Horse-riding and the Pelvic Floor in Birth

UK Midwifery Archives


These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.


Does horse-riding affect the pelvic floor?

I worked a late bank shift yesterday, taking over the care of a woman called Jill, just as her cervix was fully dilated. First baby. Spontaneous onset of labour and good progress subsequently. Entonex and Pethidine. ARM at full dilatation by midwife handing over care.

Introductions over, we settled down to wait for the urge to push… An hour passed (rest of labour ward very busy – forgot about us). I did a VE – no cervix, head at spines, baby OA. Another hour passed. J mobilising happily, well hydrated, adequate contractions. FH good.

Senior midwife “suggested” J commence active pushing. She did, nice and gently, in various positions. Still no urge. Contractions maybe weakening slightly. More time passed.

Senior midwife suggested more focused active pushing. J happy to do so as well fed up by now. Tried every position under the sun, and then some more. She pushed and she pushed and she pushed. No external progress. No urge to keep pushing. Another VE – head a bit lower, small caput, otherwise fine. FH good throughout.

Enter Registrar. VE – confirmed my findings. No reason she couldn’t deliver her baby spontaneously. Syntocinon. Legs in lithotomy. Local anaesthetic. Pelvic floor completely unyielding. Push. Push. Push. FH dipping. Episiotomy – even though head still not distending perineum. FH fine. Two more pushes. Baby born. All well. J and partner delighted – especially because she “did it herself”.

Chatting during suturing (as you do). J learnt to horse ride almost before she learnt to walk. Rides every day. I’ve always had it at the back of my mind that horse-riding strengthens the pelvic floor muscles – but have never seen this so vividly in practice.

I’ve been mulling all this over, but am still puzzled by several aspects -so would really appreciate people’s views:

Do you think that J’s difficulties in the second stage can all be attributed to horse-riding?

Why did J feel no urge to push? Is there anything else I could have done before everybody else got involved?

I detest the lithotomy position with every fibre of my being, but several people commented afterwards that “it always helps”. Is this true? Why/how?

Hannah, midwife


Senior midwife ‘suggested’ J commence active pushing. She did, nice and gently, in various positions. Still no urge. Contractions maybe weakening slightly. More time passed.

If she had no urge to push, as Mary Cronk would say: ‘Rest and be grateful’ Why encourage her to push when she had no urge? Why not wait and see and put a door stop under the door? Or is it that the hospital is more concerned about the time she is in the labour ward and wants her out as soon as possible?

Beverley


I detest the lithotomy position with every fibre of my being, but several people commented afterwards that “it always helps”. Is this true? Why/how?

I wonder:

Who were these people commenting? What is their overall experience of birth? I am willing to answer my own question, place money on the bet that they are people who usually witness only “obstetric” deliveries, ala Beverley’s brilliant definition. To the extent that this position “helps”, couldn’t it be just because in that position it is easier for the obstetric types to do THEIR thing?

Laura the cynic in NYC


Yes, you’re right, us horse riders do have a reputation for unyielding perineums – specifically any of us who do dressage or long distance, more time spent in the saddle toughening up that perineum you see. I hassen to add that this is not based on any RCTs (randomised, controlled trials), just purely anecdotal!

This is very similar to a lady I recently looked after. She also was a horse rider and had been riding since early childhood. Once she was in lithotomy with episiotomy her lack of progress was also rapidly resolved. When looking at the lithotomy position I wondered if it mimics the position of the riders legs when mounted on the horse. Perhaps the muscles of the pelvic floor develop around the riding position if you see what I mean? I think the episiotomy was the effective part of the equation. I too was amazed that the pelvic floor muscles could become so strong that they would not give to allow delivery of a baby.

Hannah


Just a quick thought – It sounds like Jill progressed nicely until the ARM. Why meddle at that point when everything had been so normal? Sounds like her contractions went off then, even though you describe them as “adequate”.

I have read some research (ages ago, sorry no references) that women who undertake regular aerobic exercise are more liklely to end up with CS -thought to be linked with “unyielding” pelvic floors whilst women who undertake relaxation and yoga have more vaginal births. Haven’t read anything about horse riding but wonder how they fared in the wild west?

