Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Writing Your Birth Plan: Tips from an L&D Nurse, PART 1 July 22, 2009

There have been many a time that I have written about the option of writing a birth plan, especially if one is planning a hospital birth.  And some of my readers have questioned me further, asking things like “I don’t know how to write a birth plan!  How do I begin?” or “There are so many websites about writing a birth plan, how do I know which one is best?”

 

Indeed when you type “birth plan” into Google you get 22,600,000 hits.  Yowzers!!  No wonder why so many expecting moms write to me and tell me how overwhelmed they are!!   And as we all know, not all websites are created equal as some are more helpful (and more accurate) than others. 

 

So since I suggest writing a birth plan so often in my posts and comments I feel that it is only proper that I write a post specifically about birth plans.  I will try to help you navigate through the sea of websites and direct you to the ones that I feel are the most accurate, truthful, easy to understand, and helpful.  I would like to make a disclaimer though:

 

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Disclaimer:  This post is riddled with my own opinion as both a consumer of health care and an L&D nurse.  I feel that this post has something to offer to the world of birth planning articles because in all of my research I found very few birth plan guides written by L&D nurses.  I found them written by mothers, doulas, midwives, and even doctors…but very few, if any, written by L&D nurses.   This is very interesting to me because if you are planning a hospital birth the first person in the hospital that you present your birth plan to is the nurse.  Sure, your doctor or midwife might (wait, scratch that….SHOULD) go over it in the office with you and if you are hiring a doula, then she will most likely review it with you as well.  However when push comes to shove it is the L&D nurse who is your go-between and except for the actual “catching” part, it is going to be the L&D nurse who manages your care throughout your labor.  While I agree that there are probably many L&D nurses who feel differently than I do about how a birth plan should be written (if at all), I can say with confidence that there are surely just as many who do agree with my take on it.

 

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Since the vast majority of women are planning a hospital birth and I am in fact a hospital based L&D nurse, this post is geared almost entirely towards women planning a hospital birth.  Although a birth plan isn’t a bad idea for a home or birth center birth, it is often less crucial.  Why?  As Leah Terhune, a certified nurse-midwife with Midwives Care, Inc. in Cincinnati is quoted in the article Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth by Amy Scott says:

 

“A birth plan is not a must for out-of-hospital births 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.  In a really good relationship with a midwife, it should be understood by the end of the pregnancy what the expectations are.”

 

 

My goals for this post are the following:

 

1)      To assist you in writing the best birth plan you can by pointing you in the direction of the best resources out there, that I have found, on birth plan writing,

2)      To review the true purpose of a birth plan and to help you write a birth plan for the right reasons, and

3)      To help you navigate through a bureaucratic hospital system often perforated with outdated dogma and run by unofficial “policies” and help you and your labor companions facilitate a positive and empowering birth experience for your whole family!

 

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What Exactly is a Birth Plan?

 

 

According to Penny Simkin, a physical therapist, doula, and author of The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions:

 

 

“The mother’s Birth Plan tells her caregiver and nurses in writing what options are important to her, what her priorities are, any specific concerns she has, and how she would like to be cared for.  The plan should reflect the mother’s awareness that medical needs could require a shift from her choices, and it should include her preferences in case labor stalls or there are problems with her or her baby.”

 

 

I like this definition of “birth plan” because no where in that definition does it state that a birth plan is the mother’s actual plan for her birth.  That is, it acknowledges what those of us who work with mothers in labor know to be absolutely true:  LABOR CANNOT BE PLANNED OR CONTROLLED.  (And likewise, when someone, including the mother, her labor coaches, or her birth attendant tries to control labor, it only spells trouble.)  Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:

 

 

“Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.”

 

 

In their article Writing a Birth Plan, findadoula.com writes:

 

“It is not possible to use a birth plan to “make” your caregivers agree to things they are not comfortable doing. For instance, if you don’t want an episiotomy but your doctor usually cuts them for most women, it is unlikely a birth plan will make your doctor change his practice.”

 

 

[For more information on choosing a care provider please check out my post: Must Read Blog: “It’s Your Birth Right!!”]

 

Also doula Kim Palena James warns that a birth plan CANNOT:

 

1. Change your health care provider’s style of practice, personality or protocols.

2. Script the nature of your labor.

3. Insure you have a satisfying labor. 

 

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What Types of Birth Plans are UNHELPFUL to Mothers and Nurses?

