Do birth plans empower or disempower women. Unfortunately, this issue is far from clear. Here at WellSpeaking, I am seeing more women and couples reporting a birth experience that did not meet their expectations and in more complex cases lead to feelings of birth dissatisfaction and trauma. Many report experiencing a lack of control, feelings that they weren’t listened to or acknowledged and even that their birth plan was completely ignored. These are couples who had done extensive birth education sessions prior to birth but still felt their expectations were very different to their lived experience.
So what is going wrong here? How can care providers such as midwives and doctors better support couples to make a birth plan that is realistic, respects a couple’s wishes but also adhere to the requirements of the hospital?
Most hospitals here in Melbourne encourage the expecting parent/s to develop a birth plan, usually in conjunction with a midwife or doctor, to ensure the plan is feasible and in line with what the hospital is capable of supporting.
https://www.betterhealth.vic.gov.au/health/servicesandsupport/having-a-baby-in-Victoria recommends that a plan B is included, in case complications arise. When thinking about a birth plan, its usually a good idea to discuss decisions with a trusted midwife or doctor, to understand how any protocols or policies of the hospital might differ.
By working in collaboration with a midwife or doctor to phrase an effective birth plan, birth satisfaction will be higher, fewer interventions will be used, and the possibility of birth trauma will be significantly lower.
Accessing the hospitals policies via their website is usually a good way to understand what hospital staff are likely to do in a range of circumstances. In this blog I will address some of the most common birth plan requests and talk about some of the reasons why birth plans sometimes don’t go to plan.
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When birth plans hit a roadblock
The various complications that could develop are often related to the level of medical intervention that a labouring woman encounters during the birth process. Interventions have become common place in maternity care according to an article published in the Journal of Perinatal Education. This article argues that routine interventions can transform birth from a natural physiological life event into a medical or surgical event. Many couples report that they were not prepared for the level of intervention, or even aware of them despite receiving extensive pre-birth education.
External Foetal Monitoring
The first and most common form of intervention encountered is often External Foetal Monitoring (EFM).
It has become standard practice to recommend EFM upon admission. EFM can be continuous or intermittent and is used for many reasons, even when the labour appears to be going well. Research shows that EFM can increase a labouring woman’s anxiety. But, foetal monitoring also raises questions for both the labouring mother and the witnessing partner around the health and wellbeing of the baby in an already tense environment.
Many couples request little to no monitoring in their birth plans, however many don’t understand the rational for EFM. EFM is used extensively in labour and birth. Foetal monitoring often becomes a focal point for hospital staff, particularly at certain stages of labour. For instance, it is natural for the baby’s heart rate to change after pain relief – such as when an epidural is given, or during the final stages of labour, particularly 2nd stage, when the cervix is fully dilated and when active pushing begins. However, EFM limits the movements of the mother in labour, and shifts focus from the labouring woman to what is going on with the monitor, disrupting a woman’s zone of concentration.
Internal EFM is often used as an alternative to external monitoring to increase monitoring effectiveness. A special device is attached to the baby’s scalp via the cervix. This is a significant intervention and one that is not often spoken about in antenatal classes or care. As well as further increasing the anxieties of the labouring mother, women are 2.5 times more likely to develop an infection post-birth, increasing the likelihood of antibiotic medication, which in itself brings complications post-birth.
Vaginal Exams
Vaginal exams are often a standard procedure for midwives and doctors to directly understand the changes happening to the cervix and the progress of the baby through the birth canal. It is common for couples to request minimal to no vaginal examination during labour. This is problematic when medical staff often only know how to assess the progress of labour via examination of the cervix. Requesting that vaginal examinations are not performed at all may not be feasible within a hospital system. However, by working with a midwife or doctor, it is important to request that these forms of examination are limited wherever possible, and only used when absolutely necessary. Research recommends that vaginal examinations be kept to a minimum. Repeated examinations increase by 7-fold the risk of infection post-birth, again raising the likelihood that anti-biotics will be prescribed.
Induction
Many birth plans request that they are ‘only to be induced if absolutely necessary for medical or emergency reasons’. Due dates often cause anxiety for hospital staff and many hospitals have polices to induce women at term or soon after due dates. It is important that expecting couples discuss these policies with their midwife or doctor, to understand
how far over the due date the pregnancy can go and what happens when this timeframe is exceeded.
