“You’re having a baby, not a labor.” That’s what I kept telling myself before giving birth to my daughter last year. Acknowledging that labor and delivery would represent only a small moment in our long relationship as mother and child helped me to relax. Instead of trying to control each detail of the labor, I prepared for an experience I could feel good about on the whole. Creating a birth plan that summed up my most important concerns helped me do just that.
Writing a birth plan allows a mother to determine her labor preferences and then communicate them to her medical team. Studies show that women who feel they have choices during labor have a more positive recollection of the experience. And that matters. The same research notes that the way a woman remembers pregnancy and birth can influence her relationship with her child later in life.
A birth plan not only improves a mother’s experience of labor, but may also help labor progress smoothly. The physiological process of labor is governed by hormones, as Erica Tempesta, a doula in Northwest Arkansas, explained to me: “Oxytocin helps your uterus contract and your cervix dilate and efface. Adrenaline interferes with this process.” If you are stressed out, labor can slow down. “Having a sense of control and choice can therefore facilitate the progress of labor by keeping adrenaline out of the picture until the appropriate time, and letting oxytocin do its work,” Tempesta said.
So how do you create a birth plan you’ll actually use in the moment? Dr. Wendy Hall, PhD, RN, told me the best birth plans have flexibility. “Mothers may change their minds about what they do and do not want when they are in the middle of their labors and thus their birth plans will change,” she said. Instead of trying to list a set-in-stone preference for each possible scenario or choice, Hall tells women to figure out what issues are the most important to them—the “bottom-line preferences”—and simply include those. Let’s review some that might come up.
How to Create a Birth Plan: Common Points to Address
To avoid being surprised with unfamiliar choices during labor, here are some things to consider ahead of time.
Where to give birth
The first thing to consider is whether you prefer to give birth at home, at a hospital, or in a birthing center. Hall told me that if you want a hospital birth, you also need to think about when you want to go to the hospital.
Who will be present
“Some women want everyone with them and others are more private and want only their partner or a support person there,” explained Nicole Bennett, a practicing midwife and PhD candidate at Ryerson University. By communicating who you want there ahead of time, you won’t have to stress about it on the day.
Drugs or no drugs, that is the question. “Women should think about whether they want to use non-pharmacological approaches to manage the pain of labor,” Hall explained. Think massage or breathing. If you’d rather have pharmacological approaches, specify your thoughts on epidurals, walking epidurals, nitrous oxide, morphine, or fentanyl.
Labor induction or augmentation
Sometimes one intervention can result in a cascade of interventions. For example, your provider may offer to break your water to induce contractions. Once they do that, you’re on the clock. Tempesta explained the cascading effect: “If labor does not begin in earnest, they may offer cervidil and pitocin to promote cervical ripening and contractions. Since the contractions caused by these medications can be more intense, you may then feel that you need an epidural to manage the discomfort. Since the contractions are stronger, they may lead to the monitor reading fetal distress, which may lead your provider to recommend a cesarean delivery.” Tempesta said it’s important for a birthing person to understand the full risks and benefits of an intervention to speed up labor before agreeing to it.
“Women may still encounter providers who use episiotomy as a common procedure,” Hall said. Routine episiotomies, or a cut used to enlarge the vaginal opening, however, are no longer best practice. You should also discuss your provider’s approach to using forceps or vacuums during labor and then note your preference around that, if you have one.
“We are used to seeing birthing parents lying on a bed, but it is really helpful to many to be upright during labor,” Bennett said. “It is good to walk, to rock, to try hands and knees.” If you feel strongly about your labor position, include it in your birth plan. You should also consider how fetal monitoring or an epidural will impact mobility.
“Women should have a conversation about their preferences for skin-to-skin contact with their babies following birth in what is called the golden hour,” Hall said. She also recommended that women consider whether they would prefer delayed umbilical cord clamping, explaining: “Studies have suggested that babies benefit from waiting a few minutes before clamping and cutting the cord.” Other after-birth decisions may include: what to do with the placenta, whether to wash the baby, and whether to give the baby vitamin K, eye ointment, screening tests, or vaccines. If you’re having a boy, you can also note your circumcision preference.
If you want to exclusively breastfeed, make a note of it so the delivery team can encourage it right away. If that is not possible, Tempesta said you should be prepared to decide whether you want to pump or use formula or donor milk.
It’s important to note blood type on a birth plan, especially if you are Rh- and will require a rhogam shot following birth.
