L & D NURSES: rate my daughters birth plan (please)

[kids]

*cringe* she discovered epregnancy.com...amazingly she is willing to let me post it and ask the opinion of experienced L & D Nurses. Most of the stuff seems like basic care and patient rights to me but I guess its better to spell it out than assume.

So, tell us what you think...

Birth Plan for:

Due Date: February 5, 2003

Patient of:

December 8, 2002

I am looking forward to sharing my birth experience with you. I have created this birth plan in order to outline some of my preferences for birth. I would appreciate you reviewing this plan, and would be happy to do so with you. I understand that there may be situations in which my choices may not be possible, but I hope that you will help me to move toward my goals as much as possible and to make this labor and birth a great experience. I do not want to replace the medical personnel, but instead want to be informed of any procedures in advance, and to be allowed the chance to give informed consent. Please feel free to ask if you have any questions or comments.

Thank you!

Labor Augmentation/Induction

 I would like to avoid induction but if induction is necessary, I would like to attempt it with prostaglandin gel or another means before pitocin is administered. If induction is attempted, but fails, I would like the option to come back at another time rather than pursue further intervention (assuming my membranes are intact and that waiting presents no danger to my baby or myself). I will base the decision to continue on the results of my baby's biophysical profiles and on my own personal discomfort.

 Please do not rupture my membranes artificially unless medically indicated.

Labor

 Please perform no routine prepatory tasks (shaving, enema, etc.), unless requested.

 I expect that doctors and hospital staff will discuss all procedures with me before they are performed.

 I would like to be free to walk, change positions and use the bathroom as needed or desired.

 I prefer to wear my own clothes, rather than a hospital gown, I realize that the birthing process will likely render them unwearable.

 I will remain hydrated by drinking moderate amounts of fluids (water, juice, ice chips).

 So I can stay as mobile as possible, I would prefer to have a heparin lock instead of an IV.

 If fetal distress is suspected and time permits, I would like confirmation of this with a fetal scalp blood sample before proceeding with other interventions.

 Please allow me to vocalize as desired during labor and birth without comment or criticism.

 Please do not permit observers such as interns, students or unnecessary staff into the room without my permission.

 Interns and students may not perform lady partsl exams.

 To preserve my privacy and dignity, I would prefer that everyone knock before entering.

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Anesthesia/Pain Medication

 I prefer an epidural to narcotic pain medication.

 I would like to try having narcotics-only administered in the epidural line before progressing to full anesthesia.

Perineal Care

 I prefer not to have an episiotomy unless it is medically indicated.

 To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop.

Delivery

 I would like the freedom to push and deliver in any position I like.

 I would like a soothing environment during the actual birth, with dim lights and quiet voices.

 I would prefer not to use stirrups while pushing. I would appreciate help from my mom and the baby's father and staff supporting my legs as I push.

Cesarean Section Delivery

 I feel very strongly that I would like to avoid a cesarean delivery

 If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making. I also ask that my mom also be fully informed so that she can assist me in the decision making.

 I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery. I would prefer general anesthesia in an emergency only.

 I would like to have a respectful atmosphere without chatter during any part of the surgical procedure.

 I would like my mom to be present during the surgery.

 If possible, please do not strap my arms to the table during the procedure.

 If conditions permit, I would like to be the first to hold my baby after the delivery. If my condition does not permit my being the first to hold my baby, the baby should be given to my mom immediately after the birth.

 If possible, I would like to breastfeed my baby immediately after the birth.

 I would like our plans outlined here for after the birth to be followed as closely as possible.

Immediately after the birth

 Please place my baby on my stomach/chest immediately after delivery.

 I would like to breastfeed my baby immediately.

 My mom and the baby's father are to be given the option to cut the cord.

 Please allow the umbilical cord to stop pulsating before it is cut.

 I have made arrangements for donation of the umbilical cord blood.

 I prefer to wait for spontaneous delivery of the placenta and do not want a routine injection of pitocin.

 Please remove my IV/Heparin lock/catheter as soon as possible after delivery.

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Newborn Care

 I would like to hold my baby through delivery of the placenta and any repair procedures.

 Please evaluate and bathe my baby at my bedside.

 Please delay eye medication for my baby until we are well past the initial bonding period (a couple hours after the birth).

 If available, would prefer erythromycin eye treatment or other antibiotic eye drops instead of silver nitrate.

Postpartum Care

 I would prefer not to be catheterized until I've had some private time to attempt urination on my own.

 Once I've had time to recover, I would like my baby to room-in with me.

 I would like permission for access to my chart and my baby's chart.

Breastfeeding

 I plan to breastfeed and want to nurse immediately following the birth.

 Please do not give my baby supplements (including formula, glucose, or plain water) without my consent, unless there is an urgent medical necessity.

 If I am unable to give my consent to any aspect of my baby's care my mom is designated and authorized to speak and act on my behalf.

 I would like to know more about breastfeeding.

 I would like to meet with the staff lactation consultant.

Additional notes

 I am planning for my baby to be circumcised before we leave the hospital.