By finding out the ways in which inductions are carried out further ensures that expecting parents are fully aware of what this intervention involves. These could be placed in the birth plan as further acknowledgement of the procedure. Other reasons for induction of labour occurs when cervical dilation progresses slowly, when waters are broken for more than 24 hours when not in labour, or when there are other risk factors at play, such as gestational diabetes or age.
Once an induction is started, the cascade of intervention is inevitable. Although there are several forms of induction, this form of intervention often results in more painful contractions, even more use of EFM, possible foetal distress, a greater chance of instrumental deliveries (forceps) and caesarean section delivery.
Epidural
More painful contractions often result in the administration of pain relief. The most common form of pain relief in labour is an epidural. However, the use of epidurals prolong the stages of labour, making it more difficult for a labouring woman to connect with her body and her contractions. Epidurals also disrupt a newborn’s feeding behaviours, further affecting the mother-baby connection and often increasing a new mother’s anxiety around feeding.
Episiotomy
Many birth plans request no episiotomies, however in may hospitals an episiotomy is often routine practice where forceps or a vacuum are used to help delivery in an emergency . It maybe useful for hospital staff to understand how the perineum stretches during the second stage of labour and if perineal stretching work has been done prior to birth. By ensuring that this information is noted in the birth plan, midwives and doctors might be encouraged to allow natural stretching to occur before cutting.
There is a high rate of further laceration to areas to the perineum, vagina and anus during an episiotomy, that can lead to long term complications such as nerve damage, incontinence and body image anxieties as well as prolonged recovery post-birth. This period of recovery is often associated with chronic pain, the use of pain medication, delayed sexual intimacy and restricted movements such as lifting, that can impact upon a woman’s sense of empowerment and autonomy.
Birth plans can empower women
A birth plan often aims to empower women and minimise the possibility of such interventions. A birth plan gives a written voice to an expectant mother’s preferences during labour and immediately following birth. The process of researching and developing a birth plan is also an important way to prepare parent/s for the experience of birth, especially when it is for the first time.
A birth plan also tells midwives and doctors about the level of understanding and knowledge that the expecting parent/s have of labour and birth and the work they’ve done to achieve this. Acknowledging policies and protocols of the hospital in the birth plan and ways to work with them provides staff with realistic expectations of how to support parent/s to manage the labour and birth, mindful of their wishes.
A satisfying birth is strongly linked to the birth plan. Satisfaction decreases substantially where changes to the birth plan are made with or without a woman’s consent, leading to anger, anxiety and depression. In situations that involve major deviations from the intention of the birth plan (caesarean sections where a preference for a natural birth is voiced), as well as the experience of other complications, birth trauma can occur. This can leave a woman experiencing flashbacks, disrupted sleep, make it more difficult to feel close to their baby and affect the connection with one’s partner, as well as give rise to an enduring mistrust of medical professionals.
Birth plans have become a routine part of pre-birth planning. However, not enough is understood about the impacts these expectations can have on parent/s post-birth, especially when the lived experience of birth is very different to what has been voiced on paper.
More could be done to discuss with expecting parents the types of intervention that are likely, given their medical profile and therefore the expectations of attending hospital staff. But greater recognition is also needed by medical staff of the often profound effects on mother and infant that routine interventions can have, and in particular the effects on a woman’s understanding of the birth process when the ethos of the birth plan has not been lived up to.
We also need to acknowledged that new parents experience a wave of interest in their new baby and their experience of birth, in the weeks following. However, this interest is often romanticised with expectations of a quick and pain-free birth. There will always be an example of an ‘ideal’ birth to be inevitably compared too. Like most things in life, the experience of birth is a singular one, unique to the history, physiology and expectations of each woman. We could do better to support new parent/s in working through their experiences of birth, whatever they might be.
I have written in another post, the unacknowledged impacts labour can have on the witnessing partner, this is only exacerbated by a cascade of intervention, in the fast moving experience of birth and where decisions need to be made around changes to the birth plan with or without consent.
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