CHAPTER 1

Ouch! What Is Happening to My Body? Help!

Ch-Ch-Ch-Changes…

How can two pregnant ladies look and feel so different? Some say they have never felt better. Their nails are strong and their hair is long. They feel beautiful and happy. They are trim and look like they’re smuggling a basketball. They glow. And then, there are the not-so-lucky. They are tired, sore, cranky, bloated, nauseous, and hating every minute of their pregnancy. They can’t sleep at night, but spend all day wishing they were in bed. They resent happy people. Their backs hurt. They feel like a sausage. And their boobs are killing them. Sound familiar?

From head to toe, your body undergoes a myriad of changes that may cause aches, pains, and discomfort. Read on for ways to treat these unwelcome symptoms and feel more comfortable throughout your pregnancy.

After talking to hundreds of patients, friends, colleagues, and doctors, we are ready to address the most painful pregnancy conditions. We understand we can’t fix your morning sickness, preeclampsia, or raging hormones. But we can help you with back pain, pelvic floor issues, and discomfort stemming from your changing posture. So keep reading!

 

Red Flags

You may be experiencing one or more of the conditions mentioned in this chapter. If your symptoms, however, are very severe or if you are experiencing any of the conditions below, contact your health provider immediately:

Red flags during pregnancy include symptoms such as:

          Fainting

          Pain during urination

          Ongoing dizzy spells

          Vomiting and nausea symptoms that are extra persistent

          Sudden body swelling

          Rapid heartbeat

          Trouble walking

          Decreased fetal activity (i.e., far less than normal to no baby movement) for more than a day

          Sharp increase in fetal movement (could indicate fetus is in distress)

          Vaginal bleeding

          Early uterus cramping (such as weeks or months before your due date)

          Leaking amniotic fluid early on, which will feel a little like a constant trickling peeing sensation

          You have a general feeling that something is wrong—mamas have great instincts so trust your gut

          Severe abdominal or back pain (may indicate an ectopic pregnancy)

          Changes in vision (could be a sign of gestational diabetes or preeclampsia)

          Frequent, painful headaches (this may be due to nerve dysfunction, changes in hormones, increased blood circulation, preeclampsia, and other causes)

         All over itching late in pregnancy (if the itching is very intense, worse at night, and involves the soles of the feet and the palms of the hands, these symptoms may indicate a liver-based condition, such as obstetric cholestasis (OC))


Back Pain

Why do so many pregnant women have back pain? A lot happens in nine months! Some changes are obvious, some are not. The obvious change is in the size of your belly. Some women carry small, some women, not so much. Whatever the size, you will feel a change, as your core’s muscular corset is offset. Your muscles and ligaments that once stabilized your spine are now being altered by the new tenant taking over your uterus. The bigger the baby grows, the less protection there is for your back as your abdominals stretch and your posture shifts forward. Your center of gravity is shifting forward with your growing breasts and abdomen and your muscles need to counteract to keep you upright. They work pretty hard in the end and you’ll feel them! Keeping your core strong and stretching your muscles is important.

Lower Back Pain

Deb complained of low back pain when she was 25-weeks pregnant. She woke up during her sleep when she moved, often felt and heard popping with quick motions, had pain every evening, and was unable to hold her two-year-old daughter who forgot how to walk after learning about her new brother in utero. She complained of spasms on the right side of her low back and she often rolled on a tennis ball to relieve the pain.

What you can do

Strengthen your butt muscles

Your gluteus maximus should be the biggest and strongest skeletal muscle in your body. If it isn’t doing its job, your smaller back muscles may get overtaxed as they compensate.

To safely strengthen your butt muscles, try the following exercise.

Bridges

          Bend both of your knees. Feet are flat and hip width apart.

          Tighten your butt.

          Lift your butt off your bed or floor.

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Bridging exercise

          Hold the position for three seconds.

          Slowly lower and repeat 15 times. Add a second set when this gets too easy.

Stretch your back and hip muscles

Tight muscles don’t work efficiently. When they’re not used properly, they get weak. When you eventually recruit them, they’re deconditioned and painful to use. The snowball effect leaves you with tight, weak, and painful muscles. So here are some stretches to do to avoid this.

Core stretch (child’s pose)

          Start off on your hands and knees. (We said earlier that it’s not OK to be in this position. However, you’re only spending a little bit of time in this position. You are moving quickly into the next pose where your belly will be supported on your thighs. So it’s OK for now. And you are going to love this stretch so it’s worth it to be on your hands and knees for a brief amount of time).

          Sit back onto your heels and then reach forward until you feel a stretch in your back.

You can modify this stretch by either separating your knees to allow a space for your belly and/or putting a pillow between your butt and ankles for comfort. You can also lean to either side to emphasize a painful side. For example, if your right side is more painful, reach your arms overhead to your left side while in the child’s pose.

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Child’s pose stretch for back pain

Hold this stretch for 30 seconds and repeat several times. Also, don’t forget to breathe.

Rotation stretch

You can stretch your mid-back muscles and the muscles in between your ribs by rotating your trunk.

          Sit in a chair and sit up straight.

          Give yourself a hug.

          Keep your hips facing forward and turn your trunk toward the left. Hold that position for 30 seconds.

          Now turn your trunk to the right. Keep breathing and repeat.

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Trunk rotation stretch

Seated piriformis stretch

          Sit with your feet hip width apart.

          Rest your foot on your opposite thigh and lean forward, as much as your belly allows.

          You should feel this in your butt on the side of your crossed leg.

          Hold for 30 seconds.

         Stretch each side twice.

Some more tips for relieving/preventing your low back pain:

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Seated piriformis (hip rotator) stretch

         Avoid wearing high heels. This will further shift your body weight forward. You need to wear comfortable and supportive shoes now.

         Modify your sleeping position. Refer to our section on sleeping pains (page 81). Steal more pillows if necessary, as you need to support your top leg while lying on your side. While changing positions, make sure to engage your abdominal muscles.

         Engage your deep core muscles (your transverse abdominals) throughout the day. Pull your belly button back toward your spine before lifting toddlers, groceries, laundry baskets, or free weights. Engage these muscles before getting in and out of bed, cars, or chairs. Don’t shoot straight up out of bed. Instead, pull your belly button back to your spine and roll to your side before getting up. And lastly, engage these muscles before you cough, laugh, or sneeze. Your back will feel better when your core muscles are supporting it. For exercises to strengthen the transverse abdominals, see the section on separated abdominal muscles (diastasis recti) on page 63.

         Walk correctly, no waddling. The more efficiently you use your core muscles when walking, the less tight and sore you will feel.

          Refer to our section on correct gait mechanics on pages 34 to 35.

         Use foam roller massage. While it would be great to have a full-time massage therapist at your disposal, we know this isn’t an option. Even our patients married to massage therapists have to beg for a session! Here is how you can massage the area on your own.

                  Stand with a 6 inch × 36 inch foam roller vertically behind your spine. Lean against it and move your body side to side. This will massage the muscles adjacent to your spine. Do this for one minute.

                  You can also turn the foam roller so that it is perpendicular to your spine and do some mini wall squats. As you squat down, the foam roller will move up your back and relieve tension in your back muscles. Good multitasking!

                  Do 10 to 15 squats.

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Foam rolling in standing for low back pain

Massage therapy

Doesn’t a massage sound nice right about now? We consulted with licensed massage therapist Nicole Kruck, LMT, to share some special tips she uses when treating pregnant clients for low back pain. Grab your partner for this one. Nicole is certified in Women’s Health and Reproductive Care, specializing in Fertility Enhancement, Prenatal & Postpartum Massage and Maya Abdominal Massage. “I have a great technique for low back pain or sacroiliac joint pain, both while pregnant and during labor. You can use a large sturdy scarf called a rebozo or a twin sheet. Fold the sheet or scarf so that it covers your hips (about 12 inches to 18 inches wide). Lie on your back and place the middle of the sheet just under your hips. Have your partner stand next to you, holding one end of the sheet in each hand. He or she will raise one side higher and then back down in a slow rocking motion. Allow three seconds with the sheet raised on one side before raising the other side for one to two minutes. This should bring relief for your low back pain and gently stretch the sacroiliac joints.” Please do not try this if you are on bed rest or have placenta previa, as it is contraindicated.

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Using a rebozo for low back pain

 

Pregnant Employees, Rights in the Workplace

In 1978, Congress passed the Pregnancy Discrimination Act (PDA) to protect pregnant workers from discrimination in the workplace. That, along with the Americans with Disabilities Amendments Act (ADAAA), guarantees the right not to be treated adversely because of pregnancy, childbirth, or related medical conditions and requires employers to provide reasonable accommodation. A reasonable accommodation is a modification or adjustment that enables a person to do the core parts of his or her job. So what is a reasonable accommodation for pregnant employees? Modified work schedules, modified workplace policies (allowing a pregnant employee to drink water in a “no drinks allowed” area), reassignment to a vacant position, providing or modifying equipment (setting up an appropriate workstation), job restructuring, or light duty. So ladies, you don’t have to tough it out if you’re in pain. Modifications can be made. It’s the law!


Deb’s back pain improved quickly. She modified her sleeping position to support her top leg while sleeping on her side. She said this helped her sleep for longer periods of time before needing to move. When she did change positions, she engaged her core muscles and moved slowly. Her favorite stretch was the child’s pose. She did this stretch whenever she felt tight and it prevented her muscles from seizing up. She massaged her back muscles while standing against the foam roller, which she kept at her office. This lessened her pain most nights. Her daughter stopped asking to be carried. She relearned how to walk when she received new pink flashing sneakers as a big-sister-present. Phew!

 

In Case You Need Even More Reasons to Get a Massage

According to a recent study:

          Massage therapy has been demonstrated to be effective during pregnancy. The women reported decreased depression, anxiety, and leg and back pain.

          Depressed pregnant women given the pregnancy massage experienced fewer prenatal complications.

          The women who received massage therapy in the study experienced significantly less pain, and their labors were on average three hours shorter with less need for medication.

          There was a lower incidence of prematurity and low birthweight in the massaged depressed women.

          Postpartum depression and cortisol levels were decreased in the massaged women. The newborns of the massaged mothers also had lower cortisol levels than the newborns of the control mothers, and performed better on the Brazelton Neonatal Behavioral Assessment habituation, orientation, and motor scales.


Upper Back and Shoulder Pain

Olivia came to us for help with her upper back, shoulder, and neck pain. She hadn’t gained much weight during her first trimester, but what she did gain was all in her chest and abdomen. She was buying new bras every three weeks and was worried she wouldn’t be able to stand by the end of her pregnancy. Olivia was a dancer with amazing flexibility. While this enhanced her dance performance, it also contributed to some of her previous injuries, as she wasn’t strong enough to stabilize her loose joints. Now that her pregnancy hormones were rising, she felt even more unstable and her muscles were working on overdrive to hold her together.

Her posture changed as her center of gravity shifted forward with her expanding belly and chest. She wasn’t dancing as much, so her muscles weren’t as strong as they used to be. Her once beautiful posture was now slumped forward and she needed some help. Her shoulder muscles ached and her upper back was killing her.

We know it is difficult to scold a woman to stand straight when her belly and breasts may be pulling her forward. But we’ll do it anyway because we want to help you! Women often experience shoulder and upper back pain from engorged breasts, changes in posture, different sleep positions, and poor body mechanics during their pregnancy. (According to the March of Dimes, women can gain two pounds in their breasts alone!)

As your pregnancy progresses, there is more stress on your upper back muscles. Your center of gravity shifts forward and your muscles are working hard to maintain your posture. Feel the muscles between your breasts and your armpits. Are they sore? These muscles are your pectoralis minor muscles. If you’re sitting or standing with hunched shoulders, they will tighten up. Ideally, your shoulders should be situated under your ears, not in front of them. But most things in life are in front of you—your desk, dinner table, baby(ies), steering wheel…. So it is common for these muscles to be tight and sore.

What you can do

Wear right size bra

It’s important to wear the right size bra, as an incorrect fit can put too much pressure on the girls and can cause mastitis (inflammation of the mammary glands) and plugged milk ducts. Additionally, supportive bras will help prevent unnecessary strain on your neck and shoulders.

We know pregnancy comes with a lot of expenses. But skimping on good bras will contribute to upper body pain and discomfort. This pain will be worse than that on your wallet. While we recommend you visit a department store or lingerie shop to have a bra expert help you select the best bra, here are some tips if you’re shopping solo.

A bra fits well if:

          It’s not too tight or too loose.

          Your breasts fill the cup of the bra leaving no loose fabric and contain the whole breast without any bulging at the top, bottom, or sides.

          The strap at the back doesn’t cut in.

          The shoulder straps don’t carry the full weight of your breasts, stay in place when you lift your arms above your head, and fit closely to your body without digging in.

          The strap round the back and the front underband lie close to your body and are at the same level at the front and back.

          With an underwire bra, the underwire lies flat against your body and supports the underneath and sides of your breast without digging in or gaping.

It is sometimes suggested that pregnant women shouldn’t wear underwire bras as the wiring can sometimes cause blockages in the milk ducts. However, there is no evidence to support this. As long as the bra fits you well and the wires of the bra aren’t digging in, there is no reason to stop wearing an underwired bra.

However, you may find it more comfortable to wear a maternity or soft cup bra. These types of bras can also be worn in bed if you feel you need extra support while sleeping.

 

Support for the Boobs

Are your boobs driving you crazy yet? According to Jené Luciani in The Bra Book, 85 percent of women wear the wrong size bra. If this is true for the general public, imagine how ill-fitted the pregnant gals are! Their elevated estrogen and progesterone levels are visible in their newly acquired huge breasts. A woman’s breasts can grow one to several cup sizes during pregnancy to prepare for lactation. For some women, this is a delight! Others complain that their breasts feel itchy from the stretched skin and extra sore from the increased volume. Breast growth traditionally begins at six to eight weeks and continues until 36 weeks, when it plateaus. But they’re not done; they will grow another one to two sizes as your milk comes in.


Stretch your pectorals

You can open your chest and stretch your pectorals with the following exercise to decrease the tightness. These stretches can be performed in a doorway or corner.

          Place your forearms on each side of the doorway.

          Stand with your feet hip width apart.

          Lean forward through the open doorway while keeping your forearms flush against the wall. Feel the stretch in the front of your chest and shoulders.

          Hold for 30 seconds and repeat with your arms positioned higher and lower to target all your pectoral muscle fibers.

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Pec (chest) stretch using a doorway

You can also perform “wall angels” to open your chest and work on your posture. This is just like making snow angels, but your legs are not involved. And there is no snow.

Stand with your back against a wall. (You can also do this sitting in a chair with your back against the wall.)

          Bring your arms out to the side with your elbows bent.

          Raise your arms upward so that your fingertips meet over your head.

          Feel the stretch in your chest and upper back. Repeat this motion 10 times. And remember, no cheating. Keep your back flat against the wall.

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Wall angels

Stretch your upper trapezius muscles

You also need to stretch your upper trapezius muscles, the muscles that sit on top of your shoulders. Do you feel like you have the weight of the world on your shoulders? Well, you may, super mama. We don’t doubt it. Or your muscles are just sore and tight and need some attention.

