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Logo of jperinatedOfficial Journal of Lamaze(R) InternationalEditorial BoardAdvertiseSubscribeAuthor InformationJournal of Perinatal Education Online
J Perinat Educ. 2007 Summer; 16(3): 47–52.
PMCID: PMC1948092

Evolution of the Birth Plan

Tamara Kaufman, LCCE, CLD (CAPPA), CLD–Trainer

Abstract

Many birth professionals are discarding the birth plan as an outdated and ineffectual document. This column discusses the past limitations and present uses of the birth plan in an effort to enhance current teaching on how expectant parents can write and use this important document. Encouraging expectant parents to prepare two separate, but corresponding, birth plans—the “Discussion Birth Plan” and the “Hospital Birth Plan”—is proposed. Teaching suggestions and possible implications are explored in order to give childbirth educators practical information to share with their class members.

Keywords: childbirth education, birth plans, birth options, birth

The birth plan was envisioned to help expectant parents prepare for the physical and emotional aspects of the birth process, plan ahead for how they want various situations handled outside of the emotions of the moment, and provide a vehicle for communicating with each other, their care provider, and the hospital staff prior to the birth (Simkin, 2007; Simkin & Reinke, 1980). Birth plans are criticized for a number of reasons, including: (a) Parents sometimes become inflexible and difficult when changes, no matter how small, to their plan are necessary; or (b) birth plans often contain outdated, useless, or defensive-sounding information. Highlighting the importance of thinking of the birth plan as an evolving document that requires information gathering, reflection on beliefs about birth, and ongoing discussion can help parents develop birth plans that do just what the plans were envisioned to do.

I have found it useful to think of the birth plan as two separate documents—the “Discussion Birth Plan” and the “Hospital Birth Plan”—used to facilitate communication first with the expectant parents themselves and their care provider and, then, with the hospital staff for events that occur during labor and birth. Each plan covers different aspects of the birth, but both serve the purpose of assisting expectant parents to make educated, truly informed decisions prior to, as well as during, the emotional drama of labor and birth, and to have the birth they want.

PROBLEMS WITH CURRENT BIRTH PLANS

In my Lamaze class, students identify the Internet as the resource they use most frequently to gather information about pregnancy, birth, and birth plans. A Google search of the term “birth plan” offers parents several choices of predesigned birth plans. However, many of the birth plans detailed on these sites are outdated. For example, several on-line, interactive tools start with questions regarding being shaved or receiving an enema. Because these procedures are no longer routine in most areas, such details may cause parents to devote too much attention to unimportant issues and cause the hospital staff to dismiss the couple as being uneducated regarding routine hospital procedures.

Additionally, most Internet-based birth plans do not explain birth options or help parents understand the possible cascading effect of accepting interventions such as continuous monitoring and intravenous lines. When expectant couples plan to use position changes and activity to cope with the pain of labor, they may not be aware that continuous monitoring could prevent them from using these options and, therefore, they do not know to start their preference list with the issue of monitoring.

On-line birth plans are frequently more than one page in length, which may inhibit the hospital staff from closely reading the plan. On-line birth plans also have a tendency to use phrases such as “unless absolutely or medically necessary”—a phrase that is not always useful when caregivers usually believe the intervention they recommend is medically necessary at the time, even if it is not evidence based.

THE DISCUSSION BIRTH PLAN

A birth plan is an approach to labor, rather than a term for a specific kind of outcome. (Wagner & Gunning, 2006, p. 1)

The “Discussion Birth Plan” can be used as a communication tool during pregnancy to help the expectant parents discuss with each other and with their care provider their concerns and questions, their preferences, and the available options. Even expectant parents who prefer to follow their care provider's advice without questioning can benefit from creating a Discussion Birth Plan. The process of creating a birth plan helps parents learn about the birth process and provides an opportunity for them to identify and discuss their concerns and desires with their care providers. Parents benefit from exploring choices in health care, discovering where the resources are to make decisions, and learning how to communicate with providers so providers will listen.

