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The most painful pregnant condition

Pregnancy can do funny things to your body. Just about everyone has heard of things like “morning” sickness, fluid retention and swelling, joint pain, and heartburn.

But there is a condition that may be the most painful side effect of pregnancy which is not talked about as often: vaginal and vulval varicose veins. In hindsight, I know that I developed this condition during the last few weeks of my second pregnancy. I didn’t realize it at the time and never got a mirror to check, but near the end I felt a lot of pressure down low in my groin and was particularly uncomfortable sitting for long periods of time.

With my third pregnancy I began to notice that uncomfortable feeling of too much pressure down low at 25 weeks. That seemed strange, the baby was not big enough to be causing that much pressure. I had trouble sitting for more than 15 minutes at a time and at first I thought it was just hip pain. Changing position seemed to help. The pain quickly became severe enough that I had to check out what in the world was going on down there.

I held a small mirror in position and when I saw my groin I almost dropped the mirror in shock. The entire external genital area was swollen to about three times its normal size and grotesquely large veins bulged out over the labia, looking as if they’d been stuffed with walnut halves. I had never heard of anything like this happening with pregnancy. I called two physicians whom I knew and soon had an explanation:

Vaginal or vulval varicose veins were caused by the expanding uterus interfering with the blood return from the legs. They were more common with “multips” (people who had experienced more than one pregnancy) and might be associated with inactivity or poor muscle tone. (I had experienced 2 months of almost complete inactivity earlier in the pregnancy, courtesy of the swine flu and a bad bought of nausea and fatigue).

Would they cause any problems with delivery? No.

Would they go away after I delivered? Yes. Immediately.

Would they continue to get worse as the uterus grew in size? Most likely.

Could they be this painful? Yes. They were VERY painful.

Was there anything I could do about it? Any treatment? No. I could spend more time lying down.

After this explanation from the physicians and a rather non-helpful visit to my own OBGYN where he confirmed what I already knew and said, “Wow. That’s a really big one. So is that one over there. Boy, that one’s huge. You’ve got a bad case.”, I began to probe the reservoir of womanly knowledge contained in my friends and acquaintances.

This condition was not as uncommon as I would have thought. I found a dozen or so people who I knew directly or indirectly who had experienced these “varicosities.” Those who had experienced it found it so painful that they crawled on their hands and knees around their house rather that walk. One said she got an epidural when she was in labor just to have relief from the varicose veins; her contractions were nothing compared to them. And with every single women I talked to, the pregnancy where the varicies developed was her last pregnancy.

The good news was that everyone I talked to recovered. Very soon after delivery they said they felt fine and could stand without pain. In the mean time, it seemed that the only thing I could do was to spend more time laying down.

When the pain got to be too much I was able to get complete relief if I positioned myself so that my heart was lower than my pelvis. In the beginning weeks I reverted to this position several times a day:Despite what I had heard, I was hopeful I wouldn’t have to lay down all day every day. We ordered a prenatal cradle with V-brace support and tried it out:It would have helped if the varicose veins had not been quite as severe and if I did not have internal swelling as well (a puffy painful area in the lower left quadrant of my abdomen that only hurt when I was upright or standing). If I had been 36 weeks instead of 26 weeks pregnant, perhaps I would have worn it all day every day and been able to be upright more. But as my belly grew so did the swelling and accompanying pain. Within a few weeks it was ineffective.

By 30 weeks I gave up and decided I had to be on almost complete bed rest. I had about 5 minutes of “up” time for every 5 hours laying down. If I was up more than that I developed referred pain in my back and abdomen and was in constant pain for at least a day. If I respected my limits, then at least I wasn’t in pain while laying down.

Each time I stood up there was a half second pause as the tissue swelled and then the pain hit. It was a strong enough pain that I had to breathe through it to keep from gasping or crying out. That level of pain continued until I returned to a horizontal position.

There was one thing that did help: exercise. I could tell from one day to the next that my pain was more tolerable if I exercised. And when my heart rate was sufficiently elevated I could be moving around without the swelling. It was such a positive thing for me mentally to be upright without that pain. Here’s a picture of my son doing “side crunches” with me: As the weeks went by I had to modify my exercise routines with more and more “downward facing dog” poses or other “hip above heart” positions to relieve the swelling and pain, and then I developed trouble breathing and had to stop exercising completely (different story). Three days after I stopped exercising I noticed the eruption of 6 additional large varicose veins. There is no question in my mind that exercise helps tremendously to prevent this condition and if you develop it, then exercise helps to moderate the pain and swelling.

