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Entries in birth plan (2)

Wednesday
Aug222007

Birth Plan - Revised (With OB Approval)

So much of this speaks about talking to the OB first. It really, really is vital to talk to your OB before entering the hospital and surprising your hospital staff and OB with your dramatic wishes for your birth. There is nothing more antagonistic than a surprise patient armed with a list of I’m-Not-Gonna’s in labor.

I know that it must be hard in many areas of the country where there aren’t choices – where you have no option BUT to show up with a birth plan that states what you are going to do – that has no approval from an OB because no OB would ever approve of your hair-brained ideas. I can’t imagine how hard that must be. I’ll write a separate version for that group, too. Later, after this version.

Regarding clothes in labor, just don’t change into the gown, that’s all. Don’t put it in the plan. Just don’t change into the gown. No biggie. They may tell you it will get dirty. So what. They may tell you they will have to cut it off in an emergency. So what. Wear what you want.

Bring your own birth ball if you want a birth ball. Bring your own bean bag if you want a bean bag. Even if you are eventually only on the bed, the birth ball and bean bag are great!

Also, the first thing when you walk in the room, ask them to bring in the birth bar. Sometimes they have to search for HOURS for that thing. Ask them to bring it. It is a great device to dangle from, hang on to, squat from… I love using it in the hospital.

(I sprinkle parenthesis throughout... they are thoughts and NOT to be added in the birth plan, but to be considered. Discard them when writing your own, please!)

IF ALL IS WELL: Our Hypnobirthing Birth Plan

We acknowledge that instant decisions must sometimes be made, but the requests made below are for a normal birth. Thank you in advance for all your help in making our birth a joyous experience.

Informed consent – as issues arise – is important to me.

• Our family desires a peaceful and quiet birth environment throughout the labor and birth. Any help you are able to offer is much appreciated.

LABOR

• When nurses ask questions required for paperwork, please use positive words and phrases with regards to labor progression and comfort levels.

• Vaginal exams only for clear clinical indications.

(You wouldn’t put this in there, but this would be for decreased fetal heart tones to check for a prolapsed cord, to check for a Malpresentation, to see what is going on if labor has taken a long while, etc. I took out the bullet point that said about ROM – remember, keeping hands out of the vagina is a guarantee that no one will rupture your membranes!)

• I am striving for an unmedicated birth. I know where to obtain anything I could need (from you!) and will ask. Please help me in my wish to remain unmedicated by not offering an epidural or other meds.

(Now that parenthesis up there ^^^^^ [from you] would stay in there)

(With regards to EFM, you will have discussed this with your doctor & hopefully, he has agreed to how I put this. I’ll put it the two most typical ways it is done. The points in the one bullet point are usually broken up into their own points. Blood is ALWAYS taken, so that needs to be removed. When you are in the hospital, the partner can certainly ask that the nurse wait to have it drawn when the mom isn’t having a contraction. That isn’t unreasonable at all… unless things are flying along… in which case, blood might not be being drawn at all! ;)

And that might be the goal – staying home until things are going so quickly a lot of this is moot. But if you are in that mid-point, where things are cranking, but not precipitous, then they might start inbetween contractions and really need to finish while the contraction is going. It isn’t helpful to stop while the contraction is going; it’s just better to hurry up and finish. It doesn’t mean the nurse needs to be painful, though. Or talk loudly. Or anything like that. Just efficient. She doesn’t need to poke around. If she is poking around. She can bloody well stop and wait until the contraction stops!

I know you don’t want either an IV or a lock, but unless your doctor agrees to nothing and you out and out refuse [which you certainly can!] you will have something. I will put in there a great way to say how you will accept something if you choose TO take something. Plus, the lock/IV is put in at the same time as the blood is taken, so it’s kind of confusing that you would separate the two bullet points far away from each other… I am looking at them, trying to put them together here. The IV goes in, the blood is taken, and the lock is capped; that is how it is done. So it isn’t any different of a procedure. Does that make a difference in how you perceive it? And it does need to go before the EFM point, so I will move it up here.)

• Our OB has agreed to saline lock only unless medications are needed.

Or

• Our OB has agreed to defer IV unless he deems it necessary. If you have questions, please ask him.

