Childbirth and the Pelvic Floor

Original Editor - Jess Bell based on the course by Ibukun Afolabi
Top Contributors - Jess Bell and Carin Hunter

Introduction[edit | edit source]

The pelvic floor can be significantly impacted by birth,[1] so much so that pelvic floor dysfunction after childbirth has been identified as a major public health issue.[2] However, it is important to remember that the pelvic floor plays a key role in childbirth.[3]

The term “pelvic floor in birth” refers not only to the pelvic floor muscles, but to the entire pelvic floor, including the pelvic organs, ligaments, myofascia, muscles and nerves etc. These structures all interact within the pelvic bowl (also known as the pelvic ring).

This page explores specific ways to help maintain pelvic health during childbirth and to enhance it after birth. In particular, it discusses the five key priorities identified by Ibukun Afolabi[3] for pelvic health in childbirth, known as the 5 "Ps".

The 5 “Ps”:

  1. Proactive prevention
  2. Pelvic biomechanics
  3. Position
  4. Pressure management
  5. Perineal preservers

1. Proactive Prevention[edit | edit source]

As mentioned above, childbirth, whether it be vaginal or via caesarean, can adversely impact pelvic health. However, the following questions can be posed:[3]

  • Is the problem giving birth itself?
  • Is childbirth inherently problematic?
  • Could the problem be something else?

Afolabi[3] argues that giving birth in itself is not the issue. Instead, the problem lies with how women are primed, expected and instructed to give birth. And she believes that this can be improved when current knowledge is applied to the birthing context.

2. Pelvic Biomechanics[edit | edit source]

Pelvic movements are generally described as rotations about one of three cardinal axes. Each rotation acts to create motion in one plane:[4]

  • Rotation about a mediolateral axis causes motion in the sagittal plane
    • Often called anterior or posterior tilt
  • Rotation about an anteroposterior axis causes motion in the frontal plane
    • Occurs when one side of the pelvis drops while the other side lifts
    • Often called pelvic drop or hike
  • Rotation about a vertical axis causes motion in the transverse plane
    • Called forward and backward rotation or anterior and posterior rotation

The following video explains the movements of the pelvis in detail.

[5]

Pelvic movements can have a positive impact on labour. The amount of intrapelvic motion will increase during labour in anticipation of birth. Maternal movement of the pelvis during birth enables babies to navigate through the pelvic inlet to the pelvic outlet, and to avoid any barriers.[3]

The videos below provide additional information on these points. The video on the left discusses the pelvic inlet and outlet, while the second video explores the benefits of movement during labour.

If barriers are encountered during the movement path of the baby and the baby is unable to navigate through the pelvis, other structures begin to absorb the forces generated by the uterus. This can place the pelvic structures under greater strain and have a negative impact on the pelvic floor:[3]

  • There can be increased compression of the pudendal nerve, which can heighten labour pain
  • The pelvic floor muscles (and the body generally) may tense up and stiffen rather than remain supple, elastic and dynamic
  • Medical interventions might be escalated:
    • For instance, a mother may be given more synthetic oxytocin to increase uterine contractions
    • This has been shown to affect the coordination between uterine and pelvic floor muscle contractions[8]

Moving and using pelvic kinetics can help stop this downward spiral and, thus, help prevent pelvic floor injury.[3] Various studies have explored the positive effect of movement on labour:

  • A Cochrane review[9] found that there is evidence to suggest that walking and upright positions during the first stage of labour can reduce the length of labour, the chance of a caesarean section and the likelihood of needing an epidural
  • Toberna and colleagues[10] discuss the role of “dance” in terms of encouraging upright positioning and movement during the first stage of labour
    • NB the authors note that “dance” is not to be taken literally in this context, but rather used to represent a range of body movements (pelvic and rhythmic body movements, upright positions, and changes in position)[10]

3. Position[edit | edit source]

A mother’s position during labour (i.e. the orientation of the whole body relative to its environment and within the wider context of gravity) can facilitate or hinder optimal pelvic biomechanics and, thus, have a direct impact on pelvic floor structures and muscles.[3]

Birth positions include:[3]

  • Standing
  • Supine
  • Semi-recumbent
  • Quadruped
  • Squatting
  • Side-lying

A large body of research shows that upright positions for birth have a positive impact on outcomes for both mother and baby.[3] [11][12][13][14] [15] Thus, in non-emergency birth situations, a mother should be encouraged to adopt whatever position feels best for her and to semi-regularly change position.[3]

This will help to:

  • Increase space in the pelvic inlet, mid-pelvis or pelvic outlet (see videos above)
    • The optimal position depends on where the baby is at the time (e.g. moving through the pelvic inlet vs the pelvic outlet)[3][16]
  • Increase uterine efficiency
  • Minimise additional tissue resistance
  • Reduce tension in pelvic muscles / ligaments and uterine ligaments
  • Enhance the contribution of the abdominal muscles and diaphragm
  • Facilitate the baby's movements
  • Conserve energy
  • Keep the pelvic floor open
  • Empower the mother

