Birth Planning

Many pregnancy websites and books suggest that you write up "birth plan" before your delivery in order to share your preferences with your care provider ahead of time. You can also have that birth plan put in your file, so that those that you come in contact with at the hospital or birth center will have access to that information. Things that you might include in your birth plan are your desires for who is present at your birth, ideas about pain management, what you want done with baby after delivery, etc.

I heard something interesting last night at my doula meeting, from some very wise and experienced doulas about how to write a birth plan. They suggested that instead of trying to orchestrate every detail of your birth from lighting to cord clamping (using the laundry list templates that you can find around), pick about three things that are most important to you about the labor and birth to write down and document. The idea is that if you focus on the big picture and less on the minor details, you will be more likely get what you want when you ask for the big things, and receive a warmer reception from your physician and attending labor and delivery nurse.

Those long lists with all of the check-boxes do have a use, however, in my opinion. These can be used as great communication tools for your partner, doula, and your care provider prior to delivery. They can not only help you form ideas about what you would like your birth to be like, but to also identify things that you can be flexible on. It is important to ask whoever is delivering your baby what they perceive as "typical" for their deliveries -- Do they encourage movement? What pushing positions are "allowed"? What is their percentage of episiotomies? What tends to happen to baby after delivery? Do they delay cord clamping? Do they take baby right away or do they put the baby on mom's chest? These types of questions can help you get a feel for your doctor's style, especially if she takes the time to answer your questions and meet your concerns, if you have any.

When approaching birth, it is important to balance a feeling of "go-with-the-flow" with "honoring mother's and baby's experience", as many aspects of your birth you just will not have any control over (timing and length of labor and pushing, how baby is engaged, etc.). This should not diminish the fact, however, that you are the most important person, save baby, in the room when you are in labor. You deserve to be respected, honored, listened to and spoken to directly. If your partner and doula are aware of your "ideal" birth, they will have the ability to support you in a way that will leave you with positive feelings about your birth experience. And if you can single out a couple of the most important things to you and share them with the hospital staff, in writing, you will be more likely to have them "hear" you without overloading them with too much information.

Picking out your most important wish for each stage of labor makes it simple:

1. What is your most important need during labor? Do you want to be allowed to move? Do you want to labor in the tub? Do you not want medication offered unless you ask? Do you not want an IV?
2. What is your most important need while you are pushing? Do you want to try squatting if baby is having difficulty descending? Do you want to push on your side (protecting your perineum)? Do you want someone to count for you or do you want silence?
3. What is your most important need once baby is born? Do you want the cord clamping to be delayed? Do you want baby immediately on your chest? Do you want to establish nursing before tests and weight are done?

Remember to share this short list with your care provider ahead of time, so they can tell you that they are completely on board for what is on your birth plan. Better yet, have them sign it. For the majority of the time that you are laboring (even if you have a midwife) you will be attended by a labor and delivery nurse who will be accustomed to "hospital policy". If you have something on your birth plan that is different than what is normally done at your particular hospital, your nurse will have your doctor's written permission in hand (they might also call them for further confirmation) to allow you to exercise your wishes without the impediment of the hospital staff. This is why a shorter list is so useful and will most likely have a warmer reception than a three page script.

If it makes you feel any better, I was one of those who brought a three page script, along with about 17 extra copies (in case it got lost), to the hospital. I don't recommend it. Everything turned out okay, but I definitely got several eye-rolls from my nurses when I asked them if they had read my birth plan.

Induction -- Risky Business or Blessed Reprieve?

Much of the information for this post was taken from Penny Simkin's book Pregnancy, Childbirth and the Newborn (pages 260-261).

Inducement, or the artificial starting of labor before it begins spontaneously, is probably the most common medical intervention during late pregnancy. While the majority of inductions are elective or planned, some are for medical reasons. A few of the most common reasons your physician might suggest this type of induction are:

• Prolonged pregnancy
• Prolonged rupture of membranes
• Fetus who is no longer thriving or growing in the uterus
• You are suffering from an illness, such as high-blood pressure or diabetes, which puts both mother and baby at risk.

When any of these conditions is presented, usually tests are performed and monitoring is done to determine the readiness of the mother and baby for birth. It is important to understand that some hospitals and physicians may have specific policies that determine when your baby is to be born (before 41 weeks gestation, within 24 hours of membrane rupture, etc.), despite the health of mother and baby. All medical interventions carry with them risks, which I'll talk more about later on, so it is important to find out what your care provider's policies are ahead of time, so that you can make sure you are both on the same page when it comes to how you would like your child to be born.

As mentioned earlier, the vast majority of inductions are for non-medical reasons, and the induction rate is increasing at the same pace as the cesarean rate (could there be a link?). There are many, many reasons that someone may decide to have an elective induction. These reasons include:

• Convenience for the caregiver or mother is the most common reason for elective induction. Many doctors work in large practices where they are only on-call during certain days of the week. A woman may want to deliver with a specific doctor and therefore will schedule when she is available. Doctors also like to deliver their primary clients' babies. They are eligible to receive the largest chunk of the fee if they attend the delivery.
• Predictability is very appealing to many women, especially those with other children, whom they will have to find care for when they go to deliver their baby. Women who experience very rapid labor and birth, or live far away, may worry that they will not make it to the birth center on time.
• For some, the last few weeks of pregnancy are unbearable.
• Both women and caregivers may worry that if they wait for the baby to be born spontaneously, he will grow too large and will not be able to fit through the pelvis and cause damage to the perineum. Please note that studies have found that fetal measurements done by ultrasound and by external measurement cannot be counted as predictors for actual fetal size. There can be as much as a 10% margin of error using these methods.
• Sometimes caregivers and their patients go ahead with an induction simply because there seems to be no apparent reason not to do it. The cervix is ripe (soft and effaced), the baby seems big enough, and the mother is ready to have her baby. The question becomes, "Why not?" rather than "Why?"

Induction is seductive. It can be one of the greatest temptations a very pregnant mother can face, but it is important to understand that it is not a risk-free procedure, especially for first-time mothers. Here are some things to think about:

• Babies have something called a "fetal-placental clock", which greatly influences when she is ready to be born. Babies continue to mature and develop in the last few weeks of pregnancy and may benefit from a few more days in the uterus.
• As mentioned, induction is not risk-free, and there is no guarantee that it will be successful. The chances of a cesarean are much greater for those that choose induction as opposed to those with spontaneous onset of labor, especially for first-time mothers (which is the group most likely to go over-due).
• An induction can take as little as four hours or as long as three days. A long or unsuccessful induction is more likely if there is little dilation or effacement before admission to the hospital, and if you are a first-time mother.
• Continuous monitoring is pretty much inevitable if you are induced. You will be limited in where you are able to position yourself (usually on your side or on your back, in bed), which can make it very difficult to deal with the intensity of contractions.
• You usually are not allowed to eat solid foods while Pitocin is running, though you can usually drink clear liquids. If you have a long wait, you can get pretty hungry.
• Induced labors, even in early labor, may be more painful and intense than a spontaneous labor, usually leading to more interventions to assist in pain relief.

If you or your physician are considering an induction, make sure that you are clear if it is medically indicated or elective. Weigh your options so that you can make an informed decision that is best for you and your baby. When offered an elective induction, some women decide to wait for labor to begin spontaneously, while other may decide to go ahead with the procedure, feeling that the benefits outweigh the potential risks. Only you will know what is best for you and your family.

Stay tuned for: Possible Ways to Get Labor Going on Your Own