Pelvic Floor Physical Therapy During Pregnancy

Today on the blog we have Dr. Gonzales, a postpartum coach and physical therapist specializing in the pelvic floor. In this post she tells us why a strong pelvic floor is so important and how you can strengthen yours through breathing & exercise pre & post birth.

So if you’re pregnant, postpartum, or even thinking about getting pregnant in the future, this post is for you.

Let’s get to it with Dr. Rose Gonzales.

Pelvic Floor Physical Therapy During Pregnancy

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The number one feeling I’ve heard that women have when I talk about pregnancy is FEAR. I guess I should back up a little. HI! I’m Rose, a physical therapist that specializes in treating pregnant and postpartum women.

I graduated from New York University in 2017 and have been passionate about caring for pregnant and postpartum women ever since my rotation in Women’s Health in graduate school. I’ve worked in nearly every setting (acute, sub acute, orthopedic, sports medicine and pelvic health) since graduation but continue to come back to what I am most passionate about: helping women navigate the weirdness of pregnancy with an emphasis on maintaining optimal physical function from pregnancy to postpartum.

That may sound like a lot of words to you but let me break it down. When a woman is pregnant she is going through 40+/- weeks of body changes, aches and pains. And, of course, preparing for the time baby makes their appearance. There isn’t a lot of prep work that goes into taking care of that person’s needs apart from OB visits.

After birth, when in the postpartum phase, a lot of women especially feel like they don’t have time to take care of their needs.

Over time, neglecting their injuries sustained during pregnancy and now into the postpartum phase, many women accept their new normal dysfunction which can lead to depression and feelings of insecurity. Rather than feeling gratitude and celebrating their body having gone through a major life milestone, they may feel as though they are mourning the body and even function they had prior to pregnancy. 

Now, you might be wondering HOW and WHY a physical therapist can help pregnant and postpartum women during this time. Well, if you are familiar with physical therapy you know that we specialize in treating the musculoskeletal system – usually in settings where some kind of trauma occurs. If you haven’t experienced pregnancy, let me be the first to tell you that IT IS HARD.

You may have heard people tell you how their pregnancy was great or maybe that they had a hard time. But from my personal experience and those of many women I treat, pregnancy is not a walk in the park, especially by the third trimester. In fact there are studies that prove how hard pregnancy is on the body. Duke University conducted a study to measure how much physical stress a body can tolerate over a period of time. They had their subjects run a full marathon 6 out of 7 days a week for up to 4 months – no, I don’t know why they did this but the study’s conclusion was amazing.

A pregnant woman endures 88% of the max capacity a body can tolerate physical stress over a prolonged period of time.

That is insane considering a woman usually carries a pregnancy up to 40 weeks. In fact, the body cannot tolerate pregnancy for longer than that. Which is why most physicians get nervous when the woman goes days or sometimes weeks beyond their due date. Pregnancy is demanding to multiple body systems. And the musculoskeletal system is a major one of concern by most women, whether they know it or not. Think about it. Most women I’ve talked to are not only afraid of the pain of labor but are afraid of:

♡ Diastasis recti (abdominal separation)

♡ Pelvic floor damage

♡ Excessive weight gain

♡ Delayed return to prior level of physical activity

♡ Ability to return to painfree and enjoyable sex 

I get it, I had those fears too because pregnancy is jam packed with unknown variables. 

♡ Am I going to get stretch marks?

♡ Am I gaining too much or too little weight?

♡ Will I be able to get through labor unscathed? 

♡ Will I be able to go back to the gym?

♡ What exercises can I do now/ what exercises SHOULD I do now?

♡ Will I damage my pelvic floor?

♡ Will I tear during labor? 

♡ Will I experience urinary incontinence?

♡ Will I get a prolapse?

♡ Will I ever lose my jelly belly?

♡ Will I need a c-section? 

Yup, I had all those questions too. 

Can we be honest with each other? 

Okay, I’ll go first: Physical therapy isn’t the only perspective you should have in regards to avoiding injury during pregnancy. But it should be one you consider because there is a time and a place physical therapy can significantly help you relieve your fears to some of the above questions and help prepare you for labor and postpartum.

What is pelvic floor physical therapy?

