• maria armstrong

Hammock or Trampoline?

Updated: Jan 21

I see it so often in first labors. Too often. Call it pre-labor or prodromal labor, this kind of labor starts with stop and go contractions, sometimes for days. Then there is intense back labor, often accompanied by stalls once the baby is in the mid-pelvis (when the baby's head is at the same level as the ischial bones). Then someone gets an epidural because of exhaustion on top of difficult pain, and bam: Fully dilated and baby descends past the ischial bones really quickly.

What happens in this kind of labor? As a baby engages and descends into the pelvis, its head is guided by the pelvic floor muscles to flex and rotate. A baby's chin needs to tuck (flex = away from the birth giver's back) and then internally rotate (ideally anteriorly, meaning the back of the baby's head is towards the belly) to accommodate for the change in diameter of the pelvis. Tightness and imbalances in the pelvic floor can cause issues in the process of flexion and rotation, potentially resulting in non-optimal positioning that doesn't smoothly fix itself and takes time, often painful time. An epidural in this scenario can allow for full relaxation of the pelvic floor and can result in better positioning.

I see this most in people who are/have been athletes or those who hold a lot of tension in their bodies. People who are so-called strong. This kind of strength is however not the goal for the pelvic floor. Flexibility is. 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 come out. Pain and exhaustion are real, and pharmacologic pain management is not innocuous.

Think trampoline as opposed to hammock

Early patterns and sensations can then become 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 a physiologic labor becomes a more medically managed labor. Early labor can therefore offer opportunities when there is still space and time, physically and emotionally.

Why not, then, prepare even earlier, as in prenatally, to optimize the pelvic floor? There is, finally, a growing focus on pelvic floor rehab post-birth which is great. More and more L&D nurses are using Spinning Babies techniques which is awesome too. But what we don't know prenatally can harm us at our very first labor. Why are Kegels – the main exercise mentioned in many prenatal and postpartum settings – so good and yet so bad, so helpful and yet so not? As doula I mostly support first time parents and I try to present information in a way that is not overwhelming, builds confidence, and is actionable. Focused pelvic floor work prenatally can be so very helpful no matter which birth route someone chooses or ends up needing. The Spinning Babies' "3 Sisters of Balance" is a good place to start. These and other techniques done prenatally become trusted movements and exercises during labor at any time, but especially when the pelvic floor needs more flexibility.

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