Prepare

Pelvic Floor Resilience: Building Strength for a Healthy Pregnancy and Beyond: Part 1

• Season 2 • Episode 20

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" We encourage women to do the exercises during pregnancy because when you contract a muscle and relax it, it becomes more under your control, so you actually have a better ability to contract and relax when you need it to relax. It also improves the blood supply to the muscles, so they're healthier muscles."

In this episode, Dr Rangi is joined by pelvic floor physiotherapist and researcher Professor Helena Frawley to explore the pelvic floor, why it matters, and how to keep it healthy before, during, and after pregnancy.

This is the first of a two-part series. In this episode Rangi and Helena discuss:

  • What the pelvic floor is and the important role it plays. 
  • What can happen when the pelvic floor muscles become weakened, including incontinence and pelvic organ prolapse. 
  • Practical ways to strengthen the pelvic floor, including Helena's evidence-based "2 and 8 is great" exercise program. 
  • The perineum, how perineal massage may help reduce the risk of birth-related injury, and practical tips for getting started. 
  • The impact of caesarean birth on pelvic floor health. 
  • Risk factors that may mean some people need to take a more proactive approach to pelvic floor care. 

As mentioned in the podcast - here are some resources recommended by Prof Frawley:

Join us next week for Part 2, where Rangi and Helena continue the conversation, focusing on recovery after birth, pelvic floor health in the postpartum period, and long-term wellbeing.

SPEAKER_01

Welcome to Prepare, the Mimisi Prinatal podcast dedicated to helping parents prepare for the journey of pregnancy, childbirth, and early parenthood. Mimesi Prenatal would like to begin by acknowledging the Rawundri Wui Warung people, traditional custodians of the land on which we gather today, and also the traditional custodians of the lands in which you're listening from today. We'd like to pay our respects to the elders past, present, and emerging, and we extend that respect to Aboriginal and Torres Strait Islander peoples listening today.

SPEAKER_05

Welcome back to another episode of Prepare. I'm Dr. Rangi DeSilva, your host. I'm an obstetrician and gynecologist, and we're so excited to be joined today by Professor Helena Frawley, who is one of our amazing colleagues who is a physio by trade, but the majority of her time is spent in academia, and she's a senior researcher in physiotherapy and an expert on the topic we're going to be discussing today, which is the pelvic floor. So thank you, Helena, and welcome again.

SPEAKER_04

Thank you, Rangi, for inviting me. And it's a pleasure to be back and discuss this topic with you that I know we're both very interested in.

SPEAKER_05

Yes, definitely. Really important for everyone, every woman, really. But today we're going to be talking about this in terms of pre-pregnancy, pregnancy, labour, and postpartum. And because there's so much to discuss, we're actually going to be dividing this up into a part one and part two. So part one will be focusing mainly on what is a pelvic floor, things before delivery in pregnancy, and also during labor. And in our part two episode, we'll focus more on what happens after birth and postpartum and thinking about the pelvic floor in the future. Sounds great. So let's start and ask what exactly is the pelvic floor?

SPEAKER_04

The pelvic floor is a region in the body. Although some people use that term interchangeably with pelvic floor muscles, but technically the pelvic floor is the muscle plus other parts of the body. So really the pelvic floor is a region inside the pelvis and it contains many different things. So inside our pelvic floor region, we have our bladder, the vagina, the bowel, as well as the pelvic floor muscles and all of the ligaments, nerves, and blood vessels that connect these structures together and help us function. So pelvic floor muscles are a part of the pelvic floor.

SPEAKER_00

Mm-hmm.

SPEAKER_05

Okay, so that's really important to note that all of those things are really closely related and sometimes interrelated in terms of how we're feeling.

SPEAKER_04

And in fact, the pelvic floor muscle is a very unique muscle in the body because it's designed to integrate with the pelvic floor function. So the muscles have a role in bladder and bowel control and uh sexual function. So they're they're very closely connected and integrated. So that's a good thing, but it it also may lead to problems that can arise.

