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'Let the blood flow'- the increase in blood flow during pregnancy.

'Let the blood flow'- the increase in blood flow during pregnancy.

Why all of a sudden do you feel like it is 3 x harder to walk up a hill or a stairwell, or why has your iron levels dropped?

Blood volume increases significantly within the first few weeks of gestation and increases progressively throughout the pregnancy. The total blood volume increase varies from 20% to 100% above pre-pregnancy levels, usually close to 45% of average woman. 

"A healthy woman bearing a normal sized foetus, with an average birth weight of about 3.3 kg, will increase her plasma volume by an average of about 1250 ml, a little under 50% of the average non-pregnant volume for white European women of about 2600 ml. There is little increase during the first trimester, followed by a progressive rise to a maximum at about 34-36 weeks, after which little or no further increase occurs." (National Library of Medicine) A non-pregnant woman has about 100ml of blood per minute flowing through the uterine artery, but in early pregnancy this increases to about 120 ml per minute. Once a woman is close to her due date, the blood flow has increased to about 350 ml per minute.

Interestingly enough the research shows that physically active women possess significantly greater vascular volumes than their sedentary counterparts.

WHY DO WE GET AN INCREASE

Pregnancy requires dramatic changes in blood flow, the most obvious being that which occurs in the uterus and the development of the placenta to make a baby grow.

WHAT OTHER THINGS HAPPEN AS A RESULT OF THIS INCREASE?

  • Blood flow to the skin increases, making a newly pregnant woman feel warmer and perhaps sweat more, particularly from her hands and feet.
  • The increase boosts the body metabolism by about 20%, creating more body heat and making pregnant women less likely to feel the cold the body temperature will often rise to about 37.8 C degrees. (Normally 37)

So if you are feeling light headed, having nose bleeds or bleeding gums there could be a very likely reason....THE BLOOD FLOW has INCREASED..

 

Prolapse and Exercise - so what is to know?

Prolapse and Exercise - so what is to know?

What is Vaginal Prolapse?

Usually our pelvic organs (bladder, uterus and bowel) are supported by a hammock of connective tissue and muscles. If this support system isn’t working as it should, it can lead to one or more of these organs descending into the vagina, which is called a ‘vaginal prolapse’. 

A prolapse can be categorized into different types – a front (or anterior) wall prolapse, which is the bladder or urethra coming down, a back (or posterior) wall prolapse, which is the rectum or small bowel coming down, or a uterine prolapse, which is the womb dropping down. It is still possible for the top of the vagina to drop down if someone has had a hysterectomy. 

It often seems to be assumed that it’s the uterus that most commonly drops down, but actually the front wall of the vagina is the most common type of prolapse to occur. 

Prolapses can also be divided into ‘stages’, depending on how far down the lowest part descends when you do a maximal downward strain:

  • A stage 1 prolapse means that the lowest part of the wall/organ is still more than 1cm inside the vagina 
  • A stage 2 prolapse means that the lowest part of the wall/organ is between 1cm inside and 1cm outside the vaginal opening. This stage of prolapse, when the organ descends to the opening, is often when women become aware of their prolapse for the first time. 
  • A stage 3 prolapse means that the lowest part of the wall/organ is more than 1cm outside the vaginal opening
  • A stage 4 prolapse means that essentially the whole organ has come outside the body – this is relatively rare. 

 

How do I know if I have a Vaginal Prolapse?

The symptoms of a vaginal prolapse are different in everyone, and it’s important to note that sometimes people with mild to moderate prolapses don’t have any symptoms. 

The most common symptoms are:

  • A bulging sensation (or being able to see a bulge) or a feeling of ‘something being there’ in the vagina
  • A feeling of not being able to completely empty the bladder or the bowel (usually because the prolapse is causing a sort of ‘pocketing’ making it difficult to evacuate).
  • Lower back or lower abdominal ‘dragging’ pain

Sometimes women can complain of a ‘heaviness’ or ‘pressure’, but this needs to be confirmed on diagnosis as this can also be a symptom of over-worked, tired pelvic floor muscles. 

