What Do Obstetricians Think About Birth Plans?……. by Dr Bianca Bryce

Saying the words “birth plan” is a bit like saying “feminism” – they are concepts that have very different meanings to different people.  Some people love them, some hate them.  There are women who couldn’t possibly think of giving birth without a 3 page, typed and formatted, laminated copy of their birth plan being distributed to everyone who may remotely come into contact with them in labour.  There are women who stress out because they don’t know what they “should” be writing on their birth plan.  A birth plan can be as simple as a list of songs that you would like to hear in labour, or what sort of snacks you would like to bring.  Many women don’t even know they exist.  So what’s the deal…?

A birth plan is basically a collection of things that you would like to have happen during your labour, birth, and postpartum.  It can be as long or as short (or as non-existent) as you want it to be.  Remember this is about you.

But I think the word “plan” is misleading.  It’s more of a collection of “birth hopes”.  Most birth plans assume that all is going to go smoothly.  And in the majority of cases that is what happens.  That’s what we all want.  What we don’t want is for you to be so invested in your birth plan that if something doesn’t happen the way you wanted, you’ll feel like you’ve failed.  Or been cheated out of the way things were meant to go.


Birth Plan

After seeing my fair share of birth plans, and more than my fair share of labours and births, I have to say my ideal birth plan would say, in big italic letters, in the middle of a pristine white A4 page “I will go with the flow” (remember we talked in my last post about labour being unpredictable, and how I really only get involved when things don’t go exactly to plan?).  But I’m coming from a position where I believe in woman-centred care, in involving women and families in the decision making processes around birth, and in making decisions that are based on what’s best for the health of a woman and her baby, rather than what’s best for a health-care system.  And in those circumstances, I think a birth plan is less necessary.  But unfortunately that is not always the case.  And that (in my opinion) is why birth plans have been developed.  I think birth plans originate in mistrust of the professionals who attend birthing women.  Looking at birth stories on the internet there are many women who have completely lost (or never had) trust in “the system”.

Many of the birth plans we see ask for things that are done as routine in most of the places I have worked – for instance “I would prefer that routine checks and weighs are delayed so that I can have skin-to-skin time with my baby”.  “I would like my partner to cut the cord”.  “I would like the baby to be birthed onto my chest”.  All good things to do.  And all things that are pretty standard.

Many women are keen for things that are not necessarily standard, but are well researched and very reasonable – “I would prefer a physiological 3rd stage” (ie to birth the placenta without an injection of artificial hormone, oxytocin), or “I would prefer delayed cord clamping”.  These are great things to write down, and also useful to remind your midwife or obstetrician of closer to the time.   If all goes well I would hope that most caregivers would not have a problem with these requests.  And in those times when things don’t go to plan, we should speak to you about which of these requests is still do-able, and which we wouldn’t recommend, and why.

This last word, “why”, is crucial – some things don’t make physiological sense, or may be risky.  For instance, if your labour has needed some help (induction or augmentation) and you are already on a hormone drip, then not giving a dose of hormone to help birth the placenta doesn’t really make sense to me – you already have the hormone in your system, so there’s not much to gain by omitting the dose at birth, and your body may be so flooded with artificial hormone that it may not respond to your body’s natural hormone at birth, putting you at greater risk of bleeding.  If your baby has meconium in the liquor, it can be crucial that the baby is checked by the paediatricians at birth – if possible before the first breath – bypassing delayed cord clamping and that first skin-to-skin contact.

There are some things that we tend to say no to as a knee jerk reaction, because “that’s not the way we do it”.  Things like delayed cord clamping at Caesarean section – it’s not the way I normally do things, but when I think about it, a lot of the time it would be a very reasonable thing to do.  If your baby is well at birth, then why not?  It won’t be practical to wait until the cord has stopped pulsating altogether (mainly because we want to get the placenta out and give the baby to you and your midwife so that we can get on with the business of sewing you back up to stop you bleeding), but there’s usually no reason why we can’t wait 30 seconds or a minute while your baby gets that little bit extra of blood and oxygen to ease the transition to the outside world.  Skin to skin at Caesarean – it’s awkward (because we are taking up most of the space on your abdomen, and you’ll have the baby in a small cramped area on your chest, and you don’t always feel 100%), but if you feel well and your midwife and your anaesthetist are happy to help you with it, then I think it’s an excellent idea.

Then there are some situations where unfortunately your birth attendants may try to tell you that something that you didn’t want is necessary, or something that you do want is not possible, without giving you any good reason.  Or giving you a blanket “it’s best for you/the baby” without explanation.  And this is where the mistrust can kick in.


Picture courtesy of Born Photography

There are certainly times (again rare) when we are truly concerned for your health or the baby’s health and where time is of the essence, and where there really isn’t time to discuss things in detail.  When this happens to a woman I’m caring for I hope that I can convey this (in pretty much those words) to them and that they feel as comfortable as they can with what I have told them needs to happen.  And I will come back and talk about it later so that they can understand where I was coming from.  And hopefully not look back on that experience as a reason to mistrust others from my profession in the future.

If you are not in this situation – if you are not having the discussion as you are flying along the corridor on the way to your emergency Caesarean, or as paediatricians are resuscitating your newborn – then I do think it is OK to ask your caregivers for an explanation of what they can and cannot accommodate, and why.  I think you should ask.  And you should get a rational, considered answer.  Even better would be if you can have this discussion PRIOR to labour, about some of the hypothetical situations where your birth hopes may or may not be practical or safe.

My hope for the future, my long term birth plan, is that all women will feel comfortable enough with their caregivers, to say “my birth plan is to go with the flow – I trust you”.   And that we can put our hands on our hearts and say that we deserve that trust.

Dr Bianca Bryce

(This article contains general information only and is not intended to replace advice from a qualified health professional. All information is written from the experience and knowledge of the person writing the post).