Plan what you can

Birth plans require flexibility, dialogue and the acknowledgement that babies don’t always follow the plan


Liz DeCarlo

When Daisy Pardo of Chicago was pregnant with her son Josiah last year, she had some specific desires for her childbirth experience. To make sure her health care team was on the same page, Pardo created a birth plan outlining the kind of labor and delivery she envisioned.

"I’d read about birth plans in What to Expect When You’re Expecting, so I decided to start writing my own," Pardo says. "I knew I wanted my husband to be really involved, so I needed something that would help with that. And I focused on natural labor, no medication. I wanted to have something written down so they wouldn’t listen to my screaming and desperation."

Birth plans, which have been around for the past 30 years or so, are a way for pregnant women to gain some control. The most successful ones are short and stick to the basics of delivery—medications, episiotomies and baby’s after care.

But even good birth plans can be controversial. Some make requests that are at odds with hospital procedures; others seem to usurp the medical staff’s control.

"In the hospital, they don’t really love the birth plan because they know you’ll demand what you want," Pardo says. "The mind-set of the hospital is that if you’re in pain, you should have drugs. Everyone was on top of me to take the drugs. They were not really happy about the plan." But if the objective is more control for the mother, Pardo’s plan worked.

Plans that work

Hospital policies and procedures do sometimes run counter to birth plans, but if expectant parents work with the hospital and do a little research ahead of time, most birth plans can be handled well by hospitals, says Don Houchins, director of nursing obstetrics and education services for St. Mary of Nazareth and St. Elizabeth hospitals in Chicago.

"Birth plans really are helpful, because they give mothers a feeling of control through the birth experience," Houchins says. "Sometimes by asking women to talk about their birth plan, it allows [the experience] to be special and meaningful, so we see that as an important part, too."

Communication is the key. Expectant parents need to discuss their requests with their doctor and the hospital’s health care team well before labor begins.

"The negative side is that sometimes women come in in labor with elaborate plans that we haven’t seen before," Houchins says.

Communication also is the way to find out if your plans conflict with hospital policy—such as the woman who wanted lots of candles in the delivery room, a no-no in a room with oxygen, Houchins says.

As soon as moms-to-be know where they’ll deliver, he recommends calling the hospital to ask for a tour of the labor and delivery floor. During the tour, women should talk about the birth plan, ask questions and get a sense of what the hospital will provide.

"If you can’t get a tour or call returned, you’re not going to get a good reception to your birth plan," Houchins says.

Keep it simple

When Ann Kauth of Chicago was in her eighth month of pregnancy, she and her husband worked with her doula, Abigail Lynn, to create a birth plan. Kauth then took the one-page plan to her next visit with her obstetrician, who approved the plan but warned her the hospital may not agree to monitor her only intermittently during her delivery.

Kauth planned to use hypnobirthing during labor, which requires few interruptions. The hospital was conducting research on pain during labor, which required nurses to ask about pain levels each hour. Because Kauth’s doctor had warned her the study could conflict with her desires, she included a section in the birth plan asking that nurses not to interrupt her to ask about pain levels.

Kauth carried a copy of her birth plan with her to the hospital and fully expected to have to fight to have her baby her way. It didn’t happen.

"We didn’t get intermittent monitoring, but they did take [the monitors] off when I went to labor in the tub," she says. "And no one asked me for my pain rating—ever."

Kauth’s birth plans had two features that made it more likely to succeed: It was short and simple and it recognized the need to accept any intervention if her health or that of her baby was in jeopardy.

"You read all these books and see these lists, and I was like, ‘Oh my God, if I was a nurse I’d have a hard time with all these requests.’ So we came up with a bare minimum," Kauth says.

Brief, direct birth plans that focus on the basics are best. Put in what you think is most important—such as IVs and pain medication and after-baby care, such as who will cut the umbilical cord—but leave out things such as "I’d like to have music or people talking softly." That can be handled by your partner, Lynn says.

Pardo’s birth plan asked that her baby not be given a bottle or pacifier since she’d be nursing, and she wanted her husband to cut the umbilical cord when the baby was born.

Talk through it

But many of these requests can be handled without a birth plan just by talking with the doctor before the birth, says Dr. Teresa Hubka, an obstetrician with Comprehensive Women’s Care in Chicago.

"We tailor our charts so they get their wishes and desires," Hubka says. "The person delivering the baby and the patient should be on the same page. As a physician who will deliver, I go through it myself."

Hubka does acknowledge that hospital staff sometimes react negatively to a woman with a birth plan.

"Will the staff read it? Some will, some won’t, some will laugh. So I tell my patients, ‘Don’t worry about it, as long as we understand together,’ " Hubka says.

Part of the reason birth plans may get a negative reaction is that they can be too rigid, not allowing for the many unexpected turns childbirth can take. Or they may be unrealistic, expecting, for example, that a doctor will refuse a woman’s request for an epidural because the birth plan requires it.

"You need to be open minded and don’t back yourself into a corner," Hubka says.

Jennifer Gagnon, a nurse midwife, agrees. That’s why she sees birth plans primarily as a useful tool for opening a dialogue between a physician and patient

"The physician and the hospital are in control of childbirth," she says. "The birth plan is the patient’s attempt to take control back and some doctors don’t like having the control taken away."

Many of the requests in birth plans are fairly standard anyway, such as the woman saying she doesn’t want an episiotomy. No one wants to do an unneeded episiotomy, Gagnon says, but "different providers have different ideas of what’s needed." If not having an episiotomy is a goal of the birth plan, she recommends rather than writing a birth plan the doctor might not follow, that you ask the doctor "What is your rate of episiotomies?"

The birth plan is a great way to communicate to your doctor your birth wishes and to discuss your doctor’s standards of care, Lynn says.

Be flexible

But don’t get too caught up in what’s not going to happen or you could wind up disappointed with your childbirth experience.

"Sometimes intervention is required and women need pain relief. We try to relieve their guilt if they change their mind during labor," Houchins says. "If there’s a little flexibility [in the birth plan], we can support the woman. If it’s too rigid, the mother feels disappointed and frustrated and often the health team does, too."

But whether the birth plan is followed to the letter or changes occur along the way, having a woman communicate with her health care team about what she hopes for during childbirth is a positive thing.

For Pardo, having a birth plan helped her ensure that the hospital staff knew what was important to her during her labor and delivery—that her husband, Joseph, be an integral part of the process.

"It didn’t come out perfect, because you can’t control everything, but I think it helps so much instead of going there completely clueless," Pardo says. "I did get to hold the baby first and my husband took him out, so the main things were there."


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