Start slowly, especially if you had no regular prepregnancy exercise routine. Consider a prenatal exercise group if one exists in your area, even if you already consider yourself a fitness expert.
Water Exercise
Water aerobics provide a good workout, nonstressful to the pelvic floor and also the joints and spine, all of which are particularly vulnerable beneath the extra weight of pregnancy. Water’s antigravity effect can provide true relief to your overworked body, especially during the last few months before delivery.
Prenatal Yoga
Yoga improves blood circulation, relaxes the body, strengthens muscles, and makes you feel great. In addition, it may help to prepare you for different laboring and birthing positions, to improve the flexibility of your joints, and to develop pain-coping strategies. A variety of poses designed to tone and open the pelvic area, and strengthen the pelvic-floor musculature, are safe for a low-risk pregnancy. Be sure to find a prenatal yoga class, or at least an instructor who is familiar with safe poses for pregnancy.
Posture and Lifting
As the uterus enlarges during pregnancy, changes in posture naturally occur. Perhaps most visibly, women may tilt their pelvis forward and throw their shoulders back as the abdomen protrudes. The result is often a poorly aligned spine, increased strain on the muscles and ligaments, and most importantly from our perspective, pressure on the pelvic floor. You’ve already learned one strategy to counteract these changes: the pelvic tilt. In the standing position, tuck the pelvis back into a position more in line with the spine, by activating the buttocks and abdominal muscles while straightening the upper back: this will improve your posture and help to protect your lower back and pelvic floor. With developed abdominal muscles, this posture will be easier to maintain. Remember when lifting to brace the pelvic floor with an inward Kegel squeeze, rather than bearing down as you would during a bowel movement; this will prevent undue stress against the pelvic floor when it is most vulnerable (see Appendix A).
Changing postures during pregnancy
What to Avoid
Steer clear of jumping and jolting exercises. The hormone relaxin makes your joints stretchier, so be sure not to force them beyond their normal range of motion, or to overstretch to the point of pain.
When starting your exercise routine during pregnancy, keep in mind some basic guidelines recommended by the American College of Obstetricians and Gynecologists:
During pregnancy, you can continue to exercise and derive health benefits even from mild to moderate exercise routines. Regular exercise (at least three times a week) is preferable to intermittent activity.
After the first trimester, avoid exercise in the supine position (on the back). This position is associated with decreased cardiac output. Prolonged periods of motionless standing should also be avoided.
Since oxygen availability is decreased during exercise, modify the intensity of exercise according to your symptoms. Stop exercising when fatigued, and don’t exercise to exhaustion.
Any exercise that involves a potential threat of abdominal trauma or loss of balance and risk to mother or infant should be avoided.
Since pregnancy requires an additional three hundred calories per day, make sure you’re eating adequately if you’re exercising.
Adequate hydration, appropriate clothing, and optimal environmental surroundings are important for body-temperature regulation during exercise.
Anytime you experience an unexplained discomfort or concern, stop and call your doctor. Warning signs include, among others: pain, vaginal leakage or bleeding, abdominal cramps, difficulty breathing, pain in the chest or legs, increased swelling, headaches, or decreased fetal movement.
Before starting any new exercise program, review the plan with your obstetrician. If you are in a high-risk pregnancy category, or have a medical condition, the exercises recommended in this chapter may not be appropriate for you.
Sources: American College of Obstetricians and Gynecologists Jan. 2002 technical bulletin; The Official YMCA Prenatal Exercise Guide.
PREVENTING CONSTIPATION
Pregnancy makes you constipated—largely an effect of the pregnancy hormone progesterone on the bowels, sometimes heightened by oral iron tablets. Avoiding constipation is important not only for your comfort but also to prevent straining on the toilet and stressing the pelvic-floor supports. You’ll also help to prevent hemorrhoids and varicosities (swollen veins) in the vulva and perineum, which can cause aching, heaviness, or heavy bleeding during labor and delivery. Winning the battle of the bowels may take several strategies, including lots of fiber and fluids, regular exercise, stool softeners, and occasional laxatives. Make a habit of bran, fruits, raw veggies, and plenty of hydration. Consult with your doctor or midwife before starting any laxatives during pregnancy. See chapter 10 for more tips.
EXERCISING YOUR MIND: THE PRENATAL SELF-HELP YOU SEEK
Countless classes and groups are available these days, ranging from mind-body exercises to full-fledged medical-review courses. The majority of these programs orient women and their partners to natural birthing techniques, controlled breathing, and relaxation: great preparation for the uncertain journey ahead, during which “mind over matter” can go a long, long way. Unfortunately, their focus on your lower body often begins and ends with the perineum and strategies to avoid episiotomy. The scope of concern needs to extend much wider to have a real impact on your postreproductive body. Still, these techniques can help prepare you mentally and provide you with a better ability to relax your pelvic floor during labor and delivery.
Learning How to Labor
EXPLORING YOUR OPTIONS FOR STYLES, POSITIONS, AND TECHNIQUES
So, I ended up going overdue and being induced … laboring for over thirteen hours and no progress. I ended up with a C-section. My OB came out to talk to me while I was in recovery and said there would have been no way I could ever have (vaginally) delivered my son.
