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Writing a Birth Plan is not difficult to do, but it is necessary to include those things which are important to you during your labor and the birth of your baby, including after-birth care for both you and your baby.
MoonDragon Birthing Services recommends each client take the time to ponder what they want and what they do not want for their birth experience and put it on paper. This will help the midwife to work with each client most effectively and to help the birthing mom to have the type of birthing experience she desires. In a homebirth situation, many of the preferences usually discussed and written into a standard hospital Birth Plan, such as having or not having labor drugs, are not an issue since we do not use pain medications in a homebirth situation. However, I still feel it is important that your Birth Plan includes all of these issues, whether it is a planned homebirth or not. Unfortunately, there will always be a few planned homebirth clients from time to time that may need a transport to a medical facility at some point during their labors or immediately postpartum. This will be where the Birth Plan will be most important. The midwife will need to have a copy of your Birth Plan included in her files in the event of a transport. This in turn can be provided to the medical team that will take over care. Of course, in the event of a transport, there is already something that is not going well and many of the preferences may need to be discussed with the medical team by the birthing mother and possibly altered or compromised. Birth Plans are not "written in stone", as they say.
WHAT IS A BIRTH PLAN?
The majority of expectant women spontaneously begin labor, progress through increasingly intense stages of labor, feel like pushing, and give birth, at approximately 40 weeks after conception. On the other hand, reliably predicting birth in any greater detail than this is basically impossible. We cannot know the day or week labor will begin, how long it will last, exactly how it will feel, how we will react, or the health and sizes of our babies. What we can do, however, is educate ourselves about the vast array of possibilities and learn which are more likely to occur. We can decide what is ideal and what we will strive for, what are the means to creating the most conducive environment for such a birth, and which people can best help us to attain those birth arrangements. We can prepare our bodies and hearts for the process.
A Birth Plan is a list of your ideals and preferences for your birth experience. It is a wonderful way to let your midwife or other health care providers know what you are hoping for during the labor, the birth, and after the baby arrives. It will also demonstrate your interest in taking an active role in the birthing process. You should print out copies for yourself, your midwife or other health care provider to add to your medical records, a copy for the hospital or birth center, and one for your doula or birthing support person. In the event of a transport to a hospital, be sure to take your copy with you and keep it available for review by any member of the medical team (you will most likely have several).
QUESTIONS TO PONDER WHILE FORMULATING YOUR BIRTH PLAN
Formulating a birth plan while you are pregnant is a good way to ensure that your wishes regarding labor and childbirth are clearly stated and respected. Do your research as you are considering what you want in your birth plan. A birth plan allows you to decide in advance what you want and what you would choose from the options you may face during the birth of your child. It is a good idea to work with your midwife, health care provider and your partner in drawing up the plan. The following are a number of things you should ask about, and decide upon, in developing a birth plan.
- Where will you have your child, and what options are open to you in that facility?
For example, do you wish to simply stay in bed during labor, or would you rather walk around or take a shower or sit in a tub? One study has shown that sitting in the warm water of a birth pool during the first stage of labor can soothe a woman's pain and reduce the likelihood she will need an epidural. Researchers from the University of Southampton in England had 49 women sit in an oval-shaped, acrylic pool during the early stages of their slowly progressing labors. The water temperatures were about 98°F. The outcomes were compared with those of 50 women who received standard care for slow labor. Those who labored in water were less likely to need drugs to aid their contractions and said they had less pain and higher satisfaction with their freedom of movement than did those receiving standard care. Discuss all of your options for labor with your midwife or health care provider.
MoonDragon's Articles: The Benefits of Waterbirth
- If you have chosen to have the baby in a private home, who will be there and what additional facilities might you need?
- If you are in a hospital, can you wear your own clothes? Listen to music? Watch a video?
- How many people will be allowed to stay with you? Do you want them to take photographs or videotape the birth?
- Do you want an intravenous (IV) line inserted during labor?
In many places, this is considered routine procedure. However, it often is not necessary.
- Do you want to be given drugs (especially oxytocin [Pitocin]) to speed up labor?
Oxytocin is often given through the IV and can make labor more painful and mothers are often less able to cope with the intense contractions.
- What type of medication (if any) do you want? If you decide against any pain medication at the time you write your birth plan, will it still be available should you change your mind at any time during labor?
- If you decide to use drugs for any pain you might experience, what are the potential side effects? Is it safe for the baby if you breast-feed immediately after using pain medication? Does your health care provider or midwife use homeopathic and/or natural remedies for pain?
