By Melinda Fontaine
I recall being eight months pregnant treating other pregnant women or new moms. I would always hear, “How are you still working full time on your feet?” I still think the most honest answer is, “Pure luck”. Every pregnancy is different, and there are a lot of things that are out of your control. We all do the best we can to take care of ourselves, which means staying informed and making healthy choices. The other common response I gave to people was, “I work with a great group of women who specialize in caring for pregnant women, so I am very well taken care of.” I wouldn’t undervalue the importance of having a support group during pregnancy. My colleagues were there to listen to my musings and complaints about pregnancy, give me advice, and treat my aches and pains. I am very lucky to have such vast experience with pregnancy professionally because I knew what to expect and how to prepare myself physically and mentally. I am also very unlucky to have such vast experience with pregnancy professionally because I know about all the worst case scenarios! The possibilities of what can happen during pregnancy are endless, but I’d like to share some of the knowledge that helped get me through my pregnancy with minimal freak-outs and discomfort.
Build Core Strength
When I first found out I was pregnant, I did two things for myself: I signed up for prenatal Pilates and I bought compression stockings. The Pilates classes were to strengthen my core in a safe, effective, and fun way. I knew that a strong core would support me while I carry a baby. The deep core muscle, transverse abdominus, wraps around one’s midsection like a corset. It is responsible for supporting the low back and hips, which becomes increasingly important as the hormone relaxin starts to make joints looser and the belly starts to pull forward. Pelvic girdle pain or low back pain affects 72% of all pregnant women1, and a strong transverse abdominus is the first defense. There are many exercises to strengthen this muscle, but I chose Pilates because I thought it would be fun and safe. My instructor was very knowledgeable about the special needs of a pregnant body and knew how to modify exercises and teach perfect form. My biggest fear about starting a new exercise regimen, especially when pregnant, was trying to keep up with the group, doing something wrong, not being corrected, and ending up injured. I also kept up my old exercise routine at the same intensity as before I was pregnant until my body started to tell me to take it easy. In healthy women with uncomplicated pregnancies, it is generally safe to do so2, but always listen to your body and your doctor. The American College of Obstetrics and Gynecology recommend moderately intense exercise for 30 minutes a day on most or all days of the week. Exercise during pregnancy has been associated with lower risk for diabetes, depression, hypertension and preterm birth3. In some cases, the increasing weight of the pregnant belly, the hormone relaxin, and underlying pathology will overpower the core muscles, and external support may be needed to alleviate pregnancy related low back pain. A sacroiliac joint belt hugs the bones of the pelvis and supports the pelvic girdle and sacroiliac joints. A maternity support belt lifts and hugs the belly to reduce abdominal and back discomfort.
Wear Compression Stockings
The compression stockings help minimize swelling and circulate blood from the feet back to the heart. During pregnancy, the volume of blood increases and the walls of the veins soften and expand. This leads to fluid collecting in the feet and legs, especially in women who spend a lot of time on their feet. For all people, pregnant or not, who spend a lot of time standing during the day, such as myself, compression stockings with light to moderate compression can help to counteract the effects of gravity and help legs feel more energized. Maternity compression stockings exert about 15 mmHg of pressure and are comfortable (although sometimes hot in California in the summer). Try different brands of knee highs or full length stockings to see what you find comfortable. I wore Juzo.
Avoid Constipation and Hemorrhoids
As pregnancy progresses, different signs will appear such as morning sickness or that dark line in the middle of your abdomen. So many changes could possibly happen that I can’t list them all. One guarantee is that the pregnant body produces more progesterone. Progesterone is the hormone responsible for relaxation of smooth muscle, such as that in your digestive system, and decreased motility in your stomach and intestines. This means that food travels through your system slower and can lead to constipation. Too much straining with constipation can lead to hemorrhoids. I recommend drinking plenty of water and eating a high fiber diet. I put my feet up on a stool when I sit on the toilet to have a bowel movement because this is the most natural way to poop. After all, most of the world poops and has babies in the squatting position to put the pelvic muscles on slack and allow the pelvis to open. I can’t tell you how many people are in love with their poop stools after they try it. Put one in your house, and everyone, young and old, male and female, will benefit. Here is a link to the one we have in our clinic in Berkeley. I also avoid holding my breath and bearing down to poop. All that pushing puts a lot of downward pressure on the pelvis and can lead to hemorrhoids, prolapse, or nerve injuries. This is such a common problem that some prenatal vitamins even have stool softeners in them. If you still struggle with constipation and/or hemorrhoids, talk to your physical therapist or doctor about other ideas.
