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(Re-post) You Buy the Hospital Ticket...

...You go for the Hospital Ride

(I originally wrote this in mid-2006. It's just as relevant today.)

Once upon a time, doulas were in the birthing arena to help women achieve the births of their dreams. I distinctly recall telling women I would be a go-between for them between the medical staff and themselves, the laboring couples. At doula trainings and gatherings, I know I heard doulas teaching each other how to be manipulative with the staff, yet soft-spoken and seeming demure and obsequious.

Doulas had code words to use that meant "Time out! Ask the medical staff to leave so you can talk alone (and by alone, I meant with me, too!) before deciding yay or nay." Doulas right in front of my face (was that a mirror I saw?) - and the doctors - said things like, "Remember when we talked about your birth plan last week and you said no matter what, you didn't want an epidural?" or "Do you want me to remind you of the risks of that position before they put your legs in the stirrups?" or "Doctor, doesn't pitocin rupture uteruses?"

It wasn't a decade before the role of the doula began shifting. Once DONA (Doulas of North America, now DONA International) jumped in and incorporated the concept of a doula into a profession, we'd already heard about "renegade" doulas that commandeered labor rooms and antagonized the staff so dramatically, doulas were threatened with expulsion from labor and delivery rooms around the country. Therefore, DONA grabbed the opportunity to squelch such power-tripping by insisting that doulas not speak on behalf of the client or her family.

Doulas were not permitted to do anything that smacked of medical or midwifery care - no fetal heart tones, vaginal exams or blood pressure checks (something many doulas had been doing for years). DONA snapped the profession's back into sharp attention, kept her hands stiff at her sides and instructed for her (the multitude of doulas) to keep her eyes straight ahead and not look around.

By doing this, DONA saved the role of a doula, if not the very word itself. Doulas began changing their spiels to encompass words such as "supportive," "reminder," and "belief in you" - removing forever, at last in any literature or in public venues, the implication of advocate or director. Accepting that the changes were the only ones that could be made, women were suddenly back in control of their own birthing destinies.

Or were they?

Back to the beginning once again, the issues that brought doula-dom into existence in the first place - archaic birthing practices, patriarchal attitudes towards laboring women and unsubstantiated reasons for a plethora of rules and regulations - remained. What's an enlightened woman to do?

Why, create a birth plan, of course.

Birth plans, in existence long before there were doulas (either in name or in idea), over time, have become more and more explicit and restrictive. I have easily read over 3000 birth plans and can tell you the grand majority of them are the same in 98% of their content.

• No episiotomy
• Allowed to move around in labor
• Allowed to eat and drink
• No formula or pacifiers
• Dad to stay with me the entire time
• No enema (yes, I still see this on birth plans)
• No shaving (unless you live in the backwoods of medical care, this is so absurd to put on a birth plan it is laughable - mostly laughable to those you are speaking to, the nurses in labor & delivery)

... and the litany goes on and on.

Interestingly, there are dozens of websites and hundreds of baby-oriented books that make a birth plan into a formula for folks to fill in the blanks. How creative of them! It is extremely frustrating getting a cookie-cutter birth plan - as mentioned above, so many are exactly alike, why does anyone write one at all? I'm all for using one of the pre-planning birth plans as a template so your own needs and desires can come out of hiding. Sure, if you don't know what your options are, how will you know what to choose? But, my point is, once you have chosen, dump the look-a-like and create your own plan... with your own words... your own personality.

And make the thing SHORT. I mean short short. A 3x5 card on one side. Double-spaced.

(I can hear the ruckus even now. "But, you're just saying you don't like them because it limits you!" or "You would say that, you medwife person. You don't want anything individual interfering with your care." Bull. I'm telling it like it is to save your butts in labor and delivery! I'm trying to help you understand how tired they are seeing birth plans, how they never read them [unless you get some alien nurse who happens to be in midwifery school] and how it is a waste of your energy to write the same same same same same same same same thing as every other person that comes onto their floor. Dispense with the extraneous and write what matters!)

• I will ask for pain medication. PLEASE DO NOT OFFER IT TO ME! (Make a pretty sign and tape it to the outside of the door. Make a couple in case it disappears.)

• Please, keep lights low unless it is crucial to my life or that of my child's. (Another great door sign.)

• Please KNOCK before entering (Door again.)

• Risks, benefits, consequences of refusal and alternatives are to be discussed before EVERY procedure on myself and my baby. (I learned that "informed consent" does not legally mean discussing risks and benefits. Watch that blanket form you sign upon check-in!!! It allows them to say they obtained informed consent.)

It’s important to remember you attract more flies with honey than with vinegar; be kind, but be direct.

So, looking at that list, doesn’t that set the stage for retaining autonomy and letting the providers know your wishes? It’s also important to be open to listening to what they have to say. They absolutely might have something valid to share. It's been known to happen. If the above points aren’t your hot button issues, make your own points - but make them succinctly.

I believe the main reason for a birth plan is to facilitate communication between the parents... allowing them to see how each other feels about such important things like pain medication, circumcision and even vaccinations. Birth plans are great for everyone talking to each other. If it worked with the doctors and nurses, all the better, but it usually makes for some pretty antagonistic and stiff discussions in a prenatal visit and a bunch of rolling eyes in labor.

