“Be Flexible:” Red Flag, Wise Advice, or Both?

Do you know this scenario? A woman takes her birth plan into her doctor or midwife for discussion. The provider reviews it and tells her, “You need to be much more flexible than this.”

It makes me cringe when women tell me this has happened. My first thought is that it’s a major red flag, assuming the birth plan is asking for a normal, natural birth. In my experience, the vast majority of women I work with are able to achieve everything on their birth plan! My hope when a woman brings in a natural birth plan is that her provider will reassure her that her requests are reasonable, that birth usually unfolds just beautifully, and barring something unexpected, there’s no reason to think she won’t be able to achieve that kind of birth. Is someone who scoffs at your plan the right provider to help guide you to the birth you’re hoping for? If they honestly don't see natural births that often, are they really a good match?

So what kinds of things might be included in a “reasonable” natural birth plan? Some common elements I see on birth plans include the following:

• intermittent monitoring with Doppler

• no pain medication, and please don’t suggest it

• please don’t ask me to rate my pain

• patience preferred over Pitocin

• freedom of movement, access to bath/shower

• eat and drink as desired

• no IV or hep/saline lock

• to push and give birth in whatever position feels best

• allow the cord to pulsate fully

• no drugs for third stage except in case of hemorrhage

• continuous skin-to-skin for 1-2 hours after birth

• decline a bath for baby

• no supplemental formula or donor milk

We see so many births that include these elements, it is sometimes hard to remember that it’s not the norm.  All of these requests are backed by solid research. It is absolutely reasonable for every low-risk woman to expect that her birth will likely unfold this way, even in the hospital environment. Of course a small percentage will run into complications and benefit from intervention, and we have to stay open to that possibility. But we also shouldn’t expect complications and intervention more than we expect a normal, natural birth.

Given that our medical system is not intrinsically designed to support these types of births, a certain inflexibility might be helpful in order to achieve a natural birth. If natural birth is very important to you, you might need to be very firm about avoiding an epidural if the birth is long or complex. You might have to insist on more time to overcome a plateau instead of turning quickly to Pitocin. You might really have to advocate for yourself and your baby and be strong to turn down a bottle being offered for normal newborn behavior like cluster feeding. Or you might get lucky and not need to advocate at all, depending on the complexity of your labor and the providers on shift at the time. But in the current American birth culture, women who go into their births planning to just “go with the flow,” especially for their first baby, often end up with a cascade of interventions they never expected. 

That said, there are certainly birth plans and expectations that would benefit from some flexibility. There are some requests that are just very hard to accommodate in the hospital, like if a woman wanted zero vaginal exams or insisted on water birth at a facility that didn’t offer that option. You really can’t have a home birth in the hospital, there are usually some trade-offs.

It’s also true that there are some times when inflexibility can actually lead to more interventions. If a woman insists on pushing only in the squatting position, or only on having a water birth, she might be closing herself off to other options that could work better for her particular journey. Birth definitely can’t be scripted and there are often some surprises along the way. Women who are flexible enough to release rigid expectations and flow wherever their labor takes them seem to enjoy their births more in the moment, and reflect more positively on the journey postpartum, too.

And we definitely don’t want women to set their hearts so fully natural birth that they will be completely crushed if they end up with an epidural or if they are one of the small percentage who benefit from a medically necessary cesarean birth. Some women have told me they skipped over the section on cesarean birth in their books or they tuned out that discussion in class, thinking it surely couldn’t happen to them. In reality, many experts believe that a 10 – 15 percent c-section rate is reasonable for an overall population, including both low-risk and high-risk mothers. Even Ina May Gaskin and the midwives at The Farm have a 1.7% cesarean rate, after all. A one in 10, or even one in 20 chance of having a cesarean birth is not so unlikely.

I tell my students that it’s helpful to reserve just a small corner of your heart for that possibility of necessary and helpful intervention – the medical tools are such a gift when truly needed! Unfortunately, there are no easy or magical answers on how to know when interventions are “truly needed.” It’s my hope for every woman that she will find a provider she deeply trusts to help guide her through her birth, and that together they can make a shared, thoughtful decision if things get complication and it seems like intervention might be helpful. The research of Penny Simkin has shown us that when women are part of the decision making process and when they are treated with respect, they usually feel good about their births long-term, even if intervention was needed.

Back to the title of this post – is it helpful or harmful to tell women to “be flexible?” Women seem to respond when providers spend most of their time reassuring them that birth works, and affirming that they should expect a normal, natural birth. Maybe the percentage of comments about staying flexible should correspond with the percentage that intervention is actually needed. For a low-risk woman, what’s that percentage? Home birth might give us some clues. Nationally, the transfer rate for home births usually comes in around 10 percent. That means about 10 percent of the time, the low-risk women having their babies at home need to be transferred to the hospital for medically necessary interventions. So wouldn’t it make sense for a hospital-based provider to spend 90 percent of their time reinforcing normalcy of birth, and maybe spend 10 percent of their energy discussing how important it is to prepare for the unexpected? Far too often, women tell me that the opposite is true – 90 percent of their comments they hear are directed at preparing for a very medical birth.
 

So yes, mamas, be flexible. But do go out of your way to find a provider who really believes in birth, and builds you up to believe that you will most likely get the natural birth you’re planning. After all, it’s a pretty reasonable expectation.

And when your baby’s birth day actually arrives? I trust your wisdom will guide you to be just flexible enough.


Written by Jessica English, CD(DONA), BDT(DONA), LCCE, owner of Birth Kalamazoo.