          Bring one arm behind your back and tilt your head to the opposite side.

          You can use the other arm to help gently guide your head forward, down, and to the side. Feel a stretch from your neck and all along the top of your shoulder. Hold for 30 seconds. Repeat two to three times.

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Trapezius (shoulder/neck) stretch

Stretch your neck

          Find a comfortable chair, sit down, and relax your shoulders.

          Tilt your head back, and look up to the ceiling.

          From this position, sidebend your neck, bringing your ear toward your shoulder.

          Feel for your collar bone on the opposite side. Pull gently down on your collar bone.

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Neck stretch

          Stick your bottom teeth and jaw out.

          Feel the stretch in the muscles on the sides of your neck. Hold this position for 30 seconds.

** If you feel lightheaded in this position, please stop and notify your doctor or midwife.

Strengthen your upper back and shoulders

In addition to stretching your tight muscles, you need to strengthen the weak ones. As your shoulders round forward, your rhomboids and levator scapulae (both located between your shoulder blades and spine) are getting overstretched, and are thus inefficient.

          Grab a resistance band with moderate resistance.

          Hold the band with your palms up and elbows at your sides. Elbows are bent to 90 degrees.

          Squeeze your shoulder blades together while pulling your hands away from each other. Keep your elbows at your sides. Focus on using the muscles in between your shoulder blades to do the work, not just your arms. You can also perform this exercise with your elbows straight.

          Try two sets of 15 reps, every other day.

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Shoulder blade squeezes, with elbows bent

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Shoulder blade squeezes, with elbows straight

Strengthen your pectoral muscles

Since you’ve stretched your chest muscles and have strengthened your upper back, try to balance the muscle forces by strengthening your pectoral muscles. Practice doing wall push-ups.

          Place your hands against a wall in front of you.

          Step about two feet away from the wall and keep your feet hip width apart.

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Wall push-up

          Keep your elbows facing slightly outward and lean your body into the wall. Make sure your body moves as one unit. Don’t let your head or hips move first.

          Return to the starting position and repeat 10 times.

Use a foam roller

The foam roller is an excellent tool for stretching your pectorals and releasing tension in your upper back. It isn’t quite as enjoyable as receiving a massage from a licensed massage therapist or your partner, but will help to decrease the tension in your muscles and bring healthy blood flow into the sore areas.

To stretch your pectoral muscles

          Lie on a 6 inch × 36 inch foam roller positioned under your head, spine, and butt.

          Bring your arms out to the side and bend your elbows so your hands and forearms can rest on the ground. This will support your vertebrae while allowing your chest and shoulder muscles to stretch with gravity.

          You can gently roll side to side to massage the muscles adjacent to your spine while stretching your pectorals. Get used to multitasking, as moms are great at this! Do this for one minute.

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Using foam roller to stretch chest muscles

To release tension in your upper back

If the foam rolling isn’t putting a dent in your tight muscles (pun intended), you might need to turn the foam roller perpendicular to your spine.

          Lie down carefully onto it and roll it under your upper back, wherever you are experiencing the most tension. You’re now emphasizing a smaller area of your back so you’re putting more pressure over it. This will feel like a deeper massage on the muscles. Do this for one minute.

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Using foam roller to roll tension out of back muscles

 

Mom Deserves a Massage

If your stubborn muscles aren’t loosening with the foam roller, stretching, and corrected posture, it is probably time to locate a licensed physical therapist or prenatal massage therapist. If you are lucky enough to have a willing partner to massage you, make sure to conveniently leave this book open in a location where he or she can’t miss it.

While lying on your stomach (or sitting if you are in a later stage of your pregnancy), your partner can massage your paraspinals, the muscles adjacent to your spine, with moderate pressure. He or she can use their palms or closed fists, whichever feels more comfortable, while emphasizing the tender areas.

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Using partner to massage upper back muscles


Stretching your chest and shoulders and strengthening your upper back shouldn’t take longer than four to five minutes (whether in a doorway or on foam roller). Yes, you have time to do this. You will feel better.

Olivia loved having her shoulders taped back and down. Picture a soldier’s posture. Now adjust so it doesn’t seem as extreme. She would keep the tape on for two to three days and this reminded her how to stand, while letting her muscles relax as the tape did its job. She did her strengthening and stretching exercises while the tape was on, and was able to hold her shoulders in the correct position when the tape was removed. Once she learned how to stabilize her shoulders, she only needed a couple sessions of physical therapy. She resumed her beautiful dancer’s posture and her shoulder pain diminished. She was able to dance throughout her pregnancy (with the help of an extra supporting sports bra).

 

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From Jill: I do a lot of taping with my patients. In this example, it supports your shoulders so your overworked muscles can relax. It is easier to maintain this healthy posture when you feel better and your muscles are less tight. You will be taught the correct stretching and strengthening exercises to maintain this corrected position. I would recommend finding a health care provider who has taken courses on kinesio-taping or McConnell taping. Both are great techniques.

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Kinesio-taping for correct posture


Bladder Issues

Cassandra’s midwife referred her to a women’s health physical therapist for urinary frequency. She was three weeks pregnant. We quickly understood the referral, as she needed the bathroom as soon as she arrived and again 50 minutes later. She found her incessant need to pee annoying, but was used to it, as it began four years earlier during her last pregnancy. She was afraid to drink too much water when she was away from her apartment for fear of not finding a bathroom when she needed one. She peed every one to two hours and three times during the night. She wasn’t sure if she woke up because she had to pee or if she was just a light sleeper.

Does it seem like your bladder is the size of a thimble? You’re not alone. We treat patients who complain about this day and night. Their increased frequency makes it difficult to work—especially when they need teacher coverage every hour to watch their classrooms. Our patients who get up three to four times each night to go to the bathroom are sleep-deprived and aggravated. All they want to do is sleep. We understand and want to help.

You shouldn’t need the bathroom every hour while you’re pregnant. You should only need the bathroom five to seven times a day to urinate. You should be able to hold your urine for at least two hours and up to five hours during the day. You shouldn’t need the bathroom more than once a night and preferably, not at all.

Let’s remember, the job of your bladder is to store urine and then empty it. Bladder and urological associations concur that a healthy bladder can accommodate one to two cups of urine, or three-quarters of a pint glass, before needing to be emptied. (Does that image help with your beer craving?) You can ignore that nagging bladder that wants to be emptied every time you sip your water. You can retrain the sensors in your bladder that are sending signals to your brain that the bladder needs to empty. You don’t need to get up and go to the bathroom as soon as your bladder starts talking to you. Tell your bladder to wait. It will listen.

What you can do

Keep a diary

Some of you will remember an outfit you wore 10 years ago but can’t remember what you had for breakfast yesterday. So you may need to keep a journal. This special journal is for your bladder. It will help you track how much you’re drinking throughout your day, what you are drinking, how frequently you’re skipping to the loo, whether you have urges to go, and if you leak urine throughout the day. With this information, you can modify your diet and voiding habits to improve your bladder function. The journal will show your improvement as you strengthen your pelvic floor muscles and retrain your bladder.

Sample Diary

DAY 1

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Note the last time you went to the bathroom. Your goal is to wait at least two hours before going again. This may sound impossible. And for some of you, it will be. But you can do it. Think: Mind over Bladder. Start with small time increments (10 minutes, 20 minutes), then work your way up. Soon two hours will pass by and you won’t even realize you held your urine the whole time. But don’t show off. Once you get good at holding your urine, you don’t have to hold it all day. You don’t want to develop any urinary tract infections. Only camels need to store fluids for a long time.

There are many reasons pregnant ladies need to urinate frequently. Your blood volume increases, causing your kidneys to do more filtering and produce more urine. Your uterus may be pressing on your bladder. Your symptoms will improve during your second trimester, as your uterus grows and rises in your abdomen. Unfortunately, your baby will drop into your pelvis during your third trimester and the pressure returns. So what can you do besides wait?

Strengthen your pelvic floor

Strengthening your pelvic floor will help support your full bladder and uterus. This won’t keep your growing baby from sitting on your bladder, unfortunately, but it can still decrease the urgency to pee. Try using Kegel exercises, which involve repeatedly contracting and relaxing the muscles that form part of the pelvic floor (see Chapter 3 for how to do these properly), to strengthen your pelvic floor. Reduce or eliminate the urge to urinate:

          Squeeze your pelvic floor muscles quickly several times when you get the urge feeling. To do this, tighten/squeeze and relax the pelvic muscle as rapidly as possible. Do not relax fully in between squeezes. Squeezing your pelvic floor muscles in this way sends a message to your nervous system and back to your bladder to stop contracting.

          As your bladder stops contracting and starts relaxing, the urge feeling subsides.

          Once the urge to urinate has subsided, you have a safe period when the bladder is calm. This "calm period" is the best time to go to the bathroom.

Just make sure not to practice your pelvic floor strengthening while urinating. Doing Kegel exercises while emptying your bladder can actually weaken the muscles, as well as lead to incomplete emptying of the bladder. This can increase the risk of a urinary tract infection, according to the Mayo Clinic.

Cassandra kept a bladder diary and, after two days, she was able to see that she was going to the bathroom more than necessary. She tried some of the strategies we taught her, such as waiting five to ten minutes before running to the bathroom and quick Kegels to retrain her bladder. She continued to use the bladder diary and saw some significant improvements by delaying her trips to the bathroom. Despite her growing belly and pressure on her bladder, she was able to wait two hours in between trips to the bathroom. She continued to wake up during the night, but that was just because she was uncomfortable. She would resist the urge to use the bathroom and fall back asleep.

After her daughter was born, she was too busy to keep a bladder diary, but she remembered our mantra: Mind over Bladder. She didn’t go to the bathroom just because she was up to feed her baby or before she left the house. She remembered what we told her about New York City: There is a Starbucks on every corner and she will never be stranded without a bathroom.

Carpal Tunnel Syndrome

Caitlyn was a musician and lost sensation in her dominant hand while playing her violin. She had discomfort while practicing and picking up her violin case. Her pain and numbness were limiting her practice time and she had planned performances for another two months before her maternity leave began. Her company didn’t offer disability leave. She needed relief so she could continue working and then care for her newborn without pain or numbness.

As if sleeping during your third trimester isn’t uncomfortable enough. Now your hand burns, tingles, or gets numb while you’re trying to sleep. And the not-so-lucky ones experience this in both hands. Carpal tunnel syndrome occurs when your median nerve, which controls sensation and strength in your hand, gets pressed and irritated in the carpal tunnel, located on the palm side of your wrist, near the base of your hand. The median nerve provides sensation to the palm side of your fingers, except for your pinky finger and outer half of your ring finger. It helps you move your thumb and fingers by controlling some small muscles in your hand. When there isn’t enough room in the tunnel for it to move freely, the nerve gets pinched and your hand can feel numb and weak.

Why does this happen? It is three times more common in women, according to the National Institute for Neurological Disorders and Strokes, due to their smaller carpal tunnel. This is consistent with a human cadaver study that measured the width and depth of the carpal tunnels in men and women. It was concluded that the shorter width of the tunnels in women may contribute to the higher incidence of carpal tunnel syndrome. It can happen during pregnancy when women retain more fluid, putting increased pressure on the nerve. Just like your legs swell during the day as you’re standing, your arms and wrists can swell when you finally lie down. If you work on an assembly line and are pregnant with a genetic predisposition, then you’re the unfortunate perfect candidate. You’ve got the trifecta.

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How Do You Know If You Have Carpal Tunnel Syndrome?

There are two easy tests we do in our offices to test it. You can ask your partner to help you with these tests. And then earn his or her sympathy for having a pinched nerve in the wrist!

Tinel’s sign test. With your palm facing up, have your partner tap the inside of your wrist with his/her index finger. If you feel numbness, pain, tingling, or pins and needles in your thumb, index, or middle finger, you might have carpal tunnel syndrome.

Phalen’s sign test. Bring the back of your hands together with your wrists flexed and fingers facing down. Let your fingers dangle for about 60 seconds. If you feel numbness, pain, tingling, or pins and needles in your hand, you might have carpal tunnel syndrome.

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Tinel’s sign test to detect carpal tunnel syndrome

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Phalen’s sign test to detect carpal tunnel syndrome

What you can do

Some simple things you can do to mitigate symptoms include repositioning your arm, splinting your wrist, stretching, and exercising. Pain-free and noninvasive treatments are likely to improve these unwanted symptoms during your pregnancy.

To minimize pressure on your carpal tunnel, you want to keep your wrist in a neutral position as much as possible. This means keeping it in line with your forearm and hand, not flexed or extended, as much as possible. Is your keyboard raised up in the back? If it is, then lower it so your wrists are in neutral and not extended. Your fingers and palms should not be lifted toward your forearm. This will only put additional strain on your wrists. Depending on your line of work, if this is not possible, at least try to keep it within a range of movement where you don’t experience the pain. If you have a desk job, you should be sitting in a chair with sufficient support for your upper back and arms.

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Maintaining proper wrist alignment at the workstation

Make sure to take frequent breaks throughout the day to relax your arms. You won’t decrease your productivity by taking a one to two minute break every hour.

You can ensure your wrist will stay in place during your sleep by using a night splint. This is a removable device that usually attaches with Velcro and is semi-rigid. At the medical supply store (or online), look for a design that will keep your wrist straight without being too bulky and uncomfortable.

Stretch your wrists

          Straighten your arm and bend your wrist down.

          Use your other arm to apply a little extra pressure on the back side of your hand. You may feel a stretch up to your elbow. Hold this stretch for 30 seconds.

Another stretch you may want to try is called the “prayer stretch.”

          Bring your hands together and position your palms in full contact with each other.

          Try bringing your elbows up and feel the stretch in the front of your wrists.

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Wrist stretch

          Hold for 30 seconds. You may use this opportunity to actually pray for relief from carpal tunnel syndrome.

You can strengthen your fingers, hands, and wrists with putty, strengtheners (such as the Digi-Flex), or power hand webs. Musicians, athletes, and professionals who work with their hands frequently use these tools. They can be found in sporting goods stores or medical supply stores. They can be found online too, but we recommend you try the different levels to find the best intensity for you. You should be able to tolerate about one minute of strengthening two to three times per day.

To take the stress off your hands and wrist muscles, you can strengthen your large shoulder muscles. This will improve your posture and allow you to use your muscles more efficiently. Refer to the section on shoulder pain (p. 10) for exercises on how to strengthen your shoulder and upper back muscles.

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Wrist/forearm stretch

If your pain is intense and these treatment options aren’t helping, you may want to see your doctor and ask for a physical therapy referral. A physical therapist can apply manual trigger point therapy, lymphatic drainage, or soft tissue massage along the nerve pathway to alleviate tight points in muscles and soft tissue and move fluid that may be trapping the median nerve. Believe it or not, treating your neck and your upper ribs may help improve the pain in your wrists and hands. Additionally, a physical therapist can instruct you on nerve gliding, stretching, strengthening, and postural exercises to reduce your pain and improve your function. Based on your daily routine and work function, a physical therapist can also perform an ergonomic assessment of your home, office, or other workplace to ensure that you are positioned appropriately. Improving your posture and wrist alignment can relieve the stress on your wrists so you’ll feel better.

