Birth planning second time around

I think I can remember my birth plan for my first pregnancy, it was focused on having a water birth in a midwife-led unit, using TENS, gas and air and breathing/relaxation techniques. I was midwife led care throughout pregnancy and hadn't really put any thought into what being induced or having a caesarean would mean, as I didn't think it would affect me. I had put alot of thought into my plan and reasons for choosing them, but in the end the preparation was lost as I was induced at the local hospital, and couldn't have a water birth, and I needed stronger pain relief than I realised... an epidural (something I'd never imagined). This time, I'm hoping for something closer to my original plan, but with birth plans for alternate scenarios just in case. Somewhere between realism and optimism.

Hindsight

No matter how much reading I did the first time, having now experienced one labour and talked to many other Mums about theirs (their first and subsequent labours) and seeing how their children turned out, I am in a much better position to hopefully write a birth plan that'll work than I was the first time. Not that there's anything wrong with being a naive first-timer, you can't become experienced through reading alone (I am still talking about giving birth here and yes, there are other parallels!). Mostly, the Mums and their children, born naturally, induced or by caesarean (local and general anaesthetic) are all blooming. Wanting to breastfeed, I am reassurred to see from the examples I know, that neither birth method seems to necessarily affect breastfeeding. Weight gain and health seems to have all been normal too. So even though I'd like to have a home birth and avoid the hospital route again, I am also less uncomfortable about the form of delivery that eventually happens, as I expect that the baby I get afterwards and my ability to take care of that child afterwards are unlikely to be any different.

Being at home

The plan for a homebirth is really my best case plan - the best birth I would like my child, myself and husband to experience. Being at home, in familiar surroundings, rather than on a hospital ward or room seems safest to me. I don't have to worry about my husband being away because he has to go and find a vending machine or make a phonecall. I don't have to worry about being left alone without a midwife for long periods of time. The midwife will be there, my husband will be there. We have all the clothes, towels, food, drink, cushions, birthing ball and other comforts we could need as we don't have to worry about forgetting to put them in the hospital bag. I can take a shower or bath in the early stages, go for a walk around the garden even.. whatever springs to mind that may be right at that time. I won't have to worry about putting anyone out by asking for some more squash to drink, or waddling about hospital corridors in a dodgy nightie and dressing gown that's too short for me! It'll also be quiet - no distant screams from a loud labouring woman in the room next to me, or bleeps of somebody else's baby monitor, somebody else's baby's heartbeat...

The description of a homebirth may seem fluffy but it'll provide me with a relaxed and less stressful environment to experience labour. The thing that had a big affect on me the first time was the feeling of being out of control and the tension and stress I felt presented itself during labour (I tensed up, so did my body and so did the course of my labour - lengthening labour - only the epidural allowed me to relax and from there, delivery was speedy). I know how important feeling safe, comfortable and in control is and being at home feels the right place for me now.

I haven't quite finalised the details yet - I would like to understand the Vitamin K injection and what it means, what alternatives are if I decide to not use it, I also need to check about the rights and consequences for me and the baby of choosing not to be induced. I've been directed to the AIMS (Association for Improvements in Maternity Services) website for information by my former NCT instructor, and have ordered some publications from there to read which should clarify and so mean my birth plan is complete very soon. Incidentally, this website is worth looking at as it provides valuable research dissemination surrounding the area of childbirth and pregnancy.

The AIMS journal article that jumped out at me today was "Challenging the medicalisation of birth", which includes a Cochrane third stage review (Volume 23 (2010-11)). This is something that I would agree is happening, the security of being in a hospital is certainly something most women have chosen, for example, only 2.5 % women have a homebirth in the UK. It was something that I felt as I was writing my birth plan too, a feeling of "surely it should be more complicated than this? I should be requiring more support in order to go through labour?" - the feeling of reassurance and security if more rather than less is being done to assist the delivery of your baby. I felt I needed more bullet points, but once I took a step back, realised that I alone should be able to deliver the baby, as long as all goes well, which as a healthy Mum and with a healthy baby inside me, I should do. Everything else is just fluffing it out. Doctors are there if there are complications, if intervention is necessary, but childbirth is not a disease, so delivering a baby should not require medical intervention. I'm not convinced that the culture of childbirth in the UK has encouraged this stance.

