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How to Un-Write a Birth Plan

Birth plans and natural childbirth go hand-in-hand, don't they?  Well, yes, and they are also often laughed at by Labor & Delivery nursing staff.  I'm not saying that this should be, but it very often is what happens.  I'm all about learning and choosing your options.  But decidedly *against* having a multi-page line by line checklist posted on your LDR door.

Here's my suggested approach.  Keep in mind that I wrote this at 2 am after not being able to sleep while all these ideas kept running amuck in my brain!

How to write a Great Birth Plan and then Deconstruct it.

First Draft: First trimester or even when you are TTC

Step One: Title this "The Way too long list"

Step Two: Create 4 sections:

1. Labor
2. Pushing & Birth
3. Special Circumstances
4. Newborn Care

Step Three: under each of these headings, list anything and everything that is important to you about your birth experience.

Now what?: Based upon your lists, consider whether or not your caregiver will be supportive of such requests.  If you know this without a doubt, then you can readily move forward to Step Four. If you are unsure or are just guessing they will be because they have been nice during your GYN visits, ask around the natural birth community and ask your caregiver directly about how they handle natural births.  These answers will give you an indication of whether or not you need to act now to change caregivers.  Be certain of this, as your caregiver's protocols will have a direct and strong influence over your birth experience.

Step Four: Choose a couple of your most important items and discuss them with your caregiver at your next appointment.  A friendly approach is best.  "How do you feel about intermittent monitoring?" goes over much better than, "I refuse to be monitored during my labor."  This dialogue will give you an idea of where your caregiver stands. A natural birth advocate will likely answer many of your unspoken questions within the first conversation.   Resistance to your questions merits follow-up, but often is your first clue to seek care elsewhere.

(Note: For newborn care, follow same process with pediatrician.)

It is here that I must interject that there is a time and a place for every practice, from the most natural to the most medical.  It is your responsibility to educate yourself by researching and asking questions so that you can determine this reasonably and responsibly.

Step 5: Review your list and note answers where you have received them and highlight questions that have now come to the top of the list.  You will want to continue your research until your questions are answered.  However, you may be able to seek this information from other sources within the birth community who are familiar with your caregiver and place of birth, such as doulas or childbirth educators.

Second Draft: After the first has been worked on a bit

Step 1: Sort through your first draft and transfer the items to a new list if you feel that they a) require further discussion or b) you have come to a compromise with your caregiver that is outside of their normal practice and needs to be noted.

Step 2: Research a bit deeper on each of these items to consider the options available to you, as well as their benefits and risks.  

NOTE: You will always have options.  They become fewer when an emergency arises, but labor and birth does not often involve true emergencies (ie, life or death).  So your first question in a moment of choice is, Is this an emergency?  If not, then proceed with standard questions: What are my options? What are their benefits/risks, advantages/disadvantages? What if we wait x time?  What if we do nothing at all?

Step 3: Take a hard look at your list.  Have you asked all the questions you need to ask? Are you satisfied with the answers?  Do you need to revisit anything?

Step 4: Consider what preparation YOU need to make in order for your birth preferences to become real - additional support, classes, tools, etc.

Final Draft: Last few weeks before EDD.

Step one: Review your previous draft and see if anything can be marked off that you feel confident is well-understood between you and your caregiver.

Step Two: Transfer only those items that the nursing staff will need to be aware of when you are checking in at your place of birth.  This should be short and to the point, friendly and easy to read.  Anything more than a minute to read will likely not be read at all.

Step Three: Make 3 or 4 copies of this single page document to share with your caregiver (prenatally), the nursing staff upon checkin, post on the wall/have on hand in your LD room and to give to the nursery staff.

A footnote on the Unexpected = C-sections

It's like hurricane preparation. You don't want to think it will really happen, but it is certainly better to be ready for it than to be caught by surprise.

Who goes with you?  The reality: Baby will be out and on his/her way to the nursery in the first 5-10 minutes.  Then mom will be in surgery for another 45 minutes or more.  It is important for mom to not be left alone.  It is also important for someone, preferably the father, to be with the newborn to record all those precious first moments for mom to later see.  Therefore, plan for who will stay with mom in the OR.  If two persons are allowed to accompany, then the father and another can go in, then father can leave with the baby and be present for his/her care.  If only one person is allowed, it is better to have a secondary person (doula?) go into the surgery and let dad wait outside ready to follow the baby to the nursery.  Seeing the surgery isn't very important for most family members, and there will be plenty of crying to hear from then on!

C-sections, VBACs and birth satisfaction: one woman's story

In the natural birth community, it is sometimes assumed that a woman who has a cesarean section will be dissatisfied with her birth experience. And in many cases, that would be correct. Or that a woman who has a natural birth with no complications will be thrilled about her experience. This is often correct as well.

But not always. In either case.

In my journey as a doula and childbirth educator, I have come to know that what TRULY makes the difference in a woman's birth satisfaction is NOT the checklist of what did or didn't happen during her labor and delivery. Rather, a woman's sense of understanding and choice in the decision-making process bears more emotional weight than any medical procedure or natural comfort measure ever could on their own.

