If you haven’t already, please check out PART 1 of this post: Writing Your Birth Plan: Tips from an L&D Nurse. Also, at the end of this post check out a birth plan written and sent to me by one of my blog’s readers who is due any day now!
#1 DO keep your birth plan short, simple, and easy to understand (1-2 pages max).
“Keep [your birth plan] short. If you need to spell out a long list of points, you may not be with the right caregiver. If most of the things you want aren’t things your caregiver is used to doing (in which case you don’t need to put them in a birth plan!), you are unlikely to get them. For maximum effectiveness, keep your birth plan to a single page.”
Writing a Birth Plan by findadoula.com
#2 DO keep the language of your birth plan assertive and clear.
“Remember to keep your language assertive – polite but clearly stating what you want. Use phrases like “I am planning” and “I would like” rather than “if it is ok” or “I would prefer.
Be specific. Avoid words and phrases such as “not unless necessary” or “keep to a minimum.” What one person thinks is “necessary” is not what another does. What one person defines as the minimum is not what the next person does. Instead, use numbers or specific situations, for example: “I am happy to have 20 minutes of electronic monitoring and if all is well then intermittent monitoring every hour for five minutes after that” or “I am happy to have a vaginal examination on arrival in hospital and after that every four hours or on my request.”
Writing a Birth Plan by findadoula.com
“Be sure to be assertive, but not aggressive when discussing your options. Do not allow your caregiver to brush off your decisions or suggest that this is unimportant. At the same time, don’t assume your caregiver [or nurses] will be hostile or uninterested in hearing what you have to say.”
How to write a Birth Plan by birthingnaturally.net
#3 DO use your birth plan as an impetus for doing your own personal research about your preferences for childbirth.
One great place to start is at MothersAdvocate.com who, in partnership with Lamaze International and Lamaze’s Six Steps to A Healthy Birth, have created a website that offers FREE, evidenced-based, educational video clips and print materials to educate and inform childbearing families on how to have a safe and healthy birth for both you and your baby. These extremely well reserached and produced materials are a MUST READ for all expecting moms!!!
The introduction handout for these video clips and print-outs entitled Introduction: Birth–As Safe and Healthy As It Can Be reads:
“While no one can promise you what kind of birth experience you will have, common sense tells us and research confirms that there are two tried-and-true ways to make birth as safe and healthy as possible:
• First, make choices that support and assist your natural ability to give birth.
• Second, avoid practices that work against your body’s natural ability, unless there is a good medical reason for them.
Lamaze International, the leading childbirth education and advocacy organization, has used recommendations from the World Health Organization to develop the Six Lamaze Healthy Birth Practices that support and assist a woman’s ability to give birth. Years of research have proven that each of these practices increases safety for mothers and babies.
The Six Lamaze Healthy Birth Practices are:
1. Let labor begin on its own.
2. Walk, move around, and change positions throughout labor.
3. Bring a loved one, friend, or doula for continuous support.
4. Avoid interventions that are not medically necessary.
5. Avoid giving birth on your back, and follow your body’s urges to push.
6. Keep your baby with you—it’s best for you, your baby, and breastfeeding.”
The topics of the print materials include:
Maintaining Freedom of Movement,
and even a Birth Planning Worksheet!!
“We cannot know the day or week labor will begin, how long it will last, exactly how it will feel, how we will react, or the health and sizes of our babies. What we can do, however, is educate ourselves about the vast array of possibilities and learn which are more likely to occur. We can decide what is ideal and what we will strive for, what are the means to creating the most conducive environment for such a birth, and which people can best help us to attain those birth arrangements. Finally, we can prepare our own bodies and hearts for the process.”
Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth
by Amy Scott
#4 DO include your fears, concerns, and helpful things for the nurse to know.
If appropriate, a birth plan can also include a few sentences regarding things you just want the nurse to know about and are important enough to make sure that every shift is aware of. For example, I once had a patient who wrote the following in her birth plan:
“My husband is a type I diabetic and at times suffers from episodes of hypoglycemia where he does not have any warning signs or symptoms. So if my husband starts to act inappropriate or seems ‘out of it’ or ‘drunk’ please offer him some juice!! I am afraid that if I am in the throws of labor that I will not notice and this is something that I am very concerned about!”