The last 5 weeks of the pregnancy I was pretty miserable. I only got out of bed to go to the bathroom or visit the doctor’s office or my weekly massage appointment with a massage therapist who lived 2 miles away from home. The massages helped and it was a nice thing to look forward to each week.

During that last month, I was never upright for more than 5 minutes at a time. I crawled to the bathroom rather than walk. I wondered if I had developed some strange psychological hyper-sensitivity to pain. It seemed to me that there was no other physical condition in the modern world where I could be in this much pain. Anything else would entitle me to some powerful pain killers, but being pregnant I was told I could try ibuprofen. It was like blowing in the wind; acetaminophen couldn’t touch this.

I tried my best to appreciate the quiet time being on full bed rest provided. I read lots of books to my two young kids:We put a mattress downstairs and once a day I got up and had a change of scenery. The kids enjoyed more cuddle time and mom attention. I was always available now and never busy doing laundry or cooking dinner. Church members came in shifts and took care of us while my husband was away from home, and my mom came 3 weeks before the baby was born to help full time.When I went into labor my husband Serge joked that labor would be nothing compared to what I’d been through already just being pregnant. That might have been true if I had not also been pregnant while experiencing labor. The varicies were still there, and I could only tolerate being upright for 5 to 10 minutes at a time.Here we are checking into labor and delivery. This was my standard “out in public” pose. For doctor’s visits the last couple months of the pregnancy I would walk where I needed to, and then find a chair and lean forward like this for relief from the pain. Or I would lay on the floor. I didn’t care at all what other people thought about this behavior; it was too painful to stand or sit.

A lot of my labor was spent leaning over the birth ball and laying on my side in bed. Labor this third time was long: 25 hours, with most of it spent stalled at 8 to 9 cm dilation. I didn’t have an epidural, partly because of personal quirky prejudice (thought of a needle in my back creeps me out), partly because I felt it would be better for us medically to be unmedicated (my blood pressure was low during the pregnancy (80/40) and the strange breathing issues I’d had made me a little nervous to introduce any additional risks), and partly because I felt the need for some assurance that I still had a decent pain tolerance.

I delivered in a side laying position with my mom holding my right leg so I wouldn’t need to expend energy holding it up. There were no complications from the varicies and I only had a very minor tear along the perineum where I had torn in previous deliveries.

Our baby was born healthy and beautiful and it was such a relief to be holding her in my arms! I was weak and exhausted, but now very hopeful that sometime soon I would be able to stand up without feeling like I’d been smacked in the groin with a baseball bat.

The two days postpartum that I was in the hospital, the nurses came every four hours to do vital signs and check out my bottom. Standard practice to make sure that any stitches are healing well and to also look at bleeding. Every nurse that looked at me gave a little gasp of surprise and exclaimed “Wow. You’re really swollen.”

I checked the view with a mirror and it was the same picture I’d seen the last couple months, which terrified me. Why wasn’t it getting better? Every doctor had told me it would go away as soon as the baby delivered. Had the interruption of venous flow been so severe that I would be permanently handicapped and never able to stand or sit without pain? I could only wait and see.

Three days postpartum: the situation remained unchanged. The area was very swollen and I had a huge onslaught of pain every time I stood up (which was not often, I only got out of bed to use the bathroom).

Four days postpartum: the varicose veins and swelling were still there. I wondered if I’d ever recover.

Five days postpartum: a significant improvement. Still painful, but not nearly as bad.

Six days postpartum: The magic moment came. I stood up in the morning to pee, and there was no pain. I could hardly believe it. No swelling, no pain. I was standing, and I was not in pain! It seemed miraculous, and completely amazing.

Since then, I have had no discomfort or problems associated with my groin, but I’ve known some women who have had perpetual troubles after a bad bought of vulval or vaginal varicose veins. The two women I know who still had difficulties years later didn’t go on bed”rest.” They continued to be upright and “toughed it out.” I think it’s better to listen to your body. If the pain is that severe, then lie down. You might be able to get by pretty well by spacing your “up time.” For example: four 5-minute intervals of standing would be much better tolerated than 20 minutes of continuous standing.

