7 Tips from a Chiropractor and Mom to Help You Have a Great Pregnancy

Pregnancy Tips to Help You Prepare for Birth

Pregnancy is an amazing time when our bodies are going through a wild ride of transitions from bloating and constipation to swollen feet and possibly even fear of the unknown. It’s also a time that we are creating a beautiful life that we will soon welcome. Even with the hiccups in life, that doesn’t mean we need to succumb to the negatives! In fact, I believe that pregnancy should be (mostly) enjoyable. Here are my top 7 pregnancy tips:

1. Focus on Core Strength & BREATHING

   To improve core strength means you are also improving pelvic girdle strength and helping cultivate a strong pelvic floor that is able to dynamically move through labor and delivery. The core is naturally activated through proper diaphragmatic breathing and moves in connection with the diaphragm and pelvic floor to help RELAX the pelvic floor. Being able to appropriately activate and relax the pelvic floor is important during labor because it may decrease 3rd and 4th degree tears and the need for an episiotomy! Another added bonus is that working on core strength during pregnancy can speed up the recovery of diastasis postpartum.

2. Avoid Constipation during Pregnancy

   I know this is about postpartum constipation, but the 5 of the 6 suggestions (+ the bonus) all may help relieve constipation during pregnancy. So go ahead, eat more veggies, stay hydrated and don’t hesitate to buy one of the best inventions ever, the Squatty Potty. Avoiding constipation can relieve pressure on the pelvic floor that can lead to dysfunction later on. Plus, who doesn’t love a daily BM?

3. See Pelvic Floor Specialist AND a Chiropractor during Pregnancy

   For some reason think this is an OR situation but what better way to move through pregnancy than optimizing your body through functional movements and adjustments? I love when mamas see both me and pelvic floor therapist to get the best outcome for their pregnancy. In my opinion, this is one of the best ways for a mama to prepare for birth because it helps her mobilize and stabilize her body in order to support the structural changes that come with pregnancy, delivery and postpartum.

4. Continue or Start Working out / Train for birth

   Training for birth isn’t about reaching new PRs or hitting every gym day at full intensity. It’s about nourishing the body through movement and listening to your body’s needs. It’s about mobilizing the body so it can move optimally while also being strong. Working out during pregnancy can even include learning different positions that can be used during labor and delivery that can help ease pain and keep you moving.

5. Take a Childbirth Education Class

   Did you know the first stage of labor could take Taking a class can help you prepare for the unknown and plan for it. That way when the time comes you aren’t surprised about the changes coming your way. Planning ahead can help you prepare for the birth you desire and just as important, create a backup plan for if things don’t go as planned. Having your ideal plan and working through decisions before you are in pain and possibly scared can be really empowering so you feel you get to make an educated decision!

6. Hire a Doula 

   Full disclosure, I am biased towards a doula. I love doulas because they are able to offer emotional support and knowledge in labor to help a mama move through the delivery process. Even with a supportive partner, a labor doula can help a mama know what to except and calm any nerves that may arise during labor.

7. Listen to and Respect Your Body

   Learn from my mistakes, please! When I was pregnant with my first I had this attitude that I was strong enough to do anything and slowing down was a sign of weakness. I literally worked an eight hour shift with zero breaks and I ate a handful of nuts while in the restroom one day. My idea back then was that strength was determined by how much I physically accomplished. If I was tired, I pushed through. If I was hungry, I held off eating until my next break. I wasn’t going to be weak and take the breaks my body was craving. Sure, I was accomplishing a lot of tasks but I was left physically and emotionally drained. This time around one of my main goals is to listen to my body and respect what it needs. Some days this means eating more food, some days it is resting more and other days I feel comfortable and confident enough to do everything. I know it’s still early in pregnancy but I already feel physically and mentally better because my soul isn’t constantly exhausted trying to check off all of the boxes. So, do what you need to do to fuel your body- that can be rest, less or more activity, less or more food, maybe it’s doing the Expectful app daily and maybe it’s doing more yoga. Each person is different and each mama’s needs can change day-by-day so tune in and check your own needs daily.