 

 

Remember how I said that you cannot control labor?  Well you also cannot control your birth attendant or the medical system.  This is why author, certified nurse midwife, and childbirth educator Pam England, CNM, MA warns mothers about “The Birth Plan Trap.”  In her book Birthing From Within she writes:

 

“Writing birth plans is becoming a ritual of modern pregnancy.  This practice began with the positive intention of encouraging parents to take a more active role in birth.  Writing a birth plan motivates parents to learn about their hospital’s routines (usually with the intention of avoiding them).  A birth plan also can be a tool to open dialogue with doctors.  Telling a doctor what you want (and seeing his/her reactions) allows insight into the doctor’s philosophy of practice and willingness to share decision-making.

 

While gaining information is advantageous, the subtle implications of writing a birth plan are more complex than many people realize.  If you look below the surface, you’ll see that birth plans are like a hidden reef on which your efforts towards deeper birth preparations may run aground.

 

In my classes I discourage mothers and fathers from writing a birth plan.  I’ve changed my mind on this issue for several reasons.  I now believe that the need to write a birth plan invariably comes from:

 

  • Anxiety and/or mistrust of the people who will be attending you;
  • A natural fear of the unknown.  Some women attempt to ease that fear, and enhance their sense of control by writing a detailed script of how the birth should happen;
  • Lack of confidence in self and/or birth-partner’s ability to express and assert what is needed in the moment.  (Birth plans may be intended to substitute for face-to-face negotiations with authority figures.) 

 

In writing a birth plan, a woman focuses on fending off outside forces which she fears will shape her birth.  This effort distracts her from trusting herself, her body, and her spirituality.  Rather than planning her own hard work and surrender, her energy is diverted towards controlling the anticipated actions of others.”

(Birthing From Within, pages 96-97)

 

 

Indeed I have met and cared for couples as an L&D nurse where it seemed like they spent the majority of their time preparing for the birth by writing a birth plan that was intended to “ward off the enemy.”  Pam England calls this “fear-based externally directed preparation” (i.e. “I don’t want this,” “I don’t want that”).  And when I work with couples like this I, in turn, spend the majority of my shift trying to convince the couple (and sometimes their doula) that I am actually on their side.   And don’t get me wrong…I completely understand where their fear comes from (they probably experienced or heard about situations like in my “Don’t Let This Happen To You: Injustice in Maternity Care Series”)!  And there are plenty of stories of unsupportive nurses and crazy on-call doctors to where I don’t blame the couple for feeling like they have to gear up to fight me for everything they want.  But all that fear and worry does NOT facilitate an empowering and positive birth experience and sadly, it sometimes becomes a self-fulfilling prophecy; indeed a mother must almost let go of “control” in labor and surrender to the power of her body and of birth.   

 

So we’ve just learned that birth plans intended to control birth or ward off the enemy are not helpful to anyone.  However unlike Pam England, I don’t take the same drastic stance as she does by recommending that couples do not write a birth plan.  Why?  Because when a birth plan is written for the right reasons and contains the right information, it can really be a helpful tool that nurses can use to help facilitate the birth experience that you desire.  So what types of birth plans are helpful to childbearing families and nurses?  What should be included in a birth plan? and, How should a birth plan be written?  Well, I’m glad you asked!!

 

What Types of Birth Plans Are USEFUL and HELPFUL to Mothers and Staff?

 

In her article Lela Davidson writes:

 

“A birth plan is most useful when you use it to:

 

1. Discuss options and choices with your health care provider. Understanding how your care provider thinks and what her normal practices are will help eliminate confusion, debate, and disappointment during labor and birth. You’ll also increase the level of trust between yourself and your care provider: She’ll understand your priorities and you’ll understand her limitations and preferences.

 

2. Communicate your personality and unique physical, emotional, and environmental needs to your labor and delivery nurse. Let her know what works best for you: A quiet environment? Whispered voices? Do you have a fear of needles? Are you worried about too many people in your room? What do you want to do for pain relief? What helps you relax? What does your partner need? What are his or her fears? Do you like to be touched? What did you learn in your childbirth classes that you’d like to try?”

 

Up for Tommorow:  Top Ten DOs for Writing Your Birth Plan

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22 Responses to “Writing Your Birth Plan: Tips from an L&D Nurse, PART 1”

  1. Emily Jones Says:

    Thanks for this post! I am more of an extremist where birth plans are concerned, I don’t think they are worth much. But then, I don’t think most women should be birthing in hospitals, which is somewhat unrealistic, given the state of home birth in this country. I appreciate the work you and other medical professionals do to effect change from the inside, and I also appreciate your even-tempered approach to helping women achieve the most they can out of their hospital birth. It scares the heck out of me to hear of any woman trying to attempt a “natural” birth in a hospital, but I feel a little better knowing there are nurses like you out there, looking out for them.

