How to think about birth plans and preferences

Written by Shalini Shah‍

With all the planning that goes into getting pregnant, being pregnant, deciding where to give birth, and then settling into life with a baby, coming up with a “birth plan” might feel like just another stress-inducing item on the to-do list. Research shows, however, that they can result in more positive birth experiences, better outcomes, and a greater sense of control when navigating the journey. They’re very much worth it.

As a Millie Guide and a practicing doula, I get the incredible opportunity to co-create birth preferences with pregnant people and their families. After over 10 years in the birthing world, I’ve learned how to partner with parents-to-be to help them find the best preferences for them and create a warm and welcoming environment for both themselves and the new baby.

What are “birth plans” or birth preferences?

In many ways, “birth plan” is actually a misnomer for the documents I co-create with the families I work with. What we’re really developing is a list of preferences for labor, childbirth, and the immediate postpartum period. Because there’s no way to fully “plan” for the unpredictability of this process — and there are instances where circumstances may shift and you and your care team's preferences may change.

If and when things don’t go exactly according to “plan,” it’s important that your birthing team knows what your preferences are in various scenarios. That’s where a physical document with preferences, which you’ve reviewed with both a doula and your care provider (more on this later), comes into the picture.

Why are birth preferences important?

The labor and delivery environment’s fast-paced energy can result in birthing people feeling like they need to make quick, high-stakes decisions with limited information — an experience that can make people feel like they’re losing agency. Understandably, in the heat of the moment, it can be challenging for a laboring person and their support team to collaborate effectively. Partners and support people may also find it tricky navigating their ever-evolving roles in the birth space. Labor, delivery, and postpartum care may also be very fragmented, meaning someone is facing a rotation of care providers on different shifts who may have varying degrees of knowledge around your preferences.

Creating birth preferences is an exercise in learning about your options in advance of labor and delivery so you can have a more informed and empowered experience during what can be a vulnerable time. Through this lens, birth preferences are a tool — and creating them is a process that allows you to explore answers to questions you may not otherwise know to ask. They also act as a quick reference guide for you and your team to come together as a cohesive unit to make informed decisions that feel right for you. Your document can be shared with other providers if shifts end, as well as your support people, to make sure everyone is on the same page. 

According to a 2010 randomized controlled trial, participants who created birth preferences reported significantly higher satisfaction with their birthing experiences, having more realistic expectations they were more likely to meet, and feeling more agency over the process. A 2017 cohort study reported many of the same findings — plus reduced rates of medical interventions and better outcomes overall, which were also echoed in other studies from 2015 and 2017. 

Millie’s founder and CEO, Anu Sharma, only decided to create birth preferences because it was one of the services her doula offered. But as she began working through the process, she realized just how valuable of a tool it was. “I knew what to expect in each possible scenario and had a clear framework for evaluating the choices that were being presented to me,” she says. “It made all the difference to feel well-informed and empowered during an experience that really wasn't particularly positive for me.”

What birth preferences can be made?

Birth preferences typically cover a range of scenarios and circumstances. Here is an overview of decision-making points you can bring up with your doula and prenatal care provider. (Note that some of these may vary based on the policies at your birthing location, but it’s helpful to know what you can expect.)

‍Environment: This is about figuring out what an birthing environment would look and feel like for you:

• People in the room (like a partner or support person, including a doula)
• Option to eat light foods and drink as desired
• Option to take photos and/or video of the labor and birth
• Quiet voices and limiting side conversations so you can focus on laboring‍

Pain management: Your provider can always share their insights on the benefits and risks of any of these choices for pain management:

• Offering non-medication options like massage, hydrotherapy (using water, such as a shower or bath, for comfort), cold and hot packs, music, aromatherapy (oils), freedom to move and be in any comfortable position, or a birthing ball.
• Offering (or not offering) medication options during delivery like an epidural (block versus spine), narcotics (opioids), or nitrous oxide (laughing gas).
• Offering (or not offering) medication options during recovery.

Labor: Your provider can also walk you through fetal heart monitoring and other preferences around labor:

• Intermittent fetal heart rate monitoring vs. continuous monitoring
• Receiving an IV vs. hydrating by mouth
• No induction if not medically necessary
• Using a mirror to see the baby crowning

Delivery methods: This is an opportunity to envision what delivery methods and procedures you’re comfortable with:

• What induction methods, if needed, are you okay with? These include ripening the cervix (prostaglandins, laminaria, balloon), rupturing the amniotic sac, and oxytocin/Pitocin.
• What assisted delivery methods, if needed, are you okay with? These include using forceps or a vacuum device.
• How do you feel about vaginal exams during labor and delivery? Would you like your provider to only perform them if it will change the management of your labor, walk you through what they’re doing, or offer pain medication?

