A Downloadable Visual Birth Plan

Confession time: I didn’t even write a birth plan for my first birth.  I know, shocking considering the fact that I’m extremely Type A and like to be in control of things.  But I was skeptical that anyone would even read it.  I was also acutely sensitive to being that mom who was dismissed & made fun of by the nurses for having too prescriptive a plan.  I thought that maybe having it all written out would set us off on the wrong foot.  And I naively thought I’d be able to remember and communicate my preferences at the time each step came up (I couldn’t.  Labor requires focus).

But now, I’m not afraid of that anymore.  I don’t care what the nurses think.  Well, that’s a lie, I do.  I want them to think – okay, I’m not going to mess with this momma, she has an opinion, and won’t be pushed around.  I demand evidence-based decisions and informed consent, and I’m not going to apologize for that.  And actually, the nurse on my hospital tour specifically mentioned that during admission, they’d review our birth plan with us.  And then the nurses decide which cases they want to be on, they’re not just randomly assigned.  So theoretically, going in with a well-laid plan means I’ll get a nurse who wants to be a part of that plan.

So, this time around, I wrote a birth plan that requires minimal reading.  I also separated it into stages so that it’s more digestible.

Birth Plan from thebestseasonofmylife.wordpress.com

I posted my plan in a local birth group that I’m in, and everyone immediately wanted a copy that they could use. So, to help other mommas out, I’m providing the plan here so you can edit it to fit your needs.

Download the PPT file so you can customize your own plan

*I recommend printing and cutting out the postpartum newborn care plan and taping it to the inside of the bassinet, so that every nurse can see it.  Note that the plan does not contain items that would be pediatrician-related.  These things are more likely to be a direct conversation with your pediatrician the morning after your birth.

Everyone has different needs for their birth – so it won’t offend me in the least if you just use my format and completely change all of the content because your plan is the opposite of mine.  It’s a good idea to run your plan by your provider and make sure that they support it, and that you haven’t put conflicting information on there.  It’s also a good opportunity to find out if you’re going to butt heads with your hospital… and might make you re-think where you give birth.

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In case you’re interested at all, and doing the research for your own birth plan, here are links to just a fraction of the evidence I’ve used along the way to make my decisions.  Note that a lot of these links have more supporting evidence and links cited at the end of the articles; I’ve read many of them.

My particular plan includes things that are concerns for me based on my last birth. For example, most might not think it’s important to put reminders on there about emptying your bladder before pushing & slowing down when crowning, since these are technically things that you’re doing.  But you might forget, and your delivery team might let you down.  

Obviously, much of your birth plan will flow from how you plan to manage labor pain, and it’s obviously a decision each individual has to make based on weighing the effectiveness vs. safety of each option.  My goal is to avoid anything that could result in a further cascade of intervention, like an epidural or artificial induction or acceleration of labor. This can be tricky, as I know that an epidural can sometimes prevent a c-section, or sometimes be the cause of it.  For example, my own mother received an epidural after she had already been pushing for 2 hours with me, because I was stuck (apparently my family just grows big babies), and if she didn’t get help, she wasn’t going to have the energy to be able to push me out on her own (and they ended up needing to use forceps on me).  In that case, it prevented a c-section.  On the other hand, an epidural can cause a drop in blood pressure that puts stress on the baby, and can result in a totally unnecessary and avoidable c-section.  It’s a slippery slope, and every woman has to make the choice that’s right for them in the moment – and if things don’t go according to your plan, you are not a failure.  Don’t even think like that.  Birth is unpredictable – it’s okay to have a plan, and even more okay to adjust that plan if you need to (but it’s NOT okay if you’re being coerced to change your plan without informed consent).  

Ina May’s Guide to Childbirth: Seriously, this book is amazing.  I’ve read it at least 6 times, and it taught me so much.  Even if you’re not planning on having an un-medicated birth, I think it’s an important read to understand how birth works, and what types of things can interfere with the process.  A little confidence can go a long way for everyone.

At my last hospital, they forced me to be in the bed while I was having back labor so that I could get my initial fetal monitoring strip – being in the bed on my back was painful.  Most hospitals are going to require a strip upon admission. But I’ve cleared it with my new hospital that I’ll be able to do it on a ball, and not on the bed.  After that, intermittent monitoring will be used every 4 hours. Thankfully, no continuous monitoring like my previous hospital required during the 2nd stage of labor.

