This week, our guest writer and award winning prenatal chiropractor Dr. Elliot Berlin, takes us through a hot button topic: breeched babies.

By Elliot Berlin | DC

 

Early in pregnancy, your baby has plenty of room to move, as you’re probably well aware. My patients often share that it’s not unusual for them to feel a sharp elbow jabbing into their ribs, some swift kicks to their belly, and even complete somersaults going on in there!

 

Usually, by week 34, the combined forces of gravity and the decreased “room to move” in your uterus leads your baby to settle head-down (in a vertex presentation) in preparation for birth. At term, around 3-5% of babies are not vertex, and those babies are said to be in a breech presentation. There are three common breech presentations: frank breech, complete breech, and footling breech.

 

If you ask a midwife, you are likely to hear that a breech presentation is just another variation of normal; ask most OBs, and you’ll hear that a breech presentation is abnormal. You’re also likely to hear that if your baby doesn’t turn before your “guess date,” you’ll be delivering via cesarean – and you have no other choice.

 

It wasn’t always this way.

 

Breech babies are a little more difficult to deliver vaginally than babies in a vertex position; as Jennifer Block writes in her book Pushed: The Painful Truth about Childbirth and Modern Maternity Care: “The breech baby demands patience; she rejects active management; she demands normal, physiological birth.” Many midwives talk about a “hands off the breech” approach for delivering breech babies vaginally. From years of observation and sharing their collective wisdom, midwives know that the more a woman and her baby are free to do their own thing, the more successful the outcome is likely to be.

 

The perceived ‘dangers’ of vaginal breech delivery had their roots in the first half of the 20th century; the ‘assisted breech’ techniques of the day, which often combined heavy anesthesia, manual pressure on the uterus, and the routine use of forceps to force the delivery of the baby’s head, could not be further away from the normal, physiological birth that Block describes. One 1953 study found that “the more manipulation is performed and the earlier this manipulation is instituted, the greater is the fetal mortality and morbidity, to say nothing of maternal injuries.” But even in 1953, Europe was already far ahead of the US in their understanding of breech birthing – a full fifteen years earlier. In 1938, the German obstetrician Erich Bracht presented an analysis of 206 successful vaginal breech deliveries, without one fetal injury or death. Interest in the “Bracht maneuver,” essentially another version of “hands off the breech,” led to more than 30 trials in Europe and South America, all resulting in dramatically better outcomes for babies and mothers.

 

Not one of those studies was translated into English.

 

 

The result? In Europe, breech birthing techniques continued to improve, while in the US, doctors increasingly turned to surgery. By 1978, 60% of breech babies were born via cesarean in the US, and by 1990, that number was 85%. Andrew Kotaska, MD, a strong critic of the “breech = automatic cesarean” attitude of most American OBs, had to travel to Germany to gain experience in vaginal breech delivery; not one North American program existed to accommodate him.

 

As Dr. Paul Crane, one of the few doctors in the greater Los Angeles area who will (very rarely) attend a planned breech delivery within a hospital, explains, “The problem is,there’s nobody who’s going to get enough training to do vaginal breech deliveries in the modern world. Ask people who are my vintage and perhaps ten years younger, they’ve all stopped practice. There won’t be anybody really willing to do vaginal breeches.” Dr. Ronald Wu, another LA-area doctor who still attends planned breech births vaginally within a hospital, concurs: “There’s no more knowledge, the skill level is being lost. Not too many people will do a vaginal birth any longer, so the experience of seeing one is not available. And if it’s not available, how can you train anyone? It [vaginal breech delivery] is a dying art.”

 

It’s a dying art for one particular reason: the Term Breech Trial. Mary Hannah,MD, a well-respected obstetric researcher, led a randomized controlled trial involving more than 2,000 women carrying in breech presentation in 121 hospitals and birthing facilities around the world. The study, published in 2000 in the medical journal The Lancet, seemed to show a significantly higher chance of “serious neonatal morbidity” in breech babies who were born vaginally. In the wake of the study, The American College of Obstetricians and Gynecologists (ACOG) recommended that planned vaginal delivery of a breech baby at term was no longer appropriate.

