Many mothers, midwives and obstetricians today favor a written birth plan as a vital tool in fostering the safest and most fulfilling birth experience for the family. Leah Terhune, a certified nurse-midwife with Midwives Care, Inc. in Cincinnati, explains that a birth plan is important "because it is a written record that shows the goals and wishes of the woman giving birth. At a time when she is especially vulnerable… when it is difficult for the woman and her spouse to make decisions, it is important for everyone involved in the birth process to know how the woman wants her birth to unfold." The birth plan, Terhune maintains, "is a great communication tool for working with your provider, and a sign that you've educated yourself." Terhune believes that in hospital settings, birth plans enable continuity of care. Where numerous nurses doctors can be working with a mother, referring to the document can give everyone similar expectations. She adds, "A birth plan communicates to the birth place, so that [its personnel] have an understanding of a woman's expectations." (Terhune was quick to note, however, that choosing a care provider mindfully makes a significant difference in the outcome of a hospital birth.)

Many decisions need to be made during labor, some of which come as a total surprise to the laboring woman. While writing a plan, a woman will have the opportunity to discover and consider these choices. Karen Crick, mother of two and certified doula (defined and discussed below), explains, "A birth plan is a very good way of exploring all the options that are available. It is a good way to start early on, before labor begins, communicating with the people who will be at the birth… The woman will feel more clear about her options if she has time to review them before the birth."

For women giving birth in birth centers or at home, a written birth plan is less crucial. "A birth plan is not a must for out-of-hospital births," says Terhune "because there is more self-education done by the mother, and most people come into the situation with the same philosophy: childbirth as a natural process." She adds, "In a really good relationship with a midwife, it should be understood by the end of the pregnancy what the expectations are."

The more medical the birth setting, the greater the need for a birth plan. In a hospital, the possible interventions are numerous and it is wise to be aware of these methods, their usefulness, their risks, and in some cases, their misuse or overuse. It can be easy to forget that in most ways birth is reliable, and that in the case of most healthy women, it can be trusted to produce a healthy baby with no more intervention than encouraging words, soothing hands and watchful eyes.
 

What to Consider

Your Care Provider

Most women use obstetricians to provide prenatal care and to assist in the delivery of their babies. Obstetricians are trained in medicine and are very aware of the problems and diseases (and their treatments) that can occur in pregnancy and birth. For women who are in an extremely high-risk category, a doctor is a perfect option. Obstetricians are more likely than other care providers to require a great deal of prenatal testing and monitoring during labor and birth. A typical prenatal visit might last 5 to7 minutes. Exceptions to this might be the first visit, and a visit in late pregnancy when birth plans are discussed. These visits can last 10 to 20 minutes.

Increasingly, women are choosing midwifery care for their pregnancies - normal and "high-risk." Certified nurse-midwives can attend hospital births and, as trained nurses, are adept at working within the medical system. Direct-entry midwives are trained in midwifery but not in nursing. Depending on location, direct-entry midwifery may or may not be practiced legally, but it is practiced, nevertheless, nearly everywhere. Midwives have trained more fully in the study of healthy pregnancy and birth, and of course can also recognize and treat many complications. CNMs have backup physicians for cases of serious complications. Many midwives also attend births at free-standing birth centers and some will attend home births. A typical prenatal visit will last 20 to 30 minutes, and can be longer early and late in pregnancy, or when a mother has special concerns and questions that require lengthy discussion. Many women appreciate midwifery because the midwife is more likely to feel comfortable discussing the social and emotional aspects of pregnancy and birth.

Some mothers choose to give birth unassisted, or with only the assistance of a spouse or an informed close friend or relative. They may or may not receive prenatal care from a midwife or obstetrician, and if they do, they won't necessarily inform that provider of their intention to give birth unassisted. The reasoning behind unassisted childbirth involves a steadfast dedication to the idea of birth as a normal human process. According to those who practice unassisted childbirth, the presence of professionally trained assistants in pregnancy and birth is an automatic admission of powerlessness and an invitation for doubt, interventions, and ultimately an unnecessarily medicalized birth.

Location of Birth

In the United States, hospitals are the most common place to give birth. Increasingly, hospitals try to transform their birthing units into comfortable, home-like settings with potentially necessary medical equipment hidden behind closet doors and picture frames.

Terhune discusses situations when hospital births are most appropriate : "The main advantages are for women with medical conditions…that increase the risk of fetal death, postpartum hemorrhage, seizures..." These medical conditions include multiples, malpresentation (breech), premature labor, very late labors, and labors where the membranes have been ruptured for long periods.

