Reducing perineal trauma during labor and delivery

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By Stephanie Prendergast

 

Who doesn’t love a crowning baby cake? If our image didn’t catch your eye the title of this post probably did if you are pregnant or thinking about becoming pregnant. Last week we presented a pelvic health quiz about the role of the pelvic floor muscles play in childbirth. This week we share the answers and will tackle your questions on how to reduce protect your pelvic floor muscles and perineum as your baby makes its way into the world!

 

Q:  What do your pelvic floor muscles do?

A: Pelvic floor muscles keeps us continent and allows us to pee and poo, prevents pelvic organ prolapse, supports our organs and joints, and helps us enjoy a pleasurable, orgasmic sex life.

 

Q: What do your pelvic floor muscles go around?

A: Bladder/urethra, rectum, vagina

 

Q: Should your pelvic floor muscles and abdominal muscles work together?

A: Yes!

 

Q: Why might women leak urine when they are pregnant?

A: The pelvic floor muscles could be tight or weak or ‘confused’ and not contracting/relaxing properly. The pressure from the baby could be exceeding the strength of the pelvic floor.

 

Q: If you leak urine when you are pregnant, what can you do about it?

A: A pelvic floor physical therapist can help you understand why you are leaking and give you an individualized plan to help.

 

Q: How often should you exercise your pelvic floor muscles?

A: This depends, we will explain below.

 

Q: What is Pelvic Organ Prolapse and how does it occur?

A: Pelvic Organ Prolapse occurs when organs start protruding into the vagina. Childbirth is the #1 risk factor for this. Weakened pelvic floor muscles and a Diastasis Recti can contribute to these issues.

 

Q: Once a person has pelvic organ prolapse not much can be done to help.

A: False. Pelvic floor physical therapy can help.

 

Q: Leakage of stool only occurs in older women.

A: False. Fecal incontinence can occur after delivery or develop at any point in a woman’s life depending on the integrity of the pelvic floor and core muscles.

 

Q: If stool leakage happens related to pregnancy or birth, it is short-term in duration.

A: False. It may continue if untreated.

 

Q: Surgery is the only treatment for stool leakage.

A: False.

 

Q: Do pelvic floor muscles play a role in orgasm?

A: Yes!

 

Q: Do the pelvic floor muscles play a role in painful sex?

A: Yes.

 

The pelvic floor muscles are kind of a big deal! Today we will tackle three of the most common questions we hear at PHRC.

 

I’m pregnant! What type of exercise should I be doing?

 

Pregnancy and fitness enthusiast, Kim Vopni, also know as the Vagina Coach, answers this question for us.

 

We’ve all heard the saying – Giving birth is like a marathon. For a marathon we understand the need to train for the big race. Birth is actually more like 5 or 6 marathons and yet little time is spent physically and mentally preparing for ‘race day’.  

 

In fitness, the concepts of strength and endurance training, tapering off before race day and recovery afterwards are common sense. When it comes to giving birth however, little attention is paid to ‘sport specific’ training and the essentials of recovery. Pregnant women need to Prepare To Push™ and ensure they prepare for their recovery as well.  Movement practices that mimic the demands of labour are key! Building strength and endurance in positions that you may find yourself in labour and birth will ensure your body is trained and ready to handle those demands efficiently. In the final weeks before birth, focusing on release work and learning how to yield against stretch and discomfort (perineal massage) will serve you well because as much as we need strength and endurance in our muscles, we also need to be able to surrender and allow the process to unfold. In our busy lives, we spend less and less time allowing and more time doing. Sometimes just doing nothing is what we need.

 

 

This is also the message to take into recovery. Build your support team before you give birth. The first week should involve nothing but breathing, breastfeeding, bathing and bonding with your babe. Stay in bed, allow people to help and support you and give you body time to heal and recover. Gradual return to movement and exercise is necessary and ‘6 weeks’ is not your goal. Birth is like a marathon but it is not a race and nor is postpartum recovery.

 

As a general rule, some key points for birth prep and recovery can be broken out into the trimesters. First trimester is about finding and connecting to your core and building your birth and recovery team. Second trimester is about building your strength and endurance in ‘sport specific’ ways. Trimester three you start to taper off the strength and endurance and transition to release work and learning to yield. Perineal massage plays a key role here as well. Finally the fourth trimester is all about replenishing what was lost in birth, ‘closing’ the body that was opened for birth and then re-connecting to the inner core/pelvic floor.

 

If you would like more information, check out Kim’s online course, Prepare to Push. PHRC blog readers can use the coupon code spblog17 for 20% off.

 

Is perineal massage effective and should I do this?

 

The answer to this question is YES. As Kim mentioned earlier, there is a time and place for perineal massage.  In a recent study in American Family Physician, 4 studies were reviewed that included 2, 497 participants. The study showed that 1st-time moms benefitted from perineal massage in the following ways:

 

  1. Reduction in perineal suturing
  2. Significant reduction in episiotomies
  3. Less postpartum pain

 

Most women reported that they would practice perineal massage again and recommend it to others. Vaginal deliveries require muscle flexibility, it is theorized that perineal massage improves flexibility, decreases resistance, and therefore reduces tearing and the need for episiotomy.

