Tips to Prevent Pelvic Floor Injury During Childbirth
Did you know that about 20% of first-time moms experience pelvic floor injuries during childbirth? This is why our PTs are strong advocates for effectively preparing your body for childbirth. If you are pregnant and interested in preventing pelvic floor injury during childbirth, you’ve found the right place; our PTs specialize in pregnancy and postpartum rehabilitation and have some helpful tips for you, listed below. We’re rooting for you during your pregnancy! Let us help you prepare and avoid injuries to your pelvic floor during your birth process!
If you are pregnant and looking for tips to prevent pelvic floor injury during childbirth, we have some great suggestions for you. Our licensed pregnancy and postpartum physical therapists specialists are routinely helping women prepare for birth and providing Push & Birth Prep practice during their physical therapy to guide women toward an empowered birth, free from pelvic floor injury. If need more than the tips below, or suspect you have some pelvic floor issues going on, and are interested in learning more about how we can help you prepare for your birth, contact us here!
Let’s start here, what is my Risk of Pelvic Floor Injury During Childbirth?
We know that 19% of women who give birth vaginally sustain a pelvic floor injury, which results in complications including pelvic organ prolapse, stress urinary incontinence, fecal incontinence and pelvic pain. Annually, about 300,000 surgeries are completed in an effort to repair and correct the childbirth pelvic floor injury. One study queried moms who were 6-10 weeks postpartum about pelvic floor dysfunction symptoms. While 6-10 weeks postpartum is early in our recovery, one look at these numbers will tell you that it would be wonderful if you can prepare by developing a plan that may be able to prevent pelvic floor injury during childbirth. The symptoms of pelvic floor injury were reported by moms as follows:
- Urinary incontinence 48%
- Anal incontinence 60%.
- “Bother”, meaning that the symptoms were bothering the mom, regarding urinary symptoms was experienced by 27% and for anal symptoms by 56%.
- Pelvic organ prolapse was reported by 29% of women, but fewer than half of these women thought it was bothersome.
- While 55% were sexually active, 66% of these active women said it was painful.
- 48% of the women stated that the sexual issues were bothersome.
Research has identified certain risk factors, many of these are modifiable, that carry a great chance of sustaining a pelvic floor injury during childbirth. Wouldn’t it be wonderful, if before birth, women were educated on safe, natural things they can do to reduce their chance of injury? That’s where our Tips to Prevent Pelvic Floor Injury During Childbirth come in handy!
Why Does Pelvic Floor Injury Occur During Childbirth?
Before we get to our helpful tips, we should understand the WHY behind these injuries. Believe it or not, we do not yet fully know the mechanisms around which pelvic floor damage occurs during childbirth.
- The leading cause of pelvic floor damage is overstretching or tearing.
- There is also some evidence that compression of the pelvic floor may damage it and, if this is the case, optimizing the time of the second stage of labor to avoid a prolonged second stage is important.
- The third cause of pelvic floor injury during childbirth is thought to be nerve damage, resulting in progressive loss of strength and function of these muscles, but this is debated if this is happening or not.
So, what is modifiable during pregnancy and labor and delivery that could help prevent pelvic floor injury during childbirth? How can we avoid overstretching, tearing, pelvic floor compression injury, pelvic floor nerve damage during childbirth? Read on for tips.
For personalized help that is customized to your needs, working one-on-one with one of our pregnancy & postpartum pelvic PT specialists, contact us here. It is our goal to prevent pelvic floor injury during childbirth.
Our PTs know that you were born to birth! You can do this! Give yourself the preparation, knowledge and practice necessary to have an empowered, informed birth! Now that we have explained what and why pelvic floor injuries occur during childbirth, let’s get into the tips you came here for!
Tip #1: Work with a highly qualified pelvic PT, preferably one who specializes in pregnancy and preventing pelvic floor injury during childbirth.
PT during pregnancy should include treatment to help your body make space for the baby to get head down (this should happen around 30 weeks gestation) and to address pelvic floor dysfunction and pelvic pain. Additionally, PT treatments should optimize your spine, hips, pelvic alignment, ribcage, breathing, head and neck position, throughout the pregnancy. This is important for mom’s to feel good and for baby to have the space necessary to move around and get into position. Our pregnancy and postpartum PTs include education and practice in how to push, positions that can help you as well as treatments to prepare your pelvic floor, hips, abdominals, breathing and low back for labor and delivery.
