In 2021, the American College of Obstetricians and Gynecologists published Committee Opinion number 819 titled “Informed Consent and Shared Decision Making in Obstetrics and Gynecology” (1). In this document, they suggest initiating conversations about delivery possibilities during prenatal care and to continue these conversations at time of admission. One of the tools that providers can use to facilitate these conversations is a birth plan. A birth plan is a written outline where patients can fill out their preferences during labor and delivery. Birth plans have been associated with increased scores for communication, satisfaction, and trust (2). Patients have also expressed increased confidence and understanding of the labor process when using a birth plan (3). Although the data is mixed on delivery outcomes, there is evidence to suggest that the use of a birth plan is associated with an increased likelihood of a vaginal delivery (4, 5), although this is not consistent across all studies (6). Additionally, birth plans have been associated with improved umbilical cord pH (7), and a reduction in the need for advanced neonatal resuscitation (5). In the post-partum period, birth plans have been associated with higher rates of breastfeeding in the birthing room (8). Given there is a growing body of evidence to suggest improved outcomes associated with birth plans, we implemented standardized birth plan counseling as a quality improvement study.

The objectives of this QI project were twofold. The first objective was to assess the ability of a shared group practice to implement a standardized birth plan protocol, and the second objective was to assess actual birth route in patients included in the implementation of a standardized birth plan protocol. A pre-approved birth plan was utilized for this study and was available in English and Spanish. Patients were included if they were in the third trimester admitted for planned vaginal delivery of a live intrauterine pregnancy. Exclusion criteria included primary language other than English or Spanish, gestational age < 28 weeks at time of admission, pregnancy with intrauterine fetal demise, admission for planned cesarean section, or admission without intent of delivery. On admission to labor and delivery patients were offered a birth plan if they did not provide their own. The birth plan was reviewed prior to delivery if the patient was amenable. The shared admission history and physical note template was adjusted to include a standard phrase to document various data points regarding birth plans. The data points documented in labor history and physical and progress notes included birth plan provision, review, and if a birth plan was declined or if the patient provided their own birth plan on admission. A retrospective chart review of all births from 1/6/2025 to 3/6/2025 at OU Children’s Hospital was performed to extract data points for patients meeting study criteria. This data collected was de-identified and stored in a password-protected Redcap database. Outcomes analyzed included proportion of patient and hospital provided birth plans reviewed further stratified by prenatal clinic and route of delivery. 

667 patients were admitted to labor and delivery at OU Children’s Hospital during the study period for a planned delivery. 448 patients met inclusion criteria for the study. Overall, 79 patients (17.6%) had a birth plan reviewed on admission. 369 patients (82.3%) either did not have a birth plan reviewed by a provider on admission or declined to have a birth plan reviewed. Each patient’s prenatal clinic was documented. The majority of patients (170 patients, 37.9%) admitted during the study period received prenatal care with a private provider at OU Physicians. 35 of these patients (20.6%) had a birth plan reviewed with a provider on admission. 127 patients (28.3%) received prenatal care at Variety Healthcare Clinics, with 16 of these patients (12.6%) having had a birth plan reviewed on admission. 96 patients (21.4%) received prenatal care at the High-Risk Obstetrics Clinic at OU, and 23 of these patients (24%) had a birth plan reviewed on admission. 30 patients (0.067%) received prenatal care at the resident-run Scissortail clinic, with 4 of these patients (13.3%) having had their birth plan reviewed on admission. 25 patients (0.056%) received prenatal care outside of the OU system, and 1 of these patients had a birth plan reviewed on admission. There was no statistically significant association between prenatal clinic and likelihood of having a birth plan reviewed on admission (p-value = 0.05). 

Regarding mode of delivery, during the study period, 56 patients (12.5%) underwent a cesarean delivery. 392 patients (87.5%) underwent a vaginal delivery. 11 patients (19.6%) who underwent cesarean delivery had their birth plan reviewed with a provider during the admission. 68 patients (17.3%) who underwent a vaginal delivery had their birth plan reviewed with a provider on admission. There was no statistically significant association between mode of delivery and likelihood of having a birth plan reviewed on admission (p-value = 0.67).

Despite implementing a protocol to review birth plans on admission to labor and delivery, the rate of uptake of this protocol was low at only 17.6%. We suspect the low adherence to the protocol was multifactorial due to personal and systemic issues, including an already high workload present on labor and delivery, time constraint on the admission process, fatigue of protocols and documentation, and switching between multiple providers from when a birth plan was provided on admission to when it needed to be reviewed. A better opportunity to implement standardized birth plan counseling may be during routine prenatal visits and should be explored. This may also allow more time for patients and their support system to review birth plans, present questions to providers, and to make patient centered adjustments to plans. There was no statistically significant association between prenatal clinic and likelihood of having a birth plan reviewed on admission. This was expected given residents admitted all patients to labor and delivery despite different sites of prenatal care and suggests that the care provided during admission was unbiased. Additional studies are warranted to determine birth plan counseling’s effect on patient and provider satisfaction.

1. Informed consent and shared decision making in obstetrics and gynecology. (2021). Obstetrics & Gynecology, 137(2).  
2. Anderson CM, Monardo R, Soon R, Lum J, Tschann M, Kaneshiro B. Patient Communication, Satisfaction, and Trust Before and After Use of a Standardized Birth Plan. Hawaii J Med Public Health. 2017;76(11):305-309. 
3. Moore M, Hopper U. Do birth plans empower women? Evaluation of a hospital birth plan. Birth. 1995;22(1):29-36. doi:10.1111/j.1523-536x.1995.tb00551.x 
4. Afshar Y, Wang ET, Mei J, Esakoff TF, Pisarska MD, Gregory KD. Childbirth Education Class and Birth Plans Are Associated with a Vaginal Delivery. Birth. 2017;44(1):29-34. doi:10.1111/birt.12263 
5. Hidalgo-Lopezosa P, Cubero-Luna AM, Jiménez-Ruz A, Hidalgo-Maestre M, Rodríguez-Borrego MA, López-Soto PJ. Association between Birth Plan Use and Maternal and Neonatal Outcomes in Southern Spain: A Case-Control Study. Int J Environ Res Public Health. 2021;18(2):456. Published 2021 Jan 8.  
6. Deering SH, Zaret J, McGaha K, Satin AJ. Patients presenting with birth plans: a case-control study of delivery outcomes. J Reprod Med. 2007;52(10):884-887. 
7. Hidalgo-Lopezosa P, Rodríguez-Borrego MA, Muñoz-Villanueva MC. Are birth plans associated with improved maternal or neonatal outcomes?. MCN Am J Matern Child Nurs. 2013;38(3):150-156. doi:10.1097/NMC.0b013e31827ea97f 
8. López-Gimeno, E., Falguera-Puig, G., Vicente-Hernández, M. M., Angelet, M., Garreta, G. V., & Seguranyes, G. (2021). Birth plan presentation to hospitals and its relation to obstetric outcomes and selected pain relief methods during childbirth. BMC Pregnancy and Childbirth, 21(1)