SPEAKER_05

Yeah, it's a good thing, but it's also quite complex, isn't it? It is a very complex part of the body. Yeah. And in terms of someone perhaps identifying exactly how to know which parts of their pelvic floor they can control or make a difference with, how would you recommend someone do that for their own body? It's so difficult to be aware of, isn't it?

SPEAKER_04

It is because unlike most other muscles in the body, we can't visualize the pelvic floor muscles. They're internal. So we can identify to a small degree whether the pelvic floor muscles are working by looking at the pelvic floor from the outside. But all we're really seeing is the perineal area around the vaginal opening and the vulner area. And when the muscles contract, you can see a drawing in of that region. In some women it's quite obvious, in some women it's not. Or if the muscles are weak, you may not see much movement at all. But to really examine the pelvic floor muscles, the only way to do it in a clinical environment is through a vaginal examination where we can feel the muscles working. But that's an internal examination may not always be required, and sometimes ultrasound imaging can give us a very good idea of whether the muscles are working. But for a woman, she can practice contracting and relaxing the pelvic floor muscles and hopefully feel a sensation of tightening and letting go. And that's a pretty good indication that the muscles are working if you can feel that sensation on yourself. You can also examine yourself. So with a finger inside the vagina, you can feel if the muscles are tightening around your finger and then letting go.

SPEAKER_05

Okay, well that's really useful. We've sort of alluded to the fact that they're important in lots of different aspects of our functioning. But why exactly is it so important, the pelvic floor, and why do we care about it so much?

SPEAKER_04

Yeah, so if any of the structures in the pelvic floor are not working optimally, we can experience symptoms or problems. If the pelvic floor muscles are not working well, we can experience reduced control of bladder and bowel. So one of their key roles is to keep us continent, which means keeping urine in when we don't want it to leak out and keeping contents of the bowel in when we need them to. And the opposite role of releasing and letting go when we need to empty the bladder or empty the bowel or have an examination or give birth, the muscles need to release and stretch in order for the baby to be born. So the muscles have a really important role in controlling our bladder and bowel function and supporting those organs inside the pelvis. And if they're not working well, that can give rise to problems, which is often what we see in clinic.

SPEAKER_05

Yeah. And I suppose there's lots of different stages where we might come across those problems with the pelvic floor, aren't there?

SPEAKER_04

That's right. Not just related to pregnancy and postnatal period. And in pregnancy, how does that pelvic floor change? The pelvic floor muscles change quite a bit during pregnancy and with the effect of childbirth. So the changes occur largely due to the influence of hormones. So when we're pregnant and our hormonal levels are changing to remodel the structures in the pelvis and prepare for childbirth, that remodelling means the muscles are going to have an increased ability to stretch under load. So during birth, the load and the stretch requires the muscle to release and let go. So there's less resistance to stretching, more relaxation in the pelvic floor muscles, which is what we need for birth. So the muscles actually undergo an enormous amount of stretch during a vaginal birth, up to two and a half times their normal length to allow for birth. So that stretching process may give rise to reduced support and control postnatally. But not everybody, not every woman who gives birth has any problem with her pelvic floor afterwards. So it doesn't happen universally. And there are many factors that will affect whether a woman will feel any symptoms or problems after birth with her pelvic floor. So there's quite a demand or a load on the pelvic floor during pregnancy, as we call it, the mother load with all those changes that occur and the weight of the uterus, the baby, and there's weight gain during pregnancy, increased circulating fluid. So all of those factors increase the load on the pelvic floor.

SPEAKER_05

And I suppose we'll go back to birth specifically. It's fascinating how the pelvic floor is so dynamic and changes significantly in birth and postpartum. But in in the pregnancy with the load and the hormones, what are some of the symptoms that people might feel as a result of that load and change in the pelvic floor in pregnancy?

