Observations on Birth Plans

[Turquesa]

First observation: Maybe it's a backlash against the increasing amount of women thinking for themselves, but I'm starting to notice hospitals that are telling women how to write their birth plans.

This hospital pretty much tells you how it's going to go and what preferences (key word) you're allowed to have.

Ditto here.

This hospital's boilerplate birth plan form does not give you an option to refuse eye goop.

And this hospital only gives you the option of an in-house doula.

There is no law saying that you have to abide by hospital policies and protocols. But these worksheets subtly place one more obstacle between women and the evidence-based care that they deserve.

Second observation...or maybe more of a question. Is there something we could call it other than a "birth plan?" A mention of a "birth plan" is usually followed by a lecture about how birth is unpredictable, yadda, yadda, yadda. Duh.

"Birth preferences" doesn't cut it either; it's easy to disregard preferences and put a spin on why you won't honor them. I'm wondering if there's a better name for it. Perhaps a "birth consent form," as in I do/do not consent to eye goop, routine EFM, etc.?

[phathui5]

The first one doesn't seem like a good guide, especially for first time parents.

The second one seems to offer a lot of good choices. I would be comfortable recommending it to parents who were choosing that hospital.

I think it's great that the one form offers you a free doula. It doesn't say that you can't use your own doula if you want to, but just the fact that they're offering it to all their patients (and that they can meet with one beforehand) is great.

[bella99]

The first one doesn't tell you what preferences you're allowed to have. The introduction to the plan states that their form addresses the "most common concern" and that women should "feel free to add any information". In fact, the last page is basically a blank page for adding additional requests/needs. The second linked plan also has additional room for additional infomration.

In fact, I think all the forms are pretty good. None of them state that you can not add information or do your own birth plan. They seem to me, that they allow the hospitals to know as much about a woman's birth plan/preferences/desires/whatever, prior to her being in labor, and so when that women arrives, they have a better idea of how to tailor their treatment to her wants and needs.

The most limited one seems to the one for the Naval hospital.

As for the doula service, I think that's great. Many women can not afford a doula, and for a hospital to offer one for free both prior to and during labor is great. The PP is correct, nowhere on that form does it state that you can't bring in your own doula, only that they offer doula services free of charge.

[turnquia]

I guess I don't see this as a downfall. On ANY of the hospitals. Here's why.

While yes, some hospitals offer less "choices" or don't have a checklist that suits all of us pretty "crunchy" type moms.

It does off CHOICES. Before a laboring mom goes into the hospital, and she is told this is what we do and your just expected to go with it. You have no choice over rooms, over to wear your own clothes, or having additional hospital staff as labor support etc. (Unless you choose to speak up when you get there or hand over a birth plan)

These hospitals are going out of their way to help provide people with Options. They may not be perfect BUT its a great start.

So even to a mom who would't write out a birth plan or heck or for a mom who would normally just go in and go with wht she's told... they are now saying hey look at some of the "options" we offer and are in support of!

[umsami]

I actually think many of these are great--and have options that I wish were available at the hospitals I've delivered at.

It also seems like many of them are promoting some options that many of us have been advocating for years--waiting until the cord stops pulsating before cutting; delaying assessment, goop, etc.; telling them not to offer pain relief, etc.

[MegBoz]

Originally Posted by Turquesa

"Birth preferences" doesn't cut it either; it's easy to disregard preferences and put a spin on why you won't honor them. I'm wondering if there's a better name for it. Perhaps a "birth consent form," as in I do/do not consent to eye goop, routine EFM, etc.?

My doula suggested the title "Birth Wishes." that is even weaker IMO than "preferences."

"Consent form" could work for the things like eye goop & episiotomy. But not a lot of the other things are "preferences." Things like baby immediately on your tummy, no 'coached' pushing, only intermittent monitoring. If baby is in distress, all of those things might have to be altered. & I personally would consent to a deviation from the plan there. Those were truly just part of my "wishes" if everything was progressing normally.

In any case, I'm a big believer in "a rose by any other name would smell just as sweet." Even if we could come up with a great name, I don't think changing the title will significantly change people's perception of what it is. Especially not once they got used to the new name & realized it was just the trendy term for "birth plan."

