I seem to have signed myself up for extra hours of work. This totally goes against my sleep ethic! But our clinic was finally reinstating some in- person antenatal classes which had been abandoned during Covid. I’d been rooting for this return to normalcy so I could hardly refuse to participate. Besides, I’m a bit of a drama queen: give me a captive audience of pregnant women any day! Loyal reader, you will not be surprised to learn that I have a lot to say! So now I regularly get to do The 36 Weeks Birth Talk. Thereby helping parents write their Birth Plan.

I guess the thing about birth plans is that babies don’t read them. Or if they do, they can’t always comply. Perhaps they feel terribly guilty about that, but we’ll never know for sure.

I love a good discussion about birth options. It’s important for us midwives to know what sort of birth the mother would like, all things being equal. There’s no wrong answers. A planned cesarean birth because she’s freaked out about labour? It might not be ideal in theory, but that doesn’t make it wrong. A homebirth after 2 emergency cesareans? Again, not exactly conventional but… doesn’t mean it’s wrong. In both cases, you’d want to explore why she’s opted for those choices (you will discover that there are always good reasons), you’d explain why she might reconsider, but you’d probably try to facilitate what she wants no matter your misgivings. Not gonna lie, I used to think that maternal choice cesarean birth was a bit unreasonable. I’ve mellowed.  Getting older, I realised that maternal mental health is what it’s all about, and the best way to promote that is to really listen.  When you listen, you don’t just hear the fear. You hear the deep-rooted reasons behind the fear. Fear isn’t always rational. Fear often promotes decisions that seem counterproductive. You probably won’t be able to change her mind though. For one thing, telling her she’s wrong literally never works. A planned cesarean birth (perhaps after a traumatic first birth) carries risks that perhaps one ought to avoid, as does a homebirth after a couple of (probably very necessary albeit unwanted) cesareans. Either way, the fear is real. And it’s exacerbated by the total unquestionning abdication of control that we expect of pregnant women. It’s a big ask. Huge. We try to make it palatable by introducing the birth plan. We expect her to have one, we even help her draft one, and then we explain why she is, in fact, wrong to have one.  Bit crazy maybe? Hell yes! And yet, bizarrely, not as crazy as you’d think. Because these birth plans, over the years, have prompted really honest and helpful discussions about how women expect to be treated, especially when things aren’t going according to (birth) plan. You’d think it’d be obvious,  you know, adequate pain relief, proper care and respect, timely discussions about potential deviations from the plan, a modicum of empathy… but it wasn’t always thus, and even today I hear really sad accounts of unnecessarily traumatic births. All in the name of the baby, obviously, which makes it extra hard to object to. Because you’re meant to be grateful. A good mother will submit to whatever it takes for her baby’s sake. A bad one will have the audacity, the temerity, to consider her own wellbeing. That’s a deeply problematic belief but it still persists, lurking unspoken in the shadows and we should call it out.

I favour the birth plan. I favour maternal wellbeing and choice. How can I possibly know what will reassure a woman  if we haven’t had ‘the talk’. But I fear for the mother who has the ten page birth plan. This woman is clearly, not unreasonably, struggling with the whole concept of labour. She’s done everything right. She was doing everything right even before she conceived. If anyone deserves the dream birth, it’s her. She’s desperately clinging to the illusion of control over the birth.  I get that. But she’s kinda missed the point of a birth plan, which merely encourages her to state her preferences but definitely doesn’t guarantee the dream unmedicated natural waterbirth that she thinks  she’s ordered and so amply deserves.

Look, I’m not one for blaming the babies, because obviously they can’t read. Plus they are small and desperately vulnerable. A wee bit more teamwork from them would be appreciated though, like, say: keeping their umbilical cords unobstructed and untangled; not breaking their own waters before time; not pooping themselves pre-birth (so many chances to do that afterwards…); maintaining a birth-friendly, preferably head-down position; not gaining too much weight (no-one wants to give birth to a hephalump); but also gaining enough weight (helps if they don’t run out of energy mid labour); not completely deregulating their mother’s blood pressure; not overstaying their welcome… you know, that kind of thing. Twenty years into motherhood, and I’m still waiting for the teamwork thing to kick in so good luck with that!

A couple of weeks ago, I was with a ten-page-birth-plan woman on the labour ward. By the time I was looking after her, not gonna lie, it had been shredded. I felt bad about that. I wished I’d seen her at her 36 weeks appointment so I could have managed her expectations. Because that’s one of the positive things about such plans: if we catch them in time, we can gently explain why her wishlist isn’t like an amazon shopping basket (next day delivery, no fuss), more like buying a few lottery tickets and hoping (but not expecting) to win big. It’s not impossible. I mean, hey, you gotta be in it to win it, right?  Although whatever happens, you do win a baby, so there’s that!

