Squats and Pregnancy (Part 1): Should they be avoided?

More and more I have been asked the same line of questions, “Can I squat during pregnancy? Is it safe to squat? Why should or shouldn’t I squat?” Here are a few considerations for squatting while pregnant. As always, it’s important to work with the body you have today and do what is best for you!

Considerations for Squatting while Pregnant

1. Squatting with abducted thighs expands the pelvic outlet, the area the baby must descend from in order to be birthed but closes the pelvic inlet (3)

   1. Squatting increases the pelvic outlet by one centimeter in the transverse diameter (side to side) and two centimeters in the antero-posterior diameter (front to back). The overall result is an increase of 28% in the pelvic outlet while squatting compared to lying on the back. (1)
   2. Due to the opening of the pelvic outlet and thus closing of the pelvic inlet, deep squatting may not be recommended for babies with a breech presentation. If the baby is in a less than ideal position, it may close off the top of the pelvis and give baby less room to move around and get into the ideal position. For this reason it is generally not recommended to perform deep squats after 32 weeks unless you know the baby is head down
2. Health Considerations
   1. Pelvic organ prolapse: If you have a diagnosis of a cystocele or rectocele, then a deep squat may not be ideal until the prolapse has been corrected
   2. Hemorrhoids: Deep squatting may increase the risk of hemorrhoids due to poorly managed intra-abdominal pressure 
   3. Other health concerns as discussed with your healthcare provider
3. If you have pain during squats, please reach out! Squats should never be painful and there may be changes we can help you with to make squats pain-free.

Training for Birth: Why Should I do Squats While Pregnant?

“Squat 300 times a day and you will give birth faster” - Ina May Gaskin

We love to train for birth - doing movements that are going to help prepare you for childbirth or help with the postpartum healing processes. Squatting is one of the movements we love! The thing about squatting is that in our Western culture, we have moved away from training our bodies to squat. This is highlighted by Alternative Birth Positions which stated, “Most North American women are not used to squatting, and cannot maintain the position for long.”(6)

While the squatting position can be a great asset during labor (see Part 3- Squatting During Labor: The Research), “squatting, even unsupported can be tiring and may need to be practiced during pregnancy.” (5) The book, Pregnancy Fitness, stated that “If you haven’t been accustomed to squatting and then try to do it in labor, you may not find the success you were hoping for.” The second stage of delivery, when your cervix is fully dilated and you are pushing, can last anywhere from 20 minutes to 2 hours. You wouldn't run a marathon without training, so why not train squats in preparation for birth? 

Squats help strengthen the pelvic floor muscles in a way that is functional and natural. The muscles utilized during a squat are the same muscles needed to stabilize the core, low back and pelvic floor. Squats are a great asset to any workout regime because they help strengthen and stabilize the body in a ways that we move everyday!

Added bonus? Just because you are pregnant does not mean you do not have to have pregnancy butt (aka mom butt, pancake butt, flat butt). We believe all butts can be peaches and squats may just help build those peaches. 

References:

1. Russell, J.G.B., “The rationale of primitive delivery positions”, British Journal of Obstetrics and Gynaecology, Sept. 1982, Vol. 89, pp. 712-715.
2. Di Paolo, Julia, Montpetit-Huynh, Samantha, Vopni, Kimberly, “Pregnancy Fitness”
3. Russell, J.G.B., “Moulding of the Pelvic Outlet”, J. Obstet. Gynaec. Brit. Cwlth, Sept. 1969, Vol. 76, pp. 817-820.
4. Penny Simkin, Janet Whalley, Ann Keppler, Janelle Durham, April Bolding, Preconception: Improve Your Health and Enhance Fertility
5. Vicky Chapman, Cathy Charles, The Midwife's Labour and Birth Handbook
6. Reid, Harris., Alternative Birth Positions. CAN. FAM. PHYSICIAN Vol. 34: SEPTEMBER 1988
7. Valiani M1, Rezaie M1, Shahshahan Z2. Comparative study on the influence of three delivery positions on pain intensity during the second stage of labor. Iran J Nurs Midwifery Res. 2016 Jul-Aug;21(4):372-8. doi: 10.4103/1735-9066.185578.
8. Gupta JK1, Sood A2, Hofmeyr GJ3, Vogel JP4., Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017 May 25;5:CD002006. doi: 10.1002/14651858.CD002006.pub4.
9. Lawrence A1, Lewis L, Hofmeyr GJ, Styles C., Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013 Aug 20;(8):CD003934. doi: 10.1002/14651858.CD003934.pub3.
10. Nasir A1, Korejo R, Noorani KJ. Child birth in squatting position. J Pak Med Assoc. 2007 Jan;57(1):19-22.

