Helpful preparation for pregnancy and birth that I wish I knew for my own

I started a prenatal and postnatal fitness course back in September 2020. It's been slow going, but I've made it to Module 4 and learned some insightful and extremely helpful things for pregnancy and birth. I honestly wish someone had told me these things when I went through mine. What you will find in this post is material learned from a women's pelvic health physiotherapist, not an ob/gyn. I believe that is why the information women receive during their pregnancies, birthing classes, and post-birth is different and quite frankly, lacking.

I understand ob/gyn's have full schedules consisting of monitoring women's pregnancies and delivering babies and thus, long, detailed conversations are not always possible. But failing to provide essential preparation techniques as well as all possibilities/scenarios during a birthing class does not serve women well. I didn't learn any of this information in the class I took and I feel that made me less prepared. Who knows, my two births, especially my first, could have been different if someone properly informed me of the full birthing picture.

What I've put together here specifically pertains to perineal tearing. I've also included some suggestions for strength training/cardiorespiratory training, and nutrition during pregnancy. I originally put this together for a friend for her first pregnancy because I want her to feel prepared and have the big picture of what pregnancy and birth entails beforehand.

Pregnancy and Birth

· Healing (both pain management and time) is dependent on the woman – some have relatively easy healing process while others have terrible pain and can take up to 1 year OR they live with symptoms for years because they don’t see a pelvic floor physiotherapist and don’t have a good support system of doctors/professionals/family

Anatomy:

· Perineum – connective tissue between vagina and anus - **this tissue starts to lengthen during pregnancy, so you want to start massaging this area throughout pregnancy to make it more flexible for stretching at birth**

· 4 grades of tearing:

· 1 – opens at skin of vagina (heals on its own and no intervention)

· 2 – vagina and portion of perineum tears (requires stitches)

· 3 – vagina, perineum, and portion of anal sphincter **depending on which part of the anal sphincter, the internal or external part, is torn, there is 3a, 3b, and 3c tears**

· 4 – torn through internal and external anal sphincter and into rectum

· Grades 3 and 4 are called an OASIS (obstetric anal sphincter injuries) and have nerve trauma

· Grades 3 and 4 should be corked at birth and then taken into surgery for repair immediately

Episiotomy - Avoid having an episiotomy because you aren’t meant to be cut in that way in that area **allow for a natural tear with the proactive preparation found above and below**

- If you do have one, start with light scar tissue massage after a few weeks

Preventing Perineal Tearing – is about what you do during 9 months of pregnancy and what you learn about your body

· In the delivery room and when you are actively pushing the baby, do not push like you are pushing a #2 out because if you do this, you are connecting/focusing on pushing out from the anus and perineum

· Instead, you want to focus on connecting to the pelvic floor and vaginal muscles so they are the source of your pushing and you aren’t relying on pushing out from the back (anus)

· Positioning during pushing impacts the safety of your perineum

o When on your back, your tailbone is tucked under and this actually causes your pelvic floor to close which causes more stretching on your connective tissues and less relaxation of them (during birth, we want you to be able to relax your pelvic floor muscles so they aren’t tight and more elastic)

o Proper birthing positions allow the perineum to open up the most with less trauma

§ On hands and knees

§ Over a stability ball

§ Over the edge of the bed

§ Squatting with support – holding onto something

· Gotta prepare for birth in the same way you would prepare for a marathon

o Don’t go into it blind – always ask questions, read, and learn to get the full picture

o Just as you would train for a marathon by building up muscular endurance and strength and work on your breathing, these same things should be done for birth

o Training your body for 9 months is the really hard part – think of pushing out the baby as you crossing the finish line, that last part is the easy part, while everything prior is the most difficult

o Learning about your pelvic floor and deep abdominal muscles (transverse abdominis, butt, and back)

§ Do I know how to squeeze through my vaginal muscles?

§ Do I know how to relax my pelvic floor? How does relaxation feel?

§ Am I connecting to my pelvic floor when I’m breathing?

· Levator Ani Defect/avulsion – full or partial detachment of the group of 3 deep pelvic floor muscles that attach to the pubic bone

o Anatomy – levator ani muscles –

§ Pubococxygius

§ Illiococxygius

§ Puborectalis (tear of this muscle: partial tear on one side of the 2 pubic bone insertions OR a full tear on both sides to make a full circle

- How do you know if you have this?

o Usually comes with pelvic organ prolapse (bladder or uterus prolapse)

o Levator avulsion increases chances of POP

o Feels like big, empty, open space down there

o Usually experience stress incontinence (pee when jumping, exercising, etc)

· Advice for Healing – birth injury is like a sports injury – needs Rest, Ice, compression, elevation

o Rest – early stages (first couple weeks) just leave it and let it heal

o Ice – freeze period pads and put into underwear for 1 min intervals

o Compression- wear loose comfortable underwear but with a pad to provide the compression you are looking for

o Elevation – side lying or elevate part of your hips to decrease the pressure to your pelvic floor

