Protecting the Pelvic Floor During Childbirth

Protecting your pelvic floor during childbirth

Vaginal birth is currently considered the safest way to birth for low risk mums. Reducing vaginal and pelvic floor muscle injury begins in pregnancy with maintaining strong pelvic floor muscles (PFM) and after 35 weeks preparing the pelvic floor with massage for the journey ahead. When labour is under way the mother and birth attendants lower the risk of injury to the vagina and pelvic floor by avoiding forced, breath holding pushing and lying on the back to birth. Waiting for urge driven labour, using warm compresses and perineal support during crowning have been shown to reduce the risk of tearing.

Pregnancy

Nutrition: Large babies (over 4kgs) are associated with pelvic floor damage and recent research indicates that overweight begins in the womb.

Exercise regularly during pregnancy according to your pre-pregnancy fitness level. Pregnant women have weaker PFM strength compared to women without children, 1 which has implications for the intensity and type of exercise followed during pregnancy. Do light to moderate exercise 3-4 times weekly: swimming is a great choice with the water supporting baby’s weight and mums can usually swim right up to their due date.

PFM training is recommended as standard clinical practice for pregnancy to reduce postpartum incontinence. Train PFMs as regularly as you clean your teeth.

Studies associate pelvic girdle pain with over active PFMs and strengthening exercises are not recommended with this condition, 2 which benefits from an individual program with a women’s health physiotherapist.

Modify damaging lifestyle habits associated with pelvic floor strain– constipation, heavy lifting and high intensity training. Avoid sudden intra abdominal pressure rises: stop picking up toddlers, shifting furniture and treat hay fever or chest infections early. Sudden internal pressure rises can overwhelm and strain a hormonally weaker pelvic floor.

Perineal massage reduces the likelihood of perineal trauma (mainly episiotomies), muscle tearing and ongoing perineal pain in women who had not birthed vaginally before. The effect of this massage is less clear for women who’ve had previous vaginal births.3 Learn how to do perineal massage for improved PFM extensibility and reduce the risk of tearing.

The birth trainer Epino is another alternative to perineal massage and a German 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.”

 Labour:

Consider birthing with a midwife as studies show they decrease the need for caesarean sections, requests for epidurals, length of labour (for first time mothers), the use of narcotics, epidurals and forceps during labour.4

Staying upright shortens the first stage of labour – walk, rest, eat and drink lightly, ask for massage over your low back and focus the shower on your back while sitting on a fitball. Researchers found upright positions shortened the first stage of labour by 1 hour and recommend women should specifically avoid lying flat and use upright positions they find comfortable during labour. 5 Listen to favourite music on your ipod during the first stage of labour for relaxation and distraction. 6

Birth:

When the cervix has fully opened, the uterus and vagina becomes one connected birthing tube and the body may rest for a while as the vagina stretches to accommodate baby’s head. Strong uterine contractions (urge directed pushing) then control the baby’s expulsion. ‘Breathing the baby out’ with urge directed uterine contractions decreases the risk of tearing internal supports and causing a vaginal hernia (pelvic organ prolapse).

Researchers compared spontaneous versus valsalva pushing (breath holding, ‘purple pushing’) in the 2^nd stage. Their findings support spontaneous pushing and women are encouraged to choose their own method of pushing.7 The incidence of instrumental births is lower in women who delay pushing.

Position for optimal pelvic joint expansion and internal space by birthing in supported kneeling and upright positions. Back lying with the knees wide apart closes the sacro-iliac joints of the pelvis. Slightly turning the knees in to birth stretches these joints further apart, making more internal space for baby’s head. If you’re exhausted or interventions are necessary, side lying is the best position to adopt.8

Water submersion provides muscle relaxation and pain relief and may shorten the length of labour.

Crowning and perineal protection

Controlled slow delivery of the baby’s head further reduces the risk of perineal tearing. Ask for warm compresses over the perineum as studies show their effectiveness in reducing perineal trauma.10

When crowning occurs fast, the perineum doesn’t have time to slowly stretch, thereby increasing the risk of tearing. In this case, perineal hand support by the birth attendant or mother is indicated. Episiotomy is used less frequently as it increases the risk of tearing in subsequent births.11 Occasionally, episiotomy and instrumental births are necessary when baby is not coping well and needs to birth quickly.