Urinary Incontinence & Your Period

Lately I have heard more and more women ask about incontinence that only occurs at certain times of their cycle. For some it is the week before their period starts and for others it is only during their period that they notice increased incontinence. Unfortunately, the research on incontinence and a woman’s monthly cycle is seriously lacking. Luckily, we do have one study that gives a little insight into cyclical incontinence. The study showed 41% of women notice their incontinence is cyclical and of those women 42% notice symptoms just before their period and 36% of women notice increased symptoms during their period.3

Leaking Before & During your Period

While we need more research on cyclical incontinence, it can be helpful to look at the research we do have—specifically increased incontinence during menopause.  Menopause, like the premenstrual time frame, is when the natural production of estrogen declines. In fact, estrogen levels are lowest right before, during and immediately after the period. These low estrogen levels can decrease ligament laxity and increase ligament stiffness.4 What this means is that approximately a week before menses occurs there is a drop in estrogen which is believed to decrease the strength of the urethra, the tube that connects that bladder to the urinary meatus (how we get urine from the bladder to the outside).

The human body is an amazing thing - it changes and adapts to the hormones that our body naturally releases and the pelvic floor is no different. In fact, the pelvic organs as well as the surrounding connective tissues are all estrogen-responsive, meaning the tissues respond and adapt to fluctuations in estrogen.2 We commonly see this effect in women with stress incontinence who are pre-menopausal due to lower levels of estradiol being produced.1  With the decrease in estrogen, the  pelvic floor and surrounding ligaments are unable to appropriately adapt to changes in intra-abdominal pressure, causing increased incontinence due to the decreased strength, increased stiffness and decreased ligament laxity.

These natural fluctuations in estrogen may also affect the orientation of the cervix. The change in orientation can affect the sphincter of the urethra, or the ability to start/stop the flow of urine efficiently and effectively. This helps us better understand that increased incontinence before and during our periods may be due to the decrease in estrogen which changes the pressure around the urethra causing it to lose elasticity and not being able to fully close and stop the flow of urine.

Leaking When Using a Tampon or Menstrual Cup

By inserting a tampon or a menstrual cup we are naturally altering intra-abdominal pressure (IAP). Altering our ability to appropriately create and maintain IAP, we alter our body’s ability to properly adapt to the environment. This is done through either hypertonic (tight) muscles that are unable to properly relax and therefore unable to create a strong contraction because it is always contracting or hypotonic (reduced tone) and are not able to create a strong contraction.

Leaking only when using a tampon or menstrual cup may also be a sign of a cystocele (bladder prolapse) masking stress urinary incontinence. A cystocele can cause the urethra to kink and actually block the flow of urine. By using a tampon, it acts as a pessary to reduce the cystocele and unkink the urethra allowing for the proper flow of urine. Unfortunately, in some cases, this proper flow of urine reveals incontinence that was previously hidden by the cystocele.

What can we do about it?

As there are structural changes taking place, it may be a good idea to re-frame your workout based on your cycle. If you are one of those that notices increased incontinence prior to your period or during, it may be a good idea to transition to lower impact exercises or focus more on the rest and recovery phase of health. Now that is not to say that you can’t exercise, it may just be a good idea to swap out double unders or box jumps for step ups + push ups or unilateral farmers carry or even Russian kettlebell swings.

As with any leaking or incontinence issue, it is important to be evaluated by someone with extra training in pelvic floor health. That way a care plan can be created based on your specific needs. To find one in your area reach out to a pelvic health provider by searching Herman & Wallace Certified Pelvic Rehabilitation Practitioners or the list of APTA’s Women's Health PT.

Resources

1.    Lu Y1, Lang JH, Zhu L. Estrogen receptors in pelvic floor for female stress urinary incontinence. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2007 Jun;29(3):402-6.

2.    Tzur T1, Yohai D1, Weintraub AY1. The role of local estrogen therapy in the management of pelvic floor disorders. Climacteric. 2016 Apr;19(2):162-71. doi: 10.3109/13697137.2015.1132199. Epub 2016 Feb 2.

3.     Bidmead J, Cardozo L, Hooper R. The impact of the menstrual cycle on urinary symptoms and the results of urodynamic investigation.BJOG. 2001 Nov;108(11):1193-6.

