Breathing Exercises for Obstetrical &

Gynecological Cases.

By

Prof. Dr. Wafaa Mohammad Kamal

Assistant professor in Physical Therapy Department for

Woman’s Health

Faculty of Physical Therapy

Benha University

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 Muscles of Respiration

a- Muscles of inspiration

1-The diaphragm is the most efficient muscle in the breathing process and
is considered the main inspiratory muscle. It moves downward to increase
the vertical diameter of the chest with inspiration.

2- Intercostal muscles (external, transeverses) increase antero /posterior

diameter of the chest through elevation and eversion of ribs.

3- scalenus, upper fibers of trapezius and sternocleidomastoid muscles are

known as accessory muscles of respiration.

If you have a lung condition, the diaphragm doesn’t work as well. So, the
body will use ―accessory‖ muscles of respiration which are not as
effective in moving air in and out. Training the diaphragm to do the
majority of the work again can help you feel much better.

b- Muscles of forced expiration.

1-Abdominal muscles (mainly rectus abdominus) when contract, push the

diaphragm upward due to increase intra-abdominal pressure.

2-Internal intercostal muscles, depress the ribs during forced expiration.

N.B.

Expiration is a passive process occurs by elastic recoil of the lung and by

relaxation of inspiratory muscles.

General principles for teaching breathing exercises

 Choose a quite warm room for the application of exercises.

 Place the women in a comfortable relaxed position.
 Loosen restrictive clothes.
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  Never allow the women to force expiration. Expiration should be
relaxed and passive to help relaxation especially during labour.

Breathing, although it is an involuntary process, can be controlled

voluntarily through specific breathing exercises to promote health, reduce
stress and improve performance.

Types of breathing

a- Deep type

 Diaphragmatic breathing
 Costal breathing

b- Shallow type

 Sternal breathing

Diaphragmatic breathing

Belly breathing or abdominal breathing is another name for

diaphragmatic breathing. The diaphragm is a large, dome-shaped muscle
at the base of lungs. It does most of the work of breathing. Fig. (1)

Fig. (1): Diaphragmatic breathing

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Position of the mother:

Crock lying position or any comfortable relaxed position. e.g. sitting,

standing, etc.

Position of the therapist:

Stride standing position at the level of waist line.

Grasp:

One hand of the therapist on the abdomen just above the level of waist
line on a horizontal position.

Command:

Take deep inspiration from your nose, make your abdomen like a balloon
and push my hand up, then expire the air from mouth with a sigh.

Uses:

It used intra-natal in 1st stage of labour during uterine contraction to

minimize pain and help relaxation.

N.B.

Ask the woman to breathe in slowly and deeply, keeping her shoulders
relaxed and upper chest quite.

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 Costal breathing

It also called chest breathing. Fig. (2)

Fig. (2): Costal breathing

Position of the mother and therapist:

As before in the diaphragmatic breathing.

Grasp:

Both hands of the therapist placed laterally on the chest wall with fingers
fanning to take the shape of the chest and both thumb directed toward
xiphoid process.

Command:

Take deep inspiration from the nose, open out your ribs and push my
hand laterally, then expire the air from mouth with a sigh.

Uses:

It used with bearing down during 2nd stage of labour, to help expulsion of
foetus.

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 Sternal breathing

It also called panting breathing

Position of the mother:

As before in the diaphragmatic breathing.

Position of the therapist:

Stride standing position at the level of the chest line

Grasp:

One hand of the therapist is placed on the sternum in a vertical position

Command:

With open mouth breathe in and out quickly lifting the sternum up and
down for few seconds.

Uses:

Sternal breathing is using at the end of 2nd stage of labour, at crowning, to

prevent bearing down during this time to avoid laceration of the
perineum.

Costal Breathing vs. Diaphragmatic Breathing

 If your upper chest is moving when you breathe then you’re not
using the lower part of your lungs, which means you’re not
breathing optimally and may experience constant shortness of
breath.
 Costal breathing engages only the top part of lungs, and remember
that the lower half of lungs is the most oxygen-rich.

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 In costal breathing the neck and shoulder muscles are overused,
leading to muscle tension and pain.
 Costal breathing can also trigger stress signals (fight-or-flight
mode) in the body, which is why breathing with your chest is also
known as stress breathing!
So, habitual costal breathing may negatively affect health, immunity,
energy reserves, mental and emotional wellbeing and we need to be
diaphragmatic (abdominal) breather rather than costal (chest) breather.
Diaphragmatic breathing exercises should be practiced 5-10 minutes
about 3-4 times per day.
Diaphragmatic breathing has proven to:

1. Improve respiratory function, by relaxing tight chest muscles and

by increasing lung capacity.

2. Improves circulatory system function by maximizing the delivery

of oxygen to the bloodstream.

3. Maintain blood pH levels (the scale of alkalinity to acidity.), as

blood acidity is neutralized with the release of carbon dioxide from
the lungs.

4. Boost the immune system

5. Maintain healthy digestive function

6. Help relaxation during labour and minimize labour pain.

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 Breathing Techniques for Pain Management during Labor

During the third trimester of pregnancy (or even earlier), woman can start
learning breathing techniques to help pain relief throughout the various
stages of labor and delivery.

