Pelvic floor muscles Their importance during and after pregnancy Pelvic floor muscles: their importance during and after pregnancy Presenter s manual p r o m o t i n g b l a d d e r a n d b o w e l h e a lt h
Notes for the presenter This resource will assist you to educate your clients about pelvic floor muscles within the ante and post natal setting. It is written in easy to use language, as you would present it to your clients. This resource is not intended as a complete self-help guide for the treatment of pelvic floor muscle dysfunction, but to raise awareness about pelvic floor muscles and their role in bladder and bowel control. A similar resource is also available as a flipchart or in a CD-ROM/manual package: Pelvic floor muscles A consumer education resource for health professionals. Ring the National Continence Helpline on 1800 33 00 66 for a copy. It is strongly advised that clients seek advice from a health professional for any symptoms relating to poor bladder or bowel control, or pelvic floor muscle dysfunction. Appropriate health professionals to see include a general practitioner, a continence and women s health physiotherapist, or a continence nurse advisor. Contact details for these health professionals are provided at the end of this presentation. This resource has been developed by the Continence Foundation of Australia in collaboration with The Pregnancy Centre. Continence Foundation of Australia September 2008 Disclaimer This resource is intended as an information guide about pelvic floor muscles and is not intended as a treatment program for specific conditions. No responsibility is taken for exercises not done appropriately or if they are ineffectual. The help of an appropriate health professional should be sought if symptoms are experienced. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Part 1: What are pelvic floor muscles and why are they important? What are pelvic floor muscles? Slide 2 What are pelvic floor muscles? This is a side view of the pelvic floor muscles in the female pelvis. The pelvic floor muscles in this picture are highlighted in red. Pelvic floor muscles are: Structured in women like a muscular trampoline from the tail bone (at the back) to the pubic bone (at the front) and stretch from sitting bone to sitting bone (side to side). The layer of muscles that support the pelvic organs. Normally firm and thick. It is a helpful exercise to find these bones and realise the small size of this muscle layer. Just put your hands under your bottom on each side, palms up and sit with your fingers under your sitting bones the pelvic floor muscle spans this space. Now find the pubic bone at the front and the coccyx (tailbone) at the tip of the spine and understand the distance which the pelvic floor muscles span. Another layer of the pelvic floor muscles also: Encircle the tubes leading from the bladder, bowel and uterus. Support the bladder, bowel and uterus (womb) in women. Note the bladder and bowel lying on the pelvic floor and the openings (urethra, anus, and in women the vagina) exiting to the outside through the pelvic floor. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Tip If you have a model of the pelvis with or without the pelvic floor muscles this can be used also to demonstrate the pelvic floor muscle position and to explain their role. Outline the position of the pelvic floor muscles in the female. Outline the position of the female pelvic organs Indicate that males have pelvic floor muscles too. This is shown in the next slide. Men have pelvic floor muscles too! Slide 3 Men have pelvic floor muscles too! Men have pelvic floor muscles too. As in women, the pelvic floor muscles are: Structured like a muscular trampoline from the tail bone (at the back) to the pubic bone (at the front) and stretch from sitting bone to sitting bone (side to side). The layer of muscles that support the bladder and bowel. Normally firm and thick. Men can stop and start their flow using their pelvic floor and hold on to wind. Advise that men can exercise their pelvic floor muscles too, and that there is a male pelvic floor muscle exercise sheet (Resource: Pelvic floor muscle training for men brochure available via the National Continence Helpline on 1800 33 00 66) and that it may be discussed and distributed later in the class. This is often good to leave until the end of the class to finish with. A brochure titled Pelvic floor muscles training for men is available free from the National Continence Helpline on (freecall) 1800 33 00 66. You may like to hand out copies of this. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
What do the pelvic floor muscles do? Support the bladder, bowel and uterus (in women) Help control the bladder and bowel Important for sexual function Support the baby during pregnancy Assist with the birthing process Help to stabilise and support the spine Slide 4 What do the pelvic floor muscles do? Support the bladder, bowel and uterus (in women) Help control the bladder and bowel Important for sexual function (sensation and arousal) in both men and women Support the baby during pregnancy Assist with the birthing process by guiding the baby s head during the delivery Work with abdominal and back muscles to stabilise and support the spine Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Tip use teaching props to explain the importance of pelvic floor function. A tip to teaching the importance of pelvic floor function is to use a Pelvic floor goody bag as a teaching prop. This is best inserted at this point, to stimulate discussion, and grasp participants attention, prior to further information from the educator. Pelvic floor goody bag The content in this bag represents functions that your pelvic floor muscles (PFM) help with. [Ask clients and their partners to name the object they have pulled out of the bag and what function they think it may represent. Some of the items will be discussed in more detail later in this resource]: Dried pomegranate the Romans would cut this in half and use as a treatment for uterine prolapse (where the uterus drops down into the vagina this will be discussed in more detail later), so the pomegranate would be used inside the vagina to keep the uterus in place. One of the main roles of the PFM is to lift up the pelvic organs (uterus, bladder and bowel) to sit in their right position Incontinence Pad urinary incontinence. Currently, about one in three women who have had a baby have an incontinence problem. Large pull up pad faecal incontinence which can occur due to pelvic floor weakness. Packet of condoms male sexual performance depends on a good blood flow. Strong PFMs work better than Viagra. Back brace PFM together with abdominals actually help to support your back acting as a natural brace. Walnut This is the size of the male prostate gland which is milked by regular PFM contractions. Small doll Yes, your PFM does help in the delivery of your baby. PFM with strong tone play a role in turning the baby as the baby is delivered Size C Tubigrip stuffed with paper This is how stretched the vaginal walls are during childbirth. Strong PFM helps to restore your vaginal walls after childbirth back to its original size (present another object depicting the original size) Dried fig At menopause (when your periods stop at about age 52), your uterus shrinks as a consequence of a drop in female hormone levels. Leakage and prolapse can occur with this loss of female hormones. Normally your uterus is approximately the size of your fist. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