If you are wondering if personalized PT might be helpful for you during your pregnancy, give us a call to speak with one of our knowledgable team members and get your questions answered.
In addition to treating any back pain, pubic pain, hip pain, neck pain, carpal tunnel syndrome, diastasis recti abdominis, round ligament pain and bladder or bowel issues during pregnancy, our PTs also provide push prep, push practice and birth preparation education, personalized to your body’s needs, your preferences and your birth plan. This birth preparation education has been found to reduce fear of labor and delivery and increase rates of non-medicated vaginal birth.
In this study, women were placed into one of two groups. Group A participated in pregnancy education program helping them learn and understand physiologic childbirth, what to expect, how to navigate childbirth and addressing fear. Group B did not receive the education. Findings revealed that a woman’s fear of birth significantly reduced after education and more of these women were able to choose an unmedicated, vaginal birth compared to the group that had no education. The research study concluded that receiving an educational birth preparation program can be an important tool to reduce women’s fear of natural childbirth.
Bonus points if your PT has rehabilitative ultrasound imaging to help you with push prep, because we use it at Purple Mountain PT and it is a wonderful way to help you see your pelvic floor muscles and learn how you can effectively lengthen the muscles while pushing, which is one important piece of preventing pelvic floor injury during childbirth.
Our PTs will use our holistic approach to assess and treat your pregnant body, getting it ready for your baby’s birthday. We coach and teach you several ways to prevent injury during your birth process!
For more information about our pregnancy and postpartum treatment program, including getting personalized assessments and treatment to prevent pelvic floor injury during childbirth, reach out to us at (616) 516-4334 or ask us a question here and we will be in touch!
Tip #2: Have a flexible, relaxable pelvic floor and learn how to let go of pelvic floor tension.
Looking at the pelvic floor injury causes noted above (overstretching, tearing and compression) it becomes clear that it is important that during pregnancy you need to optimize your pelvic floor. Ideally your pelvic floor can contract, relax and lengthen. During pregnancy, when the baby is disrupting our center of gravity and we may experience some challenges with walking, moving, etc, those pelvic floor muscles can become tightened or stiff. It is important to learn how to relax, melt and let go of tension in the pelvic floor. Learning proper stretches and positions to help relax these muscles during childbirth can help your pelvic floor prepare for birth. Our PTs check your pelvic floor in a variety of positions to help you learn which position(s) work best for your helping your pelvic floor relax and lengthen and may be optimal positions to considering when delivering your baby. A strong and flexible pelvic floor is helpful to ensure you have good support for your body, for your baby, and to help with your bladder and bowel control. Pelvic floor muscles that can lengthen and are flexible muscles also are ready to stretch, as needed, for delivery of your baby.
Not sure if your pelvic floor can relax? Uncertain what positions might be better for your pelvic floor when you are pushing? Our PTs can take the guesswork out of this and help you head into birth knowing just what works for you. We also provide you exercises to work on during pregnancy to help your pelvic floor relax and lengthen. To learn more about working with our specialist pelvic, pregnancy and postpartum PTs, call us at (616)516-4334 to speak with a knowledgable team member.
Tip #3: Begin Self Perineal Massages at home late in the third trimester, about 4 weeks before delivery.
You may be wondering what even is a perineal massage? This massage is a technique used to help prepare the area between the opening of the vagina and the anus for stretching, to help increase elasticity. A pregnant woman can perform her own perineal massage at home, or her partner sometimes has a better ability to reach the perineum. About 4 weeks before the baby is due and continuing until the birthday, performing self perineal massage to help stretch these tissues has been helpful at reducing perineal tearing during labor and delivery. If you are uncertain how to perform your perineal massage, our physical therapists can teach you what to do.
Perineal massage is recommended to begin sometime between weeks 35-37 and we always recommend that you discuss implementing this and any of our other tips with your birth provider, OB/Gyne, Midwife and PT. To learn more about how to help your pelvic floor and perineum relax, become more elastic and how to perform perineal massages, call us at (616)516-4334 to speak with one of our team members.
