Pregnancy and labor put the pelvic floor muscles to the test. Don’t worry—women with a history of pelvic floor disorders can still have a healthy, normal pregnancy and a quick return to their prepregnancy condition.

 For these nine months, your focus is quite naturally on your pelvis; that’s where so many of the changes you’re undergoing occur, and it’s where a lot of your discomfort may originate. During pregnancy, your pelvic area has to continue to make room for the fetus growing inside you. Your body increases its production of the hormones relaxin and estrogen, which loosen the ligaments in the body and allow the pelvic bones to expand to accommodate the growing fetus. As a result, your joints are more lax. Also, your center of gravity shifts forward and your abdominal muscles lengthen—and in so doing lose some strength. Your back muscles, leg muscles, and pelvic floor muscles all have to work overtime to balance out the extra weight you’re carrying and the change in your posture; this can cause neck pain, pelvic pain, back pain, and pain in the wrist, shoulder, and ankle.

  As if all this weren’t enough, your bladder is feeling the pressure of all these changes and of the growing fetus. You feel the urge to urinate more often, and many women experience some leaking.

  Even though you probably won’t experience all these bodily changes, any of them can be uncomfortable and disruptive. They can cause complications. Sometimes they’re painful.

  But of course, they’re as normal and as natural as childbirth itself. And as you’ll learn in this chapter, there is a lot you can do to mitigate the discomfort and to prepare your body for as smooth and easy a delivery and as rapid a return to prepregnancy normalcy as possible.

  Keep this in mind: You do not have to suffer. You and your obstetrician will together work out what is best for you throughout the course of your pregnancy. But don’t accept a “prescription” that tells you your pain will end “when the baby is born,” especially if you’re in the early stages of pregnancy. For one thing, that still leaves you plenty of time to be miserable; for another thing, the pain may not go away once the baby is born.

  There is a lot you can do to help yourself. The relaxation techniques and exercises you’ve learned in this book—the same techniques and exercises that helped give you a healthy pelvic floor even before pregnancy—can also help alleviate your discomfort, keep you fit during pregnancy, provide you your best shot at a smooth, easy delivery, and help you get back into fighting trim after delivery as well. The exercises in this chapter are geared specifically to do all of that, and if you find that they are too easy, or if they become too easy as you continue to do them, you can give yourself more of a challenge by referring back to the appropriate section of Chapter 3, “Keeping the Exercises Challenging.”

  Such exercises may even help you conceive. Recent research has suggested that two possible causes of infertility may be related to the pelvic floor.

  One possibility is pelvic congestion—that is, an insufficient or inadequate or ineffective flow of blood to the pelvic area and the pelvic organs. The congestion, in turn, could be the result of chronic inflammation or spasmed, overly tight muscles and tissues in the pelvis, abdomen, legs, and back.

  A second possibility is a mechanical problem. Specifically, in those patients who experience pelvic pain, pelvic floor dysfunction, vestibulitis, and/or erectile dysfunction, there could be a correlation to spasmed muscles and an irritated nerve supply or adhesions  that render intercourse difficult or even impossible.

  Both of these possibilities are still very much in the research stage. But if infertility is an issue, it is worth discussing these issues with your health-care provider. In addition, I recommend seeking a full evaluation by a physical therapist who specializes in the treatment of pelvic floor dysfunction.

  In any event, of course, you should discuss all of these techniques and exercises with your obstetrician; chances are he or she will applaud your initiative, but it’s essential that you share what you are planning. And of course, pregnancy can produce or make you vulnerable to serious problems. For any muscle or bone pain or discomfort out of the ordinary, don’t hesitate to see your physician or a physical therapist who specializes in pregnancy.

Stay Flexible and Strong

The natural way to stay fit during pregnancy, ease any discomfort you feel, smooth the delivery, and get you back to your prepregnancy state fast is really just a variation of the relaxation techniques and exercises you’ve learned elsewhere in this book. That’s because staying both flexible and strong is key to keeping your pelvic floor healthy and fit, and a healthy and fit pelvic floor is the perfect preparation for what you’re about to undergo in pregnancy and childbirth.

  To begin with, it is important to stay flexible at all times, but perhaps never more so than in preparation for labor and delivery. Flexibility is particularly important in the hip and back joints, which tend to tighten up under the growing weight of the fetus and the shift in your center of gravity. As you learned in Chapter 3, the body’s typical reaction to pain is to tighten up, which only makes the pain worse. If that happens during labor and delivery—if you tighten your pelvic floor muscles as a reaction to the pain—the baby is going to have a more difficult time passing through the vaginal canal, you’ll have more pain, and you’ll also face a greater risk of injuring the pelvic floor muscles, tissues, and nerves. So it’s terribly important as a preparation for delivery to do the Letting Go program you learned back in Chapter 3—the exercises of Part 1 of the End-the-Pain routine—from deep breathing and the pelvic drop through all the stretches except the abdominals stretch.

  The reason we exclude the abdominals stretch? Your abdomen is stretching all on its own, as the muscles make room for the growing fetus. Asking those muscles to stretch even more through exercise is not necessary.