 

 

It is recommended that women start performing perineal massage at 34-35 weeks. Women who practiced 1.5 times per week for 5 minutes reduced the need for episiotomy and women who practiced massage more frequently did not further reduce this risk. Pelvic floor physical therapists are trained to help women correctly perform perineal massage. If you cannot go to pelvic floor physical therapy, online resources are available, such as this post from Web MD.

 

We do not recommend using KY Jelly or massage oil, as suggested on the Web MD website. For more info on what lubrications we do and don’t recommend and why check out Melinda’s blog post.

 

Do I need to do Kegels during pregnancy?

 

Kegels are often included in exercise regimes to treat stress urinary incontinence and pelvic organ prolapse but their effect on labor and delivery hasn’t been thoroughly studied until recently. In a systematic review, 12 studies that included 2,243 women were examined. The studies found a few great benefits for 1st-time moms:

 

  1. Pelvic floor muscle exercises shortened the 1st stage of labor by 28.33 minutes
  2. Pelvic floor muscle exercises shortened the 2nd stages of labor by 10.41 minutes
  3. Pelvic floor muscle exercises reduced/prevented stress incontinence
  4. Pelvic floor muscle training did NOT increase or decrease the risk of episiotomy, perineal trauma, or instrumentation delivery.

 

Each of the 12 studies reviewed used different pelvic floor training protocols in terms of frequency, duration, start and stop dates, and how the women were instructed to do the exercises.  Pelvic floor physical therapists individualize programs for each patient but we need evidence for the general population for this post. I reached out to PHRC friend and pregnancy expert Julie Wiebe. Sure enough, she had the solution I was hoping for.

 

I recommended my online course for pregnant women: Pelvic Floor Piston: Foundation for Fitness. Not trying to sound like a salesman, but it is the more complete version of all the advice I cannot provide in a single blog post. It is a step-by-step guide to connecting the components of system directly impacted by pregnancy, and learning to re-balance the muscles and pressures that comprise our stability system (watch a clip explaining this here). Practicing coordinating these components and building habits now before she delivers will help make those strategies accessible out of the gate immediately postpartum. A key component is to learn to “blow before you go” (exhale BEFORE exertion, read more about that here). This helps to trigger the system automatically and blow off any pressure that could push against stitches from either a C-section or Vaginal delivery. This is critical to promote tissue healing in those first few weeks. This also prevents any added pressures on diastasis, urethral sphincters and bladders, and pelvic organs.

 

The majority of women given verbal instruction alone cannot properly perform a Kegel and Kegels, by themselves, are not sufficient for pelvic health and incontinence and prolapse prevention. The pelvic floor needs to work with your core. Julie’s program is fantastic and can help women set themselves up for success during labor and delivery. PHRC readers can receive a 20% discount using the code Recover20 until August 20th.

 

Conclusion

 

The majority of women feel like they do not have enough knowledge about childbirth and pelvic floor muscles. We hope our series is providing education and confidence! To prepare for labor and delivery and protect your pelvic floor, follow Kim’s exercise suggestions, learn and practice perineal massage, and improve your pelvic floor and girdle muscle strength and coordination while you are pregnant. If you know you are having a Cesarian section you can skip the perineal massage but the other sections still apply to you.  Please share our posts, ask us questions, and leave us comments!

 

 

More about Kim:

 

Kim Vopni is a self professed pelvic floor evangelist and is known as The Vagina Coach.  She is a certified fitness professional who became passionate about spreading information on pelvic health when she was pregnant with her first child.

 

She is the author of 2 books – Prepare to Push – What Your Pelvic Floor and Abdomen Want You To Know About Pregnancy and Birth which launched in 2015 and a second title Your Pelvic Floor – The Inside Story – which launched in April 2017.

 

Kim is the founder of Pelvienne Wellness Inc and co-founder of Bellies Inc.  She is also the founder of Kegels and Cocktails™  – a women’s health event designed to empower and educate women on the importance of pelvic health.

 

You can find her on-line at www.pelviennewellness.com and www.belliesinc.com, on facebook @PelvienneWellness and @BelliesInc, and on twitter and Instagram @VaginaCoach

 

 

More about Julie:

 

Julie Wiebe is a physical therapist who specializes in returning women to fitness and sport after injury and pregnancy. She advocates for the awareness of pelvic health issues in fitness and promotes innovative solutions for women through her blog, videos and social media. She shares her evidence-based, integrative approach internationally with both professionals and women through live and online educational programs. When not trying to change the world one pelvic floor at a time, Julie is happy to focus on her other passions: being mom to the Z’s (Zoe and Zack), and wife to David.

 

Find out more and connect with Julie at www.juliewiebept.com <http://www.juliewiebept.com/> or via social media Twitter/FB/IG  JulieWiebePT


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