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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA


Birth Plans

Easy Steps to a Safer Pregnancy - View e-book or Download PDF - FREE!
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.

Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.

See also:

Subsections on this page:

About Birth Plans

The Ethical Ob/Gyn: Don’t Dread the Birth Plan by Paul Burcher, MD, PhD [9/19/13] - This is a really helpful and thoughtful article. 

Birth plans record aspiration—aspirations that must be respected, addressed, discussed, and reviewed. However, patients must also understand that labor is a time of improvisation, and neither patient nor obstetrician or midwife can foresee the course of labor until it is over.

Expecting the unexpected - When your labor journey takes a surprising turn, learn to navigate a brand-new path by Melissa Pheterson

Routine Interventions versus Medical Solutions 
By Patricia Madden, CD(DONA)
San Jose, California

I first heard the phrase many years ago. I am pretty sure it came from Pam England of "Birthing From Within" fame. In my 14 years of experience, this is the kind of phrase that relaxes couples and doctors alike.

Most of my clients are very dedicated to having a natural birth, but as we talk, they come to understand that what they really want is to avoid routine interventions that can snowball into surgery. That simple sentence in a birth plan lets the hospital staff know that she is not against technology at any cost, but does not want the normal routine things most laboring moms get when they DON'T state a preference. The couple also does not feel as though they failed when it is them saying, "You know, I have been laboring on and off for 3 days and now in active labor for 12 hours with almost zero sleep and I am still at 4 cm. Maybe the next best thing might be an epidural."(also from Pam England)

Stating a preference:
That brings me to another thought I got from the new book by Cynthia Gabriel*, "Natural Hospital Birth." "Getting attached to your birth plan." I have learned over the years that you must say what you want or the staff will think what they routinely do will be fine. In every job people have routines. Routines makes life easier for us. The more your client talks about what she wants and doesn't want, the more staff will help her achieve her goal, because they know she is serious. At every prenatal your client should talk about her preferences...over and over, and the fact, that it is not medical solutions that solve a unforeseen problem that she wants to avoid but the routine interventions that could eventually cause the problem she wants to avoid.

What’s a Birth Plan and Why Do You Need One from pregnancycorner.com

Interactive Birthplan

Make Your Birth Plan Online!

Birth Plans

Sample Birth Plan

Many mothers include in their birth plan a request to minimize vaginal exams throughout their birth. Please advise your client to write this full sentence: "I would like the medical staff to conduct vaginal exams only when necessary and only with my full consent."

NewBorn Birthing Plan and Birth Exemptions - Birth Exemptions:

For those who are planning a hospital birth but want to evade invasive routine post natal procedures such as a Hep B shot, vitamin K injection, newborn screening, or the application of silver nitrate in the newborn's eyes, a very specific birthing plan must be submitted to the hospital in advance of the birth. Hospital staff must be informed, in advance, of your needs, wants and desires where your baby and birthing experience are concerned. The same applies to midwives. [Ed: Silver nitrate hasn't been used for many years now.]

As a birth doula I work with women who are often afraid to go for the birth of their dreams because they think they will be sad and disappointed if it does not happen that way. That is not what I think nor is it what the research has shown.  For example, women who choose to deliver without pain medications are far more likely to have that happen than women who say they think avoiding pain meds is a good goal but they will take things as they come.

What I tell my clients is that in order to have a pain med free birth, three things need to be in place:

  1. The mother must have a strong desire to deliver without pain meds
  2. The mother must surround herself with those who agree with her plan and are able to offer emotional and physical support instead of narcotics and epidurals. (Birth doulas are research documented to decrease use of pain meds and decrease other interventions as well.)
  3. The mother should be having a relatively normal labor.  If labor is very long -- more than a day of hard labor -- and/or if the labor is unusually painful because of something like fetal malposition, then all bets are off for avoiding pain meds. It may be time for plan B.
Maternal feelings of disappointment can be minimized or avoided by the mother if she is an active participant in her care. We always feel better about outcomes if we know we have done the best we can and made our own choices. This goes for all areas of our lives.  I, for example, am willing to live with the less successful design choices which I personally made when my house was remodeled. But, I am still annoyed about the undesirable decisions others bullied me into allowing.  This goes double for how I feel about my births.

