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Birth Plan Conundrum

post #1 of 31
Thread Starter 
DH and I are planning on a home birth with a CPM and, God-willing, it will stay at home. But I am also putting together a separate "hospital transfer" birth plan as back-up, and I'm in a bind about how to word certain matters.

I've heard from doulas and CBEs that it's best not to come across as adversarial, which is fair enough. One of our local hospitals suggests something similar--that patients word things in a "positive" manner.

But the problem is that for some interventions, I don't want to leave any loopholes, vagaries, or "wiggle room." Consider these two alternatives:

"I would prefer not to have an episiotomy unless it is necessary."

"Please note that I do not consent to episiotomy and intend to employ effective alternatives."

Does the second sound too adversarial? I don't want to look be the b1tchy and difficult L&D patient, but I also feel so strongly about some matters that I worry about certain terms and phrases leaving the door open to the usual obstetric mayhem--words like "prefer," "if possible," and "would like." Other words are so vague that they leave room for certain physicians to continue with routine, anti-evidence practice--e.g. "if necessary," and "avoid the 'need' for augmentation/episiotomy/forceps delivery, etc."

Is there a happy medium that I should strive for in how I should word this plan and put it together? Should I just add the word "please" more often? "Please remember that I do not consent to routine, continuous EFM."

Keep in mind also that the intro to my plan includes a phrase about how birth is unpredictable, and our requests are negotiable if circumstances warrant further discussion. Supposedly, episiotomy is necessary about 5% of the time. I just want to know that I definitely belong to that 5% should it become an issue.

Yea, I know, I know. This will almost certainly not be an issue. But my third-trimester OCD is at an all-time high right now! I'm also really tired and don't know if I'm making sense...

TIA!
post #2 of 31
I wish I had copies of my plans handy...

I did not CARE how they came across, actually. When it came to things like being "allowed" to eat and drink, not having an IV, not getting cut, I was very adamant. I believe I worded it like your second example.

The nurses and my doc had no issues whatsoever with my plan. My doc sent a copy ahead of time to the hospital, kept a copy for herself, and I brought one with me. The teams wanted to read it and followed it to a "T", no exceptions, without any problems at all.

Show yourself as strong, armed with knowledge, and knowing what you want, and you will be respected for it, not berated for it.
post #3 of 31
It's hard to say. I do like adding please a little more. Honestly, it's a little off putting to read as a nurse in that situation--however, I do get a good sense of how strongly you are opposed to something. I think that it would depend on how many items were that strongly worded. It makes more of an impact if you save it for your one or two really non negotioable things. For example, things that you can control--like eating and drinking, the continuous EFM--really, you can just take it off, you can bring and eat your own granola bars--they might come in and object, but that's the time to remind them firmly and politely about your requests. I don't think there's really any reason to include those then.

In terms of the episiotomy, I think you could word it more like,
"I prefer to tear and do not consent to an episiotomy unless a life threatening situation is occurring. Please ask me."

The part that is offputting to me is the second part where you state, "and intend to employ effective alternatives". I'm not exactly sure what you mean, and it is quite threatening language.

I can understand wanting to be clear and decisive, but so many of those situations ARE situational, especially for you if you are transferring from home, that I think keeping it short, simple, and politely direct would be most advantageous.

I'm planning a home birth and would be transferring to the hospital I work at if needed. Here are the things I'm including on my birth plan.
No circ
No hep B
Prefer to tear
Prefer IM Pitocin
Husband will accompany baby at all times
Please discuss medications before giving them to me and ask for my consent. (This due to C/S where I find some anesthesia teams routinely mildly sedate the mother, which I don't like.)
Breastfeeding only
Discuss and ask for permission to supplement with formula.
No TDAP vaccine for me at this time.

Those are the things I'd like for them to know, if we aren't able to answer for ourselves--or for an emergency c/s. So that's what I'm focusing on in the birth plan. If it's not an emergency, than my birth team and I will be able to control and advocate for us if needed about the other things.
post #4 of 31
What I focussed on with my birth plan was keeping things clear & concise. Only include the things that really matter to you. Please & thank you are always a good call.
post #5 of 31
Thread Starter 
Quote:
Originally Posted by cileag View Post
In terms of the episiotomy, I think you could word it more like,
"I prefer to tear and do not consent to an episiotomy unless a life threatening situation is occurring. Please ask me."