Caitlyn purchased a night splint and wore it while she slept. This kept her wrist in neutral for seven hours. Before practicing, she performed the hand stretching and strengthening exercises we had shown her. Caitlyn was reluctant to begin an upper body strength training program for fear of injuring her hands. Once she did, however, she was able sit with better posture and not overtax her inflamed wrists. She used her shoulder muscles more efficiently to hold the violin, which allowed her to play with her wrists in neutral. Her carpal tunnel syndrome subsided after her pregnancy, but she continued her weight program. After all, her baby would soon weigh more than her instrument and she wanted to be ready.

Constipation

Gina understood it wasn’t rational to be jealous of her two-year-old for pooping numerous times a day. Endlessly changing dirty diapers while pregnant, she wished she could poop half as much! Because she got so constipated, her biweekly poops were painful and labor-intensive. She couldn’t possibly add more fiber to her diet, as she was already consuming high fiber cereals, beans, spinach, fiber gummies, and fiber bars daily.

So why do pregnant women get so constipated? Constipation during pregnancy occurs in 11 percent to 38 percent of women. The U.S. Department of Health and Human Services describes constipation as a condition in which a person poops fewer than three times a week and the poops are hard, dry, and small, making them painful or difficult to pass.

Blame it on the hormones once again. Your elevated progesterone hormone relaxes the smooth muscles in your organs. Smooth muscles found in your digestive system are different from skeletal muscles found on your legs. You can’t voluntarily contract your intestinal muscles like you can flex your quadriceps. So you can’t control your digestion. Your smooth muscles are found throughout your body in hollow organs such as the walls of your blood vessels and gastrointestinal tract. For example, these muscles control blood flow through your arteries, move food through your digestive system, and regulate airflow in the lungs.

When your intestinal smooth muscles relax, food moves more slowly, making bowel movements less frequent. With the delayed movement of food, there is more time for water to get absorbed. This results in stools that are hard and compact, making them difficult to pass. In the beginning of your pregnancy, you can blame your sluggish intestines and dehydrated poop for your constipation. Throw in the prenatal vitamins or iron supplements and it is even more brutal. Later in your pregnancy, your growing uterus intrudes on the territory that used to belong to your intestines and rectum. Your digestion system gets compressed, making it even more difficult for your stool to move along.

What you can do

What can you do since we’ve already said you can’t control your intestinal activity?

          Try to exercise every day. Physical activity will help keep your digestive tract moving.

          Increase your fiber intake with raw fruits and vegetables, as much as you can. The Academy of Nutrition and Dietetics recommends consuming 20 to 35 grams of fiber a day for adults.

Examples of Foods That Have Fiber

Fiber Content

Beans, cereals, and breads

 

½ cup of beans (navy, pinto, kidney, etc.), cooked

6.2–9.6 grams

½ cup of shredded wheat, ready-to-eat cereal

2.7–3.8 grams

⅓ cup of 100 percent bran, ready-to-eat cereal

9.1 grams

1 small oat bran muffin

3.0 grams

1 whole-wheat English muffin

4.4 grams

Fruits

 

1 small apple, with skin

3.6 grams

1 medium pear, with skin

5.5 grams

½ cup of raspberries

4.0 grams

½ cup of stewed prunes

3.8 grams

Vegetables

 

½ cup of winter squash, cooked

2.9 grams

1 medium sweet potato, baked in skin

3.8 grams

½ cup of green peas, cooked

3.5–4.4 grams

1 small potato, baked, with skin

3.0 grams

½ cup of mixed vegetables, cooked

4.0 grams

½ cup of broccoli, cooked

2.6–2.8 grams

½ cup of greens (spinach, collards, turnip greens), cooked

2.5–3.5 grams

Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2010.

          Stay hydrated. Pregnant women should drink as much as one eight-ounce glass of water or clear fluids (like herbal teas or broth) every hour.

          Support your feet while on the toilet. The squatting position helps your pelvic floor muscles relax. You can poop with less effort and strain if your knees are situated higher than your hips. We recommend a toilet stool such as the Squatty Potty to help you assume the squat.

          Go to the bathroom when you need to. Try to use the toilet at the same time daily and relax while you’re sitting. Avoid sitting for too long, however, as this can make hemorrhoids worse.

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Squatty Potty

 

Tips for Treating Hemorrhoids

If you develop hemorrhoids, here are some treatment options that are safe for pregnancy and can reduce the burning or itching sensation.

          Take a warm sitz bath for 15 minutes as many times as needed throughout the day. Make sure to thoroughly dry your rectal area with a gentle towel.

          After you go to the bathroom, clean the anal area with a fragrance-free baby wipe or a cotton cloth soaked in warm water. Be thorough but gentle. Aggressive wiping can irritate the skin and make your hemorrhoids worse.

          If you feel sore, try this ice pack trick. Pour some water on a maxi pad, stick it in a resealable plastic bag, and freeze it. After a couple hours, stick it inside your underwear. Cover the top with some tissue or toilet paper so you don’t freeze your butt off! This will help the inflammation and you will get some relief. Remove it after 10 minutes or less if it is too uncomfortable.

          Please discuss the use of topical creams with your doctor or midwife.

          Follow the instructions in the constipation section, as constipation contributes to hemorrhoids during pregnancy.


We approved of Gina’s high fiber diet, but advised her to discuss her iron intake with her midwife. She was taking an iron supplement with 27 milligrams of iron daily, while consuming many foods high in iron. She was ingesting more iron than she needed. Her midwife made some dietary suggestions which helped her poop more. We suggested she use a Squatty Potty. Elevating her feet made it easier and quicker to poop. She found it awkward initially, but got used to it after a few days.

Heel and Bottom of Foot Pain (Plantar Fasciitis)

Kara came into the office and could only walk on the balls of her feet. She would wince when asked to put weight through her right heel. She didn’t know how she injured herself, but she told us she gained 40 pounds in the past six months during her pregnancy. It was customary for her to take off her shoes upon entering her home but walking barefoot was too excruciating and she couldn’t do it anymore.

Have you noticed your shoes have become too painful to wear? Don’t give them away yet, as you may be able to wear them again once your baby is born. Is it because your feet are swollen? Maybe. Did your feet get flatter? Maybe. Is it because your walk has turned into a waddle? Maybe. As your center of gravity changes during your pregnancy, the way you walk and stand will change also. If you gain the expected 25 to 35 pounds, most of that weight is in your front, causing you to put more weight through the balls of your feet.

One common foot condition that plagues pregnant women is plantar fasciitis. Your plantar fascia is a thick band of tissue that runs under your foot. It starts at your heel and fans out toward your toes. It supports the arch of your foot and is integral in helping you walk.

There are many reasons it gets inflamed during pregnancy. If your extra pregnancy pounds are showing up in your thighs, you may walk with your feet wider apart to avoid inner thigh chafing. This will put increased pressure under your arches and cause inflammation to your plantar fascia. Changes in your feet can also contribute to the strain on the plantar fascia. According to the American College of Foot and Ankle Surgeons, women can experience a permanent growth in their feet, up to half a size, during their pregnancy. This was also seen during a 2013 study where women’s arches were measured during their first trimester and again 19 weeks postpartum. Their arch heights and rigidity significantly decreased, while their foot lengths increased. It was concluded that pregnancy seems to be associated with a permanent loss of arch height, and the first pregnancy may be the most significant.

Your pregnancy hormones and pregnancy pounds can be blamed for your expanding foot. Just as your pregnancy hormones allow your pelvis to open for childbirth, they increase the laxity in your foot ligaments, making your feet spread in both length and width. When your foot expands in width, you will put more weight through the inside of your foot while walking or standing. This increased stress on your arch can inflame your plantar fascia, causing pain in your heel or under the arch. This is why you may hobble in the morning when you get out of bed.

How do you know if you have this condition you can’t pronounce (PLAN-ter fash-ee-EYE-tus)? Many people have pain first thing in the morning upon getting out of bed.

          Are you walking on your toes because it is too painful to put your heels down?

          Is it painful to stand after sitting for extended periods?

What you can do

          Stretch your calves and toes first thing in the morning, before getting out of bed. (See pages 40-41 for calf stretches.)

          Wear comfortable shoes and avoid flip flops. Thin-soled shoes or flip flops should be avoided along with barefoot walking. The lack of arch support and cushioning of the heel while wearing flip flops or ballet flats can exacerbate your pain. You need to adequately support your expanding foot, so a trip to the shoe department may be warranted. So yes, you read this correctly: We’re advising you to go shoe shopping!

          Do this exercise to strengthen your outer hips.

            °   Stand tall with feet hip width apart and a medium resistance band tied around your ankles.

            °   Take medium steps sideways while keeping your upper body centered over your feet. Don’t let your trunk bend to the side. This exercise is to help you stop waddling … not enhance it!

You should feel your outer hip muscles work. If you bend your knees too much, this will turn into a quadriceps workout. You want your knees soft, not locked.

Depending on your space allowance, practice walking sideways in each direction for one minute. Some of our patients do this exercise in the hallway of their apartment buildings. Others need to change directions quickly as they try to find space in their tiny apartments. Work with the space you have and strengthen those outer hips

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Walking sideways to strengthen outer hips

If this exercise gets too easy, you can double it around your ankles.

          Try inserts in your shoes to lift your arches. Generic inserts are fine during your pregnancy.

          Ice the bottom of your foot with a frozen water bottle first thing in the morning to decrease the inflammation.

          Wear a night splint to hold your foot in neutral so your plantar fascia doesn’t tighten overnight. They aren’t expensive and can be purchased in a medical pharmacy or online. However, many patients find them uncomfortable to sleep with. As if trying to sleep peacefully during your third trimester isn’t challenging enough!

          Work on your strut. You don’t need to waddle. We help women walk efficiently and with less pain every day in our offices. Here are some of our cues to walk with less discomfort.

            °   Take long and soft steps. The louder you pound your feet, the more your plantar fascia and bones need to absorb the impact. Lighter and softer steps allow your muscles to absorb the shocks better, which is what you want.

            °   Use your larger hip and upper body muscles. Let your bent arms swing and your upper body rotate slightly. You won’t look silly and you’ll be more efficient when you walk.

            °   Take longer steps more quickly. The more time you spend on your feet, the more they’ll hurt. We want to avoid this. Taking quick steps is actually easier and less painful because you gain momentum to help you move.

The power walkers in Central Park have the right idea. They use their muscles so efficiently and have their walking technique down to a science. They barely spend any time on their feet. While we don’t expect you to power walk to your bathroom in the morning, you will see the benefits of incorporating your upper body with this practice exercise:

          Walk with your straight arms glued to your sides and see how your feet feel.

          Then practice swinging your bent arms forward and back while letting your torso rotate freely. You should see this technique allows you to take longer steps more quickly, which is what you want. Now how do the feet feel?

If you have tried all the tips listed above and your pain is still limiting you from functioning at your full capacity, please talk to your doctor or midwife. He or she can hopefully refer you to a physical therapist. We will use different pregnancy-safe tools to help decrease your pain, such as cold laser therapy, tape, biofeedback (where sticker electrodes are placed on your muscles and connected to a computer screen to visibly see how your muscles are or are not working), and, best of all, our hands. We will do a full evaluation of your posture, gait mechanics, strength, flexibility, and joint mobility and study your painful areas. We will determine what is contributing to your painful feet and teach you what you can do to improve your pain.

 

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From Denise: Swimming is a great full body workout that doesn’t stress your joints. Just make sure you don’t swim in a pool that is too warm. Remember that you are exercising and increasing your body temperature. Whenever I have aches and pains from triathlon training, jumping in the pool is a great fix. The buoyancy helps take the weight off your aching joints. Avoid kicking off of a pool wall if you have plantar fasciitis. It may increase the discomfort in your foot or cause a cramp.



Flipflopitis

What is wrong with wearing flip flops? Nothing of course, if you’re just wearing them in public showers or to the beach. However, after wearing supportive shoes all winter, flip flops are a shock to the system when worn for several hours a day. As you walk, you take shorter strides and curl your toes so your shoes don’t flip off your feet and cause you to flop. This change in your walk pattern will strain your feet, not to mention your legs, hips, and back. Podiatrists get busy in the summer treating heel pain, ankle sprains, Achilles tendonitis, and other injuries associated with flip flop wearing.


Kara’s feet needed some help. Luckily, she responded quickly to our suggestions and treatment. After observing her walk on the treadmill, we gave her some suggestions to improve her efficiency. She needed to use her upper body and arms more when she walked, and take faster, longer steps. This would take the stress off her feet. We also advised her to purchase wider and more supportive shoes. She objected until we traced her bare foot on paper and cut it out. When she saw it was wider than the sole of her shoe, she agreed to purchase new shoes. She began stretching her calves regularly and got weekly foot massages at her local nail salon.

As for walking barefoot in her home, she opted for a pair of slippers and was OK with this resolution.

Lightheadedness

Mia was struggling during her pregnancy with lightheadedness. She often woke up in the middle of the night to use the bathroom and, if she got up too quickly, had to steady herself by holding onto the walls until the room stopped spinning. Other times she would squat to the ground and wait until the dizziness passed, so she wouldn’t fall over.

In your second and third trimesters, your growing uterus can slow the circulation in your legs by compressing the inferior vena cava (the large vein that returns blood from the lower half of the body to the heart) and the pelvic veins.

Lying flat on your back can make this problem worse. In fact, about 8 percent of pregnant women in their second and third trimesters develop a condition called supine hypotensive syndrome: When they lie on their back, their heart rate increases, their blood pressure drops, and they feel anxious, lightheaded, and nauseated until they shift their position.

What you can do

To avoid this problem, lie on your side instead of flat on your back. Either side is better than your back, although the left side is best. A pillow placed behind you or under your hip can help you stay on your side—or at least tilted enough to keep your uterus from compressing the vena cava.

Upon questioning Mia about her sleep patterns, it was determined that she was a back sleeper. Once she started sleeping on her side with a body pillow, her lightheadedness improved and she no longer needed the walls to hold her up. Now if only her bladder would let her sleep through the night!

 

Preg Head

Do you have Momnesia? Did you forget where you put your keys? Are you wondering if you already made lunch for tomorrow? Your raging pregnancy hormones and changing priorities may explain this. “There is 15 to 40 times more progesterone and estrogen marinating the brain during pregnancy,” Louann Brizendine, MD, director of the Women’s Mood and Hormone Clinic at the University of California, San Francisco, says. “And these hormones affect all kinds of neurons in the brain. By the time the woman delivers, there are huge surges of oxytocin that cause the uterus to contract and the body to produce milk—and they also affect the brain circuits. The brain also shrinks during pregnancy—it does not lose cells but changes metabolism and restructures. Then in the final one to two weeks, the brain begins to increase in size again and construct maternal circuits. It does not return to its former size until about six months after giving birth. You only have so many shelves in your brain, so the top three are filled with baby stuff.” Hormones may also affect spatial memory—which includes remembering where things are—in pregnant women and new moms, a British study shows. It may be evolutionary as well. Not thinking or remembering other things helps you to put all your focus on caring for your newborn.

