If you haven’t already, please check out PART 1 of this post: Writing Your Birth Plan: Tips from an L&D Nurse. Also, at the end of this post check out a birth plan written and sent to me by one of my blog’s readers who is due any day now!
#1 DO keep your birth plan short, simple, and easy to understand (1-2 pages max).
“Keep [your birth plan] short. If you need to spell out a long list of points, you may not be with the right caregiver. If most of the things you want aren’t things your caregiver is used to doing (in which case you don’t need to put them in a birth plan!), you are unlikely to get them. For maximum effectiveness, keep your birth plan to a single page.”
Writing a Birth Plan by findadoula.com
#2 DO keep the language of your birth plan assertive and clear.
“Remember to keep your language assertive – polite but clearly stating what you want. Use phrases like “I am planning” and “I would like” rather than “if it is ok” or “I would prefer.
Be specific. Avoid words and phrases such as “not unless necessary” or “keep to a minimum.” What one person thinks is “necessary” is not what another does. What one person defines as the minimum is not what the next person does. Instead, use numbers or specific situations, for example: “I am happy to have 20 minutes of electronic monitoring and if all is well then intermittent monitoring every hour for five minutes after that” or “I am happy to have a vaginal examination on arrival in hospital and after that every four hours or on my request.”
Writing a Birth Plan by findadoula.com
“Be sure to be assertive, but not aggressive when discussing your options. Do not allow your caregiver to brush off your decisions or suggest that this is unimportant. At the same time, don’t assume your caregiver [or nurses] will be hostile or uninterested in hearing what you have to say.”
How to write a Birth Plan by birthingnaturally.net
#3 DO use your birth plan as an impetus for doing your own personal research about your preferences for childbirth.
One great place to start is at MothersAdvocate.com who, in partnership with Lamaze International and Lamaze’s Six Steps to A Healthy Birth, have created a website that offers FREE, evidenced-based, educational video clips and print materials to educate and inform childbearing families on how to have a safe and healthy birth for both you and your baby. These extremely well reserached and produced materials are a MUST READ for all expecting moms!!!
The introduction handout for these video clips and print-outs entitled Introduction: Birth–As Safe and Healthy As It Can Be reads:
“While no one can promise you what kind of birth experience you will have, common sense tells us and research confirms that there are two tried-and-true ways to make birth as safe and healthy as possible:
• First, make choices that support and assist your natural ability to give birth.
• Second, avoid practices that work against your body’s natural ability, unless there is a good medical reason for them.
Lamaze International, the leading childbirth education and advocacy organization, has used recommendations from the World Health Organization to develop the Six Lamaze Healthy Birth Practices that support and assist a woman’s ability to give birth. Years of research have proven that each of these practices increases safety for mothers and babies.
The Six Lamaze Healthy Birth Practices are:
1. Let labor begin on its own.
2. Walk, move around, and change positions throughout labor.
3. Bring a loved one, friend, or doula for continuous support.
4. Avoid interventions that are not medically necessary.
5. Avoid giving birth on your back, and follow your body’s urges to push.
6. Keep your baby with you—it’s best for you, your baby, and breastfeeding.”
The topics of the print materials include:
Choosing a Care Provider,
Changing Your Care Provider,
If You Have Been Induced,
Maintaining Freedom of Movement,
Positions for Labor,
Finding a Doula,
Creating a Support Team,
Tips for Labor Support People
and even a Birth Planning Worksheet!!
“We cannot know the day or week labor will begin, how long it will last, exactly how it will feel, how we will react, or the health and sizes of our babies. What we can do, however, is educate ourselves about the vast array of possibilities and learn which are more likely to occur. We can decide what is ideal and what we will strive for, what are the means to creating the most conducive environment for such a birth, and which people can best help us to attain those birth arrangements. Finally, we can prepare our own bodies and hearts for the process.”
Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth
by Amy Scott
#4 DO include your fears, concerns, and helpful things for the nurse to know.
