“Why don’t you try squeezing something the size of a watermelon out of an opening the size of a lemon and see how hot YOU look?” –Look Who’s Talking
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.
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.
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.
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.
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.
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.
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 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.