How to Prepare for Vaginal Birth: A Pelvic Floor Physical Therapist Perspective
There are many unknowns about childbirth, and many aspects that, no matter how well we prepare, we can’t control the outcome. However, medical providers used to think that giving people education about birth and the risks associated, increased “fear” and therefore kept people in the dark to avoid “scaring them”. What we know now is the opposite: people do better, even with worse outcomes, if they have better education before birth.
Want proof? A study by Johnson et al in 2022 compared women who had and who had not received education about the pelvic floor, pelvic floor birth trauma, and prolapse. The group that had prenatal pelvic floor education showed lower childbirth trauma scores, lower depression scores, lower feelings of failure and regret, and higher pride. Increased awareness about birthing options and education has led to a surge of people wanting to learn more about how to prepare for and optimize childbirth. It is our job to educate and empower these people, and I am all for it!
Today, we take a deep dive into birth prep and recovery from a pelvic floor physical therapy perspective. I’m going to review all of the areas that I go over with birthing people and their partners. Some of this is covered in other birth classes, and those are fantastic! However, as a pelvic floor PT, my focus is on not just the birth outcome, which is super important as well, but on the pelvic floor and overall health outcomes of the birthing person in regards to bladder and bowel function, sexual health, prolapse, and return to activity and exercise. In this blog post, we are going to cover topics such as:
Birth preferences
What is the pelvic floor, and what happens during labor and delivery
What does a pelvic floor physical therapy assessment look like during pregnancy
What is perineal massage
Exercise options for stretching, pelvic mobility, and breathing
First stage of labor
Second stage of labor (aka, the “pushing” stage)
Early postpartum recovery and follow-up
Get ready for a wild ride about how to prepare for vaginal birth!
Birth preferences
I like to find out where my patient is giving birth (hospital, birth center, home), with whom (OB doc, midwife, doula), and partner/family support during labor, delivery, and recovery. We also review past pregnancy and birth history and I encourage people to ask their providers these types of questions:
“What position options will I have for labor and delivery and how will that change if I get an epidural?”
“If you have to perform an episiotomy, what kind do you perform (midline or mediolateral)?”
“Do you offer a warm compress and perineal stretch/massage during the pushing phase?”
“What is your experience with coached pushing compared to maternal pushing?”
There are a million more questions that can be asked; these are just a few, but having conversations with your provider is essential. A paper by Townsend et al. in 2020 concluded that “Perceived levels of control during childbirth are consistently predictive of satisfaction with childbirth, and have been proposed as the main variable related to childbirth satisfaction”. Discuss your desires and different scenarios to build trust and a flexible birth plan.
What is the pelvic floor, and what happens during labor and delivery
The pelvic floor is a group of muscles, ligaments, and connective tissues that line the pelvis. The pelvic floor muscles are like a sling, or hammock, that attach to the pubic bone in the front, the coccyx (tailbone) in the back, and the pelvic bones on the sides. They help us maintain bowel and bladder control, play a big part in sexual function, support abdominal and pelvic organs, and are part of the “core” along with the diaphragm, deep abdominals, and deep back muscles. For more about the pelvic floor, check out my blog post “What the heck is the ‘pelvic floor’?”
What happens with the pelvic floor muscles during pregnancy and delivery? During pregnancy, as the uterus expands, the pelvic floor muscles stretch and lengthen. The role of the pelvic floor during birth is to soften, lengthen, and essentially, get out of the way. During delivery they stretch from 25-245% of their original length and vaginal birth, especially with prolonged pushing or instrumental delivery (forceps or vacuum), can cause trauma to the pelvic floor. Decreased pelvic floor strength, bladder leakage, pain, and/or pelvic organ prolapse can result after vaginal birth. But don’t despair - this is where pelvic floor physical therapy can help people prepare for birth and recover!
What does a pelvic floor physical therapy assessment look like during pregnancy
Many of the people who come in to see me for an assessment have some sort of dysfunction: bladder or bowel issues, pelvic pain, endometriosis, painful sex, etc. However, pregnant people without any pelvic floor issues also come in to be proactive and learn more about the pelvic floor and birth. As pelvic floor PTs, we are experts in the pelvis and pelvic floor anatomy and can offer pain management strategies, education on stages of labor, body mechanics, positioning for pushing, perineal massage, partner strategies, and so much more!
Birth-prep assessment and education can be done at any point during pregnancy, but most commonly at the beginning of the third trimester, typically over 2-3 visits. I encourage people to bring in their birth partner (spouse, family member, friend) to learn as well. Additionally, people often come in weekly at the 36-week mark as they are having more aches and pains, and their pelvic floor muscles can become more tight/painful.
