There’s a decent amount of evidence suggesting those who draft birth plans are more satisfied with their birth, regardless of birth modality, compared to those who do not think through options/preferences and craft a document. On the flip side, research suggests the greatest disadvantage of birth plans–according to both patients and providers are the negative emotions when the birth plan isn't followed.
Birth preparation influences satisfaction
As we talk about in our childbirth class, birth satisfaction matters. Studies have shown that an increase in satisfaction lowers the likelihood of a postpartum mood disorder. Various, less robust studies, suggest feeling more satisfied with your labor experience influences attachment and bonding, your perception of your newborn’s behavior, your recovery process, and duration of bodyfeeding. You are likely to feel more comfortable and satisfied with your birth experience if you: 1) Take time to identify your expectations (support team, pain management, etc.), 2) have a respectful and emotionally supportive care team, 3) have open patient-provider communication, and 4) participate in decision-making during labor.
Research suggests these four factors override other influences on satisfaction such as medical interventions, pain, physical birth environment, age, etc.
Let’s dive into that first component - identifying your expectations.
It’s a Discovery Process
Drafting a birth plan—or preferences as I like to call it, is not about control and certainty. If you write a plan with the anticipation that it will be followed like an IKEA assembly instruction manual, you are setting yourselves up for an unattainable experience. You will be disappointed and left unsatisfied.
How you discover and frame your preferences is an important consideration. Let’s view crafting birth preferences as a communication and discovery process in order to:
find a team that is line with your values (see previous blog on selecting a provider)
communicate and build mutual respect with your medical provider,
grow your understanding of how your provider will care for you during labor
become familiar with labor options (take our childbirth class!)
discover birth location protocols and policies,
enhance comfort in navigating uncertainty,
develop openness to the concept of fluidity, and
discuss what makes you feel confident, what are your top concerns, and how you hope to be supported by your care team.
Steps of the Process
Close your eyes and say, This is me in labor. What do you visualize? Who is with you? What does the room look like? Maybe you can’t visualize it and you see yourself holding your baby in your arms. Freely describe whatever pops into your mind. This is your starting point. If you are the support person, do this too! What types of things do you see yourself doing? Where are you in the room in relation to the laboring person?
Start dialoguing with your provider. At each appointment, take a couple questions (see below) and discuss with your provider. Ask your provider if they have a preferred birth preference template.
Attend our childbirth education class in your second trimester. Are there things discussed that resonate with you? Are there options that make you unsettled? Are there issues you definitely want to verify with your provider?
Complete the prenatal questionnaire your DCBD birth doula team shares with you. This questionnaire is sent around 28 gestational weeks, in preparation of your prenatal consultation with a birth doula. If you haven’t taken a childbirth education class yet, there may be questions you aren’t sure about and that’s ok! Take time to reflect on these questions. The completed questionnaire (do the best you can) along with the consultation helps your birth doula team get to know you, discover ways to help you feel safe and confident, and develop their catered care for you.
Watch or attend a tour of your chosen birth location. Does this help you become familiar with the setting, logistics of getting there, and basic protocols?
Take a peek at some on-line templates. I am not a huge fan of checklist style on-line templates as they often list out things that are not available at your birth location (nitrous oxide for example, which is only available in 2-3 of our local hospitals) or take unnecessary space listing out things that are promoted and considered standard care. Standard care in our area hospitals are things like: freedom of movement, various comfort techniques like massage, shower, music, soft lighting, birthing ball, stool, squat bar, no routine episiotomy (the rate of this intervention hovers around 1% in DMV), rooming-in with Baby. However, a checklist type of birth plan is better than nothing. So, writing your birth preferences is not a way you want to spend your time, or if you believe birth is too fluid to try to plan, perhaps a checklist online template is the perfect thing for you! American College of Obstetrician and Gynecologists Sample Birth Plan, BabyCenter Worksheet, Mama Natural Visual BirthPlan.