—T.F., chat-room contributor, www.gocesarean.com
I told the doctor I wanted to avoid a C-section if possible, if he thought the baby would be OK. He told me, “Well, the head is coming down, but I’m not sure if you’re going to be able to push this baby out.” I was very sure I could, and I wanted this baby out. I had no drugs and was very, very tired. I looked at my husband, and I told him I was going to prove this doctor wrong—I was going to push this baby out. I started pushing with all my might.
—Entry on www.birthstories.com
It is seldom in life that one knows that a coming event is to be of crucial importance.
—Anya Seton
Finally, your due date arrives. The mounting flurry of plans, emotions, decisions, and preparations all start to revolve increasingly around one simple question: when will labor begin? But other questions, in the midst of it all, may have been overlooked: how have you prepared for delivery? Have you discussed your thoughts regarding forceps, vacuum deliveries, and episiotomy, and have you learned about your pelvic shape and baby’s size? After the final push, when the feedings and diaper changes begin, what will you do to ensure the most complete healing for your body? Events in the labor room may seem predestined or inevitable, but they are in fact choices and decisions—and in preparing for labor, you must understand and influence all that you can. Though your obstetrician or midwife is the driver, you should be an educated passenger.
IN THE AGE OF DESIGNER CHILDBIRTH, REMEMBER SUBSTANCE AMID THE STYLE
Childbirth today is not just a biological event, it’s a boutique industry. The traditional labor room has given way to birthing suites filled with music and massage, acupuncture and armoires, whirlpools and yoga as women and their partners are invited to participate in a well-planned drama orchestrated according to taste. Few would disagree that atmosphere and aesthetics go a long way; what a great improvement today’s labor room is over yesterday’s stark walls mounted with monitors, and metal stirrups extending like claws from an antiseptic examining table. But even today, behind all of the wi
ndow dressing lies the physical reality of childbirth—which, as you’ve learned, is still no day at the spa. Be sure your labor planning reflects as much substance as it does style. Long after you’ve forgotten the aromatherapy, fancy furniture, and parquet floors, you’ll have no regrets if you choose to make the basic principles of preventive obstetrics—rather than hospital aesthetics—your highest priority.
Coping with Early Labor
RELAXATION TECHNIQUES
Tension within the pelvic-floor muscles, due to pain or anxiety, can slow your progress during early labor. In theory, flexing or guarding the pelvic floor with contraction of the levator muscles may increase the amount of resistance against the descending fetus, as well as the degree of physical strain on a number of vaginal supports and pelvic-floor attachments. Meditation, visualization, breathing exercises, and yoga can help to keep the pelvic floor and the entire body relaxed as dilation of the cervix and descent of the fetus occur. If you’ve already found your levator muscles during pregnancy and built their strength with Kegel exercises, you should be better able to relax them.
EARLY-LABOR STRATEGIES
Especially for your first delivery, if your pregnancy was uncomplicated and your water hasn’t broken, then staying home through early labor will not only keep you in a comfortable and familiar environment it will also allow you to do a great deal of dilating before reaching the hospital. If your doctor or midwife permits, take a bath, walk, or just rest. Walking, whether it’s at home or around the maternity ward, may help to keep your uterine contractions regular and to direct the fetal head against the cervix and surrounding tissues that are in the process of dilating. It has not been scientifically proven which early-labor strategies offer the best protection for the pelvic floor.
Pushing Smart: When to Start, When to Stop, and Which Technique
Pushing during childbirth represents a few critical hours of your lifetime. A variety of positions is often mentioned, from squatting to standing. Some women are instructed to push immediately after reaching the goal of full dilation, others are encouraged to wait until the baby’s head is low, and still others are coached to avoid pushing until the urge becomes unbearable. You should understand the potential effects of these various techniques on your body.
PUSHING POSITIONS
Mothers of previous generations were invited to deliver only while lying on their backs—especially those choosing to give birth in a hospital. Nowadays, you may have the opportunity to push out your baby while lying down, sitting on a chair or stool, standing upright, or even soaking in a pool of warm water. Exploring and finding the positions that feel best can have a major influence on each woman’s comfort and sense of control in the labor room; alternating positions may even help you to better cope with labor pain. Sometimes one position becomes preferable for medical reasons: for instance, lying on your side to improve blood flow to the baby when it shows signs of strain or fatigue. But when all is well, and your delivery position is simply a matter of choice, what might the effects be on your postreproductive body?
ON YOUR BACK
The lying-down position (lithotomy) is probably the one you’re most familiar with, and is used mostly with an epidural (since numbness in the legs often occurs). Typically, the mother’s legs are held in a fully flexed and upward position during each contraction, and the chin is curled into the chest during the push. Critics argue that by working opposite the direction of gravity, lithotomy makes delivery more difficult, like pushing uphill. The more frequent objection to lithotomy is simply that some mothers feel overly exposed, more restricted in their movement, and less in control. Other women prefer lithotomy, feeling that it allows them to maximize their rest between contractions. Whether lithotomy translates into longer labor or any added risk of pelvic-floor stress is uncertain.
