Pelvic Health During Pregnancy and Beyond

During pregnancy your body goes through many changes to help you grow, carry, and birth your baby. It can sometimes be difficult to know what normal changes are, and when you should seek help. Changes can happen to your bladder, bowel and vaginal and sexual health as your pelvic floor muscles come under more pressure.

The information below will give you self-help tips to manage these changes. It will also provide advice on when, where and why to seek help if anything worries you or does not resolve.

Your pelvic floor muscles are a group of muscles that span across your pelvis. They attach from the pubic bone at the front, to the coccyx bone at the back, forming the floor of your pelvis. Pelvic floor muscles have the following uses:

  • Control – They help you to control wee, wind and poo.
  • Support – They act like a hammock to support your pelvic organs (bladder, womb and bowel) and keep them in the correct position.
  • Sexual function – They can help improve sex by increasing your sensation, your grip and orgasm.
  • Stability – They help to keep your pelvis and hips stable.

Pregnancy

Pelvic floor problems are also known as pelvic floor dysfunction (PFD). They can affect anyone who is pregnant. These problems could include:

  • Leaking pee (urine)
  • Leaking poo (faeces)
  • Unable to control wind
  • A heavy feeling or bulge in the vagina

These can happen when the pelvic floor muscles are not working properly. It is important to know how pelvic floor problems happen and what you can do to reduce them.

During pregnancy the pelvic floor muscles come under pressure. This is from the extra weight of your growing baby, amniotic fluid, placenta and your womb getting bigger. This extra downward pressure and the effect from pregnancy hormones (chemicals in the blood stream) causes stretching and tiring of the pelvic floor muscles. The stretching means your muscles may not do their jobs as well as usual.

Childbirth

During childbirth, your pelvic floor muscles will stretch for you to deliver your baby. Some women may sustain tearing of the perineum. This is the area between your vagina and bottom (anus). If this happens your pelvic floor muscles will take time to heal. It can also affect how well your muscles work. Childbirth can affect the nerves that help make the pelvic floor muscles work. This may lead to pelvic floor problem.

It is very important that the midwife or obstetrician (doctor) examines you after birth. They will ask for you to agree (consent) to the midwife or obstetrician examining your vagina, perineum and inside your back passage. This is to see if you have any tears and treat you, if needed. If you have a complex tear, we will arrange for you to see the pelvic health physiotherapy service. This is because your risk of having PFD will be higher.

You can find some useful tips on childbirth in this booklet: Fit for Birth | POGP

Perineal Health in Pregnancy, Birth & Beyond Antenatal discussion guide

You will have a discussion about your birth preferences during pregnancy and again when you are in labour. Use this information leaflet as a guide to discuss your perineal health and how you can reduce your risk of having a severe tear with your midwife. It includes information on: types of perineal tears at childbirth, risk factors for having a severe tear, the recovery, perineal massage, the use of a warm compress, birthing positions and the OASI Care Bundle.

The RCOG Tears Hub has information and support on perineal tears and episiotomies in childbirth. Download the guide here.

Please watch the video here explaining what the OASI Care Bundle is and how women can reduce their risk of sustaining an OASI (obstetric anal sphincter injury, also known as a severe tear) in childbirth. Please access the RCOG Tears Hub for available translations.

Perineal Massage

You can help reduce your risk of getting a severe perineal tear by performing perineal massage in pregnancy. Do this from 35 weeks of pregnancy onwards. Following the steps below:

  • Use a natural oil like vitamin E oil, almond oil or olive oil as a lubricant.
  • Hold one or both of your thumbs facing downwards on the inside of your perineum for 1 minute.  press down towards your bottom and vaginal walls. You will have a stretching feeling. Be in a comfortable position and keep breathing.
  • Gently massage the lower half of your vagina using a U-shaped movement for 2 to 3 minutes
  • Repeat the massage daily, or when possible.
  • You may wish to ask your partner to help with this.