Bearing Down / Pooping vs IAP

Key Differences between IAP regulation, Valsalva and Straining

One thing active pregnant mamas constantly hear is to be careful not to increase intra-abdominal pressure (IAP) because it will cause a diastasis or pelvic floor disorders. This is most common in the mamas who still lift and exercise during pregnancy. While the people who say this are all well-meaning and trying to be helpful, they often don’t realize the only way to not increase IAP is to stop breathing and that’s not beneficial to anyone! But before you decide to stop breathing to prevent an increase in IAP, let’s discuss the differences between straining (what people think of when they hear IAP), Valsalva and true IAP

Straining / Bearing Down during Pregnancy

Think of a time that you were really constipated and just wanted to go to the bathroom. That forceful pushing and straining or “bearing down" you did in order to achieve a bowel movement is abdominal straining. During straining the pelvic floor eccentrically contracts and relaxes to help improve voiding. (1) While bearing down can be beneficial in the case of constipation (but still not advised, if you have chronic constipation please reach out to a local functional medicine doctor to help you get better bowel movements), it is not ideal as we move through our daily life. Constantly bearing down/forcefully pushing or bulging the pelvic floor musculature can actually lead to pelvic organ prolapse.

Valsalva during Pregnancy

The Valsalva Maneuver is also when one bears down but in this case the pelvic floor muscle response is to contract and lift the pelvic floor to stop the flow of urine. A few studies have shown that the Valsalva can help with pelvic organ prolapse by reducing the amount the pelvic floor drops but this should only be completed with a trained women’s health physical therapist because if done incorrectly, may lead to a bearing down movement instead. (2,3) 

Intra-abdominal Pressure and Pregnancy

IAP is the pressure within the abdominal cavity and changes can be felt every time you breath. This is accomplished through proper diaphragmatic breathing which naturally utilizes the diaphragm, lower rib expansion and even the pelvic floor! As you breathe in your diaphragm expands downward and slightly outward while the pelvic floor GENTLY relaxes down to mimic the movement of the diaphragm. This movement naturally draws air into the diaphragm and increases IAP to help stabilize the low back and pelvic floor. As you breath out, the diaphragm moves upward and the pelvic floor gently lifts and tightens to support the pelvic floor and surrounding muscles. We want to breathe, stabilize and move all at same time to ensure we are not accidentally bearing down by holding our breath. This is one reason we never recommend someone hold their breath during movements as that more closely mimics bearing down.

IAP Regulation and Pregnancy

IAP regulation should be automatic, relaxed or natural and should focus on generating optimal IAP. IAP regulation includes the gentle expansion of the lower ribs, activation of abdominal and back musculature as well as the pelvic floor without bearing down. This is easier said than done though because it can take some time (and practice!) to retrain our breathing depending on the causes of altered breathing. And yes it might take a little patience to get your breathing out of your chest into your entire abdominal cavity! Once we are able to regulate IAP without thinking about it, this becomes one of the best ways to activate the deep core muscles for better control and stability.

Benefits of Intra-abdominal Pressure and Pregnancy

Dynamic Neuromuscular Stabilization is one of the leading researchers in understanding the benefits of IAP and how to properly regulate the natural changes that occur with breathing. Their research shows that IAP regulation can lead to the following benefits:

• An increase in IAP stabilizes the spine (goodbye low back pain)

• IAP “can unload the spine during static and dynamic lifting tasks” (hello better support while lifting or living)

• Provided anterior lumbopelvic postural stability (goodbye hip and pelvic pain)

• Creates balanced co-activation of diaphragm and pelvic floor (hello pelvic floor health)

• Activates the deep core muscles to allow for optimal coordination of improve joint stability

So the next time you second guess lifting or exercising for fear of IAP, remember that IAP is actually supportive! But you might want to double check to make sure you aren’t bearing down while doing that lift…nobody wants to clean that mess. 

