Birth plan.

[rivka]

By popular acclamation, here's a copy of our birth plan. We originally had a longer one that was much more polite and expressed much more flexibility, but several people pointed out to me that, although my midwife might read the long version, no one else at the hospital would. So this is one page, in snappy bullet points. It's still technically a draft - comments are welcome.

Birth Plan (Draft)

Names: rivka and curiousangel
Due date: 4/3/05
Primary caregiver: Kathy Slone Associates
Hospital: Mercy Medical Center

Additional people to be present during labor:
saoba (doula)
Pat (rivka's mother)

We recognize that no birth is predictable and that medical necessity may require significant changes to our plan. We trust our providers to help us make informed decisions during labor and delivery.

Pertinent medical background:

• Spinal fusion from T10-L2 performed in 1987.


• Artificial right hip due to congenital hip dysplasia – painful response to pressure and limited range of motion. Please do not put pressure on rivka's right leg or move it abruptly.


• Uncomplicated pregnancy, no known fetal abnormalities.

Preferences for normal labor and birth:

• We are planning an unmedicated birth but may ask for medications if delivery is unusually difficult or prolonged. Please do not offer pain medication.


• We would like to have access to a birthing tub during labor.


• rivka would like freedom to eat and drink throughout labor, as tolerated.


• Prefer to move freely during labor – no IV or continuous fetal monitoring.


• Student observation is okay – please, no internal exams by students.



• Prefer to push according to spontaneous impulse rather than being directed.


• Will accept a perineal tear if necessary, rather than an episiotomy.


• curiousangel does not want to catch the baby or cut the cord.


• Please delay cord cutting until the cord has stopped pulsing.

Preferences for unexpected events:

• Induction and/or artificial rupture of membranes only in response to fetal distress.


• At first consideration of C-section, we would like to consult with the anesthesiologist about feasibility of spinal anesthesia post rivka's 1987 spinal fusion.


• We will bring spinal fusion X-rays with us to the hospital.


• curiousangel to be present for C-section.


• Baby to remain continuously with curiousangel following C-section, if her health permits.

Preferences for the postpartum period:

• Baby to stay continuously with one or both parents, unless separation is medically necessary.


• Please delay routine infant care until after bonding and initiation of breastfeeding.


• Baby will be exclusively breastfed – please do not supplement with formula, sugar water, or a pacifier.


• If the baby is a boy, we will not want him circumcised.

Comments

[tammylc.livejournal.com]

That looks excellent. Clear, concise, to the point.

[zencuppa.livejournal.com]

1) You might want to say how many people you want in the room during the birth. This is to avoid a bunch of nurses or students driving you nuts *wry grin.*

2) Maybe state your preferences about pelvic examinations by the nurses or resident physican (I did my best to keep them at a minimum, etc.)

3) Are you planning on playing music during the delivery and do you want to use a mirror to gauge your progress?

4) Your preference regarding the use of forcepts or suction on the baby during delivery.

5) You might want to findout if the hospital has wireless continuous fetal monitoring. I only say that because during my first delivery Nick's heartbeat would drop quite low during each contraction and I *wanted* me and the doctor to know what was going on.

6) Feasible alternatives to the birthing tub, if it's not available at that time (you never know how many babies will be born that night . .. )

7) If your midwife isn't a staff member of the hospital, include her name and contact information on the birthing plan.

There, that's my two cents .. Good luck!!

[rivka.livejournal.com]

Wow, thanks for all the detailed comments!

You might want to say how many people you want in the room during the birth. This is to avoid a bunch of nurses or students driving you nuts *wry grin.*

Huh, that might be a good thought. I should ask my midwives how many hospital staff members are likely to be there.

Maybe state your preferences about pelvic examinations by the nurses or resident physican (I did my best to keep them at a minimum, etc.)

A resident shouldn't be showing up at my birth unless something has gone very wrong - my midwives have full staff privileges at the hospital, and residents only assist OBs. I think pelvic exams are only done by the midwife, and not by L&D nurses, but that's another good thing to ask about. I know that my midwife will be physically present for the vast majority of my labor, so that should cut down on interventions by other hospital staff members.

Are you planning on playing music during the delivery and do you want to use a mirror to gauge your progress?

I don't want a mirror - the examples of crowning I saw on childbirth class videos was more than enough for me. I think I do want music, but we'll bring our own player, so there's nothing we're asking the hospital to provide.

Your preference regarding the use of forcepts or suction on the baby during delivery.

This is one of those things that I'm essentially trusting my providers about. I'm seeing midwives, and they'll have to go get an OB if a vacuum delivery looks necessary. I think that pretty much assures that it won't be suggested unless there's a genuine need. So honestly? I don't want a forceps or vacuum delivery, but I'm not going to argue if my non-interventionist midwives say I need one.

You might want to findout if the hospital has wireless continuous fetal monitoring.

They don't. Their standard of care is intermittent monitoring, twenty minutes on arrival and then frequent checks by fetoscope during labor.

