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To Kegel or Not to Kegel... Is this de rigueur pelvic floor exercise always necessary? It would seem that to question the wisdom or necessity of performing regular pelvic floor exercises, or Kegels, during pregnancy, is akin to committing heresy. But I have learned that in at least a few women, myself included, Kegels may actually be counterproductive to achieving easy, episiotomy-free vaginal births. Furthermore, it would appear that Kegels have become "necessary" largely because of modern medical practice, which pays little heed to the physiology and necessity of normal, unhindered birth. Read a typical account of an unassisted childbirth (UC) and you will not find one mention of mother's having done Kegels in preparation for birthing. I think that many in the UC community do not see Kegels as being essential to birth. Or maybe they see them as most of us do: a hassle! Yet we dutifully perform them, exhorted by birthing books and our childbirth instructors. If we are doing them "right", we're doing a couple hundred Kegels each day, at least according to some teachers. I don't know about you, but I have never much liked doing Kegels. I always felt a little silly doing 'em, and I always wondered if they were really that necessary. I have learned that for a few women, they are not only unnecessary, but may even lead to needlessly difficult births. Take my own example. I have posted many naturally painless, effortless birth stories at this site, yet my first three babies' births were quite strenuous for me, and I am sure many women would have called them painful. For me, they did not hurt, except that my back hurt during part of the third birth because it had already been strained and hurt during that pregnancy. Why have my babies' births consistently been such hard work for me, though they didn't hurt per se? Is it really only because of what I wrote in my Painless Birth article, that each time, I expected birth to be very hard work, and got what I expected? Was it really a simple case of "mind over matter"? It turns out there's a likely physical reason as well. I am small and wiry, have an athletic background, lift weights and - unusual for a woman - my muscles bulk up easily without the "aid" of supplements. Our CNM, veteran of a couple thousand births, says that she has seen my sort of birthgiving difficulty in only a small number of women, specifically, athletes such as ballet dancers, horseback riders and cyclists. She says, you'd think such women would have an easier time of birth, since they are so fit, but actually, birth is often tough for them. The difficulty includes a long and/or strenuous labor, with a perineum (peri) that is strongly resistant to either stretching or tearing as baby tries to emerge. In other words, the toughened peri won't even tear, let alone stretch, even if the mother has assumed a physiologic birthing position such as all fours or an upright squat. At least some midwives have seen this phenomenon, but I think it happens seldom enough that most women and their birth attendants are completely unaware of it. I think it would probably be incorrect to say that all women athletes in a certain field (e.g. ballet or cycling) are doomed to have strenuous births. It is probably a combination of athletic training and genetics that leads some women to develop tough, stretch-resistant bottoms (inside and out). The peri is normally elastic and will stretch enormously to allow the baby to pass. Some natural, easily-healed tearing or "skid marks" may occur, but there will still be no need to perform episiotomy (epis) on most women, if they are positioned so that gravity can help the birth (full squat or variation, side-lying, or all fours). And regularly practicing Kegel exercises during pregnancy can indeed help most women increase the tone and elasticity of their pelvic floor muscles, so that these muscles become stronger and stretchier for childbirth. But in a few women, myself included, the peri and also the pelvic floor tend to be quite toned without the aid of Kegels. Our womanly parts are strong, but not as elastic as they should be. This could be from our naturally more muscular build, and/or years of unnatural stress on our bottoms. I myself was a fencer and also a cyclist for a number of years, so my lower body became quite toned, and the cycling doubtless put a strain on my pelvic floor, which may have gotten stronger to compensate. I have been strong and toned down there, ever since. I think my faithfully practicing lots of Kegels through each of my previous three full-term pregnancies only compounded the problem. I did Kegels religiously in preparation for those three births and got three episiotomies. The first two times I was in bed in the typical hospital delivery position (which practically guarantees episiotomy), but the third time I was upright and so there was no reason why an epis would normally have been needed. We tried massage and all sorts of pushing positions for nearly an hour, and my peri simply would not stretch more than halfway - wouldn't even tear - in spite of strong pushing contractions. But baby came out easily once the epis was done. We