Make a birth plan that meets your needs
Consider Different Options for an Effective Plan
Birth plans can sometimes replace direct communication between the care provider and parents, creating a false sense of security and leading to more interventions and routine procedures than the parents desired. There are ways to mitigate this downside and bring the best of both worlds together:
Create 2 targeted birth plans, one for the staff and one as a prompt for your doula and spouse
Select a provider and location that share your beliefs, goals and preferences for how to support laboring moms
Focus on communication leading up to the birth
Focus on advocacy during the labor through direct communication rather than relying entirely on the printed plan.
MAKE 2 PLANS
Birth plans are 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. I have found in my work as a doula and a childbirth educator that birth plans often give a false sense of security, are often overlooked by the staff and may lead parents to more disappointment. I highly recommend having a long plan that is primarily between you and your partner and focuses on setting the stage so to speak for an environment and participants that will facilitate the birth you want. I also recommend having a shareable short preferences 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 broad sweeping as well. This often has the most impact. (See below for an example.)
Making these types of plans may help compensate for the deficiencies in the current implementation of the making and use of a birth plan. The long birth plan is primarily helpful between you and your most intimate members of your birth team, especially your spouse who is the only one who can advocate for your wishes with any authority. Your doula would be able to remind and assist, but she can not decline procedures or intervene. Only your spouse can advocate when routine policies and procedures are not meeting your individual preferences.
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. A 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 couples have 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.
BROAD TERMS AND MODEL OF CARE: EXPECTANT VS. ACTIVE
I recommend thinking in broad terms to begin with for making your birth plan, such as cesarean rate and model of care. Expectant management being the model of care that only intervenes if there's a medical necessity and the model which encourages the mother to move freely and be in control of the process while the care provider is acting more as a facilitator (midwives by definition practice expectant management along with having special skills for facilitating the hormones, blood flow, release of tension, mind-body connection, nutrition and position of the baby) and active management being the model of care that will increase routine interventions done at certain time intervals and often restricts freedom of movement, with the care provider dominating the process. Choosing a specific model of care can determine the whole process.
I recommend going through all the things that are important to you with your partner and writing them down. Then pick your five most important broad sweeping concepts and bullet point or number them. Share them with your provider before labor, then 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 a broad sweeping concept, 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.
Your spouse taking an active role in advocating on your behalf may ensure those needs are met. It can be important for your spouse to practice before birth to develop skills and techniques to make sure that your birth plan is 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 printed sheet, 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 partner being ready and waiting to hand block the scissors for an episiotomy is sometimes the only way to stop one from being done. (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.)
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 spouse.
Your spouse 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 partner's direct advocacy.
Here is one way to begin a birth plan sheet and a few examples of broad sweeping concepts,
CONDENSED BIRTH PLAN TEMPLATE
"Thank you for your gentle participation in our birth. We really appreciate your help with the following:
We hope to maintain an atmosphere of quiet and dim lighting to facilitate the hormonal flow and to help create a peaceful space for the birth of our child.
We would like to have an expectant management model of care.
We prefer to have every procedure explained and consent given before it is done.
I have allergies to the following...
We would be really grateful if cervical exams were only offered if absolutely medically indicated and not routinely done or mentioned in the room. Please speak to my partner if medically indicated."
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 the parents prefer. The hope is that they respect those wishes, but this is not always the case. Parents sometimes need to ask to speak to the head nurse, the head OB or midwife or to request the patient advocate in the hospital to help them resolve the issue. In these cases it is important for the partner 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 flow and hormones flow well, the tension to release and for her to have the space to listen to her body. For partners 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 partners for this.
The items on the short list are items that may be broad sweeping in nature, covering a lot of ground and they may cover 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 parents' wishes. In these cases it is direct advocacy that protects the mother the most.
CONSIDERATIONS FOR A LONGER PERSONAL PLAN BETWEEN YOU AND YOUR SPOUSE
Some items that may be helpful for you to look into as part of your lager birth plan:
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 partner directly stopping the action by blocking the scissors.
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 parents requested.
Do you want hep B, vitamin k, the eye drops? It's often helpful to have a plan ahead of time between the two of you. Many times a nurse will give them very quickly because she is on autopilot. Quick advocacy and your partner placing his 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 partner 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 spouse. You can ask your care provider 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 at your hospital? This is another good question to ask ahead of time to flush out with your care provider so that you and your spouse know what to expect and what you can ask for in the moment.
How do you feel about the use of pitocin? Would you want to help facilitate the natural Flow by using half a dose with double the time in between? Also, under what circumstances would you agree to an induction? This is something that your partner would need to monitor closely to make sure that they don't routinely turn it up when you had a predetermined agreement to use it more gently, with double the time in between and half the dose for example. It takes a lot of advocacy and this is why a doula can be very helpful with supporting and reminding the spouse while also helping to facilitate comfort and good progress for the mother.
Are there any medications that you would like to avoid, such as 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 an IV Port open? If you do, you can consider having it placed on a non bending point so that you can move more freely. Many women also choose to decline this if it is important to them to not have any distractions on their body. It's a very personal choice.
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 the mother and how important communication, prior conversations and in the moment advocacy can be in combination with the birth plan.