Reconciling birth plans with reality

Following a patient's birth plan is not always possible.
Following a patient's birth plan is not always possible.

If you ask most labor and deliveries nurses or ob/gyn residents what they think of written birth plans, they will probably laugh in your face. Most will be quick to tell you the widely-held belief, “The longer the birth plan, the higher chance of a cesarean section.”

Anecdotally, I cannot dispute this adage. However, as a midwife, I believe in a couple's right to the best birth possible. I believe that patients have the right to be participants in their care and to have their wishes heard, though I always remind women that birth is a dynamic process and to keep an open mind. I also encourage my patients to bring their plans in to review with me long before delivery so we can discuss realistic expectations, identify possible knowledge deficits, and eliminate any ridiculous requests. I can also reassure couples that the obstetric team is there to work with them to have the best-possible and safest birth experience.

I think much of the stigma over birth plans arises from their tendency to convey a basic distrust of the medical system. Providers and nurses can become defensive when they feel that their judgment or care is being questioned.

Recently, I had a patient transfer to our practice very late in her pregnancy. When she came to the hospital in active labor at 35 weeks, she brought a long, detailed birth plan with her. The team was not able to accommodate some of the wishes on her birth plan due to both her rapid labor and the fact that 35-week newborns are considered near-term, which means they generally require more care at birth. The couple was very angry with the nurses and me despite our explanations of what we were doing and why.

The nurses too were very frustrated, and one vented to me that she felt like these parents were selfishly putting their own desires for certain birthing experiences over the wellbeing of their newborn. This was not the first time I've heard this concern. 

This is why ongoing communication between practitioners and patients is so vital. In this case, we had not had a chance to review the patient's birth plan beforehand. The heat of the moment of birth is not a good time to educate new parents who are excited and emotional. Fortunately I was eventually able to soothe the angry parents with detailed rationales behind our clinical decisions. In the end they were appreciative of the team's quick thinking to resuscitate their infant.

Many patients feel that a birth plan is the only way to express their wishes during labor and birth. The problems arise when parents cannot see beyond their desires for the perfect birth to the point of placing their baby at risk.

As medical professionals, the obstetric team needs to be respectful of the parents' wishes when these wishes are feasible. It is imperative that practitioners understand that birth plans are a way for couples to exert some control in a situation that often feels, and often is, uncontrollable. Birth plan or not, our job is to provide quality care while communicating with, and educating our patients as much as possible. When we can do all of this and accommodate the specifics of the birth plan, it's a bonus!

Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy Hospital in Sewell, N.J.

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