Once again, if you buy the hospital ticket, you go for the hospital ride.

If you buy a house and stand inside your palatial mansion saying to the builder, “But, I wanted a log cabin!” - the builder might wonder what the heck you were thinking going to a master-palatial-home-builder instead of a log cabin specialist.

If you want soy milk, don't milk a cow.

Why... why oh why... if you want a "home-like birth inside the hospital" aren't you considering a home or birth center birth? If you want control, why go where egotistical birth is the norm? If you want autonomy, why go where lawsuits and defensive medicine are the rule?

Ohhhhhh, because it's safer? Is that what you think? Oh!! I see. Well, if you believe hospital birth is safer and that's why you want to be there, then BE THERE - with all it has to offer... in all its guises... in all its paranoid glory. Why would you try to manipulate a hospital's/doctor's/nurse's actions any more than you would try to manipulate the car mechanic's? If they aren't good enough for you, find another! (This is, of course, where choice is an option. I don't live in a dry well.) You're hiring someone to do the best they know how to do. LET THEM DO IT.

It is so funny hearing me say this. I really did used to be the doula who could get it all for her client - I am a great doula and monitrice - but it is more frustrating than words can say when a client says things like, "No drape between me and the incision during my cesarean because I want to watch." How the heck are you going to see your pubic area? You even can't see it when you are standing upright and leaning over! The curtain isn't just because you might not want to see the surgery (if you could remotely see down that far in the first place), but it is also in case you projectile vomit into your incision.

Note: Hospital rules are not in place to annoy you. Some are really important to the life and health of you and your child. Do people forget that? (Yes.)

I do understand that a number of women don't have a choice about where they deliver... there aren't midwives, the doctors are all the same, hospitals won't let them do VBACs... I do understand. However, in that case, I have found that going along for the ride makes for a much better experience instead of fighting the whole way. I don't want that to be a rape or abuse analogy at all, but one of "if that's what I have to have, then let me be gentle about it and see how good the experience can be."

I have seen women who go in without pre-conceived plans have far better birth experiences, with less tension and worry, than women with elaborate desires and wishes written down or vocalized. Women tend to be treated more kindly if they seem to be on the same page as the nurses' and doctors' agendas. This might be wrong or unfair to some, but is the truth.

So, how would I counsel someone who medically needed to be in the hospital? I would encourage remaining open to what the nurses and doctors had to offer. If they offer something the woman doesn't want, say, "No thank you." Simple. Concise.

I’ve been to births where my clients had no scripted birth plans and who had beautiful hospital births - ones where the nurses were respectful and we were left alone a great deal of the time to talk and laugh and spend time with each other.

My concern, and the reason for writing this piece, is in unrealistic expectations - across the board... with the client, her family, the doula, the childbirth educator... even midwives. Sure, docs and nurses also have unrealistic expectations, of another sort; many (most?) believe every woman has to have an epidural to have a happy birth experience, or that no one should have a VBAC. Those untruths are as incorrect as the ones that say if a woman has a birth plan she'll have a better birth.

I simply do not see that as realistic - or even close to happening in real life world. Far more often, I watch as hard worked-for plans fall away and women feel more and more guilty and sad for the draining away of their desires. What if we worked on changing the reality of those desires? What if doulas and birth assistants and childbirth educators bluntly laid things on the line and said, "Just because your doctor agreed in the office doesn't mean it's going to happen in real time. You might never see your doctor again. Your doctor, after listening to your birth plan in the office, might know he will have to convince you once you are in labor that his/her way is the way to go.” It is almost impossible to tell what someone will do (midwives included) until after the fact.

Doctors often say there is no such thing as normal birth except in retrospect. The same can be said for a provider doing what they say they will do.

Maybe if we (doulas, childbirth educators, midwives, nurses, doctors, etc.) all got real with women, they might make different choices altogether. Maybe they would get really cranky and start demanding more humane births instead of the lip service paid, touting million-dollar renovations in lieu of hiring more nurses with compassion and a gift for listening to women in labor... not just wanting to get them drugged and quiet.

I don't know what the absolute answer is, but I do know it can't keep going the way it is... everyone fake dancing that each side is listening. Really, knives are stabbing each other, scalpels cutting bellies, women medically paralyzed, drugs given to women begging for natural births - doctors and nurses working in a haze of "what will this look like in court?" and really, really believing they are doing the best thing for the health and safety of the mother and child.

Someone needs to just speak the truth. And it starts with me.

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Reader Comments (36)

Good post.

My first reaction upon reading that women should just go with the hospital birth flow was: well, how is anyone going to change anything if they just comply? But the more I think about, the more it seems that the only way things will change in the hospitals is if women just leave it in droves. Stay home and have babies, or go to a free standing birth center.

The hospital maternity system is just so completely effed up, and there is no real incentive to change it. Women are outraged by the high c-section rates and the lack of evidence based care, but 99% of them are still birthing there. Hospitals and doctors are still collecting their money. I don't think it will be until actually significant numbers of women leave the hospital system altogether that hospitals will wake up and change.

Or maybe the solution is that the hospitals don't need to change at all. Maybe hospitals should just handle the high-risk births, since that seems to be the only thing they're really good for, and women should just birth at home or at birth centers for most of the other births.

