An OB's Birth Plan

[Poppy_Petal]

Hello,

I've been a member here for a long time but don't post because I decided nursing school with young children at home wasn't something I could personally pull off. I'm 26 weeks with my 3rd (1st 2 were hospital births) and at my last appointment my OB folding a piece of paper in half and handed it to my husband. He told us it was information on hospital policies and things and we could discuss at my next visit. All I saw was the title Dr. ________ "Birth Plan" and I was amused because I know that birth plans can be irrational and badly researched. After I read it I was less amused and now plan on finding another care provider. I do believe the OB is a good doctor and I plan on sending a polite but honest letter and I would also like to cite research in order to leave some possibility that he will rethink his position. I am having trouble finding research.

DR. ________ "BIRTH PLAN"

Dear Patient:

As your obstetrician, it is my goal and responsibility to ensure your safety and your baby's safety during your pregnancy, delivery, and the postpartum period. My practice approach is to use the latest advances in modern obstetrics. There is no doubt that modern obstetrical advances have significantly decreased the incidence of maternal and fetal complications. The following information should clarify my position and is meant to address some commonly asked questions. Please review this information carefully and let me know if you feel uncomfortable in any way with my approach as outlined below.

* Home delivery, underwater delivery, and delivery in a dark room is not allowed.

* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the

I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of "Natural Birth" promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.

* Doulas and labor coaches are allowed and will be treated like other visitors. However, like other visitors, they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby's well-being.

* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly, necessitating an emergency c-section. The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby's well being.

* Continuous monitoring of your baby's heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby's heart rate are not allowed.

* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.

* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.

* I perform all lady partsl deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.

* Episiotomy is a surgical incision made at the lady partsl opening just before the baby's head is delivered. I routinely perform other standard techniques such as massage and stretching to decrease the need for episiotomies. However, depending on the size of the baby's head and the degree of flexibility of the lady partsl tissue, an episiotomy may become necessary at my discretion to minimize the risk of trauma to you and your baby.

* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby.

* If your pregnancy is normal, it should not extend much beyond your due date. The rate of maternal and fetal complications increases rapidly after 39 weeks. For this reason, I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor. Contrary to many outdated beliefs, inducing labor, when done appropriately and at the right time, is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section.

* Compared to the national average, I have a very low c-section rate. However, a c-section may become necessary at any time during labor due to maternal or fetal concerns. The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.

[BabyLady, BSN, RN]

This doctor is absolutely, no question, out of his mind.

He is an arrogant dictator...and that is the last thing you want during the birth of your child.

[CEG]

Run! Run! Far and fast!! Only if he wrote this in 1975 does it match ACOG recommendations! Let alone actual evidence-based practices! Find a new provider now!

[CEG]

I hate to say this but this is how most docs practice even if they don't put it into writing like this doc did. I might suggest that you find a midwife. And honestly I am a huge believer that at home deliveries are just stupid. I have seen bad things happen REALLY fast in what was EXPECTED to be a totally normal and routine delivery. Times when if that delivery was going on at home both mom and baby would have died!!! A matter of a few minutes between --all is good and holy crap get into the OR NOW!!! We got about 10 seconds to get this baby out....I've seen a mom go into DIC and end up almost dying and in the ICU for weeks afterward--totally unexpected. That is a HUGE risk to deliver a home. Stupid if you ask me. As far as the Bradley method-- done by the book so to say this plan is a huge pain in the butt!! And my biggest problem with it is that it tells not to have a baby getting the meds that are standard to give on delivery-- The shot of Vit.K which is needed for the baby to be able to clot his own blood--adults produce Vit. K in the intestinal tract, by bacteria there...this does not happen right away in babies. They should get Erythromycin ointment in the eyes to prevent infections from causing blindness......this method tell parents not to allow these meds......the other benefit the baby gets from the shot is that yes they cry a bit...but in a brand new baby that is good, the crying helps them to clear their lungs....I have seen babies that didn't cry at all until that shot, despite many efforts and this was what got them crying to clear the lungs.....something they have to do.

I honestly do not believe you were an L & D RN any time in recent memory. The points that you make here are not only not evidence-based, but there is not even a factual basis of any type for many of them. You are entitled to your opinion but if you are going to give advice to anyone from a position of authority as a nurse then you need to research these issues.

[eden]

Honestly I would find a new Ob as well. Many of his guidlines are not standard practice elsewhere.

Awhonn guildlines suggest that IA has comprable, if not better outcomes then continuous EFM. Yes there are times when it is necessary and beneficial but for a low risk pegnancy there is no reason to automatically start with EFM.

Why in a normal, low risk pregnancy must there be an IV? Where I work they are most certainly not mandatory and we have never had a problem getting IV access if needed. We have guildlines as to who needs IV's but just walking in the door is not one of those criteria.

