By Melinda Fontaine
Back By Popular Demand: Here is the sequel to my 8 Pregnancy Tips. This is what a Pelvic PT/Mom wants you to know about labor and delivery. First off, you have little to no control over it. This can seem scary, so it is important to be flexible. I am a supporter of birth “plans”; I even made one myself. However, the term “Birth Plan” is a misnomer. Perhaps a more accurate name would be “Birth Ideas If Everything Goes The Way I Want And There Are No Surprises”. If anyone can be labeled as in command of this voyage, it would be Baby. Who better to control a birth than Baby?! At any moment, Baby could decide that it is time to be born and will change the flow of hormones throughout the body and start the uterus contracting. Conversely, if Baby is having any trouble, your doctor or midwife may recommend a different course of action. As GI Joe would say, “Knowing is half the battle”, so here are some possibilities of what may occur during a birth and what choices you have.
What Happens
Toward the end of pregnancy, the baby moves lower into the pelvis which is usually what starts the effacement/thinning and dilation/opening of the cervix of the uterus. Stage 1 is when Mama starts to feel contractions and the cervix dilates to 10 cm. A typical rate of dilation is 1 cm per 2 hours. Stage 2 is when Mama feels the urge to push and delivers Baby. This stage lasts 1-2 hours on average for a first birth and an hour or less for subsequent births. Stage 3, the afterbirth, is when the placenta, amniotic sac, and umbilical cord are expelled within an hour of delivery. Baby suckling at the breast helps signal the uterus to expel them. Your midwife or doctor will check the placenta to make sure it is complete to avoid bleeds. Now that you know what happens, how do you prepare for it?
Store Up Energy
Having a baby is like running a marathon in many ways. Both require an immense amount of energy. If you can, get a lot of good sleep in the days before the main event. You will also need good nutrition for energy, so eat well prior to delivery. I ate the same breakfast protein packed breakfast before running my marathon and before delivering my son.
If you plan to deliver in a hospital, you will not be allowed to eat until after the baby is delivered. This is to keep you safe in case an emergency C-section is needed. Having a full stomach during a surgery increases risk for aspiration. If you want to eat something for energy while you are laboring, be sure to eat it early on, prior to admission to a hospital.
Get Things Rolling
So you’re ready to get this show on the road? You may find yourself ready for Baby to come, but labor is not beginning or progressing as you and your doctor or midwife would like. An example would be if your water breaks, but there are no contractions, the pregnancy has continued too long, or you have been in the first stage of labor for a really long time. There are different ways to induce labor. Prostaglandins are lipids that act like hormones. They are inserted vaginally near the cervix to help it thin and open in preparation for delivery, which may initiate uterine contractions. Pitocin is a synthetic form of oxytocin, the hormone that signals the uterus to contract. Pitocin is often administered intravenously in the hospital. It may also be used to help stop bleeding after delivery. Other fun ways to get your body to start producing oxytocin include nipple stimulation and orgasm. Midwives will sometimes use castor oil to get the uterus to start contracting (side note: it is also a very strong laxative, so be prepared). Lastly, a doctor or midwife might sweep the membranes that connect the amniotic sac to the uterus, or if your cervix is already dilated, they may rupture the membranes of the amniotic sac to progress labor. To avoid putting your baby at risk, do not attempt to induce labor unless you have your doctor’s or midwife’s seal of approval.
Delivery Options
You know how Baby got in there; now how will Baby get out? The two options are through the vagina or through an abdominal incision known as a Cesarean section. For a vaginal delivery, the bones and soft tissues of the pelvis stretch and open wide enough to pass Baby through. The uterus contracts to help push Baby down and out. Mama bears down like having a bowel movement to further increase abdominal pressure and push Baby down and out. Sometimes pushing is coached, meaning a healthcare professional instructs Mama when to push. Stay tuned for Malinda Wright’s upcoming post about the ‘how to push controversy’! Sometimes a doctor has to guide the baby through the birth canal using his or her fingers, a vacuum, or forceps. Episiotomies used to be routine in the 1980s. Now they are reserved for rare instances when the perineum is impeding the progression of the delivery. C-sections may be performed in cases of maternal or fetal distress, large fetal head, small maternal pelvis, labor not progressing, Baby in an awkward position, placenta previa (placenta covering the cervix), etc. VBAC is a term that is increasingly popping up in conversations, and it means Vaginal Birth After Cesarean. Your doctor or midwife should discuss with you whether or not VBAC is a safe option for you.
Support The Perineum
The perineum is the tissue between the vagina and the anus. It has to stretch a lot during vaginal delivery, and sometimes tears when it has to stretch too much too quickly. Perineal massage is often recommended for mothers considering vaginal birth to prepare the tissue to stretch.This massage can be done starting at 36 weeks of pregnancy and involves using thumbs or fingers to hold a prolonged stretch on the tissue. This can also be assisted by devices such as
EpiNo or Materna. A physical therapist can instruct you or your partner on how and when to perform perineal massage. During delivery, the doctor or midwife can apply counter pressure or heat to the tissues to encourage good stretching.