I don't know the answer. I just know that there were many, many reasons I decided to birth my one and only baby at home. Some of those reasons fell under the category of Wanting to Be at Home, but so many fell under the category of Wanting to Stay the Hell out of the Hospital - for many of the reasons you outlined in your post.

April 2, 2010 | Unregistered CommenterLiv

I'm a new childbirth educator through CAPPA. However I took a Bradley course with my first son in 2006. I wish that my instructor had told me to put my birth plan on an index card (then it might have had a CHANCE at getting read after the emergent transfer from the birth center to the hospital). My main point on the plan was keeping the baby with me after birth. But my page-long, typed-in-tiny font plan (and yes it said I didn't want to be shaved) had so much blah blah blah on it I don't think a nurse could have noticed... I wanted my baby with me. And they never got the note. It was lost in the blah blah blahs...

I hope to help my students avoid that - index cards at most. :)
Sharing on facebook......

April 2, 2010 | Unregistered CommenterAnisa

I got a first the other day. After 12 years in L&D nursing, a birth plan that had been notarized. Really. Like by a notary public.

April 2, 2010 | Unregistered CommenterDenise

That is so odd. What did she think that was going to do? If the doc and she notarized it together, I could understand that (kinda), but just her own signature? Weird.

April 2, 2010 | Registered CommenterNavelgazing Midwife

Maybe she thought we had to follow it if it was notarized?
95% of it we did automatically at my hospital, if you like it or not! And the other 5% easily done by signing a waver.
Anyway, who knows? Probably cost her 10$ though!

April 2, 2010 | Unregistered CommenterDenise

High risk women deserve to be treated gently and with respect too. We're not just an afterthought or damaged goods. When you HAVE to be in the hospital over and over again, maybe for days or weeks at a time, it should be recognized what a hero you are for working to save your baby--not for you to be treated like a piece of luggage that's in the way, a pin cushion, or a "frequent flyer." I am typing this with swollen wrists from two rookie IV attempts in less than 24 hours. I hurt so bad and while most L&D nurses are dedicated and sweet, some can be real pieces of work, and I was tortured by one last night. I don't deserve that just because I can't have a homebirth anymore. I resent the idea that "buying the hospital ticket" (in my case it's hardly a choice) means I am entitled to be treated however is most convenient to them. I pick my battles and try to keep a sense of humor and be a good sport even when I am exhausted, terrified, and in pain. But deciding that abandoning the reform of the hospital system because women like me don't matter is profoundly insulting, and I have to call natural birth advocates out on it whenever I hear it.

April 2, 2010 | Unregistered CommenterLily

Lily, I will respond more tomorrow - don't have all the words nearby right now. But know that I *never* said women who had to be in the hospital had to lie back and be assaulted. In fact, I recommended they do exactly what you are doing... not coming in with a birth plan and picking which things are most important. I know, because I've seen it, that nurses are much less antagonistic when there is *no* birth plan and I have seen many a'woman get more (of her desires) withOUT a birth plan than with one.

I'm thinking of you tonight. I hope you're able to sleep in peace.

April 2, 2010 | Registered CommenterNavelgazing Midwife

Women themselves are driving some of the cesarean section trends by asking for inductions because they are tired of being pregnant or questioning why their scheduled induction is necessary. It's frustrating to ask a pt why they are being induced and they reply, "I don't know" and they don't care.

Women are requesting epidurals at 1 and 2cm. Are we supposed to tell them no. The Joint Commission would take issue. I can educate them and give alternatives to epidural, but some woman have decided that is all they will accept.

Too many woman are coming in w/ the expectation that an epidural will take away all sensation and they won't have to feel anything during their labor.I can't tell you how many woman beg for an cesarean section when pushing is hard or they've decided that it's too much. I've actually had to roll someone back for c-section number 2 even though she was 10cm and I could see hair!!!!

I once was very idealistic and now I only put myself out for those patients that truly want my help. Even then I'm documenting like crazy.

PS I appreciate the note card birth plan...as a doula I recognized that birth plan novels aren't read. As a nurse trying to prepare for a delivery I skim them. It's frustrating that a patient hasn't taken any time to learn what our hospital does or does not do. It's doubly frustrating when they haven't discussed w/ their doctor what their preferences are and made sure everyone was in agreement.

April 3, 2010 | Unregistered CommenterL/D nurse former doula

I remember this post. In fact - I've emailed it off to a number of my doula clients when they are trying to understand part of why I am not a big fan of birth plans. Most of my doula clients go in without a birth plan - as most of the nurses here feel that birth plan = cesarean (like if you are trying to control too much of birth, you will end up with what you least want). Of course that isn't true, but who wants to put that idea in your nurse's head? The other reason is that so much of what you can say in a birth plan you can say *with your voice*, *in the moment*, and it carries more weight for both the staff and for you. They see your strength, and you get to *feel* it. And that's really what I think my role is as a doula - holding up a mirror for women (and partners), letting them see their own strength and beauty, and letting that strength manifest in beautiful ways, in birth and beyond.

