The Birth Plan

13/05/2010

A birth plan is a few things. Firstly it is a written record of what our ideal is and what we will strive for. Secondly, it is a way of communicating to your care givers what your goals and wishes for the birth are. Thirdly it is a contingency plan which deals with all the ‘what if’s’ for when things don’t go the way we hoped

Can we really ‘plan’ our birth experiences? Well, we certainly cannot predict how long it will take, what it will feel like or guess at any other number of variables which our own individual birth experience may present us with. Labour and birth is, by its very nature, unpredictable so what does writing a birth plan actually mean and why does it help to have one?

A birth plan is a few things. Firstly it is a written record of what our ideal is and what we will strive for. Secondly, it is a way of communicating to your care givers what your goals and wishes for the birth are. Thirdly, it is a contingency plan which deals with all the ‘what if’s’ for when things don’t go the way we hoped.

A birth plan helps in a number of ways. It is a great way of preparing yourself for the task at hand. A written visualisation of how you would like the birth to be is a powerful tool in terms of mental preparation. On the other hand, dealing with the ‘what if’s’, which are often the things we fear most, can help us to see that however our birth unfolds, we have the ability to deal with things as and when they arise and that we also have our ideals if facing one of these scenarios.

A birth plan is a great communication tool for working with your carer’s and a sign that you’ve educated yourself and expect to be part of any decisions that are made. A birth plan can communicate what you want when it may be difficult for you to do so. It also acts as a written reminder for you and your support person to refer to should scenarios arise which cause confusion.

Writing Your Birth Plan

A birth plan does not have to be long-winded or overly explanatory. Given that in a hospital or birth centre setting, there may be more than a few members of staff that you may want to have read it, it is probably best to be as straightforward as possible. Or if you are having a homebirth the birth plan is still very much an important reference for you and your caregiver. Things you may want to consider when writing your birth plan are:

First Stage of Labour

  • I do not wish to be offered drugs
  • Natural methods of pain relief I would like to use are hydrotherapy, acu-pressure, massage, aromatherapy, movement, heat packs, compresses, darkness etc)
  • If I ask for drugs, I wish to be  encouraged to continue to labour naturally for as long as possible
  • I wish to move about freely and eat and drink during labour
  • I only want intermittent monitoring of the baby and minimal vaginal examinations
  • I would like to be left as undisturbed as possible.
  • People apart from my carer or support team should ask permission to enter the room. I do not wish medical students to be admitted into my room

2nd stage of labour

  • I want to adopt the birthing position that feels right to me and not be made to move
  • I do not wish to be told when to push or not push, I wish to birth my baby instinctively
  • I wish to give birth in water
  • If necessary I do not want an episiotomy, I would rather tear naturally
  • If instrumental delivery is required I would prefer Ventouse/forceps
  • I want the baby to be directly placed on me after birth, skin to skin
  • I want minimal noise and maximum privacy after my baby is born
  • I want to discover the baby’s sex for myself
  • I want the lights dimmed
  • I do not want the cord clamped until it has stopped pulsating/ I do not want the cord cut at all (lotus birth)

3rd Stage

It is worth noting that standard hospital practise is to medically manage the  third stage of labour (birthing the placenta) even if you have just given birth naturally. This involves injecting the mother with synthetic oxytocin to bring on contractions in order to expel the placenta. Birthing the placenta naturally will not take much longer than the managed 3rd stage and can be sped up by the baby suckling at the breast (this is natures way of helping th uterus to contract) The classic medical approach is to ‘tidy up’ as quickly as possible after the birth but there is no reason to just go with the flow if you want to do things your way. Things to consider when writing your plan for the third stage are:

  • I wish to deliver the placenta naturally
  • I wish to keep the placenta
  • If I need to let go of the baby to birth the placenta I wish the baby to be skin to skin with my support person

More things to consider

There are an array of procedures that hospitals routinely perform after the birth along with weighing and measuring your darling baby. These practices vary country to country and hospital to hospital so inform yourself as to what your care providers practices are. Remember these protocols are not compulsory and it is down to you to make the decisions as to what is right for you and your child. Things that you should investigate and decide upon are:

  • Vitamin K injection (colostrum is high in vit K)
  • Hepatitis B injection (Hep B is transmitted the same way as HIV and only should be given to babies who’s mothers carry the virus)
  • Treating the eyes with antibiotic ointment
  • Washing the baby (removing the protective vernix)
  • Heel prick test