Sometimes prolapse can be associated with discomfort with sex, and sometimes with bladder or bowel leakage, but again – this isn’t always the case and should be confirmed on a physical examination, because there are many people who have these symptoms without having a prolapse. 

The health professionals who work specifically in the area of Women’s Health are best placed to make this diagnosis – gynaecologists, Women’s Health & Continence Physiotherapists, or Continence Nurses. However, your GP is a good place to start and many GP’s will have a vast degree of experience in diagnosing and staging prolapses, and can then refer on to one of the aforementioned professionals for further management. 

 

How common is a Vaginal Prolapse?

Unfortunately, it’s very common for women to experience vaginal prolapse, mainly due to our anatomy. We are animals that stand upright, and have a large proportion of our body weight going through our pelvis, but we also need a wide pelvic opening to be able to birth very large offspring through!

That mix of a large pelvic opening with a heavy load on top of it is unfortunately not ideal for supporting pelvic organs.

Studies have shown that up to 50% of women who have given birth will have some degree of prolapse, with other research showing that 1 in 3 women will have a prolapse that extends at or beyond the vaginal entrance (ie a stage 2 or more prolapse). 

Unfortunately, there is a high proportion of women who will require surgery for either prolapse or stress urinary incontinence. Statistics show that 1 in 9 women will undergo one of these surgeries, which are not without risks and have relatively high recurrence rates. 

 

What factors increase your risk of Vaginal Prolapse?

The main risk factor for prolapse is having had one or more vaginal births, with specific risk factors including:

  • Forceps deliveries
  • Giving birth to a baby over 4kg (9 pounds)

Prolapse is not limited to only those who have delivered babies vaginally, however, with other risk factors including:

  • Pregnancy
  • Family history of prolapse
  • Increasing age
  • Increasing BMI
  • Constipation
  • Chronic Cough
  • Heavy lifting

The main reason that pregnancy and vaginal childbirth are risk factors is because of their effect on what is called the ‘levator hiatus’. This is the name for the space in the pelvis between the two sides of the pelvic floor, and is essentially ‘the gap into which things can fall’. 

Studies on women who have recently given birth show that this ‘gap’ in usually increased from normal for up to 4-12 months after having a baby. This is one of the main things that Women’s Health Physiotherapists will assess for when doing a vaginal examination at a postnatal assessment, because it helps to determine your individual risk for prolapse occurring or worsening with return to higher load or impact activities. 

This ‘gap’ would be increased more significantly, and more permanently, if the woman experienced a birth injury called a ‘levator avulsion’. This means one or both sides of the pelvic floor muscle having a partial or full tear away from the pelvis bone. This can also be assessed for with a vaginal examination. 

 

How is Vaginal Prolapse managed without surgery?

Pelvic Floor Muscle training, under the guidance of a physiotherapist with post graduate qualifications, is recommended as the first line of treatment for vaginal prolapse. 

We probably assume that this training is all about improving the strength of the pelvic floor muscles (measured out of 5), but studies have shown only a minimal link between a woman’s maximal squeeze pressure improving and prolapse improving. 

This makes sense, because a vaginal prolapse needs to be supported all throughout the day while you’re in an upright position, but we probably only maximally squeeze our pelvic floor muscles for 1% of the day – at times like in response to a big sneeze or lifting something that’s heavy. 

Instead, it is more likely that pelvic floor muscle training helps to decrease prolapse signs and symptoms because it improves the ‘stiffness’ and support of the area, and it decreases the ‘gap into which things can fall’ (the levator hiatus) both at rest and under load. 

Other management strategies would include:

  • Teaching women how to empty their bladder and bowels effectively and without straining
  • Determining if symptoms can be improved by incorporating rest periods in ‘anti-gravity’ positions throughout the day
  • Weight loss 
  • Exercise modification
  • Use of support pessaries

 

What is a Vaginal Support Pessary?

Vaginal pessaries are devices worn inside the vagina that help to give support to the vaginal walls. If fit properly, they should give symptom relief, be comfortable and should stop a prolapse from descending. 

