The Importance Of The Pelvic Floor In Pregnancy
Article by Dr Emma Thurston (BM,BCH,MA)
What is your pelvic floor?
Your pelvic floor is a sling of muscles and ligaments that stretch from your tail bone at the back of your pelvis, to your pubic bone at the front. They support pelvic organs and, when pregnant, your baby. The importance of the pelvic floor is often overlooked; it’s likely not the first thing you think of training when hitting the gym! Yet, they support a number of key functions, from continence to sexual satisfaction 1,2.
Today, I will be talking about the importance of pelvic floor in pregnancy. Whilst it is true that some deliveries can be more demanding on your pelvic floor than others, regardless of what birth experience you have, looking after your pelvic floor is important. The weight of your baby, the placenta and amniotic fluid all need to be carried throughout your pregnancy, putting extra strain on these muscles. Moreover, the muscles of your pelvic floor will become laxer due to the hormonal changes which occur in your body whilst pregnant. Constipation is also common during pregnancy (owed to hormonal changes and often a difficult diet), which again adds to the pressure placed upon your pelvic floor.
You can think of your pelvic floor as a trampoline: it will stretch when a weight is put upon it and it will bounce back up again. However, if your pelvic floor is subjected to extra weight for a long time, like your baby resting on it during pregnancy, the muscles can become too stretched, stopping them from bouncing back and making them weaker. When weakened, it is harder for your pelvic floor to keep stool and urine in and you might experience leaking - especially when exercising, coughing or sneezing.
No need to panic though! There are exercises you can do to strengthen your pelvic floor. Training your pelvic floor increases the ability of your body to adapt to the weight of your growing baby. Extra benefits are seen after birth too, with a healthy pelvic floor being quicker to heal and reducing the risk of incontinence after labour3,4. I therefore strongly advocate you doing pelvic floor exercises, ideally before pregnancy but definitely during it.
How to squeeze:
My recommendation is to consult a women's health physiotherapist to ensure you learn to engage your pelvic floor correctly. Many women struggle with this, however, verbal feedback has been shown to improve the technique of women performing pelvic floor exercises5. Yet if this isn’t something you wish to pursue, then you can try working your pelvic floor with these simple tips:
First squeeze the muscles around your back passage, as if you were trying to stop yourself pass wind (or pick up a kidney bean I have been told!.
Whilst holding this first squeeze, move to tighten around the vagina in an inwards and upwards motion (as if you were passing a kidney bean from the back passage to your vagina in a Mexican wave!).
Let the squeeze go and make sure you relax your pelvic floor fully.
Broadly, there are two forms of pelvic floor exercises: slow and quick. Squeezy NHS app recommends holding your squeeze when doing slow exercises for 10 seconds and allowing a few seconds pause before your next squeeze. These exercises help support your pelvic organs and your baby. For quick exercises, Squeezy recommends the contraction is just a second long, with only a second pause between squeezes. Try not to hold your breath whilst you squeeze and just breathe normally. The app recommends 10 repetitions of each, the slow and quick exercises. A women’s health physiotherapist may be able to prescribe a more tailored approach, but if you’re not looking to see a specialist, I feel the NHS Squeezy app is a good place to go. Another option could be to try the Elive app, one Rhiannon has found useful, a contraption you insert inside and use with the app and different games, similar to squeezy.
It is just as important to train your pelvic floor to relax as well as strengthening it. This is because your pelvic floor muscles will need to relax during the pushing phase of labour, and having a relaxed pelvic floor can reduce the risk of tearing or needing an episiotomy at this time 4. So, make sure you relax your pelvic floor fully between squeezes!
As with any exercise regime, consistency is key6. You could do your pelvic floor before brushing your teeth, whilst boiling the kettle or pop them at the end of an exercise session. Exercise diaries have also been shown to help you remember to work you kegels!7
Perineal massage:
Aside from exercise, perineal massage is recommended by The Royal College of Obstetricians & Gynaecologists as a strategy to help reduce the risk of tearing your pelvic floor during birth4,8. What they recommend is:
Perform perineal massage from 35 weeks onwards daily. It is particularly beneficial for first time mothers. You can choose to give yourself the massage or ask your partner to help.
Tips:
Warm bath: having a warm bath to beforehand can help you relax and loosen the muscles around your perineum.
Short nails: due to the delicate nature of these tissues, make sure you have short nails if performing the massage yourself.
Comfortable position: you’ll need to be relaxed so find a position you’re comfortable. You may wish to be on a bed, propped up with pillows and have bent knees.
