The Three Biggest Deal-Breakers to the Best Birth Plan
You’ve prepared. You’ve read every book. You’ve watched the Business of Being Born - twice! You’ve taken a childbirth class that states it can guarantee an unmedicated birth if you follow “these ‘x’ rules’. You carefully selected your birth location based on the lowest rates of epidurals or inductions or cesarean births. I’m ready! What can go wrong?
Did any of you giggle with that last question? I did. This was me. I wasn’t prepared for what my birth was going to present to me. I was blindsided by needing medical interventions that I was convinced I was going to decline if they were presented to me. I took a 12-week (yes, 12 freaking weeks) childbirth class to practice relaxation, learn not to fear birth, and empower my husband with all of the tools to support me in labor. But when the time came, I actually needed medicine. I didn’t request it. I needed it. My baby needed it.
I interviewed for my labor & delivery nursing job on my due date with this birth, 15 years ago. I was as clueless of all the twists and turns labor could take as all of you were, or are now. I was overly prepared to have a natural birth. My knowledge of birth at that time came from my childbirth classes and nursing school 14 years earlier. I was no different than any anxious new parent walking through the hospital doors.
My husband and I, excited and hopeful before our 1st birth
Our new family, minutes after my whirlwind induction and birth
My husband and I joked our first birth went from Plan A, our best birth plan, to Plan G, a plan that was non-existent until labor began. I was ill-prepared for the shift because I assumed medical intervention wasn’t for me. I’m healthy. I wouldn’t need it. My husband and I were prepared with all of the tools: comfort techniques, positive affirmations, a general understanding of the stages of labor. I quickly learned how not preparing for every possibility (including the medical ones) left me wondering if I made all the right decisions after my baby was born. I was prepared, and yet I wasn’t.
Today, I’ve witnessed over 180 births as a doula, walking side-by-side with couples through pregnancy, labor at home and hospital, that first cry of baby when they land on your chest, and through your delicate postpartum period. Prior to 2011, I witnessed births as an RN in a hospital setting known for its evidence-based, midwifery model of care. I look back at the pregnant me as someone who had blinders on, who didn’t want to consider what I would do if anything went sideways, because I was in control and I always get what I want (laughing out loud here would be very appropriate).
Over the last ten years I’ve spent in your homes as your doula, I’ve come up with The Three Biggest Obstacles to the Best Birth Plan. I’ve shared this with every couple I’ve taught and worked with, and I want to share with you.
As a nurse, I started to see a pattern as I cared for couples on postpartum. I saw myself in them as they struggled to wrap their heads around their birth. “I didn’t know what I didn’t know”. The feelings are ones of regret. Ones of wondering if we had made a different decision, would we have had a different outcome. During labor, I saw the fear and despair that couples felt, having make a decision about an option they didn’t consider ahead of time. In my Evidence Based Birth® Childbirth Class, we dive head-first into these issues so you have enough knowledge to make that Plan A to Plan G with confidence. Let’s talk about these obstacles one by one.
Obstacle #1 - Inductions
We all plan to avoid them, which is actually possible in many circumstances by knowing the evidence on what conditions warrant inductions … and when. But can we really truly avoid a condition? We don’t get to prevent gestational hypertension or going past our due date. It just happens. What are we going to do when that unforeseen circumstance arises? Inductions make labor harder for many reasons:
If we’re being induced, there is a medical reason for it (hopefully) and that’s just scary. Plain and simple. Either the birthing person or the baby isn’t healthy, or we’re inducing to prevent ill-health in the near future.
We have to make a choice to induce. Take my classes and you’ll hear time and again that you will always have the right to say no. Sometimes the hardest part is saying, “Yes, I understand the diagnosis, the risks and benefits of the recommended procedure, and I give my consent to proceed”. This was me. You’re actually giving consent to do something you swore you’d never do. Owning that decision, and finding out later that there were facts or options you didn’t know you could consider, often leaves us feeling like we failed our bodies, and our babies.
You miss the entire labor-at-home process. Laboring at home is a precious time that facilitates faster labor progress. With inductions, you’re in the hospital the entire time, being poked and prodded while your nurse says, “just close your eyes and rest”. Yeah, right. I’ve slept on many floors of L&D rooms as a doula. There is no peace in inductions. There is very little rest. There is a lot of monitoring, tubes and wires, and constant interruptions. By the time your baby arrives, you probably had scores of humans enter your room while in various states of dress and various states of mind. They all have a job to do, but simply put, it’s not like laboring at home.
One of my clients being induced with Pitocin for post dates
Inductions can be looooonnnnnggggg. Your body just wasn’t ready but there is a medical concern that forces us to make it ready. Labor is like a petulant child. It won’t start just because we tell it to start. Ever see a child stop crying in the grocery story when the parent yelled “Stop crying”? Or better yet, when the parent used fear tactics or threats to get them to stop crying? I usually walk by shaking my head quietly with the thought bubble, “Did you really think that was going to work”? Warming up to labor is a quiet process that can take weeks and needs a feeling of safety and love. Trying to slam those last 3 weeks into 1 day of poking, prodding, and fearful language can be a huge challenge.