You can leave notes for yourself on the fridge or set reminder alerts on your phone to remember where you put things. You’ll just have to remember where you put your phone.


Lower Abdominal/Groin Pain (Round Ligament Pain)

Dana was an avid cyclist and didn’t want to give up riding when she found out she was pregnant. When her belly got too big for her to keep her balance on her road bike, she switched to indoor spin classes. Dana could barely make it through a class without having terrible pain in her groin on the right side and low abdomen. She had a tough time walking the next day, but couldn’t find another form of exercise she enjoyed.

Your round ligament is often to blame for the abdominal pain during your second trimester. The pain can be achy as it stretches and thickens to support your growing uterus, or sharp if you move too quickly. It connects the front of your uterus to your groin on both sides. Your body is directing extra blood flow to your uterus, nourishing the area with oxygen and nutrients. This will speed up the healing. While this is happening, the baby is growing, moving, and turning … hopefully away from the painful area!

What you can do

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Round ligament side-bending stretch

    Avoid sudden movements from sitting to standing.

    Arise slowly from bed in the morning.

    Support the uterus with a pillow under the abdomen and between the knees when side lying.

    Wear an abdominal support garment.

    Stretch the round ligament by sidebending your trunk. Stand and lean in toward the side that hurts. This will put the ligament on slack and relieve some of your symptoms.

You can also try hiking your hip up while you are standing (the painful side). This will also slacken the ligament and relieve the strain on it.

Dana was able to continue her love of cycling … with a few minor adjustments. She didn’t move into different positions on the bike when the instructor suggested. She remained in the saddle (on the bike seat) throughout the entire class. She only turned up the resistance if she felt she could tolerate it. She wore a maternity abdominal support garment throughout the day and sometimes during spin class. She only put her foot in the pedal “cages” if she felt her groin could take the resistance. She loved that she was able to still ride, even if it was indoors.

Night Cramps

Jessica was seven months pregnant and reported that she couldn’t sleep longer than two and a half consecutive hours before she was awakened by sharp calf cramps in either leg. She described the pain as feeling like she was being stabbed in the calf by an ice pick. She moved back and forth between the couch and her bed, as she felt bad about keeping her husband awake too. She dreaded going to bed, as she knew she would awaken with pain and be irritable in the morning from lack of sleep. She was struggling at work, was too tired to exercise, and couldn’t wait for her pregnancy to end. She modified her diet to include more bananas and potassium, but still couldn’t sleep through the night.

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Hip hiking round ligament stretch

We hope you never experience this, but if you’re one of the unlucky ones that has, you know how painful these calf cramps can be. Studies show that during pregnancy, up to 30 percent of women can be affected by leg cramps. Why do they occur? One reason is that the growing uterus increases the pressure in the pelvis, reducing blood flow to the legs. Cramping is the triplet sister to swelling and varicose veins. Cramps feel like charley horses and can happen during the second half of your pregnancy, frequently or intermittently.

After discussing calf cramp prevention with numerous doctors and combing the literature, we have many helpful suggestions, but no cures. Sorry! Even though a definite cure doesn’t exist, our patients, doctors, and colleagues shared their remedies. These recommendations have helped many patients and we hope they will help you too.

 

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From Jill: While pregnant I learned that saying a quick wish before going to bed didn’t help. Even though the spasms only lasted a few seconds, my potty mouth was active the second they began. Conversations with my husband sounded like this:

“Oh f@%k, not again! Quick, help me stretch it.”

“Like this?”

“No, that kills. Try massaging it. But not that hard!!!”

“OK, just relax.”

“I can’t relax! My leg is f-ing killing me. I need to walk.”

“I will help you.”

“Never mind, its subsiding. Thank you. Good night.”


What you can do

      Move your feet in circles to improve circulation—both clockwise and counterclockwise throughout the day.

      Stretch your calves.

      Stay hydrated.

      Be extra nice to your partner so he or she will give you a calf massage.

How can you stretch your calves? The calves can be stretched without any devices or by using a stretching tool such as the ProStretch. You will want to stretch your outer gastrocnemius muscle with your knee straight and the underlying soleus muscle with your knee bent.

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Calf stretch with the proStretch device

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Calf stretches

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You can also face a staircase and place the ball of your feet and toes on the bottom step. Drop one heel and feel the stretch in your calf. Hold for 30 seconds.

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Calf stretch using a step

 

Magnesium and Leg Cramps

The use of magnesium supplements can help your night cramps. Eighty-six pregnant women participated in a 2012 study regarding the benefits of magnesium for leg cramps. Half the women took magnesium and the other half took a placebo. The results of this study show that an oral magnesium supplement can decrease the frequency and intensity of pregnancy-induced leg cramps. This was seen in half the women that took the supplement. Another study showed leg cramps are a common symptom in pregnancy and in patients with low serum levels of magnesium. A supplement could be helpful for these women.

And yet another study looked at magnesium levels in blood and urine in women who were taking oral magnesium supplements. It was concluded that magnesium levels don’t elevate in the blood, as any extraneous amounts are eliminated in urine. So are they safe for everyone? As with any change in your diet or use of supplements, you should discuss it with your doctor or midwife.

Options that have not been proven to decrease calf cramps include compressive hosiery, calcium salts, analgesics, antiepileptic drugs, multivitamin and mineral supplements, quinine alone or with theophylline, sodium chloride, and stretching exercises. In fact, pregnant women are advised not to take quinine. Even though the research hasn’t supported calf stretching as a definite cure for leg cramps, our patients have reported that it definitely helps.


We gave Jessica a ProStretch and advised her to stretch her calves at least twice a day, with one time being before she went to bed. This helped her for a week and she told us she did the happy pregnant dance. But unfortunately they came back. She started walking home from work, but that didn’t help. She began drinking diluted Gatorade throughout the day. The extra electrolytes decreased the frequency of her cramps down to once each night. She elevated the end of her bed but was too uncomfortable sleeping like this so she lowered it. In the end, she ditched her heels and wore sneakers every day. She loved fashion and hated this last resort. The comfortable footwear decreased her leg cramps to every other night, so she felt better.

Pelvic Pain

Kelsey was your typical butt clencher. Always on the go, always had meetings and appointments, always looking at her watch. Not that all Type A personalities automatically qualify as butt clenchers, but they generally are the ones who have trouble relaxing. She came to see us for pelvic floor pain. She wanted her pregnancy to be perfect and she was already in pain, just a few weeks along.

What does it mean to be a butt clencher? It means that you constantly tighten (or “guard”) your pelvic floor muscles, even when you don’t need to. You need to tighten your pelvic floor muscles when you are trying to hold in your urine or gas. However, butt clenchers are either used to tensing all their muscles in the pelvis all the time or they are tensing all the time because they are in pain. People tend to guard or tighten their muscles when they are experiencing some pain in their pelvis, but some then don’t remember how to let go and relax. And we say “butt clencher” because generally people just clench all the muscles in their pelvis, not just the pelvic floor muscles.

When most butt clenchers are told to relax, they generally respond with, “I am relaxed.” They think that they are resting and have turned their muscles “off,” but their muscles are still very much turned “on.” When people have tightened muscles for a long time, they can develop pain in the muscles because of spasms and trigger points.

And yes, it may seem as if your entire pelvis can be hurting you all at once. Among all the relevant studies, pelvic pain can occur in up to 76 percent of all pregnancies. And this is because pelvic pain can occur in the front of the pelvis, in the back of the pelvis, on one side, or on both sides. It can be due to hormonal, traumatic, or mechanical factors. But if you use our tips for treatment, you’ll be able to manage these symptoms and be able to get that nursery ready in no time.

What you can do

For Kelsey the first step was making her realize that she was clenching her muscles. We took away her appointment book, smartphone, watch, smartphone ear piece, mp3 player, and iPad, so she could focus on her body with minimal external stimulation. Kelsey had to first understand where exactly she was holding tension in her body and why. We used different techniques to improve her awareness. She closed her eyes and focused on each body part to see if it was relaxed. This helped her see that she was holding excess tension throughout her body, especially in her pelvis. We used biofeedback to help Kelsey actually see her muscle activity. This involved putting (pain-free) electrode stickers on her pelvic floor muscles, near her rectum. The electrodes were connected to our computer and she could see when her muscles were relaxed or contracted. She wasn’t able to relax these muscles initially, but by the end of the first session we came up with a treatment plan involving several exercises to relax her pelvic floor muscles.

 

Apps to Relax

Yes, we talked about letting go of your electronic devices in order to focus on relaxing your tight muscles. However, your smartphone may actually come in handy for this purpose. There are many relaxation, visualization, and meditation apps that you can download. Many of these programs have reminder alerts and timers, so all of you busy bees need only to set aside a few minutes a day to relax. The best part about these apps is that they are free!


There are different techniques for relaxing the pelvic floor muscles. Besides learning how to relax and breathe properly, learning how to stretch these tight muscles is really important. The purpose of this next stretch is to lengthen the pelvic floor muscles. These muscles generally take on the brunt of pelvic tightness.

          Lie on your back and bring your knees up to your chest.

          Grab onto the inside of your ankles to increase the stretch. Make sure your knees are pointing outward and that your thighs are in a “V” position.

          Pull up on your ankles and feel the stretch in your perineal area (basically, your “crotch”). Hold this stretch for 30 seconds at least.

          Do two to three repetitions of this stretch.

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Pelvic floor stretch

You can also be super fancy and stretch two muscles at once! You have to have good balance to perform this next stretch, or you may end up on the floor, so please be careful. This next stretch is to lengthen both the hip flexors (the muscles in the front of your hip) as well as your hip extensors (the muscles in the back of your hip) at the same time.

          Lie on the edge of your bed hugging one knee to your chest and letting one leg hang off the bed.

          Grab onto the lower leg ankle and bring it toward your buttocks. Hold this stretch for 30 seconds.

          Do two to three repetitions.

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Hip flexor and hip extensor stretch

You can try stretching one muscle at a time (this is the stretch for just the hip extensors):

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Gluteus maximus stretch

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Combination hip flexor/hip extensor stretch using a strap

You can use a stretching strap to help you further stretch the hip flexors of your bottom leg.

When it’s more than a tight pelvic floor

There are other problems that can occur when the bones in your pelvis separate, including upslips, outflares, subluxations, and muscle strains. Corrections will not be explained for these or other pathologies, as they need to be supervised by a physical therapist or other qualified health care provider. As with all exercises and treatments, please consult with your doctor or midwife before practicing them.

 

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From Denise: I have suffered from pelvic pain throughout most of my life. I have suffered from pain due to endometriosis since I was a little girl. Once I understood my pain and that I was guarding and tightening my muscles due to this pain, I knew I needed to address this. I performed the stretches described above on a regular basis. I learned to relax my muscles and breathe more deeply and efficiently. These techniques have helped me tremendously. I continue to do them daily to avoid flare-ups. Remember: stretches, breathing, relaxation.


 

Pubic Symphysis Pain/Symphysis Pubis Dysfunction

Lilly came into the office during her eighth month of pregnancy. She was clutching the front of her pelvis and was walking very slowly. What was her problem? Besides knowing that she was going to push a watermelon out of her body? She had pubic symphysis pain (also called symphysis pubis dysfunction (SPD)). This pain began two months ago. Her partner helped her get in and out of bed. She was unable to sit in small chairs with the kindergartners she taught. Her school didn’t have elevators and she needed help from a colleague to get up and down the stairs to reach her classroom. She asked her doctor to perform an early C-section, as she couldn’t make it another month with so much pain. She felt and heard a lot of clicking and popping and thought her pelvis was falling apart when she walked/waddled.

The pubic symphysis is that spot in the front of your pelvis that lies right under your zipper of your pre-maternity pants. The two halves of your pelvis are held together by cartilage in the front; this “joint” is called the pubic symphysis.

As your pregnancy progresses, the cartilage separates slightly to allow the baby to grow, drop, and be delivered. This is a response to your increasing pregnancy. The problem here is that because the front of the pelvis is not fastened together with more bone, the cartilage can react to the hormone a little too much. This can cause the bones to separate more than they need to. The separation is only supposed to be as much as four to five millimeters (which is about 0.2 inches). With pregnancy, it will increase by two to three millimeters. However, if the separation is between 10 and 13 millimeters, you have a pubic symphysis separation or “pubic symphysis diastasis.” Your separation is about half an inch. So what does this mean? PAIN! Pain from the misaligned pelvis can remain local or spread to the low back, groin, abdomen, inner thighs, and hips.

When the pubic symphysis softens to prepare for expansion, one side may shift. There are numerous culprits for this. Your baby may be spending more time on one side of the uterus. If you’re carrying multiples, one baby may be larger and stressing one side more than the other. Or, your activities may favor one side, such as only holding a child or heavy bag on your left, to free up your dominant right arm. Even more simply, you might be stronger or tighter on one side, which will pull your pelvic bones into an unfavorable position.

Whatever the cause is, when your pelvis shifts, it can be very painful. We see this often in our physical therapy practices, but pregnant women are more susceptible when their pregnancy hormones are at their highest levels. To alleviate the pain we need to stabilize the pelvis so it does not move too much as you walk.

What you shouldn’t do

          Walking lunges

          Walking up big hills

          Using gym equipment that forces your legs to move far apart in opposite directions (elliptical, steep incline on a treadmill, abductor machine)

Here are some labor positions to avoid if you have PSD:

          Giving birth on your back with legs in stirrups or on attendant’s hips or shoulders

          Semi-sitting; this tends to force the baby’s head against the pubic symphysis

          Second stage positions where the knees are pulled back toward the chest

What you can do

There are exercises you can do to stabilize your pelvis using your muscles. The muscles on the inside of your thigh are called the adductors. Your adductors connect also to the sides of your pubic symphysis. Strengthening your adductors will help keep your pubic symphysis stable.

This is one of the easiest exercises you can do to achieve this.

          Lie on your back with your knees bent and squeeze a pillow between your knees. Double up the pillow if it isn’t plush enough to squeeze.

          Squeeze for five seconds (keep breathing!) and relax.

          Do two sets of 10.

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Pelvic stabilization exercises with a pillow: hip adduction

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Pelvic stabilization exercises with a ball: hip adduction

You can also squeeze a small ball.

Or use a partner to help you with this exercise. Tell your partner to place his or her hands on the inside of your knees and resist you bringing your knees together. Your partner doesn’t have to use Herculean force, just enough to equal your resistance.

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Partner-assisted pelvic stabilization exercises

You may sometimes feel discomfort in your pubic symphysis while getting up from your seat. One inconspicuous thing you can do is squeeze your purse in between your knees as you stand up. We’re women so we’re assuming you all have some kind of purse or backpack accessory with you. Squeezing your purse (or fist if you’re traveling light) between your knees while you are getting up from a chair helps to stabilize your pubic symphysis because you are contracting those adductors again. It’s a secret. No one knows you are doing it!

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Using your purse to ease pubic symphysis pain while getting up from a chair

Similarly, this trick can be used to get in and out of a car. Instead of stepping into the front seat as you normally do, practice the following technique:

          Open the car door.

          Turn your body so you can sit on the seat with both feet on the ground.

