Tips & Tools: Pelvic Floor 

During pregnancy, how can I lower my chances of pelvic floor injury and dysfunction?

• Talk with your doctor or midwife about routine use of interventions that can increase risk for pelvic floor disorders: Ask your caregivers their opinion of the following interventions that may be used during the pushing stage of labor:
  • episiotomy (cutting the vaginal opening to enlarge it for birth)
  • lying on your back (versus various upright or side-lying positions),
  • caregiver-directed (versus mother-directed) pushing,
  • having a caregiver press on your abdomen (fundal pressure) to help get the baby out, and
  • vacuum extraction or forceps delivery.
• Tell your caregivers that you want to avoid these potentially harmful procedures and practices unless there is a clear, compelling medical reason to use them. If you don't know who will attend the birth, ask your caregivers how you can best assure that your wishes will be respected. If they are not willing to work with you to achieve this goal, consider looking for others who will work with you on this. See a complete Pregnancy Topic on Choosing a Caregiver.
• Arrange for a birth doula or someone else who can provide continuous labor support: Trained, female labor companions (known as birth doulas or labor or childbirth assistants) have practical knowledge about how to help a labor progress smoothly and get the labor on track when it doesn't. Women who receive continuous supportive care in labor from a trained or experienced woman who is not a nurse, midwife, or doctor are less likely to: have an epidural or other pain medications, have an assisted delivery, have a cesarean section, and feel dissatisfied with their birth experience. See a complete Pregnancy Topic on Labor Support.
• Establish a regular pelvic floor exercise program: Doing kegel exercises regularly in pregnancy can help prevent urinary incontinence. An intensive program of exercise appears to do more good than a less intensive one. Substituting or adding other techniques such as using vaginal cones (inserting weighted cones into the vagina and holding them against gravity) or electrical stimulation (inserting a probe in the vagina or anus that passes a low current to the muscles around the bladder, stimulating them to contract) does not appear to offer any benefit over a program of kegel exercises. The Pelvic Floor Dysfunction page in Resources A-Z will provide you with more information.
• Consider establishing a perineal massage program in the final weeks of pregnancy. You or your partner may perform this self-help routine, which has been associated with a somewhat increased likelihood of giving birth with neither an episiotomy nor a spontaneous tissue tear (with an intact perineum). The Pelvic Floor Dysfunction page in Resources A-Z provides a how-to link.

When giving birth, how can I reduce my chances of pelvic floor injury or dysfunction?

• Avoid an epidural: Epidural analgesia increases the likelihood of having an episiotomy and an assisted delivery (with vacuum extraction or forceps), and because of these, a tear into the anal muscle. The Pregnancy Topic Labor Pain describes many ways of coping with the pain of labor. Having a doula or someone else who can provide continuous labor support can also help you avoid an epidural. You can find more information about doulas and continuous labor support in another Pregnancy Topic, Best Evidence: Labor Support.
• Allow your own instincts and your body's pushing reflexes to guide pushing: When women follow their own inner sensations, they often don't begin pushing until some time after the opening of the uterus (cervix) is fully stretched, (dilated). When they do bear down, pushes tend to last only a few seconds, in contrast to more prolonged and stressful staff-directed pushing to hurry the birth along. With mother-directed pushing, women are less likely to be injured or need stitches. Pushing in this manner allows the vaginal tissues to gently stretch around the baby's descending head and may also avoid overstretching pelvic floor ligaments and muscles. (Many women with epidurals are unable to push in this way because they are numbed.)
• Give birth with your legs comfortably apart: If your perineum (the tissue between the vagina and the anus) is already at full stretch it will have nowhere to go when the baby's head is being born.
• Ease the baby out and do not push forcefully at the time of birth: Ask your caregivers how they guide women at the time of the birth to try to avoid tears into the perineum. Unless there is a medical reason to get the baby out quickly, bearing down gently, pushing in between contractions, or not pushing at all and letting the uterus do the work can help the tissues to stretch gently.

How can I reduce my chances of having an episiotomy?

