“Birth Plans and God Laughs” – with Dr. Stephanie Melka
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, welcome back Melka. We’re gonna talk about birth plans today.
Dr. Melka: Bring it.
Dr. Fox: What was in your birth plan?
Dr. Melka: Give me a healthy baby.
Dr. Fox: All right, so not a detailed birth plan.
Dr. Melka: And maybe take this tube out of my kidney that’s been there for the last seven weeks.
Dr. Fox: That’s a separate podcast.
Dr. Melka: I’m a little skewed.
Dr. Fox: Melka’s right kidney and potty mouth is a separate podcast that we’ll go into.
Dr. Melka: Oh, that’s gonna be a good one.
Dr. Fox: But in all seriousness, birth plans come up a lot. You know, we have a lot of women that deliver in our practice, not all but many of whom either present us with a birth plan or ask us about should they have a birth plan? And there’s a ton of stuff online. I mean, we were just, you know, right before this, googling various birth plans online, and we’re gonna look at some of them, you know, during this podcast. And, you know, just conceptually, just so our listeners in, what is a birth plan?
Dr. Melka: It’s basically just your vision of what your birth is. Do you have an epidural or not? How is your baby being delivered? Who’s there with you? Just sort of writing out what does that look like.
Dr. Fox: Birth plans are somewhat unique. I mean, people don’t really have plans, like written plans that they have for other sort of life events or medical events based on how you view birth. Why do they exist? Like, why do they even come to be as far as you know?
Dr. Melka: Years ago, medicine was very paternalistic. You know, obstetrics, in general, you know, you hear stories of women who were just told to do what the doctor said. Women would undergo procedures or interventions without being asked or told what was happening. And the birth plan sort of came as a way to start reclaiming autonomy.
Dr. Fox: Yeah, it’s interesting. In this country, I think most of the doctors who are trained, certainly now and for a while, have really been taught this idea of, you know, it’s patient autonomy in obstetrics, you know, she has to be involved in these decisions. And it’s true in all aspects of medicine. But I remember, literally just this weekend, someone was telling me, and he was from a, you know, country in Europe. And he said when he and his wife were there for the birth of I think their second child, he was there on business or whatever. And they’re at the doctor’s office, and she was asking questions and very routine type of questions that people ask us. And the doctor after, like, a third, he said, “Wait,” and he put his hand up he said, “I’m the doctor, just listen to me and that’s all you need to do.” And that was it, like, end of conversation, meaning get out.
Dr. Melka: Okay then.
Dr. Fox: He was like, “Whoa, like, we’re not in the U.S. anymore.” And I think that that’s how things, like you said, used to be everywhere. And there were these conversations about it. So the birth plan came about, and I think that part of the reason some doctors or midwives nowadays might not be so happy with birth plans is they sort of feel like, “Well, we’re not like that. Meaning we were trained differently, we don’t have this paternalistic view and now we’re having someone almost accuse us of it by sticking this birth plan in our face.” And I think…
Dr. Melka: The sort of crude way that I’ve heard people compare it is if you take your car to the mechanic, you don’t tell the mechanic how to do their job. So why are you telling me as your doctor how to do my job? I think that when doctors look at it that way, I think that’s why they often feel bothered by it.
Dr. Fox: Right. And I think there’s truth to that based on exactly what’s in the birth plan, right? If someone said to me, you know, “I’m gonna have a cesarean, and I want you to use this type of scissors and this suture, and, you know, use your left hand here, and your…” I’d be like, what are you, like, out of your mind? Like, you know, like, that doesn’t make any sense. And that’s sort of comparable to me telling the mechanic what to do.
However, if, you know, I went to the mechanic with my car and he said to me, “We have two options here. Like, we can choose to fix your car, it’s gonna cost you this amount of money. I think it’s likely to work for x amount of years, and you’re probably gonna have to pump more money into it again. The other option might be better to just, like, replace this engine entirely or get a new car.” In that sense, again, I have the autonomy over how to make that decision. If he just said to me, “We’re gonna do this, and I’m not gonna present the other option.” I would be a little annoyed with that.
