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Birth Plans: The Good, The Bad, and The Ill-informed

In my very limited exposure to the world of obstetrics, I have come to realize that birth plans are more popular than I actually thought.  Having the medical background that I have, having had two children myself, and now being on the other end of the delivery table, I am beginning to feel that women who make birth plans are really not as informed as they think they are.  In fact, sometimes I feel (and I’m not alone in this) that having an uninformed and unrealistic birth plan is doing more harm to the baby than good… Not to mention that they can often be insulting to the very people who are bringing babies into the world.

Don’t get me wrong, some people have reasonable, respectful plans, and they usually have the birth experience that they want.  These birth plans include such requests as: “I’d like the lighting to be dimmed whenever possible, I don’t want to be offered medications for pain, I would like to listen to my own music, I would like to be able to walk around as much as possible, I would like to limit fetal monitoring unless the baby is in distress, I do not want an IV unless it is medically necessary, If interventions are required in my labour, I would like to remain informed about my needs and my options, I would like to have skin-to-skin contact as soon as the baby is born…

These kinds of requests on a birth plan are wonderful for a few reasons: (1) they are easily attainable, (2) they fall into the realm of what “medical professionals”do anyway, (3) they inform us of your preferences for you baby’s birth, and mot importantly (4) they do not jeopardize the well-being of the baby.

Before I talk about the things I seriously dislike about birth plans, I’ll outline a few facts:

  1. As much as possible, physicians follow “evidence based practices.”  In other words, if we do something, it’s because there is evidence (research) to support it.  In most cases, if there is no evidence to support an intervention, it usually falls out of practice.
  2. Obstetricians (at least in Canada) do not want to do C-sections.  Yes, they get paid more for doing them, but not THAT much more.  More importantly, though, there is more risk to mom, more risk to baby, more work, and no evidence to support that c-sections are better than vaginal births unless there is a clear indication for it.
  3. Medical students and other “trainees” will not hurt you.  In fact, you will probably get better care when students are involved because they are studying like crazy and the physicians who are teaching them are always current and up to date on their information and their skills.  Medical students and Residents also have much more time available to dedicate to your care than the attending physicians.  Having them involved in your care will actually ensure that you are being followed more closely.  Furthermore, students are usually too scared to do something that they are not comfortable doing.  Refusing to let students be involved in your care only hinders education of future doctors.  How do you think current doctors ever learned their practice?
  4. Maternal, infant, and perinatal mortality rates are lowest in developed countries where medical care and interventions exist.  To get a reasonable idea of what happens when modern medical interventions are not used, look up the maternal, infant, and perinatal mortality rates in 3rd world countries.  By refusing modern medical interventions, you are increasing your risk of complications immensely.

So, in my very limited experience, most birth plans seem to be based on nothing but a template.  I say this because every birth plan I see have almost the exact same wording in their sentences.  These templates are likely downloaded from the internet or else provide by a doula.  I have nothing against using the internet for information or using a doula, but I do have a problem with people remaining un-informed about the decisions they make.  To support this litte assertion of mine, I have heard many physicians say that when they ask patient to bring in their birth plan ahead of time and discuss some of the items on the plan, most patients will change their minds about the choices they make because they finally understand why the interventions are offered.  (I should also mention that where I live, a doula only needs to take a weekend course on how to coach a women through labour.  Compare that to the 9+ years of training that an obstetrician receives…  Always consider your sources)

Just to give a little perspetive:

In my last 2 call shifts, we had five women present with detailed birth plans.  All five plans refused both pain medications and interventions to augment labour.  Two of the five women ended up receiving an epidural for pain but still refused to augment their labours.  Three of the five women ended up having emergent c-sections.  One woman delivered her baby in the toilet without telling anyone that she was pushing.  The one lady who had a vaginal birth progressed through her labour well, but she was one of the women who received an epidural.

In those same two call shifts, we delivered over thirty babies.  We only did five emergent c-sections TOTAL.  As I mentioned previously, three of them were  women who refused medical interventions to progress their labours.  That means that out of the other 25+ women who came in with a simple birth plan of “get the baby out safely,” 23+ delivered their babies vaginally without complications.

So 3/5 women (60%) with complicated, restrictive birth plans ended up having a delivery that put them and their baby at serious risk (and that doesn’t include the baby delivered in the toilet).  Of the 25+ women who came in without a birth plan, over 90% of them had safe and timely vaginal deliveries.

Think well and always be informed.

7 thoughts on “Birth Plans: The Good, The Bad, and The Ill-informed

  1. I understand hospitals trying to give women a say in things because its not little thing, but like you I had seen women that must think they are above everyone else and treat propel like they are little more than hired hands. Here in he US C sections are becoming much more common and Doctors don’t seem to mind, in fact I think is some docs could simply use c sections to schedule their days they could fill their days with many more deliveries and expand their practices that way.

