Prepping to Push – The Pelvic Floor in Pregnancy
As most instructors do, I attend continuing education courses every year. Last November, I attended a wonderful one day workshop with eminent women’s health physio Michelle Lyons. With 8 hours of lecture and practical exercises, there was a huge amount of information to digest and work into my existing offerings. Which I am now thoroughly enjoying getting to work on.
Now that I am expecting our first, I want to ensure that I am doing my best to maintain a strong pelvic floor and also to be able to fully relax it when in the pushing phase of labour.
I am also aware that I need to return to fitness as soon as possible to resume teaching and that begins with pelvic floor recovery. Who wants to worry about leaking when exercising, walking, running or even laughing? Not me.
Ready to learn how to create a healthy pelvic floor? Read on.
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As your baby and belly are growing, your pelvic floor is being affected from as early as 12 weeks into your pregnancy. Therefore, this is an especially important time to begin taking care of these muscles. The earlier you start, the better, but it's never too late.
A healthy pelvic floor will help support the weight of your growing baby, decrease the risk of injury during a vaginal birth and speed up recovery after birth, by increasing the circulation of blood to the perineum (the area between your anus and vagina). Another benefit is that women with stronger pelvic floor muscles may be more likely to have orgasms during sex. An orgasm is a rhythmical contraction of the pelvic floor muscles. So doing pelvic floor exercises could help you to have a more satisfying sex life!
A poorly functioning pelvic floor can lead to incontinence, urgency and frequency and pelvic organ prolapse. Other symptoms are lower back pain, pelvic girdle pain, constipation and pain during intercourse (dyspareunia).
I want women to know that these symptoms might be common after birthing a child but never normal. Simple lifestyle changes plus pelvic floor exercises can make a huge difference! Despite what the TV and magazine ads tell us, there are more options than just buying incontinence pads for the rest of your life, a few moments of your day is a really small price to pay.
Your pelvic floor is going to play a role in your overall health for the rest of your life.
Prepping to Push!!!
Not only is it important to be able to contract the pelvic floor correctly but equally so to be able to fully relax it and to gently bulge it outwards. When your baby's head "crowns" during the second stage of labour, your Pelvic Floor muscles need to relax. Some midwives believe that a relaxed pelvic floor at this stage can help prevent tearing or episiotomy.
Many women especially those who do have some incontinence problems, are concerned they will leak if they fully relax their pelvic floors. This is an important misconception to address. In order to have a functional, strong muscle (any muscle!), it needs a full range of movement. The ability to both relax and contract. Gaining this full spectrum of movement will promote stronger pelvic floor muscles than simply "Tighten! Tighten! Tighten!"
Try the following Pelvic Floor relaxation exercise:
- Find a quiet relaxing place where you can focus and lay on your side comfortably. Place one hand at the top of your bump/upper abdomen.
- Breathe softly and try to let your tummy rise and fall naturally. If your breathing is relaxed, you should find that the hand on your tummy moves up and down.
- Begin consciously relaxing the muscles of your pelvic floor, letting go like you would to pass urine or pass wind. Relax the muscles of your abdomen (particularly the lower abdomen), thighs bottom and shoulders.
A fantastic position to practice relaxing the pelvic floor is a supported Child's Pose with lots of pillows. Make sure your head is fully supported. The pull of gravity on your abdomen plus the position of your hips encourages the pelvic floor to relax. Practice every night before bed.
Just like you get knots in your shoulders that may not contract and release, the same can happen with your pelvic floor muscles. Overactive Pelvic Floor muscles have trouble completely relaxing when asked. Repeat "letting go" throughout your day. If you feel that you cannot, it's time for a visit to your women's health physio.
Pelvic Floor Contraction
Over the last few decades women have been told that they must relentlessly squeeze their pelvic floor muscles for pelvic floor health (Kegels) but more recent research has nuanced this approach.
Your pelvic floor is the band of muscles that stretches from your tailbone to your pubic bone. Think of your pelvic floor like a hammock on which your uterus, bladder and bowel rest. Your pelvic floor includes sphincters, which are the muscles that surround your urethra , vaginal opening and anus. These are the muscles that you use to stop yourself from peeing or passing wind when you don’t want to. These are the muscles we want to contract.
