EARLY POST NATAL ADVISE

Wednesday, September 19 2018

1. In what ways is the pelvic floor affected during pregnancy? 
Your pelvic floor consists of superficial and deep muscles, which give upward support to your pelvic organs (bladder, uterus and bowel) and assist with urinary and faecal continence. The less talked about fascia and ligaments (which I describe as elastic bands) connect your pelvic organs to the walls of the pelvis, keeping the organs in their normal position….phew! The effect of pregnancy on the structure and function of the pelvic floor is still largely unknown despite advances in obstetric care. What we do know, is during pregnancy hormones can lead to a lengthening of the muscles, fascia and ligaments challenging the normal day to day functioning of the pelvic floor, which is why symptoms of urinary leaking is a common symptom in some pregnancies. Other factors such as advancing age, BMI, strenuous physical exercise and smoking history have also been linked to urinary incontinence in pregnancy, which is an even greater reason to stay healthy and exercise correctly during pregnancy.

 

2. How can your pelvic floor be damaged during birth?
During a vaginal birth, the pelvic floor lengthens to allow the baby to pass through this muscular structure out into our world. The majority of the time it is smooth sailing, however, in some cases, the muscles and ligaments don’t cope as well and can be thinned, torn or pull off the bone to which they attach (avulsion). Nerve injury and vascular changes also occur during birth due to the pressure of the baby moving through the birth canal, and postpartum these can also contribute to slow and sluggish pelvic floor muscles, often resulting in urinary and faecal incontinence whilst the muscle recover. A vaginal birth can also increase the risk of fascia damage, known as pelvic organ prolapse (POP) which is the descent of one or more of the pelvic organs, with heaviness in the vagina being the usual symptom that is experienced. Prevalence of POP can be up to 50% after vaginal delivery, however, only 10-20% of that is shown to be symptomatic.

The majority of women are fine post-birth, however, we do know that factors that increase pelvic floor trauma include; forceps birth, increased head circumference, long pushing phase, 3rd or 4tn degree tears and episiotomy. I absolutely recommend that all women get themselves to a Women’s Health Physio at around 6 weeks post birth, but for any women with these at risk factors, it needs to be a priority. Trust me, your vagina will be very thankful

 

3. How soon after birth can you start doing pelvic floor exercises? 
Day zero… After cuddles and tears of course!
Now I don’t mean going all Arnold Schwarzenegger on those muscles remember you have just pushed out a baby out, so let’s show some TLC to that region as well. Your pelvic floor normally does this amazing thing, that when you sneeze or cough it responds by contracting to stop you leaking, unfortunately, this response can be altered by childbirth. Therefore doing a pre-contraction of your pelvic floor prior activities of increased abdominal pressure – cough, sneeze, sit to stand, or lifting your big ball squidyness, can help to give support to your organs and retrain the reflex. There can commonly be swelling and bruising to the vagina region early after vaginal delivery, therefore performing gentle pelvic floor contractions/relaxations can help improve blood flow and encourage healing. Remember don’t overdo it, especially if you have stitches, we want to encourage recovery, we are not training for the vagina weightlifting championships… just yet!

 

4. When should you start to incorporate core exercises after birth?
The short answer is, as soon as you are able to.
A great way to start is by incorporating gentle core activation into your daily movements whilst moving around the hospital room or home in the week post birth. . Your pelvic floor forms an integral part of your core, therefore from day one if you can start the pre-contraction I discussed above then this is a great simple and functional way to start. Incorporating good posture will also encourage better activation of your core muscles which can help prevent back issues in those early days, help you adopt good movement patterns whilst your body adapts to your new activities of being a mum and training you out of the pregnant posture you had for 9 – 10 months.

An assessment with a women’s health physiotherapist will guide you further on specific core exercises and timeframes for YOUR recovery after birth.

