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    The Trouble With Birth Plans


    “The baby’s heart rate is dropping. You’re doing amazing, but give it all you’ve got with this next contraction,” I say in my serious voice, raising my head up from between her legs so can I look her directly in the eyes. She nods back. I can see the determination in her exhausted face. Her labor has not been easy, but after 12 hours of natural childbirth I can finally see the baby’s dark brown curls bulging through her perineum when she pushes. With the next contraction I massage mineral oil into her birth canal hoping to expedite the final stages of labor as the heart rate begins to drop lower, but it didn’t work. I feel a tight band in her perineum and ask her permission to perform an episiotomy. She agrees and with the next push the baby emerges, and I place him on her chest – but despite gentle rubbing, he doesn’t cry. The nurse whisks him to the warmer, and everyone holds their breath as she applies oxygen. The tension begins to thicken as she hits the alarm to request back up nurses to help with resuscitation. Luckily, before the rest of the team arrives, the stubborn boy suddenly agrees to breathe and his oxygen-filled lungs begin to fill the room with crying.

    Six weeks later, when I see the mom for her follow up visit I ask how she is doing. She expresses frustration that she had to have an episiotomy. It was not on her birth plan, and she is very disappointed that she was not able to push him out by herself. I try to reassure her that had the baby’s heart rate not been dangerously low, she could have had him herself in a few more pushes; but she has been so focused on the idea of a “perfect birth” that anything less has left her feeling like a failure.

    This is why, when a mom hands me her birth plan, a little part of me cringes inside. Not because I don’t care about her wishes or because I’m intent on rushing the birth so I can get home in time for dinner, but because fixating on the ”perfect birth” can be a set up for failure. Despite all our planning, nature often has a different agenda.

    Of course, being prepared is essential and knowing what type of pain relief measures you would like to use in advance is great, but it’s impossible to know exactly how your body will react during labor until you’re in the midst of it. I have seen patients who were so determined to stick to their birth plan that their lack of flexibility when nature didn’t fall in line actually contributed to their C-section or labor complications. I understand the importance of minimizing interventions, but sometimes those interventions are what it takes to help labor progress and avoid a C-section.

    And lack of flexibility isn’t the only challenge I encounter with birth plans. Some birth plans include requests that I just cannot accommodate. I have seen birth plans that dictated what the birth attendants could talk about (no small talk!), the type of suture I should use (personally I would want the surgeon to use the type suture with which she felt the most comfortable) and an instruction that all birth attendants should be naked (sorry, I always wear clothes). These are definitely outliers – most requests in birth plans are common practice (i.e. skin to skin contact and delayed cord clamping) – but I’ve been doing this long enough to make sure I’ve addressed any birthing requests beforehand.

    I do believe that it is important to be educated, and I urge my patients to think through the different decisions that labor will likely entail. But instead of making a “plan,” which sound very concrete, I encourage my patients to make a “birth preferences” list. Whatever you choose to call it, be sure to review a list of your expectations with your provider before labor.


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