Lubricant: using lube is a good idea. This could be vitamin E oil, almond oil or olive oil
Thumbs: hold your thumbs as show below for about one minute. Press down towards your anus & into the sides of the vagina wall. Hold here for another minute, you will feel a stretching sensation. Remember to breathe!
Gentle massage:Gently massage the lower half of your vagina in a U-shaped motion for two to three minutes. Repeat this two to three times.
Repeat daily if possible: it might take a couple of weeks performing perineal massage for you to notice increased stretchiness in this area.
A key message I'd love for anyone reading this to take away is that you (or your partner) does not need to suffer with ongoing issues with your pelvic floor during or after pregnancy. If something is concerning you, go to your doctor or see a women's health physiotherapist. It pains me when I hear stories of women suffering with painful sex for years after having a baby, thinking it was normal and just part of being a woman they had to put up with. Your body will change having had a baby, but if you're worried about anything, get it checked out - it's not something to be embarrassed about.
Piqued your interest? Here's some resources to take your education further and empower you to understand how to have a healthy pelvic floor before, during and after pregnancy:
Resources:
The Pelvic, Obstetric and Gynaecology Physiotherapy is a great website with booklets you can download: https://pogp.csp.org.uk/booklets
NHS, what are pelvic floor exercises - https://www.nhs.uk/common-health-questions/womens-health/what-are-pelvic-floor-exercises/
We’re having a baby: my journey so far - https://rhitrition.com/were-having-a-baby/
What to eat when you’re pregnant - https://www.youtube.com/watch?v=p3i7IPID1dg&t=11s
As mentioned, my preference is for you to go to a pelvic floor specialist to ensure you are performing pelvic floor exercises correctly. However, if this is not amenable to you other options include:
Squeezy NHS app – £2.99 one off payment. They also have great resources on their website. Elvie trainer – a small gadget you can put inside your vagina which sends real time biofeedback via the corresponding app. A bit pricier at £169 (at time of writing)
Written by Dr Emma Thurston, who is a General Practitioner trainee in Dorset. She qualified from Oxford University in 2015 with a distinction in Medicine and a master’s degree in medical sciences. She is now studying for another master’s degree in Public Health from the University of Edinburgh alongside being a practicing doctor. She has a special interest in Lifestyle Medicine, is the Regional Director for the British Society of Lifestyle Medicine for Hampshire and Dorset and manages The Lifestyle Pill platform, which aims to educate and empower people about the potential healthy lifestyle behaviours have on our wellbeing. Emma’s blog can be found at, thelifestylepill.org, her Instagram channel is @the_lifestylepill and twitter channel @_lifestylepill
References:
1.) Lowenstein, L., Gruenwald, I., Gartman, I. & Vardi, Y. Can stronger pelvic muscle floor improve sexual function? Int. Urogynecol. J. 21, 553–6 (2010).
2.) Sobhgol, S. S., Priddis, H., Smith, C. A. & Dahlen, H. G. The Effect of Pelvic Floor Muscle Exercise on Female Sexual Function During Pregnancy and Postpartum: A Systematic Review. Sex. Med. Rev. 7, 13–28 (2019).
3.) Woodley, S. J., Boyle, R., Cody, J. D., Mørkved, S. & Hay-Smith, E. J. C. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2017, (2017).
4.) Schreiner, L., Crivelatti, I., de Oliveira, J. M., Nygaard, C. C. & dos Santos, T. G. Systematic review of pelvic floor interventions during pregnancy. International Journal of Gynecology and Obstetrics143, 10–18 (2018).
5.) Neels, H., De Wachter, S., Wyndaele, J.-J., Van Aggelpoel, T. & Vermandel, A. Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. Eur. J. Obstet. Gynecol. Reprod. Biol. 220, 113–117 (2018).
6.) Kim, H., Yoshida, H. & Suzuki, T. The effects of multidimensional exercise treatment on community-dwelling elderly Japanese women with stress, urge, and mixed urinary incontinence: a randomized controlled trial. Int. J. Nurs. Stud.48, 1165–72 (2011
7.) Dumoulin, C. et al. Pelvic-floor-muscle training adherence: Tools, measurements and strategies - 2011 ICS State-of-the-Science Seminar Research Paper II of IV. in Neurourology and Urodynamics34, 615–621 (John Wiley and Sons Inc., 2015).
8.) Reducing your risk of perineal tears. Available at: https://www.rcog.org.uk/en/patients/tears/reducing-risk/. (Accessed: 18th October 2019)