Susie


<< If she had no urge to push, as Mary Cronk would say: ‘Rest and be grateful’ Why encourage her to push when she had no urge? Why not wait and see and put a door stop under the door? Or is it that the hospital is more concerned about the time she is in the labour ward and wants her out as soon as possible? >>

Sadly, Beverley, This attitude is seen in most labour wards throughout the country. I’m sure the midwife involved (whose name escapes me) was well aware of the research but was constrained by the medicalised approach to the guidelines that exist on many labour wards. It is all very well knowing that good practice means looking at the research that says this is the ” rest and be thankful” phase and it is a normal part of labour which should be left to run it’s course if all is well with Mother and Baby. It’s quite another thing to justify it as a midwife when all the more senior collegues are telling you to “call the doctor this isn’t normal” and reminding you that you are acting against all guidelines. Most of us want to fit in and be seen to be doing the right thing and this is where problems occur. I personally hate the way most labour wards in this country are run which is why I work in the community ( at homebirths no one tells me what to do apart from the woman and I am guided by her) where I can give a decent standard of continuity of care and treat women as individuals. However, having worked in hospital labour wards on and off I have alot sympathy for the more individually and research based midwives who have to work within such rigid guidelines. Thankfully, there are organisations such as the NCT and AIMS around to back us up or I think I would go mad. It’s interesting that I don’t feel “constrained” to work within hospital guidelines when I am in the woman’s home. A case for encouraging more homebirths perhaps.


Thank you for replying to Beverley’s message on this point. I agree with what you say about senior staff and so on.

However, there is another bit to the equation – the mother’s wishes. If she is desperate to *do something – try anything* then that is also important. It’s not just our show.

And don’t forget, Beverley, this woman had been waiting (with the support of everybody on the labour ward) for the urge to push for several hours (as described in my original account). The point I was offering for debate was the fact that she simply didn’t seem to be getting that urge – in spite of descent of the baby’s head. I am beginning to think this was related to the state of her perineal muscles – some basic dulling of the normal reflex, maybe?

I hesitate to offer personal experience because it is usually not helpful/representative, but I never felt the urge to push *at all* with any of my babies. I rode a lot in my youth, and now wonder whether that had anything to do with it. I gave birth spontaneously each time, but only after several hours of very hard work…

Hannah, midwife


Like many ‘radical’ midwives, I’ve been there, just like Hannah. You cannot imagine the pressure of day in, day out, being up against the ‘might’ of the establishment on a delivery suite. Especially once they’ve spoted that you are ‘radical’. I almost completely burnt myself out by constantly supporting women in my care against the ‘guidelines’. I left – it was too much every shift. I now thoroughly enjoy giving proper care to women in the community without a Doctor or Sister breathing down my neck! I don’t know what the answer is, but I can assure everyone, it’s too much to ask that the few ‘radicals’ on Britains’ labour wards change the system. I now prefer to do good by stealth!

L


.It’s often down to compromise. I could have refused to have “got her pushing”, and just gone home at the end of my shift. She would then have had another midwife caring for her, maybe one with completely different views and attitude. As it was, I take some pride from the fact that, in spite of everything, I nurtured her throughout – listening to her views, protecting her from unpleasantness and discord, helping her to do what she wanted, praising her efforts, keeping her going – until she gave birth *herself*.

I recall a long thread about the effect of fight/flight hormones on labour on this list a month or so ago. I dread to think what effect the fall-out of putting a doorstop under the door would have had on J’s peace of mind, the course of her labour, her respect for the staff – and her memories of the event.

Quite apart from the fact that I needed to go to the loo occasionally.

Hannah, midwife


They were talking about this not so very long ago on the Alaska list. There were a couple of midwives who said the only epis’s they had cut in many decades of practice were to women with ‘perineums of steel’ who were either horse riders or did an enormous amount of gym-type aerobic exercise (as opposed to running or cycling or whatever.) And they were not talking about one hour second stages either – they often have women pushing for many hours. Research anyone?

Sara


Ah, yes. But from some dissolute experiences in my youth, also purely anecdotal, may I say that lovers who were also riders did have a certain pelvic flexibility which enhanced certain estatic sensations! Probably acquired from all that posting. Wondering if that could also enhance fertility? Ah, on with some more research.

Rayner (Male, non-midwife!)


In this instance I feel that lithotomy, by stretching the perineum, enabled an episiotomy to be performed long before it would have been possible in other maternal positions. And it was the episiotomy that was needed.

The ARM was done by the midwife who had cared for J up to that point. I personally would not have done one at that point, since I believe that SROM happens when the time is right. It would also have given me something else to offer J later on!

Hannah, midwife


Then Laura wrote that perhaps lithotomy is for the convenience of the doctors – to do their thing…

I have seen it work brilliantly too, with women who have been trying to push, unsuccessfully, in a semi-recumbent position. Sliding flatter on the delivery bed and raising her legs must free the pelvis/tailbone to move as they should….. think of the number of times women try to lift their bottoms off a bed when trying to deliver a baby sitting down. Some midwives shout “Keep your bottom on the bed, chin on the chest…” etc – I say, stand up, try hands and knees, or simply MOVE – give this baby room to get out and it’ll come! So I figure lithotomy isn’t just for the convenience of the docs…it helps women out the second stage delays we sometimes allow to happen.

my two cents…

Carol J.