Please see the RCOG leaflet for further advice: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-perineal-tears-poster-colour.pdf

Getting Help

It is common to be embarrassed or to think that pelvic floor problems are normal while you are pregnant and after childbirth. Please read the “How to Get Help” section below if you have any worries.

Pelvic Floor Exercises

You may have heard of Kegel exercises. That is the same thing as pelvic floor exercises, it’s just a different name.

ALL women should practice pelvic floor muscle exercises daily, especially if they are pregnant. The pelvic floor muscles should be kept strong and active just like any other muscle in the body. This will help prevent symptoms of Pelvic Floor Dysfunction such as bladder and bowel leakage or prolapse.

Your pelvic floor exercises or ‘Kegels’ can be performed in any position. Find one which is comfortable for you. You may find lying or sitting easier if your muscles feel weak and try standing when they are stronger.

Start by lying or sitting in a comfortable position. Take a moment to relax everything around your pelvis, including the muscles around your vagina and bottom. Concentrate on your bottom and imagine that you are trying to stop yourself passing wind (fart) and peeing at the same time. You can also imagine you are sucking a piece of spaghetti into your bottom. You should feel a gentle ‘squeeze and lift’ of your pelvic floor muscles inside.

When you do your pelvic floor exercises, try not to:

  • Clench your buttocks
  • Squeeze your tummy muscles
  • Hold your breath

NHS Information – What are Pelvic Floor Exercises: https://www.nhs.uk/common-health-questions/womens-health/what-are-pelvic-floor-exercises/

How Often Should I Do Pelvic Floor Exercises?

It is important to do your exercises in pregnancy because that will help you during labour and with your recovery after you have given birth. After giving birth start as soon as you feel comfortable even if you have had caesarean. Do not start if you have a catheter. You will need to wait until it is taken out.

Try and build pelvic floor exercises into your every day routine. Consider the exercises like brushing your teeth: you brush your teeth daily to prevent a problem. Daily pelvic floor exercises for the rest of your life help to prevent bladder, bowel or prolapse problems.

  • Start your exercises in a comfortable position like lying or sitting. Begin with 5 to 10 short squeezes. Have a short rest in between each squeeze (5 seconds). Then build up to 10 long squeezes. Aim to hold each squeeze for 10 seconds. You may not be able to hold for 10 seconds straight away. It is important to gradually build up to this at your pace. You may need to start with little and often until your muscles get stronger.
  • Try and repeat your exercise programme 3 times each day.
  • Build up your exercise programme over the following weeks and months. You should notice the exercises getting easier in around 3 to 5 months.
  • Once improved, carry on with the exercises once a day to keep your muscles strong.

The ‘Knack’

This means squeezing and tightening your pelvic floor muscles every time you do anything that may cause you to leak or put pressure on your pelvic floor muscles. This happens every time you cough, sneeze, laugh, lift, jump or bend. You may need to practice this before your muscles start doing this on their own.

More information on pelvic floor exercises is available here: Pelvic Floor Muscle Exercises (for women) | POGP

PFD is a term for a group of health problems caused by the pelvic floor not working correctly. These symptoms can include:

  • Leaking pee (Urinary incontinence)
  • Needing to go to the toilet more often (Overactive bladder)
  • One or more of the pelvic organs coming down into the vagina (Pelvic organs prolapse)
  • Pooing or farting without meaning to (Anal incontinence)
  • Pain when having sex (Dyspareunia)
  • Struggling to poo even when you want to (Obstructive defaecation)

Is PFD normal?

It is quite common to experience incontinence during pregnancy and after having a baby.

40 to 50% of women in their 2nd and 3rd trimesters and immediately after birth have problems with leaking pee.

25% of pregnant women can also have problems with leaking poo.

It is very important to know that these symptoms should only happen for a short time, be mild and go away quickly.

If you have major pelvic floor symptoms during pregnancy or afterwards, or mild symptoms that do not improve within 6 weeks of childbirth; then we suggest you ask you GP, midwife or health visitor to refer you to pelvic health physiotherapy. You can also complete a self-referral which you can find in the section ‘How to seek help’.  Simple treatments will often improve the symptoms and help to stop long term problems.

