it.

I think the midwest is behind the times.

November 6, 2008 | Unregistered CommenterMidwife in Wisconsin

I'm glad that you have this site, and it is very wonderful, but some of the things you discussed in what not to put in your birth plan are just not reasonable in the world of industrial medicine. I wish they were.

When I had my first daughter six years ago, I brought my birth plan in and was told that most of the things I asked for would not be available to me by a man with his patronizing hand on my knee. I fired him and got a nurse-midwife (lay midwives are not legal in Alabama). She agreed to most of my birth plan and so did the nurses, but there are still some things that you discuss here that I would not have wanted but were done to me because I didn't have them in my birth plan. For one thing, I was given a catheter even though I was able to go to the bathroom on my own and had been going every hour since arriving in the hospital once I started pushing. I hadn't been allowed to eat or drink, and I ended up with a bladder infection and a very high fever that no one would do anything about because of the catheter and dehydration. And since I didn't have good health insurance, I had to get rid of the infection on my own because no one at the hospital wanted to admit that their actions had led to the problem. They even released me from the hospital with a fever of 102.

As far as asking what the hospital has in birthing, I think this is a good idea. The hospital I went to had just renovated their birthing rooms, so they had birthing bars that could be lowered from the ceiling and birthing balls (which I used to try to get my water to break once I'd been fully dialated and effaced for two hours with no other progress). They had a few other things, but I didn't use them and don't remember.

It's so easy to give away your authority when you're giving birth, so I think that it helps many women to include these sort of things and discuss it with the care provider before they are ever administered in the hospital. These issues aren't quite as important in a home birth.

I haven't even touched the pitocin issues you addressed. I'd just recommend you read Ina May's Guide to Childbirth by Ina May Gaskin on her research into pitocin. I know that it can do some good, but it can do a lot bad, and I experienced the bad first hand because I wasn't informed about it.

November 14, 2008 | Unregistered CommenterDebra McVay

They took my glasses for my Cesarean.

It's hard to "keep your legs together" when you're on your back spreadeagle in stirrups.

At our hospital, dads stand on the other side of a wall watching babies get their newborn exams though a window. I had no idea they weren't actually IN the nursery until I went to pre-register with my second pregnancy and saw two dads watchnig their just-born babies, still naked and goopy, through a window getting prodded and poked.

I had nurses flipping on the lights in my room and marching in demanding that I feed my baby every four hours throughout the two nights I spent there.

But other than that, I think everything else you said is great.

November 15, 2008 | Unregistered CommenterJill

New reader here, and grateful that sites like this exist. Thanks for what you're doing here.

'm curious about the part where you said members of your birth team need to hear the heartbeat, INCLUDING THE MOM. Respectfully, it seems to me that (especially in the hospital setting) that could very well end up becoming just another scare tactic. You know, the old "your baby could DIE!" justification for doing anything they want to. Plus, it might make a woman feel like she isn't competent within herself, might take away some of her power and authority to labor and birth, if the attitude is that she "needs" to hear the heartbeat. That's in addition to how distracting the monitor can be for everybody. Just food for thought.

Nurses--does it ever help to have some of this stuff included in a birth plan simply so it's not completely forgotten that the mother ever mentioned it? Like maybe if you include that you don't want Pitocin in the third stage, and then you say it again when you began pushing, does that ever help increase the chance that you're heard or that your request is remembered? You know what I mean?

Re: circ, On a personal note, for my first birth I had a postpartum requests/considerations plan including a statement that we were not going to circumcise, and we still had to wait an entire extra day in the hospital before release, because the nurses thought we were waiting on the circ guy to come circ our baby...They never asked us or told us this, but it cost us a whole day. Very frustrating. Don't know what conclusion to draw from that, except that our requests weren't really paid attention to at all. =(

I think your insights into the whole birth plan issue are great. My birth preferences sheet was very similar to what you do suggest! =) Thanks for sharing your wisdom. Maybe women should start using these internet birth plans as a place to start talking about it all with their care provider in a prenatal appointment so they can then hone it down to what's really a concern for them in their particular situation and put THAT in their plan?

December 3, 2008 | Unregistered CommenterSusanB

Thanks for the explanation following the birth plan. I have to agree with others sentiments though. If you want a natural birth, you really need a home birth. I had 2 hospital births for overdue induction and obstetric cholestasis induction, sadly canceling my home birth plans. I did finally meet low risk with my 3rd and had my home birth eventually.