And so, I think that it’s really you have to compare apples to apples with this. And I think that, you know, in my experience in reviewing birth plans and talking to women about this, sort of couples about this, there’s basically the kinds that are just an extension of the conversations we would normally have. Where, you know, the things that are basically like, it has to be a certain way because this is the safe way to do it, or it is the way I know how to do it, okay. Whereas the other things where there’s, you know, a lot of options, a lot of leeway, a lot of pluses and minuses to both, you know, we sort of figure out what she prefers. But then, there’s other people who come in with sort of like these demands, you have to do A, B, C, and D, and I’m like, “I just can’t do that, like, it’s not an option for you.” And it’s not combative, but it’s just not possible, and then it’s a difficult conversation. And so, there is a wide range here. I imagine you’ve had all of those situations come up.
And so, I think that the concept of a birth plan, it’s a little bit unusual, but based on how it’s done, it can either be a very helpful process, potentially. It could be a completely neutral process where it’s done but totally unnecessary because these things are already decided upon. Or it can be a destructive process based on how the patient comes to the conversation and based how the doctor or midwife comes to the conversation. And so, I usually try to come with an open mind when we start and see which way it’s going, and then figure it out from there. Why would a patient feel that it’s important to write these things down specifically, as opposed to just asking?
Dr. Melka: A lot of it I find is what they’re told. You know, a lot of people say, “Oh, I was told to write a birth plan,” or “I was told to ask you if I should write one.” Less so, I think it’s also people who have had friends, family who have had bad experiences where the patient then feels if they put things into writing and were more proactive, that they could help themselves avoid those types of situations.
Dr. Fox: I agree. I think it’s rare that someone comes up with this idea out of nowhere. I think that either they heard about it, they went to birthing class and the instructor or whoever said, “Hey, you know, you should do a birth plan, here’s what you should do.” Or they’re reading a book, or they went online, and they sort of found it and they said, “Oh, we should do this.” Or someone said, like, “Make sure you discuss this with your doctor and make sure you put in writing.” And I guess that’s why someone would write it. And as an obstetrician, do you want someone to have one? Do you want someone not to have one? Do not really care either way? What do you view from your end of it?
Dr. Melka: I’m pretty neutral on it. I think it helps patients feel better when they write one and talk about it with us in advance. Often, things that people write down are sort of based on misconceptions. Where they’ll say, “I don’t want x unless absolutely necessary.” And it’s my chance to say, “Well, I’m not going to do that unless it’s absolutely necessary.” You know, the big one that gets thrown around is episiotomy. Patients will say, “I don’t want it unless it’s necessary.” And I can confidently say “We don’t do them routinely, we do them when there is a clear medical benefit for you or the baby.” And I think patients, when they understand that beforehand, tend to be much more relaxed when they’re in labor, knowing that we’re not gonna do all these things kind of without a reason without their consent.
Dr. Fox: I don’t really care if they have one or not. For me, the more important thing is if they have something they are thinking about or they wanna talk about, I really think they should ask me, right, or one of my, you know, partners, is it something they should bring up? I think it’s more important to make sure you have the conversations about it than to come with a piece of paper, right? If the piece of paper is the tool that you’re gonna use to organize your thoughts, “So these are the things I need to discuss with the doctor.” A lot of people keep lists and all these whatever spreadsheets, and that’s great if that’s what you need to organize it. But the paper means very little to me compared to the conversation.
So, like what you said, if someone comes with a paper, there’s a box check that says, “I don’t want an episiotomy,” that’s not helpful in the list. But if we have a conversation about episiotomy, that’s very, very helpful because she’s gonna understand sort of where I’m coming from. Am I the type of doctor that always does them? No, most are not anymore. Am I the doctor who never does them? I would say no, that doesn’t make any sense because sometimes it’s the right thing to do. And then we have the conversation, when would I do it? When wouldn’t I do it? Am I gonna tell you if I’m going to do it? Yes.
Like there’s these types of things that sort of…that conversation is critical because then she won’t be worried about episiotomy. Or if for whatever reason, you know, my answer to her is so horrible, she’ll know, and she’ll have an opportunity to go to another doctor. But just coming up with a piece of paper is really not gonna help me at all. So I view the birth plan as sort of a framework to have conversations. And if it comes in the form of a birth plan, fine. If it comes in the form of, you know, a list on someone’s iPhone like, “These are the nine questions I wanna ask you, here are the things I wanna talk about.” Great, as long as those conversations took place that’s really more important.
