What is pelvic organ prolapse?
Pelvic organ prolapse is when one of the pelvic organs pushes into the vaginal wall. This is common after vaginal birth (and sometimes c-section birth) due to the stress put on the pelvic floor throughout pregnancy, pushing, and then birth.
In the early postpartum, the pelvic organs sit lower as we begin our healing process, so it can be normal to have a pelvic organ prolapse in early postpartum. The organs will slowly lift back upwards as the pelvic floor, hip musculature, and surrounding ligaments and tissues increase in density in the postpartum.
Most folks will be asymptomatic with a pelvic organ prolapse, and I would also compare it to having looser skin postpartum. Just because our bodies are different postpartum does not mean it is less functional.
But, if we have a symptomatic prolapse that is interfering with our daily function, working with a pelvic floor physical therapist is a great start to finding relief!
Let’s explore in this blog how to minimize a pelvic organ prolapse or prevent it from getting worse in subsequent pregnancies.
What could contribute towards pelvic organ prolapse during pushing?
Several factors could contribute to a pelvic organ prolapse during pushing. One big factor is pressure. Increased pressure above the pelvic organs can overly stress the supporting structures, causing pelvic organs to sit lower.
Pushing is a pressure management activity! We increase pressure in the abdominal cavity to push baby out.
Top things that seem to be correlated with pelvic organ prolapse after pushing include:
- The prolonged second stage of labor
- Use of forceps during pushing
Let’s discuss some ways to reduce this risk!
Ways To Reduce the Risk of Prolapse During Pushing
Ways we could reduce the risk:
- Shorten Active Pushing Time by Laboring Down
- Open Glottis Pushing
- Self-Directed Pushing
- Avoid Pushing on Your Back
Shorten Active Pushing: Labor Down
One common factor correlated with pelvic floor dysfunction and pelvic organ prolapse is a prolonged second stage of labor or long pushing phase.
During pushing, the uterine contractions and fundus (top muscle of the uterus) are pushing the baby out with the fetal ejection reflex. We can then add to the uterine contractions by actively bearing down with contractions to push. But this active pushing over a prolonged period can add extra stress or damage to the pelvic floor.
So, what can we do to help decrease overall pushing time? Labor down.
In 2017, ACOG stated in their bulletin that labor down, or pausing before the start of the second stage of labor (pushing) after someone has reached 10cm should be supported for 1-2 hours.
After someone has reached 10cm (and sometimes a little before), they may experience the fetal ejection reflex, where uterine contractions push the baby lower. If the baby is in an optimal position, and there are no restrictions in the baby’s path (such as the pelvic level is more open or muscular tension is released), then the baby should move lower in the pelvis, decreasing overall pushing time.
If that baby’s position has not changed both rotation-wise or station after an hour or so of laboring down, then we may need to focus on the positioning or start active pushing.
While laboring down, usually done with someone who has an epidural, we can use the peanut ball to help adjust the pelvic diameters.
If the baby is in the midpelvis, which is most common when laboring down, we want to focus on midpelvis openers. This would involve placing the shin on the peanut ball and rocking during contractions.
If baby is lower, and in the outlet, then we can place the peanut ball between the ankles to emphasize internal rotation of the femurs.
Open Glottis Pushing: Gentle Pushing
How we approach breathing during labor can affect the nerve and structural damage of the pelvic floor during pushing.
Most commonly, the Valsalva maneuver is coached during pushing. The Valsalva maneuver, also known as closed glottis or purple pushing, is when you hold your breath as you bear down and push for 6-10 seconds. This breathing technique used over a prolonged period can cause damage to the pelvic floor (Ahmadi et al., 2017). This technique is also associated with a higher risk of tearing, as there is a more rapid expansion of the vagina and perineum (Ahmadi et al., 2017). For example, open glottis pushing was associated with a 41% intact perineum rate (no tearing) compared to the closed glottis of 19.3% no tearing (Ahmadi et al., 2017).
Open glottis pushing, or gentle pushing, is when you exhale controlled as you bear down and push. This exhale can range in strength depending on if your baby is crowning or still moving down the birth canal.
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Open glottis pushing may appear less strenuous than the Valsalva breathing technique, and it likely is less exerting and fatiguing! Open glottis can also be associated with improved maternal satisfaction.
Usually, the biggest obstacle that I see as a doula with open glottis pushing is its unfamiliarity in a hospital setting. Hosptial staff members may not be confident or sure about how to support pushing in with this breathing technique and may dismiss its benefit and effectiveness with little pushing support.
Interestingly, most of my clients who push without direction or coaching tend to push for a few seconds with an open glottis technique and then reset for several pushes with each contraction. It isn’t until someone else directs them to push with the Valsalva maneuver do they tend to follow this breathing technique.
How can we approach open glottis pushing with potentially little or no support?
I usually recommend practicing on the toilet during pregnancy when you have a bowel movement. I tend to find that my clients who have pushed in previous birth and/or practice during pregnancy tend to have an easier time understanding how to push with this technique.
Inhale to feel the perineum expand downward, then exhale downward to bear down and poop. Reset to take another big inhale down and out, and exhale to bear down.
Focus on a deep, strong exhale instead of just blowing air out when we exhale.
In addition, when we poop, the direction of effort is slightly different than when we are pushing a baby out of our vagina. So, instead of pushing like you’re pooping, push like you’re pushing something out of your vagina. It can be helpful to practice pushing your finger out during pregnancy if you are unsure. If you have experience using tampons or menstrual cups or discs, think like you’re pushing out a tampon or menstrual cup. You can feel how pushing out a tampon versus pooping is slightly different from an effort focus.
Self-Directed Pushing
One common trend in research is that mother-led pushing tends to result in the best birth outcomes for mother and baby. We tend to pause when we need some more time to stretch and expand!
Can coaching pushing be helpful, though? Absolutely!
- It can be really helpful if you have precipitous labor and feel overwhelmed by pushing.
- It can be helpful if you feel really anxious or confused and need some guidance.
- Sometimes if you cant feel your contractions because your epidural is too strong, having someone cue you when to start pushing can be helpful!
But, just because you started using coached pushing doesn’t mean you have to use it the entire time! Once you feel like you got it, transition to self-directed!
This course explore your pelvic floor anatomy, function, and how to prepare your pelvic floor for birth! This course includes educational videos, mobility exercises, relaxation drills, and how to relax your pelvic floor during labor tips.
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Avoid Pushing On Your Back
It is important to start that you position you choose to push in, is the best position. But there are some considerations: prolonged pushing in a supine position has been associated with more alterations to the fetal heart rate and increased risk of pushing intervention, such as forceps or vacuum (Curl, 2019).
The use of forceps is correlated to an increased occurrence of pelvic organ prolapse (Kamisan Atan et al., 2019). If pushing in alternative positions can reduce the use of forceps, it may be more favorable to try pushing in a variety of other positions.
There are a lot of positions available to push in, even if you have an epidural!
You can push on your side, all fours or kneeling, standing (if you don’t have an epidural), or even in a seated/throne position!
Changing positions every 20-30 minutes while pushing can also support your baby’s final rotation, so pushing length is shortened.
In Review
Decreasing the length of pushing time and pushing interventions, particularly forceps, can decrease the occurrence of pelvic organ prolapse postpartum.
We can do this by focusing on self-directed pushing with open glottis breathing, avoiding pushing directly on the back for prolonged periods, and laboring down instead of pushing once we are 10cm!
Learn more about pushing and pelvic organ prolapse in our childbirth education courses and webinars.