Birth Plan Schmurf Plan

On Friday we went to the OB/GYN for the beta Strep B test and a cervical check as Ellen was 36w2d.  Since ours is a unique birthing situation, I decided to come up with a birth preference plan in order to minimize confusion.  Ellen has never used a birth plan with any of her prior pregnancies knowing that plans don't really mean anything when it comes to actual delivery.  Still, she agreed that it would make sense to have something in writing so that the hospital was aware that Jason and I are to make all medical decisions following his birth.  I scoured the internet trying to find birth plans for surrogates and intended parents and really only found this.   My sister-in-law gave us a copy of her birth preference (she took the word plan out of the name but I think we all know it was still a plan) and I used both of those sources as a guideline to for ours.  Both plans included a lot more information about labor preferences but since Ellen wasn't concerned about that, I omitted that part.  The main things I was concerned about was having delayed cord clamping and doing immediate skin-to-skin contact with the baby. 

I had my birth preference plan in hand when the doctor walked in.  He glanced at it and said in a somewhat snarky manner, "Oh  no, she's got it written down".  I told him that I'm really not  Type-A but wanted to have things in writing since this is such a unique situation.  He then said, "Well you might as well tell me what's in it because I'm going to have to read it anyway".  I told him about my two main preferences and to my dismay, he told me it wasn't possible.  "We can do delayed clamping- no problem.  But you can't do immediate skin-to-skin.  The baby will need to go on her belly (gesturing toward Ellen) because the cord will still be attached".  He went on to say that the NICU team will then need to assess him since he will likely be under 5lbs as he is IUGR.  NICU?!? IUGR?!?  These are terms I hadn't yet heard associated with my baby.  I knew he was measuring small, but I thought he was just SGA.  I told the doctor that and he said "They're the same thing".

So what are all these acronyms anyway? IUGR stands for Inter-uterine Growth Restriction (though I've also seen it referred to as  Growth Retardation) and refers to a baby that is not growing at the normal rate in the womb.  Specifically, it means the baby is below the 10th percentile.   Our baby has been measuring small since we first went to the specialist at 22 weeks.  This is why we have the weekly appointments with the specialist where they measure his growth every other week and do biophysical profiles on alternate weeks.  His biophysical profiles have always been perfect and the specialist has never given us any reason to believe that the baby would need the NICU.  I was quite alarmed to hear otherwise from the OB.  The specialist has always maintained that thought he is behind, he is likely just a small baby.  I'm just five feet and Ellen has never carried a baby over 6lbs 8oz, so its likely that the fact that Ellen grows smaller babies and the fact that his mom is small plays a role in his size.  I was under the impression that IUGR meant there is a problematic reason that the baby is measuring small (problem with blood flow from the cord, problems with the placenta, etc) but SGA (Small for Gestational Age) meant just that- the baby is small for his gestational age but there is no known cause. This doctor was suggesting otherwise and it was certainly concerning. 

Also concerning was the fact that I was told I could not do immediate skin-to-skin contact. Skin-to-skin contact (also known as kangaroo care) entails placing the newborn naked baby on the mother's chest immediately following birth.  Research has shown this helps regulate the baby's body temperature, respiration and glucose stability in addition to enhancing bonding and helping to promote lactation in nursing mothers.  Now, I obviously won't be nursing which is why skin-to-skin felt extra important for me. I really want to have that time to be finally be mom to this baby.  I even registered for a special shirt that I plan to wear during delivery so I can do kangaroo care.  It never occurred to me that I would be unable to do so right away. The doctor told me that I would get the baby once the cord was cut, though suggested that if he was under five pounds the NICU team would get him first.   Upon hearing that, I took the birth preference plan and threw it into the trash.  What was the point of having a preference plan when my preferences weren't going to be realized?  I know that the birth process is not typically what we imagine, but now all I could see was the baby being put on Ellen's stomach and not mine, and this image hurt.

After the appointment I talked to some well-intentioned family and friends, who assured me that I would have plenty of time to do skin-to-skin, that not doing it immediately wouldn't really make a difference, that I have his whole life to bond with him, etc etc.  And while all this is true, it didn't really help in the moment.  In the end, what it comes down to is if I was the one delivering my baby none of this would be an issue. It would be my belly he would be placed  upon.   I, once again, had to grieve the fact that I wouldn't get to deliver my baby.    Just when I thought I was done crying about this....

