Birth

Physical Preparation for Childbirth

I’ve often heard touted that nothing can prepare the body for childbirth or that nothing we do can possibly make the physical experience any different. It’s a common misconception. While it’s true that there’s few experiences that come near to the physical intensity of childbirth, there are indeed a range of techniques that can help prepare the body for the physical requirements of childbirth.

Muscles of the Pelvic Floor
The birthing process requires the coordinated effort of different muscles, in particular the pelvic floor muscles. The pelvic floor is made up of several muscles that support the pelvic organs like a hammock. These muscles are under voluntary control, meaning you decide when to contract or relax them. During labour the pelvic floor muscles are supposed to relax allowing the baby to descend as surges (contractions) nudge baby down further and further until born. While the pelvic floor muscles are relaxing, muscles of the abdomen also contract to help push the baby out during the decent stage. Women who are anxious during labour tend to contract instead of relax the pelvic floor muscles, meaning when baby nudges downward with the force of surges or voluntary abdominal muscle contraction, baby is effectively pushing against an unyielding muscular wall. When a labouring woman experiences pelvic pain, this may cause her to involuntarily tighten her pelvic floor muscles, creating a cycle of ongoing pelvic pain and increased pelvic floor muscle tension.

The major muscles of the pelvic floor are the levator ani, puborectalis, pubovaginalis, and spincter urethrae (pictured below).



Promoting Pelvic Floor Relaxation

Exercise 1: The Elevator
This exercise is done to gain full control of the pelvic floor muscles, increase flexibility, and develop awareness of tension/relaxation, which is important for labour.

  1. This exercise may be done in any position, although one that eliminates the forces of gravity, such as lying down, is easier.
  2. Imagine you are riding in an elevator. As you ascend to each floor, try to draw up the perineal muscles a little more until you reach complete tension. When you reach your limit, don't let go.
  3. Now descend, floor-by-floor, gradually relaxing the muscles. When you arrive at the ground floor (no tension), take the muscle group to the basement with a gentle blowing out breath through pursed lips. This should feel as if the perineum is bulging. This is very gentle bulging of the pelvic floor, bearing down too strongly can be counterproductive.
  4. Complete the exercise by lifting up the muscle back to the ground floor level.
  5. Repeat the entire exercise and remember to breathe normally as you tighten the pelvic floor muscles. To start with, do 5 in a series, holding each muscle contraction for 5 seconds, then releasing. Try to gradually build up to a series of 50.

Practice this exercise everywhere! This exercise can be done without anyone being aware of what you are doing. Some ideas: At red traffic lights, while cooking or brushing teeth, during commercials on TV, during sexual intercourse, anytime you are waiting, especially while standing, when coughing, sneezing, laughing, lifting, climbing stairs, straining, or squatting.

Exercise 2: Pelvic Floor Relaxation
This is a relaxation exercise which should not only help to relax your muscles but also relax your mind.

Source: http://www.michellealva.com
  1. Lie down on a comfortable surface on your back.
  2. Place the soles of your feet together and open up your hips.
  3. Extend your arms straight out form your sides.
  4. Take a deep breath in through the nose into the pit of your stomach focusing on relaxing your pelvic floor muscles. Breath into your diaphragm.
  5. Exhale slowly while maintaining focus on relaxing your muscles.
  6. Visualise your pelvic floor muscles relaxing and warmth pouring into the pelvic floor region.
  7. A warm pack placed over the pubic area or lower abdomen can assist pelvic floor relaxation if desired.
  8. Try to relax for about 20 minutes.

Exercise 3 : Easy Pelvic Floor Stretch
This stretch will give you a pleasant stretch to your pelvic muscles as well as giving your muscles a chance to relax.

Source: slism.com

  1. Warm up with some light stretches to get your blood moving.
  2. Lie Flat on your back in a comfortable spot or yoga/exercise mat.
  3. Place a folded over pillow (foam rollers, and other semi-firm shaped objects can be used) under your buttocks or upper thighs.
  4. Spread your arms directly out to your sides or stretching out above your head flat on the floor for a more intense stretch.
  5. Hold this position and breathe deeply focusing on relaxing your pelvic floor muscles.
  6. You should find as you take a deep breath into your diaphragm that you pelvic floor muscles will naturally relax, also relax your anus and surrounding muscles if you are prone to hold tension in these areas.
  7. Do this exercise for 10-15 minutes a day to help promote relaxation in your pelvic floor muscles.

Note: Always consult your physical therapist or doctor before performing any new exercises. This exercise can put a bit of strain on your lower back and abdominals so please take it easy and start with a smaller pillow and work your way up.

The KEY to this exercise is to have your pelvic bone as the highest point to not just relieve the pressure of the weight of your body bearing down on your pelvic muscles but to help produce an effective stretch.
The video below will also help you in loosening those tight hip rotators in order to perform the pelvic floor relaxation easier: http://www.youtube.com/watch?feature=player_embedded&v=BW1tskfu7cI

Exercise 4 : Pelvic Floor Massage - The Tennis Ball
Massage can be a very useful tool in fighting pelvic floor tightness. When used to loosen tight muscles before a stretching session you should experience better range of movement and a more intense stretch. The muscle we are primarily trying to target here is the perineum which for women between the vagina and anus. This is a common exercise used by dancers to push blood through the pelvic floor muscles and encourage the pelvic muscles to relax.


