Birth Preferences, which matter most?

[WifeofAnt]

I'm trying to write my birth plan (planning as natural a birth as possible) and I'm wondering what I should put down and what I should 'let go'. So far my doc agrees with hep lock and intermittent monitoring to let me get up and move around during labor. He seemed pretty supportive of having a patient not wanting pain medication.

Which birth/baby preferences were most important to you?
Did you or would you let a few less important things go to make peace with the nurses?

[cileag]

I'm a labor nurse and I recommend leaving off anything that you or your support people can control ie. lights, music, food etc. I also tend to agree with the "it's better to ask forgiveness than permission" ideology. Do your thing and if someone objects, do it when they are out of the room.

Don't be afraid to be politely direct with the staff. For example, instead of having something longwinded on your birthplan about how you want your baby skin to skin for an hour for bonding, just keep holding onto your baby! If they try to bring him to the warmer, simply say, "I'm not ready yet. I'll let you know when we're ready."

For a written birth plan, I usually just recommend addressing medication/procedure stuff like:
Vit K/Erythromycin
Circumcision
Hepatitis B
Tdap for mom

Good luck!

[WifeofAnt]

Tdap for mom?? How often do you need boosters for those? I'm only 20!

[MegBoz]

Originally Posted by WifeofAnt

Which birth/baby preferences were most important to you?
Did you or would you let a few less important things go to make peace with the nurses?

Hm, it depends on so much.

First, I think most agree it's best to keep your birth plan short & sweet! ONE PAGE MAX - and bullet points so it can be easily scanned. My doula actually formatted mine for me - it was awesome! She put it into 4 blocks on one page:

1. labor
2. birth
3. postpartum/ baby care
4. c-section

I really think it makes sense to omit:
1. Whatever is standard procedure at your hospital.
For example, my hospital encouraged rooming-in, so I didn't bother to put that on my birth plan.
2. Stuff about induction
I viewed the birth plan as a document for the nurses (who are all total strangers to me!) to review when I arrived in labor. Since induction is something to discuss with your HCP (Doctor, in your case) I didn't think it belonged on the birth plan document. (Although, of course, I did include a note that I didn't want AROM or pit to 'speed things up' unless medically indicated (I forget the wording) because that IS relevant to the labor process.

I compromised on only 2 things (but my CNMs & hospital was quite good)
1. No photos or video until baby was born & stable. (It's an ACOG recommendation, so I would guess it's a pretty common hospital policy.)
I do regret this, it's a bummer. At least you could film some of labor while you labor at home before going to the hospital. Or just do it anyway & you'll get SOME footage until someone stops you (or, again, film labor while a nurse isn't in the room.)

2. Hep-lock.
They were fine with no IV fluids, but wanted it for access. Well, I don't know why, but I assumed it would be in my forearm. Nope! Hep-lock is in the back of your hand. This was annoying because it stuck out beyond my 1st knuckles. Well, I pushed on hands & knees & my wrists bother me sometimes. It can be good to be on your FISTS instead of palms since this places your wrist in a more neutral, vs. flexed position. (Such as in doing push-ups, or "tilts & tucks" (yoga "cat/cow" pose.)
Well, i couldn't do that with the stupid hep-lock.

As for how much to fight, my knee-jerk reaction is that if you DO find you have to compromise on many things, you need to switch HCPs. If their "policy" is in contradiction to what you want for birth and what you personally feel is a safe path for a normal/healthy birth, you probably ought not to be birthing there. I know sometimes we simply have no better options, so if you're stuck in a lousy place, I'm sorry & that advice isn't helpful.

I don't think you should sacrifice what you want. Follow these general steps:
1. get your doc (and anyone else in his practice if you'll get whoever is on call when you go into labor) to AGREE on your birth plan and even SIGN OFF on it so nurses can't argue!
2. Bring extra copies with you (good job for the doula)
3. Maybe have it posted on your door.
4. Ask, upon arrival, for a natural-birth experienced nurse. She'll be least likely to fight you on what you want.
5. Stay friendly, not adversarial, as long as you can. "Oh, so sorry for the misunderstanding. Doc Smith & I agreed to only 10 min of monitoring via doppler every hour. I know you're swamped with lots of patients, so we just unhooked the EFM after 10 min."
or
"Oh, I know so many mamas get epidurals, so they can't feel the ctrx & need to be told when to push, but Jane doesn't have one, so she can feel everything, so let's allow her to push as her body tells her & just give her a peaceful environment0." (so, IOW, STFU & stop yelling at her, "PUSH 10, 9, 8,"

(Again, stuff your doula can say for you.)

