How to write a birth plan that matters

What Is a Birth Plan and Why Does It Matter? 

People have had a love-hate relationship with birth plans since they first appeared in the early 1980s: Parents tend to love them, and hospitals tend to tolerate them. Simkin and Reinke created the concept of a birth plan at a time when labor and birthing were highly medicalized, and the choices and preferences of the parents were all but taken away. At the time of its creation, parents' wishes about how their labor and birth should go were simply dismissed. The idea of a birthing plan was considered anywhere from “a fashionable approach in America…” at its best to a direct attack on the medical profession at its worst. However, parents experiencing low-risk pregnancy wanted to be heard and directly involved in the labor and birthing process because they recognized the importance of being in control and active participants during one of the most important events in their lives. But why is it important to have that involvement and control? Why should parents have a say in anything that happens in the hospital? More importantly, how should parents having a normal pregnancy communicate those preferences and wishes that align with their values in a way that would be respected?

The birth of a child is one of the most emotionally and physiologically intense events in a person’s life, so it will most likely always be remembered. Interestingly, "women’s positive and negative recollections of their birth experiences are related more to feelings and exertion of choice and control than to specific details of the birth experience.” For example, one study showed that parents with birth plans had no difference in rates of c-sections and episiotomy compared to the control group. Still, the group with the birth plan had a significantly lower case of administration of epidural anesthesia. Furthermore, having a birth plan helped women have a better perceived experience and outcome satisfaction regardless of how their labor and birthing went.

According to the Robert Wood Johnson Foundation, people actively involved in their health care are the ones most likely to stay healthy, manage their conditions, and potentially have lower health care costs. This approach honors and responds to individual patient preferences, needs, values, and goals and aligns with patient-centered care, a type of care that has emerged in recent years. Medical providers encourage and often rely on their patients to be involved in aspects of their everyday health, so why not offer the same opportunity to pregnant parents on their big day? More and more parents experience some kind of intervention during labor and birthing that interferes with a natural process. Frequently, parents are not given the time to make informed decisions that align with their birthing and parenting philosophy. Some are not even given a choice. This leaves parents feeling like passive participants at crucial moments in their lives, unable to advocate for themselves and their children from the beginning. 

Luckily, times are changing. Because of the benefits of patient-centered care and the parents’ need to continue to be involved in their babies' lives, parents have started to actively take responsibility for their health and the health and well-being of their babies. This includes taking back control of labor and birthing as well. Those who understand that they have a say in the labor and birthing process actively communicate their desires and preferences. Often, they do it through a well-prepared and researched birth preference. The question shifts from “Should I have a birth plan?” to “How could I create a well-written birth plan that will honor our preferences AND the skills and knowledge of the care team?” 

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5 Tips on Writing a Birth Preference That Matters 

There are many ways parents can go about writing a birth preference. Here are the top five tips on how to do it right.

• Call it a birth preference instead of a birth plan. If you call it a plan, it will put you in a state of inflexibility. The word “plan” carries the energy of rigidity, so if things go slightly off the plan, parents may feel that they have “failed,” and feelings of failure lead to feelings of guilt. There is no place for guilt or self-deprecation in the labor and birthing room or any time after, so give yourself grace by accepting that what you put down in your plan reflects your preferences and wishes, not rules.

• Be polite and kind in your communication. Whoever ends up being on your care team when you are in the hospital is there for you. You can have a compassionate, supported, and wonderful birthing experience, and it all starts with you. Lead by example by setting the tone of respect and kindness.

• Collaborate with your care team. When communicating your preferences and wishes with your care team, think of the word collaboration as opposed to “placing an order.” When you collaborate with someone, you are open to considering others’ suggestions. Additionally, you consider them your equal, and vice versa. In such a relationship, both parties work freely together to fulfill the same goal—in this case, welcoming the baby into the world safely and comfortably with the energy of love, patience, respect, and care.

• Be flexible and realistic. Even though you are the one who is preparing for labor and birth, understand that labor and birthing are processes that are fluid and organic and driven by our babies and bodies, not our will. The majority of parents who practice hypnobirthing have labor and birth that are natural, empowering, and uninterrupted. Yet despite our best efforts, labor and birth can occasionally take a completely different turn. Stay flexible, tune into your instincts, and make an educated choice if and when the time comes. You can have an amazing and confident experience if you stay open-minded and remain an active participant regardless of which way labor and birthing turn. Remember, you and your care team are collaborating toward having an empowered and confident labor and birth, not rigidly expecting to fulfill the idea of how the birth should be.

• Be honest with yourself, but keep it short and clear. What is really important to you? Perhaps you really do not mind the care team being the one making all the decisions for you. Or perhaps you would like to be fully included in the decision-making process. Or maybe you are somewhere in between—you do not want to be the one making all decisions about every aspect of the process, but there are a couple of things that are really important to you. In any case, let your team know.

• Keep the birth preference no more than one page long, preferably one intro paragraph and a few bullet points, and mention only preferences that are truly important to you. Additionally, include a paragraph letting your care team know about your preferences in case the birth requires special attention.

  What a Well-Written Birth Preference Should Include

There is a consensus that good birth preferences should include four parts:

1. Introduction

2. Any information that is important for your care team to know

3. Sections on normal labor and birth as well as care of the newborn

4. Unexpected events (prolonged labor, cesarean birth, a premature baby, a baby that requires medical attention, etc.)
   

Part 1: Introduction paragraph 

Inform your care team of who you and your birthing partner are, who else will be there with you (ie. doula, family member, friend, etc.), what kind of pregnancy you had so far, and what you will be using as comfort management.

Example: 

“We want to thank you for working with us to welcome our beautiful baby to the world. Our pregnancy has been healthy and low-risk so far, and we anticipate having very low-key labor and delivery.

