If you read any books about pregnancy and childbirth, you’ll quickly encounter an idea called the birth plan. Birth plans have great intentions - they are supposed to be a written statement of your desires for birth, and usually are written by women wanting an unmedicated and less interventive birth experience. There are both pros — and cons — for creating a birth plan, many of which may be surprising. Here’s a rundown of their pros, the cons, and some alternatives that may be even more effective.
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PRO: Just by creating a birth plan, parents can learn what their options for birth might be. Many moms might not know what their choices are, or that they have choices in birth at all. Just by going through the process of writing a birth plan, parents learn the “whys” of various procedures, what their risks and benefits are, and what their options for alternatives might be. For example, while writing their birth plan, Sally and Joe might learn that it may be possible to have skin-to-skin contact for an hour or so after birth. They might wonder what the benefits are of skin-to-skin contact, and learn through research that it promotes bonding between parents and baby, regulates baby’s temperature, and is associated with higher success rates with breastfeeding. They might also learn that most of the nurse care that happens after the birth - weighing, vitamin K shots, hep b shot, eye prophylaxis, etc. can either be postponed for an hour or done when the baby is right on the mother’s chest.
CON: There are so many aspects of birth that can’t be planned. If you get too rigid of an idea of what your birth will look and feel like stuck in your head, you may be setting yourself up for some negative feelings when the birth does not follow your plan to a “t”. There are always surprises in birth. Consider Sally and Joe in the above example — in their birth, what happens if there was meconium present, and the policy at their hospital states that in the presence of meconium, babies must go to the warmer after the birth for suctioning and evaluation and they end up missing that skin-on-skin time they were so excited about? If parents create too small of an idea of what birth is “good” and “bad”, they may inadvertently create feelings of anger, sadness, or disappointment. And where will these bad feelings be directed? Perhaps to the care provider, the partner, the baby, God, or to the mother herself. These negative feelings can interfere with bonding, breastfeeding, postpartum emotions, and family cohesiveness - the same traits the birth plan was meant to strengthen.
ALTERNATIVE: Build knowledge of options, without closing completely down to unwished-for events. There is a time and a place for everything in birth, and that time and place is different for everyone. And you can’t control everything. If an unwished-for event is happening, you can ask if you can change the circumstances, and if you can’t, try to bring it into the experience in the most loving way possible. Additionally, you might be surprised that your preferences for birth may change dramatically depending on what is going on in the moment. No matter what happens in a birth experience, valuable insight about yourself is gained. Keeping your mind — and heart — open to whatever birth is there to teach you can help create a positive memory, no matter what the “birth fairy” has in store for you. And isn’t opening what birth is really all about?
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PRO: Birth plans can be a great communication tool between care provider and family, most effectively in the weeks before the birth. If you do write a birth plan, sharing it with a care provider (doctor or midwife) as soon before your birth as possible can be very helpful. It can help you understand your provider’s preferences for care and how well they align with your preferences for birth. Doing so early on can open a dialog where you can reach compromises with your care that work for both of you, or you may find “red flags” in your provider’s policy which might have you looking for another provider (which, if you wait too late in your pregnancy, most providers won’t take a transfer of care of a term pregnant woman).
CON: Birth plans often all look the same to providers, and most don’t take them seriously. Your birth plan might have taken you days or weeks to create and is precious to you, but to your provider, most birth plans look very similar to one another. Often, birth plans are long, dry lists of interventions to be avoided. They may only skim the plan at best. And providers often feel that, when it really comes down to it, they are going to do whatever they need to do medically, regardless of what it might say on a piece of paper. For some women in labor, it can be startling when this happens. The conversation in her head might go like this: “Doesn’t she know that I wrote I didn’t want Pitocin in my birth plan? She’s offering it to me anyway. She must think I really need it. Or maybe she doesn’t even care what my feelings are.” You can see how this inner dialogue might easily shift to helplessness, embarrassment, frustration, or anger.