 

5. What pelvic floor + core exercises do you recommend in the first 6 weeks? 
You may be told in hospital to hold your pelvic floor contraction for how many weeks you are postpartum which is a really great starting point. However, what most people don’t realise is that your squeeze and lift is only as good as your relaxation, so thinking of the ‘let go’ as much as the ‘close lift’ will help women to really make good progress with their pelvic floor strengthening. Sometimes caring for your bub in those first 6 weeks is all the core exercises your body needs, so by ensuring you activate your pelvic floor and deep abdominals during movements such as getting in and out of bed at night, or lifting bub then the great news is you have started your core exercises. Woo hoo!

One thing I would like to mention is the sexual pain after childbirth, 64.3% of women reported this in the first year following childbirth, and this should NOT be your new normal ladies. Contributing factors can be hormonal, muscle tightness or psychosocial. Doing lots of pelvic floor strengthening can make symptoms worse. Therefore, the importance of a vaginal examination and management is vital and is something we help women with every day.

 

6. How do posture and breath affect our pelvic floor?
They play a big role in optimising pelvic floor muscle activation. Poor posture can potentially increase symptoms of pelvic organ prolapse and affect how efficiently you contract your pelvic floor muscles. Correct breathing dynamics (diaphragmatic breathing) can assist with normal pelvic floor movement during activities, were upper chest breathing could possibly promote a tighter pelvic floor, or bearing down with exercises can increase pelvic floor muscle weakness and prolapse.

Good posture and breathing dynamics are also vital for passing a bowel motion…who knew!. One of my favourite tools is the squatty potty, and I would encourage all women to check out their website to learn how to poo like a pro (Visit www.squattypotty.com)

 

7. When should you see a Women’s Health Physio after birth?
We advise all women to see a women’s health physiotherapist after birth regardless of delivery (c-section or vaginal), we recommend any time after 6 weeks, mainly because there is a lot of healing that occurs in those first 6 weeks, and you will often have had the medical clearance that stitches etc… are recovering well. Often ladies are thinking about getting back into some form of exercise around this time as well, therefore assessing the pelvic floor, stomach muscles and overall body mechanics allows us to confidently prescribe appropriate exercise, as it’s not a one fits all approach. Some ladies on Instagram might be running at 6 weeks, do what is recommended for your body, not what others are doing. We can put a plan in place to get you back running or doing high impact exercise at the right time for your body if it is a goal you would like to achieve.

 

8. What tools or resources can women use to strengthen their pelvic floor after birth? 
There are so many on the market it can get quite confusing…from machines that zap your pelvic floor muscles to vaginal weights…could you challenge the record holder and lift a whopping 13 kg!? Now that’s extreme!

Your classic pelvic floor exercises ‘kegels’ have got the best research for urinary incontinence and prolapse, and an intensive physiotherapist lead program is shown to be the most successful. There are also many great apps on the market which can help with compliance, I love the NHS Squeezy one, as you can adjust it to your specific program prescribed by the physiotherapist. Sometimes electrical stimulation guided by a physio is needed when the muscles are very sleepy; this requires a probe being inserted into the vagina, which contracts your muscles, whilst getting you to contract to waken them up.

Incorporating your pelvic floor exercises into your regular exercise class is a great strategy for those who find traditional Kegels too much like a chore. Participating in postnatal specific exercise classes, run by a qualified and experienced instructor like the ones offered at Women in Focus Physiotherapy in Bondi are a great way to improve pelvic floor strength, stomach separations and keep that pesky back pain at rest.

If you can’t make it into Women in Focus, then make sure you seek out your local women’s health physiotherapist to help assist you with a recovery program and advise that is specific to your body.

By Karen Crudden
Women’s Health and Musculoskeletal Physiotherapist & Pilates Practitioner

Looking after those precious pelvic floors in pregnancy, birth and beyond…

Monday, August 21 2017

Recently Lyz Evans, our Practice Principal and Founder of Women in Focus Physiotherapy, chatted with Nadine Richards from She Births about exactly what the pelvic floor is, how it is affected by birth, and why it is so important that women look after it in the child bearing years. Lyz explains if women learn to connect with their pelvic floor prior to birth it can not only assist during labor, but also prevent ongoing issues such as incontinence in the long term.