If appropriate, a birth plan can also include a few sentences regarding things you just want the nurse to know about and are important enough to make sure that every shift is aware of. For example, I once had a patient who wrote the following in her birth plan:
“My husband is a type I diabetic and at times suffers from episodes of hypoglycemia where he does not have any warning signs or symptoms. So if my husband starts to act inappropriate or seems ‘out of it’ or ‘drunk’ please offer him some juice!! I am afraid that if I am in the throws of labor that I will not notice and this is something that I am very concerned about!”
Although this information wasn’t necessarily birth related, as a nurse taking care of this family I found this information EXTREMELY helpful to have in the birth plan!! By putting it in her birth plan, this mother felt more at ease knowing that she did not have to waste any time worrying about forgetting to tell each new nurse that took care of her. Having this in her birth plan also served as a reminder for me to pass along this important information when I was giving report to the next shift.
#5 DO review your birth plan with your birth attendant and ask him/her to sign off that he/she read and understands it.
“Add a line at the bottom of your birth plan for your doctor or midwife, and other caregivers, to sign your plan under the statement ‘I have read this plan and understand it.’ When caregivers sign your plan, they are only acknowledging to you—on the record- that they have read and understood it. They do not have to sign and say: ‘I agree.’ No matter what you tell them, they are always responsible for offering you their best judgment and skills as different circumstances arise, and then together you and your caregivers can agree on your care. This benefits you. Your birth plan will help you take responsibility for your decisions and ask to be fully informed.”
Creating Your Birth Plan, page 219
By Marsden Wagner & Stephanie Gunning
#6 DO make your birth plan personal (don’t just copy paste) and DO make sure that you understand and can elaborate on everything in the birth plan if asked.
In my humble opinion (regarding birth plans), there is nothing more frustrating for a nurse (and nothing more detrimental to a nurse’s overall attitude and view of birth plans) than to have a patient just copy and paste a general, “all-purpose” birth plan off the internet, check the boxes that “sound good”, and pass it in to a nurse with her name typed in at the top. Why? Because when a nurse (like myself) sits down to review the birth plan with the mother and her labor companions in order to start a dialogue about how the nursing staff can assist in adhering to the birth plan, it will most certainly become obvious to the nurse that the patient has done little to no research on any of her choices making it almost impossible to help the patient follow her birth plan when the birth attendant comes in and wants to do things differently.
Let me give you a few examples:
Example 1: One time I had a patient who had the following statement on her birth plan: “Regarding an episiotomy, I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage.” Now don’t get me wrong, this statement is great and it is one that I personally believe in and try to promote. So while reviewing the patient’s birth plan with her and her husband I enthusiastically said the following, “Oh, I see here you have been doing perineal massage and Kegel exercises and wish to avoid an episiotomy. That is great! How many weeks have you been doing perineal massage for?” The patient looked blankly at me and said, “What? Oh I don’t even know what that is! My sister just told me that I shouldn’t get an episiotomy so I checked that box.”
Ladies, it is really hard for a nurse to advocate for you if you don’t even understand what you are asking for!
Example 2: Almost all the birth plans I have seen make some statement about pain relief and pain medications. Again, I think that this is a great thing, especially if the mother was inspired to research all of her pain relief options (both pharmacological and non-pharmacological) and make an informed pain relief plan during the writing of her birth plan. One time I had a patient who had the following statement in her birth plan, “Regarding pain management, I have studied and understand the types of pain medications available. I will ask for them if I need them.” Again, I was very enthusiastic when I read this and said to the mother, “I see here that you have done some research on pain management. Wonderful! Have you taken any childbirth preparation classes or read any books?” The mother responded, “What do you mean?” I replied, “Well you know, like any classes or books by Lamaze, Bradley, Birthing From Within, Hypnobabies, etc.” The mother responded, “No.” I then said, “Oh, did you do any research on the internet or talk to anyone?” To which she replied, “No, not really. I mean, it’s my first time so I don’t know what to expect. My best friend just said she hated her epidural so I don’t really want one of those. Unless , of course, I really need it. We’re just going to wing it.”
