Here are some strategies for avoiding common birth plan pitfalls: 

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1. Create 2 targeted birth plans, one for the door and one as a prompt for your doula and support person that can also help you with pre-birth communication.

2. Communicate with your provider before labor and select a provider and location that share your beliefs, goals and preferences. 

3. Focus on advocacy during the labor. Prepare your support person for direct communication rather than relying entirely on the printed plan.

4. Be Specific

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1. MAKE 2 PLANS

Birth plans can be complex. There are many different options out there and it is becoming common to have birth plans with graphics that are easy on the eye and quick to read, yet packed full of preference. I have found that these types of birth plans can give a false sense of security. The sad truth is that these detailed plans are often overlooked by the busy staff, which frequently leads to disappointment.

 

To prevent this from happening, I highly recommend having a long plan that is primarily for your immediate birth team. This plan will have all of the details and information that is important to you. It will be a great reference sheet for your doula and support person. It will also help with communication before the birth when you can discuss these items with your provider to find out if you share the same goals. This long plan will help you prepare the environment and participants to facilitate the birth you want.

 

In addition to the long plan, make a short preference sheet with your top 5 (give or take one or two items) preferences that are most important to you. The short version should have items that are more personal in nature and that impact the environment. (See below for an example.) 

2. PREPARATION BEFORE THE BIRTH

The staff at the hospital can vary widely, and the most important way to ensure that your birth plan is honored is to find out if you share the same goals and beliefs about birth with the institution and providers before labor. For example, if a mother is looking for a low intervention birth, the most effective way to ensure that desire is met would be to find a birth location and care providers who have a low cesarean rate and a reputation for being familiar with and respectful of the natural process, such as midwives. The long birth plan is best made and used before the birth to set up the scenario that will bring those wishes into reality. 

 

The most common complaint with birth plans is that the hospital did not read it or respect it, therefore it is often most helpful to flush out what type of care provider you would like before the birth even happens. 

MODELS OF CARE: EXPECTANT VS. ACTIVE

It may be helpful to find out what model of care your provider offers. Expectant management is the model of care that only intervenes if there's a medical necessity and the model which encourages the mother to move freely and to be in control of the process while the care provider is acting more as a facilitator. Midwives usually follow this model of care and have skills for helping the natural process move forward more smoothly. Generally, expectant management providers work together with the mom, offering information and options.

 

Active management providers actively intervene at set time intervals. Interventions are done routinely, rather than because of a clear need. Arbitrary time limits are set on the labor and the provider frequently expects to make decisions. Choosing a specific model of care can determine the whole process.

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After you go through all the things that are important to you, pick your five most essential items and bullet point or number them. Share them with your provider before labor to make sure they will offer their support. Tape this list to your door and give a copy to your provider in the process of birth. Things, such as a quiet and dark environment would be an example of something that would impact the environment, so that when a nurse that you have never met before or a care provider or any staff member walks into the room and hopefully sees the sign on the door with the bullet points they would know right away what type of environment to help encourage when they come in the room and they would hopefully respect that. 

3. ADVOCACY

Your support person taking an active role in advocating on your behalf may ensure your needs are met. It can be important for them to practice before birth to develop skills and techniques to make sure that your preferences are respected. The in-the-moment advocacy is what really makes the difference.

 

ITEMS ON BIRTH PLANS THAT ARE OFTEN OVERLOOKED BY MANY PROVIDERS

Specific items listed on a the long version, such as not having an episiotomy done unless medically necessary are often overlooked by providers if they already have high rates to begin with. The plan really does very little to help protect the mother. The support person being ready and waiting to hand block the scissors for an episiotomy in the absence of  a clear medical need is sometimes the only way to stop one from being done. 

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An episiotomy is the cut to open the vagina when the baby is crowning to shorten the time spent waiting - which should be less than 5% according to best evidence based practices. Not all providers have met this criteria. An episiotomy is harder for the mother to recover from because it is often a deeper more damaging tear, but it is easier for the provider to stitch since it is a straight cut. This benefits the provider, but not the mother. Tears that occur naturally are often easier for the mother because it is usually shallow, superficial and often heals faster. An episiotomy should only be done if there is a clearly explained medical indication, such as concerning fetal heart decels.

 

 

Your support person is the most important person to be familiar with your birth plan and their vigilant advocacy is the most effective way to ensure its implementation. An in-person role-play can be very helpful for that! It is not the plan that protects the mother, but the support person's direct advocacy.

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4. BE SPECIFIC

If a birth plan says that the mother wants minimal vaginal exams, the care provider may interpret minimal as every hour. Being specific could help increase the likelihood of communicating effectively. One example of a specific request is to write that the mother prefers exams only be offered every 6 to 8 hours or that she prefers no exams unless requested by her or if there is a clear medical need.

 

Another common vague request is to delay cord clamping. There is a wide variety of interpretation ranging from 1 minute to 5 minutes to 20 minutes to an hour or two. If the mother wants to maximize the amount of time for placental transfusion she can also ask that the cord not be handled unless there's a clear medical need because this can interrupt and inhibit the flow and for the provider to wait at least until the placenta is delivered. An effective birth plan is one that combines specific requests with advocacy from her support person.

 

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LONG & SHORT BIRTH PLAN EXAMPLES

 

CONDENSED BIRTH PLAN TEMPLATE & CONSIDERATIONS

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"Thank you for your gentle participation in my birth. I really appreciate your help with the following:

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1. I prefer dim lighting.

