Empowering Pregnancy: Bridging Gaps with Carrie Koziol's 6-Week Prenatal Pilates Program

The idea for my 6 week Prenatal Pilates program was a labor of love in itself. As a Women’s Health Physical Therapist, I spent over 10 years in a clinic setting working with the prenatal population, and I loved every minute of it. Well, almost every minute. I loved watching their baby bumps grow and hearing the trials and tribulations that only someone who has been pregnant herself could truly understand. Things like the stress of registering for the baby shower (how am I supposed to pick one brand of bottles out of the hundreds of choices?!) or the excitement of deciding how to decorate the nursery (gender neutral or safari themed or whimsy floral designs). I loved hearing people explain whether they wanted to find out the sex of the baby or be completely surprised.

But then there were other parts of working with this unique population that could shake you to your core: problems being heard by their providers, pregnancy complications, and yes, the unimaginable heartbreak of pregnancy loss. It was this ability to be in the trenches with pregnant women that allowed me to determine the educational components they were not receiving from the current standard of care.

I started to make checklists in my patient folders of things I needed to teach them before they were discharged from my care. Things like how to exercise safely in pregnancy and how to avoid the typical pregnancy posture that contributed to tight, weak muscles in important areas of the body. I wanted them to really understand the role of their pelvic floor muscles, how to protect this area in pregnancy, and how to use perineal massage to prepare this tender region for birth. They needed to understand that pain was not a normal part of the pregnancy process and to be provided with resources for healthcare professionals that could give them relief along with the maternal supports that might help. I knew they were learning the basics of labor and delivery from their childbirth prep classes, but I needed to teach them the important stuff about positions to deliver in, how to breathe, and how to actually push the baby out (!) If I thought my clients were underprepared for birth, they were completely in the dark when it came to the necessary components of their recovery, but not on my watch.

Then came the exercise part of it. In addition to being a Women’s Health Physical Therapist, I am also a Prenatal Pilates Specialist. I got certified as a Pilates instructor early on in my career, but it wasn’t until I became pregnant with my first of three children that I came to the realization that the regular exercises I was doing and teaching my clients to do were probably not the most appropriate form of exercise for the pregnant body. So I flew from Chicago to New York to become a Prenatal Pilates Specialist through the Center for Women’s Fitness. The program transformed the way I exercised during my own pregnancies and was the inspiration behind how I designed exercise programs for my pregnant patients. Since then I’ve also gotten my Prenatal and Postpartum Corrective Exercise Specialist Certification and feel my extensive training sets me apart from almost every other fitness professional in the industry.

I started making another checklist in my patient folders (what can I say, I like lists) of all the exercise sequences I would be sure they mastered before they were discharged. Things like stretching what was tight and strengthening what was weak. Clearing up myths about pelvic floor exercises, specifically Kegels and how to responsibly work them into an exercise routine in an effective way. I educated them about incorporating safe abdominal exercises that would help them support and birth their babies without creating excessive pressure that sometimes led to abdominal stretching and the dreaded “mommy pooch” after birth. And I focused on strengthening and stretching all the deep hip rotator muscles to make sure their bodies were ready to assume the positions that were most optimal during labor.

I spent years making sure my patients were armed with the education and exercises they needed to be successful on their delivery day, and I loved when they would pop back into the clinic with their newborns to tell me how much of a difference this made when it mattered most. I knew this was something all pregnant women needed to know.

It was this education that my patients were so grateful for along with the lack of exercise class options I found during my own three pregnancies that ultimately led me to design a program that was a combination of education and exercise. And my 6 week Prenatal Pilates program was born.

Some women started physical therapy shortly after discovering they were pregnant. They felt sheepish, like they didn’t earn a right to experience pregnancy discomfort unless they were “showing.” And I always explained to them that you have the biggest surge of pregnancy hormones in the first trimester, so it’s not unusual to experience lower back pain or sacroiliac joint dysfunction early on. They had every right to be there as the women who were in the final countdown to their estimated delivery days.

Whether they were in their first trimester or last, they all shared a common bond. They all felt the unspeakable pressure of trying to do their best to grow this tiny human, and they were all a tiny bit scared about the unknowns of the big day. While each treatment plan was customized to the specific need of the patient in front of me, I detected several common gaps in the knowledge most women were receiving.

Lisa’s Story

Lisa was a workout fanatic. She ran up to 10 miles a week and was very active at her CrossFit gym. She was told by her OBGYN that she could continue doing her regular exercise routine but would probably have to scale back at some point. The further she got into her 2nd trimester, the more side eyes she received from other gym goers and from people she jogged past on the street. Her husband also wondered if she should take it easy, but it wasn’t until she started to experience some lower back pain that she finally sought treatment and learned what it truly meant to exercise safely in her pregnancy.

Teaching women to exercise safely and effectively in their pregnancies seemed like the best place to start, so it is the theme of Module 1 of my 6 Week Prenatal Pilates program.

Exercising Safely in Pregnancy

The American College of Obstetricians and Gynecologists (ACOG) has contraindications to exercising in pregnancy including certain types of heart and lung disease, cerclage, being pregnant with twins or triplets AND having risk factors for preterm labor, placenta previa after 26 weeks of pregnancy, preterm labor during the current pregnancy or ruptured membranes (your water has broken), pre-eclampsia or pregnancy-induced high blood pressure, and severe anemia. While the ACOG’s list of warning signs to terminate exercise seems fairly obvious, it’s worth mentioning given the topic of this section. “Whether you’re a seasoned athlete or beginner, watch for the following warning signs when you exercise. If you have any of them, stop and call your OBGYN:

• Bleeding from the vagina
• Feeling dizzy or faint
• Shortness of breath before starting exercise
• Chest pain
• Headache
• Muscle weakness
• Calf pain or swelling
• Regular, painful contractions of the uterus
• Fluid gushing or leaking from the vagina***

***(In my 15 plus years of working with pregnant women, not once have I seen someone with fluid “gushing from their vagina” that was like “But just let me get one more set in.” Nevertheless.)