  1. Warm up before this exercise, either with a quick jog on the spot or heat pad on the perineum just to warm up the muscles before massage.
  2. Sitting on a chair or on the floor, place the tennis ball under your perineum and gently ease your body weight onto it.
  3. Breathe deeply and relax into the ball focusing on relaxing your perineum and surrounding muscles.
  4. You may feel involuntary contractions try to focus and prevent these from occurring.
  5. Stop after 3-5 minutes.

Vaginal Dilator Therapy
Vaginal dilators (shown below) are designed with progressively increasing length and/or diameter, and are used to help a woman become accustomed to vaginal penetration and to help train pelvic floor muscle relaxation. Vaginal dilators are usually used in the comfort and privacy of your own home.


The Epi-No vaginal dilator is designed to prepare the vagina and pelvic floor for childbirth and to restore after-birth muscle tone. It consists of a silicone balloon and a hand pump with an integrated Biofeedback pressure gauge to monitor muscle-tone improvement of the pelvic floor muscles.
The German Epi-No Trial (Schuchardt et al. 2000) measured Anxiety, Analgesic Use, Length of Second Stage Labour, Perineal Outcomes and Apgar Scores after 1 and 5 minutes. The Trial found that..." with daily EPI-NO training it is possible to reduce the anxiety of birth significantly. By reducing anxiety of birth it is also possible to shorten the second stage of labour as well as the analgesics requirements. By a slower, more gentle pre-expansion of vulva and vagina regulated by the woman herself, it has been possible to reduce injuries to the vulva as well as the vagina significantly." You can buy the Epi-No here: http://www.epino.de/en/epi-no.html

Biofeedback
Pelvic floor relaxation can be practiced with specialized physical therapy known as biofeedback. Biofeedback helps to improve a woman’s pelvic floor muscle sensation and coordination. There are various effective techniques used in biofeedback. The most effective technique uses a small probe placed in the vagina (the Epi-No pictured above is one such device) or electrodes placed on the surface of the skin around the opening to the vagina and on the abdominal wall. These instruments detect when a muscle is contracting or relaxing and provide visual feedback of the muscle action. This visual feedback helps the individual understand muscle movement and aids in improving muscle coordination. Approximately 75% of individuals experience significant improvement with biofeedback. For more information on biofeedback for pelvic floor relaxation see the following links:
Pelvic floor biofeedback video: http://www.youtube.com/watch?v=731f9aDlG5Y
Study on pelvic floor biofeedback: http://www.ncbi.nlm.nih.gov/pubmed/19966605
Detailed instructions: http://my.clevelandclinic.org/Documents/Digestive_Disease/woc-spring-symposium-2013/biofeedback-for-pelvic-floor-muscle-reeducation.pdf

Other Manual Therapy for the Pelvic Floor Muscles
A trained pelvic floor physiotherapist may use specific methods to promote pelvic floor relaxation and to re-educate the correct activation of these muscles. Pelvic floor physiotherapists are highly trained and skilled in manual therapy techniques for the pelvic floor. These methods are usually progressed gradually over time and may involve:
  • Desensitising the pelvic area to touch (using physical touch or vaginal dilators)
  • Identifying specific areas of pelvic tension
  • Pelvic floor stretches
  • Massage techniques
  • Treating concurrent conditions which may present along with pelvic floor tightness such as problems with pelvic joints (SIJ joints), tailbone problems and low back problems.
  • Progressive strengthening of the pelvic floor muscles only when appropriate.

A Few Points to Remember About the Pelvic Floor
The article ‘How to Relax Your Pelvic Floor Muscles - Pelvic Floor Dysfunction’ offers some great points to remember:
  • Always be conscious of your pelvic floor muscles, if you find yourself contracting them. Relax and let them release their tension. Train your body and your mind to relax these muscles fully.
  • Pelvic floor relaxation is important but always remember whenever you are lifting anything heavy or performing vigorous exercises your pelvic floor muscles are required to contract strongly and tense in order to hold all your organs securely and support your body weight. Reteach your muscles to relax and contract when required.
  • During colder weather you may find your pelvic floor muscles are sometimes impossible to relax, use hot baths or steam rooms to help you fight the cold tight muscles.
  • Please be aware of your posture, don't lean on one leg or have your feet pointed outwards or two far in. All these types of things will put undue stress on pelvic floor muscles as they try to compensate for poor posture.

Strengthening the Abdominals
Why would you strengthen your abdominals during pregnancy you may ask? During the decent (or ‘pushing’) stage of labour strong abdominals play a major role in pushing baby out. Strong abdominals also support the exaggerated curve of the spine that occurs during pregnancy, and decreases the chances of the rectus abdominus (the 6 pack muscles) from separating (a condition called ‘diastasis’). Keep in mind that there is always a balance between strength and flexibility. Any muscle that is too toned, may lose its ability to stretch properly.

