Pregnancy

What a wild and wonderful miracle! Pelvic health physiotherapy can be an integral part of your journey during both the pre and postpartum periods. We will outline how seeing a pelvic health physiotherapist can benefit you during this time, but first, let’s review some of the changes a woman undergoes when she becomes pregnant.

How Pregnancy Affects the Body

Pregnancy affects every system of the body, including the cardiovascular, respiratory, endocrine, and gastrointestinal systems, to name a few. The most relevant system of the body that is affected for pelvic health is the musculoskeletal system.

Although the experience of pregnancy differs greatly for every woman and even between pregnancies for the same woman, most will go through similar changes to the body. For instance, as the fetus grows and as a woman’s center of mass changes, it is common for the pelvis to tip forward into an anterior pelvic tilt, causing an increased curve in the low back called a lordosis. This can contribute to tight low back muscles and hip flexor muscles (located at the front of the hip joint). 

At the same time, abdominal muscles become increasingly stretched. As breasts enlarge, the upper back tends to round, the chin juts out and shoulders roll forward. This can contribute to tight pectoral muscles at the front of the shoulder and chest, as well as stretched upper/mid-back muscles.

The whole pelvic girdle undergoes changes to accommodate the developing baby. The muscles at the bottom of the pelvis, the pelvic floor muscles, are under more demand during your pregnancy. These are only a few of the vast number of changes that a woman’s body undergoes during the course of her pregnancy. Now let’s turn to how pelvic health physiotherapy can help you maintain an active, healthy, and enjoyable pregnancy, despite these numerous changes.

Canadian Guidelines on Exercise During Pregnancy

The 2019 Canadian Guideline for Physical Activity throughout Pregnancy suggests the following:

1. All women are encouraged to be physically active throughout pregnancy (except those with medical conditions deemed unsafe by their overseeing physicians).
2. At least 150 minutes of moderate-intensity physical activity each week is recommended to achieve health benefits and reduce pregnancy-related complications.
3. Women should accumulate 150 minutes over a minimum of 3 days per week, though daily physical activity is preferred.
4. Exercise should include both aerobic (cardio) and resistance (strength) training. Gentle stretching may also be beneficial.
5. Pelvic floor muscle training (Kegels) is recommended on a daily basis to reduce the risk of urinary incontinence. The Canadian guidelines recommend women obtain instruction on proper technique to ensure optimal benefit.
6. If a woman feels symptoms such as light-headedness or nausea when she exercises flat on her back, she should modify her exercise position.

Your physiotherapist will ensure you are performing your pelvic floor muscle exercises correctly and can advise you on fun, safe exercises throughout your pregnancy, as well as suggest modifications as necessary.

Pelvic Floor Function

An assessment of your boney pelvis, hips, and low back, as well as your pelvic floor muscles prior to giving birth can be very helpful for both you and your therapist. Not only does it give your therapist a baseline understanding of your pelvic floor prior to delivery, but it can also be very educational for you. Your therapist will assess the overall function of your pelvis, including your ability to contract and control your pelvic floor muscles, as well as relax and lengthen those same muscles.

Your pelvic floor muscles have five main functions:

1. Sphincteric: They help to maintain bladder and bowel control, as well as allow us to empty our bladder and bowels when appropriate.
2. Support: They lend support to your pelvic organs, including your bladder, uterus, and rectum.
3. Stability: These muscles are part of the inner core that provides stability to the trunk.
4. Sump-pump: These muscles act like a pump to aid blood and lymph circulation in the pelvis.
5. Sexual: These muscles play an integral role in achieving penetration, erection, and orgasm.

Improve Pelvic Floor Proprioception 

The prepartum stage is the perfect time to see a pelvic health physiotherapist, as this is an ideal time to become better acquainted with your pelvic floor muscles. Proprioception refers to your ability to know where your body is in space relative to the rest of your body and your surroundings (position sense).

With regard to your pelvic floor, your therapist can help you decipher what a proper pelvic floor muscle contraction is (a Kegel) and how to achieve full relaxation of your pelvic floor muscles. The ability to produce a strong contraction and achieve complete relaxation is equally important. Timing and coordination of your pelvic floor muscles are also important skills that your therapist can help you improve on.

Bladder and Bowel Dysfunction

Bladder and bowel dysfunction can be common during pregnancy, but it is not healthy for the body and can prevented and treated conservatively. Some women experience stress urinary incontinence, the loss of urine with activities such as coughing, laughing, sneezing, or exercise. Other women may experience bouts of constipation, which can be painful, lead to the development of hemorrhoids or anal fissures, and further weaken the pelvic floor muscles.

Much can be done to help you maintain regular, healthy bladder and bowel routines. A pelvic health physiotherapist is knowledgeable in what normal bladder and bowel function is, tricks to encourage complete emptying of your bladder or bowels, how the nervous system plays a large role in the ability to easily and comfortably void the bladder and evacuate the bowels, and how exercise can both help to get things moving and help you maintain continence.

Your therapist may even be able to suggest dietary changes if needed. Again, although bladder and bowel dysfunction may be common during pregnancy, it is not healthy for the body. Talk to a pelvic health physiotherapist (link) if you have any bladder or bowel concerns.

