Prepping to Push – The Pelvic Floor in Pregnancy

Prepping to Push!!!

Not only is it important to be able to contract the pelvic floor correctly but equally so to be able to fully relax it and to gently bulge it outwards. When your baby's head "crowns" during the second stage of labour, your Pelvic Floor muscles need to relax. Some midwives believe that a relaxed pelvic floor at this stage can help prevent tearing or episiotomy. 

Many women especially those who do have some incontinence problems, are concerned they will leak if they fully relax their pelvic floors. This is an important misconception to address. In order to have a functional, strong muscle (any muscle!), it needs a full range of movement. The ability to both relax and contract. Gaining this full spectrum of movement will promote stronger pelvic floor muscles than simply "Tighten! Tighten! Tighten!"

Try the following Pelvic Floor relaxation exercise:

• Find a quiet relaxing place where you can focus and lay on your side comfortably. Place one hand at the top of your bump/upper abdomen.
• Breathe softly and try to let your tummy rise and fall naturally. If your breathing is relaxed, you should find that the hand on your tummy moves up and down.
• Begin consciously relaxing the muscles of your pelvic floor, letting go like you would to pass urine or pass wind. Relax the muscles of your abdomen (particularly the lower abdomen), thighs bottom and shoulders.

A fantastic position to practice relaxing the pelvic floor is a supported Child's Pose with lots of pillows. Make sure your head is fully supported. The pull of gravity on your abdomen plus the position of your hips encourages the pelvic floor to relax. Practice every night before bed.

Just like you get knots in your shoulders that may not contract and release, the same can happen with your pelvic floor muscles. Overactive Pelvic Floor muscles have trouble completely relaxing when asked. Repeat "letting go" throughout your day. If you feel that you cannot, it's time for a visit to your women's health physio.

Pelvic Floor Contraction

Over the last few decades women have been told that they must relentlessly squeeze their pelvic floor muscles for pelvic floor health (Kegels) but more recent research has nuanced this approach.  

Your pelvic floor is the band of muscles that stretches from your tailbone to your pubic bone. Think of your pelvic floor like a hammock on which your uterus, bladder and bowel rest. Your pelvic floor includes sphincters, which are the muscles that surround your urethra , vaginal opening and anus. These are the muscles that you use to stop yourself from peeing or passing wind when you don’t want to. These are the muscles we want to contract.

Weak Pelvic Floor muscles cannot generate a strong contraction when asked. You may find that other muscles contract instead. Common compensations include: bracing your abdomen, squeezing your legs together (inner thighs), tightening your buttocks and "bearing down" when we think we are "lifting up". Only your pelvic floor muscles should contract. Lightly press your fingertips into these muscles to ensure they are not contracting instead.

There is a way to help you check if you're doing the exercise properly.

1. Comfortably position yourself, ideally lying on your side with your knees bent. You should be wearing leggings or just your underwear.
2. Reach back and place one finger gently over your anus, now move it to the side, still quite close to the anus.
3. Begin by making sure you are breathing in a relaxed way.
4. Take a deep breath in, exhale and relax your pelvic floor muscles. Always start with "letting go".
5. Take another breath in; this time as you exhale, imagine you are closing the opening to your anus then lifting up and in. Think "close and lift".
   Count to 5 out loud, keep your throat relaxed and open (make sure you are not holding your breath!). Feel the closing and lifting movement with your fingertips. When you are learning, start with a gentle contraction until you have managed to co-ordinate your contraction with a breath out.
6. Then on your next exhale, relax all the muscles around your anus and breathe normally. For some women, a gentle push out at the end of each pelvic floor contraction will help.
7. Now try this again without your fingertips in place. Can you feel the muscles relax, close and lift up and in? Congratulations! You have effectively located, relaxed and contracted your pelvic floor.

When you have mastered this lying down, practice sitting upright on a firm chair. When you contract your pelvic floor you may feel it lift up and in and away from the surface of the chair and then relaxing back down again.

Some tightening and flattening of the lower part of the abdominal wall will happen, and that's fine. This part of the abdomen works together with the pelvic floor muscles. If you are tightening your upper tummy muscles (above your belly button) then you are trying too hard! Start again with the relaxed breathing and try a gentle close and lift keeping everything above the belly button relaxed.

Practice every one to two hours, rather than just once a day. Your brain learns better with lots of small reminders throughout the day rather than one large batch of exercises once a day (neuroplasticity). This will become much easier to fit in when you begin The Knack below.

Some visualisation cues which may help you "get these muscles going":

• Draw your pubic bone to your tail bone and the left and right sit bones together and then like a draw string bag, gently draw the entire pelvic floor up.
• Visualize ‘squeezing’/close off the urethra (as if to stop urine flow), hold this while you ‘squeeze’/close the anus (as if to stop flatulence) and gently lift. (Never actually perform mid urination pelvic floor contractions. This interferes with the relationship of the pelvic floor muscles and the bladder muscles.)
• Think about a washing line that connects from the anus to the back of your pubic bone and connect along this line.
• Nod your clitoris down toward the vaginal opening, curl your tailbone toward your clitoris, now gently imagine sucking a blueberry up off of the floor toward your head.
• Women who are familiar with using tampons can imagine squeezing the vaginal walls as if squeezing a tampon up higher in the vagina.
• Wink the anus.

