Beyond the birth plan Enhancing communication between patients and - - PowerPoint PPT Presentation

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June 13, 2019

Rebecca Amirault, CNM

Associate Professor Department of Obstetrics, Gynecology, and Reproductive Sciences UCSF

Beyond the birth plan

Enhancing communication between patients and providers

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I have nothing to disclose How do you feel about birth plans?

• A. I encourage all my patients to write birth plans.
• B. I feel comfortable supporting patients with birth

plans.

• C. I don’t feel strongly about birth plans.
• D. I think birth plans have no use.
• E. I think birth plans are dangerous and can lead to

worse outcomes.

• F. What is a birth plan?

I encourage all my patien.. I feel comfortable suppor... I don’t feel strongly abou... I think birth plans have n... I think birth plans are da... What is a birth plan?

23% 60% 1% 5% 3% 7%

I believe that birth plans increase risks of:

• A. Cesarean birth
• B. Chorioamnionitis
• C. Postpartum hemorrhage
• D. Perineal lacerations or episiotomy
• E. Low Apgar scores
• F. All of the above
• G. None of the above

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• No difference between groups for:
• Cesarean birth
• IV analgesia use
• Chorioamnionitis
• Postpartum hemorrhage
• Perineal lacerations or episiotomy
• Low Apgar scores (1 and 5 minute)

Grant et al Expertopinion vs. patient perception of obstetrical outcomes in laboring women with birth plans The Journal of reproductive medicine, 01/2010, Volume 55, Issue 1-2

Provider feelings on birth plans

• f medical personnel believe that having a birth plan is

associated with overall worse obstetrical outcomes including increasing the rate of cesarean delivery.

• f patients believe that having a birth plan is associated

with overall worse obstetrical outcomes. So why are we seeing this document so differently?

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What is a birth plan?

• A written document composed prior to delivery by the birthing

patient to:

• clarify desires and expectations for childbirth
• provide information regarding preferences for their care and

support during labor

• Birth Plan vs Birth Preferences

The history of birth plans

• First seen in the 1980s in response to a more “medicalized”

birthing environment

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Preparation For birth Preparation For birth Communication with providers and staff Communication with providers and staff Promoting a supportive birth environment Promoting a supportive birth environment Sharing personal values and beliefs Sharing personal values and beliefs

Goals for a birth plan Shared Decision making in Obstetrics

ACOG- Ethical Decision making on Obstetrics and Gynecology #390

“Respect for a patient’s autonomy acknowledges an individual’s right to hold views, to make choices and to take actions based on her own personal values and beliefs. Respect for autonomy provides a strong moral foundation for informed consent in which a patient, adequately informed about her medical condition and the available therapies, freely chooses specific treatments or nontreatments."

Inside Amy Schumer

Birth plan sketch

Criticisms

• f birth

plans

“Patients are telling me how to do my job!” Inflexibility Outdated information Aggressive

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accusatory language

Attempt to control the uncontrollable

Non evidence based information Unrealistic expectations Place YOUR criticism here

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Provider Control

Expertise Capabilities Preparedness Preferences

Patient Control

Expertise Capabilities Preparedness Preferences

Apparently The World's Top Ob-Gyns Don't Agree With Meghan Markle's At-Home birth plan

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Who influences a birth plan?

Internet

Family Childbirth educators Friends Popular culture Obstetric Providers

If you are not happy with the information provided by the internet, childbirth educators and other sources then you need to take a more active role in educating your patients.

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How do we educate our patients?

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A talk for another day

• Person Centered Communication
• Patient Led Communication
• Shared Decision Making
• Mother’s Autonomy in Decision Making (MADM) Scale
• Trauma Informed Care
• Presenting evidence based medicine to patients
• ACOG committee opinions
• Etc. etc. etc.

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What is the evidence regarding birth plans?

Kuo S, Lin L, Lin K, et al. Evaluation of the effects of a birth plan on Taiwanese women's childbirth experiences, control and expectations fulfilment: A randomized controlled trial. International Journal

• f Nursing Studies. 2010;47:806-814.

Effects of birth plan on Taiwanese women’s childbirth experiences

First randomized controlled trial, published 2010

• N=296
• Prior to recruitment the nurses participating in the study received a 12

hour seminar to review the concept of “friendly childbirth”

• Patients were divided into a birth plan group and a control group
• The birth plan group discussed the items on the generic birth plan with a

nurse in an education session.

• Each patient had a follow up session with their Obstetrician to discuss

every item on the birth plan and reach a consensus together.

• The birth plan was then signed by the patient and the Obstetrician and

placed in the chart.

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What did they find?

The birth plan group

• Patients in the birth plan group were significantly more likely to

report that they had better childbirth experiences and their expectations were better met than the patients in the control group.

• Birth plans may help patients have realistic expectations
• Birth plans may help the patients to think about how to deal

with the labor process.