Pelvic Girdle Pain

Pelvic girdle pain is an umbrella term used to describe a variety of pelvic pain conditions, including symphysis pubis pain (pain originating from the pubic symphysis, which is the joint at the front of your pelvis at midline) and sacroiliac joint pain (pain felt along or around the sacroiliac joints at the back of your pelvis on either the left, the right, or both sides). Although the pain may be felt in the area of the ligaments, muscles, and bones of the pelvis, it is important to note that the nervous system plays a large role in the experience of pain. Your physiotherapist will do a thorough assessment of your low back, hips, pelvic girdle, and pelvic floor muscles and, with your reported symptoms and medical, social, and psychological history in mind, will determine a likely cause and treatment plan to best manage your symptoms for the remainder of your pregnancy, during labour and delivery, and beyond. 

Perineal Massage

Perineal massage is a massage that can be done near the end of your pregnancy, starting at approximately 36 weeks until delivery. The purpose of perineal massage is two-fold. First, it can help prepare the vaginal tissues for delivery by increasing their flexibility, thereby potentially reducing the risk of tearing. This may be particularly helpful for a mother-to-be’s first vaginal delivery. Second, and perhaps even more beneficial, is that this exercise can help prepare the mother-to-be for the stretching sensation that may be experienced during delivery. This technique can be done during your physiotherapy appointment and can also be taught to you or your partner so that you can do your preparatory perineal massage on a regular basis in the comfort of your own home.

Birth Position: Labour and Delivery

Labour and delivery position is a topic that many mothers-to-be discuss with their physiotherapists. Many options can be explored depending on your symptoms, beliefs and expectations about the birthing process, and your physical ability. Your physiotherapist will be able to teach you breathing techniques to use during labour to help your pelvic floor muscles relax and stretch as needed, as well as explain the anatomical advantage of different positions to encourage continued movement of your baby down the birth canal depending on whether you are in early or late labour. You can discuss all possible options with your physiotherapist, helping you to feel empowered and prepared.

Postpartum

Pelvic Floor Dysfunction

Pelvic floor dysfunction can be as a result of carrying a child for 9 months and delivering either vaginally or through a C-section. Although pelvic floor dysfunction may seem common, it should not be ignored, especially because this dysfunction can most often be treated very successfully! Dysfunction may present as tension, weakness, or sensitized tissue, all of which can be treated by physiotherapy. Dysfunction may result in urinary or fecal incontinence, pelvic organ prolapse, or pain.

Bladder and Bowel Dysfunction

Similar to pelvic floor dysfunction, bladder and bowel dysfunction in the postpartum period may be common, but it is not healthy. You may experience urinary or fecal urgency immediately postpartum. Many women experience stress urinary incontinence, which is leakage of urine with activities such as coughing, laughing, sneezing, or running. Pelvic organs including the bladder, uterus, and rectum may prolapse or hang lower than usual. Constipation or inability to fully evacuate your bowels may ensue.

Each of these symptoms indicates some form of pelvic floor dysfunction. These symptoms may be a result of weak and lengthened muscles/connective tissue, tight and inefficient muscles/fascia, lack of coordination or timing of pelvic floor muscles, inability to fully relax these muscles, or pain in the pelvic region.

Treatment in physiotherapy may include learning to use the breath to relax and lengthen the pelvic floor muscles, or how to properly contract the pelvic floor muscles so that you can develop strong, healthy muscles that support your pelvic organs and assist your sphincters in keeping you continent. Education around regular, healthy bladder and bowel habits, and even ideal posture when using the toilet can be discussed with your therapist. How stress, anxiety and mood effects the function of the pelvic floor muscles is also a central component of pelvic health physiotherapy.

Painful Scars

Pelvic health physiotherapists can provide education and guidance on scar management, whether it is from vaginal tearing/episiotomy during childbirth or a C-section scar. They can show you how to start touching the painful area of your body in a manner that is not painful, perhaps using what is called a non-nociceptive treatment technique. This will help you to become reacquainted with the painful area of your body in a positive and encouraging manner. When gentle touch becomes tolerable, your physiotherapist might have you do skin rolling around or on the scar. On a C-section scar, your therapist may teach you to “pick up the scar” or gently stretch it in all directions. The goal of these daily exercises is to ensure that the tissue normalizes with regard to sensitivity to touch, is as flexible as possible, and that it doesn’t adhere to surrounding tissues.

Episiotomy

An episiotomy is a surgical cut at the opening of the vagina during childbirth that is performed by the delivering obstetric care provider. They may decide to perform an episiotomy for a variety of reasons including the health and safety of the baby, to aid a difficult delivery, or in efforts to prevent uncontrolled tearing of tissues The size of the cut deemed necessary varies, but often includes layers of pelvic floor muscles which are sutured back together after delivery. Approximately 6 weeks after delivery, these tissues have usually healed to a great extent and are ready for treatment. Your physiotherapist may recommend that you gently massage the area of the episiotomy to help the tissue become flexible and pliable once again. Gradual stretching exercises can also help this tissue become more elastic so that you can resume wearing tampons and having intercourse without any discomfort at the site of the surgical cut. The same stretching exercises can be useful for the treatment of natural tearing as well.