Being well informed increases expectant parents' self-confidence and ability to achieve their desires. A wonderful piece of research showed that when women simply asked, “Is that really necessary?” whenever an intervention was proposed during labor, the rate of unnecessary interventions dropped significantly; likewise, “Are there any alternatives?” is another powerful question (Wagner & Gunning, 2006, p. 15).

The “Discussion Birth Plan” can be used as a communication tool during pregnancy to help the expectant parents discuss with each other and with their care provider their concerns and questions, their preferences, and the available options.

Obstetricians and other hospital staff deserve respect for their knowledge and their academic achievements. However, doctors and nurses are human beings with their own opinions and experiences, which may not always match expectant parents' desires. Physicians and hospital staff may function on experiential evidence and find it hard to break their routines. It may be difficult for them to remain current with the literature and to practice according to the most up-to-date evidence. Information outside the provider's comfort zone may not be accepted into practice. Educated and respectful expectant parents can express their desires and, with the childbirth educator's help, provide the supporting evidence for the care they desire.

Questions and discussion are good! Providing expectant parents with a list of options develops meaningful conversation between parents and their provider. Just as many pediatricians recommend that parents come to their child's appointment with a list of written questions to make the visit more effective, the same principle can be applied to obstetrical care through birth plans. Prior to the 36th week of pregnancy, parents should schedule enough time with the provider to discuss their questions. The list should include questions developed from writing the birth plan, as well as questions regarding the provider's protocols for common complications.

HOW A CHILDBIRTH EDUCATOR FACILITATES A DISCUSSION BIRTH PLAN

The educator who encourages expectant parents to attend childbirth classes early in the pregnancy has more time to help them gain confidence in their decision-making skills. Educators introduce expectant parents to the many care options during pregnancy, show them how to research the options in order to form their own preferences for their care, and instruct parents on what routine pregnancy care may include. Educators also find ways to illustrate to parents what a birth philosophy is, why it is important, and how parents can go about forming one (see Figure 1). Furthermore, educators stress the importance of having realistic and flexible expectations regarding the expectant couples' pregnancy and birth. Education can take the fear out of labels such as “high risk” and create curiosity about how labels affect the care of an expectant mother.

figure JPE160047f01
Suggested Childbirth Education Class Handout that Illustrates the Need for Expectant Parents to Develop a Birth Plan

Lamaze International's (2007) updated six care practices that promote normal birth are valuable tools to use when talking to expectant parents about integrating their birth plan with evidence-based care. A handout of these care practices can serve as a starting point for parents to begin their research on options available to them. Another excellent resource for parents is The Official Lamaze Guide: Giving Birth with Confidence (Lothian & DeVries, 2005). The chapter on birth plans offers a comprehensive list of interventions and options as a starting point for expectant parents' research efforts.

Lamaze International's updated six care practices that promote normal birth are valuable tools to use when talking to expectant parents about integrating their birth plan with evidence-based care.

Additionally, educators help parents learn to approach their care provider with a combination of respect and self-confidence. This is challenging because of the current power imbalance between providers and their clients in maternity care.

The Discussion Birth Plan provides parents with an opportunity to really think about what they believe about birth and to decide what is truly important to them. It is also a chance to determine whether their beliefs, values, and viewpoints (personal philosophy) match their care provider's approach, at least well enough to continue to employ him/her. Parents have the time to determine whether they can adjust their desires, whether the care provider can adjust his/her practice, or whether they need to consider finding another care provider.

Educators can also suggest strategies to keep birth as normal as possible in the face of limited choices. For example, educators can suggest expectant couples hire a doula or plan to spend early labor at home.

The federal Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 to ensure emergency care to anyone presenting at certain hospitals and requires a care provider or particular hospital to provide treatment or care to a laboring woman, regardless of her birth preferences or ability to pay. According to Wagner and Gunning (2006), EMTALA is “a particularly effective tool for pregnant women who have no other options” (for instance, there is no other hospital in their community, or they are in the armed services, or they are a member of a managed care organization that will not comply with their wishes) or “who have exhausted other options” (such as going to another hospital) and, therefore, plan to go in labor at a hospital that has stated it will not comply with their wishes for labor and birth (Wagner & Gunning, 2006, p. 247–248). Additional information about the EMTALA and other, similar resources are presented in succeeding sections of this article.