Most trainers are aware of these, but they sometimes get lost when designing the actual exercise program. When educating trainers who work with the pregnant population, I always remind them that pregnant women are not just less fit “regular women.” Sometimes they’re more fit! Instead of just decreasing the weight they are lifting or shortening the mileage or modifying the exercise itself, it’s imperative that trainers view pregnant people through the lens of (1) The Physiology and Cardiovascular Changes of Pregnancy and (2) The Demands of the Event (AKA Labor).

Physiological and Cardiovascular Changes of Pregnancy

When it comes to cardiovascular changes, these mostly involve blood pressure and heart rate. Almost immediately upon the egg implanting into the womb, a pregnant woman experiences a total body vasodilation which can lower blood pressure. For this reason, I modify my Prenatal Pilates exercises to avoid quick position changes, choosing instead to cluster similar positions together and allow plenty of time for the blood pressure to keep up with the change in position.

Blood volume can increase by 40-50%, cardiac output increases 30-50%, and resting heart rate increases. Pregnant women who have been doing cardio-type workouts frequently wonder what a “safe” heart rate should be during higher intensity training. While many resources point to the arbitrary guideline of keeping your heart rate at 140 bpm or less, I find that number does very little to account for previous fitness levels, current fitness level, body mass index, or any other more individualized measures. Your heart rate may rise to 140 climbing a flight of stairs so does that mean we all move into ranch-style homes or take elevators for 9 months? I prefer to follow the Rating of Perceived Exertion scale. This is a scale from 6 (equivalent to no exertion) to 20 (maximal exertion). During pregnancy, staying between 11 (light) to 13 (somewhat hard) is a more accurate way to categorize exertion. Or I simply recommend using the Talk Test. If you can carry on a conversation while you are exercising, you’re doing just great. If you find yourself gasping for air every couple of words, you’re probably exercising a little too hard.

Another physiologic change to consider is the influx of pregnancy hormones that can lead to a relaxation and softening not just of the blood vessels as described above but also affect the connective tissue and joints in many areas of the body. There are two main vulnerable areas for pregnant women and those are the connective tissue between the “six pack” or rectus abdominis muscles and in the ligaments and joints of the pelvis. One study showed that 100% of women will experience diastasis rectus abdominis (DRA) which is a separation of the rectus abdominis muscles by the 3rd trimester. While women are designed to birth babies and some separation in this region is totally normal to accommodate the growing baby and growing uterus, it’s important to manage intra-abdominal pressure. In situations like posture, body mechanics, and yes exercise, keeping pressures in check can help prevent an overstretching in this region that may not spontaneously heal on its own during the postpartum period and is often responsible for the dreaded “mommy pooch”. Yes, abdominal strengthening can be beneficial and should be an essential element of prenatal fitness programs; however, it is essential to avoid creating intra-abdominal pressure that puts excessive stretch on the linea alba (connective tissue between the rectus abdominis muscles). While trainers need to be monitoring pregnant women’s engagement strategies, there are a few exercises that most people will have trouble maintaining neutral alignment and avoiding excessive pressure and thus should probably be avoided with this population. Those abdominal exercises included weighted twisting and double leg lowering excessive time in the plank position and head lifting/crunch exercises without proper pre-activation of the transversus abdominis.

The pelvis is the second region that needs careful exercise prescription during pregnancy. The ligaments around the sacroiliac joint can be affected by the pregnancy hormones along with the changes to posture and center of gravity. The pregnant pelvis loves to be symmetrical and have equal weight bearing through it. This is not the time for repetitive single leg activities, aggressive step aerobics classes, or modes of exercise like kick-boxing where one leg is planted and the other is extended upwards.

It’s also important to avoid the extremes of temperature, to wear moisture wicking clothing, and to build in extra rest breaks for hydration. Beyond the second trimester, it can be more uncomfortable to lay flat on your back to exercise so using some pillows or blankets to create an incline can be helpful for your comfort and also to decrease excess pressure on your inferior vena cava, which could lead to decreased blood returned to you and the baby.

Demands of the Event

And finally, we as trainers need to consider the demands of the event. If a client was coming to me looking to train her body for an upcoming triathlon, I would look at what is required of her during the swim, bike, and run in order to design a fitness program that would carry over to her event. Likewise, pregnant women are in training for their event as well which just so happens to be labor and birth. If you look at the various positions in which women labor during a vaginal delivery, you will see supine, sidelying, all 4s, and squatting being utilized. And while the position itself may vary, there are some specific requirements of the hips in order to make these positions successful or even an option to begin with. Stretching and strengthening the deep hip rotators is essential in pregnancy. And while we could debate all day about whether women should be coached to push or rely on the fetal ejection reflex (more on that in a minute), there is some sort of participation from the deep abdominals that should absolutely be trained for during pregnancy.

The fact that pregnant women deserve to know what exercising safely in pregnancy should look like is the reason this is the first module in my Prenatal Pilates 6 week program. I may skip all the sciency stuff and just give you the basics, and for those of you that have enough on your plate, you can rest assured that all of this is a consideration in the design of the exercises you receive over the course of that 6 week program.

"It was great to have a series of exercises to do safely that will help with the pregnancy and delivery, but also the content and discussions I found very helpful, especially being a first time mom. This is a great concept with the combination of exercise and information and I thought it was terrific.” -Audra

Designing Week Two of my program was a no-brainer. I knew it had to be about the typical pregnancy posture that so many of my patients waddled into the clinic with.