During my last birth, a hep-lock was a compromise I had to make; it was just in case I needed it.  My new midwife says there’s no reason for needing one, as I can receive intramuscular pitocin in the case of postpartum hemorrhage.  This was not provided as an option to me previously, so I’m super excited about not needing a needle in my hand, and having another way to manage bleeding.

Since I declined IV fluids, I had to bring my own food & drink to the hospital for my last labor.  I’m pumped that my new hospital actually provides food & drink to women during labor! Seriously, how are you supposed to keep your energy up without it?

I plan on at least laboring in water, as taking several showers while I labored at home last time helped immensely.  It may or may not end in a waterbirth, depending on how I feel at the time, but I’m glad it’s an option for me.

Last time I waited until I was 10 cm before allowing my doctor to break my water – and unfortunately, I did discover a small scratch on my daughter’s head from the amnihook. This time, I’m just going to let it happen it when it happens, to avoid any of the risks.

Delayed cord clamping is a huge priority for me, and it’s thankfully standard of care at my new hospital. (If you have time, this Ted Talk is great.)

The plan for placental delivery and postpartum hemorrhage is fairly fluid for me, given the fact that I had a major one during my last birth.  The main reason cited for this was the fact that I had a large baby; this means it’s harder for the uterus to clamp down fast enough.  I also think it wasn’t helped by the fact that my daughter wasn’t able to breastfeed right after birth – without enough oxytocin release, the placenta may not be delivered easily.  I’ve learned that my full bladder was also probably a factor, which is why it’s explicitly on my birth plan (women with epidurals have catheters in, and I think my birth team just forgot that I didn’t have one).  We’re prepared for what might happen again, but are not going to preemptively interrupt the natural process of the 3rd stage until and unless it becomes necessary – in which case, most things are fair game.  At that point, my baby’s out, so I’m not concerned about the effects of pitocin on him.

Regarding newborn care, the World Health Organization has pretty clear guidelines (that many hospitals don’t follow).  All of the measurements can wait until after the golden hour.  We are going to give the Vitamin K Shot, but are declining eye ointment.  We’ll give the Hep B vaccine, but are just delaying it to happen at the pediatrician’s office instead of at the hospital; all other vaccines we do on schedule.  And I’m a huge believer in protecting a baby’s microbiome at birth, so we will be delaying baby’s first bath.  If for some reason I had an emergency c-section, I’d totally be jumping on board to seed my baby’s microbiome in this new way.

My biggest surprise after doing all of my research was that very few maternity providers and hospitals practice evidence-based care.  Just another example of how you have to be your own advocate.  As long as you put more research into your birth than you do the fancy stroller you registered for, you’ll be on the right track.  You’ve got this, momma.

“If you don’t know your options, you don’t have any.” -Diane Korte

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No is a complete sentence: An un-medicated hospital birth story, and why I switched providers

I want to preface this post with this: I know women who have had great experiences with my former OB’s practice, and the hospital I delivered my daughter at.  This not a general statement about either of them, but rather, my own personal experience.  If you had a great experience with them, then I’m truly happy for you.

My pregnancy with my daughter was unexpected; I hadn’t done any research, and was sort of thrown into the whole thing the second I saw that plus sign staring back at me. When it came to making my first appointment, I went with the easiest option: the OB I had already been seeing for my annual exam for the last 5 years.  I knew a few people who had delivered with his practice, so I figured it was a good choice.

My prenatal appointments were nothing like I expected.  I thought we’d spend a lot of time talking about pregnancy, about what to do and what not to do, etc.  But for the most part, I was sent home with a bag of handouts after my first visit, and we discussed the pregnancy very little.  Most of each appointment was spent doing an ultrasound, talking about what he saw, and then what we’d do at the next appointment.  Reflecting back, I realize that my OB was what I’d call “ultrasound-happy.”  I had ultrasounds at 9, 12, 16, 20, 28, and 37 weeks.  At the time, I didn’t know that these were mostly unnecessary ultrasounds – of course I wanted to see my baby.  But these were 3D ultrasounds, and that much exposure is really not recommended unless there’s a reason for them; ultrasounds do heat tissue slightly.  They haven’t been proven to be harmful, but unless medically necessary, there’s no reason to do something that has unknown long-term risks.  But they were never presented as optional, or as an option with any potential risks.  It was just something they did, and I didn’t know any different at the time.