- What methods will be used to monitor the baby during labor?
- Do you have to have your baby in the lithotomy position (flat on your back with your feet in stirrups)?
- Will you have an episiotomy?
An episiotomy is an incision made to enlarge the vaginal opening either so that forceps or vacuum extraction can be used to hasten delivery or to prevent tearing in this area (which it really does not do! In fact, almost always, tearing occurs with an episiotomy), which takes longer to heal than an incision does (argumentative). Evidence based research has shown that an episiotomy is rarely needed if enough time is given for the tissues to be allowed to stretch on their own. Most midwives rarely have to perform an episiotomy with their clients. This procedure is more likely with conventional medical practitioners in an institutional setting.
- Probably the most important question: Are you willing to have a cesarean section, and under what emergency circumstances do they perform this operation?
- If you had a cesarean for a previous delivery, will you be supported through a vaginal birth after cesarean (VBAC) this time?
Over 24 percent of American women who give birth in hospitals undergo cesareans. This figure can go as high as 35 to 50 percent, depending on the individual hospital and the individual health care practitioner. Teaching hospitals tend to have higher rates of cesarean deliveries than non-teaching hospitals. The world Health Organization has stated that no area in the world is justified in having a cesarean rate greater than 10 to 15 percent. Cesarean births cost more than twice as much as vaginal births. It takes longer for the mother to recover (it is major abdominal surgery with all the risks involved), and the she has to remain in the hospital for an extra 2 days, on average.
The most common reason for performing a cesarean is that the mother has had one for a previous deliver. But VBAC is possible (depending on the reasons for the prior delivery and the type of incision performed), and this is something you should discuss with your health care provider or midwife.
The risk of rupturing the previous incision is very small. The reasons for emergency cesarean usually fall into the following categories:
- The umbilical cord presents before the baby (cord prolapse).
- The baby is in breech presentation (coming down the birth canal feet first, buttocks first, or sideways, instead of head down).
- The placenta breaks up or breaks away from the uterine wall before the baby is born (placental abruption).
- The placenta is covering the cervix (placenta previa).
- The baby's head is too big to fit through the pelvis (a very unusual event).
Many problems can be corrected before or during labor without resorting to a major operation such as a cesarean section.
A SAMPLE BIRTH PLAN
Birth Plan for (Your First, Middle, Last Name)
Due Date: 2/22/02 (month, day, year)
Client (or Patient) of Jane Doe, Midwife (or Dr. Jane Doe)
Scheduled to birth at home using MoonDragon Birthing Services (or other midwifery service)
(or Scheduled to deliver at Name of Medical Center).
9/9/01 (Date of Birth Plan)
Dear Ms Doe (or Dr. Doe and the Medical Center Staff):
I look forward to sharing my upcoming birth with you. I have created the following birth plan to help you understand my preferences for my upcoming labor and delivery. I fully understand that in certain circumstances these guidelines may not be followed, but it is my hope that you will assist me in making this the experience I hope for. If you have any questions or suggestions, please let me know.
Sincerely,
Your First & Last Name
LABOR
IN A HOMEBIRTH:
- I would like to have my partner (husband) as my primary support person.
- I would like to be able to move around and change position at will throughout labor.
- I would like to verbalize my contractions if I feel the need to do so.
- I would like to be able to have fluids or nutrition by mouth throughout the first stage of labor.
- I would prefer to keep the number of vaginal exams to a minimum.
- I would like to have the room dim of light, my music playing, incense or aromatherapy used, and members of my chosen birthing team to be quiet and respectful of my needs and desires.
- I want to labor in water as I choose to and only get out when I need to.
IN A MEDICAL FACILITY:
- I would like to have all the items above.
- I would prefer to avoid an enema and/or shaving of pubic hair. [This usually not done in medical facilities any longer]
- I do not wish to have an IV at any time during my labor without my approval.
MONITORING
IN A HOMEBIRTH:
- I would like a fetoscope (fetal stethoscope) used for monitoring, if possible, and a fetal doppler only as a second choice.
- I would like the number of monitoring sessions, including blood pressure readings, kept to a minimum.
IN A MEDICAL FACILITY:
- I would like to have all the items above.
- I do not wish to have continuous fetal monitoring unless it is required by the condition of my baby, and then only done with a fetoscope or doppler. I do not wish to have an external or internal fetal monitor used unless there are clear signs that my baby is in distress and only with my approval.