Ummmm, huh?!?! Now again, don’t get me wrong. I feel that I am very supportive of mothers that are preparing for a natural, or physiological, childbirth and I often write about the risks and benefits of common obstetrical interventions, including pain medication and epidurals. But ladies, your nurse can’t be the only one who is advocating for your natural childbirth. YOU have to be on board too and YOU have to understand your reasons for not wanting pain medication or epidural. Because if you don’t even know why you don’t want an epidural then the next person who walks into that room who feels differently, be it a nurse or your birth attendant, guess what’s going to happen?! You’re probably going to agree to anything said nurse/birth attendant tells you you should get, because you don’t know any alternatives.
I am not trying to say that taking a certain childbirth preparation class or reading certain books is required for a positive and empowering birth experience. But some type of research and preparation on the part of the mother and her labor companions/partner is EXTREMEMLY IMPORTANT!!
Now here’s one more example to give you the full perspective.
Example 3: One time I was taking care of a patient who had the following statement in her birth plan: “My husband and I have been preparing for and planning a natural childbirth. I am very interested in using the Jacuzzi tub for pain relief in labor and have been reading about other drug-free ways to cope with pain. I am not interested in pain medication or an epidural as I had both with my last baby and had a poor experience with both. I respectfully request that they not be offered to me. I have done research and feel that the risks outweigh the benefits.” When I asked her about it we embarked on a really informative discussion about her last delivery, in which she had persistent numbness in her right leg for 2 months after the epidural as well as a debilitating spinal headache that took required two blood patches and made it difficult for her to nurse or care for her baby during her hospital stay. She also told me that she did not like the way the IV narcotics made her feel, as she was “seeing things” and generally “very out of it.” After our conversation I felt confident in advocating for her with her doctor (who often insisted his patients get epidurals) because I knew that if I said anything to the doctor that she would, in a sense, back me up and likewise I would back her up!!
It is so hard when a patient has something in her birth plan like “I don’t want an epidural”, and hence I argue with the doctor about how the patient does not want an epidural, but then when he goes into the room to ask the patient himself, the patient says “Oh well, whatever you think is best doctor!” It really just makes the nurse look like she is trying to “push her own agenda” when in reality the nurse was just trying to follow the patient’s birth plan!!
One more thing…I don’t want anyone to feel like I am implying that a woman has to “prove” anything to me when I ask questions about her birth plan. That is NOT the case. I just know from personal experience how important it is for a woman to understand and agree with everything she herself puts in her birth plan! Remember, mothers, labor companions, and nurses work best when they are all on the same page and work as a team to facilitate a positive and empowering birth experience!!
#7 DO look at examples of great birth plans online to get some ideas.
The following is a list of some good places to start. Remember, while these websites provide a wealth of ideas, they should not be simply copied and pasted! The best and most effective birth plans are personal, NOT just a list of things with check marks next to them!!
a) BirthingNaturally.net
b) Sample Birth Plans from BirthingNaturally.net
c) ChoicesinChildbirth.com
d) American Pregnancy Association
e) BabyCenter.com
f) MothersAdvocate.com
#8 DO run through scenarios in your mind about how labor could unfold and actually talk these scenarios out with your labor companions and doula (or perhaps even your childbirth educator or birth attendant too!)
Think about all the different ways labor could unfold and how you might react if labor was faster or slower than expected; harder or easier than expected. What would you need for comfort, support and information in each of these variations? Thinking about “worst case scenario” doesn’t mean it’s going to happen. But if it does, or if any variation does, it will make you more at ease to know that your team has already talked about it and knows your wishes.
“If you knew that something would go wrong or would pose a difficult challenge during a portion of the labor and birth, what would your ideal strategy and scenario for handling that problem be? How would you want your midwife or doctor to speak with you? How would you like your spouse or another support system to help? What alternatives would you like to try, and in what order? Again, in your mind’s eye permit yourself to have the best. What would help you relax and be able to continue labor under difficult conditions?”
Creating Your Birth Plan, page 219
By Marsden Wagner & Stephanie Gunning
#9 DO try to treat researching and birth plan writing as a fun and exciting experience, not a chore!
Enjoy this time! Don’t be afraid to be creative and fanaticize! There are so many amazing thing that you can discover and learn about while doing research for your upcoming birth. It is never too early to start so don’t put it off till the last minute!
