The role of the midwife in birth planning

There has been a lot of discussion on twitter over the last week or so about the various merits and pitfalls of Birth Plans. This debate has included extensive discussion about the terminology – should we talk about Birth Plans or Birth Preferences?  Is it better to use free text, checklist options or visual presentations? In creating a birth plan are women setting themselves up to be disappointed if things don’t go “according to plan”?  How can we help women to achieve their plan? The arguments on all sides are persuasive but at the end of the day its not up to us – it’s down to the women and birth plans will mean different things to different people. They are not interested in semantics, regardless of the power of language, they just want to tell us how they would like their birth to go. They just want us to listen to them. Whatever a woman requests and however she presents the information the “plan” is only as good as the listening skills of the person who needs to help “action the plan”.


Birth plans and birth planning formed an integral part of #TheatreChallenge as talking to women about their options and choices is viewed as an essential part of care which is often neglected when women transfer to theatre but which has the power to transform birth experience. You can see the film about Theatre Birth Plans here. However I’d like to reflect more on the wider role of birth planning between health professionals and the women we care for.


There is plenty of evidence to support the fact that women want more say in their care. I use discussion of the woman’s birth plan as a key part of any admission, a way of getting to know the woman and her partner and what they are hoping to happen during their labour and birth and beyond from the moment I meet them. Its the perfect ice-breaker, a means of creating conversations, exploring expectations and putting a sense of control firmly with the woman from the word go.


So what is the evidence relating to birth plans? A recent study by Afshar et al (2017) found no difference in the incidence of LSCS for women with birth plans and no difference in length of labour. Women with birth plans were less likely to receive oxytocin, undergo ARM, or have epidural but were also less likely to be satisfied with their birth experience and felt less in control. Of course these results say nothing about staff attitudes towards the birth plans. Fink (2017) discusses a survey where only 26% of staff had a favourable view of birth plans and 1/3 believed that birth plans were predictors of poor outcome. Such attitudes are hardly likely to contribute to positive patient experience regardless of outcome. It may well not be the plan that leads to dis-satisfaction but attitudes and response to that plan in an unfolding situation. A 2012 study by Cook & Loomis concluded that positive and negative birth experiences related more to feelings of control and choice than specific elements of their birth plan.

I regret to say that time and again as a health professional I have seen women ridiculed for having a birth plan, especially if there is lots of detail or more unusual requests. For my own part I am grateful when a woman has taken the time to explore the options open to her and document her preferences before she is distracted by pain and fatigue. I wonder if a woman does not have any form of birth plan if she has been let down ante-natally in that she has not been provided with the information she needs to make informed decisions about her care. I also take exception to the idea that someone with a birth plan is inflexible. Just because someone has written down what they would like to happen does not mean they are not aware that plans may change. That is just what life is like! It does not mean we shouldn’t make plans in the first place.


At the recent RCM conference women’s expectations were explored. There was a suggestion that these expectations were inappropriate and that women expected too much from a service stretched to breaking point which simply could not deliver to a standard expected by women. Whilst reference to difficult staffing levels and workload is undoubtedly true I do not agree that women should alter their expectations of the care they wish to receive. Most women recognise the pressures faced by staff and do not complain. But this is why it is so important to discuss birth planning with women both before and during labour so women know what they can expect and can help themselves in the best ways possible. Ante-natal education plays a huge part in birth planning.


NICE guidelines require us to support women in their choices just as much as they set out time frames for delivery based on category of LSCS. Yet sadly the role of birth planning is given much less attention and women may remain oblivious to some of the options open to them, especially if such options are viewed as trivial and the situation is escalating. Yet this is the very time that we need to communicate best and try to impart a sense of control back to the woman.



Much of the discussion around birth plans revolves around whether or not a woman presents her midwife with her written birth plan when she attends in labour. Yet this debate seems to miss the point – Birth Planning is part of our role as midwives, not the job of the woman and her family! If a woman attends without a written birth plan that does not mean she does not have a birth plan, it just means she’s not written it down or that she is not yet aware of her options. Ask some midwives about birth plans and they may raise their eye-brows or roll their eyes, however ask a midwife about whether she sees herself as an advocate for women, with a duty to gain consent for procedures and most will be passionate in their response. I cannot see how this differs from birth planning! Every time we ask a woman a question about her labour we are essentially exploring her birth plan whether she presents it as such or not.