• Our OB has agreed to 20 minute strips every hour as long as the baby looks great. I will do my part to help create a good 20 minute strip.

(By mentioning at the beginning about the peaceful atmosphere, you have already set the stage that you are eliciting their help to keep it quiet and move slowly throughout the birth, so you don’t need to repeat it throughout. Also, modeling is one of the best ways to get them to do what you want them to do. BPs are done only every 4 hours unless mom has an epidural and can absolutely be done between contractions. The partner or doula can be the go-between regarding when placement of the cuff occurs and once the machine is done with its thing, take the cuff off, even if the nurse isn’t in the room.)

• After an initial 20 minute monitor strip, our OB has agreed to listen to the baby with a Doppler. If there are questions, please ask him.

• Our OB has given permission for light snacks during labor. Any questions can be directed to him.

BIRTH

• Please allow my partner/husband (your term) to guide me during pushing. No yelling at me!

• My OB has agreed to allow me to change positions throughout second stage, including during the actual birth. I expect to try the toilet, floor, chair and bed.

• My OB has agreed to allow my partner and I to catch our own baby.

• Please do not announce the gender of the baby.

• Please remind our OB that neither my partner nor I want to cut the cord; he has also agreed to wait until it has stopped pulsating before clamping and cutting.

• No pitocin after anterior shoulder! No pitocin after delivery unless warranted!

• Our OB has agreed to allow our placenta to be born naturally and without active management of third stage.

(If you don’t know what that is, please look it up.)

(Nursing a baby is a matter of course nowadays as long as the baby is healthy. Your helper/doula/partner needs to get the baby to the breast. Babies aren’t often jumping out of the womb and to the nipple… some are, but not all, so don’t be discouraged if yours isn’t. You can always do nipple stimulation by hand, too. Or visualization.)

POSTPARTUM

• We would appreciate continuing the quiet and peaceful atmosphere as long as possible.

• We’ve arranged for Oral Vitamin K for the baby; No Erythromycin in the baby’s eyes.

• We refuse the Newborn Screen & will not be circumcising if we have a boy.

(I really hope you are informed about the newborn screen before refusing it. ‘Nuff said. My prejudice showing.)

• Only breastmilk – no artificial milk or nipples

So, this is what the finished product looks like:

IF ALL IS WELL: Our Hypnobirthing Birth Plan

We acknowledge that instant decisions must sometimes be made, but the requests made below are for a normal birth.

Informed consent – as issues arise – is important to me.

• Our family desires a peaceful and quiet birth environment throughout the labor and birth. Any help you are able to offer is much appreciated.

LABOR

• When nurses ask questions required for paperwork, please use positive words and phrases with regards to labor progression and comfort levels.

• Vaginal exams only for clear clinical indications.

• I am striving for an unmedicated birth. I know where to obtain anything I could need (from you!) and will ask. Please help me in my wish to remain unmedicated by not offering an epidural or other medications.

• Our OB has agreed to saline lock only unless medications are needed.

Or

• Our OB has agreed to defer IV unless he deems it necessary. If you have questions, please ask him.

• Our OB has agreed to 20 minute strips every hour as long as the baby looks great. I will do my part to help create a good 20 minute strip.

• After an initial 20 minute monitor strip, our OB has agreed to listen to the baby with a Doppler. If there are questions, please ask him.

• Our OB has given permission for light snacks during labor. Any questions can be directed to him.

BIRTH

• Please allow my husband to guide me during pushing. No yelling at me!

• My OB has agreed to allow me to change positions throughout second stage, including during the actual birth. I expect to try the toilet, floor, chair and bed.

• My OB has agreed to allow my partner and I to catch our own baby.

• Please do not announce the gender of the baby.

• Please remind our OB that neither my partner nor I want to cut the cord; he has also agreed to wait until it has stopped pulsating before clamping and cutting.

• No pitocin after anterior shoulder! No pitocin after delivery unless warranted!

• Our OB has agreed to allow our placenta to be born naturally and without active management of third stage.

POSTPARTUM

• We would appreciate continuing the quiet and peaceful atmosphere as long as possible.

• We’ve arranged for Oral Vitamin K; No Erythromycin

• We refuse the Newborn Screen & will not be circumcising if we have a boy.