And finally…
#10 DO remember to bring your birth plan to the hospital!!
It won’t do much help to the nursing staff if you forget it at home on your coffee table! I encounter this very often at work and I always feel so badly because I know that there is usually a lot of work put into writing a birth plan. It might be best to make sure that you place a copy of your birth plan in the bag you have packed to take with you to the hospital. I have even had a few mothers put an extra copy in their car’s glove box so that they wouldn’t forget it!
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SAMPLE BIRTH PLAN
This birth plan was sent to me by a reader of NursingBirth who goes by the name “ContortingMom”. Contortingmom’s guess date is 7/17/09 and she is still “cooking” with her first baby 
I really like her birth plan for a variety of reasons. #1 She was inspired to add some stuff to her birth plan after reading a couple posts of mine (which I think is pretty cool and #2 I think it is a perfect example of a personalized birth plan!! No check boxes here! Thanks again to ContortingMom for allowing me to post her birth preferences for other moms to read and learn from!!
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Birth Preferences:
I understand that labor and birth are unpredictable and ultimately want the health and safety of both the baby and I to take precedence. In all non-emergency situations, all proposed procedures are to be discussed (benefits and risks) so I can direct the decision making with informed consent.
Your help with these preferences is very much appreciated.
Labor:
• I intend to have as natural a labor as possible – including freedom of movement, intermittent monitoring, a saline lock instead of an on-going IV, and clear liquids as tolerated.
• Due to my GBS+ status, I request only very limited vaginal exams and do not want an amniotomy.
• Please accept my request that pain medication not be offered to me. For many reasons – personal and medical, I’m striving for an unmedicated labor and delivery. If I eventually want drugs or an epidural, I’ll be the first to ask for it and understand that options change as labor progresses.
• If augmentation is necessary, I would like to try non-pharmacological methods before resorting to meds. However, if my OB and I agree that pitocin is required, I request that the it be administered following the low dose protocol and increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.
Birth:
• Please do not direct my pushing with counting or yelling. I will ask for help if needed.
• I strongly prefer a tear to an episiotomy and do not want a local anesthetic administered to the perineum.
• I plan to be as active during pushing & delivery as possible, including choosing productive positions. They will be probably anything except supine, lithotomy or “sitting squats” that put pressure on my tailbone. It’s been broken several times & currently inflamed. I also have restrictive pain from spinal injury & surgery, so please allow a position suited to my medical needs. I’ll make sure the OB has comfortable access.
• I would like to have the baby brought to my chest immediately for skin-to-skin contact & initial procedures – and to try nursing to see if it works to contract my uterus, delaying pitocin until we know.
If Cesarean Is Required:
• Please use double-layer sutures when repairing my uterus. If I have a second child, I hope to attempt a VBAC and understand this is a requirement for many doctors.
• As health permits, I would like to skin-to-skin contact with the baby, to stay together during repair and recovery, and to breastfeed during the initial recovery period.
• If my husband has to leave the operating room with the baby, I would like my doula to take his place.
Baby Care:
• We would like to spend as much time as possible with our baby after birth before being taken off for procedures and will be breastfeeding, so please refrain from giving bottles/pacifiers.
We Appreciate Your Support. Thank You!
“Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions July 9, 2009
Tags: augmentation, c-section, C/S, cesarean section, delivery, fetal distress, hospital birth, induction, L&D, labor, midwife, OBGYN, obsterician, pit to distress, pitocin
Yesterday in my post entitled “Pit to Distress: A Disturbing Reality” I wrote about a troubling way of administering the drug pitocin to augment or induce labor that some birth attendants are practicing in our country’s maternity wards. Called “pit to distress”, the intention is to order a nurse (either verbal or written) to continue to turn up (or “crank” as is the current L&D slang) the pitocin in order to induce hyperstimulation/tachysystole of the uterus so that a women is experiencing more than 5 contractions in a 10 minute period. This action, sooner or later, will cause fetal distress as research has shown that a baby needs AT LEAST a 1 minute break in between contractions where the uterus is AT REST in order for the baby to continue to receive adequate oxygenated blood flow from the placenta and not have to dip into his reserve.