6. Get adversarial if you need to. Say, "STOP YELLING AT ME TO PUSH." if you need or, "I'm pushing on my hands & knees, STOP trying to get me on my back."
(again, DH & doula need to be standing up for you too as your advocates! You're vulnerable to suggestions while in labor & can have a difficult time advocating for yourself, so that support is important.)

YOU DO NOT NEED TO "OBEY" ANYTHING they tell you. Not one single, stinking thing. NOTHING IS MANDATORY. & don't forget that.
Say "No thanks."
Then say, "NO."
Then say, "NO and get the F out of my room" if you have to.
But never forget that you can say 'no.' & never be afraid to say no. Probably most of the time they'll shrug and say, "Oh, OK."

[MegBoz]

Sorry, wanted to also add what I would NOT compromise! There are so many!
Labor:
No regular VEs.
I wrote that I consented only to one on admission to confirm I'm in labor, & 1 when I feel the urge to push to confirm I'm 10 cm. otherwise I'd rather not know how far dilated I am through labor.
(What's the point?! Then you just automatically do "labor math" & scare yourself thinking, 'oh no! I have 5 more hours to go!" but it doesn't work that way anyway.)
No AROM
No students or unnecessary people in the room - just a nurse & our MW
External, intermittent monitoring only via EFM or doppler
Freedom to move about, use the shower & tub
Eating & drinking as desired & no IV fluids without cause
Don't offer me pain meds - I'll ask if I want them
Not wearing a hospital gown (I know my t-shirt may get ruined, I'm ok with that! The gown would make me feel like a "hospital patient" AKA "sick person.")

Birth:
Don't yell at me & tell me when to push & count down
Push in whatever position
No episiotomy
Let DH catch
Baby on my belly

Baby care/ PP:
Delayed cord clamping & cutting
No cord traction or prophylactic pit
no eye goop
no Hep b
No formula or artificial nipples
no separation

CS
close my uterus with 2-stitch method
no versed (makes you forget!)
DH & doula stay with me

There may have been more, it's been 2 years, but those are all things I wouldn't compromise on EXCEPT maybe the VEs - if I were laboring in the hospital like 6-8 hours or more, I might consent to one more, but I might ask them to just confirm, "Made progress or not?" instead of blurting out a # of cms. (& obviously, it wasn't worded all like that. Ha!)

[umsami]

I honestly think that only you can decide what's most important for me. A lot of things, my OB and I discussed pre-births, so we were on the same page--thus it wasn't even necessary to put those in (episiotomies, hep-lock, telemetry for monitoring, when to clamp cord, not pushing for an epidural, etc.)

Other things the hospital was supportive of--such as exclusive breastfeeding, handing me my infant right after he was born (assuming stable), etc.

I've heard some OBs and L&D nurses say that it's easier to grant post-labor preferences, but I don't know if that holds true for all hospitals/OBs/etc.

Sometimes, hospital policy is just hospital policy--and even your OB can't get them to get around it. For example, the hospitals in Jacksonville, FL do not allow birth balls period. Doesn't matter what the OBs and CNMs say. It's written in stone and has been that way for at least 7, probably longer, years. It's a risk thing, which doesn't make sense to most people, and it doesn't matter whether or not you are willing to sign a waiver or not. : I never encountered that anyplace else, BTW.

[WifeofAnt]

Yeah my hospital has their own birth balls but DO NOT allow food. The nurse even told me to eat before I came in and on the way in because she didn't agree with their policy! Oh well. I plan to labor at home as much as I can with my doula anyway.
Its also hospital policy to take the baby for a hearing test without the parents and have at least a hep lock in place ('just in case'). The separation bothers me the most but I guess I can deal with it.

