#5 Birth Plans: Ticket to the OR

Sarah Lavonne:

We need to have a conversation about birth plans.

Justine:

Oh, do we.

Sarah Lavonne:

Slash, what I would like to say, “birth preferences.” Because I think there’s a lot of stigma, there’s a lot of back and forth. There was just, somewhat recently, a letter that went out from a certain medical group in New York City that said, “If you have a birth plan, not cool,” and created a whole lot of viral upset in the birth world. If you saw that, you can find that elsewhere. But I think it’s a good prompting for us to have a conversation about birth plans. Let’s talk about perspective. I know that you’ve thrown up some IG polls, and we still have lots of people across the spectrum, when they are in the safety of that little IG box, to say,

Justine:

We love the honesty.

Sarah Lavonne:

… “Yeah, I kind of hate them.” No, yeah. Please be honest. And we’re not looking at who says what.

Justine:

No.

Sarah Lavonne:

On those, it’s just helpful to have that perspective. And so I think, as much as to me, the shift in perspective, the shift in culture surrounding birth plans is moving forward towards a more accepting acceptance of birth plans, I think it’s important for us to have a little, quick conversation and prompt your thinking and spark your brains to consider, how do you feel about it? When a patient comes in with a six-page birth plan, do you roll your eyes? Do you say, “Ugh, she’s not going to have anything right,” or, “Ugh, she’s going to be difficult,” or “Ugh, she must have really high anxiety”? Right? A six page birth plan; I’m going to go, “Hmm. What’s going on here?” Right. That’s going to be a prompt to me. Instead of judging and writing their story, which is one of the things we say around here as well, “Don’t write their story.” That instead of writing their story go, “Hmm. Curious.” Be curious, not judgemental. Right? Isn’t that a Ted Lasso? My dad’s obsessed.

Justine:

I’m obsessed too, but I don’t know. I think that is one.

Sarah Lavonne:

I think it’s a Ted Lasso. Yeah. I feel- very proud of myself because I never quote TV. So, I feel very proud. My dad would be proud. So, be curious, not judgemental. And if the quote is wrong, I apologize. And so-

Justine:

And now, that’s a new Sarah Lavonne quote.

Sarah Lavonne:

If it’s not a Ted lasso, it’s a Sarah Lavonne. When we talk about birth plans, I think it’s important to understand both sides about why someone might be hesitant about birth plans. What’s the issue? And if you’re a patient listening to this, you can get the insider scoop about how a bunch of L&D nurses feel about birth plans.

Justine:

Well, I think, and you probably had a similar case when you were oriented to the unit and birth plans were brought up like it’s the ticket to the OR. It’s just a generalized feeling. And I never really understood it, but looking back, I guess I kind of get it, if there’s so many restrictions on the care that we can give. Nurses might think, well, they won’t let us start pit, so they had a C-section. They won’t let you get an AROM, so they had a C-section. But it’s such a generalization.

Sarah Lavonne:

Well, and I remember learning… I can picture this nurse at my very first nursing job. I was new and just like a sponge and, “Tell me all the things. Okay, great.” And a patient came in with a birth plan, and they were, “Ugh, okay. So here’s the problem with birth plans.” And they went on this whole rant, which is an alert to all of us that, for young, impressionable, new nurses, that are opinions are influential. And I remember rolling my eyes, just not having thought about it myself, to birth plans that came in. And I think there’s the component of, “Oh, I don’t want Pitocin. I want no medical interventions on this birth plan.” So then you throw your hands in the air, and you go, “Ticket it to the OR,” and then you give up on the patient. And you say, “Well, she doesn’t want this, and she needs that. And therefore, she’s going to have a C- section.” You know?

Sarah Lavonne:

And so, I think, first of all, this is an alert to all of us to assess our bias. And that could be our bias about a whole lot of things, but particularly related to birth plans. What do you think about it? And you can comment down below and let us know, how were you trained about it? What do you currently think? And what would you need to understand to have any kind of a different perspective?

