To present a birth plan or not to present one?

[msmiranda]

I'm so confused at this point I don't know whether to scratch my watch or wind my butt, lol.  I've been reading all this stuff about birth plans, and how short they should be, and how nurses make fun of them, and how they can cause hostility, and on and on.  I'm having a hospital birth in a hospital that is reputed to be natural birth friendly, but the likelihood that I will have met the OB who will be on call at the time is very low (he or she will have access to whatever birth plan I have in my computerized records, though, and my OB seemed to want me to give her something to put in my chart regarding my preferences for whoever is on call, if it is not her, to read).  I do have very specific preferences about a lot of medical issues related to the birth and postpartum period, but I am wondering whether it wouldn't be better to give the written plan only to my husband and doula for their reference, and just politely decline things as necessary when they are offered/recommended rather than giving a written document to the nurses and/or to the doctors.

OTOH, there are some routine things we will be opting out of/declining that are often done very quickly (e.g., pitocin shot during third stage, eye goop for baby) that it might be useful for the doctor and nurses to know in advance so we don't startle them by shouting "NO!" in the moment.  Perhaps I should limit my "birth plan" to just those things and we can convey the rest of our wishes orally?

I don't want anyone to roll their eyes at me, or make jokes about me behind my back, because they think I'm one of *those women* who is unreasonable and/or ignorant about birth.  (I am neither).  I am very confident in the choices that I have made, including ones that differ from how most women give birth in hospitals (which is most of them), because I have had two intervention-free births already.  But I am also reasonable and flexible enough to be able to accept an intervention if one becomes medically necessary.  I'm not sure how best to convey that to the people who will be in attendance at my birth, since it's unlikely I will have met any of them before.  If not a written birth plan, then what?  Any thoughts?

[thedenverduo]

I wrote out a very long and detailed birth plan that I didn't end up taking to the hospital.  (: It was really helpful for dh and I to be able to discuss everything and make sure we knew where each other stood.  Then in my electronic chart thing they wrote "Would like to avoid all interventions if possible." and that was that.  Everyone that came in the room knew that I was trying for a natural birth, and that they needed to ask before doing anything.

Honestly, I say go without one.  Know what you want, and make it clear that you want a natural childbirth and are going to decline some or all of the standard procedures and then let it go.  I didn't want to go in with a plan of how my birth was going to go and then be totally disappointed or unable to let go of that ideal.  My labor and delivery were totally different than what I had "planned" but I was able to be in the moment and make my choices known.  I would include something short and sweet in the computerize records, like "No pitocin. No eye goop. No Vit K shot." Or whatever so that whoever ends up being the OB can see that.

The L & D nurses are the ones who are going to spend the most time with you and want to know your preferences and ask you a bunch of questions and help you go through the paperwork.  You will be able to vocalize your wants and needs to them without giving them a birth plan.  Your dh will just have to be in the loop and ready to stop someone and say "Wait. What are you doing?" if they come at you with a needle or your baby with eye goop.

[prothyraia]

I would have a detailed written plan for you, your husband, and your doula as a reference.

I would hand something like this to your doctor/nurse for your chart:

"Birth Plan"

We are planning a natural childbirth and have some specific preferences.  Please check with us first before doing anything, no matter how routine, including ((vaginal exams, administering medication of ANY kind to mother or baby, suctioning after the birth, just 1-4 examples of things that are important to you that are very routine and might happen quickly)).  Feel free to ask in advance if you have any questions!

If there is an emergency situation, please keep us as informed as reasonably possible while you act.

Thanks,

Me, Partner, & Baby

-----------------------

If your OB practice is asking for something *now* for your records, I think it's appropriate to give them a really simple laundry list.  One list of things under the column "No", and one list of things under the column "Yes", without extra verbage or explaination.

[crunchy_mommy]

I wrote up a plan but never presented it, and I really regret it. DS's birth was traumatic for other reasons as well but just having the birth plan in place I think would have clarified some of my wishes, because things happened so fast & I was so out of it that I wasn't able to fully convey all the details in the moment (and DH was clueless). If you don't want to write up a full plan about how you'll labor etc., I would still go for the 'limited' plan, especially if you're opting out of the 'required' things (having it in writing would make the hospital less liable?) OTOH, if your DH is a good birth partner and/or you'll have a doula, hopefully they will be able to stand up for you if you're not able to yourself.