Amber’s Story

Take Amber for example. I was fortunate enough to be in between patients when she walked in for her first appointment. She was about 7 months pregnant and was carrying what looked to be a 2 year old on her hip. But that was balanced by the GIANT diaper bag swinging off her opposite shoulder. Did I mention she was wearing the cutest pair of wedge booties?! After she checked in, I observed her waddle over to the waiting room where she collapsed into one of the chairs with a heavy sigh before slumping over her clipboard to fill out her information. I didn’t see her get out of the chair to return her clipboard but we all heard her as she grunted and groaned and heaved herself up. Listen, I’m not judging. When I was pregnant, my husband used to make that beeping noise for a truck backing up every time I tried to change positions, so I get it. But there are things you can do throughout the pregnancy that may actually help prevent some of the most common pregnancy pain issues that send people to physical therapy.

Pregnancy Posture

When designing a prenatal fitness program, it’s important to take a closer look at the typical pregnancy posture. As the belly and baby grow, the center of gravity will shift forward. This is a necessary and adaptive posture switch that doesn’t need a whole lot of “fixing”, but it’s important to consider the repercussions of this shift throughout the kinetic chain. Because of the shift in center of gravity, pregnant people are bearing a little more weight in the front of their foot putting increased tension on the gastrocnemius and soleus muscles in the calf region (which is why wearing shoes with a heel, even the cute wedge booties I described with Amber above, may be like pouring gasoline on a fire). Many women complain of “charlie horse” cramps in their calf muscles that often wake them up at night as they stretch out under the covers. It’s important to build in some lengthening stretches to this region to accommodate for this posture change and to discourage heeled footwear.

There is often an increased lordotic curve in the lumbar region so exercises that lessen this curve and create articulation through each individual vertebrae can feel amazing. Both hamstrings and hip flexors can become tight so stretching here can be an important part of a prenatal exercise program as well as becoming more aware of repetitive sitting and standing positions that may be causing too much shortening of these muscles.

The growing baby and uterus often can cause the ribs to be nudged outwards and can cause compression of the tender group of nerves and arteries near the armpit, called the thoracic outlet. For that reason, emphasis should be placed on proper breath coordination and movement of the rib cage along with exercises that help lengthen and create space for the thoracic outlet (a modified Pilates mermaid stretch is my favorite!)

And we can’t forget the effect of the growing breasts which have a tendency to round the shoulders, shorten the chest muscles, and overstretch the important postural muscles in the mid back and posterior shoulder region. Without overcomplicating things, pregnancy is a time to stretch what is tight and strengthen what is weak. And sometimes, just recommending that women stop trying to squeeze their breasts into their old bra and choose a proper fitting cup and band with a wider strap across the shoulders can be a real game changer.

Posture mostly refers to a snapshot of a person when they’re still, while body mechanics encompasses their strategy for moving around the world. In Amber’s case, recommending that she utilize a stroller so she could push her toddler (while stowing her heavy diaper bag down below) helped to take some weight off her pelvis and allow her to find her neutral alignment. But we couldn’t stop there. We needed to talk about how she was getting into and out of bed, into and out of her car, up and down from a seated position, standing in line at the store or at the counter to prepare a meal, and of course how that posture was showing up when it was time to exercise.

Like I explain to my clients all the time, we need to start treating movement like we do nutrition. No one would dream of having quinoa for breakfast and then fast food for lunch and dinner and then look back at their day and pat themselves on the back for eating nutritiously. But we do this with exercise all the time. We’ll sweat it out for a 30 or 60 minute exercise session in the morning and then slump into our cars to drive or bend over our technology or collapse into the couch at the end of the night and pat ourselves on the back for exercising that morning. Our bodies are responding to the forces we place on them ALL DAY LONG, not just when we exercise. As a fitness expert, of course I encourage my clients to develop a regular exercise practice; HOWEVER, it doesn’t end there. They need to then show up to all the other tasks in their day in a mindful way from filling out paperwork at the doctor’s office to sitting at their desks to getting out of a chair. In Week 2 of my 6 week Prenatal Pilates program, finding good posture and body mechanics is the focus and the exercises that week are designed with this in mind.

"Loved the discussions that revolved around anatomy. A lot of times we are told what our bodies do, but not why or how-I appreciated learning this. Thank you!!!" –Kristen

Pelvic Floor FAQs

Here are all the varieties of questions I get asked about the pelvic floor in pregnancy and why Week 3 of my 6 week Prenatal Pilates program is solely dedicated to this important yet overlooked region:

• I was told I should be doing 100 Kegels every day; is that true???
• The influencer I follow on Instagram said doing Kegels could damage your pelvic floor; do you agree?
• My best friend had a baby last year and told me her baby wrecked her vagina. How can I avoid that happening to me too?!
• Will having a baby ruin my sex life?
• My sister used a midwife who applied oils and hot towels during labor. Will that save my perineum from tearing?
• Everyone says squatting is the best way to birth a baby; is that true?

Pelvic Floor 101

Let me start with a quick introduction to what your pelvic floor actually is and then I’ll answer these questions and help you figure out how to incorporate safe pelvic floor exercise into your prenatal fitness routine. Your pelvic floor is the group of muscles between your pubic bone and tailbone and between both of your ischial tuberosities (the bones you feel when you’re sitting up straight). This diamond shaped area of muscles at the bottom of your pelvis is your pelvic floor, but there are three layers of muscles that include superficial muscles, muscles with ligamentous attachments to your urethra, and deeper muscles that go all the way up to the level of the Fallopian tubes. You also have different muscle fiber types in this region. Seventy percent of the muscles in the pelvic floor are Type I or slow twitch muscle fibers. The remaining thirty percent are Type II or fast twitch muscle fibers. It would be impossible to do one generic pelvic floor muscle contraction (or Kegel, named after gynecologist Arnold Kegel in 1948 for those of you keen on trivia) and attempt to cover all your bases. The pelvic floor has many functions, and I like to remember them by the S’s.