4.     Reese M, Casey E. Hormonal Influence on the Neuromusculoskeletal System in Pregnancy. Musculoskeletal Health in Pregnancy and Postpartum: An Evidence-Based Guide for Clinicians. January 2015. (pp.19-39).

Understanding Pelvic Floor Disorders

Pelvic Floor Disorders

Understanding the signs, symptoms & causes of pelvic floor disorders

What are pelvic floor disorders (PFDs)?

pelvic floor disorders, pelvic pain, DRA, diastasis, women's health

First off, the pelvic floor is made up of a network of muscles and connective tissue that provide both structure and support of the pelvis and connecting joints, assist in urination and defecation and aid in sexual performance. The pelvic floor consists of three layers of muscle — the superficial perineal layer, the deep urogenital diaphragm layer and the pelvic diaphragm, including the levator ani muscle.

Pelvic floor disorders are any disorder affecting the pelvic floor, including urinary incontinence (stress and urgency), overactive bladder, pelvic organ prolapse (POP), and fecal or anal incontinence.1 Urinary incontinece and fecal or anal inconincen are best described as a loss of the body’s ability to control urination, defecation or flatulence. Pelvic organ prolapse is when the bladder, uterus or rectum drops from its normal place in the lower abdomen down into the pelvis.

How common are PFDs?

Pelvic floor disorders are fairly common, with studies showing that 23.7-34% of women have at least one PFD.2,4 Additionally, while 46% of these women had one PFD, 16%-33% of symptomatic women had two or more disorders.3 A study showed that although PFDs are common, only 25% of symptomatic women seek care.4

What are the signs and symptoms of PFD?

• Incontinence

  • This includes any amount of leaking urine, feces or even gas at any time

  • Whether you are leaking when sneezing, laughing, coughing, doing box jumps or any jumping, lifting heavy, and doing double unders, this is a sign of PFD

  • Frequent urination (more than 8 times in 24 hours) or urgency are also a sign of PFD

  • Pain with sexual intercourse, bowel movements or urination

    • This also includes constipation or feeling like you are not able to complete a bowel movement

    • Hemorrhoids - internal and external

    • Constipation

    • Pressure or pain in the lower abdomen and pelvis

      • This can include feeling like you have numbness, heaviness, bearing down sensation or bulging near the vagina

      • Low back, pelvic, SI and hip pain

        • All of the muscles of the body are interconnected. If you are experiencing pain in any of these areas it may actually be referred from the pelvic floor or referring to the pelvic floor

What are the contributors of PFD?

*Note I did not say CAUSE of PFD. I know we all want one cause, and therefore one treatment to cure PFD. Unfortunately, it is not always that easy as it is typically multi-faceted and has more than one contributing factor.*

Vaginal Birth

• A study showed that vaginal delivery increased the odds of pelvic organ prolapse but additional vaginal deliveries did not increase the odds of developing PFD.5,6,7

• Additionally, urinary incontinence is also associated with vaginal childbirth.5,8,9

• The risk of PFD is does not appear to be correlated with caesarean delivery as PFD has not been found to increase with a history of active labor or complete cervical dilation prior to cesarean delivery.6

Assisted Vaginal Birth - Episiotomy, instrumented delivery, etc.

• The use of instruments in delivery is associated with an increased risk of PFD. This includes the use of forceps or vacuum which significantly increases the risk of PFD and specifically POP.

• “Magnetic resonance images provide evidence that show that the pelvic floor regions experiencing the most stretch are at the greatest risk for injury, especially in forceps deliveries.”15 and “risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size.”16

Obesity

• Handa found that obesity is not only a risk factor for incontinence but may also accelerate the progression.8

• Another study showed that weight loss from either diet or exercise can experience a “70% reduction in the frequency of total and urge UI episodes” with a 5-10% loss of body weight.18

Birth Weight

• A large birth weight has been shown to increase risk of pelvic floor dysfunctions.16,17

Levator ani injury

• Levator ani muscles have been shown to increase with long second stage, anal sphincter tear, and older maternal age.

• A study by Miller showed that at “seven weeks after delivery, 91% of women showed some form of musculoskeletal injury that involved the pubic bone or levator ani muscle: 66% had pubic bone marrow edema; 29% had pubic subcortical fracture; 90% had levator muscle edema, and 41% had low-grade or greater levator ani muscle tear.”10

What about muscle stretching?