When I was pregnant, the only information I found online about vaginal varicose veins were occasional notes on midwifery forums and a few odd references. There was not much to glean from the internet. I did some searching tonight and found a lot more references, but still, this isn’t an issue that’s easy to find information about.

I’m hoping that this post will reach someone who has just learned that they’ve developed this condition. I would have loved to have read this when I was first searching for help and information two years ago. I would have wanted to hear this reassurance:

Yes, it is VERY painful. But you’ll be OK! Hang in there and figure out a way to spend more time in bed. Ask for help from neighbors and family. Ignore what you read about varicose veins in the legs unless you also have varicose veins there.

The pain is all positional: if your heart is above your pelvis then you will be hurting, if it’s even or below then you should feel fine (as long as you respect your body’s limits and lay down often). Exercise will help. I recommend DVDs over walking because it’s easier to modify them with downward dog or stop and rest as needed. If your heart rate is increased and the muscles in your legs are contracting then they push the blood though the veins and keep them from distending as greatly. This is why exercise provides pain relief (to a point). If you have access to a pool, swimming is ideal because you are in a supine position but also have the benefit of increased circulation.

Massage also helps, quite a bit. I went for weekly massages the last two months of the pregnancy and asked my massage therapist to work the entire hour on my hips, upper legs, and lower back. When I stood up after the massage it was like I’d been moved back in time a few weeks. The pain was much less! This relief only lasted a couple of hours, but it was still very nice.

A V-brace type of support to provide counter pressure to the groin might help, but if you have internal swelling too then this will not be a solution. Internal swelling in deeper veins often accompanies a bad case of external varicose veins. You will know you have this as well if the pain is severe and pressing your hand (or a special support) against the external veins doesn’t completely relieve the pain. Listen to your body and lie down. You don’t want to have issues for years to come. Bed rest for a couple of months is better than chronic pain following the pregnancy. The chance of perpetual issues is slight, but it can happen.

This condition will not affect your delivery much (apart from making upright laboring positions more painful) but you should not have an episiotomy because there is a potential risk of increased bleeding if a varicose vein is cut before the head comes through and deflates it. If your varicose veins are on the mild side (which still can be very painful) you might be pain free while standing the day after delivery. If they are more severe it will take longer. Be patient and rest. It will heal.

And lastly, you’re not alone. More people have experienced this than you would think, but it’s not talked about as openly as heart burn or vomiting, simply because of its location.

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To tear or not to tear?

Ask your mother if she had an episiotomy, and chances are good she will say yes. A few decades ago, they were routinely given to all laboring women with the belief that if you cut the perineum you would reduce the chances of a 4th degree tear.

A fourth degree tear is when the tearing goes completely through the perineum, all the way from the vagina to the rectum. It requires a lot of stitches to repair, and causes significant pain in the postpartum period, as well as greater blood loss and a host of problems where excretion (pooping) is concerned. Naturally, this is something that everyone hopes to avoid experiencing, and if cutting the perineum with scissors reduced the severity of tearing, we would not complain about the prevalence of such a procedure.

After nearly 100 years of routine episiotomies being performed on all laboring mothers in the belief that physicians were reducing rates of severe tearing, the first clinical trials on episotomies were conducted. Study after study during the 1980s and 1990s showed  that episiotomies significantly increased the rates of tearing.

The Cochrane Collaboration analyzes data from scientific studies to present the most up-to-date and accurate information about medical research. It’s recent review on several clinical trials show routine episiotomies to be completely unjustified; they are associated with worse rates of tearing. (1)

But what about an episiotomy when a tear is believed to be imminent? If the care provider sees that the tissue in the perineum is blanching and expects it to tear, would it be better if it were cut or if it tore spontaneously? Multiple studies suggest the answer is no, and that an episiotomy increases damage to the perineum, even when it is done in an effort to “save the rectum.” (2) (3) (4)

So how can you prevent tearing? Avoiding an episiotomy or forceps assisted delivery certainly helps. Pushing (spontaneous being preferred over the valsalva “hold your breath” technique) and position of delivery (side lying being one of the best) may also play a role. But I’m convinced that one of the biggest factors is speed of delivery.

