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, also known as pelvic floor dysfunction (PFD), can affect anyone who is pregnant. These problems could be leaking urine (wee) or faeces (poo), unable to control wind, or a heavy sensation or bulge in the vagina. This can happen when the pelvic floor muscles are not working correctly. It is important to be aware of how pelvic floor problems occur and what you can do to reduce them.

During pregnancy, the pelvic floor muscles come under pressure from the extra weight of your growing baby, amniotic fluid, placenta, and the enlargement of the womb. This extra downward pressure and effect from pregnancy hormones (chemicals in the blood stream) causes stretching and tiring of the pelvic floor muscles. The stretching means your muscles do 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 (the area between your vagina and back passage), and pelvic floor muscles which will take time to heal. This can affect how well the muscles work. The nerves that help make the pelvic floor muscles work well may be affected after birth, so you may feel you have a weak pelvic floor.

It is really important that the midwife or obstetrician (doctor) examines you after birth. You will be asked for your consent for the midwife or obstetrician to examine your vagina, perineum and anus (inside the back passage) to identify any tears and treat as necessary to avoid any further consequences. If you have a severe tear you will be followed up and referred to pelvic health physiotherapy as your risk of developing pelvic floor dysfunction will be higher.

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.

Download the guide here.

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; you may choose to try perineal massage until your baby is born. Have a look at the video on tips and advice on how to perform perineal massage safely.

  • 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 one minute, pressing down towards the anus and vaginal walls, feeling a stretching sensation. Be in a comfortable position and keep breathing.
  • Gently massage the lower half of your vagina using a U-shaped movement for 2-3minutes. Do this 2-3 times.
  • 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.

1 in 3 women experience a problem with their pelvic floor muscles at some time during their life. The most common problems are leaking with exercise, sneezing, or when coughing (stress urinary incontinence), not getting to the toilet in time (urge incontinence). Some women may have a feeling of something coming down or a heavy sensation in the vagina (pelvic organ prolapse) and some may find sex painful (dyspareunia).

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”

Remember – help is available. This page contains advice, self-care tips and information on when, where and why to seek help.

Pelvic Floor Exercises

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.

Imagine that you are trying to stop yourself passing wind and urine at the same time. You can also think of squeezing tight in the vagina. Another prompt can be imagining you are sucking a piece of spaghetti into your back passage, you should feel your pelvic floor muscles ‘squeeze and lift’ inside. Don’t hold your breath or clench your buttocks. You may feel a gentle tightening in your tummy, which are your deep tummy muscles working to help the pelvic floor.

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?

  • Try and repeat this programme 3 times a day. Start with 5-10 short squeezes and then build up to 10 long squeezes aiming to hold each squeeze for 10 seconds. You may not be able to hold for 10 seconds straight away so it is important to gradually build up to this at your pace. You may need to start with little and often until the muscles get stronger.
  • Build up your exercise programme over the following weeks and months. You should notice the exercises getting easier in around 3-5 months.
  • Once improved, continue to practice these exercises once a day to maintain strength.

Pelvic Floor Dysfunction (PFD)

Pelvic floor dysfunction (PFD) is a term for a group of related conditions caused by the pelvic floor not working correctly.

Click the titles below for more information on PFD conditions and the treatments available if you need help.

Pelvic floor dysfunction (PFD) is a term for a group of related conditions caused by the pelvic floor (muscles, fascia, and ligaments) not working correctly. These symptoms can include.

  • Urinary incontinence – leaking of urine.
  • Overactive bladder – urgency to go to the toilet often.
  • Pelvic organs prolapse – descent of one or more of the organs into the vagina.
  • Anal incontinence – accidental bowel leakage.
  • Dyspareunia – discomfort during sexual intercourse.
  • Obstructive defaecation struggling to poo

Is PFD normal?

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

40-50% of women in their 2nd and 3rd trimesters of pregnancy and immediately after birth have urinary leakage.

25% of pregnant women can also have anal incontinence.

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

If you experience any significant pelvic floor symptoms during pregnancy or afterwards, or mild symptoms that do not improve within six weeks of childbirth; then we advise that you seek help. Simple treatments will often improve the symptoms and prevent long term problems.

Stress Incontinence

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

Stress incontinence is caused by the pelvic floor not supporting the urethra (the water pipe from the bladder though which you wee)  well enough. Many women experience this when they return to activities such as running, exercise or dance classes after they have had a baby.