Although this information wasn’t necessarily birth related, as a nurse taking care of this family I found this information EXTREMELY helpful to have in the birth plan!! By putting it in her birth plan, this mother felt more at ease knowing that she did not have to waste any time worrying about forgetting to tell each new nurse that took care of her. Having this in her birth plan also served as a reminder for me to pass along this important information when I was giving report to the next shift.
#5 DO review your birth plan with your birth attendant and ask him/her to sign off that he/she read and understands it.
“Add a line at the bottom of your birth plan for your doctor or midwife, and other caregivers, to sign your plan under the statement ‘I have read this plan and understand it.’ When caregivers sign your plan, they are only acknowledging to you—on the record- that they have read and understood it. They do not have to sign and say: ‘I agree.’ No matter what you tell them, they are always responsible for offering you their best judgment and skills as different circumstances arise, and then together you and your caregivers can agree on your care. This benefits you. Your birth plan will help you take responsibility for your decisions and ask to be fully informed.”
Creating Your Birth Plan, page 219
By Marsden Wagner & Stephanie Gunning
#6 DO make your birth plan personal (don’t just copy paste) and DO make sure that you understand and can elaborate on everything in the birth plan if asked.
In my humble opinion (regarding birth plans), there is nothing more frustrating for a nurse (and nothing more detrimental to a nurse’s overall attitude and view of birth plans) than to have a patient just copy and paste a general, “all-purpose” birth plan off the internet, check the boxes that “sound good”, and pass it in to a nurse with her name typed in at the top. Why? Because when a nurse (like myself) sits down to review the birth plan with the mother and her labor companions in order to start a dialogue about how the nursing staff can assist in adhering to the birth plan, it will most certainly become obvious to the nurse that the patient has done little to no research on any of her choices making it almost impossible to help the patient follow her birth plan when the birth attendant comes in and wants to do things differently.
Let me give you a few examples:
Example 1: One time I had a patient who had the following statement on her birth plan: “Regarding an episiotomy, I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage.” Now don’t get me wrong, this statement is great and it is one that I personally believe in and try to promote. So while reviewing the patient’s birth plan with her and her husband I enthusiastically said the following, “Oh, I see here you have been doing perineal massage and Kegel exercises and wish to avoid an episiotomy. That is great! How many weeks have you been doing perineal massage for?” The patient looked blankly at me and said, “What? Oh I don’t even know what that is! My sister just told me that I shouldn’t get an episiotomy so I checked that box.”
Ladies, it is really hard for a nurse to advocate for you if you don’t even understand what you are asking for!
Example 2: Almost all the birth plans I have seen make some statement about pain relief and pain medications. Again, I think that this is a great thing, especially if the mother was inspired to research all of her pain relief options (both pharmacological and non-pharmacological) and make an informed pain relief plan during the writing of her birth plan. One time I had a patient who had the following statement in her birth plan, “Regarding pain management, I have studied and understand the types of pain medications available. I will ask for them if I need them.” Again, I was very enthusiastic when I read this and said to the mother, “I see here that you have done some research on pain management. Wonderful! Have you taken any childbirth preparation classes or read any books?” The mother responded, “What do you mean?” I replied, “Well you know, like any classes or books by Lamaze, Bradley, Birthing From Within, Hypnobabies, etc.” The mother responded, “No.” I then said, “Oh, did you do any research on the internet or talk to anyone?” To which she replied, “No, not really. I mean, it’s my first time so I don’t know what to expect. My best friend just said she hated her epidural so I don’t really want one of those. Unless , of course, I really need it. We’re just going to wing it.”
Ummmm, huh?!?! Now again, don’t get me wrong. I feel that I am very supportive of mothers that are preparing for a natural, or physiological, childbirth and I often write about the risks and benefits of common obstetrical interventions, including pain medication and epidurals. But ladies, your nurse can’t be the only one who is advocating for your natural childbirth. YOU have to be on board too and YOU have to understand your reasons for not wanting pain medication or epidural. Because if you don’t even know why you don’t want an epidural then the next person who walks into that room who feels differently, be it a nurse or your birth attendant, guess what’s going to happen?! You’re probably going to agree to anything said nurse/birth attendant tells you you should get, because you don’t know any alternatives.
