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| |    Your Birth Preferences Birth Preference Worksheet by Marjorie Greenfield, M.D. reviewed and revised by Marjorie Greenfield, M.D. I want to preface this by saying that I am an obstetrician, and I deliver babies in a large teaching hospital, so that's the environment I know best. On the other hand, I am a mother, and I understand the deep importance of your birth experience, and the desire to get your family off to the best start. My goals are to help you understand your options, so that you can express your preferences to the doctors, midwives and nurses who will be caring for you, so they can help you to have the kind of experience you are seeking. This worksheet will probably be most useful to those in the mainstream--having their babies at hospitals, with certified nurse-midwives or physicians attending. To be effective, a birth plan should reflect the options available at the location you have chosen, including the routine practices of the doctors or midwives who will be caring for you. If you decide to write up a plan, be sure to include the things that are of highest priority to you, or that are not routine at your childbirth location. Keep in mind that if the nurses and doctors are worried about how you or the baby are doing, they may recommend interventions that were not in your plan. It is good policy to commence your birth plan with a paragraph that communicates your trust and appreciation of those taking care of you, and of your intention to be flexible if confronted with the unexpected. What follows is a list of issues that you may want to consider before you have your baby. These are topics you should look into and think about, but not necessarily include in a formal birth plan. Before going through this worksheet, please see our article "Five Steps to an Effective Birth Plan." Arrival at the hospital Fetal monitoring Who will be with you? Eating and drinking Intravenous lines Music Photographs and video Pain Relief Induction or augmentation of labor Special equipment Pushing Who wil deliver the baby? What medical personnel will be there? Operative vaginal delivery Episiotomy When the baby comes out Cord blood Immediate newborn care Cesarean Breastfeeding Rooming in Circumcision Length of stay Arrival at the hospital What are the routine admission procedures at the location you have chosen? For example, most labor and delivery units no longer do enemas and pubic shaves, so there is no need to request that they not be done. Take a tour of the labor unit. Most unit teams are happy to show you around and review routine procedures. And speaking of birth plans--be sure you know how to get there, day or night, and where to park and how to get into the building if you are in a hurry! Fetal Monitoring When you arrive, the nurses will assess the baby's well-being. This will usually involve external electronic fetal monitoring for a short while. Often the routine is to keep you on continuous monitoring throughout labor. For some parents, this is reassuring, while for others it may feel unnecessarily medical or restrictive. As long as labor is going well, listening to the baby at regular intervals, called intermittent auscultation, is a safe alternative for parents who don't want continuous monitoring, but you may have to request it. If there are concerns about how the baby is doing or how labor is going, internal fetal heart rate monitoring or internal contraction monitoring may be recommended. If you don't understand the necessity of these procedures, follow the advice from the conclusion of our article: You Are a Key Participant in Your Care. Who will be with you? The team you bring with you influences the experience that you have. The baby's father is usually an important team member, and is often the only person to accompany the mother. Some parents choose to have another female family member or good friend there for additional support, and to share in this important event. Be sure to invite only those who will be helpful to you, and to let them know that the invitation is tentative, since you don't know how you will feel or how things will be going. Next: do you want a professional labor assistant or doula? A doula can be especially helpful if you desire natural childbirth, or if you have birth preferences that are out of the routine for your location. Find out your hospital's policies about the number of visitors and, if there is a limit, whether they can switch off. Many hospitals permit siblings at birth if they have attended a preparation course, and if an extra adult can see to their needs during the labor. Alternatively, children can be entertained nearby and brought in immediately after the baby arrives. Eating and drinking You don't digest very well during active labor, and the chances are you won't have much of an appetite. Find out your practitioner's beliefs about eating during labor. You will need fluids and calories to keep up your energy, especially if labor is long. This can be done by eating lightly, drinking fluids, eating ice, or by an intravenous (IV) line, depending on hospital policies, your medical circumstances, and your preference. Intravenous lines Many practitioners feel safest if you have an IV, or a small capped off IV called a heparin (or saline) lock, so that medications or fluids can be given in case of emergency. Often the hep lock, as it is called, is placed when you arrive at the hospital, and routine admission