In this article, we going to cover what pelvic floor is, the different symptoms that you may experience during pregnancy, when and why you may want to see a pelvic health physiotherapist, and different strategies that you can utilize to help prepare your pelvic floor for labour and delivery, as well as some helpful tips to help you recover postpartum.
What is Pelvic Floor Physiotherapy?
Pelvic floor physiotherapy is physiotherapy specifically for the pelvic floor muscles, which located between the pubic bone and the sacrum.
Your pelvic floor muscles are responsible for a number of very important functions.
- They help to hold up and support your bowel, bladder and uterus, and during pregnancy they also support the weight of your growing baby, the placenta and amniotic fluid. These muscles are working overtime all throughout our pregnancy.
- They assist in the control our bowel and our bladder, keeping things in and also letting things out fully.
- These muscles play an important role in sexual function.
- They also coordinate with our deepest core muscles, the transverse abdominis (TVA for short), to help stabilize and support our low back, hips and pelvis. During pregnancy, the TVA widens and stretches to accommodate your growing baby, which means that it loses some of its mechanical advantage for core stability. This causes the pelvic floor to do more work than it used to do, in order to stabilize your core.
Incredibly, incontinence symptoms during pregnancy (and beyond) are not usually because the pelvic floor is too loose. It’s usually the opposite – it tends to be too tight because it’s working overtime. If you think about any other muscle in your body, when that muscle is already maximally contracted, when you need to give it a bit extra, you will not be able to because it’s already at its max load. The pelvic floor is like this. When it’s already too tight, there’s no opportunity within the muscle to tighten it up just a little more to keep from peeing a little when you cough, laugh or sneeze. It’s already doing as much as it can. So the incontinence that you may be experiencing is likely because your pelvic floor is too tight. It’s absolutely possible that it’s too loose/weak, but that’s a much less common situation. Ideally, we would love for our pelvic floor to be somewhere in that neutral middle ground for optimal function.
What Conditions Can be Treated by a Pelvic Floor Physiotherapist?
Pelvic floor dysfunction can cause any of the following issues:
- Low back hip or pelvic pain
- Incontinence of the bowel or bladder, and difficulty controlling it
- Pain with intercourse
- A feeling of heaviness or pressure within the pelvic or perineal are
- Difficulty engaging with your core muscles
If you experience any of the above symptoms, those are all great reasons to see a pelvic health physiotherapist.
What Are the Benefits of Pelvic Physiotherapy?
The pelvic floor muscles are just like any other muscle; they just happen to be inside your body. By seeing a pelvic floor physiotherapist, you will learn which muscles are working properly, which are too tight, and which are too loose (if any). You will learn if you need to do kegels (they’re not the answer for everyone!) or reverse kegels, and not only that, you will learn how to do them properly. You will learn how to connect to your pelvic floor during birth to reduce your chances of tearing and improve your recovery, and after your baby is born you will learn how to recover better and restore your core for better function and less pain.
How Does Pelvic Floor Physiotherapy Work?
When is a good time to see a pelvic floor physiotherapist?
Generally, we recommend, in the absence of symptoms, to start around week 28-32 of pregnancy – but earlier is also fine too. If you are experiencing any of the more common symptoms (mentioned above) during pregnancy as a result of pelvic floor dysfunction, you would want to see a pelvic physiotherapist as soon as you are feeling symptoms.
The reason to come in, even in the absence of symptoms, around weeks 28-32 is to allow us some time to assess and see where things are at and help you to develop a connection with your pelvic floor to make your labour and delivery is that much easier, as well as help you guide your postpartum recovery.
What can I expect during my first appointment?
The physiotherapist will start by getting a detailed health history. This will include discussions around your bowel and bladder function, if you experience discomfort or pain with intercourse, your pregnancy, labour, and delivery history, what activities/exercises you enjoy, your sleep, diet, and water intake as well as your overall goals for treatment.
We will then provide education on pelvic floor physiotherapy, what and how we assess, what we look for and how we build a treatment plan from what we find. Next we’ll assess your general movement patterns for your low back, hips, and pelvis. As well as check for core function. We will only do the internal pelvic floor assessment if you’ve provided informed consent.
Once we’re all done, we’ll discuss the findings, treat the muscles that need treating, and send you home with some exercises to get you moving forward towards reaching your goals!
When we are looking at assessing the pelvic floor, it is most accurate to assess those muscles with an internal assessment. This helps us assess if things are overly tense or overly relaxed, what your ability is to contract and relax, and then what your overall connection and control is like. What we find during the assessment helps to guide the most appropriate exercises for you to help address what’s going on now.