The part that is offputting to me is the second part where you state, "and intend to employ effective alternatives". I'm not exactly sure what you mean, and it is quite threatening language.

I can understand wanting to be clear and decisive, but so many of those situations ARE situational, especially for you if you are transferring from home, that I think keeping it short, simple, and politely direct would be most advantageous.
. . . And that would explain my choice in "employ effective alternatives." I didn't want to go on a long descriptive tangent about compresses and "perineal massage." (Am I the only one who hates the latter term? No threats were intended there, although I'll change the language if somebody could misconstrue it that way.

Otherwise, great advice here, and from the PPs.
post #6 of 31
Don't know if this will help, but here is mine.

We are planning a homebirth for this pregnancy, and thus far, I have had an uneventful pregnancy. I fully expect to have an uneventful labor and birth. I understand that sometimes a transfer is necessary, but we didn’t plan to be in the hospital. This is a huge change for us. We appreciate your expertise in labor, delivery and care of a newborn. Please help us have the birth most like we wanted, keeping in mind that many of these are not optional due to our religious beliefs. We are not unreasonable and welcome the opportunity to discuss any alternatives.

In Labor… as much as medically safe we will:

1 Have a quiet and dimly lit room with as few attendants as possible.
2 Eat and drink instead of having an IV.
3 No Vaginal exams. They can be discussed on a case by case basis
4 Keep my membranes intact and avoid augmentation.
5 Use intermittent fetal monitoring so that I may remain mobile.

In Delivery … as much as medically safe we will:

1 Wait for the urge to push, and push without coaching in any position that feels right.
2 Not have an episiotomy. I would rather tear.
3 No speaking when baby is born, as we want her to hear our voice first.
4 Eric will announce the sex of the baby. Please do not push for information.
5 Please do not suction baby.
6 We request no augmentation of placental delivery (traction, pitocin)
7 DO NOT CUT CORD!

Cesarean Delivery… as much as medically safe we will:

1 Keep Eric with me at all times, including while spinal anesthesia is administered.
2 Photograph as much as possible. We will not take shots of any personnel’s faces.
3 Please use a double layer of sutures instead of the standard one layer.
4 Avoid the routine use of a catheter. My consent is required prior to its insertion.
5 Avoid general anesthesia and keep my arms free.
6 DO NOT CUT CORD!
7 I will breastfeed in recovery and have someone with me at all times to assist. I understand this may be contrary to hospital policy, but it is not optional for us.

Baby Care… WITHOUT EXCPETION: Parental consent will be obtained prior to conducting any procedures (routine or not), including blood draws, injections and medication. Eric will accompany our newborn at ALL times.

NO VACCINES
NO CIRCUMCISION
NO ABX EYE TREATMENT
NO VITAMIN K
NO NEWBORN SCREENING Preformed at pediatricians.
post #7 of 31
Quote:
Originally Posted by mysticmomma View Post

4 Avoid the routine use of a catheter. My consent is required prior to its insertion.
5 Avoid general anesthesia and keep my arms free.
6 DO NOT CUT CORD!
7 I will breastfeed in recovery and have someone with me at all times to assist. I understand this may be contrary to hospital policy, but it is not optional for us.
Just a note about two things that I think will be very difficult to implement.

After a spinal, you will not be able to get out of bed effectively for at least 4-6 hours and will probably not be able to use a bed pan---is there a reason you are strongly against a catheter? I just have never seen anyone not have one and with the amount of fluids that are being given to you during surgery, it's pretty sure that your bladder will be full, which can impact the contraction of the uterus. Were you planning on doing a straight catheter instead of a foley? It is also necessary to keep the bladder empty during the surgery, which helps prevent accidental nicks during the cesarean (something you definitely want to avoid!)

And secondly, in the event of a c/s, they will have to cut the cord due to the sterile field. The person catching the baby cannot transition the baby on the field, and since during a c/s, it is always a manual removal of the placenta, the surgeon/ob cannot hold baby and remove the placenta. I have never seen a lotus c/s birth and I would be prepared for them to be unable to do that.

