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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Birth Plans

[from ob-gyn-l]

I have been reading birth plans recently in an attempt to familiarize myself with the requests of patients who prepare them. Throughout my residency and first year of practice, I have not encountered anyone who has requested or prepared a birth plan.

I am open to most of the concepts in the plans. There are a number of things routinely done in L&D that are very paternalistic and done for the convenience of the providers. I can understand the impetus for the mother to avoid enemas, narcotics, shaving, routine episiotomy, and the rapid removal of the infant to the nursery.

I feel it is my responsibility to adhere to the patient's requests, however I am concerned with medico-legal liability concerning certain issues.

I have listed a few of the items that I have no experience with. I am wondering whether other list members have encountered these requests, whether there is a reasonable explanation for the request, and what the potential adverse consequences are, medically and medico-legally, of complying with these requests.

1. Eating during labor
2. Ambulation with epidural
3. Cord clamping after the pulsations cease
4. No IV access

I often see patients with birth plans, and they usually reflect what we do anyway. Here are my views on the issues you raise:

1. I don't allow patients to eat during labor. If they press, I allow clear liquids or lollipops. Our anesthesiologists are reasonably strict about this.
2. We sometimes use the combined spinal/epidural, which is sometimes referred to as a walking epidural. With a standard epidural, with local anesthetic, it's inappropriate to walk, imho.
3. I have some patients insist on clamping the cord after pulsations cease. They believe that more blood will stay in the baby that way. I try to explain that my expectation would be, with the baby above the uterus and placenta (on the mom's belly)I'd expect more cord pulsation to result in more blood in the placenta, just by virtue of gravity. I've never had a patient or anyone else contradict that. What do others think?????
4. I will allow no Iv access, with the caveat that if it's a long labor and she's getting dehydrated, if she wants analgesia, if she's a VBAC, IV access is a must.

We have several years experience with all of your issues. We have rarely used "walking epidurals" only because we've had 1 or 2 requests and those have been by patients currently pregnant. I'm still not comfortable with eating during labor, though one of our midwives (who is lurking and reading this-Hi there) used to tell patients to eat before coming to the hospital. In fairness, we've not had any problems other than fits from our Anesthesia colleagues. Most of the requests make sense, save money and create a less invasive experience. birth plans give patients a sense of control- which they need to have. Creates a team of which the doctor is a player.

We routinely allow clear liquids. At my previous institution we worked with dietary and created a "labor diet" for those admitted for long inductions or in prodromal labor. It featured low fat, low protein, high carbohydrate, easily digestible foods. Women in active labor rarely show any interest in food. If people are interested in eating in early labor I warn them that they may vomit it all up later and to avoid things they don't want to see again. I actively discourage the eating of foods which are heavy or greasy in any way.

I have limited experience with ambulation with epidural. The nurses at my current institution test motor strength and allow women to ambulate to the bathroom if they pass certain tests. I've never seen an epiduralized woman walk further than that or express much interest in ambulation.

 

3) Cord clamping after the pulsations cease

4) No IV access

I personally am fortunate in only having heard about one patient in my career requesting a birth plan with a private practitioner. (Of course she had a C/S in the end for fetal distress :-)-O).

I think it's not the plan per se that is a nuisance but the religious adherence to it :-)-O. Many of these requests are perfectly ok, and form part of the routine in many countries.

Once labour is established they remain nil per os here. We don't do many epidurals but I would think that the routine use of epidurals is the problem rather then the request for ambulation. Cord clamping? Our, fairly unsophisticated patients, who consider childbirth a natural event happening regularly :-)-O, don't like the practice of the baby on the mother's belly.

But then perhaps they haven't been informed yet that they are to bond. :-)-O

But I digress, I do believe in the reasoning that if the baby is below the level of placenta some blood may flow towards the baby, though I doubt it plays any role at all.

IV access but no IV? Why would you do this? Either she needs an IV or she doesn't. I have yet to se a labour patient where the midwives couldn't put up a drip when indicated.