SQUATTING
Many nurses, midwives, and doctors swear by this more gravity-friendly, woman-centered pushing position. You should be well supported, with the knees separated and the back arched open, not hunched over. Your arms should be grasping something higher than waist level; a squatting bar is sometimes fastened to the bed to help Mom maintain her stability. According to some practitioners, squatting can increase the diameter of the pelvic outlet by up to 30 percent, compared with the lying-down position, and helps to shift the tailbone out of the baby’s way during birth. One 1993 study of three hundred women showed the squatting position to be associated with a greater likelihood of finishing labor with an intact perineum, lower risk of episiotomy, and fewer injuries to the anal sphincter (1 percent versus 14 percent). Other studies have reported conflicting results. One Indian study found that women randomly assigned to squatting rather than lying flat were more likely to deliver quickly but were also more likely to experience maternal injury (presumably to the perineum). An Australian study recently found squatting to be associated with perineal injury in 58 percent of women, higher than any other birth position assessed. The effects of squatting on the deeper pelvic floor, for better or worse, are entirely unknown.
Squatting position
THE SITTING POSITION
Some women choose to labor while sitting upright in either a specialized chair or on a toilet seat. Advocates of birthing chairs once claimed that they led to quicker deliveries; however, the few studies performed indicate that swelling of the perineum may be more likely, and blood loss may be increased. Labial tears may also be more common. Birthing chairs are rarely used nowadays, but some women will use a toilet seat for the same purpose. An oversize birthing ball (just like those large rubber workout balls at the gym) can be used to help maintain a comfortable, wide, sitting or squatting position during certain parts of labor, but not the delivery itself.
SIDE LYING
For the woman who has had a vaginal childbirth, the side position may improve control over the speed of her next delivery, as well as helping to prevent injury in some cases. As the fetal head crowns at the vaginal opening, Mom may have a greater ability to ensure slow expulsion of the fetal head past the vaginal opening, potentially reducing her odds of a perineal injury from a precipitous delivery. A recent analysis of 2,891 vaginal births in Australia found that of all birth positions, side lying was associated with the best odds (66.6 percent) of avoiding perineal injury. The side-lying position is also sometimes recommended when the baby’s heart rate slows during labor, since it can help to increase the flow of blood to the placenta and baby.
THE UPRIGHT POSITION
Proponents of the stand-and-deliver approach have claimed that it can result in a quicker delivery and a reduced need for forceps or vacuum assistance, and there’s been at least one study supporting each of these claims. One from 1997 involved more than five hundred women and found that upright laboring was associated with decreased perineal trauma, pain, and risk of receiving an episiotomy as compared to the lying-down position. On the downside, a 1994 study found that upright birth was associated with higher rates of anal sphincter injury; others have suggested higher rates of labial tears and increased blood loss. Whether upright delivery carries more overall risk or benefit remains unclear; at present, it appears to be a reasonable alternative for some women. However, as with the sitting or squatting positions, if your perineum begins to swell in this position, it’s probably time to make a change.
HANDS AND KNEES
This facedown position can provide relief from a backache, and it may help the baby to rotate from an abnormal position—including occiput posterior (baby facing the front of your body, rather than back), which has been linked to higher rates of anal sphincter injury. It’s also possible, but not proven, that if the perineum appears headed for imminent injury, the hands-and-knees position may help to shift pressure away from that area and toward the front of the pelvic outlet.
IF IT FLOATS YOUR BOAT: WATER DELIVERY
According to some enthusiasts of water birth, the hydrostatic pressure of water against the body may benefit Mom’s lower body by massaging blood away from the sk
in and possibly reducing edema (swelling) of the perineum, vulvar area, and lower body. These maternal benefits have not been scientifically proven, but water delivery appears to be a reasonably safe alternative for those interested. Keep in mind that it’s not always safe to be sitting in water. If your doctor is concerned about fetal exhaustion or suspects a difficult delivery, a regular birthing technique may be necessary.
PUSHING TECHNIQUES
DIRECTED VALSALVA PUSHING
Valsalva is the “close your mouth and push like there’s no tomorrow” style, and the one that you’re probably most familiar with: a deep breath at the start of each contraction, blowing out, then inhaling for another ten-second push until the contraction ends. Advocates of pushing early and often maintain that without a constant effort on Mom’s behalf, labor lasts too long, creating more stress for the baby, and also for your pelvis. Critics of active pushing argue that pushing shortens labor less than you might think, while at the same time exhausting Mom, stressing her pelvic supports, and perhaps even increasing the risk for pelvic injury. According to at least one long-standing textbook on vaginal surgery, aggressive pushing before the cervix is fully dilated may severely stress the pelvic floor by pushing the cervix and its attachments ahead of the baby’s skull. Most providers recommend active valsalva pushing simply because it’s most familiar to them. In other cases, aggressive pushing becomes necessary to speed the delivery process; if the baby has an abnormal heart rate or a fever, it’s not an option to sit back and wait.
Ever Since I Had My Baby Page 9