LABOR AUGMENTATION & INDUCTION
IN A HOMEBIRTH:
- I do not wish to have the amniotic membrane stripped or ruptured artificially to induce or augment labor unless signs of fetal distress require internal monitoring in a medical facility.
- I would prefer to be allowed to try changing position, walk, use herbal & other natural labor stimulants, and nipple stimulation before being transferred to a medical facility where pitocin is administered.
- I do not wish to be put on any time restraints regarding the length of my labor as long as my labor is progressing and my baby is doing well.
IN A MEDICAL FACILITY:
- All of the above.
ANESTHESIA
IN A HOMEBIRTH OR MEDICAL FACILITY:
- I do not wish to have any kind of anesthesia offered to me during labor whether at home or in a medical facility.
- I will use breathing, relaxation, meditation and/or Hypnobirthing or other various techniques as a means to control any of my labor discomfort.
- If I am transferred to a medical facility, I wish to have anesthetic medication available only if I specifically request it.
- I do not want an epidural or any other narcotic medication.
CESAREAN
IN A HOMEBIRTH OR MEDICAL FACILITY:
- If my midwife recommends transport to a medical facility and the receiving health care provider determines that a cesarean delivery is indicated, I would like to obtain a second opinion from another health care provider if time allows.
- I would like my husband (or partner) present at all times if my baby requires a cesarean delivery.
- I wish to have an epidural for anesthesia in the event of a cesarean delivery.
- If my baby is not in distress, my baby should be given to (name of person, such as your partner) immediately after birth.
EPISIOTOMY
IN A HOMEBIRTH OR MEDICAL FACILITY:
- I would prefer not to have an episiotomy unless absolutely required for the baby's safety.
- I want to have perineal massage and support during the crowning of the baby's head to prevent tears.
- If I should happen to have a tear, I do not want it sutured unless it will not heal properly on its own.
DELIVERY
IN A HOMEBIRTH:
- I would like to choose my own position for delivery whether it be standing, kneeling, squatting or other position that is most comfortable for me.
- I would like the room to be quiet and dim of light.
- I would like to birth in a water bath, if possible.
- I would like my children and any other family members I want present at the birth as long as their presence will not interfere with my laboring and birthing efforts.
- I would like my husband and/or birthing team to support me and my legs as necessary during the pushing stage.
- I would like a mirror available so I can see my baby's head when it crowns.
- I would like to touch my baby's head as the head crowns.
- Even if I am fully dilated, and assuming my baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.
- I would like to breathe my baby out unless the urge to push is overwhelming.
- I would like to have my baby placed on my stomach/chest immediately after delivery.
- I would like to be able to touch and caress my baby while s/he is on my stomach/chest.
IN A MEDICAL FACILITY:
- All of the above.
- I do not wish to have a routine use of forceps or vacuum extraction used on my baby unless the baby is in distress and will need to be born quickly to preserve life.
AFTER DELIVERY
IN A HOMEBIRTH:
- At the time of birth, I wish to immediately put my baby to my breast to help expel my placenta.
- I do not want my placenta removed by force, but allowed to deliver spontaneously on its own.
- I would like to keep the placenta for my own uses after the delivery.
- I would like to cut the cord myself, only after it has stopped pulsating.
- I would like to have my daughter examined and cleaned in my presence.
- I do not want vitamin K or antibiotic eye medication given to my baby.
IN A MEDICAL FACILITY:
- I would like all of the above.
- I do not want my baby, if it should be a son, circumcised.
- I want to have my baby to room with me at all times and provide her/his care.
- If my baby must be taken from me to receive medical treatment, my husband or some other person I designate will accompany my baby at all times.
- I would like a private room, if available.
- After the birth in a medical facility, I would prefer to be given a few moments of privacy to urinate on my own before being catheterized.
- If I am Rh negative I want the right to refuse a Rhogam injection.
- I do not want my baby to have blood drawn, eye medication used, or any other neonatal procedure done without my approval.
- I would like to donate the umbilical cord blood.
BREASTFEEDING
IN A HOMEBIRTH OR MEDICAL FACILITY:
- I would like to breastfeed my baby on demand beginning at the moment of birth.
- Unless medically necessary and only upon my approval, I do not wish to have any bottles given to my baby (including glucose water or plain water).
- I do not want my baby to be given a pacifier.
PHOTOGRAPHS & VIDEO TAPING
IN A HOMEBIRTH OR MEDICAL FACILITY:
- I would like to have photographs and/or make a video recording of labor and/or the birth.