They can be a huge help for women with prolapse who wish to remain active or become more active. Pelvic Floor Muscle Training, while essential in the overall management of prolapse, can take a long time for symptoms to improve. Pessaries could be used in a ‘stop gap’ role to prevent further descent, and possibly give feedback on what types of things cause descent to occur, while concurrently working on pelvic floor training.

 

 

What exercise should I avoid if I have a Vaginal Prolapse?

Now this is an interesting one… and if you’re after a list of Do’s and Do Not’s, I’m sorry… it’s not coming from me!

Let’s start with what the recommendations are for exercise for general health. The Australian Government’s “Physical Activity Guidelines for Adults” states that we should participate in:

Cardio exercise:

  • >150 minutes of moderate intensity activity/week
  • OR 75 minutes of vigorous activity/week (or a mixture)

Resistance exercise:

  • >2 days/week 
  • >1 set of 8-12 reps per area
  • Maximum health benefits are gained when you would struggle to do another set

And recommendations for Bone Density and prevention/management of Osteoporosis:

  • Regularly doing a combination of resistance training and moderate to high impact weight-bearing activities

But historically (and I’m not talking that far in the past either) the recommendations for anyone diagnosed with, or at risk of, vaginal prolapse were:

  • Minimise weights
  • Keep all exercise low impact

But although well-intentioned, how evidence-based was this blanket recommendation?  And by giving this advice, are we compromising overall health (in particular our heart and bones) for the health of the vagina? 

Recent studies have looked a lot more into the pressures created in the abdomen, and more specifically in the vagina, during different types of exercise and although we can extrapolate some general information, the main message that comes out is “It’s not what you do, it’s how you do it”. 

If you give the same exercise to a variety of different women, then their individual anatomy, injuries, technique etc will mean that the way they perform that exercise results in a wide variety of different effects to their pelvic floor muscles and vaginal walls. 

It’s highly recommended that in order to tell a woman what exercise they should and shouldn’t do, we should understand:

  1. Their individual risk profile for prolapse occurring or worsening
  2. Whether a certain exercise is likely to be on the higher or lower end of the ‘risk’ spectrum

 

How do I know which risk category I fall into for Vaginal Prolapse?

A Pelvic Health Physiotherapist is a physio who has done a huge amount of extra training in Women’s Health and Pelvic Floor Health. They can do vaginal examinations to check a number of things such as:

  • The Pelvic Floor Muscle function
  • The structural support of the vaginal walls both at rest and on straining (and very important to assess this in standing too!)

There’s a specific test that we can do called ‘GH+PB’, which measures the amount of movement of the tissues at the opening of the vagina when you strain. This measurement, taken externally, has been proven to be a good indicator of what’s happening internally to the size of the space into which our organs could potentially descend. The larger the GH+PB measurement is (in cm) the higher the risk is that a prolapse could occur or worsen when the area is put under strain. 

Some important points to note:

  • It’s important to check if you currently have a prolapse (it’s not always symptomatic) but it’s just as important to pick up those who don’t currently have a prolapse but are at high risk of it developing
  • Pelvic floor muscle exercises are important but there’s a lot more to it than just getting the best maximal squeeze possible, especially for endurance activities like running and playing a game of sport (because when you think about it… how much help is a grade 5/5 squeeze going to be during a run if you’re not squeezing maximally while you’re running?)

 

Which exercises are likely to be higher risk?

There are lots of unknowns here, and we don’t know what the ‘safe’ level of intra-abdominal pressure is for preventing prolapse. We also don’t know, without individual assessment, how different women respond to the same exercise. 

But we can understand generally which exercises tend to come out as creating higher intra-abdominal pressure and perhaps these can be the ones that are more closely tested and monitored. 

Things we can assume about strength and resistance exercise:

 

  • Standing exercises have higher pressure than sitting, and both of these have higher pressures than lying down. On this note – abdominal crunches and lying down abdominal exercises usually come out as one of the ‘lowest risk’ exercises in the studies that have been done, although traditionally these have been amongst those that were the most highly cautioned against. 
  • Increasing weights and resistance increases intra-abdominal or intra-vaginal pressure

Things we can assume about aerobic exercise (note that this is probably the hardest type of exercise to investigate, but there is some exciting current research happening in this area):

 

  • Running, jogging, skipping etc are likely to be high risk due to the fact that they have an endurance nature to them, they’re always done in upright positions, and there are ground reaction forces involved.