One study specifically examined rates of perineal lacerations from vaginal delivery. They enrolled pregnant women ages 35 years and older, dividing them into two groups: one group was taught self perineal massage, pelvic floor muscle training and provided education on how to prevent pelvic floor dysfunction. The second group only received the prevention education program. Results found that women in the first group (perineal massage + pelvic floor muscle training + education) has less complications of perineal tear, episiotomy and postnatal pain compared to the second group. The first group also had a lower need for analgesia and took less pain medication during their hospital stay. The study concluded that performing antenatal digital perineal massage and pelvic floor muscle training in addition to pelvic floor dysfunction education is recommended to reduce perineal complications.
We do want to point out that perineal massage is sometimes offered during labor and delivery, between contractions, provided by your birth provider. We recommend you discuss with your birth provider about whether you want this or not. There is some evidence that hands-off birth practices (meaning no perineal massage by your birth provider) may prevent pelvic floor injury during childbirth. However, there is other evidence that maybe the perineal massage between contractions might reduce the need for an episiotomy (which automatically creates a pelvic floor injury), so may be helpful, especially if your hospital has a high episiotomy rate. So, we advise a personalized decision between you and your birth provider.
Tip #4: RELAX your pelvic floor during pushes.
This is a trickier topic, but necessary during childbirth because we don’t want you flexing and tightening your pelvic floor as your baby is passing through the birth canal. If you want to prevent pelvic floor injury during childbirth, it is very helpful to practice this concept: learn to relax yoru pelvic floor during pushes. If you are pushing your baby out and you are also tightening your pelvic floor muscles, you have a greater risk of pelvic floor muscle injury. We recommend you practice your pushing technique, in a simulated, less than 100% (obviously) manner at home and in PT to learn how to coordinate your breathing, pushing mechanics, hip position, birth position and pelvic floor lengthening. It is known to be very difficult, maybe even counter-intuitive, but our specialized PTs are amazing at teaching how this is done. Using our rehabilitative ultrasound imaging during your Push Prep PT appointments allows you to see if you are doing it correctly and lengthening your pelvic floor while you simulate pushing.
Contact us at (616)516-4334 to get personalized PT treatment and guidance in how to relax your pelvic floor muscles during pushing!
Tip #5: Use Upright Birthing Positions and Position your body in a way that feels best for you and optimizes your pelvic outlet.
Whereas we commonly have seen, on television, women giving birth lying on their back, the best thing you can do to prevent pelvic floor injury during childbirth is to give birth in an upright position. An “upright position” is a term that includes any position you choose that can facilitate gravity to assist your labor and birth. Upright birth positions also promote mobility for the mom’s body and may enable easier pushing, which can help the passage of the baby and help reduce pelvic floor injury with birth. Many of our patients have given birth on their hands and knees, for example. According to the folks at Evidence Based Birth (EBB), positions such as squatting, kneeling, or being on hands and knees can help open the pelvis and allow gravity to assist. These positions are believed to reduce the risk of severe perineal tears compared to lying on the back with legs in stirrups. We also recommend that when pushing the baby, a woman has awareness of and, if possible, slightly internally rotates her hips, because this provides slightly more space for the baby to emerge.
The general recommendation to avoid pelvic floor injury during childbirth is to avoid giving birth lying on your back. That said, we know of some conditions, such as shoulder dystocia where the position of the mom to clear the shoulder necessitates the mom being on her back and her hip flexed. So, work closely with your birth provider to let them know your preference for birth position and when the time comes for your baby to arrive, the experience will unfold as it is necessary.
Labor and delivery positions and techniques to optimize the opening of your pelvic outlet are included in our pregnancy physical therapy. Our PTs help our patients identify which positions work best for their body. Everyone is different, so we check your body, your flexibility, your pelvic floor, your preferences and help you have options in the positions your may use when giving birth. We also guide you and your partner to knowing what to avoid and to prioritize. Call us to learn more at (616)516-4334.