 

The standard of care changed practically overnight.

 

Hospitals, insurance companies, and collective practices would no longer allow OBs to deliver a breech baby vaginally unless a woman arrived at the hospital with her baby already virtually out of the birth canal. Universities and teaching hospitals stopped training students in vaginal breech delivery altogether. As Dr. Crane explains, “In 2001, [ACOG] came out with a position paper, and that paper said that unless the baby just was falling out upon arrival, we should section all breeches.”

 

The problems with the Term Breech Trial became apparent almost immediately. Professor Marek Glazerman, a researcher from Israel, re-analyzed all of the data from the Term Breech Trial, and he was the first to say ‘we made a mistake here.’ As Dr. Stuart Fischbein explains, “they took a critical look at that study and found that they included a lot of things in there that shouldn’t be included, like unplanned breech deliveries, preemie breech deliveries, breeches with congenital abnormalities, and once they had corrected for those things they found that this isn’t the way it should be.”

 

In 2006, ACOG renounced their original opinion and declared that vaginal breech delivery was safe in the care of an experienced physician. “But by then the damage was done,” Fischbein says. “I don’t think anyone coming out of a residency program now has certainly done or necessarily even seen a breech.”

 

Only ‘renegade’ doctors and midwives were left to attend planned vaginal breech deliveries, which today almost always occur at home.

 

As Jennifer Block puts it, “it is independent home-birth midwives, some of whom practice illegally, who are left attending these higher-risk vaginal births. And they are surpassing physicians in experience and expertise in the delicate matter of vaginal breech delivery. What has become a lost art in the delivery room is kept alive in women’s homes by care providers who are largely unrecognized by the obstetric profession and even criminalized in several states.”

 

Dr. Fischbein gave up his privileges to attend hospital births and quickly became a leading force in the underground movement to keep options available for women. “All things being equal,” he says, “breeches should be born in a hospital setting because you have the ability to have general anesthesia should you have an emergency. The problem is all things aren’t equal.” He acknowledges that “there are risks to breech delivery, but the risks are minimal if you follow tight protocols. We all know that planes fly safely most of the time, but we only talk about planes that crash. It’s the same thing here. When there’s a tragedy in any birth it’s sad, but they can happen just as easily from a cesarean section in the hospital or a breech birth in the hospital, or at home for that matter.”

 

Dr. Fischbein is clear in his mission: “Ultimately whatever a doctor feels, or whatever a hospital committee or administration feels, the decision really doesn’t belong to them. It belongs to the individual patient, and [in the future] people in labor are going to be coming into the hospital breech and not knowing it, and no one is going to know what to do, and that’s going to be a real tragedy.”

 

If you are late in pregnancy and your baby is in a breech presentation, you do have options. You can seek chiropractic care, acupuncture or moxibustion (offered at Berlin Wellness, of course!) to try to gently turn your baby. You can attempt “spinning babies.” You can ask for an external cephalic version (ECV), which should only ever be attempted by a highly trained doctor and assistants in a hospital setting; it is often painful, but the commonly referenced success rate is around 50%.

If your baby will not turn, you can also seek out care from doctors willing to attend a vaginal breech delivery. Dr. Wu and Dr. Fischbein are your best options in Los Angeles. Homeland star Morena Baccarin hired Dr. Wu 39 weeks into her pregnancy, and she delivered her healthy, breech baby vaginally with his assistance. You do have choices. They are not always easy or cheap, and nothing is guaranteed – but at least for now, you still have some choices.