Some childbirth educators may have more restrictions than others on how or what they may teach. It is up to each educator to work realistically and truthfully within her setting. This article addresses the ideal, not necessarily the immediate or realistic, expectations for every educator.

THE HOSPITAL BIRTH PLAN

After the Discussion Birth Plan has been developed and expectant parents have examined their desires, are aware of available birth options, and have matched their desires and wishes with the appropriate health-care provider, it is time to develop the “Hospital Birth Plan.” The Hospital Birth Plan is the document presented to the health-care staff upon admission to the hospital.

Having educated the expectant parents about common hospital routines at their particular hospital, the childbirth educator can now help them through the next step in the birth plan. The parents' first step in developing the Hospital Birth Plan is to take the Discussion Birth Plan, determine what options they have chosen that conflict with their hospital's routine, and compose a one-page birth plan that briefly lists bulleted points. A shorter, more concise birth plan for the nursing staff is more likely to be read and remembered. See Figure 2 for a notable example of a couple's one-page Hospital Birth Plan that incorporated Lamaze International's (2007) six care practices and resulted in the couple's satisfying experience.

figure JPE160047f02
Sample of a One-Page Hospital Birth Plan

The Hospital Birth Plan should include what is most important. For example, “I want my baby to stay with me, skin-to-skin, immediately after birth and for the rest of the hospital stay.” This bulleted statement makes it unnecessary to list the following statements: “All procedures done to the baby need to be done while I am holding my baby”; “I don't want my baby sent to the nursery”; and “I want my baby to have the opportunity to breastfeed in the first hour.”

HOW A CHILDBIRTH EDUCATOR FACILITATES THE HOSPITAL BIRTH PLAN

Educators must stay up-to-date on the care routines of local hospitals and birth centers in their area. Furthermore, they must regularly examine their own bias on issues of what is considered unnecessary routine, and they must teach only evidence-based practices concerning unnecessary routine. Educators are encouraged to find ways to introduce current routines to expectant parents through teaching methods that reassure parents that they do have a choice of either accepting or declining routine practices. Expectant parents will also benefit from being informed that it is always best to work through their options with their health-care provider before the birth.

Childbirth educators can use role-playing techniques to prepare expectant parents for situations they may encounter in the hospital during labor and birth. The educator can wear scrubs or a lab coat while presenting events that address common concerns or comments the expectant parents may hear and while rehearsing how parents may respond in an educated and assertive manner. Start out by wearing normal clothes for class and asking what expectant couples would do in certain situations. Then, put on a lab coat or scrubs for the role-playing scenes. This time, when asking what the parents would do in certain situations, offer advice contrary to their wishes. Many couples will change their response to fit the proposed advice from an individual appearing as a “professional.” When asked why they changed their mind, the parents often answer, “Because you said….” This is a good time to introduce an informed-consent teaching tool such as BRAND (Benefits, Risk, Alternative, Now-or-Later, Decision). Parents now role-play the situation again, asking, “What are the benefits? What are the risks? What are the alternatives? What happens if I wait to make a decision?” Giving expectant couples an easy-to-remember tool such as BRAND will help them to better assess situations in labor. Another excellent tool is Lamaze International's (2007) six care practices that promote normal birth, which can be used to generate class discussion on why some care practices are beneficial and some are not.

The educator can also demonstrate the concept of a cascade of interventions to help expectant parents identify care practices they have chosen to avoid. Additionally, educators can help parents recognize care aspects they can control in the birthing room, such as lighting, music, and thermostat. Parents should be empowered to control such things without having to request them in their Hospital Birth Plan.

Even if they do not teach the EMTALA in their classes, educators may find it helpful to be well read on this federal regulation, also known as “COBRA” or the “Patient Anti-Dumping Law.” In using specific phrases (e.g., “I hear…I understand…I decline…”), an educated, respectful patient demonstrates she or he has a clear understanding of the procedure and chooses an informed-refusal or informed-consent course of action for the treatment.