Feasible alternatives to the birthing tub, if it's not available at that time (you never know how many babies will be born that night . .. )

The only feasible alternative I can think of is a birthing room without a tub. :-) I'm not putting all my coping eggs in the birthing tub basket, so to speak, because I know that not every woman actually likes it. So it's just one of the coping strategies I'm planning on.

If your midwife isn't a staff member of the hospital, include her name and contact information on the birthing plan.

Fortunately, the midwife practice has full staff privileges and is responsible for a significant percentage of the births at the hospital. So the hospital is used to midwife deliveries, and they expect the midwife to run the show - not the doctor.

[janetmiles.livejournal.com]

I think I do want music, but we'll bring our own player, so there's nothing we're asking the hospital to provide.

Even so, it probably wouldn't hurt to mention "will bring own music and player" -- will it be battery-operated, or will you need an outlet?

[hobbitbabe.livejournal.com]

wireless continuous fetal monitoring

Okay, can I just say that this catches my imagination? Like you put a little antenna in your belly button? Or you get a USB port installed on your tummy?

[rivka.livejournal.com]

Those would be pretty cool, but actually you wear a monitor on a belt. Alas.

[kightp.livejournal.com]

I know next to nothing about birth, but this sounds very straightforward and to the point.

Me, I'd probably add things like "requires unlimited access to chocolate" ... but I'm a smart-ass that way. When I had my colonoscopy I had to restrain myself from painting a smiley face on my butt ...

[kateyule.livejournal.com]

Hey, I think the bit about access to chocolate makes perfect sense!!

It also brings to mind the legendary stipulation in Van Halen's contracts that no brown M&Ms were to be found backstage on pain of immediate cancellation of the gig... This served as a practical warning system, 'cuz if the promoters missed this point, what else had they screwed up on?

[lysana.livejournal.com]

That's a nice one. The first birth plan I ever saw read like a political manifesto. "I'll sue if you don't follow this" was the primary mood of the piece.

[rivka.livejournal.com]

Heh. How lovely for the providers involved.

I think the critical factor is to choose a provider you trust. If you don't trust your doctor/midwife, no birth plan is going to help you. If you do, there's no need to spell out "I don't want a C-section unless it's medically necessary."

Most of our birth plan is about matters of personal preference (eating during labor, Michael not wanting to catch the baby) and idiosyncratic factors (like my spinal fusion). That's because I trust that the standard practices of my midwives are acceptable. I've spelled out the postpartum/baby care stuff a little more vigorously because, after the baby's born, my midwives are no longer in charge of her care. I have to be a bit clearer about what the neonatal nurses should do, because I don't know them the way I know the midwives.

Two thoughts

[redbird]

1) Should you include the difference in your arm lengths under "pertinent medical background"?

2) You mentioned, earlier, that the midwife teaching your birth classes brought up induction as a medically appropriate response for pregnancy-induced hypertension. I assume it's omitted here because your blood pressure is so healthy.

Re: Two thoughts

[rivka.livejournal.com]

Should you include the difference in your arm lengths under "pertinent medical background"?

It doesn't really seem pertinent to me, in that I can't think of any way that it might affect labor or delivery. My right arm doesn't need careful handling the way that my right leg does.

You mentioned, earlier, that the midwife teaching your birth classes brought up induction as a medically appropriate response for pregnancy-induced hypertension. I assume it's omitted here because your blood pressure is so healthy.

If I were to develop pregnancy-induced hypertension, no one would ever look at my birth plan. It's not something that happens during the course of labor and delivery, it develops at some point during pregnancy - and it's a life-threatening emergency.

The part about "no induction without fetal distress" is in the birth plan so that no one gets the bright idea that I should be dilating at the textbook rate of 1cm/hour, or that I need to deliver right away if I'm a week past my due date. Not that I think my midwives would.

Re: Two thoughts

[ailbhe]

The part about "no induction without fetal distress" is in the birth plan so that no one gets the bright idea that I should be dilating at the textbook rate of 1cm/hour, or that I need to deliver right away if I'm a week past my due date.

Glad to read this. I try not to be a worrymonger, but I do like to see that *you* are keeping your options open, in a way that I just plain didn't. It looks like a great birth plan. Mine stated which pain relief I might be agreeable to using if I decided I wanted some, making opiates the last choice - it might be a good idea to write this down in case you ask for pain relief, they say "How about this one?" and you are in no case to do more than scream "IdontcarewhatitisdamnyougiveittoME" or similar.

(I reneged on my birth plan entirely, of course, but there you go. I was still glad I'd had one. And I'll have one again, for the c-sections).

A.

Re: Two thoughts

[eeyorerin]

My right arm doesn't need careful handling the way that my right leg does.

The only way I can think of it as being pertinent is if you get a medical professional (not your midwife, obviously) who takes one look at your arms and uses that to start a "poor lil' Rivka, you should be laboring in bed with lots of monitoring since you are a Delicate Flower" routine, or who assumes that you'll need "help" in handling the baby after birth or in self-care tasks. However, I wouldn't know how to anticipate that in the birth plan in ways that you haven't done already; your birth plan does make it clear that you intend to have a normal delivery if at all possible and that you are aware of your medical issues. Also, I'd imagine any medical professional who pulled that routine with you and yours would be dispatched in short order.