Common bladder problems:

Stress Incontinence

Stress incontinence is accidental leaking of pee. This can be when you do something that increases the pressure in the tummy. This could include jogging, dancing, jumping, coughing, laughing, bending or lifting your baby.

It is because the pelvic floor muscles are not supporting your water pipe well enough. This is the pipe from the bladder though which you pee. Many women have this when they return to activities such as running, exercise or dance classes after having a baby.

Overactive Bladder

Overactive bladder is when your bladder squeezes and tries to empty without you wanting it to.

You may have the following:

  • the need to rush to the toilet quickly to pee or
  • find you are going for a pee more often than normal.
  • wake up at night needing to pee or
  • leaking pee when rushing to the toilet. This can sometimes be a major leakage of pee which you cannot stop.

Overactive bladder syndrome is when the muscle in the wall of the bladder tightens and squeezes when it should be relaxed. When this happens, it causes you to pee more often, more urgently and at night time.

Often overactive bladder problems happen at the same time as stress incontinence.

Useful tips to help you with your bladder problems:

  • Do pelvic floor exercises often and apply the ‘Knack’
  • Try to go for a pee every 2 to 4 hours in the day
  • Drink 1.5 to 2 litres of water every day
  • Try not going to the toilet ‘just in case’
  • Try not to have things that may irritate your bladder. These include caffeine, alcohol, artificial sweeteners, fizzy drinks and anything that contains citrus

More information on how to manage your bladder: Management of Urinary Frequency, Urgency and Urge Incontinence | POGP

Pelvic Organ Prolapse

Pelvic Organ Prolapse is when your bladder, bowel or womb moves down from their normal position. This causes a bulge or heavy feeling inside your vagina.

It happens when there is damage pelvic floor which normally supports these organs and keeps them in place. The symptoms are a heavy pushing or pulling feeling in your vaginal. You may also have or notice a bulge or lump in the vagina.

Sometimes you may find it difficult to pee or poo properly. This can cause bladder infections or constipation.

You may find having sex uncomfortable or a have a feeling of something being in the way in your vagina.

Useful tips to help you with your prolapse:

  • Do pelvic floor exercises often
  • Try to lie down for short periods during the day
  • Try not to lift anything heavy. This includes shopping bags, small children, hoovers, washing baskets
  • If you have a bad cough follow the ‘knack’. Take medicine to help as soon as possible
  • Try to eat and drink food that help you poo. This will help to you being constipated.
  • Do not strain when trying to poo

More information on how to manage POP: Pelvic Organ Prolapse – A physiotherapy guide for women | POGP

Common bowel problems:

Accidental Bowel Leakage

This is when you accidently leak wind (fart) or poo from your bottom without meaning to. This is less common than urinary incontinence, overactive bladder or prolapse symptoms. However it can affect your quality of life more and be very upsetting.

It is usually caused by a disruption to the ring of muscles which surrounds your bottom due to tearing during childbirth. We also call this an Obstetric Anal Sphincter Injury (OASI) or third or fourth-degree tear. After childbirth we will offer you an examination of your vagina and bottom. This is to check for these types of tears. Unfortunately, in some cases, symptoms such as accidental bowel leakage can still happen even after we repair the tear.

Sometimes, you may start to feel the need to rush to the toilet to poo. This usually settles as your control improves.

Constipation

Constipation (problems pooing) is quite common during pregnancy and in the first few weeks after child birth. You may need to take laxatives if it does not get better after a few days. You can buy these over the counter, or ask your midwife or GP for a prescription

Useful tips to help you poo:

  • Drink 1.5 to 2 litres of water every day
  • Eat breakfast, lunch, dinner every day
  • Eat plenty of fresh fruit and vegetables
  • If you need to go for a poo you must go. Do not hold it.
  • Relax and take your time on the toilet
  • Sit with a little step under your feet. This raises your hips so they are slightly higher than your knees

More information on how to manage your bowels: Improving Your Bowel Function | POGP

Discomfort During or After Sex

After pregnancy and childbirth, you may feel discomfort during sex. Sometimes you may feel that your vagina is loose or something being in the way.