          Contract your abdominals while supporting your body with both hands on your seat.

          Keep your knees together and swing both legs into the car. Your body moves with your legs so you are facing forward.

Reverse this to get out of your car.

          Open the car door.

          Contract your abdominals and support your body with your hands on the seat.

          Bring your legs onto the ground while keeping your knees together. Turn your body at the same time so you can step out of the car without straining your pelvis.

          Keep your knees together and stand up to exit the car.

Try to avoid driving large SUVs if possible. Unless you play for the WNBA (Women’s National Basketball Association), it is often difficult to reach the driver’s seat. Taking a wide step up into the driver’s seat can further strain this painful area.

Getting into bed is a similar process.

          Sit down on your bed with both feet on the floor and your knees together.

          Engage your abdominal muscles.

          Use your hands to help you lower your head to your pillow as you bring your feet up to the bed. You should be lying on your side at this point with your bent knees together.

          Maintain your engaged abdominal muscles and roll to your back.

To get out of bed, reverse the steps.

          Engage your abdominal muscles.

          Roll to your side with your knees together.

          Use your hands to push your upper body up to a sitting position as you lower your feet to the ground. Keep your knees together as you stand up.

(Refer to the section on diastasis recti for additional pictures on how to get out of bed safely while easing the discomfort of your pubic symphysis. Just make sure you are squeezing something in between your knees as you are getting up. You can use a pillow.)

Another option for relieving pain in the pubic symphysis is to use a belt. These belts are normally used for sacroiliac pain (pain in the back of the pelvis), but they can also be used for pubic symphysis pain (pain in the front of the pelvis). If you are experiencing pubic symphysis pain, the belt just needs to be flipped around so that the compression is applied forward to the front of your pelvis. These belts apply an external compressive force to help stabilize the pelvis and help you feel less “loose.” It’s important to apply these belts properly and in the correct spot. The belts should feel snug when they are applied correctly. Always consult with a physical therapist to make sure the belt is in the correct position, because they can cause great discomfort if they are positioned incorrectly.

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Getting out of bed safely with pubic symphysis pain using a pillow

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Pelvic belt for pubic symphysis pain

 

More Pubic Symphysis Relief

          Use a pillow or cushion between your knees when sleeping.

          Use a pillow under your tummy (in pregnancy) when sleeping (see section on sleeping pains).

          Keep your legs close together and parallel when moving, turning over in bed, getting in and out of cars, and so on (see previous section on how to get out of a car).

          Satin sheets or nightwear may make it easier to turn over in bed.

          When standing, stand with weight evenly distributed through both legs.

          Move slowly and without sudden movements—taking extra care not to slip or trip up.

          Sit down to put on underwear, socks, and pants.

          Avoid “straddle” movements.

          Avoid heavy lifting, twisting movements, and any other movements you know will hurt you—for example, vacuuming can often be a problem.

          Icepacks over the painful joint may reduce inflammation.

          Stretching the hamstrings can be helpful for sciatica. (See pages 60 to 61 for hamstring stretches.)

          Use some kind of pelvic support.

          If sex is uncomfortable for you, try different positions—for example, lying on your side with your back to your partner and a cushion between your knees.

          Swimming (not breaststroke) or walking in water can be helpful for some women. Others may find that the water’s resistance puts too much stress on their joints. Do what works for you.

          In severe cases, use a walker, crutches, or a wheelchair. Your doctor can provide you with an application for a disabled parking card if necessary.

          Rest can be extremely helpful. However, it is best to keep as active as possible within the limits of your pain. Sometimes, gentle walking can reduce pain, but always take care not to overdo it. Listen to your body and your doctor or midwife.

          Ask for help. Friends and family are often your best resources. Talk to your doctor or medical professional about the possibility of organizing home help.


We advised Lilly to go up and down the stairs sideways, while holding on to the railing. This minimized her pain and allowed her to get to her classroom independently. She felt a significant improvement with the belt we gave her. It held her pelvic bones together so she no longer felt sharp pains if she moved too quickly. She did continue to take small steps, but with the brace she didn’t hear the popping or feel as unstable. She did adductor strengthening exercises daily and used a thick pillow between her knees when getting out of bed. Her midwife was very careful during her delivery and she had her baby in a side-lying position to avoid excessive strain on her pelvis. She continued to wear the belt for two weeks postpartum and her symptoms resolved.

Sacroiliac Pain

Jane didn’t know how or what she did wrong. She was just crossing the street during her lunch break when she experienced excruciating left low back pain. She could barely walk and getting into a cab would have been impossible had her colleague not been with her to help. She returned to work doubled over in pain. She was afraid to take any anti-inflammatories because she was 25 weeks pregnant. She made an appointment to see us that afternoon. She has a history of low back pain, but had been pain-free for over a year.

This is a common area in which to have pain during pregnancy. The sacrum is a large vertebra at the base of your spine, just above your tail bone. The ilia are the large bones in your pelvic girdle. If you put your hands on your waist (or what used to be your waist) and slide them down, you’ll find these bones. The sacrum and the ilia form joints on both sides of your low back, connected by strong ligaments. These joints are usually sturdy, but nothing is immune to the overpowering pregnancy hormones. The hormones relax your pelvic joints so the bones can expand and your baby can descend. This system usually works, but it isn’t perfect.

How Do You Know If You Have a Problem at Your Sacroiliac Joint?

You may experience the following:

          Pain in your low back, just above your butt, and off to either side.

          Swelling and discomfort when you touch this area.

          A sense of being out of alignment in your pelvis and low back.

          Pain can radiate into your butt, groin, legs, or low back.

          Limited motion in flexing, turning, or extending your trunk.

          Clicking or catching sensation in your low back when you try to get out of a chair or in/out of a car.

          Pain and difficulty putting on socks or pants on one side.

What you can do

Please contact your doctor or midwife if you are having these symptoms and ask for a physical therapy referral. Also, ask for permission to wear a sacroiliac belt. As painful as sacroiliac dysfunction is, this is one condition we don’t recommend you try to treat yourself. Because your pelvis is made up of many parts, it can shift in many ways. One side can shift or rotate forward or backward. Or it can shift upwards or downwards. You may start to feel crooked and unbalanced. A physical therapist can evaluate you and treat you safely while you’re pregnant. Until you can see someone, we have some suggestions to help manage your pain.

Wear a sacroiliac belt

This belt improves your pelvic stability, which can decrease your pain until you are further evaluated. We like the Serola Sacroiliac Belt.

To determine which size to get, refer to the sizing chart on the www.serola.net website. You can also check out the website to see a video on how to apply the belt.

Refer to the section on pubic symphysis pain (page 46) for more information on pelvic belts.

Bridging exercise

Refer to page 3 in the section on low back pain for instructions and pictures of bridging.

Hip rotator strengthening exercises

There are other muscles you should strengthen to stabilize your pelvis. These muscles, your hip rotators, go from your butt to your outer thigh. You can strengthen them using a resistance band or your partner.

          Tie the band around your knees while you are lying on your back with your knees bent. Make sure that your feet and knees are together and that the band is tied snug around your knees.

          Separate your knees against the resistance of the band and hold that position for three seconds (keep breathing!).

          Then relax and return to the starting position. You don’t have to pull your knees apart too far because you don’t want to stress the pubic symphysis.

          Do two sets of 10 and then relax.

 

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Pelvic stabilization exercises

Or you can use a partner for this exercise. Tell your partner to place his or her hands on the outside of your knees. You can push your knees outward against the resistance of your partner’s hands and hold for two to three seconds. Push enough to meet your partner’s resistance and don’t separate your knees too far. Remember, you don’t want to stress the pubic symphysis.

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Pelvic stabilization exercises

Jane’s acute pain resolved quickly. Her original pain at the back of her pelvis was corrected with some manual therapy and a stabilizing belt. This held her pelvic bones in the corrected position. She wore the belt every day, as she was afraid of another flare-up. She added some core strengthening exercises to her gym program and modified other components. She stopped doing lunges, single leg strengthening exercises, and high impact exercises for the remainder of her pregnancy. As she got stronger and less apprehensive, she weaned herself off the belt.

Sciatica

Sarah didn’t know who to turn to. She was told this was a “pregnancy condition” and her pain would subside after she delivered. She was only six months pregnant and couldn’t sit at her desk without pain radiating into her butt and down the outside of her right leg. She couldn’t sleep without pain and the severity was worsening throughout her pregnancy. She was frustrated and tired of always being in pain.

Another pain in the ass! How many can we have? Too many, apparently. What is sciatica? It sounds like something emerging from Frankenstein’s lab. And it can certainly feel like a monster has taken over your leg. One patient described it as “electricity spreading down the back of my leg.” Other days it feels like someone is poking your butt cheek.

Why does this happen? The sciatic nerve is a big nerve—really big. It is the longest and widest single nerve in the body. No wonder it gets into so much trouble. It comprises five nerves from your lower spine that come together and travel down the leg into the foot. It can easily get pinched in different areas on its way down the back of the leg. The nerve can get pinched by a disc in the spine or a muscle in the hips. This can cause pain starting from the low back or from the buttock. Damage to this nerve can cause muscle weakness in the leg or foot, pins and needles sensation, pain, and difficulty walking.

What you can do

The sciatic nerve can get pinched in your piriformis muscle, a muscle in each butt cheek. This can result in pain or tingling in your butt and down your leg. Your piriformis muscle is generally a tight muscle because it is in a shortened position whenever you are sitting. Stretching the piriformis muscle may seem a little complicated, but will feel great when you do. You’ll have to turn yourself into a bit of a pretzel. Let’s start with the right leg.

          Lie on your back and bend your left knee.

          Place the outside of your right ankle on top of the left knee.

          Now, reach behind your left thigh and bring your leg in close to your chest. If it is too hard, ask your partner for some assistance. He or she can help bring your left knee to your chest, which will stretch your right butt muscles. Hold this stretch for 30 seconds.

          Repeat the stretch two to three times on each side.

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Stretching of the piriformis muscle

You can also have a partner help you stretch your piriformis muscle if your belly is getting in the way. Make sure your partner stretches you slowly and gently.

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Partner stretch for piriformis muscle

If you have a foam roller, you can also try rolling out the tension in your piriformis.

          Position the foam roller perpendicular to your body on the floor.

          Sit on the foam roller and lean back with your hands on the floor behind you. Shift your weight onto one butt cheek.

          Take the leg of the side that you just shifted your weight onto and cross it over the opposite side.

          Now roll your butt cheek back and forth over the foam roller. In this position you should feel your hip rotator muscles more exposed. Roll back and forth until you feel a little easing of the tension in your bum. Repeat as often as you like.

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Foam rolling piriformis muscle

Another contributing factor to developing sciatica is having tight hamstrings. Your hamstrings start at the bottom of your butt and end behind your knee. When people have radiating pain down the back of the leg, they typically avoid taking big steps or moving the hamstring muscle through its full range of motion in order to avoid pain. This guarding can increase the tightness and the pain in the back of the leg. Also, the hamstrings are in a shortened position when you are sitting, so they have a tendency to become tight.

This stretch can also be done on your back. You may need a resistance band, belt, or stretching strap.

          Lift one leg straight up into the air and either grab onto the leg to increase the stretch or loop a band/belt/strap onto your foot to increase the stretch.

          Pull your leg toward your head and feel a lengthening of the muscle in the back of your leg. Hold this stretch for 30 seconds and repeat two to three times. Relax and then switch sides.

          If you are unable to do this yourself, ask your partner. Just make sure he or she stretches you slowly. Your tight muscles won’t relax if the stretch is too aggressive.

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Hamstring stretch

Along with stretching the muscles, you may benefit from stretching the nerves. This is called nerve gliding or nerve flossing. The sciatic nerve travels along a path that takes it through muscles, between bones, and through some tight areas, as it travels down your legs from your spine. If it gets entrapped, there will be inflammation, pain, decreased blood flow, and difficulty moving. The pain is coming from pressure on the nerve, so additional massage or foam rolling won’t help it. In fact, it will make it worse.

There are several areas where it can get entrapped, such as your butt muscles, deep thigh muscles, inner thigh muscles, or lower in your leg. The sciatic nerve has the ability to stretch five inches, which is necessary for your legs to move freely. Think about bending forward toward the floor. If your sciatic nerve is restricted and it can’t stretch with the surrounding muscles, you will have pain in that spot and you won’t be able to move very far.

How do you know if your sciatic nerve is impinged? There is an easy test.

          Lie on your back with your legs straight. You can do this on your bed or floor.

          Using your hands, slowly bring one knee to your chest and attempt to straighten your knee. Stop when you feel a strong stretch.

          Once you accomplish this, attempt to bring the top of your foot toward your shin and hold it for five seconds. If you don’t have any sciatic nerve restriction, you will feel a muscular stretch in your calf, behind your knee, or behind your thigh.

          While holding this position, bring your chin to your chest for five seconds. Your symptoms shouldn’t change.

If you do have sciatic nerve entrapment, you will feel pain at the area where it is entrapped. You may feel sharp shooting pain in your leg or back. Repeat on the other leg so you can see if there is a difference in symptoms.

What should you do if your test is positive? Time for nerve gliding. You want to “floss” the nerve.

          While lying on your back, use a strap to hold up your leg (or you can use your hands if that is comfortable for you).

          Raise your leg high enough to elicit a gentle stretch behind your leg, but no pain.

          Point and flex your foot 20 times at this height (as if you are pushing a pedal). You will feel your pain intensify and lessen as you do this, with it feeling worse as your foot is brought toward your shin and less as you point it away. Your symptoms will be strong initially, but should lessen as the sciatic nerve loosens. When this happens, you will slowly be able to raise your leg higher. This should be a slow process.

If it feels less painful, try stretching your leg an inch higher to increase the nerve stretch and then relax it for several hours. Practice this nerve gliding for two minutes, twice a day. This isn’t a lot of time—probably not enough time to listen to your favorite song—but it works.

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Nerve gliding

 

More Tips for Relieving Sciatica

          Wear flat shoes.

          Lie on pain-free side to release pressure in nerve.

          Work on posture.

          Wear maternity support to lift uterus.


Sarah survived her third trimester. She felt the most relief from wearing a maternity support. It lifted her uterus and relieved some pressure into her leg. Before going to sleep, she sat up in her bed with a heating pad on her low back/butt (at the lowest setting) for 10 minutes. This soothed her pain and allowed her time to catch up on gossip magazines. Her partner helped her stretch her tight butt muscles. This was initially painful, but felt better each time.

Separated Abdominal Muscles (Diastasis Recti)

Giovanna said during her first pregnancy she didn’t show until she was four months pregnant. By her fourth pregnancy, she was showing before she even peed on a stick. She said it looked like there was "a baguette" on her abdomen when she got out of bed in the morning. Her back pain was worsening as her pregnancy progressed. She was frequently asked if she was having twins. When she said she wasn’t, the next question was, “Are you having triplets?” She was just too large for people to accept there was one baby in there.

Has your belly button popped out? Is this supposed to happen? No, this shouldn’t happen. You probably developed a diastasis recti of your abdominals. This is a common condition, and it can be prevented or corrected with the right program.