I would agree with your philosophy of care. Most women who present with a list of birth options have the same topics. Usually they are what someone else has told them to include in their plans (i.e.. their childbirth educator, or author of a book they have read). Many times they are really not aware of, or have given little thought to what is on the list. The impression is that if they get what is on their list of care they will have a pleasant and uncomplicated experience. And unfortunately the converse is also believed. It seems to promote a certain antagonism that is not necessary, and that seems to undermine the patients trust in their caregivers.

Anyway, my $.02 worth:

1. We allow liquids - even though our anesthesia people hate it.
2. I would love to have "walking epidurals" available, but our anesthetists, nursing staff and administration are so afraid of a fall or other problem that there is much resistance (to say the least).
3. I have seen reports recommending that the cord not be clamped until it has quit pulsing. I'm not impressed with the reasoning or the science behind it. I think what the underlying message is, is that they want to be able to hold their infant immediately. If the cord is long enough, I try to facilitate this and dry the baby on the mother's abdomen and cut the cord later (or have the father do it). If the cord is too short to do this, I will cut it first.
4. We have not used routine IV access in the past 15 years. It is greatly appreciated by patients. I have not yet regretted this policy. We do require them for epidurals or any other additional risk factors that seem appropriate. Most of our patients do not have them, however.

Don't use enemas, don't shave, don't routinely do epis, healthy babies can stay as long as parents wish. Narcotics are given when requested (provided the head is not crowning or some such).

Eating during labor

Ambulation with epidural

3) Cord clamping after the pulsations cease

No IV access

This excuse works especially well if:
a) She had a PPH last time
b) She had a rapid delivery
c) She had a very prolonged labour
d) She has a large SFH (Symphysis Fundal Height) for whatever reason - Macrosomia, Hydramnios, Twins - etc.

It has been my impression that the easiest way to guarantee you will not have a "nice normal delivery" is to develop a 5 page notarized document and present it to your physician as a birth plan, requesting that he and all his partners sign it in advance (fortunately I have only seen this once). Call it Murphy's Law or whatever, but I am slightly superstitious about them.

As for birth plans, I generally honor the patient's wishes when reasonable (and most are). However, mom is completely clear on the fact that when for whatever reason the process is no longer low risk, we will have a quick discussion and probably depart from the birth plan. When presented properly I've not seen dissatisfaction with this approach. However, when we clearly have a choice of method of management, I also include mom in the decision.

The only conflict I've seen here have been due to the dad's input (sounds a little like congress legislating about reproductive rights, eh?).

We always encourage women to eat lightly (per appetite) once labor begins. Women in active labor rarely want to eat a lot. Suggest lots of clear liquids and easily digested carbos. Women in labor have phone triage with the midwife, and come to the hospital when they sound active, if there is another indication for admission or if they are anxious re: remaining at home. Once they are admitted, they have clear liquids only. I rarely have any problems with vomiting in labor, and suspect that I see it more in women who have not eaten in a while.

walking epidurals are not yet very successful in our hospital, so this is not an issue.

agreeing on delaying cord clamping as beneficial, assuming there is no need to remove baby from mom's belly. The literature supports placental to fetal transfusion with baby on mom's belly, not vice versa as suggested by a previous responder. I recently did a MedLine search on this, and enclose a "snip" from one of the articles which was in the BMJ.

4) No IV access

You sound like your birth plans are a piece of cake! I've gotten ones that request that we do no stimulation of the fetus after birth, that if a c/s is necessary, dad be the one to help the baby from the uterus and mom be allowed to touch the babe's head while it is still in utero, that under no circumstances will I listen to FHTs because we all know that Dopplers cause major brain damage, that no episiotomy be done for any reason whatsoever, etc. I'm pretty flexible, but there are situations like these when I explain why we cannot accommodate these desires.

Some of this issues was just presented at a C/Section reduction workshop. The are a number of hospitals that are allowing po liquids during labor, increased ambulation, walking epidurals and no iv access. The determining factor is that the Obstetrician determines that this is a low risk patient. otherwise you do what is in the best interests of the patient

On this side of the pond we've had birth plans for some time. Had a VBAC patient ( 3xCS ) whose ran to seven pages in the original, she managed to edit down to three pages A4, but only by using single spacing and a small type face !