I am also reminded of what Oprah often says. "When you know better you do better."  I think that is almost always true. And, if you are personally unhappy with the choices you made around your birth, keep those feelings out of the way of making the best choices you can in the present and future of parenting your precious child.

The way I see it, a birth plan gives everyone a good way to discuss things without being thought of as inflexible, and obtuse.

Also, a really fancy birth plan (hot off the computer with several fonts), with lots of detail and what not tells me more about this mother than the actual words in the plan. I can look at it and say.... 'control'. OK, so now that I know that it is in the back of my head, so when labor arrests, I can very gently begin to discuss 'control' with her. That discussion is going to be very useful in labor, more useful than pitocin.

In other words, a professional can use a birth plan to see what kind of woman they are working with - and then WORK WITH HER. Rather than see a control freak scared to death of letting go..... cos she will indeed have that c/sec (or techno-birth) if she is not worked with, i.e. talked to and held hands with and supported.

I think the process of thinking about what you hope for in labor and birth is real important. I think that taking some control and responsibility for yourself is also important. To feel like you can control everything sets the woman up for big disappointment and hurt.

I just have to throw in my two bits about birth planning. I always have a LONG 36-week visit with clients and their birth support team to talk about birth plans. My questions to them are general rather than specific. Examples are:

The final questions are: As we have this lengthy discussion, I emphasize over and over that we can't PLAN a birth per se, but it does help for me to know what that woman wants in the best of all worlds, if things went just perfectly (which seldom happens). I make sure they understand that the process of labor and birth happens of its own accord and we have to follow the path it takes us on, not vice versa. Finding out what the woman wants to have happen is helpful for me because I can try to make those things happen if the course of labor allows it, but I want her to know that best laid plans often don't work. And I tell lots of stories, like the one about the client who said "I just don't want to deliver naked on my hands and knees - it's SO undignified" and, of course, did just that in the end because it was the only comfortable position she could find. Or the women who insist prenatally that they want a waterbirth, but then change their minds in labor (or vice versa on that one, too).

In the end, there is so much wrapped up in the trusting relationship with the practitioner. I can understand how written birth plans are really important when you don't know the practitioner or nurses who will be there with you during your labor and birth. But in my homebirth practice, having things written down becomes pretty unimportant - we talk it out beforehand and the client knows that I'm going to do what I can to help her plan come to fruition, that I'm the one who will be there. That's a big reason why I really love this practice!

As a midwife, I try to address the husband's fears prior to the birth. I have them write down on a piece of paper the worst case scenario he can think of. I also ask him to address all the negative things he has heard about birth from his friends and his family. I encourage him to come to visits. We play out his fears at the end of the visit. I tell him he is not alone in feeling the way he does and put him in touch with other birthing dads who had those very same fears prior to their wives' home births. We also discuss what role they would like to play at the birth -- and then I educate him on playing that role.

I do this because I don't like surprises at births, especially in dealing with negativity and fears of "birth support people". I want to be focused on my birthing mom and her situation. She and her baby are my only concerns. So, the extra time I spend prenatally answering questions, providing information, will usually pay off in the end.

Greatest thing I was ever told about birth plans was:
  1.. Put a small introduction and in that intro put that the plan has been developed in the event of a "normal" labor. and thank them right away for *respecting your choices*.
  2.. don't demand the obvious i.e. saying you don't want a shave prep when the hospital hasn't done it for years...and other stuff like that.
  3.. keep it simple with your basic requests (food, fluids, activity...)
  4.. make *I will* statements and not *I want* (eg. I will eat and drink as desired and not I want to be allowed...)
  5.. Have a contingency plan of what you want should the labor deviate from the norm (again keep it short)
  6.. keep the plan to one page.
oh and don't make the font like -10 so the print is so small it is tedious to read, you do want them to read it.