The effects of pregnancy and childbirth on pelvic floor muscles The relaxin hormone softens the body tissues The pressure from increased weight The stretching during birth Slide 5 The effects of pregnancy and childbirth on the pelvic floor muscles What happens during pregnancy is a hormone relaxin is released throughout the body to soften the tissues allowing your body to expand as your baby grows and to allow the pelvic floor to stretch wide as you give birth. With the softening effect of the hormone relaxin and the pressure from your increasing weight, both tend to make it harder for the pelvic floor muscles to hold the pelvic organs in their correct positions In addition, the pelvic floor muscles and ligaments are also stretched at birth which can sometimes lengthen these tissues permanently. To keep the PFM as effective as possible, exercise is the key factor, as it is with all other muscles. This is possible, even during pregnancy. It is important to exercise the pelvic floor muscles to counter these weakening effects. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Symptoms of weak pelvic floor muscles Leakage of urine or faeces Having to get to the toilet quickly Difficulty controlling bowel motion or wind Not emptying bladder or bowel fully Dragging, heaviness or a bulge (prolapse) in the vagina Lack of sensation during sex Slide 6 Symptoms of weak pelvic floor muscles Weak pelvic floor muscles can have the following symptoms: Leaking urine or faeces when coughing, sneezing, laughing, lifting or exercising (called stress incontinence) Having to get to the toilet quickly or leakage on the way to the toilet (called urgency or urge incontinence) Difficulty controlling bowel movements and wind Feeling like you haven t fully emptied your bladder or bowel Dragging, heaviness or a bulge (prolapse) in the vagina Lack of sensation during sex Leakage is not normal during or after pregnancy! Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Importance of pelvic floor muscle exercises Women who exercise these muscles have less problems When done in pregnancy, it helps them to recover after the birth Training the muscles helps control incontinence Post natal exercises help the muscles recover Exercising correctly is important Get advice if unsure or problems exist Slide 7 Importance of pelvic floor muscle exercises Unfortunately there is no guarantee that none of this will happen during pregnancy or after the birth of your baby but recently conducted research has shown that those who exercise the muscles of the pelvic floor have fewer problems than those who do not. It has also been shown that it is important for the exercise to be performed correctly so if you have any doubts contact the Continence Foundation of Australia Helpline on 1800 33 00 66 and ask to be put in touch with a physiotherapist who specialises in pelvic floor management. Pelvic floor muscle training is important to control incontinence, which may start in pregnancy. Pelvic floor muscle exercises done during pregnancy will help the recovery of pelvic floor muscle function and bladder control after the birth of the child. New research shows that strong pelvic floor muscles will not make birthing more difficult, but may in fact shorten second stage of labour. Post natal pelvic floor muscle exercises have been shown to assist in the recovery of pelvic floor muscle function and to reduce or cure the likelihood of urinary incontinence in women who have had instrumental births or big babies. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
The effects of constipation During pregnancy constipation can occur from: the effect of the hormone relaxin pressure on intestines from baby growing Slide 8 The effects of constipation Constipation experienced during pregnancy from hormones and pressure on intestines from baby effect of hormone relaxin on smooth muscle of bowel, so it works less efficiently due to less room for the intestines as the uterus grows and there is more pressure on the bowel 10 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
What can help relieve constipation? F Fibre E Exercise W Water or fluid intake Toilet positioning No bowel straining Slide 9 What can help relieve constipation? Outline importance of FEW fibre, exercise and water or fluid Eat well Eat a healthy diet rich in dietary fibre to prevent constipation. We need at least 30gm of fibre each day. Eat at least 2 3 serves of fruit, 5 serves of vegetables and 5 serves of cereals and breads. It is important to get the balance right as just adding fibre to your diet without increasing your fluids can cause or make constipation worse. Please note that if the steps outlined in this section do not work in treating your constipation, see your doctor for advice. Drink well Drink 1.5 2 litres of fluid each day to prevent bladder irritation and constipation, unless otherwise advised by your doctor. Drinking extra fluids is recommended in hot weather or when exercising. Spread your drinks evenly throughout the day. Water is best. Limit caffeine, alcohol and fizzy drink to 2 3 drinks each day as they can cause bladder irritation. Always have an extra drink of water following these drinks. Exercise regularly Keep moving. Aim to exercise for 30 minutes most days and remember that walking is great exercise. Regular exercise helps with peristaltic movement (ie. the movement through the intestines). Advise of correct toilet positioning [demonstrate if possible] Use a footstool, legs apart, lean forward with hands/elbows on knees and relax abdominal muscles. This opens up the back passage for easier bowel actions and reduces strain on the pelvic floor muscles. Bowel straining can weaken pelvic floor muscles Use pelvis model to demonstrate the effect of straining to use the bowels on the pelvic floor muscles and advise that it is important not to strain during a bowel action. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 11
