What is a plan? Well, we had an extension built. We employed an architect, we told him what we wanted, he did some lovely drawings, full of measurements, specifications and loadings etc. We spoke to a few builders who looked at all the lovely drawings and few weeks later told us how much it would all cost and how long it would take to do it. Then we sent our drawings to the council, out came a man, he looked around and then wrote us a letter saying we could have what we wanted but due to the soil and how our house, and our neighbours houses looked we would have to make some changes to our plan, not major, we would still end up with the extension but the preparations (footings) and the finishing (rendering) would have to be slightly more intricate. Back to the architect, he made the changes on the drawings, back to the builder, he made adjustments to the costs and the time it would take, both increased. Our plan was ready. Needless to say it took longer and ended up more expensive, both of which we knew would happen. The weather affects the pace of building; third parties like suppliers, sub-contractors and the need for visits at certain times by the building inspector will affect progress if they are late delivering or attending. Did we consider that us or the builder had failed because we hadn’t kept to our plan? No, we were realistic and, most importantly we had the end result that we had desired, our extension.
Back to the eponymous birth plan, I think that that it should be named something different. When my children were younger they had a book called ‘ Would you rather?’ by John Burningham, it posed dilemmas like ‘ would you rather eat spider stew, slug dumplings, mashed worms or drink snail squash?’ ( it is still available but in an updated version ) I think that Birth Plans should be named ‘What I would rather’. It would go along the lines of – I would rather be able to move freely than have to stay on a bed. Or perhaps it should be an informative questionnaire to be filled in by the woman –
- Do you want to be mobile in labour ? Many women find that this helps them to cope better with contractions and can help labour to progress faster. If your baby needs to be continuously monitored it may be difficult to do this if you are moving around.
- Do you want to use gas and air? The research suggests that it does not affect baby. When you stop inhaling it the effects wear off immediately. Some women experience nausea/vomiting when using it.
- Do you want an epidural? The advice is not to have one before you are in active labour. You will need to have a cannula (small plastic tube) put in a vein. Research has shown that they may cause labour to be longer, and make it more likely that you may need help to give birth, but if it works it will get rid of the pain of contractions. Some labour wards have a limit on the number of women on labour ward at any one time who may have an epidural as they need more intensive monitoring. An epidural needs to be put in by an anaesthetist, he may not be immediately available. If the midwives or doctors believe that you may have a longer or more difficult labour they may suggest that you have an epidural.
- Do you want your ‘waters’ to be broken. There is no proven benefit from this procedure if all is straightforward but it may be necessary if you are having an induction of labour or there is need to monitor baby by putting a clip on to his head……..
and so on.
Why this musing? I really hate it when women feel that they have ‘failed’ because their birth didn’t go the way that they had planned and over the last three days I have spent a lot of time de-briefing women because of this disappointment with themselves and/or the staff. Back to our extension, we got what we wanted in the end, we had to compromise on some choices, we can look back and say that it would have been nice if it had finished earlier, that it had kept within budget, but in the end we had a positive outcome. Our plan was flexible, it was a case of ‘we would rather, but we are content’, I wish that birth plans could be viewed in that way and that women could view the outcome, a healthy Mum and baby, in the same way.
A Midwife's Muse 
It took me over 7 months from the birth of my son to feel like I wasn’t a “failure” because my highly prized and fought for homebirth ended up as a hospital birth. I have a blog post about a month ago exactly about this called Letting Go and Rejoicing http://lizzardbits.blogspot.com/2008/08/letting-go-and-rejoicing.html
In retrospect, my well researched, and precise to the minute detail, was all written in a negative and defensive way. Therefore I was setting myself up with negative thoughts for the birth and a “fail”. It took an “ah ha” moment of clarity to realize that I did not “fail” in birth, but rather “won” a successful safe med-free
vaginal birth of a healthy 9pound 10ounces baby boy!
My, now 8 month old, son is well and strong and had a great beginning to life, and besides the months of needless guilt, I came out of the birth fit and well.
I wonder how those women would get on in a place where the only birthplan is to shut up and do what the doctor tells you to?
My birth plan is going to state what I would prefer, but I’m not going to stick to it if it’s not practical. I’m not planning an epidural, but I’m not ruling it out either. I don’t think I’m ruling anything out at this stage!
I know too many women who had rigid plans that just couldn’t happen, and they were so disappointed. I’m going to try to go with the flow.
Vic – I can just imagine the press coverage, and the litigation!
Anne – I think that is so sensible. I always suggest to my women they should state their preferences but also allow for the unexpected and take advice.
I wasn’t going to write a birth plan because I thought the idea of planning a birth was ridiculous, I was going to see what happened on the day. My midwife and a friend who is a midwife strongly advised me to write one because they said the middle of labour wasn’t the time to be discussing preferences. So I did. It was a complete waste of time, my daughters birth was a complex induction and I also had pre-eclampsia. As it happens we ended up discussing my preferences in the middle of labour because so few of my ‘planned’ preferences (active labour, water, massage) were available to me. It all turned out fine, my midwives were really good at explaining the pro’s and con’s of everything as we went along, and they timed it well by discussing stuff before I got to the point where I was in too much pain to think. Afterwards I was well hacked off that my birth didn’t go to ‘plan’. I’m never writing a birth plan again. What will be will be.
with my first baby we practically expected every nurse to read the plan before she took a BP or anything to do with me! How naive!!! We slowly got better with them and for the 3rd and 4th babies I reused birth plan #2 almost word for word.