A diastasis occurs when your superficial abdominal muscles along your midline separate. Picture the ideal six-pack muscles separating into two three-packs. This can happen under many circumstances, including rapid weight gain, a growing uterus (especially when carrying multiples), excessive and incorrect abdominal work, and surgeries. It could also be a congenital condition that has been unknown until now.

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The woman in this picture gained over half her body weight during her pregnancy. Because she is thin, her separated abdominal muscles are visible. She saw a doctor when she saw her organs “bulging” through her abdomen when she sat up.

Anatomy Lesson

There are four layers of abdominal muscles.

The deepest muscles are your transversus abdominis. They originate along the sides of your body and attach at the center of your abdomen, from your breastbone down to your pelvis. They are often called the “corset muscle” to describe the orientation of their muscle fibers wrapping around your core. Their main functions are to stabilize your trunk and pelvis and maintain internal abdominal pressure. When strong, these muscles make you look better in your swimsuit as they flatten your belly, if you need an aesthetic motivator.

The middle layers are your external and internal oblique muscles. These muscles cover a lot of abdominal territory, but to put it simply, they are located on the sides of your abdomen, from your low back and ribs, to the middle of your abdomen and pelvis. The internal obliques lie behind the external obliques. They work together to twist and sidebend your trunk. They also work in conjunction with your diaphragm to help you breathe.

The most superficial muscles are your rectus abdominis. Like your transverse abdominis, they cover the front of your core, from your breastbone down to your pelvis. When well-defined in non-pregnant individuals with low body fat, these two muscles make up your dreamy “six pack.” The main functions of the rectus abdominis are to flex your trunk forward, stabilize your pelvis, and help you breathe.

Of all your abdominal muscles, the transverse abdominis are usually the weakest, and most neglected. When they’re strong, they hold your abdominal contents in place and support your spine. When they’re too weak, your belly will protrude, because now connective tissue is supporting your organs instead of a strong muscular abdominal wall. Other muscles will have to compensate to give you the stability you need. This often results in low back pain, poor posture, impaired digestion, and abdominal discomfort.

Curious how these often ignored muscles work? Try contracting them. Pull your belly button back toward your spine as if you’re trying to button your skinniest jeans. Feel them? Now it’s time to get acquainted with them, as you should be exercising them throughout the day. Strong transverse abdominis muscles are the secret to preventing and closing a diastasis.

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Who Are These Women With Diastases?

If women are pregnant, they might see a bulge along the midline of their bellies when they sit up from leaning back. Their belly button may also have popped out. They may be showing early in the pregnancy too. If they already gave birth, they may still look about five months pregnant while their baby is learning how to walk. They may have lost all their baby weight, but they still have a protruding abdomen, can’t fit into their clothes, and are insulted every time someone offers them a seat on the subway. As physical therapists in New York City, we see these women daily, both on the streets and in our offices.

 

Diastasis Recti Risk Factors

         Older women (older than 33 years)

         Multiparity

         Multiple gestation

         Carrying a larger baby (>3,636 gram or 8 pounds)

         Greater weight gain (>35 lb)

         Birth by Cesarean section


We’ve had several patients tell us about their painful plastic surgeries to repair their abdominal muscles. These women were strong and fit with toned muscles everywhere. So why did they have such problems with their abdominals? Their stories were all very similar. They did lots of crunches while they were small enough during their first trimesters. Then they switched to planks and exercises on their hands and knees to accommodate their growing bellies. After delivery, they resumed sit-ups and aggressive abdominal work to flatten their stomachs. As they burned calories galore and shed pounds everywhere, their protruding bellies didn’t improve. Countless hours and dollars were spent on personal trainers and boot camp classes. Their last resort was sadly met at the plastic surgeon’s office. So, we often hear that they wish they had known the right exercises to do while they were pregnant.

What you shouldn’t do

          Crunches, sit-ups, and exercises where both your shoulders and legs are off the ground (bicycle crunches) should be avoided, as you can’t engage your transverse abdominis muscles with these exercises. You can create a diastasis or make an existing separation worse. If you do these exercises, you may see your abdominal muscles push out as you lift your shoulders off the floor. It will look like half a football bulging out of your abdomen near your belly button. Or, you may see a gap between the muscles, which didn’t use to be there. You don’t want either of these scenarios.

          Exercises in the plank position (push-up position) or on your hands and knees should also be avoided. If the connective tissue is too thin and your muscles are separated, you could cause a diastasis or make your diastasis worse by exercising on your hands and knees. Why? Because the weight of your baby and all your organs are now pressing on the weak connective tissue in this position. You may be engaging your core muscles, but if they’re separated, they’re not helping you where you need it. You want to avoid this position.

Now picture the fight between weak abdominal muscles and a growing uterus. Yes, your baby wins from the very start. You want your muscles to stretch to accommodate your growing uterus, not the connective tissue in between.

Healthy connective tissue between the two halves of your abdominal muscles should be two centimeters wide above your belly button and half the distance below. Two centimeters is about the diameter of a penny. Are you seeing a wider gap than that? Don’t be surprised if you are. Much of the research on diastases is no longer current. However, when it was conducted in the 1980s, it showed that 66 percent of women had diastases in their third trimesters, 53 percent of these women continued to have a diastasis immediately postpartum, and 36 percent remained abnormally wide at five to seven weeks postpartum. We see much higher numbers than these in our practices. Many diastases aren’t diagnosed. When women see physical therapists for their low back pain, pelvic pain, or pelvic dysfunction, they are often treated for a diastasis recti. Their weakened core can contribute to other painful and problematic diagnoses.

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AVOID positions/exercises on your hands and knees.

Could you be one of these women? Is the connective tissue near your belly button wider than a penny?

How to check for diastasis

A diastasis can be checked both during and after pregnancy. The object is to determine how many fingers will fit in the space between the two outermost abdominal muscles and how deep they penetrate.

Five easy steps

      1.  Lie on your back with your knees bent.

      2.  Place your middle three fingers in your belly button pointing in the direction of your toes.

      3.  Relax your abdominal muscles and lift your head. If you are holding your abdominal muscles in as you check it will give you a false reading as this will make the diastasis appear smaller.

      4.  Check yourself when you first start feeling the muscles come together. Raise and lower your head a few times so you can feel how the muscles work.

      5.  Use your fingers to feel both the depth and width of the separation. You may use as little as two to three fingers or need to use all 10 to feel the muscle borders. If it looks like half a football is trying to exit your core when you sit up, this means your diastasis is large and you will need two hands to measure it.

After testing yourself, if you think you may have a diastasis, you should contact a women’s health physical therapist or a fitness professional who specializes in diastases. He or she will examine the integrity of your connective tissue between the separated muscles, measure the severity of the diastasis, and teach you the protocol to correct it. You will learn how to correctly strengthen your transverse abdominis. If you are unable to see a specialist, there are several videos you can watch to help you correct your diastasis on your own. One video we recommend is from Julie Tupler, RN. Her diastasis videos are available at www.diastasisrehab.com. Tupler Technique® Perfect Pushing® is designed for pregnant women to prevent and treat their diastases.

Please don’t worry if you do develop a diastasis during your pregnancy. You’re not sentenced to live through the rest of your pregnancy (or life for that matter) feeling like your muscles were put through a paper shredder. We’ve had many patients successfully prevent and treat their diastases. This abdominal tissue was strong at one point. You can get it strong again by working the right muscles and being careful with your movements. Treating and preventing a diastasis while pregnant may prevent you from having to deal with it later on. And remember, your belly button should not pop out! That’s a sign of weak abdominal tissue.

How to Prevent a Diastasis

Transverse abdominal exercises

Here is an exercise you can do to help strengthen your transversus abdominis muscle.

          Sit in a chair with your feet touching the floor.

          Sit up straight and remember to keep breathing while you are performing these exercises. It’s easy to want to hold your breath while you are contracting your abdominal muscles. Keep breathing!

          Practice pulling your belly button back toward your spine. Make sure that the only thing moving is your belly button. Don’t rock your pelvis back along with the movement. Don’t arch or flatten your back. Don’t raise or lower your shoulders. And don’t bring your chest forward and back. These are all cheating techniques our patients try when their abdominals are too weak.

          If you feel like you can contract your abdominal muscle and still keep breathing, then try lifting one foot off the floor. Hold it off the floor while contracting your abdominal muscles for two to three seconds.

          Place that foot on the floor and lift the opposite leg. Repeat 10 times.

          You can also try lifting your opposite arm up at the same time.

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Abdominal muscle exercises

You can also practice these exercises while sitting on an exercise ball.

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Abdominal exercises using exercise ball

You can also hold something in your hands and rotate your trunk side to side while contracting your transverse abdominal muscles.

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Abdominal exercises using exercise ball and household object

If you want to challenge yourself a little more, then try this:

          Place a pillow on the ground and kneel with both knees on top of it.

          Lift your feet off the floor.

          You will need to contract your transverse abdominal muscles to stay upright on your knees.

You can also do this by kneeling on your bed.

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Core strengthening exercises

Here’s another exercise using your handbag.

          Grab your favorite handbag (preferably with some weight to it).

          Practice pulling your belly button in toward your spine.

          Slowly raise your handbag over your head and then lower it.

          Keep your balance, keep contracting your abdominal muscles, and keep breathing!

          Now bring your handbag in front of you, chest level, with your elbows straight. Rotate the handbag to your right side, without bending your elbows. Now rotate to your left, without bending your elbows.

          Repeat each movement 10 times. This will be tough since you are working so hard to keep your balance and keeping your stomach muscles tight.

Get out of bed correctly

To prevent developing a diastasis recti:

DON’T do this:

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Incorrect way of getting out of bed

DO this:

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Correct way of getting out of bed

 

The Tupler Technique

Julie Tupler, RN, founder of the Tupler Technique®, emphasizes the importance of healing your connective tissue between your right and left abdominal muscles during your pregnancy. You want to keep it strong to prevent a diastasis from occurring if you don’t have one, and preventing it from getting larger if you do have one. According to Tupler, here are three things to remember:

      1.  You want to correctly “position” the connective tissue to take the stretch off it versus letting it get overstretched during pregnancy. You can do this by wearing a splint to keep the muscles and connective tissue together. We don’t advise this during your first trimester, when many women are nauseous. While bringing your muscles together is ideal, this will push your organs back into place and may exacerbate your nausea. Many patients enjoy wearing the splint, as it gives them more core support and helps their posture.

      2.  You want to protect the connective tissue from three things that weaken it:

              Intra-abdominal force

              Pressure

              Stretching

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Applying the Tupler Splint to manage a diastasis recti

                  Intra-abdominal force on the connective tissue comes from not engaging your abdominal muscles before you move. Other examples of putting too much force on the connective tissue occur when you cough, laugh, sneeze, exercise, carry groceries, or exert yourself in any way. Huh? Try placing your hand on your belly and cough. Do you feel it come out? Now pull your belly button back toward your spine and cough again. It shouldn’t move as much when you engage your transverse abdominis. Engaging these muscles protects the connective tissue and prevents a diastasis from getting larger if you have one. If you don’t have one it may help prevent you from getting one.

                  Pressure on the connective tissue comes when you wear a front-loading baby carrier or when you exercise in a hands and knees position. In the hands and knees position, all the weight of the organs via gravity puts pressure on the connective tissue.

                  Stretching of the connective tissue comes from forward crossover movements (tennis, golf) and movements that arch your upper back.

      3.  You want to strengthen your transverse abdominal muscles throughout the day. Strong abdominal muscles prevent back problems during and after pregnancy and help you push more effectively in labor. It is easy to get disconnected from these muscles while you’re pregnant. Your belly takes over, your posture changes, and the muscles are hard to feel. Your abdominal muscles must be strong to be able to engage them during your activities of daily living and when you exercise. Remember, using your abdominal muscles prevents intra-abdominal force on your connective tissue. The harder you work to recruit and strengthen them, the easier it is to keep your diastasis as small as possible.


Our patients with back pain during their pregnancies often feel better as they strengthen these transverse abdominis muscles. Whether you opt for a natural delivery or epidural, you’ll benefit from having strong abdominals to push out your baby. And if you have a C-section, you will benefit from your strong abdominals and correct body mechanics while you’re recovering. We frequently hear back from our patients after having their babies. They tell us their strong abs got them through a fast(er) delivery. That’s what we like to hear! As always, please consult with your midwife or doctor before starting any exercise program.

Giovanna’s obstetrician cleared her to wear an abdominal splint that held her separated muscles together. She felt more supported with the splint and her nighttime back pain improved. She stopped doing core strengthening on her hands and knees and instead did transverse abdominis strengthening while sitting or kneeling. This allowed the weakened connective tissue to heal. She learned to engage her transverse abdominis muscles correctly throughout the day, especially while taking care of her other three children. This improved her posture and she stopped sticking out her stomach unintentionally. As her pregnancy progressed, she stopped complaining about her baguette. She downgraded it to a bagel stick.

Shortness of Breath

Christianna lived in a five-story apartment building in New York City without an elevator. She walked up and down four flights of steps more than once a day. After her sixth month of pregnancy, Christianna was huffing and puffing on a daily basis. She needed to take two to three rest breaks while climbing the stairs with groceries, dry cleaning, and her purse. She was spent after her daily 66-step challenge. Christianna had run several marathons in the past and didn’t understand why she was having such a hard time breathing.

There are many reasons you may feel winded during your pregnancy. Feeling short of breath usually starts in the first or second trimester and is reported by 75 percent of healthy pregnant women by their 30th week. It is common to feel like you just can’t take a deep breath. Your breaths are short and fast. Your progesterone hormone is partially to blame here. In addition to causing constipation and reflux, it stimulates respiration. This makes you feel like you are breathing quickly. These changes may make it hard for your lungs to fully expand. This may cause more shallow breathing, and you may feel short of breath.

It isn’t surprising that your uterus pushes other abdominal organs out of the way as it grows. It pushes up on the diaphragm around the 31st to 34th week. The diaphragm is an abdominal muscle under your rib cage and is a key muscle in helping you breathe. When your diaphragm isn’t functioning at full capacity, your lungs can’t fully expand and your breathing becomes more shallow. But don’t worry! Eventually the baby will drop and your diaphragm will have a little more room to move. Let’s learn a little more about how your diaphragm works.

Your diaphragm is a dome- or parachute-shaped muscle sitting tucked up under your ribs. This muscle moves with every breath that you take. Every time you breathe in, the diaphragm moves downward toward your abdomen. During each exhale, your diaphragm moves up and pushes the air in your lungs out. This is something that you don’t need to think about since it is an automatic function in your body. You can imagine how the presence of a little bundle in your abdomen might block the diaphragm from doing what it normally does.

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Yes, You Do Have a Big Head

I’m sure sometime in your life, someone has accused you of having a “big head.” Is that an insult? No! It’s a fact. You do, indeed, have a big head. Everyone does. And it’s quite heavy as well. The average adult human head weighs between 8 and 12 pounds. That’s a lot to hold up! Your muscles are working hard to support the weight of your head and control head movement. These muscles are your postural muscles. Every second that you are upright, these postural muscles are at work. They also function as your secondary respiratory muscles. These secondary respiratory muscles need to focus on the primary job of holding up your head. They can’t be bothered with your breathing. The muscle that really needs to be focusing on your breathing is your diaphragm.