A physical therapist can offer:

♡ Guidance to exercises that you absolutely should include in your daily routine

♡ Specific exercise prescription for various pains you may sustain during pregnancy:

+ Pelvic girdle pain 

+ Low back pain

+ Neck/shoulder pain

+Shooting pain/ Numbness and tingling down arms and legs

+ Pelvic floor dysfunction (think urinary/fecal incontinence and frequency/urgency, pelvic heaviness, pain with sex)

♡ Pelvic floor birth prep to avoid tearing and prolapse

Now it’s your turn:

Injury during pregnancy and labor is inevitable. You want to avoid it and everyone has something to sell you to get you to avoid tearing, diastasis recti, pain, etc. But it isn’t as simple as all that. I know how hard pregnancy is to the body on a personal and evidence based level. According to the research, pregnancy is stressful on multiple different body systems. And what nature shows is that pregnancy is nature’s stress test to the human body. That’s also a great reason to see a physical therapist, who is trained and qualified to navigate medical complexities in a way that other exercise professionals are not equipped to do. 

So, to recap:

Pregnancy causes a strain to the musculoskeletal system and for this reason being knowledgeable about how to avoid common musculoskeletal issues during pregnancy should be a priority. Also, because pregnancy and labor are physically demanding, so much that it is akin to running a marathon 6 days a week over a span of 40 weeks, expecting to make it out unscathed is an unfair expectation on your body.

When I was working at a sports physical therapy clinic I would see SO many people who had injuries from high intensity fitness classes, cycling races, marathons, athletes in every sport at every level. What I am trying to say is that it is not fair to assume pregnancy and birth would be any less physically demanding than any of those activities. In fact, it is more demanding, requires training and your body deserves a better prep than what current advice is for the pregnant patient. 

When I was pregnant with my first, I remember feeling nervous and actually second guessing all the advice I gave my patients in regards to exercise – pregnancy is that weird. In fact, one of my unpopular opinions is that if you are going to give advice to pregnant and postpartum women, experiencing those things should be a prerequisite to giving them advice.

I didn’t know I would hold that opinion until I was experiencing it myself.

Pregnancy made me second guess my diet, my skincare, my exercise routine – everything. As I progressed through my pregnancy I emphasized educating myself on what physiological birth is as well as exercising my body to prepare for the birth and to prevent injury during labor. I remember the day following my labor going through a self assessment of where my body was at. And how I felt in regards to what it had just gone through.

I delivered at one of the top rated hospitals in Southern California and no one assessed my ability to get in and out of bed comfortably, how well I was able to engage my core and pelvic floor muscles to begin rehabbing my affected tissues, what signs or symptoms I should look for that would require medical intervention, irregularities to my vital signs that would indicate a need for medical attention, how to lift and hold my baby to prevent injury, not to mention any other tips and tricks that would have benefited any woman with rehab in the postpartum period. 

If we live in a society that respects and honors the physical and rehab needs of athletes and weekend warriors, why is the bar set so low for women who experience: 

♡ Pregnancy that last 40+/- weeks

♡ Labor that usually takes anywhere from 12-36 hours (without the necessary nutrition and sleep a person needs)  

♡ Having to take care of a newborn in various capacities and the stress that brings

♡ Living in scarcity of sleep, hydration, nutrition 

Cool, no biggie. Right?

I don’t mean to have a savior’s complex but if women were encouraged to participate in a pregnancy, birth and postpartum prep program that provided basic information on how to manage pregnancy related musculoskeletal issues maybe there wouldn’t be such terrible rates of pelvic floor dysfunction, that are increasing every year in the US by the way…. This is why I believe physical therapy needs to have a footprint in pregnancy and postpartum care,. Because I genuinely want women to have this information. I’ve seen what being uninformed and under prepared can do to a woman’s physical and mental health. And if a mother doesn’t have her health, how can she achieve her family dreams? 

Okay, so if you made it with me this far you have earned my tips with how you can specifically prepare your body, and pelvic floor, for labor and prevent dysfunction during pregnancy. Are you ready? (I’m making big hand gestures over here because it’s so important!)

Pelvic Floor Physical Therapy During Pregnancy

The first is breathing exercises.

I’m not talking about Lamaze breathing exercises, I’m talking about “whole body, feel it in your back” breathing exercises. You want to manipulate how you can channel your breath with positions and tune in to how your body feels as you breathe in. If you can accomplish those two principles, you will save your pelvic floor during labor – I promise.

The reason I am so confident is because your pelvic floor muscles neurologically sync with how your diaphragm moves – it’s how it controls your internal pressure! I’m not THAT mechanically minded but your diaphragm (the muscle of breathing) and your pelvic floor muscles work as a piston – and the best part is, you don’t even have to think about it! I’ll break it down:

♡ 360 degree breathing

If you are choosing to be in a semi reclined position focus on breathing in for a count of 5 seconds and sigh the air out as you exhale.

Next, answer these questions:

+ Do you feel resistance to your body letting air in as you inhale?

+ Can you consciously relax your abdominals, face, hands, shoulders more as you inhale?