Weak Pelvic Floor muscles cannot generate a strong contraction when asked. You may find that other muscles contract instead. Common compensations include: bracing your abdomen, squeezing your legs together (inner thighs), tightening your buttocks and "bearing down" when we think we are "lifting up". Only your pelvic floor muscles should contract. Lightly press your fingertips into these muscles to ensure they are not contracting instead.
There is a way to help you check if you're doing the exercise properly.
- Comfortably position yourself, ideally lying on your side with your knees bent. You should be wearing leggings or just your underwear.
- Reach back and place one finger gently over your anus, now move it to the side, still quite close to the anus.
- Begin by making sure you are breathing in a relaxed way.
- Take a deep breath in, exhale and relax your pelvic floor muscles. Always start with "letting go".
- Take another breath in; this time as you exhale, imagine you are closing the opening to your anus then lifting up and in. Think "close and lift".
Count to 5 out loud, keep your throat relaxed and open (make sure you are not holding your breath!). Feel the closing and lifting movement with your fingertips. When you are learning, start with a gentle contraction until you have managed to co-ordinate your contraction with a breath out.
- Then on your next exhale, relax all the muscles around your anus and breathe normally. For some women, a gentle push out at the end of each pelvic floor contraction will help.
- Now try this again without your fingertips in place. Can you feel the muscles relax, close and lift up and in? Congratulations! You have effectively located, relaxed and contracted your pelvic floor.
When you have mastered this lying down, practice sitting upright on a firm chair. When you contract your pelvic floor you may feel it lift up and in and away from the surface of the chair and then relaxing back down again.
Some tightening and flattening of the lower part of the abdominal wall will happen, and that's fine. This part of the abdomen works together with the pelvic floor muscles. If you are tightening your upper tummy muscles (above your belly button) then you are trying too hard! Start again with the relaxed breathing and try a gentle close and lift keeping everything above the belly button relaxed.
Practice every one to two hours, rather than just once a day. Your brain learns better with lots of small reminders throughout the day rather than one large batch of exercises once a day (neuroplasticity). This will become much easier to fit in when you begin The Knack below.
Some visualisation cues which may help you "get these muscles going":
- Draw your pubic bone to your tail bone and the left and right sit bones together and then like a draw string bag, gently draw the entire pelvic floor up.
- Visualize ‘squeezing’/close off the urethra (as if to stop urine flow), hold this while you ‘squeeze’/close the anus (as if to stop flatulence) and gently lift. (Never actually perform mid urination pelvic floor contractions. This interferes with the relationship of the pelvic floor muscles and the bladder muscles.)
- Think about a washing line that connects from the anus to the back of your pubic bone and connect along this line.
- Nod your clitoris down toward the vaginal opening, curl your tailbone toward your clitoris, now gently imagine sucking a blueberry up off of the floor toward your head.
- Women who are familiar with using tampons can imagine squeezing the vaginal walls as if squeezing a tampon up higher in the vagina.
- Wink the anus.
Progressing to Movement
When you have mastered the art of relaxing and contracting your pelvic floor muscles correctly, it is time to incorporate the contraction into functional movement, rather than continuously in isolation. Working the pelvic floor in isolation is not a good long term strategy. The pelvic floor needs to actively work in different positions and in a number of different activities and in coordination with the breath. When it comes to improving function, nothing is better than actually training functionally while going about your day..
The Knack: Ashton Miller et al first described this preemptive contraction of the pelvic floor musculature before a sudden increase in intra abdominal pressure (such as a cough or a sneeze) back in 1998 and it was reviewed again in 2008.
Essentially it involves bracing the pelvic floor for a sudden increase in pressure – as stated above, perhaps a cough or a sneeze, but also applicable for going from sitting to standing. Incorporating ‘The Knack’ into every transfer from sit to stand with emphasis on breathing and pelvic floor coordination can really enhance the strength of your pelvic floor.
How to do The Knack:
- Sit tall with good posture, close to the edge of your chair, up on your sit bones, feet hip width apart. Fold your arms over your chest (this way you won’t be tempted to push down on the arms of the chair!)
- Take a deep breath in, as you breathe out, allow your pelvic floor to relax.
- Take another breath in, this time with the exhale, close the openings of your pelvic floor and lift PF up whilst simultaneously rising to a standing position, ensuring that your back is in a long, neutral position. (Don’t forget to keep breathing!)