 

I hope that the demand for vaginal breech deliveries will lead more care providers to offer them to women. There are a lot of benefits and reasons why the birth process is the way it is, and when we bypass them, we lose a lot of the benefits. I’ve been busy recently creating a documentary film about what went awry with vaginal breech delivery in the US, and I consider that film part of my contribution to keeping the choice alive. But here’s the real truth: I’m a man. I have worked with many, many women who are carrying breech, but I will never be in that position myself (actually, that’s not entirely true – I was a breech baby, and my mother delivered me vaginally!)

It is up to you to stand up for choice.

 

It is up to you to demand more, and better, if you discover your baby is breech late in pregnancy. I hope that if you find yourself in that situation, you will speak up and make yourself heard – you want options. You demand options. Only a united chorus of women will bring the option of vaginal breech back, and I ask you to join that chorus – even if you do not want to birth your breech baby vaginally, or you are not carrying breech, stand up for choice. Be heard. Make it just a little easier for the next mother who finds herself with a breech baby in late pregnancy… you can do that! You, mothers and mothers-to-be, can do anything. In all my years working with pregnant women, I am inspired over and over by what my clients achieve. You humble me every day. So stand up for choices. Stand up for heads up!

Best,

Elliot Berlin | DC

 

 

Dr. Elliot Berlin is an award winning prenatal chiropractor, childbirth educator and labor doula. His Informed Pregnancy® Project aims to utilize multiple forms of media to compile and deliver unbiased information about pregnancy and childbirth to empower new and expectant parents to make informed choices regarding their pregnancy and parenting journey.

 

Find more informative media at InformedPregnancy.com and learn about Dr. Berlin’s unique wellness care at DoctorBerlin.com

 

This week, our guest writer Dr. Shirin Towfigh will discuss Inguinal Hernia’s and how they may be related to pelvic pain. 

Hi all. This is Dr. Shirin Towfigh. I am a Board Certified General Surgeon who specializes exclusively in all things hernia, with specialty in hernias among women and complications related to hernia repair. Inguinal hernias are a common and under diagnosed cause of pelvic pain. Here, I’ll share my secrets, tips, and tricks on how to accurately diagnose  inguinal hernias. Early and accurate diagnosis can lead to reduction in cost and suffering!

 

SIGNS & SYMPTOMS OF AN INGUINAL HERNIA

What is an inguinal hernia?

A hernia is a hole, usually through a muscle or fascia defect. Most hernias occur through natural weaknesses or natural holes. This is true of the inguinal region, where the inguinal canal is a natural tunnel through multiple muscle and fascial layers. In men, this allows for the spermatic cord contents to travel through. In women, it is much smaller and only fits the thin round ligament. Any hernias in this region are called indirect inguinal hernias. They are the most common among both men and women. Other hernias in the groin region include direct inguinal hernias (weakness through the transversus abdominis muscle), femoral hernia (medial to the femoral vessels, through the femoral space), and obturator hernia (through the obturator canal).

 

What is an occult inguinal hernia and how can it cause pelvic pain?

As the topic of inguinal hernias evolves, my practice has been at the forefront of studying and promoting the entity of occult inguinal hernias. These are hernias that do not present with a palpable bulge, and yet they are quite symptomatic. We see these mostly among women. In my practice, women comprise of 82% of those with occult hernias, whereas 88% of males present with the more typical hernia with a palpable or visible bulge. Many believe that a small hernia that can barely even be palpable cannot possibly cause any pain. Au contraire mon frère. The smaller the hernia, the more the associated pain. Imaging can help diagnose the majority of these hernias if there is a clinical suspicion. Hernia repair is a cure. In my series, 87% of those with occult hernias are pain-free within weeks of their hernia repair, and 93% had resolution of their preoperative pain by undergoing hernia repair.

 

How do you get inguinal hernias?

Inguinal hernias are common and can occur in a person of any age, with any lifestyle. In fact, we feel that most of the hernias that we treat have an underlying genetic component to them. If you have a relative with a hernia then you are likely slightly more likely to have a hernia. In my practice, we have noted that specifically having a female relative with a hernia confers an even stronger genetic link to hernia formation.

