Sorry another Birth Plan thread, but comments please!!! Too long or ok??

[CollieandPup]

Hi, I'm 36+1 today so thought it was time I got around to writing a birth plan. This is dc1 so not sure if it's ok or not, although a lot has been nicked from others on here. I'm trying to mentally prepare myself for it not to be read not to go to plan, but figured it's important to have what you want and your contingencies down on paper.

Anyway, how does it look? Is. It too long????

BIRTH PREFERENCES
I want to be involved in decision making before any drugs are administered or procedures undertaken. If I am unable to be consulted (for whatever reason) husband should be consulted instead
Peference to have no student doctors please

BIRTH PARTNER

• Husband to be present at all times and fully informed. In the event I am unable to consent, Ian is authorised to consent on my behalf.

LABOUR

• Home birth planned. Would like to avoid hospital birth where possible.
• Use of birth pool in early labour intended for pain relief. If in pool close to pushing stage, would like to be asked if I would like to stay in/get out.
• I wish to remain mobile as much as possible, avoid lying on my back.
• Strongly wish to avoid assisted delivery. Ventouse preferred if intervention needed. If forcep delivery is medically recommended would like to be fully inform of why and the risks before intervention. Strongly against the use of Kielland?s forceps.
• C-section to be preformed as last resort but not without full consultation with myself or husband.

PAIN RELIEF

• Wish to try with just breathing/relaxation/water/tens for as long as possible.
• Happy to use gas and air.
• I would prefer not to have diamorphine, but plan to have it available at home just in case this is needed, to avoid hospital transfer.
• Strongly against epidural unless absolutely necessary. Would like to be consulted before hand on why this is necessary, if recommended. I would prefer 'top up' epidural

INDUCTION
To be avoided unless necessary. Epidural to be administered before syntocinon drip. I would prefer 'top up' epidural.

DELIVERY
Skin to skin as soon as possible
I want delayed clamping of the cord, for at least 5 mins or until it has finished pulsating
Important that DH cuts the cord
Happy for baby to have vit-k injection.

3RD STAGE
Managed 3rd staged delivery is ok, however this must not result in early clamping of the cord unless in an emergency. Delayed cord cutting to be priority.
I would like to try breast feeding as soon as possible

CONTINGENCIES
If I need to be separated from the baby, DH to stay with the baby, not with me.
In the event that I cannot give the baby immediate skin-to-skin contact, baby to be passed to DH for skin-to-skin.
Baby not to be given formula milk without prior consultation with myself or DH.

Well, personally I would break it up into a home birth section and a hospital bit.

I'd also ask whether you do actually want to be consulted and discuss everything with the nursing staff/doctors? It may make it difficult for you to stay in 'the zone' if they feel everything needs to be very analytically discussed with you. I actually had the opposite in my plan for DD2 - that they should speak to my husband first and that, after that, he would be involved in the discussion with me (unless I asked otherwise or in an emergency).

I may be wrong, but I don't think you can normally have managed third stage and delayed clamping. If they've given the injection, they clamp, and they don't like giving the injection late because of the risk of retained placenta. (Though actually, I ended up with a late injection because the placenta wouldn't come).

You say you want water in 'early labour' for pain relief. At the hospital, you wouldn't normally be allowed in unless in established labour. If you mean at home, I would make it clear that you may get into the pool earlier than they would normally recommend, but are willing to discuss getting out if labour slows.

Hope that helps a bit.

Well OP, it is long! But it is good that you have thought about all the issues. Be prepared that things don't go as you have planned. Agree with secondtimelucky that there is an awful lot of discussion you want to be involved in. Also, there are a few things in your plan which the hospital will or won't do automatically such as they will offer you skin to skin asap unless there is a problem and they won't feed formula to your baby without asking as they are much more wanting you to breastfeed regardless of whether you can breastfeed or not. Is there anyway you can condense it into bullet points as there is too much for a midwife to read, particularly if an emergency situation arises.

I take your points about wanting to be talked to about everything which could be problematic, although my assumption is if it's an emergency they'd do it anyway and scrap the plan. The reason that's in is that I've had it drummed into me from friends who have had negative experiences, and from my NCT class, always ask WHY, what RISKS and what ALTERNATIVES. I know a couple of friends who at the time where quickly asked if 'x' was ok with no real explanation. They agreed and with hindsight feel the interventions where (at that time) unnecessary and had they been more informed they would have tried to opt for a different path. But of course I do also want to let them get on with their job.

Secondtime I wasn't sure about the injection and clamping, I need to chat with mw at my next apt. Delayed cutting most important though.