Tip #6: Get Help For and Try to Avoid Occiput Posterior (Sunny Side Up)
The ideal position for the baby’s head is Occiput Anterior, meaning the baby’s head is down, chin is tucked to their chest and facing the mother’s back. Occiput Anterior provides a more narrow width of the baby’s head through the birth canal, making delivery easier and potentially providing less opportunity for stretching and pelvic floor injury during childbirth. To help your baby get into this ideal position, we advise during your second trimester and final trimester and during labor that you are active walking, curb walking, squatting, getting on your hands and knees, sitting on a birth ball and completing pelvic circles. Avoid prolonged times lying on your back, which may restrict fetal movement and possibly allow occiput posterior to occur, leading to higher cesarean risk. We recommend instead of lying on your back during labor, you move around. If you are lying in bed during labor, use a peanut ball and lie on your side and move around. If you experience pelvic girdle pain, back pain, hip pain, pubic pain, pelvic floor tension, urinary incontinence or anal spasms during pregnancy, we recommend you work with our pelvic PTs to address these issues so that your body can be optimized to allow your baby to nestle into the right position and so you feel good!
If you are experiencing pelvic girdle pain in your pregnancy, this can limit your mobility, which isn’t good for your own health and may also impede the space your baby occupies. If this is your experience, please reach out to our PTs for help. We specialize in treating pelvic girdle pain, pelvic floor dysfunction and pregnancy related bladder and bowel conditions. Call 616-516-4334 or ask us a question here and we will be in touch.
If your baby is positioned Occiput Posterior during labor, there are higher rates of assisted vaginal delivery (forceps and vaccum) and higher rates of cesarean birth. An NIH study advises that early discovery of occiput posterior allows for earlier management of this and can reduce the risk of shoulder dystocia, increase the chances for vaginal delivery and decrease the rate of cesarean section. The most effective method of addressing occiput posterior, during labor and delivery, is to allow your birth provider to manually rotate the fetal position. This involves the provider reaching into the vagina and grasping the head. An experienced provider does so gently and carefully and the baby can get into occiput anterior.
Tip #7: Refuse Forceps use during your delivery.
Forceps are used when the baby is experiencing fetal distress in an effort to birth the baby and to reduce cesearean section rates. However, forceps carry a risk for severe perineal and pelvic injury. Vacuum is an alternative to forceps and, while vacuum, can still cause a perineal injury, the rates are lower than forceps. The other option is cesarean birth, which won’t further injure your pelvic floor.
In one study, 120 women had forceps used during delivery. 15 of these women experienced very severe injuries including 2 uterine ruptures, 4 complete perineal tears (this can be very life-changing for the mom) and 9 cervix and vaginal lacerations. If you want to prevent pelvic floor injury during childbirth, you need to understand that the use of forceps during childbirth can increase tears of all the tissue, including the pelvic floor, and can cause third and even fourth degree tears, the most serious type of tearing. 4th degree tears involve tearing into the anal sphincter, compromising fecal continence. We understand that the stakes are high, the baby is having fetal distress and decision making is quickly occurring. This is why we recommend, before your labor and delivery, that you become educated and decide if forceps are an option for you. If they are not, make it clear that you do not want forceps, that you would prefer vacuum birth or cesarean over forceps. Having a plan and a conversation with your birth provider goes a long way to easing the chaos when you have to make an emergency decision.
One thing that may prevent this emergency circumstance, is having your body optimally prepared for labor and delivery. By this, we mean excellent alignment of your ribs, spine, pelvis and hips; good abdominal strength, optimal pushing mechanics, choosing an upright birth position, being active and mobile during the third trimester and labor. All of these things can help you and your baby get through labor and delivery in a smooth fashion, so you prevent pelvic floor injury during childbirth. If you would like to work with one of our specialist physical therapists so you can feel good during your pregnancy and learn how to push, get your pelvic floor more flexibile, learn perineal massage and more, reach out to us at (616) 516-4334 or submit your question here and we will be in touch.
Tip #8: A Slow and Gradual delivery.
As said prior, a delivery that goes very fast carries increased risk for pelvic floor injury. Ideally, your baby’s birth will be steady, gradual and at a reasonable pace. Up until 6 cm dilation, labor can be slower. Once 6 cm dilation is achieved, most people take 30 minutes to 2 hours to dilate each centimeter until 10 cm.