Partner/support-person involvement: If you’ll have a partner or support person with you, what would you like for them to do?:

• Massage you and provide physical support
• Direct your pushing
• Receive the baby
• Cut the umbilical cord 

C-section preferences: What would your preferences be if a cesarean section (C-section) was the safest delivery method for you and the baby?:

• Would you want all other options to have been exhausted first?
• Would you want someone in the room with you?
• Would you want anti-anxiety measures, like someone to talk to, medication, or calming music?
• Would you want to prioritize skin-to-skin contact in the operating room? Would you want your partner to also have skin-to-skin contact?
• Would you want to have sterile gauze placed inside the vagina for microbiome seeding (in the absence of an infection or meconium)?

Newborn preferences and postpartum care: These preferences relate to what you’d like to happen right after giving birth:

• Do you want help prioritizing skin-to-skin contact for the first hour, delaying cord clamping, ensuring a family member is present for any newborn exams and procedures, or to nurse as soon as possible?
• Are there any standard newborn procedures you’d like to opt out of, including a vitamin K shot, erythromycin ointment for the eyes, a bath, the hepatitis B vaccine, or a hearing test?
• How do you feel about circumcision? What about public cord blood donation?
• Newborn feeding via breast/chest, bottle, formula supplementation, donor milk supplementation, and whether or not you’d like to work with a lactation consultant.
• Would you prefer your baby to stay in the room the whole time you’re in the hospital, during the day, only when you’re awake, only for feeding, or only on request?
• Would you prefer to stay in the hospital as briefly as possible, as long as insurance will allow, or would you rather decide later?

Creating birth preferences

These are some of the most helpful tips I’ve collected while working with thousands of families throughout my career.

1. Start early. Remember, this process isn’t just about creating a formal document. It’s a journey of prenatal education, contemplation, discussion, and discovery that results in a reflection of your unique identity and values.
   
   
2. Be concise. Begin with an introduction and include your most important preferences and needs at the top so they are seen by your care team as they rotate between shifts. Arranging your preferences into sections allows your birth team to fully read and absorb what’s critical in the immediate future. It’s okay to create multiple sets of birth preferences for different scenarios such as spontaneous middle of the night water breaking to slow and controlled induction or cesarean. 

3. Focus on what you do want. So often, as a response to hearing birth stories from loved ones (or the internet), we begin to center on all the things we don’t want to happen in our birth experiences. By focusing on your goals, how you want to be supported, and the experience you do want, you’ll have a more holistic and reassuring understanding of your vision.
   
   
4. Review your birth preferences with your provider. Sharing your preferences with your prenatal care provider as they come up, or as soon as you feel comfortable, will help expectations line up with reality. Your provider will know the ins and outs of your birthing facility better than anyone, so they can inform you of the facility’s standard practices and policies, share their medical opinion, and answer any lingering questions you may have.

5. Make copies. Upon meeting a new member of your birth team, ask your partner or doula to ensure each new person gets a copy of your birth preferences and that they understand your preferences and what you’re working toward.

6. Advocate for what you want and need. Black, Indigenous, and other people of color, or people of the global majority, often experience inferior medical care in their pregnancy, labor, and postpartum period. Because of that, Black birthing people in the U.S. have more than a three times higher risk of death related to pregnancy and childbirth than their white peers. Queer, trans, and nonbinary people, as well as people in larger bodies, are also faced with mistreatment, judgment, and pressure to surrender their identities and autonomy during their pregnancy, birth, and postpartum experiences. 
   
   Ending structural racism, homophobia, transphobia, and fatphobia are the real solutions here — and birthing people should not be expected to equip themselves with tools to protect against bias and stigma. However, some people may prefer to  proactively create birth preferences to prevent outcomes ranging from emotional and physical trauma and complications.

Having these conversations before labor is an important exercise in self and team advocacy. It establishes open lines of communication, confirms that your provider is the right fit for you, and increases you and your support team’s confidence in using your voices when interacting with your care provider

Birth plans and preferences at Millie

At Millie, anyone who wants to create birth preference plans will have the chance to. There are no requirements based on risk level or any other factors. While there’s no way to know for sure that the ideal scenario will be possible when the time comes, we firmly believe in the importance of patient-centered care and human intuition. 

Our holistic approach in supporting you gives you the opportunity to experience more integrated, continuous care when creating your birth and postpartum plans and accessing care itself. Your dedicated Millie Guide (a practicing doula) will help you structure your feelings and wants into plans and preferences that feel right for you. 

The beauty of birth preferences is that you’re creating a living, breathing document. As your thoughts, desires, and vision evolve, so can your preferences. Know that you can shift those preferences at any point. Remember, it’s all about the process. And this process is all about you and your family.