Making an informed and realistic birth plan
The most important benefit of writing a birth plan is that it forces you to think about labour and delivery and helps you prepare for what may happen. A birth plan is an ideal way to express how you would like your delivery to go; it helps you communicate with your health care providers when you are in labour and it gives you a chance to think of how you may respond if things don’t go exactly as planned.
My suggestion to patients is always to keep an open mind. Labour is unpredictable – and no one knows exactly how it may progress. I’ve certainly seen women who were disappointed because their labour did not unfold as dictated in their birth plan; for instance, they had planned not to have an epidural but ended up wanting one because the pain of labour was more than they expected or could tolerate. Or, they ended up with a caesarean section because labour stopped and the baby’s wellbeing was a concern. Don’t write things down that may prevent your health care provider from giving you the care you need in a situation you did not anticipate. State your preferences but acknowledge that you may change your mind, or are open to discussion. Sometimes couples get fixated on their birth plan and come away with a sense of failure or even guilt because things did not go according to plan. As a doctor, I want you to have a great birth experience, but even more, I want you to have a healthy baby at the end of your delivery.
Why a birth plan can be useful
A birth plan is especially useful if there are certain things you want to identify, such as: your labour support person, your preferred methods of pain relief and the order in which you would like to try them, who cuts the umbilical cord, whether or not you would like cord bloodstem cell collection, your plans for feeding your baby and whether you want the baby up on your chest right away or dried off first.
When writing your birth plan it is important to be realistic and to get your facts straight. Birth plans printed off the internet or information received during prenatal classes can often be out of touch with what we do. Unfortunately, not everyone who teaches prenatal or birth classes has worked on Labour & Delivery, be sure to check any information you may receive with your health care professional. Three concerning things I frequently see in birth plans are the statements:
1). I don’t want to have an enema or have my pubic hair shaved.
In the 20 years I have been working in our Labour & Delivery unit, I have never seen a woman in labour receive an enema or have her pubic hair shaved. This is an out-dated practice and is not a concern.
2). I don’t want a caesarean section (or forceps or a vacuum assisted delivery).
I can tell you that doctors also hope you have a normal vaginal delivery. I have never suggested, or done, an operative delivery unless I thought it was in the mum’s or baby’s best interest. Yes, sometimes a caesarean section may be done because we are concerned about the baby, only to have the baby born completely fine. The information we use, such as baby heart rate monitoring, is not without its limitations and as a result we may do more operative deliveries than are necessary, but this is only something you can say for certain after the baby is born. Be sure you understand why a labour intervention such as a caesarean section is being recommended and what your options are. Your health and safety, as well as the health and safety of your baby are always our priority.
3). Do I have to have an episiotomy?
Years ago, episiotomies were commonly performed as it was thought it would decrease the chance of a tear. While it’s certainly easier to repair an episiotomy than a tear, research suggests there is no real benefit to the procedure. I can’t actually remember the last time I did an episiotomy - except in the case of a forceps delivery when we do actually need more room. Apart from use with certain assisted deliveries or with a very large baby, episiotomies are no longer routinely done. Ask your health-care professional what the practice is in your centre.
And finally, keep your birth plan simple and short - one page at most. Be positive and focus on what you want rather than what you don’t want. Before you start to actually write out a birth plan, talk to your health care professional about the common practices in your area, such as your options for pain control during labour and how many people you can have in attendance during labour.
Download the birth plan [PDF] we have developed for your use. Feel free to add anything else you feel is important.
Information you will need for your birth plan
Once you have found out how many support people you are allowed at any one time, discuss with your partner who you would like to be present. Support people are meant to help you through what can truly be an amazing experience; but it can be a stressful time as well. If someone is not going to be helpful, or will cause extra stress, ask them to stay in the waiting area - or better still, tell them to stay at home and you will call to let them know when the baby is born.
Pain Control Options
There are several options for pain management that most centres provide. First of all, you don’t have to take any pain control - only you know how much pain you’re in and how much you can take. If you do want something, you just have to ask. Depending on how far along you are in labour, your health care provider should discuss your options. In the early stages women often find that moving around, getting in a warm bath or shower and/or having their back rubbed is helpful. Sometimes, people want or need more than that. Remember, everyone is different. Just because your best friend did it without anything doesn’t mean you have to… it’s not a competition! Options your health care provider may have discussed with you could include nitrous oxide (a gas), narcotics such as morphine, or a regional anaesthesia such as an epidural. You can start with nothing and work through everything. Consider what you might want and what order you might want them in. Discuss with your health care provider before you are in labour.
