June 30th, 2010
There’s been a lot of talk lately about physicians responding to their ‘patients’ birth plans by providing a copy of their own written birth plans of what they will or will not do, allow, accommodate, or condone during a woman’s labor and birth. The Feminist Breeder and Stand and Deliver have written recently about the hullabaloo, as have The Unnecesarean and Crunchy Domestic Goddess. The following is an excerpt from an OB birth plan that was given to a pregnant nursing student during one of her prenatal visits. Just for fun I bolded the parts I thought were the most outlandish and offensive, or simply untrue.
DR. ________ “BIRTH PLAN”
As your obstetrician, it is my goal and responsibility to ensure your safety and your baby’s safety during your pregnancy, delivery, and the postpartum period… The following information should clarify my position and is meant to address some commonly asked questions…
* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines…. Please note that I do not accept the Bradley Birth Plan.
* IV access during labor is mandatory.
* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion… Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.
* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.
* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It als
o provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.
* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby.
* I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor. Contrary to many outdated beliefs, inducing labor, when done appropriately and at the right time, is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section.
* Compared to the national average, I have a very low c-section rate… The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.
Whatever happened to ‘patient rights,’ you might be wondering? We still have them. Women birthing in the hospital may pass by the “Patient’s Rights and Responsibilities” document posted in the hallway, which they are sure to absorb between contractions on their way to their labor room. And in case you weren’t sure, the American Medical Association does in fact publicly acknowledge patient rights as well. Locating an ACOG public declaration of patient’s rights was much more challenging, hence no link, but I will keep looking.
Doctors are legally required to provide care to patients with whom they have an established, preexisting relationship. During labor and birth, you have the legal right to evaluate proposed procedures and treatments before they are done to you. You have the right to refuse a procedure or treatment. The trouble begins when your care provider perceives your wishes as a threat to their comfort level, your safety, or the safety of your baby; you have the right to push your baby out in a hands and knees position, but your doctor is worried s/he won’t be able to ‘deliver’ the baby safely (or comfortably) that way.
This kaleidoscope of ethical, legal, and clinical considerations comes up for all care providers at some time or another — and to be fair it’s enough to make a hospital provider’s head spin. How many double-binds can a doctor or midwife be in simultaneously, and with multiple laboring women? ACOG even published a guide to ethical decision-making for OB/GYNs to better navigate these circumstances in a professional, legal, and moral manner. Unfortunately in cases where ‘competing interests’ exist between birthing women, care provider, and hospital, women’s autonomy is often sacrificed in favor of provider protocols and liability concerns: I can’t deliver the baby on the birth stool because it is too far from the warmer, or the bed, or I’ll have to get on the floor…
Where does that leave women who want or need to give birth in the hospital? Should they just accept a labor and birth challenged by competing interests? No. There is a massive, beautiful, inspired, smart, powerful childbirth movement in full force. Women of all ages, races and political persuasions are reclaiming their authority and demanding humane, dignified, safe, family-centered care.
On an individual level this reclaiming involves being clear about our role in the ‘doctor-patient’ dynamic. When a woman initiates prenatal care with a physician or midwife she is, in essence, hiring that person or practice to provide her maternity care. Not all women have a choice in care providers, but women residing in areas with a multitude of care providers, including family practice doctors, nurse-midwives and out-of-hospital midwives are exercising their freedom of choice by choosing to enter into a relationship with a care provider who practices within a certain model of care. In the US, most hospital-based providers practice in accordance with the medical model of maternity care whose ideology and protocols evolved to serve the beliefs, understanding, knowledge base, and values of physicians and hospitals.
Enter the ‘You Will and You Won’t’ lists of the physician birth plans. Finally some transparency! A few lucky women are being told, before their labor and birth, precisely what their provider’s standard protocols are. No more trying to call your provider’s bluff! This transparency affords women the freedom to move beyond the ‘unknowing victim’ role and into a position of awareness, autonomy, and ownership. I think all physicians and midwives alike should offer these birth plans to their clients — they are the perfect tool for transforming the status quo in maternity care! This is exactly where we need to be to usher in the next wave of birth change.