The discomfort may be due to changes in the tissue at the entrance of your vagina. Scar tissue after a vaginal tear, or your pelvic floor muscles being too tight can cause this.

Useful tips to help with pelvic pain:

  • Do pelvic floor exercises often. Focus on the ‘letting go’ part of the squeeze
  • Relax your pelvic floor muscles a best as possible. Use mindfulness and deep breathing techniques
  • Gently stretch your pelvic floor using yoga poses such as Child’s pose or Happy Baby pose. Do this a few times a day
  • Put a bent finger into your vagina. Gently massage your pelvic floor muscles a few minutes a day. This should not feel painful

Pelvic Girdle Pain (PGP)

PGP is when you experience around your pelvis during pregnancy.

  • Around 1 in 5 pregnant women experience symptoms of PGP. This can vary from pain in your pubic bone, groin, hips, back and sometimes have sciatica. The pain can be on and off.   You may find you are more sore at the end of the day. You may have good and bad days.
  • Basic advice when you have PGP:
  • Rest often throughout the day. If you can lie down for about 15 to 20 minutes to rest
  • Do not lift anything heavy such as shopping bags, hoovers, washing baskets
  • Walk with small steps and short distances
  • Go up and down the stairs one step at a time
  • Sleep with a pillow between your legs
  • Think about taking painkillers like paracetamol when needed
  • If your symptoms that do not improve within 2 weeks, or affect your normal day-to-day life, ask your midwife or GP for help. They can refer you to physiotherapy. You can also refer yourself. The self-referral form in the ‘How to get help’ section.

More information on Pelvic Girdle Pain in Pregnancy: Pregnancy Related Pelvic Girdle Pain and other common conditions in pregnancy | POGP

Exercise during pregnancy and after can help both mother and baby.

It can help:

  • you keep a healthy weight,
  • improve fitness
  • prepare your body for labour
  • recovery after birth
  • reduce the risk of postnatal depression.

Tips during pregnancy:

Start gently
If you are new to exercise, start with 10 minutes of gentle exercise. This can be a brisk walk around the block. Work at your pace and slowly build that up to two and a half hours of weekly exercise. This does not have to be in one go, you can spread it out.

If you already exercise regularly, keep doing what you are used to. You may need to make some changes to exercise safely.

Try and aim for 2 or 3 sessions per day of some gentle pelvic floor squeezes.

Listen to your body
Do what feels right for you and do not push yourself too much. You should be able to talk while you do your exercises. If you cannot, then you need to slow down. If you feel any pain during exercising, stop doing that exercise or do less.

Good types of exercise in pregnancy:

Walking
This a great form of exercise. You can easily build it into your daily life. It is free, and you plenty of fresh air. It is a great way to get you started.

Swimming
Swimming is a great form of exercise. The water supports your weight during pregnancy. You feel less heavy in water. If you are struggling with pelvic girdle pain, then this is the best form of exercise. Start gently with a short session to see how your body responds. Slowly build it up.

If you cannot swim, stay about chest deep in the water and walk forwards, backwards and sideways. This is a good way of doing some exercise in water. You can also join an antenatal aqua aerobics class.

Running                                                                                                                                                                                                                                                                      If you are an experienced runner, it is fine to carry on during your pregnancy as you are comfortable. If you are new to running, stick to brisk walks and begin your running journey after birth.

Yoga and Pilates
These are great forms of exercise during pregnancy. If you are experienced, carry on  for a long as you are comfortable. If you have never done yoga or Pilates before start with a prenatal or a beginner’s class.

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Exercises to stop during pregnancy:

Contact sports
Avoid sports like football, rugby, basketball, martial arts, kickboxing and tennis. Do not do any sport that involve a risk of your tummy being hit.