[wombatclay]

For me personally a birth plan is the perfect time to sit down and really think about what you want/don't want and what you absolutely need/can have an ok birth without.  This is also how I presented birth plans to doula clients.  I say go for a super detailed plan!  Consider everything that could go right, everything that could go wrong, what you'd be able to look back on and feel "great" about or "ok" about or "horrible" about.  Talk with your partner and doula, check what options are available already (for instance, if the birth center doesn't have a tub then either you need to bring one or you need to leave "give birth in tub" off the list) and write that 30 page plan!

The thing is... once you've studied and researched and role-played all sorts of scenarios, break it down into just three or four things for each stage of labor and three or four things for an emergency.  And then take that Cliff Notes version of your birth plan to your care provider and get it added to your computerized file.  That way the important people (you, your partner, your doula) will have had several in depth discussions and be on the same page about all the details that may never come up while at the same time there will be a short and sweet, easy to read in under a minute, birth plan for the staff to review.

My birth plans generally had a heading with my name, partner name, doula name, my care provider name, baby's care provider name.  Then a short "we've enjoyed our previous births at hospital X and look forward to another natural labor and birth using hypnobabies!" blurb and then a bulleted list divided into early labor (heplock only, free to move/use the tub, will request medication as desired), active labor/pushing (freedom to move, no epi, delayed cord cutting, babe on my chest immediately), and postpartum (delay NYS mandated tests till 2hr mark, will breastfeed no formula/glucose/nipples, will not circ).  There's also a section for "in case of emergency" (I'm a VBAC mom so I include c/s preferences like arm free of restraint, dh to remain with babe at all times following pp wishes as possible, breastfeeding in recovery with LC support). 

Anyway, I think that a lot of the bad rap associated with birth plans comes from a sort of confusion about who the birth plan is for.  In my opinion, the birth plan is for mom/partner (and possibly doula) to really think about what they want/need.  Then once you've gotten that figured out you can bring something to your care provider and make sure that what they offer is going to match what you want while you still have time to explore options.  That said, if someone rolls their eyes or makes a rude comment to you for whatever reason.... let the head nurse know, let the hospital PR or customer care office know, and most certainly mention it on the review survey you'll be sent!  That sort of behavior may be normal and human, but it's unprofessional and has no place in the birth suite.  And remember that most hospitals will accomodate your request for a different nurse if you're assigned one who just can't mesh with you.

Good luck!

[msmiranda]

Originally Posted by prothyraia 

I would have a detailed written plan for you, your husband, and your doula as a reference.

I would hand something like this to your doctor/nurse for your chart:

"Birth Plan"

We are planning a natural childbirth and have some specific preferences.  Please check with us first before doing anything, no matter how routine, including ((vaginal exams, administering medication of ANY kind to mother or baby, suctioning after the birth, just 1-4 examples of things that are important to you that are very routine and might happen quickly)).  Feel free to ask in advance if you have any questions!

If there is an emergency situation, please keep us as informed as reasonably possible while you act.

Thanks,

Me, Partner, & Baby

-----------------------

If your OB practice is asking for something *now* for your records, I think it's appropriate to give them a really simple laundry list.  One list of things under the column "No", and one list of things under the column "Yes", without extra verbage or explaination.

I *LOVE* this.   And as for the second part, I actually did write up my list with a no and yes column without ever having heard of anyone doing it that way before (though I'm sure plenty of people have, just no one I know personally).  I'm going to bring it to my OB on Thursday and ask her which items on that list she believes it would be helpful for the doctor on call to know upfront, and then whittle it down to just those.  As for what to present to the nurses, if anything, I am going to ask on the hospital tour what they would find helpful or not, and maybe I'll just give them something like the above.  This hospital is supposedly very accustomed to natural childbirth-seeking mamas, so I hope it won't be an issue either way.

