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Friday
Dec102010

An Alternative OBGYN Birth Plan

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By Henry Dorn, MD

I read with dismay an older blog post here that showed a copy of a “Birth Plan” that an OBGYN presented to his patients which basically said “my way or the highway”. 

The only good thing about it was the directness and honesty in telling patients in advance what to expect, giving them the early opportunity to seek care elsewhere. This I believe is slightly better practice than practicing the same way but leading patients to believe otherwise until its too late to transfer care.

What was perhaps more upsetting to me was that many responders to that blogpost expressed that they felt this was absolutely representative of all OBGYNs, which I know is not the case.

Therefore, in order to suggest that at least one of us does not fit that mold, I made some “corrections” to that Birth Plan. Though perhaps not the wording I would choose, and not the final product which I intend to post on my website (which is currently being revamped), it does reflect many aspects of my OB practice. 

You may wish to reference the prior post for comparison. 

I look forward to any comments or questions and thank Jill for letting me participate on her wonderful site.

 

Dear Patient:

As your obstetrician, it is my goal and responsibility to help you make the best decisions to improve your health and your baby’s safety during your pregnancy, delivery, and the postpartum period. My practice approach is to use the latest advances in modern obstetrics. There is no doubt that modern obstetrical advances have significantly decreased the incidence of maternal and fetal complications, but there is also much we do not understand, and therefore there are no hard fast rules for managing pregnancies.  The following information should clarify my position and is meant to address some commonly asked questions. Please review this information carefully and let me know if you feel uncomfortable in any way with my approach as outlined below.

* Although I do not attend homebirths, I support patients who choose this option and work with their midwives. I like a dark room for delivery but unfortunately, our labor rooms are not equipped for water births.

* I encourage birth plans which help patients organize their thoughts  about delivery before labor starts. There are few things I object to for healthy patients, but ultimately its your decision and we cannot force any care on you that you do not desire.

* Doulas and labor coaches are allowed & encouraged and are thought to be of great benefit to patients, partners and nurses.

* IV access during labor is optional in normal labor, but is strongly encouraged when there are risk factors such as hypertension, bleeding, VBAC etc, in case emergency medications need to be administered. Healthy women should be able to drink and do not always need IV fluids, which may hinder their mobility.

* Continuous monitoring of normal, healthy women has not been shown to improve outcomes, as long as there is an initially reassuring fetal heart tracing. Intermittent monitoring is however recommended during labor.

* Rupture of membranes may become helpful or necessary during your labor, but also carries some risks. The decision as to whether and when to perform this procedure will involve a discussion between us at that time.

* Epidural anesthesia is optional and available at all times. Although relatively safe, it does likely increase the rate of C sections as they often hinder movement which facilitates fetal descent and may cause drops in blood pressure which may result in fetal distress. Some women experience severe headaches afterwards requiring and injection into the spinal column to stop the leaking of spinal fluid.

* I perform most vaginal deliveries on a standard labor and delivery bed, however there are exceptions and depend on maternal comfort and labor progress. We try to find the position that benefits the mother and baby the most.

* Episiotomy is a surgical incision made at the vaginal opening just before the baby’s head is delivered in order to speed up delivery in an emergency situation, such as a prolonged drop in the fetal heart rate. It is not performed routinely.

* I will clamp the umbilical cord after it stops pulsating, unless there is an emergency which requires moving the baby for resuscitation.

* Normal pregnancies progress thru 42 weeks.  If it goes beyond this we will offer induction, or biweekly monitoring due to somewhat higher risks. Some studies also suggest that there may be a decreased risk of C section if inductions are done after 41 wks, so this option will be offered.

* Compared to the national average, I have a very low c-section rate. However, a c-section may become necessary at any time during labor due to maternal or fetal concerns. 

I look forward to collaborating with you in your care.

Henry Dorn MD

High Point NC

 


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Reader Comments (45)

I agree with the concerns about.using "Dr. Wonderful," but I also know how excited we get to find someone who is more respectful of automony. It is sad that we often get that excited - because of what that means - and hopefully soon we will have no cause to get that excited. ;) I think it's often a good shorthand, though, in recommending a provider. Also, thank you for what you do do and know that sometimes the anger expressed is also grief at knowing what we want simply cannot be

December 11, 2010 | Unregistered CommenterANaturalAdvocate

Dr. Dorn, so glad you are here, so glad you are attending births, so glad you support midwives!