have been blessed with a fourth baby (due 11/01), and this time I am not going to do any more Kegels during pregnancy, and will try a few more pushing positions and other things that I have learned of since baby #3's birth. We may try laboring or birthing in water as well. I would so like to give birth without epis if at all possible. Recovery from epis is no picnic, and besides that, I am just really curious to see if I can avoid one. I will keep you posted.... February 2002 - I am delighted to report that we were able to avoid episiotomy this time around!! I say "we" because this was very much a team effort. I, my husband, and our nurse-midwife were all committed to doing all we could to achieve an intact peri. Per our midwife's advice, we began doing perineal massage, 5 minutes per session, 3 times a week, during the final month of pregnancy. It doesn't sound like a lot, but it made a huge difference. Another thing that really helped was hot moist compresses during the pushing stage of labor. This enabled the perineal area to relax and be ready to really stretch. And stretch it did!! All I got was one tiny tear in my episiotomy scar, requiring a single stitch afterward. It also helped that I gave birth while lying on my left side, and that baby was eased out rather than being forcefully pushed or pulled out. (Hands and knees is another good position for protecting the perineum.) Here is a page describing how to perform perineal massage. There are other webpages that tell how to do the massage, but that one describes it pretty much the way we did it, except we used extra virgin olive oil instead of massage oil. You should be aware, too, that performing perineal massage too often or too vigoriously during pregnancy, or performing it at all during pushing stage, can potentially damage the mother's tissues and actually make her more prone to tearing as baby crowns. (Midwives discuss this on a page on perineal protection.) That's why our midwife advised that we only do the massage 3 times a week, 5 minutes per session. I still can't believe how that little bit of massage could make such a tremendous difference, but it did. In case you are wondering, we did know about perineal massage when I was pregnant the other three times. In fact, we attempted it while pregnant with our firstborn. However, we didn't realize that we weren't doing it right; thus, my peri didn't get adequately stretched and prepared. That, plus my being made to give birth on my back, caused me to end up with my first episiotomy. Since we didn't know we hadn't done the peri massage right with baby #1, I erroneously concluded that peri massage simply didn't work for me, so we didn't even attempt it with babies #2 and 3. But after three episiotomies, we were willing to try perineal massage again, especially after our midwife carefully explained how to perform the massage correctly. Done right, perineal massage can be wonderfully beneficial, especially for moms like me who are very tight "down there". In one issue of Mothering magazine (No. 104, Jan./Feb. 2001) I found some sensible-sounding advice regarding Kegels in preparation for childbirth, under the sidebar "How to Prevent Tearing" (article title: "Saying No to Episiotomy" by Elizabeth Bruce, MA, CCE): In the weeks leading up to birth, Kegels are helpful in maintaining tone and blood flow, although it is possible to do too many; between 20 and 30 a day is probably about the right number. [emphasis mine] I have heard and read different opinions on how many Kegels per day is enough in pregnancy, but 20-30 a day certainly sounds much more do-able than the 100-200 I have seen recommended elsewhere. This would be something to research for yourself, and to ask your birth attendant about. In thinking about all this, I suspect it's not the best thing for women to train hard athletically, at least not in light of someday giving birth. Maybe long periods of dedicated athletic training can throw off hormones or other factors that would otherwise keep some of these women softer and more pliant, inside and out. On the other hand, high-impact sports such as running can actually lead to exercise-related incontinence (urine leakage), even in young women who've never borne children. Such women would do well to practice Kegels, to shore up their pelvic floors so they can avoid embarrassing "accidents" during workouts. Overall, women athletes may be better prepared than most Western women to fearlessly embrace the power of giving birth. However, with their strenuous training regimens, at least some of these women may be unknowingly cheating themselves out of truly easy, effortless, natural births. The very fit women in native cultures who have easy births like Laura Shanley wrote of in her book, or as discussed in Dr. Stockham's article, provide a clue as to how we Western women should approach fitness without compromising our pelvic floors and thus our potential to give birth naturally and easily. These women are fit simply as a matter of course. That is, they are fit as a result of regular, vigorous, low-impact activity such as tending crops and fetching water, not because they have purposely sought to tone and train specific areas of their