Overactive Bladder

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

You might experience the need to rush to the toilet quickly to wee or find you are going for a wee more often than normal. You may wake up at night needing to wee or experience accidental leakage when rushing to the toilet. This can sometimes be a significant leakage of urine which you cannot stop.

Overactive bladder syndrome is caused by the muscle in the wall of the bladder contracting and squeezing when it should be relaxed. The abnormal bladder muscle contractions in overactive bladder syndrome cause the urinary frequency, urgency and night time weeing.

Often overactive bladder problems are developed at the same time as stress incontinence, and you may be affected by both conditions.

Pelvic Organ Prolapse

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

It is caused by damage to the pelvic floor which normally supports these organs and keeps them in place. The usual symptoms are the sensation of a vaginal dragging or pressure and/or noticing a bulge or lump in the vagina.

Sometimes you can also develop problems with not emptying your bladder completely when weeing or emptying the bowels and can cause constipation.

Sexual intercourse may also be affected with discomfort or a sensation of something being in the way in your vagina.

Accidental Bowel Leakage

Accidental bowel leakage is when you accidently leak wind or poo from your bottom. This is less common than urinary incontinence, overactive bladder or prolapse symptoms, but has a bigger impact on quality of life and can be very upsetting to experience.

Accidental bowel leakage is usually caused by a disruption to the ring of muscles which surrounds your bottom or anus due to tearing during childbirth. This is known as a third- or fourth-degree tear. After any delivery (vaginal or caesarean section), you will be offered a vaginal and rectal (back passage) examination to check for these types of severe tears. Unfortunately, symptoms such as accidental bowel leakage can still occur even if the tears are repaired well.

Sometimes, you may develop the need to rush to the toilet to open your bowels if you have problems with accidental bowel leakage.

Discomfort During or After Intercourse

After pregnancy and childbirth, sexual intercourse may become uncomfortable, or you may feel discomfort in your vagina during sex, a feeling of your vagina being loose or open or something being in the way.

The discomfort may be due to changes in the tissues at the entrance of the vagina, caused by scar tissue after a vaginal tear during childbirth, or mismatching of the vaginal tissues after stitching.

Pelvic Girdle Pain (PGP)

The term PGP is used to describe pain experienced in the front and back of your pelvis (you may have previously heard the term symphysis pubis dysfunction [SPD] used; however, PGP is now the accepted name for this condition).

  • Around 1 in 5 pregnant women experiences mild discomfort in the back or front of the pelvis during pregnancy. If you have symptoms that do not improve within a week or two, or interfere with your normal day-to-day life, you may have PGP and should ask for help from your midwife, GP, physiotherapist or other health carer. See the how to get help section to self- refer
  • Women experience different symptoms, and these are more severe in some women than others. If you understand how PGP may be caused, what treatment is available, and how you can help yourself, this may help to speed up your recovery, reducing the impact of PGP on your life.
  • A range of management options is available to you, based on the type of PGP you are found to have.

Information leaflet: https://thepogp.co.uk/_userfiles/pages/files/POGP-PGP(Pat)(UL).pdf

Pelvic Floor Physiotherapy

Pelvic floor physiotherapy, supervised by a specialist physiotherapist, is proven to improve most mild to moderate pelvic floor problems which occur after pregnancy and childbirth. Getting support quickly if symptoms of pelvic floor dysfunction occur is important, as prompt physiotherapy helps to prevent the problem worsening and will often cure the problem.

How Physiotherapy Treatment Works

Usually, the pelvic floor specialist physiotherapist will see you for a few sessions after assessing the problems you are having. Often these will be face to face initially, with telephone follow ups to check on your progress. There may be further face to face contact if needed to help you.

A key part of physiotherapy treatment is to offer an (optional) internal examination to guide you on how to correctly do your pelvic floor exercises. The reason for this is that up to 65% of women who practice their pelvic floor exercises are doing them incorrectly and so won’t be seeing improvement with their symptoms. The examination will then help the physiotherapy team to provide you with a specific pelvic floor muscle exercise programme for you.

