Childbirth and the Pelvic Floor

Original Editor - Jess Bell based on the course by Ibukun Afolabi
Top Contributors - Jess Bell, Kim Jackson, Carin Hunter and Olajumoke Ogunleye
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Introduction[edit | edit source]

The pelvic floor can be significantly impacted by birth[1] - so much so that pelvic floor dysfunction after birth is considered a major public health issue”.[2] However, it is also important to remember that the pelvic floor plays a key role in childbirth and how the birth itself progresses.[3]

NB: When discussing the “pelvic floor in birth”, we are referring not only to the pelvic floor muscles but to the entire pelvic floor, including the pelvic organs, ligaments, myofascia, muscles, 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 - the 5 “Ps”:

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

Proactive prevention[edit | edit source]

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

  • 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 problem. 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.

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 goes lower while the other goes high and is 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. Maternal movement of the pelvis during birth enables babies to navigate through the pelvic inlet to the pelvic outlet - and to avoid any barriers.

[6]
[7]

If barriers are encountered during the movement path of the baby (i.e. cardinal movements), and the baby is unable to navigate through the pelvic path, 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 remaining 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 “interfere with the coordination of uterine and pelvic floor muscle contractions[8]

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

  • A Cochrane review 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[9]
  • 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]

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 the pelvic floor structures and muscles.[3]

Birth positions include:

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

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]

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, midpelvis or outlet
    • The optimal position changes depending on where the baby is[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 position which directly impact the pelvic floor:[3]

  • In this position, is the pelvis free or fixed?
  • Does this position allow for easy movement of the hips and / or lumbar spine?
  • Does this position allow for sacral nutation / counternutation?
  • Does this position allow for the abdominal muscles to easily contribute to pushing efforts, if needed?
  • Does this position increase blood flow and oxygenation to working muscles, tissues, organs and baby?
  • Does this position help the mother to feel fully supported, stable, and safe?
  • Does this position open up the pelvic floor?
  • Does this position work with or harness gravity?
  • Does this position put the pelvic floor muscles on an end-range stretch or allow for movement through range?
  • Is this position empowering or disempowering for the mother?

Pressure Management[edit | edit source]

A number of pelvic floor injuries can be considered pressure injuries. It is possible to generate tremendous amounts of pressure in the pelvic floor muscles during the second stage of labour (i.e. the pushing phase).[3]  

Pelvic floor injury is likely when there is a prolonged second phase of labour, particularly when combined with a non-optimal position. The goal for the pelvic or perinatal physiotherapist and the rest of the MDT is to facilitate the safe birth of the baby without creating unnecessary excessive pressure forces on the pelvic floor or causing injury to the perineum.[3]

Research and physiology support the following methods to manage pressure during birth:[3]

  • Permit the mother to use self-directed strategies - (i.e. uncoached pushing)[17][18]
  • Encourage the mother to allow her uterus to wring the baby out during the foetal ejection reflex
  • If the mother voluntarily pushes, encourage her efforts to correspond to the same timing as uterine urges.
  • Open (pushing while breathing out[19]) or closed glottis (i.e. Valsalva manoevre)[20] pushing or a combination is fine depending on the needs of the mother and baby. A closed glottis strategy will increase intra-abdominal and pelvic pressure, whereas an open glottis strategy will decrease pressure[3][20]
  • Offering calm verbal encouragement, visual feedback with mirror[21] if helpful, tactile feedback, positive visualisations, careful language
  • Encouraging a slow delivery of the head where the pelvic floor muscles have a chance to progressively stretch

Working with a pelvic floor physiotherapist during pregnancy can be beneficial. The mother can learn how to understand and interpret various sensations in her pelvic floor (such as the experience of pressure or bearing down or pelvic floor muscles contracting). She will then be able to take that knowledge into birth with her rather than being disconnected from her system or trying to learn what to do while in the middle of giving birth.[3]

Perineal Preservers[edit | edit source]

During birth, there are three layers to the pelvic floor through which a baby needs to pass:[3]

  • Pelvic diaphragm
  • Perineal membrane
  • Urogenital diaphragm

The superficial pelvic floor muscles converge at the perineal body. The perineum is the space posterior to the posterior fourchette (i.e. the band of tissue that joints the two labia minora[22]) and anterior to the external anal sphincter. This is the area that is most likely to tear during 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 pelvic floor muscles.[3]

Women will ideally have pelvic floor muscles that are both strong and resilient before birth. They must also be 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, psychologial states, as well as the social environment. The birth space should, therefore, be an area that causes minimal tension - this include both 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)[23][24][25]
  2. Work with your client to understand what “tension” feels like in her pelvic floor and how to tune into that and release it
  3. Work with your client over her pregnancy to develop a strong but also compliant, flexible, and resilient pelvic floor
  4. Teach breathing strategies that can help slow down the rate of delivery of the head

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 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. ↑ 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.
  18. ↑ 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.
  19. ↑ Yildirim G, Beji NK. Effects of pushing techniques in birth on mother and fetus: a randomized study. Birth. 2008;35(1):25-30.
  20. ↑ 20.0 20.1 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.
  21. ↑ Palompon D. Visual biofeedback: adjunct mirror intervention during stage two labor among primiparous women. Asian Journal of Health. 2011;1(1):204-16.
  22. ↑ Sommers MS. Defining patterns of genital injury from sexual assault: a review. Trauma Violence Abuse. 2007;8(3):270-80.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
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