Thanks for the responses, everyone.  I have spent a lot of time writing up my preferences and researching some issues that I wasn't totally up on, and it has been very helpful in my preparation and in getting my husband and doula prepared to advocate for me/help me advocate for myself if it comes to that.  I highly recommend it as an exercise in getting a handle on what you want and don't want out of your hospital birth.  Still conflicted about the idea of presenting a long list to doctors and nurses though. :)

[Tumble Bumbles]

We're planning an unassisted birth, so our 'plan' is more to do with a c-section, newborn procedures and so on -- due to the fact that should we be seeking medical attention in the first place, a c-section would be likely. So, keep that in mind in my reply :)

To me, I couldn't give a flip if nurses scoff at me, people think I'm one of "those" mothers or whatever as long as they respect the fact that nothing will be done to myself or my baby without my consent. Obviously,  I would use the same level of courtesy and respect I would with anyone but when it comes down to it, I'm not there to make friends. I'm there to make sure my needs and the needs of my baby are taken care of in a professional manner in keeping with the Patient's Rights as laid out by my state and with respect to my legal right to make all medical decisions concerning myself and my child.

I don't mean to sound abrasive, but this is truly the way one has to look at things in order to get their needs met in a hospital situation (in many cases). Like my husband said, it's not that they are 'out to get you', it's just that whenever you disrupt the regular 'order' of things it tends to be met with annoyance or contempt by the staff.  It doesn't mean you have to be rude or disrespectful, you can be all smiles and respect outwardly, knowing inwardly that no one is doing you a favor by treating you, they are doing a job they chose to do in a profession that revolves around service, and that they must uphold the integrity and legal rights of patients while doing it whether you're the "joke of the nurses station" or not goes a long way to ensuring you (and your partner) will be good advocates for you and your babe. I'm a 'jokey' type person, so I would probably outright say something like, "yes, I'm one of those patients but I promise I'll go easy on you" with a genuine smile while still advocating for my rights.

That having been said, our transfer plan is short - less than one page long. The top 1/3 is info about me, name, ss#, blood type, insurance info etc so they would have that all on hand as soon as I came in. The rest is one line do/do not consent statements so a copy can be kept in my chart as written documentation to support mine or my husband's verbal consent or refusal. Obviously my consent trumps my husband's but if I were non-responsive (God forbid) for whatever reason, his consent/refusal is what they would need.

 The document itself is not considered a legal document per se, but it's very useful as supporting documentation to verbal consent/refusal. Verbal consent trumps any prior written though, which is why one must be careful what they say in moments of high intensity (a mama during pushing yelling "Get this baby out NOW!!!" could be argued as consent for forceps/vacuum for example, even if the birth plan refuses consent to those procedures).

As far as the 'freedom to move' , "no cervical checks" stuff, I think that can be pretty much left out -- as your verbal refusal in the moment suffices and those things aren't something they can just do without you knowing they're moving in that direction. Usually someone will walk in "time to check progress!" then your verbal "no thanks" is enough. I think for those other issues you mentioned, it's good to have something written to serve as a reminder for you or your partner.

Remember, birth plan or not, you have the legally protected, constitutionally-upheld right to consent to or refuse any and all tests and interventions. You have the legal right to have someone with your baby at all times (yourself, partner etc).  I realize I'm a bit more...defensive?...because we are making a choice that is very much frowned upon so if we did have to go in, we sort of expect to have to be strong advocates for ourselves.

I'm sure everything will go just wonderfully.

[MegBoz]

I suspect nurses rolling their eyes at birth plans - or thinking the longer the plan, the more likely you are to have a CS - is a rare thing.

Mine was one page, broken into 6 boxes: Medication & monitoring, labor, delivery, 3rd stage, newborn procedures & c-section. With a nice intro at the top & a mention that we did Bradley method & are I'm a fitness instructor (I feel like that sometimes carries weight with people - like it's *proof* I AM fit, healthy, comfortable with my body & physical exertion, I know how to breathe so don't yell at me during delivery, etc.)

I birthed at a very NCB-friendly place, and the nurse who came on duty the morning AFTER my DS was born walked into the room, introduced herself & said, "I wanted to compliment you. You seem very well read."

