Ebbs and Flows

The pelvic floor (PF) is often times ignored in society do to the sensitive nature of the topic for some. I want to discuss how important this area of the body is in helping you during pregnancy, labor and delivery, and the postpartum stage, and shift focus away from the sexualized nature that the pelvic floor seems to only be recognized for. It is not an area that you want to place ignorance on rather place more attention on in order to embrace its purpose as a part of the lovely body we have. The pelvic floor is lymphatic, sexual, provides stability to the pelvic girdle, supports the abdominal and pelvic organs, and is sphincteric preventing urinary and fecal incontinence. Like any muscle, the 12 muscles that make up the pelvic basin contract, relax in response to intra-abdominal pressure, normal sexual, urinary, and bowel function. These muscles need to be able to contract and lengthen completely to utilize the full power of the system the support. When the PF is weak do to over-activity or under-activity a woman may experience: pelvic girdle pain, low back pain, pelvic pain, incontinence bowel/bladder, obstruction/constipation, sexual dysfunction, pelvic organ prolapse and celes.  

How can we make sure to maintain a strong and functioning pelvic floor through pregnancy, labor and delivery, and postpartum? Let’s look at the research. There is strong evidence to support that performing PF exercises in pregnancy will help reduce urinary incontinence at 35 weeks gestation, and in the 4th trimester. ¹Boyle, R., Hay-Smith, E. J., Cody, J. D., & Mørkved, S. (2012). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 10, CD007471. doi: 10.1002/14651858.CD007471.pub2 ²Hagen, S., Stark, D., Glazener, C., Sinclair, L., & Ramsay, I. (2009). A randomized controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse. International Urogynecology Journal, 20(1), 45–51. doi: 10.1007/s00192-008-0726-4³Okido, M. M., Valeri, F. L., Martins, W. P., Ferreira, C. H. J., Duarte, G., & Cavalli, R. C. (2015). Assessment of foetal wellbeing in pregnant women subjected to pelvic floor muscle training: A controlled randomised study. International Urogynecology Journal, 26(10), 1475–1481. doi: 10.1007/s00192-015-2719-4⁴Price, N., Dawood, R., & Jackson, S. R. (2010). Pelvic floor exercise for urinary incontinence: A systematic literature review. Maturitas, 67(4), 309–315. doi: 10.1016/j.maturitas.2010.08.004⁵Reilly, E. T. C., Freeman, R. M., Waterfield, M. R., Waterfield, A. E., Steggles, P., & Pedlar, F. (2014). Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: A randomised controlled trial of antenatal pelvic floor exercises. British Journal of Obstetrics & Gynaecology, 121(Suppl 7), 58–66. doi: 10.1111/1471-0528.13213. In addition, women who performed PF muscle training in pregnancy had less reports of low back pain in the 3rd trimester and at 3 months postpartum.⁶Morkved, S. (2007). Evidence for pelvic floor physical therapy for urinary incontinence during pregnancy and after childbirth. In K. Bø, B. Berghmans, S. Morkved, & M. Van Kampen (Eds.). Evidence- based physical therapy for the pelvic floor: Bridging science and clinical practice (pp. 317–336). Philadelphia, PA: Elsevier.

Even more evidence supports that women who performed PF exercises did not have a greater chance of lacerations, episiotomies, assisted birth, or cesareans.⁷Du, Y., Xu, L., Ding, L., Wang, Y., & Wang, Z. (2015). The effect of antenatal pelvic floor muscle training on labor and delivery outcomes: A systematic review with meta-analysis. International Urogynecology Journal, 26(10), 1415–1427. doi: 10.1007/s00192-015-2654-4 Performing PF muscle exercises may even shorten labor in 1st and 2nd stage for first time mamas.⁸Bø, K., Hilde, G., Jensen, J. S., Siafarikas, F., & Engh, M. E. (2013). Too tight to give birth? Assessment of pelvic floor muscle function in 277 nulliparous pregnant women. International Urogynecology Journal, 24(12), 2065–2070. doi: 10.1007/s00192-013-2133-8

Research also demonstrated that women who have supervised exercised training by a PF specialists performed the exercises better than those who were unsupervised.⁹Price, N., Dawood, R., & Jackson, S. R. (2010). Pelvic floor exercise for urinary incontinence: A systematic literature review. Maturitas, 67(4), 309–315. doi: 10.1016/j.maturitas.2010.08.004

Which leads me to tell you that this is not just about a kegel. There are ebbs and flows to the beauty of this region. The PF muscle group needs to contract and fully relax in order to function effectively (just like every muscle). Some women may need to first focusing on relaxing the pelvic floor. This is not something many women are taught except by a women’s health/pelvic floor physical therapist. If you have PF pain, difficulty eliminating, pain with intimacy, or can not feel the pelvic floor relax, then pelvic floor down training (aka reverse kegels) would be the first step towards your PF health. Overall I highly suggest you met with a physical therapist that specializes in pregnancy/postpartum/pelvic floor therapy to determine the right prescription for your health. There are many exercises outside of kegels that will help the pelvic region to provide healthy stability and support (example: walking). In addition to exercise, there are manual techniques that a physical therapist can perform to help you relax the pelvic region.

Pro Tip: Around 35-36 weeks gestation I instruct a pregnant woman to NOT kegel, rather, focus only on relaxation of the PF during inhale and only allow the passive recoil of the PF on exhale (natural process). 

As amazing as this region of the body is, it is designed to work in harmony with the breath and other structures like the core and back muscles. When a woman integrates breath work with relaxing and engaging the pelvic muscles she creates blood and lymphatic flow, encourages stress relief, and as mentioned above, may improve her pregnancy, labor and delivery, and 4th trimester outcomes. Please see my other blog post or schedule a consultation on integrating the breath with PF mobility.

Dr. Rach xoxo

*If you are a Physical Therapist and would like to learn more the research gained in this article is cited from the Section on Women’s Health Physical Therapy’s Fundamental Topics of Pregnancy & Postpartum Physical Therapy manual.