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There’s a SPHINCTERIC function because when you contract these muscles you help close the urinary and anal sphincter. But we want these muscles to be able to lengthen and relax so you can pass urine without straining and have a bowel movement without bearing down.

There’s a SUPPORTIVE function because your bladder, uterus, and rectum are suspended by ligaments inside the pelvic cavity. Things like age and gravity (and of course pregnancy) may cause these ligaments to weaken and stretch out, so we want the muscles at the bottom of the pelvis to be strong and bouncy like a trampoline to help support these organs.

There’s a SEXUAL function because the crura (or legs) of the clitoris straddle the vaginal vault. During orgasm the muscles of the pelvic floor contract and relax and we want them to know how to fully contract (and allow the crura to gently lift the vagina closer to the “G” spot) but also to know how to fully relax so that sex is more enjoyable.

And during pregnancy, these muscles also help SLIDE the baby out. Sounds dreamy, right?!

So when women ask me: “Should you contract or relax your pelvic floor muscles in pregnancy?” my answer is Yes. You should do both! We need muscles that are strong and functional, but also muscles that know how to lengthen and relax. And while learning to do a Kegel is an important step to getting in tune with your pelvic floor, aimlessly doing 100 Kegels a day will not create a powerful pelvic floor just like sucking your belly in 100 times a day will not get you a slimmer waistline. Plus, there’s over 10 different types of Kegels. You can do pelvic floor contractions that focus on the superficial muscles or the deeper muscles, you could hold the contraction for up to 10 seconds to work the Type I fibers or do quick pumps to work the Type II fibers. You can work on concentrically lifting the muscles up against gravity or eccentrically relaxing them segmentally. You get the point. Kegels are failing millions of women all over the world because they just teach you how to clench and hold.

What women really need to learn is how to coordinate these muscles with the respiratory diaphragm and how to activate them throughout the day to counteract that downward pressure that comes with increased intra-abdominal forces. When you inhale, the diaphragm plunges downwards in your abdomen which means your pelvic floor muscles need to melt and relax on the inhale to accept the downward pressure of that compression. When you exhale the diaphragm lifts upward,s and that’s when your pelvic floor should also lift upwards. We’re trying to create a coordinated piston system to manage pressure. This means there is an opportunity to engage these muscles with almost any exercise and with most activities of daily living.

The modified bridge is one of my favorite prenatal exercises. During the bridge you would start by exhaling and engaging your pelvic floor, rocking back and rolling up into a bridge, pause at the top as you inhale, then exhale (re-engage the pelvic floor) before folding from the bra line and articulating your spine down one vertebrae at a time. Once your tailbone arrives back on the mat, inhale and allow your pelvic floor to soften, melt, blossom open.

When it comes to protecting your pelvic floor, vagina, and perineum during labor and birth there are things you can do in pregnancy, positions you can use in labor, techniques you can use during pushing, and exercises you can do in recovery that will all have a positive outcome in the long run.

We’ve already talked about designing prenatal fitness routines emphasizing both the contraction and relaxation of the pelvic floor. And there’s one other thing you can do in pregnancy that may help protect your perineum: perineal massage.

Perineal Massage

Now this one is somewhat controversial because some providers are fans and others are not. When I ask midwives and doulas why they don’t spend more time educating pregnant women on the benefits of perineal massage, they’ll often point to a study done decades ago that only found a 10% reduction in perineal tears in first time moms that did perineal massage vs those that did not. While this may not be statistically significant, I think the benefits go far beyond the surface. And in order for me to explain further, we have to talk about the “ring of fire” for a second.

The “ring of fire” is the burning, ripping, tearing sensation (stick with me) that some women may feel as the baby’s head is crowning, referring to the final part of the 2nd phase of labor when the baby’s head (or whatever part is presenting first) becomes visible at the vaginal opening. This is the part of birth where the perineal tissues are being stretched to their maximum. While this sounds frightening, this is the same sensation you feel when stretching your hamstring muscles; it’s just not as scary since it’s a much larger, less sensitive area of the body. Although some birth helpers apply oils or warm compresses to this area during birth which can be helpful, it’s almost like trying to stretch your hamstring muscles for the first time at mile 22 of the marathon. And while warm compresses and oils will probably feel good on your hamstrings too, they won’t actually do much to make a tight muscle become flexible at that point in time. Because we know the demands of the “event” in birth, I think there is some value in doing some preventative stretching to get those tissues prepared for what they are going to be expected to do starting around 34 weeks of pregnancy. And that’s where perineal massage comes in. I describe doing this massage in detail and use models to help women visualize what this practice will entail. And here’s one last very important point to make. When you do a perineal massage, it will feel like the tissues are burning, ripping, tearing (sound familiar?) at first. After holding the stretching for 30-60 seconds, that sensation should go away completely leaving you with a feeling of almost numbness. If you don’t feel the strong sensation you’re probably not pulling hard enough, and if it doesn’t go away after 60 seconds you’re probably pulling too hard. But here’s the beauty of this practice. Once you’ve experienced the ring of fire sensation in your prep work (and more importantly its resolution), you will be less likely to panic when you feel the “ring of fire” during birth. When you are allowed to relax into the “ring of fire”, you can see this part of labor for what it truly is: your baby’s gift to you. Reread that. It’s a gift. Rather than shoot out of your vagina, leaving a path of destruction, your baby pauses and rests its head on your perineum, allowing your body to melt into the intensity of this moment. In this way, your perineum can gently unfold over the baby’s head like the petals of the rose slowly opening up, and (if your pelvic floor is in tip top shape) you can slide your baby out. Reread that. Slide your baby out.