Inspiration for my post came from two posts on the subject written by Keyboard Revolutionary and The Unnecesarean. Since yesterday I have received many comments regarding this upsetting trend and one comment in particular has inspired me to address the topic again:
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July 8, 2009
Dear NursingBirth,
I really enjoy your blog and I learn a lot from all your posts. I am wondering if there is a way (as the patient) to know if something like this is happening and refuse it? Is the patient always told how much pitocin she is getting and can she say at a certain point that she doesn’t want it any higher if she is making progress?
Sincerely,
Zoey
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Dear Zoey,
This is a GREAT question. I love hearing from women who desire to learn more about their choices in childbirth and become more proactive in the care they are receiving. KUDOS to you for doing both!! I have thought a lot about this and I have come up with a list that I hope you find helpful. Please pass it along to all of your friends, both expecting and not, so that we can both work to inspire more women to do as you do….that is, DO their research and DEMAND better care!!!
TOP 7 WAYS TO PROTECT YOURSELF FROM UNNECESSARY AND HARMFUL OBSTETRICAL INTERVENTIONS (including “Pit to Distress”!)
#1 Interview different birth attendants/practices before or during early pregnancy and CHOOSE a birth attendant that practices in a way that aligns with your personal childbirth/postpartum philosophy, is appropriate for your health status, and (optimally) who practices a midwifery model of care!
I wish I could scream this from the roof tops! Sometimes I feel like a broken record I say this so often but I say it so often because it is SO important!! The bottom line here ladies is that if you think you can pick any care provider you want and then just write a birth plan that clearly states your philosophy and preferences and just get what you want…..THINK AGAIN! Birth attendants are creatures of HABIT more than anything else. If they cut an episiotomy on the majority of their patients then what makes you think that if you ask, they won’t cut one on you? In fact, not only will they cut one on you but they will come up with some bogus reason why it was necessary. Likewise, if your birth attendant induces most of their patients, what makes you think that he won’t start pressuring you to set up an induction date once you hit 37 weeks!
Think of it this way, if the birth attendant has a high elective induction rate, they probably feel more comfortable managing pitocin induced or augmented labors as opposed to spontaneous labors and hence, they will probably try to do everything in their power [including persuasion (e.g. the “convenience” card and the “aren’t you sick of being pregnant” card) as well as scare tactics (e.g. the “big baby” card, the “I might not be there to deliver you if you don’t” card, or my favorite the “if you don’t your baby might be stillborn/dead baby” card)] to convince you that your labor needs to be induced or augmented with pitocin. Why? It probably is a mix between how they were taught (i.e. medical model of maternity care), what they are used to (a self fulfilling prophecy), and a desire to be the one in “control.”
Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:
“Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.” (Emphasis mine)
So PLEASE for the LOVE of all mothers and babies, PLEASE do your homework!
Of course there is always the chance that you do interview a particular birth attendant and they act one way in the office with you and then, WHAM!, are a completely different person when you step foot on L&D. I see it happen ALL THE TIME where I work. Just because a doctor gives you his home phone number and is sweeter than sugar in the office, doesn’t mean he won’t section you just to get to the company Christmas party! (This actually happened to a patient I took care of! NO lie!) So what can you do about that!
Jill from Keyboard Revolutionary recently blogged about this:
“Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We’ve all shaken our fists in righteous indignation at the rants of Marsden Wagner. We’ve listened intently to the poetic, thickly accented declarations of Michel Odent. We’ve swooned over the tender ministrations of “Dr. Wonderful,” a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.
I was pondering just now in the shower how so many of us think we’ve got a real gem of an OB (or any other doctor, really) until show time, and suddenly we’re hit with the ol’ bait-and-switch. Sometimes there are warning flags along the way, sometimes not. Sometimes the flags don’t pop up until it’s too late. It sucks that for many women, we don’t realize what a crock we’ve been fed until we’ve already digested it. How do you know whether you’ve got a bad egg or your own Dr. Wonderful?”