[nia82]

I agree with the PP - condense it. Stuff like food and drink I did anyways, I didn't care what the hospital had to say. We even ordered pizza into our LDRP room and brought vitamin water and such.
Stuff that I find essential: no episiotomy (no matter what for me is what I said basically), cord clamping (I said no), immediate skin to skin care, no eye goo, no vitamin K shot, no HepB shot, luckily 2 years ago nobody wanted to pester me with a DTaP/rubella/MMR shot (they really want to now, but just decline, unless you want it)... I had a section about c-section, stuff like one arm free, remove the catheter asap, gimme food to see if I can stomach it, etc.
This time around I have a birth plan in case I have to transfer to the hospital and will have the CNMs sign it. Stuff like no circ no eye goo etc I will have notarized and in the file before labor begins. I will also bring copies in case I end up in the hospital, post it on the door, make every person who works with us read it and completely understand they are not to give any of that junk to my child. I mostly worry about what they do to children, so that's my biggest emphasis in the birth plan (Section Baby Care).

[EmTheWife]

As a natural-minded momma who is also a labor and delivery RN, I highly recommend a very short (1/2 page) birth plan, because most nurses won't read beyond that except to scoff at the laboring mother's "audacity" to have such plans and ideals (it breaks my heart, but I've heard it from my co-workers).
Also, attempt to sound educated vs. idealistic ie - "These are my desires if both myself and the baby are in good health and no concerns are present, but I recognize that situations outside of anyone's control may occur, and I understand that the interventions proposed by my care providers are proposed for my health and safety, and that of my unborn child" or something like that. I say this b/c nurses like to please their patients, but sometimes intervention is needed for the best outcome, like mother directed pushing is great, but if the baby catcher determines that the baby is in distress, they are not going to discuss it with you, they are just going to direct your actions in a firm voice, and maybe even with a shout to get through to you in "labor land" and it's in your best interest to listen. As a mother, I'd rather be told firmly to hold my breath and push with all my might than to continue to push gently but birth a limp baby in need of resuscitation and thereby be unable to have immediate and prolonged skin to skin.
Also, it is often more effective to discuss your plans face-to-face with your nurse rather than passing them the printed out plan. I would offer them a copy, but if your nurse is on board with you, she may not need it
Be firm in your wishes, but also be gentle. The RNs are not out to get you; we work where we do because we love labor and birth.

[April422]

Consider this?
http://www.nurturingheartsbirthservices.com/blog/?p=967

[katelove]

Originally Posted by MegBoz

Well, I don't know why, but I assumed it would be in my forearm. Nope! Hep-lock is in the back of your hand. This was annoying because it stuck out beyond my 1st knuckles. Well, I pushed on hands & knees & my wrists bother me sometimes. It can be good to be on your FISTS instead of palms since this places your wrist in a more neutral, vs. flexed position. (Such as in doing push-ups, or "tilts & tucks" (yoga "cat/cow" pose.)
Well, i couldn't do that with the stupid hep-lock.

I put in my birth plan that, if I needed a cannula (I listed the reasons for which I would allow one) then I wanted it inserted in my forearm for exactly that reason.

Now, of course, it depends what your veins are like and it may be a bit of extra trouble for them but totally worthwhile IMO.

I did end up needing an IV and my midwife got someone else to do the cannula as the veins in my forearms aren't that great. It took him two goes but I was prepared for that as I really do have lousy veins and I was asking them not to use the best ones! As I said above, *totally* worth the extra effort, it didn't get in my way at all.

As far as compromise goes, I wouldn't compromise on anything which was really important but, if you feel you need to offer an olive branch then maybe include some things you are happy to have. For example, in my plan I said that I was happy to have a student midwife present if desired. I also included some things that I would do to show that I was being proactive about achieving my goals. For example, I wrote "I will maintain good nutrition throughout pregnancy" and "I will continue to exercise throughout pregnancy."
Just a few things to keep the tone positive and not just a long list of "I don't want...", "You will not..." etc

[WifeofAnt]

So far this is what I have:

BIRTH PLAN

Natural Childbirth is our goal. I know there are cases where medically I cannot have everything I would like but as long as things are going well I hope we can make as many things on this list happen as possible.