So, what is an average amount of pushing? Going too slow and pushing too long can be problematic for your pelvic floor; if you are pushing for more than 2 hours you are more likely to sustain an injury.
- For women giving birth the first time, if they have an epidural the average push time is 1.1 hours and without an epidural it is 0.6 hours. However, some women took as long as pushing 3.6 hours (with an epidural) and 2.8 hours (without an epidural).
- That said, if it is your first time giving birth and you have had an epidural, labor is not considered abnormally long until you have been pushing for more than four hours and there is no improvement in the baby’s rotation or descent.
- If this is your first time giving birth without an epidural, labor arrest is considered if the pushing phase is longer than 3 hours.
- If you have had other children, then pushing longer than 3 hours with an epidural is considered labor arrest and without an epidural it is pushing longer than 2 hours.
Allowing the baby’s head to crown slowly can reduce the risk of severe tears. This may include the practice of “breathing the baby out,” where the birthing person focuses on breathing rather than forceful pushing. Again, pushing too fast can tear things. Allow the baby to gradually come through your birth canal. A highly skilled OB or Midwife is very skilled at coaching you through the speed of delivery, if that is necessary.
Tip #9: Warm Compresses are your friend during labor.
Using warm compresses during your second stage of labor has been found to reduce perineal tearing and help with pelvic floor tearing. The use of a warm compress in the perineal area can increase blood flow to the area which can improve tissue flexibility and stretchiness of the area! The biggest benefit from warm compresses may be that they have been found to reduce the risk of the most severe tearing, third and fourth degree tearing. In one study, the women who used warm compresses has a severe tear rate of 1.9% whereas in the control group that did not use warm compresses, the severe tear rate was 5.8%. This significant decline is very meaningful, especially when considering how life altering a third and fourth degree tear can be for the longterm. Another benefit of warm compresses is they have been found to reduce the risk of tearing and pelvic floor injury during childbirth. In fact, 22.4% of women who used a warm compress did not require any stitches, because not significant tearing occurred. Whereas 15.4% of people without using warm compresses had no tearing. Warm compreses can be a readily available, low cost and easy to use option. So, talk to your birth provider or nurse and have them ready!
Tip #10: Labor Push Prep Training with the use of Ultrasound Imaging to protect and prepare your pelvic floor.
At our clinic, our licensed PTs use a specialized ultrasound to look at your pelvic floor muscles while we teach you how to push. Women tell us that seeing the ultrasound imaging while we teach you how to push, has given them an “ah ha” moment with figuring out how to lengthen their pelvic floor when pushing. Recall, that pelvic floor muscle injuries during childbirth happen most often due to overstretching, particularly stretching the muscles when it is tensed up. Through the gentle and effective coaching of our physical therapists, we help you learn how to avoid this problem, how to improve the lengthening and stretching of your pelvic floor and, thereby, ensuring you spare your pelvic floor from potential injury. Call us today to begin your push prep at (616)516-4334. Women tell us this labor and delivery push prep with ultrasound imaging has improved their knowledge and confidence on how to safely and effectively push their baby out.
Tip #11: Listening to your body and what it needs can help prevent pelvic floor injury during childbirth!
One of the most important things when it comes to childbirth is preparing your mind, body and spirit for the occasion and listening to YOUR body! Encouraging yourself to push only when you feel the urge, and resting between contractions if needed, can help in reducing the risk of pelvic floor injury during childbirth. We recommend that you calm the room, limit the number of people in the room and center your mind and body on the task at hand. I have had patients tell me that they were not bothered by additional people in the room, but, in hindsight, they may have felt a little competitive with themselves to show off a “good” or “quick” delivery and some women have confided in me that they regret allowing so many people in the birth room. Birth is a sacred time, keep it that way. Know you are born to birth and stay in your strength, partnering with your baby, your provider and your support system to get through this incredible experience.
