Childbirth Classes and Birth Plans Increase Chances for Vaginal Birth

Photo by Andy Ellison

Fewer women are taking childbirth classes in some communities. They feel they are too busy to accommodate a multi-week class or they feel that they should defer to the expertise of their care provider. They spend far more time decorating the nursery than they do planning for the actual birth.

But here is one good reason to consider taking childbirth ed classes or making a birth plan. They may lower your chances of a cesarean.

In this study, only about a third of women birthing at this particular hospital attended a childbirth education class; 12.0 percent had a birth plan, and 8.8 percent had both. This shows how underutilized these tools are in many communities.

However, those who had a birth plan had nearly TWICE the chance of having a vaginal birth as those who did not. Those who did attend childbirth ed classes had a 1.26 better chance of a vaginal birth, and those who had both childbirth ed classes and a birth plan had 1.69 the chances of a vaginal birth.

Taking childbirth ed classes and having a birth plan will not guarantee you a vaginal birth, but it is another tool in the toolkit when preparing for labor and birth.

Discussion

Of course, some L&D nurses will swear that women who come in with a birth plan have higher cesarean rates, not lower as in this study. This can be true in some situations, like those hospitals and caregivers who find it threatening when birthing women claim their independence to make their own healthcare decisions. Some will find ways to punish women who don't just automatically follow what they are told to do. A few will schedule these women for extra interventions to "teach them a lesson."

However, other hospitals truly respect women's birthing choices and will accommodate them as much as possible. One helpful thing to do is to request an L&D nurse that supports and is enthusiastic about natural childbirth but who will support your choices without judgment. Don't be afraid to request a different nurse if the one you are assigned doesn't meet your needs. Another helpful thing to do is to hire a doula, a professional labor support person, if your budget allows. Research is very clear that having a doula lowers the chance of a cesarean significantly. And of course, a provider that believes in the physiological model of birth (also called the midwifery model of care, though doctors can practice it too) is key.

Really, attending a birth is both an art and a science. The same mother with the same presenting conditions can be managed very differently by different providers. That's why it's so important to research your hospital choices and choose your caregivers wisely in pregnancy. Learning about the different choices available during birth (and the pros and cons of each) is a big part of this process. A good childbirth education class is perfect for this process, and a good birth plan helps you decide what is most important to you.

Of course, it's always important to remain flexible in your plans because unexpected things can occur. Sometimes a cesarean or other intervention is the best choice under the circumstances. Birth plans should be short and flexible, and of course the parents should take into account the advice and expertise of their birth attendants. But a road map describing where you want to go and how you'd ideally like to get there (with information about alternatives in case of detours) can be very helpful when planning your childbirth trip.

Personally, I found childbirth ed classes invaluable. I took the regular hospital classes with my first and while they were somewhat helpful, they were more a lesson in how to be a compliant patient. In later pregnancies I took various other classes, including Birth Works, Bradley, Birthing From Within, and Hypnobirthing. I found these classes much more useful so I generally recommend independent childbirth classes. Some hospital classes can be wonderful but often their content is tightly controlled by the OB staff and may not present a full spectrum of choices.

My personal favorite was Birth Works classes, which is why I became an instructor in it, but I also enjoyed Birthing From Within. I know parents who swear by some of the other classes. It's mostly a matter of finding the approach that resonates with you.

But do try to find a good independent childbirth class and get the instructor's help in making a good birth plan. It's no guarantee of a vaginal birth, but it helps.


Reference

Birth. 2017 Mar;44(1):29-34. doi: 10.1111/birt.12263. Epub 2016 Nov 15. Childbirth Education Class and Birth Plans Are Associated with a Vaginal Delivery. Afshar Y, Wang ET, Mei J, Esakoff TF, Pisarska MD, Gregory KD. PMID: 27859592 DOI: 10.1111/birt.12263

BACKGROUND: To determine whether the mode of delivery was different between women who attended childbirth education (CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan. METHODS: This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed. RESULTS: In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had scheduled a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older (p < 0.001), more likely to be nulliparous (p < 0.001), had a lower body mass index (p < 0.001), and were less likely to be African-American (p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery (CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls. CONCLUSION: Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates.

