This week, the class covered another enormous segment of ground: cesarean section, immediate postpartum procedures for mom and baby, FAQs about the newborn, prolonged postpartum issues (mother's physical & mental health) and an introductory mention of breastfeeding (I believe BF-ing is to be covered in further depth next week.) Oh, yes, and the construction of a Birth Plan - a document introduced to our industry in 1980 by Penny Simkin and Carla Reinke.

How to Write a Birth Plan.

Should You Write a Birth Plan?

What Good is a Birth Plan?

Healthy Baby'... Healthy Mother... Happy Family... How I am Going to Make it Happen?

Any one of these could be an acceptable title for a singular class session and, I believe, could warrant an entire 2+ hour class, in and of itself. Because, really, the Birth Plan ('Birth Preference,' 'Birth Wish List,' etc.) is really just a review - perhaps, a preferential ranking system - for everything previously discussed in class. It is an opportunity for expectant parents to do couple of things:

1. ensure they understand their options revolving around childbirth
2. understand medical interventions that may be presented to them during labor and birth
3. express their preferences for/against any of the above options and interventions
4. communicate effectively amongst all members of the birth team (parents, support people, maternity care staff)

Unfortunately, as is the case at our local hospital, there is a subversive hatred toward birth plans, paired with the (generally unwarranted) assumption that 'any woman who walks in here with a birth plan is setting herself up for disappointment - and likely a C-section.' This reality is echoed in the commentary article published by Simkin in the March, 2007 issue of Birth (Simkin, P Birth 34:1 March 2007 p49-51) about the study published in the same issue of Birth by Eileen Yam, et al (Volume 34, Issue 1, pp 42-48, March 2007).

And yet, common practice in many hospital settings seems to ensure that women/expectant couples who have the gall to highly educate themselves about the labor, birth and postpartum period - and who attempt to communicate their wishes to their maternity care providers, based on that education - are punished via the assumptions made about them by the people who will be caring for them.

A 2009 study out of Taiwan showed demonstrable positive effects in study participants who employed the use of a birth plan. While small (n=296) the study revealed 'a statistically higher degree of positive childbirth experiences' than the control group. While not offering proof of better birth outcomes, this study suggests that, if nothing else, the use of a birth plan aids in the woman in achieving a POSITIVE lived experience of the birth process.

In her book, Birthing From Within, Pam England states,

'The idea of planning a birth is naive; labor and birth are not events conducive to being planned. You can have a fantasy or birth plan, the hospital has its ideas, but Mother Nature may surprise all of you.'

'There are no unique birth plans. While your birth plan is unique to you, it won't seem that way to your hospital or doctor. All women ask for the same thing: respect, dignity, and support to birth naturally with minimal routine intervention and no unnecessary separation from the baby.'

The activity presented in class this week, pertaining to the construction of a birth plan was entitled, 'Making Choices.' A handout, of the same name, was given to each expectant parent/couple, containing two side-by-side lists of twenty-six paired issues pertaining to birth and the puerperal period. Examples of items on the lists are as follows:

Amniotomy Spontaneous Rupture of Membranes
Clamp cord early Wait to clamp cord
Labor starts on its own Induce me please!
Etc. Etc.

Students were to initially circle one item from each pair, representing their preference on that topic. The resulting list of twenty-six preferences was then to be tackled.

'Now,' the instructor said, 'cross off thirteen of the selections you've made.'

Having plunked myself dead-center in the room that night, I was in a great position to just sit and listen to what was happening around me. Conversations erupted around the room; expectant moms and dads now had to decide which of their preferences were less preferential than others. As if the moment were at hand, I heard women saying things like, 'I guess I don't really need that, we can cross that one off.' What didn't they really need? To wear their own clothes during labor? To make use of a jetted tub or shower? To push in an upright position?

The activity in class continued. 'Now, take 5 more off your list. Think about what really does and really doesn't matter during your baby's birth.'

There were a few groans in the room.

Moments later, the instructor urged them on again. 'Get your list down to the very basics - three to five items, tops. Which items are 'life changers' for you, as in: 'if I don't get these three things, my life will be changed forever?'

Can we really expect that of our students: to be satisfied with three items on their birth wish lists? To be ok with whatever else happens during birth, minus three things? To take this approach, I think risks making all previous efforts in class to deliver evidence-based childbirth education advocacy full of hypocrisy. One might as well say, 'I've spent the last XX weeks instilling within you the importance of things like movement in labor, staying home in early labor, using variable comfort measures, assuring proper labor and birth support, avoiding unnecessary interventions, etc., etc... but now I'm going to tell you that you have to pick only three.'

It just doesn't make sense.

By the end of the activity, I had heard the students around me say things like, 'cross off delayed cord clamping. It really doesn't matter,' and 'get rid of 'Let Labor Start on Its Own,' inducing labor is really not a big deal.'

Aren't these things a 'big deal?' Don't we spend our time, our professional lives working to help expectant parents understand why these things are a big deal?

How do YOU handle the discussion of Birth Plans with your clients?

Posted by: Kimmelin Hull, PA, LCCE

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