In some of our previous blogs, we’ve been discussing what the most recent research has been telling us about pelvic floor birth injuries and how your pelvic floor relates to your birth. We’ve learned that obstructed labor leading to either prolonged second stage, need for fundal pressure, or need for instrumental delivery, particularly forceps, substantially increases the risk of pelvic floor birth injuries. And we’ve also learned that your pelvic floor function can determine who might be more at risk of an obstructed labor. Things like a smaller levator hiatus size and co-activation of the pelvic floor while pushing can lead to an increase in the duration of the second stage of labor (pushing stage), therefore increasing your risk of a pelvic floor birth injury.
When it comes to prenatal pelvic floor muscle training and labor outcomes, the research is still unclear about the benefits. Some studies suggested that pelvic floor muscle training reduces the duration of the second stage of labor and rates of severe perineal tearing. Other studies suggest that it might not have made a difference.
But of note, one definite fact is that not a single study has indicated that pelvic floor muscle training increases the duration of second stage of labor or worsens perineal tearing - it either improves it or does not make a difference. So truly, we need more quality research to definitively say the impacts of pelvic floor muscle training on labor outcomes.
Perineal Massage
Prenatal perineal massage is a form of gentle stretching to the perineum and pelvic floor muscles with the intent to prepare these tissues for a vaginal birth. It is typically recommended starting between weeks 34-36 of pregnancy, and is beneficial to perform 3-4 times per week. Performing prenatal perineal massage has been shown to:
decrease the risk of severe perineal tears (3rd and 4th degree tears)
decrease the risk of episiotomy (episiotomies increase the risk of severe perineal tears)
decrease the duration of the second phase of labor
decrease postpartum perineal pain.
Pelvic Girdle Pain
Pelvic girdle pain is a common complaint we hear about with our pregnant clients. Pelvic girdle pain comes in many different forms. SI joint pain which typically feels like a deep pain in the low back and buttock, and symphysis pubis dysfunction (SPD) or “lightning crotch” which can feel like sharp, shooting, stabbing pain into the pubic bone, are two very common experiences of pelvic girdle pain during pregnancy.
The research supports exercise advice from a physical therapist as well as using a pelvic support belt to be beneficial in reducing pelvic girdle pain intensity and disability. Specifically, pilates exercises, which focus on breathing, core, and pelvic girdle strengthening helped to improve pain, disability, quality of life, and physical mobility during pregnancy!
Urinary Incontinence
Urinary incontinence, or bladder leakage, is one of the most common complaints we hear about with our pregnant and postpartum clients. What’s even more frustrating is that a lot of people are told that leaking during pregnancy or after you’ve had a baby is normal, and a right of passage into parenthood.
Unfortunately, for those who are already experiencing urinary incontinence during pregnancy, the research found no difference in the prevalence of bladder leakage in late pregnancy and postpartum with pelvic floor muscle training.
While the research isn’t as promising for improving leakage during pregnancy, I will say from clinical experience, we have seen plenty of clients who come to Breathe Life during pregnancy with complaints of urine leakage, and we are still able to see an improvement in their symptoms (and sometimes even complete resolution!). We are just fighting more of an uphill battle with all the changes during pregnancy, but it is not impossible!
The good news is, those who do not already have urinary incontinence and do pelvic floor muscle training during pregnancy are 62% less likely to report bladder leakage in both late pregnancy and early postpartum, and 29% less likely to have bladder leakage in the mid-postpartum period. This means pelvic therapy can both prevent bladder leakage from occurring during pregnancy and facilitates the natural healing process postpartum! AMAZING!
Prevention of Pelvic Floor Dysfunction
Speaking of prevention, in 2021, the National Institute for Health and Care Excellence (NICE) in the UK came out with an updated set of guidelines, the NICE Guidelines. NICE guidelines are evidence-based recommendations for health, and they set out the care and services suitable for most people with a specific condition or need, and people in particular circumstances or settings to prevent ill health. They specifically included the following guidance for during and after pregnancy on preventing pelvic floor dysfunction:
Encourage women who are pregnant or who have recently given birth to do pelvic floor muscle training, and explain that it helps prevent symptoms of pelvic floor dysfunction
Consider a 3-month program of supervised pelvic floor muscle training
From week 20 of pregnancy, for pregnant women who have a first degree relative with pelvic floor dysfunction
During postpartum care, for women who have experienced any of the following risk factors during birth
Assisted vaginal birth (forceps or vacuum)
Vaginal birth when baby is lying face up (occiput posterior)
Injury to the anal sphincter (3rd or 4th degree tears)
Before discharging women from maternity services, and during routine postpartum care, encourage them to do pelvic floor muscle training
Pelvic floor muscle training programs should be supervised by a physiotherapist (Physical Therapist here in the US) or other healthcare professional with the appropriate expertise in pelvic floor muscle training (such as an Occupational Therapist)
Supervision should involve assessing the ability to perform both a pelvic floor muscle contraction and relaxation
These guidelines emphasize the benefits of encouraging preventative health and wellness, specifically when it comes to prenatal and postpartum care.
Informing Women About Birth
Coverage of pelvic floor focused information and education about pelvic floor trauma during pregnancy is lacking. People who reported high levels of discrepancy between their expectations and their actual experience had the strongest association between pelvic floor and mental health symptoms. The extent to which individuals feel blindsided by pelvic floor injuries or symptoms, during an already vulnerable period, increases symptom related distress.
Providing pregnant people with accurate information so that they have sufficient knowledge to make informed decisions is considered a critical aspect of a positive birth experience. Oftentimes, this education is not happening at routine visits with a medical provider during pregnancy. Pelvic floor therapists are in a position to provide pelvic floor education to create an empowering environment for the birthing person, and to help mitigate distress in the event that a pelvic floor injury does occur during childbirth.
In summary, prevention and education are two of the main ways pelvic floor therapy can be beneficial during pregnancy. You don’t have to suffer through pain or embarrassing leakage. In fact, seeing a pelvic therapist prior to the onset of these symptoms is the best thing you can do to prevent these issues from coming on in the first place. And knowledge is power! The more you know about your pelvic floor, the more empowered you will feel going into your birth.
To start preparing in less than 2 hours, join Dr. Becca to learn how you can prepare for birth with simple tips on prenatal perineal massage, pelvic positioning during labor to minimize tearing, and how to advocate for your birth story. BONUS- Get moving again postpartum with our 6 week Mindful Movement Strategies!
Dr. Becca Jones, PT, DPT, CSCS, is a 2016 graduate of New York University with her Doctorate of Physical Therapy. Her passion for supporting people through their pregnancy and/or post partum journey inspired her to specialize in pelvic health. Dr. Becca believes in providing holistic, individualized care in order to restore comfort and build confidence to get people back to what they love.
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