Tag Archives: birth plan

Teaching about Birth Plans

Here are the steps I teach for how to develop a birth plan. I do a brief walk-through of a birth planning process. For each, describe how to do the step, who participates, and the primary goal.

  • Birth Plan Checklist – Pregnant Parent and Partner
    • Find a checklist such as http://www.pcnguide.com/wp-content/uploads/2016/03/2-Preparing-Your-Birth-Plan.pdf. The pregnant parent and the primary support person walk through this together, making sure they understand what each of the options are (and if not, learning more), and making sure the support person knows her preferences for each. There is no need to share this detailed checklist with their care providers, it’s just for their own reference – it’s worth tucking it in the bag they’ll take to the hospital in case they would like to refer back to it in labor.
  • Top 3 – 5 Priorities – Discuss with Care Provider.
    • While completing the checklist, they can determine what their top priorities are. They should discuss these with their care provider at a prenatal appointment. Will these choices be options for them during their birth process? What can they do to increase the likelihood of reaching those goals? This discussion allows them to develop realistic expectations and increase the chance the expectations will be met. (Note, sometimes this can lead a parent to re-examine whether the caregiver and birthplace choices they have made are the best fit for their goals.)
  • Written Birth Plan – To Share with Nurses at the Hospital
    • A birth plan is the primary tool for communicating with nurses about the family’s goals and priorities, and what kind of support from caregivers would be most helpful to them.
    • It should never be more than one page long (in a easily readable format.)
    • One format is to have three sections. The first describes who they are as a family and who will be at the birth and what they have done to prepare for this birth. The second gives the big picture of their preferences for labor support, pain medication, and interventions. The third is optional, and explains any special information that “if the nurse only knew this about me, they could better support me.” This is a good place to address religious or cultural preferences, history of sexual abuse or other personal history that may affect them during the birth process, any particular worries they have about the birth.
    • If parents are planning a home birth, they may not need a written birth plan for their midwife if they’ve been in deep discussion for the whole pregnancy. However, they absolutely should have a written birth plan in case of transfer. In a survey of birth satisfaction, some of the lowest rates were for people who had planned an out-of-hospital birth and transferred. They could increase the chance of a satisfying birth experience by taking time to articulate their wishes.
    • Sample birth plans are available at http://www.pcnguide.com/wp-content/uploads/2016/03/2-Preparing-Your-Birth-Plan.pdf. Feel free to print several examples to share in class to show there’s no one right way to write a birth plan.

Childbirth Educators can support students with figuring out their top 3 – 5 priorities using the Birth Plan Card Sort exercise: https://transitiontoparenthood.files.wordpress.com/2018/10/birth-plan-card-sort.pdf. Instructions are on the last page.

Learn more about the steps of teaching about Informed Decision Making, including Values Clarification, and how to make the decision after gathering information.

Decision-Making Values Clarification

In teaching informed decision-making, it’s not just about teaching birth plans, or just teaching key questions. There need to be at least four steps:

  1. Figure out your goals and preferences first (values clarification)
    1a. Choose the care provider and birth place that are most in alignment with your goals, preferences, and unique health needs (caregiver choices)
  2. Articulate those priorities for care providers (birth plan)
  3. Then if an intervention is proposed that is outside your birth plan, gather data on it (key questions).
  4. Then take that information and weigh it against your values to make the decision that is right for you. (informed decision-making)

And teaching these things is not just about Theory – we also have to Practice!

A quick note about step 1a: Ideally, this would always be the process. If I was talking to someone in early pregnancy who hadn’t yet chosen, I would absolutely cover that step. But, in childbirth classes, when I’m speaking to people in their third trimester, that choice was made long ago. So I won’t cover 1a. (But some of the other steps may lead students to question for themselves whether the caregiver choice they made was the right one.)

Let’s look at options for teaching each of those.

1. Values Clarification: The goal is to talk about what they want their birth to look like – what kind of labor support do they want, what are their views on interventions and pain medications, how involved they want to be in decision-making, and generally: what would help this birth be satisfying for them. There are many ways you could do this. I created a worksheet that could be used in class, or as a homework assignment, that would be one way of exploring these questions. The pregnant parent fills out one form with their values, the partner fills out a slightly different form with their values. Then they compare their answers and discuss them. How do they come to have a common vision of their goals and priorities? (And if they can’t, with birth, the pregnant parent’s priorities need to win in the end, so they may need to agree to that.) They can also discuss here whether their caregiver and birthplace share those values. Here’s the Values Clarification worksheet.

1a. Choose the caregivers that match that. (Check out the quiz at the beginning of the Great Starts Guide for one approach to this step.)

2. Articulate those priorities in a birth plan – learn more about what to teach about developing a birth plan. (Or see Pregnancy, Childbirth, and the Newborn for more details on our approach to birth plans.)

3. Key Questions. Here’s what we teach:
Whenever a test or procedure is offered, first ask how urgent / severe the situation is and whether you have time to ask questions, discuss options, and consider the information you’ve learned. Then, ask:

  • Benefits: What’s the problem we’re trying to identify, prevent, or fix? How is the test or procedure done? Will it work?
  • Risks: What are the possible tradeoffs, side effects, or risks for my baby or me? How are they handled?
  • Alternatives: What other options are available? What if I wait? Or do nothing?
  • Next steps: If the procedure doesn’t identify or solve the problem, what will we need to do next?