This leads me to my second point…
#2 Ask the RIGHT QUESTIONS and the RIGHT PEOPLE when researching potential birth attendants.
Two of my favorite posts from Nicole at It’s Your Birth Right! are her posts about choosing the right birth attendant entitled Choose Wisely I and Choose Wisely II. She writes:
“The decision about WHO is going to be your birth attendant should NOT be left to chance. Where you deliver, how you choose to labor, what you chose to do while pregnant and in labor, while these things are definitely important, without the proper WHO, the plan will have difficulty coming together.
I get questions, all the time from friends, friends of friends and even strangers. They want my thoughts about pregnancy, labor and childbirth. I have spent HOURS talking with women providing answers and information they should be able to get from their prenatal provider/birth attendant. I think to myself at the end of those conversations, “Why isn’t she able to get this information from her? If he doesn’t make her feel special, does not answer her questions, and doesn’t agree with her philosophy on childbirth and labor, why on earth is she allowing him to be her birth attendant?!”
When I pose this question to the women themselves, the answers unfortunately never include “Because I did my research and I found him to be the best match for me and my desired childbirth experience.” Most of the answers I receive fall into [one of] four categories, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant. They are: “She delivered my sister/girlfriend”, “She is my gynecologist,” “He is the best/most popular person in area,” and “Her office is so close and convenient to my office/house.””
Now I am not trying to say that you shouldn’t trust your sister, sister-in-law, or best friend’s opinion about her personal birth attendant but if you are going to ask such a person for advice please remember that she probably has only had limited experience with that birth attendant as compared to, say, an L&D nurse or doula, and it is important to ask her exactly why she loves her birth attendant so much. Does she love him because he trusts in birth and strived to facilitate a positive and empowering birth experience for her or does she love him because he was the only OB in the area that would agree to induce her at 38 weeks because she was sick of being pregnant? There is a difference!!
If you have done some research and found a birth attendant that you think you really like, I would recommend tapping into some community resources to get the “inside scoop” about your birth attendant. Here are some ideas:
1) Contact your local grassroots birth advocacy group like International Cesarean Awareness Network (ICAN) or BirthNetwork National and try to attend a meeting. The women that attend these meetings are often in tune with the birth culture in their community and can be GREAT resources for which birth attendants are true and which are really wolves in sheep’s clothing! Also, don’t count out ICAN as a resource even if you have never had a cesarean. We have a quite a few moms currently in my local ICAN group that are first timers and decided to start attending because they said they were learning so much about birth in general from our meetings!
2) Sign up for a childbirth preparation class that is NOT funded/run by a hospital and ask the instructor for her opinion on different birth attendants. It is the only way to guarantee that your instructor is not held back from speaking her true feelings since hospital based childbirth instructors are working for the interest and promotion of their hospital by the very nature of their job. Independent childbirth instructors like Lamaze, Hypnobabies, Birthing From Within, Bradley etc. etc. can be GREAT resources as to which birth attendants follow which philosophies because often times their clients come back and tell them about their experiences.
2) Consider consulting or hiring a doula. A doula is a great resource as to the true nature of a birth attendant because she is someone who is actually in the labor and delivery room with her clients and has as close to an “insider’s view” as you can get without actually working for the hospital. If you hire a doula to be with you during your labor, they will also advocate for you, your needs, and your birth plan as well as provide essential labor support that (unfortunately) even the most well intentioned nurse might not have the time to do.
#3 Do NOT agree to an induction of labor unless there is a legitimate obstetrical, maternal, or fetal reason for delivering the baby before natural spontaneous labor begins!! PLEASE Do NOT agree to an unnecessary elective induction of labor.
This might seem like a no brainier ladies but so many get sucked in! They don’t call it “the seduction of induction” for nothing!
Bottom line is if you want to protect yourself from such an asinine, unnecessary, and dangerous intervention as “Pit to Distress” then DON’T agree to be induced unless there is a very important medical reason!
BABIES AND MOTHERS HAVE THE BEST OUTCOMES WHEN THEY ARE ALLOWED TO BEGIN LABOR SPONTANEOUSLY AS WELL AS LABOR AND DELIVER WITH MINIMAL INTERVENTIONS!