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Another motion that occurs during respiration is the movement of your ribs. Your ribs need to move out in order for your diaphragm to allow air into your lungs. This movement is almost like a bucket handle. As you breathe in, your bucket handle (ribs) move up and out. As you breathe out, the bucket handle returns to its resting position.

What you can do

So let’s talk about ways that you can improve your respiration. Remember, your baby needs the oxygen too.

Diaphragmatic breathing

This is an ideal exercise to start early on in the pregnancy before you even start to show. Your breathing pattern will change as your baby grows. Starting the pregnancy with a proper and efficient breathing pattern is important for you and your baby.

Let’s begin this exercise leaning back in a chair.

Place both your hands on your belly, or one hand on your chest and the other on your belly. Try to become as relaxed as you possibly can. Clear your mind of your mile-long to-do list, possible baby name list, and “things I need to add to my registry” list. Focus on how you are breathing. Are you using more of your upper chest muscles? Are you taking short and shallow breaths? Or are you taking long, slow, deep breaths? Are you able to count to five while you inhale and while you exhale? Try your best to keep your upper hand “quiet.”

Move your bottom hand outward when you breathe in. Let your bottom hand come back toward your spine when you breathe out.

Relax your shoulders and your chest. Most people hold their tension here, so try and release all your tension.

Try to have the movement of your breathing come from your abdomen. Visualize your breath entering through your nose and heading down into your abdomen. As the breath passes through your body, it zaps all the tension and leaves behind loose, relaxed muscles. Feel your abdomen fill with air. As you exhale, let the air out through your mouth slowly.

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Diaphragmatic breathing

 

Sleeping Beauty

You breathe properly when you sleep. You are not tense when you sleep (unless you are having a nightmare about the awful shade of green that your partner picked for the nursery). You diaphragmatically breathe when you are sleeping. So try to get as relaxed as you can without falling asleep and you’ll see your breathing pattern change. Try to be aware of how this feels and see how much of it you can control. See if you can bring on this natural breathing pattern at least once a day. Make the time to be relaxed and work that primary muscle of respiration, the diaphragm.

Babies also breathe properly. They use their diaphragms and breathe efficiently. They haven’t learned yet to be stressed out and use their secondary respiratory muscles instead of their diaphragm. Maybe you have another little one running around the house from whom you can get tips on how to breathe.


Strengthening your intercostal muscles

As your pregnancy progresses, your baby will be taking up more and more space in your belly. This will prevent your diaphragm from going through its full range of motion. You can still practice deep breathing throughout your pregnancy but now we are going to work on strengthening the muscles between your ribs (your intercostal muscles) to help you expand your ribs/lungs more and take a deeper breath. Here’s a way you can strengthen these respiratory muscles, make your breathing efficient, and get your ribs moving.

          Wrap a resistance band around your back, keeping it level around your lower ribs. (Remember, your diaphragm is tucked under these lower ribs). Criss cross the resistance band and add tension by pulling on the ends. Keep that tension at all times.

          Now take those long, slow, deep breaths against the resistance of the bands. Remember to keep your upper chest quiet. You can also have your partner put his or her hands over your low ribs. Practice breathing into your partner’s hands. They can also apply slight resistance in order to help strengthen the muscles between your ribs.

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Breathing exercise with resistance band.

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Breathing exercise with partner.

Don’t hold your breath at any point, and stop if you feel fatigued.

Try doing a set of 10 and breathe through a count of five seconds. (You’ll also be giving your arms a workout.) Take breaks as you need them and try doing another set of 10 when you are ready.

Keep building up your breathing endurance. Your breathing muscles are just like any other muscles—they need to be worked out. It’s important to incorporate these muscles and your breathing exercises into your exercise program.

Stretch your intercostal muscles

You also can stretch these intercostal muscles that are between your ribs. Sometimes these muscles can become tight, especially if you hold a lot of tension in your upper body.

You can try this stretch sitting in a chair or half kneeling on the floor.

          Simply reach one hand overhead and lean to the opposite side. Reach over until you feel a stretch on your side. This stretch is good for the muscles between your ribs as well as the muscles along the side of your trunk.

          Hold each stretch for 30 seconds. And don’t forget to breathe deeply!

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Side trunk/rib stretch

Christianna practiced breathing against a resistance band daily as described. While she still needed to take a break at the third floor landing and found herself panting once she made it to her apartment, she reported a notable difference. The 66 steps were still challenging, but her daily activities were much easier.

Sleeping Pains

Lori noticed that her bed was getting more and more crowded every night. There was Lori, lots of pillows, her growing belly, oh, and that’s right, her partner. Lori wanted to know how she could support her belly, cuddle with her partner, and sleep comfortably without falling off the bed due to all these new components in her bedroom.

Having the right position and proper support from pillows is an important factor for getting a good night’s rest. We let Lori know that falling asleep on her left side is the safest position. As her baby grows, the growing uterus will put increasing pressure on important blood vessels, the inferior vena cava and aorta. These are the largest artery and vein in your body. Compression of these vessels in the abdomen can impede blood flow to the heart and legs. When the pressure is too much, women will literally receive a wake-up call. They may begin to sweat; notice a change in their pulses; or feel dizzy, nauseous, or lightheaded. These conditions affect 10 percent to 20 percent of women during their pregnancies.

What you can do

Lie on your left side or on your back with your right hip propped up at least 15 degrees with a wedge or pillow. The good news is, most pregnant women are inclined to tilt to their left sides while sleeping in their third trimester. Researchers looked at sleep positions of pregnant and non-pregnant women and there was a significant difference. The majority of the pregnant group adopted a sleeping position that reduced the likelihood of aortocaval compression syndrome.

 

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Safe positioning with pillow to prevent compression of blood vessels while lying on back

So how should you sleep? Use a pillow under your top leg to keep your pelvis aligned and hips in a neutral position. Pregnant or not, side sleepers should use a pillow. Without it, your top hip rotates inward and puts unnecessary strain on your hip and low back. Using a pillow behind your back will help provide extra support and prevent you from rolling back. And since you are already on a pillow-stealing binge, why not take one more? Some women feel better with a pillow under their bellies while they’re lying on their left side. This relieves some pulling and strain at the low back. A body pillow will be helpful at this point. As your pregnancy progresses, you may need to say farewell to your partner, as there may not be enough room for all of you!

 

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Sleeping position using pillows

 

 

Are You a Belly Sleeper?

If you are a belly sleeper, you are probably missing your favorite sleeping position as you grow bigger. Don’t fret! There are several options available for sleeping pillows that allow pregnant women to sleep on their tummies. These cushions have spaces or cutouts for the pregnant belly and sometimes for the pregnant boobs. These pillows are fairly expensive. Our patients have fabricated their own versions with pillows and an inflatable swimming tube.



Got GERD?

You just ate a bucket of Buffalo wings and are wondering why that burning sensation in your chest won’t go away. Don’t worry, it might have been there even if you only had one wing. According to a study done by the College of Family Physicians of Canada, gastroesophageal reflux disease (GERD) is reported in up to 80 percent of pregnancies. It is most likely caused by an increase in progesterone. Progesterone, designed to relax the smooth muscles in your uterus, also relaxes the valve that separates the esophagus from the stomach. Hormonal changes in pregnancy can also decrease movement in the gastrointestinal tract, which results in slower digestion and an increased risk of reflux. Also, as your baby continues to grow, your little bundle occupies more and more of the space in your tummy. This causes more and more stomach acids to be pushed back up the esophagus, which causes that unpleasant burning sensation.

The easiest thing you can do to relieve some of these symptoms of heartburn and reflux is to make some lifestyle changes. You can try eating smaller and more frequent meals. And make sure you eat that last small meal way before bedtime. Also, you can try sleeping on a wedge (or several pillows) so that your upper body is slightly propped up, which may relieve some of the symptoms of reflux. Additionally:

          Eat slowly.

          Drink fluids between meals—not with meals.

          Don’t eat greasy and fried foods.

          Avoid citrus fruits or juices and spicy foods.

          Do not eat or drink within a few hours of bedtime.

          Do not lie down right after meals.


Swelling

Jenifer was worried about her swollen ankles. Her socks were cutting off the circulation in her legs and she was worried about a blood clot after doing some Internet research. Her swelling would worsen throughout the day and, by the evenings, she could barely stand anymore. She was six months’ pregnant and had a two-year-old to take care of, so lying down with her legs elevated wasn’t an option for her.

Do You Also Have Cankles?

During pregnancy, you have extra blood volume throughout your body. Eight out of ten women have clinical edema (swelling) at some point during their pregnancy. You are carrying around an additional six to eight liters of water. No wonder you feel like a two gallon water balloon.

The swelling may seem worse in your feet and ankles because your growing uterus puts pressure on the blood vessels in your pelvis. Your inferior vena cava is the largest vein in your body and carries blood from your legs back to your heart. When it is compressed by your growing uterus, the blood flow slows down and pools in your legs.

Swelling is often worst in the third trimester and at the end of the day. Humidity and flying will worsen your sausage-like legs, so a trip to the Caribbean rain forest is not an ideal babymoon destination. While some swelling in the feet and ankles is considered normal during pregnancy, your doctor should be notified if it is severe. If you can press your thumb into your lower leg and still see a thumbprint after you pull your hand away, you may have pitting edema. If you notice swelling in your face or puffiness around your eyes, contact your doctor or midwife immediately. These could be symptoms of preeclampsia, high blood pressure, and excess protein in the urine that if left untreated can lead to serious—even fatal—complications for both you and your baby.

 

Fun Fact: Your Baby’s Hair Actually Might Cause Your Heartburn

A study performed at Johns Hopkins Medical Institution showed that there does in fact appear to be an association between heartburn severity during pregnancy and newborn hair. It is believed there is a shared biologic mechanism involving a dual role of pregnancy hormones in both the relaxation of the lower esophageal sphincter and the modulation of fetal hair growth.



How Do You Know If You Have Preeclampsia?

According to the University of Maryland Medical Center, you may not even experience symptoms if you have mild preeclampsia. During each prenatal visit, however, your health care provider will measure your blood pressure, test your urine, and be on the lookout for other early signs of the disease—a good reason not to miss any of your checkups.

Symptoms include:

          Blood pressure of 140/90 or higher on two separate occasions at least six hours apart

          Protein in your urine

          Swelling in the hands and face

Symptoms of severe preeclampsia include:

          Blurred vision or spots in front of your eyes

          Sensitivity to light

          Lethargy

          Nausea and vomiting

          Severe swelling

          Sudden weight gain of more than a pound a day

          Shortness of breath

          Exaggerated reflexes

          A headache that does not go away

          Belly pain below the ribs on the right side

          Right shoulder pain

          Decreased urine output

          Irritability

Your doctor will perform a physical exam and run some tests before making this diagnosis. The treatment is to deliver the baby! If it is too early in your pregnancy, you may be placed on bed rest either at home or in the hospital. Symptoms usually subside within six weeks of delivering, but your blood pressure may worsen within the first few days. And, unlucky you … if you have preeclampsia once, you are more likely to develop it again in another pregnancy. However, it is not usually as severe as the first time.

The cause of preeclampsia is unknown, but if this is your first pregnancy or you’re carrying multiples, you are at risk. If you’re over 35, have a history of diabetes, and are obese, you’ve hit all the risk factors.

For more information on preeclampsia, visit: preeclampsia.org.


What you can do

It’s good to know the swelling will resolve after delivery, but what can you do for it now?

          Stay hydrated. The Institute of Medicine recommends about 10 cups (2.3 liters) of fluids a day during pregnancy. We know it may seem counter-intuitive to drink more water while you’re already retaining too much, but it will help. Proper hydration improves your circulation so you won’t accumulate excessive pooling in your legs. Plus, more trips to the bathroom mean you won’t be sitting or standing for too long, which leads us to the next tip.

          Sleep on your left side if you can. This takes pressure off the inferior vena cava so there will be less blood flow restriction.

          Discuss the option of maternity compression stockings or socks with your doctor or midwife. The additional support will improve the circulation in your legs, resulting in decreased swelling. The lowest level starts at 8 to 15 mmHg and gets as high as 50–60 mmHg. Don’t be surprised by the price of these. They’re expensive, but your legs will thank you.

          Elevate your legs above your heart as much as possible while sitting or lying down. You have a good reason to steal all the pillows. You can even raise the foot of your bed to elevate your swollen limbs while sleeping.

          Exercise. Take a power walk outside or exercise indoors at the gym or your home. Cool down in the pool and swim some laps. Exercising your leg muscles will help your circulation and move the fluid out of your legs.

Please know, if one leg is significantly more swollen than the other, you should contact your doctor or midwife. This may be the result of a vascular condition, arthritis, lymphedema, blood clot, gout, infection, tumor, or other condition that requires medical attention. Please don’t ignore your swollen limb.

 

How Much Salt Can I Have?

Please note, we did not recommend that you decrease the sodium in your diet (assuming you currently consume a moderate amount in your diet). This is a controversial topic and the medical recommendations have shifted. Doctors used to tell women to decrease their sodium levels to lower their blood pressure and decrease water retention. No pickles for them! In 2011, German researchers conducted an animal study to study the effects of sodium in the pregnant females. It was concluded that both excessively high and excessively low levels of sodium during pregnancy have an adverse effect on kidney development in the offspring.

So how much salt should you consume? The World Health Organization recommends less than 2,000 milligrams of sodium a day (¾ to 1 teaspoon of salt) and the American Heart Association recommends limiting sodium to less than 1,500 milligrams a day (½ to ¾ teaspoon of salt). Americans average 3,600 milligrams per day, doubling the recommended consumption, according to the American Heart Association. These guidelines don’t change during pregnancy. So you can have that pickle you are craving … just cut it in half.

Jenifer stopped self-diagnosing and assuming the worst from what she read online. While she hated the idea of maternity support hose, she purchased some and they helped her immensely. She modified her work and exercise schedule too. She didn’t have the option of elevating her swollen legs in her small work cubicle, so she took frequent breaks to walk around her office, which improved her blood circulation. She walked for four to five minutes every hour. While she initially told us she was too busy to take breaks, she got hooked on the practice. She interacted with colleagues she normally didn’t see, had less leg discomfort and swelling, and felt better mentally when she took breaks from the monotony of typing. When the weather permitted, she started walking with a friend for 30 minutes after work. This improved her swollen legs and energy level in the evening.


Tailbone Pain (Coccyx Pain)

Kris was unable to sit during her third trimester due to tailbone pain. She developed low back pain from standing all day, as this was the only position she could tolerate. Her obstetrician referred her to an orthopedic doctor, who said he couldn’t help her because she was pregnant. She was told she would feel better after delivering her baby, who was putting too much pressure on her tailbone.

At this point, you’ve been sitting in your doctor or midwife’s waiting room for hours and you think that this is a pain in the ass. Or you may actually have a pain in the ass. Your tailbone, also known as your coccyx, is a little bone connected to the base of your spine. Your tailbone needs to move in order for you to deliver your baby (and to poop!). Just like all your other joints, this little joint is also being affected by your pregnancy hormones. The tailbone can feel tender and maybe even move a little too much during your pregnancy. It can be extremely uncomfortable to sit for a long time or get up from a chair.