April 3, 2010 | Unregistered CommenterKristina French

As a nurse working in rural Canada, I see lots of women through the labor and birth process. Here (at the hospital I'm working in), we have a less than 1% epidural rate, because we just can't have an anesthetist at the hospital day and night. Most women do well, and find that place they need to be to deal with the pain. We still do offer pain medications, but the closest we come to pushing any medication is when we see someone who isn't coping well. The woman who won't move from the bed, the one who screams out with every contraction right from the start, and we can see she they won't progress or are even slowing their labor because they are simply so tense. Most of the time, you can see a big difference between the women who come alone and the ones who come with support. BRING SUPPORT, especially someone you trust, who can help you find a way to deal with the massive changes coursing through your body.
And to be honest we see very few birth plans, but every time we do see one, we cringe, because somehow, those seem to be the women that end up with all the interventions, right down to c-sections. We have a 6% c-section rate, it's only for emergencies, malpresentation or repeat c-sections. So seeing the cascade of interventions is something none of us want. We're generally telling people to get up and move if they want to speed up their labors. We're showing women and their friends/partners ways to give counter-pressure, how to move with the contraction etc. But the women with birth plans... all too often show up not coping well right from the start. Too many of these women want a labor to follow their design, they seem to fight the tide of labor instead of learning to relax and let it flow through them.
Also, our polices, which is what guides our care and helps to keep everyone safe, often dictate certain care measures, such as checking fetal heart rate. Most nurses (I can't speak for all, but also can't think of any this doesn't apply to at our hospital) will try and work around women's wishes in order to follow policy. For instance, we'll ask the woman to step into her room or somewhere where we can discretely check the heart rate every 15-30 mins, but the woman doesn't have to lie down for a check. We don't strap anyone down to a monitor unless we have concerns.
I think the biggest piece of advice for those who want to write a birth plan is, don't expect to control you labor. Every woman and every labor is different, and certainly choose your provider carefully, including looking at their percentages of c-sections and other interventions, but "never say never," Birth is 90% a healthy process, 10% unexpected, and sometimes you need to try something outside of your plan in order to get the best result.

April 3, 2010 | Unregistered CommenterHeather

Sorry, NGM, my frustration was aimed more at one of the comments than at your OP. I've heard a lot of women throughout the online natural birth community take a "hard line" attitude about women who "insist" on clinging to hospitals and it just really frustrates me.

I'm at home today and resting is all I am allowed to do. :P

April 4, 2010 | Unregistered CommenterLily

I would love, absolutely love, to give birth at a birth center or at home, but after a devastating appointment at a birth center I learned that my insurance won't cover an out of hospital birth (I have medicare & medicaid, I am on social security). I can barely afford to pay my rent & live, I simply don't have the money to pay for it myself.
I had pre-ecclampsia w/ my first son, and managed to make it through an induced birth where I wasn't allowed out of bed & they were threatening c-section with just a little bit of pain meds.
I had as natural of a birth with my 2nd son (13 years ago) as you can have in the hospital (especially considering it was a rather behind the times hospital in a military town), despite the nurse asking me every 3 minutes, was I Sure I didn't want some pain medication yet? Even eventually deciding on her own she would get the order from the doctor for "when I changed my mind". She also kept suggesting that I lay down, and was nervous as hell about me being in the shower (I have no idea why). When the doctor got there I was about argued out, and ended up giving birth laying on my back which I knew was the last thing I wanted. But I couldn't argue anymore. I didn't have it in me. All of my energy was needed to focus on giving birth. My then husband was useless & I had no other support. They then both (doctor & nurse) yelled at me to push when I knew my body needed a minute to adjust, and yelled at me not to push when I knew my body was ready.
I was not a difficult patient, other than insisting on no meds. I didn't yell during labor or delivery, I didn't scream or curse or say that I couldn't do it. My birth plan, the form they gave me to fill out at the birthing class I took at that hospital.. I don't think my doctor or the nurse ever read it. So I agree that birth plans don't get you what you want.

But what Do you suggest a woman do? When her only choice is to either go to a hospital, or have an unassisted home birth (which I've seriously considered, but the father isn't in the picture anymore & even I, who believes strongly that birth is a natural process my body is designed for, don't think its a good idea to do this completely alone.

In labor, it gets too hard to argue sometimes. Too hard to say the last thing I want to do is give birth laying on my back, when they've already got you there (just for a minute of course) to check your progress after transition has hit & you are shaky & a touch overwhelmed. Too hard to explain, calmly or at all, when the pain is a million times worse in that position & your body is screaming at you to move but you are surrounded by people looming over you in that bed & you are past explaining or being able to tell them to move out of your way when they are so obviously happy you are finally in the bed where you "should" be!

I absolutely believe that I wouldn't have torn had the doctor & nurse not been in my way & in my face. If I could figure out a way to have an out of hospital birth I'd be on it in a heartbeat. Birth plans aren't the way, I'll agree & I like your idea about notes on the door. But after telling us all the ways to not get the birth we want, any suggestions on how to find a way to safely give birth the way my body is designed to give birth in a hostile setting?