A Lovely VBAC After CBAC Story

The "OMG, A Baby Just Came Out of My Vagina!" VBAC Face
(Also called The Official VBACFace™ by Jill at the Unnecesarean)

As we enjoy the holidays, it's nice to be able to share some good news for a change.  And what better news can there be than a lovely birth story, with GREAT pictures to boot?

Below is a brief summary of Melek's birth stories and some of her birth pictures, all shared with permission. You can find longer versions of her stories on the ICAN blog, which she helps run.

I love these stories and just had to share them because she has some of the best birth photos EVER.  They just brought a giant smile of happiness to my face when I saw them.  And what better time of year to share them?

I always love to share VBAC (Vaginal Birth After Cesarean) stories.  This one is particularly poignant to me because she had a CBAC (Cesarean Birth After Cesarean) when she tried for her first VBAC, as I did also.  And yet we both went on to have VBACs afterwards.

Many care providers assume that once you've had a cesarean, somehow your body is just not capable of birthing a baby vaginally.  Research shows that most of these women can, in fact, birth vaginally if given the chance to VBAC, but many are erroneously told they cannot.

And if you've gone for a VBAC and ended up with another cesarean instead, care providers almost without exception assume that you are somehow "broken" and cannot possibly have a vaginal birth.

Yet the experiences of Melek (and me, and many others I know) show that it is possible to have a VBAC after having gone through a CBAC.  And research shows that VBAC after more than one prior cesarean is definitely possible and reasonable.

It's important to note, of course, that not every cesarean or CBAC mother goes on to have a VBAC.  Sometimes it's truly not possible, sometimes medical considerations make it prudent to have a repeat cesarean, sometimes the mother is just done having children or doesn't want to consider laboring again, or sometimes she simply cannot find a supportive provider.  A vaginal birth is not the end-all, be-all of birth.  You are a mother regardless of how your baby arrives.  

But even so, there is something wonderful about women finally able to get their desired birth, something incredibly special about women who keep pushing for VBAC despite lack of support from some in the obstetric establishment, something incredibly brave about the tenacity of women who persevere despite medical professionals telling them that they are "broken*" or "damaged," something incredibly affirming about women showing that their bodies can give birth vaginally after all.

This is one of those stories.

Congratulations, Melek, we are so happy for you.  Congratulations on your new baby.  Thank you for being willing to share your birth pictures and your joy with us all.  Bless you and all your children.

*Sometimes when a birth story like this (i.e., someone who felt "broken" by their cesarean, etc.) is posted, some people's feathers get ruffled.  It's important to remember that this is one woman's story, one woman's perceptions about her births, and it doesn't have to reflect your own reality or opinions.  It's okay if your story is different.  Be happy for her anyhow.

Melek's Stories

Baby #1 (Cesarean):

Risked out of a birth at a birthing center with midwives because of essential hypertension, Melek was induced and ended with a c-section.  She was emotionally devastated when her doctor told her, "Well, all your babies will have to be born by cesarean and seeing how difficult this pregnancy was, you should probably only try for one more.”  She felt broken and damaged.

After the disappointment of her first birth and her doctor's discouraging words, Melek let her health habits slip for a while.  Realizing that she wanted to avoid intervention in a future pregnancy, she made an effort to improve her health. [Trigger warning for brief weight loss talk in the original story.]  In time, she was able to get off her blood pressure medications and conceive again.

An abbreviated version of this story can be found here, near the top of the entry.

