Hammock or Trampoline?
I see this often, in first labors especially: Labor starts with a long pre-labor; the kind of labor that starts and stops multiple times, sometimes for days or even a couple of weeks. A variation of this is an early labor that presents itself with short yet transition-like, painful contractions that do not yet dilate the cervix. Both patterns seem to indicate a body working hard to get a baby aligned and engaging. Once things progress, there can be intense, and possibly, continuous back pain, that can be accompanied by stalls in active labor, transition and/or pushing.
Mid-pelvis area
When someone has intense back pain, I usually assume that the baby is probably somewhere in the mid-pelvis: the top of the baby's head is approximately at the level of the ischial bones where space is tight. (You can see the ischial bones as inward protrusions inside the opening in the picture below.)
What is happening? A baby is finishing or trying to finish their rotation to align optimally in order to descend further. As a baby engages and descends into the pelvis, its head is guided by the pelvic bones and pelvic floor muscles to flex and rotate. A baby needs to tuck its chin (also called flex because it flexes away from the birth giver's back) and then rotate (ideally to face your back) to accommodate for the change in diameter of the pelvis.
As a baby engages and descends into the pelvis, its head is guided by the pelvic bones and pelvic floor muscles to flex and rotate.
Tightness and imbalances in the pelvic floor and/or a baby that has other ideas or needs can prolong the process of flexion and rotation, potentially moving with a non-optimal position that doesn't smoothly fix itself, takes time, and is often more painful, especially if a baby is also bigger. An epidural in this scenario can allow for full relaxation of the pelvic floor and can result in better positioning when good positioning with peanut ball and pillows is purposefully used while resting. If someone is not in the hospital, it requires grit, determination, and a lot of trust and support to move through this kind of labor, with a labor tub preferably. This type of labor has been the most common reason for transferring to the hospital from home or birthing center in my experience.
Strong pelvic floor
We are all in our bodies differently and utilize our bodies in various ways. Some of this is learned behavior, like holding in our tummies because flatter tummy... People who hold a lot of tension in their bodies can anchor themselves using their pelvic floor a certain way. Athletes may have non-flexible strength in their pelvic floor. People who are so-called strong or have a strong body tone may need to learn to let go of tone and learn to be comfortable with what this feels like. People who are great at doing kegels properly (at best) or squeezing only the sphincter muscles (at worst), need to also focus on being able to let the pelvic floor go the other way, as in, bulge out or downward (which should be part of proper kegels but often gets lost in translation). To give birth we need to release and let go. Mindful pooping is a great way to practice all of this. Look it up!
Think trampoline as opposed to hammock.
Our pelvic floors need flexibility. This is what it means to have a healthy pelvic floor. Flexibility is responsive and creates space. Think trampoline as opposed to hammock; natural bounce as opposed to tautness. A strong fist is unable to grab anything unless it can open. A strong pelvic floor is only as strong as it can relax and this is sometimes a learned skill that may require professional evaluation and support. Kelly Dean, MPT and Founder of The Tummy Team, explains it more below.
When talking about physiologic labor, we often talk about letting the pain guide us and I think we tend to mostly refer to the time when things become more intense. However, the sensations and patterns early on are very much worthy of our attention. While all kinds of labor patterns can be part of normal – and stop-and-go labor as well as back labor are no different – knowing this is only helpful up to a certain point. The head still needs to flex and rotate to descend. Pain and exhaustion are real, and pharmacologic pain management is not innocuous.
Early patterns and sensations are an opportunity for action. No one is an inactive participant in the labor process – not the baby, not the person giving birth, nor the doula, the nurse, or the provider. By the time someone is in active labor, however, and when it becomes obvious something is needed, it often means adding discomfort and pain to an already intense experience in the hope that things improve. Or it means physiologic labor becomes a more medically managed labor. Early labor can therefore offer opportunities when there is still space and time, physically and emotionally. Good support and recommendations for moving, resting, and positioning can be helpful.
Early patterns and sensations are an opportunity for action.
We can also prepare even earlier, as in, prenatally, to optimize the pelvic floor. Using the Spinning Babies 3 Balances mindfully and adding bodywork from a PT and/or chiropractor if possible can be a great tool to address imbalances and tightness early on.
There is a growing focus on pelvic floor rehab post-birth which is great but preventing is better than restoring. More and more L&D nurses are using techniques to improve positioning which is awesome too, but they aren't usually involved with this in early labor and they are not around prenatally. An out-of-hospital midwife will be in a much better position to support you prenatally and in early labor as are doulas.
As a doula, I mostly support first-time parents and I expect the journey to be longer and more demanding. I try to present information prenatally in a way that is not overwhelming, builds confidence, and is actionable. Focused pelvic floor work prenatally is very helpful for long term pelvic floor health as well, no matter which birth route someone chooses or ends up needing. Pelvic floor work, especially when done prenatally, becomes a repertoire of trusted movements and feeling, allowing for easier adjustments as labor progresses and shows its demands.
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