  2. Sarah Says:

    I’m excited to read the next post! In our childbirth classes years ago, my teacher urged us students to write a long birth plan to begin with, in order to discuss (policies, etc.) with our providers. Then, with the help of the provider, to narrow it down to a one-page, bulletted (not paragraphs!) list of items that may be out-of-the ordinary for that particular hospital or in case our provider was not on call (continuous monitoring, amniotomy, etc.). One of the most important things I remember about her instructions was that she encouraged us to use “yes, please” and “no, thank you” phrases on our bullets.

    I found these pointers to be very helpful, and our birth plan was much more succinct and readable than some 4+ page ones (hospital generated, if you can believe that!) that I’ve since encountered. What nurse/attendant has the time to read all that?

    I’m sure you will address these types of things in your next post. I love your informative, thought-provoking entries. I look forward to reading each of your posts, and gleefully pull up a chair when I see you’ve updated your blog.

    Keep it up!

  3. Laura Says:

    I’m study hypnobabies, and the one thing that program encourages is to call it “Birth Preferences” rather than a Birth Plan but it’s basically the same thing.

    Also a question. Do you think it’s a good idea to have a seperate birth plan for C-section? I am absolutely planning for a natural birth and would be incredibly upset if we couldn’t do that but in the off chance that it’s just completley unavoidable, is it a good idea to have a specific birth plan just for that and what kinds of things can we request to make the C-section a more positive/bonding/special experience?

    Thanks! I love your blog!

  4. mac0517 Says:

    I didn’t realize, until I read this, that when I invision a birth plan it is wriiten to “ward off the enemy”. And you are absolutely right, your birth plan should be a tool to find the right provider so that when you’re in the hospital setting you don’t have to fight for your wishes; they’re already know and agreed upon. You open my mind a little more every time you post. I hope everyone I refer your blog to reads it, it is SOOOO beneficial to all woman.

  5. MrsW Says:

    I’m in something of a bind, because although it seems my OB/GYN is fairly allowing for my state (Mississippi), she is constantly answering my questions for labor with “I don’t want to promise anything that would be under the care of the nursing staff more than myself.” I think if she saw a birth plan she’d say the same thing. I’m starting to get the feeling that my doc suspects she won’t be attending my labor (I am due the day after Thanksgiving) so I will be at the mercy of whatever doc in the practice is on call and my nurses. Any advice on how one would prepare for this, with a birth plan and all? I’ve heard bringing in food for the nurses is good. 😉

  6. enjoybirth Says:

    Oooo, I can’t wait to see what your Top 10 are.

    In Hypnobabies we actually call them Birth Preferences instead of Birth Plans, because as we all know birth is not plannable. 🙂

    I just posted the BEST birth plan I have ever seen on the Hypnobabies Blog. http://www.hypnobabiesblog.org

    There is also a Hypnobabies MP3 giveaway going on there too.

  7. Tam Says:

    I have given birth to 3 children and have written two birth plans. Truly, for myself, the birth plans were really a way to open a discussion between myself and my OB (same one for the last two births). Unfortunately, she was not able to attend my last birth – but then again, neither did the OB on call. It was way too fast (from onset of labor to birth – less than one hour. From arriving to the delivery room to birth, maybe 10 minutes?).

    However, the nurse in charge (not my nurse) ran over everything I wanted. I wanted a heplock (discussed with my OB and she talked to her partners about it and they were fine with it too) instead of an IV. This nurse tried to force me into it and refused to call the on-call OB to see if he would “allow” a heplock. I knew that heplocks were allowed because for my second birth, at the same hospital, I was “allowed” one.

    My point is, birth plans don’t mean much unless you are using them as a preference. IJohn Steinbeck wrote “The best laid plans of mice and men oft go awry.” And boy that certainly fits with birth plans. I say write them and use them to open discussions with your midwife/ob/nursing staff (if you have time…LOL! I did not!).

  8. Tam Says:

    Oops… Wasn’t John Steinbeck, it was Robert Burn’s poem, “Ode to a Mouse”. And I have the quote incorrect…pardon my blunder!! It should have read

    “The best laid schemes o’ mice an’ men
    Gang aft agley,
    An’ lea’e us nought but grief an’ pain,
    For promis’d joy!”

    Either way, it does seem apt with birthing plans.

  9. Jill Says:

    I’m intrigued to see the rest of your commentary on this! I am way too cynical about birth plans…if you have the right care provider you shouldn’t need one, and it seems like when you do make one it just gets used for toilet paper. :/ Hopefully you can help me bust this bubble of negativity I have around the whole idea!