Two additional teaching tools to empower expectant parents in their requests for desired care practices are The Pregnant Patient's Rights and Responsibilities (Haire, 1975) and The Coalition for Improving Maternity Services' (2000) brochure, Having a Baby? Ten Questions to Ask. Educators can ask class participants to explain the rights and responsibilities in their own words. Armed with this knowledge, parents will be better equipped to make informed decisions of consent or refusal.

POSSIBLE IMPLICATIONS FOR THE EVOLVED BIRTH PLAN

At first, presenting the birth plan as two separate documents—the Discussion Birth Plan and the Hospital Birth Plan—may seem complicated. However, the usefulness of each document for expectant parents and care providers warrants adding both plans to the childbirth-education curriculum. If childbirth educators encourage the use of birth plans as a two-pronged tool to educate expectant couples and help them communicate with each other and their care providers and hospital staff, more parents may ultimately have the birth they want. This type of planning encourages expectant parents to examine their beliefs, the best evidence, and the available options before deciding on a birth plan. This type of birth planning may also encourage hospitals to offer care options that address patients' concerns and needs for particular services. Care providers who previously believed birth plans signaled difficult patients or automatic cesarean births may begin to see that the easiest births are those involving parents who took the time in advance to talk and listen to their care provider in order to develop a birth plan. Birth plans may not influence immediate change in care practices; however, over time, they may help increase women's real choices. The birth plan remains a relevant and important tool in preparing for birth.

Footnotes

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifFor more information about making informed decisions, visit the Web site of Childbirth Connection (formerly Maternity Center Association): www.childbirthconnection.org

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifDetailed and evidence-based descriptions of all of Lamaze International's updated six care practices that support normal birth are presented in this issue of The Journal of Perinatal Education (see pp. 11–43).

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifTo help expectant parents research their birthing options, childbirth educators can recommend the following resources: Lamaze Parents magazine, The Thinking Woman's Guide to a Better Birth, by Henci Goer, and The Official Lamaze Guide: Giving Birth with Confidence, by Judith Lothian and Charlotte DeVries. These resources, and many more, are available from the Lamaze Bookstore and Media Center (www.lamaze.org or call toll-free 877-952-6293).

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifAny of the doula-certifying organizations can provide expectant parents with helpful information on how and where to locate a doula in their area. Also, the Belly Women Web site (www.bellywomen.net) offers information on finding free or low-cost doulas.

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifFor more information on the Emergency Medical Treatment and Active Labor Act (EMTALA), log on to www.emtala.com

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifIn addition to BRAND, another popular informed-consent teaching tool is BRAIN (Benefits, Risks, Alternatives, Intuition, Nothing). For more information, log on to www.4adoula.com/downloads.htm

An external file that holds a picture, illustration, etc.
Object name is JPE_fx1.gifTo view the brochure titled Having a Baby? Ten Questions to Ask, log on to the following link at the Web site of the Coalition for Improving Maternity Services: http://www.motherfriendly.org/resources/10Q/

REFERENCES

  • Coalition for Improving Maternity Services. Having a baby? Ten questions to ask. 2000 [Brochure]. Ponte Vedra Beach, FL: Author.
  • Haire D. The pregnant patient's rights and responsibilities. 1975 Minneapolis, MN: International Childbirth Education Association.
  • Lamaze International. The six care practices that promote normal birth. [Entire issue] Journal of Perinatal Education. 2007;16(3)
  • Lothian J, DeVries C. The official Lamaze guide: Giving birth with confidence. 2005 Minneapolis, MN: Meadowbrook Press.
  • Simkin P. Birth plans: After 25 years, women still want to be heard. Birth. 2007;34(1):49–51. [PubMed]
  • Simkin P, Reinke C. Planning your baby's birth. 1980 Minneapolis, MN: International Childbirth Education Association.
  • Wagner M, Gunning S. Creating your birth plan: The definitive guide to safe and empowering birth. 2006 New York: Perigee Books.

Articles from The Journal of Perinatal Education are provided here courtesy of Lamaze International
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