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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