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The Pilates Push

How to help pregnant clients have a smooth delivery

By Debra Goodman, MSPT

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Pilates and pregnancyPilates can be a wonderful tool to help women feel great during and after pregnancy. A modified Pilates program with emphasis on diaphragm and transversus abdominis strengthening will help to support the growing uterus, prevent low back pain and improve posture. Many people don’t realize it, but core strengthening also helps pregnant women during the pushing phase of delivery.

Prenatal Pilates instructors are in a great position to help pregnant women obtain the strength for pushing as well as to educate women on how to push properly.

The Typical Hospital Push
Many of us have heard this story at one time or another. A pregnant woman is positioned on the bed. Attendants are holding her legs. As they see the uterine contraction occurring on the monitor, they coach her to hold her breath as they count, “One! Two! Three! Four! Five! Six! Seven! Eight! Nine! Ten!” The pregnant woman’s face turns bright red as she performs this push. The monitor indicates that the contraction has ended, and the woman rests for a moment. The monitor lights up again as another contraction begins. Again, the pregnant woman is coached to hold her breath and bear down. This time she releases some air in the middle of the push. “Don’t let your air out as you push!” reprimands the nurse. This situation continues for over two hours. Concern begins to arise because the baby’s heart rate begins to drop. Eventually, the doctor decides to do an episiotomy in order to get the baby out more quickly. After the episiotomy, the baby eases out, and everyone is relieved that mom and baby are OK. The birth is deemed a success.

This is a typical example of a delivery situation in a United States hospital. Although the mother and baby were OK, was this really the best method for delivery? Could the episiotomy have been avoided?

In this example, the medical team coached the pregnant woman to push out her baby using a technique called a Valsalva maneuver. The definition of Valsalva maneuver is to forcibly exhale against a closed airway. Interestingly enough, this specific technique is contraindicated by the American College of Obstetricians and Gynecologists because it is dangerous and can temporarily cut off blood supply to the uterus and affect the oxygen supply to baby and mother. So, it is very surprising that medical professionals are instructing women to push in this manner for, in most cases, several hours.

The average pushing time is two hours for first-time mothers. Pushing while using the Valsalva maneuver has the effect of creating a great deal of pressure, but aside from the issue of the temporary reduction in oxygen supply, this method of pushing has other negative consequences to the mother’s body:

1. Increased likelihood of diastasis recti.
The Valsalva maneuver places outward pressure on the abdominal wall which presses against the weakened and vulnerable linea alba and may contribute to its stretching and further weakening.
2. Increased likelihood of vaginal tears or the need for episiotomies. A Valsalva maneuver results in reflex tightening of the pelvic floor. Contraction of the pelvic floor muscles is counterproductive since it is necessary for the pelvic floor muscles to stretch and open during labor.
3. Increased likelihood that a woman will be left with red marks over her face and neck. The Valsalva maneuver creates so much pressure in the head and face that it can cause small capillaries to burst from the pressure.

Exhalation Pushing: A Healthier Alternative
The irony of the situation is that women who deliver their babies naturally without any drug intervention do not spontaneously use this method of pushing. When women push naturally, they tend to make sounds, which means they are releasing air. They grunt, they huff, they scream, they make “sssssssss” sounds, they make low growling sounds from the deepest parts of their throats. Women who birth their babies without being coached don’t hold their breath for 10 counts. Instead, the inner wisdom of their bodies helps them to recruit their “powerhouse.”

Using their natural intuition, women actually utilize a strategy to recruit their diaphragm and transversus abdominis. This is called exhalation pushing. The diaphragm is our major respiratory muscle, but along with its role in breathing, it also has the very powerful role of regulating pressure in the abdominal cavity. People often forget that the transversus abdominis is also a breathing muscle. We certainly use it to help stabilize the spine. However, it also has a role during forceful expiration like during coughing, laughing, sneezing, yelling, blowing, and of course, pushing during delivery. When called to the task, the outer abdominals also assist the transversus abdominis during activities that require intense strength. When a woman who is pushing grunts, makes “ssssssss” sounds or makes deep, throaty noises, essentially, she is partially closing her airway, but forcefully pushing air through. The forceful blowing of air through a small opening helps her to recruit the diaphragm and the transversus abdominis, and when these two muscles work together, they can create very powerful compressive forces and pressure on the uterus.

Why Don’t Women Push the Way Nature Intended?
All women possess the innate knowledge of how to push their babies out. However, most women don’t know this, and they are rarely told this information. By the time a woman arrives at her birth, it is unlikely that she has ever seen another birth and has little idea what actually happens during a birth. This fact does little to empower women and fosters fear because women don’t know what to expect and rarely hear positive birth stories. We live in a society that generally views the obstetrician or midwife as the person in charge of the birth instead of the pregnant woman. The pregnant woman is viewed as the patient even though she is not actually sick. In addition, in the United States, the majority of pregnant women opt for medicated births even before the labor has begun, which furthers the roles of the doctor in charge and the pregnant woman as the patient. Therefore in this kind of situation, the birth attendants end up directing women through the labor and delivery, and they have been trained to coach women to perform the Valsalva maneuver during pushing.