Legally ( again in a British context ), if the woman is seeking is in your mind dangerous for her or the babe, you are obliged to advise her against such a course, if she persists then it is her responsibility. If you act against her wishes you will potentially be liable for a suit of battery ( civil offence ).

My understanding ( which I don't think has been clarified by the courts ) is that if an obstetrician acts inappropriately at the request of the mother ( say elective CS at 34 weeks for "social reasons/maternal request" ) and the baby suffers harm as a consequence, the mother can then bring a case against the obstetrician on behalf of the child, but that she herself has no legal liability ! My further understanding is that this can only apply to inappropriate interventions ( like the CS above ), it cannot be said of omissions, where the mother refused. Therefore not establishing IV access ( as above ), where the woman refuses it against advice, cannot be claimed as negligent.

I wonder a bit about your list:

1) Eating during labor

2) Ambulation with epidural

3) Cord clamping after the pulsations cease

4) No IV access

The best laid plans of mice and men! Our midwives even go as far as to schedule a one hour session with each couple to lay out their "birthplans". Really all we, and the parents want is a healthy baby and a healthy mother. I get a sordid sort of enjoyment out of watching couples tick off and throw each of their wishes out the window as labor progresses. They really don't seem to care once labor has started. Their behavior becomes much more goal directed, the end is the goal in itself, and the means becomes secondary.

I think birth plans must be a West Coast thing -- I never saw one in 4 years of med school (Charlottesville, VA), 4 years of residency (Temple, Philadelphia, PA) or my first 3 years in practice (suburban Philadelphia). Lots of my patients here (Lake Tahoe, CA) write birth plans.

I tell my patients I will TRY to respect their wishes but they must trust my judgment. I tell them my number one priority is healthy mom/healthy baby, number two is a pleasant birth experience for the couple and number three is having all this happen before my bedtime :-) . Frankly, most of the things on their lists are things I've never even SEEN done (enemas, shaving)

 

1) Eating during labor

2) Ambulation with epidural

3) Cord clamping after the pulsations cease

4) No IV access

Many of us on the list are a "little older" and have seen things like preps & enemas" done as routine. I have to laugh after training at a hospital doing 15,000 deliveries/year. Everyone was shaved and everyone got an SSE.( no it's not a contest if you know what that means). Many women in the 1980's were seeing physicians who wouldn't change their practice because of the way they were trained. This comes from the time when physicians set the standards of medical care and what you learned in training was etched in stone. It was also during the time of malpractice-mania so doc's didn't dare deviate from the way they were trained. If you had an adverse outcome, but you followed protocol, you could at least defend yourself.

I think this spurred the development of birth plans, as women wanted to regain some control over their care. Clear liquids in labor would be heresy to that training. A second stage over 2 hours????? That was something you would only suggest after a few margaritas.

Docs, we can't even decide how many days a patient needs to stay in the hospital anymore. We aren't allowed to do medically necessary procedures. I see birth plans as a minor issue. I've been following patient requests for years. As Burger King says, "have it your way". Any one of us can follow standards of care and allow patients to have a birth in the style they prefer. It's called customer service.

This is one of Hill's Rules: "The fastest way to a Swan-Ganz catheter is to have a detailed birth plan." My favorites are the patients that start out their first OB visit saying "I want you to sign here that I won't have a c/section" or something similar. Invariably the Bradley method patients used to come with birth plans that started in the waiting room and led across the street to labor and delivery (you'll note the past tense).

In Pasadena, I get a fair share of Birth Plans, and I have developed a philosophy. Most of the patients care much more how you respond to their Birth Plan, than what is actually on it! They want to know... are you flexible? Do you care about their desires and preferences? Can they talk to you? I usually tell them that I will always try to honor their birth plan as long as the labor is proceeding smoothly and safely. In the event of a problem, I tell them that I will likely have to intervene based on my medical judgment, and in some cases, this means throwing out the birth plan.