Good idea to seperate home from hospital.

Timothy the thing about ff is in there as this did actually happen to a friend of mine. I can't remember the details but she had a c-section and a few complications and they ff baby which she was unhappy about and wasn't gone that long and in her opinion he could have waited/be fed donated breast milk. It shocks me that they took that decision for his first feed. She's very angry about it.

More succinct bullets- ok!

Fair point about skin to skin, but then at my ante natal classes they've saud to be clear it's what you want. Grrr they want you to tell them everything but also be concise!!!!

Collieandpup that is shocking about your friends baby being FF without her permission. I would have been angry about this as well.

Also, you/DH can ask lots of questions yourself without the need to put everything down in black and white and you can refuse an option whether its in your plan or not. IME midwives tend to talk through what they want to do and give you options but appreciate this may differ from hospital to hospital etc.

It's not really about letting them get on with their job, it's about letting you get on with yours. It may sound silly, but most women really do need to 'go into themselves' and cut out the world to birth their baby. There's a whole scientific explanation about how engaging the logical brain can impede the hormones necessary to get things happening. I am sure others could give a better explanation. I took the decision that although I wanted to do all the BRAIN stuff you're talking about, it needed to be DH who did it (preferably in another room initially) and then came to me after that. I also felt that he and I could have a quicker, clearer conversation then I would with the medical staff, as I totally trust him and wouldn't have to be so analytical about it all.

I've had another look and have a few more suggestions if you don't think I'm being too arsey.

What I would do is start with a general introduction, explaining in bullet points the atmosphere and type of birth you are trying to achieve - a lot of which will be self evident from the fact you want a home birth. You can include a general request to have anything discussed with you and to avoid any interventions if not necessary (although TBH, if they are suggesting them, they think they are necessary, or at least beneficial, it's just that you might not) I would then write the plan for a home birth, with a supplemental section at the end on transferring. There is no real point your home birth midwives dwelling on stuff about epidurals and forceps, so put that all together.

Looking at my birth plan, a few things you haven't said. Do you want gas and air and pethidine suggested, or do you want to actively ask for it. Do you want to be assisted to push? How do you feel about internal examinations? Student midwives? (I've heard they can be marvellous to have at a home birth. Extra pair of hands for all the little jobs so you get the main midwife's full attention). Do you know the sex of the baby and, if not, do you want to find out for yourself, have your DH tell you, etc?

I think on the interventions you might want to re-think a bit. You are strongly against the use of Keillands forceps - do you mean you would prefer to go for a section if that looks likely? If so, say so because at the moment it also says a section should be a last resort. They don't do these things unless they feel there's a real issue, but at the moment your birth plan doesn't give much idea of 'least worst'. I know it mentions ventouse, but there are many reasons that isn't always viable.

I wouldn't bother putting anything on induction, as a discussion on that is likely to be in a midwife or consultant appointment and not with your birth plan in hand. Instead I'd do a section on augmentation of labour - syntocin and ARM. Probably within the bit on hospitals (although I think they can break your waters at home).

Do you have any thoughts about student MWs? Internal examinations?
Do you know the sex of the baby? If not, who would you like to announce it?
Do you have any thoughts about episiotomy? Stitching if you tear?
If you are delivering in the pool or crouching, do you want to 'catch' the baby when he/she comes out? If you are reclining more, do you want the baby delivered onto your stomach/chest?

I am quite suprised at some of the points included. Where else exactly is your husband going to be if not with you? There is some hidden assumption in this that he will be forbidden from being part of the birth! I am also interested in the assumption that things are done without consent. The NCT really need to get with it and update themselves. Noone is going to do anything or give you anything without explanation and consent. It just doesn't happen. The whole thing reeks of you know best I am afraid.

Re third stage as a pp said delayed cord clamping for as long as 5 mins is not part of an actively managed third stage. If syntometrine has been given and the cord is left to cease pulsating one train of thought is that it results in over transfusion of the baby.

Your friends may be unhappy with interventions in their care but the truth is, in these situations, that we never really know the facts do we?

Sorry if that's all a bit harsh but you can tell I think that birth plans are not helpful, an outdated concept and can undermine the relationship between woman and midwife. It really is not my intention when I go to work to go against the wishes of women and I just feel sometimes this is what is implied.

Sorry, just my opinion.

Are you a midwife Laluna? I agree that you don't want the birth plan to set up an adversarial relationship, but equally don't you think it can be quite an effective mechanism for getting across information? I wouldn't have wanted to sit down and give a midwife a long briefing on my first labour whilst in my second labour, but my birth plan had a few points about my first labour to explain my views (e.g. that due to a very bad experience with ARM bringing my OP labour to a shuddering halt, if it was to be discussed I wanted it done first with my husband and out of my earshot initially).