She adds that "there are borderline positions. We meet [the three midwives comprising Midwives Care, Inc.] once a month and we look at individual cases, and we have to decide for ourselves."

Terhune is realistic, though, about the disadvantages and risks of typical, modern medicalized birth. For starters, she asserts, "A woman instantly faces a one-in-four chance of having a c-section by walking into a hospital to have a baby." She further notes that separation of mom and baby is more likely in a hospital, which can influence bonding and the ability to breastfeed.

In many cases, doctor or CNM (more commonly true of physicians) will not be with the patient at the hospital for the majority of labor, and will be only arriving just before the birth. Hospitals vary widely in their acceptance of individual preferences, their familiarity with unmedicated childbirth, and their willingness to allow mothers to control the care of their newborns. Furthermore, adds Karen Crick, "it's unclear whether mothers and babies are in touch with their normal hormonal instincts and responses when they are in a strange environment."

When a risk of complications is present, a hospital is the best place to give birth. When risks are normal and low, a free-standing birth center or prepared home are safe and beautiful places to bear a child. Birth centers vary as to how much and which technology is available to women. Giving birth at home almost always means very little medical technology available, although CNMs will generally carry resuscitation equipment and the necessary drugs to slow or stop postpartum hemorrhaging and other minor complications.

Timing of Departure for Hospital or Birth Center

If a woman feels threatened or even slightly unfamiliar, labor may slow or stop. For this reason some mothers choose to remain at home throughout early labor and some of active labor. Others choose, or are instructed by their caregivers, to come earlier. Some wish to avoid a car ride while in heavy labor. This is a negotiable decision that need not be firmly made in advance. Simply know the advantages and disadvantages of arriving early and later.

Testing, IVs and Monitoring

Procedures vary, but nearly every hospital does some or all of the following. A blood sample may be drawn to check for many things. In most cases, the information gained by drawing blood during labor can also be gained by getting a blood sample in very late pregnancy (within a few days of labor is ideal). An IV may be started and fluids given. An external fetal monitor may be used to obtain a baseline reading of the baby's heart rate and movement. Usually further monitoring sessions will be required at regular intervals. Some women choose to have the blood drawn and the fetal monitor used for a brief period, and compromise with only a "heparin lock" instead of an IV. This involves the insertion of the needle and small connection for an IV tube, but the connection is not actually attached to the tubing and IV bag. A woman with a heparin lock can then move about freely as soon as the fetal monitor is removed. If fluids or other medications become necessary, the tube need only be inserted into the connection that has already been injected into the vein.

Each of these procedures can be very difficult to endure when labor is underway. An IV or heparin lock and blood draw can be time consuming, painful and requires that the mother be still. The fetal monitoring requires being still and often reclined numerous times for at least 10 minutes, usually 20. This is often an extremely uncomfortable position (not to mention counterproductive to cervical dilation) for laboring mothers. The use of each of these procedures is the decision of the patient. Hospital staff may refer to them as hospital policy and consider them mandatory; nevertheless, the laboring woman may refuse any of them. As with all items on a birth plan, each woman should consider the reasons for each of these and discuss your preferences with your OB or midwife.

Clothing, Eating and Drinking

Some women prefer to wear their own clothing during labor. Others prefer the hospital gowns because they are loose and can be soiled, discarded and replaced with ease. Many women find that any clothing at all is a nuisance. Eating and drinking during labor can be very important, particularly if labor is long. Fatigue can cause labor to slow and the laboring woman to give up. Regular nourishment prevents this. Hospital staff don't like women to eat during labor because they could need general anesthetic during an emergency c-section. Under general anesthesia, there is a small chance of the woman vomiting and aspirating the vomit, which can lead to serious complications. One must weigh the risks associated with the unlikely chance of an emergency c-section (assuming a normally healthy pregnancy) against those associated with hunger and fatigue. Indeed, "failure to progress" in labor can lead to c-sections, and such "failure" can often be partially due to fatigue. Most hospitals will allow water or ice chips for hydration, but if blood sugar is low and energy is required, IV fluids with glucose are likely to be preferred over food by the staff. In this case, consider that being attached to an IV restricts movement and positioning, a vital factor in encouraging labor to progress and the baby to descend into the pelvis. Usually a woman will not feel like eating much during labor, so just a nibble of bread or a sip of juice can often suffice to boost her energy enough to cope with a long labor.