Delivery Position

The position in which you deliver your baby matters as well. While many women mistakenly think squatting is the safest position for your pelvic floor, research does not support this. While squatting in short doses can help open the pelvis, squatting and bearing down for long stretches can create pressure problems like hemorrhoids or increased risk for pelvic organ prolapse. Research supports two positions for being protective to the perineum: side lying and the all 4’s position. The beauty of side lying is that it’s a position that almost every birthing person can assume with a little help, even if an epidural has been administered.

Knowing these are positions you may wish to assume in birth, it’s imperative that these are positions you exercise in leading up to birth so that you have the range of motion and flexibility (and muscle memory) to assume them in the midst of labor. The exercises in Week 3 of my Prenatal Pilates program have an extra emphasis on contracting and relaxing the pelvic floor in a variety of positions for this very reason!

"I have loved your class and it has been so helpful for me. I totally got what I wanted out of it and feel like I have such a better understanding of how to involve my pelvic floor and core in exercises and daily living. Thank you!!!!" –Sarah

Pain in Pregnancy

I met Swapna in a Prenatal Pilates group class several years ago. She was around 6 months pregnant at the time, and as we went around the room sharing everyone’s latest pregnancy updates, she shared that she had been experiencing back pain for the last 3 weeks that wasn’t improving. I knew she had recently seen her OBGYN, so I asked her if she brought it up. “My doctor said back pain and pelvic pain are normal because, after all, I’m 6 months pregnant.” Hmmmm. I’d love to see that listed in a textbook somewhere.

While discomfort in pregnancy can be common, it is NOT normal, and women’s reports of pain and discomfort should NOT be shrugged off with a “Well, what do you expect, you’re pregnant.” Pain is not a natural and expected part of the pregnancy process, and there’s a lot we can do as healthcare professionals to help relieve common pregnancy discomforts. We want you heading into labor and delivery feeling strong and capable; not limping into your big pain with a laundry list of aches and pains before you’ve even experienced your first contraction. There’s a lot that can be done to help women who are experiencing discomfort in their pregnancy from chiropractic care to physical therapy to massage and bodywork. And of course nutritious movement prescription.

In Module 4 of my Prenatal Pilates program, I discuss common pregnancy ailments and give some “try at home” remedies for each one. The most common pain complaints I saw in my 10 years in the clinic were by far sacroiliac joint dysfunction and pubic bone pain.

Sacroiliac Joint Discomfort

The sacroiliac joint is the area where the sacrum and ilium join. If you put your hands on your hips with fingers towards the front of the pelvis and thumbs pointing backward, it’s the area near your thumbs on each side. There are many reasons this is a hot button area for pregnant women. There is usually significant strain on the long posterior sacroiliac ligament and the short posterior ligament along with the sacrotuberous ligament. Asymmetries in typical movement patterns can also cause a sacral rotation that may contribute to pain in this region. Physical therapists are really good at addressing this region with a combination of manual therapy and exercise techniques.

Pubic Bone Pain

The pubic symphysis is the joint between your left and right pubic bones in front. Pregnancy hormones cause ligaments in this region to loosen and flexibility in this joint can contribute to discomfort here. Once again, encouraging symmetrical movements through the pelvis, stretching tight muscles that may be contributing to malalignment and using muscle energy techniques can be helpful.

The good news, most pain in the sacroiliac and pubic joints resolve with the birth of the baby. But until then, getting help from a healthcare provider trained in common pregnancy complaints will not only keep you comfortable but will allow the pelvis to be as symmetrical as possible which ultimately helps the baby have a clear path in the birth canal.

Maternal Supports

For both of these common areas of pregnancy pain, maternal sacral supports can be extremely beneficial to help provide some pain relief. I like to offer a show-and-tell of these braces in the module for Week 4 of the program. Most of the time, you know a brace is working if it causes instant relief. Of course, bracing alone is not the only answer, but it can be a bridge to relieve your discomfort enough while you are searching for the root cause. In the exercise portion of Week 4, I like to point out the specific purpose for each exercise. When I designed this exercise program, I held each exercise under a microscope of sorts. If it didn’t serve a specific pregnancy-related purpose, it didn’t make the cut. If there was something I needed to add to address a common pregnancy complaint, I found a way to work it in and then teach you why you were missing it!

“I just wanted to shoot a quick email and say thank you for everything in this week’s class! I learned so much, and I’m hoping to continue to improve as time goes on. I do so much better when someone explains why certain exercises are important and the body mechanics behind the workouts, and your sessions absolutely did that. It’s so much more motivating when I actually understand the “why.” Thank you again!” –Sarah

Labor and Delivery

Don’t get me wrong, I adore every week of this 6 week Prenatal Pilates program. They are all like my children, and I’ve poured my heart and soul into every one of them. A mother shouldn’t pick favorites, but…..the Week 5 Module on Labor and Delivery holds a special place in my heart. I think it’s because I share things in this module that linger in your mind. Listen, I’m a visual learner and those skills definitely came in handy when designing this section. While the other modules were based on my extensive education, this one was inspired by my own delivery experiences.

I took a series of Hypnosis for Childbirth classes that shaped the way I approached my own labors. And birthing my children with the knowledge that comes from being a women’s health physical therapist allowed me to see where my preparation (and 6 year degree and my hours of continuing education classes and the stack of books I read and the podcasts I listened to) left blanks to be filled in only after I had been through it and made it out on the other side. I started cataloging all the things I wish I had known or practiced; things that may have made labor easier or made my recovery smoother. And then I started incorporating some of that education into the patients I worked with to see if it resonated. When multiple women reached back out after their own births to say “I’m so glad you taught me x,y, and z” or “The things I practiced made a difference”, I knew I needed to put it into my program.