Re: Two thoughts

[rivka.livejournal.com]

The only way I can think of it as being pertinent is if you get a medical professional (not your midwife, obviously) who takes one look at your arms and uses that to start a "poor lil' Rivka, you should be laboring in bed with lots of monitoring since you are a Delicate Flower" routine,

You'd be surprised at the number of people who don't even notice my arm until they've known me for a while.

But I know what you mean. One of the reasons I put "uncomplicated pregnancy" in the "pertinent medical background" section is that I was afraid the previous two points would be setting off people's high-risk pregnancy alarm bells.

Re: Two thoughts

[minim_calibre]

(I've just dropped in from friendsfriends, and was reading as I'm due about two/three weeks after you.)

It's not something that happens during the course of labor and delivery, it develops at some point during pregnancy - and it's a life-threatening emergency.

That's not completely true. In rare cases, PIH/preeclampsia/eclampsia can manifest during labor with no previous symptoms. It can also manifest during the first days/weeks after delivery. (Due to mild PIH, I see the university's maternal hypertension specialists as well as my regular OB. They're very careful to spell out what can happen, what to look for, and all of that.)

[elisem.livejournal.com]

Looks pretty good to me. It's clear and it's short.

[popefelix.livejournal.com]

Looks good to me!

[minnehaha.livejournal.com]

Bringing the x-rays is a great great idea. Know the dates of them, 'cause if it comes down to it, someone will ask.
K.

[wiredferret.livejournal.com]

Sounds excellent!

[edschweppe.livejournal.com]

Thanks for being willing to share this - and thanks for providing the "blow-by-blow" account of your pregnancy. I've only been involved with one birth - my own - so it's great to be able to "read over your shoulder", so to speak.

One minor bit of curiousity: what is the reason for waiting until the cord has stopped pulsing before cutting it? Is there a risk of blood loss or some such?

[rivka.livejournal.com]

what is the reason for waiting until the cord has stopped pulsing before cutting it? Is there a risk of blood loss or some such?

Yes. When the cord is clamped, the remaining blood in the cord and placenta doesn't make it into the baby. If the cord is clamped and cut early, the baby's blood volume can be reduced by 25%, and the volume of red blood cells can be reduced by up to 50%. Also, cord blood is full of stem cells, which might have health benefits for the baby.

Some doctors think that early cord cutting helps prevent jaundice, which is caused by the baby having trouble breaking down red blood cells because her liver isn't mature yet. But that link isn't proven, and jaundice is easily treated anyway. Mostly, early cord cutting is a convenience for doctors - it means that the baby can be taken away instantly following delivery for exams, etc.

[edschweppe.livejournal.com]

Mostly, early cord cutting is a convenience for doctors

Ah. I thought it might be something like that. I once took the EMT certification course; I vaguely remember that the protocol for a field delivery involved wrapping the baby in a blanket and giving same to the mother, delivering the placenta and storing same in a plastic bag, and leaving the cord intact for the folks at the hospital to deal with. On the other hand, most of the EMT protocols were based on a stabilize and transport model, rather than a treat-in-place one. On the other other hand, that was over a decade ago and my recollections are therefore suspect :-)

Anyway, I think it's great that you're making sure that your needs, and those of Lil' Critter, get prioritized ahead of "doctor's convenience." And thanks again for sharing with your faithful audience!

[ratphooey.livejournal.com]

As long as it's still pulsing, the cord is transmitting good stuff to the baby. Seriously good. Super-premium. High octane. Would you pull your car away from the gas pump while it's still flowing? :-)

[edschweppe.livejournal.com]

Would you pull your car away from the gas pump while it's still flowing? :-)
No, but then again, I figure the danger of spilled gas is greater than that of a not-quite-full tank. I used to run nuclear reactors in the Navy, and each fluid system had its own, slightly different, approved filling method. Sometimes you closed the inlet valve with the fill pump running - especially if you didn't want to risk backflow. Sometimes you shut the pump off before closing the valve; other times you'd let the pump run dry..

Babies aren't nuclear reactors, so I thought I'd ask. :-)

[ratphooey.livejournal.com]

Hi! You don't know me, but I followed a friend's link to your journal and have been reading with great interest.

Your birth plan is great, especially the up-front acknowledgement that things don't always go according to plan. Our first child was born in September, and very few things went the way we'd originally envisioned. However, I'm proud of the fact that, at every turn along the path, I (we) made what I believe was the best possible decision.

It's wonderful that you're being so thoughtful about it all.

[rivka.livejournal.com]

Thanks so much!

I have been repeating to myself that "no battle plan ever survives contact with the enemy." Not that birth is an enemy, but you know what I mean.

I do trust that my midwives will advise me well if things go wrong. I'm planning to rely a lot on that.

[ratphooey.livejournal.com]

Having caregivers you trust is essential. I actually changed caregivers partway through my pregnancy in order to be sure of that, and it was the single best thing I did.

[windsea.livejournal.com]

Excellent -- clear, straighforward, to the point.

My very best wishes for not having to use any of "unexpected events" part :-)