Sunday, January 30, 2011

Thoughts on birth plans

Desiree of Hitting My Stride recently asked about birth plans--should she write one? If so, what to put in it? Is it too presumptuous to plan for an event that includes a lot of unknowns and uncontrollable factors? (She has two rare blood clotting factors that make hospital birth a necessity and induction fairly likely if the baby doesn't come by 38-40 weeks.)

I was thinking about what I'd say in response, and my first thought was: let's back up a bit first. Before even thinking of writing a birth plan, or list of birth preferences, or whatever else you want to call it, you need to know what is routine practice at your specific hospital. The last thing you want to do is write up a birth plan full of things that are totally irrelevant at your hospital. That will make the staff laugh or roll their eyes or label you as a control freak.

So first off, before you even think of writing up a birth plan, head to your hospital and talk specifics with the L&D nurses. For example, if you really want immediate, uninterrupted skin-to-skin contact after the birth, ask the nurses how likely it is to happen. What about skin-to-skin after a cesarean? If the mom or baby needs additional attention after the birth? If something is not routine practice, ask them what you need to say or do to make it happen. Go through all of the things that really matter to you. Ask the nurses which things won't be an issue and which you'll need to clearly communicate ahead of time.

Some things will need advance planning, such as wireless and/or waterproof telemetry. Some hospitals have telemetry, while others do not. If you know you'll be having constant monitoring (for example, for an induction) but want to have more freedom of movement, ask about wireless monitoring now, while you're still pregnant. If they don't have it, insist they order it! Ask to speak to the person who is in charge of ordering equipment and see what you can do to ensure they have the proper equipment in time for your birth. Or let's say you want to have access to nitrous oxide (aka gas & air or laughing gas) or TENS units for pain relief. These are both rare in the United States, although quite common in other countries such as Great Britain. You'd definitely need to inquire about them in advance.

My next advice--which Desiree seems to have down already--is don't worry about including any of the little things that you shouldn't even be asking permission for. The don't ask, just do kind of things. Eating and drinking if you're hungry, moving and changing positions, music, lighting, unhooking yourself from the monitors to move/go to the bathroom/etc (especially if, like most women, you have no specific reason to be on constant monitoring). Just do these things and don't take any flak from the nursing staff. Make sure your birth partner knows about these things and can buffer you from the nursing staff if you deviate from their policies or routines.

A third suggestion would be having two separate plans: one for the hospital staff with your most important preferences, and a longer, more detailed one for your partner, husband, or support person. Write down all of the things you want your support person to remember for you, so you don't have to remind them when you're in the middle of labor. Things like keeping the room lighting low, keeping you hydrated, helping you into different positions, asking you if you've had enough time to make X or Y decision, reminding both you and the staff of your preferences.

Now let's get back to the birth plan for hospital staff. Once you've eliminated all of the things that are irrelevant to your specific hospital and/or provider, write down the most important things in the briefest possible way. Keep it short and easy to read. Use lots of bulleted points, rather than long, wordy sentences. Don't go into any long-winded preambles. When I say short, I mean short. If you can make it fit onto an index card, all the better. Here's an example of how to communicate your pain relief preferences:
Pain relief:
~ Do not offer or suggest pain medications. If I want something, I will ask.
~ Do not ask me to rate my level of pain; please make up a number if required for your charting.
~ Please offer or assist with non-pharmaceutical comfort measures (showers, warm baths, birth balls, movement, changing positions, etc).
Instead of going into detail over every separate procedure, think of writing a general directive to ensure you are giving full informed consent. Something like this:
Please ask for my permission before every procedure, examination, medication, or intervention (including vaginal exams, AROM, episiotomy, routine infant procedures, etc).  If it is not an emergency situation, ask if I have had enough time to consider my options and review the alternatives before consenting to the procedure. 

When you arrive at the hospital, you can request a nurse who has experience with unmedicated labors (if, like Desiree, this is important to you). Have your birth partner talk to the admitting nurse and say something like "She really wants to labor without pain medications and labor and push in upright positions. Could you assign us a nurse who would be excited to help make this happen?" They might be too overstaffed to meet your request, but they might also be able to arrange nursing assignments to give you a nurse who loves working with unmedicated moms. This doesn't mean you are locked into having a "natural birth," just that you'll have more support for your initial desire to labor without pain medications.

My final thought is that planning for birth is like preparing proactively for breastfeeding. There are the individual choices you make and have control over during pregnancy, such as provider or place of birth. There are the institutional protocols and provider preferences that will influence what happens to you during labor and birth. And then there are the unpredictable, uncontrollable events that may throw you a curveball during labor. Birth plans are primarily for the second category of events--navigating institutional routines and employee protocols that may or may not be what you want, and may or not be beneficial for your or your baby.

