Care of the pelvic floor during pregnancy, birth, and postpartum.

Pregnant women are often bombarded with advice and information about how to optimize their health and that of their developing baby throughout pregnancy and postpartum. "Be sure to take prenatal vitamins, don't drink caffeine, get enough rest, limit your fish intake, and exercise regularly" are just some of the instructions pregnant women receive from their caregivers, educators, and friends. Amidst all the important information that is conveyed to pregnant women, often underemphasized is how to properly care for the pelvic floor during the childbearing year and beyond.

The Pelvic Floor

The pelvic floor is a supporting structure for the pelvic and abdominal organs, including the bladder, rectum, and uterus, and forms a "sling" from the pubic bone to the coccyx (tailbone). It is comprised of the levator ani muscles and the coccygeus muscles, as well as the surrounding fascia. A healthy pelvic floor contracts efficiently to hold the flow of urine or feces despite coughing, sneezing, or laughing. It also relaxes appropriately to allow full bladder and bowel emptying without unnecessary bearing down. It is important to have good strength in the pelvic floor muscles before, during, and after pregnancy. When the pelvic floor is strong, it is better able to help push the baby out. It also can respond better to the demands to stretch and expand to allow the passage of the baby during birth. A strong pelvic floor also helps prevent incontinence (leakage of urine) in pregnancy and post-partum. Several factors specific to pregnancy affect the integrity and functioning of the pelvic floor.

The pelvic floor in pregnancy. During pregnancy, the weight of the uterus on the pelvic floor causes these muscles to stretch and become weaker, resulting in incontinence for half of all pregnant women. (1) Activities that result in holding the breath or bearing down can further weaken these muscles. For example, pregnant women often experience constipation due to changes in hormones and gastrointestinal motility. Straining to have a bowel movement increases stress on the pelvic floor and further

The pelvic floor in childbirth. The greatest demands are placed on the pelvic floor muscles during labor and childbirth. During vaginal birth, the pelvic floor stretches to its maximum to allow for the passage of the baby. This significant amount of stretching weakens the pelvic floor, and if not addressed, incontinence could be a problem postpartum and later in life. If, however, the pelvic floor is unable to stretch, the woman could experience tears or an episiotomy, which once healed result in scar tissue that could be a potential source of weakness and/ or pain. Cesarean surgery spares some trauma to the pelvic floor, but if performed after the onset of labor there is still a risk for injury to these muscles from pressure and stretching as the baby descends. (2) However, since a cesarean section is major abdominal surgery carrying its own risks, it is better to use other techniques to help reduce trauma to the pelvic floor.

The pelvic floor in the postpartum period. Studies suggest that as many as 25% of women experience incontinence post partum. (3) Women who deliver vaginally or with forceps, have sutures in the pelvic floor muscles, smoke, or experienced incontinence during pregnancy are at increased risk of postpartum incontinence. Interestingly, however, episiotomies do not appear to contribute to this problem. (3,4) Many women are uncomfortable discussing incontinence with their health care provider, therefore it often goes untreated. A study of postpartum women found that they were reluctant to mention the problem, but wanted their providers to question them about symptoms and provide suggestions for treatment. (5)

How to Prepare the Pelvic Floor During Pregnancy

Exercising the pelvic floor muscles when pregnant can help significantly reduce incontinence both during pregnancy and postpartum. (6) Although many women are familiar with the term "Kegel exercises", they often don't know exactly what they are or how to perform them.

To exercise the pelvic floor muscles, women can be instructed to envision pulling the muscles of the tocks, thighs, and abdominals should stay relaxed. One of the simplest ways to learn to contract the pelvic floor is to stop the flow of urine while on the toilet. This technique can be used to verify which muscles to isolate, but should not be repeated often, as it can cause urinary tract infections.

When learning the Kegel exercise, contractions can be held for 3-5 seconds, and repeated 10 times, 2-3 times per day: Very rapid Kegel exercises should also be performed. To do this, the pelvic floor muscles should be tightened as fast as possible, then relaxed quickly, for a series of 5-10 rapid contractions.

Another variation of the standard Kegel is the "elevator" variation. The pelvic floor muscles are pulled up a little, then a little higher, then a little higher, like an elevator climbing up 3-4 levels. The muscles can then slowly release down little by little, as if making stops on each floor. Pelvic floor contractions can also be performed when coughing, sneezing, or lifting to help reduce pressure on these muscles.

Although it is important to learn how to contract the pelvic floor muscles, it is equally important to understand how to relax them. After each Kegel contraction, women should focus on fully releasing the muscles down. This can help reduce straining during bowel movements and promote improved ability to relax during labor and birth. (Adequate water and fiber intake in conjunction with a regular exercise program can also help reduce constipation-related pelvic floor strain.)