Now, there are also unacceptable birth plans. I had one...No C/S, No Pitocin, No Fetal Monitoring, No IV, etc...This patient saw me for the first visit only, I then told her to find another doctor (I even gave her some names of my more "naturally oriented colleagues."

Bradley patients tend to have the more detailed Birth Plans, bit I have noticed there are two types of Bradley patients. Those who go to Bradley because of an innate distrust and dislike of the medical profession, and those who like the fact that they get so many classes! The latter group has no clue about the anti-doctor agenda, but within a few classes they usually figure it out. By the way, is Bradley a national phenomenon or just a California (West Coast) thing?

One more item: what about fetal monitoring? Intermittent external, vs. doptones. Comments?

Regarding the specifics:
clear liquids O.K.,
walking epidurals - people ask while pregnant, but seem not to ask once they are in labor
cord pulsing - I put the baby on mom's abdomen, so I clamp quickly to try and avoid pumping fetal blood back into the placenta
IV - I encourage routine IV or saline lock as an "insurance policy" but I allow no IV for the low risk patient, based on an informed consent type discussion.

We get a few birth plans, and they are useful as starting points to discuss the various issues and we will try to comply as best we can. However, the length of the plan is generally inversely proportional to the number of complications encountered and therefore the length of time before we're no longer using it!

1. Labor is an aerobic event. I allow a laboring patient to eat anything she would eat if she was on a long bike ride or running a marathon.

3. It only takes an extra minute

4. A small risk; but is the patient is taking enough oral fluids and not becoming dehydrated; I have never had any problems getting an IV in if needed, i.e. for a c/s.

I couldn't resist adding my 2 cents on the eating issue. I have attached a copy of a protocol which I wrote with the collaboration of our OB Anesthesiologists 9 years ago here. It has worked well - they're happy, we're happy, and the CNMs who practice here are happy with it.

Note from Bruce Speyer: I have made copies of this article available by the web at: (original wordperfect version) (microsoft word version) (plain text version)

I have listed a few of the items that I have no experience with. I am wondering whether other list members have encountered these requests, whether there is a reasonable explanation for the request, and what the potential adverse consequences are, medically and medico-legally, of complying with these requests.

 

1) Eating during labor

2) Ambulation with epidural

3) Cord clamping after the pulsations cease

4) No IV access

PERSONALLY, I EXPLAIN THE REASONS FOR EACH OF THESE TO THE PATIENT AND IF THEY STILL REFUSE, I SAY IT IS TIME FOR YOU TO GET A NEW DOCTOR WHO WILL LET YOU DO THESE THINGS AND DOESN'T MIND BECOMING DEAD MEAT.

I have seen and aided in the creation of many birth plans. Never once have I viewed a patients request as mindless or petty. Your observation, I'm afraid, has the distinctive ring of a patriarchal and invalidating position. As the provider of my patients AP and IP care, I view their 'birth plan' as an opportunity to give back some control. A woman in control of her birth, through knowledge and sound advise, stands a much better chance of a "pleasant and uncomplicated experience".

That pretty much mirrors what I do, too. I try to avoid episiotomies, especially in multips, and point out to women in their 36 week "discuss labor" talk that epidurals, especially early ones in primips, may be associated with an increased chance of Cesarean. You correctly point out that, once in labor, all of the "little things" that they are worried about seem much less important, and when I talk to most patients, they will admit that their friends told them the same thing (i.e. who cares if you have to be catheterized; just get me the drugs!)

I guess we're putting in some more IVs because of routine GBS cultures and treatment.

Previous listers correctly mentioned that those who are inflexible (militant) are the real problem. I do tire of having to spend 10 minutes explaining something that should take about 10 seconds to 99% of Moms, i.e. yes you are a 35 weeker who is bleeding, so you'll need an IV, or somesuch.

I have a homemade handout that they read prior to the 36 week talk, and it works well to avoid birth plans, because it goes over the basics, and fills in the gaps from classes.