Saturday, June 11, 2011

Why I Hate Birth Plans


Recently on a physicians' forum I came across a tragic story about a home birth gone bad. The doctors on the forum were mercilessly critical of the individuals involved, but I couldn't disagree with them. Their tone may have crossed the line from anger over the tragedy into disrespect or even cruelty, but I can't say I blame them entirely - there's a part of every conscientious physician that does get enraged over what's perceived to be preventable catastrophe, and sometimes venting the outrage in private (which this forum was supposed to be), among others who understand, can release some of the tension raised by the story.

There seems to be a wide chasm between expectant women who distrust or perhaps even hate doctors and doctors who see themselves as the protectors of human safety and life and who thus sometimes see such mothers-to-be as close-minded, willfully uninformed, and even selfish. From the physician's point of view, a) "natural" isn't synonymous with "safer;" b) pregnancy causes physiologic changes that can sometimes pose real dangers to mother and infant - DANGERS, not just inconveniences or discomfort; and c) a rigid "plan" for birth is nonsensical in light of the possibility of unplanned concerns necessitating prompt and sometimes life-saving intervention.

Don't get me wrong; I firmly believe in women's right to express PREFERENCES and to have those preferences respected as closely as possible when safety allows. Of COURSE I would never insist on placing an epidural in a woman who preferred to give birth without one. But I resent the kind of pseudo-feminist culture that creates guilt or a sense of "failure" in women who feel they would like an epidural to relieve childbirth pain. I've heard it so many times; a tearful woman saying "I'm a failure" because natural childbirth became medically assisted childbirth. No woman should ever feel BAD about bringing a new life into the world. That, and the social signals that engender it, I definitely resent.

And despite the title of this post, I don't actually hate birth plans. I had one myself. I scrapped it in the end and decided to just trust in the process, and take things a step at a time, and actually have face-to-face conversations with my caregivers, but I did draft one. A birth plan that is meant to clarify preferences is a good thing. A birth plan, written or spoken or just held in one's mind, that is meant to be a binding contract for a physician, come hell or high water, is stupid and ultimately, in my opinion, wrong. The priority should be the baby's and mother's SAFETY, not the parents' "birth experience." If the so-called birth "plan" interferes with safety, it has to go, and any parent who insists on adhering to it under such circumstances doesn't deserve to be a parent. What I hate about certain birth plans is the unspoken attitude or culture behind them that seems to declare that nothing is more important than the mother's "birth experience." This is irresponsible and wrong.

So when a screaming doula verbally abused an obstetrician colleague of mine recently for going to stimulate a baby who was cyanotic and was making no respiratory effort - and when I say screaming, I mean I was three doors down attending to someone else and I could hear her yelling at my colleague at the top of her lungs - I felt the same anger that the physicians on the forum were feeling over the home birth disaster. My colleague was doing her JOB, protecting the baby's life and ensuring the mother's safety, according to standards that have been carefully studied, and here was this medically untrained woman interfering with this physician's care and potentially threatening the life of the child by screaming at the doctor that clamping the cord and stimulating the baby were against the parents' wishes. The baby's safety didn't seem to matter; it was all about the parents' wishes. THAT kind of ignorant, selfish "care" is completely inexcusable, yet in certain circles is glorified and touted as advocacy of women's rights and empowerment of mothers. There's nothing empowering about medical ignorance, stubbornness, or selfish adherence to a dream of a birth experience contributing to a child's death.

Here's what I would want all expectant mothers to know about giving birth at our hospital. Pregnancy may be natural, but it can also be dangerous. If you show up at our door, we're going to bend over backward to protect you and your baby, but we're going to do so according to the high standards of safety to which we've been trained to adhere. Please tell us what you prefer, by all means - we do want to create as wonderful a birth experience for everyone as we can - but we also have to put safety above EVERYTHING. We would be bad doctors, and morally culpable people, if we did any less.

31 comments:

"Dr." G said...

OMG I couldn't agree more. You have completely read my mind regarding this "birth experience" ideology.

K said...

Totally wholeheartedly agree! Wonderful, wonderful post that should be branded into a booklet given out at all "birthing classes" in every hospital in the country!

Meighan T said...