• Involvement in decision making, increased patient’s feelings
• f control over the childbirth process, which in turn is

associated with a more positive experience and greater overall satisfaction with childbirth.

Suárez-Cortés M, Armero-Barranco D, Canteras-Jordana M, Martínez-Roche ME. Use and influence of Delivery and birth plans in the humanizing delivery process. Revista latino-americana de enfermagem. 2015;23:520-526. 22

Use and influence of delivery and birth plans in the humanizing delivery process

Quantitative study, Spain in 2015

• n=9,303
• Patients who arrived on Labor and Delivery with a birth plan had

a significant

• Increase in Skin to Skin contact
• Increase in use of different positions
• Decrease in episiotomy
• Increase is NSVD
• Decrease in induction
• Increase in delayed cord clamping

Afshar Y, Mei JY, Gregory KD, Kilpatrick SJ, Esakoff TF. Birth plans—Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study. Birth. 2018;45:43- 49.

Birth plans--Impact on mode of delivery,

• bstetrical interventions and birth experience

satisfaction

Prospective cohort study from 2017

• n= 300
• Patient were recruited on admission to Labor and delivery and

divided by those who came with a birth plan or without one. What did they find?

Differences in outcomes

• No difference between

groups for:

• Cesarean birth
• IV analgesia use
• Chorioamnionitis
• Postpartum hemorrhage
• Perineal lacerations or

episiotomy

• Low Apgars (1 and 5

minute)

• Patients with birth plans

were less likely to:

• Have Pitocin

augmentation

• AROM
• Use an epidural
• Have a baby admitted to

the NICU

• Though there was no

difference in total length

• f stay for neonates

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Difference in patient satisfaction

• On postpartum day 0 they were asked about:
• Overall satisfaction with birth experience
• If the birth experience was what they expected
• If they felt in control of their birth experience
• The birthing parents with birth plans consistently reported lower

scores on all measures of the satisfaction questionnaires.

• Specifically they were less satisfied with their birth

experience, less frequently felt their birth experience met their expectations and felt less in control.

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I can’t get no…

Whitford HM, Entwistle VA, Teijlingen E, et al. Use of a birth plan within Woman‐held Maternity Records: A Qualitative Study with Women and Staff in Northeast Scotland. Birth. 2014;41:283- 289.

Why did these studies show different outcomes for patient satisfaction?

• The glaring difference between these studies is prenatal

education and discussion.

• 2015 and 2017 studies both report prenatal discussion could be

a influencing factor. “A supportive antenatal opportunity to allow discussion of options may be needed to realize the potential benefits of routine inclusion

• f birth plans”

Afshar Y, Wang ET, Mei J, Esakoff TF, Pisarska MD, Gregory KD. Childbirth Education Class and birth plans Are Associated with a Vaginal Delivery. Birth. 2017;44:29-34.

Childbirth education and birth plans

Retrospective cross- sectional study for singletons >24 weeks

• Cedars- Sinai Medical Center in 2017, n=14,630
• 4 categories:
• Those who attended CBE and wrote a birth plan
• Those who just attended CBE
• Those who wrote a birth plan, but did not attend CBE
• Those who did not attend CBE or write a birth plan
• Primary outcome was mode of delivery

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What did they find?

• Patients who participated in either CBE alone, birth plans alone
• r both had higher rates of vaginal delivery
• Vaginal delivery rates:
• 74.3% for patients with birth plans
• 64.9% for patients without birth plans
• After adjusting for covariates of age, gestational age, BMI and

race patients who had attended CBE and/or had a birth plan still had higher rates of vaginal deliveries.

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How to develop a birth plan:

A guide for providers

Tips for providers

• Talk to your patients about birth plans during prenatal visits
• Provide evidence based education to patients
• Discuss hospital policies/ practice agreements
• Open conversation between care providers and expecting

parents regarding concerns, questions, preferences and available options

• Listen to your patients with an open mind
• Consider if the request they have is safe, even if it is unusual

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What kind of birth plan is best? Checkbox Checkbox Algorithm Algorithm Pictogram Pictogram Personalized Personalized

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www.thebump.com

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Checklist birth plan

Spontaneous labor unripe cervix Prefer use of prostaglandin Ripe cervix Prefer Pitocin Prefer no augmentation Prefer to wait for spontaneous urge to push If slow slope prefer Pitocin to arom No Yes IOL at 39 weeks intermittent monitoring

Algorithm birth plan

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Pictogram birth plan Personalized birth plan

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Whitford HM, Entwistle VA, Teijlingen E, et al. Use of a birth plan within Woman‐held Maternity Records: A Qualitative Study with Women and Staff in Northeast Scotland. Birth. 2014;41:283-289.

Whitford sample birth plan

• How do I feel about labor and birth?
• What are my expectations?
• Who do I want with me during labor and birth?
• What environment do I want for labor and birth?
• If everything is straightforward, how do I want my baby’s heartbeat to be

monitored during my labor?