Sarah Lavonne:

Because I have shifted in my perspective, over the years. And especially having worked with patients in the outpatient setting now, prior to their births, I think birth plans can be a super effective tool in helping initiate conversations. But to me, part of the problem with birth plans is that, if we’re working through the old perspective and the old culture that we’re trying to change, it’s, “They ask too many questions.” That it’s that same perspective of, “Well, they shouldn’t. I’m just going to tell them what to do. And if they have a strong perspective about, say, pit, “I don’t want Pitocin,” what do we do as providers? “Well, what if this? What if this? What if this? Well then…” fill in the blank

Justine:

Why did they even come to the hospital?

Sarah Lavonne:

Right, right.

Justine:

I think too, it’s kind of interesting that labor nurses, if you’re going to go give birth to a baby, I would bet the majority of us would have a plan. We know what we want.

Sarah Lavonne:

One million percent.

Sarah Lavonne:

Oh, I’d be the worst patient ever.

Justine:

We’ve called the off-duty anesthesiologist to come in, the day we’re going to be there. We know what nurses. And so, maybe we didn’t have it written down, but we have a plan.

Sarah Lavonne:

Right. And we know what we want, and we know what we don’t want. We know who we want in the room, who we don’t want in the room.

Justine:

Exactly.

Sarah Lavonne:

That’s a birth plan.

Justine:

We know what room we want.

Sarah Lavonne:

Yeah.

Justine:

We don’t want that room. That room’s cursed. We want this room.

Sarah Lavonne:

Yes. Exactly. Exactly. So, I think we need to remove it from the paper and think bigger picture here, that from a patient perspective… I had a really interesting conversation with one of my nursing friends, who’s maybe not the most in love with labor and delivery. She’s been around for a while. Justine’s smiling because she knows exactly who this person is. She is the classic, “I hate my job. I am traumatized by work. Ugh. I never care if I see a birth again.” Right? And from her perspective, she actually said, “I was thinking about it the other day. And if I was a patient, if I came in with my birth plan, I feel like it would be showing that I did my homework. ‘Here you go, provider. Look, I did the work. I thought about what I wanted.’ But then you walk in, and you get, ‘Ugh, birth plan,’ or, ‘Ugh, none of that’s going to happen. None of this is realistic.’ Or, ‘Oh yeah, that’s fine.'”

Sarah Lavonne:

And I think that’s the other piece. That you look through the quote, unquote “normal birth plan” that you’re, “Yeah, it’s everything we do.” You’re, “Oh yeah. Yeah, I’ll just set this aside. This is just what we do,” versus acknowledging the patient to say, “Look at what you did. Amazing. You thought about this stuff.” And it’s sort of an alert too, that they’ve done some work prior. That she even said for herself that, “I would be so bummed if somebody was, ‘Ugh, poo-poo on my homework.’ That, ‘I did my job, what I thought I knew what to do.'”

Justine:

That’s so true. I love that she had that realization. But I think too, on the flip side of that, we get annoyed at patients that don’t do any of the work. Like, “You haven’t done one class?”

Sarah Lavonne:

That’s such a good point.

Justine:

Right? So, where’s the happy medium? They’ve done all the work, but they didn’t write it down. They’ve done all the work, but they don’t have any preferences.

Sarah Lavonne:

Right.

Justine:

Which one do we want?

Sarah Lavonne:

Right. Do you want them coming in educated and knowing how they feel about certain things? Because really, that’s all it is. It is a tool and a communication tool between them, so they don’t have to remember. Think about how hard it is for us to remember all the medical terminology or this entirely new obstetric language, where they’re saying, “Oh, okay. When I’m learning about azithromycin eye ointment, I learned about it. I can’t remember what it’s called; the goopy stuff in their eye. And so, I’m going to write it down when it’s fresh in my mind and say, ‘Yeah, I feel cool about that.'” Or the hepatitis B vaccine or skin to skin. “I learned about skin to skin. Ooh, that sounds so delicious.” Right? That I know about that. And I can go through in a practical way and share with you that I did the education and then my feelings about it.

Justine:

Curious, I’m going to be a little devil’s advocate here.

Sarah Lavonne:

Great.