Otherwise, I think it's a pretty great example of a simple, direct birth plan. I like when people recognize there are different needs for c/s vs vag birth.
post #8 of 31
I had a planned hospital birth. In my birth plan, I used language that told the providers "this is not optional"* (unless medically necessary--and some of the things ended up being not done as I was only there for 15-20 minutes before my baby was born).

But, here's mine:
*Explain all procedures before performing, to include: risk of the procedure, benefit of the procedure, if there is an alternative and the risk/benefit of the alternative, and the risk if we decline or delay performing the procedure in question.

First Stage of Labor
*No time limits on the first stage of labor or on progressing to the “next centimeter”
*Minimal Vaginal Exams
*Knock and await acknowledgment before entering room
*No persons not directly involved in care—no residents or interns “to observe”
*No restrictions on mobility.
*Intermittent external monitoring
*Heparin lock
*Clear fluids, water, ice chips for nutrition and hydration.
*Do not offer pain medication. If I request pain medication, first offer non-medicinal options, or remind me how close I am to birth. (since I had my kids present, I almost changed that to getting an epidural just so they would not "freak" so much...but the baby was born too fast)
*Attempt natural methods (walking, change in position, going to the bathroom, nipple stimulation) before pitocin or an amniotomy if augmentation is deemed necessary.

Second Stage of Labor
We plan on taking both still and video pictures of the birth prior to and immediately following the actual delivery, but not during the delivery itself.
*Push in whatever position “feels right” at the time, using my husband, doula and/or nurse to support me as necessary for pushing (squatting bar available, if I want to use it).
*Bear down spontaneously
*No time limits on the second stage of labor
*Prefer to tear rather than have an episiotomy
*I'd like a mirror available to see and to touch my baby's head at crowning
*Cut cord after pulsation stops
*Place the baby directly on my abdomen/chest and perform all exams there.
*I do not consent to the Hepatitis A or B vaccine, application of eye ointment or administration of vitamin K.
*I am breastfeeding my baby. Do not offer formula or glucose water or a pacifier.
*Discharge from the hospital as soon as possible.

Assisted Vaginal/Cesarean Birth
*Spinal/Epidural
*My husband and doula present
*Pictures taken once baby is born
*Screen lowered to view baby immediately after birth
*Touch the baby
*Baby given to my husband immediately. Husband will go with baby and doula stay with me.
*Breastfeed as soon as possible in the recovery room

*If my baby needs more intensive medical attention than can be offered in a rooming-in situation, I'd like her father or me to accompany her to the NICU, if possible. Otherwise, a health care provider with appropriate identification may take my baby to the NICU to provide care.
* If admitted to the NICU, I'd like to breastfeed my baby. If not possible to directly breastfeed, I'd like to express milk and have her fed by tube rather than bottle. I'd like open visitation for parents and for us to be involved in her care to the maximum extent possible.
post #9 of 31
I think Mystic Momma is on the right track (well, duh- it's very well thought out! :P)

From what I've been reading, the best way to approach a birth plan is to put in what you want instead of what you don't want.

So instead of "I do not consent to an epis" you would say, "I want to tear naturally." Or instead of "do not remove the baby once he is born" you'd say, "I want the baby velcroed to me immediately after birth."

The worry with being to abrupt or insistent (from what I've heard) is that L&D nurses/ dr's get pissy and won't read it through or will just chuck it, because you're just one of "those" women.

I didn't write one for my first birth (midwife attended home birth) but i kinda wish I had, there are a lot of things i would've done differently. This time is probably going to be a hospital birth, unfortunately, and I am DEFINITELY making a birth plan!
post #10 of 31
Quote:
Originally Posted by cileag View Post
In terms of the episiotomy, I think you could word it more like,
"I prefer to tear and do not consent to an episiotomy unless a life threatening situation is occurring. Please ask me."

The part that is offputting to me is the second part where you state, "and intend to employ effective alternatives". I'm not exactly sure what you mean, and it is quite threatening language.
I LOVE your wording!