In the Lamaze Institute for Normal Birth’s MUST READ patient education bulletin entitled Care Practice #1: Labor Begins on Its Own, author Debby Amis, RN, BSN,CD(DONA), LCCE, FACCE, and editor Amy M. Romano, MSN, CNM write:
Okay, enough said!
#4 If you have to be induced or augmented with pitocin for a true medical or obstetrical reason, be honest with your nurse about how you are feeling and have one of your labor companions keep track of how often your contractions are coming.
And this does NOT mean for your labor companion to “monitor watch”!! It’s not a TV for goodness’ sake!
Research has shown that due to the risks of pitocin, continuous electronic fetal monitoring (CEFM) is a safety requirement for anyone being induced or augmented with it. However, remember CEFM is a machine and machines have limitations. The tocodynamometer or “toco” is “pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper.” However, depending on your body type, how “fluffy” your abdomen is, your position, and your gestational age, the toco might not be recording your contractions appropriately. You might be having contractions every minute but the machine is not registering them. This is why I always remind women that they have to tell me how they are feeling.
If you are being augmented or induced with pitocin your nurse SHOULD:
1) Be palpating (feeling) your fundus (top of your uterus above the belly button) before, during, and after contractions periodically throughout your labor to judge how strong they are (mild, moderate, or strong). Palpation before and after contractions also assures the nurse that your uterus is actually coming to rest (is soft) between contractions, which assures that the baby (and mom!) are getting a break! Remember, unless you have an IUPC (intrauterine pressure catheter) in, the toco can only tell the nurse how far apart and how long the contractions are NOT how strong they are! That’s right! Unless you have an IUPC in, the height of the contractions on the monitors is ABSOLUTELY MEANINGLESS! So therefore the only way for the nurse to know how strong the contractions are is to TOUCH your belly and ASK you!
2) Ask you about your pain level (for example to “rate” your pain on a scale of 0 to 5 or 0 to 10) regularly during your labor unless you have specifically asked her not to ask you about your pain.
3) Give you periodic updates on your progress and the progress of the pitocin.
[Note: I can only speak for myself here but what I do when I have a patient on pitocin is first and foremost to explain the process of titrating the pitocin and what the desired outcome is (and according to our hospital’s policy the desired outcome is moderate to strong contractions that are coming every 2-3 minutes, or 3-5 in a 10 minute period), as well as keep her informed throughout the process when I am increasing or decreasing the pitocin and for what reason. For example, I might say “It looks to me like you are contracting every 4 minutes. What is your pain level? Do you feel like you are getting an adequate break? Would you like to change position? I would like to increase to pitocin to achieve a more regular pattern. What do you think?” or “It looks like the baby continues to have variable decelerations in his heart rate despite all of the position changes we have tried. I am going to give you a small IV fluid bolus and turn the pitocin down some to see if it helps to resolve the decels. The baby’s variability is still very reassuring and she is still having accelerations so she is doing well. I just would like to keep her that way!” Your nurse should be keeping you “in the loop” so to speak and if she is not, it is your right to ask questions!]
It is also important to remember that that running pitocin is much more of an art than a science. Therefore you might think she is being “mean” if she is increasing your pitocin since you are only contracting every 6 minutes but remember, running the pitocin lower than is needed to cause cervical change isn’t going to help you either. No nurse wants her patient to end up in the OR for “failure to progress” because she didn’t turn the pitocin up enough. There is a happy medium somewhere that most nurses are trying to find. So please, know that sometimes, even if you really feel like those “every 6 minute” contractions are strong enough already, it is important for the nurse to titrate the medication to achieve an effective labor pattern that promotes a vaginal delivery with a healthy baby.
If your nurse is NOT doing these things then it is your right to ask questions!!! However, please remember for your own sake that when asking questions, one attracts more flies with honey than vinegar. Don’t start yelling at her or demanding a new nurse. Give her a chance and ask questions first! She might just be so busy that day that she is in the zone. Most nurses are happy to teach when asked!