Fail to Prepare, Prepare to Fail

It might also be that parents-to-be are geared up for expecting a more medical scenario by the preparation that they get in pregnancy (What to Expect When You're Expecting* books for example - how to become more neurotic in 300 easy pages...), the expectation of perfection in how you behave when pregnant, what you eat, what you do... being yourself and being sensible isn't enough. You need guidance from an Expert. I know I'm being sarcastic here but I was just as pulled in by the book in my first pregnancy as I imagine most are - reassurred by just how much detail I could go into each week, month, trimester of my pregnancy. I absorbed it all and then re-read and re-read it. I became rather dependent on the information in it, rather than thinking for myself and beyond the problem-answer approach. It left me with an internalised list of all the potential problems and pitfalls of pregnancy and childbirth, instead of a sense of trust in the ability of my body to be pregnant and have a baby by itself.

The question is how to find a balance between the two. To not go into pregnancy blind, but instead with a healthy, informed expectation of what's to come. One that whilst it respects the presence of the medical support available, doesn't also strip Mums of any faith in their own capacity and potential for having children. I'd like to be as relaxed as one of my friends, who described her only preparation for homebirth as "getting a TENS machine and celebrity juice on the TV", she delivered her second baby at home with no medication, didn't even manage the birthing pool! He's a healthy, chilled out little 9 month old now. If Mums experience a medically-biased pregnancy and childbirth that has included more intervention than perhaps necessary, what kind of parent is it setting them up to be? Can you blame them for being nervous and unsure?

Dependent state?

Doing anything for ourselves just isn't enough. It is perhaps tenuous, but parallels can be found in our experiences of the wedding industry, beauty industry, dieting, sports, schooling... we seem to be made to need extras for anything to be good enough. Am I making sense here?

So I'm 32 weeks and counting, we'll see what route my delivery takes in the end and if my opinions have changed!

*What to Expect When You're Expecting has been criticized for promoting paranoia and fear among pregnant women for focusing on complications and for its extremely strict dietary guidelines. Murkoff also has no medical training and has been further criticized for stating she asks obstetricians to comment on manuscripts only late in the writing and editing processes.

More reading:

Homebirth website (though not updated since 2006, so doesn't include the recent Oxford birthplace study)
- Something I found interesting was the page on antenatal preparation for home birth, which actually applies for any birth, in particular the information about optimal foetal positioning. It recommends activities like swimming and yoga to swing the baby around so that it is positioned for ease, rather than difficulty, of delivery.

Caesarean website
- Includes a comprehensive birth plan suggestion list

My birth plan (draft) - in case of interest: 

I wanted my wishes to be followed so tried to write it so that the key points are easy to see, and any unnecessary text avoided, so that less is likely to be missed or forgotten when being read by the midwife/midwives. Hopefully it does this.

My goal is to have a birth at home, although have alternate plans should I need to go to hospital for an induced birth / caesarean delivery. I would like my husband to stay with me for all scenarios.

1. Home Birth

First and second stages

I would like to manage the labour pain in the following ways:

· Remain active and use whatever position I find comfortable. Please encourage me to stay off my back!
· Breathing techniques
· TENS machine
· Move throughout the house and to use the bath or shower
· Birthing pool, should it be suitable during labour
· Entonox
· I would rather avoid having my waters broken

After our baby is delivered, please allow me skin to skin contact and to breastfeed right away.

Third stage

I would like a delayed actively managed third stage, but with cord clamping and cutting delayed until the cord has stopped pulsating. After this, I would appreciate it if you could administer drugs to help me deliver the placenta.

In case of transfer to hospital

· If transfer by ambulance becomes necessary, please do not strap me in on my back - I would prefer to be on my side, to make contractions easier to deal with.
· I would like to have an epidural if further pain relief required.

2. Caesarean Section

I would prefer:

· To remain awake with epidural or spinal block anaesthesia
· If the lights were dimmed at the moment of birth
· To breastfeed the baby as soon after birth as possible
· Skin-to-skin

3. Induction

I would prefer:

· My waters not being broken unless necessary
· Wireless monitoring in order to maintain as active a birth as possible
· Propess instead of prostin gel pessaries
· A morning induction appointment rather than overnight
· The same pain relief applies (TENS, Entonox, epidural) – I would like to make sure that an epidural is available in advance.

I would prefer to avoid induction altogether, unless there are harmful consequences to my child if born any later. I would rather maintain my plan to birth at home beyond my due date.