Drafting birth preferences is done over time. It may take multiple conversations with your provider, attending a childbirth class, and having your prenatal consultation with your birth doula before you feel ready to commit anything to paper.
Documenting your Preferences
You want to keep your preferences concise and focused on the most important aspects of who you are and what you envision. Bullet points are easier to read for clinical staff than full grammatically correct sentences. There are many scenarios, paths, and possibilities when it comes to childbirth. My advice? Stay fluid and focused on shared informed decision making. A brief, positive,1-3 page document with bullet points is a great format to use.
What is uniquely you?This is the top issue(s) you want your care team aware of.
I have hearing loss on my left side. If I don’t have my hearing aid in, I will not be able to understand you if you speak to me from the side/behind.
I am extremely cautious about environmental toxins and COVID. Please wear masks when entering the room and try to avoid introducing plastics (cups, utensils, wrapping) near my space.
What is your 30 second top-line summary?
This unassisted pregnancy is after 5 years of fertility treatments. We know this process is unpredictable, but we are extremely risk averse. At any sign of concern, we want to speak with our provider to get the full picture.
I embrace the idea of having an unmedicated vaginal birth. Please don’t offer an epidural unless I mention it first. Then, please openly discuss options and tradeoffs with me at that time.
How do you want your support team and medical providers to help?
I anticipate feeling safe and confident when________________
It is quiet / I have my favorite tunes playing when there are only female providers / when I have trauma-informed care when I am not exposed, keeping myself modestly covered / when I am part of shared informed decision making with my provider / I am left undisturbed to labor on, without a lot of interruptions / When I have pain medication on boardAdjustments to the environment and your body are encouraged in local hospitals (lighting, sounds, scents, movement), so I won’t spend a lot of space listing these things out ).
How will you navigate uncertainty? It is great that your preferences address your ideal scenario, but also spend time on the variations, too. If-then statements are great to use!
If an induction is medically necessary, I want to continue to aim towards an unmedicated birth. Here, I am extremely open to sleep-aids.
In the event of a cesarean birth, …
Common Pitfalls
The out-of-synch birth plan
The out-of-synch birth plan is when your desires don’t match what is feasible at your selected birth location. As mentioned, an aspect of this comes with using online checklist style templates. Here are some examples:
I want to birth in the tub.
However, in your selected birth location, tubs are only utilized for laboring (not birthing) and are only available in 2 out of 12 rooms. Truly if you desire a water birth and that is top priority, then I encourage you to explore a different birth provider and facility! I want a walking epidural. In our area hospitals, once you utilize an epidural, you will remain on the bed. While the modern medication and dosage may allow for excellent motor control and pain relief, you still will not be off the bed. But, you can shift, shimmy, kneel, sit, rotate as much as you desire ON the bed.
The 6-page birth birth
Some studies show that a higher number of requests on a birth plan is associated with decreased satisfaction. When birth workers see more than a 1-3 page birth plan, we grow concerned. Do you hold a lot of fear about the process? Do you want to orchestrate and plan every single element? Do you have adequate knowledge about the labor process? Is there going to be sadness or anger if all the things on those pages don’t come to fruition? Are you able to peel away some of the details and share the most vital aspects of how you want to be supported and meet your baby?
The rigid birth plan
Are you making tons of statements that are rigid and restrictive? I don’t want, I want, I will not … Ask yourself, are all these non-negotiable? Can some be rephrased to better reflect an understanding that labor and birth is organic, unique, nuanced, and varied? What is my non-negotiable?
I have heard some families say, “Well, I guess I can throw my birth plan out the window.” They approach their preferences as all or none. Their preferences didn’t discuss options or plan b’s.
There are basic core things such as dignity, respect, and being heard that are never going to be put aside by your birth doula team. If there are changes to your labor and birth vision, you should be aware of the reasons for this shift. You will either give your consent or your refusal for care. And yes, some things may need to be on hold or modified. And thus, enters the practice of embracing uncertainty, awe, wonder, and fluidity. Remember, you are more likely to be SATISFIED with your labor experience if you remain fluid and involved in shared informed decision making.