There have been a couple studies showing lower rates of tearing associated with delivering the baby’s head in between contractions rather that during a contraction. (5) This is a common practice among midwives, but rarely seen with obstetricians.

Not surprisingly, the studies I saw of midwife attended births had dramatically lower rates of third and fourth degree tears than surveys of births attended by OBGYNs. For example, a study of 1,211 women delivered by midwives showed only 14 women with third or fourth degree tears (6). Another large study where most births were attended by midwives showed only 0.25% (96 out of 38,252) women experienced severe tearing.(7) Most studies that I saw with obstetricians attending the deliveries had higher rates of tearing. The highest one I saw reported that 7.4% of the women experienced 3rd or 4th degree lacerations.(8)

I have a friend who has 5 children and has experienced fourth degree tears with two of her deliveries. She gave me permission to share her stories here, and I think her births are a vivid example of how strongly speed of delivery influences tearing.

Brandy obviously has an amazing pelvis that has no trouble birthing a baby. Here are brief snapshots of her births:

Baby 1:

Went to the hospital because her water broke. Didn’t feel contractions and was assumed to be in early labor until transition, which happened very quickly. Told the nurse (who hadn’t checked her yet)  that she needed to push and the nurse didn’t believe her. She pushed with the next contraction, and there was panic and commotion as the nurse went to get the midwife and they tried to get a tracing on the baby’s heart rate. Since they couldn’t find a heart beat they were yelling to push, push, PUSH! And Brandy did: with the next two contractions (and in between them) she pushed with all she had and the baby came out like a football, super fast. Brandy had broken blood vessels all over her face and upper body from the strain of pushing, as well as a fourth degree tear all the way through to the rectum. The stitching, blood loss, and postpartum pain in the perineum were much worse than the delivery and took a long time to heal.

Baby 2:

After such a quick first delivery there was some concern that she wouldn’t be able to make it to the hospital with this baby. At 41 weeks a vaginal exam showed some dilation and Brandy was told to come in with the next contractions she felt. She did, and the midwife broke her water at 4 cm, Brandy had a few hours of regular more intense contractions. Then she was tired and laid down to rest. The contractions stopped. The midwife checked her and found her fully dilated. “You’re 10 cm.” She said “Let me know when you feel another contraction and I’ll come back” and then the midwife left the room. (!!!) Suddenly, there was an intense contraction and Brandy was pushing (“It was like vomiting the opposite direction- there was no stopping it”). Her husband ran to the hallway to call for help, and when he returned the baby was delivering and Brandy was panicking because she was alone. She was laying on her back with her feet resting on the bed. The baby was out in two pushes. The midwife barely made it back in time. The baby had her hand up and her hand was born with her head. There was a mild second degree tear.

Baby 3:

This one was a planned homebirth. She called the midwife when she had painful contractions 7 to 10 minutes apart. (Nearly a week prior to this she had several days with non-painful contractions and had dilated to 3 cm). She thought maybe she needed to empty her bladder. She sat on the toilet for a few minutes and tried to pee, and then realized that the effort to pee was actually pushing the baby down. The next contraction she tried her best not to push and called to her husband “I need you now!” He came in and saw that the baby’s head was crowning. Her water broke then, and her husband said “We need to get you to the bed.” In between contractions he helped her stand up, and just the act of standing up was enough to push the baby out. They both caught the baby in their hands and wrapped her in a towel. This baby was born just about as quickly as the first two, but Brandy was trying very hard not to push so that she didn’t birth the baby into the toilet, and she delivered in between contractions. There was no tearing.

Baby 4:

This one is back at the hospital and induced with cytotec because Brandy was having frequent non painful contractions and starting to dilate. Had 8 hours of labor with sharp pains, then her water was broken. Shortly after the amniotomy she felt that she was completely dilated. She was directed to get into the standard hospital position, being partly reclined on her back with her knees bent and legs held up. The Doctor said “You can push now” and her husband said sternly: “She will do whatever she feels she needs to do.” Nurse and doctor did not offer further directions or instructions and Brandy breathed the baby out much like she had with her third, pushing as little as she could. She had a second degree tear requiring several stitches but it healed well.