• Talk with your caregiver about limiting episiotomy to medically urgent situations: Research does not support cutting an episiotomy for the following reasons:
  • to prevent tears into the anal muscle
  • to prevent pelvic floor disorders
  • to enable easier repair (stitching) than a tear
  • to promote better healing than a tear
  • to avoid problems in first-time mothers
  • to avoid problems if your baby seems to be large, and
  • to avoid problems if your caregiver thinks that a tear in the perineum is about to occur.
• Talk with your caregiver about not using an episiotomy should an assisted vaginal birth become necessary: Not having an episiotomy with a vacuum extraction or forceps delivery greatly reduces the likelihood that you will have a perineal tear into the anal muscle.
• Designate someone on your support team to remind you to remind your birth attendant when it comes time for the birth that you don't want an episiotomy, and clearly express your wishes at that time.

How can I reduce my chances of having a vacuum extraction or forceps delivery (assisted vaginal birth)?

• Arrange for a birth doula or an experienced friend or relative provide continuous labor support: Women who have this kind of support when giving birth are much less likely to have an assisted vaginal birth than women without such support. This kind of care can help you avoid the need for an epidural, help a labor progress smoothly, and get it back on track when it doesn't.
• Avoid continuous electronic fetal monitoring (EFM), whenever possible: Women who have continuous electronic fetal monitoring to keep track of the baby's heart rate during labor are more likely to have vacuum extraction or forceps deliveries. Despite this, their babies are not born in better condition compared with women whose babies are monitored at regular intervals using a handheld device (Doppler), the EFM machine, or a specialized stethoscope. (Continuous EFM is used to monitor side effects of some interventions such as giving synthetic oxytocin Pitocin or "Pit" in an IV to start or strengthen contractions or epidural analgesia; it is also used when women in labor have a uterine scar from a previous cesearean section.)
• Push in an upright or side-lying position or even on hands and knees. Avoid lying on your back (supine position) or on your back with legs in stirrups (lithotomy position,). Some hospital beds can be adjusted to help you get comfortable in an upright or side-lying position. A trained labor support companion (birth doula) can help support you in these positions. You can also get help from the nursing staff or your partner.
• Avoid time limits for pushing: Ask your caregivers to be flexible about the time needed for the pushing phase of labor, provided that you and the baby are doing well and some progress is being made.
• Let your body guide your pushing when possible: If your cervix is fully dilated and there is no medical reason to hurry, consider waiting to push until you experience the "urge to push" (a powerful rhythmic reflex to bear down) or until your baby's head is about to be born. Waiting up to 2 hours or more for these situations somewhat increases your likelihood of having a spontaneous vaginal birth (with neither vacuum extraction nor forceps) and may help avoid a difficult delivery if you are a first-time mother who has had an epidural. Waiting until the urge to bear down appears to help other mothers as well.

How can I reduce my chances of pelvic floor injury or dysfunction if I have an epidural?

• Delay pushing: After your cervix is fully dilated (stretched open), wait to push until your contractions bring the baby down.
• Don't set time limits for pushing: As long as you and the baby are doing well and at least some progress is being made, there is no reason to hurry the pushing phase.

After the baby is born, how can I strengthen my pelvic floor and avoid pelvic floor dysfunction?

Throughout life, how can I avoid pelvic floor dysfunction?

• Maintain a healthy body weight: Losing excess pounds can reduce symptoms as well as reduce your chance of developing diabetes, a condition that may also be associated with leaking urine (urinary incontinence).
• Avoid smoking: If you cannot quit completely, limit the number of cigarettes per day to decrease your chances of urinary incontinence. This can reduce coughing, which may lead to improvements.
• Keep doing your kegel exercises: An intensive program of pelvic floor exercises can both prevent and treat urinary incontinence.
• Avoid hormone replacement therapy (HRT): Higher-quality studies have found that use of hormone replacement therapy is associated with urinary incontinence.
• Minimize repeated urinary tract infection and irritation: These are associated with urinary incontinence. Treatment can improve symptoms.
• Avoid having a hysterectomy, when possible: Surgical removal of the uterus appears to increase your likelihood of having urinary incontinence. There are less invasive ways to treat many problems that can lead to hysterectomy.