Justine:

What about the birth plan that’s going around? And I have a copy of it in my phone, but I don’t know where they get it from. But it’s been going around of the, “My rights over my birth.” And it says, “Legal Notice on the top.” And it looks like a contract. And it says things like, “I will not allow any hospital employee to deny me my right to…” And it is pages. Pages long. But some of the examples are, “A support person,” “To labor in the way I want to,” “A spontaneous labor,” “To record my labor in birth,” “To refuse any unnecessary Cesarean.” That you cannot deny a gentle Cesarean birth. Which, if anyone doesn’t know, a gentle Cesarean would be skin to skin after. And that’s a lot of pressure

Sarah Lavonne:

But is that pulling the baby out on a sterile field?

Justine:

It doesn’t say. And it even says, like here, “They cannot deny me my right to leave the hospital and take my baby home if there’s no medical issues present-

Sarah Lavonne:

Wow.

Justine:

… as this is considered kidnapping and is also a crime, according to the-

Sarah Lavonne:

Oh my gosh.

Justine:

This one’s from North Carolina Common Law False Imprisonment. It’s very, very scary-looking.

Sarah Lavonne:

Intense.

Justine:

Okay?

Sarah Lavonne:

Yeah.

Justine:

And so, my encouragement… I know maybe some people are listening to this have had this come around, and it’s been going around, could be opposition from the nurse perspective. But I think, as what you said earlier, if I got this in my hand, first of all, I know it exists. But I would be, “All right, I have to be better,” in the sense of I would have to put on my A game to build so much trust and so much rapport because there’s something that happened that made this patient feel like they needed this legal document to come to the hospital.

Justine:

And whether it was to them or their loved ones, something happened. They didn’t just print this off saying, “Oh, this looks nice.” That there was a reason.

Sarah Lavonne:

Right.

Justine:

And so, I think that we put on our little detective hats as nurses, and we have to figure out, how can we do the best for them, without being scared of the ramifications of this document? Without taking it to every single person on the unit and being, “Look at this,” in a way that just fuels the fire of, “This is not okay,” when in fact it’s a birth plan. It’s just a very-

Sarah Lavonne:

Yikes.

Justine:

… intense one.

Sarah Lavonne:

I’m scared of this birth plan.

Justine:

Yeah. And I think that’s normal and totally understandable. And it’s just remembering to not write their story.

Sarah Lavonne:

It’s the idea that we don’t know why, but I’m sure that they have a good reason for it. I did not make that one up. I don’t remember where it came from. But I love it because it goes back to that, “Don’t write their story.” And we’re not entitled to their story. Right? But just like you said, if this comes in, there is fear of the hospital system. They have been told, or they have experienced some sort of fill in the blank. And again, I don’t want to write their story, but it could be, for the sake of this episode, that it could be abuse. It could be assault. It could be a really poor outcome, experience, whatever, whatever in the hospital system that affected them so deeply that they feel like they need to be this strong in their preferences and alert their care team this much that they’re watching.

Sarah Lavonne:

And like I said, I would be very intimidated by this birth plan. And I would feel like I’m going to get sued any second. Now, the reality of this birth plan is that they are asking for the same thing. So I think it’s easy to see something like this and go, “Oh my God. I am so overwhelmed. I’m going to get sued any second. I’m going to do something wrong.” And that’s, like you said, to me, my first alert would be, I’m going to work very hard to build rapport. I’m going to work very hard to go out of my way with consent and giving so much control in their hands. And let’s be honest, continue to offer the exact same care that hopefully you’re offering every other patient, knowing that this patient has some sort of story in their background where there is mistrust of the medical system.

Sarah Lavonne:

Now, I would still go through every component and say, “Okay, in the case of a Cesarean, is your preference a gentle Cesarean?” And to me, when we’re talking birth plans, there’s very intentional language that we can use that, “These are your preferences.” On my template that I have on my site for patients, it’s birth “preferences,” not “plans.” We know that we can plan all we want, but it doesn’t always go that way. That’s why I say “flex and flow.” But our preferences can be shared.