Position changes are great to keep labour moving, best thing you can do is use gravity. One of the first things you do if baby is having decels in the heartrate is to change mom's position.

You are most certainly within your right to refuse an AROM, yes it may be helpful but certainly should not be done without your consent.

Where I am most ob's still deliver in stirrups but there are some that are more open to other positions. While most ob's do not like to delay cord clamping most will respect your right to have it done, barring an emergency.

I'm sorry but there most certainly is a higher risk of complication and c-sections when induced. There is no evidence that it is unsafe to deliver a healthy woman at 40+/41+ weeks as long as the baby is monitored and yes you always have the right to negotiate whether or not you need a section, depending on the reason for it, that is all a part of informed consent.

[KittyKat19]

******

[Dayray, RN]

First let me say that I don't agree with a lot of the things he says in his "plan" I also think that you need to find a doctor that approaches birth plans as a discussion aimed at arriving at a plan that is both safe and addresses your desires and concerns that you can both agree on.

That being said, I cannot help you with resources to refute his birth plan. it is written completely in line with ACOG guidelines with a few exceptions) and the latest accepted research. ACOG guidelines are set up as a template based on statistics which is the accepted way of directing medical care. It does not mean that those things are the best for you in your particular pregnancy or situation it is instead safety by statistics (i.e. this works for 90% of people and 1% will have sever problems if you don’t do it this way)

The things I see in here that don't have anything to do with ACOG are ( as I went threw these I see that I actually don’t agree with most of it but I do see where he is coming from lol):

HOME delivery, water birth and delivery in a dark room- home birth is great (if it goes well), horrible if it doesn’t: most of the time birth goes well with little need for intervention and usually those interventions are simple however if problems develop they can be catastrophic when you are out of hospital because it takes 5,10,15,30,60 minutes to get to a hospital and that may be too late.

Water birth is fine but unless your practitioner is trained and comfortable doing them it can be dangerous. just think of bending over in a weird position and trying to do the things you normally do without falling in the tub also if you really want water birth please make sure you watch a few tapes of water births before you make your final decision.

dim room - the thing he is worried about here is not being able to see. many times problems with delivery and possibility of tearing can be seen ahead of time if you have a clear view. that being said if you spend some time with the patient before delivery then your eyes are adjusted and you can see better also doctors tend to sit or stand at the foot of the bed away from the patient . if you are sitting near the patient on the foot of the bed or with them on the floor, couch, stool you can not only see better but can easily feel with your hand the same things you assess with your eyes.

not accepting birth plans/ Bradley - The underlying idea he has here is good but the harshness and finality with which he states it is insulting and in and of its self would make me look for a different practioner. what he is trying to do here is head off any weirdness that comes up. these things are rampant on the internet and coming from childbirth advocates with little education or experience. so i can see why he wants to state he wont do those things but again it needs to be a discussion and not a edict from him.

not accepting Bradley- The way he puts it and the finality with which he states it is again a red flag. Again i can see his point here however. The Bradley method works well for some people although i don’t particularly like it the problem comes because for some reason Bradley has been embraced by the most devote anti-medical birth advocates some but not all bradley instructors teach a distrust of the medical profession in general also the idea of the father as a protector is great except that if the father is a control freak or is unsympathetic to the women’s pain he becomes a huge problem it was not the internet of original Bradley but the father is told it is his job to keep the mother from taking pain medicine and they sometimes become abusive in keeping her from doing this also I have strong opioins that it is the mothers decision to take pain medicine even if she makes that decisition when in labor , yeah you offer other ways of dealing with labor and confirm her decision several times before actually giving them but it is her decision and she does not need a guy to make her feel bad or like a failure because of it. aside from any of this i find it really really strange that bradley has been embraced by so many child birth advocates. I have known several nurses that worked with Dr Bradley. All of them describe him as mean demeaning, paternalistic and some times abusive in his practice in reading his book and considering his method you can see this. ( ia m sorry for the personaly opioin here) Bradley works fine for some people and if you like it you shoudl use it.

Douala’s and labor coaches as visitors - I completely agree with this one. doulas can be great they can also be horrible when their agenda is not to give you a good experience but to serve an agenda of their own: either unmedicated child birth at all costs, a desire to be a nurse or doctor and make nursing/ medical decisions, or placeing their desire to experience your birth above the desire to help youhave the best experience or to learn even at the expense of your comfort. I have worked with hundreds of doulas and only had problems with 2 of them and a few others that i didn’t have a problem with but saw them as spectators more then labor support. in most cases even overly aggressive doulas can be worked with when you refocus them on the patients well being and experience but in the rare cases you cannot they need to be removed. I have to wonder though. it is so rare that these problems come up, why did he feel the need to put it in print.

