By Amy Fearn
“Have you started your pelvic floor exercises?” the midwife asked during our postnatal check-up. Ten days before, I had given birth to my daughter after a long and stressful labour. I was anaemic, my stitches had fallen out the following week, and although the midwife assured me everything was healing normally, exercising ‘down there’ was the last thing I wanted to do!
I first experienced stress incontinence a couple of months after giving birth. I occasionally did my pelvic floor exercises, when I remembered, but did little else for more than two years. Unsurprisingly, it didn’t go away. In fact, it got worse, to the point where I experienced so much discomfort that I couldn’t walk without wearing a pelvic support belt and was struggling to pick up my then two-year old daughter, who wasn’t particularly heavy. I’m not alone, incontinence is surprisingly common after childbirth, with 76% of women leaking at 3 months post-partum still leaking 12 years later, according to a study by MacArthur et el. But just because it’s common, doesn’t mean that it’s normal or you should just accept it.
Over the course of these two blogs, I’d like to:
- Introduce you to the pelvic floor muscle group
- Look at the common symptoms of a dysfunctional pelvic floor
- Briefly cover the basics of correct pelvic floor activation
- Discuss the changes the pelvic floor undergoes during pregnancy and birth
- Talk about how you can improve pelvic floor strength and function during and after pregnancy
- Discuss exercise considerations for pregnancy and the postnatal period
Pelvic Floor 101
The pelvic floor muscle group is a complex hammock-like structure made up of muscles and connective tissues (fascia) arranged in four distinct layers. It’s situated at the base of the pelvis and is attached to the walls of the pelvis from the pubic bone at the front to the coccyx (tail bone) at the back. The pelvic floor muscles (PFM) work with the other deep abdominal muscles (transverse abdominus, diaphragm and multifidus) to help stabilise the spine during movement and are often referred to as the foundation of the core.
The PFM support the bladder, bowel and uterus (in women), play an essential role in maintaining continence, increases awareness and sensation during intimacy and contracts to withstand loaded pressure (coughing, sneezing and jumping). The PFM also work with the diaphragm during breathing, so good posture and correct breathing mechanics are essential for function!
The PFM are an area we often don’t think (or talk) about. We expect them to do all the things mentioned above each day, but it’s not until something goes wrong that we realise just how much we take it for granted. The number of people experiencing pelvic floor related issues is increasing. The latest statistics report that over 14 million adults in the UK have problems with bladder control and 6.5 million have bowel issues. And that’s only the people we know about. Many suffer in silence, too embarrassed to seek the help and support they need. Before we go on to look at the prenatal and postnatal PFM, let’s have a look at some of the symptoms of pelvic floor dysfunction.
Pelvic Floor Dysfunction
PFM dysfunction (PFMD) can happen at any stage in life and for all sorts reasons, not just pregnancy and childbirth. Some common symptoms of PFMD include:
- Stress incontinence (urinary and/or faecal)
- Urgency incontinence (urinary and/or faecal)
- Overactive bladder (urgency resulting in frequent urination)
- Pain during sex
- Incomplete emptying (bladder and/or bowel)
- Pressure, heaviness, dragging sensation or bulging in the pelvic area
- Reduced abdominal strength and function
- Diastasis recti (separation of the abdominal muscles)
- Musculoskeletal pain in the pelvis and lower back
If you’re reading this and nodding your head, don’t just ignore it. It’s essential that you visit your GP or local Women’s Health Physiotherapist (WHP) for diagnosis, advice and treatment. PFMD rarely goes away on its own, it usually just gets worse over time. Issues with the PFM have been normalised. You’ve no doubt heard or seen the adverts for female incontinence products further normalising something that is not normal. There’s little encouragement to practice good pelvic floor health habits yet learning how to correctly contract and relax the PFM can help manage or completely restore pelvic health!
Contracting and Relaxing the Pelvic Floor
Research has shown that around 30% of women perform their PFM exercises incorrectly when following written instructions, therefore it’s essential to seek the guidance of someone such as a WHP or a fitness professional with specialist training in PFM awareness. Here are some tips for correctly engaging and relaxing the PFM:
- The PFM and diaphragm work together during breathing. Good breathing technique is essential, and this is the most important place to start! With chest and shoulders relaxed, place one hand on the side of the ribcage and the other hand on the abdomen below the belly button. When you inhale you should feel the abdomen and ribcage expand and push slightly against the hands. The diaphragm contracts and the PFM relax.
When you exhale, you should feel the ribcage and abdomen contract and draw back from the hands. The diaphragm relaxes and the PFM contracts. The PFM should be working in synchrony with the diaphragm during each breath. In general, you should try to exhale on exertion to protect the PFM during exercise.
- The pelvic floor is made up of 3 areas, the back, (lower bowel and anus), the middle (vagina and perineum) and the front (bladder and urethra). It’s important to contract and relax all 3 areas. To contract the PFM, gently lift and squeeze all 3 areas whilst continuing to breathe normally, then release and lower the PFM with control. Because the PFM is not visible, closing your eyes and visualising the PFM whilst you’re doing this can really help with ‘feeling’ what’s going on. The brain recruits the muscles it thinks it needs, so it’s important to pay attention to other muscles, such as those in the thighs and buttocks, to ensure they don’t ‘help’ to bring about a PFM contraction.