A MUST read for any of you that are currently or planning to get pregnant, have already had children or simply are just keen to learn more about your your own pelvic health. Ladies, you only get one pelvic floor so lets spread the word on why we need to look after it.

For those ladies currently pregnant, make sure you also check out the She Births program, a scientifically verified birth preparation course that will ensure both you and your partner feel informed, supported and empowered leading into your birth. Check out their courses here or head over to their birth focused blog.

Pelvic Floor

At She Births we recommend for women to have a pelvic floor assessment prior to birth – can you explain why this is so important? How can a women’s health physio prepare you for birth?

It is wonderful that She births educates its women on the importance of the pelvic floor, as for the majority of women it is not until the child bearing years that they have even heard of the pelvic floor, let alone given it much attention. To understand why it is so important to have it checked prior to birth, first we need to understand what it is and what it actually does…

The pelvic floor is an intricate web of muscles, fascia and ligaments sitting deep within the pelvis spanning the base from the tailbone to the pubic bone. It is actually made up of 8-9 individual muscles that join together with the fascia to close off the pelvic outlet, hence creating the ‘floor’ of the pelvis. Although a relatively small muscle that is hidden from view, its importance should not be underestimated as it has some of the most critical functions in the entire body including:

• Keeping closure around the bladder to prevent urinary leaking

• Keeping closure around the rectum to prevent bowel leakage

• Providing a support system to the uterus, bladder and bowel to prevent downward descent (Pelvic Organ Prolapse)

• Provide sensation and tone required for enjoyable pain free sexual intercourse

• Provide the muscle activation to facilitate an orgasm

• Work with the deep abdominals and ‘core’ to assist with stability of the spine, hips, pelvis and rib cage

• Works with our diaphragm to ensure optimal breathing patterns

• Being able to open and fully relax at times when exiting from the pelvis is required such as when urinating, opening the bowels and of course birthing a baby!

Historically the focus for the pelvic floor has always been based around strengthening, however in recent years year’s we have realized that just like any other muscle in the body the pelvic floor has the potential to a become excessively tight (hypertonic) and this can become incredibly problematic for some women. Clinically, we are now seeing an increase in the number of women presenting with hypertonic pelvic floors and the reasons for this seem to be multifactorial in nature mainly based around lifestyle and behavior choices choices. Factors such as high level participation in exercise such as Pilates, pole dancing and weight lifting can encourage over activation of the pelvic floor, and constipation from poor dietary choices can lead to chronic straining and a pelvic floor that is always in spasm. The impact of today’s fast paced lifestyle has also lead to a pelvic floor that is constantly ‘switched on’ as a result of a lack of relaxation, diaphragmatic breathing and high anxiety and stress levels.

During birth the requirement of the pelvic floor is incredible as it needs to stretch beyond 3 times its normal length, can you imagine if you had to stretch your hamstring 3 times its normal length? It would end up at a 90 degree angle behind your head, not possible! The pelvic floor truly a remarkable piece of anatomical engineering, however in order for this impressive stretch to occur the muscle needs to have good flexibility and be able to completely relax during the crowning phase in birth. If a woman has a hypertonic pelvic floor that cannot fully relax or stretch then you can imagine how this has the potential to impact or prevent achieving a normal vaginal delivery.

One of the main reasons we encourage women to have their pelvic floor checked in pregnancy, is so that we can help determine what type of pelvic floor they have, and therefore how we can best help them. If a woman has a weak pelvic floor then a specific strengthening program will be given so that the pelvic floor can continue to support the bladder, bowel and uterus throughout the pregnancy and in the post natal period.

If a women however has a hypertonic pelvic floor, then we will work with her to restore optimal breathing patterns, work manually through the vagina and pelvis to help release overly tight muscles to ‘ down training ‘ and help restore normal mobility and length required for birth. This can be incredibly empowering and life changing for a woman who has always held tension in her pelvic floor.

Regardless of what type of pelvic floor a woman has once in the final stages of pregnancy, a Women’s Health Physio can work with her to teach her how to achieve full relaxation of the pelvic floor to achieve opening of the pelvic outlet rather than closure, which is what is required in birth.

