Did I forget anything? (birth plan)

[msmiranda]

I hope that this is just an exercise in finding out some information and not something I will need to use, but I have my 16 week appointment on Thursday and decided to compose a list to see how willing the docs would be to honor my preferences.  I did phrase the list as a negative, in part because I don't have very many requests for the nurses or doctor that are affirmative in nature, and in part because I think it is the most effective way to communicate what I want/expect.  Like it or not, women like me are a deviation from what they normally see and do, so I'd rather be direct about that. 

My situation is this:  I have an HMO that severely limits my choice of doctors, and there is a large call schedule so I will not be able to meet every doctor who could potentially be there for the birth.  Probably I won't meet any other than the two I've already met.  I will see this one OB, who I like, for the rest of my pregnancy.  [I have a midwife and am actually planning a homebirth, so this is mostly shadow care, but I'm interested in knowing what this practice is like for women who can't afford home birth or don't feel comfortable with it).

Anyway, I mostly wanted to post this to see if I have forgotten anything important!  What do you think?

In the absence of a clear medical indication, I will NOT consent to:

1.      Cervical checks during the final weeks of pregnancy.

2.      Ultrasounds in late pregnancy to estimate the baby’s weight.

3.      Induction of labor (any method).

4.      Routine administration of IV fluids during labor.

5.      Vaginal exams during labor, except at my sole discretion.

6.      Pitocin augmentation during labor.

7.      Amniotomy during labor (I would consider it in the second stage).

8.      Continuous electronic fetal monitoring.

9.      Limits on mobility during labor, with the exception of during intermittent fetal monitoring (if it is not possible to maintain mobility during monitoring).

10.Internal fetal monitoring.

11.Any type of anesthesia or analgesia, unless requested by me.

12.Pushing in lithotomy position.

13.Episiotomy.

14.Immediate cord clamping or cutting.

15.Active management of the third stage, including administration of pitocin (either via injection or IV), cord traction, or manual placenta removal.   

16.Cesarean section.

17.Removal of baby from my arms immediately after birth. 

Routine procedures/practices to which I will consent:

1.      Hospital gown.

2.      Hep lock/saline lock.

3.      Intermittent fetal monitoring.

I am reasonable and well informed.  I understand when interventions are medically necessary and would consent without hesitation should such a situation occur. 

[msmiranda]

And I should add, I prepared a separate list for newborn procedures and everything that occurs after the birth, since those are really things to take up with the hospital rather than the OB.

[Turquesa]

One question: Are you against ALL intermittent fetal monitoring?  The use of auscultation (usually a Doppler) is evidence-based, non-invasive, and allows you freedom of movement in labor because you're not attached to machinery.  If you don't object to a Doppler, you could rephrase it as, "routine, continuous internal or external electronic fetal monitoring."

In case you DO end up medically needing electronic monitoring, you should probably include something about how if the monitor indicates fetal distress, the staff definitely needs to double check the heart rate with a Doppler.  EFM is notorious for giving "false positives," (i.e. indication of fetal distress where there isn't any), which could lead to an unnecessary cesarean.

There's a lot of debate out there about whether or not it's a good idea to phrase things "in the negative," e.g. "I do not consent."  There was a thread going about this some time back.  A lot of hospitals actually coach women on how to write their birth plans and claim that it's best to say, "if possible," or "I would prefer." 

Personally (and I think most people disagree with me), I'm all for saying "do not consent."  Words like "if possible" leave to much room for staff to do what they want and spin it into a "necessity." 

Maybe to take an "edge" off of it, though, you can slip a "please" into your wording.   "In the absence of a clear medical indication, please be aware that I do not consent to the following..."

And maybe end it with, "Thank you for getting our growing family off to a good start!"

[msmiranda]

Intermittent monitoring is in the "I will consent" list, so no, I'm not opposed to it at all!  I would prefer doppler to the EFM, but I'm not sure whether that is offered at the hospital I would (but hopefully won't!) be going to.  I will find out when I take the tour, I guess!

Re your other point, yeah, I will have to talk to the OB about what "clear medical indication" means.  Basically it means that *I* will have to be convinced that there is a medical indication that necessitates whatever it is they are recommending.  Fortunately I have a pretty good knowledge base ... although were I to have to go the hospital route, I would definitely do some additional studying. 

Oh, I should also add that this is just a list that I'm taking to show my OB at my appointment, not the official "birth plan" that would end up in my file (probably not, anyway).
 

Originally Posted by Turquesa 

One question: Are you against ALL intermittent fetal monitoring?  The use of auscultation (usually a Doppler) is evidence-based, non-invasive, and allows you freedom of movement in labor because you're not attached to machinery.  If you don't object to a Doppler, you could rephrase it as, "routine, continuous internal or external electronic fetal monitoring."

[MegBoz]

Originally Posted by msmiranda 
In the absence of a clear medical indication, I will NOT consent to:

1.      Cervical checks during the final weeks of pregnancy.

2.      Ultrasounds in late pregnancy to estimate the baby’s weight.

3.      Induction of labor (any method).

JMHO, but I don't feel the need to include these on a birth plan. Mostly because I view the birth plan as a document to remind your doc or MW of your preferences when you show up in labor - and to inform the nurses (since you've never met them before.) These 3 items wouldn't occur in the hospital anyway - they'd be at office visits (or scheduled at office visits). Late PG VEs are easy enough to avoid, just don't take your pants off when the nurse walks you into the room. If the doc asks about it, it's easy to address then. (Although I can see how you'd want to discuss it with the OB.)