- Once you are standing, allow the pelvic floor to relax (and again, don’t forget to breathe!).
Initially, combining the breathing alongside the drawing upwards of the pelvic floor whilst moving will all seem a little bit complicated. Try to practise this standing up after every visit to the loo. Keep practising until it becomes second nature. Once you get used to it start to introduce the Knack every time you stand up from a chair. Getting up from a seated position is essentially a squatting pattern, it is a functional movement we do many times every day.
The Knack is a preventative measure that will keep our pelvic floor in excellent shape for years to come.
The perineum is the area of tissue between your vagina and anus. Perineal massage is a way of manually stretching the tissues around the vagina in the last few weeks of pregnancy in preparation for giving birth vaginally. Daily perineal massage can increase the area's ability to stretch and reduce the need for an episiotomy and fewer natural tears and bruising. This is particularly beneficial if you are having your first baby or if you have scar tissue there. Perineal massage can also help with your recovery after the birth by increasing blood flow.
It is usually carried out from week 34 onwards, not recommended if there is a history of premature birth, premature rupture of membranes or a vaginal infection.
Personally, I plan to practice perineal massage once a day for the last month of my pregnancy. I feel that doing the massage will give me the confidence to know what the vaginal walls and perineum can do and that the area really can stretch. Therefore I know that the baby will be able to slide through. I will worry less about tearing and can relax when the baby is crowning and allow my body to do what it is designed to do.
So if you fancy giving it a go here`s what you do;
- Make sure your hands and nails are clean or if your partner is assisting you, that their hands and nails are clean. A good time is after a bath or a shower because the pelvic floor muscles will be warmer and your skin softer. This makes the perineum more comfortable to stretch.
- Get comfortable and relaxed in a place where you feel safe, secure and will not be interrupted (very important when trying to relax sphincter muscles). Lying on your side with some pillows between your knees is s a good position as the bump won`t get in your way.
- Lubricate your fingers, thumbs, and perineal area with an unscented natural oil such as pure olive oil, grapeseed oil or a personal lubricant. Do not use synthetic oils such as baby oil or petroleum jelly (Vaseline).
- Be gentle, a vigorous touch could cause bruising or swelling. During the massage, avoid pressure on the urethra (urinary opening) as this can lead to irritation or infection.
- Reach your hand behind so you can reach the vagina. Insert 2-3 fingers about 4cm inside the vagina. Gently but firmly pull the vaginal opening back towards your rectum, until you feel a tingling. It shouldn’t hurt or burn. Keeping the pressure on as you slide the fingers side to side to stretch the vaginal wall laterally for 1-2 minutes. Finally, massage the tissue between the thumb and forefinger back and forth for about a minute.
- Focus on relaxing your perineum as much as possible during the massage. Being able to relax through this feeling of increased pressure is the real goal here. With time and practice, as your perineum becomes more elastic, you will increase your ability to relax and you can increase the pressure towards your rectum.
- It should not feel painful. If you feel pain at any point, stop and try again another time. If you continue to find this painful speak with your midwife or doctor.
It is hard to fix a problem that is constantly being made worse. Some habits can make life tougher for your pelvic floor, especially toileting habits, which obviously really involve your pelvic floor!
First things first, how do you sit on the loo?
Never hover over the toilet, always fully sit on the toilet with your feet fully flat on the floor or a step. You must do both to allow your pelvic floor to relax. This is key for having a strain free bowel movement and fully emptying your bladder. Worried about ‘germs’ on the toilet seat? If you must, clean with an antibacterial wipe first or carry some seat liners.
The best way to have a bowel movement. Ideally, your knees should be higher than your hips. Be creative in how you achieve this. You can buy a step or elevate feet on rolls of toilet paper – as long as your knees are comfortably higher than your hips. I use my giant tub of Epsom salts. The next step is to lean forwards and rest your elbows on your thighs; this helps get your tailbone (the coccyx) out of the way and opens up the exit route.
When you are ready to move things ‘down and out’ it is really important not to hold your breath! Instead, think of blowing all the floaty seeds off a dandelion or blowing out birthday candles – a long slow steady gentle exhale as your GENTLY bear down. This will help move things ‘down and out’ without stressing your pelvic floor. When you are finished, do a pelvic floor contraction (close the opening around your anus and lift up and in). This may happen spontaneously on it's own. This signals to your brain that you are all done.