Progressing to Movement

When you have mastered the art of relaxing and contracting your pelvic floor muscles correctly, it is time to incorporate the contraction into functional movement, rather than continuously in isolation. Working the pelvic floor in isolation is not a good long term strategy. The pelvic floor needs to actively work in different positions and in a number of different activities and in coordination with the breath. When it comes to improving function, nothing is better than actually training functionally while going about your day..

The Knack: Ashton Miller et al first described this preemptive contraction of the pelvic floor musculature before a sudden increase in intra abdominal pressure (such as a cough or a sneeze) back in 1998 and it was reviewed again in 2008.

Essentially it involves bracing the pelvic floor for a sudden increase in pressure – as stated above, perhaps a cough or a sneeze, but also applicable for going from sitting to standing. Incorporating ‘The Knack’ into every transfer from sit to stand with emphasis on breathing and pelvic floor coordination can really enhance the strength of your pelvic floor.

How to do The Knack: 

1. Sit tall with good posture, close to the edge of your chair, up on your sit bones, feet hip width apart. Fold your arms over your chest (this way you won’t be tempted to push down on the arms of the chair!)
2. Take a deep breath in, as you breathe out, allow your pelvic floor to relax.
3. Take another breath in, this time with the exhale, close the openings of your pelvic floor and lift PF up whilst simultaneously rising to a standing position, ensuring that your back is in a long, neutral position. (Don’t forget to keep breathing!)
4. Once you are standing, allow the pelvic floor to relax (and again, don’t forget to breathe!).

Initially, combining the breathing alongside the drawing upwards of the pelvic floor whilst moving will all seem a little bit complicated. Try to practise this standing up after every visit to the loo. Keep practising until it becomes second nature. Once you get used to it start to introduce the Knack every time you stand up from a chair. Getting up from a seated position is essentially a squatting pattern, it is a functional movement we do many times every day.

The Knack is a preventative measure that will keep our pelvic floor in excellent shape for years to come.

Perineal Massage

The perineum is the area of tissue between your vagina and anus. Perineal massage is a way of manually stretching the tissues around the vagina in the last few weeks of pregnancy in preparation for giving birth vaginally. Daily perineal massage can increase the area's ability to stretch and reduce the need for an episiotomy and fewer natural tears and bruising. This is particularly beneficial if you are having your first baby or if you have scar tissue there. Perineal massage can also help with your recovery after the birth by increasing blood flow.

It is usually carried out from week 34 onwards, not recommended if there is a history of premature birth, premature rupture of membranes or a vaginal infection.

Personally, I plan to practice perineal massage once a day for the last month of my pregnancy. I feel that doing the massage will give me the confidence to know what the vaginal walls and perineum can do and that the area really can stretch. Therefore I know that the baby will be able to slide through. I will worry less about tearing and can relax when the baby is crowning and allow my body to do what it is designed to do.

So if you fancy giving it a go here`s what you do;

• Make sure your hands and nails are clean or if your partner is assisting you, that their hands and nails are clean. A good time is after a bath or a shower because the pelvic floor muscles will be warmer and your skin softer. This makes the perineum more comfortable to stretch.
• Get comfortable and relaxed in a place where you feel safe, secure and will not be interrupted (very important when trying to relax sphincter muscles). Lying on your side with some pillows between your knees is s a good position as the bump won`t get in your way.
• Lubricate your fingers, thumbs, and perineal area with an unscented natural oil such as pure olive oil, grapeseed oil or a personal lubricant. Do not use synthetic oils such as baby oil or petroleum jelly (Vaseline).
• Be gentle, a vigorous touch could cause bruising or swelling. During the massage, avoid pressure on the urethra (urinary opening) as this can lead to irritation or infection.
• Reach your hand behind so you can reach the vagina. Insert 2-3 fingers about 4cm inside the vagina. Gently but firmly pull the vaginal opening back towards your rectum, until you feel a tingling. It shouldn’t hurt or burn. Keeping the pressure on as you slide the fingers side to side to stretch the vaginal wall laterally for 1-2 minutes. Finally, massage the tissue between the thumb and forefinger back and forth for about a minute.
• Focus on relaxing your perineum as much as possible during the massage. Being able to relax through this feeling of increased pressure is the real goal here. With time and practice, as your perineum becomes more elastic, you will increase your ability to relax and you can increase the pressure towards your rectum.
• It should not feel painful. If you feel pain at any point, stop and try again another time. If you continue to find this painful speak with your midwife or doctor.