 I would like still photographs taken during labor and after (not during) the birth as space and circumstances permit.

 In the event that unforeseen circumstances arise and I am unable to make care decisions for myself or my baby I designate and authorize my mom to act on my behalf including the giving of informed consent.

[bagladyrn, RN]

Please ask her to keep in mind, as well as on paper, that childbirth never goes exactly as planned/expected. Keep an open mind on changes in the plan, and realize that the L&D staff are not your adversaries, are there to help, not to inflict unneccessary procedures. I've had the unfortunate experience of a rigid husband insisting on a full explanation before any action as his wife was bleeding out and baby's hr was in the 60's because their birth plan demanded it. My response was less than polite.

[OBNurseShelley]

I agree, all sounds pretty standard and most of it can be deleted, most of it is up to the doctor, not the nurse's choice, i don't know anywhere that an L&D nurse would do something to you wtihout explaining it, tho in an emergency it might be a fast explanation. She mentioned having mom in the OR if a c-section was necessary, we only allow 1 support person in the OR which is usually the FOB or husband, but it can be whoever. I agree with the above posts, shorten it to one page, take out all the standard stuff and she will be fine

[HazeK]

First: Did she attend formal birthing classes?

Second: Has she contacted a lactation consultant prior to delivery?

Third: she should review her plan of care with the L&D unit manager to see what unit policies might conflict with her plan of care!

Fourth: if her MD is part of a group, she had better get EACH ONE of the group to SIGN off her birth plan, prior to laboring! Yes, this may mean extra office visits and extra expense! Otherwise, another MD might not accept her birth plan kindly! (I've even had MD's refuse to care for pt's with birth plans, saying: "if the patient doesn't trust my judgement, they need a different doctor!"

Fifth: does she realize how silly it sounds for her to go through this lengthy birth plan to protect herself and her baby from unwanted medical interference....and end it by saying she wants a chunk of her son's flesh cut off, against the recomendations of the American Academy of Pediatrics?

Sixth: she needs to understand that some nurses will take this as a sign of lack of confidence in the care they provide....others will just put the cesarean section papers on the chart when she is admitted!

I'll "PM" you with some other ideas!

Happy Grandmothering!

Hugs!

Haze :-)

PS How old is this daughter, that she has such "control issues" and lack of confidence in the medical and nursing professions????

[finallyRN]

I agree with most of the other posts that the birth plan is a little long. She can discuss this with either her doc or someone at the hospital she is planning on delivering at. They can help her eliminate things that wouldn't be done normally ie shave prep and enemas.

I found two statements that I want to comment on though:

„h I expect that doctors and hospital staff will discuss all procedures with me before they are performed.

---we as nurses and doctors do not usually do anything to a patient without telling them first. If it is an emergency we will usually do things quickly and give the patient a quick explanation as we do it. They need to understand that what we are doing is most likely for the sake of their babies and themselves. I am always willing to explain in more detail the rational for things I do in an emergency situation when it is no longer an emergency situation

„h I feel very strongly that I would like to avoid a cesarean delivery

----When I read this statement on a birth plan I get so upset. We do not go into a situation thinking we are going to do a c-section. We all know that c-sections have many more risks. We do not do unneccesary c-sections if the patient does not want it. The nurses and the doctors will do everything within our control to avoid a c-section. We do not willy-nilly decide to do major abdominal surgery just for the heck of it.

As a labor nurse these are the two biggest problems with this birth plan that I have. Just remind your daughter to have as much of an open mind as possible. We would try to accomadate all her requests as long as her baby and herself were not in jepordy.

Just my 2 cents.

Meg

[SmilingBluEyes]

PERSONALLY, AS HER LABOR NURSE, I would do my best to honor each and every word here---- I know for a fact, each patient doing this (asserting her wishes via a birth plan), is attempting to take back and/or keep her power throughout hospitalization........it is indeed intimidating being a hospital patient. Labor horror stories abound.

That said, PLEASE explain to her, hospital personnel consider childbirth a healthy, natural process and we make every attempt to treat it as such. I think just having all interventions thoroughly explained as to rationale goes a long way to securing trust between patient and staff. BUT I DO AGREE w/THE POSTER ABOVE WHO SAID MAKE SURE EACH AND EVERY PHYSICIAN OR MIDWIFE IN HER DR'S OFFICE KNOWS AND SIGNS OFF ON THIS....THEY are the ones who make final decisions regarding care throughout the process most the time, not us.

And have her hire a DOULA if possible. This person can pamper the laboring family and communicate wishes to the staff/midwife/physician for her when she is either unable or feels too intimidated. And like said above, remind her to be open to possible changes and aware that things MAY change--- and sometimes FAST--- if the health status of either herself or her baby dictate. There again, a doula can be helpful as a reassuring presence in times like this.

Good luck to you all. I wish you a healthy, happy delivery and new baby!

[Lausana]

Grandma Nancy I think she's doing great at really staying on top of her pregnancy-planning ahead & getting advice from the best :) She's got time to work out the unneccesary bugs in her plan!

>

[imenid37]

doula idea is great! super suggestion! that would be a great gift from grandma, but mom and dad should pick the doula of course.