Yes – as in McRoberts position for shoulder dystocia. Until a recent RCM study day on the subject, I didn’t realise just how flexed the woman’s legs have to be for this to be effective.

However, I’m now convinced there was no bony impediment to J’s progress in the second stage – simply perineal. She’d tried every posture in the book (and many without) – including “stepping” – which usually has a magical effect. And, towards the end, J *wanted* to lie down. It was as if her body realised (long before I did) that everything else was a waste of effort.

I so agree with what you say about movement. I rapidly learning that there is no one ideal position for labour – it’s the ability and freedom to move that counts.

Hannah, midwife


Do you think that J’s difficulties in the second stage can all be attributed to horse-riding?

This is always going to be so hard to isolate – we all want to look for reasons why things did not turn out as planned. If this woman didn’t ride, what would the other possible explanations have been? It’s certainly not the case that all keen riders have difficult second stages (I know you weren’t suggesting that), as my mother was winning prizes in a horse show 3 days before I was born (approx a month late…)! She had a horrible induced labour but a good second stage and just a tiny tear, which she is still proud of to this day.

I can imagine that riding might do some peculiar things to your pelvic floor, but it should also have some very positive effects, such as encouraging good upright postures as far as foetal positioning is concerned (try slumping on a horse and see where it gets you!), awareness of the pelvis and body movements, etc.. , so to reassure this mother (and other riders), it might be worth stressing the positive side of their exercise as well as encouraging yoga, perineal massage, and other things that might help relax the pelvic floor.

Angela


I have read some research (ages ago, sorry no references) that women who undertake regular aerobic exercise are more liklely to end up with CS – thought to be linked with “unyielding” pelvic floors whilst women who undertake relaxation and yoga have more vaginal births. Haven’t read anything about horse riding but wonder how they fared in the wild west?

Susie


I’ve heard mention of this before – women saying that they had to have a c/s ‘because I was so fit, my pelvic floor was just too tight.’. While this may be a great comfort to mum, it doesn’t ring true to me. If it was just the pelvic floor that was the problem, wouldn’t an episiotomy sort the problem?

No – this doesn’t make sense to me either! – Hannah, Midwife

Or could it really halt progress so far up the birth canal that episiotomy and the dreaded assisted delivery was not an option? Presumably it shouldn’t affect the rate of dilation in any case?

No – didn’t effect dilation (very quick progress, in fact) – but certainly seemed to slow things down long before the head was on the perineum – unless the perineum was unusually thickened… – Hannah, Midwife

I wonder if instead, a history of regular aerobic exercise is linked to the baby’s position. In ‘understanding & teaching OFP’, Jean Sutton mentions that women who have very tight abdominal muscles may be prone to posterior babies in their first pregnancy as there is less space at the front of the uterus for the baby’s bulky back. It is a lot easier to understand how a higher rate of posterior babies could lead to a higher rate of caesareans.

Angela


I’ve had a very different experience of horse riding in a family. All sisters pushed out babies without delay or damage. However it may be interesting to note all had varicosities so that may have helped!

Heather


The only time I remember doing an episiotomy ‘for a rigid perineum ‘was in the case of a woman who was an avid horse-rider. the labour progressed beutifully up to that point, just as Hannah described it. Are there other solutions out there?

Soo


I wonder whether an osteopath would be able to help, if treated in pregnancy? The reason I suggest this is because the osteopath I visited performed a rather worrying technique to test my pelvis floor – with me on my side, 2 fingers applying increasingly deep pressure on perineum, just to side of seat bone. The idea being that the pelvic floor relaxes as it is stretched. My pelvic floor was too firm on one side, so she recommended I stopped doing pelvic floor exercises. She showed my husband how to do it, as it is supposed to speed up dilation. If you know you have a client who is a keen horse rider it might be worth checking out.

Tikki


I hesitate to offer personal experience because it is usually not helpful/representative, but I never felt the urge to push *at all* with any of my babies.

I understand the hesitation, but personal experiences often highlight the wide range of ‘normal’ and sometimes they alert us to something that is widespread but each woman thought she was the only one. For example, a personal experience of one woman approaching AIMS saying that she had been conscious during a caesarean section under general anaesthetic resulted in AIMS alerting the medical and midwifery profession that this was a not uncommon complication! Until we raised the issue everyone believed that it did not happen and those women who reported it were told that they dreamed it and they were the only ones who had ever experienced it.

Beverley Lawrence Beech
AIMSUK@aol.com
www.aims.org.uk


AH updated 13 July 2000


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Posted on

April 12, 2013

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