I was surprised & then realized & said, "Thanks! But, how do you know?"
She said she'd read my birth plan!

Not only did she bother to read the plan the day after the baby was already born, she complimented me on it!!! (Was very typical crunchy plan - I want to birth in any position that feels comfortable, immediate skin-to-skin, no pit unless necessary for labor or 3rd stage, no eye goop, etc.)

The lactation consultant also bothered to read it. (I know because she asked me about teaching fitness since excessive exercise can inhibit milk production - which I knew - I only teach 2 days per week.)

I say definitely write one. If you sense you have the type of nurse who would roll her eyes at it - request a new nurse! Although I do recommend keeping it to one page, keeping it brief (mine was all bullet points) & not bothering to include things that are standard anyway (like rooming-in, if that's standard)

[kltroy]

IME, it's good to have a brief birth plan with the things that really matter.  We also had electronic medical records, and I watched as my family doctor typed in most of my preferences for the birth during a prenatal visit.  Turns out, she was out of town for the birth, so I got the on-call doctor.  He was really great and mentioned on more than one occasion that my doctor had done a good job writing things down.  As a result, my birth plan was followed TO THE LETTER. 

I did not ask for stuff that was already "standard operating procedure" (like rooming in with my baby).  I also did not ask for stuff that was not relevant to the birth (like circumcision).  And the real key is that I designated my mom and husband to *remind* people of what I wanted when it became relevant. For example who cares about delayed cord clamping when I'm still in active labor?  It is important to remind someone right after/as the baby is born.  Etc etc. 

So I say, do it, but keep it short and sweet.  And designate someone to be a "reminder".

[lmoore7156]

Who cares if the nurses make fun of a birth plan? That's their issue, not yours. I call mine "Birth Preferences."

Everyone is SOOO different in their preferences. Though in this community, we tend towards the natural, many of my girlfriend's birth plans will read something to the effect of, "GIVE ME THE EPIDURAL AS SOON AS IS HUMANLY POSSIBLE!" Doesn't look like that's your preference.

For example, I don't want perineal massage. Many natural birthers do.

A birth preference can start with something like this:

We request 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. We would appreciate being assigned a nurse who enjoys working with couples who have prepared for natural birth.

In the event of an emergency situation with either myself or my baby, I am happy to discuss, however briefly, any measures which may be deemed medically necessary prior to their implementation; and, in the event of a normal birth we prefer the following:

Then just list the few things that are very important to you that you don't have to conitnually repeat. This also helps if the nurses change shifts while you are there. Remember, you are the consumer. You are PAYING for a hospital birth. It is totally reasonable to let the staff no what kind of birth your prefer. It helps them.

[msmiranda]

I ended up calling mine "birth preferences" too!  At some point after posting this thread, I took the hospital tour and talked to my OB and decided that having something written would be worthwhile.  I shortened it as much as possible, and I did a separate one for the nurses, with the stuff they need to  know the most, and one for the doctor.  The doctor one is already scanned into my records, and I'll bring the nurse one to the hospital.  The nurse one is one page, the doctor one goes onto a second page but not by much.  Here is the nurse one:

XXXXXXX BIRTH PREFERENCES	These are our decisions regarding our care during a normal/uncomplicated labor, birth, and immediate postpartum period.  Thanks in advance for your cooperation!
CONSENT	Always obtain verbal consent before doing anything to me or baby
IV	Saline lock only
FETAL MONITORING	Intermittent monitoring (please assist with remaining in a standing or kneeling position during monitoring if possible)
VAGINAL EXAMS	None until ready to push, or at my discretion
PAIN MEDICATION	I will ask for it if I want it – no need to offer
PUSHING	(1) Side lying position – please do not ask me to lie on my back (2) Self-directed – please do not count to 10 or otherwise direct my pushing (3) Expressions of encouragement (e.g. “you’re doing great”) are welcome
THIRD STAGE	Expectant management – no pitocin shot, cord traction, or uterine massage please
TIME FOR BONDING/NURSING AFTER BIRTH	Please allow as much time as we need to have skin to skin bonding with baby and nurse for the first time before asking to take baby to be weighed.   (About 30 minutes)  Apgars taken while baby is on mom.
NEWBORN PROCEDURES IN LDR ROOM	(1) Please administer Vitamin K shot (2)** NO eye ointment please** (we will be happy to sign a form if necessary)

