Early Post Natal Advice
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