[canoehead, BSN, RN]

I liked it. Although it goes over things that are already routine there is no way for a layperson to know what is routine and what isn't at their hospital.

There is nothing addressing external fetal monitering. Is she willing to have continuous, or would she like to specify intermittent auscultation? Definitely have to clear that one with the MD.

If I was her and my membranes hadn't ruptured and I was at 5cm or more I would want someone to do it artificially, just to get the labor over with.

Having the door closed and knocking may be difficult because everyone's attention is elsewhere, and they may not hear a knock. Labor room doors are pretty thick, so it's also hard to hear the "come in." Many staff may find this one hard to remember...but there is always a curtain around the bed and you could put a sign up reminding people to announce themselves before barging in.

No students or interns- very good thinking.

I would add something to discourage the yelling and counting during the pushing stage. She seems to want a quiet private atmosphere. They can cue her without yelling.

At my hospital we do not restrain a woman's arms for a Csection, unless she is under general anesthetic. She is just instructed not to touch the drapes. I would want my arms free too.

For the delivery...when she writes she wants a respectful atmosphere without chatter. I know what she means, but perhaps she could put it differently, maybe " focus on the birth, and avoid distracting mum with unrelated discussion in the room."

Best of luck to you and your family.

[at your cervix]

I agree with most everyone also. When pt's ask me about birth plans, I always encourage them to understand why they are requesting something and not just to request it because it was there to click on on the web site. The pulsating umbillical cord is a perfect example. I have not actually found any sound medical advice that says that it should stop pulsating before being cut. Some believe that it gives the baby "all of the blood" and believe that if it is cut before it stops pulsating that the baby may have decreased blood volume. The flip side of that is that mother nature knows what she is doing. There is actually extra blood volume in the cord and if it is left too long before it is cut, the baby will actually get too many rbc's and could become jaundiced etc... Therefore, I always suggest that pt's really research the choices, find both sides of the story and then make their decision. I have found that most people that request to wait to cut the cord request it only because it was a choice that they could click and never even knew that there could be problems from waiting to cut the cord.

I noticed that she requested an epidural with only narcotics however, requested no IV narcotics. Although theory states that narcotics in the epidural space don't get to the baby, I disagree, I have had many babies born shortly after a narcotic epidural bolus that have had low apgars at 1 min and responded nicely to narcan. Narcotic only epidurals do not work as well as ones with meds such as marcaine or ropivicaine. The other issue that I can see with this is that she requests no stirrups and to deliver in any position that she would like, this may not be possible if she has an epidural. I am not suggesting that she necessarily change any of these requests, I just think that it would be a good idea for her to understand that she may need to decide which is more important to her-epidural or no stirrups. This will prevent any disappointment when she gets her epidural and then when it comes time to deliver is so numb that she can't deliver in a squatting position.

I would also strongly suggest that she shorten her birth plan. We have a theory where I work that has proved itself time and time again that the longer the birth plan, the higher the chance for a c section-most common cause for c section-failure to progress. (and no, I don't work with MD's that are quick to do a ftp c-section.)

[Mimi2RN, ASN, RN]

I always think about the baby. I have had a baby dripping green, and still purple, and daddy was pulling up mom's gown to put the baby on her belly. The baby needed help, and no-one had talked to the parents about the meconium, and the protocol for mec deliveries. After all, they had a birth plan.............Mom may be fine, but babies can go through a lot of stress, and the families with birth plans sometimes see everything fall apart. Somehow, everyone expects a perfect delivery and baby, and it doesn't always happen. Talk to your daughter about potential problems, so she will understand that we have NALS procedures in the event of trouble.

Chances are everything will go well, just add "if possible" to the birth plan, we don't put the baby on the warmer to be mean, but the baby is a separate patient, sometimes needing extra care and attention.

Is this your first grandbaby? My son an d-i-l delivered their first a few months ago. Mec, of course......and I couldn't be in there as her mom needed to be there (and I do babies, and attend high risk deliveries)

[semstr]

WOOOWWWWWW, so this is for real, isn't it?

I thought it was a joke of you Kids-r-fun! But after reading all the serious replies, I thought hey, this must be real.

Sorry, very innocent question from me maybe, but what happens when she doesn't make or announce this birthplan?

Something like that is not known here at all!

You can tell your wishes about an epidural etc., but all the other things are decided by the midwife or/ and by the dr.

Woow, must tell my midwife-friends about this!

Good luck for your daughter! (and you too, granny-to-be) Renee

[mother/babyRN, RN]

Way too long...Ideas are good. Streamline. By the time ( if anyone did read it in entirety), her labor would probably be over. If an intervention of an emergent nature was needed, it would be done anyway...And if the "hep" locke is a saline locke ( as in many institutions), it most likely will not be patent if they need to use it to switch to IV, as with an emergency or to begin pit....And, prior to the pain of labor, just about everyone is SURE they will not require intervention...That often changes...There are a lot of good ideas in that plan, but as I said, I think it is too long and repetative.....Hope she has a magnificent experience and a healthy baby!