References:

1. https://www.researchgate.net/publication/51038641_Misconception_of_the_Valsalva_maneuver 

2. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/uog.4082

3. https://www.ncbi.nlm.nih.gov/pubmed/22771226 

4. http://www.rehabps.cz/data/DNS_IJSPT_paper.pdf 

5. Nachemson AL, Andersson GBJ, Schultz AB Valsalva maneuver biomechanics Effects on lumbar trunk loads of elevated intraabdominal pressures. Spine. 1986;11:476–479

6. Hodges PW, Gandevia SC. Changes in intra- abdominal pressure during postural and respiratory activation of the human diaphragm. J Appl Physiol2000;89(3):967–976

7. Hodges PW, Eriksson AE, Shirley D, et al. Intra- abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005;38(9):1873-80

8. Gardner-Morse MG, Stokes IAF. The effects of abdominal muscle co-activation on lumbar spinestability. Spine. 1998;23(1):86–92

9. Gandevia SC, Butler JE, Hodges PW, et al. Balancing acts: respiratory sensations, motor control and human posture. Clin Exp Pharmacol Physiol.2002;29(1-2):118-21

10. McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol.2003;13(4):353-359

Top 4 Reasons to See a Chiropractor during Pregnancy

Woot. Woot. You are having a baby! If your pregnancy was anything like mine, you have lots of questions about basically everything. Hopefully I get to answer one of those questions - Why would I need a chiropractor while pregnant? Here are my top 4 reasons to see a chiropractor during pregnancy:

1. Relieve Low Back & Pelvic Pain
   Did y’all know that you do NOT have to be in pain simply because you are pregnant? Sure 50% of pregnant mamas have pain, but that doesn’t mean it’s normal or that you have to suck it up until the baby arrives. In fact, chiropractic, acupuncture and exercise can all help relieve back pain and pelvic pain.
   

2. Optimize Pelvic Alignment & Remove Tension on Ligaments and Tendons
   That was a fancy way of saying that chiropractic can help with those aches, pains and also put the pelvis in a position that is best for giving birth. The Webster technique works by focusing on sacral adjustments that balance pelvic muscles and ligaments. This means the pelvis can move freely to help birth that baby.
   

3. Counteract Changes in Gravity / Posture
   Fun little fact, gravity ALWAYS wins. As that beautiful baby of yours grows, so will your abdomen. The pretty graphic below shows some of the side effects you might feel thanks to gravity and shifts in posture. Seeing a chiropractor trained in pregnancy can help you balance those natural changes to minimize pain and discomfort.
   

4. Prepare for Childbirth through Movement
   There are exercises you can do during pregnancy and also delivery to help you through childbirth. Depending on what’s going on with your body that could be a deep squat or maybe a squat to parallel, maybe it’s an inversion or side lunges. That’s the beauty about the human body - they aren’t all the same! Seeing a chiropractor during pregnancy can help you prepare for childbirth by finding the right exercises for you!

Does a Diastasis Recti Always Require Surgery?

It’s not uncommon that moms hear that diastasis is only healed via surgery. This information typically comes from a review published in the Surgical Endoscopy in 2017 that stated, “Physiotherapy can achieve a limited reduction in inter-recti distance (IRD) during muscle contraction, though the impact of this finding on patient satisfaction, cosmesis, or function outcome is unclear.” The study, titled The general surgeon’s perspective of rectus diastasis. A systemic review of treatment options was written by all surgeons and compares surgical outcomes to physical therapy outcomes. 

What is a “Normal” Diastasis Recti ?

Before looking at the research, it is important to understand what “normal” really means.  First, there is a natural, physiological distance between the two rectus mucles. According to Beer, the normal width of the linea alba at 3cm below the umbilicus is 16mm, 22mm 3 cm above the umbilicus and 15mm at the xiphoid  in women who have not given birth. Mota stated that for women who have given birth, these numbers can increase to 9-21mm 2cm below the umbilicus, 17-28mm cm above the umbilicus and 12-24mm 5cm above the umbilicus. These values are the normal (not just common) ranges for women who have and have not given birth.

A Critical Look at “The General Surgeon’s Perspective” on Physical Therapy

The General Surgeon’s Perspective article stated that, “Current literature does not describe the successful treatment of DRAM or a reduction of IRD… following physiotherapy.” 

Well, when looking at what the Surgeon General’s states, it appears physical exercise is not a realistic option. The key is to look at what physical exercises were actually performed. Specifically many of the studies included planks, Russian twists, curl-ups, reverse curl-ups and trunk curls. All of these exercises are generally on the list of exercises to AVOID when you have a diastasis. Therefore, the reasoning behind why these exercises were chosen is questionable. This was most notable in the 1st and 2nd study where all of the exercises performed over a 3 month time period are generally contraindicated with a diastasis.