And the other thing is when someone’s in labor, it’s not like surgery, or they’re, like, asleep, then we sort of…they go to sleep, and they wake up it’s done. Like, we’re talking the whole time. You know, they’re awake, I’m awake, everyone’s awake. And so, you know, we’re in another room and these conversations are ongoing. So, like, for example, a lot of people put in their birth plan about “I don’t want Pitocin unless A, B, or C.” And I’ll be like, “Well, fine, but, like, why are we deciding about Pitocin now, when you’re 32 weeks pregnant sitting in my office?” I’m not giving it to you now, right? If I think you need it in labor, we’re gonna talk about it. I’ll say like, “Here’s what’s going on, here’s why I think you need Pitocin, you ask any questions you have. And good, we’ll decide then.” So a lot of the decisions that people are trying to, you know, grapple with and work out just don’t make sense to do it earlier.
Dr. Melka: The few that are deal-breakers people know about well in advance of even coming to our practice. You know, things like, I want a waterbirth, or I want to be in a birthing center, you know, those are things we don’t offer, we don’t have those. I don’t know that I’ve ever had, like, something that major come up.
Dr. Fox: You know, sometimes people…it happens rarely where someone will in the middle of pregnancy, or, unfortunately, sometimes towards the end say, “I need to be delivered by one of these three doctors,” because they’re men, because they’re women, because I don’t like the others, whatever it is. And we’ll be like, “Well, like, that’s sort of not how we do things, we have a schedule [inaudible 00:10:53].” And that’s tough. And so, that’s something that, yes, if someone has a very specific request, and they’re not sure it’s an option, that needs to be discussed early because this is the reality. Either you’re gonna have to, you know, accept that or find somewhere else that’s appropriate for you. Like is that waterbirth? Like, yeah, if you want to have a water birth, we don’t have tubs, you know, it’s just not an option, you know, we can’t really do it.
And so, those are the things… How would someone know if it’s a deal-breaker or not a deal-breaker? I think anything that involves, like, personnel, equipment, you know, something, you know, it’s probably a good idea to ask, early on in the process. Most people don’t have those expectations when they come to our practice or any practice, it’s sort of like, get it. But some people are just surprised maybe they’re from another country where it’s sort of, you know, usual in every hospital to have certain things. And so, it is important to ask early. But again, I don’t find that that’s such a big thing. What are the specifics that people put into a birth plan?
Dr. Melka: Oh my god, there are so much. This was the point where I said, “Let’s Google it, let’s find birth plans.”
Dr. Fox: What are some of the wildest things you’ve seen in birth plans?
Dr. Melka: Delivering at the time of the eclipse.
Dr. Fox: Oh, that’s a good one. Were you able to accommodate that request?
Dr. Melka: It was not me, I believe the doctor involved came close.
Dr. Fox: I had someone who wrote in their birth plan “If I go into cardiopulmonary arrest, I would like to be resuscitated.”
Dr. Melka: That’s good to know.
Dr. Fox: Yeah, I was like “Was there a thought we wouldn’t?” I was like, “Oh, okay, check.” I had another one that said, “I want an episiotomy.” I said, “Are you sure this isn’t…”
Dr. Melka: Clarify.
Dr. Fox: …”is that not a typo?” She said, “What do you mean?” I said, “I’ve read hundreds, thousands of birth plans, there’s never been one that asked for an episiotomy. They all asked to not have an episiotomy.” She’s like, “I don’t know, that’s what my birth teacher said. Let me go back and see which one she was talking about.” It’s probably the not is what she meant is my guess. Those are two pretty interesting ones, I guess. Some people do around New Years, they wanna go right before right after. I don’t know if it’s so much a birth plan as much as like, hey, that’d be pretty cool.
Dr. Melka: The tax deduction. “If I deliver before the new year, I get a tax deduction, and I’ve already hit my deductible for the year.” I’ve had that in a birth plan.
Dr. Fox: Yeah, that’s a big one, that is definitely a big one.
Dr. Melka: Some of the stuff is the setting who’s there? You know, I’m in labor, I’m going to be there with my partner, wife, husband, boyfriend, whatever, my doula. I would like music, I don’t want music, who do I want involved? I only want senior nurses, female nurses, doctors, not midwives, midwives not doctors. Then there’s the requests of like the interventions.
Dr. Fox: And again, I think with things related to personnel, that is something to talk about beforehand.
Dr. Melka: Very early on.