Birth plans also help ensure that you remain more in control over your individual, personal choices. Because if you really want an unmedicated birth, but the hospital staff and routines all push you towards having an epidural, you're going to have a hard time accomplishing your goal. Or if you want lots of uninterrupted skin-to-skin contact, but the hospital routinely takes babies to the warmer and only returns them after examining, weighing, bathing and swaddling, you'll probably find your arms empty after the birth. The birth plan itself does not ensure that your wishes will be followed. But it is a starting point for communicating what is most important to you. 

Labor and birth have unpredictable, uncontrollable elements. We cannot make these magically disappear simply by waving a birth plan around. But a lot of what happens to women during labor doesn't occur because of Mother Nature, but rather because of hospital routines, employee protocols, liability protection, and providers' preferences and training. This is where planning and preparation can make a difference.


  1. I love this!! I am going to definitely refer people to your post over at

    But also... nurses can't and absolutely shouldn't be making up things (pain scale numbers) to place in a patients chart. I think the most important word to remember here is DEFER. That word will get you very far in the medical world. If you decide you don't want to give them a number, make it clear you won't be giving numbers from the outset, and they can write in the chart "pt deferred". It's a magic word. It lets them know, you don't want it, but you don't have to say much and feel like you are being a squeaky wheel. When I went in to my son's 1st pedi appt. I was very scared to defer most of the vaccinations, but I just said "I think we are going to defer X, Y, and Z" and they didn't even blink an eye.

    It's also much nicer than "refused" which has a negative connotation!

  2. Excellent!

    When people ask me about birth plans, I say "FIRST, figure out what kind of birth you want - THAT is your plan. Now find a provider and location that specializes in that type of birth." When my clients come to me with birth plans they've printed off the internet, I try to explain that a birth plan is more about figuring out their objective and knowing what to do to increase your chances of achieving that objective. For example, if their main objective is to avoid a cesarean at almost any cost, yet their birth plan says "Please offer me pain medication as soon as I arrive," I try to explain to them that their objective may not be matching up with their "plan." Let's talk about what you want, and what the likeliest path to get you there is. THAT is a birth plan. And I firmly believe that every woman SHOULD have a plan! Preparation can make for a safer, more satisfying birth experience -- and if everything goes wrong, at least she is informed enough to know why, or what questions to ask about what went wrong.

    As far as what the hospital should see - I say they get nothing more than a couple index cards taped to the door that say "DO NOT OFFER ME DRUGS" or the whatever it is that's most important to the mother. An 8x11 printed, bound, laminated birth plan just gets laughed at at the nurses station (if they even bother to take it at all.)

  3. I read Desire's wonderful post about birth plan's and my first thought was, I wonder how Rixa would respond? Great to read this.

  4. I think this is a great post! I had a birth plan for my son's birth at a very intervention friendly hospital. While, my "don't mess with me" laboring woman attitude helped me as well. The staff read and was extremely respectful of my plan. I didn't make a big deal about the plan itself and just slipped it into the materials for my chart. It was OBVIOUS that everyone who entered my room had read my birth plan. I think this really contributed to the fact that I achieved a natural birth and my son never left my side during the entire stay. I think it is irrelevant to say that the nursing staff will laugh at a plan. Who cares if they laugh, as long as your plan is followed.

  5. As one who is about to give birth, I've found that even better than writing up a specific birth plan is to (a) talk about it with my spouse so that he understands what I really want/don't want and (b) hire a doula.

    When I first found out I was pregnant, I kept thinking how wonderful a doula would be at the birth. So after thinking about it for a few weeks, I researched doulas in my area and started the interviewing process. I love the doula I found and just talking with her about things that I would like to avoid (Pitocin) and my preference on drugs (want to be encouraged to labor as much as I can handle without drugs) has been much more beneficial than writing an actual birth plan.

    It also helps that I am delivering with incredible midwives at a very baby friendly hospital.

  6. Great post on birth plans-it never occurred to me to actually talk to the L&D nurses beforehand and find out exactly how things go-or to request a nurse who is excited about a natural delivery.

    Thanks Rixa!

  7. Great post!!
    Just a tiny note - nitrous is NOT rare in Canada! We use it all the time up here, it is a wonderful option to have available.

  8. Nicole--I'll note that change. Thanks!

  9. What great tips - thank you so much for your insight!! I love the idea and even the wording of requesting a nurse who is excited to help unmedicated moms - what great phrasing!

    And I especially love the separate birth plan idea, for the hospital and my husband. He and I have started talking about his role in this and how different it will be from the role of my doctor and nurses. We're not 100% on the same page yet, but we're getting there!

    Thanks again for the great advice!


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