My 2 cents on natural birth/birth plans

SiennaGreen · Aug 11, 2007

I applaud you for your maturity and honesty and for treating your patients like intelligent, thoughtful, individuals. I wish all did the same but have personally experianced serious strong arming and threats to contact child services because I did not want continual fetal monitoring. no offers of signing any waiver or discussing the benefits versus hassles. I'm sure your patients appreciate your handling of oneof the most special times in a woman's life.

Jo Dirt · Aug 11, 2007

People who have so many issues with hospitals shouldn't be there. I was unfamiliar with birth plans until I read about them here.

And what's with this "natural" business? Natural doesn't always mean better.

Some of these people need to get a grip.

HappyNurse2005, RN · Aug 12, 2007

I am a new poster here and I have read a lot of debates on birth plans....controling dads....refusing this refusing/that ect....so here is my 2 cents.
When presented with a 14+ page birth plan I politely expain that "this is a hospital and not a jail" you have the right to refuse and and all procedures/interventions ect.
For example...That the hospital's policy is that you only eat ice chips during labor . However I can not stop you from physically drinking fluids and eating, I can only inform you of the hospitals policy and rational. If you choose to not comply with this policy that is your choice and I will need to sign this AMA form that states you have choosen not to comply with the doctors orders.
This speech can be altered to fit any request.....this is all done very politly and with professionalism....
I inform the pt/couple that her health and safety and that of her baby's is the hospital's number one priorty. I inform the patient that refusing to comply with hospital policy does not change the "excellent level of care that she and her baby will receive" It only minimalizes the risk of liability to myself and the hospital. (which may or not be true depending on the circumstances)
For example.....having a patient refuse continious monitoring....I once had a patient sign an AMA form in which I wrote...
I_________ am declining continious monitoring. I have agreed to intermittent monitoring in accordance with AWWON guideline. I understand that in some circumstances my baby's heart rate may increase or decrease and go undected for 5-30 minutes depending on my stage of labor. I am aware that these changes could result in the injury or death of my baby.
I have done this on more that one ocassion....place a sticker on the form....witness it...and put it in the chart. My managers are aware of this and have never commented....I have had 1 doctor thank me and say....good thinking!! I have no idea if this would be legaling binding or not. But something is better that nothing....
I addition to the "do not offer me pain meds" or my personal favorite...."my husband/coach and I have a secret code...he will let you know if I decide to get an epidural"
I states the following...
"I am leagally obligated to inform you that you have IV pain meds and an epidural avaliable to you, and after this conversation I won't bring up the E word again unless you bring it up first....IF at any time you ask for an epidual we will change positions, take a trip to the BR...or just take a moment to regroup. Then if you ask for an epidural again in 15 minutes I will make that happen. The rules are....you have to ask for it twice 15 minutes apart"
I have always had this agreement welcomed!! I have been thanked...send cards, flowers, and letters saying from patients "That nurse supported my decision to go natural"
These are just some tips I have developed through the years...

see, when you say "14+ page birth plan" that comes off as snide and unsupportive, or maybe as just making fun of it.

and, they have to sign AMA for intermittant monitoring? really? i would only think that would be necessary if they were high risk and cont. EFM was indicated (pitocin use, etc) sounds like a scare tactic "these changes could result in death of the baby".

anyways

TrudyRN · Aug 12, 2007

see, when you say "14+ page birth plan" that comes off as snide and unsupportive, or maybe as just making fun of it.
and, they have to sign AMA for intermittant monitoring? really? i would only think that would be necessary if they were high risk and cont. EFM was indicated (pitocin use, etc) sounds like a scare tactic "these changes could result in death of the baby".
anyways

She's only telling them the truth. The truth is often scary. She has a right to protect herself and a responsibility to be truthful with the patient. She must be doing something right. She's got a lot of experience in her specialty.

SmilingBluEyes · Aug 12, 2007

Sadly, bad things can happen in the hospital or at home. I will say, from what I learned from two friends who went through nightmare litigation with a doctor in the wake of a very bad outcome, AMA forms are not worth the paper they are printed on, when it comes to protecting you in court. Sad but true. They can still sue and win, if their lawyers are sharp and can produce excellent nurse and physician experts to support their cases. We accomplish such forms the mitigate the potential, but there is no protection on earth that will help in some cases.

And as much as I support free choice, I am pretty certain in the case of a horrible outcome, that was indeed not the fault of hospital personnel or the doctor, suit would be considered in a very large number of cases. It's the way things are. True negligence should be discovered and dealt with. But sometimes, no matter what we do right, bad outcomes can result. It's horrible for everyone when they do. And AMA forms notwithstanding, people are going to sue.

Here is what I think of birth plans. They are a very legitmate attempt by people to take back their birth experiences from what they feel is an increasingly dangerous, hostile, and pro-(sometimes needless)-intervention environment in most hospitals. In most cases, respectful appreciation of folks' needs, and wishes as well as a little education/ communication can go a long way toward a "meeting in the middle". This is my experience, anyhow. Failing that, of course, AMA documentation is necessary. Just don't think it will protect you fully in the end. Because it may not, especially in cases where policy and procedures may be violated by nursing/medical staff in rendering well-intended and competent care. In these cases, in particular, you well may not have much to stand on.

justjenny · Aug 12, 2007

I work NICU so I get to see the babies in "natural" situations where the result is bad. The most recent was a young mom refusing a c-section and instead pushed for 3 1/2+ hours...the baby required rescucitation for 10 minutes after delivery....we finally heard it cry down on the unit after it was 12+ hours old. It was okay and was able to go back to mom, thank goodness, after some time. Some babies we get are intubated, lines, etc. from a bad home birth, etc.