Stages of Labor

I like reviewing the stages of labor. The active phase of labor is when your cervix typically dilates from 1 cm (the size of a cheerio) to 7 cm (the size of the top of a soda pop can). This is when contractions typically get longer, stronger, and closer together, and positioning can be really important. Getting your baby to descend into your pelvis is almost like getting a key to fit into a lock. Sometimes you have to wiggle and jiggle it a little bit which is why being in upright positions that use gravity as your friend and utilizing dance like motions of your hips can be really helpful. Some suggestions would be to labor with your arms draped over your partner’s shoulders while you gently sway your hips back and forth. Another position that works well is sitting on a birth ball and making circular motions or figure 8s.

This is also the phase of labor where things may “stall” and your provider may start making suggestions for medications that can speed things up (a conversation for another day). Sometimes it’s a result of residing in your sympathetic nervous system or “fight or flight” system. You see, when your body thinks you’re in danger, it will prioritize saving your life over birthing a baby. Blood flow will leave your internal organs (and cervix) choosing to flood towards your periphery, preparing you to flee or fight for your life. But we need a rich blood supply in the cervix to help it continue to shorten and dilate in labor which is why it is essential to find ways to stay in your parasympathetic nervous system or “rest and digest” nervous system. The way to stay relaxed will differ for everyone. Maybe it involves the support team you’ve surrounded yourself with or the music you play in the background. Maybe it’s the lighting or the relaxation techniques you’ve practiced throughout your pregnancy. Being able to calm your mind and body is so essential that I filmed 5 special video meditations (that took months of research and two weekend long continuing education classes) that I include in my Prenatal Pilates program. Because when you let fear take over, it creates a vicious loop. Fear creates tension in the body and that tension creates pain which leads to more fear. It’s no secret that this Fear Tension Pain (FTP) cycle is often responsible for the number one reason the cascade of interventions might need to be introduced due to what is often labeled as “failure to progress” or FTP. Coincidence? I think not.

The second stage of labor is the transition/pushing phase of labor where your cervix will dilate from 7 cm (size of a soda pop can) to 10 cm (size of a bagel). There is a hallmark emotion that goes along with this stage of labor, and that is doubt. With each of my labors, there was a “come to Jesus” moment where I grabbed my midwife and made her look me dead in my eyes because I didn’t think I could do it, and I needed her reassurance. Had I known that this overwhelming doubt in my abilities was actually a sign that I was close to meeting my baby, I think I would have welcomed the doubt and felt comforted by it.

In addition to there being hallmark emotions in this stage of labor, there are hallmark positions that your pelvis shifts into to help your baby move through the birth canal. And the positions you assume in labor can work for or against you. We talk in Week 3 about the benefits of side lying and all 4s to protect your pelvic floor, but in this module I like to remind women why the standard dorsal lithotomy position might make it harder to work with your body to birth your baby.

How to Push

I also think the way we cue women to push can make a big difference. This is another controversial topic. I did an entire webinar on How to Push and got several angry comments about how women shouldn’t “push” their babies out, but instead they should rely on the fetal ejection reflex which is when the body expels the baby involuntarily without forced pushing. I agree!!! In a perfect world, we could rely on this reflex, also known as the Ferguson reflex. But in order for that to be reliable, there needs to be 3 factors working in complete harmony. (1) A mother must feel well-rested, well-fed, supported by her birth team and safe in her environment. (2) The baby must move through the birth canal in perfect cardinal planes. (3) The contractions must be powerful and productive. If any one of these three essentials is out of whack, we are looking at a situation where a pregnant person might need to be coached to push.

With all three of my births, the cues I was given involved some version of “bear down in your bottom like you’re going poop”. Now, because we’ve all pooped before, that cue can be helpful AT FIRST to help a woman connect to the proper region. But, and this is a BIG OL BUT, once she has a vague idea of the muscle group being utilized, it is imperative to change the cue. I’m a rule follower. So I pushed like I was pooping for all three of my labors. And I probably actually pooped on a few occasions. But when giving birth to my third child who was 10 pounds with a head in the 95th percentile, this cue to push like I was pooping certainly did more harm than good. In the days following that birth, things didn’t feel right down there. Finally I asked my husband to please take a look for me. I pulled down my pants and bent over and his statement is forever burned into my brain. He said “Something is hanging out of your butthole and it looks like a tiny head of cauliflower.” Turns out it was the combination of a rectal prolapse with a few angry hemorrhoids. When we ask women to bear down hard in their bottom while pushing, we are doing them a disservice and we are giving them cues that go against basic anatomy principles. There may only be a few millimeters from the vaginal opening to the anal opening, but I would argue that changing the direction of the push and cueing the right “hole” can make a huge difference in the quality of the push and the ability for the woman to recover afterwards.

When the baby is descending into the birth canal and emerging from the vaginal (not anal) opening, it usually takes the path of the letter “J”, dipping down underneath the pubic bone and then emerging from the vaginal opening (not the anal opening) in cervical extension. Asking women to visualize this “J” shaped path while pushing with cues to “bring your baby’s head toward the sky” can help them direct the push towards the proper orifice. 

GRAB MY FREE HOW TO PUSH WEBINAR HERE:
https://www.carriekoziol.com/prenatal_how_to_push

How to Breathe

And speaking of breathing, there is a better way to breathe during pushing. If you’ve watched any Hollywood movies you’re probably used to hearing women coached to take a big breath like they’re going underwater, hold their breath, and then bear down hard in their bottom (which we’ve already addressed above) while a nurse counts down from 10 to 1. The camera pans to the birthing woman/actress who is usually red-faced with jaw clenched as she screams some profanity at the birth partner for “getting me into this mess.” You get the point. That is known as “purple pushing” and for a whole host of reasons, it is not the first choice for breathing techniques.