There is a lot of medical jargon surrounding inductions. Many diagnoses. Many treatment plans. Many policies. Many ways to monitor your health and that of your baby. Inductions can be as far from an “low-intervention” birth as you can get. If avoiding interventions was your goal, inductions can leave you with many questions if you’re not prepared. This was me.
Obstacle #2 - Back labor
This client is discussing an epidural with the midwife after an induction turned into excruciating back labor. Notice her posture of her hands in fists, holding all her tension close to her body
“My back is breaking”! If you’ve experienced back labor, you may be reading this and swear this description doesn’t come close. Back labor occurs when your baby is head down, but is spun around 180 degrees, facing your front instead of your back. In this position, the pointy part of baby’s head, effective in helping to dilate your cervix and descending through your pelvis with ease, pushes on your tailbone and sacrum instead, causing excruciating back pain. It’s a variation of normal and rarely leads to permanent physical harm in the birthing person or baby. However, it can absolutely call for a plan change in labor. Here are a few reasons why:
Back labor slows down progress. When baby is facing the birthing person’s front, otherwise knows as Occiput Posterior, OP, or simply posterior, they’re not lined up correctly for an efficient exodus from our pelvis. They simply get stuck, and they don’t have to be big for them to get stuck. Think of our babies and pelvises as the “square peg trying to exit out of a square hole”. Anything other than the ideal position can slow down our labor.
This type of labor causes intense pressure on our tailbone and sacrum. The contractions seem to last longer because after the contraction is done, the birthing person still feels baby rising back up off their tailbone, requiring the birthing person to cope with the contraction longer than they really need to. The pain in the back starts long before and ends long after the true contraction itself.
Back labor accelerates exhaustion because the birthing person is working twice as hard to cope, for twice as long per contraction. After hours of this, you’ll see their fists curled up by their chest, just shaking - literally bracing - for the next contraction that they know is coming. The memory of the birth is nothing but the pain in their back.
Birth partners need to be armed to the hilt with comfort techniques to help their partner cope. They have to be on their game. Their continuous presence and support cannot fail. It’s emotionally exhausting to watch someone they love go through this, and it's physically exhausting to provide the comfort measures required to help the birthing person cope with such a labor.
This client suffered with excruciating back labor as her midwife provided hip pressure to help her cope
Obstacle #3 - Exhaustion
Exhaustion in labor can exist on its own, or it can be compounded with either back labor or an induction. Inductions and back labor will exhaust your mental and physical resources. Eventually, your energy well runs dry if birth isn’t efficient, and it takes the best laid plans for an unmedicated birth right along with it. But exhaustion can also exist on its own, in the absence of an induction or back labor:
Spontaneous labor almost always begins at night. Night time is when our oxytocin levels are at their highest in the last month of our pregnancy, and it’s usually the time of day when our contractions begin. If we:
Don’t try to roll over and go back to sleep, or if
We’re too excited to fall back asleep, or if
The contractions don’t allow us to fall back asleep, by morning, you’ve been up for 24+ hours and if a baby doesn’t come soon, we inevitably run out of steam
A typical labor for a 1st time parent is about 24 hours. Now, that’s a very wide bell-shaped curve with lots of people hanging out on the edges, but you get the picture. Would anyone plan for a 24 hour road race and go out on a bender the night before and not sleep at all? That’s akin to what happens if we don’t try to sleep/rest through the initial phase of labor. By the time the sun rises again, you’ve been up for 24+ hours, you’re exhausted, and you still have a long way to go.
Our bodies don’t work well when we’re exhausted. Plain and simple. We’re not coming in 1st in that road race after partying all night. We need lots of nourishment, hydration, and sleep to do this job well. Take away just one of those basic needs in labor, and it can go sideways very quickly.
This couple finally hit a wall at their free-standing birth center after laboring for 30+ hours with little rest
So what’s a pregnant person to do?
I was an avid sailor in my pre-baby years. Sailors know they cannot control the wind and the weather but that doesn’t mean we cannot make our ship go in the direction we want it to go (in this photo, it was to the nearest island with a covered beach bar)
“Okay Jen 😕. It seems like all is lost if any of these things happen”. Well, not exactly. Knowing what can happen helps us develop a game-plan. These obstacles can obliterate even the most holistic of birth plans. Have I helped couples navigate each one of these with minimal changes to their birth plan? Hell-to-the-yes! All is not lost if these things happen. We cannot control everything, but we sure as hell can adjust our sails when the wind changes direction. That’s what open-minded childbirth preparation is all about. If we only plan for an epidural, or we only plan for a natural birth, we’re turning our backs to the wind and assuming it’ll blow only in the direction we want. Life is rarely that straight forward.
