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September, 2005, Vol. 05, Issue 09 >> Women's Health

Pelvic Floored

By Elaine Stillerman, LMT

A good friend and colleague of mine attended a professional seminar this past June in New York City called "Challenges in Women's Healthcare: Urogynecology for Primary Care Providers." All of the speakers and most of the attendees were doctors, but there also was a smattering of physical therapists, like my friend, and occupational therapists.

The general topic of the seminar was the female pelvic floor, in all its glory and with all its problems.

As my friend relayed to me (and I have the course material to back all this up), one of the doctors gave a speech on "The Effects of Pregnancy and Childbirth on the Pelvic Floor." Supported by many impressive studies, the doctor proffered that a vaginal birth is responsible for urinary and anal incontinence, pelvic prolapse, sexual dysfunction, pudendal nerve damage and pubococcygeal muscle damage. The cure? Cesarean section!

The other doctors fastidiously took notes. A few doctors and several allied professionals questioned the doctor's findings. For instance, were these births augmented and were there obstetric interventions (e.g., forceps, episiotomy)? Were the laboring women in these studies given Pitocin or any pain medications that blocked sensation? How were they pushing during active labor? What position were these women in while giving birth? Were they taught exhalation pushing and how to use their transverse abdominis during labor, or were they directed to "hold their breath, bear down and push?" Were any of these women in the studies taught correct Kegel exercises during pregnancy or given physical therapy during postpartum recovery? Were any of these case studies performed on women who had water births?

None of these valid points was addressed in the lecture, but C-sections nonetheless were hailed as the best way to avoid pelvic floor complications after childbirth.

I'm floored. OK, let's look at the pelvic floor during childbirth. The compression of the fetus on the muscles of the pelvic floor, along with the effects of progesterone and relaxin, softens joints and ligaments and allow these muscles to stretch and bulge. The bladder and ureters also lose their tone during pregnancy (even if the birth is surgical). But Kegel exercises have been proven to maintain and restore functional integrity to the pelvic floor (antepartum and postpartum), and the position in which the gravida labors can have a tremendous impact on the strength of the pelvic floor.

In addition, the directed pushing needed as a result of anesthesia or labor position is responsible for many of the long-term weaknesses of the pelvic floor. Known as the Valsalva technique (holding the breath and forceful bearing down), this method of pushing encourages fetal hypoxia (lack of oxygen), perineal tears, increased intrathoracic pressure, increased cardiac output and blood pressure, slowed maternal pulse rate and damage to the pelvic floor. It might be a vaginal birth, but one that was poorly guided.

During the pushing process, the laboring woman should be in a squatting or semi-sitting position to widen the pelvic outlet and work with gravity, not against it. The woman should exhale, or allow the air to escape from her lungs as she pushes, to reduce pressure on the pelvic floor. Some care providers actually prefer for the woman not to push at all in the early second stage of labor, because the natural forces of uterine contractions move the fetus quite handily down the birth canal. The focused pushing only is used to expel the fetus from the birth canal. In this way, little pressure is exerted on the pelvic floor and little, if any, damage is done.

Prenatal care and postpartum recovery should include exercises and physical therapy, if necessary, to maintain and restore the pelvic floor muscles. Birthing in female- and fetus-friendly ways can do more to keep the pelvic floor intact than a traumatic surgical procedure.

Instead of a surgeon recommending surgery as a preventative measure, why not teach women (and their doctors) the most effective way to maintain and respect their bodies during pregnancy and childbirth?


  1. Enknin M, et al. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford: Oxford University Press, 2000.
  2. Goldberg R. "Ever since I had my baby..." The effects of pregnancy and childbirth on the pelvic floor. Challenges in Women's Healthcare: Urogynecology for Primary Care Providers, June 2005.
  3. Hansen S, Clark S, Foster J. Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Obstetrics and Gynecology 2002;99(1):29-34.
  4. Mayberry L, et al. Use of delayed pushing with epidural anesthesia: findings from a randomized, controlled trial. Journal of Perinatology 1999;19(1):26-30.
  5. Pagana K and Pagana T. Mosby's Manual of Diagnostic and Laboratory Tests, 2nd ed. St. Louis: Mosby, 2002.
  6. Petrou S, Coyle D, Fraser W. Cost-effectiveness of a delayed pushing policy for patients with epidural anesthesia: The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group. AJOG 2000;182(5):1158-1164.
  7. Sampselle, C, and Hines, S. Spontaneous pushing during birth: relationship to perineal outcomes. Journal of Nurse-Midwifery 1999; 44(1):36-39.

Click here for previous articles by Elaine Stillerman, LMT.


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