Birth Plans, part 2

A reader comment from yesterday's post made me realize that I wanted to cover a bit more about birth plans and hospital birth in general.

She wrote:

I think that this whole "birth plan" era has also unfortunately ushered in a huge amount of antagonism between patients & nurses, which is just SO upsetting to me (as a nurse). Believe it or not, we WANT you to have the birth that you want, but sometimes things just don't go the way they are "planned." Welcome to parenthood, that's your first lesson that kids never stick to the plan!

Sometimes people have the impression that giving or receiving a birth plan is an opportunity for scorn and eye rolling. It certainly can be...I have clients ask me all the time if they will be annoying the staff with a birth plan. I've also heard care providers jokingly speculate that the people with the longest birth plans are the ones who get cesareans...and the implication is that it's all their own fault. I hate to hear this...the people saying it just have not met the right kind of birth plans (and the mindset that goes with them)! Just as I think birthing women should not be dogmatic, I would love it if care providers also took responsibility for not mentally penalizing people for their earnestness.

A big part of the equation that usually can't be planned for is the luck of the draw with the assigned nurse. Sure, some nurses can be invested in women having as few needs as possible, in them being quiet or not "suffering". However, I find that most nurses (and everyone really) can get on board with a just about any birth plan if they are approached from a place of respect and acknowledgment that they are there to help. Find your inner Dale Carngie: "We prefer that you don't offer us medication, but we sure would love some ice chips and another pillow!" or consider saying, "Here's what we would prefer/what is important to us...can you help us with that?". Most people are decent human beings.

When there is an adversarial approach, it is likely caused, in part, when people are not well matched with the care providers/birth place (you know what they say about not going to a fast food restaurant if it's fine dining you are after). But also when people are coming from a place of fundamental distrust. There is this fine balance, I think, between being prepared to advocate for yourself (as well you should) and going in looking for a fight. 'Cause if you look for a fight, you are more likely to find one. Hostility is not going to help anyone, including the birthing woman, who will surely need to be able to trust and surrender. An atmosphere of distrust or upset can actually stop labor from progressing...those stress hormones are like kryptonite to the hormones that progress labor.

Instead, iron out as many details before you go into labor and make sure you are comfortable with the answers you are getting from all your care providers. Ask what is typical, where there is wiggle room, under what sorts of circumstances interventions might be typical. Consider hiring a doula. Labor at home for a good long time if you can. And, as I have written before, picture your care provider telling you you need an intervention you really don't want...in your gut, do you trust them? If the answer is no, if you are finding that you are still anticipating an uphill battle, make peace with the fact that you may be with the wrong practice or planning to birth at the wrong place for you and then do something about it.

Again, I'm not suggesting you jump on a conveyor belt of unwanted interventions...I'm suggesting you find out whether the conveyor belt is there at all before you get there and then respectfully pick you battles.

Birth "plans"

I spent last night and then again this morning reviewing an incredibly lovely client's birth plan. Um - it shouldn't take that long. And it should fit on one page. No one else (in a hospital birth at least, which is who this post mostly concerns) is going to really read it if it's way too long or complicated. They don't want or need a preamble. Make it easy for them - think bullet points. And know that they can't really sign off on incredibly specific requirements...sure, you'd like a heplock (if medically necessary) in your left hand if you are right handed, but what if they can't find a vein there? See where I'm going with this? Not for nothin', but I think sometimes some childbirth educators or resources out there can get hung up on dogma and end up doing a disservice to people who might expect that all they have to do is show up with the plan. It's not that simple...birth happens within the culture of our society and of individual institutions (unless you are having a home birth) and practices. So it behooves you to approach that micro-culture in a way it can understand most easily. And do your homework before you go into labor to make sure you are with the right care provider and birth place for the type of birth you want.

Don't get me wrong - I think the exercise is very valuable for the woman/couple. I consider it part of my job as a doula and childbirth educator to make sure people understand their options and know what will typically happen if they do not express a preference. The process is important (for those who want it) even if "the plan" never sees the light of day. It's also a great jumping off point from which to have a discussion with your care provider.

But a potential downside is that sometimes women and couples think that it is somehow a binding document or that it can be the end of the discussion with their care provider. I know that's what I thought when I was pregnant with my first. For some wacky reason, my care provider (an OB) actually signed my birth plan, complete with preamble. I was an attorney at the time - I thought we were set (and as it turns out, we were - everything cooperated). But what about the others in the practice? What if my birth hadn't gone the way it did? I think I would have been upset - we had a deal, right? And yet plans have to be flexible...if I am taking a trip and plan to take the very scenic and lovely Road X, but Road X is under construction, I need to find a way around it. I'm not talking about caving to every intervention thrown at you - not at all! I'm simply saying that you need to have an understanding of what you are getting or giving up with your choices and when trading in one preference might, in the big picture, keep you more on track with where you want to go and how, generally, you want to get there. I'm talking about avoiding bigger interventions.

I prefer the idea of "Birth Preferences" because that's what they are. And I suggest that instead of just one big talk, there be a continued mentioning of preferences at all subsequent appointments, just to keep reminding them who you are and what's important to you (there are a lot more "yous" than there are of "them", as in other patients). I also suggest that you consider making the receptionist aware that extra time is needed at the appointment where you intend to have the initial birth plan talk. Nothing like trying to be heard and having your care provider looking at the clock or having her hand on the door handle (though if that's the case, it might be time to consider a new practice!).

So when I am faced with an incredibly detailed birth plan, I know it's time for a talk about big picture. It may be that every item can be adhered to with no issue. But what if someone is dead set against an IV and then vomits for hours and labor stalls due to dehydration? Sometimes a little intervention can save a bigger intervention. That's why they are preferences. It's good, I think, to always consider what the next best thing is too...