SPEAKER_04

Yes. Often a feeling of heaviness, and that's understandable from what we've just discussed, the the load will give that feeling of heaviness. Loss of control of urine is actually very common during pregnancy. So we call that incontinence. If it's from the bladder, it's urinary incontinence. If it's from the bowel, which is far less common, it's fecal incontinence. So if there is so much load and pressure that it overcomes the ability of the pelvic floor muscles to close and tighten and support, there can be some leakage of urine. So that's a very common symptom during pregnancy. It increases during pregnancy. So by the third trimester, over half of pregnant women will have experienced some leakage of urine during their pregnancy. And this drops to about a third by eight weeks postpartum. Okay. So for many women it improves and recovers, but for some it doesn't. And so it becomes a postnatal problem that we need to address. So that sensation of heaviness, the leakage of urine when you cough or sneeze or exert yourself, or when you feel that sensation of urgency with a full bladder, they're common symptoms that mean the pelvic floor is underload and not always getting it 100% right during pregnancy.

SPEAKER_05

Yeah, which is understandable because it's such big changes over a relatively short period of time that your body's going through. Yes. Is there anything that people can do before pregnancy or even during pregnancy to try and support that pelvic floor and reduce those symptoms?

SPEAKER_04

That's a good question. We actually have good evidence, so there's a lot of confidence that we can have in doing pelvic floor muscle exercise training during pregnancy as a prevention for developing incontinence postnatally.

SPEAKER_03

Okay.

SPEAKER_04

So if you start your pregnancy and you've not experienced incontinence before, if you do pelvic floor muscle training during the pregnancy, you can have a good chance of not having any problems postnatally. So that's a good preventative strategy we can do during pregnancy. Before pregnancy, we don't have as much evidence of whether if you start pelvic floor muscle training before your first pregnancy, can that prevent incontinence during pregnancy or postnatally? But it's it's a good idea. It's a logical thing. It's a logical thing to do, and exercise is always good. So in fact, there are some women who do experience incontinence before their first pregnancy, and that is in fact one of the strongest risk factors to having incontinence postnatally. So it's actually not the incontinence during the pregnancy that predicts how you'll be postnatally. It's if you have pre-pregnancy incontinence. And that occurs in about 12% of women that from childhood or during their teenage years they have experienced some leakage of urine when they didn't want to. So having that is a risk factor. In fact, recent research tells us that it could be higher in some risk groups, ironically, athletes. So people who play high impact sport or do a lot of impact exercise, they have much higher rates of incontinence. Really? So it may be that if you've done a lot of high impact, you may have had incontinence before your first pregnancy. Now, we don't know what the long-term effect of that is. If you stop that high impact exercise, your incontinence will go away. So again, it's it's a good idea to do the exercises to prevent or treat any incontinence that you do have.

SPEAKER_05

Okay. That's really interesting. I would have thought that high impact exercise would help to strengthen the pelvic floor.

SPEAKER_04

You would think so intuitively, but no, it doesn't. In fact, the groups with the highest rates of incontinence are the high impact sports women.

SPEAKER_01

Wow.

SPEAKER_04

So we've done some research on that over the last few years. And depending on the sport, the higher the impact, the more the leakage. For example, in gymnasts and trampolinists, up to 80% of young fit women. So they don't have any of the risk factors that we would associate with incontinence. They're quite fit and strong in other muscles.

SPEAKER_02

Yeah.

SPEAKER_04

But it seems to be the load and the impact overwhelms these tiny poor pelvic floor muscles, which are very small and they're having to work very hard under load. Obviously, the less the impact of the sport, the less the risk of leakage.

SPEAKER_05

Yep. And so for those people, would you recommend that they start those pelvic floor exercises as well?

SPEAKER_04

Pre-pregnancy, indeed. Often, though, we don't have an opportunity to talk to women about that because we don't have a contact point with them before their very first pregnancy.

SPEAKER_05

Yes.

SPEAKER_04

So that's where community awareness is so important. And that they hear about these muscles and these exercises from family and friends and reading good quality information.

