Do birth plans grate on your nerves?

CEG · Jul 14, 2009

Birth plans aren't so bad if people research things out a little more, i mean our hospital hasn't given a routine enema for a labor pt in like thirty years why are people still writing that crap (literally) down still Please talk to your dr, hosptial... It will save time when pts write out the 4 page birth plan,, it they would be aware of current practice..

Truly it is difficult for a pt to be aware of current practice. In all honesty many docs are not aware of nursing practices and will often tell their patients what they want to hear. Your hospital may no have done routine enemas for 30 years but many have since then. The hospital where I worked as a nurse had about a 50% episiotomy rate although current practice recommendations say routine epis is harmful. Where I am as a CNM student the rate is

L&Dnurse13 · Jul 14, 2009

I am ok with birth plans, I am there for the pt and to help their labor go as smooth as possible. That is my job. I want every pt to look back and remember their delivery with joy, not sadness. I don't mind the walking or position changes, but we are not a birth center we are a high risk unit with a level 3 NICU that does over 400 deliveries a month. A lot of these are transfers for PIH, HELLP, etc... It needs to be discussed with the doc prior to labor. If I have a pt with PIH or IUGR, no I am not comfortable with them off the monitor. I have seen too much. Pts really need to educate themselves prior to labor. I have had pts on insulin drips have food brought in then end up with a BS of >350, get mad at me because it was in her birth plan that she would eat during labor. Just need a little more education.

RNperdiem, RN · Jul 14, 2009

I'm trying to imagine what an equivalent plan would look like for SICU, my department.

There isn't a lot of refusing of pain meds. Inflated expectations of a grand "experience" are rare, and there is less controversy about best practices.

RAYLO! · Jul 15, 2009

Truly it is difficult for a pt to be aware of current practice. In all honesty many docs are not aware of nursing practices and will often tell their patients what they want to hear. Your hospital may no have done routine enemas for 30 years but many have since then. The hospital where I worked as a nurse had about a 50% episiotomy rate although current practice recommendations say routine epis is harmful. Where I am as a CNM student the rate is
I completely agree that it is difficult for a pt to be aware of current practice. Many of providers tend to not be up front of what many hospitals allow or not allow.. It just does seem to me interesting, at least @ my facility birth plans have increased, but enrollment in childbirth classes have decreased. A great deal of pt's receive most of their info via internet, instead of from the source... Birth plans are a great idea, but i have seen some that couples did even bother changes fob's name. For birth plans to be taken more seriously, there should be greater discussion between all parties involved...

bluemorningglory · Jul 15, 2009

we got a birth plan the other day for a c-section!! for a c-section!! saying dad would cut the cord, the baby would go straigth to her, blah, blah, blah.... it was really pretty funny! the best part of the whole thing was dad passed out in the or. no, he didn't get to cut the cord! = )

Maybe nursing is not a good place for you. :uhoh3:

bluemorningglory · Jul 15, 2009

I had birth plans with my deliveries but they were well thought out and not completely crazy. I can see staff being frustrated with the demands of someone betted suited to a home birth. On the other hand, small requests(Dad cutting cord if baby is ok) seem very reasonable. While I have no desire to be a l&D nurse someday, I will try to accommodate a laboring patient as much as I can with the safety of both mother and baby in mind:)

lamazeteacher · Jul 16, 2009

I had birth plans with my deliveries but they were well thought out and not completely crazy. I can see staff being frustrated with the demands of someone betted suited to a home birth. On the other hand, small requests(Dad cutting cord if baby is ok) seem very reasonable. While I have no desire to be a l&D nurse someday, I will try to accommodate a laboring patient as much as I can with the safety of both mother and baby in mind:)

Some students in childbirth education classes, have been told by their mothers and grandmothers, that they should have a c/s, due to their own prolonged and ?difficult labors and births. They give their first OB (in a group practise) information about that, and assume that the chart reflects their comments (which doesn't happen). Unwilling to acknowledge that a patient is on a path they won't necessarily follow, the OB agrees that yes, he/she will do a c/s, without adding, "if your labor goes the way of your maternal line". With the high stats on c/s today, it's likely that one would become necessary/possible.

However, the patient is determined, but not pushy about it while pregnant, and the doctor is relieved that the matter hasn't come up again. The patient goes to superficial classes (like "How to have the Happiest Baby on the Block") (Huh?) and somehow thinks a definite scheduling of her c/s has been done.(huh?) Since so far, having a healthy baby supercedes unmet expectations, and the baby and mom did come through L&D without any damage done (except to her trust in physicians). It may be that "after baby blues last longer, perhaps the sadness seems more profound, if she's lucky. (Lucky, because the unhappiness is expressed, rather than witheld, only to smolder for a long while and possibly become a latent depression.)

I've seen the above scenario a few times, in the 35 years I taught Lamaze classes, and discussed the importance of crying, when a few women say they're "really, really happy" (without true expression of that) and haven't cried yet, when I called them to see how their labor went. I told them to cut onions, to get it going. There is a reason for the "blues" (as expressed by the song, "I guess that's why they call it the blues"). I discuss their feelings about the baby, to see if they voice negative feelings, serious anger toward the baby, or disappointment/lack of reality, in touch with their parenting role, ask who feeds the baby (not that it's bad if the mother doesn't, but it hints lack of involvement), to gauge any predisposing factors for pp psychosis. If I get that type of response, I ask to speak to their partner/spouse/mother, and ask them to encourage any expression of sadness, and let mom participate in the care of her baby as much as possible.

