How To Make A Birth Plan
by: Kimberly Ambrose
of Open To Birth
The words ‘birth’ and ‘plan’ make an oxymoron when they’re put together, like jumbo shrimp and free tickets for sale. No one can decide how their birth is going to go. A birth plan is not a contract with your baby or your care-provider. A birth plan is an expression of your preferences for how your birth is handled. By figuring out your personal preferences and planning for the ‘what ifs’, you can go into your labor feeling prepared. A birth plan can mean different things for different families, and can cover everything from planning the hospital or birth center route to your personal requests for your baby’s postpartum care. You have more options than you think when it comes to your labor and delivery. You can and should make a fully researched and thorough birth plan, but I have two things for you to keep in mind when creating your birth plan. First, depending on who you hand it to, they might not have time to go over a long and detailed plan before they have to go into another room and memorize someone else’s birth plan. Keeping it as simple as possible will help everyone work together, your preferences can be heard and your care team won’t have to study what looks like a list of demands from a movie hijacker. Keep it simple, 1 – 2 pages should be enough to plainly state your preferences. Second, know that requesting something does not make it guaranteed. If you request to birth naturally and end up requiring the use of vacuum extraction or Pitocin, you may need to accept that medical conditions dictate the labor and delivery process for the well-being of you and your baby. You can request that your preferences be considered when medically necessary decisions are made.
When doing a Google search for ‘birth plan’ or ‘birth plan template’, a lot of helpful options present themselves. The question of, “how to make a birth plan?” is much broader than many people think. You can get creative with the way you communicate with your team. You can list your preferences using the least amount of words all on one page for easy reading. You can also make a sign for your labor space so that anyone coming into the room will know your preferences. You could have a sign taped to the door that says ‘Please do not offer any pain medication, if I want it I will ask for it. Thank you for supporting our natural childbirth.’ Or you could tape a card over your bed that says ‘No episiotomy please’. There’s no right way to make your preferences be known. There’s only a wrong way to do it and that’s to not communicate your needs to your care team.
The following is an overview of your options and some background information on some of the more popular and recent birth trends. Also included are options for some of the more sad what if’s. I don’t want to make anyone upset, but going through the possibility of a tragedy can help us address our fears and face the realities of the gravity of planning for childbirth in a healthy, productive manner. Use this information in any way that is best for you and your family. Everything suggested may not apply to you, or all of the following may apply to you. You can use this as a starting point for your birth plan.
The Birth Plan Basics:
- Are you planning on having a natural, unmedicated birth? Are you planning on using pain-killers, like an epidural? Do you not have a preference and are you open to where your birth will take you?
- Do you oppose having an episiotomy and prefer to allow the vaginal tissue to tear naturally if it needs to?
- Do want to avoid a cesarean as much as possible?
- Would you like to be able to get out of bed and move around the room?
- Do you want to be able to drink something other than water throughout your labor? Do you want to be able to wear your own clothes?
- Would you like to birth in a tub or pool? Do you want the possibility of using a water source?
- Would you like to use a birth ball during labor? Would you like to be able to try different positions, both out of bed and while in bed? Would you like to have something to pull on, such as a suspended fabric or a “pushing pole” that attaches to some hospital beds? Will you be able to bring in a birth ball? Will they have a birth ball available if you request one?
- Will you have to have IV fluids through the entire labor and delivery or can you choose not to have IV fluids unless there are signs of needing extra fluids? Will electronic fetal monitoring be continuous or can you choose to not use EFM unless medically necessary? Can you request not to have your blood pressure checked unless necessary or to have it checked less often?
- Can you request not to have cervical checks unless you ask for them or there are signs of a problem? Checking the cervix for it’s dilation and effacement is necessary to know where you are in your labor, however it can be painful. Also, anytime something is inserted inside of the body from outside there is an increased risk of infection. Limiting the number of cervical/vaginal checks can keep the chances of infection down and allow you to focus on coping without interruption and added discomfort.
- What are your options for pain relief? Do you have the option to use narcotics or a saddle-block instead of an epidural?
- Would you like your children or other family members to be able to be present for the birth? What is the maximum number of people you can request to be present in the delivery room? If you have a cesarean section, how many people will be allowed to be with you in the operating room? Can you bring your Doula into the operating room? Can your Doula be present during an epidural injection?
- How soon will you be able to begin breastfeeding? Can you request that your baby only be breastfed or bottle-fed? Can you request that water or sugar water not be given to your baby?
- How long will you be able to stay in the hospital after having a natural birth? A medicated birth? Cesarean birth?
Most of these questions can be answered by taking a tour of the hospital or birth center where you plan to deliver. You wont have to write all of these into your birth plan, but it will help you and your family prepare for the birth experience you are going to have. If the hospital policy is that you can get out of bed and you can use different positions, but you can’t have any food or beverages that the hospital does not allow, then you can plan for your experience and be aware of what options are available to you when birthing with that hospital. Some choices will be decided by your health insurance provider. You may not be covered for the use of a tub or pool for a water birth, or your insurance may not cover the services of a midwife. To set yourself up for the kind of birth you’d like to have you’ll have to ask questions, express your preferences, and shop around.
