Tag Archives: informed choice

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/

Medical Mindset Tool

When making choices about medical care, are you a maximalist or a minimalist? A maximalist may use lots of tools to prevent and treat problems. A minimalist may try to use as few tools as possible, letting things run their natural course. What kinds of medical tools do you use? Natural remedies and self-help techniques or medicine and technology? A maximalist naturalist might prepare for birth by attending prenatal yoga, drinking raspberry leaf tea, and frequent love-making to get her oxytocin flowing. A minimalist technologist might choose a hospital birth with an OB, but ask for as few interventions as possible.

Helping your students or clients understand their medical mindset may help them in choosing care providers and birth places, and may also help them explain their decision making in labor to their partners and care givers. There are a few tools you can use to learn more and help your clients to understand this idea.

Jerome Groopman has written a book on Your Medical Mind: How to Decide What is Right for You. (He also wrote How Doctors Think and some other great books.) You can read an article which summarizes it here: http://news.harvard.edu/gazette/story/2012/02/%E2%80%98your-medical-mind%E2%80%99-explored/ or watch a video here that presents the idea to medical professionals: http://practicalbioethics.tv/2012/06/11/jerome-groopman-pamela-hartzband/when-experts-disagree.html

Kim James and Laurie Levy discuss this in their childbirth classes and with doula clients. They designed a worksheet you can find here: http://kimjames.net/Data/Sites/3/groopmanspectrumsforlamaze2012landscape9.24.12.pdf

I liked their idea, but found the worksheet complicated and a little dense on information for my client population, so I made a simplified version of the worksheet. Click here for the PDF. If I were using this in a class, I might give one copy to the pregnant parent, and one to the support person to fill out separately, then compare and discuss.

[Added on 7/28/15: a 2-page version of the handout that looks at more factors that affect decision-making. Find it here.]