Dr. Fox: Right. Whether you write it down or not, definitely talk about it. Because, for example, sometimes someone will say, “I only want, you know, a woman to deliver me.” Like, great, we can’t guarantee that, it’s just not an option. We can try and here’s how we can try, here’s what we can do.” But that’s something you need to know well in advance. Or like you said, with nurses, we don’t choose which nurses take care of you. So we can’t guarantee you a certain nurse. Or I don’t want residents involved in my care, or I do want residents…
Dr. Melka: I’ll throw in a plug for our earliest podcast, I think on residents and teaching hospitals. I think that request comes up a lot. And a lot of that is just sort of incorrect information. Or patients say, “I do not want residents.” And I’ll tell them “We can’t accommodate that.” You know, if you’re coming in and we’re not available, the residents see you. They get your induction started. They help us whenever we need a second set of hands. You know, that I guess also personnel.
Dr. Fox: Yeah, we view them as part of our team. And so I say, “Listen, we can try, here’s what we can try to do.” You know, it’s also different if someone’s coming in for a scheduled cesarean versus not. I mean, there’s different situations, but ultimately, that’s something that has to be discussed early. So, definitely, you know, equipment, location, personnel, things like that. If you have special requests, absolutely discuss it as early as possible. Again, write it down, don’t write it down, but have that discussion. Okay, then what about the second category you’re talking about interventions?
Dr. Melka: It’s I don’t want blank unless medically necessary. And that blank is everything: induction, cesarean, forceps, vacuum, episiotomy, breaking my water, just everything. I view that as a great time, you know, in prenatal visit to discuss like, what is labor? How do we manage labor? Why do we do those things? You know, we don’t do forceps on every baby. But if you need to be delivered quickly and your alternative is forceps, a C-section, or an unhealthy baby, forceps might then be the right choice for you.
Dr. Fox: I agree. I think most of the interventions that we’re talking about are not elective. The main elective one is like an epidural, right? So I want an epidural, I don’t want an epidural. And [inaudible 00:15:58] for that one, discuss it, don’t discuss it, put it in your birth plan, don’t put it in your birth plan, it’s your choice. So ultimately, whatever you wanna do is gonna be fine.
There’s exceptions, but basically, that’s okay. You don’t have to think too much about it in advance. You don’t have to tell us in advance. Like, whatever you wanna do, we’re okay with it, right? If you want an epidural, great, if you don’t, great, you know. If you wanna talk about it, the pros and cons, you know, risks and benefits, we’re happy to have the conversation. But it’s not something you need to, like, put in writing because we’re fine either way. So, it doesn’t really make a big difference.
Dr. Melka: That is a request that sometimes has come up that I personally can’t go along with, where patients will say, “I don’t want an epidural. Even if I ask for one, do not give me one.”
Dr. Fox: Oh, no, that’s…
Dr. Melka: I will tell them I was like “I can’t do that.” I’ve heard of patients that have code words where “Unless I use this code word, don’t give me an epidural.” And I’m like, “I can’t do that.” You know, if you’re saying you want an epidural, I have to take care of you. I can’t go by a piece of paper rather than what you’re telling me.
Dr. Fox: And I tell them that you can’t expect all the nurses to know this, and the anesthesiologist to know this. We can’t have these elaborate plans over what you can or can’t say. So, yeah, no if someone says, “You can’t give me an…like, don’t ask me about an epidural. Don’t let anyone ask me about an epidural because I may give into it.” I’m like, “What do you want me to do?” Like, how am I gonna possibly, like, make sure that no one walks in your room and ask you if you want an epidural? Like, I just can’t.” I say, you know…
Dr. Melka: And that’s also when someone calls me in labor, that’s also how I help them decide is it time to go in or not? You know, if they say, “Well, I’m getting really uncomfortable and I want an epidural,” I’ll say, “Great, head in now, get settled, you’ll be more uncomfortable. By the time you get there, you’ll get your epidural, it will be perfect timing. And if you don’t want one, I can encourage you to stay home a little longer.”
Dr. Fox: Right. So I meant really just I want one versus don’t want one. But the very specific and detailed plans about not wanting one, I agree, that’s…you know, people come in with [inaudible 00:17:52] say, listen, I was like, “Come on, you know, we have to be realistic here, you know, this hospital has anesthesiologist, someone’s gonna ask you. If you ask for an epidural, no one’s gonna be like, ‘Well, you didn’t say the safe word.’” I mean, it’s just, you know, we have to take care of you, this is not how we function, you know, it’s just not sort of reasonable in that sense.