[happysmileylady]

I don't know, they seem to me to offer a lot of options and then also have a place to add your own comments. Much of the options listed seem to be the most common concerns that people have regarding how they want their birth to go. And none of the forms seem to be a reqirement-meaning that I didn't see where they said they wouldn't abide by any other written form or plan.

[Turquesa]

Well, it won't be the first time on MDC that I've stood alone on an issue. Oh well. It's a small soapbox, so there's probably only enough room for one of us.

For the uneducated parent, these forms are a quiet way of suggesting limited option. For example, there is no mention of a choice NOT to have eye goop. It will happen. And you may only use an in-hospital doula (there's no mention of an OOH option).

One of them says:[/RIGHT]

We will initially monitor your baby’s heart rate on the fetal heart monitor. This will take approximately 20-30 minutes. After this, we will monitor your baby intermittently.

If you actually want to forego EFM altogether in favor of the more evidence-based practice of intermittent ausculation.....well, there's no mention of that option.

Yes, it's nice that these hospitals are accepting birth plans and helping women weigh their options. But they need to let them know ALL of their options. There are more than these forms would have us believe.

If I were the client, I would obviously challenge these. But it may not even occur to other women that they have a right to do so.

[umsami]

I don't think it's the hospital's job to educate women on all the potential options available to them. Reality is, that we live in a very litigious society--much more so than any other Western nation--and hospitals do need to protect themselves somewhat... just as women do as well.

Women need to do their own research and make their own decisions. Even then, for the hospital, allowing some of these options put it at risk of lawsuits--because while a woman may make a choice to do xyz, if there is an adverse event to either Mother or Baby, it won't matter why the Mom chose in her birth plan. The hospital and physician will still be libel.

For example, if a hospital gave an opt-out on the erythromycin, and the women chose it, and then the baby ended up with vision issues as his Mom or Dad was one of the 1.2 million with chlamydia or 300,000 or so with gonorrhea in the U.S.--no doubt there would be a lawsuit filed against the hospital--regardless of whether or not the Mom chose this option or not. (Remember, those are people diagnosed--the total numbers are probably much higher.) Chlamydia particularly has risen greatly in the past 10 years--and there's a very good chance that the Mom would not know her status or the status of her partner. (While OBs may test women at the beginning of pregnancy, they do not require testing of a woman's partner... or usually testing later in the pregnancy.) There is no screening board on the merit of such lawsuits, if one is filed... then you must defend yourself, which costs money. Furthermore, many states require prophylactic antibiotics of newborn infants by law... so if a hospital/physician does not administer it, they further put themselves at risk of litigation, fines, etc. It could be viewed that the physician did not practice the standard of care--which would make him/her libel to quite potentially a hefty judgment. Even if the woman did opt-out, the courts would likely hold that the physician, being "medically trained", etc., should have known better and known the risk and given the infant the ointment regardless. That's the reality of practicing medicine in the U.S. today--and just part of the reason why some women in parts of the country have no access to an OB or CNM.

[MegBoz]

Originally Posted by umsami

Even then, for the hospital, allowing some of these options put it at risk of lawsuits--because while a woman may make a choice to do xyz, if there is an adverse event to either Mother or Baby, it won't matter why the Mom chose in her birth plan. The hospital and physician will still be libel.

<snip>

Even if the woman did opt-out, the courts would likely hold that the physician, being "medically trained", etc., should have known better and known the risk and given the infant the ointment regardless.

I vehemently disagree.

The courts realize that informed consent is the law. Docs do not have the legal right to "give the ointment regardless." Quite to the contrary - it's actually a crime for a doc to perform a procedure or administer a drug when a patient says "no" (granted, we all know they're not prosecuted for it, but that is still the law.)

Judges uphold the laws on the books... they don't pass moral judgments on what they feel docs "should" be doing.

I won't deny that "defensive medicine" (i.e. "Cover your a$$") plays a role in why docs tend towards intervention rather than expectant management in so many cases (even though the latter is often the evidence-based practice.) However, that is only a part of the picture. In both the books "Thinking Woman's Guide" and "Born in the USA" the authors describe how it's much more complicated than that. I think Dr. Marsden Wagner still has an essay online called, "Fish can't see the water they swim in." OBs intervene because they see a need (because they see PPH, Fetal distress, etc.) but they don't quite see how their interventions caused the problem in the first place. They're too entrenched & this is all they know of birth to see anything else.

