Ask Nurse Stewgler: The thing about birth plans

These days, the question you hear most as a pregnant woman is, "Have you written your birth plan?". Sure, folks still ask about your due date and strangers on the street will inquire about the gender of your unborn one, but those old school inquiries seem to take a back seat to the birth plan.

I'm sure my sense of this is skewed. I work at a busy Manhattan hospital where the well-heeled patients check their blackberries between contractions. They've planned every aspect of their lives to the Nth degree -- of course they'd turn up with a birth plan. As we gain more and more control over our fertility, we seek more and more to control the birth experience too. It all goes hand and hand, I guess.

I really appreciate the spirit in which the birth plan is intended. I feel strongly that if more people exerted demands over their health care, our system would serve us all better. It is dangerous to put yourself lock stock and barrel into the hands of your health care provider -- we should never abdicate that much control over our own bodies. A birth plan is evidence that this person has done research about what to expect from her hospital stay -- a great sign!

But here's what I've come to know about birth plans -- they almost always come to naught. The folks who arrive on L & D with a three page type-written list of all of the medical interventions they refuse to consider, seem to always end up in hysterics when the reality of birth starts to diverge from their plan. It's so sad to see those folks wasting emotion and energy lamenting the loss of their birth plan.

I tell people that the experience of childbirth is a lot like parenting. You can organize and plan all you want, but when the kid has a melt down in the middle of the perfect day you planned you'll just have to roll with the punches and work around it. Childbirth is the same way.

When I'm at work, I take birth plans seriously. I make time to read them and talk about them with the patients. I ask questions about the motivation behind each request or decision and I try, when necessary, to point out places where their requests run afoul of hospital policy or state mandates for patient care. Mostly though I try to prepare folks for possible forks in the road right from the start.

For example, a common statement on your average birth plan is this, "I want the baby placed immediately on my chest with as much skin to skin contact as possible." No problem. That's pretty much standard operating procedure -- even the seriously old school docs will put the baby directly on mom's chest. But, if in the midst of labor we find that there's meconium in the amniotic fluid, the baby will first be taken to the warmer first to have his airway suctioned out (if the baby aspirates meconium it can lead, in some cases, to pneumonia so we want to get as much out as possible). I think it helps to explain this early on so if it happens folks are prepared.

I think this is the best possible scenario -- an educated consumer and a health care provider having a dialog. If everyone considered their birth plan as nothing more than a conversation starter, we'd be OK. Things go wrong when folks expect that their birth plan is a set of demands etched in marble.

Before I became a L & D nurse I took part in a three day doula training course just to get some experience in the non-medical aspects of birth. On day two we broke into pairs to go through a birth preferences exercise. We were given about 20 cards -- each one had an option on either side of the card. They said things like hospital birth/home birth, pain medication/unmedicated birth, access to food & drink during labor/ice chips only during labor. There was even a card that said "Healthy mommy & baby" (there was nothing on the other side of that one).

The idea was that you would ask the pregnant woman to go through and turn each card to the side that reflected her preferences for the birth experience that she imagined. Once she'd made her choices, you'd ask her to flip five cards over to the other side. There were plenty of things that seemed like no big deal -- you could flip over five without "losing" much. Then, you'd ask her to flip over five more, and then three more after that. By the end she'd be left with her four or five absolute stone wall resolutions for her birth experience.

That's reality folks. Even if you're CERTAIN that you won't consider anything other than the details on your birth plan, you might change your mind when the going gets tough. Every person is different and every birth is different -- there's just no predicting how it's going to go.

So by all means, write your birth plan. Talk about it to strangers on the bus. Have the small of your back tattooed with "NO epidural". But when you do, please save yourself and your providers some grief by softening your language -- "I would prefer..." rather than "I refuse...". Once it's written, ask yourself if it sounds like a dictum that might court ire from your providers or a polite set of talking points that will inspire collaboration. Remember that the medical establishment is not out to thwart your ideals, they work hard to see that you are happy with your care. But in the end, they care only that mom and baby are healthy.

So remember that you can't control a force of nature. Be prepared to roll with the punches. Keep in mind that when it's over no one on the subway will ask how close your actual birth experience came to your birth plan. They will ask how you feel and they will coo over your gorgeous little one. And that, my friends, are the only two things that matter.