Birth Plans

Mention that you have a birth plan and most people who work in Labor and Delivery or Neonatology will cringe. It's mainly because we have all seen parents cling to their birth plan when we thought that it went against the baby's best interest. I guess in a way the birth plan alerts us that a parent will only be upset if things do not go as expected. See the birth plan presumes a healthy, uncomplicated delivery, that everything will go as planned. And well those of us who work in a Neonatal Unit live in a world where that rarely happens. Remember I am only called to the delivery of infants when something is going wrong.

Some medical people hate birth plans because they immediately presume that the family will be needy. I differ here. I must confess, I do not cringe when I hear that a parent has a birth plan. In fact, I think that when the delivery is uncomplicated, that they are great. The birth plan tells me that this family has put a lot of thought in to how they want this special moment in their life to unfold. To me, a birth plan is written with love. And I will always do my best to honor a birth plan. But once the baby is at risk, well... I throw the plan out the window. Because all of us who had older sisters with bad relationships know that love can be blind and does not always lead us down the right path. I would rather that a parent take a healthy baby home and be a little angry that I did not follow the plan.

So I was not at this delivery, but a close friend of mine was. The mother and father were very specific in their plan. They did not want any drugs used during labor. They did not want their infant to have chemicals in her when she was born. They want a vaginal delivery and for the baby to be placed to breast within one minute of birth. They did not want antibiotic creams in the eyes and they did not want a Vitamin K injection. They were young (twenties), educated, attractive and had private insurance. From the outside, it appeared that life was unfolding easily for them.

They parents also have an Obstetrician who wants them to have the experience they want. So when the labor stalls, the OB does not encourage the use of pitocin (a medication that stimulates labor). Instead he waits. He let the young woman push for over three hours. The infant is not being traced with a scalp monitor because the family does not want invasive monitoring. Instead a belt around the mother's stomach is used to monitor the heart rate. It is not uncommon for the belt to "lose" the baby's heart rate for several minutes at a time or pick up the mother's heart rate by mistake and give a false sense of fetal well being. The infant begins to have serious dips in the heart rate after one hour of pushing. The dips are starting to get longer and take more time to recover. Recovery is when the heart rate has returned to its pre-contraction rate, referred to as baseline and typically 120 to 160 beats per minute. One might think that a woman would never have a heart rate of 150, but during labor this often occurs.

The decelerations tell me that the infant is stressed. During the contractions the oxygen level dips and the heart rate follows. The fact that it takes longer for the heart rate to recover tells me that the time of hypoxia is becoming greater. My friend suggested a cesarean section and was quickly dismissed. This is not a Neonatologist's call (cop out). Okay, it is not my expertise (this is the truth). The Obstetrician has years of experience with laboring mothers that I d0 not. The Obstetrician has two patients and must consider both the health of the baby and the health of the mother. However one thing that I am certain of is that if this mother had walked in off the street, had medicaid and no relationshiop with the Obstetrician, she would have been sectioned two hours ago.

The baby was born vaginally after three hours of pushing. She was bruised, had a slow heart rate, was not moving or breathing and her color was grey. My friend placed a mask over the baby's face and immediately started giving oxygen. She began to pump the oxygen bag to force air into the lungs. The baby was still grey and not moving. At this time a minute had passed and the father came over to my friend and asked if his daughter could go to the mother's breast. My friend tells the father that his daughter was not breathing and that she needed to give the baby oxygen. And that she'll bring her to mom when she was doing better. The baby did not go to the mother's breast. She went to the intensive care unit. The father doesn't really understand, but the first flicker crosses his consciousness that something could go wrong. Could? Had.

The little girl ended up on a ventilator because she wouldn't breathe and she started to have seizures that were difficult to control. She was on high doses of Phenobarbital (anti-seizure medication), antibiotics and blood pressure medications. The following day I stood at the bedside with the father. She was a beautiful baby. Everything perfectly formed and developed. The father was heartbroken and sick. He looked at me. It's crazy he said. My wife didn't even take pain medications because we wanted everything in the baby's system to be natural and now you guys are giving her all these powerful medications. I share a sliver of his sadness. I say a sliver because I can never really know how he feels. I hope to never feel what he was feeling.

Many people blame the birth plan but I blame the medical system and the Obstetrician. As physicians we have abducated our position of authority. Birth plans are created for healthy, full term infants in the midst of an uncomplicated delivery. But plans must be flexible and must place the health of the infant first. As physicians and nurses who work in perinatology, we need to educate parents and risk losing friends in order to do what we know is best.

I think that every prospective parent should give thought to how they want their baby's birth to unfold. And that a birth plan is a good idea. But the first line should read: At the first sign of trouble tear this up and do whatever is necessary to preserve the health of my baby.