I always wondered if the next appointment would finally be the one where we’d start talking about my birth plan; he hadn’t asked me about it yet.  It made me nervous that he hadn’t brought it up – I felt deep down that it was probably a bad sign.  By the time my 24 week appointment rolled around, I finally asked if we could discuss it.  I told him I wanted to plan for an un-medicated, low-intervention birth.  His response?  Um, okay.  Most women don’t tell me they’re doing an un-medicated birth until they show up and it’s too late for an epidural anyways.  Just be prepared for the chance that it might not turn out the way you want. 

Not the response I was expecting or hoped for.  Where was the support?  Where was the encouragement?  Instead, he chose to immediately cast doubt on my plan?  I had no illusions, I knew that birth doesn’t necessarily always go to plan; but that didn’t mean that I didn’t have the right to express my preferences.

As I was leaving that appointment, he felt the need to tell me a birth story about a woman who wanted a natural birth, refused induction, and had grand ideas about the baby just falling out of her.  But then she of course had to have a really high intervention birth that resulted in a c-section.  “She had wanted to be like an animal in the wild, like some sort of cow,” he smirked.  Is he really making fun of another patient right now to me? 

I left the appointment uneasy.  Uneasy about how this doctor had reacted to my plan, uneasy about how he had laughed about another patient’s “ideas”, and uneasy about what I was going to do next.  I knew one thing for certain: I couldn’t stay with this doctor. He had shown me his true colors.

However, for some reason, I was scared to switch practices.  Call it inertia, or fear of the unknown. So I took the easiest step I could: started seeing the other doctor in the practice.  I was relieved to find out that he was supportive of my birth plan.  He was open to doing delayed cord clamping, and said I could labor however I wanted to.  The rest of the pregnancy went smoothly, and I felt like I was in good hands.

However, what I didn’t realize was that there is a difference between being supportive and knowledgeable about natural birth.  When it came right down to it, my husband and I were on our own to make this happen.  (In hindsight, a doula would have been extremely helpful, but we were naïve in thinking we wanted this experience to be about just us.  Little did we know that a hospital birth involves very little privacy anyways).

And your doctor is only one part of the equation; the other part is the hospital they deliver at.  He happened to deliver at what is locally known as the “baby factory.”  At the time, this felt like a comforting idea – man, they deliver so many babies, they must know what they’re doing.  Reflecting back, the idea of a factory is exactly what it sounds like – high efficiency, high intervention.  I had no idea that I was walking into a situation where the nurses rarely see physiologic birth.  When I tell people now that I had an un-medicated birth there, they look at me like I’m a unicorn with 2 heads.  Here’s an abbreviated version of the story:

I labored peacefully at home for 9 hours before going to the hospital, as I knew that was my best chance for sticking to my birth plan – I was already dilated 6 cm by the time I arrived, and was in active labor.  When being admitted, I asked the charge nurse if I could be paired with a nurse who was experienced with natural birth.  Oh all our nurses are supportive of natural birth, she chirped.  Not so.  My labor & delivery nurse was the opposite of natural birth friendly.  She immediately offered me an epidural, even though I had explicitly told her I wasn’t interested.  I was wary of how my time with her was going to go based on this very first interaction.

After some time on the monitor and getting admitted, she finally left. I began alternating between 3 positions:  sitting on the edge of the bed, sitting on my yoga ball, and on my hands and knees on the bed.  This is when my husband became a HUGE help to me, and really stepped up.  As the contractions became closer and closer together, my needs were changing by the minute.  He provided my back with much needed counter-pressure, fetched me water and juice, got me a cold washcloth with my lavender oil, and helped me through each and every contraction.  I truly couldn’t have done it without him.

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And then the nurse came back.  She doubted me when I said I was progressing quickly – oh you’re a first time mom, you have at least a few more hours before we need to call your doctor again.  I insisted again that things were moving quickly.  She reluctantly checked me, and she did so roughly; she was clearly used to women on epidurals who couldn’t feel it.  She was shocked to find that I was right, that I knew what my body was doing, and she sprang into action, getting the room ready for delivery and called my doctor again.  She pushed the epidural idea at me one more time, as it’d be my last chance – I told you lady, it’s not on the menu for me. Leave. Me. Alone.