IV access- I have mixed feelings on this one but I think it should be left up to the patient as long as they don’t have factors that make their labor high risk. there is nothing more beautiful then a women sitting in a rocking chair or walking for a few hours and then delivering with no cervical exams, Ivs or meds and little interferance from us at the same time there is nothing more terrifying then having a post partum humoring without IV access in most cases i can start an Iv and give meds in 30-60 seconds but I fear for the times that i cannot and there are other emergences when IV access is even more critical it is defiantly safer to have an IV and its only a small discomfort but if you don’t have any risk factors and understand the risks of not having one it is your right to say no.

Continues monitoring after 4 cm - the only guild line i know for that is AWHONN's guideline for intermittent monitoring. if you don’t have any problems or reasons to watch closely i.e. non reassuring heartones, abnormal growth, placenta issues like low lying, partial abruption or previa, bleeding or something else. then AWHONN's minimum fetal monitoring is heartones every 30 min preferably before during and after a contraction for about 3 min with 20 min strip every 2 hours and continues while you are pushing. I generally follow AWHONNs recommendations and if something makes me feel i need to watch closer we talk about it. the only ACOG guidelines i know of are for monitoring following decels I am sure they have a guild line for intermittent monitoring that is similar to AWHONNs. his position on fetal monitoring is excessive but i know why he takes this position some times weird stuff happens and the only way to be 100% sure we catch them is to have you on the monitor all the time. I see his point but with AWHONNs guideline and assessment as well as info from prenatals i think it is relatively safe to let people be at least a little free during labor. you can find lots of studies that prove fetal monitoring is not that reliable ( and it really is not 100% or even clsoe to it) but it is all we have and legally if we don’t use us it we are up the creek also i wouldn’t use AHWONN guild lines when writing a letter to a doctor. They tend to scoff at guid lines set by a nursing organization.

epidural - it is true that the current research says that epidurals do not hamper labor in any way. But any person who works in obstetrics can tell you that’s not true. there are also doctors who go the completely opposite way and say that you need to wait until 4 cm and that too is not true. the simple answer is that when to get an epidural is a joint decision between you and the people caring for you. You can of course override everyone one else and get one whenever you want but it can slow things down or in some cases stop them. I usually tell my patient to tell me when they want it and we will talk about it. 99% of the time when patients ask they can have one with little risk of slowing things.

delivering in stirrups - Position for delivery is not (as far as I know) addressed by an ACOG guideline. there are studies showing that lithotomy position is not the best and sometimes harmful. that being said doctors (not midwives or nurses) are trained in school and in residency to assess everything and deliver babies in Lithotomy position. when you are in another position it changes your pelvis and moves the landmarks doctors use to assess your pelvis and the decent of the baby- which can make it harder to anticipate problems or help you not to tear and really to make sure they don't drop the baby when its delivering. I personally hate stir up's i think they are uncomfortable and have known them at times to hurt. it also just makes things seem so cold and a bit scary. I know doctors are comfortable with them because it keeps your pelvis open and your position content allowing them to assess things better. I don’t agree with this item but I understand his motives for writing it. I think sometimes doctors get a bad wrap people assume that they force issues about position / surface only because they prefer it. it is true that the standard position for delivery was developed with more consideration for the doctor then the patient. Doctors however are not forcing a certain position out of selfishness or control issues its because it was the way they were taught and they fear complications in other positions. I have known some that deliver in other positions but they are rare and i assume they how to deliver in other positions threw trial and error you can imagine how scary that is for them though, trial and error with human life..

deliveries only on standard labor and delivery beds- again this goes to this training and abilities to assess/ perform maneuvers to deliver. it is probably safer to do this in the rare case if a complication its allot faster to have people on a bed but most of the time you can anticipate complications (not always) and then say we have to be on the bed. it is pretty easy to move to a bed or out of other positions if need be also it is beneficial for many women to be on another surface or in another position so again well i see his rational i don’t agree with him

episiotomy - i think his explanation of the reason he performs episiotomy and the things he does to avoid it are good but the way he says "at my discretion" worries me honestly necessity of episiotomy is rare and there is no way a patient can judge it for them selves so it does need to be left up to the doctor. So a discussion (before delivery) needs to be had of what his thoughts are on episiotomy, factors he would use in making a decision to cut and what his % of episiotomies is, the fact that he felt the need to spell it out makes me worry about how often he does them. sense he is the one that has to make the decision you have to decide if you agree with his basis for making that decision.

clamping the cord- this one is a hot topic lately. years ago i did a lot of research on this I was able to find some evidence and suggestion within the medical community that this could be beneficial. I was not able to find any studies that set parameters for how long to wait how to assess how much blood the baby was getting or the babies need for additional blood. also there is some risk of the baby getting too much blood. because of this I am not comfortable with letting the cord pulse. I have heard that their are more recent studies suggesting parameters for how long, why and how to do this but i haven’t seem them. also problems i have seen arise from this are patients refusing to let the doctor cut the cord when the baby has thick me conium or other complications needing treatment. even the benefits of delayed cord clamping (which have not been quantified by any study) are over shadowed by the babies need to breath or the risk of me conium aspiration.

