Friday, January 15, 2010

To Birth Plan or Not to Birth Plan?

Not to be controversial, but this is an issue that is brought to me all the time. Many sites, when talking about doulas, have listed as one of our jobs "aiding in creating a birth plan". To be honest, I'm not such a big fan of birth plans. I have never found a great birth plan contributed to a great birth. I prefer to focus energy on helping a woman stay home, if appropriate, until she is in ACTIVE labour (which often doesn't have everything to do with how far apart contractions are). A simple "thanks or no thanks" with a smile from her partner when options are presented by the hospital can suffice. That a woman wants to "go natural" is pretty obvious after a time.

Let me tell you my experience of birth plans. Occasionally, the staff will take the time it takes to read it, agree with what you are asking for, and do their best to respect it. Lots of times, they take it, read it, and then go to the nurses' station and roll their eyeballs, saying, "Oh, great, she's here with a BIRTH PLAN!", and I don't mean in a particularly friendly tone. I have even seen on more than one occasion a mother hand a birth plan to a doctor only to be told, "no, I don't have time to read it. We treat everyone the same here."

I think it's important not to expect that all staff members will be happy you were a good consumer and made a birth plan in order to assist them in helping you how you want to be helped. I tell you this, because the importance of writing a plan is strongly emphasised in books and websites. Parents-to-be are often really hurt when their efforts, which they were encouraged to make by books and classes, are not met with enthusiasm. There is absolutely nothing wrong with having an outline telling people what you would like for your birth, and often even hospitals claim to encourage this. In theory. But in practice, I have seen a lot of strong reactions against them. Alas, more negative than positive. This is a surprising reality, but there you go.
I think these are some of the reasons:

1) When people download birth plan templates from the 'net, they are sometimes quite long. And detailed. Given how incredibly busy Montreal nurses are, often taking care of 4 patients at a time, any other detail they're asked to take care of is just another burden. While they're not against having you be happy, the truth is that many of them feel a lot safer with you on epidural, constant monitoring, and synto, to control your contractions. Your ideas, though they will usually try to respect what you want, are contrary to their own beliefs about birth, as some truly can't understand why you may not WANT to be monitored all the time, or not receive an epidural when you start getting louder than normal. A birth plan doesn't change this belief, PLUS gives them more to do in reading it. It may be in your best interest to not risk making a nurse feel, without your intent, more overworked, as well as a bit defensive about the "list of demands". True, we shouldn't have to be responsible for others' reactions when we are presenting something reasonably and with good intentions, but this is your birth....a potential environment of tension may not be a battle you want to fight in this instance.

2)Most of the things you mention are things most reasonably informed people want anyway, so the details of "I prefer to be mobile during labour" or "I don't want an episiotomy unless necessary" become boring for them to read after awhile.

3)Some birth plans are so specific and long, that you may not be thought of as an informed consumer wanting to create the potential for the best outcome possible, but as potentially inflexible, which worries the staff. While the vast majority of couples would not argue with a serious medical decision, sometimes the staff get nervous that if you made this kind of "insurance" against interventions, you may object if they really have to jump in and do something to help you. Part of writing a birth plan may be about the element of fearing potential victimization. Some doctors and nurses get a little defensive wondering that you may be thinking you will be a potential "victim" of theirs, and it could make the room tense. The truth is, you are going in as a strong birthing woman, and worrying you are going to potentially be subjected to a bunch of procedures you don't want is based upon fear. Fear makes you tighten up and doesn't help labour. Okay, neither does plying you with intervention requests, but the former you actually have control over, the latter you don't, birth plan or not. It just could be that going in calm, with the trust that even though there are many different ideas, all want the same: a healthy mom and baby, and that most human beings try to be basically respectful of each other, you may exude an energy that attracts dignified, and conscientious behaviour.