Key questions to ask about birthing positions which directly impact the pelvic floor are:[3]

  • Is the pelvis free or fixed?
  • Does this position enable movement of the hips and / or lumbar spine?
  • Does this position enable sacral nutation / counternutation?
  • In this position, can the abdominal muscles easily contribute to pushing, if required?
  • Does this position increase blood flow and oxygenation to muscles, tissues, organs and the baby?
  • Does the mother feel supported, stable and safe in this position?
  • Does this position open up the pelvic floor?
  • What affect does gravity have on this position?
  • Are the pelvic floor muscles on an end-range stretch or able to move through range in this position?
  • Is the mother empowered or disempowered in this position?

The following videos provide information on upright positions during childbirth.

4. Pressure Management[edit | edit source]

Various pelvic floor injuries are related to pressure; a tremendous amount of pressure is generated in the pelvic floor muscles during the second stage of labour (i.e. the pushing phase).[3] Pelvic floor injury is more likely when there is a prolonged second stage of labour, particularly when the mother is in a non-optimal position. The goal for the pelvic or perinatal physiotherapist and the rest of the MDT is, therefore, to facilitate a safe birth without exposing the pelvic floor to unnecessary / excessive pressure or causing injury to the perineum.[3]

The following methods can help to manage pressure during birth:[3]

  • Use of self-directed strategies (i.e. uncoached pushing)[19][20]
  • Encourage the mother to allow her uterus to wring the baby out during the fetal ejection reflex
  • When a mother pushes voluntarily, encourage this pushing to occur at the same time as uterine urges
  • Open glottis pushing (i.e. pushing while breathing out[21]), closed glottis pushing (i.e. a Valsalva manoeuvre)[22] or a combination of the two are fine depending on the mother's and baby's needs
    • A closed glottis strategy increases intra-abdominal and pelvic pressure
    • An open glottis strategy decreases pressure[3][22]
  • Providing calm verbal encouragement, visual feedback with mirror,[23] tactile feedback, positive visualisations and careful language can be beneficial
  • Work to encourage a slow delivery of the head, so that the pelvic floor muscles are able to progressively stretch

Women who work with pelvic floor physiotherapists during pregnancy have the opportunity to learn how to understand / interpret various sensations in their pelvic floor (such as the experience of pressure / bearing down or contracting the pelvic floor muscles).[3]

5. Perineal Preservers[edit | edit source]

During birth, the baby needs to pass through the three layers of the pelvic floor:[3]

  1. Pelvic diaphragm
  2. Perineal membrane
  3. Urogenital diaphragm

The superficial pelvic floor muscles converge at the perineal body. The perineum is the area most at risk of tearing during a vaginal birth. A tear or an episiotomy can affect postpartum pelvic floor function and lead to myofascial pain, sexual dysfunction, pelvic organ prolapse, or hypertonicity of the pelvic floor muscles.[3]

The perineum is the space between the posterior fourchette (i.e. the band of tissue that joins the two labia minora[24]) and the external anal sphincter.

Ideally, a mother's pelvic floor muscles will be strong and resilient before birth, but also able to progressively yield and stretch. It can be counterproductive to the uterine efforts if the pelvic floor muscles are unable to gently release during birth. Thus, it can be hugely beneficial to help women connect to their pelvic floors prior to labour.[3]  

The pelvic floor state is also affected by spiritual, emotional, psychological states, as well as the social environment. The birth space should, therefore, be an area that causes minimal tension - this includes the mental space (mindset) and physical and emotional spaces.[3]

Specific methods to help preserve the perineum that can be offered by pelvic floor physiotherapists include:[3]

  1. Teaching perineal massage and internal massage during the last few weeks of pregnancy, starting at around 36 weeks[25][26][27]
  2. Working with clients to help them understand what “tension” feels like in their pelvic floor and how to recognise and release this tension
  3. Working with clients during their pregnancy to develop a strong but compliant, flexible, and resilient pelvic floor
  4. Teaching breathing strategies that can help slow down the rate of delivery of the head (see video below)

[28]

References[edit | edit source]