OP, is it possible to have one appointment with your midwife's backup OB to discuss things like this? Presumably if they're working with a homebirth midwife they'll be fairly crunchy themselves?
post #11 of 31
Quote:
Originally Posted by Astraia View Post
I think Mystic Momma is on the right track (well, duh- it's very well thought out! :P)

From what I've been reading, the best way to approach a birth plan is to put in what you want instead of what you don't want.

So instead of "I do not consent to an epis" you would say, "I want to tear naturally." Or instead of "do not remove the baby once he is born" you'd say, "I want the baby velcroed to me immediately after birth."

The worry with being to abrupt or insistent (from what I've heard) is that L&D nurses/ dr's get pissy and won't read it through or will just chuck it, because you're just one of "those" women.

I didn't write one for my first birth (midwife attended home birth) but i kinda wish I had, there are a lot of things i would've done differently. This time is probably going to be a hospital birth, unfortunately, and I am DEFINITELY making a birth plan!
I especially like when people phrase it like you said above because it acknowledges that you are aware of what might happen--like the tearing. It is very frustrating to have a contradictory birth plan such as, "I don't want an IV" and "I'd like the option of an epidural." Those are not able to coincide. You HAVE to have an IV for an epidural.

The second reason to keep it short and only include what's REALLY important is quite realistically because the more you write, the harder it is for me to remember and help you implement it. I think too that there's sort of a generic "unmedicated birth" birth plan--which has all the things 2lilsweetfoxes specifies. If someone transfers from home, or tells me she doesn't want pain medication, than my rule of thumb is to do all those things--move around, encourage fluid if you don't have an IV, intermittent monitoring etc. Things that are a big more uncommon might be lotus birth for example.

Anyway, I really like birth plans and do my best to support them, but admit to being busy and distracted sometimes, which is why the shorter the better since we all know I might only get to read it once before a baby pops out, or something else crazy happens.
post #12 of 31
Quote:
Originally Posted by cileag View Post
"I prefer to tear and do not consent to an episiotomy unless a life threatening situation is occurring. Please ask me."
ITA with that whole post. I was goign to say the same there here on episiotomy - this statement clarifies that you are willing to take the risk of tearing & you take that risk upon yourself.

As for the tone of the plan, I would guess that it's most important not to come across as beligerent & adversarial in how you talk to them. (Even if the written plan has that adversarial tone.)
So maybe it's not as crucial if the written plan has the stronger wording?
post #13 of 31
Quote:
Originally Posted by cileag View Post
For example, things that you can control--like eating and drinking, the continuous EFM--really, you can just take it off, you can bring and eat your own granola bars--they might come in and object, but that's the time to remind them firmly and politely about your requests. I don't think there's really any reason to include those then.
I think that's a really good tip. Why make yourself seem more adversarial by including things that you can say in person if they come up?
post #14 of 31
All good points that have been made so far. The only thing I would add, which I've mentioned on many other threads, is that it works best to remind hospital staff and your doctor about aspects of your birth plan AS THEY BECOME RELEVANT. Nobody cares that you want to delay cord cutting when you're only 6 cm. But they DO care when the baby is about to be born. Designating someone like your husband, mom, whoever, to do this, is very effective. Case in point: I wanted to catch my own baby, but by the time my baby was that close to being born I would not have remembered that detail (gee, wonder why??) Anyway, my very helpful and awesome mom said, minutes before my baby was born, "Karen, do you still want to catch your baby?" That was a great way to remind both me AND my doctor that I had planned that.

ITA about not bothering to "ask for permissioN" for things like eating, drinking, moving around, etc. Just do what you want to do, and send your husband out to talk with them if anyone bugs you about it.
post #15 of 31
Thread Starter 
Great wording from Mysticmomma and 2lilsweetfoxes. Thanks!

In most cases, I replaced “do not consent to” with “decline” (as if some of these interventions were hors d’oevres at a party! )

For episiotomy: “The mother does not consent to episiotomy and is willing to tear naturally.” Sorry Charlie, but I do feel strongly about that one.

I also kept “do not consent” for certain neonatal treatments that, as I’ve been warned, become so automatic to hospital staff that it’s easy to forget not to do them.