In general, an initial visit typically involves the assessment of posture, alignment, breathing, abdominal/core activity, pelvic stability, strength, endurance, motor control (how muscles contract and relax), range of motion, and palpation - feeling joint mobility and areas of muscle and fascia. For most pregnant people, an assessment of the pelvic floor muscles can be very helpful.
This assessment may be performed externally or internally with a gloved finger assessment through the vaginal opening. This allows me to assess the superficial and deep pelvic floor muscles to determine areas of pain/tenderness, strength, endurance, ability to relax, coordination, and any areas of tightness or restriction. It’s also a great way to check how a patient simulates pushing out a baby. When I have them “bear down” or do a “valsalva” push, I am looking and feeling for the pelvic floor muscles to relax and open up rather than tighten and clench. I like to assess this with open and closed glottis pushing and in different positions that they may utilize during delivery.
Then, we discuss the findings, and treatment may include manual therapy, body mechanics, posture education, pressure management strategies, and a home exercise program. We also cover birth education, perineal massage, sexual health, educate on the possibility of cesarean birth, and provide education for the early postpartum healing and recovery. All assessments and treatments are performed in accordance with patient comfort and consent. Precautions or contraindications for an internal pelvic floor muscle assessment or treatment may be a high-risk pregnancy, placenta previa, a history of multiple miscarriages, or if the patient is restricted from exercise and/or penetrative sexual activity.
Perineal Massage
Although perineal tears occur 53-79% of the time with first-time vaginal birth, the risk of a large-grade tear (3 or 4) is only 3-7% and don’t necessarily always lead to pain or dysfunction. Additionally, we now know that preventively, prenatal perineal massage can:
Reduce the risk of grade 3-4 tears
Improve postpartum perineal pain and would healing
Facilitate a shorter 2nd stage of labor
Decrease the risk of postpartum fecal incontinence
Facilitate better APGAR scores for the baby
Check out my blog post “Perineal stretching during pregnancy: does this help prevent tearing with vaginal birth?” to learn more!
Exercise options for stretching, pelvic mobility, and breathing
I teach stretches and pelvic mobility exercises that people can do during pregnancy and can be great for hip and pelvic mobility and flexibility. For stretches, there are many inner thigh options in varying positions that also stretch the pelvic floor muscles. The mobility options can be used with or without a ball and can help with low back, pelvic, and hip range of motion. These stretches and mobility exercises can be done during labor as well, and I recommend that people try them out during pregnancy for familiarity and to determine what feels good.
If the pregnant person has pubic symphysis pain (PSD) or pelvic pain, I recommend taking caution with any stretch or mobility that stretches the inner thighs. Additionally, if they have pre-existing pelvic organ prolapse or vulvar varicosities, I advise caution with a deep squat stretch. Mobility exercises and stretching should feel good, so if it doesn’t, make modifications or avoid doing that exercise.
Breathing: Diaphragmatic breathing is great to do throughout the day during pregnancy, labor, and early postpartum. Diaphragmatic breathing can calm the nervous system, stretch the ribs and middle back muscles, and increase movement and blood flow to the pelvic floor muscles. This isn’t belly breathing - we want the ribs to move because the diaphragm is located at the bottom of the ribcage. The diaphragm and pelvic floor work together with breathing: when we inhale, the diaphragm gets lower and the pelvic floor muscles relax, and as we exhale, the diaphragm comes back up and the pelvic floor muscles come back to baseline.
This is how I teach it: “In sitting or standing, place your hands on either side of your ribs. As you inhale, you should feel your ribcage getting wider side to side and bigger front to back. Think of an umbrella opening and your pelvic floor muscles relaxing. As you exhale, your ribs move down and in, like an umbrella closing. Try to do slow breaths in and out rather than focusing on how big your breath is”. The patient can practice this at any time throughout the day but also when stretching or doing perineal massage.
First Stage of Labor
The first stage of labor begins with the onset of regular contractions and ends with complete cervical dilation (10cm). During the first stage of labor, the cervix is thinning (effacement) and dilating (opening up). In early labor, the cervix is dilating from 0-5cm, and during active labor, which lasts, on average, 4-8 hours, the contractions are closer together and the cervix dilates to 6-7cm. The transitional time is when the cervix dilates from 7cm to full dilation (10cm), and the contractions are very intense. Here are some tips for the first stage of labor:
Time your contractions - use an app (there are many available)
Contact your medical provider/doula when you go into labor
5-1-1 rule: when contractions are 5 minutes apart and last for 1 minute, and this has been going on for an hour, it’s time to head to the hospital. Refer to your medical provider about this, as this may not be specific to your case, or your provider may follow a different plan.