Lizzardbits – Sorry I took so long to respond, but had to read your blog first! It really does sound as though your birthplan, especially the homebirth element, really coloured your whole perception of your son’s birth because he was born in the hospital. I’m so pleased that you are able now to just have joy in your baby and dismiss the change of plan. It does sound though that even if you didn’t get to give birth at home that everything was wonderful.
Freddie – You see, that’s the whole thing with plans, they have to be updated! If a woman hasn’t mentioned gas and air, I will still ask her if she wants it. If she has said that she wants to be mobile, and then starts reclining on the bed, I will check that she is happy with this and offer to help her up again! Perhaps the adage should be ‘Go with the flow’!
mumof4 – I do try to follow the birth plan, but sometimes ‘little detours’ have to be taken, birth is a completely individual process for every woman and baby so one size does not fit all.
We had a birth plan for our extension. Unfortunately it didn’t cover what would happen if the builders had a wobbly and left us half finished! Any ideas anyone?!!
Lucy – That happened with a loft conversion we had years ago, the boss did a runner. We ended up employing the ‘lads’ directly, ended up being cheaper and the building control guy from the council was really helpful, I think my emotional state tugged at his heart-strings.
I didn’t have a birth plan, I had a birth manifesto. And it reflected my ultimate fear, that my caregivers would do things to me I didn’t want and I would be unable to refuse and that is precisely what happened. So much for the birth plan.
Now that I am a labor and delivery nurse I view mothers with birth plans very differently than my coworkers. As a women’s labor nurse,if she comes to the hospital with a birth plan I know what the underlying message is – she doesn’t trust me and she may or may not trust herself. It is therefore my responsibility to rebuild that trust by giving her as much control as possible about the things she can control and reassuring her that all is normal with the things she can’t. My goal is not to argue with her choices but to gently encourage her to let go.
I think in most birth plans the purpose behind writing them is fear of some sort or another and it is the fear that needs to be addressed.
Secondly I think that in most cases women who write birth plans may instinctively know that birth is best when interventions are kept to a minimum. (How many moms ask for forceps and episiotomies in their birth plans)And what they need is reassurance and encouragement that yes she can do this, her body is perfect. By writing a birth plan she is stating what she believes and she is hoping you will say “Yes, I believe this too. You have nothing to fear. I will protect you.”
In the end is that not our job as health professionals: to protect the health of our clients as much as if not more than to fight disease.
Erinladryn – Hmmm, not too sure about a birth plan always being indicative of a lack of trust, I really do believe that for many women it is just what it says, it is their own plan of how their labour will progress and be managed. You point out that women do not request epis or forceps, forceps no, but episiotomy, well they write on their plans ‘I would rather have a cut than tear’ or ‘ If I’m going to tear please do an episiotomy’. They may not ask for forceps, but there are plenty who request a far more dangerous option, a section, or indeed an epidural which is known to increase significantly the need for instrumental delivery.
I will always discuss a woman’s birth plan with her prior to the birth. I let her know that we will follow it but that there may be times when it becomes necessary to change course slightly, but that everything will always be explained to her and her partner and that nothing can, or would, be done without her consent.
I wonder how a woman having her first baby can construct a birth plan when she has no idea what contractions feel like 🙂
Hello Emma, have skimmed your blog, will read more later.
Good question! I suppose that they have listened to the experiences of friends and family, read bits here and there, gone to childbirth preparation classes (!!!) and decided how they are going to approach this experience. With first babies it has got to be individual assessment of the information they have received, in subsequent births it is going to be previous experience. Even that is unreliable though as every birth is different.
This is one of the reasons why I really am not sure of the birth plan appellation, ‘birth ideas’ or even ‘wish list’ perhaps would be better?
A ‘wish list’ sounds much better to me than a birth plan, it leaves room for surprises. And thanks for visiting my blog – feel free to comment on anything you like.
midwifemuse – I’ll give you that. I have only seen a few birth plans and they all had the same basic message : no interventions please. They were all Primips and they all ended up in the OR. In fact it has become a (not so funny) joke that if a prim comes in with a birth plan we usually expect the exact opposite of her plan. I hate this manner of thinking and I frequently ask myself why this is so.
I like the idea of calling it a “wish list” or “Birth preferences” Which like emma states would leave room for surprises and allows a woman to communicate preferences. But calling it a “birth Plan” implies an expectation of being able to control every detail. And to me needing to control something so primal is indicative of fear. I could be wrong.
One of the things I like to do is to talk with the women and their partners who come in before labor for whatever reason and feel out what their expectations are regarding birth. Most I find are unfortunately fearful of the process in general or of the perceived pain. I love to relay their fears with happy easy birth stories. And I encourage them to keep an open mind – it might not be that painful or you may surprise yourself with how well you can deal with it. I love Ina May Gaskin’s idea of changing the perception of birth through the telling happy birth stories.
Erinladyrn – Have you read Dr Amy’s, Homebirth Debate, entry about Birth Plans?