Planning for Inductions
We need to educate ourselves on the most common diagnoses that can lead to inductions. Due dates and Prelabor Rupture of Membranes (PROM) are the 2 most common reasons for induction in the U.S. Your provider suspecting you have a big baby is the 3rd. In the Evidence Based Birth® Childbirth Class, we examine all three of these diagnoses in-depth so you know what the evidence supports and you’re prepared to have informed conversations with your provider. The evidence drives guidelines and policies. Knowledge of the most up-to-date research gives us the confidence to ask the right questions and advocate for the plan that best aligns with our values.
Asking your provider “Will I be allowed to go past 40 weeks” is putting them at the center of your care. That really should be you! Remember, they are not the deciders, you are. The EBB® Childbirth Class helps you focus the conversations around your values and the evidence, and not what your provider wants you to do or what the hospital policy says you can (or cannot) do.
Planning for Back Labor
With back labor, we need to have a strong team of labor support around us to cope with this difficult form of labor. There are lots of acupressure points, positions, and comfort measures that your partner can use to help you cope. Most babies do turn - they kind of have to with most pelvis shapes. Having a team that knows how to help you cope and conserve your energy, and having the confidence that you and your baby are okay, allows you both to focus on “working the problem” - trying to get your baby to turn.
Planning for Exhaustion
With exhaustion, sadly, we don’t know we’re in it… ’til we’re in it. Many of us fail to look ahead and recognize that this is a long process and that we need to conserve our energy early so we have something left in the tank when the big stuff hits. At some point, we all cross that bridge into more intense labor that requires us to work with it. If that bridge comes early in your labor journey, you’re one of the lucky ones. The challenge is to recognize when that bridge is still far off, and when resting is more important than “making labor go”. Bouncing on the ball at 3am when we could be sleeping can backfire on us. I frequently teach my clients to “let labor come to you”. If you go chasing it, it’ll run and hide and you will waste valuable time and energy looking for it. If you wait for labor to “declare itself” and you eat, drink, and sleep while you’re waiting for that declaration, you’ll have more energy stored up for the task at hand when you need it.
You didn’t fail…
I call these obstacles because they frequently cause us to reevaluate our plan. I like to reframe the goal of a “natural birth” to a goal of an “unmedicated birth” or a “low intervention birth” because it helps us acknowledge our goals while recognizing that sometimes in birth, medicine has a place. The term “natural birth” carries with it a pass/fail outcome. If I planned for a natural birth, but I needed an epidural to cope with back labor and help me progress to 10cm and pushing, then I failed at a natural birth. “I tried for a natural birth but I ended up with an epidural on day 3 of my induction”. I hear that phrase all the time as the parent feels the need to justify why they “failed”. That first step over the threshold into parenthood is met with defeat. That’s a lousy way to start.
Planning for a low intervention birth acknowledges that medical interventions have their place. Knowing our options doesn’t mean we still can’t have a goal of a low-intervention birth. Knowing our options means we want to own our decisions, medical and otherwise, and not just toss it all up to the Gods and hope that we are “strong enough” to handle it. It’s not about strength, it’s about knowing your options.
All the strength in the world won’t hold back a desperate need for the birthing person to sleep if their induction takes 3 days. All the strength in the world won’t stop the most committed birthing people we know to melt into a ball of goo after 6 hours of excruciating back labor with little break. All the strength in the world will not help a birthing person find comfort and rest when her labor lasts for 24+ hours and standing up is the only position that helps them cope with contractions.
After laboring for 2 days, this couple finally got some much needed sleep after requesting an epidural
I have been doing this long enough to have confidence that anyone can labor unmedicated, but when we are presented with these obstacles, that goal can be a little harder to reach. If we request medicine so we can sleep or cope with back labor or have enough energy in the tank to push, did we fail? If our labor stalls at 7cm for hours after starting an induction 2 days ago, did we fail? Hell no, you did not fail! And you won’t feel like you failed if you go in prepared for what may happen, what issues we may need to address, and what options we may need to advocate for. I love helping you take ownership of every decision in labor, even Plan G. Plan G is still a plan.
The Evidence Based Birth® Childbirth Class doesn’t help you avoid all of these obstacles. Birth mimics life, and life is unpredictable. However, this class will break down what all of these obstacles can entail and how to make the right decisions for ourselves around these obstacles, should they arise. Ownership of the decisions we make in labor may not change what needs to happen, but it empowers us to be at the center of this process and not just giving the process over to someone who may not have the same goals or values that we do. It’s that kind of empowerment that can help couples overcome and recover from the most difficult of births. Nothing feels better in labor than saying, “We’ve talked about this. We know what we’d like to do”.
Confidence is the first step. Go into this experience with knowledge and you’ll have the confidence to navigate the various crossroads as they arise. Educate yourself on all of your options, not just the medical ones and not just the non-medical ones. All of them. Classes like the Evidence Based Birth® Childbirth Class leaves no stone unturned and leaves the guilt trips at the door. Unbiased and fact-based. It’s why I happily offer this online group class to couples everywhere. It empowers by leaving the decisions up to you.