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Medical / Legal Q&A:

BIRTH PLANS, DELIVERY PREFERENCES
(AND OTHER PAINS OF LABOR)
by Dan Groszkruger, JD, MPH

A: Birth is a momentous occasion and some expectant parents would no sooner entrust the esthetic details of this most personal event to doctors and staff than they would invite them to redecorate the nursery. However, when a patient’s suggestions could compromise safe medical management of mother or child, it’s time to talk.

The key, of course, is to have a thorough discussion with the patient long before the delivery date. Set a deadline, early in her prenatal care, for your patient to submit a formal birth plan. OB patients need to know early that although you are willing to entertain some of their ideas regarding ambiance and comfort, you will not compromise on measures that are medically indicated to ensure a safe delivery. Such a discussion will clarify the patient’s expectations and prevent late-term surprises. While lighting, music, and pain management options are examples of relatively benign requests that you may be willing to accommodate, you may consider other items, such as I.V. access, to be non-negotiable matters. Explain to the patient why a particular request is unacceptable or medically contraindicated as well as the specific risks involved in refusing your recommendations. For patients requesting home births, remember that the MPT Agreement excludes coverage for any birth initiated outside of a JACHO-approved facility.

Even if you generally agree with the birth plan, include a caveat in your discussion. Explain that any provision of the plan is subject to change, based on the physician’s judgment at the time of delivery of what is medically necessary to ensure a safe delivery. Inform the patient that this also includes discontinuing any request that interferes with the concentration and performance of staff. Make sure you document this conversation in the medical record, including any revisions to the plan, informed refusal, and the risks involved in rejecting your medical advice!

After discussion, the majority of patients will readily defer to their physician’s expertise. If not, you should consider discharging the patient from your care at a point when it is still safe to do so. Before such a discharge, however, you will have to make sure that her condition is not so emergent as to be considered abandonment.