[Comtessa]

My first birth was a HB transfer at a very NCB-unfriendly hospital.  Having a birth plan in my file, signed by my OB, ended up being enormously important for me to get the closest thing as possible to the birth I wanted.  The routines and procedures of the hospital were NOT in my favor, which meant that I certainly had to advocate for myself and the baby verbally during my stay, but having the birth plan helped me avoid some of the verbal fighting I would have had to do otherwise.  I think that having things written down and signed says, "I am damned serious about this and I WILL make a stink about it."  That's enough to make at least SOME folks glance at the plan before walking into your room. 

Probably the most important reason to write a birth plan is that it gives you an opportunity to discuss your preferences with your HCP ahead of time and find out what items might be an issue.  For example, I had "wait up to 1 hour for placenta to deliver naturally" on mine this time, and my MW said, "I really can't wait 1 hour, but 30 minutes is reasonable for expectant management," so I listened to her and changed it.  It's helpful for me to know that ahead of time, so I don't get angry with her in the moment for what I perceive to be "active management" on her part.  KWIM?  It's good to know where they feel they really can/cannot compromise for legality reasons, safety, etc. 

A good HCP will also give you some advice about how to advocate for yourself with the rest of the hospital staff.  For example, I put on my birth plan "in case of C/S, if DH must leave with the baby, please allow a second support person inside to accompany me."  My MW told me that this doc is ok with a 'doula' stepping in, but might balk at having my mother come in (for example), so I should just call her my "doula" and it would be fine.  This is very good information to have ahead of time.  I can think of lots of examples where my HCP's have given this kind of advice based on what I wrote in my birth plans. 

I think that birth plans can cause hostility or amusement when they are a little ludicrous -- like the person who writes "No IV" on her plan but right below it says "I want an epidural."  Obviously she has no idea what she's doing with that birth plan, because one cannot get an epidural without IV fluids.  Others put things on the birth plan that are outdated or show a lack of information about the hospital.  Writing "please do not shave my pubic hair" is probably unnecessary at most hospitals these days, for example (though it's not completely unheard of).  Likewise, if nobody in your HCP's practice does routine episiotomies, you can probably leave it off your birth plan, but if you know that some of them are a bit scissor-happy, you might want to make a strong point of saying DO NOT CUT ME on your birth plan.  A well-written, respectful, clear, concise birth plan that stays away from outdated, silly or outrageous requests, though, should really not be met with ridicule. 

It reminds me a little of the contracts that performing artists send ahead for their gigs -- most of them have a section for personal requests, and most of them are perfectly reasonable (i.e., "please have 5 bottles of water available backstage and a private area to change clothing"), but some are totally ridiculous ("three bowls of yellow M&M's to be waiting for us in our dressing room when we arrive at 2 am").  The ridiculous ones cause a great deal of eye-rolling and annoyance among staff at the concert venue (especially when you're the chosen M&M sorter), but really, they don't raise eyebrows, otherwise. 

Now, I'm fortunate to have a lot of hospital choices in my area (you might not have those sorts of options), but I chose my birth hospital this time specifically based on the nurses' responses to the question "do you recommend bringing a birth plan?"  If they say something like, "the longer the birth plan the more likely the C/S," (which I heard at hospital #1) or "well, come with ideas of what you want, but don't write it down and tape it to the wall or anything" (which I heard at hospital #2), I keep looking until I find a more supportive environment.  The hospital I chose makes a strong point of encouraging written birth plans from every woman who walks into L&D. 

I see the birth plan as an extra layer of insurance -- alone, a birth plan is not enough, but combined with strong verbal self-advocacy from you and your partner, AND a HCP who knows your preferences and has agreed to honor them, AND a hospital with reasonable policies and procedures, it means you're pretty likely to get the birth experience you're hoping for.