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Saturday
Jul282012

Making a Hospital Birth Plan

Interestingly, I’ve been asked about this post several times in the last couple of months, so thought I’d re-post it. While it was originally written in 2008, very little has changed. I only removed the note about episiotomies since they really are done so infrequently now. If they are still done where you live, feel free to add a line about prefering to tear to an episiotomy or an episiotomy only for emergency reasons. Otherwise, I found it surprising how identical the plans were even four years apart, yet they really are the same.

I've also been asked if this can be shared in childbirth classes. I don't mind as long as you attribute it to me, please, with my blog's url, too. I'd also love to know if you're using this for your clients. And, to those that have, thanks for asking.

Birth Plans on the Internet are woefully out of date.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

Onward....

_________________________________________________________________

My Birth Preferences List

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

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

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

Labor

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

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

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

Birth

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

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

Cesarean

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

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

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

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

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

Baby Care

- No Erythromycin eye ointment, please.

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

- No vaccinations are to be given at this time.

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

_______________________________________________

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

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

Labor

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

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

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

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

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

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

Birth

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

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

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

Cesarean

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

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

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

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

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

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

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

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

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

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

1. You will be letting your wishes known.

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

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

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

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

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

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

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

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

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

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

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

(More on attitude and goals further down.)

Baby Care

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

     1) Because they don't have gonorrhea or chlamydia

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

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

     4) Because they feel it is invasive.

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

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

Families might choose to avoid the Vitamin K:

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

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

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

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

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

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

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

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

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

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

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

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

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

Finishing Thoughts

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

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

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

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

Be sure you even want to have a hospital birth plan. If you choose to create one and discuss it with your doctor/s and nurses, be judicious in what you request.

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

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

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Reader Comments (5)

Interesting that you should note that episiotomies are being done less than in the past. I have been in a [midwifery-led] system for so long that I have been used to that for years, but I do remember working in the US in the 70s when an epi seemed to be done at least 90% of the time, in the belief that it would prevent pelvic floor collapse when the woman became elderly.

I will take issue with the concept that a tear is better than an episiotomy, however. I have seen appalling sequelae with tears, which necessitated repair in the OR under general anesthesia and patients reported dysparunia ever after. Up to a point, that is due to the skill of the person delivering the baby, but there are some women who have perinea which simply shred at the least pressure.

July 28, 2012 | Unregistered CommenterAntigonos CNM

What a great post/resource! I may give this link to my clients in the future to help with birth plan writing.

July 28, 2012 | Unregistered CommenterPHDoula

Everything I've read about Vitamin K now refers to what was called HDN as Vitamin K Deficiency Bleeding (VKDB), which may be importnat if people want to research current info on Vitamin K for for themselves.

I really don't get this pain scale = nursing staff must offer drugs business. I chart on pain all the time and yes occasionally have a pt who declines meds yet admits to pain. I just chart something like "pain 4/10, analgesics declined" and then we are both just peachy. Any reason this would not fly in L&D nursing?

August 5, 2012 | Unregistered CommenterLori

Lori, how helpful is it to the mother if she's in a zone, has a good ritual or rhythm going, to ask her to change her focus to determine how painful contractions are at the moment? As a doula I've never had a client NOT ask for pain meds when she felt labor was becoming unbearable. I realize that nurses are required to chart something but if avoiding pain meds is the goal of a laboring woman then asking about what she wants to avoid is not in HER best interest. Perhaps the pain scale could be utilized once a woman indicates that she wants some sort of pain medication. Or the nurse could ask if there's anything she can do to help mom be more comfortable. That opens up discussion about what she's experiencing and if a mom expresses that she's really struggling and feeling overwhelmed by the pain then the nurse, at that time, could ask if she's thinking about pain meds or would like some suggestions for position changes or comfort measures that her partner can assist with, and use the pain scale for providing meds as needed. I'm not a nurse but my perception is that if a woman asks for an epidural, she's going to be given one. It doesn't matter if she's rating her pain as a 4 or a 10. Same with narcotics. Much different than after my cesarean and I stupidly tried to go without meds. I was really hurting but rated my pain at about a 5 because, as awful and miserable as I felt, I couldn't really assess exactly how much, compared to having my arm chopped off, I was hurting. The LPN told me I had to rate it at a 7 or more to get strong meds, which I needed to deal with the severity of the pain.

October 13, 2012 | Unregistered CommenterRachel

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