• Only breastmilk – no artificial milk or nipples

Sunday
Aug192007

Let's Critique a Birth Plan

Since writing this blog piece, the author of the birth plan removed it from public view, so reading the complete plan is no longer possible. Because it was originally published publicly, I've chosen to leave the post as it stands. I will, however, remove the link to the original post. It seems the author might not have been quite ready to have the birth plan shared with the Internet when the search engines picked it up (I received two alerts from two separate search engines), but she left the birth plan up for 4 days before making it private.

I commented on her own blog, thanking her very much for the great learning opportunity she was offering. I continue believing this was a great object lesson for many of us - from childbirth educators, birth book authors, and student midwives to pregnant families, doulas and anyone else who works in the childbirth field I've not mentioned by name.

I thank her for sharing, even if it wasn't intentional.

BIRTH PLAN: WATER BIRTH USING HYPNOBIRTHING

So, I encourage you to go read the whole birth plan first and then I will take parts of it and critique it here. Why are we going to do this exercise? We've talked about this before... remember? Birth plans shouldn't be longer than a 3x5 card long. That's a start. This birth plan, which came across my email as a Google Alert ("Natural Birth") is ripe for using as an educational tool for childbirth educators, doulas and student midwives.

Shall we? (I'll put the birth plan's words in green.)

In advance we thank all our healthcare providers for their skilled care and kind support. We have tremendous gratitude for your assistance and know that during our labor and birth we may not be able to verbalize or show our appreciation. We have tremendous respect for our care providers and want you to know that while we have very specific requests for our birthing experience, that if need be we will always listen to and consider medical advise if a medically emergent situation should arise for mom or baby. Thank you for helping this to be a truly beautiful, natural, once in a life time experience for our family.

Too wordy! Instead of my saying this 8000 times, suffice it to say this birth plan is far, far, FAR too wordy. It behooves the hospital client to remember their nurse almost always has at least 2 and usually 3 patients to attend to at the same time. Reading something this long would be nearly impossible to do.

"It is not only that we want to bring about an easy labor without risking injury to the mother or the child; we must go further. We must understand that childbirth is fundamentally a spiritual, as well as a physical achievement...The birth of a child is the ultimate perfection of human love" - Grantley Dick Read

A quote? Egads. Do not waste space on a birth plan with a quote.

All natural birth has a purpose and a plan; who would think of tearing open the chrysalis as the butterfly is emerging? Who would break the shell to pull the chick out?

This could almost be seen as insulting to the hospital staff. Of course, we natural birthing people see it as right and beautiful, but (many of us feel) the majority of hospital maternity workers tear open the chrysalis long before the butterfly is even ready to emerge... and anesthetizes her during the experience as well. I'd just as soon see this quaint quote left out. They will just roll their eyes at the person who puts it in their birth plan.

The patience and understanding of medical caregivers to refrain from any practice or procedure that could unnecessarily stand in the way of our having the most natural birth possible.

Quiet room, dim lights, our chosen music. We also ask that Dawn not be engaged in conversation and that caregivers converse between each other outside of the room, unless addressing a emergent situation. If permission is needed for a emergent medical procedure please keep discussion brief, with a respectful quiet tone, addressing both mom and dad.

Please open and close door to labor room quietly, with respect for mothers privacy and concentration.

Bullet points should be used. Throughout the entire birth plan, there are typos... two being found in the last line above. It should read: Please open and close door to labor room quietly with respect for mother's privacy and concentraction. Actually, if I were their doula, I would encourage their making a sign to put on the door that said, "OPEN DOOR SOFTLY!" and that would be the end of that bullet point right there.

Please refrain from using terms such as "pain", "hurt", "intense", "hard labor" or making any suggestion of pain being experienced. Please do not offer pain medication at any time. Please do not ask the strength or scale of contractions.

I would bet that in 95% of circumstances, they will say, "I know you don't want me to say anything about pain, but I have to ask just once. Where on a scale of 1 to 10 is your pain right now?" Nurses hardly talk to patients who have support people except during admission... at least until they are pushing, so it isn't that big of a deal, this asking them not to mention words of pain. I also believe that just your saying these words on a birth plan... your telling them not say these things is asking for them to say them over and over again. To think is to create.