Activities in which you might fall
Avoid activities such as skiing, horseback riding, climbing, gymnastics and skating

Activities that involve lying on your back
After the first trimester, as you baby grows and gets heavier, try to avoid activities that involve lying on your back (for example: bench pressing or meditating lying on your back). This can reduce the blood flow to the uterus.

Activities that involve holding your breath
When you are lifting heavy weights you often hold your breath. This can be dangerous for your baby. It increases the pressure in your tummy.

Scuba diving
This can lead to decompression sickness, which can be dangerous for your baby.

Exercise at high altitude
Exercising above 6000 feet can lower the amount of oxygen that reaches your baby. This is  because at that height, the air is thinner.

Exercising in hot and humid weather
You may find it harder to control your internal body temperature. Exercise in hot and humid weather can be dangerous for you and your baby.

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Tips after giving birth

Start gently
Begin with a regular short walk as soon as you feel comfortable after giving birth, and slowly build up the distance. It is important to start daily gentle pelvic floor exercises as soon as you feel ready.

Wait for your 6-week postnatal check
Wait until you have had your postnatal check with your GP before you begin sports such as  aerobics or running,

Be mindful of your recovery time
You may have been told that your body will be back to normal 6 weeks after giving birth. For some women this may be longer. It could be longer if you have had a complex delivery or a caesarean section. If you feel any pain, stop or reduce the amount of exercise you are doing.

Symptoms of pelvic floor dysfunction
You may need to see a pelvic health physiotherapist if

  • you notice any leakage from your bladder
  •  are struggling to control your bowels
  •  you feel a bulge in your vagina
  • you have pain in your pelvis when you return to exercise

You can find how to refer yourself  in the section ‘How to seek help’.

You can find more information and exercises in:

Pelvic Floor Physiotherapy

Pelvic Health Physiotherapy helps to improve most mild to moderate pelvic floor problems. These are problems which you may have during and after pregnancy and childbirth. Getting support quickly helps to stop the problem from getting worse. It will often resolve the problem.

How Physiotherapy treatment Works

For your first assessment the physiotherapy team will offer you a phone or face-to-face appointment. During your first assessment they will:

  • Ask you questions about your symptoms teach you basic pelvic floor exercises
  • Talk to you about how to manage your symptoms.

The team may be offer you a follow up appointment so they can do a physical examination. This may involve an examination of your vagina, rectum or both You can choose if you want to have this examination. They will check your pelvic floor and how to do your exercises correctly. If you do the exercises correctly you will see an improvement in your symptoms. The examination will help the physiotherapist to plan the right exercise programme for you.

If your pelvic floor is weak or you struggle to find your pelvic floor the physiotherapist may use tools to help you. These could be biofeedback or muscle stimulation. Biofeedback shows you how well you are contracting your pelvic floor muscles. A small vaginal electrode registers the activity of your pelvic floor and displays this on a screen for you to see.

Muscle stimulation is using a small vaginal electrode to get your pelvic floor muscles working. and will help you to learn how to use your pelvic floor muscles properly. The exercises and techniques you learn will often give you lifelong skills to keep your pelvic floor working well and healthy.

Your physiotherapist will also talk to you about your lifestyle for your bladder and bowel health. Physiotherapy treatment may often last for 3 to 4 months. This gives your muscles time to get stronger. You should see an improvement in your symptoms.

Physiotherapy works if you stick with it. You have to put the work in to see the benefits.

What happens if physiotherapy does not help?

Most symptoms of pelvic floor dysfunction will improve with physiotherapy. If you still have symptoms after finishing your physiotherapy treatment, the physiotherapist will contact your GP. They will ask your GP to refer you to a doctor specialising in pelvic floor dysfunction. This will be either be:

  • a uro-gynaecologist. This is a gynaecologist who specialises in bladder, vaginal prolapse or pelvic pain problems
  • a colorectal surgeon. They specialise in pelvic floor problems which affect the bowel.