Sarah Lavonne:

And so I would ask that, you as my care team, would do everything you can to respect my preferences and help me safely accomplish the preferences that I have here.

Justine:

Yeah.

Sarah Lavonne:

Right? And our responsibility is to, first of all, respect them, understand what they want, and pursue their preferences. Right? Just like you, as a nurse. I love that comparison that if I want to be in room five, and I come in in labor, guess what? Everybody on the unit, because they love you and you’re a staff, they’re going to do everything they can to try to help you get in room five. And so, are we providing the same type of care and respect of the preferences to every patient in that way?

Sarah Lavonne:

I think that that is what they deserve. Now, when we’re starting to risk safety, that’s where my nurse brain goes of, “Okay, but they’re refusing a Cesarean at all costs. Maybe it is important to know what your labor laws say.” Or not labor laws. “What your laws say about who they prioritize based on state.”

Justine:

Right. And by “prioritize,” do they prioritize the mother, the birthing person, or do they prioritize the child’s life?

Sarah Lavonne:

Right.

Justine:

And that will differ.

Sarah Lavonne:

In California, there’s a priority of the mom or the birthing person. And they get to choose that, if they refuse a Cesarean, you better listen. And if it results in a demise of the baby, then it does.

Justine:

That’s their right.

Sarah Lavonne:

They have all right. They do so. But that’s state by state.

Justine:

So, I would to challenge nurses listening to this, that are rolling their eyes at the beginning of it. And are, “Ugh, I still hate them” to maybe approach them differently. Being more open to them. Thinking of them as preferences than a solid plan. Birth plans, I would say, are not black and white. Right? They would be gray. And maybe thinking of it like that, educating in that way. But also, Sarah…

Sarah Lavonne:

What?

Justine:

You said a quote that I’ve always liked that I’m going to share that when you’re explaining birth plans and going over, say the patient says she doesn’t want Pitocin. And that’s it. “I don’t want Pitocin.” And you ask them, “Can you tell me what you know about Pitocin?” And you say the thing of, “I want you to refuse out of a place of knowledge, not a place of fear.” And I think that’s a great line. And do you want to elaborate a little bit on that?

Sarah Lavonne:

Yeah. I think that we have to understand that patients can refuse anything. And that goes back into that legal document. Can they even say this? Yeah, they can. And it’s important for us to know, what are the patient rights? We talk about that in the first month of mentorship, right? I have an entire YouTube video on this, for patients to understand that they are not fully out of control. That this is their labor birth experience. That they are responsible for every single decision that they make. Mind you, when a patient is refusing something, something in me or-

Justine:

I’m going to challenge you. “Declining” something.

Sarah Lavonne:

Thank you. Fair. When a patient is declining an intervention, or they have opposition to an intervention, or there’s resistance to something that is being suggested at the bedside, that it is our responsibility, as the medical provider, to assure that they understand what they’re declining. And not just, “Uh, fine. They’re that patient.” Right? That our obligation to the patient, in a shared decision-making sense, is that they fully understand the decision that they’re making.

Sarah Lavonne:

And so, what’s our job as nurses? Is nursing education. And if the information has not been initially given by the provider, then our job is advocacy, to get the provider in there and say, “Hey, this patient is declining this. Do you want to come in and explain why we’re making this suggestion?” And when you’re talking to the patient, it’s, “No problem. I want to hear all about that. And I really would love to understand why you’re hesitant about this, or why you’re declining this.” Fill in the blank whatever the scenario is. “My job as your provider is to assure that you are making safe decisions out of education and not fear.”

Sarah Lavonne:

So, first and foremost, this goes into our patient education on mentorship: I give an acronym ATV, where you Assess, Teach and Verify. And so, the first assessment tool is: “Help me understand why you’re hesitant about an epidural,” Pitocin, AROM, whatever it is. Fill in the blank. And then you listen. And you actually listen to understand. And you’re not listening to convince because they will scope that out so quickly. It’s, “Oh, interesting. Okay. So, what I’m hearing is that you believe, or you’ve heard the education stated, that once you get an epidural, it’s a ticket to the OR. That that is going to lead to a C-section. Would you be open to some perspective based on my experience and my expertise? No? Okay.”