Who is in Attendance?

When deciding who to invite, it can be helpful to let these people know that the invitation is tentative, and that as labor progresses people will be called on an as-needed basis. Some women prefer solitude during labor, while others benefit from many or a few family members and friends. Increasingly women are discovering a type of hired support person called a doula. Doulas are people educated in pregnancy, birth and postpartum issues (such as breastfeeding ) who provide informational, emotional and physical support throughout pregnancy, labor, childbirth and the early postpartum period.

According to Crick, "The doula is the woman who mothers the mother. For her there is no other agenda than providing support for the laboring woman," in whatever form that might take. "Statistically, mothers hiring doulas have a 25% reduction in the length of labor, have a 50% reduced risk of C-section, are 60% less likely to request an epidural, have a 30% reduced risk of forceps use, and have a 40% reduced risk of pitocin use. Women with doulas have improved success with breastfeeding and mother-infant bonding."

Many families believe in having siblings present at birth. This can be very beautiful. Young children (and older children that have been properly prepared) do not have the same fearful associations with blood and pain that adults have learned. A frankly informed toddler or preschooler who has a supportive adult in her presence is usually excited and proud to be there when her sibling is born. Some mothers, however, feel certain that the presence of their older child would inhibit them from concentrating on labor. Many mothers decide to play it by ear, having their older children nearby but not in the same room throughout labor, and available to be called in before or just after the birth. Most hospitals permit siblings at birth if they are free of colds or other illnesses and have attended a preparation course.

Pain Relief

Women can rely on many very effective, non-pharmacological means of pain relief. Non-narcotic pain relief is preferable because the narcotics in injections and epidurals reach the baby, and because babies born with such drugs in their system are more likely to have various difficulties (trouble nursing, extreme sleepiness, delayed bonding. Receiving an epidural can be painful and means being automatically "catheterized," given an IV, constant use of an external fetal monitor, and being restricted to bed. Epidurals usually slow labor, and can even stop it, leading to the use of pitocin. Many women continue to feel back pain for months or years after an epidural. It is a decision that should be made with awareness of the risks. Some non-analgesic and non-anesthetic pain relief methods are massage, heat, counter-pressure, hydrotherapy, aromatherapy, positioning, visualization, TENS (Transcutaneous Electrical Nerve Stimulation), and acupressure. For more information on these techniques, see the "For Further Information" section at the close of this article or consult a childbirth educator, a midwife or a doula. Some obstetricians are knowledgeable in these techniques, but most are not.
 

Second Stage: Pushing and Birth

Spontaneous Pushing

Once the cervix has dilated to 10 centimeters, many women begin to feel an urge to push. Some do not feel it right away. At times, labor slows or even stops after dilation is complete and the woman is given a natural "rest." Resist the urge or the instruction to push before the urge to push is present. Occasionally women never feel one at all, and in this case if contractions are still coming on regularly, pushing is still very effective when done during contractions. If an epidural is in place, the urge to push will not be present and some guidance will be necessary in the timing of pushing, but again it can be quite effective for some women even under complete numbness. For others, epidurals make it very difficult to help a baby out.

Episiotomy

An episiotomy is an incision made to the perineum during pushing, that enlarges the opening of the vagina. Many obstetricians do episiotomies routinely, or nearly routinely. Ask yours what their rate is. Anything over 25% is quite high. For many midwives, episiotomy is quite uncommon. For Midwives Care, Inc., the rate is under 1%. With warm compresses, vitamin E or olive oil, and calm coaching through pushing, there is almost never a need for a woman's genitals to be cut. If the baby is showing signs of distress, exceptions should of course be made. At times, women will have perineal tears when an episiotomy isn't given. Many times, there is no injury whatsoever to the perineum. Some doctors believe that a straight cut will heal more quickly and with less discomfort. Others say that with careful stitching (necessary for large tears and for all episiotomies) and proper postpartum care, tears and straight cuts heal similarly.

Cleaning, Weighing, Warming, Noise, Light, Examining and Other Pokes and Prods of Varying Necessity

After delivery, the warmest place for a baby to be while adjusting to the cooler environment is under a blanket, skin-to-skin with Mother. Many women specifically ask that the lights be low and the noise be minimal, so that the drastically heightened stimuli don't overwhelm or frighten the baby. Weighing can be delayed for as long as the family would like - an hour or two is fine. The baby can be gently wiped in Mother's arms, although the vernix need not be removed. It can be rubbed in instead, as it is very good for newborn skin.