Birth Plan vs. Birth Essay

We decided to move away from "birth plans" and use "letter of introduction" instead - letting the nurses know who you are what your beliefs are and what you would like for your birth experience. I think it sounds better than "the plan".

I like "Letter of Introduction."  My sample I give clients or students is called "Birth Preferences" for the same reason.

It also encourages wording like, "If there is no reason for concern about the baby or myself, I may prefer to: use the shower/bath, walk,...etc" to show the nurse that the parents understand that their preferences may or may not change in labor, and that of course they understand that needs may vary depending on health indications.

There most certainly is. I am just as leery in homebirth practice of those who come with a very rigid plan. I have an occasional client who scripts their birth down to every detail and they are of course the very ones who end up with the long drawn out, painful labors. They are also more likely to have big issues and disappointments prenatally.

There are also those who come from a previous bad experience..especially VBACs who are very rigid. Sometimes they will refuse things that make me very uncomfortable. I had a lady last summer who refused me to monitor the baby in labor because it reminded her of her C/S. This puts me in the very awkward position of not being able to do the things that make homebirth a safe option or having to put up a big fight and play the bad guy to do so. Not a fun place to be.

You raise some key issues here. I have become very wary of detailed birth plans. We have a general preferences checklist to try to simplify things. Throughout the pregnancy I work to help clients begin to relax and trust the right brain more. I suggest that they more they try to control things, the more complicated things get, and that they needed to strive to become well informed about everything, and then develop some sort of philosophy about their labor. In reality, when labor happens they need to give in and let the labor unfold. They cannot control it, except to work with the birth force. I also suggest they write a "birth essay" about what the birth will mean to them and their baby, This can be very revealing. I don't put many parameters on it, for the "Birth Essay" should just be the ideas they are thinking about. It is different than the birth plan, or preference checklist. I'm really fascinated by the psychology of birth. Has anyone found any good books on this topic? How do you approach it with your clients?

I am surprised at you! Not support those detailed birth plans? I am joking of course. Sorry you guys can't see my face or hear my voice. I even had a couple, who were in law school, come in with a BIRTH PLAN that looked like, was written like, a legal contract, and wanted me to sign it. It took all my control not to fall on the floor laughing. I like the idea of a birth essay, of parents writing what the birth experience means to them, which is usually totally different before than after. I explain to my clients, when they are about half way through their childbirth preparation classes, that they will be hearing a lot about birth plans. I explain that if they have found a good class, and I do try to point them in that direction, they will have heard all about many different interventions, options, experiences, etc. I explain that I would like them to take some time, and use the written form to help them clarify their thinking about what is important to them, and WHY. I tell them that their decisions should be based on their own thinking, not that of a third person, not even me, and on their own good research, not inflammatory popular press. I will give them copies of articles about each point, if they wish, but I do not push it. Then I tell them that when they have finished it, to schedule a birth plan appointment, which will give us twice the usual time, and we will go over the wish list, point by point. I find that couples really come to understand that they can't script a birth, that if we could script Mother Nature, we would not have tornadoes, or earthquakes, or floods either. Neither they nor I can guarantee a perfect birth. Sure wish I could. We will just do the best we can together to work towards fulfilling their wishes, keeping the healthy baby/healthy mom first in our minds. Seems to work well.

At the ACNM convention, one workshop described the use of a Birth Essay to get in touch with what was really important to the mom/family as compared to a birth plan, in whatever format. I plan to incorporate this into my practice, and hearing their expectations in this form provides the opportunity for me to talk with the moms about giving in and letting go to labor. Anyone ever tired anything like this?

I hope you went to my presentation at the ACNM Convention in Boston, Building Skills for the Effective Emotional Care of Childbearing Women.

I met you at one of the educational sessions and I said that I recognized your name from this list.

My work as a midwife incorporates an enormous psychological slant. As I said at my presentation, I have been using the birth essay for the past 12 years, as one of the many tools of discovery for both the woman, her partner, and myself and ultimately my colleagues.

As a tool of self discovery, the birth essay can be, for the woman, a wonderful way to get in touch with her unconscious feelings and desires about her birth.

