Guest post by: Amadea S. Kezar M.Sc.
PT – Pelvic Health Physiotherapist
The pelvic floor. We know it’s there but it often isn’t until something goes wrong with it that it becomes a presence in our daily life…and unfortunately this becomes a reality for about a third to half of women postpartum. The pelvic floor can take quite a beating during pregnancy and postpartum!
Take heart though, this is not the end of the story. There is a lot a woman can do to rehabilitate the pelvic floor, you just need to know where to start. For this post we are going to touch on two lesser discussed topics, perineal tears and pelvic organ prolapse but we should really start at the beginning.
Pelvic Floor Anatomy and function
The pelvic floor is about 1 inch thick and is made of up of three layers of muscle (14 to be exact), fascial connective tissue, and nerves. This hammock of tissue extends from the pubic bone in front to the coccyx at the rear, and laterally to the inner walls of the pelvic basin. The floor has openings through which the urethra, vagina and rectum pass. Functionally we should be able to voluntarily contract and relax the pelvic floor (think holding back gas and letting go to urinate) AND it should reflexively contract about a quarter of a second prior to effort. Effort is any exertion (cough, sneeze, lifting, sit to stand…running) that increases abdominal pressure. Abdominal pressure pushes down and out which means it has the potential to push what’s in (fluids and organs) out if it is not adequately supported by a pelvic floor contraction. “Achooo!…uh oh”. Beyond maintaining our urinary and anal continence and pelvic organ support, the pelvic floor also plays a role in sexual pleasure through sensation and
The postpartum problems – What a royal pain in the … perineum
We see most perineal tears during the first delivery. Other risk factors include high birthweight, forceps delivery, long second stage of labour and well, genetics. There are four progressive stages of perineal tearing.
- GI – involves the skin of the perineum
- GII – Skin and perineal muscles (superficial pelvic floor)
- GIII – Skin, perineal muscles and partial anal sphincter
- GIV – Skin, perineal muscles, full thickness anal sphincter
After a tear the muscles may not contract as well because of protective inhibition, lack of elasticity due to scar tissue, or nerve damage. Depending on the level of inhibition and muscles involved incontinence difficulty controlling flatulence may be a problem. Scar tissue can also be quite uncomfortable because it is dense and not very flexible which can lead to perineal irritation during sitting, walking, bowel movements or intercourse.
Pelvic Organ Prolpase
About 50% of parous women have some degree of prolapse. Interestingly this problem can be independent of pelvic floor muscle dysfunction and I see women with beautiful pelvic floor contractions that still have organ descent. The reason is that the ligaments and connective tissue (neither very elastic) stretch during the weight of pregnancy and during delivery. Once stretched they can’t adequately support the weight of the pelvic organs and so they descend.
The most common forms of prolapse are the bladder (cystocele), the wall between the rectum and the vagina (rectocele) and the uterus. Women often note a vaginal or rectal heaviness or feel a lump at vaginal entrance when washing which alerts them. Other symptoms of prolapse may include urine leakage, difficulty urinating, constipation like symptoms. With a bladder or uttering prolapse women may feel as though they want or need to push the bulge back in and up (it’s okay to do that by the way…they move quite easily) or in the case of a rectocele they need to support the back wall of the vagina in order to fully evacuate (also just fine to do). If the pelvic floor is weak we certainly want to strengthen it to offer support and to share the load with the already over worked, overstretched connective tissue. This usually can relieve the feeling of heaviness and improve the urine leakage.
So what’s the fix? Have your symptoms evaluated by your physician and simultaneously your nearest pelvic health physiotherapist. These are very different exams, one is medical the other is functional and for best outcome you need both! In the meantime you can start with this:
Get a squatty potty! Go get yourself a step stool and keep it in front of the toilet. When you have to have a bowel movement place your feet on it so that your knees are higher than your hips. This will reduce strain to the perineum and the pelvic organs…it’s just good potty posture.
Begin waking up your pelvic floor with gentle contractions (Kegels) as early postpartum as possible. Gently tighten and draw the anus in and up like you’re holding in gas. Hold the tension for a few seconds and then fully relax the anus feeling for it to lower. The key is to regain muscle control, not just brute strength and to begin mobilizing the tight tissue from the tear.
FOR THE TEAR:
- A warm wash cloth compress can be soothing for 10minutes at a time. (read Jenny’s post on the subject here)
- Once a physician has said the tear is healed then you can begin stretching. Insert your clean thumb into the vagina, gently contract and relax the pelvic floor feeling for the rise and drop of the muscles under your thumb. When the pelvic floor is relaxed gently press the thumb down toward the anus (it would be the 6 o’clock position if the vaginal entrance were a clock) and hold for 15-30 seconds. Repeat the same manoeuver to either side of the original position at 4 and 8 o’clock. I would suggest using a little lubricant or coconut oil on your thumb for this (if you don’t have nut allergies). Do 5 sets daily.
FOR THE PROLAPSE:
- Avoid constipation, high impact activity (jumping), abdominal crunching, and holding your breath during exertion (termed a Valsalva).
- Get “The knack” of your pelvic floor. The knack is a pelvic floor contraction before effort or exertion to protect the organs from excess pressure. The most common exertion in postpartum is picking up baby so remember to pull in and up before lifting. Other common ones include standing up from a chair, getting out of bed and I’m sure you can think of others.
Now keep in mind this is just the tip of the iceberg! If you are experiencing any of the symptoms mentioned, or even better, want to ensure the pelvic floor is in good standing BEFORE any of this becomes a problem, then please consult your pelvic health physio… their job is to get you back to function!