When their doctor isn't in accord with patients' expectations, usually no lawsuit ensues, as it wouldn't pass the arrainment, since no error resulting in actual physical damage to mom or baby occurred. However, the mom may later avoid becoming pregnant again, and purposely goes to another member of the group for her pp check-up, and later to a different group for her routine care. Extensive follow-up isn't appropriate, unless more support is requested. Sometimes if asked to be their lactation consultant, I can see if mom is heading into a close relationship with her baby. Usually several telephone calls happen, and if I see trouble brewing, I'll suggest to a family member at the home who has related well with me, that a psychological consult be scheduled. Then I have to stand back and let them deal. :nurse:

HvnSntRN · Jul 18, 2009

When we see a birth plan at the front of a chart, it's almost guaranteed that the delivery was by emergency c-section for maternal or fetal distress. These are the ones that need Code Pinks, etc.

One of my colleagues created a spoof birth plan that included almost every ridiculous request we'd ever seen. She included things like "My partner wants to kiss the baby's head as it crowns" and "He'd also like to chew through the umbilical cord the way nature probably intended" and "we'd like to be in the jacuzzi so he can shave my perineum during labor for better photographs of the delivery". Of course, she finished with "But seriously, all we want is a healthy baby - whatever is needed to accomplish that is fine with us."

CARCAM75 · Jul 19, 2009

LOL!! Yes birth plans can be excruciating for the Labor Nurse and everyone else involved.

The approach that I take is I sit with the patient and spouse/ Significant other, etc and I read over the birth plan with them. Even if someone else has done it - like the MD/ Midwife, etc - I like to go over it again with them because I will be the labor nurse tending to their care 90% of the time and it is I who will be immediately intervening/ harrassing/ throwing a wrench - possibly- in their experience. Its also been my experience that sometimes the providers mislead these patients into "Oh yeah, we can do everything that you want, bring on the birth plan. It's totally your experience and we're going to jump through hoops to accommodate you when you come in to have your baby." The labor nurse makes or breaks the entire laboring experience of the laboring patient.

I ask questions as to why they don't want an epidural and/or pain mgmt - a lot of their reasons are based on misinformation from friends/ family members/ television/etc. I then correct any misinformation that they have. Then I tell them what they can expect from their experience here on the labor & delivery unit, immediate recovery period (the fundal massages and why we do them) and a little about post-partum processes (I don't do postpartum and so I tell them only what I know). I inform them of the reasons why we intervene and inform them of the importance of monitoring fetal heart tones while they are laboring, tell them about the mechanism of contractions and how they affect the baby - dilatation and distress - tell them what our interventions are in case of fetal distress (the turning and oxygen application, fluid boluses, possiblitities of needing and Intrauterine pressure catheter and/or and internal scalp electrode). I tell them why we give the erythromycin, vitamin K and Hepatitis B immunization shots to the babies post delivery, etc. (It never ceases to amaze me how little factual knowledge pts have compared to the inaccurate info they come in with regarding baby meds/immunization,etc) As I go through the birth plan with them I inform them of the requests that are possible to incorporate, impossible to incorporate (sometimes they are high risk patients and they request no monitoring, no interventions of vital signs, etc. and that is just not going to happen for a PIH pt) and a definite NO -GO to incorporate in their care. I answer any questions that they may have and what I don't know the answer to I tell them I don't know but I will find out and get back to them. I get the answers or have someone (doctor or counselor or postpartum charge nurse, etc.) come and explain further, etc.

At the end of my little information session (I usually do this on admission if I am getting them fresh from triage or when I get them at shift change) they are more informed about the reality of what to expect on the labor unit, they understand the SEVERITY of the labor process - it's not like TLC and Discovery Health programs portray it to be (I hate those laboring programs) - they understand why I need to intervene like I do WHEN I do and they are more compliant. Over all, they don't stress ME out while I'm caring for them (because they know why I need to do what I'm doing and when) and they get as much out of the laboring experience that they want. More than anything, they KNOW that I'm not trying to take anything away from or ROB them of what they would like to accomplish. They still feel empowered and in control of their labor experience. The birth plan is just another way of the laboring patient to say I WANT TO BE IN CONTROL OF MY LABOR EXPERIENCE. By letting them know what is possible and not possible, they feel like they still have some control of the situation and they really value that they've taken part in their care.

I think laboring patients get so caught up in the NATURAL is GOOD, MEDICAL is BAD that they come in with an attitude against the medical establishment when it is needed. I always tell them, we don't sit around as medical staff and say, 'Oh she's really comfortable , lets go see how we can mess that up' or 'You know what, lets just go have a c/s for the hell of it'. When we intervene, it's usually necessary. Otherwise, we would leave you be.

When I was in nursing school (a short while ago, I graduated in 2006), one of the biggest things (and MOST VALUABLE thus far) that I learned was patient teaching. An informed patient makes a great deal of difference in the caring process. The caregiver wins and the pt wins. Another big thing that I learned is that it's not a bad thing to admit that you just don't know. Nurses aren't omniscient. We are human. Never act like you know everything. When you don't, say you don't, but always say "I'll look into that for you" or something to that effect. So the patient knows that you actually care.

Some labor nurses will probably say, wow, she has enough time to do all of that? No, I don't ALWAYS have enough time to do this counseling/ education, and as with anything else, some patients can receive this information and some can't. Everyone doesn't have the same thought process or learning ability, but you still have to assess your patient and the situation to know when is the right time to say X, Y, Z. However, the additional 15 minutes on admission or at shift change that you spend educating the patient, makes up for the 5-10-15-30mins or 1 hr of your shift overall that you'll spend back and forth in the patients room fighting with them when/if you need to intervene.

Overall, I say all of this to say that the birthing plan doesn't have to be a big ole scary monster..... we can change it to a Shrek or a Sully :)) (Those of you who are fans of the animated children movies Shrek or Monster's Inc. will get that analogy)

Thanks for reading!