Recently I wrote a brief blog about side planks in pregnancy. This topic came up because a client of mine had signed on to an app which gave her specific exercises for each week in her pregnancy. At the 20 week mark her app told her to start doing side planks as they “can be a great way to strengthen your abdominals and core for delivery.”
This isn’t the first time that I’ve heard fitness and health professionals recommend abdominal strengthening exercises for birth. It really puzzled me – why do we need strong abdominal muscles for birth?
I reflected on my own birth – at the start of second stage labour, my body pushed all by itself. I certainly wasn’t making it happen – I was just going along for the ride!
Now those that know me know that I am a HUGE advocate of exercise in pregnancy. Basically I think it is essential and is a magic bullet for helping just about everything – from reducing risks of blood clots and gestational diabetes, to helping manage anxiety and depression, reducing back and pelvic pain, improving sleep quality…the list goes on and on.
We definitely want to maintain (and improve if we can!) our muscle strength and fitness in pregnancy for all of the above reasons. But do we really need strong abs for birth itself? What is the role of the abdominal muscles in labour?
I asked a few experts for their opinion. A HUGE thank you to the following:
Tracy Donegan (TD) – Midwife, author and founder of the Gentle Birth Program
Sami Cattach (SM) – Pelvic Floor Physiotherapist and Restorative Exercise Specialist – Body and Birth Physio
In a normal physiological birth, how does the baby move down through the birth canal?
TD “ It’s often surprising for mums to hear that the 2nd stage is a reflex – just like a sneeze, or the way you blink when something comes towards your eye. You were never taught these reflexes – they just happen.
As your baby descends deep into the pelvis your baby’s head triggers Fergusons reflex (also known as the fetal ejection reflex) and your body automatically starts to nudge your baby down with or without you. The top of the uterus (fundus) gets thicker and thicker and moves down behind your baby – like a tube of toothpaste. When you think of how our body works when you vomit. Your body throws up….so in labour it’s like your body is throwing ‘down’. You’d never say oh I had a dodgy curry last night and was pushing up vomit all night….you’d say you were throwing up….it’s the same with the 2nd stage….your body does all the work for you.
It’s an irresistible urge that you can’t ignore. Think of how the bowel works – pushing when you don’t have the urge to push is like me instructing you now to go and have a bowel movement immediately when you don’t feel the need to go! Think of a time when you really really needed to go….did you need someone to coach you? Did you need to do anything else other than find a bathroom, sit down and relax? Whether you sit on the toilet and do Olympic pushing or bring a book (men are great at this) the poop still comes out!!! When you think of it how did humans get born for the thousands of years before Midwives and Doctors came on the scene? Who is coaching the cows and sheep in the fields or the women who have accidental homebirths or give birth in the car? When a baby is born unexpectedly at home or in the car those mums were literally sucking those babies back in but the body has other plans.
The good news is that you don’t need strong abs for labor – the uterus does so much of the work for you (even with an epidural) and there’s no exercise you can do to make your uterus work more efficiently. Some small studies do suggest that Raspberry Leaf Tea can act as a uterine toner and some women experience a shorter pushing stage after consuming RLT in the 3rd trimester. However having a strong core in pregnancy can help avoid back pain in pregnancy and after.”
PWO –“During a physiological birth your body and baby really work together. When your hormones are triggered in the right way, you use gravity and you work with your baby, there really is no need to do anything else.
Your hormones will trigger the right responses and the muscles of the uterus will work together to help move the baby out. This is known as the Ferguson reflex, however it is a shy reflex and we need to make sure it is not interrupted at this stage.
Most people don’t realise that their baby is not passive in all this either, he/she is wriggling and finding the easiest way out. I always recommend clients watch a breast crawl, of a baby straight after birth, so they can sees just how active and capable their baby is.”
What happens if you push too hard?
TD: In recent years women have been led to believe that they need to be taught how to push – that there is some magical secret technique that only an ‘expert’ can instruct you in. What most mums to be don’t realize that these expert ‘techniques’ that include holding your breath for long periods of time puts her baby at risk. Nobody told her that ‘purple pushing’ could damage not only her baby, but her bladder, her pelvic floor and perineum. In fact many hospital classes encourage it and other women tell these mums to ‘listen to your Midwife – she’ll show you how to push’.
There are a number of studies comparing coached vs spontaneous pushing. In 2003 the WHO recommended removing coached pushing from practice. Mother led pushing is protective for your baby. When you hold your breath for sustained periods of time the oxygen to your baby, uterus and perineum is turned off, cardiac output is affected as well as your blood pressure.
Research from 1957 describes the damage to the muscles of the vagina and support ligaments after coached pushing so the new research is reaffirming what we already knew to be the case – that ‘purple pushing’ is harmful for women and their babies and the more Mums can educate themselves about local maternity practices the better.”