Just fyi, in 2 different hospitals in the Toronto (Canada) area, I've had staff receptive to natural childbirth who attempted to aid my efforts. My 1st birth the nurse took one look at my uninformed birth plan (I really hadn't researched.) and recommended I use the tub and gave my husband instructions on how to help me. The next shift came on I sounded pathetic after 24 hours (Long shift?!) of pitocin, no sleep and my focus was lost. The next nurse walked in, took a moment to read my birth plan and helped me calm down, regroup and focus. I gave birth vaginally in 2 pushes within 5 hours of her coming in. They put baby on my chest and waited for the placenta to come out. They then left and came back later to check her out and put her on my breast. I'm glad the nurses took the time to read my plan and the Dr on call gave me time and space. No pressure.

I had my Midwife for my second and the Dr and Nurses were wonderful even before my Midwife arrived. They respected my wishes (no iv, cervidil, determine bishop score, AROM if station low enough) and prepared a bath for me. I felt supported and confident that they wouldn't steam roller me.

My 3rd, we had to work with an ob/gyn when we were determining if I had OC again. Another Dr out of another hospital. I sought out a second opinion (which differed). After much discussion, even though we disagreed, she was respectful of my decision and signed off my paperwork after we discussed risk/benefit.

In my experience there are respectful hospitals nurse's/dr's and they are so valuable! They made all 3 of my birth experiences wonderful memories that I wouldn't want to change. Even when my body wasn't co-operating, I didn't walk away feeling out of control and vulnerable after the birth. I felt empowered and that I had been given a fair shake by my health care providers. Just thought I would share so that you know how much of a difference simply caring about a patients wishes can make to the experience.

December 6, 2008 | Unregistered CommenterEmily

Random commenting on an old post, but ...

"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."

IME, this is not true. At least at the hospitals around here. With my first, I had a stereotypical hospital birth with pitocin and an epidural. As soon as the epidural was in, catheter. As soon as I started pushing, catheter out. As soon as the baby was born, catheter BACK IN. I didn't want it, told them as much, but my legs were half-numb from the epidural and they did it anyway. Ignored my screaming, crying and pain. When I got to my room, I asked for it to be removed IMMEDIATELY. No dice. Three hours later, they came in and pulled it out. Then threatened that if I didn't pee within half an hour, they'd put it back in ... But they wouldn't give me anything to drink, either.

Out of all of my friends and family members that have babies (and there are a lot of us) and delivered at the same hospitals, this is normal for a medicated birth. I had a natural hospital delivery with my 2nd and avoided the catheter - but was still threatened in my post partum room with one, if I didn't pee within the hour.

May 21, 2010 | Unregistered CommenterKatie

When you have an epidural, there is no choice... it is part of what you are getting when you get one.

When someone is wanting a natural birth, probably the major reason one writes a birth plan in the first place, a catheter anything a woman would routinely get.

May 21, 2010 | Registered CommenterNavelgazing Midwife

I have just read your article on birth rape, and then I read this post on birth plans...when you read the two together as I just have, it seems like a lot might have changed in a few years?
As a mother wanting to achieve a spontaneous and physiological birth in a hospital setting, I believe it was extremely important for me to be explicit about not giving permission to have access to my veins or cervix as per protocol. My birth plan also stated that I did not consent to the cord being touched or cut unless at my request. The birth plan stated I would be having a physiological third stage.

I don't know many other women who have given birth, but like me, those who did experience active management of the third stage describe it as painful, interferring with being able to hold and observe their baby immediately after birth, and resulting in retained placenta and post partum bleeding for 10-12 weeks as 'normal'. We might have had a natural and drug free labour and birth, but then hospital policy resulted in immediate intervention and interference with natural hormones, most often with us uninformed about what is happening and without having given consent.

April 17, 2011 | Unregistered CommenterKate

99.9% of this is spot on. When I wrote my birth plan for my second daughter, who was born in Sept. 2010, I wrote everything down that I could, mostly for my benefit and my husbands. I gave birth in a military hospital where I had never met my attending OB (they only had midwives there from 6am-6pm), they had a shit ton of rules (constant fetal monitoring, mandatory IV, etc, etc.) and I wanted to have the jump on them by firstly, making sure that they knew that I knew the rules of the hospital and secondly, making sure they knew that I didn't want what they had to offer.
I was in full blown labor when I checked into L&D, and had a precipitous birth, with my daughter born in the triage room. I think that the only reason I got the better part of my birth plan was because of that and that alone. I think if I was to give birth again in a civilian hospital, I would definitely keep a lot of that stuff off of my birth plan. But the way military hospitals are regulated, I felt it was necessary.

April 22, 2011 | Unregistered Commentermrs. obie

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