I am not trying to say that taking a certain childbirth preparation class or reading certain books is required for a positive and empowering birth experience. But some type of research and preparation on the part of the mother and her labor companions/partner is EXTREMEMLY IMPORTANT!!
Now here’s one more example to give you the full perspective.
Example 3: One time I was taking care of a patient who had the following statement in her birth plan: “My husband and I have been preparing for and planning a natural childbirth. I am very interested in using the Jacuzzi tub for pain relief in labor and have been reading about other drug-free ways to cope with pain. I am not interested in pain medication or an epidural as I had both with my last baby and had a poor experience with both. I respectfully request that they not be offered to me. I have done research and feel that the risks outweigh the benefits.” When I asked her about it we embarked on a really informative discussion about her last delivery, in which she had persistent numbness in her right leg for 2 months after the epidural as well as a debilitating spinal headache that took required two blood patches and made it difficult for her to nurse or care for her baby during her hospital stay. She also told me that she did not like the way the IV narcotics made her feel, as she was “seeing things” and generally “very out of it.” After our conversation I felt confident in advocating for her with her doctor (who often insisted his patients get epidurals) because I knew that if I said anything to the doctor that she would, in a sense, back me up and likewise I would back her up!!
It is so hard when a patient has something in her birth plan like “I don’t want an epidural”, and hence I argue with the doctor about how the patient does not want an epidural, but then when he goes into the room to ask the patient himself, the patient says “Oh well, whatever you think is best doctor!” It really just makes the nurse look like she is trying to “push her own agenda” when in reality the nurse was just trying to follow the patient’s birth plan!!
One more thing…I don’t want anyone to feel like I am implying that a woman has to “prove” anything to me when I ask questions about her birth plan. That is NOT the case. I just know from personal experience how important it is for a woman to understand and agree with everything she herself puts in her birth plan! Remember, mothers, labor companions, and nurses work best when they are all on the same page and work as a team to facilitate a positive and empowering birth experience!!
#7 DO look at examples of great birth plans online to get some ideas.
The following is a list of some good places to start. Remember, while these websites provide a wealth of ideas, they should not be simply copied and pasted! The best and most effective birth plans are personal, NOT just a list of things with check marks next to them!!
b) Sample Birth Plans from BirthingNaturally.net
d) American Pregnancy Association
#8 DO run through scenarios in your mind about how labor could unfold and actually talk these scenarios out with your labor companions and doula (or perhaps even your childbirth educator or birth attendant too!)
Think about all the different ways labor could unfold and how you might react if labor was faster or slower than expected; harder or easier than expected. What would you need for comfort, support and information in each of these variations? Thinking about “worst case scenario” doesn’t mean it’s going to happen. But if it does, or if any variation does, it will make you more at ease to know that your team has already talked about it and knows your wishes.
“If you knew that something would go wrong or would pose a difficult challenge during a portion of the labor and birth, what would your ideal strategy and scenario for handling that problem be? How would you want your midwife or doctor to speak with you? How would you like your spouse or another support system to help? What alternatives would you like to try, and in what order? Again, in your mind’s eye permit yourself to have the best. What would help you relax and be able to continue labor under difficult conditions?”
Creating Your Birth Plan, page 219
By Marsden Wagner & Stephanie Gunning
#9 DO try to treat researching and birth plan writing as a fun and exciting experience, not a chore!
Enjoy this time! Don’t be afraid to be creative and fanaticize! There are so many amazing thing that you can discover and learn about while doing research for your upcoming birth. It is never too early to start so don’t put it off till the last minute!
And finally…
#10 DO remember to bring your birth plan to the hospital!!
It won’t do much help to the nursing staff if you forget it at home on your coffee table! I encounter this very often at work and I always feel so badly because I know that there is usually a lot of work put into writing a birth plan. It might be best to make sure that you place a copy of your birth plan in the bag you have packed to take with you to the hospital. I have even had a few mothers put an extra copy in their car’s glove box so that they wouldn’t forget it!
