What is going to happen to my pelvic floor next time I give birth?

This article is in reply to a reader who developed prolapse after her first baby and now has “many concerns about how my already damaged pelvic floor would cope with another pregnancy and labour”.

Let’s begin by addressing prolapse control and prevention well before labour starts when you’re thinking about a second or third pregnancy.

Before another pregnancy:

Ideally allow 2 years between babies to rehab the pelvic floor, improve posture, rebuild abdominal and trunk muscle strength, restore bone density and reduce pregnancy weight gains. Give POP the attention it deserves and rehab as thoroughly as any other type of injury for maximal strength gains.

Obtain an accurate diagnosis of the type and grade of prolapse: this is done by vaginal examination and by trans labial ultrasound (US). The US can also report on the width of the levator hiatus (LH).

Women with a wider LH (the internal distance between the levator muscles) are at risk of developing POP. Focused pelvic floor muscle training (PFMT) reduces the width of this internal space along with improving muscle thickness, responsiveness and strength. Evidence shows 5 months of consistent pelvic floor muscle training (PFMT) under physiotherapy supervision can reverse pelvic organ prolapse or reduce symptoms. http://www.nih.no/en/about-nsss/latest/newsarchive/2010/march/the-effect-of-pelvic-floor-exercises/

Consider the type of exercise you choose postpartum as strenuous exercise can overwhelm weaker pelvic floor control, leading to further internal strain. Replace running with walking, swim and bike ride and follow the guidelines for pelvic friendly exercise.

 During pregnancy:

Nutrition: Large babies (over 4kgs) are a risk for pelvic floor damage and recent research indicates that overweight begins in the womb. http://www.sciencedaily.com/releases/2013/01/130110075406.htm

Professor Jenni Brand-Miller is currently investigating low GI diets during pregnancy with the aim of reducing child obesity. http://sydney.edu.au/perkins/people/jennie-brand-miller.shtml

Exercise regularly during pregnancy according to your pre-pregnancy fitness level. Do light to moderate exercise 3-4 times weekly: swimming is a great choice as mums can swim up to their due date.Pregnant women have weaker PFM strength compared to women without children1, which has implications for the intensity and type of exercise followed during pregnancy. Train PFMs as regularly as you clean your teeth. PFMT is recommended as standard clinical practice for pregnancy, unless you have pelvic girdle pain, which studies associate with over active PFMs. 2.

Modify damaging lifestyle habits associated with UI – smoking, constipation, heavy lifting and high intensity training. Avoid sudden intra abdominal pressure rises: stop picking up toddlers, shifting furniture and treat hay fever or chest infections early. Sudden internal pressure rises can overwhelm and strain a weak pelvic floor.

Protect the abdominal midline: all abdominals join into a central band that’s undergoes major stretch during pregnancy. Avoid sit up movements and certain poses in pilates (eg: hundreds) and yoga (wheel, boat poses). Strengthen abdominals using stretch bands sitting on a fitball or standing. Lift PFMs and breathe out as you execute the resistance part of the exercise. This pattern coordinates all abdominal muscles with PFMs leading the action.

Perineal massage by the woman or her partner once or twice a week from 35 weeks reduces the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain. http://www.holditsister.com/content/perineal-massage

Perineal massage is effective for women who had not birthed vaginally before, but the effect is less clear for women who had previous vaginal births.3

When POP worsens during pregnancy, an internal vaginal pessary support plus wearing compression shorts helps control the symptoms.

Labour:

Become educated about birth choices, the risks and benefits of different types of births and interventions used and how you ideally wish to birth. Speak with birthing attendants beforehand and learn the birthing centres policies and procedures, which may override your birth plan.

Consider birthing with a midwife as studies show they decrease the need for caesarean sections, requests for epidurals, length of labour (for first time mothers), the use of narcotics, epidurals and forceps during labour.4

Listen to favourite music on your MP3 player during the first stage of labour for relaxation and distraction.5

Staying upright shortens the first stage of labour - walk, rest, eat and drink lightly, ask for massage over your low back and let the shower run on your back while sitting on a fitball. Researchers who found upright positions shortened the first stage of labour by 1 hour recommend women should specifically be advised to avoid lying flat and use upright positions they find comfortable during labour.6

Birth:

After the cervix is 10 cms dilated, the body may rest for a while allowing the vagina to stretch and accommodate the baby’s head before urge directed pushing starts.Researchers compared spontaneous versus valsalva pushing in the 2nd stage and support spontaneous pushing and encourage women to choose their own method of pushing.7 Midwives advise to ‘breathe the baby out’ to avoid forceful bearing down and breath holding. The incidence of instrumental births is lower in women who delay pushing.