Pregnancy complications or concerns
If specific issues have come up during your pregnancy or previous labors, make a note of them. For example, if you are trying for a vaginal birth after caesarean (VBAC), include that in your birth plan and communicate it to your medical team.
If you don’t feel strongly about a point and want to make a decision in real-time, it’s OK to not include it in a birth plan. As Hall said, you want your birth plan to include your bottom-line preferences, instead of being an exhaustive list of nice-to-have choices.
And of course you can’t plan for everything, including how your baby will respond to labor. Remembering that may help you keep expectations in line and avoid one of the downsides of writing a birth plan. A 2003 study noted that women can have “feelings of failure if the birth plan is not followed and disappointment with the birth experience if expectations are not met.” If the unexpected happens and you have to deviate from your plan, know that you can still stay involved in the decision-making process.
Tips for Writing a Birth Plan
Now that you know what topics you might want to consider when writing your birth plan, here are some ways to make sure it’s effective.
Do your research.
Start wide with information gathering. The book Expecting Better by Emily Oster provides data and personal insight into major pregnancy and birth decisions. In addition to reading, sign up for a birthing class and hospital tour and discuss your various labor options with your doctor, midwife, or doula.
Avoid outdated information.
Including preferences for outdated practices will simply distract from more crucial choices. For example, it is no longer common for doctors to administer enimas to women before labor, so you don’t have to address that. Your birthing class and doctor visits should give you a good sense of what is relevant.
Avoid language like “unless medically necessary.”
As one research paper explains, this phrase makes it easy for caregivers to ignore patients’ preferences. Instead, simply list your preferences.
Build in flexibility.
Instead of trying to account for everything that might possibly happen, prioritize your biggest concerns and try to avoid absolutes.
Keep it to one page and short bullet-points.
If you prioritize, it should be easy to keep your plan short. Bullet points make it easier to refer to during and after labor.
Write it at 36 weeks.
At this point, you’ll hopefully have a moment to reflect after doing your research. It’s also close enough to your due date that you’re less likely to forget everything you planned.
Share it with your care provider.
Run your birth plan by your doctor or midwife to see if she finds it reasonable and complete. She can also answer your outstanding questions. This conversation is a chance to practice communicating your preferences and advocating for yourself.
Discuss it with your partner or labor advocate.
It’s important that your partner, doula, or other supporter is familiar with your needs. It helps to have someone to back you up during labor, and you may be unable to communicate effectively yourself when the time comes.
A Sample Birth Plan
I gave birth in November 2017, and this was the birth plan I used:
- Avoid induction (Pitocin to speed up stalled labor OK)
- OK to break waters if labor is stalling
- Avoid routine episiotomy
- Epidural as late as possible so I can lay on side, move around as long as possible
- Self-administered epidural so I can try to limit dose around pushing time
- If water breaks and labor hasn’t started, wait as long as possible before inducing labor
- RH- shot (RhoGAM) for mother who is O- blood type
- Do not wash baby for 24 hours and leave vernix on
- Skin to skin for at least an hour after birth
- Exclusive breastfeeding beginning asap
- Let umbilical cord pulsate before clamping / cutting
This plan helped me visualize the type of labor I wanted, without getting too specific. So how did it go? In the end, I had to get an episiotomy. But because I believed it was necessary, it stayed in line with my flexible preferences. I was practically begging the midwife to give it to me after pushing for 40 minutes, and my baby ended up having a head size in the 97th percentile.
Even though my water broke before contractions started, I was able to avoid inducing labor with Pitocin and waited a full day for it to start on its own. In the end, I did get Pitocin to speed up labor once it started. And the self-administered epidural worked out well. I upped the dosage while my cervix dilated (and I slept), but eased off of it when it came time to push. I was also able to execute my after-birth preferences, too. Thanks to my birth plan, I felt I had a sense of control and choice.
If you’re expecting a baby, hopefully these tips will help you create a birth plan you’ll actually use. And if you’re overwhelmed by all the information out there, keep these two sentences in mind:
- “Is that really necessary?”
- “Are there any alternatives?”
Research shows that asking these questions whenever an intervention is proposed reduces the rate of unnecessary interventions. “Birth has its own logic and you can’t control outcomes,” Tempesta said. “But you can give yourself some peace of mind my knowing that you made the best choices available to you at the time, based on the knowledge you had, and the freedom to act on that knowledge.”