#5 Learn about and practice non-pharmacological methods of pain relief as part of your childbirth preparation and consider not getting or postponing an epidural until all other methods of non-pharmacological pain relief have been exhausted.
Okay, I know that this one is a bit controversial but please here me out first.
It is the truth that pitocin contractions, especially when the pitocin is being abused, are typically stronger and longer than spontaneous labor contractions. Also, being that you have to be on continuous monitoring can also limit your movement and hence, one of your most effective and instinctual coping methods for the pain. For this reason, many people feel that it is crazy for a woman to go though a pitocin labor without an epidural. And when “Pit to Distress” is in play, it is truly unbearable to both experience and to witness. However, if pitocin is administered compassionately and appropriately it is important to know that an epidural is NOT an absolute necessity. I have seen many women do it without an epidural and many who have done it with an epidural. So if you have to be induced with pitocin and you desire an “unmedicated” birth, your hands aren’t completely tied. You CAN do it. However, I have said time and time again, I would rather a woman have a vaginal delivery with an epidural than a cesarean section without. That being said, the pitocin and epidural partnership has a dark side too.
While an epidural can help the woman relax and allow the pitocin to work more effectively, most birth attendants that practice “Pit to Distress” persuade and even bully their patients into getting an epidural specifically so the nurse can “crank the pit” without the woman objecting. But I would like to remind you that even if you can’t feel those contractions, your baby IS feeling them. Also, epidurals themselves CAN and DO cause fetal distress and anyone who tells you that epidurals pose no risk to the baby is being dishonest! At my work, we nickname this the “ten by ten”. That is, almost without fail, many women who get an epidural are is likely to experience a whopping fetal heart rate deceleration lasting approximatly ten minutes about ten minutes after she is put back to bed, which of course throws everyone into a tizzy.
All of a sudden mom finds herself with her face planted into the bed, her ass in the air, a mask of oxygen on her face, an anesthesiologist pushing adrenaline into her IV to increase her blood pressure and a doctor with his hands up her vagina screwing a monitor onto the baby’s head. Most babies do recover from said decel and go on to deliver vaginally. But it is NOT rare for the baby to NOT recover which lands mom…you know where….in the OR. And guess what! Since she already has that epidural in place, why they can just cut her open even faster!
Please know that I am not condemning any woman who requests an epidural in labor, especially if she is on pitocin. I just want all you women out there to know that sometimes that epidural that they keep waving in your face is just a way for them to shut you up so they can CRANK the pit.
#6 If you feel like you are contracting strongly at least every 2-3 minutes (3-5 in a 10 minute period) and the nurse or birth attendant desires to increase your pitocin, you might want to consider requesting a vaginal exam.
Now, I know limiting vaginal exams is very important to many women as they are invasive and uncomfortable/painful. I completely understand! However, if your care provider wants to increase the pitocin and you feel it is unnecessary, asking for a vaginal exam is a way to reveal if you are making any cervical change. If you ARE making cervical change then there is no real need to continue to go up on the pitocin! Remember the TRUE goal of pitocin administration is to stimulate an effective labor pattern that causes cervical change. It is NOT (despite how many birth attendants practice) just about getting a patient to “max pit.” Every woman is different!
Lastly,
#7 You could always try writing something about pitocin administration in your birth plan.
For example: “If deemed necessary, I would like to try non-pharmacological methods of labor augmentation and induction including (blank) first before resorting to pharmacological methods. However, if my birth attendant and I agree that pitocin will be administered to me, I request that the pitocin be administered following the “low dose” protocol and is increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.”
I will be very honest with you. If your birth attendant or hospital does not practice in this way, it is doubtful that this request will be granted. However, I suppose it can’t hurt and is worth a shot! At least it can provide a sympathetic nurse with another platform on which to argue with the birth attendant if necessary (like, “But Doctor X, your patient has specifically requested a low dose pit protocol!”)
This should be a last resort! Remember, writing something in your birth plan does not guarantee you it is going to happen if your birth attendant doesn’t practice that way! Please refer back to point #1 about choosing the RIGHT birth attendant for you!!!
All My Best,
NursingBirth