Questions for Consideration
Below are questions you can use to identify options, your preferences, and priorities. Choose a few to write down and go over at future appointments with your provider. Attend our childbirth class to think through some choices and ask questions.
1. During Late Pregnancy:
How is care managed as you approach - or pass - your estimated due date?
What are common reasons your provider determines as medically necessary to recommend induction? How do you feel about the option for induction?
Does your provider suggest/offer cervical exams at the end of pregnancy? Does your provider respect your preference to have - or not have - these checks?
2. During Labor:
If water releases before contractions begin, are you comfortable staying home until contractions begin (in most cases this is within 12 hours)? What does your provider suggest?
What are your provider’s protocols around care for GBS positive (Group B Strep) laboring people - including the situation if your water releases when you are at home?
Do you feel comfortable laboring at home for early labor? When does your provider suggest going to the birthing location?
What are the admission procedures when you arrive? (Is your support person and/or doula permitted to accompany you in the triage area; COVID-related considerations?)
How do you feel about the common practice of having an IV hep/saline lock upon hospital admission? Do you want to make special requests for this procedure?
What are your provider’s or hospital suggestions on hydrating and eating during labor?
Can fetal monitoring be done intermittently? What situations warrant continuous fetal monitoring? Are cordless or wireless monitors available?
How do you feel about non-medical pain relief (hot/cold, massage, water, sound, breath, freedom of movement, labor support, etc.)?
How do you feel about pharmaceutical sleep aids (Benadryl, Tylenol PM, Ambien) or pain relief options (narcotics, nitrous oxide, epidural)? Do you want staff to offer these options to you while in labor?
Who will be managing your care (when/how often will the provider be with you)? How do you feel about medical fellows, residents, students providing care?
What type of communication with your provider works best for you?
In what situations might your provider suggest augmenting (speeding up labor)? What options are you open to trying - movement, positional changes, nipple stimulation, artificial rupture of membrane, administration of Pitocin)?
What are your preferences around cervical/vaginal examinations during labor?
3. During Pushing & Birth:
What pushing positions are likely to make you feel strong and confident? Does your provider promote freedom of movement and upright pushing positions?
What type of pushing method do you prefer (directed/counted, spontaneous/birther-led)?
What methods does your provider use to support your perineum (warm compress, lubrication with mineral oil (some hospitals use baby wash as lubrication and you will need to specifically request otherwise), perineal massage and stretching?
Who will announce sex of baby, if unknown?
Do you have any cultural/religious traditions to be upheld at the time of birth?
In an unexpected event (cesarean birth or baby needs assistance in the NICU), are there preferences you would like honored?
4. Immediately Following Birth & Newborn Care:
At birth, do you desire for the baby to be placed directly on your skin with a drying towel/warm blanket over top?
How long do you want to sustain uninterrupted skin to skin (first hour or more of life)?
Do you wish for the cord to be clamped later than 1 minute? More than 1-3 minutes?
What do you want done with your placenta? (Do you want to see it, have the provider/facility dispose of it, donate it for regenerative medicine, or take it home for personal use)?
What is your preference for feeding your baby?
What newborn procedures do you want done the first 1 -2 hours of life (erythromycin eye ointment, Vit K injection, Hep B vaccine)?
When do you prefer Baby has their first bath? Some point during hospital stay? Wait until you get home?
If you are having a boy, will you want to leave the penis intact? Circumcision during your hospital stay or later on?
Once you draft your birth preferences, pass it along to the birth doula team for input and make sure you discuss it with your provider.
Also, it is very ok if you choose not to write a plan. From your birth doula team, “We got you!” either way.
~ Rena, Birth and Education Expert*
*If you are a DCBD bundle client and haven’t already registered for your Childbirth Class, check your inbox for details or email Elizabeth Parish for help. If you are not a current client, feel free to register for classes on our website.
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