OTHER CHOICES
IN A MEDICAL FACILITY:
- My support people are my midwife, doula and designated family or friends and I would like them to be present during labor and/or delivery.
- I want myself and my support team treated with respect and consideration at all times by all medical providers.
- If I choose to have religious rites or ceremony(ies) performed during the labor/birth/post-delivery, I do not want the ritual to be interfered with by medical staff.
- I want my baby and I to be released as quickly as possible after the birth to return to my home.
WRITING A BIRTH PLAN FOR A GENTLE BIRTHING EXPERIENCE
Many mothers, midwives and health care providers today favor a written birth plan as a necessary tool in fostering the safest and most fulfilling birth experience for the family. A Birth Plan important because it is a written document that shows the goals and wishes of the woman giving birth. At a time when she may be especially vulnerable and when it may be difficult for the birthing mom and her partner to make decisions, it is important for everyone involved in the birth process to know how the birthing mom wants her birth to unfold. The Birth Plan is a way of communicating these desires with your midwife or other health care provider. It is also a sign the you have educated yourself about the birth process and possible interventions that may arise during your birthing experience. In a medical facility setting, Birth Plans enable continuity of care where you may have numerous nurses, physicians and other health care providers working with the mother. When a Birth Plan is available, the medical staff will have an understanding of a woman's expectations.
Many decisions need to be made during labor, some of which may come as a total surprise to the laboring mom. While writing a plan, a woman will have the opportunity to discover and consider these choices. The Birth Plan is a method of exploring all the options that are available and to start, before labor begins, communicating with the people who you have chosen to be at the birth. The expectant mom will feel more clear about her options if she has time to review them before the onset of labor and birth.
For expectant moms giving birth in birth centers or at home, a written Birth Plan is less crucial. A Birth Plan is not essential in out-of-hospital births because there is more self-education done by the mother, and most people come into the situation with the same philosophy and goals that childbirth as a natural process. During the prenatal care sessions, a great deal of discussion and exploring possibilities occurs between the birthing mother and her midwife. A good relationship usually develops and expectations are understood by the time the birthing mother goes into labor.
The more medically oriented the birth setting, the greater the need for a Birth Plan. In a hospital, the possible interventions are numerous and are often used routinely. It is wise to be aware of these methods, their usefulness, their risks, and in some cases, their misuse or overuse. It can be easy to forget that in most ways birth is reliable, and that in the case of most healthy women, it can be trusted to produce a healthy baby with no more intervention than encouraging words, soothing hands and watchful eyes.
CONSIDERATIONS
YOUR CARE PROVIDER CHOICES
Most women use obstetricians to provide prenatal care and to assist in the delivery of their babies. Obstetricians are trained in medicine, pathology, and in surgery. They are very aware of (and expect) the problems and diseases (and their treatments) that can occur in pregnancy and birth. However, because of their intense training in complications, they have very little experience with the natural, normal, healthy aspects of pregnancy and birth. They will be more likely to use interventions that may not be needed during a normal routine delivery than other practitioners. Obstetricians should only be used by women who are in an extremely high-risk category. Obstetricians are more likely than other care providers to require a great deal of prenatal testing and monitoring during labor and birth. A typical prenatal visit might last 5 to 7 minutes. Exceptions to this might be the first visit, and a visit in late pregnancy when or if birth plans are discussed. These visits can last 10 to 20 minutes. Of all types of practitioners, you will spend the least amount time with this one throughout your pregnancy and during your labor and the birth of your baby. You may or may not have the same practitioner when you go into labor (they will often have other practitioners covering for them), so it is wise to get to know other members of their medical staff. Physicians do not provide labor care, instead they rely on the nursing staff to provide this function to the minimum capacity. More times than not, you will be laboring alone without the support and encouragement you may need for a successful delivery. They will often only arrive just in time to "catch" the baby, and then they will be off again to other realms. They will be the most rigid in their practice and least likely to work with your birth plan (many think a birth plan is a nuisance) if you are wanting a natural, unmedicated, gentle birth experience.
