Re: An OB's Birth Plan
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
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