If your pelvic floor is weak or you struggle to locate your pelvic floor the physiotherapist may use tools such as biofeedback. This is a device which shows you how well you are contracting your pelvic floor and it can form a helpful part of treatment for some people with pelvic floor dysfunction. Electrical stimulation is using little electrodes to stimulate the contraction of your pelvic floor muscles and will help you to learn how contract your pelvic floor muscles effectively. The exercises and techniques you learn as part of pelvic floor physiotherapy will often give you lifelong skills to maintain the health of your pelvic floor.

As well as pelvic floor exercises, your physiotherapist will also help you with lifestyle advice for bladder and bowel health. Physiotherapy treatment may often last for 3-4 months to allow time for the muscles to develop to then see improvement in your symptoms.

Physiotherapy works if you stick with it! Evidence shows 3-4 months of physiotherapy will improve urinary or prolapse symptoms. your physiotherapist is there to guide you with advice and your exercise programme; however, you have to put the work in to see the benefits!

What happens if physiotherapy doesn’t help?

Most pelvic floor dysfunction symptoms will improve after supervised pelvic floor physiotherapy. If you are still experiencing pelvic floor problems after completing a course of physiotherapy, then we will recommend that you see a doctor specialising in pelvic floor dysfunction.

This will be either a urogynecologist, a gynaecologist who specialises in pelvic floor dysfunction problems or a pelvic floor specialist colorectal surgeon, who looks after pelvic floor problems which affect the bowel.

Your physiotherapist will usually be able to refer you on to the specialist doctor, as all pelvic floor specialists work together in a multidisciplinary team. A small number of patients may need to have operations to treat stress incontinence or pelvic organ prolapse, or to have specialised procedures to help with overactive bladder problems or accidental bowel leakage.

Perinatal Pelvic Health Service (PPHS)

Who are we?

The Perinatal Pelvic Health Service (PPHS) team consists of two specialist physiotherapists, Obstetrician and a specialist midwife who all have a special interest in pelvic health. The team care for women with obstetric (pregnancy) physiotherapy problems who are booked to deliver at the Shrewsbury and Telford Hospital NHS Trust. The PPHS team provides physiotherapy support to women through their pregnancy, childbirth, and the post-natal period (up to 12 months after giving birth).

Where are we?

We have two sites, one at Princess Royal Hospital and one at Royal Shrewsbury Hospital, we will inform you which site your appointment will take place once your appointment is arranged.

At Shrewsbury and Telford Hospital NHS Trust we have launched a pelvic health project to provide a pelvic floor health care system for everyone who is having a baby. You will be provided with the following to support your pregnancy and birthing journey.

  • Everyone will be offered antenatal education on pelvic health… Go to antenatal classes to book on to these sessions. You will be given information on how and when to do your pelvic floor muscle exercises.
  • All staff within maternity will receive specialist education to give them the knowledge to support you during and after your pregnancy.
  • Your community midwife will discuss your pelvic health at your routine antenatal appointments. Make sure you tell them of any concerns or worries.

How to get referred if I have a problem?

For a referral to PPHS, you can do a self- referral by clicking on this link or contact your Midwife, GP, Obstetric consultant, or health visitor.

Once we have received your referral we will look to see if it is urgent or non-urgent depending on the information you give us in the referral. Then you will receive a letter in the post asking you to call the therapy department to book an appointment to see a physiotherapist. The appointment is approximately 45 minutes long.

Alternatively, you can contact our therapy department on 01952 282880 which is in use Monday-Friday 09.00-17.00hrs or send an email to sth-tr.therapycarecentre@nhs.net or sath.pphservice@nhs.net.

Meet the Team

Matt Wood – Consultant Obstetrician

Linda Van Doorn – Lead Clinical Physiotherapist

Hannah Evans – Specialist Midwife

Elizabeth Stork – Physiotherapist

Pelvic health antenatal classes:

  • These are classes designed for all service users and support partner and will cover all topics regarding pelvic health in pregnancy, childbirth and after birth.
  • To book onto these sessions please click on this link to find a date and time to suit you.
  • We currently offer all classes virtually and aiming to offer face to face classes in the spring of 2023.
  • We can also offer face to face support for anyone who needs it.
  • We can also offer translation services if English isn’t your first language, or if anyone who needs reading support etc.

It is important to take care of yourself after childbirth. Remember to continue with your pelvic floor exercises. Start as soon as you feel able (once your catheter is out if you have one after birth), build up your exercise programme to increase strength in your pelvic floor muscles.

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

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

Birth Trauma Association – https://www.birthtraumaassociation.org.uk/

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

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