We also recommend that women have one assessment with a Chiro or Osteo prior to birth – How is physiotherapy different from Chiropractics and Osteopathy?

Chiros, Osteos and Physios all have very different training so approach the body in differing ways, in many cases we can work harmoniously together to help women achieve optimal outcomes.

The main difference when seeing a specifically trained women’s health Physiotherapist is that we will do an internal check of the muscles, ligaments and organs within the vagina to check their tone and function and how this may impact the rest of the pregnancy and upcoming birth. We also utilize sophisticated real time ultrasound equipment that provides women with a visual of how their abdominals and the pelvic floor function, a wonderful way for us to educate and teach women.

Specifically trained Physios will undertake a thorough inside – outside ‘Pelvic Health Check’ for a pregnant woman. This will usually include:

• Checking the alignment and stability of the pelvis and hips to ensure it is has symmetrical mobility required to minimise any pelvic girdle pain in pregnancy but also to prevent restriction of pelvic opening required during birth.

• Assessment of the abdominal wall, rib cage and breathing patterns to address achieve optimal abdominal support and prevent excessive loads whilst the abdominal anatomy is so dramatically altered.

• Internal assessment of the pelvic floor muscles via a vaginal exam (After 12-18 weeks gestation)

• Use of real time ultrasound on the pelvic floor and abdominal muscles for feedback on activation – a wonderful teaching tool for women.

• Education on what that individual woman needs to do to optimise her pelvic floor and pelvic health for the pregnancy, birth and postnatal period.

• Prescription of a home exercise program to encourage pelvic floor and abdominal strength or relaxation.

• Discuss regular exercises habits and what is suitable for the individual.

 

After birth, what happens to your pelvic floor? How can you strengthen it?

A vaginal birth is essentially the biggest load that your pelvic floor will EVER have placed on it, and studies show an average of 25 – 35% reduction in Pelvic floor strength following birth. We also know that in 80% of women the nerve the innervates the pelvic floor (the pudendal nerve) is bruised and some times partially damaged from the birth so the messages it sends to achieve activation of the pelvic floor occurs much much slower.

As a result greater than 50% of women will experience urinary or bowel leaking in the first few weeks and months following birth, so don’t be alarmed if this occurs. If the birth was slightly more complicated requiring an episiotomy, forceps, venous, long second stage, or a very large baby then these women are often more likely to feel the impact to the pelvic floor in the months following birth.

The good news is for the majority of women if a specific pelvic floor program is performed daily then good pelvic floor strength and control will return. In the early days, Women should reconnect with the pelvic floor on the post natal ward as this is an essential part of encouraging the pudendal nerve to regenerate and the muscles to reactivate. Starting by activating and holding gently for 1 second and repeating 5 -10 of these a few times a day is enough to get started. Timing this at that same time as feeding baby is a great way to remember to do them.

Once this becomes easy then the endurance and hold time should be increased. The term ‘ use it or lose it’ definitely applies to the pelvic floor, and if you want it to be with you and support you through life then you need to give it a little love and TLC in its time of need!

How do you know if you’re doing pelvic floor exercises correctly?

Unfortunately the answer to this question really is that you need to have it checked by a Women’s Health Physiotherapist to be 100% sure you are doing it correctly. Even the ultrasound cant 100% confirm a correct activation and breathing patterns will come into play.
We know from research that when the general population are given instructions on how to do a pelvic floor activation that greater than 50% will do it incorrectly, of which 25% were found to be actually bearing down rather than lifting up (Eeek!) If a woman doesn’t have access to a Women’s Health Physiotherapist and wants to check herself the best way would be to insert a clean finger into the vagina, and when activating the pelvic floor she should feel a tightening and a ‘suck’ up of the finger inwards and upwards. She should be able to breathe and hold for 10 seconds without the finger being pushed out.

My advice to women is to be proactive in their childbearing years is to find yourself a good Women’s health Physiotherapist and be sure to see them at least once in pregnancy and then again at 6 weeks post natal. These appointments will potentially save your pelvic floor in the long term.