Breastfeeding

Care providers are often more of a hindrance than a help when it comes to establishing breastfeeding. Often institutions will not ‘check out’ a mother and baby until the baby has regained a certain amount of weight. In their hurry to tick boxes, institutions often encourage mothers to give their babies formula to speed up this process. Mothers often comply as they are made to feel worried about the babies weight gain. This practice is hugely unhelpful to establish breastfeeding (more about that later) It may be worth writing in your birth plan:

  • Do not give my baby any formula
  • If formula must be given I wish the baby to take it from a cup and not a bottle

The contingency plan

It is a good idea to write a birth plan for, well if things don’t go to plan. Better to think about how you would deal with these situations should they arise rather than be reeling from the shock of it at  the time. Episiotomy vs tearing, forceps vs Ventouse have already been mentioned so finally here are some things you may want to consider writing should a c-section delivery be required:

  • I would like my partner/ doula/private midwife with me
  • I would prefer (type of anaesthesia)
  • I would like the lights to be as dim as possible and the room quiet as my baby is born
  • If it is not possible for me to be skin to skin with my baby then I wish my partner to be skin to skin with the baby until I can be
  • I wish to delay cord clamping/ not clamp

This may seem a lot if things to consider but the reality is that we live in a highly medicalised society, one that interferes greatly with the natural process of giving birth. You can have the birth you want but within this modern day system of care you will need to get informed and get pro-active to get what you know is your right as a woman.

NBR posted on two birth and parenting forums asking women who had a natural birth in a hospital or birth centre what things helped them achieve the birth they wanted. Here is their invaluable advice.

Choosing your care provider

Not everyone has the luxury of choice when it comes to choosing the hospital they give birth in, however if you do live in a place with more then one option, then do your research to find the best place for you.
“The hospital I chose matched my beliefs”

“I really looked into my obstetrician and made sure his beliefs about birth matched mine”

“Go public, with midwifery care, private hospitals are businesses, they need to make money and you are a client”

Fools rush in………

Timing your arrival at hospital is important. Going in too early can slow your labour down. Once you are admitted into hospital, the length of your labour will be monitored. It varies but you have around twelve hours to give birth before you may need to negotiate to avoid interventions, due to hospital policy.

“I stayed home as long as I could, so was 9cm by the time I got to the hospital, and yeah it did slow down”

“Labour at home for as long as you are comfortable, and then some”

“On the ‘what you can control’ side – yes, wait as LONG as you can before fronting up to hospital. I clearly remember ringing and the midwives saying ‘not yet, not yet’ a few times. From memory, almost every single woman in my group who transferred out of birth centre did so because they ran out of time”

Make your Environment

There are many things you can do to ‘own your space’ in a hospital. Think of it as marking your territory!

“I made up a recording of favorite songs to take. We weren’t allowed candles, but I really should have taken a favorite pillow or some other comfort item”

“Ask them to turn off as many lights as they can, and try for a room with a bath”

“To me, dark and quiet/silence was essential – luckily my midwives barely spoke a word”

“We set up two salt lamps, which provided a beautiful glow in the room and a calm atmosphere – and when we were transferred to the main labour ward we set up the lamps exactly the same and switched all the monitor screens around so I couldn’t see them, and muted all those machines that go ‘ping’. I barely knew I’d switched rooms”

“ For private hospital patients, get them to take the television out of the room. I’d love to have a study done on the effects of the TV being on in the labour room”

Understand what you are dealing with.

All hospitals and birth centres differ and will have their own rules and regulations. Informing yourself as to what these policies are, how they can affect you and what you can do about them is essential.

“My experience was mainly at a family birth centre, but I was transferred to the main labour ward due to a ‘complication’. Darn hospital policies”

“Be aware of the things that make hospital staff nervous. I can appreciate I had a great experience because I had a physiologically normal unfolding of birth, and was largely left alone. All those little ‘tipping points’ where they start putting on the pressure, that’s what you need to have strategies for”

“I asked many questions in birth classes about hospital policy in various situations and the midwives were very good at explaining the basis for the policies, and ways to ‘circumnavigate’ them”

“Really do your research on the ‘risks’ of natural birth vs interventions, ie you don’t have to believe everything you hear, and ‘they’ can’t always make you do things that you don’t want to”

“It was all about making myself as informed as I could be so that I felt confident to argue a point if need be with any medical person. I totally agree with the asking about hospital policies and why they do things a certain way so that you can argue against it if need be”

“I did my research and insisted on what I wanted – telling them I knew the risks, etc and I had made an informed decision”

The Birth Plan

Writing out a clear birth plan and going through it with your care providers before the birth and when you show up at the hospital is important. A clear birth plan will show hospital staff that you are well-informed and expect your choices to be respected.

