Tuesday, July 26, 2016

Why a birth plan should be called a birth WISH LIST

As I have written about on my Blog previously, my first biological delivery went horribly wrong in every sense of the word. (Click here to read a flashback from JB who was obviously there.)  My pregnancy with Abigail was equally challenging (an appendicitis and quick flight out to Germany is proof of that.) Seeing that firsthand made me quite aware how go-with-the-flow you must be in both pregnancy, childbirth, and parenthood. I continue to hear from mom's asking me how they can plan for their birth. I asked my friend Tara, a family medicine OB in California to share her opinions on this with my readers. I find her post incredibly interesting and enlightening.


My friend Tara on her job as a family physician. Tara became one of our good friends during JB's years in medical school at The Mayo Clinic. We also travelled to Nigeria and South Africa together for six week. Tara will not tell you this, but she is truly one of the most brilliant women I have EVER met. I encourage you to read her post below and share it with everyone you know! Tara and her husband Kelvin (also a doctor) have an adorable little son -- Iver -- Hannah's twin brother lost at birth I think.

I am a family physician and see patients of all ages in my practice, but my passion is delivering babies. I believe in and support women choosing natural childbirth if they wish (had one), breastfeeding if they desire (still going strong, after 19 months), and have even used essential oils on myself (all while believing wholeheartedly in vaccines. You know what is natural?? Dying of smallpox and polio is "natural."). I am also a planner.

Image result for funny birth planThat being said, it is my opinion that, effective immediately,  birth PLANS should be renamed "birth WISH LISTS." While we all have an "ideal" (mine is a child who sleeps through the night and doesn't kick and scream with every diaper change and attempt at getting him in a carseat), a good "birth wish" might include:  spontaneous labor that is only a few hours long, with contractions that are strong enough to dilate you steadily and push a baby out without causing pain with which you can't cope, without any need for an IV, complications or antibiotics, and which ends in a vaginal birth without tears, this is not the norm. 

  • Sometimes preterm labor starts and gives you a 24-weeker who stays in the NICU for another five months. 

  • Sometimes the water breaks preterm and you need to be on bedrest with monitoring in the hospital for weeks.

  • Sometimes the water breaks prematurely, before any signs of labor, and it's safer to induce labor than to, well, just hang out waiting for infection to set in.

  • Sometimes there is hypertension, or low amniotic fluid, or growth-restriction, or baby is late (42 + weeks), and it is safer (for the baby and/or mom) to induce labor than to wait.

  • Sometimes, the body and the uterus (and the mind) get tired and there is need for medical "augmentation" (strengthening of contractions) with Pitocin or by rupturing the membranes artificially.

  • Sometimes there is a large tear which can cause pain, and even pelvic floor issues later.

  • Sometimes there is bleeding (catastrophic) like an abruption, which can lead to maternal hemorrhage, and fetal death if an emergency cesarean is not performed.

  • Sometimes there is a uterine rupture, or a cord prolapse, which requires the same, prompt action.

  • Sometimes the head is not down at term, and a safer delivery choice is an elective cesarean (if other maneuvers have failed).

  • Sometimes, after 6 hours of pushing, it's time to "call it."

Just in the past five years, I have had many patients refuse many of the above recommended management plans, because they conflicted with their "birth plans."

Image result for google medical degree mugI know I have an M.D. behind my name, and it may be tempting to feel threatened by hospitals or medical providers who learned their medical knowledge from Mayo Clinic and not Jenny McCarthy or Google University. However, please remember that I am also a moral person (and a mom), and we are all wanting the same goal-- a healthy mom and a healthy baby, and that I would be devastated by the loss of either patient.  I feel that the only thing about labor and birth that is predictable and that you can "plan for," is that labor, birth, AND PARENTING, are unpredictable. It is my opinion that birth plans need to go out the window because being flexible and relinquishing control is the first thing you need to learn about being a new parent.

I have seen babies, whose moms refuse antibiotics or didn't get adequately treated for group B strep, become septic, and need multiple lab draws, IV antibiotics, and hospital/NICU stays.  At my hospital, women still routinely refuse penicillin (or even screening for GBS), to my disbelief. 

I have not personally seen vitamin K-related bleeding in a neonate, because of widespread use of intramuscular vitamin K given at birth.  But another provider in my clinic had a case last year, because, in their birth plan, parents had decided to withhold this shot for their newborn (an alternative that some parents request, oral vitamin K, is not very effective. There is a good article, and more information on a variety of topics, on the website Evidence-Based Birth).

One of my pediatrics patient was a neonate who had to be hospitalized at UCSF NICU for apnea due to pertussis, which can be prevented, or its incidence drastically reduced, by maternal TDaP vaccination between 27-36 weeks with each pregnancy (this anti-vaxx mother had refused vaccines for her older child from birth, too).

  • I support women's ability to walk, move, and eat and drink in labor and think that the advantage of position changes and gravity are helpful for labor progress and pushing; that being said, I fully support a woman who opts for an epidural in labor, because, if it helps her cope and helps her baby arrive safely, that's all that matters (even if the original "birth plan" says otherwise).

  • I catch babies underwater for those low-risk moms who want a water birth, even though the bodily fluids (and solids) in the tub sometimes gross me out, and I fear falling in, and of having back pain from crouching awkwardly.

  • I do delayed cord clamping routinely, because it has benefits for reducing infant anemia, even though it adds a few minutes to the third stage of labor, and often makes me late getting back to clinic (or to my family).

  • I support breastfeeding, but I also support moms who for whatever reason (they couldn't, it was too difficult, or they didn't want to) chose to formula-feed (a FED and growing baby is all that matters).

  • I have routinely been performing "Gentle Cesareans", where we drop the drape and hold up baby to let mom see the baby as he/she comes out, do delayed cord-clamping on the surgical field (if baby is vigorous), and promote skin-to-skin time (and breastfeeding) and with baby on mom's chest in the operating room until the case is finished, even if it's a bit harder for me to sew sometimes with mom's head of the bed up.

  • I allow women to do anything they want with their placenta, even though I tend to gag a little when I see them chugging down placenta smoothies in the delivery room (yes, this happens).

  • If parents want to deliver the placenta attached to baby ("Lotus-birth") and keep the baby connected for weeks, that's ok by me, because I don't have to smell it daily, and the baby is out.. and presumably doing well.

  • I take care of moms who choose home births after weighing risks and benefits knowing that, for most women, it will go well, although it's still safer for the baby to be born in a hospital.

  • I want women to make empowered and informed choices for themselves, and their children, but I want them to be safe choices.

  • I just want a healthy mom and a healthy baby.

So please, if you have a "birth plan," please rename it a "birth wish list," and know that obstetrics, birth, and parenting are unpredictable and, at times, even dangerous. We are on the same team.

1 comment:

Patricia Ehlert-Abler said...

Nice. I like Birth Wish Plan.