Stay active: walk, side step up and down on a stair or curb to mobilize the pelvis, do mobility or stretch exercises from above, etc. The idea is to try to facilitate downward mobility of the baby utilizing gravity, so upright movement can be helpful. You don’t have to be constantly moving, but changing positions every 30 minutes, even with an epidural, can be helpful. Taking a shower, bath, sitting backwards on a toilet, etc., are also some things people find helpful for managing pain during labor.
Epidural: Even with an epidural, you can still change positions. You can move from lying on your back (supine) to side-lying and possibly hands and knees with assistance. In one study by Hickey et al, they found that women who used a peanut ball during the first stage of labor were 50% less likely to have a cesarean birth. Additionally, changing position frequently was associated with reduced length of the first and second stages of labor.
Pain Management
TENS: TENS units send mild electrical pulses to the spinal cord and brain through electrodes attached to the skin, typically placed on the lower back and sacrum. These pulses stimulate the nerves, potentially inhibiting the transmission of pain signals to the brain. They can also increase the body's production of endorphins, which are natural pain relievers. Using a TENS unit is a fantastic option to manage labor pain drug-free. A randomized control trial by Njogu et al. in 2022 concluded that TENS reduced pain and shortened the active labor phase. Consider the Elle TENS machine for labor and delivery pain management.
Breathing strategies: Learning different breathing strategies can be very helpful for labor and delivery. This can help with pain, pelvic floor muscle relaxation, pressure management and assist with pushing. I also like to educate about open-glottis vs. closed glottis (Valsalva) techniques with pushing but for labor, we don’t want people holding their breath. In addition to diaphragmatic breathing, you can try different ways to exhale by thinking of the following: “ssss”, “shhh”, “mooo”, “ffff”, “haaaa”, blowing bubbles, blowing out birthday candles, etc. Your belly should bulge out a bit, not suck in with this. I like to have people practice this at home in different birth positions. They can also practice a few times in different positions with pushing, but in limited repetitions. If the person has trouble “feeling” their pelvic floor with pushing, they can practice visualizing the perineum with a mirror or use their hand or finger for feedback.
Partner strategies may include massage, cupping, compression on the pelvis, sacrum, counter-pressure techniques, etc.
Epidural: Even with an epidural, you can still change positions. You can move from lying on your back (supine) to side-lying and possibly hands and knees with help. In one study by Hickey et al, they found that women who used a peanut ball during the first stage of labor were 50% less likely to have a cesarean birth. Additionally, changing position frequently was associated with reduced length of the first and second stages of labor.
Second Stage of Labor
The second stage of labor begins with complete cervical dilation and ends with the birth of the baby. It consists of a “latent phase” - the time between complete cervical dilation until the person gets the urge to push, and an “active phase” with active pushing.
“Laboring down” is known as delayed pushing to allow for passive descent of the baby after the cervix if fully dilated before starting to push. This has been shown to help the baby descend, conserve energy, shorten the pushing phase, and reduce the incidence of assisted delivery (forceps and vacuum), cesarean birth, and episiotomy. It’s important to consider changing positions every 5-30 minutes during this phase, which can lead to a shorter second stage of labor, fewer forceps/vacuum and cesarean deliveries, and better perineal outcome (Simmaro et al., 2017).
The latent phase can last from 30-120 minutes and is patient-led - once the person feels the urge to push, the baby’s head has reached the pelvic floor, and they have reached the “active phase” of the second stage. A reflex is triggered and the person starts to feel an urge to bear down, or the baby’s head becomes visible at the vaginal opening.
Birth positions for pushing
The American College of Obstetrics and Gynecology recommends for most people giving birth “no one position needs to be mandated nor prescribed” (2017). While there is no one “best birth position”, a systematic review and meta-analysis by Berta et al. (2019) reported that “flexible sacrum positions (kneeling, sidelying, birthing stool/squatting) led to shorter duration of the second stage of labor”.
In a large study by Evander et al. (2015), they found an increased risk of grade 3 and 4 tears when people gave birth in the lithotomy position (lying on their back) and less risk in sidelying. It’s also been shown that squatting and birth seat positions have shorter second stage of labor but also can have increased risk of perineal trauma, and the risk is higher for those who have already had a vaginal delivery. If someone is going to give birth on their back, in a reclined position, I recommend using a folded towel under the sacrum to decrease pressure on the tailbone and allow for movement (the tailbone can move backwards and get out of the way) as the baby comes out.