C/S non negotiable - umm i really have problems with the finality of his statements anyway unless you have a baby that is in distress, you are bleeding or have some other risk of you or your baby dieing you can take some time to discuss things and make a decision.

It sounds like he has had problems in the past with patients demanding extreme things and possibly having bad outcomes due to those demands (which every practitioner has). He writes this plan to head off problems before they come up. The problem with that is by doing so he has completely removed any room for judgment and gone with an ULTRA safe plan.

I don’t like his plan over all and I think it puts all the power in his hands and that it is too rigid and removes any room for assessment to guide his decisions it also does not allow for your input. that being said I don’t think he is an evil man. I think he wants to be safe and has developed a plan that keeps him legal, following current recommendations and allows him to sleep at night because he is doing everything on the safe side. his plan is the "perfect plan" for the doctor. it will useualy deliver a live baby with minimul risk to his professtional reputaion or pocketbook and with little need for him to use his own assessment or problem solving skills. liek others have said Run for the hills , find someone else but don't tell the guy off or think of him as mean i really think he is trying to be a good doctor and is just a bit misguided

[obgoddess]

I may be superstitious, but I find that a lot of the people who have strict birthing plans end up having happen exactly what they did not want to do.

[shortstuff31117]

Shocking...So much against what research shows...although I bet that's what most OBs would write out if they actually went to do it...

[rnheart]

You know I am almost kind of proud of this Md he actually had the b---s to put into words what the majority of Ob's are doing and not telling their patients until they are forced to stay in bed on the monitor( not even allowed to go to restroom) and up in stirrups with a vaccum or a 36+6 week induction on a cesearean section table for failure to progress when they are not even ready for labor all because the Md is going out of town on vacation, - and doesnt want anyone else to deliver his patient, and the patient thinks its because the Md likes her. BS it is for the money.

Now having ranted about all that I do not approve of this Md's practices at all and wish you all the luck in the world.

REMEMBER KNOWLEDGE IS POWER!!!!!!!

[SmilingBluEyes]

I echo those saying to find a better fit for you. This may be an amazing provider, but not the right one for you. Sounds very very impersonal and cold. I would not like this. I wish you the very best.

[Spidey's mom, ADN, BSN, RN]

This unfortunate attitude may have something to do with the litigation against OB docs and high malpractice rates.

Sad - but maybe they feel "pushed" to over-"medicalize" Labor and Delivery. http://www.amazon.com/Pushed-Painful-Childbirth-Modern-Maternity/dp/0738210730

I worked in a small rural hospital with one L&D nurse and one doc at delivery - the truth is, if something turned on a dime I truly appreciated having that IV already placed.

And things do turn on a dime.

steph

[Poppy_Petal]

I wanted to update...

Here I sit holding a healthy almost 4 month old baby boy and part of me wants to send a thank you card to this doctor because if he hadn't been so extreme I probably would have had a hospital birth and almost everything he listed would have been done because that's just the way things are at hospitals here and it's hard to argue when you're in labor. I was so irritated with the hold OB attitude after his "birth plan" that I went almost to the complete opposite and had a midwife assisted birth in an extremely low tech birth center. Toward the end (I went to 41+5) I had many moments where I wished I had stayed so I would have someone who would "enable" me to risk my health, the babies health, and my low intervention birth and just get that kid out of there. It's hard to resist going the super intervention route when you're exhausted, uncomfortable and just done being pregnant and it's a pity doctors are so ready to take advantage of this or at least ready to humor you without disclosing the risks. As it was I went to the birth center at 12:30pm (after 24 hours of steady labor), had him at 3:20pm in tub with nothing hooked to me and doppler monitoring done after every few contractions, no pushing instructions and I delivered an 8#15oz baby on my side in tub without a tear and went home at 6:20pm. It was amazing that left almost entirely to my own devices (the only thing they had to make me do was drink water in between contractions I never would have thought of it by that point) I knew exactly what my body needed to do even if it went against their advice. I prolonged the pushing stage by raising the pitch of my screams so that not every contraction would be too productive and I think that's what allowed me to deliver him with no tears even though I have a problematic episiotomy scar. I only had a "skid mark" or two and didn't even need to use the peri bottle when I urinated. I don't think this birth hurt any less than my previous two hospital births but it was just so much better.

Thanks all -especially to the wonderful L & D nurses who advocate for their patients and not just for the OB and the hospital.