In the happy haze of early pregnancy, you're probably already thinking of baby names and planning to shop for baby clothes. The reality of labor and birth may seem extremely far off — which makes this the perfect time to start planning for the arrival of your baby by creating a birth plan that details your wishes.

What's a Birth Plan?

The term birth plan can actually be misleading — it's less an exact plan than a list of preferences. In fact, the goal of a birth plan isn't for you and your partner to determine exactly how the birth of your child will occur — because labor involves so many variables, you can't predict exactly what will happen. A birth plan does, however, help you to realize what's most important to you in the birth of your baby.

While completing a birth plan, you'll be learning about, exploring, and understanding your labor and birthing options well before the birth of your child. Not only will this improve your communication with the people who'll be helping during your delivery, it also means you won't have to explain your preferences right at the moment when you're least in the mood for conversation — during labor itself.

A birth plan isn't a binding agreement — it's just a guideline. Your doctor or health care provider may know, from having seen you throughout the pregnancy, what you do and don't want. Also, if you go into labor when there's an on-call doctor who you don't know well, a well thought-out birth plan can help you communicate your goals and wishes to the people helping you with the labor and delivery.

What Questions Does a Birth Plan Answer?

A birth plan typically covers three major areas:

1. What are your wishes during a normal labor and delivery?

These range from how you want to handle pain relief to enemas and fetal monitoring. Think about the environment in which you want to have your baby, who you want to have there, and what birthing positions you plan to use.

2. How are you hoping for your baby to be treated immediately after and for the first few days after birth?

Do you want the baby's cord to be cut by your partner? If possible, do you want your baby placed on your stomach immediately after birth? Do you want to feed the baby immediately? Will you breastfeed or bottle-feed? Where will the baby sleep — next to you or in the nursery? Hospitals have widely varying policies for the care of newborns — if you choose to have your baby in a hospital, you'll want to know what these are and how they match what you're looking for.

3. What do you want to happen in the case of unexpected events?

No one wants to think about something going wrong, but if it does, it's better to have thought about your options in advance. Since some women need cesarean sections (C-sections), your birth plan should probably cover your wishes in the event that your labor takes an unexpected turn. You might also want to think about other possible complications, such as premature birth.

Factors to Consider

Before you make decisions about each of your birthing options, you'll want to talk with your health care provider and tour the hospital or birthing center where you plan to have your baby.

You may find that your obstetrician, nurse-midwife, or the facility where they admit patients already has birth-plan forms that you can fill out. If this is the case, you can use the form as a guideline for asking questions about how women in their care are routinely treated. If their responses are not what you're hoping for, you might want to look for a health provider or facility that better matches your goals.

And it's important to be flexible — if you know one aspect of your birthing plan won't be met, be sure to weigh that aspect against your other wishes. If your options are limited because of insurance, cost, or geography, focus on one or two areas that are really important to you. In the areas where your thinking doesn't agree with that of your doctor or nurse-midwife, ask why he or she usually does things a certain way and listen to the answers before you make up your mind. There may be important reasons why a doctor believes some birth options are better than others.

Finally, you should find out if there are things about your pregnancy that might prevent certain choices. For example, if your pregnancy is considered high risk because of your age, health, or problems during previous pregnancies, your health care provider may advise against some of your birthing wishes. You'll want to discuss, and consider, this information when thinking about your options.

What Are Your Birthing Options?

In creating your plan, you're likely to have choices in the following areas:

Where to have the baby. Most women still give birth in the hospital. However, most are no longer confined to a cold, sterile maternity ward. Find out if your hospital practices family-centered care. This usually means the patient rooms will have a door, furnishings, a private bathroom, and enough space to accommodate a family, including the baby's crib and supplies.

Additionally, many hospitals now offer birthing rooms that allow a woman to stay in the same bed for labor, delivery, and sometimes, postpartum care (care after the birth). These rooms are fully equipped for uncomplicated deliveries. They're often attractive and have gentle lighting.

But some women believe that the most comfortable environment is their own home. Advocates of home birth believe that labor and delivery can and should occur at home, but they also stress that a certified nurse-midwife or doctor should attend the birth. An important thing to remember about home birth is that if something goes wrong, you don't have the amenities and technology of a hospital. It can take a while to get to the hospital, and during a complicated birth those minutes can be invaluable.

For women with low-risk pregnancies who want something in between the hospital and home, birthing centers are a good option. These provide a more homey, relaxed environment with some of the medical amenities of a hospital. Some birthing centers are associated with hospitals and can transfer patients if necessary.

Who will assist at the birth. Most women choose an obstetrician (OB/GYN), a specialist who's trained to handle pregnancies (including those with complications), labor, and delivery. If your pregnancy is considered high risk, you may be referred to an obstetrician who subspecializes in maternal-fetal medicine. These doctors have specialized training to care for pregnant women with medical conditions or complications, as well as their fetuses.

Another medical choice is a family practitioner who has had training and has maintained expertise in managing non-high-risk pregnancies and deliveries. In some areas of the United States, especially rural areas where obstetricians are less available, family practitioners handle most of the deliveries. As your family doctor, a family practitioner can continue to treat both you and your baby after birth.

