The Birth Plan: How to Make It Work for You and Your Patients

Jennifer L.W. Fink, BSN

Disclosures

September 22, 2017

If you cringe when you see a patient clutching a birth plan in her hands, you're not alone. In a recent online survey of approximately 600 obstetricians and midwives, just 26% had a favorable view of birth plans and nearly one third said they believed that birth plans are predictors of poor obstetrical outcomes.[1]

In some cases, the existence of a birth plan seems to increase the likelihood that a woman will be dissatisfied with her birth experience.

"We found that the more requests you had, the more dissatisfied you were with your labor," says Yalda Afshar, MD, PhD, one of the authors of a 2016 study that highlighted the inverse relationship between birth requests and patient satisfaction.[2] And in some cases, she says, "despite getting the care they preferred, the birth-plan mothers described feeling less in control and were less satisfied with their birth experience."

Yet, the same study also found a positive correlation between the percentage of birth-plan requests fulfilled and patient satisfaction. Women who had more than one third of their requests fulfilled during labor and birth were much more likely than other women to say that they were "satisfied" or "very satisfied" with their birth experiences.[2]

Medscape recently spoke with obstetricians, certified nurse midwives, and obstetric nurses who say they've managed to harness the potential benefits of birth plans while decreasing the likelihood of dissatisfaction and disappointment. Here are their tips for creating and working with flexible, functional plans.

1. Initiate the Discussion Early

"Talking about birth preferences months in advance is so much better than talking it over for the first time in labor," says Scott Sullivan, MD, director of maternal-fetal medicine at the Medical University of South Carolina.

The sooner you begin discussing birth interventions and pain relief in labor, for instance, the more time you have to share information and answer questions. Dr Sullivan begins discussions of childbirth classes and birth plans "on the very first visit," he says. "Some patients are a little timid about things, and it may take a couple of visits before they even ask what they really want to ask, like do I have to have monitoring all the time?" Commonly, birth preferences will evolve over the course of pregnancy.

It's especially important to talk about any risk factors that increase the likelihood of complications during birth. Mothers who have hypertension or preeclampsia or babies with intrauterine growth restriction, for instance, need to know that those conditions may necessitate extra monitoring and intervention during labor and delivery. Discussing possible complications and interventions well before labor allows mothers to create birth plans that may "be a bit more realistic," says Shadman Habibi, CNM, MSN, a nurse midwife with University of California, Los Angeles Obstetrics and Gynecology.

Not all patients want to create a formal birth plan, and that's perfectly acceptable; discussion of preferences is more important than completing a form. Women who are planning to create a document, however, should be encouraged to share it around 32 or 34 weeks of pregnancy. "I want to see the birth plan a few weeks prior to labor. Seeing the birth plan gives me a reference point to their point of view so I can address any concerns," says G. Thomas Ruiz, MD, an ob/gyn at Orange Coast Memorial Medical Center in Fountain Valley, California.

2. Think Preferences, Not Plan

The word "plan" denotes a specific and orderly process. Birth, of course, is highly unpredictable, and it's impossible for the mother or provider to foresee how labor and birth will unfold. That's why Dr Afshar encourages use of the term "birth preparedness document" rather than "birth plan."

Any deviation from a plan can be seen as failure, which may explain why women who don't get what they planned frequently feel disappointed, she says. Changing the terminology from "plan" to "preferences" underscores the fact that changing circumstances may necessitate a change in medical management. Encourage patients to include their wishes for an ideal, everything-goes-well birth, but help them understand that some wishes may fall by the wayside if the mother's or baby's health is at risk. Together, discuss which options are most important to the family and which fall into the nice-but-not-necessary category.

Habibi encourages her patients to use words such as "hope" and "if" in their birth plans. She also discourages the use of absolute statements.

If a patient writes, 'I do not want Pitocin under any circumstances,' I may say, 'Let's revise this, because Pitocin sometimes saves lives.'

"If a patient writes, 'I do not want Pitocin under any circumstances,' I may say, 'Let's revise this, because Pitocin sometimes saves lives.' I may suggest something like, 'If my placenta is coming spontaneously, if I'm not bleeding heavily and everything is fine, I'd rather not have routine Pitocin after birth,'" Habibi says.

3. Standardize Options

Choice is good, but too many choices can lead to inflated expectations and dissatisfaction. That well-known psychological phenomenon, known as choice behavior, may explain why a 2016 research study found that birth plans that included 15 or more requests were associated with an 80% reduction in overall satisfaction with the birth experience.[2]

One way to prophylactically avoid that dilemma is to develop and use standardized plans. Dr Afshar helped create a one-page plan that's currently in use at Cedars-Sinai Medical Center in Los Angeles. The plan includes the patient's name, names of support people, and sections for labor preferences, birth preferences, and newborn preferences. The labor preference section includes a few options for pain control: walking epidural, standard labor epidural, IV medication, and nonmedicated birth. Birth preferences include cord clamping options (immediate or delayed), while newborn preferences address cord banking, disposal of the placenta, newborn medication, and infant feeding. The document also includes simple discussions of the evidence behind recommended choices.

