Monday 25 September 2017

The Dos and Don'ts of writing a birth plan, according to a top Irish obstetrician

Are birth plans a hindrance or are they a help? Tara Corristine reports

Birth Plan
Birth Plan

Making a plan

Pregnancy can be a confusing time: masses of information and unfamiliar medical terms are presented to us at every turn. So a birth plan may seem like a way of regaining a modicum of control over our labour - but are we instead telling the experts how to do their job or, worse, tying their hands?

A birth plan, a document that you share with your obstetrician and midwife, details what you would like to happen during your labour. Many websites offer a template, and antenatal classes and hospital guides often encourage mums-to-be to put pen to paper. But is a birth plan really necessary?

Professor Mary Higgins, consultant obstetrician at the National Maternity Hospital, points out that if you are happy with all of the education you have received from your midwife or obstetrician, then writing a birth plan isn't necessary. However, if there are particular preferences, a birth plan is a good way of opening a dialogue while there is still time to address any issues.

"It's definitely useful. We need to sit and talk to people about their expectations before they come in, in labour, in pain and in distress, because you don't want to stress them more when they are saying they want a water birth and we don't offer that. People can share what they would like and we can let them know what is realistic and the advice I would give them. Hypnotherapy? It's great and we can match you with a midwife who has been trained in hypnotherapy."

Where confusion arises are birth plans from American websites that mention procedures that aren't practised in Ireland. "People will often get birth plans from the internet, and they read stuff that's happening in the States that we just don't do. They will write: 'I really don't want to have an enema.' I have never in my entire career given someone an enema - we don't do that anymore; that went out with the ark. Or they will write that they don't want to be shaved. I don't shave someone unless they have to have a caesarean section where you are operating in the hairline and you want to get hair out of the way because there is a risk of infection. It seems as if there is a mismatch of the information - you're getting a very unrealistic idea of what we do."

Birth plans often list processes that happen as standard in labour, such as skin-to-skin contact when the baby is born. "Everybody gets that: you don't have to write that down. Of course, there is a qualifier that if the baby isn't coping with transitioning to life outside the womb, you will need your baby looked at by a paediatrician, so we won't be able to do skin to skin."

But a birth plan can be useful where there are salient details from the current or a past pregnancy that should be shared. A previous caesarean section means that the mother will need to wear a heart monitor when in labour, which can limit her options. "We need to monitor the baby's heart rate all the way through. The worry is the scar on the uterus from the previous section could break down and the first sign of this is the baby going into distress. It's very rare but if it does happen, we need to know early so we need to monitor the heart rate all the way through. People will often object to that, as they don't want to be tied to the bed, so we have wireless monitors so you can be on your ball or birthing stool, but you can't be in the pool."

Pelvic girdle pain is a good example of an issue to be shared with your medical team, as it can limit the range of motion available and may reduce the positions during labour that mothers can manage. "Where a woman has had previous problems with PGP, we have to be careful with her hips - that's really important to know."

Management of pain relief is another topic birth plans cover and, here, Professor Higgins' advice is to remain open-minded and flexible when putting pen to paper. "We have noticed that people will say, 'I don't want to have an epidural,' and if you write that, and if you change your mind, that's a very difficult position. You are saying, 'I do not give consent to this procedure,' and now when you are upset, you're changing your mind. There have been anaesthetists who have said, 'I am not going to put the epidural in - it's an elective procedure, you don't have to have it and you have told me, "I don't want to have an epidural.''' Do you really want to tie yourself into saying, 'I don't want this?' Rather, say, 'I prefer not to, but I realise I may need to.'"

Where labour is slow, oxytocin can be administered, which can make contractions stronger and more regular, and is another area where Professor Higgins cautions against writing a birth plan of absolutes. "People will say, 'I don't want to be speeded up in labour,' but if you are at two centimetres for six hours, at that rate you will be in labour for three days. We can ask if they want a hand, and most people will say yes."

The area of assisted delivery can be an immovable point for many women, and understandably so given the unfamiliar language and unpalatable explanations. An assisted delivery is where a vacuum device (ventouse) or forceps is used to help the baby out of the birth canal and is recommended where the mother may be tired from pushing for a long time, or if the baby is almost out but the heart rate has become a worry. But the alternative may mean undertaking unnecessary measures. "Who would want a forceps? But if you're pushing and your baby's heart rate drops and we could deliver your baby by forceps in three minutes versus: you've told me you don't want to have forceps, which means I am in a difficult position if I do this. You're now saying I have to do an emergency caesarean section, which can take up to half an hour to do, half an hour that your baby is in distress."

Another no-no for many women is an episiotomy - a small cut in the tissue between the vagina and the anus that is often needed with a forceps or ventouse delivery. It is another procedure doctors will only perform where necessary - and when the alternative is a tear into the back passage, this is one point worth being flexible on.

While some women rail against the idea of a caesarean section, others may actively prefer it, for many reasons, including anxiety about giving birth. An open, honest discussion with your doctor and midwife can allay those fears and, where possible, allow them to put procedures in place that can make the birth experience a positive one.

For those women keen to have a vaginal birth, ticking the 'no' box against the caesarean section is a given. But there are instances where it is the only option, either in unplanned circumstances where labour isn't progressing or the baby is in distress, or as an elective procedure - if the baby is breech, if there is pre-eclampsia (pregnancy- related high blood pressure), or if the placenta is low-lying. "If someone is having a planned caesarean section, we would send them to classes specific to them, as they are going to have a very different birth experience to a woman who has a natural birth. You want them to have targeted education."

While the big work may be over, the third stage of labour can generate its own preferences, ranging from preserving the placenta to delayed cord clamping. Placenta encapsulation is growing in popularity here, with advocates saying it can boost milk supply and energy levels, and ease the baby blues. This is an issue worth noting on a potential birth plan and discussing with your medical team, as it may require the placenta to be treated in a specific manner such as birthed onto a clean sheet, stored in a cool box or frozen.

Delayed cord clamping is where you wait a minute or two to allow the baby to benefit from the blood in the placenta. "Some patients will ask us to delay cutting the cord until it stops pulsating," says Professor Higgins, "and that could take three or four minutes, sometime up to 10. But it has been shown that the longer you leave it, the more blood the baby will get, and there is a higher rate of jaundice. The result is that the baby is more likely to need phototherapy, and is separated from Mum, and that's not what anyone wants. So it is recommended that if you are going to delay cord clamping, do it for a minute or two - you get all the benefits and none of the problems, and most people will agree that makes sense."

So, ultimately, speaking to the professionals involved, sharing any worries or fears and remaining open-minded and flexible when presented with their advice is the key to creating a birth plan that works for all parties.

Irish Independent

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