A birth plan sounds like a brilliant idea -- you write down your wishes so that your doctor knows how you feel about everything from pain meds to c-sections, and B Day goes exactly as you've envisioned it. Reality check: Births don't always happen the way we want them to. Still, putting together a record of your hopes and preferences will help you understand your labor and delivery options. Your plan will also be useful as you inform your caregiver of your views on variables such as induction or episiotomy. Whether or not you write down your choices, ask yourself these questions, and chat with your physician about your answers, before it's time for the big push.
Do I want to receive medication for the pain?
Whether you plan to go "natural" or to say yes to any painkiller available to you, it pays to know the options.
Systemic drugs, including narcotics and sedatives, are primarily used in the early stages of labor to take the edge off the pain. They act on your nervous system, so may cause drowsiness, disorientation, or nausea.
The pitfalls of these meds are important reasons why doctors and delivering moms usually prefer epidurals, which block the pain from the waist down, leaving you comfortable but alert. Until a few years ago, women who hadn't yet dilated to at least four centimeters were dissuaded when they asked for an epidural. Doctors believed that the painkiller's numbing effect would interfere with labor, prolonging it and possibly prompting a c-section. But the American College of Obstetricians and Gynecologists (ACOG) now advises that a woman in labor should receive pain relief at whatever point she asks for it.
The ACOG also notes that studies are inconclusive regarding a link between epidurals and c-section risk. A recent landmark study published in The New England Journal of Medicine demonstrated that a "combined spinal epidural" does not increase a woman's chances of needing a cesarean (in fact, the study notes, in some cases the procedure may hasten birth). Laura Goetzl, M.D., an assistant professor at the Medical University of South Carolina in Charleston, declares, "There's no reason to suffer in early labor. It's very reasonable to ask about the option of a combined spinal epidural."
Even if you don't plan to accept pain relief, it's good to know what choices you have should you change your mind. Discuss your thoughts with your caregiver -- and don't wait until labor is in full swing to do it. To learn more about epidurals (including traditional, "walking," and combined spinal epidurals), sign up for the Babytalk Pregnancy Planner and visit the Birth Options Planner.
Will I need a c-section?
About one in five births is performed by cesarean -- one may even be planned if your baby is in a breech (feet/bottom first) or transverse (sideways) position, or if you have preeclampsia or an active herpes infection. Surprise cesareans happen when labor stalls or problems arise in the womb. If you need one, you'll most likely have an epidural or spinal rather than a general anesthetic; the former options offer "the chance to see the baby right away," says M. Kelly Shanahan, M.D., an ob-gyn and chief of staff at Barton Memorial Hospital in South Lake Tahoe, California. During a c-section, a doctor usually makes a horizontal incision through the skin and abdominal wall, moves the muscles aside, and opens the uterine wall. The incision is closed with stitches that dissolve in the body.
How do I feel about electronic fetal monitoring?
The word on fetal monitoring is that it's constricting -- and that makes many moms-to-be want to avoid it. In the early stages of labor, nurses will often go the low-tech route, using a stethoscope or handheld ultrasound device to check the baby's heart rate at set times. But if you plan to give birth in a hospital, you can pretty much expect an encounter with a fetal monitor at some point, particularly in the later stages of labor.
External fetal monitoring involves the placement of a pair of belts around your abdomen; they're connected to equipment that measures the baby's heart rate as it responds to your contractions. On the upside, such a contraption doesn't necessarily confine you to bed. If it's used in early labor, you may be monitored for as little as 15 to 20 minutes an hour. Cordless and even waterproof models may allow you to move around more freely. Even if you're tethered to a machine by cords, you may still be able to get out of bed while being monitored in order to, say, sit in a rocker. But once you're in active labor or you've been induced, you and the monitor are likely to become fast friends.
Most restrictive of all is internal monitoring: It involves an electrode being inserted through the vagina and attached to the baby's scalp. Not surprisingly, it requires you to stay planted in bed -- which may not be optional, anyway, since this method is most often used when external monitoring suggests that the baby may be in trouble. "We also use it if the mother is extremely overweight, in which case it's harder to track the heart rate externally," says Michelle Sang, M.D., an ob-gyn in private practice and an associate clinical professor at Oregon Health Sciences University in Portland.
Is induction for me?
Your doctor may want to jump-start labor for many reasons: You're past 41 or 42 weeks, your blood pressure is high, your water has broken (infection risks rise if delivery doesn't follow within 48 hours), or you're full-term and your husband has taken next week off. Induction might entail the doctor breaking your water by rupturing the amniotic sac with a plastic tool or "stripping," a.k.a. performing a rough pelvic exam; she may also use Pitocin, a synthetic version of the natural hormone that starts labor, or Cytotec, a cervix-softening prostaglandin. "Contractions normally start mild and build up," Dr. Shanahan says. "With Pitocin they are strong from the start. Some think Cytotec better mimics natural labor." (For a vaginal birth after a cesarean, Cytotec is never used, since it ups the risk of uterine rupture, which, although rare, can be deadly.)
