Pregnancy and the Pelvic Floor

Pregnancy changes your body in amazing ways, but some of those changes are less welcome than others. On today's episode, Melissa Nassaney, physical therapist and founder of Full Circle Pelvic Health in Warwick, Rhode Island, talks about how pregnancy can affect the pelvic floor and what you can do to address those changes when they happen - and sometimes, even before. 

For more information about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram, Twitter and Pinterest.

Music:
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

Say good-bye to leaks and pads and hello to confidence! Elitone® is the only FDA-cleared treatment for stress, mixed and urge incontinence. As an external, wearable treatment, it’s the easiest and most effective thing you can do to get back to a regaining control of bladder leaks.  Go to www.elitone.com and use code NAFC24 for $25 off. 

Transcript

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers, all available at NAFC.org. 

Welcome back to another episode of Life Without Leaks. I'm Bruce Kassover, your host, and joining us today is Steve Gregg, the Executive Director for the National Association for Continence. Welcome, Steve. 

Steve Gregg: Thank you, Bruce. It's great to be here. Really looking forward talking to one of our favorite people, Melissa, physical therapist and pelvic floor specialist. So, so exciting time. 

Bruce Kassover: Excellent. Well, thank you. Yes. Melissa Nassaney is the founder and owner of Full Circle Pelvic Health in Warwick, Rhode Island. And she's also one of the main contributors to the National Association for Continence's Pelvic Floor Health Center. Thank you for joining us today, Melissa.

Melissa Nassaney: Thanks, Bruce. It's great to be back. 

Bruce Kassover: Excellent. One of the things we want to talk with you about today was about pregnancy and how that can affect continence issues and not just the physical side of things, but also the emotional component that you often see from people who come to you for help.

Melissa Nassaney: Yes, this is one of my favorite topics to discuss.

Bruce Kassover: So, you know, a lot of, a lot of women and new mothers or expectant mothers don't even have an idea of what may be in store for them when it comes to how pregnancy affects their pelvic floor. What happens? What can they expect? And what are some of the complications that sometimes happen?

Melissa Nassaney: That's a really great question, Bruce. So when it comes to pregnancy, the mother's body does phenomenal amounts of changes. There is not one area of a woman's body that's not affected by pregnancy. So, when it comes to the pelvic floor specifically, your pelvic floor, because it's part of your core, you know, it's in your pelvis, it's almost in a bowl component of your pelvic area.

That bowl is housing the uterus and the growing fetus, so that weight, you know, the exciting weight that we see when the baby gets bigger and bigger and bigger, that weight though carries right on to that pelvic floor, and so that's a little bit of additional stress and strain on the muscles over time, but it's a gradual change over time, so it's nothing alarming, but it can cause some issues along the way. 

So women sometimes during pregnancy will notice that they might be leaking a little bit more when they're exercising. And also maybe that they have to go to the bathroom a little bit more often. And so, yes, it's partly because of the growing uterus in the baby, but it's also the stress and strain on the pelvic floor muscles as well to keep up with all of that.

Bruce Kassover: Now, I'd imagine that if you, you know, this is happening during pregnancy, you know, there's a timeframe on it. So you sit there and say, okay, I'm going to suffer through some issues that are unpleasant, but after nine months, I'm not going to have to worry about that anymore. Is that true?

Melissa Nassaney: Nope. That is, yeah, so I would say for the most part, a lot of women can, you know, their pelvic floor… again, we're thinking like, you know, somebody's not even, you know, sure that their pelvic floor has had any kind of impact during pregnancy. So they may not experience leakage, but the women who do experience leakage, sometimes it's a very temporary thing.

It could be happening, you know, just while they're breastfeeding and their hormones are still a little bit not back to baseline, or it can be, you know, they're returning to exercise, you know, they were given the go ahead at six weeks to go back to exercise, but their pelvic floor might not be ready. So that six week mark is basically saying that your things are in progress for healing. It's not the thumbs up that we tend to attribute to that six-week mark. We just think, okay, thumbs up. We can go and get back to life. But it really is the start of the healing phase for the pelvic floo.

Bruce Kassover: Okay. So if they find that they have issues that persist what sort of common issues do some women experience? And in fact, how common is it? I mean, is it, is this something that, you know, just a handful of women might encounter, or is this something that's happening more regularly that we might hear about?

