Writing Your Birth Wishes

One of the services that I offer as part of my doula packages is help in writing a birth plan.  Some people may have providers who encourage them to make a birth plan, or encourage them not to.  Others may feel like they don't need one because they are flexible.  In today's post I want to clear up some common misconceptions about birth plans so that you can decide if it is something that you would like to do.

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Flexibility is Key

First of all, it is important to remember that a birth plan is not set in stone.  When it comes to birth, it is important to be flexible.  You may have a beautiful vision of exactly how you want your birth do go right down to minute details.  It is fine to fantasize about the perfect birth, but in reality, your birth may not go exactly as planned.  If you close yourself off to anything that falls outside of your perfect vision, you may find yourself disappointed in what may have actually been a lovely birth experience.  Things happen that may be out of your control, and it is important to be able to go with the flow.  

Don't worry about what worked well for your sister or your best friend when they were in labor.  Don't even rely too much on what worked for you in a previous labor.  Those are great starting points for ideas of what to try, but don't limit yourself.  Wait to see what this labor will bring.

You may be aware that most births aren't complicated, and that a common cause of complications is what we call cascading interventions, where one intervention leads to another, leads to another, etc.  This makes many people adamantly opposed to any kind of intervention.  However, it is good to remember that almost every intervention can be a good thing when used correctly.  No one wants an episiotomy, but sometimes it is necessary to get baby out in an emergency.  Pain medication can slow things down and cause baby's vitals to decel, but when used at the right time with the right women, they may give mom just enough of a rest to help her progress.  

When writing out your birth wishes, make sure to include something along the lines of "We are aware that complications can arise during the labor and delivery process, but we would like to limit interventions to only what is medically necessary."  Then perhaps when you list your wishes, say something like "We would like to avoid an episiotomy unless medically necessary, and would prefer to tear rather than be cut."  This phrasing communicates your desire while letting your care provider know that you can be flexible in an emergency.

Make sure you're on the same page

One reason why care providers may try to talk parents out of writing a birth plan is that they may have had patients who have been very demanding, and they see it as the parent's trying to override their authority. This is actually a good reason to write a birth plan.  You always want to share your wishes with your care provider ahead of time to gauge their response.  If your provider is opposed to anything that you find to be especially important like delayed cord clamping, or being allowed move around or eat during labor, you will likely want to find a new provider.  

Are you with a group of doctors and/or midwives?  Make sure that you share your wishes with each of them, and that they are all on board.  If not, feel free to talk to some other practices to see if you can find someone who is more on board with your desires.  

Are you restricted by insurance?  See if there are any doctors in your group who are on board with your wishes and ask them if there is a way to ensure you will get someone who will work with you regardless of who is on call that day.  That may not be an option, but you will never know if you don't ask.

It is also a really good idea to find out statistics for your birthplace/provider.  You can find out the Cesarean rate not only for the hospital, but for your individual care provider.  You can also find out statistics for other interventions you might want to avoid such as episiotomies, or Pitocin.  These statistics are public and they have to be provided upon request.  You can look up the Cesarean rates for your hospital at cesareanrates.com.

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Find what is important to you

A birth plan shouldn't be more than a page long.  That means that you should only include things that are important to you.  If your care provider says that something you would like is routine or encouraged at your birth place, you don't have to include it on your birth plan.  For example, if you want to be able to move around and not be restricted to the bed, and the hospital you are going to encourages movement, you don't need to include it.  Keep it short and to the point.

It should also be well organized and easy to scan quickly.  Try bullet points with the important part highlighted.  If you want to provide reasons or descriptions that is fine, but make sure a busy nurse can scan it quickly and get the gist.  For example:

Unless medically necessary, we would like to:

•    Please don't ask about pain medication or offer it as a suggestion.  We know they are available and will ask if we
     are interested
•    If contractions are decreasing or inconsistent, let us try more natural methods before Pitocin is administered.  Do
     not administer Pitocin without mothers consent.
•    I would prefer to tear naturally rather than be cut.
•   We are aware that it is important to make sure baby is doing well, but would prefer not to have monitors on at all
     times.
•    I would like to be able to get up and walk around.  If monitors are required, I would like access to a telemetry unit if
     possible.