In addition to pelvic floor exercises, taking measures to optimize fetal positioning can also help reduce perineal trauma. Babies presenting in an anterior occiput position place the least amount of strain on the pelvic floor, as the smallest diameter of the baby's head makes contact first, allowing these muscles to stretch more gradually. Awareness of good posture and body mechanics during daily activities in conjunction with regular exercise may help improve fetal positioning, thereby decreasing the risk of perineal trauma. In addition to prenatal preparation, there are also techniques that can be used during labor and birth to help reduce pelvic floor injuries.

Reducing Pelvic Floor Trauma During Birth

During labor and childbirth, efforts should be made by caregivers to protect the pelvic floor from tearing or episiotomy. The use of warm compresses and olive oil on the perineum have been proposed as means to allow the perineal tissues to relax and stretch. Good hydration throughout labor and birth is also important so the pelvic floor will be able to stretch more easily. (7)

Birthing positions that are more upright and gravity-assisted will help ease the baby's descent, which could help spare injury to the pelvic floor. Positions such as on all fours and supported squatting help open the pelvic cavity optimally and relax the pelvic floor, reducing the risk of tears. In addition, women should be educated to avoid pushing before they feel the urge. Pushing too soon can cause the tissues to swell, making them less expandable and more susceptible to trauma. The birth attendant can also take care to make sure the shoulders birth one at a time to decrease the amount of stretching of the pelvic floor muscles. (7)

Women can also be educated about the risk of pelvic floor" injury due to epidural anesthesia. Women with epidurals have less sensation and may not feel the urge to push or be less effective at pushing. As a result, the incidence of forceps or vacuum deliveries increases, and one study found instrument deliveries triple the risk of pelvic floor trauma. (8) Modalities such as TENS, warm whirlpools, or hypnobirthing can be effectivealternative pain relieving techniques.

Perineal massage during birth has been proposed as a means of reducing trauma to the pelvic floor. Studies have found, however, that there is no benefit of perineal massage during labor in terms of reducing tearing, postpartum pain, or incontinence. (7,9) One homebirth study found that perineal massage increased tearing when performed during labor due to increased swelling of the tissues; however, when done during pregnancy it may help improve awareness of how to relax the muscles in preparation for birth. (7)

Pelvic floor recovery postpartum. Following childbirth, women may experience pain, weakness, and/or incontinence. It is important that women understand how to help the pelvic floor heal to prevent chronic problems from developing.

Cold packs can be used to help reduce pain and perineal swelling within the first 48 hours after birth. In addition, warm sitz baths once or twice daily will help keep the perineum clean, reduce discomfort, and improve circulation to help the tissues heal. This is especially important for women with tearing or an episiotomy, but can be soothing even if no tears are present. One study found cold sitz baths to be more effective for pain relief.10

It is safe and beneficial for women to begin Kegel exercises within the first few hours after birth. It may seem difficult or impossible to contract the pelvic floor, but initiating gentle contractions will help the muscles regain their strength and function, which will help with the transition to motherhood.

Conclusion

Pregnancy and childbirth certainly present a challenge for the pelvic floor muscles. Educating pregnant women about what they can do during pregnancy, childbirth, and postpartum to optimize the condition of the pelvic floor is an important component of childbirth education and maternity care. This knowledge can empower women to be proactive about protecting the pelvic floor at all phases of the childbearing year.

References

(1.) Eason E, et. Al. "Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study." BMC Pregnancy Childbirth. 2004 Feb 19;4(1):4.

(2.) Heit M. et al. "Prevention of childbirth injuries to the pelvic floor". Curr Womens Health Rep. 2001 Aug;1(1):72-80.

(3.) Hvidman, L. "Postpartum urinary incontinence." Acta Obstet Gynecol Scand. 2003 Jun;82(6):556-563.

(4.) Burgio, K et al. "Urinary Incontinence in the 12-month postpartum period". Obstet Gynecol. 2003 Dec;102(6):1291-1298.

(5.) Mason L, Glenn G Walton I, Hughes C. "Women's reluctance to seek help for stress incontinence during pregnancy and following childbirth". Midwifery. 2001 Sep;17(3):212-21.

(6.) Morkved, Set al. "Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single-blind randomized controlled trial". Obstet Gynecol 2003 Feb;101(2):313-9.

(7.) Bruce, Elizabeth. "Everything you need to know to prevent perineal tearing". Midwifery Today. Issue 65.

(8.) Caroll, TG, et al. "Epidural analgesia and severe perineal laceration in a community-based obstetric practice". JAM Board Faro Pract. 2003 Jan-Feb;16(1):1-6.

(9.) Stamp G, et. al. "Perineal massage in labour and prevention of perineal trauma: randonrised controlled trial". BMJ 2001 May; 322: 1277-1280.

Alicia Silva, MSPT 

Alicia Silva, MSPT is a physical therapist and author of Preventing and Managing Back Pain During Pregnancy. She can be readied at [e-mail].