blood tests can be drawn through it. The downside to an IV is that it is connected to a fluid bag on an IV pole, and can restrict your ability to walk around and go in the shower, both helpful comfort measures for labor. A capped off IV doesn't usually restrict you, but may feel like an unnecessary medicalization of your birth experience. Epidural anesthesia always requires an IV, as does cesarean section delivery. Music There is nothing that can change the mood in a room like music. Find out if there are tape or CD players available in the labor rooms, or if you should bring your own. Bring music for all different moods, so that you have some choices. Photographs and video If you want to take pictures or video, check on the hospital policies before the big day. Some labor units don't allow pictures during vaginal birth or cesarean, while others have fewer restrictions. If you are going to take a lot of pictures, consider bringing someone with you for that purpose. You don't want your main support person to be fussing with a camera when you need his attention! Managing labor contractions Your plans for labor relief may be the most important part of the birth plan. In many hospitals, the default mode is epidural given when you enter active labor, generally around 5 centimeters dilation. If that is what you want, it won't take much preparation ahead of time to make it happen. But if you have other ideas, planning can make a difference. If you are worried about pain in early labor, and don't like the idea of waiting that long for relief, you will need to educate yourself about non-medical comfort measures and intravenous pain medications and talk to your practitioner ahead of time about options. It is also your right to request an epidural before the protocol allows for it--after all, as long as you are really in labor, the worst that will happen if you get your epidural too early is that labor will slow down and you will end up with a cesarean--and that may not seem like such a terrible thing at that moment. If natural childbirth is your goal, be sure that those who come with you can help you towards that target. Your coach(es) will need to know about non-medical comfort measures, and must be able to tolerate you looking uncomfortable, a difficult task for many husbands. If you or the baby's father has concerns about his ability to be your sole support, consider bringing a female friend or relative, or hiring a professional labor assistant or doula to help you through. No matter which of these ideas fits you best, think ahead about what you want your coaches to do if you look like you are in pain. Do you want them to offer medications, or to only provide them if you ask? I have even seen birth plans which say not to give pain medications "even if I scream for them," but I am always uncomfortable not allowing for a change of mind. If you don't want medications or epidural offered, be sure to inform the nurses and doctors who are taking care of you. Induction or augmentation of labor Sometimes labor either hasn't started or is going too slowly, and induction or augmentation of labor is recommended. Learn about the different methods for induction, both natural and medical, and under which circumstances induction or augmentation might be indicated. Special equipment Birthing beds and showers in the labor room are pretty standard, but other equipment may not be so available. A tour of your labor unit will show you what the rooms are like and what is available. The following is a list of things you might want to ask about ahead of time, if they sound appealing or helpful to you.
You can push out your baby from many positions. Some nurses or doctors may recommend one position that they think works best, but most find that varying the pushing position is the most effective. Sometimes the way the baby is coming down will indicate a position for pushing that will be most successful. Some positions aren't practical if you have an epidural. For example if your legs are weak, squatting may not be possible. And speaking of epidurals, some experts believe that waiting until you have an urge to push, rather than starting to push as soon as you reach 10 centimeters dilation, may help to avoid the need for vacuum and forceps (See Operative Vaginal Delivery below). It seems that early pushing may be exhausting and ineffective, while pushing after the contractions bring the baby further down and you have more urge may work better. If you are interested in trying this approach, ask your doctor or midwife about her philosophy. Who will deliver the baby? Ask ahead about who will actually be delivering the baby. Some practices have you meet all the doctors before you come in for labor, but some are too large to make that practical. If a nurse-midwife or family doctor is caring for you, find out whom she will call and how long will it take him to get there if a medical problem arises. What medical personnel will be there? You may be surprised at the number of staff members who may attend a hospital delivery--your OB, nurses for you and the baby, the anesthesia team if you had an epidural, a pediatrician or two if any problems are expected, and that doesn't include students and residents. If you have strong feelings about who is in the room at the time of birth, discuss it with your doctor or midwife ahead of time, and remind the nurse who is caring for you during labor. Operative vaginal delivery Learn about vacuum and forceps, so that you