Haemorrhoids - what to do? Haemorrhoids are anal cushions full of veins that come down out of the anus What can help haemorrhoids? Minimise straining to use bowels Pelvic floor muscle exercises Discuss with doctor or midwife Post natal physiotherapy treatment using ultrasound Slide 10 Haemorrhoids what to do? Haemorrhoids are the result of anal cushions full of veins that come down out of the anus. They are also known as piles. They are usually noticed as lumps outside of your back passage (bottom), and they can cause quite a lot of pain or discomfort. Some people can have haemorrhoids however without feeling pain. Haemorrhoids may also be itchy at times. For more information refer to the fact sheet titled What are haemorrhoids? Aspects to highlight are: Minimise straining to use bowels i.e. no pushing or grunting. Doing pelvic floor exercises helps to prevent haemorrhoids or stop them from getting worse. www.thepregnancycentre.com Fact sheet What are haemorrhoids? This includes: Haemorrhoids are the result of anal cushions Try not to strain when using your bowel full of veins that come down out of the anus. They are also known as piles. They are usually Straining will continue to place pressure on them and may noticed as lumps outside of your back passage cause them to increase in size, rather than decrease or go (bottom), and they can cause quite a lot of away. Place your feet on a footstool when you use your pain or discomfort. Some people can have bowels, this will help to open up your back passage more haemorrhoids however without feeling pain. easily. Take your time when you use your bowel so that Haemorrhoids may also be itchy at times. you are less likely to strain. If these occur then speak to your doctor or midwife about them. Post natal treatment on the maternity ward includes ultrasound by a physiotherapist if it is available on your maternity ward. Ultrasound is not done on haemorrhoids during pregnancy. Sometimes women may experience haemorrhoids for the first time during pregnancy or after the birth. They can be caused by the hormonal changes of pregnancy that soften the walls of the veins and cause them to protrude so that you can feel them outside your bottom. The extra weight from the uterus on the bowel and pelvic veins may also contribute to the development of haemorrhoids. Constipation during or after pregnancy can increase the chance of haemorrhoids developing, so it is important that you gain further advice if you are constipated rather than allowing it to continue. The pushing stage of labour can also place strain on the pelvic floor and back passage area, and this may be when haemorrhoids first occur. Sometimes women may notice blood on the toilet paper after passing a bowel motion. If this occurs, or you notice haemorrhoids for the first time, check with your doctor or your midwife if you are in hospital. What can be done to help haemorrhoids? There are creams that can be used on the haemorrhoids that help to make them more comfortable. Creams with steroids in will help your haemorrhoid reduce in size, ask your pharmacist for advice. Doctors can treat haemorrhoids that do not go away by themselves. Usually during pregnancy and after childbirth, haemorrhoids may be temporary. This means that they will often reduce in size or go away completely with other treatment. Support your perineum area when you use your bowel Use a pad or toilet paper to hold your perineum area (at the front of your back passage and over your vagina). This will help to reduce the amount of downwards strain on the back passage area. Take something to make it easier to go to the toilet There are natural products that can be taken to help make it easier to go to the toilet after you have had your baby and during pregnancy. Your midwife, doctor or pharmacist can give you advice on what is safe for you to take. Consider your diet and fluid intake Make sure that you have an adequate amount of dietary fibre and drink plenty of fluid. This will assist your bowel motion to be soft and easier to pass. Ice While in hospital, midwives usually have ice pads or packs available that can be placed over the haemorrhoids. This will help reduce the swelling and discomfort that you are feeling, making you feel more comfortable. They can be easily made at home if you do continue to need them. Simply dampen a sanitary pad with a little bit of water, and place it in the freezer until you need it. These can only be used once, for hygiene reasons, as you are usually still bleeding at this stage. Pelvic floor exercises Pelvic floor exercises can sometimes be uncomfortable to do initially if you have haemorrhoids, so just gently concentrate on lifting the back passage up and then Reproduced with kind permission from The Pregnancy Centre For further information visit www.thepregnancycentre.com Contact the National Continence Helpline on 1800 33 00 66 or www.continence.org.au Continence Foundation of Australia The Pregnancy Centre 2008 page of 2 Related fact sheet: What are haemorrhoids? 12 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
What can help varicose veins? In the legs: Support stockings Supporting legs when resting Leg exercises For vulval varicosities try: Pelvic floor exercises Ice packs Lying down Firm pants and a bulky pad Slide 11 What can help varicose veins? Varicose veins can also occur in the legs and around the vulva. When in the legs, or there is leg swelling support stockings will help. So will resting when possible with legs supported, and knees supported. Foot and ankle exercises also help with venous return and these include foot and ankle movements up and down and in circles and calf pumping by moving the heels up and down when standing. When in the vulva, called vulval varicosities, they may be assisted by pelvic floor exercise/ice packs and lying down. Compression by firm pants and a bulky pad against the vulva may also assist with some relief. End of Part 1: What are pelvic floor muscles and why are they important? Any questions? Slide 12 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 13
Part 2: How to exercise your pelvic floor muscles Learning pelvic floor muscle exercises 50% of women will do the exercises wrong when learned from a pamphlet Incorrect technique can make a problem worse Correct technique is Step 1 in the training process It is not easy to know if the muscles are working correctly Slide 14 Learning pelvic floor muscle exercises Research shows that up to 50% of women trying to do pelvic floor muscle exercises from a pamphlet get the technique wrong. Correct technique is important when doing pelvic floor exercises; otherwise they won t help and could even make the problem worse. Note: Getting the technique correct is the first step in the training process, and needs to be emphasised while teaching the exercises in a class or individual client setting. Everyone seems to think that a person should intuitively know how to do pelvic floor muscle exercises, but they are quite complicated muscles which are hard to isolate. Because they are hidden from view, it is not easy to know if they are working correctly. New and specific instructions have been developed to enhance the teaching of pelvic floor exercises. 14 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