Apart from that, I’m going to send a draft in to my doula and trust her expertise.

Quote:
Originally Posted by Delicateflower View Post
I LOVE your wording!

OP, is it possible to have one appointment with your midwife's backup OB to discuss things like this? Presumably if they're working with a homebirth midwife they'll be fairly crunchy themselves?
Unfortunately, it’s a whoever’s-on-call arrangement, so I’ll have to word it with that in mind.

Quote:
Originally Posted by kltroy View Post
The only thing I would add, which I've mentioned on many other threads, is that it works best to remind hospital staff and your doctor about aspects of your birth plan AS THEY BECOME RELEVANT.
Great point. It's a bit much to ask that the on-call doc and nurse memorize the whole plan on the spot….even if it is short and to the point. It's not much to ask that DH and my doula learn it, though!

Hey, while I’m thinking about it, is there a hospital left in the country that does the whole shave-and-enema thing? Or can I trust that it’s an obsolete practice?
post #16 of 31
I'm fairly certain the shave/enema is obsolete!

My doc called the hospital after I called her, letting them know I was coming and that I was completely hands-off. That helped a great deal, even though they had a copy of my plan... the doc confirming it made it much easier for them to ignore me... lol!
post #17 of 31
I wonder if you could get away with something as brief as:

Do not touch or perform any medical procedure or administer any medications to either my baby or myself without my express written or verbal consent. Verbal consent needs to be given in the presence of witnesses.
post #18 of 31
Quote:
Originally Posted by Turquesa View Post
Hey, while I’m thinking about it, is there a hospital left in the country that does the whole shave-and-enema thing? Or can I trust that it’s an obsolete practice?
I'm pretty sure you could remember to decline that before it actually happened, right?
post #19 of 31
Quote:
Originally Posted by Turquesa View Post
Great wording from Mysticmomma and 2lilsweetfoxes. Thanks!

In most cases, I replaced “do not consent to” with “decline” (as if some of these interventions were hors d’oevres at a party! )

For episiotomy: “The mother does not consent to episiotomy and is willing to tear naturally.” Sorry Charlie, but I do feel strongly about that one.

I\
If you don't want an episotomy then when they hand you the consent for vaginal birth with possible episiotomy and repair form upon admission to the hospital, cross out the episiotomy part and write "DO NOT CONSENT" and I guarantee you won't get one unless you give verbal consent in the moment.

If you sign the consent, you've consented and regardless of what your birth plan says, it'll be almost impossible to stand up in court if you're cut. Cross out that consent where it's there in black and white and you have a much stronger position if something happens against your wishes.

Remember, when you sign those admission forms you're giving them permission to treat you and your baby to the best of their ability and standard of care. Sure, you can revoke consent at any time, but verbal revocation of said consent is virtually impossible to prove. It boils down to we say they say. So read an sign forms wisely.
post #20 of 31
Quote:
Originally Posted by cileag View Post
Just a note about two things that I think will be very difficult to implement.

After a spinal, you will not be able to get out of bed effectively for at least 4-6 hours and will probably not be able to use a bed pan---is there a reason you are strongly against a catheter? I just have never seen anyone not have one and with the amount of fluids that are being given to you during surgery, it's pretty sure that your bladder will be full, which can impact the contraction of the uterus. Were you planning on doing a straight catheter instead of a foley? It is also necessary to keep the bladder empty during the surgery, which helps prevent accidental nicks during the cesarean (something you definitely want to avoid!)

And secondly, in the event of a c/s, they will have to cut the cord due to the sterile field. The person catching the baby cannot transition the baby on the field, and since during a c/s, it is always a manual removal of the placenta, the surgeon/ob cannot hold baby and remove the placenta. I have never seen a lotus c/s birth and I would be prepared for them to be unable to do that.
I too am intersted to know why you woulf refuse the catheter if - God forbid - you needed a C section?

And as for the cord cutting, if it is about pulsing you were after, it is possible. Routine usually dictates that they clamp it propmtly, whether it is a true emergency or not. However, if it is not a time of life threatening danger, you can request that they delay clamping. They will cut it and let your support person trim it.
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