Birth Plan: Yes or No?

I take offense to being called pushy. So I already had my panties in a knot before I got passed the by-line on Katrina Onstad’s article in Chatelaine about birth plans.

Don’t be so pushy

Making a “birth plan” is about more than being prepared. It is about being in control. Here’s why letting go of all that is way harder – and that much better.

In her article, Katrina explains that she was keen to develop a birth plan when her midwife told her that “the best plan is no plan at all“. While she was initially uncomfortable with the idea of things being unknown and uncontrollable, she eventually embraced it and submitted to the experience of giving birth and had exactly the birth she wanted, without having planned for it. She also mentions the disappointment of women that plan every minute detail of their birth and then end up with an emergency c-section.

Midwives versus obstetricians

What Katrina perhaps didn’t take into account though is that there is a substantial difference between the model of care of a midwife and the model of care of an obstetrician.  As Henci Goer explains in The Thinking Woman’s Guide to a Better Birth, “whether you have a C-Section or any other procedure or medication in labour has little to do with your or your baby’s condition. What happens to you depends almost entirely on your caregiver’s practice style and philosophy“.

For example, the Society of Obstetricians and Gynaecologists of Canada reports that more than 1 in 4 babies are delivered by C-Section. This is alarmingly high. The World Health Organization says any rate higher than 15 per cent signals inappropriate usage. I couldn’t find a good statistic on the c-section rate for women whose primary caregiver was a midwife, but the midwives that I interviewed in my search for a birth attendant had a transfer rate of 6% to the hospital during childbirth, a portion of which would have ended up with a c-section. Much lower than with obstetricians!

Katrina had a midwife, so that was already a big step towards avoiding unnecessary procedures. Midwives view birth as a normal experience and epidural use, induction, c-section, vacuum or foreceps extraction, and many other procedures are less likely to be used in a birth where the midwife is the primary caregiver than in one where an obstetrician is the primary caregiver.

Being able to trust your birth attendant to make good decisions is important and can be helpful. I have one friend that had a birth plan for her first birth, but not for her second because she was using the same midwife and knew that they were in agreement about the type of birth she wanted, so she didn’t need to write it down. If you agree with your birth attendant’s philosophy and approach to birth, then maybe you don’t need a birth plan and can “submit” to the experience and trust your birth attendant to guide things in the right direction.

Unfortunately, most women that have an obstetrician as their birth attendant (by choice or by default because it was the only option available to them), often find themselves in a “team care” situation. This means that whoever is on duty when they go into labour is the person that will deliver their baby. As if that isn’t bad enough, that doctor will only show up for the last 5 minutes or so of the birth, leaving the patient with a resident, medical students, and nurses that they have never heard of and never met prior to being in labour. People rotate in and out of the room. You don’t know them, you don’t know their thoughts about birth, you don’t know their personal experiences, and you don’t know their aspirations. Perhaps the nurse attending your birth had two elective c-sections and thinks it is the best way to give birth. Perhaps the junior resident is really keen to pratice her skills with the vacuum extractor. Perhaps it is just so busy in the labour and delivery ward that evening that they tell you if you think you might want an epidural, you’d better get it now, even though you aren’t feeling much pain yet.

In addition, obstetricians seem to approach birth as a medical condition that needs to be fixed and helped along, rather than something that is natural and normal and that will take place on its own time line. They approach problems that come up along the way with a series of high risk interventions, rather than considering low risk strategies for dealing with those problems. One high risk intervention, often leads to another. A woman’s obstetrican may decide she needs to be induced even though her body isn’t ready to give birth. They may first try breaking her membranes, which puts the birth on a timeline (the hospital often must deliver the baby within 24 hours of breaking the membranes due to risk of an infection). If breaking the membranes doesn’t get things moving, they may use drugs to move it along. The induction can cause very painful contractions which may result in the recommendation of an epidural. The epidural means that the woman can no longer feel what is going on in her own body and also cannot walk around and do other exercises that might help the birth move along. As a result, her progress may be slow and she might end up in an emergency c-section.

My own experience

The birth of my first child was not what I wanted. I used the approach Katrina suggested. I submitted to the care of my birth attendant, an obstetrician in a team environment at a hospital. I was scared of the pain and hadn’t done much research about the birth or about the risks of various interventions. I didn’t have a birth plan. I ended up with an epidural early in my labour when I wasn’t experiencing any pain because the nurse said “if you want an epidural, you’d better get it now or it might be too late“. I spent an uncomfortable night lying on a bed, restless and uncomfortable, hooked up to machines, waiting for things to move along. I was lucky that I didn’t end up needing further interventions other than a vacuum extractor and my son was born the next morning. I was stuck in my bed after the birth, still unable to move around because of the epidural, really wanting a shower but not able to get up to have one. I couldn’t get up to get a glass of water, to use the toilet, to change my son’s diaper. I completely submitted to the care and decisions of my birth attendants and I wasn’t happy.

