“There is nothing, whether total instinct or total reliance upon technology, that can guarantee a perfect outcome, a perfect dance, for every mother and baby,” Sarah Buckley, MD.1
Ultimately it is the birthing mother that has the rights and responsibility to make the decisions she needs to make during birth. We must keep in mind that birth is multi-faceted. How a woman views her birth experience is impacted by many factors. A woman views her sense of control over her birth from the internal, what is going on inside her mind and heart, to the external, what those around her are doing. How her decisions are viewed by others can impact her care and can impact how she feels about her experience. A woman’s view of herself as mother can be influenced by her culture or beliefs. She brings with her to birth all that she is and those around her should respect and honor her in this process as she negotiates what is right for her during pregnancy, birth, and the postpartum period.
Making room in the plan
Written birth plans were introduced during the 1980’s in Europe and America in response to the increasing medicalization of childbirth. They were originally introduced as a tool to educate and empower women, encourage shared decision making, facilitate communication about expectations, and develop trust between women and their caregivers.2 In a search of Google on birth plans, over 439,000,000 results can be found. Many of the main topics include templates, generators, visual plans, VBAC plans and plans for first time moms. Top questions include: how can I have a natural birth, and are birth plans important? What is missing is often the spiritual, emotional and mental preparation needed for birth. Checking off boxes does not help a woman prepare for the hard work of labour or what to do when things do not go as expected.
All women who are preparing to birth, intentionally or unintentionally, develop a birth plan. There is no ‘right’ way to plan, only what each individual woman does based on her experiences, beliefs and decisions. How women prepare for birth is as varied as women themselves. Some women may not want to learn about the process or may not want to think about what her options are. She may decide to, “Trust the doctors” or, “Go with the flow”. Some woman may spend many hours reading, researching, watching videos or talking to friends. Some women attend prenatal classes to learn more. A birth plan may be a written document, or an idea in the woman’s head. Through all her interactions she begins to create her own set of beliefs and philosophies around birth.
“A mother could have every intervention in the book and still be birthing in-awareness. When she is aware of what she is feeling, emotionally and physically, and she is in her self-awareness, then she is gentle with herself and those who are working with her. She is acting and speaking from that deeper knowing. When she cannot change what is happening, ‘Out there’ she brings attention to what is happening within her. She does not abandon herself, her ‘inner-Child’ or her spiritual practice.” -Pam England.
Although there is no right way to plan to birth, in writing a birth plan a woman may focus on the things she hopes for, rather than what things she does not want or which she fears will shape her birth. When focusing on the negative it can distract her from trusting herself, her body, and her spirituality. Rather than planning what is in her control, her own hard work and surrender, her energy is diverted towards controlling the anticipated actions of others.3 A woman should also have flexibility in her birth plan. This can be impacted by those who attend her, where her birth takes place, type of pain control or medical intervention, the length of hospital stay and the quality of care. While she can be focusing on the positive, she is leaving room to consider the ‘what-ifs of birth.
How others’ opinions influence birth
There also needs to be flexibility in the environment the mother births in. Structured healthcare protocol that is not in a woman’s control can affect how she feels about her experience.4 A loss of choice can cause emotional trouble and affect bonding with the baby. The birthing mother is the one with the most interest in what happens to her baby. The ways in which a woman’s obstetrician views birth can impact the options that are presented to her and influence the decisions she makes before and during childbirth. A care provider’s knowledge, whether based on experience, study and research, or from a philosophical basis, is highly influential in a women’s planning. It can influence what happens during management of labour or if changes are made to the initial plan.4
“As perhaps the most important set of healthcare decisions you will ever make, you need and deserve to have unbiased facts both the pros and the cons about the different types of maternity care available to you. You are entitled to excellent labour support and fully informed consent. No matter how the course of labour unfolds, you, as the pregnant woman at the center of it all, have ultimate responsibility for creating an experience for yourself that is as safe, stress free, and satisfying as possible. You are entitled to plan then enjoy the birth experience of your dreams, as much as the mysteries of nature allow.” -Marsden Wagner.