2. Please minimize words and speak softly.

3. I prefer to have every procedure explained and consent given before it is done. 

4. I have allergies to the following...

5. Please do not mention cervical exams in the room.

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These are helpful and relevant to have placed on the door, because staff are often coming in to offer exams, give medication or talk loudly and when they read the list they may be reminded of what is preferred. The hope is that they respect those wishes, but this is not always the case. Sometimes it is necessary to ask to speak to the head nurse, the head OB or midwife or to request the patient advocate in the hospital to help resolve the issue. In these cases it is important for the support person to step in with friendly polite diplomacy, not get caught in an endless loop of back and forth with the staff and most importantly to not absorb the staff's stress or mood. Staying peaceful and chill for the mom is essential to maintaining a sense of peace in her environment to help the blood and hormones flow well, the tension to release and for her to have the space to listen to her body. It may be helpful to remember that just because someone else has an emotion does not mean that you have to have it too. We can choose to stay calm while we firmly say no thank you to an intervention. Practice and role play can help prepare for this. 

 

The items on the short list cover a lot of ground and they may identify a topic that is connected with common actions that are done immediately upon entry into the room. Items on the longer list are important topics that can be addressed before labor by choosing a care provider who shares your goals and practices a model of care you prefer. Items on the longer list are also items that often need more in the moment advocacy. They often happen spontaneously in the room and may be done by a care provider on auto-pilot who is very busy going from mom to mom or a care provider who disregards the expressed wishes. In these cases it is direct advocacy that protects the mother the most. 

 

CONSIDERATIONS FOR A LONG PLAN

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• Do you want to reduce the statistical chance of having a cesarean or episiotomy as part of your birth experience? Find a provider with a low rate of cesarean and episiotomy. Discuss how you feel about these procedures being done routinely versus being done in an absolute medical need. According to the most recent best evidence-based medicine practices cesarean rate should be close to 20% or less and episiotomy rates should be less than 5%. Plan for in the moment responses, like your support person directly stopping the action by blocking the scissors if both baby and mom are doing fine and the episiotomy is for convenience rather than a clear medical need.

• How long do you want the cord clamping to be delayed? A lot of parents ask for delayed cord clamping and this is interpreted very differently from one provider to the next. Many parents would prefer the cord clamping to be delayed until after the placenta is out, even waiting for an hour or two after. Being specific with the timing is often the most helpful thing that can be done when communicating with a care provider. Advocacy in the moment is also often the only way to make sure that your wishes are actually respected unless the provider already routinely delays clamping for the time you specify. Many care providers are very quick to cut the cord. They can easily forget what was requested.

• Do you want hep B, vitamin k, the eye drops? It's often helpful to discuss this ahead of time. Often a nurse will administer these items very quickly because she is on autopilot. Quick advocacy and your support person placing their hand out to block a needle or the eye drops so that they are not done without consent can be the most important thing to prevent it from occurring. 

• Do you want to have freedom of movement and be able to remain upright which is associated with the potential for a 54% reduction in fetal heart rate issues? This is another important point to discuss with care providers ahead of time and find an institution that is very encouraging of movement if it is important to you. It is also another opportunity for your support person to advocate for you if the issue comes up and to firmly let the staff know that you will continue moving and that you both appreciate them helping to facilitate movement by working around your needs to get their job done rather than asking you to restrict your movement for the convenience of the staff. It can also help shorten the pushing stage and increase the satisfaction of the process for the mother. It's a really important topic to think of ahead of time and to strategize between you and your support team. You can ask your care provider before the birth if they're comfortable with you staying off the bed the entire time if that's what you desire. Their response can tell you a lot about what your birth with them might look like. If you desire a peaceful environment free of conflict you may want to find a different provider if the answer is not satisfactory.

• What type of monitoring do you want and what type of monitoring is offered with your provider? This is another good question to ask ahead of time and to flush out with your care provider so that you know what to expect and what you can ask for in the moment. 

• How do you feel about the use of pitocin and in what circumstances would you want to access this? Do you want pitocin after the birth, even if the whole process was drug free? Under what circumstances would you agree to an induction or pitocin augmentation? You may choose to make a predetermined agreement to use it more gently, with double the time in between and half the dose for example. If a pitocin drip is started during the labor it may be helpful to have your support person monitor closely to make sure that the staff doesn't routinely turn it up. A doula can be very helpful with looking for this and reminding the support person, while also helping to facilitate comfort and good progress for the mother.

• Are there any medications that you would like to avoid? One example is cytotec which is also known as misoprostol and is used off-label, is experimental and is associated with an increase in worse outcomes? It is an ulcer drug and it's not approved by the FDA for use in pregnant women, so many women plan to decline this when it is offered. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/misoprostol-marketed-cytotec-information

• Do you have any other preferences or special considerations that are important to you? Do you want to eat and drink freely? Do you want to wear your own clothes?

• Do you want an IV Port open? One option is to hydrate yourself while having a saline or hep lock. If you decide you want this, you can consider having it placed on a non bending point so that you can move more freely. Many women choose this over an open IV. They hydrate themselves rather than having fluids dripping into their body directly. The fluids may dilute the labor hormones and may inflate the baby's birth weight. Many women also choose to decline the port entirely if it is important to them to not have any distractions on their body. They may not want it placed at all, even if the fluids are not started and it's locked off. It's a very personal choice. If you have specific preferences about the IV Port, then talk to your provider ahead of time to see if they will support your choice.

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In summary, consider the use of the birth plan and how it can best serve you. Keep in mind the limitations that a sheet of paper has in protecting you and how important communication, prior conversations and in the moment advocacy can be in combination with the birth plan.