The real work and discovery really comes in what you do with the information. If you, as the midwife, read it and say, thank you for writing this essay, then not much has been accomplished other than the sharing of information and the personal discovery the woman may have had in doing the writing exercise. However, if the essay becomes the focus of the next prenatal visit or two or three and processing happens, then the essay has provided everyone with an opportunity to become something really powerful.

As far as people who refuse procedures such as the woman who didn't want to be monitored because it reminded her of her C/S. Several things may have been happening. First, she may still have had work to do in processing her first birth. Second she may have had resistance to someone in authority such as yourself because of who you may represent to her, i.e. if she had an issue with her mother. Third, this woman may have had some magical thinking going on that if she refused the intervention that some how that would prevent anything bad from happening. Fourth, she may have been trying to exert her control which may mean that she was feeling scared or terrified on a deep level that might have been beyond her conscious awareness. Of course, she may have none of the above and had just decided to refuse the monitoring for what ever her reason that made sense to her at the time.

Where I see my responsibility is avoiding a situation where a polarization takes effect, where she gets what she wants and you don't or vice versa. Rather I try to explore what may really be going on. I find one of the best ways is asking questions.

So often when someone refuses something that we think they really need we rush to try to explain and clarify and urge why this is necessary. I ask the woman to explain her reasons to me. How did you come to the decision that she did? Depending on how she answers, you may find she needs some more information or you may sense an irrational element to her explanation which I feel is almost exclusively a sign that there is an emotional issue attached to this decision.

In attempting to unearth what that may be, ask clarifying questions and then keep going and going with it. For example if you asked her, Why don't you want to be monitored, her answer may be, it reminds me about my C/S, you may say what about your C/S, she may say, feeling like things were being done to me, you may say, how did that make you feel, she may say like I was out of control, you may say when you are out of control what does that mean to you etc. etc. etc. Hopefully when you get to the bottom line there will be a realization and a detachment of the emotional issue from what it is that you are trying to accomplish and the woman can then be free to make a sound informed decision for herself.

Birth Essays and Related Emotional Work

I am a staunch believer and have used a birth essay with clients for twelve years. I never request a birth plan always an essay and have gotten back an array of glorious writings, and interestingly enough, some of which resemble what you and I would refer to as a birth plan.

What I have found most interesting in doing this work, is that my explanation about writing the essay to the woman and her partner, has remained over time pretty much the same, maybe with some variations to individualize the request but it is overall the same. What I get back is always different and unique. I have learned to work with these differences as a jump off point for our discussions. I also have learned in how to screen for red flags and look for the metaphors in the writings or the meaning behind the meaning.

At the ACNM Convention in Boston I co-presented with a psychologist that I collaborate with and refer clients to, by the name of Debbie Issokson. Our presentation was, Building Skills for the Emotional Care of Childbearing Women. The following is an excerpt from part of this presentation and is about my work with the birth essay.

In 1985, I began working as a midwife at an out of hospital Birth Center. It was there that I discovered the use of a wonderful tool in caring for the emotional needs of my clients. It was the use of a birth essay.

The birth center midwives would ask clients to write their expectations for their birth down on paper in an essay form. Seems simple. So I thought. I knew all about birth plans, but what I discovered was that this was very different.

I didn't appreciate the powerful insight that this tool could provide. Until meeting a client....she was a 23yo Primigravida who when reviewing her birth essay with me, had chosen to focus on writing about such things as,

If there has to be a choice between my baby's life and mine I want the baby to be saved.

If I am dying or the baby is dying, then I want a priest called to administer the last rights.

And so on, and so on. It went on in this vein. When I questioned her about this, she said that it brought her great comfort to make her wishes understood. I didn't pursue going any further and accepted her explanation.

Well, I happened to be the midwife on call when this woman came in, in labor.

Early on, I had to call in my birth assistant to help me because I could not labor support and manage her by myself.

She appeared to be terrified, she was thrashing about with her contractions, and hyperventilating. Because nothing I was doing seemed to be working, I finally took her husband aside and said to him that her behavior was unusual for this stage of labor and asked him if there was anything that he knew that could shed some light on what was going on for her emotionally.