Things we can assume about Crossfit-style exercise:

 

  • In low risk women (those who are young and have never had children), there is unlikely to be a negative impact on prolapse between those who choose to do Crossfit compared to those who choose to do ‘gentle’ exercise (but there are likely to be many benefits in other areas of health)
  • There is limited/no research on prolapse risk in women who are considered ‘high risk’

Things we can assume about pilates exercise:

 

  • Most pilates mat and reformer exercises are considered low risk and are unlikely to increase intra-abdominal or intra-vaginal pressures significantly (many are performed in lying down and with relatively low resistance)
  • There are lots of benefits to pilates but in isolation it doesn’t meet the guidelines mentioned previously about Disease Control and Prevention and needs to be considered in conjunction with other forms of exercise. 

 

How can a Women’s Health Physio give you individualized information about the type of exercise you should consider?

A Women’s Health Physio should be able to put all of this together and come up with a plan that suits you regarding an exercise regime. 

They might assess you and find that you’re very low risk for prolapse occurrence or worsening, and then you can work out together whether any monitoring needs to occur as you increase your load and intensity in your workouts. 

They might assess you and find that you’re currently in a high risk category and they can help you to work on a pelvic floor program (and possibly a pessary fitting) to allow you to gradually return to the exercise you love with close monitoring. 

They might assess you and find that you fit somewhere in the middle. Perhaps there are certain things that either make your prolapse symptomatic, or that cause vaginal wall descent without you realizing. Rather than advising you to stop exercising completely, they should be able to help you to come up with regressions or variations of these movements, and perhaps supplement them with other forms of exercise that you enjoy to allow you to still meet the health guidelines. 

 

Some final points to remember about Prolapse and Exercise…

  • Exercise is vital to overall health, and women unfortunately often decrease exercise due to fear of worsening a prolapse. 
  • Remember that a large number of exercises that were previously suggested to be ‘not pelvic floor safe’ don’t actually have much evidence to back that up (and might be really good for overall health)
  • Individual assessment and reassessment is key – and remember that you can’t assess prolapse or risk of prolapse with only an external examination. So if you’ve only had a real time ultrasound screening assessment on your abdomen, this isn’t able to be used to determine your risk profile. 

If you’d like to see a specialist physiotherapist in Western Australia, there’s online Directory for both private and public referrals:

Also, if you live in Perth or Mandurah, we have compiled a list of post-graduate trained physiotherapists who are particularly good with pregnancy, postpartum and exercise – see the FitRight website!

And remember – the whole aim of FitRight is to keep you moving, even if you do have a vaginal prolapse. Chances are that multiple women if every one of our classes are managing a prolapse and the instructors will be aware of this and know how to modify the classes to suit individual needs. 

Whether you’re pregnant, early postnatal, a Mum of young children or heading into peri-menopause, we have classes to suit you!

 

Article was written by Taryn Watson owner of FIT Right. She holds a 

So you are off to the Hospital to deliver you baby… what are the essential items to pack into the bag?

So you are off to the Hospital to deliver you baby… what are the essential items to pack into the bag?

Packing your pregnancy bag is a job you will either do too early or too late. It's never too early to gather together all the essentials you'll need during labour and birth, and for after your baby is born. Even if you're not planning to have your baby in a hospital or birth centre, you may need to go in unexpectedly, so try to have a bag packed by the time you're about 36 weeks pregnant.