“ My friend had a natural birth in hospital. She had a very detailed, firm birth plan. She made herself knowledgeable and came across as very confident”

“My preparation for birth involved doing as much research as I could on all aspects and making sure I was confident with the choices in my birth plan”

Support People

Whether it be your husband, friend, sister or mum who is with you, make sure that they know what you want. They should be as informed as you are about the birth and how the hospital operates. Remember, you are going to be busy giving birth! Your support person/people are there to make things easier for you.

“My partner also knew what I wanted, and was ready to back me up”

“Make sure your partner is aware of what you want, so if a midwife suggests something that he knows you don’t want (eg. to actively ‘push’, to get on the bed etc) he can remind her and be your voice.”

“My partner offered regular sips of water (silently!), good for hydration in a warm bath and a stuffy room”

“As well as the birth plan, I had check-lists for everything to help my partner and sister-in-law – what to pack, when to call hospital, what will happen when, reminder of the different stage of labour, etc. Yes, initially we thought it was a bit of overkill, but it meant we didn’t forget anything in our last-minute rush and everyone knew what they had to do.Partner was with me the whole time, doula helped us negotiate the hospital system and sister-in-law kept the peace of the room – it worked brilliantly”

Hired Help

Hiring a doula or private midwife to accompany you to hospital may be the best thing you can do. Not only will you have a constant and familiar figure with you but statistics show that hiring a professional to advocate for you reduces your chances of c-section, episiotomy and forceps delivery by half. Perhaps what is invaluable about a doula or midwife is that they will look after your interests leaving you to get on with more important things.

Doulas doulas doulas. Cannot impress enough. Independent midwife HIGHLY recommended”

“I had a natural birth in a hospital. It is possible. I wrote a birth plan out, and hired a doula – a doula is essential”

“My best friend had a VBAC in hospital. I believe she achieved that because I hounded her until she hired my midwife to take with her. I would not enter the hospital system without a very switched on midwife advocating for me”

“My main advice: hire a doula or private midwife who you can trust to look after your interests”

“Hire a doula. Can you put a price on having someone experienced in birth, telling you you’ll do a great job and talking through your worries”?

“I hired a wonderful Doula and it was by far the smartest thing I did. You can not place a $ figure on the knowledge and support such a person can provide. Mine spent 3 nights away from her husband and kids to be with me while I laboured – now that is commitment”!

It’s not just about getting there on time

Nearly all women in the west today give birth in hospitals, a large percentage of whom want to give birth naturally. Some achieve this without any preparation but they are the lucky few. So many women have been left startled and confused by the journey their births have taken within this system of care. Preventing this happening to you is about understanding the protocols of your chosen caregiver as well as getting informed about how an unfamiliar environment can affect you in labour.

Don’t Worry!

You can have the natural birth you want in hospital. It is important to look at what challenges you may face within this system of care so that you can prepare yourself ahead of time. Hospitals are places that look after people who are sick. Pregnant women do not fall into this category and yet are often treated as if they have an illness. Feeling like a ‘patient’ makes us feel passive and helpless but natural birth is a healthy and safe function that your body is perfectly designed to perform. The only person a woman should submit to when giving birth, is herself.

Hospital policies are not about individuals

Much ‘box ticking’ takes place in hospitals. These institutions rely on order, rules and routine to function optimally. This undoubtedly is essential to the day-to-day running of a hospital but is not conducive to giving birth. Birth is not “one size fits all” and every woman will experience it differently. The time it takes to give birth varies dramatically from woman to woman, some women will want to be left alone, others will want more support. Birth needs flexibility and there is room for manoeuvre within the system if you understand how it works. This requires asking questions of your caregivers before you check in at the front desk with 5 minute contractions!

Routines

The procedures that women in a labour ward are commonly subjected to are inductions (when labour has not progressed within the policy time limit or if you are past your due date), routine cervical examinations, permanent monitoring of the baby, observations by student medical staff and midwives changing shifts.

Room for negotiation

The knock on effect of one or more of these factors can alter the course of a normal labour. Apart from when your midwife comes to the end of her shift, all other interferences are negotiable.

