Birth plans: Managing patients’ expectations

SUSAN OLMSTEAD: As an obstetrician, tell me about how you feel about birth plans.

DR YALDA AFSHAR: I really support a woman’s decision to prepare for pregnancy, for childbirth, and to experience them in a way that she feels empowered. And if that includes writing a physical birth plan, then so be it. I’ll support that decision. ­ e cohort of women who have birth plans is actually increasing in Labor and Delivery (L&D) throughout the country. We have to be cognizant of that. As I’ll discuss a bit later, the term “birth plan” is pretty restrictive. I’m trying to use “birth preference” more because we know that birth really can’t be planned. So these are preferences that can be shared.

MS OLMSTEAD: ­That’s a very good point. Do you encourage patients to write out their birth preferences or do you wait for them to bring up the topic?

DR AFSHAR: I don’t bring up the topic of a birth plan, per se, but I bring up birth choices. I love to have that discussion prenatally, antenatally, before a woman presents in active labor. ­ That’s really what I think the whole point of a birth preference document should be. It should kind of heighten the therapeutic alliance between the mom and the provider. And it should be a little bit of back and forth, some shared decision-making.

I don’t encourage my patients to write down their preferences, but if they do, I support that. I steer them towards more evidence-based decision-making in creating a birth plan. In the United States, birth plans aren’t the norm on L and D whereas in other countries and areas, such as the UK and Scotland, they’re part of the national maternity record and a standard of care.

MS OLMSTEAD: I didn’t realize that. In other countries, is there a national form that’s used universally?

Related: Managing patients' expectations

DR AFSHAR: Yes. There is a universal, standardized birth-preparedness document.

MS OLMSTEAD: What about patients who write up a birth plan and have unrealistic expectations? How do you help steer them toward more realistic expectations of birth?

DR AFSHAR: ­ That’s actually a big issue in this era of shared decision-making. We know that women who have a higher number of birth plan requests are less satisfied with their birth experience. The fewer things that are fulfilled from their birth document, the more unsatisfied they are. I think what’s important is that if someone lists something that’s unrealistic and not part of the standard of care, we discuss it.

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This is an issue with a lot of birth plans that are found on the Internet. Many of them include outdated procedures like prophylactic enemas and routine episiotomies. ­ The American College of Obstetricians and Gynecologists has had a stance against both of those procedures for a while now. We need to focus birth preferences on things that are a little more tangible, real, and in touch with day-to-day L & D.

I use the topic of birth preparedness to tell my patients that I come to work every single day saying, “How can I make the life of moms in labor better? How can I ensure a safe pregnancy outcome for the mom and the baby?” And I think that spelling that out helps establish a little more trust. A birth document can be a tool to foster that.

MS OLMSTEAD: I’m sure that helps patients feel a lot more con‑ dent and comfortable. If you were to develop the ideal plan, one that you would hope a patient might come to you with, what would it include?

DR AFSHAR: We’ve actually started developing such a tool. The ideal plan, for me, would be a decision-making tool that says, “­The evidence shows this about xyz. What is your preference about that?” or “­The evidence shows that a vaginal delivery is associated with better outcomes for xyz.” ­ Then a patient would choose. The focus is on evidence-based practice recommendations in labor, birth, and for the newborn. Ideally, it should be 1 page and very simple.

NEXT: What an online survey found

MS OLMSTEAD: I’m sure you help patients understand that labor is unpredictable and things happen that may cause the plan to shift. Is that right?

DR AFSHAR: Absolutely. Labor is dynamic. One of the most important discussions to have with the patient is about the fact that neither the provider nor the mom has any control over the course of labor. We can try to optimize some preferences, but really, in the end, labor kind of plays out. So, preparedness is important.

MS OLMSTEAD: It sounds as if you are very in touch with what moms want and eager to work with them. I suppose that’s the takeaway message.

DR AFSHAR: Yes. We recently looked at birth plans at a larger, provider level. We did a national online survey about plans and childbirth education that was distributed through professional societies and social media. We heard from about 600 respondents, 76% of whom were obstetricians and the rest were midwives. ­ The results were pretty surprising.

Only 26% had favorable views of birth plans. About 67% actually did not recommend birth plans. ­ Thirty percent felt they were predictors of poor obstetrical outcome. ­Those with more years in practice had more favorable views of birth plans as did those with higher obstetrical volume.

Next: Don't fear the patient with a birth plan

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These are not national sentiments but I think they do suggest a trend. Moms are asking for birth plans and it’s important that ob/gyns believe in a therapeutic alliance and shared decision-making with their patients, and that we start bridging the gap on our end.

MS OLMSTEAD: Dr Afshar, thank you so much for talking with us.

DR AFSHAR: It’s been a privilege.

Ms Olmstead is the Editorial Director of Contemporary OB/GYN.

Dr Afshar is a Maternal-Fetal Medicine Fellow in the Department of Obstetrics and Gynecology, University of California, Los Angeles.