SPEAKER_05

And their community health practitioners like GP or sexual health nurses.

SPEAKER_04

That's right. And it's important that they receive their information from a reliable source. For example, there are some myths that people have heard, things like if you do too many pelvic floor exercises, you'll make birth too difficult because your pelvic floor muscles will be too tight. Yes, and they won't relax.

SPEAKER_05

I did want to ask you about specifically actually. So that's a myth that it's being debunked.

SPEAKER_04

Correct. In fact, there's good evidence from lots of controlled trials, so good quality studies that show doing pelvic floor muscle training during pregnancy does not make birth more difficult. Great. So we can put that with to rest and encourage women to do the exercises during pregnancy. Because when you contract a muscle and relax it, it's becoming more under your control.

SPEAKER_01

Oh, great.

SPEAKER_04

So you actually have a better ability to contract and relax when you need to relax. And it improves the blood supply to the muscle, so it's a healthier muscle.

SPEAKER_05

Okay. That makes sense. So in improving your blood supply, it's more under your control.

SPEAKER_04

You've got more connection to your pelvic floor muscle, so perhaps during labour when you're being encouraged to relax your pelvic floor, you'll have a better ability to identify where that muscle is and what it means and how to do it.

SPEAKER_05

Yeah, because those muscles are so difficult to identify on the corner. Correct. So because they're so difficult to identify, how would you recommend someone who perhaps doesn't really feel confident about where those muscles are or how to contract them to start those exercises?

SPEAKER_04

It's a good idea if you can discuss with a healthcare professional who, like your GP or a pelvic floor physiotherapist or gynecologist, to get a good instruction. But there are some good information online. It can be difficult to find reliable sources of information online. But generally, if you think about what the muscles do and where they are, so if we just go through one now perhaps together. Yes, what I do when I'm teaching somebody how to identify their pelvic floor muscles and they've never done it before. I show them a picture, an image of the muscle, and show where those muscles are around the front passage, which is the urethra from the bladder, around the vagina, and around the back passage. So if those muscles are going to contract, they're going to squeeze those three openings together. So we start with squeeze and tighten around your front, middle, and back passages and lift up inside. And now let go. So if you do that, you should have a sensation of squeezing and lifting around the front, middle, and back, pulling up inside, and then when you let go, you should feel that release. If you're feeling a lot of other muscles like your tummy and your buttocks and your legs, you're not isolating it as well as we need to because they're big dominant muscles, and they're going to jump in and help if your pelvic floor muscles are not very strong. So it's really important to focus on that sensation around the front, middle, and back passages, tightening and letting go. So that's just the way I teach women to first identify their pelvic floor muscles. So that contraction and relaxation gives you a sensation. And then we build up the exercises so that we're working on improving the muscle function. So you might start with holding for a few seconds, relaxing for a few seconds, and doing a couple of repetitions in a row. While there's no recipe for the magic number of how many to do, some colleagues I work with in the UK, we did a project on pelvic floor muscle exercises for women during pregnancy and how we can help midwives teach women how to do pelvic floor muscle exercises. So what we did in that research was two and eight is great. Oh great. Which is a really nice, easy way to remember. That means you do two sets of eight repetitions. Okay. So if you can do two and eight, that's great.

SPEAKER_05

A day?

SPEAKER_04

A day.

SPEAKER_05

Great. Two and eight a day. Yes.

SPEAKER_04

So it's a good way to start. You don't have to do it every day for life. So even if you do it three times a week, that's great.

SPEAKER_05

Fantastic. Seems like an achievable thing. It is, really.

SPEAKER_04

It's only going to take two minutes each time.

SPEAKER_05

Yep.

SPEAKER_04

Each set.

SPEAKER_05

And I suppose, unlike other exercise, it's something that you can really do at any time, isn't it?