§ Grade 3 or 4 tears (and avulsion): be very careful how much you lift and the force you are generating in that area; don’t overdo it

o Can be difficult to stand or walk for some women

o At the same time, it’s important to get up and move if you can tolerate the pain – don’t stop all movement

o Wait until 6 weeks to start light massage on your scar from this repair because one usually has fecal incontinence too

§ All about finding the balance between pain management and the incontinence

o Peeing – to help with the burning sensation, squirt warm water on the vulva and urethra

o Pooping – sit normally on the toilet with feet on ground (do not elevate them) and put towels under your thighs to relieve pressure

§ Don’t strain, take your time

§ Drink glass of water

§ Try to relax your pelvic floor and go everyday

§ Try abdominal massage (big circles from right pubic bone to right rib cage, then left rib cage to left pubic bone)

§ Constipation is normal but don’t be afraid to go, just empty your bowels

§ More frequently you move them, the easier it will get and with less discomfort

How can tearing affect your pelvic floor function:

§ Initial aftermath is pain – pelvic floor spasms

§ Then it’s a domino effect after that – causes muscles to be more overactive, then more tight

§ From there, develop symptoms such as:

o Urgency of bladder

o Urge incontinence

o Constipation

o Hemorrhoids

o Painful sex

o Fecal incontinence (usually with OASIS injury)

Types of exercise during pregnancy

As with life in general, being stronger, fitter, and having good endurance (heart and lung function from cardiorespiratory exercise) will tremendously help during pregnancy and birth. Take it from me, my first and second pregnancies and births were totally different. I did nothing with my first and lifted during my second. If I had exercised during my first, it would have made it easier on my body. And, that’s what we want, to make things easier. It’ll still be hard, but if you can take steps during pregnancy and prior to birth to help with both, I recommend it. First births are usually harder just because they are the first; with subsequent births, your body “knows” what is to come and therefore, what it should do.

You will be nauseous and tired, oh so tired. Aches and pains will arise. But, take advantage of the times where you do feel energized to get moving and workout. Strengthening your muscles, learning to relax pelvic floor ones, stretching, and massage will all help throughout the entire process. It could mean the difference between days long labor and hours of pushing to less of both. You really can’t go wrong with being stronger.

Cardiorespiratory: Aim to walk outside everyday – walking is so underrated and this will help during the hours-days long labor you might have

Strength train: 2-3x/week even if it’s just for 15-30 minutes a day

· Glute bridges (early on during 1st trimester) – butt muscles

· Supine banded hip march (early on during 1st trimester) - butt

· Goblet squats to a bench/chair – butt and legs

· Sumo squats – more for butt

· Step ups – butt and legs

· Pelvic floor pumps/lifts – pelvic floor and abdominal muscles

o To engage your transverse abdominus, think about pulling in the area half way between your belly button and pubic bone – pull this area into your spine

o Practice gripping a marble from the front, middle, and back for pelvic floor

o Also learn how to relax your pelvic floor with stretches

· DB RDL – bilateral or single leg supported -butt, hamstrings, and back

· Rows – back

o Bent over rows early on in pregnancy

o Use bands to help achieve a pulling motion

· Simple isolation exercises for arms – bicep curls, tricep kickbacks, and front/lateral raises and rear delt flyes for shoulders

Stretches to relax your pelvic floor:

§ Side lying position: use pillow for head/neck support (do 5-10 reps each side) **GOOD for all trimesters of pregnancy**

o Doesn’t matter positioning of knees/hips/feet

o Relax lower abs and belly

o Inhaling/exhaling (don’t force air out) and focusing on relaxing belly/lower abs and learning how to let it hang to floor

- Prone position: lying on stomach with hands making a triangle on forehead (do 10-15 reps) **GOOD for 1st trimester and as long as your belly isn’t too big**

Focusing on your breathing again

On inhale, let belly fill up and also feel expansion in your lower back

- Happy baby pose: supine position (do for 10 breaths) **GOOD for 1st trimester when it’s still appropriate to be lying on your back**

o Bring knees in like for a hip crossover stretch, then put elbows inside your knees and grab your feet

o Draw shoulders down into floor

o Knees pulled into the floor

o Feet flexed

o This will lengthen through your tailbone down to the floor – keep lower back flat to ground and draw tailbone down

o Regression- can have feet together

Nutrition:

· Drink tons of water

· Protein, carbs, fats (consider working with a registered dietician) to help with macros and total calories

· Moderate indulging

· Lots of complex carbs and fiber to help with pooping (both during pregnancy and first day or two after giving birth to help with passing that first bowel movement)

o Constipation is normal but don’t be afraid to go, just empty your bowels.

o More frequently you move them, the easier it will get and with less discomfort

I really do hope you find this helpful for your own pregnancy/birth. Please reach out with any comments or questions. Stay strong.

Shaheed, Heba. “Perineal Tearing, Episiotomies, and Pelvic Health after a vaginal birth.” Postnatal Fitness Specialist Course. Sydney, New South Wales. Lecture.

Mundell, Jessie. Postnatal Fitness Specialist Course. Alberta, Canada. Lecture.