Hm. Well, I totally agree that this kind of rigid mentality that some women have is not necessary, and leads to a lot of unhealthy postpartum guilt for some moms. Having said that though, I know a lot of women who approach their prenatal care/delivery with apprehension due to either bad past experiences or the horror stories of their friends. I think it may be a bit of a blanket statement to say that these women are "uninformed". They may not be physicians, but that doesn't mean they don't know anything about giving birth. I think we can all agree that the C-Section rate in some hospitals in the US is a bit high to say the least and there is a backlash among some women who don't like the direction they see OB care going in with regard to "unnecessary" intervention. Everyone knows that there are plenty of times when a C-Section or other medical intervention is necessary for the pregnant or laboring mom or baby. But there is also evidence to suggest that less intervention can yield just as many positive outcomes in low-risk patients. I am not a proponent of home birth--too many risks, but I think there is some merit to giving women a bit more freedom to labor/deliver in the way that they feel most comfortable instead of what's easiest/quickest for the physician/hospital. I think the biggest key is that these patients need to have an open line of communication with their OB so that everyone can be on the same page and be respected--both patients and physicians.
I firmly believe that there should be more resources available to both patients and physicians in regard to approaching a l/d with an openness toward natural birth. We need to find a way to bridge the gap between the extreme natural birth advocates (Like those who are for unassisted home births) and the members of the medical community.
Also, I have NEVER met a doula who would yell at a physician. Unbelievable. Just goes to show you that there are unprofessional people in ALL professions.

Anonymous said...

APPLAUSE APPLAUSE APPLAUSE. Somewhere in the past 50 years we've gone tragically wrong and lost sight of the desired outcome= a healthy baby and a healthy mom. I don't know what happened that made women start to think it was all about them.

T. said...

I completely object to the phrase / idea / suggestion of "unnecessary" intervention. I have personally never seen it. If we go to C-section, it's because the baby DOES NOT LOOK GOOD. PERIOD. We intervene because we truly feel that if we don't, SOMETHING BAD IS GOING TO HAPPEN. That's our JOB, by definition.

Anonymous said...

Well, I think people often react to recent history, even when many practices have changed in the present. It may be uninformed, but it's the natural human response in all areas. I just read a great book, "Birth," by Tina Cassidy that outlines how birth was made deadly when it was taken over by ignorant doctors (mostly men) from midwives. Granted much of this piece is historical, but the affects stayed with the l/d world to the present, as she describes. I think things have gotten a lot better. Many women who re-pioneered home birth in the 1970s are against it now because women are no longer essentially bound and drugged through their delivery ... instead, women are given a reasonable amount of autonomy in hospitals, as well as a greater degree of safety in most cases. This is all good. I just can't blame women for reacting to trends that have only very recently turned positive. It's unfortunate when that is unleashed on well meaning individual doctors who were probably not even practicing even through more recent dark moments in child birth history - but again, that makes sense to me, at least, in historical context.

Jim said...

I like aviation analogies when patient safety is being discussed.

I see a "birth plan" as similar to a "flight plan." You might take off "planning" to fly directly to West Palm Beach, but you might change your "plan" out of respect for that towering thunderstorm between you and your "planned" airport.

I see epidural and similar invasive analgesic interventions as similar to a parachute. There's a difference between safely parting company with an airplane that isn't behaving as you "planned" and skydiving.

An aside about "natural" childbirth. I crusty old OB RN once consoled a patient who was beating herself up about not having her baby as "planned," but with a detour to OR for fetal bradycardia. "Sure, you had a 'natural' childbirth. That is a baby in the bassinet, isn't it? If it were a litter of puppies, we'd have to talk. But a baby is 'natural'." Even the new parents had to laugh...

Meighan T said...

@T.
Are you really saying that you've NEVER seen a laboring woman being given pitocin when she didn't HAVE to have it (As was the case with my labor--I was dilating at a very good rate, and they still gave me pitocin, so much in fact that my contractions started to put a strain on my son)? Or women being induced because it was more convenient for them to pick when they would go into labor? I have a close friend who wanted to attempt a VBAC and was STRONGLY discouraged from even attempting it even though there wasn't anything in her medical history that would suggest she couldn't at least attempt it under hospital supervision. She was basically told by her OB she had to have a C-Section or find a new doctor. I understand that physicians are under a tremendous amount of pressure and are bound by both hospital regulations and their own fears of malpractice lawsuits. But in my humble opinion there is something fundamentally wrong with the direction we are headed when there are hospitals with 40% C-Section rates.
In all honesty, If you work in a hospital where this never happens, I would surely like to know where it is so I can deliver my future children there! Sounds wonderful!