Dyspareunia

Dyspareunia refers to the experience of painful intercourse. This can occur in the postpartum phase for a few reasons. First, tissue injury from natural tearing or an episiotomy can leave that area feeling more sensitive than usual. Perhaps you healed with or without the intervention of sutures. Either way, the area of injury can feel painful to touch or stretch. See above sections for information and tips on scars and episiotomies. Second, the postpartum period can be a time of vaginal dryness, particularly if you are breastfeeding. Repeated application of lubrication during intercourse is a must. If you can, find a lubricant that is paraben and glycerin free, without any fancy effects such as warming or cooling. Additionally, your physician might prescribe vaginal estrogen such as Vagifem or Premarin to help relieve vaginal dryness, which can greatly diminish pain with intercourse.

Pelvic health physiotherapists use many different approaches to treat dyspareunia including education, desensitization strategies for both the tissue and nervous system, scar tissue mobilization, and accommodators (cylindrical objects of progressively larger sizes used to help the vagina and brain become accustomed to stretch once again). This is all with the goal of helping a patient enjoy sex once again!

Diastasis

Diastasis is the separation of the right and left rectus abdominis muscles or the “six-pack” muscles due to stretching and thinning of the linea alba, which is connective tissue that runs vertically from the bottom of your ribs to the top of your pubic bone, joining the right and left sides of your abdominal muscles. During pregnancy, it is normal for the linea alba to stretch to accommodate the growing fetus. For some women, the gap between the abdominals shrinks back to its pre-pregnancy state quickly and without effort. For other women, the gap remains.

If this is the case for you, the focus at physiotherapy will be on how to manage the pressure in your abdominal cavity as you go about the activities in your daily life, including lifting your babe, sitting up out of bed, and returning to exercise. For example, if you hold your breath and lift something heavy or do a sit-up, the pressure in your abdominal cavity increases, potentially resulting in a “doming or tenting” appearance down the midline of your stomach along the stretched linea alba. Your therapist will teach you how to use your breath and engage your inner core muscles to prevent this bulging. More than focusing on the gap closing, it is important to focus on generating tension in your inner core muscles so that the linea alba feels somewhat firm to your touch when your core is engaged. This will ensure your core is stabilizing and supporting you in an ideal manner.

Core Strengthening

Core strengthening begins with your inner core, which includes the following four muscles: your transversus abdominis (your innermost ab muscle that wraps around your midsection like a corset), pelvic floor muscles (at the bottom of your pelvis that run from your pubic bone to your tailbone), diaphragm (your primary breathing muscle) and multifidus (back muscles along your spine). Focusing on your inner core ensures you are properly stabilizing and supporting your trunk and limbs for efficient and healthy movement.

Your therapist will teach you how each of these muscles works together in a synergistic manner and will show you how to engage each of these muscles correctly, all the while breathing comfortably. For example, your therapist might ask you to think about stopping the flow of urine/passage of gas to activate your pelvic floor muscles. Or, they might ask you to imagine pulling together the bones at the front of your pelvis on the left and right sides in order to activate your transversus abdominis. When you have learned to activate your inner core, your therapist will progress your exercises to include larger muscles groups, eventually working into functional movements such as squatting and lifting, all the while engaging your core in an effective manner.

Returning to Exercise

Exercise has so many benefits on whole-body health including mental and emotional well-being that it is imperative to include in the postpartum period and beyond. This should include many different types of activity for a well-balanced diet of daily exercise. For instance, a good place to start is with low impact aerobic activity such as walking or swimming. Strength training of large muscle groups in both the upper and lower limbs can help with functional movements such as lifting your ever-growing baby in the carrier. Stretching can help to ease muscle stiffness and aches from assuming new postures like the one you perform during breastfeeding.

Additionally, it is recommended that women start pelvic floor exercises in the immediate postpartum period to reduce urinary incontinence. In general, it is suggested that a woman avoid high impact activity such as running or aerobics or rigorous strength training until at least six weeks postpartum. However, for many women six weeks is too soon to return to prepartum activity levels. The return to exercise needs to be considered on an individual basis with your therapist, but must always be done in a graduated manner.

Exercise can be gradually increased once your inner core is functioning optimally, and in the absence of any pelvic floor dysfunction such as vaginal heaviness/pressure, urinary leakage, or pain. Your therapist will be happy to develop an individualized return to an exercise plan for you based on your prepartum fitness level, current symptoms, and fitness goals.

In the meantime, a good goal to aspire to is a minimum of 15 minutes of aerobic exercise most days of the week, working up to 150 minutes of moderate-intensity exercise accumulated throughout the week. Strength training can be done three days a week and stretching most days of the week. Pelvic floor muscle training can be done daily. No matter what your regime, it is imperative to remember to listen to your body. When it is fatigued, take a break, if there is pain, modify or stop the activity. Returning to exercise in the postpartum period should not be a race, but instead, a time to be gentle with your body. Don’t forget it just performed the miracle of bringing a tiny human into this world!