  10. Erin Says:

    I think part of the usefulness in the birth plan takes place before the birth itself. It gives a couple a chance to really talk out issues, expectations, fears, what they hope will happen – with each other, and then with their practitioner. How the dr. responds to the birth plan can give a lot of information to the couple on how s/he might respond during birth, telling them things they didn’t know before. But really it can be invaluable to the couple as well, to help them understand all the facets of the process. There were definitely things we talked about with the doula and had in our birth plan that we decided we didn’t care about in the moment (delayed cord clamping, for example), but others we weren’t expecting (being asked about the Hep B vaccine) that turned out to be important to us. So for me a birth plan is about a) preparation for me, my husband and b) opening up conservation with various folks who will be at the birth – doula, nurses, dr/ midwife. I agree with Jill that with the right person – in my case, a great midwife and OB (OB called in b/c of complications) I didn’t “need” my birth plan. But I was still glad we had done it.

  11. Erin Says:

    opening “conversation” not “conservation”. Hehe. (not enough coffee yet)

  12. […] childbirth, nurse, nursing If you haven’t already, please check out PART 1 of this post:  Writing Your Birth Plan: Tips from an L&D Nurse.  Also, at the end of this post check out a birth plan written and sent to me by one of my […]

  13. Michelle Says:

    We had to have a hospital induced birth last time, though we had planned for a homebirth.

    When we went in the day before and they decided to induce the nurse told us to make out a birth plan, and the doctor agreed.

    We quickly made just a few points…basically:

    let me labor alone as much as possible
    no episiotomy or breaking waters
    no immediate cord cutting

    Simple really…I think maybe we had 7 points in all.

    We discussed each point with the nurse and the doctor. We even asked if my DH could catch.

    The doctor initially agreed to everything we asked, including delayed cord cutting and no extra interventions.

    That quickly ceased. I was strapped to monitors and every time I unhooked the nurse came in and told me I could have a few more minutes and she’d have to hook me back up.

    THe doctor asked me EVERY time she came into the room if I wanted my water broken.

    As we reminded her each time we saw her not to cut the cord, her response changed from no problem to she hopes she remembers. Our nurse at one point said she would reminder her.

    Later the doctor (with the nurse agreeing) said that people come in with their birth plans and no one sticks to them. SO they mean nothing to her. That she just does what comes natural to her.

  14. Meg W, RN Says:

    I love your blog! thank you so much! I wish I could get all potential patients to take a look at this…
    Often we get birth plans that outline all the things we normally do for women and their families anyway- with this underlying sense that our patients are afraid that we are going to do all these out of practice things to them!
    Most L&D nurses really are on the same page and want to truly advocate for their patients and help them have the best possible experience. But unfortunately, as reflected in some of your other blog posts, certain Docs (and maybe Nurses also) are continuing to push their own agendas on patients and intervene when unnecessary. Hopefully as we increase awareness in our patients and encourage them to advocate for themselves in a positive manner, these unneeded interventions will wane.
    In regards to part 2, it is disheartening when women do not know why it is they checked off or wrote what they wanted in their birth plan. I can share with them what I know, but a 5 to 15 minute conversation does not substitute good prior research and knowledge, especially if one comes in the throwes of labor and does not have the emotional energy to devote to educating themselves of 9 months worth of information in 20 minutes.
    I am also just getting into Pam England’s book- and love the theme of individuality of every labor and following the twists and turns of the process as they come. You just never know how each labor is going to progress, what she may or may not need, or want as time passes.
    Knowledge, advocacy, and flexibility may just be the most important tools couples can arm themselves with when entering the hospital for labor.
    Again, Thank you so much! I am in love with your blog! Keep it up!

    • NursingBirth Says:

      Meg W, RN, you write “I can share with them what I know, but a 5 to 15 minute conversation does not substitute good prior research and knowledge, especially if one comes in the throwes of labor and does not have the emotional energy to devote to educating themselves of 9 months worth of information in 20 minutes.”

      All I can say is YES YES YES! I feel your pain!!

  15. […] L&D nurse blogger who has done extensive research on the topic and wrote a 2 part series on Writing Your Birth Plan- Tips from an L&D Nurse over at nursingbirth. I would highly recommend you check it out especially if you plan on a […]

  16. Katie Says:

    I would love to get your opinion -and that of others- on the plan I have put together so far. If possible (crossing fingers)!!