Increasingly, women are choosing midwifery care for their normal and high-risk pregnancies. Certified nurse-midwives (CNMs) can attend hospital births and may be found in birthing centers. As trained nurses, are adept at working within the medical system. CNMs must work directly under a physician. CNMs have backup physicians for cases of serious complications. Some are more naturally oriented than others. Some are more commonly called "medwives" as compared to "midwives." Some CNMs were homebirth midwives before pursuing a CNM degree. However, they are more likely to work within your birth plan outline than their physician counterparts, as long as it does not interfere with established hospital protocol and the guidelines of the physician that they must work under. Their prenatal visits are usually longer, but, as with physicians, you may not get care from the same midwife every time or at the time of delivery. CNMs are more likely to work with you and offer some labor support and encouragement, depending upon how busy they may be at the time of your delivery. Most CNMs are unable or unwilling to do homebirths.
Direct-entry midwives (DEMs) are trained in midwifery but not in nursing. Depending on location, direct-entry midwifery may or may not be practiced legally, but it is practiced, nevertheless, nearly everywhere. Some states require DEMs to be licensed (LM) or certified (CM, CPM) to practice in the state. Other states are more relaxed and may or may not have any certification or licensing procedure available for DEMs. Midwives have trained more fully in the study of healthy pregnancy and birth, and of course can also recognize and treat many complications. Many midwives also attend births at free-standing birth centers and some will attend home births. A typical prenatal visit may last 30 minutes to an hour, and can be longer early and late in pregnancy, or when a mother has special concerns and questions that require lengthy discussion. DEMs emphasize good nutrition, health lifestyles, and client education, informed decision making, and client responsibility and empowerment. Many women appreciate midwifery because the midwife is more likely to feel comfortable discussing the social and emotional aspects of pregnancy and birth. DEMs work primarily with healthy low to moderate risk pregnant moms and know when to refer the mom onto another health care provider for further evaluation and/or care. They have established birthing guidelines, but are most flexible of all the practitioners in working with individual birthing clients. DEMs will provide care throughout your pregnancy, during your labor and birth and afterward and you will most likely have the same care giver throughout the birthing experience. DEMs are most likely to work with your birth plans as long as you are wanting a natural, unmedicated, gentle birth experience.
Some mothers choose to give birth unassisted, or with only the assistance of a spouse or an informed close friend or relative. They may or may not receive prenatal care from a midwife or obstetrician, and if they do, they won't necessarily inform that provider of their intention to give birth unassisted. The reasoning behind unassisted childbirth involves a steadfast dedication to the idea of birth as a normal human process. According to those who practice unassisted childbirth, the presence of professionally trained assistants in pregnancy and birth is an automatic admission of powerlessness and an invitation for doubt, interventions, and ultimately an unnecessarily medicalized birth.
LOCATION OF BIRTH
In the United States, hospitals are the most common place to give birth. Increasingly, hospitals try to transform their birthing units into comfortable, home-like settings (thanks to the homebirth movement of the 70s and 80s) with potentially necessary medical equipment hidden behind closet doors and picture frames.
Hospital births are most appropriate for women with serious medical conditions that may increase the risk of fetal death, postpartum hemorrhage, seizures, and so forth. These medical conditions may include multiples, malpresentation (breech), premature labor, very late labors, and labors where the membranes have been ruptured for long periods.
There are borderline health-related situations that midwives must look at individually and decide for themselves whether or not a potential client would be a good homebirth choice.
Each expectant mom must know the disadvantages and risks of typical, modern medicalized birth. For instance, a woman instantly faces a one-in-four chance (or higher at some teaching hospitals where it may be up to 60% or more) of having a c-section by walking into a hospital to have a baby. Separation of mom and baby is more likely in a hospital, which can influence bonding and the ability to breastfeed.
In many cases, doctor or CNM (more commonly true of physicians) will not be with the patient at the hospital for the majority of labor, and will be only arriving just before the birth. Hospitals vary widely in their acceptance of individual preferences, their familiarity with unmedicated childbirth, and their willingness to allow mothers to control the care of their newborns. Furthermore, mothers and babies may have difficulties with being in touch with their normal hormonal instincts and responses when they are in a strange environment. This may produce longer, more difficult labors and deliveries.
When a risk of serious complications are present, a hospital may be the best place to give birth. When risks are normal and low, a free-standing birth center or prepared home are safe and beautiful places to bear a child. Birth centers vary as to how much and which technology is available to women. Giving birth at home almost always means very little medical technology available, although some midwives will carry resuscitation equipment and the necessary medications (herbal and/or drugs) to slow or stop postpartum hemorrhaging and other minor complications.