By the time I met her, she’d started an induction process that definitely wasn’t on the wish list. She was on the hormone drip that she’d meant to decline. And within a few more hours, she was having an epidural that she was positively terrified of (but really needed). Interestingly, she didn’t object to having a cesarean birth and often stated her preference to deliver this way sooner rather than later if it was looking likely that her labour was heading that way. She wanted to avoid recovering from a cesarean after a prolonged and exhausting labour. Obviously reasonable. And so we had agreed one final check on her progress at 6pm with a view to going for that cesarean if, as we pessimistically predicted, things had stalled. As luck would have it, she was now fully dilated and ready to push, but now her baby was showing signs of unease,probably because of his mother’s powerful cervically-stretching contractions. All our lovely certainty about how and when her labour would end went up in smoke as we now had to explain that a c section when fully dilated does carry a few extra risks. But also that  her slightly distressed baby might need to be born quickly, possibly sooner than she could predictably push him out unassisted, thereby necessitating an instrumental birth. That was categorically not on the birth plan. Not gonna lie, I’ve never seen instrumental births on any birth plan. Ever. Truly, I understand the mega-reluctance. But look, no first birth is a walk in the park; the baby expulsion process, even when it works, is unbelievably hard.  Sometimes mother and baby need help. In the good old bad old days, help was not forthcoming and the consequences weren’t great.  The help is vastly better now but… baby still only has two exit options, neither of which are particularly appealing from the mother’s point of view. The emergency exit involves breaking glass (crazy not to use it if there’s no other way); but if you can be pulled to safety using the just-about accessible conventional door which was always designed to be an exit, well, less broken glass. Using this analogy to explain how door-extraction reduces the risk of breaking glass when the baby’s future siblings make an appearance is a bit of a stretch, but let’s just say baby number one will have modified the door into a more baby friendly shape on his/her way out. The door still works, I hasten to add. Its hinges better oiled, maybe. Closed but not locked, I suppose? Low level lighting guiding subsequent escapees towards the traditional exit, perhaps? OMG, enough with the analogy!

Look, I know women have been doing Childbirth since the dawn of time, I know we’re strong, I know Childbirth isn’t an illness, I know most of us can do this miraculous thing as nature intended, without intervention from well-meaning but occasionally patriarchal, condescending, insensitive and faithless medics. But.. the system is hardly perfect. Even when it works according to blueprint, it has some serious design flaws. Some of us need a bit of help. Both can be true. Also, thankfully, all the obstetricians I work with are truly caring, sensitive, and above all, great at their job. The truth is, we’re all on the same team. Team mother-and-baby, because both are inextricably linked. A sick mum always leads to a sick baby. And vice versa. A distressed baby needs to be born, for sure. If the cervix is wide open, it makes sense to help the baby out via the conventional exit. I think we have to accept that the help will necessitate stitches, and there’s the mega-ick factor. No-one in her right mind wants stitches down THERE. Of course not. But down THERE (despite the more glaring of design flaws, namely that it isn’t always as stretchy as it needs to be) does actually heal really well. A cesarean requires many more stitches, albeit not down THERE. Obviously this seems more palatable. We all understand that at a visceral level. Which is why, when women ask for a planned cesarean birth, we are quite likely to nod and accept. And I don’t think that’s such a terrible thing.  I’m not saying it should be plan A because it comes with plenty of risks, but I’ve been a midwife long enough to know that the ick factor is a complete deal breaker for some women. The harsh reality is that this is the only childbirth choice that a woman can meaningfully make, one which keeps her firmly in control, the only one which doesn’t come with a dozen ifs and buts and maybes. The same can hardly be said of all the other birth plan so-called choices, all of which come rife with caveats and disclaimers and uncertainty.

Of course, most of us can handle the uncertainties of childbirth. We don’t like it, hell no! But we muddle through, we cope. Just like my ten page birth plan mother did. Kudos to her.

She pushed like the woman on a mission that she was; the obstetrician gently pulled and that baby was born,  mildly dazed but fully capable of vocalising his displeasure!

And the mother? I spoke to her a few days ago to see how she was doing. I explained that I felt bad about about her birth plan decimation. I told her about our debriefing clinic which I thought she’d be signing up to immediately. But she was basically recovering nicely, seemingly not as traumatised as I’d imagined. Now, it’s not her job to make me feel better, but I felt better. As midwives, we are often in the unenviable position of mediating between the mother (with her carefully researched birth plan),  and the clinical decisions which kinda need to be made which are in direct contradiction to said plan. We often feel really bad. We’re on team mother-and-baby but it can feel like we’re on team baby at the expense of team mum. We know mothers suffer but we know that ultimately they are fundamentally on team baby too. They have spent nearly ten months obeying all the pregnancy rules (some of them only very loosely based on actual risks) to give their child every conceivable advantage. But that’s not an excuse to violate the mother’s bodily autonomy.  It’s a constant negotiation. And it starts with the birth plan. Which the baby hasn’t read.