It happened again last week. I shredded my patients carefully thought out birth plan. I didn’t literally shred the two page birth plan, but rather destroyed what she had planned for her birth experience. And at the end we had a healthy baby and healthy mom, which is an Obstetrician’s ideal birth plan. But it was the in-between that mattered for her and that is what I mangled. She didn’t want to be induced but yet had dangerously low amniotic fluid levels at 8 days past her due date, requiring induction to prevent a stillborn. She wanted a short labor, ideally less than 8 hours. With an unfavorable cervix and need for induction, her labor duration was just short of 24 hours. She wanted to experience labor without pain medication but requested an epidural when in active labor. She wanted to freely move about the room during labor and baby to be monitored intermittently rather than continuously. Due to the low-level of amniotic fluid and concern for fetal distress with contractions, she needed continuous monitoring. She wanted a vaginal delivery but needed a cesarean due to fetal distress and failure to progress. She wanted skin to skin bonding time with baby for the first hour after delivery but due to breathing difficulties, baby was moved to Special Care Nursery 10 minutes after birth. Her perception in the days following birth was that the medical community had failed her in that she didn’t have the “experience” that she had anticipated.
Although birth plans can be helpful as a starting point to discuss expectations, I find that too many women focus on their WANTS during labor and not the needs of their unborn child. If a physician is telling you that the health of your child is in danger and you need to be delivered, should we be arguing about the fact that you didn’t WANT an induction? If the physician is telling you that your baby is in danger of suffering long-term brain injury due to lack of oxygen and that you need a cesarean, should we be discussing that you did everything possible to have a vaginal delivery and don’t WANT a cesarean.
With women having fewer children and childbirth becoming an increasingly safe experience, women seem to set themselves up for unrealistic expectations of an event that will only occur once or twice in their lives. That experience needs to be near perfect with pictures/video extensively documenting the event. Each month hospitals review scorecards detailing pain management expectations, whether medical personal adequately explained procedures, the quality of the food etc. While this is important information that medical providers need to reflect on, I also think there needs to be a recognition on the patients end that a failure to meet their expectations is not necessarily anyone’s fault. If the pain of childbirth is too unbearable and you ask for the epidural that you didn’t want when you walked in the door, it is not the fault of the physician for starting Pitocin because you were not making progress in labor. If the epidural didn’t relieve 100% of your pain, it is not the anesthesiologist fault for faulty placement. In emergent situations, there may not be time to explain all of the risks and benefits of a certain procedure. Hospital food is designed to be healthy and in adequate proportions. If you are used to the taste and proportions of fast food, you will be disappointed in what is served.
Reduction in the risk of childbirth has decreased tremendously in the last 100 years. In the early 1900’s, 1 out of 90 women died of childbirth complications. 200/1000 babies died before their first birthday. Instead of fearing childbirth as in the past, women now enter the labor room with expectations of a perfect outcome, both for themselves and their unborn child. The overwhelming majority of the time we are able to meet these expectations. But due to the increasing epidemic of obesity, hypertension and diabetes, coupled with delayed childbearing, the maternal mortality and complication rate is sharply increasing. A complication such as postpartum hemorrhage related to maternal obesity, hypertension and prolonged labor is something we cannot prevent but can only manage once it occurs.
As often as reasonably possible, I try to honor my patients wishes in labor if those wishes do not interfere with the health of the baby or the mother. I have allowed a woman to cook a pot roast in a slow cooker in the labor room because she thought the fragrance would help with pain control. Intermittent monitoring of the infant while moving freely about the room and shower/bath is fine. Eating snacks during labor is fine as long as you realize that you may see them in another form if you are prone to throwing up. I allow women to take their placenta home to be dried and eaten. However, there are times that a doctor may know more about the correct course of action than a patient. And that is when the patient needs to trust that we are doing what is best for both their health and the health of their child. As I often tell patients, “The childbirth experience is just the first part of parenting where things may not go as expected. If you are going to enjoy the journey, you can’t get too caught up in the particulars!”