April 5, 2010 | Unregistered CommenterHeather R

As a doula and childbirth educator in a large Canadian city, birth in a hospital is just a conveyor belt. Some days there are so many women coming in that they just want to hurry the process along, get them moved and out of the way. Wanting a natural birth in the hospital can be a challenge, unless you labour at home as long as possible. We have midwives, and they are fantastic women, but or society of OBGYNS keeps their numbers low. They can only have 4 primary births a month (they are secondary midwives to another 4 and come only close to birth). They have a requirement (in my province) to attend both home and hospital births. This means they need hospital priviliedges and this is where they get stuck. We have just shy of 100 new midwives every year and many new midwives have nowhere to practice because there are just so few spaces available until the hospitals see the value.

I have been doing the birth plan on an index card for a while just because then at least we as a team know what is truly important for this family. Then when we are in the room, we know where we need to ask more questions and what battles are worth taking on (usually partner does this).

Thank you for that post (again). I hope that up here, we open up midwives as an option to all women who are having normal pregnancies.

April 5, 2010 | Unregistered CommenterNicole

Wow! Amazing post. I had the birth I wanted in the hospital with a doula to help guide us through. I looked into alternatives...we have no birthing center, I'd have to pay for a midwife at home out of pocket and that's just not possible for us right now. I found an OB who's more like a midwife than some of the CNM's I've heard about at birth circle. Having a midwife in the comfort of your own home doesn't promise you the birth of your dreams. I think a woman needs to educate herself and pay attention to personalities/beliefs when interviewing anyone she hires to help her when she delivers.
As for birth plans...I had one of those novellas cut and pasted from a popular website and my doula helped me make cliff notes out of it on a 3x5 card. We still joke about the length of the original, but it was helpful for her to see what I was thinking.
I'm glad I found your site and will probably spend way too much time reading other posts and neglecting my laundy, thanks! ;o)

April 5, 2010 | Unregistered CommenterMishaLee

This is interesting because my OB, hospital and doula have all recommended a birth plan, though mine is quite short and full of the boilerplate things -- basically, I want to be allowed to move around during labor and not tied to an IV or continuous monitoring. (And I'm in a hospital b/c I'm high risk). The hospital wants it b/c the things I want, though common for NCBs, are not the standard in the hospital and they want the OB to sign off before they allow them. The OB wants the plan so that the other docs in the on-call group know that we discussed these things ahead of time and she is fine with them. And the doula thought it was a good way to have a structured conversation with the OB to ensure that we are on the same page ahead of time. In my situation it seems like the writing it down part is as much about communication b/t the docs and hospital and it is about me trying to control things in advance by writing it down. Given that my OB will not be at the hospital for much of the birth even if she is on call, I'm not sure how this communication would be accomplished without the birth plan.

April 5, 2010 | Unregistered CommenterAndrea

@Andrea: Tell us what happens after the birth. I'd love to hear how the birth plan helps or doesn't help.

April 5, 2010 | Registered CommenterNavelgazing Midwife

I'm convinced It's not easy for any women in any circumstance when having a hospital birth. Including the elaborately over planed "Bradley Birth" couple who wishes are disregarded by staff, or the women who is a willing participant buying into the hospital birth experience (planed induction, planed epidural ).

I think it's as likely for either women and their partners to be treated disrespectfully by the doctor, staff, berated, hollered at and abusively touched.

April 5, 2010 | Unregistered Commenterdewi

OMG you are my hero! As a nurse I have been trying to express these feeling to others lately but haven't been able to say it as eloquently as you. I may have to start keeping handouts ;)

You're absolutely right though, if you go to the hospital you bought the ticket....go for the ride.

April 5, 2010 | Unregistered CommenterMelissa

Yes! I have given birth twice in a hospital with a midwife. Both times I was encouraged to write a birth plan, and both times I did not. Why? Did I not care what happened? No, I did my research ahead of time and found a hospital and provider who had stats and recommendations that fell into place with my ideals about birthing. I knew what their policies were and also knew what I would not want in certain situations. When my midwife asked me why I didn't write a birth plan I told her that we had already discussed all my major concerns and wishes for birth, and she had informed me about her policies and birthing procedures. I wouldn't still be seeing her if I didn't agree with her or trust her decisions. There was a chance that my midwife wouldn't be there when I gave birth (she was part of a practice) but I knew I would be willing to tell any dr or nurse no if I didn't agree, and I had a husband who would back me up. In fact, with my second child I told the nurse when I arrived what I was looking for in my nurse...she chose to switch out with another nurse! I didn't even suggest that, I just told her what I needed in terms of support and she decided that she wasn't the right person for the job. I went on to have a very successful, fun, hospital water birth!

April 5, 2010 | Unregistered CommenterDanielle

With my first, I had an excellent hospital birth, with an excellent OB. Honest to God. I found out later that my OB had apprenticed with midwives to learn more about the midwifery model of care, which probably had a lot to do with it. But even before she was present, I was in a room with the lights kept low; I came in with ctx every 3 minutes and told the nursing staff I would ask for an epidural when I was ready, and they never mentioned it again; my room had a private labor tub, a birth ball and rocking chair, loads of posters explaining positional changes. My nurse said, utterly forthrightly, that while they don't do water birth at this hospital, "we can't force you to get out of the tub if you don't want to, so. . . keep that in mind."