When you breathe with a forced inhalation like that, the diaphragm acts like a plunger that descends down in the abdominal cavity making it the “driver” of the push. But when you breathe during an exhalation, the diaphragm rises, allowing the muscles closest to the uterus to be the “drivers” leading to a much more accurate push. Pushing with an exhalation sounds like this: Take a deep breath in through your nose, direct the breath to the back of your throat, and then exhale as you breathe down behind the baby and all the way around towards your pubic bones. Not only is this a safer push, but it follows the “J” path the baby takes making it a beautifully orchestrated and coordinated effort between the diaphragm and pelvic floor. (***Note, the forced inhalation “push as hard as you can” push does have its usefulness. In the event of an emergency it can be a very effective way to get the baby out as soon as possible. Just keep in mind that rarely is a push like this really needed).

Sidenote on Birth Plans vs Birth Preference Lists

All the things you learn in my program, things like how to push and how to breathe and what positions to use in labor, can be “hot air” if the birth team you’ve assembled is not on board. You will usually have a conversation about how you want birth to go with your provider around 34 weeks or so. But if you plan to give birth in a hospital setting, you will mostly be interacting with the hospital staff and labor and delivery nurses who may not be privy to your wishes and desires. That’s where a birth preference list might come in handy. Listen, I’m a planner. So for me to tell you to “ditch the plan” is very out of character. I’m not saying abandon the idea of thinking about your birth and how you might want it to go. Not at all. But a plan sounds so finite, so definitive, so written in concrete and the very nature of birth requires you to be open to paths that might deviate from the one you’ve carved out in your mind. Instead, think about writing down a birth preference list. This gives you and your partner an opportunity to convey your wishes to the birthing staff while leaving the flexibility that might be necessary to have a positive birth experience.

Sidenote on Doulas

According to DONA (Doulas of North America), “Like travel guides in a foreign country, birth and postpartum doulas help support new families through the life changing experience of having a baby.” Think of a doula like your own personal birth coach; their focus is solely on you. For women with reluctant partners, my friend and doula extraordinaire, Nicki Worden says it best: “Your partner knows you best, and a doula knows birth best, so together we make a great team.” A doula’s job is to include your partner in the big day and act as the “middle man” between your wishes and the duties of the birth team. After years of working in the birth space, I think one of the best things you can do to try to achieve the birth you want is to hire a doula. If it’s not in your budget, research doulas in training as they often offer significant discounts.

Module 5 is my favorite because it’s the one I get the most feedback on from women after they’ve given birth. They tell me their birth team was shocked at how well the pushing went. Or have never seen a client that in-tune with her body. Or the women report healing much quicker than with previous births where they didn’t use the breathing and pushing techniques they learned here. When we take the time to teach women how their bodies work, the outcome is revolutionary.

 "I can’t thank Carrie enough for her help and recommendations- this has been BY FAR my best pregnancy, delivery, and recovery and that has so much to do with her help!"--Monica

"My labor and delivery was fast and I pushed him out with NO VACUUM AND NO HEMORRHAGE!! (My previous two children were both vacuum and one hemorrhage) Hooray!!! I feel like my labor and delivery was much more successful because my core was prepped and ready, I knew how to correctly push, and I was able to channel that each contraction brought him closer to me. Carrie, you are AMAZING! I am so grateful for your class and support! If you’re pregnant, get yourself signed up for Carrie’s prenatal class- you will NOT regret it!! "--Brittany

"I've been doing really well after this pregnancy--probably the best I've ever been post-partum. I think a lot of it has to do with how in shape I was this time around... I think that the strategies that you talked about regarding labor really helped me. I didn't hardly tear this time, and feel that I pushed correctly for the first time. And I was bouncing around feeling great only days after. I think it really makes a difference to understand your body and how it works." -Sara

“Your classes and advice were seriously life changing. I went from wishing to have a planned C-section to have 3 unmedicated births. Your knowledge and tips are things that forever changed me.”—Kate

The Missing Piece

My goal in designing the 6 week Prenatal Pilates program was to give women a comprehensive and complete look at pregnancy and birth while filling in the gaps in education and exercise that I knew they weren’t receiving in their standard care. It’s only as a result of being in the trenches with pregnant women for over 15 years (and being in the arena three times myself) that I was able to identify the bridges that were needed to help women have better outcomes. Combining the education with the expertly designed exercises was a seamless way to leave women feeling empowered and prepared for their big day. There was just one missing piece.

Postpartum Recovery

I saw Neha just 6 days after she gave birth. She came into the clinic tired and sore and utterly confused. She had been leaking urine since her vaginal delivery earlier that week and was shocked that she was still bleeding. She felt unprepared and overwhelmed, and in addition to trying to heal her own body, she was also trying to keep a tiny human alive. It was all too much.
I kept hearing from women that they felt totally unprepared for the 4th trimester or the six weeks after delivery. The standard of care is for women to return for a postpartum check up 6 weeks after giving birth, which means for those initial 6 weeks they felt isolated, alone, questioning, and confused. There’s so much happening in the minutes, hours, and weeks after birth, and we do women a great disservice by leaving them alone on an island to figure everything out. That’s the motivation behind Module 6. I wanted to teach women what to be prepared for from the minute they delivered their baby until they had their 6 week check up.

When we talk about the stages of labor, it’s important to understand that Stage 3 is the delivery of the placenta which can take up to 30 minutes after the birth of the baby. You may be asked to supply a gentle push but this stage of labor should not be rushed nor should anyone be tugging on the umbilical cord to urge the placenta out sooner. After the placenta is delivered, the uterus should contract to the size of a grapefruit but is often still palpable above the level of the pubic bone. Your nursing team may massage your abdomen to help with uterine involution and this can be uncomfortable at times. With adequate rest it should descend below the pubic bone in a few weeks. Afterpains are strong, menstrual-like cramps that occur as your uterus begins to contract back to its usual shape. Afterpains intensify with breastfeeding and with each subsequent pregnancy.

