At the time of writing this blog, Dr. Katie is 33 weeks pregnant with her second child, so this topic is very fresh and close to our hearts. We wanted to take this opportunity to discuss the purpose and benefits of seeing a pelvic floor therapist BEFORE giving birth. Pelvic floor therapy has been around for decades and we are thrilled to see the push towards preventative, prenatal physical therapy to keep mommas moving and to prepare the body for birth. Oftentimes, we work with Moms of grade school age kids who tell us “I wish I knew about this after my first pregnancy!” and we tell them “I wish you knew about this DURING your first pregnancy!” With multiple pregnancies and as we approach menopause, what could have been a fairly straight-forward rehabilitation process can become more complex. With the being said, it is never too late to make changes in soft tissue restriction, motor control and coordination as it relates to function and pelvic health. Below we will go into greater depth of the benefits of making that appointment during your pregnancy.
1) Pelvic Floor Coordination
One of the things we do prenatally in pelvic floor therapy is assess the coordination of the pelvic floor. While we generally hold off on internal work unless it is necessary, we can look externally to make sure the muscles are able to contract, relax and bear down efficiently. This coordination is important for efficient pushing during labor. Oftentimes, women have poor body awareness to this movement and think they are lengthening through the pelvic floor, but are actually contracting instead. If this is the case, it may prolong the pushing phase of labor and/or increase the risk of tearing with vaginal birth.
Hint: if you are regularly constipated, pelvic floor coordination could be the root of the problem! To have a bowel movement, we need to drop and lengthen the pelvic floor muscles and generate appropriate intra abdominal pressure to bear down and push stool out. The mechanics for childbirth are the same! With cueing, breath work and assessment by a skilled therapist you can bring awareness and motor control to the pelvic floor muscles to efficiently push out stool or a baby. You can assess at home with a mirror or camera while trying to contract and relax your pelvic floor.
2) Understanding Your Connection to Breath to Prepare for Labor and Pushing
Yes, I know we talk about breathing a lot! While it may be redundant, it is SUPER important, especially for birth preparation and labor. The reality is most of us don’t breathe well. We tend to breathe solely into our chest and upper cavity, especially when we are in pain or are stressed. As baby grows, the ribs accommodate by flaring outwards to create more space. It is very common for pregnant women to start breathing from their neck and upper thoracic cavity as there is less room for the diaphragm to descend. Understanding how to tap into your diaphragmatic breathing allows for better relaxation, more oxygen uptake and a better ability to work with your body to progress labor. Movement of the diaphragm (the huge respiratory muscle under our ribcage) stimulates a very important nerve in our body called the vagus nerve. The vagus nerve has many functions, one of which is to tap into your parasympathetic nervous system. The PNS is considered our “rest and digest” nervous system and is what is more active when we are relaxed. We should be giving birth in environments and moods similar to those in which we have sex and go to the bathroom. If you are in a state of alarm or significant stress because of pain or fear or various other reasons, your labor may stall and the chance of intervention (wanted or unwanted) goes up. Being able to control your breath is a great way to keep your PNS on board during labor. It is also just a great tool to have in general for stress and anxiety before, during and after pregnancy. Having the assistance of a pelvic floor physical therapist can help you dial in your diaphragm and give you more confidence in your breath and movement patterns prior to birth.
There is also a great article that was pushed by Berkeley discussing the benefits of breath work and mindfulness for yourself and your baby which I often share with patients. The link for that article is below. Some of the key things to remember is breath work helps regulate cortisol, or stress hormones, being sent to your baby. It also helps with the baby’s heart rate variability, or the ability of the heart to speed up and slow down, which is important for the health of the baby overall and during labor. Check it out!