SPEAKER_04

Some people can. Yeah. When you're learning, you probably shouldn't try to coordinate doing those exercises with something else because it does need a bit of concentration to make sure you've got the right technique. So when you're starting, I would recommend not combining it with sitting at the traffic lights or filling the car with petrol or washing the dishes. Correct. That that's what we call a very high-level function where you're combining different muscles and movements and activities. So when you're starting, best to just give it that two to four minutes of three times a week of undivided attention. As your muscle control improves, of course you're going to be more skilled and be able to multitask, if you like, and perhaps incorporate the exercises into something else that you're doing.

SPEAKER_05

Okay. And this might seem like a silly question, but would you recommend when you're first starting out practicing those exercises to be sitting or standing or lying?

SPEAKER_04

Yeah, that's a good question. Because the muscles are anti-gravity when we're standing up, that means they have to work uphill against gravity. It may be easier to start lying down. Okay. Then progress to sitting and eventually standing. Okay. That makes sense. If you think about when do you need these muscles to control best to prevent any incontinence and support the pelvic organs, it's when we're under load or under impact, which is usually standing, walking, running, carrying, lifting, etc. So it's good to start exercising the muscles when there's no extra load, lying down with your knees bent, sitting in a chair, and then progress to more challenging activities.

SPEAKER_05

Yeah. Okay, great. And I suppose, as you said, the description that you gave is a really great one for those people who just can't get to a perfect full physiotherapist for whatever reason, or their health professional in the community isn't confident to perhaps examine them and guide them. But that's a really great summary of which muscles we're trying to identify and what it might feel like. And to try not to contract those other big muscles like the tummy, the legs, the bottom muscles, and really focus on those muscles around the three passages. The three options the urethra, the vagina, and the back passage.

SPEAKER_04

Yes, and I think for the majority of women pre-pregnant or even during their first pregnancy, there's probably no reason the pelvic floor muscles can't work. They might have not been activated before because we don't grow up thinking about our pelvic floor muscles. No, we don't. So for a lot of women, by the time they're pregnant, that's the first time in their life they've actually connected to their pelvic floor muscles. So they're going to be not super strong to start with. However, they're not damaged or impacted in any way. So for the majority of women, that kind of an exercise program should be sufficient to give them a sensation of the correct exercise. However, if there is a reason why your pelvic floor muscles may be more compromised or you're at higher risk or you do have symptoms, and if doing that simple program that we just did together doesn't help, then I would very much recommend you do try to see a pelvic floor physiotherapist to get a really good assessment of how your muscles are working and hopefully some individualized, custom designed exercise programs that should really help. Exactly. So it should help the majority of women without extra professional help. But for those who do need it, it's a very good idea.

SPEAKER_05

Fantastic. Instruments and tools that people try and market online. Yes. Is there anything that is actually evidence-based and does help with those pelvic floor exercises, either before or during pregnancy?

SPEAKER_04

Yes. Devices can be very helpful as a supplement, and particularly for people who do have some compromise to their pelvic floor muscles, and I certainly use them in research in particular populations that wouldn't benefit from them. However, if you don't have a reason for your pelvic floor muscles to be compromised or affected pre-pregnancy, you probably don't need them. The exercises themselves should be sufficient. Okay. During pregnancy, we're quite hesitant to introduce a device into the vagina for hygiene and safety reasons. So they tend not to be recommended for use during pregnancy. So we don't use or recommend any devices to be put inside the vagina during pregnancy. And the same for a certain period of time postnatally. It could be six weeks, could be eight weeks, up to three months, depending on how your pelvic floor was affected by birth and how much recovery time it needs before it's safe to introduce a device into the pelvic floor. But beyond the pregnancy and childbearing year, there's actually less evidence than we thought that using devices as biofeedback or as a supplement to your exercise program is necessary. If you have a really good quality exercise program that's well supervised, you may not need a device as well. Okay. But if you're on your own and you can't see a health professional for geographical reasons or financial or many of the barriers that women face to seeing a pelvic floor physiotherapist, then the device might be really useful.