These breathing techniques give something to focus on and help redirect

the mind away from perceived pain. Learning breathing techniques and
keeping a steady rhythm can help stay calm and relaxed by soothing
nervous system.

These breathing techniques might help pregnant woman respond more

positively to the onset of pain. Each time breathe deeply, it sends a
message to brain to relax and calm down. Then, the brain sends this
calming message to various parts of body. In turn, feel body relax.

1-Yoga breathing techniques

Helping you stay calm and strong even during the most painful moments
of labor. All yoga techniques use diaphragmatic breathing.

a- Box Breathing

This exercise is so effective in soothing the nervous system and calming

anxiety during high-stress situations

Deep breathe through nose and engage lower belly, this will ensure get
some quality deep breaths in.

Step 1 – Inhale for 4 counts

Step 2 – Hold for 4 counts

Step 3 – Exhale for 4 counts

Step 4 – Hold for 4 counts

Step 5 – Repeat Steps 1-4 for a minimum of 10 cycles (just over 2.5 minutes)

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b- Ocean’s Breath

Remember to breathe through your nose, engage your lower belly, and
tighten the back of your throat as you breathe to produce the ocean sound.

Step 1 – Inhale for 5 counts

Step 2 – Exhale for 5 counts

Step 3 – Repeat Steps 1-2 for at least 15 cycles (2.5 minutes)

C-Alternate nostril breathing

It involves alternating exhales and inhales between the right nostril and
the left nostril. Breathe out and in through one nostril, while the other
nostril is closed and vice versa, repeating the sequence.

Breathing alternatively through each nostril activates parasympathetic

nervous system, which increases the calming, relaxation, stress resilience.

D-Mindful Breathing

Find a comfortable and quiet place, assume comfortable relaxed position,

and follow these steps:

Step 1 – Take a deep breath and relax, with your eyes open or closed.
Step 2 – Close your eyes and drop all your concerns now, like setting
down a heavy bag.

Step 3 – Now focus on your natural flow of breath (not long, not short,
but natural). Bring your full awareness to the sensation of your breathing.
Step 4 – Start counting your breaths softly — count from one to ten, and
then start over.

Step 5 – Get more and more absorbed in your breathing.

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 Step 6 – Now, bring your attention to the presence of the thoughts that
are moving through your mind. Take notice of them, then gently bring
your focus back to your breath. This is the most critical step of practicing
mindfulness meditation.

Step 7 – Feel a growing sense of peacefulness within as you keep settling

into the breath with more focus. You may bring the meditation to an end
by opening your eyes, stretching out your hands, and getting up.

2- Cleansing Breath Technique

The use of a cleansing breath before and after every contraction is

important. It is an exaggerated, deep breath, usually done by breathing in
through the nose and out through the mouth. The purposes of this breath
are to:

o Allow for increased oxygen to the baby

o Internally signal you that a contraction is beginning and to remind you to

begin concentrating on breathing, focusing, and relaxing.

o Externally signal your partner and anyone else assisting with the labor
that a contraction is beginning. They can then offer assistance, such as a
back massage or verbal encouragement.

o Allow for blowing off residual tension after a contraction is over.

o Give your baby a boost of oxygen at the end of the contraction.

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 3- Slow Paced Breathing Technique

o Take a "cleansing" breath at the beginning of a contraction

o Continue to breathe evenly in and out with slow, easy deep

abdominal (diaphragmatic) breathing.

o Pace is approximately half your normal respiratory rate (12-14

time/minute). Inspire from nose for 4 sec, expire from mouth with pursed
lips for 6 sec., and continue for 6 time/minute.

o As contraction ends, take a "cleansing" breath, breathing out slowly, and

relaxing completely.

4-Modified Paced Breathing Technique

o Start using this technique when the contractions get more intense during
active stages of labor. Use same steady rate throughout uterine
contraction but accelerated than in slow paced.

o Easy, regular, rhythmical breathing, accelerate rate of breathing with a

frequency of approximately twice your normal respiratory rate.

o Relaxed movement in abdomen with more use of intercostal (chest)

muscle, (costal breathing).

5-Patterned Breathing Technique

o In the end of first stage and beginning of the second stage , speed
the breath according to rate of contraction
o Take a "cleansing" breath at the beginning of a contraction

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 o Inhale slowly through your nose and exhale through your
mouth. Accelerate and lighten your breathing as the contraction
increases in intensity.
o As your breathing rate increases toward the peak of your
contraction, breathe in and out lightly through your mouth. Keep
your breathing shallow and light at a rate of about one breath per
second.
o As the contraction decreases in intensity, gradually slow your
breathing rate, switching back to breathing in through your nose
and out through your mouth.
o When the contraction ends, take deep finishing breath—exhale
with a sigh.

References

1-Andrew Weil, MD, https://motherhoodcommunity.com/diaphragmatic-belly-

breathing/ UPDATED ON JANUARY 11, 2022.
2-https://motherhoodcommunity.com/breathing-technique-for-labor-childbirth-pain-
management/UPDATED ON JANUARY 26, 2023

3-Karkada R, Noronha A, Shashikala K, Bhat P, Nayak S: "Effectiveness of

antepartum breathing exercises on the outcome of labour: A randomized controlled
trial"reservations, 2022, 11:159.

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