My 2 cents on natural birth/birth plans

[feebebe23]

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...

[canoehead, BSN, RN]

It is scare tatctic when you say "if you don't have EFM your baby's HR can go down but may not be dectected for 5-30 minutes".

It's scary, but it's also true.

If a parent wants to deviate from protocol I tell them I will support whatever decision they make, but I am also obligated to explain why the protocol is there. I can't assume common sense in anybody, especially in a stressful situation. Even the most educated parents have been OK with that.

If the hospital says to do EFM we are pretty much stuck as nurses, and have to act as if it is important. However if the patient declines it after I do my spiel I will be less likely to bring it up again in a "are you sure you don't want that?" moment.

[tvccrn, ASN, RN]

It's not stating the facts because evidence suggests otherwise. Why not tell them that EFM is subject to misinterpretation, is subjective (2 people can interpret the same strip differently) and there is evidence that IA is just as good, in terms of outcomes?

No, the fact is that if the monitoring isn't on the drop in heart rate will go undetected for 5-30 minutes, however long it's not monitored. That has nothing to do with the subjectiveness of such monitoring. After all you can't detect something that not being watched.

tvccrn

[tvccrn, ASN, RN]

but she did say that, in the OP. to quote hte OP: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.

IMO, she didn't say it in a way that I consider a scare tactic. She simply stated that the patient would be aware of the results. If she had said that it was a definite outcome just because of the undetection, that would be a scare tactic.

tvccrn

[eden]

EFM is subjective. What someone may call a late, someone else may say it's early or miss it entirely. What one says is average variablity, someone else may call decreased. The differences in those interpretations change your plan of action. FHR do drop but it's when and where that is a concern, if you are adept at interpreting strips and let's face it, not everyone is especially when you are new to the field.

The FHR drops with an early decel but we all know that earlys are a benign finding.

Are you telling me there are no protocols for the use of IA in your (general your) facility? Or is just that you (again, a general you) are more comfortable with the use of EFM( because it's fine to prefer one method over the other but don't insist it's hospital policy when there may be other guidelines in place)? It's when there are really rigid policies I find alot more resistance with patient.

I myself like using both and am comfortable with both methods.

At my facility we do an initial strip of 30 minutes. If it's reactive we listen q15 and if a decel is heard, then we listen after the next contraction. If I don't like what I hear I am the first to pop them on the monitor to see what's going on. Depending on the second strip we either continue or go back to EFM.

[midwife2b]

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.

Having been in such situations, I agree with Deb 100%.

Families need to feel that they've been treated well, their choices respectfully addressed, and their needs have been met. The AMA documentation did not save us from several lawsuits and investigations over the last few years when I worked as a L&D nurse. As our attorney so aptly stated, "Policies are for the institution. Guidelines are for the people, and you cannot dictate behavior in a free country".

FWIW my ladies are "forbidden" to have more than one page on their birth plan :) Their plans actually addresses more newborn and postpartum issues than labor ones, because we talk about the unpredictability of the birth process. Less is more, and a lot of times less is better. That's how our midwifery service "meets in the middle".

[CMCRN]

I don't mind a well thought out birth plan and use it to start a discussion and help pts feel comfortable. What bothers me is long birth plans downloaded from the internet and when I bring up a point for discussion or clairification they don't even know what they have in it, that is a waste of my time.

[feebebe23]

I don't know how I feel about this term "scare tactics"

your appendix if infected....if we don't take it out surgically it will explode and you can get septic and die....scare tactic?

there is a high risk of blood loss during this surgery...we will do everything we can to minimize blood lose....but if you refuse blood products there is a chance you could bleed to death...scare tactic?

e-mycin eye drops are to prevent your child from developing an eye infection that could lead to blindness...scare tactic?

you do not have to have an epidural....it is a choice...billions and billion of women have labored and given birth w/out an epidural...but if you choose not to have one it will hurt...A LOT....scare tactic??

everything we do in healthcare is based on risk/benefit....informed consent or scare tactic....aren't they really the samething???

[Jolie, BSN]

At my facility we do an initial strip of 30 minutes. If it's reactive we listen q15 and if a decel is heard, then we listen after the next contraction. If I don't like what I hear I am the first to pop them on the monitor to see what's going on. Depending on the second strip we either continue or go back to EFM.

You are essentially stating that EFM has the potential to detect variations in FHR sooner than IA, or that may not be picked up at all with IA. That may or may not translate into a better outcome for mom and/or baby, but it is not a "scare tactic" to inform parents that EFM may provide important information regarding fetal heart rate in a more timely manner than IA.

[waterfall99]

Personally, I don't mind a birth plan, I'm all for natural birth if that's what you choose. I will do whatever it takes to support a laboring mom, and help her have the birth experience she would like, but they also need to trust me, that I/We know what we're doing, and if we're suggesting something there's a reason.

I think new nurses especially get so flustered in trying to take care of someone who doesn't want CEFM or epidurals, because they don't know what to do???

A few nights ago this girl came in and was 7cm with a bbow, and did not want anything done. Everyone kept saying..."oh she needs an epid" her nurse was saying "i wish she'd just get an epid, how do i monitor her intermittently, blah blah" it was lack of confidence.

Frustrating to me

[biker1]

Really enjoy reading about others experience with birth plans. I think it all depends on the community you are working in. I would welcome a patient thinking ahead enough to ask for natural birth or having a birthing plan. Most of the women I see have one plan, "give me an epidural as soon as possible and induce me now because I am tired of being pregnant. Would like to see the mother worry about what is best for the baby and not what is comfortable for her.

[eden]

Sigh, you're really not listening to what I'm saying. The OP said "changing this may result in injury or death of my baby". That is a scare tactic plain and simple.

Please show me where I said EFM has no use. It does have a use but it does not need to be the only thing used, that is why AWHONN guidlines exist. Studies have shown that only using EFM leads to many unecessary primary section due to strip misinterpretation and many a "bad strip" ends with a baby with apgars of 9 and 9. I absolutly see why the US, in particular, has these soaring section rates with higher morbidity/mortality rates then some other places.

[CEG]

.

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.

.

Here's the thing: scare tactic or not, this is NOT true. Research has shown, and AWHONN teaches in the intermediate fetal monitoring class, that outcomes are no worse with IA than with CEFM. So there is no greater risk of death or injury to the baby than there is with CEFM. What there is a greater risk of with CEFM is unnecesary intervention including c-section and the greater morbidity/mortality that comes with all those interventions. Do you tell your patients that?

There is NO difference in outcomes between IA and CEFM and call it whatever you want, but telling patients anything other than the truth about it is lying. Telling them the relative risks and benefits of each method and allowing them to choice without "playing the dead baby card" to sway them towards what you want would be a much better option.