But the other interventions, you know, episiotomy, cesarean, induction, oxytocin, you know, IVs, I think if someone feels very strongly about one of them or all of them, it is important to discuss. And the main discussions is really like you said, why would we do it? Under what circumstances? Why do we think it’s better versus not doing it? And I think, again, those are important conversations for people who have strong feelings about it. Because ultimately, I think it’s not wise to put, you know, hardline stops on care that you can receive and say to your doctor, “You can do everything except this.” It’s like, well, what if that’s the best thing for you?
And it’s sort of…it puts the doctor in a tough spot. And frequently, with just conversation, you can get a really good sense of what are the fears? What are we trying to avoid? What exactly is going on? And different doctors feel differently. If I see a birth plan, I try not to have anything where it’s like, we are not gonna have this, you know. And anything that says we’re not gonna have it unless necessary, well, all those things we don’t do unless necessary, we don’t just do them. You know, we don’t just say, “Hey, we’re doing a C-section, you know.” We always do the medically necessary, and…
Dr. Melka: And they’re all things that facilitate a vaginal delivery. You know, that’s the other thing I explain to patients, you know. For example, your water broke, you’re not in labor, if you wanna facilitate a vaginal delivery, you should be induced, you know. Or if the baby’s heart rate is dropping, and you need to get the baby out quickly, and you’re fully dilated, and you can have forceps or a vacuum, it’s that or C-section. So I think also talking through patients, what happens if they don’t have that, what are the risks of that?
Dr. Fox: And I think that when someone has, you know, any of those “I don’t want this unless it’s medically necessary,” the way I read it or I sort of ask them to rewrite it is, “I don’t want any of these until we discuss it, you know.” Which is really saying, I wanna have a normal relationship with my doctor because that’s what should happen anyways. Meaning if you have a doctor who’s just walking and doing things to you without talking to you about it, you know, unless it’s like a dire emergency, that’s probably not a good relationship from the start.
And so, if you wanna just clarify, hey, like, I do wanna be involved in these decisions and discussions, which is, I would say, the default. But if you wanna just clarify that that’s the default, great. But to put these, you know, hard lines, I think sometimes cause more problems than they fix for the person who wants them. Because it may set up one of those combative situations where the doctor feels that he or she is being dictated, you know, how to do their job, and to do it, you know, well. Whereas in reality, it’s usually just, I wanna be involved in these decisions. I wanna know why you’re doing something. I don’t want you to do something just, you know, for the hell of it. Which again, we don’t do. But if there’s a fear of that, let’s talk about that.
And ultimately, you know, if I’m having a conversation with someone… And, you know, 99 out of 100, go fine. Because once they present the birth plan, we talk about it, everyone’s good at the end. But occasionally, someone’s really pushing me on this to say, “No, you can’t.” And I would say like, this is not a good, like, situation here, right? You clearly don’t trust me. You have no trust in me, you don’t like the way I practice medicine or the way I do things, you’re not in the right place. Like, I can’t change who I am. It’s like you can’t go to someone who’s about to…a pitcher is about to start the World Series and you say, “You have to throw lefty now and you’re righty. They’re like, “I don’t do it that way. Like, I could, I just won’t be as good.”
So if you want me to, you know, practice in a way that I’m not…you know, you’ll have worse outcomes, you know, because I’m not doing it the way I was trained to do it. But those are really the exceptions. It’s almost always just, I wanna talk about these things because I want to understand them better. And that’s why it’s important. I think there’s also a third aspect, which is stuff related to the baby that comes in the birth plan a lot.
Dr. Melka: And a lot of that has now become much more routine at the hospital. You know, I tell patients, I deliver the baby vaginally, delay cord clamping, put the baby on your skin or on your chest skin to skin. Breastfeeding is the default unless there’s some medical need for supplementation. Or if you want supplementation, the nurses will delay the eye drops and vitamin K to let you have some bonding time. You know, whereas years ago, it was like baby delivered, got whisked off to the warmer and then a half an hour later got brought back to mom.
Dr. Fox: Right, maybe.
Dr. Melka: Maybe. And I think patients are then very reassured, you now. And I tell them I’m like, “The second the baby deliveries, you’re not gonna remember what’s written down in the birth plan.” But everything that’s written down here in most of these plans is now what we do pretty routinely.
