Why don’t we hear more about the pelvic floor during pregnancy and birth?
This is a great question that I hear primarily from two groups of women: my peers, physical therapists whose rallying cry has been, “what is pelvic floor physical therapy and why doesn’t everyone know about it?”, and postpartum women, who come to my office seeking help for childbirth-related injuries to the pelvic floor. Most of them feel blindsided by what they didn’t know or understand and blame themselves for not knowing the right questions to ask!
If an injury is sustained from the delivery, there is feeling of isolation, of not knowing how to get the care they need. Postpartum pelvic floor therapy is the norm in certain countries where childbirth is less medicalized and midwifery care is the norm. In general, we do not have this culture of collaboration for postpartum care and as a result, postpartum women are tremendously underserved in their needs.
What can we do to change this for women?
There needs to be a paradigm shift in the way we view women’s healthcare through the childbearing years and beyond. Despite the need for collaborative care, we cannot rely on the medical profession alone to understand or advocate for the musculoskeletal issues that impact pregnancy and childbirth. Physical therapists are oriented towards evidence-based care, but there are not necessarily evidence-based birthing practices occurring.
Empowering women in their journey to motherhood must include information about how pregnancy and birth can affect her pelvic health. Post-partum women have an especially difficult time getting acknowledgement of their birth injuries and then what to even do about it. I find this to be true whether it is a natural, unmedicated birth or a cesarean. Typically, a woman sees her birth attendant 6-8 weeks after delivery and if she reports pain with sex or bladder issues, the most frequent response is “give it time.” As long as the physical exam is deemed “normal” and there is a discussion of birth control, she is considered discharged. If she is lucky, she will get referred. The bottom (no pun intended) line is the majority of women who experience these kinds of issues do not get any information or referrals.
To paraphrase Penny Simkin, who started as a PT but is one of our most veteran birth educators, birth matters. Women remember how they were taken care of. We should come together and take care of women, including their birth injuries. The good news is that social media platforms are starting to create awareness. Concurrently, there is a huge shift towards patient centered prenatal care and birthing options that includes a very vibrant doula community and many more women choosing to give birth with midwives in homes, birth centers and hospitals.
How do you work with women to make Kegel exercises more palatable?
Getting some type of feedback that you are performing it correctly is really the key. That’s where pelvic floor PTs can really make the difference. We can evaluate the pelvic floor strength and even tell if it’s actually in spasm. Once you can activate it then you can learn how to integrate it functionally so you can get back to exercise or just simply lifting your baby without peeing or feeling pressure. There are some new small devices coming on the market that you can use with an app on your smartphone, but I’m old school. Use what you have – your hand, a vaginal dilator, a finger. You have to feel it to own it.
For women who have experienced some pelvic floor weakening after giving birth, where do you recommend they even start?
If the issue involves massive bladder leakage that doesn’t resolve in a few days, you must see a pelvic floor therapist right away. The muscles of the deep abdominal wall and breathing diaphragm are so critical to pelvic floor muscle function and can really benefit from coordinating this after birth. Again, having some knowledge before giving birth and learning some basic concepts so you can identify a problem and get the right help immediately, is crucial.
Are there some things that you recommend ALL women do to maintain healthy pelvic floors and core muscles during pregnancy, and in the first year postpartum?
Identify your pelvic floor and deep abdominal muscles and if you can’t, see a pelvic floor PT. Understand that they play a role in your bladder, bowel and sexual function. Try something low-tech: stop your pee in midstream. If you can do that easily then congrats, you just contracted and released your pelvic floor. If you can’t or can do it for just a second, then you may have weakness or overly tight muscles. The second trimester of pregnancy is often marked by a hormone shift that contributes to sometimes terrible constipation. If you are straining and pushing, you are over stretching your pelvic floor muscles and possibly contributing to weakness of the posterior pelvic floor. Eating whole grains, beans, prunes-whatever it takes to keep constipation at bay is critical. Get a Squatty Potty to help relax while pooping. Learn about the perineum, the more external part of the PF so you can start performing self-massage to help the tissues stretch and recover from birth. Even if you had a tear and stitches, recovery will be easier because the tissues have become more pliable and resilient. Know your growing abdominal wall and what diastasis is. It’s important to keep it from getting worse and know what exercises are best before and after birth.
Are pelvic floor disorders a normal part of aging?
Pelvic floor disorders exist throughout the life span. They can include childhood bladder and bowel dysfunction, pelvic pain during young adulthood and prolapse disorders after childbirth, vaginal dryness and dyspareunia with menopause. Aging affects hormone levels so many women peri-and post menopausal have vaginal dryness, pain with sex or lack of libido. Pelvic floor PT along with some hormone and non-hormone based creams can really help restore tissue tone and function.
Debra Goldman, PT, MA, PRPC
Debra was born and raised in New York City, where she returned to pursue a career in modern dance, after receiving an M.A. in Dance and Human Kinetics from George Washington University. Following her own dance-related injuries, she became fascinated by the burgeoning field of dance medicine, and earned a B.S. in physical therapy from Northwestern University’s Feinberg School of Medicine. After graduating, Debra returned to Manhattan and for 12 years she worked at orthopedic and sports medicine clinics in the financial district. She also created a practice with a focus on pre-natal and postpartum issues, located in New York’s only freestanding midwifery-run childbearing center. In 2002, Debra relocated to New Jersey, where she immersed herself in the study and practice of her true professional passion—healing pelvic floor dysfunction. Debra’s work is informed by her love of movement, her continuing commitment to excel in delivering skilled hands-on care, and helping to empower all patients to take responsibility for their own care. In 2014, Debra received certification through the Herman & Wallace Pelvic Rehab Institute. She is proud to be part of the inaugural group of highly experienced pelvic floor therapists receiving this recognition. Learn more about or contact Debra at http://www.fourcornersphysicaltherapy.com/.