Delayed cord clamping – One thing obstetricians and midwives worry about is that the placenta will have difficulty coming out. It has become a common routine procedure to clamp or tie the umbilical cord into knots in order to stop the flow of blood and quickly cut the cord s the delivery of the placenta can be managed. The blood in the umbilical cord is going from the placenta into the baby. This exchange of oxygen and nutrients has been going on since fertilization, the baby has never breathed oxygen on it’s own until the moment of birth and first breath. After birth, while the newborn is stabilizing in her new environment, the placenta continues to flush the baby with oxygen and nutrient-rich blood. Then, baby begins breathing on her own and the placenta begins to detach from the uterine wall, being pushed out by contractions. As the baby begins breathing on his own and the placenta is being delivered, the placental blood-flow will shut off and the remaining blood will go into the baby. The umbilical cord goes from dark in color and plump to white, translucent and limp. This is recognized as the best time to cut the cord, once baby has had a chance to fully benefit from the placenta. You may have to request delayed cord clamping.
How would you prefer your birth space to be arranged? It’s true, you can’t come into the hospital and start hanging curtains and plugging in lamps, but you can ask to have the lights lowered, you can bring in a laptop to play music. If you have a photo or an item that helps you, you can bring it with you and put it somewhere in the room or hold it. You can even ask that everyone who comes into your birth space be quiet and speak in low volume so you can focus on relaxing. You can ask to turn the lights up, put some energetic music on and (safely) dance and sway your way through labor. Think about having control of your space in order for you to feel good so you can work through your labor at peace. The book Homebirth In The Hospital by Stacey Marie Kerr MD brings attention to the need for and the benefit of creating a more home-like presence in a hospital delivery. Bringing in a live band and a turkey dinner may not be possible, but you can work with your care provider to create a space that’s going to encourage your happiness and wellness for a positive birth process.
What if my healthcare provider does not support almost anything in my birth plan? If you want a vaginal birth after cesarean, but your insurance coverage does not work with anyone who does a VBAC you may have to find a midwife who will work with you and pay out of pocket for their services or find another insurance provider. If you want a water birth and are not offered those resources by anyone local to you, you may have to plan to deliver somewhere that does offer water birth, but may be an inconvenient trip. You may have to request a certain doctor or midwife at the hospital or birth center you are delivering at in order to work with someone who supports some or most of your preferences.
What if I end up requesting an epidural, when I tried for a natural labor? This happens, sometimes a woman’s labor goes on for a long time, sometimes a baby is turned in a certain way that results in it’s head pushing against Mom’s sacrum and causes low-back pain on top of contractions (known as back-labor). Sometimes you need an epidural. You may still want to use positioning to encourage the baby’s descent. Some hospitals have birthing beds that can be refitted and adjusted so they are more like a big chair. You can spread your hips and allow the baby to come down using gravity while under the leg-numbing effects of an epidural. You could also be propped up on pillows to encourage this same effect. You may want to have your birth partner sit behind you, supporting you. Getting an epidural is not the end taking an active role in your labor.
And how about your baby? Depending on whether or not the hospital or birth center you’re delivering at is a part of any programs for improved maternal care, such as Kangaroo Care or the Mother-Centered Maternity Care program, you may have to request to have skin to skin contact with your baby in immediate postpartum. In previous years nearly all hospitals policies were to take the baby from the mother and immediately begin to administer treatments and analysis. We still do this today, but hospitals are beginning to see the benefits of allowing as much time as possible before taking a newborn from the warmth and smell of it’s mother. You may have to ask for them to wait to take the baby until the baby has calmed down and stabilized. It’s important to take the baby’s vital signs and make sure there are no interventions necessary to save a newborn’s life. However, you can request that these vital signs be taken while the baby remains in physical contact with you, ideally baby’s belly down on Mom’s chest or belly.
Do you want to wait for your baby to have it’s first bath? Recent research suggests that the white, creamy coating on a newborn, called Vernix Caseosa has antimicrobial proteins that fights off bacteria. According to scienceandsensibility.org, “…the sebaceous (oil) glands of the fetus produce these peptides during the third trimester to act as a host defense mechanism, providing a barrier-type protection from the above-listed [sic] agents while in utero”. This creamy coating plays a role in preparing baby for and stabilizing baby through the intense first moments of life in a new environment. When a newborn receives a bath this coating is washed away, along with all of the benefits it naturally brings with it, including regulating the newborn’s body temperature and holding in hydration. Rather than washing it away, you can request a bath be delayed until after you’ve been able to rub the vernix into the baby’s skin, so he can take in all of the antimicrobial protection and super hydrating effects.
Routine suctioning of the baby’s nose and throat – For most hospitals it is routine procedure to suction the baby’s airways as soon as the baby’s head is born with either a bulb syringe or a deep suction hose. This is to protect the baby from any mucus or meconium getting lodged in his airways and blocking his first breaths. According to the International Guidelines for Neonatal Resuscitation, “Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures….the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life….” An infant will not take their first breath until they have been fully born. There’s a 90% chance that your baby will breathe fine on his or her own with less invasive assistance, such as rubbing her back or skin to skin contact. As long as the umbilical cord is pulsating with blood from the placenta, the baby is receiving oxygen. You can ask that suctioning be delayed until after the baby has been fully born or only be done if necessary.
