A Pelvic Floor PT's Birth Plan: the long version.
I’ve seen a couple of these from other pelvic floor PTs on Instagram in the past and I’ve been getting asked a lot about my own birth “plan” lately. I posted an abbreviated version on instagram earlier but I wanted to take the opportunity to elaborate on things a little further. Plan is very specifically in quotations here because it’s really more of my birth *preferences* in an *ideal* scenario. I tend to see the most trauma (emotional and physical) from my patients when things didn’t go according to plan, when someone tried too hard to stick to their plan when it wasn’t working for them, or when they felt they had no agency. Like so many things in life, when reality varies significantly from expectations, it creates turmoil. So I’ll let you in on my preferences and why, but keep in mind, this is all from a pelvic floor PTs perspective, there are MANY other things at play during delivery. Mom and baby safety are priority one, but I would say a very close second is mom's long term health, which can be, unfortunately, often overlooked when making decisions during labour and delivery.
Background:
First just the background: I will be delivering in a hospital and my primary care practitioner for this pregnancy is a midwife. I’ve been fortunate to have an uncomplicated pregnancy to date and work with a fabulous group of midwives who are incredibly supportive. We are very fortunate in Canada, particularly BC, to have access to outstanding midwifery care. I think there are still a lot of misconceptions about midwifery - the most common question/comment I get is "oh you're with a midwife- you don't want to be with a doctor? So are you doing a home birth?" Midwives are highly trained birth professionals who have hospital privileges. They can also do home births if that's your preference. In BC, they are covered under MSP and if you have an uncomplicated pregnancy, you have the choice to either work with a GP who does obstetrics or a midwife. Typically you need to find your own midwife, but you do not pay extra for a midwife and traditionally they are known for providing more patient-centric care. This is not a knock on other birth professionals- just a comment. Obstetricians on the other hand are highly specialized and typically reserved for more complicated pregnancies and they generally require a referral in our system. A doula (still often confused with a midwife) is not a midwife, they are a birth support person. They cannot deliver your baby, but they are tremendous for providing emotional and physical support during delivery and have been shown to reduce the need for pain management along with many other benefits (Bohren et al 2017). They are not covered by MSP in BC. I do not have a doula, but I would highly recommend one if you feel you need additional support through your delivery. I'm digressing- but just want you to have the info. On to the preferences.
1. Vaginal Delivery
I will be attempting a vaginal delivery because at this time there’s no indication for a planned C-section, but I am not dead set on a vaginal delivery, if something isn’t right, I am very open to a C-section (and know that if something emergent occurs, I may not have a choice) but I also recognize that it is a major abdominal surgery that comes with its own territory for recovery.
2. No Epidural
I would like to avoid an epidural, not because I have a desire to experience pain or want to be a hero, but because it is my strong preference to move around as much as possible during labour and to deliver ideally in quadruped (on hands and knees), but at the very least, not on my back because we weren’t really designed to deliver babies that way (you see this in movies because it looks better cinematically and it was traditionally done because it’s easier for docs to see/access what they need to- or in some cases medical reasons require it). Epidurals can also lengthen the pushing phase of labour (where a lot of the pelvic floor injury can occur) because it's harder to be guided by your contractions, but this isn't the case for everyone. If I’m in labour for a very long time and completely exhausted or not managing pain well, I’ll absolutely take the epidural. My hope would be for a light one (known as a "walking epidural") so I can change positions but that isn’t always possible ("walking epidurals" are notoriously difficult to achieve) and I’m aware of that.
3. No instrumentation
I would hope to avoid forceps because these are associated with perineal injury particularly levator avulsion (van Delft et al 2014), which refers to a portion of pelvic muscle tearing away from where it attaches on the bone. It is known to increase the risk of pelvic organ prolapse (Dietz 2015). Again, if something emergent arises- I’m not closed off to the idea entirely. As I mentioned previously, baby safety is number 1, but mom’s long term health is also very very important. If forceps are suggested, my partner or I will ask the following questions:
1. What are the alternatives and how much time do we have to make that call?
2. What type of forceps (outlet, mid, or high). Outlet (or low) forceps are used when baby is mostly descended through the birth canal and typically just stuck under pubic bone. At this point if you opt for a C-section, you've experienced a lot of the perineal/pelvic floor trauma that can occur and baby may need to be pushed back up the birth canal to perform a C-section- so now you're looking at recovering from a C-section and almost the equivalent of a vaginal delivery. Mid or high forceps are used when baby is further up the birth canal, and as a result can cause even more damage to the pelvic floor- I personally would likely opt for a C-section over the use of mid or high forceps if it were an option at that point.
3. Are we certain baby is in the appropriate position for forcep usage? Baby must be in the correct position for a forceps delivery to be appropriate. Chances are, your practitioner knows this, but do not hesitate to ask- (also for clarification, if it comes to forceps, generally a midwife would not perform this, an obstetrician would typically be involved by this point).
4. Is there a size issue here? Known as cephalopelvic disproportion, which is just a fancy term to describe the fact that baby's head is too big for mom's pelvis.
5. If I opt for a C-section at this point am I putting baby at risk?
6. Have you done this before? It's important that the practitioner is appropriately trained and experienced with forceps, it's okay to ask this question. That being said, sometimes a situation is emergent and you need to make a call in less than ideal circumstances.
4. No episiotomy
Episiotomies are not common practise in Canada at this point as natural tearing has shown to be better for healing and the initial thought that episiotomies prevented more extensive tearing has been shown to not be true. Exceptions to this are when a shoulder is stuck behind your pubic bone, baby’s heart rate is abnormal and so he needs to come out quick, or when forceps are used, in which case they are associated with decreased incidence of anal sphincter tearing (Muraca et al 2019).
5. Limit pushing time
If I have not had an epidural and been pushing for 60-90 minutes *with ZERO or extremely minimal progress/descent* I’ll be asking about a C-section. Although the ACOG recommendation is greater than this for nulliparous women (women who haven't had babies yet), pushing for greater than 2 hours is associated with increased risk of levator avulsion (van Delft et al 2014), which is ultimately associated with greater risk of pelvic organ prolapse. It's important to allow enough time for your body to figure out how to push correctly, but if you've reached an hour or more with minimal progress, it's a good time to consider other options.
6. Spontaneous non-directed pushing
This is simply my preference and what it means is I would prefer to try and listen to my body about when to push and not be told when to push. This tends to result in shorter, more frequent bursts of pushing through each contraction rather than one or two longer pushes through each contraction. That being said, I may be terrible at this and need the coaching, and that's totally okay with me.
7. Manual splinting of the perineum
Your practitioner has to be comfortable with this, but it isn’t a complicated technique. It's essentially a fancy way of saying, using a hand to support the perineum through pushing, there is some evidence to suggest this reduces perineal tearing. (Pirhonen et al 1998).
Those are the big ones. Unforeseen things may arise, and that’s okay. If you have questions about this- don’t hesitate to ask me.
I want to stress the importance of flexibility during delivery, of being open to changing your plans, and most importantly of not judging yourself when things need to change. You did not fail. You are no less woman, no less superhuman because you took pain meds or had an epidural or needed a C-section. Please also know, you have choices and you’re allowed to ask questions. And if things don’t or didn’t go according to plan and you end up with a C-section after pushing for 3 hours, or forceps are used, or you have a levator avulsion, or pelvic organ prolapse- I promise you, you are not broken. Prolapse and tears and avulsions sound scary as hell but these things happen. Bodies can recover, although an avulsion may not heal, there are still things you can do, and it is never too late to seek treatment.