  1. Van Geelen H, Ostergard D, Sand P. A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques. Int Urogynecol J. 2018;29(3):327-38.
  2. Burkhart R, Couchman K, Crowell K, Jeffries S, Monvillers S, Vilensky J. Pelvic floor dysfunction after childbirth: occupational impact and awareness of available treatment. OTJR (Thorofare N J). 2021;41(2):108-15.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 Afolabi I. Childbirth and the Pelvic Floor Course. Physioplus, 2022.
  4. Lewis CL, Laudicina NM, Khuu A, Loverro KL. The human pelvis: variation in structure and function during gait. Anat Rec (Hoboken). 2017;300(4):633-42.
  5. Dr. Jacob Goodin. Hip Joint & Pelvic Girdle Anatomy: Joint Movements. Available from: https://www.youtube.com/watch?v=n8iNhG4xJVc [last accessed 10/1/2022]
  6. About Medicine. What is the True Pelvis? - Pelvic Inlet & Outlet Anatomy. Available from: https://www.youtube.com/watch?v=NB0-8WCo9X4 [last accessed 10/1/2022]
  7. Kim Vopni - The Vagina Coach. Make childbirth easier. The pelvic inlet and pelvic outlet in birth positions. Available from: https://www.youtube.com/watch?v=_SnE79Q2rp8 [last accessed 10/1/2022]
  8. Karahan N, Arslan H, Çam Ç. The behaviour of pelvic floor muscles during uterine contractions in spontaneous and oxytocin-induced labour. J Obstet Gynaecol. 2018;38(5):629-34.
  9. Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013 Oct 9;(10):CD003934.
  10. 10.0 10.1 Toberna CP, Horter D, Heslin K, Forgie MM, Malloy E, Kram JJF. Dancing during labor: social media trend or future practice?. J Patient Cent Res Rev. 2020;7(2):213-217.
  11. Zang Y, Lu H, Zhang H, Huang J, Ren L, Li C. Effects of upright positions during the second stage of labour for women without epidural analgesia: A meta-analysis. J Adv Nurs. 2020;76(12):3293-306.
  12. Berta M, Lindgren H, Christensson K, Mekonnen S, Adefris M. Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2019;19(1):466.
  13. Zang Y, Lu H, Zhao Y, Huang J, Ren L, Li X. Effects of flexible sacrum positions during the second stage of labour on maternal and neonatal outcomes: A systematic review and meta-analysis. J Clin Nurs. 2020;29(17-18):3154-69.
  14. Healy M, Nyman V, Spence D, Otten RHJ, Verhoeven CJ. How do midwives facilitate women to give birth during physiological second stage of labour? A systematic review. PLoS ONE. 2020;15(7): e0226502.
  15. Watson HL, Cooke A. What influences women's movement and the use of different positions during labour and birth: a systematic review protocol. Syst Rev. 2018;7(1):188.
  16. Kjeldsen LL, Blankholm AD, Jurik AG, Salvig JD, Maimburg RD. Pelvic capacity in pregnant women, identified using magnetic resonance imaging. Acta Obstet Gynecol Scand. 2021;100(8):1454-62.
  17. Beaumont Health. Upright Positions | Beaumont Labor and Birth. Available from: https://www.youtube.com/watch?v=B6jkU_3CaeA [last accessed 10/1/2022]
  18. Bridget Teyler. HOW TO GIVE BIRTH | Top 3 BIRTH POSITIONS To Give Birth In. Available from: https://www.youtube.com/watch?v=OEew83tcxrY [last accessed 10/1/2022]
  19. Schaffer JI, Bloom SL, Casey BM, McIntire DD, Nihira MA, Leveno KJ. A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. Am J Obstet Gynecol. 2005;192(5):1692-6.
  20. Lee N, Gao Y, Lotz L, Kildea S. Maternal and neonatal outcomes from a comparison of spontaneous and directed pushing in second stage. Women Birth. 2019;32(4):e433-e440.
  21. Yildirim G, Beji NK. Effects of pushing techniques in birth on mother and fetus: a randomized study. Birth. 2008;35(1):25-30.
  22. 22.0 22.1 Barasinski C, Debost-Legrand A, Vendittelli F. Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study. Midwifery. 2020;91:102843.
  23. Palompon D. Visual biofeedback: adjunct mirror intervention during stage two labor among primiparous women. Asian Journal of Health. 2011;1(1):204-16.
  24. Sommers MS. Defining patterns of genital injury from sexual assault: a review. Trauma Violence Abuse. 2007;8(3):270-80.
  25. Abd-Ella N, Kandeel H, Gouda A. Effect of Late Pregnancy Self-Perineal Massage on the Perineal State of the Primiparturients. Tanta Scientific Nursing Journal, 2021; 23(4): 52-73.
  26. Hajela N, Turner KA, Roos J, Rivera M. Effectiveness of prenatal perineal massage in reducing the risk of perineal trauma during vaginal delivery in nulliparous women: a meta-analysis and evidence based review. J Women’s Health Dev. 2021;4(4):136-50.
  27. Álvarez-González M, Leirós-Rodríguez R, Álvarez-Barrio L, López-Rodríguez AF. Prevalence of perineal tear peripartum after two antepartum perineal massage techniques: a non-randomised controlled trial. J Clin Med. 2021;10(21):4934.
  28. Bridget Teyler. BREATHING Techniques for an EASIER LABOR | How To Breathe During Labor | Lamaze | Doula. Available from: https://www.youtube.com/watch?v=qKDujazvDGM [last accessed 10/1/2022]