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SAMPLE BIRTH PLAN
This birth plan was sent to me by a reader of NursingBirth who goes by the name “ContortingMom”. Contortingmom’s guess date is 7/17/09 and she is still “cooking” with her first baby 
I really like her birth plan for a variety of reasons. #1 She was inspired to add some stuff to her birth plan after reading a couple posts of mine (which I think is pretty cool and #2 I think it is a perfect example of a personalized birth plan!! No check boxes here! Thanks again to ContortingMom for allowing me to post her birth preferences for other moms to read and learn from!!
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Birth Preferences:
I understand that labor and birth are unpredictable and ultimately want the health and safety of both the baby and I to take precedence. In all non-emergency situations, all proposed procedures are to be discussed (benefits and risks) so I can direct the decision making with informed consent.
Your help with these preferences is very much appreciated.
Labor:
• I intend to have as natural a labor as possible – including freedom of movement, intermittent monitoring, a saline lock instead of an on-going IV, and clear liquids as tolerated.
• Due to my GBS+ status, I request only very limited vaginal exams and do not want an amniotomy.
• Please accept my request that pain medication not be offered to me. For many reasons – personal and medical, I’m striving for an unmedicated labor and delivery. If I eventually want drugs or an epidural, I’ll be the first to ask for it and understand that options change as labor progresses.
• If augmentation is necessary, I would like to try non-pharmacological methods before resorting to meds. However, if my OB and I agree that pitocin is required, I request that the it be administered following the low dose protocol and increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.
Birth:
• Please do not direct my pushing with counting or yelling. I will ask for help if needed.
• I strongly prefer a tear to an episiotomy and do not want a local anesthetic administered to the perineum.
• I plan to be as active during pushing & delivery as possible, including choosing productive positions. They will be probably anything except supine, lithotomy or “sitting squats” that put pressure on my tailbone. It’s been broken several times & currently inflamed. I also have restrictive pain from spinal injury & surgery, so please allow a position suited to my medical needs. I’ll make sure the OB has comfortable access.
• I would like to have the baby brought to my chest immediately for skin-to-skin contact & initial procedures – and to try nursing to see if it works to contract my uterus, delaying pitocin until we know.
If Cesarean Is Required:
• Please use double-layer sutures when repairing my uterus. If I have a second child, I hope to attempt a VBAC and understand this is a requirement for many doctors.
• As health permits, I would like to skin-to-skin contact with the baby, to stay together during repair and recovery, and to breastfeed during the initial recovery period.
• If my husband has to leave the operating room with the baby, I would like my doula to take his place.
Baby Care:
• We would like to spend as much time as possible with our baby after birth before being taken off for procedures and will be breastfeeding, so please refrain from giving bottles/pacifiers.
We Appreciate Your Support. Thank You!
Pitocin Protocol for Labor Induction/Augmentation Decoded July 9, 2009
Tags: cesaren section, hospital birth, hyperstimulation, L&D, labor and delivery, OBGYN, pitocin, pitocin to distress
Dear NursingBirth,
Just curious, since I’m not a nurse but AM looking into a future of nursing or midwifery… on the Pit pump, is the max number that is shown 20? Or is it 60? The reason I ask is because I had an unnecessary induction via my own decision (not that I truly wanted to, my husband was going to be out of town and first baby.. I was scared to possibly not have him around). I was labored with pit for 12hours with 11of those hours having a broken amniotic sac. My doc said I would have my baby between 5-6pm and I believe they went above the max to make that happen (she was born at 5:47 pm). Months after I had my daughter (which was quite painful not having an epidural) I found pictures of me laboring in my husband’s phone. And the machine said 69… I was wondering if that is still a norm or what. I refuse to have pit administered ever again casually if there is not a dire need… Hell I might not ever deliver at the hospital ever again unless truly needed!
Sincerely,
Amanda
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Amanda,
This is a GREAT question. Okay here it goes…
The way it works at the big city hospital that I used to work for (and many others for that matter) is that the bag of pitocin that is used is premixed by the drug company in the concentration of 20 Units of Pitocin per 1 Liter of Lactated Ringers or Normal Saline. (Some do 10 Units of Pitocin per 1 Liter of fluid but I have never worked with this concentration so I’ll stick to what I have the most experience with). This is in large part so that nurses do not have to mix their own, hence making less chance for medication errors.