Baby 5:

This one at the same hospital and with the same doctor as their 4th baby. Baby induced two days after due date with pitocin drip. The water was broken when she was about 4 cm dilated. The doctor stayed in the room for about and hour and a half, and when she was nearly completely dilated he said she could push if she wanted. She felt some pressure to push since the Dr. suggested it and the nurse got her into the default delivery position laying on her back with her knees held up high on either side. She was then told to push and pushed with the first contraction, then realized that it did not feel good to push like that.  She tried to breath normally and pretend she wasn’t having a contraction when the next one came. She felt a little nervous and scared and she wasn’t sure if it was okay that she hadn’t pushed during that second contraction. The third contraction came and Brandy was again told to push. She did, and the baby came out very quickly. She had a complete fourth degree tear again and it didn’t heal well. At 3 weeks post-partum she had to go into surgery and have the stitching redone because a hole had opened up between the vagina and rectum above the perineum. She had 4 months of incredibly limited mobility: she couldn’t take long strides when walking, going up or down stairs was difficult. It over a year before things healed completely so that she could have a bowel movement without intense pain.

In these 5 births, none of the babies were macroscopic (too large), none were posterior. Forceps were not used and episiotomies were not cut. Brandy obviously had a pelvis that birthed babies easily, and the key was to not push them out too quickly. The largest baby (8 pounds 8 ounces) was the third baby delivered at home with no tearing.

(And for you first time moms out there who are reading this: don’t worry; it is very rare for someone to deliver babies this quickly.)

It’s so worthwhile to talk to your nurse and Dr. about preventing tearing when you are in labor. Warm compresses and perineal massage have not been shown to reduce rates of tearing (6), but you might as well try them. They will certainly not cause worse tearing like the episiotomy, and they may serve the important function of reminding those attending the birth that preventing a tear is important to you.

Hopefully, they will be paying attention to how quickly the head is descending and once the head is crowning they will tell you and help you to push gently with contractions (or not at all if possible) and deliver the head slowly in between contractions. If you do not have any medication you may feel a “ring of fire” as the head crowns, which is your body’s way of telling you not to push.

Too often the cure (stitches) is preferred over the prevention (a gentle and slow delivery). But I think most care providers are happy to help you achieve this if you ask for it and remind them (and of course if the baby’s heart tones are reassuring).

(1) Carroli G. Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst. Rev. 2000;(2):CDOOOO81.

(2) Dannecker C. et al. April 2004 Episiotomy and Perineal Tears Presumed to be Imminent: The Influence on the Urethral Pressure Profile, Analmanometric, and Other Pelvic Floor Findings-Follow-up Study of a Randomized, Controlled Trial. Acta Obstetricia et Gynecologica Scandinavica Vol 83, Issue 4, p 364-368

(3) DiPiazza et al. June 2006. Risk Factors for Anal Sphincter Tear in Multiparas. Obstetrics and Gynecology; Vol 107, Issue 6, p 1233-1237.

(4) Clemons et al. May 2005. Decreased anal sphincter lacerations associated with restrictive episiotomy use. American Journal of Obstetrics and Gynecology. 192(5):1620-5.

(5) May 2007. Albers et al. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. Journal of Midwifery and Women’s Health. Volume 52, Issue 3, p 246-253

(6) Leah et al. Dec 2010. Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Tauma at Birth: A Randomized Trial. Journal of Midwifery and Women’s Health. Vol 50, Issue 5 p 365-372

(7) Groutz et al. April 2011. Third-and fourth-degree perineal tears: pervalence and risk factors in the third millennium. American Journal of Obstetrics and Gynecology. Vol 404 Issue 4. Pages 347

(8) Dandolu et al. 2005 Risk factors for obstetrical anal sphincter lacerations. International Urogynecology Journal.Vol 16, no 4, 304-307

My favorite prenatal exercise DVDs

It is difficult to underestimate the value of exercise. Sometimes when you are pregnant you have health issues that make it impossible to exercise. But whatever you are able to do will help tremendously with both your birth and recovery and your general well being. If at all possible, find a way to make daily exercise part of your life during your pregnancy. You will be so grateful that you did!

I have tried many different prenatal exercise DVDs over the years. Here are my favorites:

Jennifer Wolfe’s Prenatal Vinyasa Yoga Props needed: yoga mat, strap (optional).