During normal pregnancy, the pelvic floor muscles can stretch over 3 times the usual length to allow for the descent of the baby’s head.11,12

A study performed on rats showed that the pelvic floor muscle fiber length increases between 21-37% and the quantity of extracellular collagen matrix increases by 140% in the pelvic floor muscles. The collagen matrix is a normal protein that “may shield the muscle fibers from excessive mechanical strain during delivery by providing a parallel elastic element that limits fiber strain.”14 This study showed that the extracellular matrix remained elevated at 12 weeks postpartum but the fiber length returned to normal.

It’s easy to look at these numbers and think, “holy cow, my pelvic floor just stretched three times the usual length, that can’t be good,” but the body actually does this to help prevent pelvic floor dysfunction by allowing the pelvic floor muscles to open and move in preparation for the baby’s arrival. This is one reason that one thing we regularly say at BIRTHFIT is “slow is fast” because it takes time for the body to naturally heal.

What can I do about it?

While pelvic floor disorders are common, they are not normal and should not be minimized or ignored. If you are experiencing any sign or symptom of pelvic floor dysfunction, please reach out to a women’s health physical therapist near you. Not sure where to start? Check out these resources to find a local women’s health physical therapist near you. If you’re local, I’d love to help you on this journey!

• United States: http://www.womenshealthapta.org/pt-locator/ 

• Canada: https://www.pelviennewellness.com/apps/find-physio

References:

1. Hallock JL, Handa VL. The epidemiology of pelvic floor disorders and childbirth: an update. Obstetrics and gynecology clinics of North America. 2016;43(1):1-13. doi:10.1016/j.ogc.2015.10.008.

2. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ, Prevalence of symptomatic pelvic floor disorders in US women.Pelvic Floor Disorders Network. JAMA. 2008 Sep 17; 300(11):1311-6.

3. Gyhagen M, Åkervall S, Milsom. Clustering of pelvic floor disorders 20 years after one vaginal or one cesarean birth. Int Urogynecol J. 2015 Aug; 26(8):1115-21.

4. Rortveit G, Subak LL, Thom DH, et al. Urinary Incontinence, Fecal Incontinence and Pelvic Organ Prolapse in a Population-Based, Racially Diverse Cohort. Female Pelvic Medicine & Reconstructive Surgery. 2010;16(5):278–283.

5. Quiroz L, Muñoz A, Shippey SH, Gutman RE, Handa VL. Vaginal Parity and Pelvic Organ Prolapse. J Reprod Med. 2011;55(3–4):93–98.

6. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic Floor Disorders 5–10 Years After Vaginal or Cesarean Childbirth. Obstetrics & Gynecology. 2011 Sep;:1.

7. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG: Int J O&G. 2012;120(2):152–160.

8. Handa VL, Pierce CB, Muñoz A, Blomquist JL. Longitudinal changes in overactive bladder and stress incontinence among parous women. Neurourol Urodyn. 2014;34(4):356–361.

9. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG: Int J O&G. 2013;120:1548–1555.

10. Miller, J., Low, K.L., Zielinski, R., Smith, A., DeLancey, J., and Brandon, C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015; 213: 188.e1–188.e11

11. Hoyte, L., Damaser, M.S., Warfield, S.K. et al. Quantity and distribution of levator ani stretch during simulated vaginal childbirth. Am J Obstet Gynecol. 2008; 199: 198.e1–198.e5

12. Lien, K.C., Mooney, B., DeLancey, J.O., and Ashton-Miller, J.A. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004; 103: 31–40

13. Alperin, M., Lawley, D.M., Esparza, M.C., and Lieber, R.L. Pregnancy induced adaptations in the intrinsic structure of rat pelvic floor muscles. Am J Obstet Gynecol. 2015; 213: 191.e1–191.e7

14. New directions in understanding how the pelvic floor prepares for and recovers from vaginal delivery. Nygaard, Ingrid. American Journal of Obstetrics & Gynecology , Volume 213 , Issue 2 , 121 - 122

15. Ashton-Miller JA, Delancey JO. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11:163–176. PubMed PMID: 19591614. eng.

16. Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470–8. doi: 10.1016/0029-7844(96)00151-2.

17. Dietz HP, Wilson PD. Childbirth and pelvic floor trauma. Best Pract Res Clin Obstet Gynaecol. 2005;19:913–24.

18. Wing RR, Creasman JM, West DS, et al. Improving Urinary Incontinence in Overweight and Obese Women Through Modest Weight Loss. Obstetrics & Gynecology. 2010;116(2, Part 1):284–292.

19. Bump RC, Norton P. Epidemiology and Natural History of Pelvic Floor Dysfunction. Obstetrics and Gynecology Clinics of NA. 1998;25(4):723–746

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.