Pushing: now the real fun begins
Pushing positions with or without an epidural: discuss the following with your birth provider - hands and knees, sidelying, on knees and leaning forward on a birthing ball, squat, reclined, etc. It may be helpful for positioning to facilitate increasing the pelvic outlet space (anterior pelvic tilt and hip in internal rotation).
Coached vs. Maternal Pushing: Coached pushing is when the birthing provider “coaches” the mother on both when to push and how to push. Typically, the birthing person is told, at the onset of a contraction, to take a deep breath and hold it while bearing down as much as possible for approximately 10 seconds. This is repeated with every contraction until the baby is born. This type of pushing is considered closed glottis pushing (you may hear the term “purple pushing”), which does generate a large downward force, but also puts the most pressure on the pelvic floor muscles.
Maternal pushing: The pregnant person waits until they feel the urge to push before initiating bearing-down efforts. Only when there is an urge to push do they bear down, which may not happen right after full cervical dilation is reached. This offers flexibility: the person can wait until the peak of the contraction before pushing, push for a shorter duration, choose to breath-hold or not, vary their pushing intensity, and not bear down for every contraction.
I encourage patients to talk with their birth team about pushing options beforehand. Studies have shown that while coached pushing may result in a slightly shorter second stage of labor, breath holding and pushing for 10 seconds can contribute to maternal cardiovascular stress, changes to the fetal heart rate, and postpartum pelvic floor dysfunction.
I don’t believe closed-glottis pushing is “bad”, but if it can be used in limited amounts, and mixed in with mostly open-glottis pushing (the birthing person making sounds like growling, grunting, moaning, or any other form of letting air out), the outcome may be better.
Early postpartum recovery and follow-up
There are many products that can be helpful during the early postpartum period. You don’t have to go out and buy everything imaginable, but here are some options to look into and consider:
stool softeners (Colace, Miralax)
disposable underwear, maxi pads
peri bottle
witch hazel perineal cooling pad liners, perineal healing foam or spray, perineal ice pads
squatty potty
belly band support (no waist trainers)
pelvic support garments
Other ideas that are covered during the birth prep sessions that can be helpful:
✅Cold pack to perineum: first few days, 20 min. on and off to decrease swelling and soothe tissues
✅Sitz bath 3-5 days after initial healing, heating pad for your back
✅Early postpartum bladder and bowel health: peppermint oil if difficulty initiating bladder, no straining, protect perineum with tissue with BM for the first week or so, prevent constipation
✅Mobility progression: general advice is week 1 and 2 bed and bedroom,, week 3 around house, week 4 around block, but recovery and endurance can vary. As bleeding and pain improve over the first 4 weeks, if there is an increase after being active, it’s best to reduce your activity until things feel better.
✅Early postpartum body mechanics: out of chair, in, out of bed, rolling, picking up baby, child, etc. - “exhale with effort” and possible pelvic floor muscle contraction
✅Sleep, nutrition, nervous-system calming (humming, diaphragmatic breathing, etc.) options
✅Breastfeeding body mechanics education
✅Return to activity and exercise: walking, supported, body weight exercises, progress duration, resistance, single-leg, etc.
Postpartum Follow-Up
A pelvic floor physical therapy virtual visit can be during weeks 2-5 if desired, and an in-person visit is typically at 4-6 weeks. We do need clearance from your medical provider (typically at 6 weeks) prior to doing an internal pelvic floor muscle assessment. Here are some things I like to assess/review during the postpartum visit:
Posture, alignment, ribs, breathing
Muscle assessment: abdominals, hips, glutes, pelvic floor
Diastasis recti (DRA) assessment
Education: bowel and bladder function, return to sexual activity, body mechanics, pressure management, and return to exercise progression
There are so many unknowns and uncontrollable factors during pregnancy and birth, but the more you know, the better you are going to feel as a whole. I hope you found this blog post helpful and maybe even learned something new! If you or anyone you know is pregnant or newly postpartum, please share this with them!💛
Are you pregnant or postpartum and looking to work with pelvic floor PT and you live in the greater Minneapolis, Minnesota area, let’s work together! Contact me to learn more.
Did you like this blog? Here’s what’s next on your reading list:
Perineal stretching during pregnancy: does this help prevent tearing with vaginal birth?
What the heck is the “pelvic floor”? And why should you care?
Who needs pelvic floor Physical Therapy?
Disclaimer: The information in this blog post is for general purposes only and is not intended to be used as medical advice, diagnosis, or treatment. Refer to your medical provider for all questions and concerns regarding your individual care.
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