I was about to go through transition – what most people call the hardest part of labor.  Thankfully, the nurse left the room again, so I got to do this in peace.  Slow-paced breathing and focal points were no longer enough to manage the pain, so I changed my breathing pattern a few times, using the He-Blow breath and the fast-patterned breathing techniques we had learned.  I never thought that vocalization would be a useful technique for me – I always thought it was cheesy when I saw it in the birthing videos, but it turned out to be extremely helpful.  Repeating phrases like “I can do it” and “I trust my body” were essential in distracting me.  When I could no longer say these phrases myself, I asked my husband to talk to me throughout each contraction, repeating the phrase “You’re doing it.”

My doctor arrived to check in on my progress.  My water still hadn’t broken yet, so he provided me with two options:  Either he could break it for me, or he could go do a c-section he needed to do, be back in 1 hour, and see if it had broken on its own and if I was ready to push when he got back.  I knew I’d have my doctor’s undivided attention if I waited the hour, so that’s what I opted to do.

The next hour was pretty hard – and this is what helped me understand why many women choose to get an epidural.  If I hadn’t been prepared with all of the breathing, visualization, vocalization, and comfort techniques, it would have been scary.  But the preparation allowed me to remain confident, and take everything 1 contraction at a time, with my husband’s help.  I don’t think I’ve ever been so focused in my life – and I don’t think I’ve ever felt so powerful.  I remember thinking of the word “power” in my head, convincing myself that my body had the power to do this.  I did everything I could to relax my body and my muscles in between every contraction.  Near the end of this hour, the contractions were practically on top of each other – sometimes I only got a 15 second break in between them.

When my doctor showed back up, he said I was at 10 cm, and he broke my water. Now there were 3 nurses in the room, and I was supposed to start pushing.  All of a sudden my quiet, peaceful labor bubble was filled with people telling me what to do.

The 2 new nurses were supportive, as was my doctor.  But like I said, supportive is not the same as knowledgeable.  They weren’t used to women eating and drinking during labor – so they didn’t to remind me to empty my bladder before pushing, resulting in some pretty ineffective pushing for a while.  They also fell into the norm of directed pushing, where they’d yell out when to push, and count to 10 loudly 2-3 times per contraction, until I was pushing so hard that veins were popping out of my head.  All of these things are unnecessary and counterproductive when having an un-medicated birth – they weren’t allowing me to listen to my body. And they’re actually damaging to your body and pelvic floor. I knew that holding my breath during pushing wasn’t good (a relaxed jaw means a relaxed body and cervix), but they kept telling me to do it that way. I didn’t think my body was ready to push – all I wanted was to take a little break before starting again.  But they were yelling at me to push during every contraction.  And when everyone in the room is telling you what to do, it’s extremely hard to stop the show and get off the stage.  I know I didn’t feel comfortable with what was happening, but I was too swept up in the moment to know how to make it stop or ask for anything else.  Their direction had taken my power away.

Going back to my first negative nurse: apparently the position I was pushing in wasn’t “convenient” for her, because the monitor kept slipping off of my belly.  She repeatedly told me it’d be easier for her if I was on my back.  I refused, I wasn’t comfortable in that position.  She asked if she could use internal fetal monitoring, since I was moving around so much.  I’m sorry, you want to screw an unnecessary electrode into my perfectly healthy baby’s head because I’m moving around while in labor and you have better things to do than to hold the monitor still on my belly?  Never mind the fact that continuous fetal monitoring isn’t evidence-based?   Her negativity was just too much for me, it was shutting my body down.  I don’t consider it a coincidence at all that my daughter was born 15 minutes after this nurse’s shift ended and she had left the room.

Even though I tried pushing in different positions, they eventually pressured me onto my back (which is the most convenient position for them to see what’s going on, but unfortunately happens to be the position that your pelvis is the smallest in.)  Gravity was no longer helping me, and my daughter was stuck for a while behind my pubic bone.  By the time my daughter was crowning, an hour and 45 minutes into pushing (which, by the way, is a perfectly normal amount of time to push as a first time mom), they should have told me to slow down to protect my perineum; instead, their impatience made them tell me to push harder, making my 10 lb. 1 oz. daughter come barreling out of me.

Yes, at the end of the day, I accomplished my goal of having an un-medicated birth.  But it didn’t mean that it was the birth experience I desired.  It doesn’t mean that I was respected during it.  I had to fight for it.  I had to refuse unnecessary IV fluids, I had to demand wireless monitoring, I had to turn down continuous pressure to get an epidural; I had to simultaneously stand up for myself while trying to relax and focus on the hard work of labor.