Birth planning goes far beyond a written document. Birth planning is about conversations, informed choice, empowering women. Its about dignity and respect. Its about ensuring that women are aware of their options. Some women spend lots of time researching their options and ensuring they are up to date with current practices and recommendations. Other women do not have access to the resources which empower them to make decisions about their care. And some women do not wish to make choices. They prefer to leave such decisions to the care givers who they believe will make the best choices on their behalf. But this in itself is a birth choice and should be respected as such. Others may not have been given the opportunity to engage in conversations. Part of our role as midwives is to create these conversations, ideally during the ante-natal period, but if not, then at the earliest opportunity, even if this is when the woman attends in labour.


Women who do attend with a written birth plan are often viewed with suspicion – how will they react if things don’t go according to the plan? They are often viewed as being inflexible just because they have written what they would like to happen down. This is an unjustified response. Written birth plans are starting points for conversations and most women will be grateful to any professional who takes the time to explore their plan, even if this is to suggest that elements of it may not be possible due to a specific situation or hospital policy. However if we are saying something is not possible then we really do need to think about why we are saying no, and at the end of the day we do need consent for anything we do or chose not to do as practitioners. We also need to support women in their choices and decision-making. We are there to guide and inform but ultimately choices are down to the woman and as practitioners we need to advocate for the women in our care. Sometimes it is easier to say something is not possible than to push boundaries, go against the norm or risk getting into trouble for breaking the rules.

I have no idea what the quote below refers to. I’m pretty sure its not to do with birth plans but it is an interesting concept. Society encourages us to set goals and plans in our lives from an early age. What do we want to be when we grow up? Think about family planning! Have you made plans for retirement? What are your holiday plans this year? People are encouraged to write their goals down to make them real and to share them with other people to create a support network which will allow them to achieve their goals. From the star chart for the toddler, and the promise of treats to the child that scores well in a test, to structured plans such as Weight Watchers or a personal fitness programme in adulthood or the making of a will, we all create plans and we all present them in some way. But when it comes to a woman making a plan for one of the most important events in her life, when she sets out her aspirations, her targets, her goals for her birth experience, she is often met with criticism and the plan itself is viewed as negative, as if it somehow tempts fate and inevitably leads to deviation and distress. Why would it be right to plan for all other aspects of our lives but not birth?



For women who go to theatre birth planning is just as important. Women may or may not be aware of their options in theatre. They may feel that everything has suddenly moved beyond their control. This can be disempowering and is a significant contributor to poor patient experience. Placing a degree of control back with the woman can be liberating and empowering in a time of emotional stress.


Birth plans incorporate many different elements of a birth. Women may express preferences about mode of birth, pain relief options, episiotomy or feeding choices. They may also reflect the importance of practices such as skin to skin or optimal cord clamping. Or they may simply reflect who they want as a birth partner or what music they want to play.

As health professionals there is a temptation to give priority to the things we rate as most significant and play down other aspects of a birth plan. Some professionals may see skin to skin as less important for example simply because it is not a priority in their unit and focus instead on pain relief options. However we need to recognize that if a woman has included it in her birth plan then it is important to her. Furthermore if things don’t go “according to plan” then other aspects which did not seem important before may suddenly gain importance and have the power to return a sense of control to a women.

For example a woman who was planning a pool birth went on to develop complications which resulted in an emergency LSCS at 29 weeks. Her plans for waterbirth, skin to skin and optimal cord clamping could not be supported but she was happy to do what was recommended for her baby at the time. In an effort to return an element of control the midwife asked if she would like music playing at the birth. The woman chose to have reggae playing. This small decision left her feeling empowered and gave her something else to focus on, contributing positively to her birth experience despite the difficult circumstances. This did not form part of her original plan as she did not “plan” to go to theatre but the on-going process of birth planning by her midwife meant that the plan adapted to the situation. Little things can have a big impact.


