Birth Plans for High Risk Pregnancies

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Feeling forgotten when it comes to a birth plan because you have a high risk pregnancy? Most birth plans are geared toward low risk pregnancies and may not apply to your high risk birth. That doesn’t mean that you don’t get any say in your delivery! Having a high risk pregnancy can make labor and birth more complicated and will require certain adjustments from a low risk birth plan, but there are absolutely things you can do to customize your labor and birth. Whether you want to keep things as natural as possible, or just want to be prepared and learn about what you might expect in the hospital, having a birth plan in a high risk pregnancy is still a great idea! Read on to learn more about the different options!

    Many pregnancies are labeled “high risk” and are often all treated similarly once the label is applied. However, there is actually a range of risk within that category, and what is high risk to one provider may not be to another. For example, a 36 year old who is otherwise healthy will be considered high risk in some practices because she is of “advanced maternal age” (over 35 at the time of delivery), but her risk is not the same as someone with uncontrolled type 2 diabetes and preeclampsia. The birth plan options here are not meant to be all or nothing, and they may not apply to your particular situation. They are meant to give you ideas of alternatives to the “default” care in your hospital, and to give you a starting point for discussion with your provider. If in doubt, or you are not comfortable with your plan of care, always ask your provider why they have made a particular recommendation, and don’t be afraid to get a second opinion.

I will present common options you might see on a “low risk birth plan”, and then discuss how that may or may not apply to your labor and birth, and what you may be recommended to have instead for your high risk labor.

“I’d like to go into labor naturally” or “I’d like to wait until 42 weeks to be induced”

For many high risk conditions, the recommendation for delivery may be sooner than when your body would naturally go into labor. For example, pregnancies with preeclampsia or gestational hypertension are recommended to be induced at 37 weeks, while controlled insulin dependent diabetes, or fetal growth restriction with normal dopplers, are recommended at 39 weeks. When a particular gestational age is recommended for induction, it is usually because research has shown that continuing pregnancy past this point increased the chances of complications and poor outcomes. For other conditions, such as advanced maternal age, or someone attempting a vaginal birth after cesarean, for example, no earlier delivery is recommended than the standard “by 42 weeks”. Having a “big baby” is NOT an indicated reason for early induction as long as there are no diabetes or other complications. If you are being induced, talk with your provider about if your cervix is favorable (measured by using the Bishop score), and if it’s not, make sure they start with a cervical ripener (cervidil, foley bulb, or cytotec are commonly used ripeners you may be offered) to increase the chances of a successful induction.

“I’d prefer my water to break on it’s own”

As long as the labor is progressing normally and the baby is tolerating labor, this request is perfectly reasonable. Sometimes in high risk pregnancies, the baby can become stressed in labor and can have drops in the heart rate (this can happen even in low risk pregnancies if the baby becomes stressed). Many times, providers will recommend having the water broken if this happens so they can place “internal monitors” through a vaginal exam to better monitor the baby and contractions. The “fetal scalp electrode” is a small spiral that is placed on the baby’s scalp that monitors the heart rate continuously and provides a more accurate reading than an external monitor. The “intrauterine pressure catheter” (also called an IUPC) is a small tube that lays next to the baby within the uterus and monitors the strength of the contractions (an external contraction monitor can tell when a contraction is happening, but not how strong it is). The IUPC may be recommended if labor is not progressing normally and the provider needs to determine if contractions are adequate, if contractions are difficult to monitor due to maternal position or obesity (accurate assessment of contractions is important for adjusting pitocin), or if the baby is having drops in the heartbeat and the provider needs to see where they are in relation to the contraction. Some providers routinely rupture the membranes early and automatically place internal monitors in high risk labors, even without an indication. There is no indication for routine use of internal monitors, and if your provider recommends them, be sure to find out why. If the baby continues to have drops in the heart rate that don’t respond to normal measures, an IUPC can also be inserted to start an “amnioinfusion”, where saline is infused back into the uterus through the IUPC tube to help cushion the baby and take pressure off the umbilical cord.