Many of this birth plan's requirements are negative for the care providers - against what they normally do - and when they are shoved out of their comfort zone (when any of us is), they can make it miserable for the patient demanding these changes. And, in my experience, they go out of their way to make things miserable for the birthing family... purposefully annoying them with small or large things they specifically asked the nursing staff not to do.

Minimal vaginal exams and only with permission. My preference is to have one cervical check upon a completed admission EFM that supports evidence of strong, active labor to establish dilation and a second cervical check at suspect of reaching full dilation, if needed to advise Dr. Rollins.

This is a strange request altogether... more like a couple of them rolled together into one bullet point. Minimal vaginal exams in and of itself, of course is a terrific request. But, instead of putting it on a piece of paper, when they come at you with a gloved hand, just keep your legs closed and say, "No."

I request my bag of water to stay intact and for it to rupture spontaneously with no assist.

Wellllllll... ya gotta keep people's hands outta your vagina if you don't want your membranes to "accidentally" break.

Minimal EFM after initial admission strip, unless medically emergent. No saline lock or IV unless medically necessary. Blood pressure and doppler tones to be taken minimally without breaking mothers concentration with conversation or brisk activity. No blood draws unless medically emergent and with permission only.

Interesting choice of words... saying "unless medically emergent." It isn't uncommon for the hospital staff to say things are medically necessary (I don't think I've ever heard the term "emergent" used) and to find a way to convince a laboring couple within a few moments why something should be done when initially they thought they would never ever ever think they would consider having it done. BE CAREFUL SAYING "NO" to something.

And this birth plan is rife with "with permission only." Well, permission is granted already upon admission when the papers are signed. Someone needs to educate this couple of that because they look foolish otherwise. It's birth plans like this that make (many) nurses snicker behind those attempting natural childbirths' back - mostly because the person writing the plan is simply ignorant, not stupid.

I request to eat light snacks and drink tea, juices, water and 7-up during labor.

You can request it all you want, but if your doctor or hospital refuse it, you are screwed. Some people are finding it is best to just eat quietly (when no [medical] one is in the room). Instead of you requesting it and putting it on your birth plan, discuss it with your physician and have him/her put it on your standing orders at the hospital! That's the best of all ideas.

To allow labor to take its natural course without reference to "moving things along".

Why are you having a hospital birth? Please read my When You Buy the Hospital Ticket You Go for the Hospital Ride blog piece. The deeper this birth plan goes, the more controlling it gets. How does this person really expect a hospital to not utilize the standard tools to click a labor along? Do they really believe they will let someone labor for 3 days without concern that the hospital administrators and lawyers wouldn't have met to ask the doctor what his game plan is and why he hasn't done a cesarean already? Push for 6 hours without having the doctor's head spin off its spindle as he worries about what he'll say up on the witness stand because the presumption will be the baby will have some serious postpartum recovery issues? While the healthy and alive mother and baby are utmost, EVERYTHING IS DONE WITH THE COURTROOM LOOMING AS THE BACKDROP OF THE LABOR & DELIVERY SUITE! To expect your wishes of an unhindered birth to occur in a hospital is absurd.

I repeat:

To expect your wishes of an unhindered birth to occur in a hospital is absurd.

(I almost just want to stop here.)

No augmentation of labor via Pitocin or stripping of membranes.

Don't say "No." laughing How's that for negative talking? Saying "no" to something gives it an enormous amount of energy. Stripping of membranes in a labor and delivery suite? That isn't even something that is done and makes the author sound ignorant.

I'm sitting here thinking, "You could say, 'Use of pitocin after discussion' or 'Use of pitocin only when warranted," but they believe that's the only time they use pitocin! They don't feel they use pit randomly; so it's just silly to try and say to them to only use it when it's necessary.

The use of a birthing ball if one is available and the freedom of choice to walk and change positions as needed. The freedom to use the floor to find comfortable laboring positions.

Do you KNOW what's on a hospital floor?!? BLECH!!!!!!!!!! (Apparently, according to a commenter, some women do get on the floor with covers and sterile drapes. That seems more appropriate - covered sounds great.)

To allow natural bithing instincts to facilitate the descent of the baby, with mother directed breathing down until baby crowns. Use of hypnobirthing breathing techniques during birth of baby...no Lamaze promts please. Perineal counter pressure if needed to slow the birth of babies head.