Melissa Nassaney: It is very, very common. So this to say, statistics vary between like one and three and one and four women have some pelvic floor disorder. And then there's four major areas. You know, bowel issues, bladder issues sexual dysfunction or prolapse. So honestly, any one of those issues can happen postpartum. 

Bruce Kassover: And they can, I know you mentioned that some of them can be temporary, but some of them can persist for a while afterwards, if not treated.

Melissa Nassaney: Yeah, that's true. So, you know, there's still, unfortunately, that stigma that oh, leakage after pregnancy is normal. It's just, you know, part of, you know, part of the aftermath so to speak, but it's, it doesn't have to continue. So again, I think the more women understand that they have pelvic floor muscles and muscles need to be trained, just like any other muscle, like going back to the gym kind of thing, your pelvic floor really could benefit from going back to the gym for for the same reason, and then that can really, over time, nip the, the leakage issues in the bud. 

The downside is that a lot of times when women aren't addressing those issues, there's an emotional component that's involved with that because they get concerned. You know, they're a lot of times fearful to go to the gym. A lot of women will tell me, “you know, gosh, I only wear black leggings to the gym in case I have an accident,” or, “you know, I won't partake in this class, this particular class, because there's so much jumping and if I, if I don't empty my bladder three times during the class, I'm gonna leak,” you know, so they feel really limited in their ability to participate in those exercises. And, you know, even newer moms, you know, who have kids on a soccer field and, you know, they want to jump up and scream and “yay” or take their kid to the trampoline park, those are things that are definitely nail biting, so to speak. 

Bruce Kassover: I can imagine. So when somebody comes to you, well, first, I would imagine that for a lot of women, you know, 6 weeks, 9 weeks, you know, a few months after pregnancy, there's still going through a lot of physical and also hormonal changes that may magnify, I would imagine, some of the emotional impact that they're experiencing as well. 

Melissa Nassaney: Yes, absolutely.

Bruce Kassover: And when they come to you then, so do you find that it's not just a matter of managing the physical issues, but helping them sort of understand that, that there is light at the end of the tunnel? 

Melissa Nassaney: Yeah, absolutely. I usually try to explain to my patients, you know, whether they're at six months or three months or nine months, that it really does take a longer time than we really can appreciate for the body to heal. 

You know, when we think about somebody who has a sprained ankle, you know, we kind of rate them as, you know, a mild sprain, a moderate sprain, or a severe sprain, but we don't really have that same application to the female pelvic floor after they've had a baby, you know. So every birth experience vaginally can cause some trauma, you know, to the tissue. So we're not saying this is a grade one sprain or grade two sprain, but we need to be aware of how those pelvic floor muscles are functioning and supporting the pelvic, the pelvic organs before that mom returns back to her exercise and her, even, sexual activity. You know, is there any tearing that happened during birth that needs to be addressed? You know, is there pain or scar tissue developing with that that has to be addressed? Those are all parts of the healing. And, you know, we'd love to think that, you know, all the tissue heals within 2 to 4 weeks. But again, you know, if someone's breastfeeding or maybe even under a lot of stress or not getting a lot of sleep being a new mom, sometimes those healing, the healing process can be delayed. 

Bruce Kassover: The human body is unbelievable, isn't it? I mean, you would imagine when you see what actually happens with childbirth that things would ever go back to normal, because there's a lot going on.

Melissa Nassaney: There is definitely a lot going on.

Bruce Kassover: 

Steve Gregg: Melissa, I have a question. We're hearing a little bit more frequently conversations now about physical therapy with someone like you between child one and two and N, and does doing physical therapy or exercises that have been guided by you help between the first and second and the next child? Are there reasons that they should be seeing you early, either before they become pregnant or as soon as they become pregnant as a preventative exercise?

Melissa Nassaney: Yeah, Steven, that's a great question and I'm excited to answer that because this is one of my soapboxes I love to, when I'm, when I've done other podcasts, I love to talk about how you want to really understand your baseline, like what is your baseline pelvic floor muscles doing before you have that second baby?

Because a lot of times when a woman's had her first child, it's just, full steam ahead. So they're taking care of the baby. They're a new parent. They're trying to juggle work. And so a lot of times, you know, their own pelvic floor, their own body needs are not being met initially, you know, then sometimes, you know, the things start to settle down, they get in a rhythm.

And then, you know, a year or so later, they're thinking of baby number two, you know, but they don't know what the, their baseline pelvic floor function is from their first delivery. So it is really helpful for the mom to kind of get that information. And, and again, they would get that from a pelvic floor physical therapist.