So our legal system & "defensive medicine" is not wholly - or even mostly - to blame for our atrocious maternity 'care' in America.

Anyway, regardless, women have the right to decline any and all care & that hasn't changed.

[umsami]

I think you'd like to believe that women have that right... but here in FL, there has been at least one case where a woman was given a court-ordered c-section. So, that right may sound nice--but in practice, judges and physicians (and hospitals afraid of risk) are working to overturn that. Actually, a little research shows its happened in at least 12 States. If they're willing to do major abdominal surgery on somebody without consent, do you really think a little eye goo is going to stop them?? http://www.advocatesforpregnantwomen..._c-section.htm

Yet hospitals in at least a dozen states have obtained court orders to compel unwilling women to undergo this major abdominal surgery. And while Marlowe was able to escape the scalpel, other patients were operated on-- despite their verbal or even physical resistance. In a tragic 1984 case, staff at a Chicago hospital forcibly tied a pregnant Nigerian woman who had declined a c-section to her hospital bed with leather wrist and ankle restraints. ...

Also, prophylaxis antibiotics (eye goo) for infants is the law in all 50 States. It is recommended by the AAP, AAO, and CDC. The law in Washington even specifies that it must be done within 1 hour of birth. http://www.seattlebirthnet.com/files/newborneyepdf5.pdf So, as much as you may think you have the right to refuse, you may not. You might, at best, get them to delay application--but in some States, you simply aren't going to be given much choice. And even if you do sign a waiver, knowing that the physician and hospital can still be sued (reality of medicine in America,), they may still give your child the antibiotics.

It just takes one lawsuit. For example, in 2004 or 2005, a woman's husband fainted during her epidural... hit his head... and died of a brain hemorrhage. She sued. Thus, in both hospitals I've delivered in New York and Florida, a birth partner may not be in the room when an epidural is administered. http://www.parentdish.com/2005/07/10...ral-wife-sues/

In the city where I live in Florida, birth balls are not allowed at all due to one woman falling and hurting herself. Once again, we all lose out because of defensive medicine. This has been going on for at least 7 years, possibly longer. And it's unlikely that the hospital's lawyers are going to OK them, because even if it's a frivilous lawsuit (and yes, to me, falling off of your own birth ball is frivilous)... they still have to pay attorneys, etc. to defend themselves. Not worth the money--much easier to say "no."

Why do you think there are so few CNMs and CPMs out there that will attend homebirths? It's all about insurance--and whether or not they can even get OB backup.

Quite frankly, if an OB or pediatrician tried to defend themselves using Henci Goer or Marsden Wagner, it wouldn't work. It doesn't matter if their work makes sense--or even if they can back it up with various studies. Why?? Because the board-certifying organizations have already listed the standard-of-care... and if you go against it, you've basically lost the lawsuit. Period. That is the gold standard--regardless. Until they change their position, a doctor and hospital is at risk for going against them.

Defensive medicine is a huge part of how physicians and hospitals operate--regardless of what the American Trial Lawyers say. Until we see substantial tort reform, don't expect to have that many real choices. Where I live in FL, even though parents have to sign a form regarding limited damages if the child has brain issues (NICA), OBs still pay around 150k-200k per year for malpractice insurance... and those are OBs without any significant judgments against them.

[MegBoz]

Originally Posted by umsami

I think you'd like to believe that women have that right... but here in FL, there has been at least one case where a woman was given a court-ordered c-section.

Yes, I'm aware of that story. I read about it in the fantastic book, "Pushed" by Jennifer Block & I think it was also mentioned in "Born in the USA" by Dr. Marsden Wagner.

However, it is a rare event. Even ACOG recommends against using force & court order to compel a woman into CS. Just because it has happened does not mean that we do not have the right to refuse.

Also, prophylaxis antibiotics (eye goo) for infants is the law in all 50 States.

Actually I believe the law is that it must be offered to parents. Not sure - as it's just what I've read here on MDC. I remember reading that it is law in NY state, but I thought for many other states, again, the law is just that it must be offered.