Sarah Lavonne:

Most of the time, that’s not going to be what’s said. What’s going to be said is, “Sure. I’ll listen.” Right? “And I’m just telling you. And the reason why I want to explain this is because I don’t want you to look back with regret on your labor. And in this circumstance, your medical team is making this recommendation because we believe it will be beneficial to you in this way. Ultimately your decision, and I want you to feel confident in the decision that you make without looking back, going, ‘Hmm. I wish I would’ve done something different.'” Explain the rationale, blah, blah, blah.

Sarah Lavonne:

“This is why we’re making that suggestion. What questions do you have? What concerns do you have? I noticed that furrowed brow. Tell me more about that. And how do you feel about it? Do you want a second to talk with your support team about it? We don’t have to make that decision right now. Just think about it. That’s it. We’re going to hang out. We’re doing what we’re doing. There is no rush in this circumstance.” Blah, blah, blah. “And I know this is really important to you. And so, maybe we could bring the doctor back in and discuss some other options.”

Sarah Lavonne:

Because we’re never giving alternatives, as nurses. That’s really hard not to do when we know there are likely alternatives or other options. But, “Why don’t I call the provider back in here? Would it be helpful if I called the provider back in here to discuss” X, Y, Z, “or see if there might be some other options?”

Justine:

Or get them on the phone, if you don’t have providers in house.

Sarah Lavonne:

Yeah, fair.

Justine:

Yep. I think too, doing it that way, Sarah, there are some interventions that they tell me their reasoning why; I’m, “Yeah. You know what? You’re right.” I’m thinking about they don’t want an FSC. And they talk to me about why. Or they don’t want a hep B vaccination. And I think we initially sometimes see these, “No hep B.” “What do you mean?” Then you talk to them, and they’re, “Well, I really want to do it at my first peds appointment.” Or, “I’m doing a different timeline. I’m doing all of them just differently.” So, it’s nice to dig a little more. And then you just feel better about the care you’re giving too. And you learn as a nurse.

Sarah Lavonne:

Exactly. And I think that, very often, we’re used to seeing things a certain way. And so, when it’s just different, I think a lot of times we’re uncomfortable with different. One of the things I grew up saying, because I grew up overseas, was “It’s not right, it’s not wrong, it’s just different.” And so often, I think, in labor and delivery, that’s actually a reasonable thing to say, because we’re not like… Obviously, if there’s an emergency C-section, you have a prolonged decel, the heart rate’s in the thirties, the right answer probably is to move to the back. Right? For safety’s sake. But if we’re talking give a hep B vaccine right now or 24 hours from now; it’s not right, it’s not wrong, it’s just different. You know? And so, even using that as a frame of reference or a lens to look through. I feel like we got off topic, but it all comes back to birth plans and preferences.

Sarah Lavonne:

That the question then is, for us to assess: is it okay that our patients come in with preferences? And in order to have preferences, they should have done some education. And if we’re weighing the two, does it feel better that they’ve done the education and come in with some preferences that we may or may not be able to accommodate? Yeah. And I think part of the art of being an expert labor and delivery nurse is the art of that interpersonal communication and patient education. And having some of these quote, unquote “tough conversations,” that to me, don’t have to be tough if we’re not approaching them in a defensive way, where it’s, “Well, but…” It’s, “Okay.” I’m open, I’m soft, I’m slow. I sit down. My body language is relaxed. Of, “I would love to understand why that’s important to you.” And leave it at that.

Sarah Lavonne:

That we’re curious, not judgemental. And that we’re actually seeking to understand our patients and then fill in the gaps of their education so that they can make educated, not fearful, decisions. And so that we can still, at the same time, respect their preferences and help them have the birth that they really dream of.

Justine:

Thank you for spending time with us here during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us if you subscribe, rate, or leave a raving review and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram. Now, it’s your turn to take what you learned today, apply it to your life, giving honorable, open care to every single patient you care for. See you next time on Happy Hour with Bundle Birth Nurses.