I could go on and on about how great it was. Every single stereotype of a hospital birth was absent. How come? Well, the fact that I live in a large city in the PNW where there is a lot of competition for maternity care, including several FSBC's in the county, probably has a lot to do with it. The women in this area have voted with their dollars and their feet, and the hospitals have learned that if they want to capture the maternity market, they have to do what WE want. I know from friends' stories that once you get outside the Major Rich Metro Area I live in, the hospital experience gets dramatically less accommodating.

So I guess my point is, ladies, please keep fighting the good fight. The decisions of women ten years ago to begin exploring childbirth outside a hospital led directly to my great in-hospital experience. By voting with your feet and your wallets, you have forced the system to change. You are making the difference, not just for those who choose a hospital birth, but for those women for whom a hospital really is the only safe place to labor and deliver. Thank you, and please don't stop. I'm doing my part by choosing a birth center birth for my current pregnancy. :-)

April 6, 2010 | Unregistered CommenterKathryn T.

I love this post. As a CBE, I always encourage couples giving birth in hospital to have a short, concise and clear birth plan and to be open to changes.

I also encourage them to put their names in bold letters on the top, and to put their birth plan on the door of their room.

I have seen all to often the RN;s in our local hospital being shuffled between rooms and they have no idea who is really who. Couples become "room 1" or #8 and they have no idea what their names are and resort to 'honey', dear, and 'sweety', or Mom and Dad, which is just so condescending if you can't even remember the name of the woman you met 5 minutes ago.

This is a bit beef of mine!

April 7, 2010 | Unregistered Commentererin

Hey there,

Thanks for this post, it is a very informative look into birth plans from the other side of things. unfortunately, i'm from Illinois, where midwife attended home births are illegal and there are very few, if any, stand-alone birth centers.. So I basically made a birth plan with my midwife that goes along with exactly what she recommends. It's mostly to make sure there's a document that I've helped make that says what I would like in case she can't be there and I get handed to another midwife, nurse, or doctor in the hospital along the way.

Anyways, I wanted to let you know that I referenced this post in a post on my own blog. Check it out at http://squirrelymama.blogspot.com/2010/04/on-birth-plans.html or check out my whole blog at http://squirrelymama.blogspot.com

April 7, 2010 | Unregistered CommenterCheryl Friedman

A large part of me encouraging my doula clients to make a birth plan comes from them not being educated about their options. Some women just don't know that they HAVE options. When they start to think about a birth plan, they start to educate themselves, and that is the whole goal. We are lucky in my town that many of the nurses (especially at one particular hospital) do read birth plans, as well as the providers and midwives. As a doula, I encourage my client and their partner to determine which items on their plan are of utmost important to them, and which they can afford to let go if necessary. It also helps me, as their doula, understand the birth experience they want, so I can do my best to help make that happen.

I agree, for the most part, that if women choose to birth in a hospital they need to understand that sometimes, they will not have the options that they want; however, I disagree that if you "buy the hospital ticket, you go for the hospital ride." If women sit back silently and let themselves become victim to the system, no change will ever occur. I guarantee that if there were legal CNMs to practice home birth here, they would be in high demand. Same with a birth center. Since the only option around here is the hospital, women need to try to stand up for what they believe in, while having the end goal in mind of a healthy mom and healthy baby.

April 9, 2010 | Unregistered CommenterJill

My mouth is hanging open after reading that post, and all I can say is kudos to you. Being a doula and childbirth educator myself, I can't tell you how much I appreciate the honesty and realism that you shed light on in that article. I appreciate your no-nonsense way of speaking and of your no-holds-barred manner. This is a site I'll keep referring to and upon which I'll enjoy seeing additional posts. Well done!

April 9, 2010 | Unregistered CommenterMichelle

I really enjoy your blog, but I feel strongly you missed the mark here. There are lots of reasons for women to have hospital births, and those who fear homebirth have just as much of a right to a safe and respectful hospital birth as those who have (real) health issues that require them to give birth in a hospital.

My husband comes from a long line of medical doctors and was concerned about home birth. I could have insisted, and thought about doing so, but for many reasons, I instead searched high and low for a provider (OB) who I felt confident in.

This doctor, Malcolm DeSouza in Washington, DC, is a true gem. Everything I wanted from my childbirth, I got -- most importantly a healthy baby. There was nothing we couldn't discuss and negotiate, including eating during labor (which was against standing orders and hospital policy). Not only did he read my birth plan, he reminded me several times to write one. You miss an opportunity to educate women here. While you're right that the birth plan is not necessarily for the OB to read DURING THE BIRTH, it is for the OB to read in the office, long before the birth, to help a mother understand how he would react to certain circumstances and what he will allow (and more importantly, support) and what he may not.

Despite an early complication (water breaking and copious bleeding) I was admitted to the hospital before the onset of labor for extremely heavy bleeding after my water broke. Because Dr. D knew how much I wanted a natural childbirth, my doctor made the rare offer of letting me go home to continue to labor there once he examined me and had a listen to baby. I was "allowed" to eat during labor, I skipped an IV, and my doctor came in early to check me instead of leaving it in the hands of an L&D nurse or OB on staff. I could write pages about the considerate care I received and the respect this doctor paid to my wishes, but I realize that might be digressing.