This DVD gets my top vote because in addition to building good muscle tone it helps you practice breathing and relaxation, which come in handy during labor. I also love that it has the option for 15, 30, 45 or 75 minutes of exercise. The 30 and 45 minute options were my favorite and I did them most often. The two times I did the 75 minute workout I liked it too, but it is difficult for me to find that much time to exercise on a consistent basis.

The DVD has basic sun salutations with appropriate modifications for pregnancy (upward dog is not a pose that works well with a pregnant belly). It does a lot of lunges and has a good section in the introduction about how to move into a lunge. There are 4 people in the DVD: Jennifer Wolfe leads the workout (not pregnant) and three pregnant yogis behind her show modifications for each of the three trimesters. I give it top marks for muscle building and strengthening, and for getting my blood flowing and my entire body feeling warmed and comfortably stretched. It is physically challenging and I love the relaxation and positive thoughts about birth. The introduction also has some great little tips about good poses and coping techniques for labor.

 

Erin O’Brien’s Prenatal Fitness Fix Props needed: couch, chair.

This is a fantastic DVD. If you are only going to get 1 DVD and you have practiced yoga before and enjoy it, then get Jennifer Wolfe’s DVD. If you do not like yoga then get this DVD. Hopefully you’ll have both; it’s nice to have some variety in your exercise routine.

This DVD has two parts. A 40 min long aerobic workout and a 20 minute strength building workout that you can do with the help of a partner. The aerobic workout includes things like squats, pushups (on the wall or side of a couch), lunges, and ends with some floor work. There is a trailer you can watch on the amazon.com site that will give you a peek. It’s all put together with a easy to follow design and I like her personality and encouraging banter, and that she reminds you to get drinks of water . Great DVD for muscle building and for getting that heart rate way up. I love that she gives several variations of most of the exercises so you can adjust up (or down) as needed. I always broke a good sweat doing this DVD. It felt so good!

My 4 year old and 2 year old loved this DVD because it has some interesting camera work. ( for example: picture goes to black and white for a few seconds, then back to color, a couple times they split the frame so you see 2 or 3 Erin O’Brien’s working side by side).

 

Postnatal Rescue with Erin O’Brien. Props needed: none.

You can get this in a 2 DVD set with the prenatal fitness fix. I like this DVD. It has three segments to start with once you get to your 6 week mark. They are 15 minutes long each and once you finish one you can move on to the next more challenging version. They are very specifically targeted to the muscles that are most affected by birth, and I was amazed how difficult they were when I started them, and then after doing them daily I was so pleased by how easy they were two weeks later. I had a very difficult pregnancy/birth/ recovery with my third birth, and this DVD was so helpful in the recovery. Top marks for being only 15 minutes long (anything longer is difficult to commit to with a new baby), for being effective and realistic. And top marks for a sensitive and kind presentation from Erin O’Brien in the introduction about the challenges of the postpartum period.

 

The Perfect Pregnancy Workout with Karyne Steben. Props needed: hand weights (I’d recommend 3 pounds), a chair, and a step stool (optional, but recommended).

This DVD is a toning workout that gets your heart rate up (not quite as much as the Erin O’Brien Fitness Fix), and strengthens your body, especially the arm, back, and leg muscles. There are some side crunches and modified sit ups as well, and of course a warm up and cool down. The introduction is very informative, and it can be watched in either English or French (the acrobat Karyne Steben is French Canadian). Karyne is the only person featured in the DVD (and she looks 8 months pregnant (or more)), but there are little windows with “beginner”, “intermediate”, and “advanced” options for most of the exercises shown, which is such a nice feature.

This was one of the first prenatal exercise DVDs I discovered, and 6 years later I still like it and use it. It was a great companion through 3 pregnancies and a good help during the postpartum period to help with getting back into better shape.

 

Prenatal Yoga with Shiva Rea. Props needed: yoga mat (optional), chair.

This one is okay, but not that great. Good marks for being relaxing and leaving me feeling moderately stretched afterwards, but I never felt like it elevated my heart rate or challenged me physically. There are three women who show modifications for the trimesters and poor Poppy (third trimester) pretty much sits on a chair the entire workout. There is a massage section to show your partner how to give you a massage as a bonus.