  • If your care provider wants to induce you, you or your support person can negotiate more time. If it is unavoidable (make them give you a damn good reason as to why it is) have a say in the type of induction and discuss the possible implications with your doctor.
  • Examinations to see how far you have dilated are routinely done as often as every 4 hours in many hospitals. This invasive procedure is uncomfortable and very distracting. Experienced midwives should be able to see your progress not just by internal exams but also by watching your behaviour. The outer signs of a woman in labour are very strong indicators to where things are at. Make sure the midwife asks before performing cervical examinations, and if you don’t want one, just say “no, not now.”
  • It is normal for a babies heart rate to fluctuate during labour. Unnecessary panic can arise when the babies heart rate is listened to too often. Constant foetal monitoring is totally unnecessary in a women who is labouring naturally so make sure that your baby is monitored intermittently by your midwife.
  • Student medical staff do need to learn, but you most certainly do not have to be the guinea pig in this scenario. You may be in a public building, but treat your room as your own private space. If any unwelcome people enter you have every right to ask them to leave.

How hospital environments impact on birth

External distractions can be regular occurrences in a hospital. Talking, lights, observation, noise and eye contact can all have an impact on a woman in labour. These things may seem insignificant and yet the simplicity of silence and darkness can have a profound effect as to how a birth unfolds. These are simple but important details. Having strategies to create an environment in which to feel safe and undisturbed will certainly help you to give birth naturally in an ‘un-natural’ place. If this involves taking enough personal objects along to redecorate a small house, then so be it! Why not?!

The First Hour after Birth

No matter how your baby arrives in the world, the significance of the first hour after the birth cannot be over emphasised. Most caregivers now realise the benefits of immediate skin to skin contact for mother and baby. Mother and baby should ideally be left together without distraction for the first hour after birth. This is a magical moment. Hospital routines such as cord clamping, weighing, measuring, heel prick test and injections can wait. If, for any reason you could not be with your baby this time, then have the baby skin to skin with your support person until you can do so yourself. Give equal importance to what happens after your baby is born when writing your birth plan.

Retain your Autonomy

Perhaps it is the years we all spend in institutional education that makes some of us submissive in front of figures of authority. Mothers to be often don’t want to ask questions of their doctors and midwives purely because of the authority they exude. It is their job to put you at your ease and tell you everything will be alright but this should not put you off asking as many questions of them as you like and questioning every decision that is made on your behalf. Communication is a key element of good care. This is not about being obedient, although polite and friendly will most certainly work in your favour. Friendly but firm is the best way to negotiate. Better still, have your support person do the negotiating on your behalf, while you concentrate on more important things.

Unlearn your Fear

09/02/2010

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“The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown”
H. P. Lovecraft

Have you ever stopped to think that there is a reason to want a natural birth? That it is something to want, to aspire to? That it is nothing to fear?

Perhaps there is something niggling at the back of your mind, a curiosity about what giving birth without intervention might be like? What it might be like for you. If you are curious, explore further. Your curiosity will lead you to answers which will replace your fear with confidence and self-belief.

“Fears are educated into us, and can, if we wish, be educated out”
Karl Augustus Menninger

“When you fear something, learn as much about it as you can. Knowledge conquers fear”
Unknown author

“Knowledge is Power”
Francis Bacon

To remove fear you must arm yourself with information. Information about the wondrous things your body is capable of. Information about how different drugs can affect your body during and after birth. Information about hospital rules, and how they can influence your birth experience. Information on how to make things work for you within the hospital system. Finally, just to be clear, information about how amazing giving birth can be.

I Hope I get Lucky……..

Having a positive birth experience is not down to luck. You can prepare yourself for this extraordinary, life changing event. The preparation is 97% mental. Your body already knows what to do, if you will let it. Informing yourself about the everyday miracle that you are capable of will have you trusting in your body and looking forward to the birth of your baby.

Drowning in a Sea of Information

We live in a fast moving world. At the click of a button we have access to millions of answers, often contradictory ones. There are endless books written about pregnancy, birth and raising babies, all with their own angles, appealing in some way to every one of us. The effect of all this information at our fingertips is overwhelming. It may just seem easier to cross that bridge when you come to it.

You are busy. You are working up until the end of your pregnancy. You probably have a book called “What to Expect when you are Expecting” and enjoy reading about your babies developments month by month. Is this as far as your research into pregnancy and birth extends? Perhaps you have put the birth to the back of your mind thinking “the midwives and obstetrician at the hospital are great, they will tell me what to do on the day, everything will be fine….”

There is something comforting about relinquishing what happens to our bodies and making it the responsibility of the well-educated man in the white coat. When we are ill, and can made better because of someones expertise we should be eternally grateful for the wearers of white coats. Birth, however, is not an illness or something to be fixed, but a function that the female body is perfectly designed for and like most things in nature, cannot be improved upon by science.