- All muscles have two types of fibres, slow twitch for endurance and fast twitch for power. Around 70% of muscle fibres in the PFM are slow twitch, to provide continuous support for the pelvic organs. It’s important to train both the fast and slow twitch fibres, aiming for 3 sets of 10 repetitions daily for each. It’s better to do a few good contractions rather than several poorly executed ones, so start slowly and build up the repetitions and sets gradually over time as PFM strength and endurance increase. It’s fine to do each set at a different time of day, for example, morning, afternoon and evening. Remember, it can take up to 16 weeks to achieve a significant improvement, so keep going!
- Consistency is key, so find a time of day that works for you and stick to it. If you’re having problems remembering, the Squeezy App is a great place to start and was created by a leading WHP, Myra Robson, in the UK.
Now that we’ve covered some pelvic floor basics, let’s have a look at what happens to the PFM during and after pregnancy.
Pregnancy and the Pelvic Floor.
As we discussed earlier, one of the functions of the PFM is to support the bowel, bladder and uterus. During pregnancy, two main factors can affect PFM strength and function.
Firstly, the PFM are subject to additional load from the increasing weight of the growing uterus and secondly, pregnancy hormones increase the elasticity of ligaments and connective tissues, including those that make up the PFM. Whilst the loosening of connective tissues is essential to allow the joints of the pelvis to stretch during delivery, it can also contribute to weakness in the PFM, leading to PFMD. It’s important to understand that these effects extend to all joints throughout the body, and that joint instability elsewhere (knees, feet, hips etc) can also affect the PFM. Ligaments and connective tissues are not designed to stretch the same way as muscles do and will not bounce back if they become over stretched.
An additional problem experienced by some women during pregnancy is constipation. This is caused by the increase in progesterone, which has a relaxing effect on smooth muscle tissues, including those found in the digestive tract. The resulting slower transit of digested food can increase the likelihood of constipation, which places additional force on the PFM during bowel movements. If you are experiencing constipation, try elevating your feet when you’re sat on the toilet so that your knees are slightly higher than your hips. You can do this using a specialist stool (no pun intended) to support both feet or by placing a small packet of toilet rolls under each foot. A light-hearted take on how this approach helps with constipation can be found here.
How to Support the Pelvic Floor During Pregnancy
Being more aware of the challenges faced by the PFM and understanding the functional connection between the PFM and abdominal muscles is particularly important. Commencing a programme of PFM exercises and PFM relaxation techniques helps to maintain connection to the core throughout pregnancy and prevent PFM weakness during and after pregnancy. As with all other muscles in the body, the PFM needs to be able to relax too, otherwise it can’t contract effectively. Think about it, how many bicep curls can you do with a 5kg weight before the muscle becomes tired, 15? 25? What happens when your bicep becomes tired from too much work, can it still contract effectively with each repetition, or does it start to fatigue and hurt?
Learning how to relax the PFM is particularly important during the second phase of labour because it can help to reduce the risk of tears or additional trauma, which in turn, will help to speed up recovery during the postnatal period. The pelvic floor is a muscle just like any other. I think it’s easy to forget this because we can’t see it, and because talking about this area of the body is still embarrassing for many women. With all the changes taking place to the PFM during pregnancy, you might be wondering if it’s still ok to exercise, which brings me on to my next point…
Can I still exercise during pregnancy?
Yes, definitely! The Royal College of Obstetricians and Gynaecologists (RCOG) and the American Congress of Obstetricians and Gynaecologists (ACOG) both recommend exercising during pregnancy. In addition, there are many health benefits, provided you are in good health and your pregnancy is progressing normally, including:
- Reduced symptoms of pregnancy during the first trimester
- Decreased risk of developing diabetes
- Maintenance of bone density
- Reduced back pain
- Improved posture
- Enhanced wellbeing
- Increased energy levels during the second and third trimesters
- Improved sleep during the third trimester
- A shorter and easier labour
- Quicker return to pre-pregnancy weight and fitness
- Reduced depression
However, before you launch straight into a new exercise programme, it’s important to discuss exercise with your prenatal healthcare provider as not all types of exercise are suitable for all women. If you were not used to exercising before becoming pregnant, it’s essential to seek advice from a trainer qualified in prenatal fitness to ensure that any exercise undertaken is appropriate to you as an individual, as well as being effective, functional and PFM-friendly.
If you were already active, then it is possible to maintain your level of activity, with modifications to accommodate your growing bump, whilst adding in some PFM muscle training. Again, I would recommend seeking advice from a suitably qualified trainer to reduce the risk of injury or over exertion. Here are a few key points to bear in mind when exercising during pregnancy:
- Basal temperature is higher during pregnancy. Dehydration can further increase body temperature, so it’s important to stay adequately hydrated.
- A lot of physiological changes take place in a woman’s body during pregnancy, affecting energy levels, blood pressure and posture, so it’s important not to overdo it on the exercise front. Aim to exercise at a moderate intensity – you should still be able to hold a conversation during moderate aerobic exercise.
Above all else, be mindful of how you feel and listen to your body. It’s very common for women to become tired very quickly and very often during pregnancy. Honour your body during this time and rest if you need to.
In the second part of this blog series, we’ll look at how delivery and the postnatal period can affect the PFM and discuss the best course of action for PFM rehabilitation and return to exercise postnatally.