T. said...

I was mainly talking about C-section - we do not cut people open for FUN but rather to save a child who is not thriving.

As for VBACs - I agree wholeheartedly with STRONGLY discouraging anyone who wants one. "Hospital supervision" isn't enough. Does the hospital have a well-stocked blood bank? 24-hour surgical and anesthesia coverage? Technological resources to deal with disasters? There isn't an "ideal candidate" for a VBAC because there's no reliable way to predict whether someone's uterus is going to rupture or not. Is it really work the risk to mother and child just for the sake of a "birth experience?" Not in my book.

Meighan T said...

@Jim--I LOVE that analogy :)

@T.
I'm quite sure a C-Section is never done for "fun" and I'm certainly sorry if I gave the impression that I think that is the case. I really do believe you personally want the best, safest outcome for your patients and their babies. It's also true though that there are OB/GYN's out there who are quick to jump to a diagnosis of "failure to progress" without giving a second thought to it. I've seen it happen--it's not uncommon. I once heard an OB casually comment about a patient: "Pit em, rip em (episiotomy), and stitch em" This kind of disgusting one-size-fits-all mentality simply should not be applied to a laboring woman. There ARE times when medical intervention is necessary, but as I said before, patients and doctors need to have a healthy amount of respect for each other in order for a birth to be a success on both ends. If a doctor comes into a delivery with a "my way or the highway" mentality what good does that do the patient in the end (I'm talking about things like positions to push in, whether they want pitocin or not, etc--NOT true emergency situations)? They walk away feeling like they weren't listened to and may end up having such depression about it that it has longer lasting ill effects (Which can and has lead to decreased ability for mom and baby to bond well in the beginning). A lot of OB's simply want one outcome--patient and baby end up healthy. But why can't the desired outcome be patient and baby healthy and handled RESPECTFULLY?
Bottom line is this--a patient needs to understand that a birth plan is a good way to communicate your IDEAL of how you would like your labor/delivery to be handled. But be expecting that almost nothing in life goes exactly as planned and have some flexibility and trust that you've made the right choice in your doctor and that they will truly have your (and baby's) best interests at heart. A physician needs to understand that a woman who has her heart set on a natural labor and delivery should have this desire followed so long as it does not put her or baby in danger. I really don't see how that's too much to ask.

Meighan T said...

Also, in my friend's case, the answer is yes. She would have delivered at the largest hospital in our town, which is a learning hospital for the nearby medical school.

T. said...

I've not seen obstetricians at my hospital ever handle patients disrespectfully or fail to engage in true dialogue with patients and their families. It's probably the best obstetric group I've worked with so far. I've only seen the opposite - patients and family members yelling at and completely disrespecting nurses and physicians. How about the latter actually LISTENING to OUR concerns - is THAT so much to ask, given that safety should be EVERYONE's top priority?

T. said...

P.S. Not only are our obstetric doctors great but also our labor and delivery nurses. They are on the whole OUTSTANDING and I would have no qualms about delivering at my own hospital if I ever had occasion to. In general women can labor as they wish, try out different positions, have family present, etc. but the clinicians also strictly uphold national guidelines for the health and safety of mothers and their babies. Patient care trumps all whether patients can appreciate that or not.

Meighan T said...

That's awesome that you work in such an environment! I wish every L/D dept in every hospital was that way :) And you're right, as I said earlier, the ultimate goal should be respect BOTH ways!

Margaret Polaneczky, MD (aka TBTAM) said...

Well said.

Anonymous said...

If only for the comments on this post is this entry worth reading. As a RN many doctors are very disrespectful of patient preferences and this is not exclusive to l/d. If we are to truly acheive pt. centered care, the patient needs to be LISTENED TO and feel HEARD. I love the "Flight Plan" analogy. My midwife made a "card hand" analogy for me. Sometimes you need to give up one card to keep the other cards in your hand. (i.e. for me, going in for induction after my water broke and not waiting around for active labor to start. She gave me more than 24 hours to wait and see, but informed me if I were to become febrile I would need to trade in more of my cards. This made perfect sense to me and I went in for my "mini - induction". I was still able to have a "natural water birth" with out analgesia. But it took communicating with my midwife and the hospital staff regarding out pitocin plan. I only required 15cc of pit in order to establish an active labor pattern, then we backed off the pit, and I had the baby in less than an hour in the water as originally planned. It wasn't the normal "pitocin protocol" but it worked and in the end required much less intervention (i.e. epidurals, or analgesia and the cascade of side effects.) Being a well informed consumer of medical care is crucial too. p.s. if I was unable to get into an active labor pattern I was NOT against going up on the pit, but I didn't want the pit ramped up just because that is what they are "supposed to do". there are SO many nursing protocols that are void of any critical thinking it is VERY SAD! We aren't allowed to think anymore.