Study #4 showed a 1 fingerbreadth (1.33in/33.78mm) improvement in diastasis recti. The initial evaluation started at less than one month postpartum and only lasted for 2 weeks. Considering that the normal width of a diastasis is 1 fingerbreadth, a decrease from 3.5 to 2.5 finger breadths decrease in 2 weeks (at 6 months postpartum) reflects improvement.

Studies #3, 5, 6 all focus on overall trunk and hip stabilization rather than transverse abdominis or oblique activation. These are also the studies where the measurement of the linea alba at the end of the treatment plan were within the normal range. Although the end results of the diastasis measurements are considered within normal for function, based on the initial starting point, the General Surgeons determined this is not significant.

Surgery for Diastasis Recti

A study published by Akram and Matzen in 2014 in the Journal of Plastic Surgery and Hand Surgery stated that “Rectus diastais is by itself not a true hernia and, therefore, not associated with the risk of strangulation. Repair is mostly done due to cosmetic reasons. The condition does not necessarily require repair.” Furthermore, Akron stated that studies done on abdominoplasty repairs in combination with plication of the linea alba concluded that most evidence is of low quality.

Is Surgery for a Diastasis Recti the Only Option?

My question to you is this, would you immediately jump to surgery for an ankle sprain without trying physical therapy first? The General Surgeon’s article recommends surgery over physical therapy for this musculoskeletal complaint. However, guidelines recommend physical therapy and exercise for a trial of 9 visits over 8 weeks for abdominal sprain. It is possible a diastasis may require surgery down the line; however, surgery should be considered after conservative care/physical exercise has not yielded benefit.

References

1. The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715079/#CR34 
2. https://www.ncbi.nlm.nih.gov/pubmed/11726260?dopt=Abstract
3. https://www.ncbi.nlm.nih.gov/pubmed/14964586?dopt=Abstract
4. https://www.ncbi.nlm.nih.gov/pubmed/24256310
5. https://www.ncbi.nlm.nih.gov/pubmed/19637295
6. https://www.ncbi.nlm.nih.gov/pubmed/29494833
7. https://www.ncbi.nlm.nih.gov/pubmed/27475817 

Additional Information on the 6 Physical Therapy Reviews listed by the Surgeon General

Here is a review of the physiotherapy reviews:

1. Walton, L.M. (2016): After 18 visits (3x/week for 6 weeks) there was a decrease in inter-recti distance from 10.97cm to 6.63cm measured 2cm above and below the umbilicus.
        The exercises performed during this program included supine strengthening compared to planks, posterior pelvic tilts, kegels and Russian twists.
2. Emanuelsson, P. (2016): After 36 visits (3 months, 3x/week for 12 weeks) 87% of the exercise patients were unsatisfied with the results of their training therapy and opted for surgical intervention after completion of the training program.
        Exercises included reverse curl ups, v-sits, trunk curls, trunk curls with a twist, and vacuum exercises.
3. Khandale, S.R. (2016): After 40 sessions (5x/week for 8 weeks, 30 minutes/day) Small decrease in inter-recti distance from 25.3mm to 21.9mm above the umbilicus and 21.9mm to 19.0 mm below the umbilicus.
        Exercises included head lift, pelvic lock, plank, superman and double leg raise.
4. Acharry, N. (2015): After 4 sessions (2x/day for 2 weeks) Starting at less than one month postpartum, decrease in inter-recti distance from 3.5 fingerbreadths to 2.5 after 2 weeks.
        Exercises included head lift, pelvic tilt, and pelvic clock with bracing.
5. Litos, K. (2014): After 18 sessions (2x/week over 16 weeks) Case report starting 7 weeks postpartum to 4 months postpartum, inter-recti decrease from 11.5cm to 2cm and improvement of patient-specific functional scale from 4/30 to 30/30.
        Exercises included core stabilization exercises and strengthening of the hip and trunk muscles, including standing “wall hold”, shoulder curl-up with bracing, modified plank with TA hold, birddog, lunge walk holding 10lbs weight, bosu lunges, bosu alphabet, squats with 4lbs, overhead squat.
6. Sheppard, S. (1996): Unknown sessions started 2 years postpartum an re-checked 4 months later. The inter-recti distance decreased from 60mm to 7mm.
        Exercise included prone-kneeling.