He said to me,

You have to promise not to tell her that I told you.

As soon as he said that, he validated what I was suspecting and somehow I knew what he was going to say before he spoke.

He went on to say that she had had an abortion the year before and since that time was racked with guilt and shame, to the point where she was meeting with a priest weekly throughout the whole pregnancy.

She was convinced that something terrible was going to happen and either she would die, the baby would die, or the baby would be born with terrible anomalies as a punishment to her.

She was fighting her labor because she was terrified of delivering her baby. The safest place for her baby to be was to keep it inside and not let it out.

Just having this knowledge allowed me then to take better care of her and I am happy to say that by doing and saying things to quiet her fears, she was able to pull it together for herself and proceed to go on to have what I judged to be a non traumatic birth.

What this birth taught me was that the clues were right there before me. I didn't recognize them, and how wonderful it would have been, to have identified this woman's issue before labor, so that appropriate intervention and processing could have be done.

I have continued and still to this day use the birth essay as a tool to unearth issues and as a way to more intimately get to know my clients better.

The birth essay has, by far, proven to be the single most useful tool that I have in rendering emotional care to pregnant women.

I have found that the essay provides a window for me, as the care provider, in which I can take a look inside. It allows me the opportunity to screen for potential problems, to individualize my care and to maximize a closer and trusting relationship.

Briefly, to explain, a birth essay allows the pregnant woman to express herself in written form about her expectations of her upcoming birth.

During a prenatal visit, I present the idea to her by saying,

I ask all of my clients to do this. I have found it to be a wonderful tool in helping you to prepare for your birth. I would like you to take time out to write an essay about what your expectations are for this birth.

Now for all of you midwives, it is important to not tell her what to write. Leave it open ended, and up to her to choose what to write about. Ideally, you want her to write with a free flow of consciousness. This will allow the unconscious thoughts she is having to be expressed. It is important not to share the psycho-dynamics of the process with her.

Continuing on, I will elaborate and suggest to her to close her eyes. Think about going into labor, think about birthing your baby and think about immediately following the birth. Let the feelings well up, then put pen to paper and start writing what ever comes to your mind. Don't worry about spelling or grammar. There is no grade. There is no pass/fail.

I do go on to explain the difference between a birth plan and a birth essay, as this can be a source of confusion.

A birth plan gets into the do's and don'ts for what you want and don't want during your labor and birth a birth essay describes how you are feeling about the process.

I add that certainly she can incorporate into the essay any special requests that will help her through her labor, that she would like us to be aware of, but I tell her that I am mostly interested in how she is feeling about her upcoming birth; where she is emotionally before labor begins. I'll list some feelings for her i.e., are you feeling happy, scared, terrified, joyful, peaceful, worried etc.

Sometimes, I give an example of what someone else has written, if the woman is having a hard time grasping what it is I am asking for.

I'll also explain how the essay is helpful to me and my colleagues. I might say, "The essay provides us with a way to see if there is anything we need to focus on before you go into labor and it helps us to individualize our care for you."

I believe that, for the woman, the essay provides her with a way to bring into focus how she is feeling emotionally.

I will also ask that the woman and her partner to both write an essay. In explaining this, I ask that they do it separately from one another and not to discuss it ahead of time. I instruct them that after finishing their essays, then they can exchange and read them.

This can be an absolutely wonderful exercise for the couple and I tell them this.

I might say,

Doing this exercise can help you both see, if you are in sync with one another, or if you have different views that perhaps neither of you were aware of.

The essay sometimes offers me a glimpse into the strength of their interpersonal relationship. Sometimes couple issues may come up in this fashion.

I explain that there is no pressure to do the essay. It is meant to be helpful not a burden.

Most women and their partners that I request write an essay, do complete one. I think it is because I emphasize how helpful it is to them and to their midwives.

If the woman and her partner doesn't write an essay, sometimes, that can also be very telling and insightful, as to what may be going on for them emotionally.

I request the essay be done by 36 weeks. I don't like to introduce the idea too early in the pregnancy because many women are not in touch with how they are feeling about their birth until it is much closer.