Bleeding may resemble a heavy period for the first few days and it would not be abnormal to experience a “gush” especially with position changes or to pass a few small clots. Blood color will go from red to pink to brownish and will last for 2-6 weeks. Abnormal bleeding would be saturating a pad in 2 hours or less (vs 4-6 hours), or bleeding that slows down but then picks back up, or cramping and clotting after the first few days. Other reasons to reach out to your provider would be foul smelling vaginal discharge or running a temperature.

It is not abnormal to experience a strong urge to urinate and then to notice that you may be urinating before you make it to the bathroom. Thankfully you are usually wearing a heavy pad. During a vaginal delivery, your pelvic floor muscles and perineum have endured an extreme stretch. This overstretching in combination with the swelling and presence of potential stitches, may result in decreased ability to contract the muscles responsible for closing your sphincters in the first few days after delivery. Your body has an amazing ability to heal and that should improve within the first week or so. If it continues or worsens, talk to your provider and see if you can get a referral to see a women’s health physical therapist.

Latrice was a client who took my Prenatal program very early on in her pregnancy. She loved it so much she took the whole 6 weeks again and swears she heard things the second time around that landed differently. She was really concerned about her recovery and spent just as much time planning her 4th trimester as she did thinking about her birth plan itself. I encourage all my clients to plan for their recoveries. In Latrice’s case, we worked together to pick out a postpartum binder she was planning to wear for the first 6-8 weeks after delivery. Binders can be helpful to help create the tension that is necessary for healing while providing a proprioceptive cue to encourage better posture. They should be applied as demonstrated in Week 6 of my Prenatal Pilates program and not used as a stand-alone solution but rather in conjunction with the appropriate recovery exercises. By the 6-8 week mark, it’s time to remove the binder and restore your core strength. Deep breathing and gentle, isometric deep abdominal and pelvic floor exercises can be started in the first few weeks after a vaginal delivery. I recommend waiting until your 6 week check-up to receive clearance from your OBGYN before resuming exercise after a C-section.

Sidenote on C-sections

If I had more space in my course, I would dedicate one whole module to C-section education. The fact of the matter is, most first time moms do not schedule a planned C-section yet the C-section rate in the United States averages about 32.1%. That means almost 1 out of every 3 births ends in a C-section. Sometimes that is just the way your baby was meant to come into this world, but sadly many C-sections can probably be prevented with better education and preparation by taking workshops and programs like this one.

Unmedicated, vaginal births get placed on a pedestal that I’m not sure they entirely deserve. The true heroes of birth, in my opinion, are the women who labored to the best of their ability and then ended up with a C-section they weren’t planning on. Remember, a C-section is a major surgery and will require more rest and recovery than a vaginal delivery so plan appropriately. Sometimes constipation and gas can be a real bugger after abdominal surgeries like this one. Chewing gum after surgery may help your digestive system to get back on track.

Remember, after a C-section you have 2 incisions: the external one you can see and a much deeper incision made through the uterus to help retrieve the baby. Once full soft tissue healing has occurred (usually 6-8 weeks) these scars need to be addressed with skilled manual therapy techniques. Find a physical therapist trained in visceral massage or look for a Maya Abdominal Massage therapist in your area.
 

We made a list of “jobs” Latrice was going to need to outsource to someone else for at least 4-6 weeks that included meals and house cleaning. She built a nursing “throne” which is a special area (one on the first floor and one on the second) where she planned to spend a lot of time feeding the baby. She purchased a nursing pillow for each area, had a little side table all set up for her phone and water and book and remote controls, and spent some thoughtful time on choosing a chair that provided optimal back support. We talked about body mechanics and problem solved how she would do repetitive tasks like change diapers and give baths in positions that honored her body’s natural curves. And we even designed a 6 week recovery plan for gentle exercises, most of which consisted of rib mobility and breath coordination and gently nudging her deep abdominals and pelvic floor muscles back to life. As a result of her active involvement in her recovery planning, Latrice sailed through the 4th trimester with flying colors. These same tips are the central focus of the Week 6 module in my Prenatal Pilates program because I want you to sail through too!
 

"Carrie is an inspirational and knowledgeable instructor. She has a thorough knowledge of the recovery needs of a postnatal body, and teaches women how to protect, heal, and recover their bodies after childbirth. The structure of the class was lovely; I really enjoyed the discussion/education time before doing the Pilates. Carrie puts such an effort into helping women transition into motherhood with their whole lives, not just their physical recovery. This is a class (Postnatal Pilates) EVERY woman should take after giving birth and I'm so glad I found it."
-Katie, RN (Labor and Delivery), IBCLC (Lactation Consultant), CCE (Certified Childbirth Educator)

Over the years I’ve heard hundreds of birth stories. Many of them quite positive and memorable, and many of them….disappointing, lacking, not what women expected, and occasionally even traumatic. I’ve learned through the vulnerability of women who were willing to share their hearts with me that a positive birth story isn’t just defined as one where the mother and baby were healthy and well. It didn’t have anything to do with whether the mom had an unmedicated vaginal birth or was induced or had an epidural or ended up with a C-section. And it rarely mattered if she gave birth in a hospital, birth center, living room, bath tub, or car on the side of the road. What mattered most was that the mom felt like an empowered part of the decision making process that led to the birth of her baby (however that baby arrived). And while assembling a supportive birth team is wildly important, feeling empowered and prepared is just as important. Empowered doesn’t mean having all the answers. And prepared doesn’t mean having a 10 page birth plan. Empowered and prepared are actionable steps you take during your pregnancy to educate yourself about the possibilities and train your body to birth your baby. That is the entire mission behind my 6 week Prenatal Pilates program, and I challenge you to find a more comprehensive program that combines education and exercise so that you can approach your delivery day with the confidence and strength that you did everything you could to tackle the most miraculous feat your body will ever accomplish.