How to do pelvic floor exercises Sit tall and lean slightly forwards Focus on the pelvic floor muscles Relax the thigh, bottom and tummy muscles Breathe out and gently tighten around your front passage Breathe normally Identify the muscles and relax Breathe out and gently tighten around your back passage Breathe normally Identify the muscles and relax Slide 15 How to do pelvic floor exercises Have all the women and their partners act out the following instructions. Sit with a straight back, leaning slightly forwards so that you can focus on their pelvic floor muscles. Relax the thigh, bottom and tummy muscles. Breathe out, and tighten the muscles gently around your front passage as if trying to stop the flow of urine flow. Then breathe normally as you hold the pelvic floor muscles tight. Women should squeeze the vagina and lift it up inside the pelvis. Men should lift their testicles up and in. Identify the muscles that contract when you do this and then relax. Breathe out, and tighten the muscles of your back passage gently as if trying to stop passing wind Then breathe normally as you hold the pelvic floor muscles tight. Identify the muscles that contract when you do this and then relax. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 15
How to do pelvic floor exercises (continued) Draw up the front part of the vaginal wall Feel a lift in the muscles Feel the front and back passages working Focus more on the front part of the pelvic floor Slide 16 How to do pelvic floor exercises (continued) Now draw up the front part of the vaginal wall, feeling a lift in the muscles you should feel your back and front passages working. Focus more on the front part of the pelvic floor, like when holding on to a full bladder. You can check you are using the right muscles when you are doing a wee by stopping it but this is just a check and not the exercise. This should only be done once during a wee and you should easily be able to start again to finish the wee. Myth buster It is a common misconception that pelvic floor muscle exercises are done by stopping the flow of urine over the toilet. Stopping the flow of urine on the toilet is not an exercise, but a way of identifying the pelvic floor muscles, feeling the sensation of the contraction and noting how that particular part of the pelvic floor works to shut off the urethra (front passage). This is not an indication of whether the pelvic floor muscles are strong or weak. 16 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
How to check you are using the right muscles Correct technique is very important If you are doing your pelvic floor muscle exercises correctly you will: Feel a lift and squeeze inside your pelvis Feel a letting go when you relax your pelvic floor muscles Keep your chest, upper tummy and ribs relaxed Keep breathing normal and quiet: don t hold your breath (the pelvic floor muscles are below the belt holding the breath can have a negative effect, so keep breathing) Slide 17 How to check you are using the right muscles Correct technique is very important. If you are doing your pelvic floor muscle exercises correctly you will: feel a lift and squeeze inside your pelvis feel a letting go when you relax your pelvic floor muscles keep your chest, upper tummy and ribs relaxed keep breathing normal and quiet. Don t hold your breath as this does not help. The pelvic floor muscles are below the belt and not up high. Holding the breath sometimes can actually result in bearing down on the pelvic floor, so it is important that this does not occur. Important note There is no evidence to show that a strong pelvic floor in pregnancy will make birth harder. More women experience problems due to a weak pelvic floor than pelvic floor muscles which are too strong. It is important to practice relaxing the pelvic floor muscles and practice this when doing the exercises so that they can be voluntarily relaxed; eg. for examinations or the birth. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 17
Practicing in different positions Photos courtesy of The Pregnancy Centre Slide 18 Practising in different positions Practising while standing Have all the women and their partners act out the following instructions. Now let s stand up. Lean forwards on the wall or on your partner with your arms and to relax the muscles of your thighs, bottom and tummy Now feel a lift and squeeze inside your pelvis feel a letting go when you relax your pelvic floor muscles keep your chest, upper tummy and ribs relaxed Note: Encourage squeezing in and lifting up the pelvic floor muscles by sucking or drawing them up into the pelvis. Using different words can help encourage the correct feeling. A lift and squeeze should be felt inside the pelvis. No-one should notice that you are working your muscles on the inside, so stand in front of a mirror and check that you look relaxed on the outside! Your legs and buttocks should be relaxed It is OK to feel the lower abdominal muscles gently tightening during pelvic floor muscle exercises As you practice pelvic floor exercises it should get easier to do without having to concentrate so much Ask women to determine in which position the exercise felt easier to do and to choose that as the preferred position to do their exercises in. If they are able to do the exercise while standing (ie. gently lifting and holding their pelvic floor muscles and lower abdominal muscles in during standing activities), then encourage this position. Pelvic floor exercises can become harder to do later in pregnancy, but it is still important to continue to exercise them. It may be easier to do when lying down on your side or in a hands and knees position with the weight of the baby off the pelvic floor. Begin exercising early in your pregnancy, so that you really know them well later in the pregnancy when the baby is heavier. 18 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Other ways to identify your pelvic floor muscles Note these can be discussed with the class as additional ways to identify the pelvic floor muscles. Sensitivity to the class dynamics and the individual responses to the pelvic floor discussion needs to be used when including these. Other ways to check your pelvic floor, which may assist pregnant women to become more familiar with their pelvic floor muscles include: Women who are familiar with using tampons can imagine squeezing in the vagina as if squeezing a tampon up higher in the vagina. With your hand on your perineum (the area between your front and back passages), you can feel it move slightly inwards as you tighten your muscles. Using a mirror, watch your perineum as you tighten your pelvic floor muscles. You should see your perineum pull upwards away from the mirror. You should not see any bulging downwards. Sitting down, place your hands under your bottom, feeling on the inside of your sit bones (the two bony areas you sit on). A small amount of movement can be felt as you squeeze your pelvic floor muscles (again do not tighten your bottom). Lying on your side or while standing up, touch the end of your coccyx (tailbone), and feel it move slightly forwards as you tighten your muscles. Tighten around your partner during intercourse some degree of squeeze should be felt. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 19