Yet when I became pregnant again, I still debated whether it was worth switching practices & hospitals just to potentially have a better experience.  Once again, I was scared of the unknown.  Was it better to go with the devil I knew?  Could I be better prepared this time?  I think you create a strange emotional connection to the person who assisted in delivering your baby, even if it wasn’t the perfect experience.  They were there with you in your most intimate and vulnerable of moments.  You were high on birth hormones.  And after all, he did save me from bleeding to death of a postpartum hemorrhage.  All of these things gave me pause.

But I was making excuses.  At the end of the day, we all deserve to be treated with respect in childbirth.  Regardless of the type of birth: homebirth, hospital birth, epidural, induction, c-section, VBAC – whatever.  We all deserve care providers who practice evidence-based medicine.  We deserve informed consent.  I know too many women who had unnecessary c-sections because of a cascade of interventions that were done without their consent.   You ever want a reality check about the current state of maternity care, go read some birth stories on ImprovingBirth.org’s Facebook page.  Birth trauma is real – up to a third of mothers describe their birth as traumatic.  These stories have literally made me sob myself to sleep because they are so distressing.  Too many providers are ignoring the role the mother has in her own birth. This is so hard to explain to a first time mom – you assume that your providers practice evidence-based care, you assume that everything they do is the best thing for you.  But maternity care has become so screwed up – so few providers even know what a normal birth looks like.  You have to be your own advocate. My birth wasn’t traumatic; but it wasn’t respectful care.

So I made the leap.  I’m now with a midwifery practice that delivers at a hospital with the lowest c-section rate in the state (less than half the rate of my first hospital).  It’s the opposite of a baby factory – there are only 6 labor and delivery rooms, and they offer water birth.  I’ve also chosen to use a doula for this birth.  And I finally feel supported.

After our first midwife appointment, and then again after our hospital tour, my husband looked at me bewildered.  You mean everything you had to fight for before is just standard of care here?  Limited ultrasounds. Food & drink during labor.  Low lighting, showers, and tubs in labor & delivery rooms.  Non-directed pushing.  Delayed cord clamping.  All of it standard and supported.

And more than just support – knowledge. I asked the first midwife I saw about non-directed pushing.  She immediately started giving me examples of how women naturally push, and even started making low guttural sounds to demonstrate how it helps open you up.  (Basically the opposite of holding your breath and pushing until you’re purple in the face.)  Every appointment involves talking about birth, answering every question I have, and coming up with a plan.  They understand and trust physiologic birth, and the default is no intervention.

And more than just knowledge – respect.  I’ve heard the same message over and over again from this practice: you’re in charge of your own healthcare.  You have the right to refuse anything.  I’ve been given options with everything that has come up.  There’s this test you can do, here are the pros and cons, it’s your choice if you want to do it or not.  No thanks, I don’t need a test with a high false positive rate,  I already have enough anxiety about this pregnancy.  You can choose 1 of 3 options for gestational diabetes testing.  Awesome, I choose jelly beans over that gross glucose drink any day.  Your baby is measuring big, so you’re eligible for another ultrasound at 37 weeks if you’d prefer.  But you can also decline it.  Sweet, I’ll decline it, because I’m not scared of a big baby, my body’s done it before, and I won’t do anything different (e.g. get induced early) even if he is big.

At my most recent appointment, I was chatting with my midwife about the hospital policies for postpartum care.  Even though this new-to-me hospital purports to be more baby-friendly, you never know which nurse you’re going to run into.  She said something that no healthcare provider has ever said to me: No is a complete sentence. 

If they want to take the baby off your chest to do footprints and measurements?  No is a complete sentence. They can do those things while he’s still on your belly.

If they want to take your baby to the nursery to do the admissions process?  No is a complete sentence. They can do that process in the room.

If they say that they have to do an exam in the nursery because they don’t have the staff to do it in the room?  The staffing isn’t your problem.  No is a complete sentence.

I was amazed.  Here my midwife was, handing me back my power.  Telling me to stand up for my choices.   And telling me that she would support me.

I don’t know how my birth will go – but I feel confident that I’ve chosen a provider who will give me the respect that I deserve, and involve me in decisions.  And if I wasn’t confident of that, then I wouldn’t be afraid to switch providers again, even late into my pregnancy.  It took me a while to get to this place.  I know a midwife isn’t right for everyone’s situation – I know you can find respectful care with an OB too if that’s what you need.  But it means you have to raise your expectations.  If you’re not receiving the care you deserve – find someone else.  It’s never too late.

No is a complete sentence.