This DVD still does have the benefits of teaching relaxation and breathing, and I always felt better after doing it (even though I didn’t feel I had done much). The stretches definitely do help with some of the aches and pains commonly associated with pregnancy. But this was the one prenatal DVD that I didn’t return to in my postpartum period. If you are still able to walk a few miles and want to maintain your strength and stamina throughout your pregnancy, I’d recommend Wolfe’s Prenatal Yoga, Erin O’Brien’s Prenatal Fitness Fix, or The Perfect Pregnancy Workout way before this one.

 

And of course walking is great exercise for pregnancy. Swimming, water aerobics, or a yoga or aerobics class at a local gym can all be wonderful ways to exercise. But sometime it can be difficult to find the time and means to get out of the house, and I think it’s invaluable to have an option that you can do in your living room.

When push comes to shove

Directed pushing is the most commonly used approach during the second stage of labor (that’s from when the cervix is 10 cm dilated till when the baby is born). Most often the mother will be directed to hold her breath to the count of 10 and push. The goal is to repeat this “hold your breath while I count to 10” three times during each contraction until the baby is born.

Spontaneous pushing is when the mother is allowed to push (or not push) in whatever manner she feels she should. Most women make some noise when they push and are not holding their breath for more than a few seconds.

For over a decade there have been studies showing that spontaneous pushing is associated with better outcomes than directed pushing, and there are more than a few researchers calling for reform in this area.

A 2011 review of randomized trials of directed pushing (“Valsalva”) verses spontaneous pushing concluded:

“The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour…  spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.” (1)

What to know about pushing:

Holding your breath for more than a few seconds at a time is not helpful, and if directed pushing is continued for long periods of time it is detrimental to the baby (decreased blood flow to fetus and lower oxygen levels, associated with abnormal heart rate patterns and lower apgar scores at birth) and it is also detrimental to the mother (postpartum bladder and urinary troubles and more severe tearing are more likely with directed pushing).

There is no correlation with length of pushing and negative outcomes (for baby or mom) as long as the baby’s heart rate is being monitored. That means it is just fine to be in the pushing phase for two or three or four or five hours…; there is no time limit as long as that baby’s heart rate looks good. A long second stage is only disadvantageous if the mother is using a directed pushing technique and holding her breath.

What to do about it:

Push when you feel like pushing (and not before). You do not need to start pushing at 10 cm. The pushing sensation (Ferguson’s reflex) is more closely associated with station than with dilation, and most people feel it when the baby’s head is at +1 station.

Don’t be afraid to be vocal. It’s better to make noise when you push (or be exhaling or blowing air out) than to hold your breath.

If you have an epidural try to have the dose adjusted so that you have enough sensation for pushing: ideally you should feel an urge to push and you should be able to move your legs and the muscles in your lower body.

If you have an epidural that is blocking all physical sensation and you have no desire to have your dose lowered so that you feel the urge to push, delayed pushing or passive fetal descent is a better approach than directed pushing. Passive fetal descent means that you take a nap or watch a movie until the baby is near crowning. You let the uterus do the job of bringing the baby down, and then only push as the head and shoulders are born (as directed by the care provider).

Why in the world would anyone tell me to hold my breath while they counted to 10?

It is surprising that directed pushing has lingered as long as it has. Perhaps some quirks of human nature come into play: we are creatures of habit, and we are not as patient as we should be.

In easier births where the pushing phase is short directing pushing does not appear to significantly impact the birth. In more difficult births the blame is placed elsewhere (fetal distress, failure to progress, or Celphalopelvic Disproportion (CPD)) and the directed pushing is assumed to have helped the effort rather than to have caused additional problems.

And lastly, there is a seemingly logical premise behind directed pushing: the attending care provider believes that the shorter the second stage is, the better the outcome will be for the baby. So push! Push harder! Till your face turns purple! Let’s get that baby out!

If you find yourself surrounded by an enthusiastic group of cheerleaders at your delivery coaching you to hold your breath for a count of 10 while you push, remember:

You can ask to do spontaneous pushing or delayed pushing (passive fetal descent) instead.

Your care provider should be familiar with the terms. These approaches are becoming more common and the evidence supports them as a better option for you and your baby. (And in my opinion, they’re much more pleasant to experience!)

 

1. May 2011; Prins et al.; Effect of spontaneous pushing verses Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. Volume 118, issue 6, p 662-670
And since the night is late, I’ll paste my remaining references below, in no particular order. The information in the above bullets under “what to know” and “what to do about it” did all come from research papers published in reputable scientific journals, but I don’t have time now to do detailed footnotes.