Vitamin K injection – All newborns are born with low levels of vitamin K which is responsible for preventing hemorrhage (blood loss) by enhancing blood’s clotting ability. In a small percentage of newborns, cerebral hemorrhage or gastrointestinal hemorrhage can occur. Adding vitamin K to your diet during pregnancy will not make up for the deficiency because vitamin K does not pass well through the placental wall. Lack of vitamin K in infants can lead to a rare bleeding disorder that can show up suddenly at up to 6 months of age. One injection at birth can prevent this deficiency. There is an oral alternative to the injection that is being used by some hospitals in the U.S but the oral vitamin needs to be given to the baby at least 3 times. The optimal amount to be given and the dosing schedule is still being tested for better outcomes. You can request the oral alternative, if available, if you would prefer that your baby not receive an injection. Either way, your baby should receive vitamin K in order to prevent the possibility of sudden internal bleeding.
PKU Screening – Certain metabolic disorders, including a PKU test, are routinely screened for at birth using a heel stick blood sample. These disorders have devastating effects that are best handled with early detection and treatment to ensure the best possible outcomes. This is the least controversial newborn baby care procedure because the benefits outweigh the risks.
Hepatitis B vaccine – Hepatitis B is a disease that is transmitted via infected blood and sexual intercourse. The vaccine is given at birth in the hope of catching as many people as possible. It is not required for administration at birth and may be given at any time in childhood or adulthood. Some hospitals do not give hep B vaccines at birth, but your baby’s pediatrician may offer it.
Silver Nitrate or Antibiotic Eye Ointment – To prevent the chance of blindness due to gonorrhea from an infected Mother, hospital-born babies are given silver nitrate or other antibiotic drops in their eyes, even if the Mother previously screened negative for this or other STDs in her pregnancy. Silver nitrate causes pain, burning, swelling and blurred vision for the first days of life and in the vast majority of cases, is not needed when the Mother is known to be free from infection.
Circumcision – Some religions require infants to be circumcised. There are no proven medical benefits to the procedure. There is little research supporting male circumcision as a routine procedure and is now considered a cosmetic procedure. The American Academy of Pediatrics no longer supports circumcision. The majority of circumcisions are done with no anesthesia. Some care-providers will use a topical anesthetic creams, however these may take up to 45 minutes to fully numb the area, so the cream may not be active when the surgery is performed. Also, these topical creams have not been approved or studied under use for newborns. Consider getting more information on this subject before making a decision.
You are your child’s first and foremost advocate. You can see to it that they do not receive unnecessary medical treatment that carry any risks of negative side-effects. At the same time, you have to make sure they are getting the treatment they need to prevent any illnesses or deficiencies. Talk with your obstetrician or midwife about your options for your baby’s immediate postpartum care. Talk with your family about your options so you can make a plan that works for you and your newborn.
Now let’s talk about the ‘what if’s’. I know, it’s a bummer and it’s uncomfortable to face, but the realities are that things can go wrong. Most of the time, if you are working with a qualified team of professionals you and your baby will be okay and if you do come into a problem your care team can handle it and do whatever needs to be done to keep you both safe. By going over the possibilities and planning for them you can healthfully deal with them if a tragedy should occur. I wont go too far into the details, but I will provide you with another general overview of things to consider.
For some women having a cesarean section would be a nightmare and the opposite of how they view their birth. If you do end up requiring a c-section how long will you have to stay in the hospital? Will the baby have to sleep in the NICU or can you have the baby room in with you while you recover? Will you be able to see the delivery of the baby by having the surgical curtain lowered or removed? Will you be able to do skin to skin contact once the baby is born and stable? Will you be able to begin breastfeeding and if so, how soon?
What if you die during childbirth? Do you have things set up for your family to care for themselves and the baby? How would you like things to be handled? Who will take care of your child if you are a single parent? Do you know where to turn for support while you are grieving, either a family member, group services, or the help of a professional therapist?
What if your baby dies? How would you like the funeral care to be handled? Would you like to spend some time with your infant before passing them over to funeral care? Would you like the baby to taken as soon as possible? Would you like to have keepsakes made for you and your family? Would you like to hold the baby or have photos taken? Do you know where to turn for support while you are grieving, either a family member, group services, or the help of a professional therapist?
Okay, enough of the negatives, let’s get back to the positives! Setting yourself up for a positive and healthy birth experience means getting the information you need so you can make the best decisions possible for yourself, your body, your baby, and your family. Making a birth plan with the help of your loved ones and a Doula can help take the pressure off of making these heavy decisions on your own. You may know exactly what you want and can quickly work up a plan, or you may be struggling with a particular option. You also may be avoiding making any decisions. Wherever you are at in your process, just know that you have options and you have help. It’s your job to let your preferences be known and to advocate for your choices.