Pelvic Floor Health in Pregnancy, Birth and Postpartum

What is the pelvic floor?

The pelvic floor is a group of muscles at the bottom of the pelvis which supports the bladder, bowels and female reproductive organs including the uterus and vagina. The main jobs of the pelvic floor include effective elimination of urine and feces, and pleasurable sexual function. Problems with the pelvic floor can cause incontinence and pain during intercourse. Pregnancy and childbirth are a very important and impactful time for the pelvic floor, and ensuring pelvic floor health during pregnancy can have a positive effect on the labor and birth process. Read on to learn how to assess and prepare your pelvic floor health for labor, birth and postpartum.

3. See a Pelvic Floor Therapist

A pelvic floor therapist can provide personalized guidance and exercises tailored to your body’s needs. If you can, we highly recommend seeing a pelvic floor PT during pregnancy so they can help prepare you for birth. You will then also have a relationship with this care provider should you require pelvic floor PT after birth (which most folks do). Schedule a consultation to address any concerns and ensure optimal pelvic floor health.

Pelvic Floor Postpartum Recovery

Below is an article written by our friends at Mount Tabor Physical Therapy in Portland, Oregon, titled “I’ll be ‘healed’ and ready to go back to everything 6 weeks postpartum, right?!”. It was written by one of the co-owners and doctor of Physical Therapy Laura Luitje, as she describes her own experience with her pelvic floor health through the perinatal experience, as well as what she has learned through working with many parents in their journeys.

Pelvic Floor Postpartum — advice from a PT

After my twins were born, I was desperately treading water in a choppy sea of newness: breastfeeding with all its challenges, trying to get sleep and help my babies to sleep. My body, my abdominal muscles, my pelvic floor, my cesarean incision, all entered my overtaxed awareness briefly, mostly as thoughts about how I was going to stay healthy as a new mother and “bounce back”... or something. I didn’t love that I still “looked pregnant,” but there were a lot of other things on my plate.

When I went for my 6 week check up with my obstetrician, she briefly peeked at my scar and I honestly don’t remember if she gave me a pelvic exam. She asked some questions and just like that, I was walking back to my car, “cleared for activity”.

My scar did heal and when the twins were 8 weeks old, I started experimenting with exercise while holding them. But when changing their diapers in the car, going for walks wearing both of them and getting back to work I didn’t feel “healed”. My low back pain was increasing, I was getting numbness in one foot and I felt old and creaky. I finally sought help from a pelvic floor physical therapist for my abdominal separation (diastasis rectus abdominis) and learned that although my scar had healed, my abdominal muscles, my rib cage, my breathing and my posture all had habits carried over from my pregnancy. I needed help to analyze each of them so that I could retrain, have less pain and feel more capable. To get my abdominal muscles working again, I had to use my pelvic floor muscles, which was news to me!

The media is full of before and after images of famous people who’ve had babies and then show up in a bikini 8 weeks later, looking like nothing in their lives has changed. The reality is that all bodies carry on with what they’ve been doing until we give them new information and instructions. Our abdominal muscles continue operating as if there were a baby inside us until we teach them otherwise. Our pelvic floor muscles may be in a state of paralysis after the huge event of letting a human through the birth canal; making sex painful if they are guarded or making exercise difficult due to weakness or leaking urine. Our glutes may have gone to sleep because the postures of pregnancy and carrying babies around don’t call them into action.

The word ‘healing’ is most accurately applied to the wound closing through scarring, rather than the body’s overall readiness for an activity. There are a few potential physical ‘wounds’ with giving birth: perineal tearing, tearing through other areas of the vulva and vagina, episiotomies and of course, cesarean birth incisions. Our tissues do about half of their healing by 6 weeks postpartum (tearing or cesarean incisions) and the majority of their healing by week 12 (with scar remodeling continuing for about 2 years post-injury). A study looking at abdominal incisions can be applied to cesarean scars: it found that abdominal fascia healed to 51%-59% of its original tensile strength (ability to withstand force) by 6-weeks post-surgery and 73%-93% of its original tensile strength at 6-7 months postpartum. (Ceydeli et al. 2005), so racing back to high impact exercise without guidance can be dicey.

Wound healing aside, the muscles that make it possible for us to do the all the things (exercise, running, getting up and down off the floor, wearing babies, picking up babies and putting them down about 1,000 times a day) may also need some retraining.

In response to the confusion around postpartum readiness to start heavier exercise like running, a group of Irish pelvic physiotherapists put together guidelines to help us evaluate where we stand. It looks at the strength of our big muscles (the glutes, the calves, the hip muscles and quadriceps) and asks us to try hopping, leaping and walking to see if we can complete these without pain, incontinence or vaginal heaviness.

For the pelvic floor muscles, they advise:

● A strength score of 3 out of 5 on a manual muscle test performed by a pelvic floor physical therapy specialist

● Ability to perform the following in standing*:

○ 10 fast contractions

○ 8-12 reps slow holds (6-8 seconds at maximum force)

○ 60 second hold at 30-50% contraction strength

* Research indicates that almost half of people are performing pelvic floor muscle contractions/kegels incorrectly, and in a way that could make symptoms worse, so getting specialist feedback on how you’re doing is wise.

They also recommend having a pelvic floor specialist assess how well supported our pelvic organs are by the pelvic fascia to help determine if a support such as a pessary (device placed inside the vaginal canal to support the vaginal walls) would be advisable to prevent further heaviness or pelvic organ prolapse.

Their recommendations include:

● A low impact exercise progression for the first 3 months of the postpartum period (hint: no jumping or running).

● A pelvic health assessment with a specialized physical therapist (as early as 6 weeks postpartum) to look at the abdominal wall and pelvic floor.

● A screening for risk factors if returning to sport at < 3 months postpartum:

○ Pre-existing hypermobility conditions (e.g. Ehlers-Danlos)

○ Breastfeeding

○ Pre-existing pelvic floor dysfunction or lumbopelvic dysfunction

○ Psychological issues with coping through too much exercise

○ Obesity

○ Cesarean Section or perineal scarring

○ Too few calories coming in relative to calories needed by the body for our

activities (including producing breast milk)

○ Abdominal separation (Diastasis Rectus Abdominis)

They recommend against beginning running if you have any of the following during or outside of running:

● Urinary and/or fecal incontinence

● Pressure/bulge in the vagina

● Ongoing or onset of vaginal bleeding, not related to menstrual cycle, during or after attempted exercise (low impact or high impact)*

● Pain

*(this should prompt a return visit to your OB or midwife)

Their recommended timeline for getting back to running/exercise if you don’t have any symptoms? 3-6 months postpartum. This is much longer than the 6 weeks many of us have in mind as we plan our return to exercise. It can feel disheartening to be told to wait longer when you want to get moving and feel strong again. But the good news is that seeking help from a specialized pelvic floor physical therapist can move you along with more confidence and knowledge.