Is There a Right or Wrong Way to Push?


A common phrase in labour wards is to "hold your breath for 10 seconds, bear down, and push" (also called ‘purple pushing’, ‘closed glottis pushing’, or the ‘Valsalva Manuever ‘) . This puts a lot of pressure and strain on the pelvic floor muscles, possibly contributing to incontinence and hemorrhoid issues. Purple pushing can contribute to increased blood pressure, stress to the baby and popping blood vessels. As a reflex response the amount of blood pumped by the heart decreases. Death has been known to occur in cases where the blood pressure rises enough to cause the rupture of an aneurysm or to dislodge blood clots. In releasing the breath blood pressure falls; this, coupled with standing up quickly, commonly results in the incidence of blackouts. Women do not need to hold their breath. Breathing is much more effective and safe.

A More Effective Way to Use Your Muscles
Women who learn how to contract their abdominals and breathe out at the same time during labor, will get the most effective push possible. The pelvic floor muscles need to be relaxed during pushing in order to ‘let baby through’, which is easier to do if you are breathing out. Relaxed pelvic floor muscles also mean less stress will be put on those pelvic muscles, reducing the risk of incontinence and hemorrhoids.


Most Important Muscles
The deep transversus abdominis is the innermost abdominal muscle. It encircles your trunk like a corset and involuntarily contracts when you sneeze, exhale, or pull your belly in.


The action of this muscle compresses the abdominal cavity, and yes, it can also help you push during labor. During the decent stage of labor, you ideally draw in the deep transversus abdominis muscle and relax the pelvic floor to let the baby out. This mode of action will allow you to more effectively push your baby out rather than relying on pressure and tension from the rest of your body (eg. face, jaw, shoulders, arms, and legs).

Celeste from Mom Bod Fitness blog offers an interesting analogy (though she originally used a ketchup bottle for this analogy):


Picture a 1/2 full toothpaste tube. If you turned it upside down and wanted to get all of the toothpaste out, you wouldn't squeeze near the cap, you could barely get anything out. This is what happens when women try to push a baby out with their pelvic floor muscles. But if you squeeze the bottle up higher, from behind the bulk of the toothpaste, you will be more effective at getting it all out! When women use their transverse abs (up higher) they can do a much better job pushing the baby out. Just like the base at the bottom of the toothpaste tube should be open and relaxed, so should the pelvic floor muscles.

Toning the Abdominals
Transverse abdominus muscles can be toned using an exercise involving deep slow exhalations of the breath.

  1. Get into a position either lying flat on your back on the floor, on your hands and knees, or upright with your back against a wall. You might like to place a palm on your belly while you do this exercise.
  2. While trying to maintain a flat back, inhale deeply and release the muscle tone of the belly. Exhale deeply contracting the transverse. Imagine that with each exhalation you are tightening a corset around your middle and drawing their baby closer to your spine.
  3. You could also imagine that you have a 30cm ruler next to you. As you contract the abdominal wall, try to bring the belly into the 20cm mark on the ruler.
  4. Each time the belly is drawn in, count out loud. 1-2-and so forth. You can start by just counting up to 20 and throughout time maybe move up to 75 or 100.

Preventing Diastasis
Beyond understanding how to strengthen the abdominal region, it is important to understand how not to exasperate the diastasis. While it is normal to have some separation of the rectus abdominus muscles during pregnancy, more extreme diastasis can be prevented from just a few mindful movements.
Be mindful about movements like:

  • The way a woman gets in and out of bed or a chair, and how she lifts things can often increase separation.
  • “Kicking up” to seated from a reclined position or pushing up to standing when seated.
  • Moving from an upright position to a supine position without either using their arms to lower herself. Ideally they should be rolling to their side and then onto their back
  • Lifting heavy objects (or small children) incorrectly
  • Navasana which tends to “bulge the belly.”

All of these movements can be detrimental, as these actions usually cause a woman to push her belly out. That pushing out of the belly can in fact push the rectus abdominus apart can also cause extreme separation, as it can force the uterine wall to push between the rectus abdominus, increasing the separation between them.



Sources:
http://expectus.hubpages.com/hub/How-to-Relax-Your-Pelvic-Floor-Muscles-Pelvic-Floor-Dysfunction#
http://www.med.umich.edu/bowelcontrol/patient/teaching/Bowel%20Function.pdf
http://obgyncare.com/pelvic_floor.html
http://www.fascrs.org/patients/conditions/pelvic_floor_dysfunction/
http://www.fitpregnancy.com/exercise/prenatal-workouts/ready-set-push
http://prenatalyogacenter.com/blog/your-abdominal-muscles-can-help-you-push-your-baby-out/
http://exerciseandpregnancy.blogspot.co.nz/2011/10/using-right-muscles-to-push-during.html

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