bodies in a years-long, focused, unnatural manner à la ballet dancers and some other women athletes. Nor have they weakened their pelvic floors by frequently subjecting them to high-impact activities such as running or gymnastics. I am not saying that runners or dancers should give up their respective sport or art. Rather, it would be nice if they (and their parents, if they are still girls) could go into these activities fully informed, knowing of the risks beforehand, so that they can take appropriate measures as and when indicated. For the rest of us, it would appear that regular, vigorous, low-impact activity such as swimming, walking or low-impact aerobics, is the key to achieving fitness without overly straining or jarring any part of our bodies, including our female organs. I would like to hear from any other moms out there who have had to deal with the problem of a stretch-resistant peri, especially any who have been able to overcome it with subsequent episiotomy-free, natural births. It is apparently an uncommon problem that most women don't need to worry about. In fact, most women who plan to give birth, especially in hospital, should prepare with Kegels, since some medical interventions, such as the lithotomy position (mom giving birth on her back) or the use of forceps, are very hard on mom's pelvic floor and can indeed weaken it. Most, maybe even all, vag-birth moms should also do Kegels postpartum to get their stretched bottoms back into good working tone. In fact, doing Kegels throughout life can help make sex more satisfying and prevent the urinary incontinence that has become more and more common among middle-aged and older women. I suspect that these older baby-boomer women are becoming incontinent at least in part because they had their babies during the "twilight sleep" era of the mid-20th century, when babies were routinely wrested from the birth canal via forceps. and, more on what women can do to protect themselves Natural childbirth vs. Caesarean sections (thanks to Laura Shanley for pointing out this article to me!) The gist of this article is that "prolonged, strenuous pushing during vaginal birth weakens the pelvic floor, therefore more caesareans should be done". It contains a lot of OB-provided misinformation, in my opinion. The article implies that vaginal birth is, by itself, damaging to the pelvic floor, when the truth is that it's the way doctors mismanage birth that can lead to pelvic floor damage. Rather than do more caesaerans, doctors should let their patients assume more comfortable, instinctual birth positions, such as all fours or an upright squat. They should also refrain from telling women when or how hard to push, but let women push according to instinct and comfort. Medical folks admonish all of us to not strain at bowel movements, so it makes no sense that they do not hesitate to exhort mothers to push hard during the second stage of birth. Hard, prolonged, forced pushing can not only lead to pelvic floor damage but also hemorrhoids, oxygen deprivation in baby, and broken blood vessels in mother's face. If doctors would let us get up off our bottoms, we wouldn't "have" to push so hard, and birth would proceed more gently and naturally. If we are to have less pelvic floor damage, than doctors would do well to be more patient and less eager to have us push too hard, too soon, or to use damaging instruments on us and our babies (forceps, vacuum extractors, scalpels) in an effort to hurry birth along. The "Natural childbirth vs. Caesarean sections" article is an indicator of where conventional childbirth practice may be headed in the US, and should serve as motivation for women to be more proactive in their preparation for giving birth, especially in hospital. Most of us would do well to faithfully practice those Kegels both before and after delivery, to help our bottoms withstand and recover from the medical interventions that occur too often in hospital birth: supine or semi-reclined birth position, forced pushing, and application of instruments in second stage. Kegels may be seen as a self-protective measure, preparing mothers for the rigors of the typical hospital birth as opposed to truly natural, unhindered birth. If you and baby are healthy and you don't want to put either of you through the unnaturalness of hospital birth, I encourage you to investigate birth in a freestanding birth center or at home. If you choose to have a birth attendant (doctor or midwife), be sure they approach the birth process with patience and respect. Benefits and risks of episiotomy - long, technical, informative - a must-read Wet Pants in Female Athletes - Discusses how practicing Kegels can help the pelvic floor to support the pelvic organs during high-impact activities. See also Bane of Female Athletes, Incontinence, Can Be Treated. The Art of a Kegel - excellent article with description of two types of Kegel exercises The book Birth and the Dialogue of Love gives the best explanation I've seen on how parents can help protect mom's perineum from tearing or "needing" an episiotomy during birth. Includes helpful drawings.
Background from Lynn's Bordered Backgrounds
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