Labor
If my support people are present I would prefer being left to labor alone in peace.
I would like to be free to change positions and walk around during labor and request intermittent fetal monitoring and saline/heparin lock to allow me mobility.
During a vaginal exam, I prefer at no time to have my membranes broken.
I would prefer to keep the number of vaginal exams to a minimum.
I realize that many pain medications exist. I'll ask for them if I need them.
If I am not already in active labor but my waters have broken, I prefer to use natural induction methods unless my waters have been broken for more than 12 hours or I show signs of infection.

Delivery
I would like to avoid a Cesarean. If a cesarean is necessary I would like my husband present.
I would like to be allowed to choose the position in which I give birth, including squatting and hands and knees.
Do not lay me on my back unless absolutely necessary, I have back problems that make this position very painful.
I prefer to push instinctively. As long as I do not have an epidural do not tell me how or when to push unless necessary for Baby A‘s safety.
I would prefer not to have an episiotomy (but if I need a tear repaired please use a local anesthetic).
I strongly prefer that the umbilical cord stop pulsating before it is clamped.
Pass Baby A over to breastfeed immediately after birth, please delay all non-emergency procedures until we have had time to bond.
Please no eye ointment or vitamin K unless medically indicated.

After Delivery
I plan to keep Baby A near me following birth and would appreciate if the evaluation of Baby A can be done with Baby A on my chest, with both of us covered by a warm blanket, unless there is an unusual situation.
I do not want Baby A circumcised.
Baby A will not be receiving any vaccinations during our stay.
I would like to meet with a lactation consultant.
Please do not bathe Baby A, we would like to give him his first bath.

It was originally over 3 pages when I first started, this fits on one page. Any suggestions on rewording?

[katelove]

I would be more specific about how many VE's you want. Their minimum might be every 2hrs KWIM?

[Lucy&Jude'sMama]

I'd say no to the hemp lock. I refused to sign paper for drugs and said that my partner or I could sign it if necessary. Not saying you should do this... I just remember every poke and prode bugged the hell out of me when I was in labor so I would avoid as much of it as you can. Instead I had a nurse come in every hour telling me to drink water. That was annoying when it wasn't a nice nurse but then I had a nice one who would very gently remind me and quickly leave the room. She was awesome! Sadly she wasn't there the whole time.

Anyways it's my personal opinion and experience that the less you are tied down or poked about with the easier natural labor is... Ok well not easy but it's easier to get into the right headspace. :-)

[umsami]

Originally Posted by WifeofAnt

So far this is what I have:



It was originally over 3 pages when I first started, this fits on one page. Any suggestions on rewording?

I don't think you need the circ bit. Before a child can be circumcised (it is done by the OB), you need to sign a consent, etc. It also is not always covered by insurance--so usually this involves talk of payment/costs as well. In my experience, the OB will ask you ahead of time if you plan to circ, etc. Even then, prior to circing, they would need your signature on a consent form authorizing the procedure.

[fruitfulmomma]

I generally birth at home, but last one I went into L&D for monitoring and scribbled out a note that said something like 'No Misoprostol /cytotec, no vaccinations, no vitamin K unless trauma presents and prefer oral, no circumcision.' and signed it. Nurse seemed okay with all of it, except told me that they don't carry oral k, which I was okay with doing the shot if the baby needed it anyway.

I was induced with my third and also was very clear that I was NOT to be given Misoprostol /cytotec. That is something I absolutely will NOT compromise on. I ended up only needing AROM to get things going though.

As far as in my home, things that are important to me are wanting it quiet, being left alone unless asking for something, and letting me follow my own instincts to push when my body tells me to.

[MegBoz]

Oh yeah, mine was also titled "Birth Wishes", had an intro paragraph that talked about how we're glad they, at the hospital, are part of our "birth team" & how we've been working towards a natural birth through good nutrition, exercise, & the Bradley method. To elucidate the fact that I truly am fit & in touch with my body, I also mentioned that I'm a fitness instructor & yoga teacher.

It was NOT an accurate reflection of how I sincerely felt - "We trust you & are glad to share our birth with yo!." But my doula wrote it & I agreed it was a good idea.

