As a Women’s, Men’s and Pelvic Health Physiotherapist, Total Physiotherapy Manly Vale’s Louise Henderson shares her reflections on what women wish they had been told about their pelvic floor before having a baby.
“I wish somebody had told me …” or, “Nobody told me….” is a comment I hear at least once a week from women who have recently had a baby.
It can relate to all kinds of situations from how tired they’d feel, how hard it is to breastfeed, how amazing childbirth can be, how good are cuddles with a newborn. Most women come to see me at Total Physiotherapy about their pelvic floor and their comments are along the lines of “…nobody told me I could lose bladder control,” “…nobody told me I might develop a prolapse,” “…nobody told me I might struggle to control wind or faeces,” “…nobody told me sex might be painful,” “…nobody told me it might be months before I could run without feeling like everything is going to fall out.”
These comments worry me most when I hear them – not from a woman at her 6-week postnatal screening but three, five, 10 years or longer from childbirth when they include the additional statement “…nobody told me I could get help” or “I thought it was a normal part of having a baby.” This disturbs me as a physiotherapist because I know they can be helped and it’s so much better to provide that help early on.
I can’t really say why nobody told them – maybe it was assumed the facts would make women unnecessarily fearful, or that the women would prefer not to hear, or maybe the women didn’t know who to ask. My best advice is to be excited and curious about pregnancy and childbirth – there may be times that you need to ask the questions to get all the information. Seek general information from reliable sources and look to your ante-natal care provider, your midwife, your doula, your physiotherapist for guidance regarding your individual situation. Remember – knowledge is the power to help you be prepared and not alarmed.
With regard to your pelvic floor, here are some accurate information and advice to get you started:
- Keep up your general exercise. As the pregnancy progresses, you may find you need to move to lower impact forms of exercise such as swimming, yoga or pilates. If you are previously not an exerciser, don’t take up running marathons but at least timetable in some walks and maybe a pregnancy specific exercise class. Regular exercise is associated with better health outcomes for mother and baby.
- Do your pelvic floor exercises (Kegels) and learn how to do them properly by consulting a women’s health physiotherapist. These exercises will help reduce the frequency and severity symptoms of urinary incontinence (leakage) during and after pregnancy. A small percentage of women will have pelvic floor muscles that are “overactive” – in other words they have trouble letting go. Signs that you may have overactive pelvic floor muscles include pain/spasm with intercourse or difficulty/pain with using a tampon. It is particularly important to learn how to relax the pelvic floor in preparation for a vaginal birth.
- Seek physiotherapy treatment for any pelvic girdle (sacro-iliac or pubic symphysis) pain.
- Perineal massage is a technique that can be used in the later stages of pregnancy to help prepare for a vaginal birth.
- Attend prenatal education classes.
- Discuss a birth plan in detail with your care provider (midwife or doctor). This includes previous birth history and your risk factors for a tear or other complications.
- Ask what strategies you can use during pregnancy, labour and birth to reduce this risk.
- Discuss the care that might be offered to you during labour and birth. This includes what could be involved if you are offered: induction, epidural, episiotomy, instrumental delivery (forceps or vacuum), or a caesarean section, as well as pain relief and anaesthetics.
- Remember that childbirth can be unpredictable – it may be smoother than you expect or more challenging. Having an understanding of the potential challenges and solutions prior to labour will help your decision making and trust in the midwives and doctors in the “heat of the moment.”
Potential pelvic floor problems and solutions
It is important to remember that for all of the symptoms outlined below, you are much more likely NOT to experience them and if you do, help is out there.
Episiotomy and Perineal tears
The perineum is the area between the vaginal opening and the anus. This area (the skin and superficial muscles) stretch significantly during vaginal birth. The pelvic floor muscles can stretch up to three times their normal length during birth! Sometimes the perineum will not stretch sufficiently, and the doctor may suggest an episiotomy (small cut) or sometimes a tear might occur.
There is now a Clinical Care Standard in Australia to help reduce the incidence of tears. Some valuable information is summarised here – for more detail go to this website. https://www.safetyandquality.gov.au/standards/clinical-care-standards/third-and-fourth-degree-perineal-tears-clinical-care-standard/information-women-third-and-fourth-degree-perineal-tears-clinical-care-standard. Perineal tears are common; most are small and heal well either naturally or with stitches. Some perineal tears are more serious and require surgical repair (i.e. repaired in the operating theatre).
Tears are usually graded by ‘degrees’ from one to four according to how much of the area is affected. Third-degree tears are further divided into 3a, 3b or 3c. It is the more extensive 3rd degree and the 4th-degree tears that may lead to bladder or bowel symptoms either soon after birth or in the future.
What is the chance of sustaining a 3rd or 4th-degree tear?
These tears are slightly more common in first-time mothers who give birth vaginally, occurring in 5 in 100 women. For overall vaginal births, it is 3 in 100. Or you could say 95% of first-time mothers will not sustain a 3rd or 4th-degree tear.
Can you prevent a tear?