To conclude then I really don’t think we should use the term “birth plan” or “birth preference” – this relates to a noun. A fixed entity which implies something which has been completed. In contrast birth planning is a process which adapts and evolves with changing situations. Planning is a verb. To quote my old English teacher “its a doing word” – it reflects an ongoing discussion between the woman and her health care professionals which needs to continue throughout the birth experience and beyond. Birth planning can relate to  ideas presented by the woman as her preferred choices for birth but can also include elements that the woman might not be aware of as options and can adapt to changing situations around birth. Birth Planning is an essential part of our role as midwives and its importance should never be under-estimated.



Thank-you for reading

Please share

♥ Katherine ♥



Every unit should do #TheatreChallenge…



guide1-e1510140132250.jpgWhen our Birth Outside The Box team decided to facilitate staff lying on the table in theatre in order to gain insight and generate discussion about ways we can improve patient experience in theatre, we had no idea how popular and powerful the project would become. Our initial film was seen by thousands within a few days and the internet was soon buzzing with discussion of our little project.

“Why did it have so much impact?”

I think it was because it was such a simple idea, which was fun, and because we made it so easy to participate. Because we took photos of everyone and used them to illustrate ideas via facebook and twitter it meant that even team-members who couldn’t or wouldn’t come to theatre were still able to participate adding comments to the posts so they still played a part.

The popularity of the project has meant that several trusts are now considering doing their own #TheatreChallenge and it will be fascinating to see how the project evolves in different environments. Many people keep asking me how to do Theatre Challenge so I thought it was worth a blog post which sets out all the steps we took and the things we had to consider but bear in mind that every unit is unique so you may face different challenges in your unit and equally you will all have different experiences depending on how your unit works to start off with.



You need to make sure everyone is on-board with your project and you need to ensure that the “sub-teams” are also included. They might not be keen on your idea to start off with but try to include at least some members of each team at each stage of the project. This gives them ownership and they will be more likely to spread the word.




We have 2 theatres on our labour ward so we decided that if theatre 1 was free then there was very little danger of needing to use theatre 2 in a rush. So theatre challenge took place in theatre 2 when theatre 1 was empty. Your ward may well work differently so you need to work out a plan which works for you.



Don’t be dis-heartened if you meet with some resistance at first. There is always a way round every problem. I was initially told that issues relating to infection control and access would make the project impossible but once we came up with a plan and spoke to theatre team managers they were happy to support us and we’ve not had any issues at all with using the theatre. We posted laminated copies of the dress-code etc on the door of theatre 2 and in handover room so everyone knew what they needed to do.


You can view the film we made here:   It didn’t take long to make and we involved theatre team in our filming.




You really don’t need very much kit for theatre challenge. Obviously you will need a set of drapes but if you store them somewhere safe the same set can be re-used. That’s about it! Just make sure that there are plenty of scrubs for people to wear.






We experimented with different scenarios but none of it was pre-planned. We just put people on the table and let the conversations evolve. It was interesting learning how the theatre bed and all its component parts worked. You might find it useful to have a member of theatre team present to help you with the attachments.



We created pledge forms for staff and feedback forms for the women and we also created a display so that staff could reflect before and after the challenge and comments from facebook were included in the display. All pledges were then added to the display as we went along. You might decide to use a newsletter instead or have a formal meeting for staff reflection.


“If you don’t have a forum then you really should. Its an excellent way to share unit news, articles relating to CPD and encourage staff to attend study days and conferences.”

We found using our unit’s private facebook forum an excellent way of involving staff who weren’t there on the first day and letting people know when we were aiming to have a session. Most of the the time it was impromptu. We shared photos on the forum with comments and this encouraged people to reflect on their own experiences. All participants were made aware that pictures would be posted and encouraged to post their own photos. I have to say that any initial concerns that staff might be inappropriate were quickly dispelled. Everyone posted responsibly and thoughtfully. This allowed us to post some emotive images that normally would never be shared from theatres and this in turn prompted lots of discussion and ideas. Posts on twitter gave the project a much wider reach and meant that professionals from other units were also able to contribute. A post on our local MSLC page also generated useful contributions from women who had been to theatre with the “tilt” being a big issue for these women.

