Tuesday, January 26, 2010

Revisiting Birth Plans

I'm always on the look-out for birth plans that catch my attention for using a novel technique or strategy that in some way can garner cooperation and respect from hospital workers when parents try to communicate their needs. Since there is such a disparity between practice and evidence in birth services, most of the time, women who prepare birth plans are trying to get the evidence based practices employed in their births rather than what is on the contrary typically done during hospital births.

Below is a birth plan a mother shared with me recently. The reasons I think it is worth sharing are:
  • It recognizes the need for intervention in some situations and does not overinflate or minimize the risk of birth. Perhaps by framing the topic with "birth in inherently dangerous" hospital workers will be more receptive to reading the desires of these parents. While recognizing the risks and dangers, it emphasizes the fact that birth is typically normal. This balanced view, I hope, will earn the respect of birth workers.
  • The parents include the reminder that they have the right to informed consent and given concessions when consent might not be able to be obtained, while at the same time remaining firm that consent is necessary.
  • The father is explicitly stated as medical proxy if the mother at some point becomes unable to make decisions for herself, or even if she wishes at some point to grant the proxy to her husband verbally. This shows in a clear manner that the husband is involved and needs to be respected in the case that he states any decision.
  • Hospital staff are not obligated to support the provisions listed in the birth plan, but are merely stating that they have read it. This should be less threatening than the typical birth plan which generally presents a document asking hospital workers to make some sort of commitment to upholding the provisions; something that most workers are very hesitant to do for fear of liability.
I understand that birth is inherently dangerous, and, if the situation warrants it, interventions can be good, even lifesaving, that being understood, the vast majority of births are a normal, natural process that need little more than ‘the tincture of time’ to reach a safe and healthy end.
I understand that, at any time, my written or witnessed verbal consent may be given and will override any previous non-consent or refusal. I understand that in a true emergency there may not be time to fully explain or receive consent for a life saving procedure, and I will not attempt to interfere with life saving interventions. I expect every attempt will be made to give me any information possible before, during, or immediately following any emergency situation.

My husband and I, as legal guardian and rightful biological parents of Baby (last name here) have the right to informed consent and to choose to consent or refuse any and all medical interventions or procedures given to our child, both before and after birth. I, as an adult of sound mind and legal rights, have the right to informed consent and to choose to consent or refuse any and all medical interventions or procedures to my body, before, during, and after labor. My husband is my chosen medical proxy for all medical and legal decisions should I be unable to make decisions on my own behalf.

_____________(patient/mother)

_____________(medical proxy/father)

I/We do not consent to:
Ø Artificial rupture of membranes (AROM) before full dilation and effacement
Ø Induction of labor prior to 42 weeks by any means physical or medical
Ø Augmentation of spontaneous labor by any pharmaceutical means
Ø Epidural or other pharmaceutical pain management
Ø Continuous electronic fetal monitoring (EFM)
Ø Frequent pelvic exams
Ø Episiotomy
Ø Cesarean Section
Ø Coached pushing
Ø Immediate cord clamping or cutting
Ø Formula or glucose water for infant
Ø Separation from infant
Ø Eye salve for infant
Ø Vitamin K shot for infant

I/We will:
Ø Eat and drink as my body demands during labor
Ø Labor and deliver in any position comfortable
Ø Allow intermittent fetal monitoring using a Doppler or fetoscope
Ø Allow rupture of membranes if waters have not naturally broken by full dilation and effacement to avoid a birth in the caul
Ø Allow pelvic exam at least once per four hours of labor provided consent is obtained before each exam
Ø Use water, heat, cold, massage, movement, change in position, and other non-pharmaceutical means to cope with labor pains and to help labor progress naturally
Ø Push as my body demands, making every attempt to inform provider when I am ready to start and when I am pushing

I/We expect/demand:
Ø My husband will be there for labor and birth unless life saving measures require all non-medical personnel be removed.
Ø Immediate skin to skin contact with infant unless life saving measure makes this impractical: Baby is to be taken from my womb to my stomach or chest, depending upon length of cord. Any vitals or physical check of baby can be accomplished while baby is on my chest. If cord is extremely short, too short for baby to be safely placed upon my lower abdomen, every attempt will be made to retain cord connection for at least 60 seconds before clamping and cutting.
Ø Cord will be left intact until it stops pulsing: Baby and mother are to remain connected unless life saving measure makes this impossible, many life supporting measures can be safely and readily done with cord intact, allowing baby to continue to receive oxygen and blood through the cord, which has been show to increase positive outcomes.
Ø Placenta will be allowed to birth normally: Cord traction and forced delivery of placenta has been shown to increase risk of hemorrhage, we will attempt to nurse, try nipple stimulation, and continue to push during contractions as my body indicates until placenta is delivered naturally.
Ø Baby is to remain in room: Baby will not be separated from mother/father, all vital checks, physical exams, and other medically indicated newborn procedures can be done with baby in the room, after a reasonable amount of direct skin to skin bonding we will allow baby to be weighed and, if agreed upon, washed in room by nursing staff/hospital staff as needed.
Ø To be consulted and given full information on all procedures performed on baby:
We consent to standard weight/measurements and heel prick for state mandated blood testing, however, we expect to be informed when these things or any other procedures or tests are about to be done, we may ask for a delay or more information before continuing.

Signing does not indicate personal or medical agreement, opinion, or recommendation, it indicates only that signee has read the document.

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2 comments:

Mommy Bee said...

HAving all the signatures is a nice idea...but one thing I must say is that I heard (from a nurse no less) that they get so many birth plans that they rarely read the whole thing, and generally just skim the first page, or even the first half page. Therefore her advice was to keep it short and very simple. I took that advice to heart and my birth plan was a one page bulleted list. Yes I discussed it all with my OB in advance, and he had a slightly longer copy in my files, and my doula had one too...but the copy I gave to L&D was short and sweet and I am pretty sure it actually got read. :)

Jenne said...

The other type of birth plan I've posted about before is one where all the pertinent information fits on a 3x5 index card.

I still can't help but think that in all reality birth plans are rarely read. I have heard from so many providers that they are typically laughed at and ignored.