In some cases, patients may report a physical activity, such as lifting or moving a heavy object, associated with their hernia. They may have felt a tear or burning sensation in the groin at the time of this activity. Did that activity actually cause the hernia? We don’t know. Most likely, the patient always had a hernia, though occult or asymptomatic, and the strenuous activity resulted in further opening of the hole, or more content pushed through the hole.

Most inguinal hernias are asymptomatic, that is, there is no pain or discomfort associated with them. There may be a bulge in the area of the groin. Also, most of the time, the bulge is reducible.

 

What are risk factors for hernia formation?

Activities that are thought to increase hernia formation include those that increase your abdominal pressure. These include straining to have a bowel movement, straining to urinate, long or multiple labors, repetitive heavy lifting of objects, chronic cough. This is why treating of constipation, cystocele, rectocele, asthma, bronchitis are important prior to any hernia operation.

Obesity has not been validated as a risk for hernia formation, but it has been shown to increase abdominal pressure. It is possible that there is an overall underdiagnosis of hernias among the obese, as they are asymptomatic and a bulge is poorly discernable on examination.

Nicotine use has not been associated with development of a primary hernia, however, it confers a higher risk of an incisional hernia or hernia recurrence after hernia surgery. This is because nicotine directly affects the quality of collagen deposition during the healing process. In my practice, the patient must be nicotine-free (no smoking, gum, or patches) for 6 weeks prior to their hernia repair and is encouraged to be nicotine-free afterward.

 

What activities should be restricted with a hernia?

Fortunately, most activities, including almost all exercises, have not been shown to increase abdominal pressure. These include sit-ups, bench press, weight lifting, dead lifts, and other exercises which one may think would “hurt” a hernia. Only two exercises—jumping and leg squats—have been associated with increase in abdominal pressure, and thus may increase the risk of hernia formation.

Patients who exercise regularly are less likely to have hernias. This is especially true among women. I regularly encourage patients to exercise both before and after their hernia operation. Yoga and Pilates are especially great for abdominal core and pelvic floor strengthening. Cycling and most gym exercises are also helpful. Golfing is safe. I tend to discourage crossfit-type exercises, as they tend to involve a lot of jumping, leg squats, and rapid movements with weights. Anecdotally, I have seen a disproportionate number of patients with groin pain after P90X and Insanity –type workouts.

Exercise is protective of hernias and in many cases can strengthen the pelvic floor and help reduce symptoms of hernias. Most of us hernia specialists do not recommend restriction of activity once a hernia is diagnosed.

 

What are key questions to ask to diagnose an inguinal hernia?

A detailed history is indispensible. By the time I finish my history taking, I can reliably predict if my patient has a hernia as the cause of his/her pelvic pain.

Most men will first complain of a bulge in their groin. Of course, that will most likely be from a groin hernia. There are very few other causes of bulge in that area, especially if it is a reducible mass. A physical examination will help confirm this.

Women with inguinal hernias more commonly present with groin pain than with a bulge. These are sometimes referred to as “occult” or “hidden” hernias. The pain is felt at or above the level of the groin. Half of the patients will have pain that may radiate up to the hip area, around to the lower back, into the testicle or vagina, to the scrotum or labia, down the front of the leg, and/or to the upper inner thigh region. Hernia-related pain never extends below the knee and is never at the buttock or down the back of the leg.

Symptoms can range from a dull discomfort to a disabling searing pain. The size of the hernia does not correlate with the severity of the pain. In fact, the reverse may be true: the smaller the hernia, the more pain associated with it. This may be due to increased pressure within the smaller defect.

Most patients with inguinal hernias have activity-related symptoms. Any activity that places extra pressure onto the inguinal canal and pelvic floor can theoretically cause pain at the hernia. This includes prolonged standing, prolonged sitting, bending, getting in and out of bed, getting in and out of the car, coughing, laughing. Sexual intercourse and/or orgasm may be painful. In women, ¼ of my patients report worsening pain during their menses.