Ladies, listen up

The one person who really needs to have faith in you, is you. It is not your obstetrician, or your midwife. It is not your husband, your mum, your sister or your best friend. (although hopefully all of them will be in no doubt of your abilities) They can support you, but ultimately you are the one that needs trust in what your body is capable of. The groundwork you do will give you tools, both physical and mental, to realise the positive birth experience you want. There is a part of you, that knows you can do it. Listen to that voice. Trust in your body and prepare yourself. The aim of this blog is to help you with that preparation, guiding you towards invaluable information that will have you anticipating the birth of your baby with excitement.

“Inaction breeds doubt and fear. Action breeds confidence and courage. If you want to conquer fear, do not sit home and think about it. Go out and get busy”
Dale Carnegie

Perhaps you are empowered at the thought?

“An intricate and exquisitely balanced combination of hormones is necessary to trigger all the functions of labour and birth. The subtle, complex interplay of changing hormone levels during the birth process is one of the most fascinating and little understood aspects of pregnancy and birth in the modern world” Ina May’s Guide to Childbirth

The hormones that the female body produces in labour are simply amazing. Prostaglandins, oxytocin, beta-endorphins, adrenalin, noradrenaline and prolactin all working wonders within the bodies of mothers and babies, bringing them into the world and giving each the best possible start.

The purpose of this post is to discuss how fear in the mind of the labouring woman has a knock on effect on this hormonal interplay and can inhibit the birth process. The two hormones being examined in this case are oxytocin and adrenalin.

Oxytocin, the Love Hormone

Every moment in your life when you felt good, for example; when you had dinner with friends, got married, were hugged or kissed, were made love to and or (!) had an orgasm, there was a hormone that was making it so. The hormone you should thank for all these wonderful experiences is oxytocin.

Maybe you would not associate being in labour with any of the feel good events mentioned above, and yet it is this hormone of love that is optimally coursing through us when we are in labour.  It’s importance during and after birth cannot be underestimated. In labour, oxytocin causes the uterus to contract and in turn the cervix to dilate. When a mother pushes her baby out, oxytocin levels are the highest they will ever be in a woman’s lifetime. This is important for two reasons. Firstly, the mother and baby (whose oxytocin levels have also peaked) lock eyes for the first time and fall deeply in love. This stimulates the let down reflex in the woman’s breasts to facilitate breastfeeding. Secondly, the oxytocin will keep the uterus contracting so that the placenta comes out. Oxytocin at this stage in labour greatly reduces the risk of postpartum haemorrhage. Oxytocin is the essential ingredient in the recipe of birth.

Adrenalin the Fear Hormone

When we are afraid, the hormone released is adrenalin. This triggers the “Fight or Flight” response in us. In a nutshell, what happens is large amounts of blood rush away from our organs and go straight to our limbs so we can either run for our lives or stay and fight whatever is scaring the hell out of us.

In the first stage of labour, Adrenalin impedes oxytocin for this very reason. The uterus requires a huge amount of oxygenated blood to function optimally. When the fear sets in and our adrenal glands open, this takes the blood away from where it is most needed. This interference makes contractions much more painful and it s-l-o-w-s e-v-e-r-y-t-h-i-n-g- d-o-w-n. To quote Ina May once more; “If Oxytocin is the accelerator of birth, then adrenalin is the brakes”

From an evolutionary perspective this made sense. Imagine the cave woman in labour and along comes a sabre tooth to eat her. Adrenalin rushes through her body, hindering oxytocin and stopping labour so she can run for her life. An evolutionary response that has ensured our survival on the planet.

In a modern-day setting, it is very common for a woman to be progressing beautifully through the first stage of labour, secure in her home environment, only to arrive at hospital to have everything slow or come to a stand still as a result of feeling uneasy in the unfamiliar surroundings. We may live in a very different world to our ancestors but our primitive instincts remain unchanged.

Remove the Fear

“Our doubts are traitors and make us lose the good we oft might win, by fearing to attempt”
William Shakespeare

When a woman faces every contraction and new sensation in her body with fear, adrenalin will upset the hormonal balance, making the first stage of labour longer and more painful. In a hospital setting this can result in a cascade of interventions that will alter the experience of birth. However, when a woman prepares herself mentally and replaces fear with curiosity and tension with excitement, she will develop trust and confidence in her innate abilities This will set the scene so these hormones can play out as they were meant to, rewarding the woman with the most powerful natural high of her life and giving her and her baby the best possible beginning.

Recommended reading and links

Read Dr Sarah Buckley’s fantastic explanation of the birthing hormones and their individual roles here

Gentle Birth, Gentle Mothering by Dr Sarah J Buckley

Ina May’s Guide to Childbirth by Ina May Gaskin

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