Baby #2 (CBAC):

After getting off her blood pressure meds, Melek planned a home birth with wonderful midwives.  When she went into labor, however, baby's position was not quite optimal and labor was long and slow, then turned hard. Some non-reassuring signs were found and a hospital transfer was made.  She ended up with another cesarean, but while disappointed, did find the experience empowering in the end.  She wrote:

I was expecting to be devastated if I had a repeat c/s, but I was surprised with how not only content, but happy I was about my birthing. I had worked so hard for two days, listening to my body and working through contractions. I felt really respected by the hospital staff. No one ever once made me feel bad about being a home birth transfer. In fact, the OB that delivered Emre told me that he is sorry that it ended in a cesarean because he knew how badly I wanted a natural childbirth and how hard I worked for it. He didn't downplay the importance of my birth to me and that was so very special to me. I felt respected, validated and valued by every single person who was part of my birth experience. I never knew that a CBAC could feel like that.

Melek's full CBAC story can be found here.

Baby #3 (VBA2C): 

Melek spent a lot of time emotionally processing her first two births while preparing for her third.  She also prepared physically, utilizing Maya Abdominal Massage to help break up any scar tissue, chiropractic care to help promote a good fetal position, and acupuncture near term to ready her body for labor.

Her midwives were totally supportive, but, like many CBAC moms, she had many concerns that something was going to interfere with her much-desired VBAC.  She despaired that she would have another big baby, would go well past her due date, and that as a result, baby's head would be big and not mold-able enough to be born vaginally.

In the end, she had the baby a week past her due date, one with a big head that did not mold, and he was another sizable baby (9 lbs. 13 ounces).  And she still had a VBAC.

And what a beautiful VBAC it was.

Full story can be found here.

More Birth Photos

Here are some more birth photos from Melek's VBA2C (Vaginal Birth After 2 Cesareans).  Keep in mind that some are from a cell phone, and I re-posted the picture from the top of this post to show its context in the birth story (and because it may be one of my all-time favorite birth photos!).  I couldn't get Blogger to rotate the second-to-last photo, but it was too wonderful to omit, so turn your head to the side and enjoy her giant smile of joy anyhow.

in labor

Best VBAC Photo Ever?

overwhelmed 

snuggling up

beaming with joy

the happy family

Birth Story Video: Jennifer's Waterbirth

Here is the birth story and wedding/birth video of a plus-sized mama I thought readers might enjoy.  It's not a short video (about 6 minutes) but it's well worth watching!

Below is the mother's story (which includes 4 previous miscarriages) and what she wants other women of size to know about pregnancy and birth.

My name is Jennifer. I live in southern Oregon and am a midwife apprentice. I have attended many births and have caught 4 babies under supervision. Of the many births I have attended, a good handful have been to plus-size mommas. 

Two off the top of my head were between 300-400 lbs. Both mommas had very healthy uneventful pregnancies and wonderful easy labors, and both mommas delivered in water at home. Water is great for plus-size mommas because it allows you to move more easily into different positions.  

I myself am a plus size momma. I am 5'6" and started my pregnancy at 232 lbs., about size 18. I finished my pregnancy at 276. I know doctors like to tell you to only gain 15 lbs. if you're "obese" but that's one of many reasons I didn't choose a doctor! I am a firm believer that as long as you gain your weight on healthy food then you gain what you need, and restricting food can cause issues in pregnancy. Nutrition is key in pregnancy, especially protein!   

I had a wonderful very healthy pregnancy with a midwife, and gave birth to a beautiful baby at home on Christmas eve.  A baby girl,  9 lbs. 12 ounces, 20.5 inches. 

Being plus size and pregnant is a challenge but I think it's because we set up obstacles in our minds. Will I look pregnant, how much weight will I gain, will I be able to handle the physical demands of labor, will I be bullied into tests and procedures because I'm overweight? 

Remember that you are a strong, intelligent, beautiful woman who can birth a healthy baby, regardless of your weight. If you aren't comfortable being your own advocate, then hire a doula! Get educated, know your options, and don't forget to celebrate this beautiful rite of passage!