Nausea and/or bloating are common complaints associated with hernias. I see this more often among my patients with pain. It seems that the nausea and bloating are the patient’s manifestation of groin or pelvic pain. Contrary to fears, most hernias contain fat only. It is uncommon for inguinal hernias to contain intestine, unless they are large. Even most scrotal hernias contain fat as their primary content.

 

What are tips to performing an accurate exam for inguinal hernia?

 

The patient should be examined in standing position. This allows for gravity to accentuate any small hernia.

I approach the inguinal hernia exam in a very anatomic way. First, I identify the anterior superior iliac spine (ASIS) and the pubic tubercle. The line from the ASIS to the tubercle delineates the inguinal ligament. A typical inguinal hernia will be felt along this line, usually at the 60:40 mark (i.e., 40% of the way up from the tubercle, 60% away from the ASIS). Remember that the inguinal canal is typically oblique.

If there is a mass felt anatomically lateral to this 60:40 mark, which is thereby lateral to the femoral pulse, then this is not a hernia. More likely causes of masses felt lateral to the femoral pulse include abscess, lymphadenopathy, femoral artery aneurysm, or AV fistula.

 

What are examination findings for an inguinal hernia?

Large inguinal hernias of the indirect type, will have a scrotal (or labial) extension. If of the direct type, the hernia will jut out perpendicular to the lower abdominal wall skin. These are usually reducible and non-tender.

Moderate-sized hernias typically present with a bulge. While the patient is standing, you should be able to see this bulge. I compare the left and right sides and check for disparity in the groin area. Based on anatomic landmarks, you should be able to feel a soft mass, often reducible, rarely tender. Alternatively, a more invasive digital examination may be performed if you are unsure if there is a hernia. In men, use your index finger and start at the mid-scrotal skin; use this as your entry. Follow the spermatic cord cephalad and up to the inguinal canal. Feel the pelvic bone and slide your finger over the bone. Slowly and gently feel the lower abdominal muscles. Feel to feel for a weakness in the direct space. In women, an examination via the labia minora or alternatively through the vaginal wall may rarely be necessary. If you are unsure if there is any hernia, ask the patient to slowly bear down or cough.

For small hernias, an obvious mass or bulge may not be easily seen or palpated even after the maneuvers described above. In my experience, tenderness alone at the internal ring (the 60:40 mark) is diagnostic of an occult inguinal hernia and demands further workup, such as imaging, to confirm the suggested diagnosis. We found that point tenderness at the internal ring is 88% specific for an occult inguinal hernia.

 

DIFFERENTIAL DIAGNOSIS OF INGUINAL HERNIA VS OTHER SOURCES OF PELVIC PAIN

What are the various causes of pelvic pain?

Pelvic pain can arise from the abdominal wall, pelvic floor, intestines, uterus, ovaries, hip, and spine.

How can you determine if an inguinal hernia is causing or contributing to a person’s pain?

There are two very specific findings you can elicit from the history of the person that will raise inguinal hernia high on your definition

   1. Activity-related pain

The symptoms of a hernia are often made worse with activities, similar to the symptoms of myofascial pelvic pain and unlike the symptoms of other pelvic pain (gynecologic, urologic, etc). Hernias are typically worse with activities that cause an increase in abdominal wall pressure. This includes pain with prolonged sitting, prolonged standing, bending, coughing, and laughing. This also includes pain with activities that involve engagement of the abdominal wall, such as getting in and out of a car or bed, pulling open a heavy door, lifting a heavy object/pet/child, and sexual orgasm. Not all patients have every single activity-related pain, but they usually have a series of them. It is uncommon to have constant unrelenting pain alone without exacerbation with activities. In these situations, the patient may have an incarcerated hernia or femoral hernia.