Manage Pain
The all too common image in the media of a woman screaming in pain during delivery is not necessary. The process is painful, but there are ways to manage the pain. There is no one right way to have a baby. Pick the pain management technique that is right for you and your baby. Epidurals and other medical pain relievers are often very effective at reducing pain. Hypnobirthing involves techniques to release the fear and tension associated with birth and to use one’s subconscious mind to thwart the feelings of pain. I chose hypnobirthing, and it worked unbelievably well – No really, my next three nurses all had to verify that the story they heard about my birth was true. A partner or doula can give massage and counterpressure to the pelvis and low back to relieve tension, and a warm shower or bath may also feel good.
Educate Yourself
You will be faced with certain decisions that you have to make for Baby, so think about them beforehand. Would you like to delay clamping the umbilical cord to allow Baby to get extra blood from the placenta? Would you like to bank Baby’s cord blood to store stem cells for your family or others? Would you like to do skin-to-skin, which is when Baby is placed on Mom’s bare belly as soon as possible after delivery? Routine baby care can be done while Baby is on Mom’s chest. Would you like your Baby to receive antibiotic eye ointment to kill possible bacteria that can cause blindness, a Vitamin K injection to prevent possible internal bleeding, and the Hepatitis Vaccine? Would you like to breastfeed? Will you offer Baby a pacifier, which has been linked to preventing sudden infant death syndrome (SIDS) and may interfere with breastfeeding. When would you like Baby to have the first bath, and who should be there? Who will be Baby’s pediatrician? If Baby is a boy, would you like him to be circumcised shortly after birth? The US is split on this decision about 50/50 right now.
Ask Questions
Six weeks after the birth of your beautiful baby, you will see your doctor or midwife. They will check you out and if everything is fine, they will give you the all clear to have sex and start exercising. Take this time to discuss your plan for birth control now that you are cleared for sex and have your doctor’s attention. If you notice anything uncomfortable when you do return to sex and exercise, call your doctor. They will often not follow up with you until your next PAP unless you bring it up. Common complaints are that sex is uncomfortable due to scar tissue or muscle spasm, that urine leaks out when you cough, laugh, or sneeze, and that there is a heavy feeling in the vagina. These may all be treated with physical therapy, so ask your doctor for a referral. Another complaint after a C-section is meralgia paresthetica, which is a compression of the nerve that runs down the outside of your thigh and creates a feeling of tingling, numbness or pain in that area.
How PT Helps
Have you heard the myths about how it is “normal” for mothers to pee when they laugh, lose the tone in their abdomens, and have pain with sex? Well, the cat’s out of the bag now…though these are common, they are NOT normal. They are signs that something is off within the body. Physical therapists help mothers with urinary and bowel problems such as incontinence, as well as prolapse, diastasis recti, and pain. Stephanie Prendergast is giving a lecture today at the Sexual Medicine Society of North America conference in Las Vegas on Physical Therapy for Postpartum Sexual Wellness. Check out her slides.
Postpartum Care
Baby is not the only one who needs tender loving care after a birth. What about Mama? Abdominal binders worn during the first 6 weeks after delivery help the uterus to return to its pre-pregnancy size and approximate both sides of the rectus abdominus to reduce diastasis. Vaginal delivery or a significant amount of labor prior to a C-section will create swelling in the vagina. Ice, witch hazel, and elevation help to reduce swelling. Every time someone asked me if I needed anything, I asked for a fresh ice pack. Scar massage to vaginal or C-section scars will improve healing. Estrogen levels plummet after delivery, so new moms may note dryness, urinary incontinence, or painful penetration. Since the vagina is so sensitive to estrogen levels, a topical estrogen cream can be very useful. Breathing is affected in pregnancy when the baby is large enough that it limits the excursion of the diaphragm. Good posture helps with breathing and prevents future injuries. Postpartum doulas help families learn about how to care for Baby and Mama and help with chores and errands to reduce the workload for the family.
At the end of the day (or days), your baby’s birth story is what it is: a miracle! The story of how this miracle occurs is special and unique. Be proud Mama!
Share your birth story or delivery tips in the comments section below!
All my best,
Melinda
Melinda is a native of Concord, California and is part of our Berkeley team. Melinda earned her bachelor’s degree in exercise biology from UC Davis and her doctorate in physical therapy from Simmons College in Boston. When she’s not at PHRC, you’ll find her either dashing around in her running shoes or cooking up delectable meals in her kitchen. She’s famous for her killer baked chimichangas and her inability to stick to a recipe.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.