  Instead of the 11 exercises of Letting Go, therefore, do only 10. And if you find that it is just too tough, as your stomach expands, to do the butt stretch, do only nine of the exercises, excluding the butt stretch as well as the abdominals stretch.

  It is never too late or too early to start practicing these tension-easing exercises. Whether you are in your first trimester or your last, a half hour of Letting Go stretching will stand you in good stead when those contractions start and you find yourself on the delivery table with your obstetrician or midwife telling you to “push” the baby out. These exercises will also help you feel more flexible—and therefore more comfortable—during the months of your pregnancy.

Ease Your Delivery: The Preventive Massage

Massaging the perineal body is an excellent way to prepare the vagina for delivery; it may make your time easier and less painful, and it can help prevent difficulties, complications, and injuries. (Refer to Figure 1.3.) Start massaging the area at any time, but by all means begin a regular program of massage at least six weeks prior to delivery. At that time, you or your partner should start gently stretching the tissues at the vaginal opening as well. That means doing the internal pelvic massage you learned back in Chapter 5, only in this case, you’re not probing for sore points, you’re actually stretching the sides of the vagina outward and downward.

  Lie on your back with a pillow or two behind your head and another under your upper back. Remember to visualize your pelvis as a clock on which your pubic bone is at the 12 o’clock position and the anus is at 6 o’clock. Insert the index fingers of both hands about an inch into the vagina at the 3 o’clock and 9 o’clock positions respectively. Gently stretch the sides of the vagina out and down. Hold the stretch for 20 seconds, then relax for 20 seconds. Do this three times, once a day, right up until delivery. It is excellent preparation for delivery, and it can help you avoid an episiotomy and prevent vaginal tears.

Gain Strength: The Kegel Question

Just as important as relaxing the tension in your pelvic floor muscles and readying the tissue for delivery is strengthening the muscles. As discussed in Chapter 4, the key to strengthening the muscles of the pelvic floor is the Kegel, and many women wonder whether Kegels are appropriate during pregnancy. The answer is yes, with some qualifications.

  It is true that the growth of the fetus puts extra pressure on the bladder, and this causes some increase in frequency of urination; it’s a cliché that pregnant women are constantly in need of a bathroom. But this should not be seen as an invitation to just keep on doing Kegels. Moderation is needed. Here’s the rule of thumb:

  If you are not leaking, do 20 Kegels once or twice a week: 10 for two seconds, relaxing for two, 10 for 10 seconds, relaxing for 10 seconds. This will maintain your pelvic floor muscle strength without overworking the muscles.

  If you are leaking, even just a little, do the 20 Kegel reps a few times a day—no more than three times—depending on the severity of the leaking. Again, hold the position for two seconds, relax for two, hold for 10 seconds, and relax for 10.

Gain Strength: More Exercises

Strengthening is essential to keep you fit during pregnancy, to smooth your delivery, and to make your return to normalcy fast and easy. These exercises keep your legs, upper back, and abdominals strong—and you’ll be grateful for the results. (Once your baby is born and starts growing—fast—you’ll be particularly grateful for that upper body strength.)

  If you’ve been doing these exercises all along, start with 20 reps of each—30 if you can! If you’re new to them, start off with 10 repetitions of each and work your way up. Remember to breathe and to rest between reps.

Pelvic Tilt

On your back, knees bent, feet flat and hip-width apart, tighten your abdominal muscles by sinking your belly button toward your spine—as if you were zipping up a tight pair of jeans—and tilt your pelvis upward toward the ceiling. Hold for 10 seconds, then relax for 10 seconds for one repetition. (Refer to p. 80 in Ch. 4; do with or without Kegels.) If you find it difficult to do the pelvic tilt during the last stages of pregnancy—if, like many women, lying on your back is uncomfortable or makes you short of breath—do the quadruped baby lift later in this section instead.

Squats

Stand with feet hip-width apart, feet forward of the line of your shoulders and slightly turned out. Tighten your abs. Slowly, on a count of three seconds, bend your knees as you lower your buttocks to a maximum of a 45-degree angle—or as close as possible. Lean forward slightly as you do this but keep your back straight—as if you were about to sit down on a chair. Make sure your knees don’t go forward of the line of your toes. Rise back up to a standing position, also on a three-second count. Relax for five seconds. (Refer to p. 60 in Ch. 3.)

Bridge

Do this only in the first four months of pregnancy. After that, the fetus will be too big, and the exercise can decrease your blood flow as you lift.

  Lie on your back with knees bent, feet flat and hip-width apart, arms at your sides. Tighten your abs. Slowly raise your pelvis. When you reach the top of the bridge, hold the position, then slowly lower the pelvis. Relax. (Refer to p. 57 in Ch. 3.)

Quadruped Baby Lift

Get down on all fours on your hands and knees. Hold your head in a straight line with your spine, with your chin tucked in. Keeping your back and neck straight, tighten your navel up to your spine, contracting your abs to “lift the baby.” Hold for five seconds, relax for five seconds.