Position for less pelvic floor trauma: supported kneeling and upright positions allow the pelvic joints to expand.If you’re exhausted or interventions are necessary, side lying is the best position to adopt.8

Water submersion provides muscle relaxation and pain relief and may shorten the length of labour.

Ask for warm compresses over the perineum as studies show their effectiveness in reducing perineal trauma.9 Controlled delivery of the baby’s head slowly between contractions further reduces the risk of perineal tearing. Stronger PFMs may help reduce the speed of delivery.

It’s important to reduce the use of episiotomy as it increases the risk of second degree or worse tearing in a subsequent birth.10

Forceps compared to Ventouse (suction) are associated with higher risk ofepisiotomy, 3rd and 4th degree tears with or without episiotomy, vulval and vaginal trauma and flatal incontinence.11

Epidural increases the use of instrumental delivery; a risk factor for anal sphincter injury.12 Occasionally episiotomy and instrumental births are necessary when baby is not coping well and needs to birth quickly.

To maintain maximal perineal integrity with subsequent births, engage a midwife, choose an upright or side lying position, try spontaneous or self directed pushing (no breath holding), use warm compresses on the perineum and controlled delivery of baby’s head. The majority of vaginal births are uncomplicated and when allowed to proceed with evidenced based management of the perineum, outcomes for perineal integrity are favorable.

The data from several studies ‘suggest that pelvic floor muscle tone in the 6 months after birth may be a function of the degree of trauma experienced with birth. Beyond 6 months, the degree of regular exercise (pelvic floor and generalized) may play an important role in pelvic floor recovery after childbirth.’13,14,15

Allow 6 months for focused pelvic floor and abdominal rehab, slow weight loss and getting back into regular activity before ramping up strength exercises and returning to sport or gym (sometimes with modifications). Invest in pelvic floor health and consult a women’s health physiotherapist to improve pelvic floor function, close abdominal muscle separation and reduce postpartum perineal or pelvic pain.

A caesarean section birth may be advised for future births when significant tearing has occurred into the anal sphincters in a previous birth.16

References

1.       Resende A, Petricelli C, Bernardes B, Alexandre S, Nakamura M, Zanetti M. Electromyographic   evaluation of pelvic floor muscles in pregnant and non pregnant women. Int Urogyn J. 2012 23:1041-1045

2.       Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, et al. Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. Int.U.J.Pelvic Floor Dys. 2005;16(6):468-474.

3.       Beckmann MM, Garret AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of SystematicReviews. 2006; Issue 1. Art. No.: CD005123. DOI: 10.1002/14651858. CD005123.pub2.

4.       Hatem M, Sandall J, Devane D, Solanti H, Gates S. Midwifery-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. 2008; Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

5.       Phumdoung S, Pool M. Music reduces sensation and distress of labour pain. Pain Management Nursing. 2003;4(2):54-61.

6.       Aasheim V, Nilsen ABVika, Lukasse M, Reinar L. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews.2011;Issue 3. Art. No.: CD006672. DOI:10.1002/14651858.CD006672.pub2.

7.     Prins M, Boxem J, Lucas C, Huttone E. Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. British Journal of Obstetrics and Gynaecology. 2011; 118:662-70.

8.     Dahlen, H. (2009). The relationship between maternal birth positions and perineal outcomes in women giving birth in a birth centre over 12 years.Peri Soc A & NZ 82.

9.       Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews Issue 2. Art. No.: CD0000111. DOI: 10.1002/14651858.CD000111.pub3. 2009; Issue 2. Art. No.: CD0000111. DOI: 10.1002/14651858.CD000111.pub3.

10.    Dahlen, H., Homer, C., Cooke, M., Upton, A., Nunn, R., & Brodrick, B. ‘Soothing the ring of fire’: Australian women’s and midwives’ experiences of using perineal warm packs in the second stage of labour. Midwifery, 2009; 25(2), 39-48.

11.    Alperin M, Krohn M, Parviainen K. Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery. Obstetrics and Gynecology. 2008; 111:1274-8.

12.     O’Mahoney F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database of Systematic Reviews. 2010; Issue 11. Art. No.: CD0055455. DOI: 10.1002/14651858.CD005455.pub2.

13.    Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database for Systematic Reviews. 2005; Issue 4. Art. No.: CD000331. DOI:10. 1002/14651858.CD000331.pub2.

14.    Fleming N, Newton ER, Roberts J. Changes in postpartum perineal muscle function in women with and without episiotomies. J Midwifery Womens Health 2003;48:53–9.

15.    Gordon H, Logue M. Perineal muscle function after child- birth. Lancet 1985;2:123–5.

16.    Albers L, Borders N. Minimising genital tract trauma and related pain following spontaneous vaginal birth. Journal of Midwifery Womens Health. 2007; 52:246-53.