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Prepare alternate plans

I encourage my clients to make a couple of different birth plans to cover different situations.  Keep them in your birth bag and only pull them out if necessary.  

The first one is what you would ideally like to happen.  These are your main birth wishes which I have talked about above.  Your birth wishes should include sections for labor, delivery, and postpartum care.  Include what is important to you.  

The labor section can include things like the example in the last section.  The delivery section can include things like pushing positions, if you want delayed cord clamping, if you are donating cord blood, if you would prefer no Pitocin for delivering the placenta, if you are keeping your placenta, etc.  The postpartum care plan can include things like if you want or don't want baby to have formula, if you don't want your baby to have the vitamin K injection and/or eye ointment,  if you would like your baby to room in with you or be taken to the nursery, etc.

The other plan I suggest writing is what to do in case of an emergency, or if the worst should happen.  No one wants to think about a medical emergency happening to them.  I recommend taking a look at your options for a worst case scenario, making a plan, and putting it away where you don't have to look at it unless it becomes necessary.  You can make sections for surgery, as well as what your wishes would be if mom and/or baby was very sick or didn't make it.  You can also make those into two separate plans.

For the surgery section, you can include things like who goes in with mom, who goes with baby if baby goes to the NICU/nursery, etc.  If the Cesarean is non-emergent, you will have time to discuss your wishes.  Most Cesareans are non-emergent.  If you agree to a Cesarean, and have time to sit in the room and wait, it is not an emergency, and you can feel free to discuss your wishes with the doctor.

You will know there is an emergency if your care provider seems worried or tense and a whole lot of medical staff with flood into the room.  If you have an emergency, it can be very scary.  Even if you don't get to pull out your plan and review it, it is a good idea to have thought about it and know what  you would prefer to have happen if possible.  If there is an emergency, there will not be time to pull out your emergency plan. 

Regardless of why a surgery is called, it is a good idea to discuss what your options are and what might happen with your doctor at a prenatal visit.  If you are birthing in a hospital with midwives, they can give you a good idea of what will happen, and can tell you which OBs they work with in case you want to talk to them.  In a surgery, it is actually the anesthesiologist who calls all of the shots, so the OB does not have complete control.

Here is an example of what a surgery plan may look like:

In the event that I need surgery, these are my wishes.  I am aware that in an emergency situation, some of these may not be possible.

•   At least one of mom's arms left free to interact with baby.
•   Baby placed on mom's chest after delivery.
•   If baby has to go to the nursery, dad will go to the nursery as well.
•   Doctor makes a horizontal (bikini) incision, double-layer stitching to close.

The other part of the emergency plan is deciding what you would do in a worst case scenario.  Some examples of when this would be needed is in the event that baby and/or mom are in the ICU, or if one of them dies.  No one ever wants to think about these things, but in the event that something bad happens, you may be glad that you planned ahead and aren't faced with hard decisions when you are emotionally compromised.

In Conclusion

In conclusion, a birth plan isn't required, but it can be a good tool for figuring out your preferences and making sure that your care provider is on board.  It can also help take some of the pressure off if you have made decisions ahead of time, and had time to research all of your options.  While you are putting together a plan, if you come across something you don't know much about, you have time to learn more rather than figure out what you want when you may be emotionally compromised.  Learning more about your options is also a way to prevent being talked into something that you don't want.  Some medical staff can be very good about making any intervention that they want to perform sound really good while minimizing the risks to mom and baby.  Knowing about them before hand will help you make a better informed decision.

If you have any questions about what you have read here, feel free to ask in the comments, or email me.

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