    Parents: Names
    Hospital: Named
    Doctor: Named
    Doula: Named
    EDD: 11/08/09

    Overview: Due to the fact that I am planning on a VBAC, I have done extensive research on all potential risks/complications associated with such a birth. I am also aware that in any birth, emergency and unforeseen complications may arise. As best as possible I have also included my plans for such scenarios. I appreciate your help in bringing our little girl into this world.

    Early Labor:
    • I am planning to stay home until active labor has started. Since we live almost an hour away from the hospital and my previous vaginal births were quick, it is possible that I may arrive at the hospital before much progress has been made. Depending on labor stage upon arrival, I would like the opportunity to return home/leave the hospital if active labor is not imminent.
    • I will be drinking/eating only clear liquids/foods once labor has begun and until active labor has started.

    Active Labor/Admission:
    General
    • Upon admission, if an IV is required due to the nature of my birth (VBAC), I prefer a heplock to be inserted instead of a full IV line. I will continue with water/ice chips to prevent dehydration.
    • I would like to leave my contact lenses in unless an emergency arises and they must be removed.
    • During labor, I would like access to the tub/shower as long and often as needed. If water has broken, I will use the shower and not the tub to prevent possible infection.
    • To assist with labor, I would like the following available to me: birthing ball, birthing chair, squat bar
    Monitoring
    • Understanding the need to ensure the safety of our baby, I understand the need for monitoring. I request that intermittent fetal monitoring be used unless distress is suspected.
    • As long as there is no fetal distress, I prefer to remain on/return to intermittent monitoring until delivery.
    • I prefer no internal monitoring be used unless there is evidence of fetal distress via external monitoring. Such instances would include (but not limited to) loss of heartbeat.
    Pain
    • It is my intention to have an un-medicated delivery. I am aware of all pain options available to me and will request pain meds if desired. I have used Nubain in 1 of my vaginal deliveries so I would like that option left available to me upon request.

    Intervention/Augmentation
    • I prefer that there is NO artificial rupture of membranes (AROM). If there is a medically relevant reason for this to be done, I will be open to the suggestion and will decide based on the facts at that moment.
    • As discussed with my Dr, I understand that augmentation meds may not be available to me as a VBAC patient. If augmentation is suggested, I will consider the pros and cons and make a decision at that point.
    • If for any reason augmentation is used, I would like full control of levels and any/all increases and decreases.
    • If labor appears to have stalled at any point, I want the freedom to change positions and/or wait for it to continue as long as desired and as long as the baby is stable.
    • During any stall of labor, I will continue with monitoring as suggested to ensure the safety/health of the baby. (Portable fetal monitoring would be preferred at this point so that continued motion may occur.)

    Delivery:
    Pushing
    • I want the freedom to move and re-position as desired during all phases of labor. During delivery, I will likely push while on hands and knees (facing the bed) or over the birthing chair however, would like the freedom to push in the way most comfortable and effective.
    • I would like only my Doula or my husband to guide/direct me. If other assistance is needed, I will request it at that time.
    • I would prefer no episiotomy and prefer the option of tearing instead. We have been massaging the perineum in preparation for delivery. As long as possible I would like that to continue during labor and delivery.
    • Please do not pull on the placenta but wait for it to naturally deliver on its own. Excessive bleeding would be the exception to this request.
    Immediately following delivery
    • Do not cut the umbilical cord until it has finished pulsing and turned white.
    • I intend to attempt nursing immediately following birth.
    • Please do not wash/rub off the vernix from the baby. I will be rubbing as much of it into her skin as possible instead.
    • Please do not administer the Vitamin K shot or the eye gel.
    • We request full rooming-in with our baby and Dad will accompany baby for any/all procedures that need to be done out of our room.

    Emergencies:
    As mentioned previously, we do understand that birthing a child is not a scripted event and emergencies can arise. Any and all medical procedures (emergency or not) are to be fully explained in advance and will include any natural/non-surgical options.
    ~(outline emergency examples where c-section would be acceptable/???)

    I have read and understand the wishes of (us) and will, to the best of my ability, assist them in having a VBAC delivery as outlined above.

    (Signature lines for Dr, Hospital Nurses, Doula and ourselves)

  17. […] Writing Your Birth Plan: Tips from an L&D Nurse, Part I […]

  18. […] could for a successful VBAC by planning a drug-free/intervention-free childbirth, you wrote up a birth planthat you painstakingly went through “line by line” with your physician early on in your […]

  19. really? Says:

    Its crazy that you say that your Doctor can perform an episiotomy if you request that they dont….’ I do not consent’ is a legal term.

  20. […] Writing Your Birth Plan: Tips from an L&D Nurse, Part I […]


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