Quadruped Opposite Arm and Leg Raise

Still on all fours and holding the abdominal muscle tight, lift your left leg and right arm simultaneously while keeping your pelvis square to the floor. Hold for three seconds, then lower both arm and leg. Relax. Tighten the ab muscles again, and now raise your right leg and left arm. Hold for three seconds, lower, relax. (Refer to p. 59 in Ch. 3.)

Hip Adduction

On your back with your knees bent and feet hip-width apart, tighten your abs and squeeze a pillow or ball between your knees and hold the position for 10 seconds. Relax for 10 seconds. At the five-month marker, switch to doing this seated. (Refer to p. 79 in Ch. 4; do with or without Kegels.)

Hip External Rotation

On your back with your knees bent and feet together, tighten your abs and slowly separate your knees—feet still together—until the knees are about 24 inches apart. Add resistance by pressing your hands against the separating knees. (You may also use a resistance band.) Hold the position for three seconds and then slowly return your knees together in the center. Relax for five seconds. (Refer to p. 78 in Ch. 4; do with or without Kegels.) You can also perform this exercise in a seated position once you have reached five months.

Helpful Hints

There’s so much to think about during pregnancy that it’s easy to forget some of the basics. While it’s important to do the relaxation techniques and exercises in this chapter, it’s also essential to keep up your cardiovascular routine as best you can—but be sure to monitor your comfort level and your breathing. If you find that your breathing is labored, slow down; if you feel discomfort or pain, cut back.

  Posture is particularly important during pregnancy. Your bodily changes affect your stance and posture, and holding yourself upright of course gets more and more difficult as the fetus grows. Go back to Chapter 7 and practice the standing and seated posture exercises as often as you can. The better aligned you are, the less chance of injuring yourself, and the more strength you’ll have for carrying your newborn.

  Watch your body mechanics too. It’s particularly important during pregnancy—mostly because of the shift in weight—to take care that you use your legs when you bend down to pick something up, not your back. Refer back to the photos on page 124 in Chapter 7, which demonstrate poor lifting and proper lifting. Be careful lowering yourself into a chair; hold on as you get seated. Slouching can be hard on the body, so stash a cushion behind your back when you’re sitting down; it will support your posture.

  If you have severe discomfort in your butt or low back region, give yourself the sore points massage you learned in Chapter 5. If that doesn’t help, ask your health-care provider or physical therapist about using a sacroiliac support belt; these can be obtained from medical supply houses and are easily found via Internet search. This is a kind of splint that helps stabilize the pelvis and the sacroiliac joint, the joint below the spine that expands during pregnancy in order to accommodate a growing fetus. The belt effectively relieves pressure on the lower back and sacroiliac joint. However, it is essential to get a correct diagnosis from someone who specializes in pregnancy-related back pain.

  Cushions can also help, both in easing the discomfort of lying down and in supporting your posture. As mentioned, you can use cushions to support your back, and try a cushion under the butt—to take away tailbone, pelvic, or sit bone pain.

  Where nutrition is concerned, your doctor has certainly advised you about the best diet. But it’s very important to avoid constipation, so keep away from the simple carbohydrates and from fried and high-fat foods, remember to eat fiber regularly, and refer back to Chapter 6 for a brush-up on ways to stay regular.

Once Your Baby Is Born

Certainly you’re eager to get back to your prepregnancy fitness level. The best way to do that is to keep up with the exercises and relaxation techniques described in this chapter—only more so: more reps, more resistance, more exercises. Obviously, don’t start any exercise program until you have recouped fully from childbirth and have received approval from your doctor.

  If you had a healthy vaginal delivery, your vaginal muscles and tissues have temporarily stretched, and Kegels are the best way to bring the muscles and tissue back to top form. But the rule of thumb is still operative: If you’re leaking, do Kegels up to three times a day; if not, do them once or twice a week.

  As to other exercise and certainly as regards your return to a cardiovascular routine, challenge yourself.

Some Precautions

There are exceptions, of course. The stretching of the abdominal muscles that occurred during pregnancy sometimes results in what’s called a diastasis recti—an actual separation of the abdominal muscles. In due course, the separation is bridged naturally, and most of the time, the muscles will return to their prepregnancy closeness—but not always. So you can speed the process—or make it happen—by hugging your tummy as you do your pelvic tilts. Literally give yourself a hug—right below your ribs and above the pelvic bones, thus scrunching the muscles into a state approximating their normal, prepregnancy closeness. Hold the hug for 10 seconds, and do 10 reps twice a day.

  After a couple weeks, add the more challenging abdominal exercises with the tummy hug, shown in Chapter 3, on pages 54–56. Also, abdominal binders specifically to help with this condition are available via the Internet.

   If you suffered a vaginal tear, had an episiotomy, or delivered your baby via C-section, you will want to talk to your doctor about scar tissue mobilization—that is, a way of massaging either an internal or external scar, whichever your condition left you with, so that you don’t get permanent adhesions that could produce pelvic floor dysfunction or lower abdominal pain. Ice can ease the discomfort in the initial stages. Ice the area for up to 15 minutes as many as five times a day to calm the painful nerve endings and any inflammation. Alternatively, you might want to do the contrast bath described in Chapter 7. Then ask your health-care provider how to do the scar tissue massage to prevent pelvic floor and abdominal muscle disorders.