Now let’s talk Risk Factors for Developing a Pelvic Floor Injury During Childbirth
Here are ten well-documented risk factors for developing pelvic floor damage during childbirth. These include:
- Second Stage of Labor: Position, Pattern, Intensity, Length of Time, Types of Pushing
- Urinary incontinence before pregnancy
- Asian or White ethnicity carries a greater risk for pelvic floor injury
- Older Age at first birth
- Greater BMI
- Family history of Pelvic floor dysfunction
- Baby weight >4kg (8.82 pounds)
- Mother’s height < 160 cm (5’3”)
- Occiput posterior position of baby
- Forceps use (operative delivery) during delivery
Are any of these risk factors for pelvic floor injury during childbirth modifiable? Yes, they are.
You have some control over #1, your second stage of labor position, when you push, how your push. You may have some control over the development of an occiput posterior baby position. You have some control over whether you consent to forceps or not. You may have some control over the baby’s weight, especially if you have any blood glucose issues during pregnancy. If you are worried that one or more of these factors may affect your birth process, contact us to get personalized information and help to prevent pelvic floor injury during your childbirth process at (616)516-4334.
If the leading cause of pelvic floor damage during childbirth is overstretching or tearing, is there anything I can do to help my pelvic floor become stretchy?
It is helpful to understand that something magnificent happens in the third trimester, to prepare your body for birth. During the third trimester, your body naturally becomes a bit stretchier in the perineum and pelvic floor area. However, research shows that some women have more tension in their pelvic floor, potentially increasing their risk for pelvic floor injury during childbirth.
If this is you, then you need to be more proactive with addressing your pelvic floor health.
Doing things like:
- perineal massage,
- pelvic floor stretches,
- diaphragmatic breathing,
- meditation,
- push preparation simulation,
- deep squat poses and other items our PTs teach you
can help improve the problem of high tone pelvic floor dysfunction. We know that when pregnant, the body sustains changes in movement patterns, neuromotor coordination, muscle strength, sometimes persistent pain and myofascial restrictions. These issues need to be addressed during pregnancy, to enhance your performance during labor and delivery, to improve your comfort when pregnant and to optimize your postpartum recovery. These issues necessitate repeatedly working on your strength, movement patterns, pelvic floor function, spine and pelvic alignment and more.
We Understand That Preventing A Pelvic Floor Injury During Childbirth is High on Many Women’s Wishlist! We Hope These Tips Support You To Achieve Your Goal!
Our PTs understand how stressful and beautiful the process of childbirth can be! Here at Purple Mountain PT we are here to guide and support you during your pregnancy, to ensure you have a smooth and successful delivery process with the least amount of risk of injury possible. We invite you to come to us for our birth prep program, to prepare your pelvic floor and reduce your risk of pelvic floor injury during childbirth. Using our holistic methods to address any pelvic floor tension, pelvic girdle pain, abdominal wall issues, back pain and more, you will optimize your body to have an empowered birth. Our Rehabilitative Ultrasound, stretching exercises, core and abdominal training, perineal massages and much more are personalized to your needs and so helpful to getting your through your labor and delivery! We have been able to help many mothers have successful births with minimal to no tearing. And have helped countless women achieve their goal of a vaginal birth after cesarean. If you are giving birth soon or in the future it is never too late or too early to begin Pelvic floor therapy to improve not only the process of childbirth but also navigating postpartum or just daily life before getting pregnant or prepping to have another. Contact us to get started with pelvic floor therapy today, at (616)516-4334,
Peace,
Founder of Purple Mountain PT.
Purple Mountain is a specialty pelvic health, spine and TMJ clinic helping adults and kids feel their best. We love to work with pregnant and postpartum moms, helping you be strong, empowered and living your best life.
You may be interested in these articles:
Exercise in Pregnancy: A Physical Therapists Perspective
Postpartum Abdominal Help in Grand Rapids, MI
Why Does My C-Section Scar Hurt Years Later?
How to fix Diastasis Recti without Surgery
What Can Pelvic Floor Physical Therapy Help With?
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Dieb, A.S., Shoab, A.Y., Nabil, H. et al. Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial. Int Urogynecol J 31, 613–619 (2020)
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Pierce-Williams et al. (2019): Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: A systematic review and meta-analysis of randomized controlled trials. J Matern-Fetal Neonatal Med.
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