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According To Plan

24 November, 2010

No matter how carefully thought out, nothing ever goes completely to plan. When we are talking about birth plans, that is especially true. However, careful research and preparation as well as a well written birth plan can make an enormous difference.

During my first pregnancy I read all the standard books on pregnancy. I read current magazines. I watched pregnancy programs reality TV style, courtesy of pay TV. I’d decided that I wanted to labour as naturally as possible, but as I really didn’t know what to expect. My obstetrician (I didn’t realise you didn’t have to have an obstetrician) never asked about my intentions for the birth, and I never brought it up. While I ended up being induced, and having gas and pethidine for the pain, the birth was fairly smooth and quick.

During my second pregnancy I did a lot more reading. I read Pinky McKay and scoured the web. I attended the midwives clinic at the local public hospital. I wrote a comprehensive birth plan, covering all contingencies. In the end, the birth plan was hardly needed as I only just made it to the hospital in the back of an ambulance. However, it did communicate important information to the midwives who attended the birth (I did not want to have the oxytocin injection nor have the cord cut immediately – things I wouldn’t have been able to tell them in the time we had!) so my efforts weren’t wasted.

In my third pregnancy, I found myself revisiting my old birth plan and developing a new one. Most of my desires didn’t change, although I was less shy in stating so. My birth plan wasn’t welcomed by the midwifery staff in the antenatal clinic, however it was respected in the labour ward. Perhaps due to the middle-of-the-night nature of my hospital admission, the registrar and all the midwives who attended me in my birth had read my birth plan.

Things didn’t go to plan. My waters broke early, shortly before the 37 week mark considered to be term. My baby’s heart rate was abnormally high and not dropping enough after I was rehydrated. I was not yet in labour, despite being 4-5cm dilated, although having a few niggles. With my consultation, the decision was made to augment my labour with an oxytocin drip.

At every turn, my wishes were respected. I was allowed to sit on a chair for my labour, instead of being confined to the bed, despite needing continual monitoring. I was also allowed to labour in the shower. Despite protocol stating that a paediatrician had to be present at the birth and my baby whisked away to be examined before being placed on my chest, there were only two midwives and my husband present at the birth and my baby was placed directly on my chest after the birth. Despite never having problems delivering the placenta before (having delivered it in two minutes in my previous labour), the staff were happy to allow me to wait an hour before intervening at all – which only mean increasing the oxytocin drip a little. In the meantime, the cord was left intact until I requested it to be cut, over an hour after our baby’s birth. At every turn, my wishes were respected, and where they couldn’t be followed exactly, I was consulted and informed about the options. I feel I would not have been treated with as much respect had I not stated my wishes in advance.

Some studies have shown that most women found developing a birth plan to be beneficial, even though they did not feel the birth plan was followed in up to 50% of cases, where other studies have shown little benefit to the mother during pregnancy and labour from completing a birth plan.

The downsides to birth planning can include an implied lack of trust in the labouring woman’s caregivers, the ambiguous ethical and legal issues surrounding birth plans and how authoritative they are and the labouring woman’s potential disappointment with a birth that did not go according to plan, especially where a large amount of medical intervention is required, where there are adverse outcomes (such as infant mortality or morbidity) or where the birth experience is perceived as traumatic.

On the more positive side, a personalised birth plan, that includes a couples wishes and fears, enables individualised care to be given. There seems to be much ridicule and little regard given to “tick the box” birth plans that proliferate the internet and many popular magazines and books. These personal birth plans are particularly important when the model of care does not include continuous care by one birth attendant. Sometimes there are several different caregivers during the same labour and there can often be little time to discuss needs and wishes. However, professional opinion seems to be that personal communication and discussion is much preferred to the less personal medium of a written birth plan, where the circumstances allow.

Birth plans can be valuable as they encourage a pregnant couple to consider their desires and wishes, research possible options and ask questions of their caregivers and the policies of their chosen birth environment. This process also allows the couple to identify their fears and confront them or at least inform their carers of them, enabling their caregivers to provide the care they need.

In my experience, birth plans are not always well received prior to the birth. However, I have found them invaluable for communicating my wishes in advance, allowing a labour and delivery midwife who is sympathetic to our views of birth to be assigned to us. It has ensured that our wishes were respected when there was no time to communicate these wishes prior to the birth. Finally, it gave me the opportunity to confront my fears about birth and a successful outcome. I’ll be writing a birth plan during any future pregnancies!

This article first appeared in the Kindred Magazine newsletter.

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