Read on to hear one woman's story of her journey through two very different, yet ultimately similar birth experiences...

JESSICA'S STORY

Ever since I could remember I have been scared of childbirth. Not of pregnancy, but just of the birthing experience. I carried a tremendous amount of fear regarding my perception of the pain of childbirth and just the unknowns in general. Needless to say, when I learned that my husband and I were expecting our first child, I was all about the epidural.

I never took anytime or interest in educating myself. I mean really educating myself. Of course I read the generic materials that are out there, i.e. “What to Expect When Expecting” and read articles on various websites. Don’t misunderstand me, those resources are great; however, they are very “middle-of-the-road” …….for people just like me. I knew I didn’t want to feel any sort of uncomfortable sensation and would be getting the epi ASAP!!! So what was the point on learning anything further, right???

So here I am, four days past my due date (what seemed to be an eternity to me) and my water breaks at home. Contractions are about 10 minutes apart and are very mild. We head to hospital where I was examined and found to be 3 centimeters dilated. They ask me if I want an epidural and I immediately say, “Yes, the sooner the better,” as far as I was concerned. I received my epidural shortly after 7 am. I am now lying limp on the bed, what were already spaced out contractions are now slowing down even more due to the epidural. A pitocin drip is started to speed things back up. Most of day passes and after 5pm I am fully dilated. I push a few times for the nurse and maybe 4 or 5 times for my doctor. After a handful of pushes (literally a handful, I’m not lying) he says he doesn’t like the way the baby’s heart rate is looking and said that a c-section is necessary.

What do I say!?! I was completely unprepared for this. A cesarean section? Really? I didn’t want one but since I knew absolutely nothing I had no reason to disagree with him; I certainly had no educational knowledge to base any decision off of… 12 hours after being admitted into labor and delivery my daughter was born via cesarean section.

It wasn’t long after her birth that I began to find myself in a bit of emotional turmoil over the method by which my child was brought into this world. I was feeling as if one of nature’s most natural events had been stolen from me and that I had missed out on something amazing. I wanted to know more in depth what lead to this and what could’ve been done differently to have prevented this outcome, so I began my research. It was during this time that I really became enlightened on so many aspects of birthing, not just pertaining to my specific situation but also about the trend that our country was in regarding c-sections, the fact that my current doctor had an obnoxiously high c-section rate among his patients, and birthing knowledge in general. It was my goal to become as educated as I could regarding the subject of childbirth.

I knew that we would eventually have another child so I began to read everything that I could about VBACs, I even posted an online ad asking VBAC mothers for advice. I hounded nearly all of my friends (especially the ones who had delivered without any pain medications and another who had had a VBAC) with questions. Yeah, I was pretty obsessed with knowing all that I could. All of this new knowledge was wonderful, but it left me feeling and knowing that I had somewhat failed. I had failed to be more proactive during my pregnancy and perhaps, had I made different decisions, the entire outcome could’ve been different.

After the c-section my doctor had given me a list of very generic reasons why the surgery was necessary, one of which was that my pelvis was not shaped properly and, therefore, not conducive for a vaginal delivery. When I had discussed the possibility of a VBAC with him for the next delivery he was very negative and unsupportive. He said I could try but only if I were induced, which made no sense to me since induction increases the risk of uterine rupture. In so many words he basically said, “You can try but you will probably fail.”

I left his office in even more emotional turmoil. Not only did I have enough self-resentment over the complete absence of my involvement and my blind faith in the medical system in my first labor, but now I was questioning that maybe my body was not able to vaginally deliver a baby. Perhaps my body was broken.

Soon afterwards I consulted with a doula who gave me wise advice and who also helped me deal with and sort out some of the emotional issues that I was facing. She referred me to a few VBAC supportive doctors in the area and encouraged me to explore my options. I took her advice and did just that. I knew that I wanted a second opinion regarding my pelvis and that if I would attempt a VBAC then my best chance of success would be to be under the care of another physician.

I chose one of the referred physicians and requested that my previous physician send all of my medical records to my new OB. My new OB did a pelvic exam and found that, in her opinion, there was nothing wrong with my pelvis. We discussed what happened with my first birth and she reviewed my medical files that had been sent and concluded that I was a perfect candidate for attempting a VBAC.

Throughout my second pregnancy I continued my research, every day becoming more emboldened and positive that I could successfully do what my body was designed to do – deliver vaginally. I read numerous books and attended a Positive and Prepared Childbirth class, which was incredibly informative and useful. I created my birth plan and reviewed it with my husband and doctor. We were all on the same page. I had discussed with my doctor that I was hoping to go without any medical intervention and deliver naturally, but that I wasn’t ruling out pain medications either. If I were unable to cope or had no energy left, knowing that I would not have energy to push, I would consider other options. It was important to me to have resolved before the baby was even born that I would not feel bad or come down on myself if I needed pain medications or an epidural, or that if after giving it my all a c-section was needed then I would be okay with that. My doctor was very supportive; she really took her time with me. Each visit it became more apparent that she was truly interested and involved in my well being and that she recognized and supported what was important to me.