For my second birth, I wasn’t able to have a midwife (long and complicated story involving government red tape), so I opted for the same obstetrician environment, but decided to have a doula to provide support for a natural and normal birth. I knew that my doula would be there for my entire birth or on the odd chance that she couldn’t be, I knew that her backup that I had also met would be there. She would be a consistent support for me, not part of a rotating cast of characters in the labour and delivery ward.  Through my own research and with the support and experience of my doula, I did develop a birth plan. I made sure that my doula and my husband were familiar with it. I reviewed it with the obstetrician that saw me during one of my last appointments. I ensured that every person that was involved in my care in the labour and delivery ward had a copy of my birth plan. The birth went exactly as planned. It was quick, I was comfortable, I was able to move around, and I wasn’t offered and didn’t need any medical interventions.

My Birth Plan

For those that are interested, here is a copy of my birth plan (with some personal details removed). There are lots of great resources online and books that can help you to develop a birth plan and I highly recommend doing your own research and discussing your findings with your birth attendant(s) as you develop your plan.

My name is _____ and I am accompanied by my husband ____. This is our birth plan for the birth of our second child (a baby girl named ___), due _______. We are hoping to have a natural and unmedicated birth with the assistance of our doula, _________ (or her back-up _______).

We are looking forward to working with the Doctor and staff to ensure we have a healthy baby. Below are our wishes for a normal and uncomplicated birth. If complications do arise we are open to making adjustments to our plan after we have been made aware of our options. We wish to have all procedures, tests and interventions explained and discussed prior to being performed if the situation allows.

First Stage

• Unmedicated birth: Please do not offer pain medication – I am aware of my options and will request pain medication if I choose to use it.

• Speeding up labour: I would like to avoid Pitocin. I would also like the amniotic sac to remain intact until it breaks naturally.

• Fetal monitoring: My preference is for intermittent external fetal monitoring.

Second Stage

• Choice of position for pushing: I would like to choose what position is most comfortable and appears to be yielding the best result. I may choose to change positions several times while pushing to increase comfort or improve the pace.

• Reduce Chance of Tearing: I would like to have a compress used on the perineum to reduce the chance of tearing.

Third Stage and First Hours After Birth

• Cord cutting: We would like to wait until the cord stops pulsing before it is clamped and cut. My husband does not want to cut the cord.

• Bonding/Nursing after Birth: Please place the baby directly on mom’s chest without washing and allow nursing as soon as possible. Please administer any necessary testing while the baby lies on mom’s chest. We prefer administration of eye ointment and vitamin K to be delayed until after the baby has had the opportunity to nurse.

• Checking for and releasing tongue tie: Our son was tongue tied and this significantly impaired our start at breastfeeding. Since tongue tie can be hereditary and we would like to avoid similar problems, if the baby does not latch on immediately after birth, we would like to have her tongue checked immediately and, if necessary, have the frenulum clipped as soon as possible.

• No artificial nipples or supplementation: We are planning to breastfeed. We would like to avoid all artificial nipples (bottles, pacifiers) and do not want the baby to receive any supplements (e.g. sugar water or formula).

• In event of unanticipated separation of mother and baby:
  In the event that mother and baby have to be separated after birth for any reason, I would like my husband to remain with the baby and to make all decisions regarding the baby’s care.

Concluding Thoughts

If nothing else, the process of developing a birth plan led me to research and think about what type of birth was best for me and my baby. It had nothing to do with frivolous wishes. It had everything to do with having the safest possible birth for both of us and avoiding unnecessary medical interventions.

That said, if someone did have wishes for their birth that I think are frivolous, I think that it is their right. Some people spend tens of thousands of dollars making every detail perfect for their wedding day and I would argue that the birth of a child ranks up there with a wedding among the most important days of a person’s life, so if someone wants specific music playing, wants the lights dimmed, or wants a toast when all is said and done, then I think that is their right and it is better to think about it in advance and plan for it, than to have regrets later.

I didn’t have a problem with the idea of things being uncontrollable or unknown, but I wanted to be prepared for the possibilities and wanted to understand the options available to me and the risks of various approaches prior to being in the labour and delivery ward. There is no WIFI there that I am aware of, so Googling things at the last minute was not an option!

If you know that your birth attendant will make the right decisions for you, then go ahead and skip the birth plan. But if you aren’t certain that is the case, then plan plan plan and plan some more. And don’t let Katrina Onstad tell you that you are being pushy.

Tagged as: Birth Plan, Chatelaine, Katrina Onstad, midwife, obstetrician