• How will I cope with my labor/ contractions?
• My feeling about vaginal examinations to assess my progress during

labor are?

• How would I like to give birth (positions)?
• Discovering the sex of my baby- do I want to find this out for myself?
• After my baby’s birth?
• Other questions or special requirements
• Relevant information from any previous births
• Discussion of preferences for labor and birth
• Signature of maternity care staff

Vector birth plan

Values: What are the patient’s core values and goals of the birth? What are their fears? What is most important to their in the birth process

Environment: Who does the patient want with them in the labor and delivery process? What would help them to feel confident and relaxed Comfort: What resources does the patient want to have available to their comfort and support Treatment: are there specific forms of treatment that the patient does or does not want? Why? Options: If labor does not go as expected, how will the patient address her

• ptions for intervention?

Recovery: How does the patient want to initially interact with the baby? What are their preferences for bonding, feeding, and care after birth?

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If we are going to preach patient autonomy and shared decision making we have to honor a document that helps patients express their desires.

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Do we have more time?

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Is there evidence to support commonly found requests in birth plans?

• Doula support
• A calm, quiet birth environment
• Mobility and position changes
• Intermittent monitoring
• Perineal support
• Delayed cord clamping
• Skin to skin contact

Doula support (continuous labor support)

YES

• Increase in NSVDs
• Decrease in cesarean births and instrumental vaginal birth
• Shorter duration of labor
• Decreased use of regional analgesia
• Decrease in newborns with a low five-minute Apgar
• Less likely to report negative ratings of or feelings about their

childbirth

• Fewer patients with depressive symptomology postpartum

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Calm, Quiet Birth Environment (low lights/quiet voices)

YES

• Design influences safety and quality in healthcare in general
• Patient satisfaction in the healthcare environment overall is linked to
• Space, light, noise, air quality, views of nature and privacy
• A quiet and calm birth environment has been proven to decrease

stress for the patient but also for staff, thus leading to increasing safety

• Decreasing stress for the patient also increases the likelihood of a

safe satisfying birth environment.

• Of note: nurses and providers need to be able to see in order to

safely give medications and perform some activities and procedures.

Upright Maternal position, 1st stage of labor

YES

• Associated with shorter first stage and an increase in NSVDs
• Upright position in the 1st stage of labor was approximately 1 hour and

22 minutes shorter then recumbent position

• Most significant difference for patients who were walking vs

recumbent, but also found for sitting, standing and squatting vs recumbent

• Patients randomized to walk compared to those recumbent supine or

lateral were

• more likely to have an NSVD
• Less likely to have operative vaginal birth
• Fewer cesarean births
• No difference in neonatal outcomes

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Upright Maternal Position in the 2nd stage of labor

MAYBE

• With an epidural
• No significant difference in cesareans, operative vaginal deliveries and

postpartum hemorrhage

• Without an epidural
• Decreased duration of 2nd stage (unclear)
• Reduction in operative vaginal deliveries
• Reduction in episiotomies
• Possible increase in 2nd degree tears
• No clear difference in 3rd or 4th degree tears
• Fewer abnormal fetal heart rate patterns
• No clear difference in the number of babies admitted to Nicu

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Intermittent Auscultation vs Continuous fetal monitoring

YES – for low risk patients

• No significant difference in:
• overall perinatal death rate
• Cerebral palsy rates
• Infant mortality
• Continuous monitoring was associated with
• Increase in cesarean sections
• Increase in instrumental vaginal birth
• Decrease in neonatal seizures

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Perineal Support

YES/ Sometimes

• Hands on vs hands off approach: no difference in 3rd and 4th

degree lacerations, but decrease in episiotomy with hands off

• Antenatal digital perineal massage decreased trauma requiring

suturing and episiotomy for primiparas

• The use of warm compresses on the perineum is associated

with a decreased of 3rd a 4th degree lacerations.

Delayed cord clamping-

YES

• Benefits: higher hemoglobin at 2-12 months of age, increase in

serum ferritin and total body iron during the first year of life

• Risks: theoretical risk of Jaundice that is less then 2%.
• For term newborns not requiring resuscitation
• NRP recommends: at least 30 seconds
• WHO recommendation: at least 1-3 minutes after birth
• ACOG recommends: at least 30-60 seconds
• ACNM recommends: at least 5 minutes
• Preterm- highly recommended
• 30-60 seconds

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The Golden Hour/ Skin to Skin contact- YES

The first 60 minutes of postnatal life

• Care that supports newborn and maternal transitions
• Includes:
• Delayed cord clamping, skin-to-skin contact for at least an hour,

performance of newborn assessments on the maternal abdomen, delaying non- urgent tasks for 60 minutes and early initiation of breastfeeding

• This positively influences:
• Neonatal thermoregulations
• Decreases stress levels in the birthing parent and the newborn
• Improves bonding between the newborn and the birthing parent
• Increased rates and duration of breastfeeding

Thank you