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Discussion Starter · #1 ·
Someone recently posted a really great birth plan that she had prepared for an emergency transfer to the hospital. It didn't have most of the main stuff you would have for a planned hospital birth (no continuous EFM, no routine IV, being allowed to drink/eat, etc) because it would only be used in case intervention was actually NEEDED. Now I can't find it!

I really don't need much, because if I were to transfer my midwife would go with me and run interference with the staff, who know her very well. And her backup OB is 'one of the best MWs she knows'. So what I'm looking for is just 'unusual' stuff that they may not be used to people declining.

For example, in The Thinking Woman's Guide, Henci Goer talks about the risks of bolus IV fluids. I have 2 cousins and other stories that have made me really wary of getting too much IV fluid. I don't know that this is something most moms would usually object to, especially in the midst of being prepped for a C/S, for instance.

So I want to have a very short birth plan to give my MW (and discuss with her beforehand, of course), so that she will know about anything out of the ordinary that I won't want done. Does that make sense? Any other thoughts? What did you put in your (emergency transfer) birth plan that you think was a very specific request, a bit on the 'unusual' (not sure of a better word) side?

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Here's our transfer birth plan. If we transfer, we'll be going to the hospital where I work as an L and D nurse, so most of these are in response to questions I know will be asked. I also wanted to give a list of people who might be there since I appreciate knowing who is who in the birthing room. Otherwise, if we're going in, it means the whole plan has changed and so flexibility will be the name of the new game. These are just the things that wouldn't change no matter c/s or vag, epidural or not etc.

If you are really concerned about a fluid bolus, you could decline or ask that your iv rate be turned down if you're just in labor, but if you are getting an epidural, or a c/s, I don't think they will be very flexible. The purpose of the fluid bolus is to help maintain your blood pressure, which almost always drops during anesthesia placement. I wouldn't decline it.

Our Birth Information

People who might show up:

Jim, husband
Janet, my mother
Amy, sister-in-law
Kim, Certified Professional Midwife, Licensed Midwife
Gretchen, Certified Professional Midwife, Licensed Midwife

We'd like to see the CNMs if we don't risk out. Otherwise, no residents please.
Dr Wonderful for a pediatrician.
If possible, I'd like to avoid rooms 353 and 354. (This is where we often have our fetal demise babies and so there are too many negative associations)

We don't know the sex of the baby--if possible we'd like Jim to announce it.

No thanks, we decline the Hepatitis B vaccine here in the hospital.

No thanks, we decline the erythromycin eye ointment.

Yes please, we would like the Vitamin K shot.

No thanks, we do not plan on circumcision.

No thanks, I'll skip the TDAP and the flu shot.

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Discussion Starter · #4 ·

Originally Posted by cileag View Post
If you are really concerned about a fluid bolus, you could decline or ask that your iv rate be turned down if you're just in labor, but if you are getting an epidural, or a c/s, I don't think they will be very flexible. The purpose of the fluid bolus is to help maintain your blood pressure, which almost always drops during anesthesia placement. I wouldn't decline it.
Thank you so much for responding. That is very helpful.

According to the Thinking Woman's Guide:

Jaundice and breathing difficulties (in addition to blood/electrolyte dilution, glucose issues & inflated birth weight) at birth are almost certainly due to large amounts of IV fluid being given preoperatively in an attempt to prevent low blood pressure from spinal or epidural anesthesia. ... You may wish to refuse this since studies, including a random-assignment trial to preload IV fluid or not, show it doesn't work anyway.
Parenthetical note added by me. I was concerned that this is not a point they will be flexible on. Something to talk with my midwife about and maybe have my doula watch for the rate that they are given if it were to come to that.

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We just had a c/s stat last night for fetal distress (with fhts in the 60s) after a mom's bp dropped after her epidural placement. The evidence might be inconclusive, but in a situation such as that, the hospital is going to try anything they can to get your BP up---they do other things too as well btw, but I can't imagine them negotiating at that point.

The best thing to do is avoid an epidural---and if it's a c/s, then it's anesthesia who will be administering medications etc, and I have never found them to be very flexible.

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Do you mean after a c/s? Or before for augmentation?

For augmentation purposes, yes due the fact that Pitocin is usually administered in very small amounts (starting at 3 cc/hr), you need a mainline running concurrently. If I have a patient who's unmedicated otherwise, and drinking fine, I usually turn that down to about 50 cc/hr.

During the surgery itself, you'll probably get a liter of Lactated Ringers, and then after the placenta is out, they'll start Pitocin running pretty quickly (after a vaginal birth too, we usually run IV pitocin in very quickly as well--but that you have more flexibility with). In recovery, most OBs order an additional bag of pitocin to be administed (due to the increased blood loss of a c/s) at a more moderate rate--125 cc/hr for example and then when that is done, if the patient is not eating or drinking, we hang a dextrose solution (D5 LR) at 125/hr. But not concurrently.

I'm sure other hospitals have different policies, but that's a general idea of what might happen.

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In my experience, most homebirth transfers are a bit dry going in. As most homebirth transfers are for long labors, and it's hard to maintain hydration over a 24-36 hour labor, that IV can be really helpful in making the uterus contract efficiently and improves natural pain control. Pretty aggressive IV fluids can be a part of going into the hospital. I think it can make sense to keep 'em running until the mother is passing nice light yellow pee and then turn it down to minimum. This is something that good nurses do automatically. Newer, less experienced or too-busy nurses can let it slip. No one wants you fluid overloaded. It just doesn't help you out.
Here's a previous post of mine.

