As your due date arrives, the flurry of plans, emotions, decisions and preparations all begin to revolve around one simple question … when will labor begin?  But other key questions, in the midst of it all, may have been overlooked:  How have you prepared for delivery?  And after the final push, when the feedings and diaper changes begin, what will you do to ensure the most complete healing for your body?  Events in the labor room that may seem predestined or inevitable, are in fact choices and decisions – and in preparing for labor, it’s essential that you understand and influence all that you can.

Relaxing in Early Labor.  Tension within the pelvic floor muscles, due to pain or anxiety, can slow your progress during early labor.  If you’ve already ‘found’ your levator muscles during pregnancy and built their strength with Kegel exercises, you should be better able to relax them during this stage.

Options for Pushing: Though much remains to be learned about the ‘best’ pushing methods for preventing pelvic floor injury, you should be aware of the basic options.

Which Position?  Many mothers of previous generations were invited to deliver only while lying on their backs.  Nowadays, you may have the opportunity to push out your baby while lying down, sitting on a chair or stool, standing upright, or even soaking in a pool of warm water.  Lying-down (‘lithotomy’) is the most common position, whereby the mother’s legs are held in a fully flexed and upward position during each contraction.  Many nurses, midwives and doctors recommend the squatting position, which may help to ‘open’ the pelvic outlet during birth.  Although one study showed squatting to be associated with less perineal injury, anal sphincter injury and episiotomy, other studies have reported conflicting results. The sitting position has been advocated by some women, sometimes using a specialized birthing chair – which has been associated with quicker deliveries, but also greater risk of injury to the labia and perineum, and increased blood loss.  The side-lying position may allow some women greater ability to slow the expulsion of the fetal head past the vaginal opening, potentially reducing the risk of injury resulting from a fast or uncontrolled birth. Indeed, one large study found that of all birth positions, side-lying was associated with the best odds of avoiding perineal injury.  Finally, although some studies have shown the standing position to result in a reduced need for forceps or vacuum assistance, other studies have associated this position with increased anal sphincter injury, labial injury and blood loss.

When to Begin?  Delayed pushing means resisting the urge to push for a period of time, even after the cervix is fully dilated, thereby allowing the fetus to ‘passively’ descend through the birth canal.  Medical literature dating back to the 1950’s suggested that avoiding pushing appeared to result in lower risk of forceps delivery and injury to the perineum.  More recent studies have confirmed that ‘difficult deliveries’, forceps and perineal injury may indeed be less likely among women who delay pushing, or push less forcefully.

How Long is Too Long?  There was once a time when ‘prolonged labor’ meant a truly epic and dangerous struggle for mom, often lasting for several days.  That period of time, we came to understand, introduced major risks for both mother and baby.  But even today, defining the true ‘limits’ of normal labor remains a question. Will the length of labor influence the function of your bladder, bowel and pelvic floor later on?  Long pushing stages have been associated with diminished pelvic nerve function afterwards, and increased risk of flatal incontinence (inability to control gas) and bladder dysfunction. Pushing longer than three hours warrants discussion with your doctor, to review the potential effects on the pelvic floor.

Adapted From:  “Ever Since I Had My Baby: Understanding, Treating and Preventing the Most Common Physical Aftereffects of Pregnancy and Childbirth”, by Roger P. Goldberg, MD MPH