What's my stand on forceps and other instruments?
During about one tenth of births, doctors turn to forceps or a vacuum extractor to get the baby out. This is often the case when the baby's heartbeat becomes slow or erratic in its journey out of the womb, you're too tired to summon that final push, or you've pushed for hours with little progress. These tools don't necessarily cause problems, but they have been known to bruise the baby's head or tear the vagina or cervix. It's rare, but the use of these instruments during delivery can also increase the risk of tears to the anal sphincter, which controls bowel movements.
"Forceps are wonderful in the right hands," says M. Kelly Shanahan, M.D., an ob-gyn and chief of staff at Barton Memorial Hospital in South Lake Tahoe, California. "Unfortunately, a lot of physicians coming out of training don't have the experience." Vacuum extractors, she notes, are softer and can be more forgiving to the mother, but they carry some of the same risks to the baby as forceps do.
Ask your physician about his or her qualifications for delivering with forceps or a vacuum. That way, you'll hopefully feel less anxious should the need for them arise.
Can I avoid an episiotomy?
Ouch alert: Some deliveries require an episiotomy, a small cut made between the vagina and rectum to ease delivery. But your doctor should have a good reason for doing it, since data shows that episiotomies can lead to unpleasant outcomes, including a more difficult recovery, a greater chance of incontinence, and sexual difficulties. As a result, many practitioners now allow the tissue to tear naturally, after which it appears to heal more easily.
The ACOG has renounced the routine use of episiotomy, but some old-school practitioners continue to perform it as a matter of course. So it's wise to know your doctor's position on the procedure long before you go into labor.
"The generation of doctors who performed them without thinking is nearing retirement," Dr. Shanahan says. "But it's still worth the discussion." Keep in mind that an episiotomy is the right call if your baby is in distress, if forceps or a vacuum extractor are needed, if the child is in a breech position, or if the baby's head has emerged but his or her shoulders are lodged inside the birth canal.
How can I know that my ob-gyn will honor my birth plan?
Discuss your plan (and contingencies) with your caregiver long before you're at the hospital. "When you're in labor is not the time to explain your point of view," says Jerri Hobdy, a certified nurse-midwife and program director of the Midwifery Institute at Philadelphia University.
Experts offer inside tips on getting the birth you want:
If you disagree with your doctor's birthing practices, switch physicians right away. To find a new doctor, "call the delivery unit at your hospital and talk to nurses," suggests Mary Jean Schumann, R.N., director of nursing practice and policy for the American Nurses Association. "Ask them who they like."
Don't waste time with an out-of-date birth plan form. "A lot of birth plans that people use have been floating around since the late '70s or early '80s and address outdated practices like having an enema and shaving the pubic hair," says Dr. Shanahan. "We don't do those things anymore."
Tour your hospital or birthing center. "Sometimes people put things in birth plans that aren't available," says Ashlesha Dayal, M.D., an ob-gyn at Montefiore Medical Center in the Bronx, NY. Be open to learning about alternatives. If a hospital can't provide a water birth, it may offer comforts such as birthing balls or squat bars.
Appoint your spouse or labor coach to look out for you. Assign him or her the task of hunting for the anesthesiologist if you want pain relief, or finding the ob if it seems like it should be time to push. "Women often don't realize that once they go into labor, they may not be able to be their own advocate," Schumann says.
Make clear your personal and religious preferences. "Maybe you'd like prayers said immediately or for the father to be first to hold the baby. It's good to have that written down for hospital staff," says Jerri Hobdy, a certified nurse-midwife and program director of the Midwifery Institute at Philadelphia University.
Find out who will deliver if your caregiver isn't there. It will likely be one of your doctor's or midwife's partners; make sure they know your preferences as well, Schumann advises.
Avoid absolutes. "The words always and never don't have much of a place in labor and delivery," Hobdy says. "Don't say, 'No medication.' Say, 'I want to try to avoid medication.' That's more realistic."
Be flexible. "Nothing is written in stone," says Robin Dietel, R.N., a labor nurse at St. Joseph's Hospital in Marshfield, WI. "Labor is unpredictable. We never know what to expect, but if you have a birth plan, at least we will know your preferences and try to accommodate them."
Beth Howard is a Babytalk contributing editor and mother from Charlotte, North Carolina.