My point is simply this: I'd wager that most women who have hospital births DO buy a ticket and have no problem with the ride. They are not the ones who will be spearheading reform. And don't kid yourself into thinking the "droves" of women leaving hospitals for home birth will drive reform. The hospitals don't need you! There are plenty of other women to take your beds.

The educated woman who wants a natural childbirth in a hospital, knows her options, chooses a care provider carefully (if she can) and knows how to respectfully advocate for herself (and teaches her husband how to do the same), the woman who, above all else, trusts her body and is not as easily led to believe it is misbehaving, the woman who is confidant in childbirth because she understands it, and the woman who has a birthplan but also knows it inside and out, so she can recite it as needed to hospital staff, these are the women who will help make natural (normal!) childbirth more of a norm in hospitals.

Well, that and a handful of successful lawsuits for unnecessary cessareans.

Anyway, the bottom line is that all women deserve respect. And yes, SOME nurses respond better to meek, acquiescent women who know how to choose battles and don't come in with strident tones and boldfaced birthplans, but the more confident nurses run into confident women who advocate for the birth they deserve, the more nurses will understand how birth works.

I, for one, am actually kind of glad that one of the two nurses I had during labor and delivery was an "eye roller" about natural birth. I enjoyed proving her wrong at every turn. (and it was kind of fun to start responding to her pain scale questions with outlandish replies like "9 bazillion squared" and "negative 17" when she kept hounding me about the pain scale despite me asking her not to).

May 11, 2010 | Unregistered Commenterfmb

The thing is, most women do NOT have a choice in finding a birth positive care provider like you did. They are educated and know their options, but the option of a natural-birth-oriented doc is all but missing.

I've done 27 years of birth and not "some" nurses, but *most* nurses are snidely disgusted with birth plans. I've listened to nurses for over two decades as they stand at the nurse's station, groaning about a woman's birth plan, picking it apart, making fun of it and, the very common phrase, "You might as well just put a C on her forehead" repeated over and over again.

It's great that you had the wonderful birth you did, but it's good to know just how different and special it was in this obstetric climate.

May 12, 2010 | Registered CommenterNavelgazing Midwife

I'm not arguing that unsympathetic nurses are the norm. But you're making one of those A or B arguments as if those are truly a woman's only two options. Many of us are finding, no, let me rephrase, demanding!!!, a provider who treats birth with respect, even in a hospital. If every woman simply assumes that she has to endure the ride because she "bought the ticket," what room have we left women to make and demand real change? I don't question your decades of experience and, in fact, truly respect them, but sometimes those who have been doing it a long time are the least able to see the opportunties to change the way it's "always been." Anyway, I do understand that many (not all) women do not have the option to hire a better doctor, but that's not exactly what you said. You basically outlined the scenario as if it will be true for every single woman, regardless of care provider. If that's all we have to aspire to, why should any of us bother to find care providers who really ARE making a difference? And if women are told to eschew the hospital above all else, what reward is there (besides the reward of knowing you've done the right thing, which is important but doesn't keep the lights on) for care providers who respect women if women who would most benefit from those types of providers are either figuring "what the heck, I bought the ticket?" Homebirth is safe and probably a wonderful option for almost every woman. But for those who, for whatever reason, must go to the hospital, I really don't believe telling them they bought the ticket, so (in so many words) suck it up, is going to help them much. Instead, empower them to remember their environment, learn about informed consent, and learn to use it! While my labor went really well, I have dozens of friends whose labors did not. Those who managed a vaginal birth out of it, I might add, were those who were not afraid to "buck the system" and who came in prepared to get the very best out of their hospital situations. The ones who were the most vulnerable to horrible situations and interventions are the ones who didn't prepare, thought birthplans were "type A," and so on.

May 13, 2010 | Unregistered Commenterfmb

This post shed some light on creating a birth plan, so thank you for that. I am birthing in a hospital because I live in the middle of nowhere and have had zero luck in finding a midwife. I am not comfortable with UCing an hours drive from a hospital. So I get a little sad to be told that I bought the ticket, now take the ride. My options are so crappy. I deserve a respectful birth even though I will be in a hospital.

June 9, 2010 | Unregistered CommenterErin

I worked with a mother recently who had a 3 page birth plan. I told her the birth plan was more for us (her birth team) than for the hospital staff, and she insisted that couldn't be true, and that the nurses MUST read it.

Well, we get checked in and she tries to hand the nurse her birth plan. The nurse doesn't even look up from the computer and just says "I don't need to see that!." The mother sits there, dumbfounded, and repeats "but this is my birth plan!" And the nurse responds "Does it say anything on there about the baby? It does? Okay, then give it to the baby nurse.. I don't need to see it."

A few minutes later I walked out into the hall and caught two nurses bitching about the mom.

A few hours into her labor, the mother ends up firing this nurse after the nurse played the dead baby card - the nurse wanted the mom back in bed for monitoring, and the mom, in the middle of a contraction, asked for a minute. The nurse then started saying "Oh, I guess we don't care about the baby then, as long as mom is comfortable.. hrm??" Mom's mom was a nurse too, and got into a huge fight with the nurse. Minutes later, that nurse is fired.

Having said all that, do I tell clients that birth plans are useless? Nope! I insist that we work together to create a birth plan - BUT, I make sure they know that I'm probably the only person in the room who will give a crap about that birth plan. I wouldn't be able to do my job if we hadn't clarified her wishes with me far in advance though.