Now, I know some you anti-hospital people out there are shaking your heads at me, wanting to eradicate the "naivete" right out of me, but hear me out, remembering too that I am myself a home birther who attends mostly hospital births. I KNOW unwanted interventions are often done, and that we need to be aware of protecting our experience by refusing many interventions unless they're truly medically called for, without being able to control negative reactions. I KNOW victimization happens. This is, sadly, a price women sometimes pay when they choose to birth where they want technology and medical people available in the instance of an emergency. Even knowing there may be challenges, women still DO choose to give birth in hospitals, and need real, practical advice. There are ways to try to create the friendliest environment possible. From what I've seen, putting the effort into a birth plan creates a risk of tension, and the less tension, the better. Not having one does not create automatic permission to be the recipient of every intervention under the sun.

4)The term "birth plan" is pretty close to oxymoronic (is that a word?), perhaps similar to "ordered chaos" or "friendly fire". Writing a plan, obviously, in no way, shape, or form makes what you want or don't want happen or not happen. Sometimes making sure you have support to make decisions you want, and going with the flow of your labour is better than worrying too much about potential resistance. We simply cannot control those who enter our space in a hospital, or our birth outcome, and I have not seen a birth plan create a better outcome or attitude because it existed. Coming to the hospital in such active labour that there's no space to really discuss things is a better option (providing that is appropriate for your situation) because there is little time for more than a routine once over,never mind a big dialogue about preferences.

Hospital staff members have seen MANY birth plans, and there are mixed reactions when
you present them, from appreciation, to downright annoyance. So if you're going to make one, know in advance that they won't always be met with friendliness. I have even worked at a hospital which has you check off options you want for your care as a form of birth plan, and I swear they never look at them, because they always want to hook you up on a routine IV even if on their plan it requests you check off "IV" as an "option". It is surprising how many things are paid lip service to in order to appear progressive ,even though when push comes to shove, they are not truly presented as "options", but a part of a routine. So you create tension by refusing too. I'm not saying not making a birth plan will render everything fine and dandy, it just doesn't seem to make a huge difference. If someone is really into making one, I support them in doing so.

If you do not make a birth plan, chances are, you're going to be okay, as long as you know your options and make your choice when they're presented. Remembering that you are the consumer, and that you are allowed to refuse interventions that are suggested to "speed things up" or "slow things down" or "lie this way" or "make pushing more efficient", if those challenges come up. If you are feeling extremely mistrustful of the hospital environment, and feel like you are going to be terrified and fighting the whole time, then you should definitely explore the option of not giving birth there. There are alternatives to hospital birth, and tons of resources to help you with that decision. I personally felt like that, if I may share. I walked into the hospital where my doctor caught babies, and while I really liked her because she had let me grill her even with a load of pregnant ladies in her office and agreed to listening to my baby with a fetoscope instead Doppler, I had a deep, visceral reaction to the idea of being in labour there. I researched, and found home birth to be the best option for me. I did give birth in a hospital once, just near the end of the labour, and it was fine. My husband and midwife buffered any attitude that was presented, and besides, I was too far into labour land to notice. People may have told me how to push or in what position, I don't remember. I just, in good confidence, lay on my side and gave birth, pushing in my own way. I have no particularly bad memories. I did not have a birth plan because being in the hospital was totally unplanned.

While I don't think a detailed birth plan is necessary for a good birth, I do think having a couple of really special requests that you have spoken to your doctor about in advance is important, just in case your doctor isn't at your birth (which is entirely possible). To get this in writing simply as something you and your doctor have agreed on may cut through any arguments. They may be things that are not regularly requested at all. For example, delaying the cutting of the umbilical cord, or requesting that your baby remains on you skin to skin for at least an hour after birth. Also, special circumstances should be mentioned. I had a client who had tragically lost her husband during her pregnancy. We made absolutely sure that with every changing shift, she would not be asked, "where is the baby's father?". Another mother who had had a double mastectomy asked in writing for people to not constantly ask her why she was not breastfeeding her baby. I would consider this more a "wish list", which is friendly, as opposed to "birth plan", which may be perceived as rigid, even IF it's qualified by "providing all is well with my baby and me".

.