It really bugs me that women are not routinely sent for pelvic floor rehabilitation following a birth, if you were to undergo surgery for a hamstring tear you would 100% be sent by the surgeon to a Physio for months of post operative rehabilitation, why does this not happen for the pelvic floor?! ?We have a long way to go in Australia and I would love us to look towards France whose government provides 6 -8 sessions of routine government funded pelvic floor Physiotherapy to help restore function post birth. Go France! Perhaps one day we will get there, but for now we either need to move to Paris or be proactive with our pelvic floors.

After all you only get one of them so please make sure you look after it!

Read the full blog post via She Births here.

Jogging 3 weeks post birth?! Please don’t.

Friday, January 15 2016

To mums out there who have seen Michelle Bridges recent post about the exercise she is doing at 3 weeks post natal, then you would be right in feeling confused by her recommendations.

It boasts about her 56 min interval work out, which is comprised of 32mins of jogging and 24 minutes of walking. She goes on to say “Remember! I’m a professional trainer & have been training for 30yrs. So! For you please dial this down to 15 – 20 mins of total work.”

Michelle recommends you reduce the length of her workout, however has failed to identify that the real issue is not the length rather the type of exercise: Jogging!

 

IMG_5935

 

The reduced 20 minute workout would still include 12 minutes of jogging, which for a woman who has just had a vaginal birth or cesarean delivery is quite simply irresponsible, and would NOT be recommended by an experienced health professional.

If an individual decides to jog soon after giving birth, this is their choice. However as a public figure encouraging women who’s body types, birth and fitness histories are unknown, to start jogging is quite frankly concerning. It could potentially cause a woman more harm than good in these early stages, especially to the pelvic floor and the ligaments that support the bladder, uterus and bowel

After seeing this post on Tuesday, and letting it sit with me for a few days, I have become increasingly frustrated by the incorrect message that are promoted by the fitness industry especially for women in their childbearing years. As a health professional working in Women’s Health for over a decade, there is a duty of care to provide women with the correct information on how to best look after their bodies. I cannot tell you how many times I’ve heard comments like “If only I knew about the damage returning to exercise too early could cause. I might not have ended up with these problems.”

As I’ve noted in the past, I’m a great supporter of Michelle and the work she does in building healthier communities throughout Australia. But now what I’d love to see is Michelle using this time as opportunity to promote a positive post-natal message to her audience. Like rebuilding of the pelvic floor, deep abdominals and postural muscles that are so dramatically weakened during pregnancy. Or instead of jogging, encouraging more appropriate low impact cardio options such as the stationary bike or cross trainer.

 

So what exactly is wrong with jogging at 3 weeks post-natal?

Jogging is an exercise that results in a high impact force called a ground reaction force that travels through the body when the foot strikes the ground. This impact requires strength and stability from the joints, ligaments and muscles in the body to maintain good control, preventing injury and tissue damage.

In the post-natal body the ligaments and muscles have a reduced ability to generate strength due to the physical and hormonal changes of pregnancy and birth. These changes coupled with the downward force of gravity with vertical exercise such as jogging or jumping means that if undertaking high impact exercise, then excessive strain is being placed on already weakened structures including the pelvic floor and pelvic girdle, potentially causing a new mum long term damage.

 

Pelvic Floor Diagram

 

So what exercise can you do safely?

The most important thing to remember is that all women have different body types, have had different birth’s and have different levels of fitness leading into the pregnancy, so returning to exercise at the right intensity is individual. Start with low impact exercise such as pelvic floor exercises, pilates, yoga, stationary bike, cross trainer, and swimming (after your 6 week check) and build gradually from there.

If you are a runner or keen to return to more high impact exercise, then I highly recommend you see a Women’s Health Physiotherapist from 6 weeks who will assess your pelvic floor, postural alignment and abdominal muscles to ascertain the right exercise for you. Then to keep motivation up, find an experienced trainer or fitness group who specialises in the post-natal body who can guide you in your safe return to full fitness.

Ladies, remember you only get one body and one pelvic floor, which has been gifted to you to enable the growth of your special little human. So please, show it some respect and look after it.