Dr. Fox: And I think that’s been a good change and so, like you said, the default is to do delay cord clamping, skin to skin, the things that people ask for. And if someone doesn’t want it, they’ll just say. And often, again, these are things…
Dr. Melka: And we ask
Dr. Fox: …at delivery.
Dr. Melka: …we’ll say, you know, the nurses ask that.
Dr. Fox: Where do you want us to put the baby after birth, you know?
Dr. Melka: And some people don’t want that. Some people are like, “I don’t wanna see a gross looking brand new newborn, I’m gonna pass out, go bring the baby, get it cleaned up, and then bring it back to me.” And that’s fine.
Dr. Fox: Wipe all that shmish [SP] off the baby, you know, before I’m gonna hold this kid. Yeah, and again, those are things, you know, just to make sure and to discuss. We have had situations where women don’t want their babies administered certain medications, and some of those can be delayed, some of those are required by state law. And so it’s really not our call, and some of those are optional. And so, these are things that if someone has a specific request, again, just to make sure that it is an option to either delay, or defer, or, you know, decline any of these things for the baby because there’s some that you can and some that you can’t.
Ultimately, it’s not even our call so much, most of it is with the hospital and the pediatricians. Because even though we’re there, we’re not really “in charge” of the newborn after the birth, and we hand the baby off to the nurses or the pediatricians. But it is something to bring up. So let’s see, let’s go online. Let’s see what else is there. So I’m not gonna list the websites but here’s a six-page birth plan, that’s impressive.
What is the plan for the delivery? Okay. Who’s gonna be in the room with you? Okay. So this is a good one like so, for example, there is, you know, about having parents or other children. And that is something to bring up because hospitals sometimes have policies about how many people can be in the room. Is there an age requirement? They have to be above a certain age. Or sometimes these policies change, obviously, with COVID and they change in flu season.
And so that, again, personnel is a good thing to bring up in advance. You know, if you have another child, what’s your plan, right? Because if, you know, you, your partner, and your child come and you’re in labor and the hospital says your child can’t be here, someone’s got to take that person home. And so, these are things you definitely wanna plan in advance. During labor music, lights, quiet room, how many exams you’re doing. Again, this also is a lot about personnel, about what clothes I’m gonna wear, not I the doctor but I the patient. I don’t think I’ve ever had anyone ask me to wear something in particular for their birth. Though that’d be pretty cool. Hey, you know put on this, you know.
Dr. Melka: I’m sure there’s some…
Dr. Fox: Put on this Nets jersey for me when you deliver.
Dr. Melka: I’m sure there’s some baseball fan that asked you to take off your Cubs ID chain.
Dr. Fox: Oh, yeah, that has gotten ugly at times. Yeah, I’ve had some… Yeah, I delivered a Cardinals’ fan and they were very upset by my Cubs [inaudible 00:25:36] had to take it off. It was a thing and then they asked for Miller who was…
Dr. Melka: I was gonna say did they make Miller come in?
Dr. Fox: Yeah, Miller came in with his red Cardinal scrub pants.
Dr. Melka: Nice.
Dr. Fox: Oh, God, it’s awful. Yes, things like eating and drinking in labor, there’s different policies in different hospitals. That’s a separate podcast because I’m not always in favor of all the policies in the hospitals. But there are, they exist. And so, that’s something to ask about.
Dr. Melka: And the music is not an us thing, it’s a patient thing, you know. Patients should bring, you know, speakers to connect to their iPhone. I was gonna say iPod, but I think that dates me nowadays.
Dr. Fox: Oh, dear yeah, it’s your Walkman.
Dr. Melka: Discman actually.
Dr. Fox: Yeah, I be Walkman, you be Discman. I mean, that is something…again, we’re more than happy for someone to have music when they’re in labor. Even during C-sections, most of us are okay with it. Except for Dr. Silverstein [inaudible 00:26:27], who always took over the playlist himself.
Dr. Melka: Had to play his own music.
Dr. Fox: No, he would take requests, he would do what they…but had to be from his, you know, list. We’re all generally very comfortable people playing music, pretty much whatever they want. Same with the lighting unless we need lighting to do something, they can have it usually any way they want.