My contractions began at home on April 26^th, three days before my due date, around 8:30 pm and were about 15 minutes apart and lasting for about 25 seconds or so. The contractions were not at all what I was anticipating. There was no build-up to their intensity and no let down either. Contractions hit with full force/intensity from the very beginning, remained at that level for the entire contraction and were very painful. I labored at home until the contractions were 5 minutes apart and lasting for about 45 seconds. At that point we left for the hospital and I was admitted around 2 am on April 27^th. By the time 5 am rolled around I had been awake for nearly 22 hours, my contractions were coming every one and a half minutes and were one minute in duration. I was completely exhausted and was only getting a 30-second break between contractions. Because the contractions were so painful and the break between them was so miniscule, I could not even begin to relax. I was examined and was found to be dilated 7 centimeters.

At that point I asked for the epidural, I knew that I could give no more and that if I did not get some rest I would have no energy or will power to push. Considering that my first child was not “pushed out,” I knew that the pushing process was a crapshoot – could be fast or could be very long. I received the epidural and got some much needed rest. Later on I was examined and was fully dilated, but the baby was still relatively high at zero station so my doctor decided to let me rest a little more and allow the contractions to move the baby down a little further. Once the baby moved down enough, I began pushing. I pushed for about 45 minutes and delivered a beautiful, healthy baby boy. I was so ecstatic and proud – my body WASN’T broken. I delivered as I was designed to do!

Within seconds of delivering Judah, without even pushing, my placenta came flying out. That’s when my doctor knew something was wrong. I was bleeding heavily and there were no signs of it slowing down. Since I was a VBAC, my doctor’s first thought was to check to see if the site from my previous c-section incision had ruptured, but it had not. There was no rupture anywhere in my uterus.

At that point they realized that my uterus was unresponsive. It had stopped contracting, a condition known as uterine atony. Because of this condition the large blood vessels in my body that fed the placenta were continuing to bleed out. They were giving me pitocin and vigorously massaging my uterus in an attempt to help it begin contracting again. It wasn’t too much longer before I was being whisked away to the operating room. My doctor continued to work on me and they began a blood and plasma transfusion. I was knocked out at that point. I woke up in ICU, intubated. I was told that they got my uterus to contract but had done an ultrasound and saw pockets of fluid in my womb. Not knowing if it were blood (meaning I was still hemorrhaging internally) or just benign fluid they decided to measure the pockets, wait one hour and conduct a second ultrasound. If the second ultrasound’s measurements showed growth then they would need to do a c-section in order to fix the problem. Well, the measurements showed growth so a c-section was performed. Turned out that it was not blood, it was indeed just benign fluid. The surgery wasn’t needed after all, but I am so glad it happened.

While they were in there, two important things were discovered. The first was a uterine rupture, but not from my previous incision site. This rupture was in another location and was believed to be the result of all of the intense massaging that was administered. The second discovery was shoddy work performed during my first c-section. There are 7 layers of abdominal muscles that must be separated when performing a c-section. Apparently my previous doctor did not reattach those muscles when closing me up. Simply put, when my current doctor opened the site from my previous incision the first thing she saw was my womb! She did not have to go through all the muscles that one would normally have to go through. As a result of this “unnecessary” yet much needed surgery, a secondary uterine rupture was fixed and my muscles were reattached.

Please let me clarify that what happened to me that day was not due to the fact that I had a previous c-section. All indications point to the likelihood that I had developed preeclampsia during labor. Uterine atony and postpartum hemorrhaging could just as well have taken place during a c-section. Believe me when I say this was a very dramatic experience. In order to keep this story from being entirely too long, I’ve left out several other details of things that took place. But despite all of this, I feel more emotionally whole and restored than I did before, and not just because God said it wasn’t my time to die but because I successfully birthed my child into this world. I experienced that indescribable event.

It’s amazing the difference that mindsets and medical care providers can make (whether it be an OB/GYN or a midwife). Looking back at my first experience, my mindset at that time and my doctor at that time was a combination that lead to an unwanted outcome. Then there was my second experience, my redemption, where I decided to face my fears and arm myself with the necessary knowledge. I sought advice, found a caregiver who supported me on my journey and continued educating myself. I made informed decisions that I believed would lead to an outcome that I desired and it was a success!

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Look, ma, no hands!

How many of you would agree that internal exams during labor are just plain awful?  Well, I can't promise that they'll ever go away, but SarahVine shares some tips in her blog on other signs of progress to look for - on the Outside! I can't wait to add this to my doula work.

http://sarahvine.wordpress.com/2010/03/07/how-dilated-am-i-assessing-dilation-without-an-internal-exam/

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http://womantowomancbe.wordpress.com/2008/04/27/checking-dilation-without-a-vaginal-exam/