Question: Under what circumstances do you find AROM necessary?

December 11, 2010 | Unregistered Commenterabundant b'earth

To ANaturalAdvocate,
I believe you are asking what aspects of my training have led me to the point that I am now.
For starters, I came into medicine indirectly, as I had planned on doing molecular biology research, with the MD as an adjunct degree. I went to the Medical University of South Carolina in an MD/PhD program, but after working on my research portion for a while, realized that late nights all alone with a test tube was not my destiny.
So it was with a background in research and basic science that I entered my clinical years. I fell in love with surgery, but not the culture. I liked family medicine but missed the OR. Then on my last rotation did OBGYN which was a little bit of everything. And caught lots of babies. I was introduced to midwives there and attended a number of deliveries with them and was made aware of their skills. I also learned that if you don't mess with things too much, babies usually come out.
At Albany Medical Center in NY, I was blessed with having Dr Edelstone as a chairman. His philosophy of approaching each patient as a complete person, not just a FHR tracing or a disease, really stuck with me. We were taught to deliver breeches, VBACs, twins, use forceps, and in his words "be an OBGYN", not just a surgeon who can do a C Section if the baby doesn't fall out. There too were attendings such as Ellen Biggers who practiced in a very humanistic way, Dr Renee Samelson, who had huge compassion for her patients, and others who rounded out my thinking. Some others however, practiced in ways that turned me off, and I learned at least as much from them.
When I finished, I knew I wanted to work with midwives, and so joined a practice in High Point with a Birth Center and midwifery practice. This was a perfect model for me, but the physican owner and I differed in our business approach and I left the practice.
This gave me the opportunity to do a sabbatical for a year in New Zealand, which has midwives and the primary care providers for pregant women, with consultant physicians taking care of only true high risk patients and problems. I witnessed a safe collaborative system with many homebirths and excellent outcomes.
When I returned to the States, I vowed to create a practice that would incorporate that model, which is what I am still working on developing. I currently officially back up several homebirth midwives in the state, provide consultation and care for patients of many others when the need arises and am working with NC Friends of Midwifery and other groups to expand midwifery to CPMs as well.
I believe that the biggest hurdle we have is ignorance in the US OBGYN community of the validity of midwifery care, and that more docs would feel as I do if exposed to the same. Most of us would really prefer to be handling the more complicated cases, which is what we trained so many years to do, and would gladly turn over some of the normal ones to other providers, if we knew that medicolegally we were protected, and the community supported that model.
More than you probably wanted, but there it is. Gotta cut back on the Saturday coffee.

December 11, 2010 | Unregistered CommenterHenry Dorn MD

I enjoyed not only the original post, but the ensuing comments, especially Dr. Dorn's.

My first four children were born (in a hospital) with a doctor who took a nearly identical approach to Dr. Dorn's. It wasn't until probably after my second child that I realized that he was the exception to the unfortunate rule, and that many of my other friends were not just choosing their c-sections or epidurals, but pushed into them by "the system" or docs who DO look at them as just a FHR tracing or whatever. The doctor for my 5th was fabulous, but only because I insisted on being left alone. I do credit him for honoring that, but for most of his patients, he takes a more run of the mill approach (except that he almost never does episiotomies)... I can't help but think that he could be SO MUCH MORE of an advocate for women and their birthing, and in the medical world. I think I'm going to copy this and mail it to him.

December 11, 2010 | Unregistered CommenterKaren Joy

Nice, nice, nice. I myself choose midwife assisted home birth, and also live no where near NC, but I would recommend you to the people I know who live there!

I do have one question, and it's a legitimate one that i have always wondered. Why would it be necessary to cut and clamp the cord early in the event of needed resuscitation? My thought would be that if a baby isn't breathing, it should be ensured oxygen through the cord and placenta. Is there some reason resuscitation is not possible at the foot of mom's bed (or, you know, wherever she happens to be giving birth)?

December 11, 2010 | Unregistered Commenteradrienne

All I can say is Hell's yeah on that last comment Dr. Dorn. I think if I post my other sentiments I might highjack the thread.