TIMING OF DEPARTURE FOR HOSPITAL OR BIRTH CENTER
If a woman feels threatened or even slightly unfamiliar, labor may slow or stop. This may mean artificially inducing and/or augmenting labor with powerful drugs and end up having unwanted pain medications that can negatively have affect on the unborn baby. For this reason some mothers choose to remain at home throughout early labor and some of active labor. There will be less chance of unwanted interventions if a mother waits until her labor is active and has progressed significantly before going into the hospital. Others choose, or are instructed by their caregivers, to come earlier. Some wish to avoid a car ride while in heavy labor. This is a negotiable decision that need not be firmly made in advance. Simply know the advantages and disadvantages of arriving early and later. However, keep in mind, most medical facilities have time limit guidelines in place for labor and if your labor is not progressing as quickly as they think it should, you are more likely to end up on pitocin and/or having a cesarean delivery.
TESTING, IVs & MONITORING
Procedures vary, but nearly every hospital does some or all of the following:
- A blood sample may be drawn to check for many things. In most cases, the information gained by drawing blood during labor can also be gained by getting a blood sample in very late pregnancy (within a few days of labor is ideal).
- An IV may be started and fluids given. A compromise may be made with only a "heparin lock" instead of an IV. This involves the insertion of the needle and small connection for an IV tube, but the connection is not actually attached to the tubing and IV bag. A woman with a heparin lock can then move about freely as compared to an IV. If fluids or other medications become necessary, the tube need only be inserted into the connection that has already been injected into the vein.
- An external fetal monitor may be used to obtain a baseline reading of the baby's heart rate and movement. Usually further monitoring sessions will be required at regular intervals. Some women will be able choose to have and the fetal monitor used for a brief period. If the heparin lock is used, as soon as the fetal monitor is removed they will be able to move around more easily.
Each of these procedures can be very difficult to endure when labor is underway. An IV or heparin lock and blood draw can be time consuming, painful and requires that the mother be still. The fetal monitoring requires being still and often reclined numerous times for at least 10 minutes, usually 20. This is often an extremely uncomfortable position (not to mention counterproductive to cervical dilation) for laboring mothers. The use of each of these procedures is the decision of the patient. Hospital staff may refer to them as hospital policy and consider them mandatory; nevertheless, the laboring woman may refuse any of them, but she may need to be very persistent about it.
As with all items on a birth plan, each woman should consider the reasons for each of these and discuss your preferences your midwife or other health care provider.
CLOTHING
Some women prefer to wear their own clothing during labor. Others prefer the hospital gowns because they are loose and can be soiled, discarded and replaced with ease. Many women find that any clothing at all is a nuisance. However, in a hospital setting, modesty may be more of an issue than it would be at home.
EATING, DRINKING, NOURISHMENT DURING LABOR
Eating and drinking during labor can be very important, particularly if labor is long. Fatigue can cause labor to slow and the laboring woman to give up. Regular nourishment prevents this. Hospital staff don't like women to eat during labor because they could need general anesthetic during an emergency c-section. Under general anesthesia, there is a small chance of the woman vomiting and aspirating the vomit, which can lead to serious complications. One must weigh the risks associated with the unlikely chance of an emergency c-section (assuming a normally healthy pregnancy) against those associated with hunger and fatigue. Indeed, "failure to progress" in labor can lead to c-sections, and such "failure" can often be partially due to fatigue. Most hospitals will allow water or ice chips for hydration, but if blood sugar is low and energy is required, IV fluids with glucose are likely to be preferred over food by the staff. In this case, consider that being attached to an IV restricts movement and positioning, a vital factor in encouraging labor to progress and the baby to descend into the pelvis. Usually a woman will not feel like eating much during labor, so just a nibble of bread or a sip of juice can often suffice to boost her energy enough to cope with a long labor.
WHO WILL BE IN ATTENDANCE DURING LABOR & BIRTH
A decision about who will be in attendance for the labor and birth may be a restriction in a hospital birth. When deciding who to invite, it can be helpful to let these people know that the invitation is tentative, and that as labor progresses people will be called on an as-needed basis. Some women prefer solitude during labor, while others benefit from many or a few family members and friends. Increasingly women are discovering a type of hired support person called a doula. Doulas are people educated in pregnancy, birth and postpartum issues (such as breastfeeding ) who provide informational, emotional and physical support throughout pregnancy, labor, childbirth and the early postpartum period. A doula can be a very helpful addition to your labor team, especially in a hospital setting.
The doula is the woman who mothers the mother. For her there is no other agenda than providing support for the laboring woman, in whatever form that might take. Statistically, mothers hiring doulas have a 25 percent reduction in the length of labor, have a 50 percent reduced risk of C-section, are 60 percent less likely to request an epidural, have a 30 percent reduced risk of forceps use, and have a 40 percent reduced risk of pitocin use. Women with doulas have improved success with breastfeeding and mother-infant bonding.
