...and They Have a Plan.

Last year, while I was preparing for my maintenance of certification exam, I came across this practise question in a review textbook:

1. The patient asks you about birth plans during her initial prenatal visit and inquirers as to your attitudes toward pregnant couples who wish to participate in decision making for the conduct of labour and delivery. How would you respond?

A. Birth plans are not a good idea; usually something goes wrong and the couple is disappointed
B. Birth plans are not a good idea; they frequently lead to unresolved guilt to the couple
C. Birth plans should be avoided; perinatal morbidity and mortality are usually increased
D. Birth plans are an excellent idea; everything always goes according to plan
E. Birth plans are a good idea; they involve the couple in the planning for the baby's delivery and can be an important part of the prenatal, postnatal and postpartum care

Here is a situation where I would argue that you have to read the questions carefully. If they are asking, 'what is the best answer?', then obviously they are leading you to select choice 'E'. However if the question were phrased 'what is the correct answer?', then I would go with choice 'A'. When I was working on Labour and Delivery, the majority of my patients were young girls for whom nothing about their pregnancies nor births were planned. However, there is something about the body at that age that is conducive to giving birth. Many of my patients had the all natural, unmedicated, intervention free vaginal births that the older patients on the floor desperately wanted. I always detected a sense of slight annoyance whenever one of the nurses was caring for a patient with a birth plan, but more so, the universal consensus from the nurses, to the midwives and obstetricians, to the anaesthesiologists and the OR techs, is that the more detailed the birth plan, the more likely the delivery would end up as a Cesarean. Even the Unit Clerk would ask about booking an OR if a patient handed her a 5 page birth plan upon her admission.

My thoughts on birth plans is that they can lead the couple to focus too much on the process and not the outcome and too often, disappointment is expressed when things didn't go according to plan. When Myrtle recounted her birth story, she described that she starting feeling cramping and uncomfortable around 11 PM. She went to bed and woke up around 5 the next morning and could tell she was contracting. She walked around her tiny condo for an hour and as the contractions picked up, they decided to go to the hospital. She was 5 cm upon her arrival and little Myrtle was born via a Vacuum Assisted Vaginal Delivery at 11:45 AM on her due date. Barely 12 hours of labour. Most of my patients and my infertile jealous self could only dream about having a delivery so perfect. Yet to Myrtle, there was one flaw. "I had to have an episiotomy, which I did not want." she complained. Oh, for fuck's sake Myrtle. It's not like you're at the deli and you're telling the guy behind the counter that you don't want pickles on your sandwich. I wanted to say these words to her, but as little Myrtle was in the Newborn ICU with breathing issues, I held my tongue.

Co-worker is the only patient I know who had a birth plan that went according to plan right to the letter. She drafted it right after learning she was having twins; 'I want a C/section'. Prior to learning of my placenta issues, my birth plan would have been 'let's just see how things go...' which has really become the approach for the since the discovery of the previa. As the placenta had moved past the os by 32 weeks, I no longer needed to be delivered between 36 and 37 weeks, but it still hadn't moved enough to allow for a vaginal delivery. So we had yet another follow up at 35 weeks and 5 days. The placenta was now 1.5 cm away from the os. It needs to be 2.0 cm to permit a vaginal attempt. The perinatologist that I usually see was on vacation, so of course, the one filling in offered a completely different opinion. He suggested re-scanning at 38 weeks to allow the placenta a little more time to move, and if it does, and as long as my blood pressure is controlled and the resistance index of the umbilical artery is normal, then I could go to 39 and a half weeks before he would induce. (The original perinate recommended delivery between 38 and 39 weeks due to my chronic hypertension).

So the latest birth strategery looks like this: If the follow up scan at 38 weeks indicates that the placenta has not moved enough, then we'll schedule my C/section the following week. If it has cleared 2 cm, then we'll induce at 39 weeks and 4 days, if I don't go into spontaneous labour before then. Hopefully not on July 4th. The petty aspect of my birth plan is that I desparetly want to avoid a 4th of July baby out of consideration for my English in-laws. It just feels like it would be very in-your-face to have their grandchild born on such an American holiday. Husband and I have discussing the pros and cons of each option. At times, the suggestion of a vaginal delivery makes me wishful for the conveniences of a scheduled C/section and most importantly, the opportunity to have my stomach muscles reapproximated. Other times, I feel that since we've come so far from a possible accreta and potential hysterectomy, then I sort of owe it to myself to try to avoid any major surgery by attempting a vaginal delivery. There are a few awkward logistical issues. My parents booked their flights when we thought I'd be delivery early and the baby would be 2 weeks at the time of their arrival. Now there is a chance they could arrive a week before the baby. Additionally, as we have been anticipating a Caesarean delivery, we've been factoring 8 weeks disability. My actual return date (not the one assigned to me by the DS) is predicated upon our trip back east at the end of October. If I have a vaginal delivery, it will be more costly as I'll only get 6 weeks leave and will have to take two weeks unpaid. Just as I was reflecting how shitty it is that women have take this into account with delivery decisions, Husband cheerfully piped in, "Best case scenario: you go to 39 weeks and 4 days, but ended up needing a C/section anyway!' Sometimes it's amazing how such simple concepts can rule the male mind...

So now that we've established a p-l-a-n, it's going to invite the Universe to fuck with it. The first potential variable is my blood pressure. It has been so good, I've almost been back in denial on whether or not I really have chronic hypertension. I tested myself by taking my Labetalol a few hours late and obtaining a reading. It was creeping up to 132/88. Sorry Jane, it's the real deal. I also know my well controlled blood pressure doesn't provide too much reassurance as I've seen patients go from zero to full blown severe pre-eclampsia in a day, if not, within hours. The other variable is Jate himself or herself, who won't stay head down. I suppose the former gymnast in me should be proud that he/she is essentially doing cartwheels in my uterus. At my twice weekly NST appoinments we've seen the head on the left side, the right upper side, cephalic presentation for the perinatologist, and most recently spine down transverse with the head on the right lower side. It's been like Mark Twain's description of the weather in New England; just wait a few minutes and it will change. I feel a little more encouraged as baby can spontaneously vert into a cephalic position and I've been doing the Forward Leaning Inversion and Breech Tilt, which is supposed to help with a transverse baby. I've been trying to determine the position, but it's hard to do Leopold's maneuvers on yourself as your hands are at the wrong angle. When a transverse presentation is confirmed, it feels as if I have something sitting across my lap, and I have much more pressure on my bladder when baby is cephalic. Transverse presentation is a little more frustrating to manage than a breech. If an external version is to be attempted, then an induction should follow immediately if successful as transverse babies are more likely to vert back than a breech. It's also recommended to deliver between 38 and 39 weeks as there's a higher risk for cord prolapse if spontaneous rupture of membranes occurs.

Alas, we wait and see. I still have no idea when, how or why I'll be delivered...