So What Do We Do?
As prenatal Pilates instructors, we often have the unique privilege of working with pregnant women consistently. We can provide the exercise tools to help them feel great during pregnancy, but these same exercises will also help when it comes time to push. Strong abdominal muscles and a strong diaphragm will give women more power with each push.

However, along with exercising these muscles, it is also helpful if Pilates instructors can impart information on how to push using the exhalation technique. Providing women with the knowledge of what a Valsalva maneuver feels like and what exhalation pushing feels like will help women understand how the two techniques are different and how they feel physically. Women can appreciate how exhalation pushing allows them to recruit their abdominal muscles and feels much more organic. In preparation for pushing, it is also beneficial for pregnant women to examine how they perform a bowel movement. The mechanics used for pushing during a bowel movement are very similar to the mechanics for pushing out a baby, but pushing during delivery obviously requires much more force. If women examine and practice exhalation pushing during pregnancy, they will have the knowledge of how to do it by the time the birth arrives and will be able to draw upon this skill even if they end up with a medicated birth and do not have full sensation.

The following are some preparation for pushing exercises to do with pregnant clients:

1. Experience the Valsalva Maneuever: Seated, Take a big breath, hold your breath and bear down for 10 counts. Notice how that feels in the abdominals, pelvic floor, head, face and chest. Women will likely experience pressure in their head and face, pressure against their abdominals, pressure against their pelvic floor and an overall unpleasant feeling.

2. Experience Exhalation Pushing: Seated, take a big breath and blow the air out forcefully while making an “SSSS” sound. Notice how that feels in the abdominals, pelvic floor, head, face and chest. Women will likely feel their abdominals recruiting with a downward direction, without unnecessary pressure on the pelvic floor and with no pressure in the head and face.

Unfortunately, preparation for pushing is rarely taught in most childbirth preparation classes. Women are lucky if they are able to obtain this information prior to the birth. This is where Pilates instructors can make a difference and empower women as they approach their births. Passing on this information can help women learn how to take care of their bodies during pregnancy and birth.

About the Author
Debra Goodman, MSPT, is a licensed manual physical therapist with specialties in women’s health, dance medicine and sports medicine. She has been a physical therapist for Westside Dance Physical Therapy, New York City Ballet, School of American Ballet and the Kane School of Core Integration. Debbi has had a private women’s health/orthopedic practice in New York City, and now has a private practice in the Albany, NY, area. Debbi is one of the few physical therapists trained in internal evaluation and treatment of the pelvic floor muscles. In addition, she is specifically skilled in treatment of pregnancy problems including: sciatica, back/neck pain, pelvic pain and rib pain, and postpartum problems including: cesarean section recovery, urinary incontinence, pelvic/vaginal pain and post-delivery scars. Debbi also teaches continuing education workshops for physical therapists, trainers and Pilates instructors focusing on educating professionals on exercise during pregnancy, and she is an instructor for prenatal and postpartum group fitness classes.

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Posted on Tuesday, May 5, 2009 at 10:58AM by Registered CommenterAmy Leibrock in , , | Comments5 Comments

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Reader Comments (5)

Most obstetricians recommend that women preparing to conceive visit the gynecologist to talk about everything from diet to genetic risk factors and healthy pregnancy. For women with a chronic illness, such as psoriasis, prepregnancy is a perfect time to talk about treatments that will be safe during pregnancy and breastfeeding

May 5, 2009 | Unregistered Commentertubal reversal

I am in my first trimester and I am eating right and everything is going smoothly. Yet my main concern is how bad my allergies have been acting up. Today they were so bad I had to take a spray of myFlonase over the counter. My one question thatI was going to ask is it okay and safe to take my allergy medication so early on in my pregnancy?

October 30, 2009 | Unregistered Commentermommy1

Wow, I wish I had seen this article before I gave birth recently. Holding my breath while pushing felt so counter-intuitive. I opted to have a natural birth in a hospital, but my baby was sunny side up and it was a very difficult labor. Instead of being yelled at to hold my breath and being made to feel like I wasn't a "good pusher" while instinctively not holding my breath, I could have tried to educate those around me before being in full blown labor - not the best time to discuss pushing techniques! I really hope that healthcare professionals who are involved with laboring women become more educated about this issue. Thank you for a wonderful article.

July 25, 2010 | Unregistered Commentermeg

how would you approach a doctor or nurses about pushing methods?? would I just do it on my own? and let the nurses yell all they want?

August 8, 2010 | Unregistered Commentermaria

Pelvic floor, quigle exercises and functional core strengthening is one of the ways to have an easier time at delivery and after.

June 16, 2011 | Unregistered CommenterCharlotte Chiropractor

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