Perinatal Pelvic Health Service (PPHS)

1 in 3 women will have a problem with their bladder at some time during their life. The most common problems are:

  • leaking pee when you exercise, sneeze, or cough (stress urinary incontinence),
  • not getting to the toilet in time (urge incontinence)

1 in 10 women will struggle with the control of their bowel.

1 in 12 women may have a feeling of something coming down or a heavy sensation in the vagina. This is called pelvic organ prolapse. Some may also find sex uncomfortable or painful.

There are lots of reasons women tell us why they may not seek help with pelvic floor problems. This includes:

  • “It’s normal after childbirth”
  • “I’m too embarrassed to talk about it”
  • “What if treatment is painful or risky?”
  • “I’m too busy with my new-born baby”
  • “I don’t know that help is available”

Perinatal Pelvic Health Service (PPHS)

Shrewsbury and Telford Hospital NHS Trust (SaTH) have a service called the Perinatal Pelvic Health Service (PPHS). The service supports all women who are due to give birth at SaTH. We offer information and treatment for:

  • symptoms of pelvic floor dysfunction,
  • pelvic girdle pain
  • other pelvic floor related problems.

This is available through their pregnancy, childbirth and up to 12 months after giving birth. The PPHS team includes a specialist pelvic health physiotherapist and a specialist pelvic health midwife.

You will have the following support during your pregnancy and birthing journey.

  • Antenatal education on pelvic health. Go to the Pelvic Health Workshop section to find out how to book on to these sessions. You will get information on how pregnancy and childbirth affect your pelvic floor muscles. Learn how to recognise any problems, how and when to do your pelvic floor muscle exercises and when to ask for help.
  • Your community midwife will talk to you about your pelvic health at your antenatal appointments. Make sure you tell them of any concerns or worries.

Your physiotherapy appointment

The pelvic health physiotherapist to talk to you about your referral. You will get either a phone call or letter to let you know when and where your appointment is. They will give a contact number in case you have any questions or you need to change your appointment.

Your appointment will be about 30 to45 minutes. You will be able to choose between a phone call or face to face appointment.

How to get referred if I have a problem?

You can ask your Midwife, GP, Obstetric consultant, or health visitor to refer you.

You can also do a self- referral by clicking on this LINK.

You will need to download the form, fill it in and then send it to sath.pelvichealthtriage@nhs.net. If you are unable to use the self-referral link, please contact us by:

Pelvic Health Workshop

Come and join our specialist Perinatal Pelvic Health team to learn about the importance of taking care of your pelvic floor during pregnancy and childbirth. You will learn how to recognise symptoms of pelvic floor dysfunction, how you can help yourself and what support you can get.

Who can attend?

This workshop is for all pregnant women within Shropshire, Telford and Wrekin. It will be delivered in English. Please let us know if you need any support to take part. Unfortunately, we are currently unable to offer translations options for these sessions.

This session will include:

  • What is the pelvic floor
  • How pregnancy and childbirth can change things
  • Symptoms to look out for
  • How to strengthen your pelvic floor
  • Caring for your bladder and your bowels
  • Techniques to reduce the risk of perineal tears
  • Caring for yourself after birth

Ask your Midwife to refer you via BadgerNet or you can use the self-referral form.

It is important to take care of yourself after childbirth. Restart your pelvic floor exercises as soon as you feel comfortable to do so. If you have a catheter, wait until this has been taken out before you start your pelvic floor exercises. Start gently with 5 to 10 short squeezes three times per day. Slowly build your exercise programme to strengthen of your pelvic floor muscles.

Advice on pelvic floor exercises: Pelvic Floor Muscle Exercises (for women) | POGP

Advice after you have given birth: Fit for the Future | POGP

Here are a few more resources to help keep you fit and healthy after childbirth.

The MASIC foundation – https://masic.org.uk/

Bladder and Bowel Foundation – https://www.bladderandbowel.org/

Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) – https://thepogp.co.uk/