Exercising your pelvic floor muscles Warm up with three quick flicks and let go When easy, hold the lift for longer (eg. 3 secs up to 10 seconds) Breathe normally Repeat it up to 10 times Maintain correct technique Three times a day Seek help if you cannot: Feel your muscles hold or relax Feel a definite lift and squeeze Feel the squeeze and breathe at the same time Seek help if you cannot stop the flow of urine Seek help if you aren t confident or are not making any progress Slide 19 Exercising your pelvic floor muscles Warm up your muscles with three quick flicks and let go Then once this is easy, hold the lift for longer (eg. 3 secs or anything up to 10 seconds), before relaxing Make sure you continue to breathe normally while you lift up If you feel comfortable doing this, repeat it up to 10 times Make sure you use the correct technique while breathing quietly, keeping everything above the belly button relaxed This can be done three times a day. This is a very general suggestion that should be tailored to individual needs if you think your pelvic floor is weak 20 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Where to get professional help National Continence Helpline freecall 1800 33 00 66 Information about local continence services, continence and women s health physiotherapist, or continence nurse advisor Staffed by continence nurse advisors who offer free information, advice and support and a range of resources Australian Physiotherapy Association Call (03) 9092 0888 to find your nearest continence and women s health or pelvic floor physiotherapist Also visit www.physiotherapy.asn.au and click on Find a Physio or look in the Yellow Pages Slide 20 Where to get professional help National Continence Helpline (freecall) 1800 33 00 66 The National Continence Helpline (freecall) 1800 33 00 66 can provide information about local continence services, and the name of your nearest continence and women s health physiotherapist, or continence nurse advisor. The Helpline is staffed by a team of continence nurse advisors who offer free information, advice and support and can provide you with a wide range of information resources. The Helpline can also provide you with general information and advice about issues relating to bladder and bowel health. Note: As a health professional presenting this talk, you may be able to provide your own business cards or the business cards or contact numbers of local continence and women s health or pelvic floor physiotherapists or continence nurse advisors. Australian Physiotherapy Association If you are unsure about local physiotherapy services contact the Australian Physiotherapy Association on (03) 9092 0888 to find your nearest continence and women s health or pelvic floor physiotherapist. You can also visit www.physiotherapy.asn.au and click on Find a Physio or look in the Yellow Pages. Contact these associations if you: cannot feel your muscles hold or relax cannot feel a definite lift and squeeze cannot squeeze and breathe at the same time cannot stop the flow of urine don t feel confident doing pelvic floor muscles by yourself don t feel that you are making any progress Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 21
Ways to remember to do the exercises Tighten when you laugh, cough, sneeze and lift (referred to as the KNACK or bracing) Find a routine: link with daily activities Use reminders sticky notes, dots, screen savers After the birth when feeding Record your progress: Write down your hold time and number of repetitions Repeat this at intervals to monitor your pelvic floor progress and any changes Exercise regularly throughout your pregnancy Slide 21 Ways to reminder yourself to exercise your pelvic floor muscles Tighten your pelvic floor muscles when you laugh, cough, sneeze and lift. This is often called bracing or the knack and should be done if urine leaks out during these activities. Find a routine. Tip ask participants for ideas of how to link with daily activities. For example, link in your pelvic floor muscle exercises with daily routines such as your shower, doing dishes, while at the computer, before brushing your teeth or whilst in bed at night. Use reminders to exercise such as sticky notes or red dots, screen savers or traffic lights (but make sure that your back is in a straight position if you are doing them while sitting on a chair or in the car). After the birth, you can do the exercises while you feed your baby. Encourage personal recording of pelvic floor muscle status Tip: You can time women within the antenatal class by counting out loud so that they can note their hold time. Repeat at least twice, so with the second repetition they can aim to hold for a second longer. Time pelvic floor holds and encourage to note or record how long they can hold their pelvic floor contraction for, and how many they can do in a row. This may change during pregnancy and having a baseline indication of hold time and number of repetitions during pregnancy can provide something to aim for in the post natal period. After the birth the muscles often feel weaker, which is normal/common. It is very important to get the muscles back to their normal function as soon as possible after the birth. The time taken for this can vary. 22 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Encourage women to perform pelvic floor exercises regularly during the rest of their pregnancy The exercises described here provide an introduction to pelvic floor muscle exercises. People with problems will benefit from an individually tailored and monitored pelvic floor muscle exercise training program. Encourage women to seek further advice and assistance if they are not sure if they are doing their exercises correctly or if they do have a problem that already exists. It is important to note that incontinence can have many causes and should be individually assessed before starting a pelvic floor muscle training program. Pelvic floor muscle exercises help One in three women have a bladder problem after having a baby Start early prevent small problems from becoming worse Age is no barrier to starting a pelvic floor muscle exercise program It is never too late to start For urinary frequency in pregnancy, tighten when you get an