+ Do you feel like the air is able to fill the corners of your ribs, spine, pelvic floor, butt, chest?

Try this exercise in a side bent stretch position and ask yourself those same questions. 

Try this exercise in a child pose position.

Try this exercise in a supported deep squat position.

Principle: As you inhale your lungs fill with oxygen that causes the body to feel increased pressure that should be felt to the spine, chest, belly and pelvic floor/butt. When you inhale the body reacts by accommodating to the increased pressure via relaxation and lengthening muscles. 

♡ Pelvic floor lengthening exercise 

Focus on your inhale. As you breathe in, channel your breath down. 

Imagine your pelvic floor moving like an elevator into the basement level as you inhale.

If this is hard to imagine, try to visualize the elevator as you sit on the toilet – your pelvic floor relaxes every time you urinate! 

Don’t worry about your exhale breath, nor about pelvic floor strengthening exercises (I’m talking about the Kegel, which is great, but not yet).

Principle:

As you inhale, the body is trying to find equilibrium and stabilize the internal pressure rather than experience too much pressure in its system. In order to do this the pelvic floor muscles must relax, the vertebrae in the back should move slightly – in fact, you may experience hearing a crack or two! If you are pregnant, you won’t experience too much accommodation at the belly because of the growing baby.

We want to tap into this natural reflex to facilitate pelvic floor relaxation and lengthening. Bring awareness to this act and know what it feels like so it can be replicated during labor. During labor, you want your pelvic floor muscles to get out of the way to accommodate the baby as it travels down the birth canal.

Contrary to popular belief, your pelvic floor does not push the baby out, in fact, it needs to let the baby out by being flexible. You want to practice this exercise in different positions to use your breath as a means of stretching areas that need to accommodate the air as you inhale.

♡ Pelvic floor strengthening exercise 

Now, focus on your exhale. No more sigh exhales, you will breathe out using pursed lips. As you breathe in imagine you are suppressing gas – you should feel an anal wink type movement occur. This is your posterior pelvic floor muscles working!

After inhaling with the intention of relaxing your pelvic floor, exhale again but this time imagine you are suppressing the flow of urine, this is your anterior pelvic floor muscles working! 

If you are a visual person, imagine your muscles picking up a blueberry from your underwear or slurping a milkshake. The movement should feel as though you are lifting and drawing in. Remember the elevator analogy, imagine that elevator moving from the first floor to the penthouse! 

Principle:

Just as inhaling facilitates pelvic floor relaxation so does exhaling facilitate a pelvic floor contraction. If you are having a hard time feeling this contraction, don’t feel bad – these muscles are subtle and aren’t really meant to do these types of exercises outside of a real life function. If you feel like you aren’t getting much movement as you try to contract, your pelvic floor may be in a resting state of contraction. In this situation, you want to focus on lengthening your pelvic floor on the inhale before trying to contract on the exhale. 

♡ The supported deep squat

This isn’t so much an exercise as it is building the endurance to hold this movement. You can use this position to practice labor by focusing on your inhale and emphasizing pelvic floor relaxation. If you are choosing this position to labor in then this is a great exercise. If you struggle with constipation, this is a great exercise for that too.

Principle:

As I already mentioned, you want your pelvic floor to get out of the way when it comes time for labor. You don’t push the baby out with your pelvic floor. In fact a pelvic floor that is too tight can cause the issues you want to prevent – think tearing and prolapse. In order to prevent injury like that from occurring, practice laboring in the position you think you’ll be in and try to relax the pelvic floor in that position. Of course we can’t stimulate a contraction but you can imagine how hard it would be to relax when you are experiencing a gut punch contraction.

In fact, a contraction is just that – it’s the uterus contracting involuntarily to push the baby out. When the time comes and this is happening to you, don’t fight the contraction. Remember to inhale the baby out and avoid contracting the pelvic floor. 

There is a lot more I want to say but I think this is a good place to sign off. If you are interested in hearing more tips you can find me at @drrosegonzales on Instagram.

I want you to be able to love the delirious time with your new life partner.

I don’t want you to spend a second worrying about your pelvic floor and question your ability to heal. Rather, I want you to have the information and support you need from the comfort of your home immediately postpartum. Not 6 or 8 weeks – or whenever it’s convenient for your medical team. This is your special time and you shouldn’t waste a second of it. 

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Hope you guys loved this post & now know some exercises that can help strengthen your pelvic floor. Be sure to follow Dr. Gonzales on IG for more tips.

x, The Skinny Confidential team.

+ stalk Lauryn’s pregnancy weight gain & loss.

++ check out these tips for an all natural birth. 

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