      2. Pain to the touch

Aside from myofascial pelvic pain, very few other causes of pelvic pain are reproducible to the touch. Patients with pelvic pain due to inguinal hernia will be able to point to you exactly where the pain is felt. If you know your anatomy, you will notice that their pain is at the inguinal canal. They will point at or above their groin crease in an area between their anterior superior iliac spine and their pubic tubercle. They may also have sensitivity to touch. They will report pain when leaning over a sink, such as to shave their face, wash dishes, or brush their teeth. They may be unable to wear belts, jeans, or constrictive underwear. Some patients come to my office wearing baggy sweatpants; the women tend to wear soft leggings or skirts. When examined, they may hunch over in pain and be hypersensitive to touch.

 

Can it be the Gastrointestinal?

It is not uncommon for patients with inguinal hernias to also be constipated, which likely contributed to the hernia in the first place. Also, they may have pain when their colon is full, just before a bowel movement. When straining, they may have lingering pain after a bowel movement. Some present with nausea and bloating. This is a manifestation of their pelvic pain and there is no actual intestinal involvement with their hernia. I have seen a lot of patients with hernias that had colonoscopies and full gastrointestinal testing as part of their workup, which was normal.

 

Can it be Gynecologic?

The female patient’s pain may increase during her menses. I see this in ¼ of my female patients. This has to do with the hormonal changes during that period. Unlike endometriosis, however, symptomatic hernias have no pain-free episode in between the menses. Also, with endometriosis, there should not be pain felt at the inguinal canal. In rare instances, there may be an endometrioma in the abdominal wall or endometriosis implant along the round ligament that may mimic symptoms of a hernia.

Inguinal hernias may cause pelvic pain during sexual intercourse. This is true among both men and women.

Pelvic floor disorders are related to inguinal hernias. In essence, all are some form of pelvic floor dysfunction, weakness, defect, and they share the same genetic and other risk factors. It is not uncommon to have an inguinal hernia among women who already have known cystocele, rectocele, or other pelvic floor weakness. The reverse is also true.

 

Can it be Orthopedic?

Patients with orthopedic issues, such as disorders of the hip, tend to limp, shift their weight to the other leg, and have pain with certain activities involving the hip, such as running and yoga. Hernias do not cause a limp and patients in general bear weight equally, though in extreme pain, they may wish to favor the contralateral side. In such situations, a hip exam can be diagnostic. This is done by placing the patient in supine position and passively flexing and then rotating the hip internally and externally to assess for pain and restriction in range of motion. Patients with hernias should not have pain or any restriction in motion.

 

Can it be Neurologic?

This is a tricky one. Hernias, especially the occult ones that present without a bulge, may have a neuropathic component as their primary complaint. This is typically pain in the genitofemoral distribution (upper inner thigh, scrotum, labia) as this nerve can travel through the inguinal canal and be impinged by the herniating content. Ilioinguinal neuralgia-type symptoms may also be experienced, especially in larger hernias, due to the anatomic proximity of the nerve overlying the internal ring with impingement by its contents. Sometimes patients undergo direct nerve blocks in the groin region to address this problem. In my experience, we see an increase in their pain if they have an inguinal hernia, and a decrease in their pain if there is a true neuropathic injury as the cause of their pain. I believe the reason for the increase in pain is that the addition of local anesthetic results in volume and added pressure to an area that is already under pressure from the herniated content. In this case, further nerve blocks and even nerve ablations, etc., will not help and may cause further damage to the patient. I see a large number of patients that are initially sent to a pain management to undergo medical and percutaneous ablative techniques to address neuralgia, whereas the cause of their pain was an occult inguinal hernia. Almost all of these patients also had tenderness on examination and activity-related pain. It is important to note that ilioinguinal and genitofemoral neuralgia do not occur spontaneously or de novo. That would be extremely rare. They usually occur due to direct injury either surgically or from a traumatic penetration. Without this history, an inguinal hernia is the most likely cause of ilioinguinal or genitofemoral neuralgia.