- Discuss with your care provider if you have any individual risk factors that might predispose you to a tear.
- Pelvic floor exercises (performed correctly) and perineal massage in the later stages may offer some protection.
- There are some strategies during labour that can also protect the perineum – see link above.
Recovering from a tear
- Short term – detailed advice regarding wound care and healing is included in this link https://www.safetyandquality.gov.au/sites/default/files/2021-04/recovering_from_3rd_4th_degree_perineal_tear_perineal_tears_ccs.pdf
- Medium term – follow up with your care provider and a pelvic floor physio who will help you with symptoms that may occur in some women following a 3rd or 4th degree tear. These include:
Pain – good management of pain and swelling and scar healing can reduce the likelihood of longer-term pain. One concern for women in the longer term following a tear can be pain with intercourse. Receiving good advice and treatment early on can reduce the risk.
Bladder and bowel control – the tear can have an impact on the ability of the pelvic floor and anal sphincter muscles to function properly leading to lack of control of urine, faeces, or wind. It is imperative to get these muscles working as best they can to prevent problems now and into the future – even if you have no current symptoms.
Emotional well-being – some women will describe a birth experience that involves a tear as being traumatic. It is helpful to debrief the birth with your care provider and seek professional support where needed.
- Long term – a tear may influence choices for future births. It is important to discuss this with an experienced doctor or midwife when planning subsequent births.
Instrumental delivery (Vacuum/Forceps)
There are circumstances where a vacuum or forceps may be needed to deliver your baby such as if your baby becomes distressed and needs to be born quickly. Both forceps and vacuum increase the risk of a third or fourth-degree tear. Aside from being associated with a third or fourth-degree tear, a forceps delivery increases the likelihood of developing a pelvic organ prolapse at some time in the future. Early assessment of your pelvic floor muscles, especially prior to returning to high impact work or exercise, means that you can strengthen the pelvic floor muscles in order to support the pelvic organs.
Leakage of urine will occur in up to 1 in 3 women who have ever had a baby (and not just those who have vaginal births). Leakage with downward pressure on the pelvic floor such as cough, sneeze, lift or laugh can commence in pregnancy – reported by up to 64 % of women. Happily, the incidence and amount of leakage reduce just by doing your pelvic floor exercises correctly. For some women, it improves after birth, for others, it is more problematic. Down the track, it may occur with running or jumping. Pelvic floor muscle exercises have great success in resolving these symptoms, especially when prescribed and supervised by a pelvic floor physiotherapist.
A more disconcerting situation is a very small number of women who develop neuropraxia during birth. This means there has been some pressure on the nerve that takes information to and from the bladder, brain and pelvic floor muscles. They may have no awareness that they need to empty, they stand up and have no control over the bladder. Fortunately, this usually improves quite quickly with natural recovery and some physio treatment.
This includes urgency, lack of control of wind or faeces. These are less common than urinary symptoms with 25-50% of women reporting loss of control of wind or bowel motions during pregnancy, dropping to 10-26% postpartum. Again, seek help early for pelvic floor assessment from your women’s health physio. Constipation can also be a problem following childbirth (vaginal or caesarean) – seek advice to manage it properly to avoid strain on the pelvic floor or the caesarean wound.
This describes the descent of the bladder, uterus or rectum and can be felt as a heaviness, lump, or bulge in the vaginal area. These symptoms are reported by approximately 12% of women in the first year postpartum. It can be very difficult to differentiate between a true prolapse and the expected stretchiness that occurs postpartum. The symptoms and degree of “stretchiness” resolve naturally and rapidly for some, take up to a year following the birth for others and may not return to pre-pregnancy levels for everyone. Should you be experiencing these symptoms, it is best to see your pelvic floor physiotherapist who can assess and monitor your symptoms, teach you correct pelvic floor exercises and advise on other strategies – particularly around return to exercise.
Pain with sex is reported in around 35% of women in the first year postpartum. Aside from some potential stretch on scar tissue and altered response of the pelvic floor muscles, there are hormonal changes due to breastfeeding, general tiredness and potential distraction of a crying baby that can all reduce arousal, desire and lubrication that can contribute to a painful experience. Use of a lubricant and choice of position can help. The most important advice is not to ignore the pain. Again, seek help from your pelvic floor physio who can advise on the correct management for you.
So now I read through all of the potential problems I can see why maybe nobody told pregnant women about them, as it can sound a little scary. If you do experience any of these symptoms, please do not put up with them. Seek help from an experienced women’s health physiotherapist.
Louise is part of the Women’s, Men’s and Pelvic Health team at Total Physiotherapy Manly Vale along with Rebecca Rutherford, Margo Joyner and Laura Wickens. The team is passionate about delivering high quality, evidence-based care to all women experiencing problems associated with their pelvic floor. Louise has completed her Masters in this area of physiotherapy; Rebecca is halfway along the journey to her Masters; Margo (who is also a parenting educator) and Laura (currently on maternity leave) also have extensive experience in leading pre and postnatal exercise classes.