Here's a link to a blog post from a midwife. She talks a lot about issues with birth plans and has a lot of different posts about not being able to change the ride with a piece of paper.
I'd recommend checking out a few of her posts, if you have the time. The one I linked to has her thoughts on the plan.

I do recommend writing out a long birth plan for your birthin' minions. It's great for your husband, best friend, doula, MIL, etc. to know the run down. The typical minion's reminder for an average MDC mama might say: no vax, no eye goop, no circ, BREASTFEEDING, no episiotomy, no pain medication, let me walk around, no IV, no baby in the nursery. But that's not for your care providers. It's so anyone can answer for you, and is on the same page on your team.

For the providers - I recommend something hand written on a single side of paper. You want it to be read, after all, and they are busy. Also, I wouldn't recommend outlining the above list. They should ask you for each thing and you'll just give your answers.

Here's a copy of a birth plan I have - it's in big, colorful font:
Birth Plan
Please give a full informed consent before all procedures
Sounds -keep the music playing
Lights -keep the lights low
Smells -use only mild types of things - no essential oils
Photography - take lots of photos - I don't think I'll mind the flash at all
Laughter -I really like the sound of happy people, let's see how this goes…
Please listen to heart tones with a fetoscope for as long as possible.
Please don't push on my legs too much - I have a sore hip joint
Lots of warm perineal compresses, please
I would appreciate lots of counter pressure to slow the descent of the baby's head
I am planning a lotus birth - if all is well, leave the cord until after the placenta delivers
Colostrum & Breastmilk only - no pacifiers or formula
No hepatitis B vaccination and no circumcision
Ask me about Vitamin K for the baby
In case of Caesarean Section
Anesthesia - please limit mediations that cause drowsiness
Breastfeeding - permission granted for anyone to help get the baby latched!

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There was a good thread on this topic a while back:

As far as fluids go, my experience was that getting the IV made me feel a LOT better after two days of labor at home (including throwing up a good deal of the fluid I was drinking). It gave me the strength to go on and have my baby normally... I wouldn't have declined it.

Here was our transfer birth plan.

Dear hospital staff: We appreciate you being here to support us through the birth of our first child! We have spent a lot of time researching the medical evidence for all of the decisions listed here, and we feel confident in the choices we have made. We thank you for respecting them, especially when they fall outside of "usual" hospital procedure.

We are preparing for a home birth. If we are in the hospital, it is because we require some intervention that was unavailable at home. Therefore, we are very prepared to be flexible on everything listed below if medical necessity arises. Barring a major medical crisis, we ask that you please discuss with us any and all interventions, allowing us the opportunity to give informed consent to any procedure you suggest.

In labor:
• Please offer us the minimal amount of medical intervention necessary for the health and safety of mother and baby. Like most natural birthing couples, we prefer to avoid routine procedures (continuous EFM, IV, epidural or pain relief drugs, Pitocin augmentation, etc.) unless clearly necessary for a safe birth.
Be prepared to fight for anything in this category that you really find important, but be willing to let a lot of it go in the case of a transfer. In my case, I needed an epidural to get some sleep - so I knew that there was no way I'd avoid most of these things once I requested the epidural. I just stayed aware of what I could decline, and I made sure I avoided those things - like internal monitoring, for example, or routine Pitocin.
• I am GBS negative and allergic to many antibiotics. Therefore, I do not consent to any antibiotics without evidence of infection.
• We request that two or three support people be available in the labor and delivery room with us at all times. This will include up to two doulas and/or our family members.
(we had to fight for this one, but they finally gave in.)

After the birth:
• The baby should be placed skin-to-skin with its mother immediately. This time is precious to us and we strongly desire that there be no physical separation of mother and baby for at least the first hour after birth.
this was way against hospital procedures, but the OB supported us and we managed to get what we wanted.
• We will use direct skin contact to maintain the baby's body temperature rather than a warmer. again, against policy, but they were super supportive of this.
• Please delay cord clamping until the placenta is delivered, or at least as long as feasible.
• Please allow up to an hour for the placenta to be delivered naturally. Please do not rush this process. We request no routine Pitocin for this purpose unless it is clear that breastfeeding is not working to stimulate uterine contractions.
I had to ask them to take the Pitocin bag off my IV stand and carry it into another room, just to be sure this request would be honored. I'm glad I did, because the nurse said, "but you're sure to need it!" and anyone who thinks that way is probably not going to pay attention to this line item in a birth plan.

For the baby:
• The baby is not to leave our room at any time for any non-emergency reason while we are in the hospital. If an emergency arises, one or both parents will follow the baby at all times.
• No Vitamin K shot (unless bruising or birth trauma occurs)
• No Erythromycin eye ointment, please.
• No vaccinations are to be given at this time.
"at this time" is a good way to not set yourself up for a vaccine lecture.
• No formula or pacifiers at any time, please.
• No antibiotics without evidence of infection.
• No screening tests of any kind are to be given without our explicit and specific permission.
• Please do not bathe the baby. We would like to give our baby its first bath. We recognize that this means you may need to wear gloves while handling the baby; thank you for doing this.

In case of a Cesarean section:
• we are not squeamish and would like to be able to watch as the baby is born.
• Please place the baby skin-to-skin on mom's chest as quickly as possible after it is born, health permitting. If she is unable to hold the baby, please place baby skin-to-skin with dad.
• If the baby must leave the room for emergency reasons, dad will accompany him/her.
• We request that the mother have at least one support person in the O.R. and recovery at all times; if the father must leave, please allow another support person to step inside to accompany the mother.

Thank you for taking good care of us and our baby!
We appreciate your support and care.

____________________________ mom
____________________________ dad

Approved by:
____________________________ obstetrician
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