Pelvic Floor Physiotherapy Treatments, Techniques and Exercises
It would be helpful to get an assessment with a pelvic floor physiotherapist early in the third trimester. In that session, we will get a general idea as to what’s going on with your pelvic floor. Usually follow-up appointments are recommended within a few weeks after that first appointment. During that follow-up session, we will cover deep breathing in a variety of different labour positions as well as perineal stretching, if that’s indicated for you.
You will come to learn through physiotherapy assessment and exercises that deep breathing is a really big aspect of what we do. The reason for that is that there is such a fantastic connection between your diaphragm muscle (it’s a big flat muscle at the top of your belly and goes right from your front to your back) and your pelvic floor. It’s helpful to think of your “deep core” as a canister system – think of a can of pringles! Your diaphragm is up at the top and your pelvic floor is at the bottom. As you inhale, the diaphragm should descend and the pelvic floor should also lengthen downward. As you exhale, they both return back to the start position. They should both go in the same direction at the same time. So if you are breathing well and connecting those properly, the benefit is that your pelvic floor will be taken through a gentle range of motion which will help to reduce tension and sensitivity, which is very very helpful for labour and delivery. Spoiler alert: most of us don’t do this – it’s a skill that needs to be taught.
A common misconception is that you need a strong pelvic floor to push the baby out, when in reality, we need a relaxed pelvic floor to let the baby out. So it’s important to learn how to connect with your pelvic floor through your breath.
Place one hand on your chest and the other on your abdomen. Take a couple of really good deep breaths. What do you feel happening there? Do you feel the upper hand moving more or the lower hand or both? What you want to encourage is for that lower hand, the one over your belly, to be moving more than the one up at your chest.
Visualization is super helpful when it comes to pelvic floor function. Try to imagine that your diaphragm muscle and your pelvic floor are one big balloon. As you inhale, that balloon inflates and as you exhale, it deflates. As you inhale, the belly rises and expands, and the pelvic floor opens and lengthens. As you exhale, everything simply comes back to the start position. When you are breathing this way, you should not feel like you are forcing anything. It should feel just like a really good deep relaxed breath. This is one of the really great ways to learn that connection with your pelvic floor. We recommend practicing this so that over time, you can sense your pelvic floor opening or releasing or relaxing as you inhale and simply settling back as you exhale.
This is a key component of learning how to connect with your pelvic floor and something that we really emphasize and work through during our sessions. For a visual demonstration of this breathing technique, sign up for our Pelvic Floor Basics for Birth Class, available in-person and on-demand.
Strengthening your pelvic floor
The other thing that we will assess is the strength of your pelvic floor. If you are experiencing issues with bladder control, it’s a common assumption that the reason is because our pelvic floor is relaxed or weak. However, the opposite could be true.
It could be that things are overly tense and that’s not allowing us to have that full connection and control over the increasing pressure of a cough or a sneeze. In this scenario, we want to make sure that we are doing that deep breathing to release that tension.
However, if it turns out that you do need to strengthen your pelvic floor, then we want to do kegels or pelvic floor contractions. We have come across a number of scenarios where individuals think they are doing that properly but then during assessment, we find out that they are not. In order to find out if you are truly connecting with your pelvic floor appropriately both with the breath as well as with the contraction, we highly recommend you have an assessment done by a public health physiotherapist so they can guide you in terms of what you need to be doing differently. Our pelvic floor physiotherapists help optimize that connection and make sure you’re getting the most out of the exercise you are doing.
Breathing and Labour Positions
As mentioned earlier, the best time to come in for labour preparation is between weeks 28-32 of your pregnancy. At that session, we do the breathing exercises, described above. We’ll also talk about doing the same breathing techniques in a variety of different labour positions. Anything that is using gravity to your advantage is a fantastic position to practice in.
Common positions might be on all fours sitting or on an exercise ball. You might find you like to roll or walk or sway, or kneel leaning forward on something. Or maybe you like to stand leaning forward or maybe you love a deep squat. Honestly, any position utilizing gravity to your advantage is extra helpful, so we encourage you to practice the deep breathing in those positions to start learning how to connect with your pelvic floor. It will make it that much easier during labour and delivery because the connection has already been created.
Another thing we go over is perineal stretching. A common concern we hear is that we are worried about tearing during labour and delivery. With perineal stretching, the idea here is that you then learn how to do that properly on your own so that you feel confident going home to create those changes in those tissues.