What you can do

Since you can’t put off your gestational diabetes test forever, when you finally go to the lab, bring a cushion with you. You will be glad you have it as you wait for your bloodwork to be completed. And while you pray that the test is negative so you don’t have to give up donuts, donut cushions are not the answer. Donut cushions are good for other pelvic conditions such as trauma to your perineum after delivery, but not for sacroiliac pain or tailbone pain. These cushions actually make the condition worse because they are compressing the areas that are actually causing you pain.

So what is the answer? U-shaped cushions, such as the Tush Cush. There are wedged U-shaped cushions that are made for this type of pain. The opening of the “U” goes to the back. People generally use these cushions incorrectly, and sit on them like toilet seats with the opening in the front. This won’t relieve your tailbone pain. The wedge shape takes the pressure off your tailbone by tipping your pelvis forward and restoring your low back curvature. So take this with you on long drives, to doctor appointments, your office, or restaurants. Take it wherever you will be sitting for long periods of time and you’ll notice a definite decrease in your tailbone pain.

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Using a seating cushion at the workstation for proper posture and comfort

Kris’s preg head made her forget where she put her Tush Cush one too many times. She kept leaving it places and got tired of replacing it. She did feel better when she used it and was happy to finally sit without pain. She corrected her standing posture and was able to relax her pelvic floor muscles. This was significant for two reasons—it reduced the pressure on her tailbone and helped get her pelvis ready for labor.

 

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From Denise: I am a triathlete and spend a lot of time sitting on a bike. Sometimes it’s a spin bike at the gym, but most of the time it’s my road bike. Sitting on a small bike seat for hours definitely causes its fair share of bum pain—even while wearing a pair of bike shorts with butt padding that makes it look like I am wearing a diaper. Whenever I have pain in my bum from riding, I use this cushion for long car rides or sitting at my desk. I’m also diligent about performing the stretches and strengthening exercises that we mention in the pelvic pain section of this chapter (page 42). So don’t worry if you have a pain in the ass. Be dedicated about taking care of it and it will feel better.


Learning to relax your pelvic floor muscles is also an important part of easing tailbone pain. There are muscles in your pelvis that connect directly to your tailbone. If the muscles are tight, then that can cause tailbone pain. There are several things you can do to relax your pelvic floor muscles. In the section on pelvic pain in this chapter (page 42), we review stretches you can do to target the tight muscles in your pelvis.

 

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The Tush Cush

Varicose Veins

Brenda stayed active throughout her pregnancy. She taught martial arts and ran three times a week. Her swollen and bluish legs scared her running partner and class participants more than her medical team. Her socks left indentations in her swollen calves. Her skin looked like it was going to burst open. She felt best after exercising. Her doctors said the varicosities would resolve after delivery, like they did after her previous two pregnancies, so they weren’t concerned. Her biggest problem was sleeping at night. Her legs throbbed and kept her awake. She had dull pain in her lower abdomen and she developed varicose veins around her vagina. She was afraid to have sex and didn’t know how she would deliver a baby without rupturing her inflamed veins.

Don’t let these blue veins make you blue. Varicose veins are superficial, twisted, and enlarged veins most commonly seen in the legs. Healthy veins have one-way valves that help keep the blood flowing back to your heart. If the valves get weakened or damaged, the deoxygenated blood pools in your legs. This increased pressure can cause pain, fatigue, achiness, heaviness, burning, or throbbing for some women. Others don’t experience any pain, but have swelling and skin discoloration. And yet some women report no symptoms.

Varicose veins are a common condition during pregnancy, seen in 33 percent of women after delivering their first baby and 55 percent in women who have delivered two or more babies, not including twins. The great saphenous vein, found in the inside of your leg, is a common area to have varicosities. (You can often see and feel this vein on your inner knee.)

What are the risk factors?

          Women are two to three times more likely than men to develop varicose veins

          Obesity or excessive weight gain

          Family history

          Age: between 30 and 70 years old

          Pregnancy

          Use of birth control pills

          Prolonged standing or sitting

 

 

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From Jill: I don’t mean to strive for perfection, but I give myself a perfect score here. I received my first pair of support hose as a teenager. Just what every girl wants. During my waitressing days, I was on my feet for several hours a day. Since my mom developed painful varicose veins during her two pregnancies, she was kind enough to share her stockings so I could avoid her struggles. So just like my mom, I donned my support hose to work. But unlike my mom, I wore a stained International House of Pancakes dress over them.


 

Why are they worse during pregnancy? Blame it on the hormones once again. Researchers have studied whether pregnancy alone can cause varicose veins or if elevated hormones are the culprits. Blood work in pregnant women with varicose veins was compared to the blood work in women without them. It was concluded that women with varicose veins had significantly higher levels of progesterone, the hormone that plays a role in maintaining pregnancy.

Additionally, the veins in your legs are enlarged from your increased blood volume and the impact of your growing uterus. Your uterus puts pressure on the veins in your pelvis, which impedes the blood flow from your legs and consequently causes increased pressure and pooling in the veins.


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Please note ladies, crossing your legs won’t give you varicose veins. This old wives’ tale has been repeatedly disproven.


These swollen veins aren’t isolated to your legs. You can develop them at your rectum and anus, where they are called hemorrhoids. The good news is, they often resolve after delivery. The bad news is, pushing can make them worse. For your hemorrhoids, please read our section on constipation.

Vulvar varicosities are varicose veins in the vulva. Who knew there were so many places to develop varicose veins? The vulva includes all the external female genitalia. Vulvar varicosities are generally not an indication for a cesarean section. If you are worried about tearing, having an episiotomy, or rupturing the varicosities during labor, then please discuss this with your doctor or midwife. Research, however, shows that women with vulvar varicosities can be allowed to attempt a vaginal birth regardless of their severity.

What you can do

While there is no cure for varicose veins, here are some tips for keeping your veins strong and healthy:

          Stay active to keep your muscles strong and facilitate good circulation in your legs.

          Follow your doctor’s or midwife’s weight gain recommendation.

          Elevate your legs above your heart when resting as much as possible.

          Sleep on the left side so your uterus doesn’t put pressure on your inferior vena cava, which is the large vein carrying blood from your legs to your heart.

          Don’t stand or sit for long periods of time. If standing for prolonged periods is unavoidable, shift your weight to each leg frequently. Make sure to take breaks once or twice an hour if you’re sitting for extended periods.

          Wear maternity elastic support stockings. Though they have not been proven to prevent varicose veins during pregnancy, they have been shown to improve leg symptoms and prevent pooling at the groin.

          Wear vulvar support garments (or you can put a maxi pad in a pair of maternity biker shorts).

          Avoid tight clothing and belts.

          Avoid high heels. Wearing low heels or sneakers will use your leg muscles more efficiently and help your circulation.

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The V2 vulvar support garment for vulvar varicosities

          Maternity belts and pregnancy supports can decrease the pressure in the abdomen and pelvis to improve blood flow.

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Maternal supports can lift the belly to improve leg circulation and varicose veins

Brenda’s doctors were right. Her varicosities disappeared within three and a half weeks after delivery. All of them! She wore compression socks daily. She wore compression stockings in the evenings, which decreased the throbbing in her legs and allowed her to sleep. She tried a perineal support garment for her vaginal varicosities and found it too uncomfortable. She was still afraid to have sex, so she refrained until her vaginal varicosities subsided. She had a planned C-section without any complications.

Additional Help from Acupuncture and Chinese Herbal Medicine

As physical therapists, we can help alleviate many of the discomforts of pregnancy, but there are some that are outside our area of expertise. Since we can’t help you with your morning sickness, anemia, and either breeched or overdue babies, we refer to a profession that can! Acupuncture and Chinese herbal medicine have been practiced for centuries and are used for a myriad of health problems, including pregnancy symptoms. Many of our patients have experienced the benefits. We consulted with acupuncturists and Chinese Medicine Herbalists Jill Blakeway, MSc, LAC, and Mary Sabo, MSc, LAC, at the YinOva Center in New York City.

Here is what they had to share.

Acupuncture

Acupuncture is a good choice for many pregnancy ailments because it offers drug-free relief for a number of disorders. We often use it as relief for conditions that people see as a normal part of pregnancy, such as morning sickness, sciatica, back pain, pubic pain, edema, and fatigue. We also use it before the birth to promote an efficient labor or to initiate labor in women who are past their due date. We use moxa and acupuncture to help breech babies turn into a safe position for delivery.

It’s important to pick an acupuncturist with experience in obstetrics because there are acupuncture points that are contraindicated in pregnancy because of their tendency to promote contractions. However, in the hands of a well-trained and qualified acupuncturist, acupuncture is an extremely safe form of treatment for pregnant women.

The following conditions are treated with acupuncture, but you can also practice them with applied pressure at home. Any point we discuss can be used for acupressure simply by applying pressure with fingertips to the indicated point. Gently press until a deep ache is felt and hold for 30 seconds to a minute. These spots can be pressed as often as needed.

Breech position

Madeline had success with acupuncture: “After a very scary and difficult labor that lasted 40 hours with my son who was ‘sunny side up,’ I swore I would never do that again. But as everyone warned, I forgot how awful the experience was and we decided to have another baby. When I got pregnant again, I was terrified of giving birth and made my midwives promise that they would check me frequently to make sure the baby was in the correct position before I went into labor. And if the baby wasn’t, I wanted to plan a C-section. Sure enough, at seven months, they told me my daughter was breech. The weeks passed, and there was no change. At about eight months, the midwives started encouraging me to think about an ECV (external cephalic version) if the baby didn’t turn. I was terrified—I had heard that they were very uncomfortable, not always successful, and (although rare) could hurt the baby. It seemed to me that this was the perfect opportunity to have the ‘simple’ C-section, but they disagreed. So, we set a date for the ECV, and in the two weeks leading up to it I saw an acupuncturist twice a week for moxibustion. The acupuncturist held a lit mugwort ‘cigar’ over my pinky toes for a few minutes, until the heat was uncomfortable. I was told it shouldn’t hurt, and it didn’t. I performed the moxibustion on myself every night at home for two weeks. Finally the day for my ECV came. I was about eight and a half months pregnant, and still terrified. I will never forget the look of amazement on my midwife’s face—the baby had turned and was completely in the right position! I was thrilled and almost in disbelief that the baby had turned so late in my pregnancy. To this day, I am absolutely amazed that the acupuncture and moxibustion worked. The experience truly led me to look at alternative and Eastern medicine in a completely different way.”

We use a well-known acupuncture and moxibustion protocol to encourage a breech baby to turn, which involves warming a point on the small toe. We must admit that when we first learned about this in graduate school, we were skeptical. It seemed improbable that burning an herb above someone’s toe could have any effect on her baby’s position. However, over the years we have seen it work over and over again. In fact, it is one of the most tested points in Chinese medicine and has a success rate of anywhere between 69 percent and 85 percent in successive clinical trials.

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Moxibustion for breeched baby

We usually find that we have better results with this treatment if we see the mom before week 37 of her pregnancy because after that the baby can be too tightly wedged to move. We treat the mom lying on her side and place three or four small acupuncture needles at strategic points. We then use moxa, which is made from an herb—mugwort—that is formed into a stick that looks like a cigar. We hold the smoldering end of the moxa stick above the acupuncture point close to the nail bed of the little toe. We ask the mom to continue to do this for 15 minutes twice a day and we give her moxa sticks to take home so that her partner can do this for her. The feeling is one of relaxing, gentle warmth and should not feel too hot or burn.

The treatment seems to create a bit more space in the uterus, which the baby can use to turn if she feels like it. It may also signal the baby to move and shift position. During the treatment moms tell us that their baby is moving a lot more than usual as they react to the sensation of having more space. If you feel the baby turn, you should stop the treatment and ask your doctor or midwife to check the baby’s position.

We like this treatment because it is gentle. If the baby does not turn there may well be a significant reason why not so we prefer that our patients don’t do the kind of manipulations that force the baby to turn. The beauty of the moxa treatment is that it only gives the baby more room and does not try and move the baby itself.

Constipation

Because laxatives are not recommended during pregnancy, acupuncture can be a very useful, drug-free way of managing constipation alongside dietary changes. The main point for pregnancy-related constipation (SJ6) is on the arm. It is located about three finger widths up from the wrist in a small depression between the two bones in your arm.

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Acupuncture for constipation

Fatigue and anemia

In cases of anemia we do give Chinese herbs as well as suggest diet changes. For fatigue and heaviness of the limbs, we’ve found acupuncture particularly helpful.

Labor induction

If a patient is past her due date and facing a chemical induction we sometimes do acupuncture to try to help get things started. Some points just above the inner ankle help promote dilation and some points help promote mild contractions. SP6 is located a hands width up from the prominent bone at the inside of the ankle. There is often a slight indentation in the skin, about the size of a pencil eraser, that can be felt at this point.

Morning sickness and nausea

There are different patterns of morning sickness in Chinese medicine and each requires a slightly different approach, but all the acupuncture point prescriptions have one point in common that relieves nausea: PC6.

At YinOva, we needle this point during a treatment and then place magnets on it secured by small sticking plasters. The patient goes home with the magnets attached to keep the treatment going as long as possible. The point is well researched and its efficacy established.

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Acupuncture for morning sickness and nausea

You can treat this pressure point on your own. It is located two fingers from your wrist crease, in the center of the wrist, between the two tendons. Gently press until a deep ache is felt and hold for 30 seconds to a minute. This can be done as often as needed to alleviate waves of nausea.

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Pressure point for morning sickness and nausea

Musculoskeletal pain

The most common pains we treat with acupuncture are back pain, pelvic pain, rib pain, carpal tunnel syndrome, and leg cramps. All are effectively treated by acupuncture, which is a great choice because it is drug-free. We choose points with different functions to break up muscle spasms, reduce inflammation, interrupt nerve signals, and change the perception of pain in the brain.

Varicose veins, hemorrhoids, and vulvar varicosities

Acupuncture can improve blood flow and reduce the risk of inflammation and clots. Varicosities including hemorrhoids and vulvar varicosities are attributed to central qi dropping in Chinese medicine. We have found treatment to be very effective, with women usually noticing improvement the day after treatment. However, acupuncture isn’t necessarily a cure for these conditions. Rather, it provides pain relief and prevents symptoms from worsening as the pregnancy progresses.

Chinese Herbal Medicine

Chinese herbal medicine is used throughout Asia to treat women during pregnancy and postpartum. Usually the herbs are prescribed as custom tailored formulas containing 6 to 15 herbs. At YinOva we try to give pregnant women as few herbs as possible during pregnancy, preferring to use acupuncture as a first-line treatment. However, we do administer herbs for cases of severe morning sickness, edema, headaches, and fatigue. Because each herbal formula is individually tailored it’s important to see a board certified herbalist to have a formula specifically designed for you.

We understand you may be struggling during your pregnancy. And you may curse us out when you turn the page and see that we’re now telling you to exercise. The next chapter discusses all the myths and truths about exercising for two.