T. said...

About the card-holding metaphor: I think it's awful. For one thing, it presupposes adversarial rather than collaborative negotiation, and it's the patient setting the adversarial tone. Why be adversarial at all, and turn patient care into some kind of game? Silly.

For another thing, the metaphor conjures up a very negative image of a patient who is HIDING things from those who need as much information as possible to provide the best care possible. It's an undignified image, in fact: a woman withholding helpful things and failing to be completely HONEST, whether the "cards" represent information or decisions.

Intentionally incomplete communication - i.e., dishonesty - is self-defeating and sets oneself up for dissatisfying or unsafe care. How irresponsible. Moreover, there's only one person who should be "holding cards" in any delivery: the BABY.

Anonymous said...

@Meighan T: As far as physicians quick to jump to the conclusion that the patient is failing to progress, have you considered that that is because so much can go wrong so quickly?

Quite honestly, any physician willing to do a VBAC would be considered by most irresponsible because, exactly as T. said, despite NUMEROUS studies and meta-analyses across time, there is now way to predict which patients will and won't rupture, AND the consequences to the mother of rupture are catastrophic and likely FATAL. In this country, the standards of care are determined research, and we practice evidence-based medicine... Just because SOME studies show that positive outcomes CAN come from waiting longer instead of performing a C-section, it by NO means means that a MAJORITY of research shows that same trend. Your statement was synonymous with someone saying that one anecdote should be considered as the general trend. Our government spends ludicrous amounts of money studying things just as this, and even more money paying organizations to collectively compare numerous studies on single subjects, comparing and contrasting studies, and determining if each study is even powerful enough to have even been significant enough to be considered as a single data point on the trend.

Furthermore, what do you think will happen to the doctor of a woman who allows a VBAC and it goes wrong? He/she will most likely be sued, or the attempt will at least be made. Saying that physicians should do what patients tell them despite risks to the patient would be the same as complaining that a bus driver refused to go 100mph around a sharp curve despite a passenger wanting to do it, or complaining that your hair stylist refuses to cut your hair with a chainsaw. The beauty of our healthcare system is that people can CHOOSE their doctor. If they aren't happy with the standards that the doctor follows, instead of demanding that they get what they want from one particular doctor, they can simply do some research and find one who will do what they want before deciding who to pay. You don't own your doctor. They aren't obligated to do whatever you want them to do. They went to college for eight years, then to residency for multiple years afterward, and are still required to continue their education afterward, not to mention the years of experience they've had in caring for patients. If you think that an hour long internet search gives you more education than all of that, feel free to do your appendectomy in your bathtub at home.

T. said...

@Anonymous from 6/23, 6pm: amen, Amen, AMEN.

mamadoc said...

As my dear daughter, who gave birth 4 dyas ago ovserves, "this is such a first world issue." When ssked at the hospital about her "birth plan" her answer was "just get me and the baby home health and at approximately the same time." People don't understand that while birth is anatural process it used to (in this country) and still (in many parts of the world) has real potential to kill you dead.

T. said...

@mamadoc: EXACTLY.

T. said...

P.S. - Congratulations on the birth of your grandchild!

Plastic Surgery said...

Awesome article! Physicians should understand that a woman has her heart set on a natural birth should be the desire to follow until the mass or the child at risk. I really do not understand how it is asking too much.

Anonymous said...

I had the scary-ass-pregnancy-from-hell, with no known risk factors for it going in. Kiddo wasn't expected to make it, 4 months bed rest miserable with pre-e and a list of other acronyms. Told at 24 weeks "you really shouldn't try this again..". Fast forward to csection at 35 (yep that's right- go me!) weeks. Csection done in main OR with NICU team there because neither one of us was expected to do well and that way we both had ICU teams waiting for us.

I was actually asked about my birth plan Seriously? "get outta here alive with a healthy baby." There were some bumps on the way (failed epidural, baby too stressed to stop surgery- ow ow ow ow ow) but I was up walking, carrying my peanut-sized bundle, 3 hours later. She just finished kindergarten, with talk of skipping at least 1 grade in the fall.