December 11, 2010 | Unregistered CommenterSaanenMother

Terrific! What a refreshing post.

One tiny detail stuck out to me, as a VBAC mother. Why do you recommend IVs for VBACs?

December 11, 2010 | Unregistered CommenterJill P.

In response to the last 2 questions:

I agree that it may seem illogical to cut the cord of a distressed baby, however if a baby really needs oxygen promptly, getting it under a warmer (out of the puddle of amniotic fluid) and on a firm surface where chest compressions and bag mask ventilation can be properly applied, or the lungs suctioned seems the more prudent option. This would be more likely to be the case if there was an abruption, tight nuchal cord, prolonged shoulder dystocia, or similar issue.

As for IV access with VBACs, I believe that although VBAC should be an option for mothers, it is a higher risk situation c/w a normal pregnancy. Should a rupture or hemorrhage occur, the ability to support the mother with IV fluids, or other medications immediately, vs trying to place an IV in someone with very low blood pressure, (which I have experienced and is no fun), might make a significant difference. Having a IV capped off and ready if needed seems a minor inconvenience, and does not limit mobility etc.
Also, given that we have been fighting an uphill battle to keep hospitals on board with VBACs, it is a small concession that keeps admins happier as well. If they feel that the women choosing VBAC are increasing their risk by refusing what has been standard management for so long, there is a significant risk that VBAC might simply be disallowed in that institution. So its 50% medicine and 50% politics in my opinion.
I would say however that if it were me, I'd have the IV.

December 11, 2010 | Unregistered CommenterHenry Dorn MD

I am an OB who left a hospital due to pressure from administration to do more C. sections. My rate was 8% year after year--compared to 26 %! I also am a mother who has 3 children-. One pushed for 5 hours---forceps. Next pushed for 5 hours C. Section. Third VBAC--successful.

I still offer VBACS, still will do a breech delivery, and I DEFINITELY want IV access for high risk. I started my Thanksgiving this year with a woman who came in after 2 previous C. Sections. She was 8 cm. I called the team in and I got there in 8 minutes form a dead sleep! The OR was set up but she was going quickly and I have done VBACS after 2 C. Sections before. I thought---Hey she is fully dilated--she'll probably deliver this baby before we can do anything surgical. She started to push and then GUSH!!! WATERFALL OF BLOOD!! Crash C. section---baby out in 4 minutes--the uterus had ruptured, the baby head was outside the uterus, and THANK GOD we had IV access and anesthesia was in house and the OR team ready next door! APgar 9 and 9!!

I am all for low intervention---ambulate, dim lighting, no episiotomy, deliver in what ever position you want, Partner cuts cord, early skin contact, delay eye drops and Vit K for first hour to give mom and baby a chance to see each other---you don't NEED OB's for the majority of deliveries--but when the S*** hits the fan in OB---there is a TREMENDOUS amount at stake!--and you must mover extremely quickly--we needed to get her to the OR-and asleep---not spend two minutes getting an IV in! YOu just gotts work in OB for a while to see that while most of hte time everything goes smoothly---sometimes things don't---drug users, seizures, heart attacks in labor, diabetes, kidney failure, pulmonary embolism or worse amniotic fluid embolism---text books are full fo the disasters--and SOMEBODY needs to take care of these women---we MDs are not ALL bad---every one I know loves their job and truly wants to do their best---and it sure is frustrating to see us sterotyped as knife happy power tripping women haters in the press---now I got go to bed at the hospital---I have a VBAC who just arrived--so I will spend the next few hours away from my family--and we DON'T get paid extra for being at the bedside for hours--so it must be the love of the job!

There are a lot of us out there plodding on ---trying to do the right thing.

December 11, 2010 | Unregistered CommenterHelen S

I agree that it may seem illogical to cut the cord of a distressed baby, however if a baby really needs oxygen promptly, getting it under a warmer (out of the puddle of amniotic fluid) and on a firm surface where chest compressions and bag mask ventilation can be properly applied, or the lungs suctioned seems the more prudent option. This would be more likely to be the case if there was an abruption, tight nuchal cord, prolonged shoulder dystocia, or similar issue.

Could you not bring the cart to the baby, instead of taking baby to the cart?

December 11, 2010 | Unregistered CommenterKathy
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