And this way here, they can know whether, you know, what's their baseline strength. Can they even do the Kegel? Can they relax their pelvic floor? So a lot of times, you know, I'll see moms who may come to me for lower back pain and they're like, “I want to get this lower back pain taken care of before I have my second pregnancy. I had this come on during my first pregnancy. I didn't really take care of it. Now I'm pregnant again.” So. I will actually assess their pelvic floor through biofeedback. And a lot of times we notice that their pelvic floor is non-relaxing, so it's not completely letting go. You know, and my wonder in my brain is, you know, how long has this been going on? Was it since the first pregnancy and it's been all these years or you know, is it a result of the back pain or is the back pain a result of the pelvic floor tension? And so, that is so crucial to work on, relaxing those pelvic floor muscles before they give birth again. 

Steve Gregg: How soon after giving birth can someone start thinking about coming to see you to begin this, either preparing for number two or understanding my baseline or making sure that I've minimized any long-term leakage?

Melissa Nassaney: So if I, if I see them before they have their baby, usually they're given instructions on when to start some gentle pelvic floor contractions, but the pelvic floor contractions that I usually instruct them to do are more of a self-assessment so that they can get an idea of like, okay, what does it feel like today?

And then they can do gentle self assessments with Kegels for the next couple of weeks. When they go back to their physician, whether it's at a four or six week mark, I usually encourage the patient to ask their physician to examine their pelvic floor muscles. 

Steve Gregg: I think one of the things that we're starting to see are interest in prevention and so either their mother leaked, if they've had that conversation with their mother, or their friends have leaked and they have had those conversations, and quite possibly a conversation with a primary care doctor hasn't been as satisfactory from a lower severity. And so there's a great deal of interest in prevention. And so anything we can, at NAFC, we can do to encourage getting early to a physical therapist sounds like it would be a really smart thing and a really good thing. Both, “I'm thinking about getting pregnant,” or “I just had a baby,” or “I just had a baby and eventually I'm going to want to have another one.” Anything we can do from a prevention standpoint sounds like it would be worthwhile. 

Melissa Nassaney: Absolutely. So prevention is a really important aspect of pelvic health because we, again, want to know what our baseline function is so that we, if there is any deficits in the strength or endurance of those pelvic floor muscles or pain or previous history of prolapse, can we work on mitigating those to the, you know, whatever potential that that patient has at that time. Can we get those results as close as possible before they have another baby? So that would definitely be a course of physical therapy to address that and then afterwards, you know, for prevention. 

You know, just because somebody gives birth, whether it's vaginal or cesarean birth, your pelvic floor muscles are affected in both scenarios. And so having an assessment of your pelvic floor function and your core function for both of those birthing methods is really helpful for preventing further damage from happening going forward.

So again, if somebody is given the thumbs up that they can. Go back to exercising at six weeks but yet they're not able to have a contraction and their core muscles are significantly impacted from pregnancy, they are at higher risk for prolapse, especially if it's their second baby. We don't want to send them out on the track if we don't know if they can, if their pelvic floor muscles can actually support their organs.

So it's really important for prevention of further issues, pelvic floor disorders. So we want to make sure that that mom postpartum, whether it's a cesarean birth or a vaginal delivery, we want to make sure that mom can contract their pelvic floor, that they can coordinate it with their abdominal muscles and their lower back muscles, so that when they're doing their favorite exercise after, after having a baby, that they are, are allowed the most optimal support. 

Last thing we want to do is, is six months postpartum, be excited about getting back to exercising and then find out we have a bladder prolapse. We want to prevent that, and knowledge will help with that, and awareness and then talking about it and researching about it.

I'm understanding that these are things that we don't tend to hear about or talk about as much postpartum. And then when it happens, it's a, it's an awful surprise. And a lot of times women will say, “Well, I never heard that I could even prolapse.” A lot of times it is temporary though. I do want to stress that factor.

So prolapse after having a baby can be very temporary and a lot of it can be related to whatever stress or strain the pelvic floor muscles went through or whatever the connective tissue went through during the birth journey and the hormonal changes and breastfeeding. So a lot of times, you know, it is time that will continue to improve that person's healing throughout that phase.

So again, if they're feeling a little prolapse symptoms at four months, you know, that could be resolved by six months, but it's definitely not six weeks.

Steve Gregg: Could you take a minute and just talk a little bit about what prolapse is? There may be some people that don't know, and that's a very significant health related issue. So how would they know and who should they see if they suspect that prolapse is occurring?