Dr. Melka: Labor is pretty civilized, you know, we watch TV, the lights were out, we took naps. I mean, you know, occasionally, someone would turn the lights on and forget to turn them off. But for the most part, like, these are all routine things now.
Dr. Fox: Yeah, I mean, generally, for people in labor, if everything is going well, no one’s really gonna come into the room unless they have to, right? A nurse has to check on you, check your blood pressure, and, you know, do this, do that or the doctor. But otherwise, it’s really people are happy to leave you alone. We can see the baby’s heart rate from outside the room, there’s central monitoring, and if there is a concern, you have a call bell, you can do that. And most people are very happy to let, you know, patients or partners just, you know, have labor to their own experience unless they want so.
And then there’s a lot of stuff here about fetal monitoring. And that’s…again, that’s like, you know, procedures, like, we do it for a reason. And if you really, you know, feel strongly about it one way or another, that’s great to have a conversation about, again, before labor. Because sometimes there’s just policies involved and sometimes it’s how the doctor practices and he or she is gonna have some leeway, but maybe only to a certain degree, and you just have to know where that lies. There’s a whole section here on pain relief. Again, there are things here that sometimes aren’t an option.
Dr. Melka: And it’s such a hard thing to plan for.
Dr. Fox: Right, you don’t know how much pain you’re gonna be in.
Dr. Melka: Right, I tell patients “You don’t know what kind of a labor you’re gonna have.” You know, if it’s your first baby and you come in after eight hours of contractions and you’re 9 centimeters, that’s a very different setup than contracting for a day and being 2 centimeters.
Dr. Fox: Right. And also what’s available, you know, acupuncture is…we don’t do that, you know, I’m not skilled to do that, and not that you want me doing it, you’re my burden. If someone offers it and it’s an option, fine. There’s a lot about, you know, positions in labor or positions when pushing. Generally, most obstetricians and midwives are fine with all the above, as long as it allows us…you know, if we have to do fetal monitoring, is that still an option. And also, many of these positions are not doable if you have an epidural, your legs have to be strong enough to support a squat, if you wanna squat when you’re pushing or, you know, in labor. So just the feasibility of some of these things.
And then yeah, there’s a whole section of episiotomy and then what to do with the baby. And then a lot of stuff about cesarean if it ends up happening. And again, this really…you know, just to go back to this, there’s the few things that we said that really need to be discussed in advance. If you have a specific request that may not be available, personnel, equipment, whatever it is.
After that, I think it’s just…a birth plan is useful for people who need a reminder of what to talk about with their doctor. And if it requires like, hey, I don’t even know what to think about, let’s pull up a birth plan and see how many of these things I really care about, or don’t know about, or wanna ask about, and circle them, or check them, or whatever, and then have the conversation with the doctor. If someone feels more comfortable having it written down, you know, I’m totally fine with that. I’ll usually go over the birth plan with someone. If there’s anything there that I think is not doable or I wanna amend based on our conversation, I’ll literally write it on the birth plan. And then I’ll just sign it and put in your chart and say, “I’ve reviewed this, it’s cool, you know, we’re all on the same page. All the questions are answered.”
But other than that, I don’t think it’s necessary. So when someone says, “Do I need a birth plan?” I was like, “No, like, you know, just ask me the questions you wanna ask. And if you don’t know what to ask I can, you know, help you with that.” And if someone wants to do it, as long as it’s approached in a way that’s working with your doctor and midwife to find out what’s, you know, the right thing and the best thing as opposed to a combative way. Which, again, is the exception, but it happens periodically, is important. And no one should feel pressure that they have to do and if they don’t have questions, like you said, you know, your friend the birth plan was, you know, two people in three people out. And people frequently have those, they’ll be like, “Yeah, my birth plan is nothing. I want epidural and a healthy baby, does that work?” And I’m like, “Yeah, that’s fine, you know, we’ll talk.”
Dr. Melka: And at the end of the day, most people don’t want a C-section, you know, most people want a virginal delivery. Most people like if you were to say, “Do you want forceps, or do you not want forceps?” Most people are will be like, “Well, I don’t want them.” You know, most people want a low-risk vaginal delivery, and that’s our goal no matter what’s written down, whether people verbalize it or not. You know, I joke with patients, you know, I’ll say like, “I don’t wanna do a C-section, like, that’s more work for me. It’s much easier for you to do all the pushing, me to get all the credit for the delivery rather than make me work.” You know, all joking aside, our number one goal is healthy mom, healthy baby. And then next after that, I think would be vaginal delivery.