Typos in Red. This is all in one bullet point! Please proof and correct typos before giving your birth plan to anyone. Or putting it on the Internet.

Or putting your comments on someone's blog. (Sorry, I couldn't resist.)

It should read:

To allow natural birthing instincts to facilitate the descent of the baby with mother-directed "breathing down" (I would add "of the baby") until the baby crowns. Use of Hypnobirthing (technically, that should be capitalized, but I didn't want to get out the red pen again) breathing techniques during the birth of the baby... no Lamaze prompts, please. Perineal counterpressure if needed to slow the birth of baby's head.

Please do not shine bright lights toward baby during birth, keep lights as dim as possible during labor and birth.

? ? ? ? ?

Even if lights are kept dim, lights will be shined onto your perineum and that is where the baby comes out, so the baby will have lights shined on him/her during the birth. (Unless your care provider doesn't use lights during the birth as a few care providers do not use, including Dr. Wonderful and a commenter.)

I ask once again. Why is this person birthing in the hospital?

Please allow 30-45 minutes for natural delivery of placenta with No pitocin administered, No manual removal, No cord traction.

You can't see my eyes bugging out, can you? Now, I've learned from all the smacks upside my head not to say "You will NEVER see..." but I would LOVE to hear from someone who has seen a placenta be allowed/permitted to be naturally born taking 30-45 minutes in a hospital while the care providers waited and watched with their hands in their laps. I'm trying hard not to laugh at how absurd that even sounds coming out my fingers! As if that could ever, ever happen. Anyone?

(Well, a commenter, Dr. Jen, a great Family Doc came foward and said she has waited 30 minutes for placentas before, so there you have it. I am speechless - and delightedly so! Good for you, Dr. Jen! If she is one, she can't be alone. Thank goodness! So, perhaps the birth plan writer isn't so odd after all? But, I would suspect - in the majority of cases - this request is unrealistic. I would suspect Dr. Jen would agree. Yes?)

Did this person who wrote this birth plan discuss this with their care provider and the doctor say, "Sure! Put that in your birth plan!" Or was it just a wish plan they just decided to write and believe the hospital would follow. I believe it was the latter (but am not 100% sure).

(I am really glad that Dr. Jen uses a birth plan as a spring board and I would love to see more care providers do so - and listen to clients do that!)

Oral vitamin K to be used. No injections for baby. If boy - no circumcision.

Unless you have prepared for it, hospitals don't typically have oral vitamin K... do they? Is that something new they are doing? Or would they look at someone asking for that as if they were also asking for the pharmacy to make their placenta into capsules.

No injections for the baby. At all? Under no circumstances? What if the baby is sick? Has hypoglycemia? There are caveats all through the birth plan. This is one place a caveat might be a good idea. And putting circumcision in a birth plan is bordering on bizarre. Circumcision does not occur in birth anymore - and hasn't for a LONG, LONG time. If you want the nursing staff to roll their eyes at you but good, putting a note about circumcision in your birth plan is certainly the way to do it.

No PKU testing, heel prick, or blood draw for baby.

Again, if the baby is ill, then the baby is going to be poked. That's just the way it goes. And PKU (officially called Newborn Screening) testing is done on the second day or so postpartum... this is also not a birth plan point.

No use of Erythromycin or any eye salve to allow optimal sight for bonding.

Eye salve? What is eye salve? Where did that come from? Choose your words very carefully when writing something like a birth plan. The last thing you want is the staff laughing or rolling their eyes at your choices or your hard work.

Please place a blanket or chux on scale prior to weighing.

Does anyone not?

I've just learned so much from listening to nurses discuss Birth Plans over all these years and it is so much better to set your stage before you ever set foot into the hospital than to expect the birth plan to make your whole experience Nirvana.

And haven't we heard women speak about their birth plans being ignored (or sabotaged) enough to know that long involved speeches get us nowhere? And might even get us sent to Hospital Hell?

I vote for families who want convoluted birth plans to:

1. Have a home birth

OR

2. Have a birth center birth

OR

3. Have a CNM in the hospital

OR

4. Find a Dr. Wonderful

OR

5. Get your ducks in a row BEFORE labor begins so you don't have to fight once you are in labor.

AND

6. Hire a doula to help you with your support and care, but NOT to speak for you.

Comments?