Melissa Nassaney: Yeah. So prolapse is when we have a pelvic organ, one of the organs that lives in that pelvic bowl, tends to change their position and where they're, they normally are, so the bladder can move towards the opening of the vaginal canal. We can even have a rectal prolapse. We can have a uterine prolapse. Two organs that most commonly can prolapse after having a baby is the uterus and the bladder. The uterus is a little bit more of a more significant issue and that should be checked out immediately. Well, both should be checked out immediately, but the uterine prolapse needs to be definitely identified by the doctor. 

A bladder prolapse can happen right away, or it can, it can gradually happen over time, or it can be, gradually become apparent with, as the mom gets more physically active. 

So maybe in the first six weeks, she may not notice it. It might not be present on exam when she has her follow up with her gynecologist. But then as she's on her feet more, lifting that baby that's growing more, then she starts to notice, “Huh, I feel a little pressure in my vagina.” And that's usually how a prolapse presents itself. It's, it's pressure in the vagina. And sometimes it can even come with just lower abdominal pressure and even lower back pressure. 

In a more significant scenario, it can be where they're washing in the shower and they can feel a ball in the vagina opening. So again, it can be very alarming and in either situation, it's just important to go back to your gynecologist, have them assess your pelvic floor organs and see what's going on. And that's crucially important before anybody starts an exercise program. 

Bruce Kassover: So tell me what happens to if a woman doesn't pursue treatment?

Melissa Nassaney: So, yeah, that's a great question because, you know, again, a lot of times the mother is really busy kind of working through her everyday life and can put aside the urinary leakage.

But, and sometimes it doesn't resolve on its own. You know, that's the best case scenario, that it resolves on its own and it gets better and there's no issues. But when it does still hang around and now we're looking at six months postpartum, nine months postpartum, I, that's a really good time to, or sooner, but that's a really good time to say, “Hey, like, this might not be going away on its own,” you know, and again, initial physical therapy, it doesn't have to be a treatment where you know, twice a week for six weeks.

So it can vary on what you need at that time in your life. So it's good to kind of talk about those goals with your physical therapist. But if it's not adressed right away, you know, that could be leading to some decrease in strength long term of the pelvic floor muscles, you know, and then that can lead to fair support over time, you know, and if there's weight gain over the years, that also can put stress and strain on the pelvic floor if it's not treated initially for strength and endurance training.

But also there's other things like constipation, too, that can also strain the pelvic floor. So a lot of times what happens is I see a person who says, “You know, initially my leakage started just with laughing, coughing, sneezing and exercise. But now it seems like I'm leaking when I have, yhen I see the toilet or I leak when I put the key in the door.” So now there's additional issues other than the first one. And then sometimes they'll say, “You know, I have constipation and I noticed that the more I strain to have a bowel movement, the more I leak the rest of the day.”

So again, all of those are indications that there's some kind of a pelvic floor issue going on. And again, it doesn't always mean that strengthening is the key. So that's why it's really important to kind of get that pelvic floor assessed and really understand, like, what's behind the issues that they're, the patient is experiencing.

Bruce Kassover: So if that's the case, do you recommend that they just call up a physical therapist directly, go to their primary care physician, what's the best route for, for, for somebody who's getting concerned?

Melissa Nassaney: Yeah, I always encourage patients to talk to their primary care physician. But if they feel more apt to just, you know, take it on themselves, which is really important, I think women should be advocating for themselves for their pelvic floor health, absolutely, you know, seek a physical therapist. I do want to mention that occupational therapists also treat pelvic floor disorders as well. So they can see a pelvic health therapist in their area. You know, maybe talk to her friend because believe it or not, you know, more than 50% of women after having a baby have some issues with pelvic floor, so it's a good chance if you have five friends that half of those friends probably have a pelvic floor issue and we're probably already seeing a pelvic floor therapist. 

Bruce Kassover: It’s great to hear you say it because you know, the more that we can get people to feel comfortable talking about these things, the more people will actually seek the help that can really change their lives. So I appreciate that. And I think we appreciate you joining us today. So thank you again, Melissa. We really value your contribution and also everything you've done with the National Association for Continence's Pelvic Floor Health Center as well. Your contributions have really been important there. So thank you for your time and your insight.

Melissa Nassaney: Thanks Bruce. Thank you, Steve. It was a pleasure to be here with you today. 

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin MacLeod.

More information about NAFC is available online at NAFC.org.