As a doula, I require all of my clients to put together a birth plan, discuss it with their care provider, and to provide me a hard copy. I make very few exceptions to this requirement. I believe firmly that a birth plan is a critical piece of the puzzle in good perinatal care.

As much as we want to believe that our prenatal care is individualized, it often is not. Even home birth midwives can get into a “this is how I always do it” habit, though that is far less likely. Still – I have learned to never take anything for granted when it comes to care providers.

I spend a good amount of time with each client in helping them form their own unique birth plan, and provide them with role-playing opportunities that teach them how to have open, honest, and clinical discussions with their provider about their individual needs. If I am hired late into the third trimester, that is almost all I end up doing prenatally – birth plan work.

It’s that important.

That said, I don’t particularly care for the term “Birth Plan,” and I use it only because that’s the common vernacular. I think the word “Plan” conjures up images of precise blueprints and/or legally binding documents. A birth plan is neither of those things, and the sooner we understand that, the better.

Instead, I believe that birth plans are tools designed to help you, your care provider, and any staff you encounter to communicate effectively about your individual needs and expectations regarding your care.

It provides a basic framework that helps your care provider and staff to better care for you, but it does not legally bind them to your every whim and wish.

Instead, a birth plan gives you and your care provider an opportunity to pursue individualized care together, and to be on the same page before you go into labor. It has the potential to build rapport, trust, and respect between you and your provider–a critical factor in enjoying a positive, healthy birth experience, no matter what the circumstances end up being.

For this reason, I really prefer the term “Birth Preferences,” “Birth Goals,” or even “Birth Desires.” Those make a lot more sense to me. When a birth plan is viewed this way, it is often much easier to mentally and emotionally process anything that derails those plans.

Birth is still unpredictable, and there are no guarantees, no matter how safe we have made it. The reality is that birth is like any major event we plan: There will always be at least one thing that does not go the way we expect it to, for good or ill.

Mommas get sick. Babies get sick. Babies get into funky positions. Mommas get exhausted. Heart rates get wonky. Side effects of drugs happen. Things stretch on longer than we thought, or go far faster than we anticipated.

Stuff happens.

Overall, birth is a safe and healthy process, but it has a lot of variables within a very wide range of Normal. Accepting that fact, and writing a birth plan with flexibility in mind is key to processing those funky things that happen during our births.

I find that the most flexibly written birth plans get the most respect from staff. They see clearly that my client has done her research, and has realistic expectations. Frankly, I find that my clients are more likely to get exactly what they want when their language is open and flexible.

I also find that when things get weird in a birth, staff and providers tend to bend over backwards to keep the spirit of the plan intact. They seem to view themselves as being on my client’s side, and try very hard to make it work within the parameters this particular labor has laid out for them.

My clients come out of these births processing all of it in a very healthy way. They understand that they don’t have to like what happened, but if they felt respected, understood, and as though their choices mattered, they are often okay in the long run. They understand that it’s okay not to be okay for awhile. They grieve the stuff they didn’t like, but are grateful for the support and good care they received within the circumstances their birth chose for them.

Care they might not have received had they not communicated clearly what they hoped for, ahead of time, via their birth plan.

So, when writing your birth plan, be careful about the language you use. Really examine how it comes across, and how you view your relationship with your care provider. Some basic tips:

• Open with a sentence like: “We understand that circumstances may arise that preclude the following desires, but we expect to be fully informed before consenting to any procedure that may be proposed, and we appreciate your help in achieving a healthy and pleasant birth.” This lets them know you understand that birth has a lot of variables, and that you are willing to work with the staff.
• Have a short introductory sentence or two explaining your overall desires. (Natural birth? Well-timed epidural?) The staff will automatically know what requests will go along with that, and you can eliminate a lot of specifics. For example: If you know you want an unmedicated birth, and state that fact right away, you won’t have to tell them you’ll want to move around, have dim lighting, etc…
• Keep it simple. It shouldn’t be more than one page long.
• Use bullet points and clinical language.
• Tailor it to your provider’s practices, as well as the protocols at your place of birth. If you know they do rooming-in, you don’t need to request it.
• Do your research. Take an independent childbirth class. Hire a doula.
• Take your first draft to your provider and ask specific questions. “Under what circumstances might you do an episiotomy?” This helps you know if something needs to be added or taken off the plan.
• Have a cesarean plan. Look up “Family-Centered Cesarean,” and choose your top 3-5 items you think might be important, and add those.

Be decisive and clear in your desires, but remember to stay open as well. Choose carefully your hills to die on, and let everything else go if it becomes necessary. Ask questions. Even if all you can think is to keep asking “Why?” That one word can gain you a lot more information when a decision becomes critical. Open your eyes, and walk forward confident in your desires, your ability to birth, and your ability to make good decisions for you and your baby.

You are already a good mother. Go for it.

I could write mountains of information on this subject, but this post would get too long. Did you write a birth plan? Why or why not? Do you feel your desires were respected? Do you feel it created a sense of cooperation with the staff who cared for you? Why or why not?

Grace & Peace,
Tiffany

This question was posed on her facebook wall by my mentor, Desirre Andrews. I appreciate the thought that her questions provoke, and the way she challenges me to dig a little deeper and search out what my answer would be to this question.