I shed my tears.  More than once.   Then I pulled myself together and met Jason and some friends for a quick bite before we saw Interstellar.   The next morning, Jason and I headed for a baby prep-filled day-  a Baby Essentials Class from 9-12 followed immediately by Infant CPR from 12-2.  I was a bit nervous about how I would feel being the only woman in the class who wasn't visibly pregnant, but soon realized we were all just clueless first-time parents learning to swaddle.  After the class we went over to our good friends home to pick up car seats and tons of baby toys that they so graciously passed along to us, dropped off an extra car seat at Jason's mom's house, and went to Buy Buy Baby to get some last minute essentials.   It was an educational, exciting, exhausting day but it helped me shift gears a bit beyond the delivery room and into baby's room.  

Ultimately, I decided that I am going to print out a new copy of the birth preference plan.  I think trashing it might have been a little rash.  I do still think its important that the hospital is aware of our situation.  I will likely make some changes on the new copy involving either asking for the skin-to-skin with the baby following the delayed cord clamping, or removing the delayed cord clamping request all together.  At a physician friend's recommendation, I did some more research on delayed cord clamping and it seems while it is beneficial for premature babies, it is not necessarily beneficial and may even prove harmful (causing dangerously high volume of red blood cells or increased risk of jaundice).  I intend to speak to the OB about this at our next meeting, and also want to express the reasons behind my desire for being the first to have skin-to-skin with the baby.  I am hopeful that together we can come up with a solution that is best for the baby but is also sensitive to our situation.

Oh, and about that baby being IUGR and being under 5lbs at birth? We went to the specialist again on Monday. The doctor confirmed what I had thought all along- there is constitutional IUGR (meaning baby is just constitutionally small) and pathological IUGR (meaning something is wrong with the baby or the womb that is preventing proper growth).  As suspected, he believes our baby is just constitutionally small.   And Baby O had a growth spurt!  He is 5lbs5oz and in the 7th percentile!  NICU SCHMICKU!

Since I had a hard time finding a Gestational Surrogate/Intended Parent Birth Plan to use as a guideline, I'm including my original one here.

ELLEN M (GESTATIONAL SURROGATE) AND JASON AND KERRI ORANSKY (BIOLOGICAL/INTENDED PARENTS) BIRTH PREFERENCE

Attendants: Chris M (Ellen’s husband) Jason and Kerri O (Intended Parents)

OB/GYN: Dr. Ramani, Eagles Landing OBGYN

            Pediatrician: Dr Deneta Sells, Intown Pediatric and Adolescent Medicine

We would like to thank the Piedmont Henry staff in advance for helping us achieve our goal of natural childbirth via gestational carrier!  Ellen M, the gestational surrogate, is carrying a baby boy that was conceived via Kerri O’s egg and Jason O’s sperm.  They are the biological parents of this baby and will be making all medical decisions for him upon birth.  We know this is a unique delivery situation and hope that with this plan we can minimize confusion and have a beautiful birth experience for all involved. Ellen has had four previous natural deliveries and would like to attempt a natural delivery for this baby as well. We are aware that childbirth is unpredictable and are willing to be flexible should Ellen or baby be in danger.  The below preferences have been discussed with Dr.Ramani.  We are aware that many of our preferences differ from the staff’s normal routine, so thank you for your support and understanding!

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Delivery Preferences:

• We ask your support in assisting us to find the most effective and comfortable position for pushing (gravity-positive), and would ask to avoid directed pushing – allowing Ellen to push when the urge is felt.
• Natural tearing is strongly preferred in lieu of an episiotomy.  Please discuss with us if an

episiotomy is deemed medically necessary.

• Ellen would like to take the crowning stage slowly and requests warm compresses/perineal massage to help avoid any unnecessary tearing.

• We prefer the placenta be delivered naturally.
• To allow for bonding with the biological mother, we would like immediate skin-to-skin contact between Kerri  and the baby.  Please delay all tests for as long as possible.
• Delay cord clamping/cutting until pulsing has stopped, before it is cut by Jason.

Newborn Preferences:

• We do not want our baby to receive the HepB vaccine.
• We are planning an out-of-hospital circumcision procedure.
• If the baby needs to be taken to another area for testing, we request that a parent accompany him at all times.

Emergency Procedures:

• In the event of a C-section, we request that Kerri and Jason remain for the entirety of the surgery and for Kerri and Jason to stay with the baby until the family can be united.  If an additional person is allowed, Ellen would like her husband Chris to be present. If only one person is allowed, Kerri will be the designated person.
• We would like immediate skin-to-skin contact between Kerri and baby as soon as possible following delivery.
• If the baby requires NICU care, we request the right to feed and care for him as much as possible, including the opportunity to provide Kangaroo Care.