 

*Feb 1993; Thomson. Pushing techniques in the second stage of labour. Journal of Advanced Nursing; Volume 18, Issue 2,
*Nov 1997. Petersen et al. Pushing Techniques During Labor: Issues and Controversies. Journal of Obstetric, Gynecologic, and Neonatal Nursing. Volume 26, Issue 6, p 719-726
*May 2007. Albers et al. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. Journal of Midwifery and Women’s Health. Volume 52, Issue 3, p 246-253
*June 2005. Simpson et al. Effects of Immediate Versus Delayed Pushing During Second-Stage Labor on Fetal Well-Being: A Randomized Clinical Trial. Nursing Research. Volume 54, Issue 3, p 149-157

Breathing during labor

Here you have a brief guide about breathing in labor:

In case the video doesn’t work (it’s my very first youtube posting) or you’d like a second run through, the brief summary is: if you can no longer have a conversation or walk during a contraction, you should begin slow even breathing. Most people take between 3 to 6 breaths to get through a contraction. Positive affirmations are great to incorporate into your breathing. For example: “Welcome the contraction.” “I’m glad you’re here” or “I’ll be holding my baby soon.” Try to remain relaxed. Smile!

As the intensity builds you may need to vocalize. Do what feels right and trust your instincts, but do not fight the contractions. If you become too tense or get in a cycle of apprehension and fear then you are more likely to hyperventilate. If you are hyperventilating you will often begin to feel dizzy or your face and hands may tingle or become numb. If you begin to panic and hyperventilate, then patterned breathing can be helpful. In the video I demonstrate an old Lamaze technique: “ah hee, ah hee, ah hee, ah hoo.”

If you aren’t able to breath through the contractions and patterned breathing is not helpful perhaps other comfort measures (change in position, getting in the shower or tub) will help you return to your slow breathing. Or maybe you will want medication for pain relief. But hopefully if you feel overwhelmed and don’t think you can handle the contractions then that means you are almost done!

If you are expecting, I hope this is helpful to you in your labor. 🙂

Just Relax!

I attended a difficult birth this weekend that was a powerful example of the incredible effect relaxation and tension can have on labor:

I estimated that the first 10 hours of intense labor at the hospital had approximately 230 contractions. These contractions were at least a full minute long (some where much longer) and my client experienced most of them with rapid breathing, yelling, crying, and tensing all the muscles in her body- and there was no change in dilation. She was 2 cm when we checked in, and still 2 cm after all that work.

Most doctors don’t like to give epidurals before 4 cm, but after that long with no progress and mention of previous vaginal trauma that might be contributing to her tension and inhibiting labor, the Dr. allowed an epidural and she was finally able to have some relief. The epidural slowed down labor and she only had about 10 contractions in the first hour after it was administered. She was calm and breathing quietly and slowly during these contractions (she was asleep for most of them). When her cervix was checked one hour after the epidural she was 7 cm dilated.

Over 200 contractions while tense, and no change in dilation.

10 contractions while relaxed, and 5 cm change in dilation.

It’s easier to say “Just relax!” than to do it, especially when you are in pain. Tension can be a common reaction to pain: drop a hammer on your foot or stub your toe real hard and the reflexive response is to tense all the muscles in your leg and yell. Your breathing will be rapid, just for a few breaths or as long as the throbbing lasts.

How can you learn to relax during labor?

Practice before labor begins!

Here’s something anyone can do:

Slow breathing and meditation. Every day take 5 to 15 minutes and practice some slow deep breathing. In for a steady slow count of 8 to 10 seconds, and out for that same slow count. Practice focusing on various muscles and relaxing them while you breathe, or practice some visualizations: floating on clouds or being in a place that has special significance to you. A great time to do this is when you are laying in bed ready to fall asleep.

There are many birth preparation programs (such as hypnobabies or hypnobirthing) that put a lot of focus on learning to relax and eliminating any fear and tension surrounding the birth experience. They can be very worthwhile preparation.

And relaxation techniques are not only helpful for labor, they can come in handy during any stressful time. If you’re expecting to have a baby (and then go through the incredible experience of parenthood, which is definitely stressful at times!) do some exploring in this area and find something that works for you.