“#TheatreChallenge has given staff the confidence to try new things to improve patient experience and allowed staff to see things from the point of view of the different professionals involved in care”




I cannot begin to stress enough just how much fun we had doing #TheatreChallenge. However amidst all the laughter was a huge amount of learning. Lying on the table is incredibly powerful, especially when the drapes go up.




The project created a buzz in our unit which is still there. The atmosphere in theatre is different. Staff feel enabled to try new things and to ask women what would help their experience. Not only did the project enable staff to see things from the woman’s point of view but its also allowed the theatre team to see it from the midwives point of view and vice versa. Doctors became aware of issues facing midwives such as the importance of skin to skin and midwives were able to see things from the anesthetists’ point of view. This has helped to create a more cohesive team in theatre. It is notoriously difficult to change practice in any unit but #TheatreChallenge has created a forum whereby multiple ideas can be considered at once and because these are being viewed in the context of the bigger picture with all members of the team included they will hopefully be more likely to be successfully implemented.





Thank-you for reading. Please share

Katherine x

My Own Journey with #TheatreChallenge


#TheatreChallenge was a project @ Royal Derby Hospital run by the Birth Outside the Box Team. During the week of the 9th – 15th October 2017 we arranged for staff to be able to lie on the table in our labour ward operating theatre in order to gain insight into how it feels to be a woman transferred to theatre and to generate discussion of ways we can improve the birth experience for these women. This blog entry is about my part in this project and how it has changed me as a midwife and as a person.

Why is a birth centre midwife talking about theatre experience?

Our @DerbyBOTB team had facilitated several projects including changing the way beds were set up on labour ward and a new aromatherapy training day and guideline. The aim of the forum is to bring midwives, doctors and other team members together with the common goal of increasing rates of physiological birth and improving patient experience for all births regardless of mode of birth or where they occur. We now wanted a project which would appeal beyond the midwifery team so we could involve obstetricians, anaesthetists etc in our work.


We realised that theatre patients represented the group of women as far removed from pysiological birth as you can get and when we looked into our unit’s statistics we realised that well over 1/3 of all our women went to theatre in 2016. That was a lot of women! I tried to think of a good way to engage staff in an activity that would encourage us to think of ways we could improve the birth experience for these women, and inspired by #MatExp and their #LithotomyChallenge project it occurred to me that lying on the bed in theatre would be a really simple way to get people participating and thinking.


So I started talking to people about my idea – only to be met with blank looks. People couldn’t really see how this would change anything. Even people who listened to me couldn’t see how it could ever happen – how on earth would I get permission to use theatre? how would we fit in round unit activity? Why would we even want to do this? Undeterred I kept rabbiting on and looking back I can see how key this is to bringing about change. Unless you are a really public figure, no matter how good your idea is, people will generally smile sweetly and move on when you first start talking. The key thing is that you persist.


Then I got lucky. I found someone who “got” my idea. And suddenly I wasn’t just rabbiting on anymore – I was having a conversation! I saw a tweet recently “Conversations are the smallest unit of change”. This is so true! I started having conversations with my buddy on our BOTB WhatsApp group and the other members of our group gradually got sucked in by our enthusiasm. And suddenly it wasn’t just a conversation between 2 people anymore – it was a project!

“Conversations are the smallest unit of change”

We wanted to get across the key message that the woman’s pespective is very different to ours so we made a simple little film by attaching a gopro to someone’s head and pushing her round to theatre on a bed. You can watch the film here – its amazing how powerful the effect is!

We posted the film on our unit’s private facebook page to start conversations with staff. We had a HUGE response. We divided the posts into 8 themes and created a display around each one which included information, references to local and national guidelines, images and quotes from the group.

  • Skin to skin in theatre
  • Optimal cord clamping
  • Dignity
  • Babies that go to NICU
  • Theatre Birth Plans
  • Keeping families together
  • Theatre Environment
  • Teamwork

You can view the 8 mini films here:However we wanted to include ideas from beyond our unit so we created a twitter account @DerbyBOTB and posted on twitter too. Within days our little film had been viewed thousands of times. Aware we needed to keep the momentum going we created 8 mini-films around the themes and posted these as well. By the time we got to #TheatreChallenge week our own unit and units across the country were buzzing with discussion. The reach was amazing!