My ___(birthing partner, spouse, parent, sibling, doula, etc.) will accompany me during labor, birthing, and postpartum, and we will be doing ___ (hypnobirthing, water immersion or shower, soft music, etc) for comfort management.”

Part 2: Inform them of any additional relevant information, such as:

• medical issues related to this or any other previous pregnancy. The hospital will have your medical records but it does not hurt to put down the important information.

• any difficulties, such as fears and phobias, that they should pay attention to (fear of needles and blood, white coat syndrome, fears that will impede care, etc.)

• any special cultural and religious preferences

• any emotional and physical needs

• any negative experiences with doctors, hospitals, or hospital staff that they should be aware of (keep minor discomforts out of the plan. Include only what can affect the wellbeing of the mother or the baby)

• reactions to medications, routine and non-routine procedures (such as fear or anxiety surrounding vaginal exams, loss of control, being naked, etc.)

• anyone who is NOT permitted to be present during your stay

• anything else that is important for them to know
  

  Example:

“We have had a normal pregnancy so far but would like to bring your attention to a couple of things:

• (In case of fears): I have had ___ (white coat syndrome) for the past ten years, which makes my ___ (blood pressure spike up when it is measured).

• (In case of phobias): I / my birthing partner have a severe fear of ___ (needles/bodily fluids/blood) and can ___ (faint) at the sight of it.

• (In case of any cultural preferences and requests): We kindly request that you do not offer us pain management since I cannot take any due to my cultural background. (Note: In Japan, for example, it is believed that any discomfort the birthing person experiences is a blessing because it prepares them for the arduous work of caring for the baby.)

• (In case of allergies): I have a ___ (mild, moderate, severe) allergy to ___ (medication, silicone) and require an epinephrine shot if exposed.”

  Part 3: Labor, birth, and postpartum 

  Section 1: Here is where you let them know what you would like them to do during labor and birthing.

  Example:

  1. We would like to let labor progress at its own time and pace.

  2. I prefer for my membranes to release on their own.

  3. I prefer not to receive any unnecessary intravenous fluids.

  4. Kindly let us ask for pain management options if the need arises instead of offering them to us.

  5. We prefer intermittent fetal monitoring rather than continuous monitoring.

  6. I prefer minimal vaginal exams rather than routine. I do not want to know how dilated I am.

  7. Whatever else is important to you
     

  Section 2: Postpartum

  In this part, you let your care team know how you would like to handle routine tests and procedures for your newborn: eye ointment, shots, blood draws, hearing tests, and first bath. You might want to find out in advance what is already considered a standard of care. For example, some hospitals wait for one minute to cut the cord, some allow two minutes, and some do it shortly after the baby is born.)

  Example: 

• After the birth of our baby, we would like:

• skin-to-skin contact for at least an hour immediately after birth (you might want to check if this is already something that is a standard of practice where you will be giving birth)

• wait with cord clamping and cutting until it has stopped pulsating (Note: this is assuming you are not having cord blood banking)

• delayed antibiotic ointment in baby’s eyes

• ample time with the baby for breastfeeding
  

  You can also use this space to indicate yes or no to circumcision for boys, as well as your preferences for the first check-up by a pediatrician. For example, would you like your baby to be seen by the pediatrician on call or have your chosen pediatrician conduct the first check-up?

  Part 4: Special Circumstances

  In The Win-Win Birth Plan pamphlet by Penny Simkin, there are a few suggestions for addressing special circumstances. In the case of a true medical emergency, your choices will probably be limited for the safety of the parent and the baby. However, regardless of what is going on, you can still actively participate in the process.

  Examples:

  “We understand that special circumstances such as induction and c-section may arise despite our best efforts. In such a case, we wish to:

  (Option 1): stick as close as possible to the same birth preferences as long it is safe for the parent and the baby. If additional procedures are required, we kindly ask you to allow us some time to discuss them. 

  (Option 2): comfortably rely on my caregiver to make all decisions about recommended procedures on my behalf instead of consulting me.

  (Option 3): comfortably relying on my caregiver to make decisions about recommended procedures except for ___.

  (Option 4): In case the baby should need any additional medical intervention that requires being separated from the parents, we prefer that  ___ (name and role of whoever will be designated to stay with the baby) stay with the baby at all times if possible.

  (Option 5): Any other variation of what is appropriate for you and your baby. 

  Tips on Communicating Your Birth Preferences with Your Provider

  Now that you have created your preferences, it is time to communicate them to your provider. Here are some tips to start the conversation. 

• Start talking to your care provider as early as 24 weeks. It will take a few appointments to communicate all your preferences to your provider.

• Pay close attention to the way your provider responds. Is your provider supportive and willing to listen? What are their thoughts on letting your body take its time to labor and birth the baby? What kind of language does your provider use- supportive or authoritarian? How do you feel about that? Some parents find it comforting to have a provider who is hands-on and takes charge, others do not.

• How likely will your provider be at the hospital on your big day? Is there anyone in the office who might be unsupportive of your preferences?

• What are your provider’s statistics? What are the team’s thoughts on labor induction (ideally ok for high-risk, not ok for low-risk)? How often do they administer Pitocin or release membranes in low-risk pregnancies?

• Finally, bring 2-3 copies of your birth preference to your regular appointments to leave them with your care provider and a few copies to the hospital when you are in labor.
  

  Conclusion

  Ultimately, you can be as involved in labor and birthing as you want. The key is to stay relaxed, open-minded, and flexible. It is all about communicating your preferences with your team and educating yourself on what procedures are routinely done in your chosen hospital. With your care team, you can have a safe and beautiful birth that you will remember for the rest of your life. 
  

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