Perineal stretching has two main benefits:
- It helps to get you used to the sensation that you feel as the baby is crowning – that’s that “Ring of Fire” sensation that you may have heard about. Perineal stretching is meant to create a burning stretching sensation. No, it is meant to not be fun, however it is beneficial because it gives you the opportunity to prepare for that sensation and try to learn how to relax into something that is not overly enjoyable.
- It helps to take those tissues to a position where they’re not used to being, which creates change within those tissues.
Research supports doing perineal stretching starting around 34 weeks.
Labour and delivery strategies
We usually recommend a follow-up appointment at around 37 weeks. At this session, we go over a variety of Labour and Delivery strategies. Some of those include positioning for labour and delivery, pushing strategies to prevent tearing, and postpartum recovery.
When it comes to pushing strategies, there are two main methods that we typically push in. The first method is what’s most common in the hospital setting. It is called the valsalva method where you hold your breath and bear down like you’re trying to have a bowel movement. You may find as you do that that you feel a lot of bulging pressure in that pelvic floor. The second method of pushing focuses on a relaxation of our pelvic floor to help encourage the baby out, by helping the pelvic floor open and lengthen gently.
Postpartum movement and activity
The most common question we get postpartum is, “what can I do or should I do movement or activity wise in those early couple of weeks postpartum?”
What we tend to recommend in that scenario is to first reconnect with your breath so that is that deep belly breathing that you’ve learned through previous sessions that will help you to re-engage with your core. The second thing that you want to do are light pelvic floor contractions or kegels, which you’ve learned how to do correctly in your prenatal appointments. Those kegels should be pain-free. If for any reason there is any pain as you are doing it, wait a couple of days and try again. Don’t assume that if you’ve had a tear that it will be painful because it might actually feel fine! Give it a try and see how it goes.
The last thing that’s really helpful is walking. Walking is so good for so many reasons but again, take it slow and easy. Make sure you’re paying attention to your body and the signals it is sending you to know if you’re doing an appropriate amount of activity. You’ll know if you need to take it easy by the amount of postpartum bleeding you experience. If you overdo it, you may find that you bleed a bit more than usual (it’s ok – just take it easy the next day!). You might feel the start of pelvic heaviness or pressure. You might feel the start of or increasing low back hip or pelvic pain, incontinence of the bowel or bladder, or feel super fatigued later on that day.
If any of those things are happening, those are pretty sure signs your body is trying to communicate with you and tell you you need to take it easy. If none of those things are happening, then that’s essentially your green light that what you are doing is okay. So you can do this for another few days and gradually increase it a little bit and see how you feel.
The bottom line is, in those early weeks postpartum, it is okay to move, and we encourage you to move! – but you do want to be gentle and listen to your body. We prefer to give you the education around how to listen to your own body as opposed to giving you a set time frame because everybody’s labour and delivery experience is going to be different. We don’t want to assume that your experience is going to be the same as the next person because that’s highly unlikely! If you just open yourself to listening to your body and paying attention to these things, that will help guide you in terms of your exercise and activity in those early postpartum days and weeks.
Postpartum follow up session for pelvic floor physiotherapy
We highly recommend that you wait six weeks after delivery until you see a pelvic physiotherapist. This is just a general guideline to allow your tissues to have a chance to recover and heal – these guidelines are the same regardless of whether you’ve had a vaginal delivery or a C-section. You do not have to wait until you see your OB or Midwife, you can come in before you see them if you would like or you can wait till afterwards.
In that postpartum session, we will go over general movement patterns. We will re-assess your core, assess for diastasis which is abdominal separation, and make sure things are healing. We will look at your pelvic floor, we’ll look at any scar tissue that may be there so that we can help start to address any of those concerns with the overall goal of optimizing your recovery and your return to activity.
Pelvic floor physiotherapists in Toronto and Newmarket
We recommend checking in with a pelvic health physiotherapist to make sure that you are connecting to your core and doing your breathing and exercises properly, so that you are actually benefiting from the exercises and not wasting your time doing it incorrectly. Please reach out to our team or make an appointment in our Toronto or Newmarket studio if you have any concerns or questions. We look forward to seeing you at our clinic to help prepare you for your labour and delivery, and to help you recover postpartum.
We also offer a Pelvic Floor Basics for Birth Class which is available in-person and on-demand. In this class, we provide a visual demonstration of the techniques and exercises mentioned in this article.