And doctors aren't the only health care providers a pregnant woman can choose to deliver her baby. You might decide that you want your delivery to be performed by a certified nurse-midwife, a health professional who's medically trained and licensed to handle low-risk births and whose philosophy emphasizes educating expectant parents about the natural aspects of childbirth.

Increasing numbers of women are choosing to have a doula, or birth assistant, present in addition to the medical personnel. This is someone who's trained in childbirth and is there to provide support to the mother. The doula can meet with the mother before the birth and can help communicate her wishes to the medical staff, should it be necessary.

Your birth plan can also indicate who else you'd like to have with you before, during, and immediately after the birth. In a routine birth, this may be your partner, your other children, a friend, or other family member. You can also make it clear at what points you want no one to be there but your partner.

Atmosphere during labor and delivery. Many hospitals and birthing centers now allow women to make some choices about the atmosphere in which they give birth. Do you want music and low lighting? How about the freedom to walk around during labor? Is a hot tub something you'd like access to? If possible, would you like to eat or drink during labor? You might be able to request things that may make you the most comfortable — from what clothes you'll wear to whether you'll have a VCR or DVD player in your room.

Procedures during labor. Hospitals used to perform the same procedures on all women in labor, but many now show increased flexibility in how they handle their patients. Some examples include:

• enemas. Used to clean out the bowels, enemas used to be routinely administered when women were admitted. Now, you may choose to give yourself an enema or to skip it entirely.
• induction of labor. At times, labor may need to be induced or sped up for medical reasons. But sometimes, practitioners will give women the option of getting some help to move things along, or giving labor a little more time to progress on its own.  
• shaving the pubic area. Once routine, shaving is no longer done unless a woman requests it.

Other procedures that you can include in your birth plan are requests about fetal monitoring, extra birthing equipment you'd like in the room, and how often you have internal exams during labor.

Pain management. This is important for most women and is certainly something you have a lot of control over. It's also something you'll want to discuss carefully with your health care provider. Some women change their minds about pain relief during labor only to discover that they're too far along in their labor to use certain methods, such as an epidural. You'll also want to be aware of the alternative forms of pain relief, including massage, relaxation, breathing, and hot tubs. Know your options and make your wishes known to your health provider.

Position during delivery. You can try a variety of positions during labor, including the classic semi-recline with the feet in stirrups that you've seen in the movies. Other choices include lying on your side, squatting, standing, or simply using whatever stance feels right at the time.

Episiotomies. When necessary, doctors perform episiotomies (when the perineum — the area of skin between the vagina and the anus — is partially cut to ease the delivery). You may have one if you risk tearing or in the case of a medical emergency, but if there is an option, you can discuss your preference with your provider.

Assisted birth. If the baby becomes stuck in the birth canal, an assisted birth (i.e., using forceps or vacuum extraction) may be necessary.

Cesarean section (C-section). You might not want to think about this, but if you have to have a cesarean, you'll need to consider a few things. Do you want your partner to be present, if possible? If you have a choice, would you like to be conscious or unconscious? What about viewing the birth — do you want to see the baby coming out?

Post-birth. Decisions to be made about the time immediately after birth include:

• Would your partner like to cut the umbilical cord?
• Does your partner want to hold the baby when the baby emerges?
• Do you want immediate contact with the baby, or would you like the baby to be cleaned off first?
• How would you like to handle the delivery of the placenta? Would you like to keep the placenta?
• Do you want to feed the baby right away?

Communicating Your Wishes

Birth plans are relatively new inventions, and your doctor or nurse-midwife may not be completely comfortable with them. For this reason, make sure you communicate clearly that you intend to create a birth plan.

Give your health care provider your reasons for doing so — not because you don't trust him or her, but to help ensure cooperation and to cover the possibilities if something should go wrong. If your caregiver seems offended or is resistant to the idea of a birth plan, you might want to reconsider whether this is the right caregiver for you.

Also, think about the language of your plan. You can use many online resources to create one or you can make one yourself. Here are some tips:

• Make your birth plan read like a list of requests or best-case scenarios, not like a set of demands. Phrases such as "I would prefer" and "if medically necessary" will help your health care provider and caregivers know that you understand that they might have to alter the plan.
• Think about the other personnel who'll be using it — hospital staffers might feel more comfortable if you call it your "birth preferences" rather than your "birth plan," which could seem as though you're trying to tell them how to do their jobs.
• Try to be positive ("we hope to") as opposed to negative ("under no circumstances").

Once you've made your birth plan, schedule a time to go over it with your doctor or nurse-midwife. Find out and discuss where you agree or disagree. During your pregnancy, review the birth plan with your partner periodically to make sure that it's still in line with both of your wishes.

Strive to keep the plan as simple as possible — preferably less than two pages — and list them in order of importance. Focusing on your priorities will help ensure that the most important of your wishes are met.

You may also want to make several copies of the plan: one for you, one for your chart, one for your doctor or nurse-midwife, and one for your birthing coach or partner. And bringing a few extra copies in your labor bag is a good idea, especially if your doctor ends up not being on call when your baby is born.

Although you might not be able to control everything that happens to you during your baby's birth, you can play a role in the decisions that are made about your body and your baby. A well thought-out birth plan can help you to do that.

Reviewed by: Larissa Hirsch, MD
Date reviewed: February 2008

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