I agree regarding the husband being present. Maybe the OP wants the midwife to forcibly restrain him if he goes off for a snack ( - only teasing OP. I know how hard it is to decide what to include).

I also think, sadly, that there is a lot of bad practice out there. In my first labour an anaesthetist discussed 'a scoliosis' over my shoulder with the nurse without explaining anything to me about what was going on and scaring the shit out of me. I was also told that they would be breaking my waters, and in my sleep deprived state I didn't object. I'm not sure that anything I'd have put in a birth plan would have changed that, but it's a couple of examples of lack of consultation.

collie I think it looks fine, just maybe use bullets to make it easier to read. Only other thing I would add is if you want OH to announce the sex (if you don't already know it). The idea of a separate home and hospital plan is a good one. I didn't really think about the home one, although I'd discussed what I'd like with my MW beforehand. Things like having the lights dimmed and minimal vaginal examinations helped me to feel really relaxed so maybe consider if you'd like that sort of thing. Good luck!

Collie - looks like you've covered most things (good luck BTW!)

The other thing that I've recently added to my birth plan is that should we transfer to hospital I am happy to donate my cord blood if appropriate.

RE Student Doctor/Midwives you'd never be in their sole care and it often is quite handy to have someone else in the room so don't be concerned. What I didn't want was a stranger in there watching and taking notes... An active, useful, participant was fine though. The student midwife in with me was super lovely.

Most important thing is that although you have thought through every event - the doing is very different to the thinking. Don't beat yourself up if it doesn't go to plan, nor beat up the midwife or doctor if they have to over-ride your birthplan for the safety of your child - it can happen, but they are the experts so generally it is done for a bloody good reason.
Emergency measures - csections/forceps etc are just that - emergency measures and full consultation is great in theory but if push comes to shove action is better than discussion.
I think a birth plan is good from the point of view of focusing your mind on what is to come, and particularly good for a first time mum, but not as helpful for the professional who is coming into the situation from a clinical point of view.
Good luck and hope it all goes brilliantly!

I had a birth plan, really just so my DH, who was completely in denial up to the last, knew what I wanted!
But my midwife didn't read it and I didn't feel it necessary at the time.

I'm an anaesthetist and have been present at hundreds of births, mainly the ones where things have not gone to plan. Please try to go in with just the aim of healthy mum + healthy baby. Really the whole birth "experience" is load of tosh IMHO. Midwives and obstetricians are there to help and guide you through an incredibly challenging moment in your life, they have trained for years for this.

As for the 3rd stage, I looked into whether or not to go with a managed stage and it is one of the few things there is good evidence for that it saves lives. Syntocinon makes you much less sick than syntometrine though, so you could ask for that? Delayed cord clamping I also looked at and up to 1 minute can improve you babies haemoglobin but as much as 5 is likely to overtransfuse and lead to a jaundiced baby, from the literature I read, so I didn't bother.

Epidural never absolutely necessary, but more than 50% of first time mums end up with one. If you're willing to consider it, maybe put that rather than how strongly against it you are. If you ask for an epidural in labour and your birth plan says no epidural you will still be given one; what you want at the time will always override what you have said before.

A little of track maybe but for me I hated the thought of losing control of the situation the most and I found natal hypnotherapy to be fantastic in this regard. I felt calm the whole way through.

Yes my DS birth was painful but it was the most amazing, fantastic moment of my life when they put his warm wriggling little body into my arms and I cherish that moment far more than I remember any pain. Would do it again tomorrow.

Best of luck and I hope it goes well for you.

I had a home birth second time around 6 months ago. I did one side for Birth plan and the other for in emergencies (i.e. preferences if ended up needing the hospital). They liked the fact I provided two laminated copies (one attached to pregnancy notes and one spare to hand as neccessary)

I hope it goes well. Look forward to it :)

Thanks everyone for your comments again

second you're suggestions are really useful. I think the idea of having DH as the first person to speak to is worth thinking about... I'm not sure though, I worry he'll just go blank. He does know most of what I want, but I think he's only just realising he's going to have to do more than hold my hand and rub my back

Take your points about stating DH is to be involved, although I was coming at it from the POV that not every partner would be, so it's needed stating. DH is allowed to go to the loo.... But only during allocated toilet breaks suggestion of general intro is good, and general statement for them to discuss interventions rather than repeating myself. Def want to be encouraged to not have drugs if I start to crack so that should be said I suppose-thanks.

