Childbirth and the Pelvic Floor
A woman’s body goes through a lot of changes during pregnancy. The most noticeable ones are the growing abdomen and changes to the breasts. There are many more changes going on internally – the uterus goes from weighing around 2 ounces to 2 pounds. Muscles and ligaments stretch and become more mobile.
The pelvic floor supports the increasing weight and the core muscles compensate for the changes in the pelvis. This often leads to dysfunction of the pelvic floor. As the baby grows so does the belly and your alignment changes to accommodate. The pelvis tips more forward which forces the pelvic floor into less than optimal positions.
The biggest challenge to the pelvic floor is childbirth.
During a vaginal birth as the baby descends through the pelvis, there is potential injury to the tissues in the vaginal canal, the nerves, the pelvic floor and the perineum. The soft tissues may tear, and bones could be fractured. During the pushing stage there is an increase in intra-abdominal pressure against the pelvic organs.
What is the perineal skin – this is the skin between the vaginal opening and the rectum and the tissue directly beneath the skin.
85% of women will sustain some degree of perineal trauma.
First time moms who push for more than 2 hours and subsequent births where mom pushes for more than 1 hour are more likely to have a third degree or fourth degree tear.
Types of tearing
First Degree Tear
These are the least severe and involve on the perineal skin. This may or may not require stitches and usually heals within a few weeks.
Second Degree Tear
These involve the skin and the muscle of the perineum and may extend deep into the vagina. Typically, these require stitches and will heal within a few weeks.
Third Degree Tear
These extend into the muscle that surrounds the anus. These require repair and take longer than few weeks to heal. Stool leakage and painful intercourse could occur.
Fourth Degree Tear
These are the most severe and extend through the anal sphincter and into the mucous membrane that lines the rectum. These require repair and take longer than a few weeks to heal. Stool leakage and painful intercourse could occur.
When a woman is pushing for a short period of time, the tissues aren’t able to gradually stretch which can cause trauma. But a long period of time pushing can weaken the pelvic floor resulting in loss of stability and integrity of the muscles.
What about an episiotomy? Isn’t it better to have a surgical cut then risk tearing?
Episiotomies are no longer common practice in Canada and are usually only reserved if baby needs assistance being born such as using forceps or a vacuum. Sometimes a small cut is needed to create more space for baby. An episiotomy can cut through the transverse muscle of the perineum. Natural tearing normally doesn’t cut through that muscle. Natural tearing heals quicker than an episiotomy.
If labour ends in a caesarean birth, there is still trauma to the pelvic floor.
The woman still has the same hormonal and postural changes during pregnancy and the same weight of the baby is on her pelvic floor.
A caesarean may be elective, or a trial of labour could have occurred and could include the mom pushing for some part. A caesarean may be called because the mom “failed to progress” after a certain number of hours, baby’s or mom’s heart rate goes too low or high, mom has too much bleeding or mom’s been pushing, and baby isn’t making their way.
People often forget that a caesarean is major abdominal surgery and involves an incision through the abdominal wall and through the uterus.
The incision goes through all layers of muscle, fascia and connective tissues. This leaves layers of adhesions inside the body. The caesarean scar that is seen on the outside only shows 10% of its tissue trauma.
What can you do to help your pelvic floor during the pushing stage?
The best position for childbirth is lying on your side. This position during the pushing stage of labour is most likely to preserve your perineum. Trying to avoid lying flat on your back as this puts pressure towards the back wall of the vagina and increases intradiscal pressure. Squatting, being on all fours or on knees helps spread out pressure around the pelvic floor.
Most women who have received an epidural end up lying on their back, semi reclined in a knee to chest position during the pushing stage. This is due to loss of sensations in the lower body and not be able to hold themselves up in a squatting position or be on all fours. Talk with your healthcare provider and see what their thoughts are on positions during pushing and if where you are delving such as a hospital, has a policy.
Pelvic Floor Exercises
Seeing a pelvic floor physiotherapist during pregnancy can help as they will help stretch and massage the pelvic floor muscles and tissues. They often will show you exercises you can do at home to help such as Kegels and perineum massage. Massaging the perineum increases blood flow to the area and helps increase the viscoelasticity of the pelvic floor and can help prevent tearing. Perineum massage also gives you the opportunity to feel discomfort in this area to train the pelvic floor and your brain for the sensations with childbirth.
Throughout pregnancy trying to maintain proper posture and alignment, helps keep the pelvis in a neutral position. If you sit a lot, trying to sit on your sitz bones and not your sacrum. Having a tucked-under tailbone can shorten and tighten the pelvic floor. Practice in front of a mirror and try to adjust.
Trying to switch your shoes and wear minimal ones, meaning flats. Wearing shoes with heels, pitches the body forward and the pregnant belly already does that.
Try to stretch your legs, hamstrings and ankles daily. Roll out at your ankles and point and flex at the ankle.
Women who give birth will remember the moment and experience for the rest of their lives. Preparing for labour and childbirth ahead of time can help alleviate fears. It’s also good to know what to expect and help prepare the body for the sensations of labour.
Just had a baby?
Join us at Padma Yogi every Friday afternoon for a class to help retrain and tone the pelvic floor and abdominals.