Many families believe in having siblings present at birth. This can be very beautiful. Young children (and older children that have been properly prepared) do not have the same fearful associations with blood and pain that adults have learned. A frankly informed toddler or preschooler who has a supportive adult in her presence is usually excited and proud to be there when her sibling is born. Some mothers, however, feel certain that the presence of their older child would inhibit them from concentrating on labor. Many mothers decide to play it by ear, having their older children nearby but not in the same room throughout labor, and available to be called in before or just after the birth. Unlike the old days, some hospitals permit siblings at birth if they are free of colds or other illnesses and have attended a preparation course. At a homebirth, this is usually not a problem or an issue.
PAIN RELIEF
Women can rely on many very effective, non-pharmacological means of pain relief. Non-narcotic pain relief is preferable because the narcotics in injections and epidurals reach the baby, and because babies born with such drugs in their system are more likely to have various difficulties (trouble nursing, extreme sleepiness, delayed bonding. Receiving an epidural can be painful and means being automatically "catheterized", given an IV, constant use of an external fetal monitor, and being restricted to bed. Epidurals usually slow labor, and can even stop it, leading to the use of pitocin. Many women continue to feel back pain for months or years after an epidural. It is a decision that should be made with awareness of the risks. Some non-analgesic and non-anesthetic pain relief methods are massage, heat, counter-pressure, hydrotherapy, aromatherapy, positioning, meditation, visualization, Hypnobirthing techniques, TENS (Transcutaneous Electrical Nerve Stimulation), and acupressure. Consult a childbirth educator, a midwife, or a doula for more information about these methods. Some obstetricians are knowledgeable in these techniques, but most are not.
SECOND STAGE CONSIDERATIONS
PUSHING & BIRTH
Spontaneous pushing may occur once the cervix has dilated to 10 centimeters. This is the time many women begin to feel an urge to push. Some do not feel it right away. At times, labor slows or even stops after dilation is complete and the woman is given a natural resting break. Resist the urge or the instruction to push before the urge to push is present. Occasionally women never feel one at all, and in this case if contractions are still coming on regularly, pushing is still very effective when done during contractions. If an epidural is in place, the urge to push will not be present and some guidance will be necessary in the timing of pushing, but again it can be quite effective for some women even under complete numbness. For others, epidurals make it very difficult to help a baby out.
In my homebirth practice, unless there is a reason for doing otherwise, I try to have my birthing moms "breathe" the baby out and only push when the urge is totally irresistible. This allows for the stretching of tissues as the baby descends and there is less chance of tears or "skid marks" from the birth. A way to practice this technique prior to labor is to do it during bowel movements by using slow, relaxed breathing as the feces descends in the colon and out the rectum, letting the intestines do the work. It prevents pressure on any possible hemorrhoids and tears and bleeding.
EPISIOTOMY
An episiotomy is an incision made to the perineum during pushing, that enlarges the opening of the vagina. Many obstetricians do episiotomies routinely, or nearly routinely. Ask yours what their rate is. Anything over 25 percent is quite high. For many midwives, episiotomy is quite uncommon. The rate is usually under 1 percent for midwives. With warm compresses, vitamin E or olive oil, and calm coaching through pushing, there is almost never a need for a woman's genitals to be cut. If the baby is showing signs of distress (and with forceps and vacuum extractions in the hospital) exceptions should of course be made. At times, women will have perineal tears when an episiotomy is not given (or tear along old episiotomy scars). Many times, there is no injury whatsoever to the perineum. Some health care providers believe that a straight cut will heal more quickly and with less discomfort. Others say that with careful stitching (necessary for large tears and for all episiotomies) and proper postpartum care, tears and straight cuts heal similarly.
ENVIRONMENTAL & NEWBORN CARE
After delivery, the warmest place for a baby to be while adjusting to the cooler environment is under a blanket, skin-to-skin with Mother. Many women specifically ask that the lights be low and the noise be minimal, so that the drastically heightened stimuli do not overwhelm or frighten the baby. Weighing can be delayed for as long as the family would like - an hour or two is fine. The baby can be gently wiped in Mother's arms, although the vernix need not be removed. It can be rubbed in instead, as it is very good for newborn skin.