Kimberly D. Gregory, MD, director of maternal-fetal medicine at Cedars-Sinai, says that "standardizing choices to a limited set improved satisfaction." Standardized plans are easy for staff to digest as well. When staff are familiar with the form, they can quickly scan it and grasp the necessary information.

4. Establish Realistic Expectations

Your patients need to know what is and isn't possible, given the parameters of your practice and the proposed birth setting. If your patient desires a VBAC, for instance, but your hospital doesn't allow VBACs, "the most conscientious thing you can do is refer her to a place where she can have what she wants," Dr Gregory says.

Talk through possible deviations from a patient's desired birth. For example, Dr Ruiz tells patients, "Sometimes pain causes the pelvic musculature to tense up, and it's possible that an epidural will allow the musculature to relax and the baby to descend. You may not have an ideal natural childbirth, but you may still get your vaginal birth."

Dr Ruiz also candidly outlines why he may not be able to honor certain requests. "It's my job as a physician to say, ‘Based on my experience, this is safe, this may not be safe. We can do this, we may not be able to do that.'"

It's equally important to educate staff about how to respect women's wishes. Habibi works with many low-risk women who desire a nonmedicated birth and advises them to write in their birth plan that they do not want their pain assessed hourly, despite the fact that such assessments are common practice. Such questions can be intrusive and distracting for women who are focused on managing labor pain, so Habibi talks to nursing staff about how to handle the conflict between the patient's wishes and the nurses' need to meet institutional expectations. "You can write, 'She declined to rate her pain,' and then you don't have to ask that question anymore because that is the patient's wish," Habibi says.

5. Explain and Negotiate

When a patient presents a birth plan or preferences, consider it an opportunity to open a dialogue. Ask questions to determine why she has included specific requests; understanding her underlying concerns can help you clear up any misconceptions and ease any fears.

"The first thing you always do is acknowledge that you've read and understand the plan," Dr Ruiz says. Then begin to address potential sticking points, such as fetal monitoring.

If there's a disagreement between the birth plan and standard obstetrical practice, outline the scientific evidence supporting the standard practice. When it comes to fetal monitoring, Dr Sullivan explains that the purpose of monitoring is to check the baby's well-being. "I'll make my pitch and discuss the science; then I negotiate what I can get," he says. "If the patient says, 'No monitoring' and my stance is continuous monitoring, I may say, 'How about every 15 minutes? Every 30 minutes? Once an hour?' I'll even go to auscultation. I'll take what I can get as long as the patient understands the risk."

Address patient fears directly. A woman who writes, "I don't want a peripheral IV" may see the IV as the first step toward a C-section. "Some patients think, once I get the IV, I'm going to get Pitocin and then I'm going to have a C-section," says Rachel Edelstein, RN, BSN, a labor and delivery nurse at the University of Virginia Medical Center. Talking about a woman's fears and demonstrating a desire to help her meet her overall goals—a vaginal delivery, if possible—may make it easier for a patient to accept an IV during labor.

"I tell patients, 'We don't want to use your IV if we don't have to, but if things change and we have to give you blood to save your life, it's easier to have that IV access already in place," Edelstein says.

6. Share Patient Preferences With the Team

The best birth plan is useless if the team assisting in the birth is unaware of its existence. At many hospitals, written birth plans are scanned and uploaded to the electronic medical record. That's a good idea because it's a convenient, centralized location that's accessible to all team members, including on-call staff and consultants. Encourage all team members to check the record before bothering the family with questions that are commonly addressed in birth documents.

At many hospitals, written birth plans are scanned and uploaded to the electronic medical record.

When an on-call provider who is not familiar with the patient's birth plan shows up at the hospital, Edelstein "tries to get hold of the provider before they get hold of the patient," to share the patient's preferences. This quick briefing prevents the provider from inadvertently doing or saying anything that might be in direct conflict with the patient's birth plan, and it goes a long way toward building trust between the patient and providers.

You can also use birth plans to pull together the best possible team for a birth. Some nurses, for instance, love working with families who want a natural birth, while others are more comfortable working with women who have epidurals.

7. Acknowledge and Explain

If situations arise during labor that necessitate deviation from the birth plan, explain what's happening to the woman and her family, and give them time to process the new information, if at all possible.

Edelstein recently worked with a woman who wanted a nonmedicated delivery. But after more than 24 hours of labor and multiple position changes, the baby hadn't been delivered and the mom was approaching exhaustion. The birth team suspected that an epidural might allow the mom to relax and facilitate a vaginal birth, so they discussed the possibility with the family.

"We told her what we were thinking and why, but we also acknowledged that this wasn't what she planned on. We gave her time and didn't put pressure on her; we didn't have her make a decision right then and there while we were in the room. She felt respected and empowered, and that helped," says Edelstein. The woman ultimately had an epidural and a "fantastic vaginal delivery," Edelstein says. "She was thrilled and really appreciated our counsel and explanation."

If a medical emergency doesn't allow time for discussion, plan to spend some time with the patient a day or so after birth, reconstructing the delivery. "Help her gain an understanding of what was done and why," Edelstein says. "At most, it will take 5 minutes, but it means the world to the patient and her overall experience."

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