3) Stabilization Exercises to Decrease Discomfort During Pregnancy
We know that pregnancy increases laxity to our joints and ligaments, which can often cause malalignments and pain to occur. I’m sure if you or any of your friends have been pregnant, you are familiar with terms like “lightning crotch”, “pubic symphysis dysfunction”, “SI pain”, “sneeze pee”... the list goes on. While most of these issues resolve after birth, they are often preventable and tend to worsen with each subsequent pregnancy. The good news is there are some very simple stabilization exercises you can be doing to help prevent these discomforts from arising or reducing the pain if they are already there. Most people generally only think of prenatal yoga or gentle stretching as appropriate exercise during pregnancy, but in reality women need more of core stabilization, hip, glute, and low back strengthening to help support their changing body structure.
Every woman is different and not every exercise is for every woman but, in general, exercises that tend to help women feel strong and decrease pain during pregnancy include deadlifts, squats, clamshells, banded walks, quadruped donkey kicks and side planks. Not to mention, after the baby comes there is a lot to schlep around to appointments… baby, car seat seat/carrier, diaper bag, etc. Functional strengthening with a focus on form for squatting, lunging and deadlifts protects your back in the postpartum period and in the long run. This is by no means an all encompassing list, and a skilled pelvic floor PT can cater your program to your needs or limitations.
4) Preparation and Guidance for Postpartum Rehabilitation
This is a big one. Why is there so much misinformation around postpartum rehabilitation and movement? Conventional wisdom says to wait 6 weeks to do anything, and then go back to normal and do everything you were doing before once you are cleared by your doctor (sex, exercise, etc). Just as rehab around ankle fractures has changed (we don’t see casts much anymore, do we?), the advice around postpartum rehabilitation needs to be more specific and accurate. Again, every woman and body is different. Healing rates and recommendations should be altered if you had a C-section or vaginal birth. Other factors such as sleep, stress, physical and emotional support, breastfeeding all need to be taken into account when considering what is appropriate for the exercise load we are giving a woman after birth. These are discussions that pelvic floor PT’s will have with women prenatally to prepare them and give them some understanding regarding appropriate timelines for return to exercise. Here are a couple quick tips that I will often share with patients.
For the most part, women can start with light breath work and very LIGHT pelvic floor contractions for the sake of decreasing inflammation and improving blood flow day 1 postpartum. This is not meant to strengthen the pelvic floor, it is meant to slowly help rebuild the neuromuscular connection between the core and pelvic floor, improve healing and help to restore postural support. Again, depending on how the woman is healing and feeling, she can start with very light stretching and supine mat exercises by the end of the first or second week.
Women should be grading their walking and general activity off of their bleeding. Any bleeding that is worse from one day to the next is an indication you have done too much and need to allow your body more rest. Remember, your uterus is shrinking and healing an open wound the size of your placenta in the first few weeks following birth. We want to be moving at a rate that promotes this healing, not hindering it. Having these discussions prenatally can really help to build a woman’s confidence around movement and helps to empower them with their own healing.
5) Establishing A Support Team Before The Baby Arrives
The reality is, entering motherhood is the most beautiful and challenging of changes. It can be empowering and isolating at the same time. There are also just so many things you can’t predict or plan for. We are advocates for preparing as much as you can beforehand and then being flexible and open to the things that don’t go according to plan. Having an established support team beforehand can help improve the sense of confidence if difficulties do arise. Providers to consider around birth include, but are not limited to, pelvic floor PT’s, prenatal and postpartum chiropractors, acupuncturists, doulas, midwives, OBGYN’s, mental health specialists, massage therapists, etc. The goal would be to have an established relationship prior to birth and to understand the role of each provider, so you know exactly who to call when you need that specific specialty.
Prenatal Pelvic Therapy is a form of preventative medicine. This service can help improve pain before birth, build confidence around the body’s capabilities during birth, and mitigate any problems that may arise after birth. We need to shift our thinking around care for women around birth. It is unnecessary for women to go months or years after birth suffering from prolapse, painful sex, incontinence or pain. The way we do that is through education and prevention. We hope you found this blog useful, and if you have any questions feel free to reach out with any questions!
Health & Happiness,
Dr. Carly and Dr. Katie