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    1. That’s what I have heard, but I don’t think it is common practice here, at least not in my area. I don’t think it is right or appropriate for doctors to be doing c/s for convenience. It goes against the general principle of “do no harm”

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  2. I’m inclined to believe there were other issues contributing to the failure of those women with birth plans, but as we’re all human and full of foibles, it’s difficult to pinpoint what those issues may have been. However, I suspect fear may have been an underlying factor. Nothing like a bit of fear to throw a woman’s natural hormonal responses into reverse.

    I think this fear stems from the war that is currently raging about birth, with the rapidly increasing C/section rates adding fuel to the fire. Women are becoming frightened of losing their power in hospitals and I think this is the root of the problem.

    Birth is undoubtedly one of the most amazing and life altering experiences that many women have, and something that powerful creates strong emotional responses in people. I’d like to see the day that all women could feel as safe to give birth in a hospital as they do in their own home. But first, the doctors and midwives need to listen and learn from each other, and hospitals need to use evidence based research comparing natural birth at home with interventions in a hospital. I learned about birth through the medical model, and believed home birth to be unsafe, but when I delved deeper, I discovered that many of the practices in hospitals, are based on theory alone, and those based on research,usually relate to studies where one intervention is compared with another.

    I’d love all doctors to experience how the hormones related to birth behave when the mother feels safe, without time limits, hospital policies and protocols, and strange faces surrounding her.

    I agree with what you say about he mortality rates in third world countries, and lack of good professional care is definitely a factor, but so is lack of hygiene and a healthy diet,

    As a midwife who worked alongside obstetricians in both hospitals and homes, I know there is sometimes a need for medical intervention in birth, but I’m also aware of how feeling safe and in control of your environment can prevent many of them..

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    1. Julie, I completely agree with you about everything you have said here. Undoubtably, there are major contributing factors to these women who failed to progress in labour. The biggest problem with their plans, however, was their refusal to deviate from their plan when things were not going well.
      I think things are significantly different between birthing practices here in Canada and in the US and that’s what kind of fuels this problem for us. We have a much lower c/s rate here, with the majority of ours being elective for repeat or malpresentation. We do very few emergent or un-indicated c/s.
      We also have some amazing midwives who work along side of the obstetricians and they all have privileges to deliver in the hospital. They usually have successful deliveries according to their plans and most of the time the medical staff never becomes involved in their care. I highly respect what the midwives do for their patients, and part of the reason for that is because they are educated in their trade and they respect their limits. They will often consult obstetrics when there is a problem and their patients are quite amenable to receiving small interventions.
      I have seen quite a few women who have requested an intervention free labour, but when something wasn’t right, they were receptive to discussion about their options and they accepted something as simple as artificial rupture, and they then continued to have a successful labour.
      The problems we seem to have with birth plans is that women are getting advice about their labours from the Internet or from doulas who have very little training and they are refusing to be open to discussion about things when there is a problem. All of the women I described here absolutely refused to accept any discussion about what might have been happening with their body or with their baby. None of them had midwives and it was unclear where exactly they were getting their information from. I think in childbirth, you can have many expectations of what you’d like, but things can change fast and things can go unexpectedly and you have to be willing to compromise. Health care providers are not the enemy, but we certainly feel as though we are when we are faced with these types of situations.

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  3. This is what I mean by the war surrounding birth. There are women who have had bad experiences in hospitals because they haven’t been respected in the past, and they sometimes identify the hospital staff as the enemy to be resisted at all costs. There was a sad case in Australia last year with a newborn death. The information I receive in Scotland is limited and all media-sourced, but from what I could gather, the mother was transferred to hospital too late because the midwife feared how she would react when she made the suggestion. I once cared for a very strong, determined mother who felt very negative about what happened when she had her first baby in a hospital, and I was terrified I might have to tell her we needed to transfer. However, that fear would never have stopped me from being very insistent if I had been concerned, but I’ve also heard of some mothers who have chosen to birth unassisted rather than go to a hospital if they couldn’t find a midwife game enough to take them on.

    Ideally, it would be nice if we could eliminate those original bad experiences. It’s a big task, but more obstetricians like you is a move in the right direction.

    I thought you were in the US. How did I get that wrong??? Not paying enough attention…

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  4. I didn’t really have a birth plan for my son, but for my next I will be (and Am) more knowledgeable about birth and things that go along with it… My birth with my son was traumatic. The eipdural was placed in the wrong spot and only half of my body went numb, the doctors waited a good 30 minutes before they came in (after I said I have to push), the doctors were RUDE, and it was just an unpleasnt experience.

    People who make “birth plans” are control freaks. No one knows how their body is going to react to labor. No one knows if baby will get stuck or if there will be another medical problem. The only thing my birth plan would consist of is “Give me a C-Section if you need to, other than that, we’ll go with the flow” Which is basically what we did with my son’s birth. (I had no idea what was going on 3/4 of the time. Now I know better)

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