Forceps when compared to Ventouse (suction) are associated with a higher risk of 3rd and 4th degree tears with or without episiotomy, vulval and vaginal trauma and flatal incontinence.12 Epidural increases the use of instrumental delivery; a risk factor for anal sphincter injury.13

To maintain maximal perineal integrity when giving birth, prepare the perineal muscles in later pregnancy, engage a midwife and choose an upright or side lying position. Use spontaneous or self directed pushing (no breath holding), warm compresses on the perineum and slow, controlled delivery of baby’s head. The majority of vaginal births are uncomplicated and when allowed to proceed with evidenced based management of the perineum, outcomes for perineal integrity are favorable.

For further information on improving pelvic floor outcomes

1. Resende A, Petricelli C, Bernardes B, Alexandre S, Nakamura M, Zanetti M. Electromyographic   evaluation of pelvic floor muscles in pregnant and non pregnant women. Int Urogyn J. 2012 23:1041-1045
2. Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, et al. Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. Int.U.J.Pelvic Floor Dys. 2005;16(6):468-474.
3. Beckmann MM, Garret AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of SystematicReviews. 2006; Issue 1. Art. No.: CD005123. DOI: 10.1002/14651858. CD005123.pub2.
4. Hatem M, Sandall J, Devane D, Solanti H, Gates S. Midwifery-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. 2008; Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.
5. Aasheim V, Nilsen ABVika, Lukasse M, Reinar L. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews.2011;Issue 3. Art. No.: CD006672. DOI:10.1002/14651858.CD006672.pub2.
6.    Phumdoung S, Pool M. Music reduces sensation and distress of labour pain. Pain Management Nursing. 2003;4(2):54-61.
7.    Prins M, Boxem J, Lucas C, Huttone E. Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. British Journal of Obstetrics and Gynaecology. 2011; 118:662-70.
8.    Dahlen, H. (2009). The relationship between maternal birth positions and perineal outcomes in women giving birth in a birth centre over 12 years.Peri Soc A & NZ 82.
9. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews Issue 2. Art. No.: CD0000111. DOI: 10.1002/14651858.CD000111.pub3. 2009; Issue 2. Art. No.: CD0000111. DOI: 10.1002/14651858.CD000111.pub3.
10. Dahlen, H., Homer, C., Cooke, M., Upton, A., Nunn, R., & Brodrick, B. ‘Soothing the ring of fire’: Australian women’s and midwives’ experiences of using perineal warm packs in the second stage of labour. Midwifery, 2009; 25(2), 39-48.
11. Alperin M, Krohn M, Parviainen K. Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery. Obstetrics and Gynecology. 2008; 111:1274-8.
12.  O’Mahoney F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database of Systematic Reviews. 2010; Issue 11. Art. No.: CD0055455. DOI: 10.1002/14651858.CD005455.pub2.
13. Anim-Somuah M, Smyth RMD, Howell CJ. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005,Issue4. Art.No.:CD000331.DOI:10.1002/14651858.CD000331.pub2

Mary O’Dwyer is a women’s health physiotherapist helping women overcome life-altering issues of incontinence, pelvic organ prolapse, pelvic and sexual pain. She is a graduate of the University of Queensland and the University of Melbourne and has lectured at Griffith and Bond Universities on the Gold Coast. Mary runs pelvic floor workshops for women, fitness trainers and physiotherapists.

To promote a clearer understanding of pelvic floor health she has written Hold It Sister – the confident woman’s guide to a leak free life.

Her latest book Hold It Mama focuses on the pelvic floor during pregnancy, birth and beyond. Recovery information after vaginal and caesarean births and safe exercise programs makes this book a must read for new mums who want both children and a healthy pelvic floor.

Mary consults at Physiocare, Maroochydore on the Sunshine Coast.

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