SC: “Bearing down can occur when someone holds their breath while pushing which creates a much more generalised downward pressure caused by the diaphragm. This means instead of the uterus and deep abdominal core muscles (TrA) helping to push only your baby out, there is more pushing down onto pelvic organs (including the bladder and bowel) and stretching of the ligaments that hold up these organs. In some cases, this can contribute to pelvic organ prolapse.
Also, under pressure or load, the reflexive response of the pelvic floor muscles is to contract and lift up, though this is the opposite of what we want those muscles to do during childbirth. Optimally, we want the pelvic floor muscles to be as relaxed or as supple as possible to allow for less resistance to baby’s descent.
PWO – “Pushing too hard is not good for mum or baby. It puts way too much strain on both of them. I really don’t understand why there are still care givers who will instruct mums to do the “Valsava Pushing Technique when the evidence is quite clear on this. Babies have better APGAR scores when Mums works with her body rather than forcibly pushes their babies out.”
Is this different when an epidural is insitu?
TD: “One of the tradeoffs of having an epidural is that you lose mobility and it can be more challenging to birth upright. Often times it’s the staff who find it challenging rather than mom. I’ve worked with moms who have been facilitated to birth on all fours even with an epidural. With an epidural in place the uterus still nudges your baby through the pelvis and by giving moms more time (3-4 hours of passive descent) especially first time moms we can improve the odds of mom having a normal vaginal birth. Be sure to include in your birth preferences that you would like extra time for passive descent or laboring down as it’s also commonly known as.”
SC: “An epidural will affect the mother’s ability to move around and help baby descend into the birth canal, and may limit what positions she can the be in to deliver. It can also affect the ability of a woman to sense when and how to push, which can sometimes lead to more generalised bearing down or more forced pushing as if for a bowel movement. Clinically, this seems to correlate with a higher likelihood of postpartum rectocele.”
Do you recommend abdominal muscle training in pregnancy to specifically to help with birth?
SC: As baby grows during your pregnancy, the muscles lining the uterus get bigger and increase in number to prepare for the big event of pushing baby out. Your uterus really is the main ‘pushing’ muscle during delivery, as opposed to your diaphragm or abdominal muscles. I don’t specifically recommend abdominal core training for birthing, though functional core strength and whole body strength is essential to help support the rest of the body and increasing weight of baby, and then to support you during labour and delivery.
What can women do to optimise the second stage labour?
PWO: “To optimize second stage I recommend:
– Trust your body and your baby: if you are over thinking the process you can dull the hormonal triggers that are meant to happen at this point
– Learn some relaxation techniques so you can really relax your body and allow it to open as it should.
If you are doing perineal massage, make sure you are doing it for the right reason. Perineal massage is not about making yourself more stretchy, it is about teaching yourself to relax to that sensation
– Use gravity. If you think about the physics of what is happening the downward energy of the uterine muscles is massively weakened if you are lying on your back. You are also making it hard for your baby to do all the turning and negotiation of the birth path that he/she is trying to do.
– Make sure no one tells you to “PUUUUUUSSSSSHHHHH”. It is like going to the loo for a poo, if people stood outside the door yelling “Push. Push, Push” you would most likely get “stage fright” and lose the urge. Exactly the same thing happens in birth, you will lose the shy Ferguson Reflex.
Make sure that you write in your birth plan that no one is to direct you to push then get your birth partner to ensure everyone respects your wishes once you are birthing your baby.
– Don’t announce when you feel 2nd stage has started. You will feel a change and possibly like you want to poo, just keep it to yourself. If you announce it, lights might go on , VEs might be performed, trolleys might be wheeled in and the clock will start. 2nd stage can take a while as there are actually 3 phases of second stage and there is no need for heightened activity at this time. Remember the Ferguson Reflex is shy.
– Do an Hypnobirthing course. This really will give you the edge as not only will you understand what your body and baby are doing, you will have some excellent tools and techniques to use.”
SC: “Optimising the second stage of labour cannot be separated from preparing the whole body for pregnancy and childbirth. You need healthy, supple pelvic floor muscles, a strong and functional core and good support from all of the surrounding muscles of the hips and pelvis which come from moving and exercising well throughout your pregnancy. Learning how to relax your pelvic floor, breathe with your diaphragm is key.
More specifically, here things I would recommend…
– Perineal massage
– Hands and knees squat prep (from my eBook/video series/youtube video “Drop it like a Squat”)
During second stage:
– Positioning that allows some assistance from gravity and no resistance to the mobility of the sacrum and coccyx (i.e. not lying on your back)
– Exhaling during big pushes which will help recruit your TrA and avoid bearing down with your diaphragm”
Some useful articles:
To learn more about health and wellness in pregnancy, as well as some tips that you can use to prepare for YOUR birth, head to our pregnancy club page.