Women were encouraged to use language that was polite and friendly but also flexible. 2 However, since the birth plan’s introduction, a care provider’s view was, and has often been negative. Research has shown that a woman having a birth plan may irritate staff which can adversely affect obstetric outcomes.5 Care providers may believe women with birth plans have unrealistic expectations and are inflexible in making changes to their plan when necessary.2 Yet it has also been recommended that care providers need training in understanding the purpose of birth plans and how to help women achieve their goals.5
Therefore choose your birth helpers carefully. Your support team may include all the individuals who assist with planning and giving birth, doctor, midwife, nurses, doulas, friends, family, photographer, partner…all of whom can influence how you plan or prepare for birth.4 Caregivers should be open to listening to the birthing mother and what her wishes are, with respect and honour. Giving birth is not always easy and those present should have faith in the ability of the birthing woman. Many women have found that having a birth companion such as a doula, can be a trustworthy source of information. From being a basic source of knowledge to providing physical support, she can help as you go through labour.2 By meeting with several different doulas prenatally, you can find one that will best fit with your needs during birth. Finding a doula can give women confidence in making choices during pregnancy and birth, you will find out more about her role as you work with her prenatally.
With all those people around it can be difficult to be in the moment and to witness the mystery of birth. Try not to get distracted by the busyness around you, remember your baby is on this journey with you. We are more able to respond to our body’s instinct when we fully inhabit our bodies. Although learning how to fully inhabit our body can be difficult, challenging and can be a lifelong learning process, we can do practices during pregnancy to help prepare us for those moments. It can be difficult during labour when surrounded by so many people and at such a vulnerable time but with support and understanding a birthing woman can be in the moment.
Communication and education
Birth plans can, however, help compassionate caregivers provide a woman with continuity of care and they can see how best to help as labour progresses. A caregiver’s responsibility is to offer their best judgment and skills as different circumstances arise, then together you can agree on your care. In a 2005 study, women who had the highest causes of satisfaction with their birth experience felt there was good communication with the care providers, followed by good support during birth.2
Birth plans are not just about the final document either, they are about the preparation a woman has put in to understanding her options in childbirth. While only a piece of paper it reflects the hopes and expectations of the birthing woman. A woman still has the ability and the right to change her mind and make different decisions based on what is happening in the moment. Yet, the birth plan can help you to take responsibility for your decisions and know what to ask to be fully informed. It is an educational process, helping you learn about options and evaluate the risks and benefits of various interventions.6 For instance, a mother may have planned to not receive an epidural during labour, but her labour has been very long and tiring, and she is feeling overwhelmed and exhausted. Based on what she has learned through her own research, classes, information provided by her care-givers and her own inner knowing; she feels the next best thing for her, and her baby is to accept the epidural. She knows that even though this is an unexpected part of her labour she will be able to meet her needs and those of her baby’s with confidence. Women who understand the benefits and risks of such a procedure are also better able to face some of the challenges associated with it postpartum.
“Doctors and midwives know a great deal about childbirth, but their knowledge has limitations, one of which is its externally oriented objectivity. Even with their experience and good intentions, their judgement is not perfect. It is important to remember that as mothers we have exclusive access to vital information about what is happening in our bodies. Ideally, both kinds of knowing (objective and subjective) are utilized in decision-making.” -Pam England and Rob Horowitz.
There are many things that a woman can do prenatally in order to prepare for when, or if, during her birth things may take an unexpected turn. These preparations start long before birth. A great first step is to begin asking your care provider questions about your care, and birth. Women may feel like they are unable to ask for more information. A woman may be worried that if she asks questions or that she may not be heard. Penny Simkin asks, “Should women have a right to directly express their concerns and preferences and have them heeded by their clinical caregivers?”5 A woman does have the right to ask questions for herself and her baby. Before birth a woman can go over her preferences with her care provider. By starting to ask questions in the office she can start to feel comfortable in communication with those around her. Asking questions can help you make decisions as they come up during labour. Using the BRAINS acronym can give you the tools you need to know what to do next. What are the Benefits? What are the Risks? What are the Alternatives? What do my Instincts say? What if we do Nothing?, at least long enough to think? What would make me feel Safe or Satisfied? Think about the questions we would ask ourselves before buying a shirt, a car or a house. Before birth women can practice asking questions in everyday life. Have you ever gone shopping for a new car? How would you ask questions in order to get information? What about buying a house? How would you ask questions to make sure you are making a good decision? Or in the smaller things like buying a new shirt. Have you every asked question about it? Like what is it made of? Is it the right size? What is the price? Is there another color I can pick? Start finding ways to be comfortable asking questions and start to notice how you feel about hearing the answers.