 

You are now armed with all of my secrets on how to diagnose inguinal hernias! If the inguinal hernia is symptomatic or increasing in size, address all risk factors for hernia formation and consider surgical repair as an option.

For more extensive details about this specific topic, I invite you to read my book, The SAGES Manual of Groin Pain.

If you have questions about hernias and their related issues, go to www.HerniaTalk.com. This is a free discussion board with surgeons who contribute to answer your questions.

 

Finally, if you would like to have a consultation with me, either online or in person, go to for contact information.

Best,

Shirin Towfigh, MD

Renowned hernia specialist Dr. Shirin Towfigh is the only surgeon in the Western United States whose work is entirely dedicated to treating all types of abdominal wall hernias and their complications. Her rare focus on using all technologies and surgical modalities available in treating this particular area has made her possibly the nation’s single most respected hernia doctor.

Dr. Towfigh’s received her Bachelor’s degree with College Honors from UCLA and her Medical Doctorate from UC San Diego. She completed her surgical training and research at UCLA in 2002 (ranked “Best in the West” for 24 straight years byUS News and World Report), and is board certified in General Surgery by the American Board of Surgery. As a respected medical professor, she has trained medical students, residents, and fellows in Minimally Invasive Surgery at the USC Keck School of Medicine, LA County + USC Hospital, and the Norris Cancer Center.

 

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Are you unable to come see us in person? We offer virtual appointments!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical and occupational therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical and occupational therapistss committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical and occupational therapistss via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical and occupational therapistss, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical and occupational therapists who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.

 

 

 

From NPR¹ to Men’s Health ², the right way to poop has become an increasingly hot topic for discussion. In fact “Put Your Constipation Woes Behind You,”  is consistently our highest ranking blog every week. Oh, and if you haven’t seen the knight and unicorn bestowing the benefits of the squatty potty³, go watch it now! So,  why is poop such a widely discussed topic and what really is the right way to evacuate?

 

According to a study by Shahid et al in 2012)⁴, “constipation affects up to 28% of Americans.” More Americans suffer from constipation than die from heart disease every year.⁵ While constipation may not be an imminent cause of death, you don’t need a medical degree to realize that if you don’t take out your trash regularly, the house is going to stink. And without doing a PubMed or google search for the prevalence of constipation in America, a walk into your local drug store will tell you that many Americans need laxatives to help them poop. Now we see why this is such a hot topic!

 

The constipation epidemic is significantly prevalent among children as well as adults. A study by Wald et al gathered data on 1,142 children and found that approximately 10% of children ages 5-8 suffered from constipation⁶. If the parents don’t know how to poop properly, how are they supposed to train their kids?

 

To understand how to solve a problem, it’s helpful to start at the source. So let’s go back to how constipation is defined! According to the Mayo Clinic⁷, “constipation can be defined as having less than three bowel movements per week or difficulty passing stool that can lead to excessive straining.” Constipation can be due to a blockage, nervous or musculoskeletal system dysfunction or hormonal imbalance.

 

And now for the solutions.

The Mayo Clinic suggests increasing your fiber, adding a laxative, exercising regularly, prescription medications, and surgery. Two other key solutions not listed by the Mayo Clinic include  going to the bathroom only when you have the urge and avoiding the excessive straining that constipation induces. Here’s why this is so important.

 

By ignoring the urge to poop on a regular basis, you may be creating a vicious cycle that can lead to chronic constipation. This is the scenario: You get the urge to poop. Assuming you are an adult with an intact nervous system, and you are NOT having diarrhea (that’s a different story), you can override the reflex to poop. This reflex is triggered when your rectum is stretched and is known as the parasympathetic defecation reflex. By contracting the external rectal sphincter, you stop the reflex and movement of waste toward the anal canal and suppress the urge to poop⁸. If you do this repeatedly the body’s intrinsic poop train does not get triggered as easily because the rectum is now less sensitive to the incoming signals. You’ve basically trained your body to “tune out” the incoming signal to void. So when you do finally go to the restroom, now you have to strain because the signal, ie. peristalsis, has gotten quiet. Peristalsis is the body’s way of moving waste through the colon and it requires no conscious effort on your part.⁹ Therefore, as best you can, when you have the urge to poop, go!