Maybe people need to be encouraged to just have a birth "guideline.". Express a couple preferences that are important to them, with education that the end result is more important than the process.

Anonymous said...

I couldnt disagree more, giving birth is as natural as digesting food. Some people have stomach viruses and need a shot of steroids to jump start the natural process, and thats great that we have the people and resources to provide that. If a mother dosnt want something done to her child, there should never be a resistance by the medical staff, who is paid by the patient. If i pay for a service, i expect that provider the adhere to my wants, what ever they are, however odd they might sound, so long as they are within reason.

T. said...

There are so many things wrong with the above statement I don't even know where to start, but the most important point I want to address is you are a PATIENT, NOT a CUSTOMER. I don't have to do what you want if I consider it UNSAFE for you and your child. If you want someone to provide what you want no matter what, go to some quack who doesn't care one bit about your health and safety - a good doctor is going to adhere to high standards of care regardless of public/patient opinion. You don't pay me; my anesthesia group pays me, and they pay me to do the RIGHT THING for patients whose well-being I care deeply about.

Anonymous said...

I can't love this enough. As a reformed victim of the cult of woo, I really appreciate that you use your experience to relieve some of the burdens natural child birthers think they carry. Birth is out of your control, you don't own your birth, and it's impossible to become truly educated in the matter by your EDD. While I think it's great to have a list to share with your care provider of things that you are comfortable with vs things that you have some anxiety about, I think birth plans set up an ideological experience that is not going to play out the way you want and can contribute greatly to PPD.

Aleah said...

I love this!

And to the commenter stating " there are SO many nursing protocols that are void of any critical thinking it is VERY SAD! We aren't allowed to think anymore."... I'm concerned about where/how you received your education. Critical thinking was emphasized at the very beginning of my nursing career, and every day protocols are reinforced, improved, and new ones created - all due to critical thinking and evidence-based practices.

Pope Bunnyface said...

As someone trying for my first and, like an anonymous commenter above, a reformed victim of the cult of woo - bravo.

After hearing my friends talk constantly about how they failed or were too weak or felt manipulated by 'unfeeling' doctors, I can't understand how they could just totally miss the point. They had a baby. Isn't that what they got pregnant for?

Honestly, the "birth experience" brigade creep me out. Giving birth is meant to be incredible because you get to meet your baby for the first time. If people are seeking instant self-esteem, empowerment, sense of identity or an orgasm.. why did they get pregnant in the first place? The uber-crunchy brigade's hysterical war-cries about the immeasurable benefits of things like breastfeeding seems pretty insignificant when you consider the incredible risks they are willing to inflict on their babies in the pursuit of their 'perfect birth'. Someone needs to shake them and say for once and all "IT'S NOT ALL ABOUT YOU".

I have some ideas about what I'd like my (eventual birth) to be like, but I can also admit that I've never had *that birth* before, and the reality of that birth could be radically different for anything I hoped/planned for, no matter how much googling I've done. This is true for every woman, whether she has never had a baby or has had 17. Things can change so quickly and problems you never imagined can arise in an instant - would you trust yourself, panicking and hurting, or the people who had actually trained for and experienced every possible scenario?

abbysmummy said...

I want to thank you for voicing what I have thought for a while now. I am a physician and a mother and the most important thing for me was that I delivered a healthy baby. I didn't care if that meant an induction, fetal scalp monitor, AROM, C-section, whatever, I just wanted my baby to be safe. When I was a resident, I was called to the delivery of an emergency C-section for an all-natural home delivery that had gone wrong.
We worked on that baby for so long, I had burns on my forearms from performing chest compressions under the warmer. She did not make it and I will never forget her. Women today have lost sight of the fact that the point is not to have some wonderful transcending birthing experience but to deliver a healthy baby safely.
A "medical" birth is not a sign of failure. I ended up being induced and I had an epidural and I think my delivery was wonderful because my baby and I both made it.

Ryan said...

I just came across this blog and was impressed with this post. I am a pre-medical student who is very interested in OB/GYN and my wife and I just had a baby 3 month ago. I have found that there is a lot of contention around birth and the different approaches. I have seen women on both sides of the spectrum from natural at home birthing to medicated and sectioned being criticized about the choices they made. I feel like we should all be understanding of the process and celebrate new life no matter the way it happens. Anyways, great blog!