So on to your plan, WifeofAnt:

"where medically I cannot have everything I would like"

I can't put my finger on it, but I just don't like this wording. I think you're trying to say, "I understand situations may arise where medical needs may necessitate a deviation from my wishes." In that case, it wouldn't be that you are not getting what you "would like" cuz if intervention is truly necessary, than I think that intervention IS what you "would like" in that case. KWIM?
My paraphrasing is lengthy & wordy, but instead, I'd go with something like:
"As labor can be unpredictable, we understand that you may need to deviate from this plan at times.”
(Taken from the above link)

I'd leave out the water breaking stuff. That is something that WOULD be discussed with you, so I just don't think it warrants a bullet point on the written plan. Besides, if you're not in active labor & your water breaks, you shouldn't go to the hospital, right? You try on your own at home to get labor going. & if it gets going 20 hours post-PROM, when you arrive at the hospital, you may want to say they broke like 10 hours previously (Since many hospitals insist on birth 24 hours post PROM - one way or another (so, IOW, CS!)
(I wouldn't personally turn to pharmacological induction methods at only 12 hours post-PROM unless there were signs of infection, but that's another issue.)

"Please no eye ointment or vitamin K unless medically indicated."

Rephrase to, "Please no eye ointment, also no vitamin K unless medically indicated."

Eye ointment is never "medically indicated" unless you have an STD! So I wouldn't leave that loop hole open. (OK, OK, Ha - I know that's paranoia, but still, I'd rephrase as above to not leave it open to interpretation. So they can't say, "Oh, you don't have a recent negative STD test on file here, so you may be positive for an STD, therefore the eye goop is indicated."


"I would like to meet with a lactation consultant."

Just a warning, but the MWs & Nurses at my hospital were awesome! However, I repeatedly met with all 4 of the LCs & all but one were DREADFUL! I mean, awful. Terrible. Thankfully we persevered in spite of them, but just a heads-up. I feel stupid for it now, but it honestly just didn't occur to me to be as suspicious of the quality of care I might receive from an LC as I was from nurses & MWs.

[nia82]

I don't like the wording about eye ointment and vitamin K if medically indicated. They will tell you that is always indicated as they cannot trust you to have cheated or your husband might have cheated and thus the former STD testing is obsolete and you might have chlamydia and co anyways and hence it is super dooper important baby gets the eye ointment. The on call ped with DS told us he will die for sure if he doesn't get the vitamin K shot. So they will always tell you it is necessary.
We bought oral vitamin K, hospitals do not have this available in the US. You can buy it at www.birthwithlove.com. Btw the on call ped looked pretty stupid when I told her we used oral vitamin K, to which she said doesn't work, I was like really, so back in Europe all the kids must be dying then! They do not expect you to be educated and get very pushy. Obgyns and peds are all bullies in my experience. All of them.

[WifeofAnt]

Thank you. I've reworded some of those problem areas (still leaving no-circ on there just in case).

[justKate]

I know this might sound negative, so please don't take it that way. It sounds like you've done all of your research and you know what you want. You sound like me.

If I had to do it over, I would put my birth plan on an index cards and laminate them. One side for me, one side for baby. And then train/trust my Huz or Doula to help make my planned birth happen, every step of the way.

Me side:
I do not consent to an episiotomy.
Please listen to my husband.
Please respect my space and my wishes.
Please give me time to talk with my husband before making decisions.

Baby side:
I do not consent to eye goup (put in proper term).
I do not consent to the administration of the Hep B vaccine.
I do not consent to the circumcision of this child.
Baby S is not to leave my side.
If it is necessary for Baby S to leave my side, s/he is to be accompanied by my husband P at all times.
Please allow us to give our baby her first bath.



DD's birth was crazy--long long labor, emergen-c-section. But my wishes were respected and that was ultimately what a birth plan was about for me. My husband made those things happen--he changed all of DD's diapers; gave her a bath (no soap! ). He stayed up for 74 hours while I rested.

I hope that you have someone strong that will be your advocate. That, I think, is the most important part of a birth plan. Happy Birthing!!