Most “low dose” pitocin protocols (as was the policy of the big city hospital I used to work for) is that pitocin is started at 2 milliunits per minute (mu/min) and increased by 1-2mu/min every 15-30 min to a maximum of 20mu/min. The goal: To obtain an effective and adequate contraction pattern of 3-5 contractions in 10 minutes (and no more) that cause cervical change. However, IV pumps infuse in milliliters per hour NOT milliunits per minute and therefore there are conversion charts that nurses follow. In this concentration, 2mu/min converts to 6 milliliters per hour (mL/hr) and therefore if you do the math 20mu/min converts to 60mL/hr. So no, you are not going crazy! The pump most likely did read 60!
[Addendum 3/30/2010: In order to get a 1:1 ratio of milliunits/min to milliliters/hour the concentration of pitocin must be 30 units of Pitocin in 500mL of LR (or D5LR). Hence when you do the math, 2 milliunits/min equals 2mL/hr and so on and so forth. At a community hospital I worked at in the beginning of 2010 (which I not so affectionately refer to as "Bait & Switch Community Hospital"), the pitocin was hung in this particular concentration and the orders typically read: "Start pitocin at 2 milliunits per minute (mu/min) and increased by 2mu/min every 15-20 min to a maximum of 34mu/min." This was by far the scariest order for pitocin I was ever faced with and is one of the reasons that I am leaving this hospital!]
Okay, so if a doctor wants to go above “max pit” which, according to the “low dose pitocin protocol” that a big city hospital I used to work for follows, is anything above 20mu/min (60mL/hr), then they have to write out an entirely separate order. At that hospital the “absolute max pit” is 30mu/min (90mL/hr). Now, the higher the dose and the longer the infusion runs for the greater the risk for side effects and adverse reactions.
These potential adverse reactions include (source: RxList Drug Guide)
1) Potential adverse reactions in the mother:
2) Potential adverse reactions in the fetus or neonate related to hyperstimulation of uterus:
3) Potential adverse reactions in the fetus related to use of oxytocin in the mother:
Remember the most serious of these adverse reactions occurs when pitocin is run at concentrations higher than 20mu/min for hours or even days of induction. But unfortunately this abuse of pitocin does happen.
There is also something called a “high dose” pitocin protocol. The way the big city hospital that I used to work for described it (right after it said that we were NOT allowed to order/follow it at our hospital) is the following: Pitocin is started at 6 mu/min (18 mL/hr) and is increased by 1 to 6 mu/min (3 to 18 mL/hr) every 20 minutes until a maximum of 42 mu/min (126 mL/hr). Now, I am sure that there a subtle variations on this, for example, some birth attendants/hospitals that follow this protocol will only do “high dose pit” on nulliparous women (first time moms). However, again, the higher the dose and the longer it is infusing for, the greater chance of complications and adverse reactions.
Now the other option could have been that the hospital that you went to uses bags of pitocin with a concentration of 10 units per liter instead of 20 units per liter. If this is the case then everything would be doubled. With a 10 unit/liter concentration, 2mu/min would actually be 12 mL/hr. So that could be the case as well, although that is more unlikely.
Now again, other nurses might report slight variations in this but I am confident that many hospital’s pitocin policy looks a lot like the ones I’ve worked at both in nursing school and as a nurse.
Last but not least please check out a great post from Jenn, a doula who blogs at Knitted in the Womb Notes. She wrote a post a while back entitled My Rant On Pitocin and she actually copied the package insert from the pitocin bag that the nurse hung. What saddens me most about that story is that at one point her client was considering just “going ahead” with a cesarean because the higher they put the pitocin the more the baby deceled. However LABOR was not causing the baby distress…the ABUSE of PITOCIN was causing the baby distress! That’s why when I hear things like “The pitocin was causing my baby’s heart rate to decel so they did an emergency c/s and Thank GOD because that OB saved my baby” I want to vomit. Okay so if I STAB you and then bandage your wound so you don’t bleed to death….did I save your life???
Thanks again for your great question Amanda!
All My Best,
NursingBirth