June 21, 2010 | Unregistered CommenterAnonymous for this one

I have a chance of being high risk like my mother was with my brothers and I... I am also a midwifery student. My mother's pelvis was tilted and fused. no natural childbirth for her, as hard as she tried with me (her oldest).
I only have one preference, and to many it's sounds horrible, especially considering my position in the birth community.
If you give me an epidural by force (like they did with my best friend... they refused to treat her unless she got one.), C-Section or no C-Section, I will not have a needle in my back, and I will sue your everloving pants off. I'd rather be put under.

July 11, 2010 | Unregistered CommenterBecca

I fully agree with your ending, saying that we should "get real" with women and tell them the truth of the situation.. and that then maybe they'll push for change. But that change isn't going to happen unless they vocalize their desires with both their doctors/midwives and the hospital. Then they need to vote with their feet/money by shopping around for and choosing a supportive provider and setting.

But what if there is no supportive provider and setting.. no midwives practicing home or birth center birth, and no in-hospital providers that are supportive of natural childbirth. Does that mean she should just accept that she has to take whatever is given to her? That seems to be what you're saying. But I disagree. The only way the providers and hospitals will ever change is if women start demanding that they do.

Now this does not mean that they should wait until the birth and then show up with an elaborate birth plan. Birth needs to be talked about from day one. A birth plan should be a tool to help a woman discover her options and then she needs to start talking about what she wants.. early and often.. with both her doctor/midwife and the hospital staff. Then the birth plan itself should become nothing but a reminder of what has already been discussed.

October 28, 2010 | Unregistered CommenterJeanine

FWIW, I would LOVE to have a homebirth or birth center birth next time. I tried the first time...no midwives/centers near me! It was over an hour drive. We didn't have reliable transportation. The second time I was attempting a VBAC, state laws prohibited me from being at a birth center, but the midwives there were willing to take me at home, except my baby turned footling breech at almost 38 wks. By law, the midwives had to transfer me to a doctor. A doctor who would not consider VBAC, and would CERTAINLY not consider breech VBAC.

For a third baby...I will not be able to find a VBAC friendly doctor (yes, I have been through every scenario possible...the biggest issue is the on-call doc, even if MY doc is willing for a TOL, the on-call doc isn't - and there's no way to get around that, if I show up, he will want to re-sect). B/c of the laws, a midwife would be risking her license & insurance to assist me at home. I will *have* to attempt an unassisted home birth. I feel it's dangerous, and I don't want to do it...but I will do what I have to, in order to prevent a re-sect. I can't afford a 3rd section! My husband is military now (he wasn't for the first 2 births), and he could be gone...leaving me to take care of 2 children + a newborn ANYWHERE in the world. I can't possibly handle recovering from a c-section as well.

February 19, 2011 | Unregistered CommenterMaegan

VERY good stuff-
I think I will try to be more honest about hospitals in my classes and less....nice. People need the truth about where they are choosing to birth.
Thank you for writing this-

March 18, 2011 | Unregistered CommenterS Clark

As a doula in the Midwest, I believe birth plans are always a good idea at our hospitals. Why? Because the birth culture in our small town is old school, litigation minded, and generally so unconcerned with the desires of a mom to birth naturally that it often becomes a mockery. Informed consent is nonexistent. Hospital policies are archaic, to put it bluntly.
The clear, concise and well informed birth plan, complete with disclaimer about "birth being unpredictable" and " this is just a plan" etc. probably does tend tp provoke doctors and nurses to a degree. But with CPMs not having legal status in my state and years of no home birth CNM within 150 miles, we don't have a choice. I feel a birth plan's best application is in the prenatal appointment with her dr. Sometimes it's the only way a woman will have the confidence to have these important conversations with her dr at all! I encourage clients to ask that the plan be put in their chart and bring extra copies to the birth. But at the actual birth, I try my very best to create an environment of cooperation. My specialty is to be disarming with L&D nurses: we are not enemies, we appreciate you, we need your help :) and most importantly, I AM NOT SMARTER THAN YOU, I WILL NOT TRY TO DO YOUR JOB. Often, a good attitude will negate any ill feelings about a birth plan. I just feel, based on my experiences in our local hospitals, that birth plan benefits do much more good than harm. Just offering a different perspective. Love your blog!

May 21, 2011 | Unregistered CommenterCecelia

Now that I'm doing all hospital births again, I'm working on Birth Plans again. Mostly so *I* know what clients want and can be their walking birth plan, but a couple of places *have* asked for their birth plans and they *seem* to pay attention... until things get going, then it's SOP all the way.

But, hey... there's always hope, right?

And dang hooties... so sorry you have to work in such a challenging location. My thoughts are with you.

May 21, 2011 | Registered CommenterNavelgazing Midwife

"Why... why oh why... if you want a "home-like birth inside the hospital" aren't you considering a home or birth center birth? If you want control, why go where egotistical birth is the norm? If you want autonomy, why go where lawsuits and defensive medicine are the rule?"


Some of us have utterly no choice but to go to a hospital having to rely on Medicaid funding that only pays CNMs in hospitals!

July 30, 2011 | Unregistered CommenterOubli

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