You might want to write something like: “I would like to try to labour and deliver without any pain control but if I request something I am open to suggestions so please discuss all the options available to me.”
Monitoring your baby’s heart rate
The only way we can know how your baby is doing during labour is to listen to his/her heart rate. We can do this intermittently with a doptone (the same hand held device that we use in the clinic) or continuously with an external heart rate monitor, held on by a strap around your waist or with an internal scalp electrode. The recommendation for intermittent monitoring is to listen to the baby every 15-30 minutes during the first stage of labour (up to 10cm dilated) and every 5 minutes during the active second stage of labour. (We listen to the baby’s heart rate for 30-60 seconds after a contraction ends). The benefit of intermittently listening to the baby is that you are free to get up and move about but it doesn’t offer as clear a picture of what the baby’s heart rate is doing. If you are considered high risk, or if there is something being done out of the norm (for example, you are receiving oxytocin), we will recommend continuous monitoring to keep a closer eye on your baby. If we are having problems monitoring the baby’s heart rate or are concerned with what we are seeing, we may recommend an electronic scalp electrode. This is a little electrode that attaches to the baby’s scalp. It is certainly very safe but is not routinely done.
All of these efforts are to monitor your baby’s wellbeing. It is really an indirect assessment of how much oxygen your baby is getting during labour. If we are concerned about the baby’s heart rate, we may suggest getting a drop of blood from the baby (baby scalp blood sampling); it’s like diabetics taking a drop of blood from their finger to test their sugar, except in this case we take a drop of blood from the top of the baby’s head (or their bum if it’s coming down first!). Based on the blood test for oxygen, pH or lactate, we will be able to better inform you about your baby’s wellbeing.
You might want to write something like: “I would prefer to have my baby’s heart rate monitored intermittently. If you think I should have continuous monitoring of my baby’s heart rate, please explain to me why and if you are concerned about something.”
Positions for Labour and Birth
No one position is best for everyone at all times. Some women prefer to walk around and hold on to something or someone during a contraction. Some prefer being on their hands and knees, or on their side or on their back. Everyone is different and as labour progresses you’ll likely find different positions feel better. The same is true for delivering your baby. Some women deliver on their hands and knees, some on their sides and some on their backs. Speak to your health care provider about what practices are common where you’re planning on delivering. There is no research to tell us what labour or delivery position is best. Different practitioners have their preferences but it is not based on any good study. Ask questions about what people do and identify what your preferences are.
You might want to write something like: “During the first stage of labour I would prefer to move around as long as I am comfortable and able with the support of my partner. At the point when I move to a birthing bed, I would like to try different positions to see what feels right for me.”
There are all kinds of reasons why your health care provider may discuss some sort of medical intervention with you. Again, keep an open mind. No woman wants to have forceps or a vacuum or a caesarean section. But what happens if you’ve written down that you don’t want any kind of medical intervention and your baby gets stuck, or despite your pushes the baby doesn’t come down, or your health-care provider is concerned about your baby’s heart rate. Similarly, if you state that you don’t want an intravenous but end up deciding to have an epidural, you will have to have an intravenous before you get an epidural. State your preferences but don’t make it impossible for your health-care providers to help you and your baby.
You might want to write something like: “If we agree that I have to have help delivering the baby, I want you to help me understand which way is best for my baby and me.”
Who do you want to cut the umbilical cord? Do they delay cord clamping at your centre? Have you planned for cord blood banking? Do you want the baby put directly on your chest or dried off first? Do you have any specific religious or cultural beliefs? There may be other things you want to consider. Speak to your health-care professional.
Feeding your baby
If you are planning on breastfeeding, we will support you, starting within the first 30 to 60 minutes. If you are planning on bottle feeding, let your nurse and support people know and we will help you get started. We are there to respect your decision…but if you need help making the decision either before labour, during labour or afterwards, we are there to help you.
There may be other things you want to consider or discuss. Put them down. Talk about them. Ask questions. The birth plan should be a way to facilitate discussions with your health-care team.