urge to go. This can sometimes help to delay an urge, but don t push through any discomfort Slide 22 Pelvic floor muscle exercises help Encourage women to seek help if unsure if doing pelvic floor correctly or if having any bladder or bowel control difficulties One in three women will have a bladder problem after having a baby Symptoms could include leakage of urine with a cough or sneeze or during sport A lot of women who come in for treatment for bladder problems when they are older, had a small problem after they had their children which became worse as they got older. This may have been prevented if they had done their pelvic floor muscle exercises and perhaps sought advice Age is no barrier to the benefits of pelvic floor muscle exercises. There is evidence to suggest that older people are just as likely to benefit from pelvic floor muscle exercises for incontinence as younger people. Urinary frequency Reduced space for the bladder means smaller bladder capacity Pelvic floor strengthening may assist sometimes. Tightening the pelvic floor when you get an urge to go can sometimes help to delay an urge, but don t push through any discomfort If you have a problem seek treatment early, otherwise the problem may worsen with any other pregnancies and age Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 23
End of Part 2: How to exercise you pelvic floor muscles Any questions? Slide 23 24 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Part 3: Your pelvic floor muscles after pregnancy Your pelvic floor muscles after pregnancy It takes time for the muscles to recover Hormonal effects last up to 6 months Start pelvic floor exercises soon after the birth Women with stitches can start the exercises early too Slide 25 Your pelvic floor muscles after pregnancy Also known as post natal restoration. Like your abdominal muscles it does take time for the pelvic floor muscles to get back to their usual state after the birth. The effects of the hormone relaxin on the body can last up to 6 months in some women after the birth. It is important to reduce the load on the muscles in the first few months to help them to recover by not lifting unless absolutely necessary, bracing before you lift, sneeze or cough. Pelvic floor exercises can be started soon after the birth, even if you have stitches as the exercises do not put strain on them. This will help the muscles to recover more quickly. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 25
Returning to sport Start with low impact exercise High impact exercise is not recommended for at least 3 4 months The Boat Theory Courtesy of The Pregnancy Centre Slide 26 Returning to sport Start with low impact exercise initially such as swimming (once bleeding ceases), walking or cycling when comfortable. Low impact exercise programs are recommended but check that they are suitable for post natal women. It is recommended that you do not return to high impact exercise for at least 3 4 months as the pelvic floor is not able to withstand the force (like a slack trampoline). Refer to the fact sheet Returning to sport and exercise and the birth. (Use the Boat Theory to explain the effects on the pelvic organ supporting ligaments with early return to higher impact exercise. Need diagram of boat theory) Imagine the following: The pelvic floor is the water level. The pelvic organs (bladder, uterus and bowel) are like the boat sitting on the water. The ropes holding the boat to the wharf or jetty are the ligaments, which help to support the pelvic organs. When the water level is normal, the boat just sits on the water and there is no tension on the ropes. When the water level goes down, ie the pelvic floor muscles are being stretched during pregnancy and the birth, there is tension on the ropes or the ligaments. If the water level stays low, ie the pelvic floor muscles stay slack and weak, over time the ropes/ligaments become stretched. By going back to running or high impact sport too soon, the ligaments are stressed by the exercise and lengthened even further and are more likely to stay stretched. This can contribute to the development of a prolapse, for which surgery may be needed to repair it. To lessen the need for surgery pelvic floor exercises are essential to restore the level of the water and tighten the ropes. Seeking advice early if you do think that you have a prolapse is important. See the fact sheet titled What is a prolapse? for more information. 26 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
www.thepregnancycentre.com www.thepregnancycentre.com Fact sheet Returning to sport or exercise after the birth Fact sheet What is a prolapse? Women may incorrectly believe their sport and other high impact exercise is taking care of their pelvic floor muscles. Participating in sport, running or other high impact activities during pregnancy and early after childbirth may actually reduce pelvic floor muscle strength and cause long-term bladder and bowel problems or pelvic organ prolapse. When all care and precautions are taken you can minimise the risk of these developing. How does returning to sport or exercise too soon after the birth affect my pelvic floor muscles? Have you heard of the Boat Theory? This is one way to help you think about the role of the pelvic floor muscles in supporting your pelvic organs. Imagine that your pelvic floor is the water level, while your pelvic organs (your uterus, bladder and bowel) are the boat sitting on top of the water. The boat is attached by ropes (your supportive ligaments) to the jetty. Now if the water level i.e.your pelvic floor muscles is normal, there is no tension on the ropes. After pregnancy and the birth of your baby, your pelvic floor muscles can be stretched, so the water level is lower. Imagine if the water level stayed low for years. If your pelvic floor muscles do not strengthen up again, by you doing your exercises, then there is much more tension on the ropes or your supportive ligaments. If this continues, then the ligaments can overstretch and weaken, and there is more risk of you developing a prolapse. This may occur soon after the birth, or in the years to come. Refer to the factsheet on About prolapse for more information. If your pelvic floor muscles strengthen back up again, then there will be no ongoing tension on the ligaments supporting your pelvic organs, and therefore less risk of developing a prolapse in the future. Imagine however what would happen if you added jumping, running or bouncing type of activities to a pelvic floor that was still stretched. This could further weaken your muscles and place extra tension on the supporting ligaments so they are more likely to become overstretched and weakened. This can result in your pelvic organs dropping down, as there is less support for them from above and below, and a prolapse occurring. So you may feel fine on the outside, but