Create a checklist and get ticking :)

 

What Mum needs for her hospital pregnancy bag:

  • Maternity bras
  • Nighties including an old one or a large t-shirt to wear in labour. It will probably get a bit messy, so don't buy anything special or tight to wear in hospital.
  • Dressing gown. This will be useful if you end up pacing hospital corridors in early labour. You'll probably also want one on the postnatal ward. Hospitals can be very warm, so a lightweight one may be better. A dark colour or busy pattern will help hide any stains.
  • Casual day clothes: include a pair of leggings that have supportive belly band with non intrusive seams. It helps with the repair of this area.
  • Slippers/shoes: Backless slippers that are easy to get on and off. Thongs work well, too.
  • Breast pads
  • Maternity pads plus lots and lots of undies
  • Heat packs. Many hospitals have a limited number of heat packs but are happy for you to bring your own. Check first, though, that your hospital allows microwaved heat packs (some have banned them), and has a microwave available so you can heat the packs.
  • Toothbrush, Toothpaste, Makeup, Hairbrush, Deodorant, Shampoo, Conditioner plus Hairbands, clips or a headband. If you have long hair, you may want it tied up or clipped back. And if your hair is shorter, you can keep it off your face with a soft headband especially during labour.
  • Lip balm: your lips can dry out quickly on a warm labour ward and from the air conditioner on the ward.
  • Any medications you have been taking (please bring the medication to the hospital to show your admitting doctor and arrange for this medication to be returned home)
  • Your Medicare card, details of your health insurance (if you have private insurance) and any hospital paperwork you need. Your birth plan (if you have one) and antenatal card, if you were given one.
  • Storage containers for glasses, contact lenses, hearing aids, or dentures. Note that your glasses may fog up when you're in the throes of labour, and you won’t be able to wear contacts if you're having a caesarean.
  • Things to help you relax or pass the time, such as books, magazines, games, knitting or a tablet. You may also want to download some fun and distracting apps on your phone to keep you occupied during early labour.
  • Music device, Phone and charger
  • Snacks and drinks for during and after the birth. Most women are able to eat and drink during labour and those early few days of breastfeeding when you can eat anything in sight. The hospital will have food and drink available, but you may prefer to pack a few things that you know you like. Great ideas are: Fruit, unsalted nuts, chips, muesli bars, honey sandwiches or and popcorn are all good options.

 

Some optional extras depending on the type of birth and/or what you have put into your birthing plan:

 

  • Massage oil or lotion if you'd like to be massaged during labour. You may also like to borrow or invest in a massage roller or similar aid, so your birth partner can massage you for longer.
  • Birth ball. This can help you find different positions of labour, and may also help you manage the pain of contractions. Check whether the hospital has the right size for you. If not, take your own. Remember to bring a pump so your birth partner can inflate it for you.
  • Oil burner, if you'd like to use aromatherapy oils. Check with your hospital because most have won't allow open flames, but you may be able to use an electric burner.

What baby needs:

 

  • Baby clothes and a blanket to take your baby home in
  • Newborn nappies and extra wipes (especially if you like a certain variety)
  • Dummy or pacifier if you choose to use one
  • Formula, bottles, teats and sterilising equipment, if you plan to formula feed
  • Olive, apricot, almond oil for coating baby's bottom before the first nappy goes to make cleaning easier
Help...Antenatal classes online

Help...Antenatal classes online

Many pregnant Mums are facing the news that their antenatal classes have been cancelled at their delivery hospital. If you are a first time Mum or a Mum with a large gap in between these classes offer a great base. They give pregnant Mums an information bank on what to expect in delivery, options for birth, bathing, sleeping, changing nappies and a whole heap of practical tips and tricks when navigating the birth, delivery and early few days.

Many hospitals and birthing rooms have had to cancel these for the near future due to CON-VID19. Not having this access can increase the anxiety, fear etc for the expecting Mum.

 

We have done a bit of a run around and here are some paid/unpaid courses that we have found:

 Nourish www.nourishbaby.com.au $100 for Guide to healthy pregnancy, Guide to positive labour and feeding success. There are other options.
Hypnobirthing Australia www.hypnobirthingaustralia.com.au $499 for 3 hour private session. $199 online course
Baby Centre www.babycentre.com/childbirth-class FREE and has 7 chapter modules
About Birth www.aboutbirth.com.au $85 6 months unlimited access. 55 individual videos, 14 resource downloads.
Mama Lee Midwife www.mamaleemidwife.com.au $129 for 6 week membership- 4 classes on labour, packing a bag etc
Birth Beat www.birthbeat.com $397 for 12 months access to 9 modules