 

Now let’s talk about how to avoid excessive straining. This topic has inspired footstools such as the squatty potty and research studies alike to find the best pooping alignment. Straining can lead to hemorrhoids, anal tears, rectal prolapse, pelvic floor dysfunction and pudendal neuralgia⁷, none of which are pleasant to say the least. Straining increases when trying to poop while using the modern day toilet. It’s simple biomechanics really. If you are trying to push something out of a tube that’s closer to a right angle than a straight line, it will be more difficult. However, when your knees are higher than your hips, what is known as the “anorectal angle” increases, helping the poop to get out.⁸ The anorectal angle is the angle between your rectum and anus – the final exit point. Normally our knees are level with or below our hips when we sit on the toilet – not helpful for the anorectal angle. We also have the research to prove squatting is helpful. A study by Dr. Sikirov demonstrated that people strain less when they squat versus when they sit. There is a statistically significant difference¹⁰.

 

It is evident and proven that squatting or a squatting position helps you poop. But what if you are squeezing when you think you are pushing? Extremely counterproductive. I have seen this repeatedly in my patients. I ask them to bear down or bulge like they are having a bowel movement and instead they squeeze. So let’s say you’ve done everything right. You poop when you are supposed to. You squat on the toilet. You eat well, take fiber and exercise daily. You’re not on any meds that would cause you to be constipated. And you’re still having trouble pooping. Well, maybe you are squeezing when you should be bulging. You’re not alone in this. But what to do?

 

A mirror is a great tool!

 

Recline in bed, place a mirror where you can see your perineum and anus. Try squeezing, you should see your perineum and anus lift. Then try bulging or bearing down, you should see your perineum and anus bulge. Or if you’re more adventurous, try using a finger in the shower. Insert a lubricated finger into your anus and practice squeezing and bulging. Squeezing will feel constricting. When bulging you should feel your finger moving down and out. It is important to be able to do both actions and to know the difference. The muscles in your pelvic floor need to go through their full range of motion to function effectively, just like any other muscle in your body. If you only knew how to lift your arm, how could you pick anything up? You need to allow your arm to extend to reach an object and only then do you bend your elbow to pick up the object. If you are still concerned about how to poop, consult with a pelvic floor physical therapist.

 

So, let’s recap. What did you learn in our poop lesson for the day?

1. Go when you have the urge.
2. Get into as close of a squatting position as you can
3. Make sure you are bulging correctly.

 

Viola!

 

 

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http://www.npr.org/sections/health-shots/2012/09/20/161501413/for-best-toilet-health-squat-or-sit

http://www.menshealth.com/health/pooping-wrong

http://www.squattypotty.com/

J Clin Gastroenterol. 2012 Feb;46(2):150-4. doi:10.1097/MCG.0b013e318231fc64. Chronic idiopathic constipation: more than a simple colonic transit disorder. Shahid S1, Ramzan Z, Maurer AH, Parkman HP,Fisher RS.

http://www.cdc.gov/heartdisease/facts.htm

J Pediatr Gastroenterol Nutr. 2009 Mar;48(3):294-8. Bowel habits and toilet training in a diverse population of children. Wald ER1, Di Lorenzo C, Cipriani L, Colborn DK, Burgers R, Wald A.

http://www.mayoclinic.org/diseases-conditions/constipation/basics/treatment/con-20032773

Herman and Wallace inc. Pelvic Rehabilitation Institute. Pelvic Floor Level 2A. www.hermanwallace.com

https://www.gutsense.org/gutsense/sensitivity.html

https://vw-squattypotty.storage.googleapis.com/uploads/2015/03/03/files/Straining-study.pdf