Things to consider when preparing your birth plan

As you enter the third trimester you'll likely be looking at creating a birth plan. Here's some things to consider.

Towards the end of your pregnancy, you and your lead maternity carer (LMC) may spend some time together going through a birth plan.

Think of it as a time for you and your partner to sit down and really think about how you might like things to go and highlight anything that is of particular importance to you. People often come into their first pregnancies with preconceived ideas about birth so talking through how things might go is a fantastic learning opportunity for all.

WHEN DO YOU MAKE A BIRTH PLAN?

Birth plans are made during late pregnancy, as their content assumes that normal and healthy pregnancy progress has occurred up until that point. If a birth plan was to be made early or mid pregnancy, then unexpected events such as bleeding or waters breaking would render the birth plan invalid. In these cases, your LMC will guide you on what must be done for the safety and health of you and your baby, and the ability to take into account your preferences and options become limited. Beyond a certain gestation, you’ll have a lot more say in what you’d like or not like to happen!

The birth plan is best run through in a quiet and relaxed environment, usually in the location where you see your LMC for prenatal visits. It is usually added on to a standard appointment between 35 and 37 weeks gestation – this allows for plenty of time to discuss matters before the big day, and also leaves time for resolution of any issues raised.

WHO GOES THROUGH THE BIRTH PLAN?

You and your LMC are the core decision-makers during the birth plan. Your support person(s) will usually be most welcome to attend, as a few of the standard questions raised have relevance for them also. Your support people may also wish to ask further questions, and very importantly will serve as extra ears listening to the information from your LMC.

Additional people may also formulate a birth plan besides your LMC, a good example being when a pregnant woman has mental health needs. In most places in New Zealand, a separate maternal mental health service exists and these experts will provide specific input to help achieve the best perinatal outcome. Similarly, a woman with complex medical needs would usually receive extra plans tailored to her circumstances.

WHAT IS CONTAINED IN THE BIRTH PLAN?

A usual birth plan is composed of a series of questions ranging from safety checks and Ministry of Health mandated information right through to personal preferences. At the start, your LMC will note a checklist of basic baseline data, including your height and weight, blood pressure, blood type and due date.

Place of birth, meaning home, a birthing unit or a hospital, will be considered. If the intention is to have your baby at home or a low-level birthing unit, the birth plan will need to include guidelines and options for transfer to a hospital during labour (or even postpartum) if an emergency situation arises. People distant from hospital will naturally consider geographical factors when deciding how and when transfer will occur.

Support people to be with you during labour may be identified in the plan. Most birthing scenarios (including hospital birth) allow for multiple people to be with you according to your wishes. Naming them on the birth plan is good for communication, as your health professionals during labour may need to enlist their aid as well as help them to help you!

WHEN TO CALL?

Labour onset is the next point of discussion: the all-important question of ‘when to call’ when labour starts. As the onset of labour varies widely between gradual and quick, gentle or intense, it is good to be reminded of the guidelines that help you decide when to call.

Two general principles apply here: firstly you should feel free to call if wishing to access pain relief, and secondly when your contractions are regular and predictable and less than five minutes apart (regardless of your level of pain). You’ll also be reminded of other signs of imminent labour, such as the waters breaking, or the mucous ‘show’ being noticed. Most importantly, this discussion should note the danger symptoms, such as severe pain and bleeding, which warrant immediate contact with your LMC. Some LMC's will also at this point discuss the possibility of labour induction, where your birth is made to commence using interventions under direct medical supervision. This negates the need to know ‘when to call’, but it is certainly a good time to have your questions about labour induction answered!

PAIN RELIEF

The pain relief plan for labour is in some ways the most important part of any birth plan. The choice to use pain relief, and in what forms, is entirely up to you. Only you will experience your labour, therefore your subjectivity is paramount when considering this. In addition to its subjectivity, pain relief also has the widest number of options.

Most women planning for their first labour will keep an open mind about their options, while others might base their decisions on birth stories told by family and friends. Thresholds for pain relief vary widely, as does the availability of pain relief options at your intended place of birth. Whilst you may omit or commit to any option, birth plans are not entirely inflexible and you could always change your mind on the big day and in the heat of the moment!

TYPE OF DELIVERY

The mode of delivery needs to be discussed next. Heading into birth, there are only two options here: vaginal birth or Caesarean section. Vaginal birth can be further divided into ‘assisted’ vaginal birth (referring to the use of obstetric forceps or vacuum cup, both of which aid the maternal pushing efforts). C-section birth is divided into planned and unplanned (commonly called emergency C-section). As vaginal birth remains the usual and default option, further discussion serves to give more information around the circumstances of assisted vaginal birth and C-section. Finally, information around episiotomy (vaginal skin incision during delivery) is mentioned.

AFTER BIRTH

Once the baby is born, the birth plan encompasses important points to consider for both the mother and the baby immediately after birth. For starters, who would like the chance to cut the umbilical cord? Many support people feel a little unsure of this, but with a guiding hand it is an easy thing to do and a nice ritual at the moment of birth. Who would like to keep the placenta? For some cultures, the baby’s membranes and placenta are considered special and are not disposed of without ceremony or acknowledgment. In all circumstances, as a medico-legal entity the afterbirth tissues must be either returned to the family unless the right to dispose of them is signed over to the healthcare facility.

The management of the third stage of labour (delivery of the afterbirth) has either medicated or natural (physiological) options. Some mothers are strongly advised to use medication to reduce blood loss after delivery and the birth plan should account for such cases. The option of early skin-to-skin is encouraged and should also be discussed in the birth plan so everyone knows what to expect – all going according to plan of course!

VITAMIN K

Birth plans also provide a way of pre-consenting to the administration of vitamin K to your newborn. Ideally this is given soon after birth, therefore ensuring consent and providing education around vitamin K is best done well ahead of the big day. Some couples will either wish or require a paediatrician to be present at the birth, another important note covered in the birth plan.

POSTNATAL CARE

Postnatal considerations for the mother are queried next. The place of birth may differ from where you spend time afterwards – particularly if you’ve had a birth in hospital and without complications. Families may choose to return home (if not having had a home birth) or to stay in a maternity facility where they can rest and receive independent professional advice.

Birth plans also ask about intended mode of feeding, whether breastfeeding or bottle/formula feeding is planned. As with most birth plan questions, these are great opportunities to provide education around expectations and troubleshooting. Looking forward, the birth plan will inquire as to the level of support at home, identifying any special needs or considerations there. Social workers might be involved to maximise the care and support if required.

Lastly, the Ministry of Health mandates some reminders to be on every birth plan: a reminder about safe sleep positioning for your newborn (on their back) and a reminder about postnatal contraception. This last question may seem bizarre, though in most circumstances it is yet again a timely opportunity to touch on an important and sometimes neglected aspect of reproductive health. For example, women having their final child by C-section may consider concurrent sterilisation as part of the surgery. Other women may wish to have another baby as soon as possible and seek information around that.

I hope this article has introduced the importance of the ‘birth plan’ – in spite of the fact that birth plans (and this article!) ironically highlight the reality that during birth, nothing might go according to plan. What a birth plan does very well, however, is provide a milestone in the antenatal period signalling the delightful inevitability of your baby’s arrival!

Dr Nick Walker is a specialist obstetrician working in public practice at National Women's Hospital and private practice in Auckland. He divides his time between these roles and helping his wife care for their four children.