I had on my birth plan that we didn't want the eye goo and not one of the 3 MWs (CNMs) even blinked at that, nor did the nurses. DS didn't get it, nor did anyone even mention it.

Actually, and from all the reading I've done on MDC, I don't think my experience is that unusual. You say no-- they don't do it-- end of story. Sure, absolutely, sometimes they do it anyway and/or harass you, but, again, I don't think my experience of declining without problem is altogether rare.

Quite frankly, if an OB or pediatrician tried to defend themselves using Henci Goer or Marsden Wagner, it wouldn't work. It doesn't matter if their work makes sense--or even if they can back it up with various studies. Why?? Because the board-certifying organizations have already listed the standard-of-care... and if you go against it, you've basically lost the lawsuit.

Well, yeah, I wasn't suggesting that a doc bring the books in as a defense. What I said was that, according to these 2 who are experts on maternity care, 'defensive medicine' is NOT the only (or even predominant) cause for the anti-evidence based care in America today.

and, actually, Dr. Wagner has been called in to court as an expert witness numerous times.

Until we see substantial tort reform, don't expect to have that many real choices.

So, I admit I'm a little anti-hospital birth for healthy women because, well, we all here know the reasons! But I don't think the situation is SO bad as to say, "don't expect many real choices."

It's not easy and it takes work, but it's absolutely possible to have a natural birth in a hospital where your wishes are honored. I know, because I did it! & I've read many other stories like mine. (And sure, maybe it is outright impossible in some hospitals) but to act as though all [or vast majority of] decision making abilities are stripped from birthing women in America is an unfair exaggeration.

[umsami]

No, I know it's possible. But not all hospitals are accommodating... and not everybody has a choice in where they deliver. There may only be one or two hospitals in the area... or one or two OBs in the area. And if you don't play by their rules, your choice is a homebirth or traveling significantly for the birth.

I guess my whole point was while some things in a birth plan may seem perfectly reasonable to us (and they are)... from the hospital or the OB's standpoint, they aren't... and they can't always grant the request even if they want to. That's why many hospitals and OBs say that they will try to honor birth plans/requests--but nothing is set in stone. It's also why I think that women need to prioritize their wishes/requests--know which battles you're willing to fight.

The eye goo truly is required by law in all 50 States... even though some OBs/peds might allow Moms/Dads to opt out for their kids. My guess is a lot depends on how friendly the State is to other exemptions, such as for vaccines... but I don't know for sure.

[Turquesa]

Somebody recently posted this in a different thread (which one it is escapes me!), and it home so much that I bookmarked it:

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

Most birth plans can be summarized thusly: “You will treat me with respect at all times and I will maintain the autonomy that I had before entering your hospital. Before you touch me or intervene in the normal course of my labor/delivery, you will discuss it with me and obtain informed consent.”

Women aren't doing birth plans to "plan" their births. They're doing them out of a fundamental mistrust of our nation's maternity care system. In order to regain this trust, maternity care providers have a long road ahead of them.

[MegBoz]

Originally Posted by umsami

In the city where I live in Florida, birth balls are not allowed at all due to one woman falling and hurting herself. Once again, we all lose out because of defensive medicine.

I was thinking about this this morning while I worked out with my stability ball.

So I'm a fitness instructor & have trained with Resist-a-Ball. I learned a lot of great tips I pass on to my students to not fall off the ball. But ya know what? Most people do at least once! Seriously! And when it happens in my class, I usually say that - I usually reply, "Don't worry, everyone falls off a few times, I think it's a right of passage." Of course I'm trying to make them feel less embarrassed, but it actually is also true!

But we still have stability balls in all the gyms I work for & still use them in class.

I guess that proves the point that the medical field is more wary of lawsuits - which I suppose is a results of the facts that lawsuits are more common & the payouts are larger than fitness clubs.

Still, I'm very thankfully I [likely] don't have to set foot in a hospital & even if I did, the hospital where I had DS is quite NCB-friendly & has balls. But if I was faced with that, I'd be tempted to fight just purely on principle. (being bossed around doesn't sit well with me. HB is definitely the way to go for me!)