I think the AMA form is a great idea....but I would question also whether it holds up in court...I wonder if the hospitals legal department would give an opinion on the form???

Jenny

33-weeker · Aug 12, 2007

Not sure about the AMA forms. It think the best you can do is document what the patient refused and that you discussed the risks and options, notified the doc, doc discussed risks w/pt., etc. and cover yourself.

As a home birth mom with a birth plan for both labors, I see both sides. It is a shame that people feel they need to have them. There is not many options for birth for many. It's often a choice between home or hospital with few birthing centers - then there's the question of insurance coverage. Even though I knew I could refuse procedures in the hospital, I didn't want to spend my labor and birth at odds with the staff over policy. I wanted to enjoy the experience and focus on dealing with labor.

feebebe23 · Aug 12, 2007

The reason I stated 14+ page birth plan is because I see these pages and pages of things that seem in my opinion to be "no brainers" for example:

I do not wish to be sperated from my husband...

I want to breastfed as soon as possible after delivery...

I want the baby to remain with me unless medically necessary.....

as one of my all time favorite pieces of birth plan literature

" In the event that my infant's heart rate goes below what is normal, I would like to change positions and use oxygen for 3 minutes prior to the discussion of c-section"

When I read things like that it makes me think.....that they think...we don't know what were doing.

I want to say "in the event that your baby's heart rate dips below normal.....I will not be refering to your birth plan for instruction."

to response to an earlier post....at my facility it states on the preprinted orders that all patients admitted for labor are to have continious efm and toco.

my hospital also states that all VBACs in active labor must have internal monitoring.....therefor a VBAC who refuses srom and/or internals must sign a form that they are refusing to comply with hospital policies....

I don't like the term "scare tactics"......I perfer to tell it like it is....

for example:

If you wanna VBAC...cool no problem....you want to refuse continious monitoring....that's fine.....you want to refuse a hep lock....that's your choice.....but when your uterus ruptures, and you have crappy veins, and your baby is going down the tubes, and it takes 8-9 minutes and 7 sticks to get an IV in BECAUSE YOU REFUSED TO HAVE A HEP LOCK. Don't tell me that we didn't get the baby out fast enough!! apgars 1/3/6. Don't tell me that you choose to have a hospital birth "just in case" and we didn't live up to our end of the bargin.

This was not my patient....and the hospital settled....because the nurse did not properly document the refusal of these interventions, she did not document that she informed the patient that theses were hospital policies, she did not document that she informed the patient of the risks associated with the refusal of IV access, she did document the fact that the pt refused IV access, she did document that she notified the MD of these refusals, and that he did not come to the hospital and counsel the patient. They got a settlement....why "because no one told us that these were the rules....we did want a minimaly invasive labor and delivery.....THAT NURSE and THAT DOCTOR violated their own hospital policies.

Moral of the story.....I don't care what the birthplan says....if they refuse an IV you clearly inform them that in the event of an emergency not having a heplock in place could delay the C/S by precious minutes...and you chart it....it is not a scare tactic...it is the truth!!!

33-weeker · Aug 12, 2007

I see nothing wrong with listing things like wanting baby placed on abdomen, or going to breast, etc. I want parents to let me know of things like this because I don't mind doing it if I know that's what they want and baby is in reasonable shape. Every place and nurse has a different routine of how they do things. There's nothing wrong with those kind of comments. That's just good communication.

You've got to give folks the benefit of the doubt, but I admit it can get annoying. When it comes to things like what to do if HR drops, that's getting a little too detailed - but probably stems from anxiety, or medical background + horror stories or personal experience in a place where there has been excessive intervention. A respectful and kind heart-to-heart with this type of parent would probably go a long way to putting them at ease about what they can expect.

I have the luxury of having had my kids at home with a midwife. Sometimes just mentioning when making conversation helps tremendously in deling with anxious folks like this.

bagladyrn, RN · Aug 12, 2007

I totally agree with what you are saying. I am equally blunt with my patients, informing of them of their right to refuse any intervention, but informing them of all the risks and benefits of both having and refusing the intervention, including the fact that some interventions may mean the difference between life and death or serious injury to themselves or the baby. I document every bit of this and the patients quoted response.

I don't see this as "scare tactics". I see it as treating them as adults who are taking on the biggest responsibility of their life and deserve to be fully informed.

33-weeker · Aug 12, 2007

I have no problem with speaking the truth if it is done with respect and in a professional way. I'm the first person to speak up for true informed consent.

I'm also the nursery nurse who makes it a point to tell parents of RDS social inductions/sections exactly why their barely 37-week kid (or their 39 by dates, 36 by exam kid) is having trouble breathing and in NICU on oxygen. I'm all for informed. Too bad I don't get to inform them until after the damage is done.