I think, overall, there is an assumption in our country that an epidural is a panacea. The concept of labor with an epidural on board is one of passivity and a desire for separation from the experience because of fears about the process of labor. Whether those fears are well-founded or not really does depend on the individual, and is not the subject of this post. I would very much like to see a more realistic, knowledgeable view of epidurals begin to take prevalence in my community, and the world at large.

As a doula, I know that I can bring my community closer to that vision, one mother at a time. So, here is my answer to the question posed in the title of this post:

I usually tell someone that they don’t “need” a doula (if they want to get all technical), in that they can definitely have their baby without one. Yet, I would never say that a doula is a luxury, either. There is too much benefit to the presence of a doula, supported by scientific evidence, to label them luxuries. Not to mention the fact that women, for all of our world’s history, have always supported women during birth. Women need women who believe in them at their births. Period. Again – a subject for another lengthy post.

Moving on.

In the specific case of a mom planning an epidural, a doula can really help to optimize the use of this particular tool — maximizing its benefits, and minimizing the risks associated with it — if that’s what she wants.

A doula can help a mother stay calm through the procedure, and prepare her ahead of time to have realistic expectations of what epidurals do and do not do. Contrary to popular belief, epidurals are not a panacea. They vary in effectiveness for many women, and come with some side effects that are common enough that every woman who wants one should know about them.

A woman with a doula who has educated her ahead of time who experiences, for example, the drastic drop in blood pressure that can go along with an epidural, will know that the nurse will come in, place her on her side, put an oxygen mask on her face, and give her medication to raise her blood pressure immediately. The nurse will act, she will not ask. This prepared woman will be less susceptible to fear as the nurse takes quick action. The unprepared woman may end up scared out of her wits, and experience fear for her baby because of this process, if she did not know ahead of time that it could happen. A doula can prevent the latter circumstance. Doulas can help take fear out of the equation for women.

Along the same lines, a doula can assuage the fears of a woman’s partner, and reassure him/her that what’s going on is common, normal, and that mom and baby are likely to be okay. Partners who love these women so much often forget all they learned, as their gut takes over, and having a doula there for reassurance can really bring a sense of peace to the partners, freeing them to be fully present in their relationship to the laboring mother.

Doulas can also give women tools to cope with labor up until the time the epidural is placed. Mom is having a natural birth up to the point the epidural is in place, after all! A woman and partner equipped with basic labor coping skills and techniques will be able to handle whatever their labor throws at them up to the point the epidural can be placed.

Many moms, without the presence and preparation of a doula, may not know that the timing of an epidural is critical in avoiding some of the risks (both for herself and her baby), and maximizing its benefits. For one thing, an epidural placed too early can cause labor to slow down enough that Pitocin will be needed, beginning the lovely “Cascade of Interventions” all of us in the birth community are familiar with.

Without a doula, a mom may not have the confidence to believe she can handle labor beautifully until the time comes that an epidural would be more to her and her baby’s benefit than a risk. A doula can bring a strong sense of “I can do it” to the labor room, and help a mother to gauge when the time is right for her epidural.

Once the epidural is in, a doula will help a mother assume multiple positions that can keep it working well, keep her pelvis moving, and encourage progress. Progress in labor is directly linked to the amount of movement mom is able to do, and a doula knows this. She can help a mother and her partner work to keep an active role in her labor by maneuvering mom into alternating positions. Since epidurals are gravity-based, this also helps keep the pain relief on a more even keel, and minimizes uneven sensation.

A doula can also walk moms through what pushing with an epidural might be like, and teach them about different options for that stage. She is equipped to help them advocate for the option to “labor down” (a technique that can help preserve mom’s energy for more active pushing when baby is much further into the pelvis/birth canal), instead of beginning active, hard pushing as soon as she reaches full dilation. She can help mom assume different positions every few contractions, to maximize baby’s ability to descend and rotate well. This can also minimize the risk for forceps or vacuum extraction being needed.

After the birth, during the postpartum visits, a doula can help walk moms through any after effects she may be experiencing. She will have prepared the mother to recognize signs of a spinal headache (one possible side effect that is fairly common, but not overly so), and to get help quickly for it. She can help moms understand the back pain that may come along with it; the longer recovery time often associated with it; and – if it was on board for more than four hours – the side effects that her baby may experience. Usually, a baby might be sleepy, and have trouble latching on for the first time.

Once a mom is fully equipped with all the information about an epidural, she is equipped to take any side effects in stride, without fear. She knows that they may happen, and she accepts and owns her decision. She can come out on the other end still satisfied with her experience, even if she has experienced some negative side effects, when she is fully informed and fully supported in the way that only a doula can really do.

So, do moms planning an epidural need a doula?

You tell me.

This is just the tip of the iceberg regarding the knowledge a doula can bring to an epidural birth. If you are a birth professional, what would you add to this? If you are a mother who chose an epidural: Did you have a doula? If so, how did she help you? If not, would you want a doula the next time? What was your experience – doula or no doula?

This is a safe place for you to share – so, please do!

Grace & Peace,
Tiffany