can understand the issues if the topic comes up. Sometimes assisted delivery is medically necessary, and sometimes it is recommended but optional. You may want to think ahead about how to negotiate with your medical team, especially if you think you may have a difference of opinion. If you have strong feelings against operative vaginal birth, cesarean may be the alternative, so be sure to understand all the possibilities. Episiotomy Episiotomy is an incision made to enlarge the opening of the vagina before the baby is born. There are pros and cons to episiotomy, depending on the situation. Ask your doctor or midwife under what circumstances she is likely to do an episiotomy, so you can know what to expect. It is fine to state a preference here, but I don't recommend refusing to have one under any circumstances, since there are times that it is needed for you or for your baby. When the baby comes out The moment of birth is always amazing. Try to remember to open your eyes and look as your new baby emerges. As long as all is going well, do you want him handed immediately to you, or dried off and cleaned up a bit first? Check on the policies of your birthing unit and practitioner if this matters to you. Do you want your partner or another support person to cut the umbilical cord, or do you want your practitioner to do it? Remember to ask ahead of time if you have preferences, since things move pretty fast right at delivery. Cord Blood If you are planning on saving or donating umbilical cord blood, arrangements usually need to be made ahead of time, and the doctor or midwife has to follow specific procedures after cutting the cord. Immediate newborn care Newborns are wet and get chilly quickly. Your baby will need to get dried off, and mucus may have to be suctioned from her airways. This can either be done while she is in your arms, or close by on a little cart, where oxygen, a warmer and suction are available. If she stays with you, she can be kept warm by your body heat under your blankets. If there are any problems, even mild issues like mucus in her airways or meconium, the baby's first stool, in the amniotic fluid, the nurses or pediatricians may take her to the cart where they can assess her and treat her. If this happens, the staff may get caught up in their routine newborn care and forget to bring her back to you right away. Once she is stabilized, feel free to ask if what they are doing can wait, so your baby can be with you for her first moments of life. Routine newborn care, including antibiotic eye ointment, must be given by law, but can usually wait an hour or two. Cesarean Many couples don't think ahead of time about the possibility of cesarean, yet in the US one in four babies is born this way. If your doctor recommends cesarean the necessity may be obvious to you, but if you have questions, there is usually time for discussion. You will be more satisfied with your experience if you feel comfortable with how the decision was made. Because cesarean isn't that rare, it is reasonable to think ahead about how you might want things to go, even if you are expecting to deliver vaginally. Often, even an urgent cesarean can be done under regional anesthesia (spinal or epidural) so that you can be awake and hear your baby's first cry. If you are awake for your cesarean, most hospitals will allow your partner or another support person to stay with you in the operating room, but often the number of people is limited to one or two. Find out the policies on photos and video. If you will be asleep for surgery, visitors usually are not allowed--since they aren't needed for your emotional support and also it really isn't pleasant to see your loved one under general anesthesia. Assuming that you are awake for the birth of the baby and all is well, feel free to request that your partner holds your baby as soon as possible. Sometimes the staff gets caught up in the routine newborn care after the OB hands the baby to them, but often it can wait, and your family can start bonding right there in the operating room. Breastfeeding Do you plan to breastfeed or bottle-feed your baby? Do you want your baby to get a pacifier if she is fussy? Learn about these issues, so that you can communicate your desires to the hospital staff. Rooming in One mother may want to have her new baby with her 24/7 while another may want the baby to go to the nursery so she can get some rest while she can. You don't need to decide this ahead of time, but it is good to know there are options. If you have a private room (which may cost extra) your partner can probably stay in the room with you and the baby, if desired. Circumcision If you are planning on having a ritual circumcision, arrangements will need to be made with a practitioner in the community. For more information on non-ritual circumcision and the circumcision decision, see our articles. Length of stay Some new mothers want to get home as fast as possible, while others feel best with the rest and support that in-hospital round-the-clock nursing care provides. New moms just learning to breastfeed can benefit from the education provided by the postpartum nurses and lactation consultants in the hospital. In 1999, the US congress passed a law that requires insurance plans to pay for 48 hours of hospital care after vaginal births, and 96 hours for cesarean. Leaving earlier than that will depend on your wishes and how you and the baby are doing.
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