Some hospitals and doctors perform a blood test on babies routinely to check for iron and glucose levels. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology now recommend against these routine tests. Just after birth, the babies' blood levels can vary widely due to any number of factors (particularly if the labor and delivery involved medications) and will usually regulate themselves within the early hours.

Vitamin K Shot

The vitamin K shot is given to aid in blood clotting. If your newborn is going to be circumcised, the mother may consider this shot a good precaution. Furthermore, if the birth was not smooth, and there is any chance of internal bleeding, it is a good precaution. However, with a normal birth and a healthy newborn, severe blood loss is an unlikely risk and the vitamin K present in colostrum suffices nicely.

Antibiotic Ointment

Antibiotic eye ointment is used to protect babies from infection during birth, should the mother have contracted a venereal disease during pregnancy (a test for VD is routine in early prenatal care). If a woman has been monogamous and her partner has been as well, there is no risk of such infection, and the ointment is unnecessary. Overuse of antibiotics is becoming a serious problem, as many bacteria are forming resistance to the drugs, making them ineffective. It is socially responsible to use them only when necessary, and sensible to not give unnecessary drugs to a newborn baby. This antibiotic ointment is required by law, but waivers are available to sign. It is typically necessary to ask for these specifically.

Circumcision

Routine circumcision is medically unnecessary. It is a very painful procedure, with psychological risks as well as the same physical risks of any other surgical procedure. It is important to be educated about this issue before deciding to alter the genitals of a baby. Further reading is listed at the end of this article.

Vaccinations

Making decisions about vaccination can be a very complicated task. Some vaccines are basically safe and effective; others commonly produce mild to severe reactions in infants and should be seriously examined. The effectiveness of certain vaccines is questionable. Pharmaceutical companies profit immensely from vaccines, as does the entire medical community. In short, vaccines have usefulness, but also risks. It is wise to read and ask questions of many people, including individuals who have nothing to gain or lose by vaccines being used routinely. There is a very thorough and evenly represented set of writings in an issue of Mothering magazine, referenced below.

Separation

If a woman wants to be sure her baby is responded to and cared for promptly, it is wise to keep the baby near. Newborns in some hospital nurseries are allowed to cry for long periods, given bottles of formula and pacifiers, given vaccines without notification, and even circumcised without asking! Of course, administering vaccines and performing circumcisions without notification are rare mistakes, but they do occur. Nursing staff will allow babies to cry and offer formula and pacifiers less rarely. Some women consider it important for their newborns' cries to be met with their loving arms instantly. Furthermore, offering new babies artificial nipples can result in "nipple confusion," a term used by lactation consultants and breast-feeding counselors to describe a troublesome condition that leaves the newborn unable to coordinate a proper latch and suck on a human breast.

A Few Tips on Style

Some experts recommend a short, concise birth plan, outline style. The advantages to this are that many people get a feel for your wishes easily, and a caregiver who is hesitant to cooperate with special requests won't be irritated by a lot of reading. However, for many obstetricians and most midwives, a more personal and thorough written description is helpful. Based on conversations throughout pregnancy, both mother and caregiver should already be familiar in a general way with the plan. Some details, however, may have never been discussed and the written birth plan can finalize these. There is no need to include issues that are certain to be irrelevant. For example, most hospitals no longer do routine enemas and pubic shaves; therefore, there is no need to write a request that it not be done. These sorts of written requests can be seen by some hospital personnel as insulting.

A birth plan should include issues that are most crucial to the mother, those which will go against what is routine at the place of birth, and those about which the mother and caregiver may not be already aware.

Some believe the short, concise style to be outdated. Crick says, "Birth plans are so individual that there isn't anything that has to be on it… The old traditional bullet point birth plan is perhaps not the most effective thing. Write a more essay style birth plan. Simply, a letter to the various people at the birth, visualizing how you want the birth to go."

According to Terhune, "The parents' attitude toward the whole process is so important. If you are planning natural childbirth … the requirement is to trust birth. But it doesn't mean that birth is always perfect. If a couple takes on self-responsibility and understands the risk, and they…believe that the safest place is out of hospital, we honor that decision. 'Trust in birth' doesn't mean 'I know nothing will go wrong.'"

Many women have unspoken and unconscious fears, doubts or simple concerns about labor and delivery that can come out during the course of writing such a letter. The birth plan is one tool for preparing the heart and mind for the glorious process of childbirth. It is an experience worth entering with our eyes open, aware of our options, our risks, and our maternal power.