Beware of Incontinence
Instead of, or in addition to, struggling to get waste out, some pregnant women struggle to keep waste in. I’m referring to incontinence (or leaking) of urine, feces, or gas. In pregnancy, this is most common due to the pelvic floor being asked to do too much work. (There are other possible causes as well, so talk to your physical therapist.) Besides doing its usual tasks of supporting the pelvic organs and pelvic girdle and maintaining sexual function and continence, the pelvic floor is asked to hold up an extra 7 lbs of baby, 1 ½ lbs of placenta, 2 lbs of enlarged uterus, and 2 lbs of amniotic fluid. Something’s gotta give, and when it’s your pelvic floor, you end up leaking. Often this improves after delivery, but it is not a normal part of pregnancy or being a mom. It is an indication that something is not working right, and it should be evaluated. The pelvic floor may be too weak or too strong, which brings me to my next point…
To kegel or not to kegel
Another guarantee while you are pregnant is that you will undoubtedly hear from someone, “Do your kegels”. To be honest, this kind of makes my skin crawl because you can’t blindly prescribe any one exercise to every woman. Kegels are a strengthening exercise. I wouldn’t tell a person with a strong pelvic floor to do kegels any more than I would tell a competitive weight lifter to run a marathon. Not only is it not necessary, but it may also be harmful. A pelvic floor that is too tight could lead to incontinence, retention, urgency, frequency, or pain. Doing kegels could make these symptoms worse, your pelvic floor may need to be lengthened before it is strengthened. On the other hand, a weak pelvic floor could really benefit from kegels to decrease incontinence and prolapse and improve ease of delivery. It is impossible to tell which kind of pelvic floor someone has without a manual exam from a physical therapist, so take the advice to “do your kegels” with a grain of salt.
Another common pregnancy tip for the 2nd and 3rd trimesters is to avoid lying on your back. This is sound advice, especially as the baby gets larger. The weight of the baby can press on the vena cava (a large vein in your abdomen responsible for returning blood to your heart). This can make mom start to feel lightheaded and can be serious if it is not corrected quickly by changing positions. The increasing size of a pregnant belly also stretches the muscles of the abdomen. Sometimes, the recti abdominis (or 6-pack muscles) can separate creating a soft part in the middle of your belly above or below your belly button called a diastasis. I avoid doing sit-up type exercises that would further stress and pull apart these muscles. Diastasis is very common during pregnancy and is more likely if your belly grows quickly or if you have had multiple pregnancies. It can go away on its own after delivery, or you may need a physical therapist to teach you how to correct it. Lastly, carrying around extra weight in the front of your body means that the muscles in the back of the body have to work overtime to keep you standing upright. The gluteals (buttocks) are one such group of muscles. If these muscles feel tight, painful, or uncomfortable, getting a massage or rolling them out on a foam roller can feel really good. Wearing sneakers with good arch support will also support muscles further up the leg by creating good alignment, and they give added compression at the foot, in addition to the compression stockings discussed above.
Take a Class
At the end of about 40 weeks, the baby will be born. Sometime before then, I recommend taking some sort of childbirth class. There is no one right way to birth a baby. As a mom, you have many choices to make. It is hard to make decisions during delivery because you are physically and emotionally exhausted. Learn as much as you can about what to expect before, during, and after delivery, and think about your preferences. That being said, you cannot control what is going to happen and you may make changes to your preferences in the moment. Some things to think about include: where will you deliver, vaginal or cesarean, who will be with you, what are your pain management options, who will cut the umbilical cord, will you vaccinate, who will be your Baby’s pediatrician, will you circumcise, will you try to breastfeed. I also find it comforting to know a little about labor and delivery including how to know when you are in labor, what does labor consist of, when will you start pushing, what will happen after the birth, what tests will be provided to the baby after birth, etc. If you are birthing at a facility, take a tour.
Something that might not be covered in a typical birth class is practicing pushing and finding good positions for you during labor. I do this with all of my patients who are preparing for delivery. A large number of women don’t know how to push a baby out on their first attempt. Good pushing involves a soft relaxed pelvic floor to allow for easy passage of the baby and a strong abdominal contraction to increase the pressure in the abdomen above the baby and help push baby down and out. The most effective pushing position for each woman is different and some positions will not be possible after an epidural. Curling up as if doing a sit- up could help increase abdominal pressure to bear down. Being in an upright position such as squatting uses gravity to help the baby come out. Hands and knees can also be a nice way to labor without the weight of the baby on your back. Use a chair, bed, or partner to lean on as well. Try multiple positions ahead of time and see which ones feel comfortable to you, so you will have some ideas to try during labor. For more information on labor and delivery, stay tuned for future blog posts.
Veteran Moms: Do you have any other tips you would like to add to this list?
Melinda Fontaine, DPT
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.
Bergström C et al. (2014). Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation. BMC Pregnancy and Childbirth,14, 48. doi:10.1186/1471-2393-14-48
American College of Obstetrics and Gynecology (ACOG). (2002, reaffirmed 2009). ACOG Committee opinion number 267: Exercise during pregnancy and the postpartum period. Accessed July 2015 via the web at: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Exercise-During-Pregnancy-and-the-Postpartum-Period
Domingues M R, et al. (2015). Physical activity during pregnancy and maternal-child health (PAMELA): study protocol for a randomized controlled trial. Trials, 16, 227. doi:10.1186/s13063-015-0749-3
Pregnancy weight gain: What’s healthy? Mayo Clinic. Accessed July 2015 via the web at http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy-weight-gain/art-20044360?pg=2