be unable to see what is occurring on the inside. This is why some women may not notice a prolapse occurring until they return again to exercise, unaware that there is the risk of this happening. This is what happened to Jondelle (not her real name). Read her story, and compare the difference with her experiences after her first and second babies. Jondelle s story (used with permission) After the birth of her first baby, Jondelle returned to A grade sport after only 5 weeks. Jondelle had no problems day to day with her pelvic floor muscles or bladder control. Although she always went to the toilet before a game, she experienced a small amount of urine leakage while playing, and felt damp in her underwear after a game so she needed to wear pads while she played. Then she developed a bulging down below, and found out that the front wall of her vagina, which supports the bladder, had dropped down. This is called a bladder prolapse. Jondelle went to see the physiotherapist when her baby was 8 months old, who advised her that because her pelvic floor muscles were still weak, she should consider stop playing sport to allow them to recover from the birth. In addition when Jondelle coughed, her pelvic floor dropped considerably, and the bladder prolapse increased. This indicates that any time any downwards pressure occurred on her pelvic floor muscles, then this could be happening. This may occur during a cough, sneeze, while lifting her baby or anything heavier than her baby, while pushing a full shopping trolley and certainly with any bouncing or running type of activities. Jondelle s pelvic floor exercise program included working the muscles together with a cough, to aim to reduce the amount of every day pressure on the pelvic floor muscles, otherwise the prolapse would just continue to worsen over case. Unfortunately there is not a lot you can do about A prolapse is the name used when an organ in this, apart from following the advice under What can I do your pelvis (your uterus, bladder or bowel) drop if I have a prolapse? as a precaution. Also, diligently doing down into the vagina instead of sitting in their your pelvic floor exercises may improve the ability of your normal position. This can cause a heaviness, pelvic floor to support your pelvic organs. dragging or aching type of feeling in the vaginal Pregnancy area, which often feels worse at the end of the day, and better in the morning or after lying Pregnancy weakens the pelvic floor muscles due to down. Some women also notice lower abdominal the weight of the growing baby, and due to the relaxin aching and backache due to having a prolapse. hormones, which soften the ligaments in the body together A bulge in the vaginal area may also be felt, and with the fascia in the pelvic floor. If the pelvic floor muscles sometimes this bulge may actually be felt outside are not strengthened during pregnancy, they are more likely of the vaginal opening. Another way many women to stretch and weaken, which may increase the chance of describe the feeling of having a prolapse is that a prolapse occurring. There is not much that we can do it feels like everything is going to fall out. to control the amount of relaxin hormone in our body, but we can strengthen our pelvic floor muscles so that they do provide the best support possible for our organs. Why do prolapses happen? Childbirth The pelvic organs are supported from above by supportive ligaments and from below by the pelvic floor muscles and After the birth of your baby, your pelvic floor muscles are fascia (fibrous tissue within the pelvic floor). If either or usually stretched, unless you had a caesarian without both of these structures weaken, there is less support for going through the pushing stage of labour. If your baby the pelvic organs and they can start to drop down. is quite big when he or she is born, or you were pushing for a long time (more than two hours), or you needed There are many reasons why this could occur. These include: help to have your baby (suction or forceps), it is likely that Having a weak pelvic floor. your muscles are more stretched. They often feel quite weak and when you stand up or walk around, it may feel Not doing your pelvic floor muscle exercises regularly like things are dropping down, or everything is going to can increase the chance of your pelvic floor muscles fall out. weakening during and after pregnancy. This means that they are less able to support your pelvic organs, and more If the muscles are not strengthened and toned up again after pressure is placed on the supportive ligaments. If these the birth, and remain stretched, then there is more chance of stretch, then it is more likely that the pelvic organs can a prolapse developing at some stage in the future. drop down and a prolapse can occur. A strong pelvic floor The effect of gravity on a weak pelvic floor soon provides more support for your pelvic organs, and hence after the birth may reduce the chance of a prolapse developing. A lot of walking or being on your feet in the first few days Body type or weeks after the birth can mean your muscles get Some women have softer connective tissue than others, tired more easily and stretch more. This can cause an which means the ligaments that support your pelvic uncomfortable dragging or heavy feeling down below in organs loosen more easily. This means they are more likely your vaginal area. Frequent rests lying down are important to stretch during pregnancy and childbirth or after, so there at this stage, and only walking for short periods at one may be a higher risk of developing a prolapse if this is the time can prevent or reduce this feeling until your muscles strengthen. Reproduced with kind permission from The Pregnancy Centre For further information visit www.thepregnancycentre.com Contact the National Continence Helpline on 1800 33 00 66 or www.continence.org.au Continence Foundation of Australia The Pregnancy Centre 2008 page of 3 Reproduced with kind permission from The Pregnancy Centre For further information visit www.thepregnancycentre.com Contact the National Continence Helpline on 1800 33 00 66 or www.continence.org.au Continence Foundation of Australia The Pregnancy Centre 2008 page of 4 Related fact sheets: Returning to sport after the birth and What is a prolapse? What is a prolapse? Pelvic floor muscles (firm tone) Pelvic floor muscles (slack tone) Slide 27 What is a prolapse? This diagram shows the difference between tight and slack pelvic floor muscles and how the bladder and the bowel have dropped down to cause a prolapse. A prolapse is the name used when an organ in your pelvis (your uterus, bladder or bowel) drop down into the vagina instead of sitting in their normal position. This can cause a heaviness, dragging or aching type of feeling in the vaginal area, which often feels worse at the end of the day, and better in the morning or after lying down. Some women also notice lower abdominal aching and backache due to having a prolapse. A bulge in the vaginal area may also be felt, and sometimes this bulge may actually be felt outside of the vaginal opening. For more information refer to the fact sheet What is a prolapse?. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 27