“I’d prefer intermittent monitoring instead of continuous fetal monitoring”

Research shows that continuous fetal monitoring (being hooked up to the monitors to continuously monitor baby’s heart rate and contractions) in low risk pregnancies does not improve outcomes over intermittent fetal monitoring, where the heart rate is listened to every 30-60 minutes in labor and every 5-15 minutes as delivery approaches. With intermittent monitoring, you can move around more and get in any position you feel comfortable in. Even with this research, the standard of care in hospitals even for low risk pregnancies is continuous monitoring. With a high risk pregnancy, continuous fetal monitoring will likely be strongly recommended by your provider so they can keep better track of the baby. If medications are being used to start or speed up labor, or if you have an epidural, you would be required to have continuous monitoring (even in a low risk pregnancy) because these can cause changes in the baby’s heart rate.

“I want to be able to get up and walk around in labor”

Walking around in labor is ideal. It helps with pain control, keeps labor progressing, and helps the baby navigate the pelvis. With continuous monitoring, people often feel stuck in bed. However, “bedrest” is not automatically a requirement of continuous monitoring. Some hospitals have portable monitors (also called a tele monitor or walking monitor) that allow you to walk in the halls or even get in the shower or tub. Many nurses do not offer up that they have these devices, so be sure to ask. Even if your hospital does not have these, the cords to the monitors are fairly long and still have enough length to walk in the room or sit on a birthing ball. Some conditions, such as preeclampsia requiring magnesium sulfate, or having an epidural, do require bedrest. If this is the case, ask your nurse to help change your position every 30 minutes, or a least hourly, to help keep labor progressing. “Sims position” (imagine sleeping on your stomach, with your bottom hip out, and your top knee bent and resting over on the bed) is a WONDERFUL position for patients with epidurals that mimics “hands and knees” position, and is great for helping babies rotate in the pelvis. Many nurses are not familiar with this position, so make sure you ask them to include it in position changes and be ready to help them position you. Some hospitals also have “peanut balls” that can be placed under or between your legs to help change the angles of the pelvis for the baby.

“I’d prefer not to have an IV during labor” “I’d like to be allowed to eat and drink in labor”

Some hospitals require a “saline lock” (just the IV catheter inserted but no IV fluids running) by policy, others just place it and start fluids as part of their routine care. If your pregnancy is high risk, it will likely be strongly recommended that you have at least a saline lock placed, even if fluids are not running. Some conditions make it more likely that the baby will not tolerate labor well (fetal growth restriction, oligohydramnios/low fluid levels, and uncontrolled diabetes, for example), and IV fluids are part of “intrauterine resuscitation” (things that are tried to make the baby less stressed). In an emergency, a saline lock that is already in place can save precious minutes, especially in an emergency cesarean. Depending on the situation, you may be able to decline routine IV fluids unless there is a particular reason that warrants them. You likely will not be able to eat food in labor if there is an increased likelihood of cesarean section (anesthesiologists worry that you can vomit the food during surgery and aspirate on it, basically breathing it in). Unfortunately, many hospital policies do not let even low risk women eat in labor for this same reason, even though it is not evidence based. Some providers will order clear liquids (juice, water, jello, broth, popsicles, etc) for labor patients, others order ice chips or nothing at all. If a cesarean section is likely imminent (the baby’s heartbeat is dropping and they are trying to stabilize it, or you have a medical condition that is worsening, for example, then it is recommended to have nothing by mouth until everything is sorted out. Otherwise, clear liquids are usually acceptable.

“I’d like to have a doula”

DEFINITELY ok! I can’t recommend a doula enough in a high risk pregnancy. High risk labors can be scary because so much is unfamiliar and can change quickly, but they can help guide you in the questions you should be asking your provider, provide reassurance, and be your advocate. A doula can not make medical recommendations as they do not have medical training.

“I’d like to push and deliver in different positions”

In the hospital, the most common delivery position is reclining back, with the feet up in stirrups. There is no evidence based reason for this, it is purely provider convenience or patient request. With almost any high risk condition, you can push and deliver in any position in the bed as long as the baby is tolerating labor (side lying, squatting, hands and knees, etc) and you do not have a medical condition that would not allow for being up. If there is a reason that you can not be up on hands and knees or squatting (if you have an epidural, or decreased mobility, or just preference), you can still be assisted in changing positions from side to side during pushing. If there is a possibility of a vacuum or forceps delivery, then you will be asked to be reclining back with feet in stirrups for the procedure.