I think the value of leaving them off means there are fewer line-items on the plan for nurses to review, so they are therefore less likely to miss something.

"13.Episiotomy.

14.Immediate cord clamping or cutting.

15.Active management of the third stage, including administration of pitocin (either via injection or IV), cord traction, or manual placenta removal.   

16.Cesarean section."

Regarding episiotomy and active mgmt, I think it might make you appear more informed to state, "I do not consent to episiotomy for any reason other than serious fetal distress." i.e. that leaves no room for a moron doc who actually thinks he's "saving you" from a worse tear or an upwards tear and therefore he thinks it IS medically necessary. You could also state you don't consent to 3rd stage active mgmt for any reason other than PPH. Again, docs may think simply having to wait is "medically necessary" Ya know, the diagnosis of "retained placenta" because it hasn't spontaneously detached in 15-20 minutes. (rolling my eyes.)

You could also add, "And I prefer to breastfeed to help the uterus clamp down & placenta deliver." Again, to show you're informed and you WILL take some alternative action to prevent PPH & retained placenta. Not that I think it's "crucial" but it is a best-practice & BFing immediately is something I presume you'll want to do anyway.

I also don't think I'd put CS as a simple line-item of "things I won't consent to." I really don't think there are that many OBs out there doing CS without even a BS/ straw-man reason. You could maybe state, "CS for any reason other than fetal distress." i.e. you won't consent for the BS reasons like suspected fetal macrosomia, CPD, failure to be patient -i mean progress- etc.

I think clarifying things like that might actually make you appear more well-educated and informed to the OBs & nurses who would be strangers to you. Might also help reduce animosity.

Finally, did you want to consider a CS section? I planned a hospital birth with my DS & my doula laid it out for me on one-page (one-side) in 4 quadrants, 1 square for CS. Things like wanting DH & doula with me, not consenting to Versed.

I'm planning a transfer plan now for my HB & am putting a lot more thought into the CS section because obviously the only way I'll be in the hospital is if something is going wrong, and therefore if I'm in the hospital, I think a CS would be more likely than it was the first time. I'm going to add wanting to see the baby be born & have immediate skin-to-skin & I'll discuss that with the MW to see if it's even possible. Although on the skin-to-skin, I'm tempted to do it anyway - to give DH instructions to simply take the baby out of the nurses hands & put her on my chest as long as she's obviously breathing fine. Better to beg forgiveness than ask permission, ya know? Besides, she's OUR baby - they have no right to "deny" me immediate skin-to-skin, but I digress.

Originally Posted by Turquesa 

Personally (and I think most people disagree with me), I'm all for saying "do not consent."  Words like "if possible" leave to much room for staff to do what they want and spin it into a "necessity." 

:( Unfortunately, the fact of the matter is that you don't need to "give" the staff "room to do what they want" - they have the room and they will take it. :( I've heard time and again of episiotomies being performed while mama screamed, "NO, I do not consent" or wasn't even TOLD it was happening and the worst part is that she has no legal recourse. It is considered part of a "standard of care" - unlike say putting scissors up the mama's nose & cutting here there (even though personally I would prefer my nostrils be cut than my vagina without cause.) I read about it in Pushed how a lawyer fighting pro-bono for maternity rights often gets request to sue for anti-consent epis & she won't take the cases because they are simply un-winnable. Pathetic & horrible fact.

Point being, the "do not consent" wording in a birth plan is not a guarantee to protect you anyway. Although I do think the phrase "I do not consent" is worthwhile to remember to say out loud in the moment - but not any more "protective" when written into a plan.

[msmiranda]

I should not have said "birth plan" in my title, since that's not really what this list was.  It was a preliminary list of things I took to the OB to gauge her reaction to the kind of specifics I mean when I say I want a "natural birth" (which to many OBs just means, no C-section, maybe no pain meds).  And again, it's pretty much theoretical because I won't be using an OB unless I transfer, at which time natural birth would be out the window anyway.  This was more of an academic exercise. 

But anyway, I am  happy to report that she really didn't bat an eyelash at ANY of them other than saying she recommends induction at 41w (but that of course I had the right to request expectant management instead).  I was just curious whether, if I couldn't afford to pay a midwife out of pocket or wasn't comfortable with OOH birth, someone like me who wants a normal birth could expect a lot of pushback or whether they would be supportive within reason.  She actually said that everything I listed sounded very reasonable and that I seemed well-informed.  Of course there have been plenty of instances where doctors say "sure honey, whatever you want" and then it's a whole different story when you actually show up at the hospital, but I didn't read any discomfort with normal birth on her face at all.  She didn't seem remotely threatened by my having composed such a long list or in how I worded it.  

I will turn in an actual birth plan later on to be put in my file, but it will be much more weighted toward c/s and the like because it would only apply in the case of a transfer.  And of course I have my separate list of newborn stuff that I will ask the hospital when I take the tour. 

[dejagerw]

Have you thought at all about putting all or some of the items into what you do want instead of what you don't.  For example, someone just glancing at the birth plan, might not see the "I do not consent" part.  They might just see "episiotomy " "immediate cord clamping".  Maybe you should state things that are desired.  "No episiotomy, I prefer to tear naturally", "delayed cord clamping" "No pain management unless requested by me" "immediate skin to skin contact".  I think it might be easier for someone to read if they're reading what you want.  It will also come off a little less abrasive IMO.  You could also probably leave off the list of "things you will consent to".  I'm sure it's pretty much assumed you will consent to those things.  You might also want to put your newborn list together with this list just to be sure it's not missed.  A separate page might be easily overlooked.