Post natal physiotherapy: how it can help After stitches: Ice pads or packs can help Ultrasound treatment 12 24 hours after the birth For scar tissue pain Pelvic floor exercises help recovery Support stitches during a bowel motion Haemorrhoids: Ultrasound treatment can help Pelvic floor recovery Early pelvic floor exercises Safe post natal abdominal exercises (not sit ups or curl ups) Importance of rest and lying down Slide 28 Post natal physiotherapy: how it can help Physiotherapy after pregnancy helps by providing: Treatment for stitches to reduce pain, swelling and discomfort around the stitches includes ultrasound after the first 12 24 hours and the use of ice pads or packs during the first 48 hours following the birth, and continuing until pain subsides. Sometimes the use of 2 ice pads, one underneath the other, at once can help the pads to stay colder for longer. Treatment for scars that hurt. Once the scar is healed, some people can have pain during intercourse due to the scar tissue not stretching as easily as the rest of the vaginal opening. Ultrasound treatment can help, so do not put up with this if you experience it. Treatment for pain in the post natal period, which can sometimes occur when the pelvic floor muscles tighten up protectively, causing intercourse to become difficult and uncomfortable. Sometimes when the pelvic floor muscles fail to relax properly, this can cause the bladder and bowel not to empty properly. Women may have had this occur prior to becoming pregnant and this should be identified during pregnancy if possible, to allow the woman to have pelvic floor physiotherapy treatment prior to delivery. Ultrasound treatment to help with haemorrhoids, and make them feel more comfortable. Assistance with pelvic floor recovery with an early start to pelvic floor muscle exercises. Women who know their pelvic floor muscles well before the birth usually find it much easier to do the exercises after the birth, particularly for women who have stitches. Pelvic floor muscle exercises are encouraged on day two preferably or day one if the woman feels up to it. It is beneficial to start doing pelvic floor exercises early after the birth even for women who have stitches or haemorrhoids. Because the exercises cause an upward movement of the perineum, they shouldn t damage the stitches. They may pull on the stitches, but it is actually good to do to get the muscles working again and to help them recover. Early pelvic floor exercises will help to improve circulation and promote healing of stitches. 28 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
After vaginal birth they often feel slacker and less effective than during pregnancy. It is common for the muscles to feel weaker for a short time, but it should get easier to feel the muscles contract each day. If not, further advice should be sought early on after the birth. Minimise the effect of gravity on the pelvic floor muscles by avoiding excessive walking around for the first few days after the birth. Lying down as much as possible is encouraged. Post natal physiotherapy: how it can help Toilet positioning: To minimise stretching of the pelvic floor, ligaments and nerves Support perineum and stitches during a bowel motion for at least six weeks Use a footstool and lean forwards Restore normal bowel urge Go when you need to go (don t delay) Slide 29 Post natal physiotherapy: how it can help (continued) Advice on toilet positioning to help restore normal bowel patterns To minimize stretching of the pelvic floor and the ligaments and nerves during a bowel action, support the stitches and perineum with a pad or toilet paper and gently press upwards. Support the perineum during a bowel action for at least six weeks after the birth. Lean forward with elbows to knees and lumbar spine straight. This is the optimum position for using bowels as it puts the bowel at the right angle and reduces stretching of the pelvic floor muscles. A footstool may further reduce the need to strain. Advice on normal bowel urge for normal bowel patterns Advise that the normal peristaltic action occurs either after waking up, or after a meal. If the urge to use the bowels is ignored or not heeded, the sensation may reduce or go away, and the faeces stays in the rectum where water is re-absorbed and may become harder to pass. This can commonly occur in the early post partum period, delaying (going to the toilet to use the bowels) because the baby requires attention or if a woman has a fear of bursting the stitches or if the stitches are painful. Adequate fibre and fluids help to keep the motions softer. Tip to remember for the mornings is: Mornings: hot drink > exercise/housework > breakfast > go Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 29
Post natal physiotherapy: abdominal bracing exercises No sit ups Checking of abdominal muscles Teach how to do exercises while sitting, standing, holding baby, and lifting Progressions of further ideas for safe postnatal abdominal muscle exercises Courtesy of The Pregnancy Centre Slide 30 Post natal physiotherapy: abdominal bracing exercises Assistance with post natal abdominal muscle bracing and information on progressing with post natal abdominal muscle exercises. Sit ups are not encouraged in the first few months after having a baby. The pressure downwards that occurs as a woman lifts her head can place downwards pressure on the pelvic floor muscles and can increase the risk of prolapse. Abdominal muscle bracing can be done easily while sitting, lying on the side or in standing in the early days after the birth. This will help to provide support to the spine and once learned women should be encouraged to brace their abdominal and pelvic floor muscles while lifting their baby. 30 Pelvic floor muscles: their importance during and after pregnancy Presenter s manual
Post natal physiotherapy Other treatment available for: Back pain Pelvic floor problems Wrist pain Mastitis and other breast conditions Other discomforts Seek treatment rather than put up with these problems Slide 31 Post natal physiotherapy Treatment for back pain, pelvic floor problems and any other discomforts such as wrist pain. Encourage to seek treatment rather that put up with these problems. Although problems can be common they are not normal during pregnancy and/or after having a baby, so it is important to seek treatment early if any problems are experienced. Pelvic floor muscles: their importance during and after pregnancy Presenter s manual 31