“I’d like to avoid routine episiotomy”

DEFINITELY still ok to have in the birth plan, even for high risk patients! A prolonged fetal heart rate deceleration, a vacuum being placed, or a shoulder dystocia would be some reasons that an episiotomy might be recommended.

“I’d like immediate skin to skin after the birth” “I’d like delayed cord clamping”

As long as the baby is healthy and vigorous (breathing, normal heart rate, good muscle tone) after delivery, many babies can go immediately skin to skin. If the baby is not vigorous and requires resuscitation, especially with meconium present (the baby had a bowel movement before birth), or has a medical condition requiring immediate evaluation, the baby will typically be taken to the warmer and evaluated by the pediatrician and then brought back for skin to skin if stable. As long as the baby is able to stay skin to skin, delayed umbilical cord clamping is also possible. Some hospitals are able to resuscitate the baby at bedside while the cord is still attached, but most take the baby to the warmer. If the baby does need to be taken immediately, then cord “milking” is an option prior to cutting to help more of the baby’s blood get to the baby.

“I don’t want routine pitocin after labor” “I’d like to wait for the placenta to deliver spontaneously”

Pitocin is routinely given through the IV after delivery in hospitals to decrease the chances of postpartum hemorrhage. A low risk pregnancy is also usually low risk for hemorrhage, and postpartum pitocin may not be needed. However, many conditions that make pregnancy high risk, such as preeclampsia, uterine infection, or having been on pitocin to induce or augment labor for a long period (it is used in a much smaller dose during labor) can also make hemorrhage more likely. Research shows that bleeding in these situations can be decreased by “active management”. This includes postpartum pitocin and gentle traction on the umbilical cord to help the placenta come out faster. Talk with your provider about if you are at high risk for hemorrhage in your particular situation.

“I plan to breastfeed”

DEFINITELY still ok! If your baby has a medical condition that makes breastfeeding difficult, you can pump and feed the baby that way. Some situations may make breastfeeding not recommended, such as use of certain medications for maternal conditions, HIV positive maternal status, or maternal substance abuse. However, many doctors and pediatricians are not well versed in different medications and breastfeeding and may default to “just bottle feed” if they are unsure, out of caution. If you are on medications, or you or your baby have a medical condition that may make breastfeeding difficult, try to talk with a lactation specialist before delivery so you have support in place and can be prepared for what to expect.

I always recommend bringing your birth plan with you prenatally to review with your provider, and having them sign it with any adjustments. Have them make a copy to keep in your chart, and bring one with you. That way, if someone else is on call other than your usual provider, they know that you already gotten the “ok” for something that is not routine, and you have a backup if your chart copy happens to be “misplaced”. Also, you may need to remind your provider if you want something that is not routine right before it would normally be time for it (declining episiotomy, delayed cord clamping, declining pitocin). Even if they have the best intentions, they may forget and default to their routine out of habit. Give this job to your partner, support person, or doula, as you will likely be working hard and preoccupied in the moment.

If you want something different than what your provider recommends, talk with them about it: Why do they feel that way? Can they show you the research that supports it? What are the risks, benefits, and alternatives? Can you have some time to think about it? If you still don’t feel comfortable with their recommendation, do some research of your own (Real research. Blog posts of opinions and crowdsourcing on facebook don’t count!). If you find something credible that supports your position, bring it with for your provider to read and discuss further. Especially because your pregnancy is high risk, you will likely be asked to sign a form saying you are going “against medical advice” if you choose not to follow their recommendation. This form helps protect the provider if there is a poor outcome.

Birth is unpredictable. Don’t get your heart set on any one particular piece, or think that if something changes off your birth plan that you have “failed”. Sometimes in high risk pregnancies, the complication becomes what is focused on, and the patient becomes an afterthought. A birth plan is a wonderful way to help you prepare for labor, give you a vision of how you would like your labor to be, give you a tangible way to discuss your plans with your provider, and keep your labor individualized.

Please leave any comments or questions below. I love hearing from you!

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