You may be surprised to hear that physiotherapy has a role to play in your preparation for birth. Most of us will be familiar with childbirth education and prenatal yoga classes as the pillars of preparation for expecting mothers. These classes are extremely beneficial, but the pelvic floor is usually overlooked. The pelvic floor undergoes immense strain during birth, but far too often it’s assumed that this is just part of the birthing process. Preparing for your birth with guidance from a pelvic health physiotherapist can provide mothers and birthing persons a number of strategies to help them reduce injury to the pelvic floor and manage their labour and birth experiences. This blog post aims to give you the knowledge you need to experience the birth you’re hoping for.

Let’s start with positioning. Most of us are very familiar with the image of a mother laying in the hospital bed her entire labour or her pushing on her back with her feet in stirrups and their maternity care provider at the end of the bed getting ready to “catch” baby. We’ve all seen it in movies, magazines, and textbooks. What if I told you that there are multiple positions women can labour and give birth in? According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), they recommend all healthy pregnant mothers and birthing persons choose the position they are most comfortable with.

But, if we only know that one position, what choices do we have?

Pelvic health physiotherapists have the knowledge and skillset to teach expecting mothers and their birthing partners (I always encourage birthing partners to attend appointments) a variety of positions to choose from. These positions use gravity to their advantage and take pressure off the tailbone and allow the birth canal or pelvis to expand further. Positions such as squatting with a birth bar or stool, being on all fours, and side-lying, are all considered positions that take pressure off the tailbone.

But labour is an exhausting and taxing activity on the body (hydration and light snacks are key!), and you may get to the point where you just want to lie down. That’s absolutely fine! You need to find the position that feels best for you. This is where a peanut ball will become your best friend, because it allows mothers and birthing persons to lie down comfortably while maintaining the pelvis in an open position. And if it’s time to push and you’re comfortable on your back, we have creative ways to reduce pressure on your tailbone, even if you have an epidural.

But we can’t forget about breathing. The way we breathe has a tremendous effect on our pelvic floor, and even more-so during labour and pushing. I normally have my patients start practicing their deep breathing at the start of the third trimester. But don’t worry if you’re only a couple of weeks away from your due date–you still have time. The key is to practice consistently. Because of the busy and chaotic lives we have, many of us don’t really know how to engage in deep breathing. It’s not any easy skill, but it is an important one for labour and birth because it allows us to release tension in our pelvic floors. A tense pelvic floor can make labour and pushing more difficult and cause more injury to these muscles. Training your body, through your breath, to release tension with your contractions can also help you cope with the intensity of your contractions. Seeing a pelvic health physiotherapist can help you understand how to engage in deep breathing and how to release tension in your pelvic floor.

But what about pushing? How many of you have been told or have heard of the saying “hold your breath and bear down like you’re having a bowel movement?” This can be an effective cue for mothers and birthing persons who have no connection or experience with their pelvic floor. But since you’re reading this, I am sure you are interested in becoming more connected to yours. The SOGC Clinical Practice Guidelines tell us that expecting mothers should use the pushing strategy that is most comfortable for them and start pushing when they feel the urge to push. But, like I mentioned before, if mothers are only familiar with one strategy, their options are limited.

There are two main types of pushing techniques that are discussed in the research, directed pushing or spontaneous pushing. Directed pushing is the process of taking a deep breath and holding it while bearing down for a period of time as directed by your healthcare provider. Once you are 10 cm dilated, you may be directed to start pushing. Spontaneous pushing refers to the pushing technique that is triggered by a woman’s natural reflexes when the baby descends into the birth canal. With this technique mothers and birthing persons push when they feel the urge to push, and push 3-5 times per contraction, usually using open glottis breathing to push. This is when mothers exhale forcefully and engage their abdominal wall to aid their pushing. This is also known as breathing down your baby.  This form of pushing is thought to be more effective and less fatiguing and associated with a shorter pushing stage, which decreases the strain on the pelvic floor muscles. I like to have my mothers and birthing persons practice these forms of pushing in a variety of positions in clinic with their birthing partners and then I have them practice these techniques when they have a bowel movement.

I can’t forget to mention perineal massage. Unfortunately, there has been some misconceptions regarding the idea of this exercise. Its purpose is not to “stretch out” your perineum, but rather improve your body’s ability to tolerate tissue stretch and keep your muscles relaxed. You see, like any muscle in the body, when we experience too much stretch, our muscles will naturally want to contract through built-in reflexes. This is especially the case when we experience pain. Many expecting mothers and birthing persons, without knowledge of their pelvic floor, go into their birth experience with a tense pelvic floor. During labour and birth, those intense bouts of pain can promote further tension of your pelvic floor. This can hinder the descent of baby’s head into the birth canal and potentially require an episiotomy and/or use of forceps or a vacuum to help birth your baby. Research has shown that perineal massage can reduce your risk of an episiotomy, but it does not reduce your risk of tearing. And this may seem scary, but we now know that a natural tear is better for tissue healing than a surgical cut. So, when should you start? Research shows us that you can start doing these exercises as late as 35 weeks of pregnancy.

And last but certainly not least, pain management. There are pharmacological and non-pharmacological options available to mothers and birthing persons to manage their pain. The choice is yours. It’s important to initiate the conversation with your maternity care provider to learn about your pain management options. One of the things I discuss frequently with my patients is the difference between pain and suffering. No mother or birthing person should be suffering through their birth experience and it’s important to understand this. Having a communication strategy with your birth partner and team is an important part of addressing your needs in your labour and birth experience. There are a variety of techniques and strategies that pelvic health physiotherapists can teach expecting mothers and birthing partners to help them manage and cope with their pain levels based on pain science research. These strategies include relaxation and distraction techniques, hydrotherapy, positioning, breathing, and movement. The goal is to give you as many tools as possible to achieve this for your labour and birth.

Hopefully this provided you with some insight into how pelvic health physiotherapy can help mothers and birthing persons with their birth preparation. Don’t be shy to reach out! I am always happy to answer questions.

Grecia Alaniz is a pelvic health and orthopedic physiotherapist in Toronto with a passion for working with mothers, birthing persons, and persons with pelvic pain. She strives to empower her patients by providing the knowledge and tools for them to accomplish their goals. As someone with endometriosis, Grecia understands the importance of understanding the whole person, and not just their symptoms. Through her training with experts in pelvic health, Grecia has extensive expertise in assessing and treating a variety of complex urogenital and ano-rectal conditions. Grecia completed both her Master of Science in Physiotherapy and Bachelor of Science in Kinesiology at McMaster University. She is currently completing her PhD at Western University, where her research is focused on the ways technology shapes maternity care providers’ management of risk in childbirth. She is also a member of the Canadian Physiotherapy Association (Orthopaedic Division & Women’s Health Division), the International Association for the Study of Pain, and the International Pelvic Pain Society.