If I have someone that I feel is particularly anxious early on, then I may ask her to do two. One now to speak to her present feelings and one later to speak to birth.

The next visit plan on plenty of time to discuss what she has written. This is a natural time for her to bring her partner, especially if both have written an essay.

Sometimes I have her read what she has written, but as I am usually pressed for time, I have her give a synopsis of what she has written highlighting the salient points. I do the same with her partner, if present.

I also like to have time to read the essay again, at my leisure, paying close attention to how it makes me feel. I may schedule another visit or two to finish our discussion about the essay after I have made this review.

I always look for red flags by what has been written or what has been emoted in me while reading the essay, i.e.

Taking out of the essay, I will address any issues and focus my discussion on clarifying information, pointing out the strengths that the woman is exhibiting and forming a plan with her.

I may also make some suggestions, if needed, that she may benefit from, for example, the use of:

In particular, for the partners, if they haven't already commented on this themselves, I will take the opportunity to bring up at this time how some partners have a difficult time watching someone they love in pain.

Watching their loved one may bring up feelings of helplessness, impotence, and frustration.

I will explain that, I on the other hand, as the midwife, when I look at a woman in pain who is having a baby, I see that she is coping with something that is part of the physiological process of birth and that I don't see her as someone that I need to rescue from that pain.

My challenge, is to find different ways to help her through her labor and birth.

I add, you may need to rethink how you approach supporting and helping her and if you don't know you can always look to the midwife as a role model and model yourself after her.

I always thank the woman and her partner for taking the time to write. I love the individuality and creativity that each person expresses through their essay.

I ask her permission to have a copy of the essay with her records in labor and delivery so it may be available to review for whichever midwife is on when she comes in.

By always presenting the request for the essay in the same way to each woman, the essay remains a constant; you will be truly amazed with the array of differences in what you get back. In time, after working with this tool, you will be able to look back and make your own comparisons and come to your own understandings.

In the course of my work, I have been continuously reminded that women are indeed complex, having evolved from a variety of past childhood and adult experiences and they usually present with diverse emotional needs.

In trying to tend to these emotional needs, I know and understand now that giving advice is just not enough.

The birth essay has provided me with a way in which my client and I could work together to meet her emotional needs.

Bradley Birth Plans

The other issue is that while they may be nice and knowledgeable folks, the Bradley teachers are not the ones sitting at the bedside , managing the labor AND taking the same kind of responsibility that you and the parents are taking. Again, to be seen as the enemy is a hurtful thing when I see myself as trying very hard to NOT be interventive, but still have a safe birth.

Feedback on the "birth plan page":

I just wanted to comment on the birth plan page as a patient.  I was linked to this page by Google.com while researching Bradley Births and I was discouraged to read such negativity about birth plans, Bradley instructors and moms by some of the midwives.

Two midwives told birth plan stories dealing with mentally disturbed patients (the c-section and the woman who had issues with a previous abortion and her Catholic upbringing). Then many midwives talked about the "control freak" patients that bring in birth plans.  As a patient I can say that neither I nor any of the women in my class are mentally disturbed or "control freaks".  However, every pregnancy book, pregnancy class and pregnancy board on the internet encourages moms to make these.  In fact, the women who bring in the plans that have "fancy fonts" are not super freaks, but probably ran across the same site I did on babycenter.com which has an automatic birth plan maker that prints out - in fancy fonts - a plan in 30 seconds; much quicker and easier than typing your own!

Furthermore, on a more positive note, my Bradley instructor has a wonderful relationship with my midwife and they have only complimentary things to say about one another.  I do not see my midwife as "the enemy", nor does she see me as an aberration of normalcy.  In fact, my midwife told me that she was glad that I'd be taking Bradley classes, because in her practice, Bradley moms generally make the best patients.

And in fairness, there was one overwhelmingly positive post by a midwife who wrote about using birth "essays" and about how they contribute to how much she loves her job.  That's the kind of mid-wife we (Bradley moms) are all looking for!  I'm glad that my midwife isn't as jaded as some of those that posted on the board!


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