Never strain when you are urinating – just relax and let it go….no pushing it out to go a little faster. If you haven’t got time to urinate, you need to adjust your priorities. Seriously!
Aim to last at least two hours between urination. Use your bladder capacity! If you ‘go’ when you don’t really need to, you are training your bladder to become oversensitive to stretch. When you go, you should have a good amount of urine – at least 7 Mississippi’s worth (One Mississippi, Two Mississippi….Seven Mississippi). No ‘Just In Case’ trips to the toilet. If you feel the urge to urinate early, do some quick squeezes of your pelvic floor (Close & lift, Relax, Close &lift, Relax, Close & lift, Relax) along with some slow deep breaths. This tells your bladder to relax and stop contracting. You are in charge of your bladder, not the other way round!
On the other hand – your bowel is pretty much in charge of you! When you feel the urge to have a bowel movement, make your way to the toilet. If you consistently put off the urge to have a bowel movement, you can interfere with certain brain/bowel reflexes.
What to do about constipation
Constipation, which is common in pregnant women, is a huge factor in pelvic floor dysfunction. It’s nobody’s idea of a good time. So how do we get the "perfect poo"?
- Be predictable! Your bowel doesn’t like change – have you ever noticed when you travel, it can take a day or two to have a good bowel movement? Try to eat at roughly the same time every day.
- Your body needs to move, inactivity creates sluggish digestion. Incorporate a short walk into your daily routine.
- Drink plenty of water. Don’t drink it right before or during meals as it may hamper your stomach acid breaking down the nutrients. However, restrict bladder irritants such as fizzy drinks/caffeinated drinks/diet drinks. Making sure you have a good water intake is super important for keeping your bladder healthy, your digestive system moving and your brain thinking clearly. Your urine should be clear enough to read through (not quite sure how you would test this…) but do bear in mind that certain vitamins, supplements and foods can alter the colour of your urine.
- Drinking a warm beverage first thing in the morning starts the day off right! A hot cup of caffeine can be an excellent bowel stimulant but if you are not a coffee drinker, some warm water with a slice of lemon will also do the trick.
- Add more fibre to your diet. Begin by gradually adding more vegetables, beans and high fibre carbohydrates. Don’t add huge amounts of bran or wheatgerm – this can overwhelm an already stressed system. Soups and salads can be a great way to add both fibre and water into your daily food intake.
- I have had great results with drinking a shot glass of prune juice at night before going to bed. Some occasional shots throughout the day when I was feeling uncomfortable.
- Adding three tablespoons of freshly ground flax-seed to your morning porridge can also help get things moving.
- Remember, it is not just that ‘we are what we eat’ but ‘we are what we digest and absorb’. Upping probiotics and prebiotics may be helpful – fermented foods, yoghurts with ‘live’ cultures, dark green leafy vegetables, bone broths can help get the most out of your food.
- Create a more relaxing, calm environment to dine in. TV and radio off, chewing properly and taking a break during your day to enjoy your food.
When to seek assistance from a professional:
Disclaimer: This article is not a substitute for the advice of a health professional. The exercises described may not help if done incorrectly or if the training is inappropriate for your body.
If you are not sure if you are contracting your pelvic floor correctly or if you are having problems and pelvic floor exercises are not helping you. Go see your women’s health physio and truly take care of yourself. They can assess your pelvic floor function and tailor an exercise programme to meet your specific needs.
I hope you have found this article to be helpful and you will feel the benefits throughout your pregnancy and beyond!
Please share with your fellow expecting family and friends.
I am Emma McAtasney, founder of a boutique Pilates studio in Dundalk, Ireland. BASI trained Pilates instructor, BarreConcept instructor and prenatal and postnatal exercise specialist.
I developed my Belly Only Pregnancy Programme in order to provide a library of workouts for expecting mums to have access to throughout their pregnancy.
I love working with successful, courageous women from all over the world – like yourself – to give you clear, applicable information, support you in truly creating core strength, fall in love with your strong and healthy body and focus on living your best life!
Together, let’s create a lifestyle that gives us health and happiness for a lifetime!