It would be all too easy to stop with the key questions, thinking we’ve done our job, but we just missed they key point of decision making: MAKING THE DECISION!

We need to remind them that although their caregiver is an expert source of information and advice on benefits and risks, that only they can take into account all their goals and priorities and make the choice that is best for them. We also need to acknowledge that sometimes the choice we need to make is NOT something we wanted. But we want parents to feel in retrospect, that the choice they made DID line up with their values, and WAS the best decision available at the time.

4.Teaching Informed Decision-Making. Check out my next post for this one… https://transitiontoparenthood.wordpress.com/2015/07/31/teaching-informed-choice/

Birth Plan for Hospital Transfer

Someone requested a sample birth plan for hospital transfer.

This is probably longer than ideal, but is an example of what one could look like.

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Birth Plan, in case of Hospital Transfer

Hello,

My name is X, my husband is Y. Our first child was born by cesarean 10 years ago, and our second was a VBAC 7 years ago. With this birth, we had planned a home birth with no pain medication and few interventions. However, the fact that we are now at the hospital indicates that I need additional monitoring and/or medical procedures, and we are grateful for your assistance in providing this needed care to usher our third child into the world.

This birth plan expresses some of my preferences, so they can be taken into account and balanced with medical necessity. The ones I feel most strongly about are related to how our baby is cared for in the first hour of life.

Preferences:

  • Coping Techniques: As much as possible, we would like to continue to cope with the labor as we would have at home: with minimal interruptions, freedom to move around and continue whatever coping rituals we have developed. If there are decisions that need to be made, please talk with Y about them first. It will be helpful to me to stay in my “birth zone” – an instinctive, emotional space; but if I am asked a lot of questions, I will slip into my academic brain, which tends to block my pain coping skills and labor progress.
  • Routine Interventions
    • Monitoring: I understand that continuous fetal monitoring is standard with VBAC. I would prefer external to internal monitoring.
    • Food and water: At minimum, I would like to consume clear liquids in labor, as is per guidelines from the American Society of Anesthesiologists.
    • IV: I have often been told that my veins are small and tend to roll, so are difficult to insert an IV into. If an IV becomes necessary, I would ask that you pick a staff member who is particularly skilled at insertion.
  • Augmentation
    • Pitocin: fine. No prostaglandins or misoprostol, due to increased risk of rupture.
    • Amniotomy: would prefer to delay till baby is well positioned (OA)
    • Epidural: If pain-related tension is delaying progress, it may be a reasonable tool
  • Pain Medication
    • IV narcotics: are not effective for me; I feel mentally out of control, and don’t gain sufficient pain relief
    • Epidural: If I request it, I would like to start with a low level dose of medication to enable as much mobility as possible; if PCEA is available, this would be ideal
  • Second Stage management
    • I would like to be able to use positions other than semi-sitting (side lying, or hands and knees), especially if my baby is suspected to be large. If I have epidural anesthesia, I may need support getting into and maintaining a position.
    • If possible, I would like to use spontaneous pushing, following my own urge to push and own instincts rather than directed pushing. If I do not have an urge to push, I would prefer to labor down (passive descent), unless time is of the essence
  • Cesarean. I understand that an emergent situation, such as a uterine rupture, could lead to the need for cesarean under general anesthesia. However, if a cesarean is needed but not emergency, here are my preferences for the procedure:
    • Y will accompany me in the O.R. (And my midwife, if possible.)
    • If possible, I would appreciate that baby be delivered slowly through the incision, allowing for a more gradual adaptation, as described in Smith, Plaat, and Fisk, “The Natural Cesarean”, 2008 July; 115(8): 1037–1042 http://tinyurl.com/la83t2; however, this isn’t a high priority for me.
    • I would prefer that the screen be lowered during delivery so I can see the baby.
    • I would prefer internal repair and double-layer suturing.
    • Should I become shaky or nauseous, I would like to handle that with natural coping techniques. I do not want to be given any medication that will make me fall asleep, or cause any amnesia effects during that first hour with my baby.
    • I want skin-to-skin contact with baby as soon as possible, preferably with breastfeeding initiation in the O.R. during repair (with support from Y)
  • Care of the Baby in the First Hour (Highest priority for me)
    • Would like to delay cord clamping and cutting till cord has stopped pulsing
    • Whether baby is born vaginally, or by cesarean, I would like as much of its first hour as possible spent skin-to-skin on my chest. If, for whatever reason, baby cannot be skin-to-skin with me, then it should be skin-to-skin with Y.
    • As much as possible all newborn procedures should be conducted with baby in parents’ arms. Bath, weighing, and measuring can be delayed till after initial breastfeeding.
    • Breastfeeding to be initiated in the first hour after birth, ideally by allowing baby the time to self-attach.
    • Routine procedures
      • Eye ointment should be given as late as possible (one to two hours, as per state requirements) after vaginal birth; but as early as possible after cesarean
      • Vitamin K and Hepatitis B: Can be given per standard protocol
    • Care of the Baby Until Discharge
      • As long as baby is well, baby is to remain in-room with parents at all times, with family providing care, and minimal disruption
      • If baby needs special care, then a parent or family member will accompany the baby at all times, holding the baby skin-to-skin as much as possible
      • No formula or other supplements to be given without express written approval from a parent, and supplementation to be given by spoon, cup, or SNS, not bottle.

Thank you for your time and attention to my preferences, and thank you for the care you are providing to our family.

X and Y