Yes, c-section over keillands which I suppose isn't clear.

Happy to have student mw, just don't want student doc poking around if I end up having to transfer.

Baby is a boy so no sex annoucements needed (I hope!)

What do you mean by 'do I want assistance pushing'.... I wish someone could do it for me!!

laluna I appreciate you replying although i didn't ask if people thought I should have a birth plan, just views on its content. I disagree completely that a birth plan is pointless. For most women labour is a natural process that should require minimal intervention and so women should have the freedom to influence what it's like- that's the whole point of patient lead services which is the heart of the NHS vision.

I'm quite suprised you don't think interventions occur without consent. As I said earlier, I have had lots of friends have issues with their care, it's not just the NCT being 'out dated'. I think in the main issues arise when people are told x is being done (as stated by second) or being asked in a way that implies there is no choice, and so the patient is not making an informed decision. This DOES happen, in maternity and many other services.

I don't think the plan reeks of 'I know best' either, and resent that comment. It's comments like that that de-empower patients from taking control of their Heath and care decisions. Obviously health professionals are highly trained, but they don't always know what's best for you and they are not infallible!

magnum thanks for your lovely post. My birth plan might suggest I have an idealistic view of what labour will be like, but in all honesty I am totally open to the fact that it's likely not to go that way. But as you said, it helps focus your mind on what you want and dont want, and something to aim for if all does go without complications. As much as I don't want x y or z, the most important thing is that the baby gets here safetly, I just want to try and use the plan to avoid x y z happening before they needed to- which in the experience of people around me can happen.

I've bought the natal hypnotherapy cd, although only listened to half once. I couldnt sleep so stuck it on but I was too tired to get through it all.... But it did relax me enough to fall asleep!!! Ive heard good reviews of it, just not sure if it will work for me yet...but I'll persevere. Anything is worth a go!

architien laminated copies!!! Impressive!!

Collie the CD works even better if you fall asleep with it on :)

Collie it's great that you have thought about your preferences and committed them to paper but do remember you will be there!! Most of what you have outlines you will be able to tell them yourself.

And if you can't speak, your DP will be there! So make him read it and make sure he understands and is able to advocate on your behalf.

By the time anyone read my birth plan for DD1 I had already had pethidine and an epidural (strictly verboten under Emmalina's rules) and the midwife smiled politely and wheeled me off for a necessary caesarean.

With both my labours once they were underway, all I wanted was my baby. Everything else went out the window!

Ha ha, perhaps I should have said 'coached' or 'guided' to push. I meant, do you want to push based on your own instincts, or do you want them to talk you through it (This wouldn't generally be what you see if you've watched US One Born Every Minute by the way. Not the 'chin to chest, hold your breath' technique. That's very outdated). For example, I had in my plan that I wanted to push based on my own instincts but have guidance on crowning on when to pant, etc, to try and minimise tearing (although DD2 had other ideas and shot out like a speeding bullet!).

BTW, pushing isn't always that bad. I'd had forceps with DD1 so had no comparison, but DD2 pushing was fab, way better than the supposedly ok latent phase and very quick. Didn't hurt at all.

In terms of initial consultation being with your husband, do bear in mind that, for as long as you're at home, there won't be much intervention wise that they'd be discussing. maybe ARM (don't know if they do that at home), hospital transfer. They wouldn't be talking about continuous monitoring, or syntocin or any of those things. The other stuff - like getting out of the pool, changing positions, etc, would need to be discussed with you anyway. You could decide that you want to create a calm, dark, quiet atmosphere at home, with initial discussions with your DH, but that things are different if you're at the hospital. Just a thought...

NB Add in that you want a qualified experienced person to carry out any stitching, not a student. And that you want an anaesthetic (epidural if need be) while it is done

The important bits are "qualified," "experienced" and "anaesthetic"

and "not a student"

;) HTH xx

Re the active third stage, it is absolutely possible to wait until the cord has stopped pulsating and then administer the oxytocic or indeed wait for up to 3 minutes following administering the oxytocic before clamping and cutting. Delayed cord clamping is very beneficial to the baby and is being practiced as gold standard certainly in my unit. If you have a normal delivery at home with no intervention then you are a prime candidate for a physiological 3rd stage but I accept that isn't everyones bag. There is a wealth of evidence out there to be read about the third stage, some schools of thought believe that although with an active 3rd stage you lose less blood lost delivery, your loch in the post natal period is heavier, ie you have an amount of blood you are going to lose and the method of third stage just varies it's distribution. Does that make any sense?

Loch? bloomin iPhone, I meant lochia.