Preparing the body
Birth has a physiological process, there are certain things that need to happen for a baby to be born. This can be an instinctual process, but sometimes this process can be disrupted. A woman’s hormones play an important role in the process. Oxytocin is one of the naturally occurring hormones that increase as labour begins and throughout the process. This process can be helped by a mother feeling safe, loved and supported by those around her. If this is interrupted by use of artificial oxytocin or a mother is feeling unsafe then it can change how labour happens. During pregnancy a woman can prepare to support this process by taking care of herself, by getting a massage, taking a walk, connecting with friends, getting body work done or taking time with her partner. Women can prepare physically, mentally and emotionally ahead of time by taking steps such as attending an independent childbirth preparation class, talking to a counsellor or taking a prenatal yoga class. We can learn to work with our birthing bodies internally and externally. Often a woman who moves from the comfort of her home to the hospital setting will find her labour slows down. In the hospital she and/or her partner can shut the door, turn lights down, move and use massage.
Remember to use your body freely during birth, be as active as your body desires, or if you feel ‘stuck’ try moving around or to a new position. Your plan may be to remain unrestricted, but circumstances may change where you are unable to be free. If monitoring is needed a woman may be close to the machine if there are wires. She can be on a ball, on hands and knees or leaning over the top of the bed. If a telemetry machine is available, she can go for a walk or be leaning over the bed. Sometimes the belt may need to be adjusted because of movement, but it is okay to ask for help readjusting. If an epidural is used and you are confined to a bed, getting help to rotate every ten minutes can help keep you moving and help support your baby as he or she rotates through the pelvis. You can go from your back to your side, remember to keep your pelvis in an anterior pelvic tilt being aware of if your pelvis is tilted forward or not. Then you can rotate to the other side. Try and stretch your legs as much as you can.
Physical preparation of practicing birth positions during pregnancy can help a woman see ways her body might move during labour and may help her find positions that are comfortable and help labour progress. To help with postures and positions being instinctive during birth; go ahead and physically try different birth positions, even ones you do not think would be your first choice. Our bodies need nourishment and hydration to work efficiently. Prenatally, good nutrition is very important when preparing to birth, as well as making sure you are drinking enough clear fluids. During labour check in to see if you are needing nourishment. Try to aim for a sip of water, or other clear fluid, after every few contractions, and a bathroom break at least every hour. Touch relaxation is another tool that can be practiced prenatally. It helps condition you to expect pleasure, rather than pain, to follow tension. Find out which type of touches (light and feathery or deep pressure, and where you hold tension or find relaxation) and what kind of massage relax you best. Do a head to toe progression check to see where you are holding tension. Have your partner apply a warm, relaxed touch to that area as your cue to release the tension.
Our relationships with loved ones are an important factor in birth. Be comfortable with your emotions, loving and sexual feelings with your partner during labour, if it is applicable and feels right. Your partner can remember that just being there and believing in you will help both of you as you go through labour and birth. Your partner does not need to know everything about birth but will be the person who can love and accept you through the process. Sometimes a nice deep kiss during labour can help you to open and relax. You can practice that to! Even if we are birthing without an intimate partner, we can still ask members of our birth team to use massage or touch, bring comfy items from home, dance, or use self-stimulation as ways to increase oxytocin during labour.
Preparing the mind
One difficult aspect of in the process of mentally preparing for birth is looking at our past experiences and beliefs. This can help free us up emotionally, physically, and spiritually for birth. One in five women have had some sort of sexual abuse in their life, for many of these women birth can bring up memories or feelings of those times. Maybe someone told a frightening and traumatic story about their own birth that is causing fear of labour. Perhaps something someone unknowingly said or did during a previous labour has influenced a woman’s feelings. By finding counselling or a trauma worker and talking about it with your care providers a woman can understand how to work through those emotions during labour.
“No single decision, no one doctor, and no mother is solely responsible for a birth outcome. It is over-simplified to blame or praise any individual or isolated event for how a birth turns out. Our challenge is to live with ambiguity, embrace the birth that happened, and move on with our family into its future” -Pam England.
One tool to help with relaxation is by using your five senses. Practice this technique before labour so it will come easier for you: feel the floor under your feet or be aware of what your body is touching. As your eyes move from left to right; notice five things you see, breath; notice four things you hear, breath; notice three things you feel, breath; notice two things you smell, breath; notice one thing you taste, breath.