Dr. Fox: Right, I totally agree. I appreciate we’re talking about birth plans, a lot of people feel very strongly about this. If someone is listening and is pregnant, and never had a birth plan, never thought of having a birth plan, great, maybe this open, you know, sort of the discussion for things. “Oh, I do wanna talk about that, you know, with my doctor, let me make sure to talk about that.” Or “Maybe I do wanna come up with a birth plan,” great. Or someone has a birth plan, they may wanna revisit it.
And if someone is upset that we’re not totally gung-ho on the birth plan, I think just to rethink, what exactly is the purpose of your birth plan? And it really should be to make sure that, you know, I’ve had a conversation with my doctor or my midwife, we’re on the same page, we all have the same goals. They know what I want and, you know, I know what the limitations are with this. And we’re all entering this on the same team. And that’s really the most important thing.
And if someone feels that their doctor or their midwife is, you know, an opponent and not a teammate, that’s a situation you should get out of. It’s just not a healthy situation to be in. It may end up working out okay, but there’s a lot of room for problems there. And certainly, it’s just not pleasant for anybody involved. But as I said, for the most part, these are really positive conversations. They’re educational, they’re informative, you really get a sense of who people are and what they want. And I think most people come out of these conversations feeling a lot better about what’s gonna happen in labor and not worse.
Dr. Melka: And I think it also helps when things don’t go according to plan for a patient. You would know better than me if it was studied or not. But, you know, if your outcome is not what was in your birth plan, are you more likely to be depressed or not? You know, anecdotally, I think so. Anecdotally, when I see these patients for postpartum and they had a C-section and didn’t want it or whatever it was, you know, I think there is more of a component of depression, anxiety. But I think when we’ve had these conversations in advance, you know, they don’t feel it’s the doctor’s fault type of thing.
Dr. Fox: Right. As Andre always says, “It’s about managing expectations.” And it’s just…you know, because again, if someone was hoping…again, we’re talking about everyone is healthy, right. If someone ends up not being healthy after delivery, that’s its own situation. But everyone comes out healthy. But if someone was really eager to have a birth without an epidural, or maybe eager to have a vaginal birth and not a cesarean and it didn’t work out that way. And the baby’s healthy, and they have the perspective that “Yeah, I’m happy, everyone is healthy, but I really preferred a vaginal delivery, or to do without an epidural,” or whatever, you know, that sort of desire was.
I agree that if it’s something that wasn’t spoken about and there wasn’t a conversation about it, and their expectation was this is really gonna happen, this is really gonna happen. And then suddenly, in labor, it changes, and they feel like it was a letdown. Yeah, I think they’re gonna have much more of a bad taste about it, or maybe even some lingering, you know, feelings, whether it’s, you know, depressive or anxious or something like that. Whereas if there was a conversation about well, these are the expectations, this is sort of what we do, this is why we change plans and how, and it’s explained either in advance. Or even in labor, if the conversation is really thorough and it’s good, and people get a sense, I do think that there’s less regret over how it played out.
I do agree, because a lot of times when I talk to people about their birth experience, either with other groups or with our group, where they really just feel bitter about it. Again, even though everything worked out okay and they know that, but they just feel like it doesn’t sit right with them. It’s usually because they felt there wasn’t a discussion about it, that they just were left out of it, or, you know, the doctor didn’t explain it to me, or I didn’t have a chance to ask questions, and I didn’t feel comfortable with it. And it’s usually that more than the fact that it changed from what they were expecting. And so, that’s why this concept is helpful. Again, the paper isn’t what’s helpful, it’s the conversations, I think, are very helpful for people before they deliver or while they’re in labor. All right, Melka, awesome.
Dr. Melka: Love it.
Dr. Fox: Good. All right, I’m awaiting… Oh, we did a birth plan for our holiday party.
Dr. Melka: We did.
Dr. Fox: You and I did the mock birth plan?
Dr. Melka: Yes.
Dr. Fox: Yeah, we’re not gonna read that on the air, I think, that’s probably gonna get censored. All right. Well, thanks for listening. Thanks for coming Melka. Have a good day, everyone.
Dr. Melka: Thank you.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
The information discussed in “Health Woman” is intended for educational uses only, it does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.