#TheatreChallenge mini films on YouTube

#TheatreChallenge week became #TheatreChallenge MONTH as so many people wanted to take part and it was challenging utilizing an active theatre space around unit activity. However we felt it was really important not to exclude anyone who was keen to participate. We had all sorts of people on the table:





WP_20171019_08_24_34_Pro…….. our housekeeper,

WP_20171009_14_45_12_Pro…….. HCAs 

22815361_10214847399727477_4778408373077167283_n…….. even some hospital governors!

We continued to post photos of participants on Twitter and Facebook along with thought provoking comments from our participants. The impact was HUGE! All sorts of ideas were put forward for things we could change – from dimming the lights and playing music to moving the resucitaire and keeping families together for return to theatre events. Not everyone agreed about the things we should do and not all of the changes will ever come into practice but the crucial point was that we started the conversations!

You are your own change inspirational quote

The following week our unit was hosting its own “Progressive Birth Conference – #ProgBirth17” and somehow I found myself as one of the speakers. This was nerve-wracking – I’d never done anything like this before – however #TheatreChallenge had been so important in our unit that it felt important that someone should talk about it at our conference so that someone ended up being me!


I got such an amazing reception. It was incredibly empowering and moving to see my own colleagues so full of passion. I spoke about #TheatreChallenge and presented the film I’d put together to show what we had achieved:

#TheatreChallenge – The Movie

However I also tried to make the point that we are all responsible for change. No matter how small and insignificant we feel, change has to start somewhere and remember – Conversations are the smallest unit of change!


We quickly realized during #TheatreChallenge that change has to be a team effort. If you want to facilitate skin to skin in theate then you need the anaesthetist on board to position the stickers for monitoring out of the way. If you want to facilitate optimal cord clamping then you need the theatre team to cover the baby with a sterile towel so it doesn’t get cold. We therefore made including the whole team one of our priorities with the tag line 1 woman = 1 team.


I passionately believe that staff need to believe that they can bring about change and that one of the most effective things any unit can do is to empower their staff to facilitate change. Innovation is a huge driver and the NHS claims to be passionate about change with specific departments focused on innovation and leadership. But on the shop floor it can feel very different. Midwives often feel they have little power to bring about change so they often don’t try. Students bursting with enthusiasm seem to fade into subdued practitioners very quickly. I am constantly being told that “Women need to drive change” not midwives. But midwives are meant to be advocates for the women we care for and midwives are women too.


I am not special. I don’t posssess any superpowers which mean that I can bring about change when others can’t. The reaction of my colleagues at our local conference demonstrated that they share my passion and enthusiasm. And the reaction on twitter shows this passion is shared far and wide. I do attend conferences as a way to rekindle my enthusiasm when my mojo has been under fire and I do find twitter an excellent resource for evidence to support my ideas and as a means of sharing my passion. But every single midwife and student midwife out there has the power to do the same. You just have to believe in yourself and your idea.

Hand holding a Social Media 3d Sphere

I feel that #TheatreChallenge has changed me as a midwife and as a person.

#TheatreChallenge demonstrated that I (and YOU) have the power to create ripples and that my ideas (and YOUR ideas) are just as valid as those put forward by public figures and institutions. I have always been full of passion but I think I have been “quietly passionate” – I’ve never been the one to put my hand up in meetings or try to out-talk my adversaries. But I have discovered that social media is a great tool to get your message out there without having to shout. In an age when so many practitioners feel they are not heard, twitter especially is a great way of speaking out. And with so many women out there telling us that birth experience is just as important as patient safety we need to start speaking up on their behalf.


However once you discover that you do have the power to make people listen you will start to gain confidence. Suddenly I find myself feeling positive about speaking at scary meetings or presenting in public spaces. I am still daunted by this don’t get me wrong but I am fueled by a deep inner passion which is carrying me beyond nervousness and shyness. #TheatreChallenge has helped me to find my voice. I hope you can find yours!


presentation (2)

Thank-you for reading. Please Share.

Katherine x