- Childbirth: Protecting Your Pelvic Floor 08/29/2017
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Childbirth: Protecting Your Pelvic Floor
The second stage of labor – the period between when your cervix is fully dilated and when the baby is born – is a physically demanding, mentally challenging, ultimately rewarding experience. This is the time when your body begins to expel your baby from the uterus, and when you begin pushing in concert for your baby to be born. Your hormones will help to keep your body functioning, but how you push can impact how long it will take. Out of necessity, your pelvic floor muscles and your perineal tissues can be stretched and torn in the process. How you manage this part of your labor can impact how severe (or minimized) the damage.
If you haven’t had pain medications, you will be instructed to push as soon as you feel the urge to do so. If you’ve had an epidural for pain relief, you may not feel the urge to push at all. Your provider may suggest you “labor down” – meaning the epidural medication will be discontinued and you will be allowed to wait until the effects of the epidural wear off and you feel some sensation to guide your pushing. In other cases, you may be guided by the hospital staff on when and how to push even if you cannot feel the sensations of doing so.
Different doctors and hospitals have different parameters for how long a woman can push before intervention. Some interventions are more directly related to your pelvic floor health than others. You may experience an episiotomy (a surgical incision to enlarge the vaginal outlet) or assisted delivery (with forceps or a vacuum extractor). You may also experience a perineal tear, which is often less severe than a surgical incision (episiotomy). If pushing goes on for too long, your provider may suggest cesarean surgery.
How you breathe can help
If you’ve ever watched a birth scene in television or film, you’ve probably seen women holding their breath and pushing. And that’s what is typical in most hospital births. When it’s time to start pushing, a nurse may suggest talking a deep breath in and holding it while bearing down – maybe even while counting to ten. Ten is a long time to hold your breath when you’re doing hard, physical labor. You may tire faster – and your uterus might too – because you aren’t getting the oxygen you need. This can affect your baby, too, causes changes in the heart rate that can lead to other interventions.
Instead, experts recommend breathing through the pushing, sometimes referred to as spontaneous bearing down. As you feel the urge to push starting, take a deep breath in then release it slowly as you push. You can likely do this several times during each contraction, then rest in between, breathing normally to recover. Women using this spontaneous method may grunt or moan while pushing – which some believe can help to relax the pelvic floor. While directed, forceful bearing down can cause unnatural pressure on the perineum, bursts of gentle, mother directed spontaneous pushes can protect the pelvic floor from undue damage.
A recent meta-analysis showed no difference in outcomes between these two types of pushing, but the studies used were not high-quality. The authors suggest, “women should be encouraged to push and bear down according to their comfort and preference” (Lemos et al, 2017). Other researchers say that spontaneous bearing down shortens the length of second stage and improves maternal satisfaction, even if it doesn’t decrease intervention rates (Yildirim & Beji, 2008).
Positions make an impact
Historically, women are depicted and described as giving birth in upright positions. Whether sitting on a birthing stool or using a rope or pole for squatting support, women knew that gravity could help the baby descend. Additionally, these positions allow the mother’s tailbone to move out of the way and her pelvis to remain mobile so that baby’s descent isn’t impeded by mom’s anatomy.
Despite the overwhelming evidence that positions such as squatting, standing and side-lying are more effective for birthing a baby, only 10% of women in the US use them when pushing. Another 23% report birthing in a semi-reclining positon (which may be better than lying flat on her back, but still puts her body in an unnatural position for birth). In fact, most women give birth lying on their back, or with their feet in stirrups. These positions cause the baby’s head to put undue stress on mom’s perineum, making damage to the pelvic floor much more likely.
While squatting does open the diameter of the pelvis allowing more room for baby to move through, it is tiring for most women to sustain squatting. Side-lying, hands and knees and semi recumbent positions allow for more relaxation, less back pain and improved perineal stretching (as opposed to tearing).
If the force of the presenting part (most often baby’s head) can be controlled, the perineum can be protected from excessive stress and damage. Spontaneous pushing and upright positions are a start, but physically supporting the tissues can help, as well.
Warm Compresses: When a birth partner uses a moist warm compress against the laboring woman’s perineum during pushes, it’s less likely that she will experience perineal trauma during the birth. This can be as simple as placing a washcloth in a basin of warm water, then wringing it out and holding it against her bottom during contractions.
Perineal Massage: By massaging the perineum in the final month or so of pregnancy, women may find that it stretches more easily during birth. This may be a fun exercise to do with your partner! Be sure to use a gentle lubricant, and use enough pressure that you can feel the stretch. Research shows that when a woman does this this type of massage one or twice a week from the 35th week of pregnancy, she is less likely to need an episiotomy or to have prolonged pelvic floor pain in the postpartum (Beckman & Stock, 2013).
Perineal support: This counterpressure technique can be used by your midwife or obstetrician to slow the crowning so that baby’s head doesn’t damage the pelvic floor tissues.
Getting back into shape after birth
As soon as you feel up to it after the birth, start regular Kegel exercises. Within the first 24 hours after birth, start contracting and releasing your pelvic floor while lying on your back with your knees bent. When you first begin, try holding the contraction for 3 to 5 seconds and repeating 10 times 3 times per day. Work your way up to holding for 10 seconds at a time by the end of the first postpartum month. Imagine the pelvic floor as a soapy sponge that you’re squeezing underwater – you’re squeezing out soap, and allowing the sponge to fill with water when releasing. This is what Kegels are doing for your tissues – squeezing out the old blood, and pulling in fresh blood to help with the healing process. This strengthening will return the pelvic floor to its pre-pregnant state sooner, will speed the healing of any incision or tear to the perineum, and will lessen the risk of complications, such as urinary incontinence or pelvic organ prolapse.
Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub3.
Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub3
DiFranco, J. T., & Curl, M. (2014). Healthy birth practice# 5: Avoid giving birth on your back and follow your body’s urge to push. The Journal of perinatal education, 23(4), 207-10.
Lemos A, Amorim MMR, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD009124. DOI: 10.1002/14651858.CD009124.pub3.
Yildirim, G., & Beji, N. K. (2008). Effects of pushing techniques in birth on mother and fetus: a randomized study. Birth, 35(1), 25-30.