Practice visualization techniques. Mental imagery has been shown to be a useful tool to help relax and refocus. Find what images best help you: perhaps rolling waves, waterfalls, meandering streams, or walking on the beach. Picture your uterus ‘hugging’ your baby and pulling itself up over his adorable little head. Imagine the cervix getting thinner and more open with each contraction. Imagine yourself reaching down to bring your baby to your breast and smelling his or her wonderful scent. They use of a labyrinth can is yet another useful tool; you can have a picture or a model and follow the path with your eyes or feel the path with your hand. For some women the need to connect to the earth and nature are important. Walking outside can go a long way to help you refocus during labour. If you cannot be outside, prepare ahead of time to have something to help you focus. Sometimes a woman may feel she has no control over the outside influences around her, but she can have control over her thoughts and use tools such as non-focused awareness or affirmations. Write out affirmations that you can look at, such as, “I feel confident that I will labour and give birth the way I want to”, “our baby feels my calm confidence” or, “I will breathe slowly and deeply to relax my muscles and bring oxygen to our baby.” Tapping (EFT) is a technique that can help a woman to reconnect to herself and her baby.7
Building in daily life practices before birth will help you act instinctively when a change happens. Take time daily to turn your attention inward. Commit to a regular time where you can be quiet for at least ten minutes., perhaps early in the morning, by doing so it will help develop a rhythm and grounding to your daily life. Sit up straight, open the chest. Come into a, “Quiet mind” and practice being aware of your breath. As you sit quietly be aware of any questions you may have and as you sit and listen you may feel answers start to come to you. You may just be aware that you had questions, or other realizations. Now Later you can then express those thoughts through writing, painting, dancing, or any other way you like to be creative. Connect and talk to your baby during this time. During birth you can use this to help slow down a racing mind in order to know what questions or answers you need. Habits are learned by repetition so practice techniques daily that will help you to be calm and able to cope. Labour is just a continuation of your life; it is not more than you.
The spirit within
Spiritual beliefs and practices can be an important aspect of birthing. The spiritual and emotional aspects of birth are such that they are not always so easily written in a birth plan. Women need to do what is important for them to make their birth easier, this may be hard to put in writing. Perhaps prayer or meditation is an important aspect of your life, you may include that in your plan, or it may just be something you do. If something unexpected happens during the labour, taking a moment for prayer may help you. Prayer, meditation, and daily affirmations can be helpful in preparing to birth and are especially important when your birth takes an unexpected turn. They can help you to relax and focus on decisions you may need to make. For some women, memorizing scriptures can be a great comfort. For others yoga practices can help them stay centered. Pregnancy can be a spiritual time for women as they feel more connected to their beliefs or their culture. They may reach out to their faith community for support and guidance.
Birth is instinctive in all mammalian babies. Babies know how to get themselves born and have an active participation in the birth process. Of course, babies are born in many different ways, in many different places, and at many different times and maybe not in the ways we may have imagined; it does not mean they are always born vaginally in an optimal position. We can work with our babies prenatally to help them find a position that is best for them. Through bodywork, nutrition and movement we can work towards the best outcome. Be aware of your baby as he/she grows and changes during your pregnancy. Use a fetoscope to hear your baby’s heart, feel with your hands the position of baby and talk and sing to connect. If an unexpected change happens you can take charge of your attitude, emotions, and responses to pain or fear by taking a breath and connecting with your baby, no matter what is going on around you. Check in and connect with your baby during labour, many mothers will rub their bellies during labour as the feel baby move down. A mother will find positions, move, and rock during labour in ways that will help baby move down. Sing and talk to your baby as the waves of labour wash over you both.
Be kind and gentle with yourself, no matter how your path unfolds. All labours are individual and unique. Loving yourself and your baby through this life-changing event will give you confidence as you keep taking one step forward at a time.
1. Gentle Birth, Gentle Mothering by Sarah Buckley
2. Effect of implementing a birth plan on women’s childbirth experiences and maternal & neonatal outcomes; Amal Faraht, et.al; Journal of education and practice; Vol. 5. No.6, 2015
3. Birthing From Within by Pam England and Rob Horowitz, Partera Press, 1998
4. The impact of choice and control on women’s childbirth experiences, Katie Cook, Colleen Loomis, Journal of perinatal educations; Vol 21; No. 3, Summer 2012
5. Birth plans: after 25 years, women still want to be heard; Penny Simkin, 2007
6. Creating Your Birth Plan by Marsden Wagner, The Berkley Publishing Group, 2006
this article appears in the Spring 2019 issue of Birth Issues magazine www.birthissues.org