ALTERNATIVE: Don’t rely on a piece of paper as a crutch — talk face-to-face. I recommend, whether you write a birth plan or not, to talk to your provider about his/her usual policies for such things as episiotomy, induction, indications for cesarean, etc. as soon as you can in your relationship. And I recommend you ask direct questions that require real answers. If you say, “I’d like to avoid episiotomy, is that possible?” consider how the answer might be different than asking, “How often do you find episiotomy necessary in your practice, and for what reasons?” No piece of paper can be a replacement for the give-and-take that a real conversation holds. If you are afaid you’ll forget what you want to talk about, jotting down some questions before the appointment to pull out if you forget can be helpful. If you are intimidated by the idea of talking with your provider in such an open way, consider why you might feel this way. Is it because you fear their response won’t be what you wished for? If so, maybe you know in your heart already that you may not have yet found the right provider for you. But the conversation is inevitable if your wishes for your birth are different than your provider’s, and it’s much easier to have the conversation before you’re in the middle of labor. As another doula I know says, “would you rather have this conversation with your panties on or with your panties off?”
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PRO: Birth plans may give a woman a voice when she may not have the mindstate in labor to have one. Women in labor without drugs, especially toward the end of labor, are working very hard, expending the same amount of calories that an athlete uses to run a marathon (no joke!) During this physical ordeal, it takes a great amount of concentration and they may have trouble finding energy enough to tell the doctors or nurses their preferences. Additionally, unmedicated women in labor enter a sort of trance state, brought on by hormones present, that create a frame of mind which helps a mother cope through the hard work of birth. When a woman is in the middle of “Laborland”, it may be distracting for her to have to come out of it and into her cognitive mind to speak of her preferences for birth. If the providers have read the birth plan, they will know your preferences ahead of time, and the mother will not have to be bothered.
CON: Many providers have a strong bias against birth plans. There is a belief among many providers that birth plans lead to cesarean section, although the research doesn’t bare this out. Consider what just the presence of a birth plan might be doing to the mindset of the people who are to care for you. Often a laundry list of things that providers are being told they can’t do can make them feel like their hands are tied to assist you in your birth. The people you are relying for compassionate care may be aggrivated by you just for the existence of your birth plan.
ALTERNATIVE: There are ways to communicate, even in the middle of birth’s intensity. Most things in a typical birth plan can be said in the moment instead of written out. This way you only have to address the issues that come up in your birth. This may preserve the feelings of your birth team and in turn make for a better birth experience. If you are having difficulty speaking in the intensity of birth, you can wait until you are between contractions to address the issue, or you can have your partner speak to the provider (doctor, nurse or midwife) on your behalf. You don’t have to give all the reasons in the middle of birth - if you are offered something you’d like to avoid, just a simple “no thanks” may do. However, if something comes up in your care, you or your partner can take the time to explore it more fully by asking questions before you make a decision. You can ask about benefits to procedures, what risks they hold, what other interventions come as a “package deal” with the procedure, any alternatives you might be able to try first, and so on. Acknowledging the provider’s good intention for offering the change in your care first can help to keep the dialog friendly - for instance, “I understand you’d like to break my water to get labor to progress.” THEN ask about the risks, benefits, alternatives and so on. Most people find that if they have the ability to be involved at this level in their care, they feel better about the entire birth experience.
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CON: Just because you wrote something down doesn’t make it happen or not happen. Often women get so caught up in the resulting imagery of writing a birth plan that they think they are creating a reality. But many have noticed (myself included), that whatever isn’t “invited” to the birth often finds a way to crash the party. If your biggest fear is of cesarean, will writing “I wish to avoid a cesarean section” really help you avoid one? As Pam England, creator of Birthing From Within, says, “Birth is what’s happening while you are busy making birth plans.”
ALTERNATIVE: Prepare for all possibilities. Instead of just writing you’d like to avoid something, learn about alternatives so you can suggest them as things come up. Or, you have strong fears around a particular event happening, you may be able to deal with these fears beforehand so if this event becomes the next best thing in your care, you are more prepared. You might explore your emotions through birth art, for example, or see a counselor to work through past events and their emotions that may find their way to your birth. You could experiment with techniques such as relaxation, meditation, guided visualization or hypnotherapy to distract you through an event which might cause you distress. Or, for some people, learning all you can about a feared procedure can be helpful.
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There’s no clear answer whether birth plans are good things or bad things, and each family must make the decision for what is right for them. But understanding both sides of the birth plan debate can be helpful when making the decision whether or not to expend time writing one, or use that same energy to learn ways to communicate that may avoid the pitfalls that are commonly associated with a written plan for birth.