Some hospitals and doctors perform a blood test on babies routinely to check for iron and glucose levels. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology now recommend against these routine tests. Just after birth, the babies' blood levels can vary widely due to any number of factors (particularly if the labor and delivery involved medications) and will usually regulate themselves within the early hours.
VITAMIN K
The vitamin K injection is given to aid in blood clotting. If your newborn is going to be circumcised, the mother may consider this shot a good precaution. Furthermore, if the birth was not smooth, and there is any chance of injury and/or internal bleeding, it is a good precaution. However, with a normal birth and a healthy newborn, severe blood loss is an unlikely risk and the vitamin K present in colostrum suffices nicely.
EYE ANTIBIOTICS
Antibiotic eye ointment is used to protect babies from infection during birth, should the mother have contracted a venereal disease during pregnancy (a test for VD is routine in early prenatal care). If a woman has been monogamous and her partner has been as well, there is no risk of such infection, and the ointment is unnecessary. Overuse of antibiotics is becoming a serious problem, as many bacteria are forming resistance to the drugs, making them ineffective. It is socially responsible to use them only when necessary, and sensible to not give unnecessary drugs to a newborn baby. This antibiotic ointment is required by law, but waivers are available to sign. It is typically necessary to ask for these specifically.
CIRCUMCISION
Routine circumcision is medically unnecessary. It is considered a cosmetic surgery. It is a very painful, traumatic procedure for the infant (no medication is given for pain), with psychological risks as well as the same physical risks of any other surgical procedure. It is important to be educated about this issue before deciding to alter the genitals of a baby.
VACCINATIONS
Making decisions about vaccinations can be a very complicated task. Some vaccines are basically safe and effective; others commonly produce mild to severe reactions in infants and should be seriously examined. The effectiveness of certain vaccines is questionable. Pharmaceutical companies profit immensely from vaccines, as does the entire medical community. In short, vaccines have usefulness, but also risks. It is wise to read and ask questions of many people, including individuals who have nothing to gain or lose by vaccines being used routinely.
MOTHER-BABY SEPARATION & BONDING
If a woman wants to be sure her baby is responded to and cared for promptly, it is wise to keep the baby near. Newborns in some hospital nurseries are allowed to cry for long periods, given bottles of formula and pacifiers, given vaccines without notification, and even circumcised without asking (be careful what papers you sign... read them carefully!). Of course, administering vaccines and performing circumcisions without notification are rare mistakes, but they do occur. Nursing staff will allow babies to cry and offer formula and pacifiers less rarely. Some women consider it important for their newborns' cries to be met with their loving arms instantly. Furthermore, offering new babies artificial nipples can result in "nipple confusion," a term used by lactation consultants and breast-feeding counselors to describe a troublesome condition that leaves the newborn unable to coordinate a proper latch and suck on a human breast.
WRITING YOUR BIRTH PLAN
Some experts recommend a short, concise birth plan, outline style. The advantages to this are that many people get a feel for your wishes easily, and a caregiver who is hesitant to cooperate with special requests won't be irritated by a lot of reading. However, for many obstetricians and most midwives, a more personal and thorough written description is helpful. Based on conversations throughout pregnancy, both mother and caregiver should already be familiar in a general way with the plan. Some details, however, may have never been discussed and the written birth plan can finalize these. There is no need to include issues that are certain to be irrelevant. For example, most hospitals no longer do routine enemas and pubic shaves; therefore, there is no need to write a request that it not be done. These sorts of written requests can be seen by some hospital personnel as insulting.
A birth plan should include issues that are most crucial to the mother, those which will go against what is routine at the place of birth, and those about which the mother and caregiver may not be already aware.
Some believe the short, concise style to be outdated. Birth plans are so individual that there isn't anything that has to be on it, The old traditional bullet point birth plan is perhaps not the most effective thing. Write a more essay style birth plan. Simply, a letter to the various people at the birth, visualizing how you want the birth to go.
The mother and her partner's attitude toward the whole process is so important. If you are planning natural childbirth, the requirement is to trust birth. But it doesn't mean that birth is always perfect. If a couple takes on self-responsibility and understands the risk, and they believe that the safest place is at home, we honor that decision. 'Trusting in birth' doesn't mean 'I know nothing will go wrong.'
Many women have unspoken and unconscious fears, doubts or simple concerns about labor and delivery that can come out during the course of writing such a letter. The birth plan is one tool for preparing the heart and mind for the glorious process of childbirth. It is an experience worth entering with our eyes open, aware of our options, our risks, and our maternal power.
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