SPEAKER_05

Great. That's really good to know. Thanks, Selena. You mentioned that pelvic flow exercises before and during pregnancy are useful for preventing those symptoms like urinary incontinence. What if you already have urinary incontinence either before or during pregnancy? Is it too late to start pelvic flow exercises? Can there still be benefit?

SPEAKER_04

Yes, that's a really good question. You would think, of course, it's always a good idea to do exercise and treatment for leakage. The problem with starting during pregnancy, if you've already got leakage, is you may not see an improvement because you're going against the natural flow of pregnancy of increasing load and weight and hormonal softening. So it's hard to know if you did the exercise, are you preventing it from getting worse? Yeah. Or are you making no difference? Are you just maintaining the maintaining or Which is actually therefore improving because without it you might be worse. So we we recommend that that everybody does pelvic four muscle training during pregnancy to prevent existing symptoms from getting worse, but also for postnatal recovery.

SPEAKER_05

So everybody should try and see a pelvic four physiotherapist in their world in the ideal world, but if not, trying to do those exercises is still really beneficial.

SPEAKER_04

Yes, and there are some good websites and self-help resources that we can add to the podcast list. Yeah, but we'll put it on the show notes, that's great. That women can feel confident that it's good quality information. Yeah, fantastic. And no myths.

SPEAKER_05

Yes, exactly. Trying to debunk the myths. One of the other things that I think people get quite concerned about in pregnancy and with birth is trauma to the perineal region and the pelvic floor. Yes. There are lots of different ways that that trauma can occur, and sometimes that happens through perineal tears, sometimes it can happen through what we call an episiotomy, which is where we make a cut which is about 45 degrees off-center to prevent any damage to the bottom muscle or the anal sphincter. And we'll have a separate episode about that in more detail. But what I wanted to really focus on is is there anything that people can do that we have evidence for that can reduce the risk of that occurring in birth?

SPEAKER_04

Yes. Well, we know, as we discussed before, that there's evidence doing pelvic floor muscle training during pregnancy can prevent onset of incontinence. But the actual trauma that occurs during the process of birth, there is evidence that perineal massage commenced late in pregnancy can actually reduce pelvic floor injury that occurs during birth. So that can be commenced in the third trimester, and the way it works is to improve the elasticity and allow stretching of the perineum so the perineum is less likely to tear or with an episiotomy extend during birth, therefore reducing the risk. So the way we recommend women can do that during pregnancy is from about 34 weeks onwards. So only the last six weeks.

SPEAKER_03

Okay.

SPEAKER_04

You can do it once or twice a week. You don't need to do it more than that. That's what the evidence shows us.

SPEAKER_03

Yeah.

SPEAKER_04

And only five minutes per session. So you're doing massage to your perineum for five minutes, once or twice a week. It's quite manageable. And the way you actually do it, slightly awkward on yourself, particularly with your pregnant belly, using your thumbs just inside the entrance of the vagina. So encircling one thumb and then the other thumb. But it's got to be inside. You're not massaging the skin on the surface, you're massaging more of the tissue from the inside. Okay. Because remember the baby's coming from the inside to the outside. So with both thumbs, and you can have a little bit of oil on your thumbs to help make it more comfortable to insert your thumbs. Just vegetable oil. Yeah. Anything in the kitchen. Okay. Massage oil, provided it's it has no perfumes or scents in it. Okay. But whatever.

SPEAKER_05

So natural oils.

SPEAKER_04

Natural oils. Anything you can eat is going to be safe to put inside your vagina. That's fair enough. It's a grip. Avocado oil or macadamia nut oil. Any of those.

SPEAKER_05

Okay, great.

SPEAKER_04

So with a little bit of oil on your thumbs, you insert both thumbs just inside the entrance to the vagina and then push back and stretch out to the sides until you feel a strong stretch sensation. So start gently, build up slowly. It shouldn't be painful. Don't give yourself such a stretch that you actually feel pain. That's important. That's very important. And hold each stretch for two minutes.

SPEAKER_05

Okay. Because when your thumb's out on the outer edge, correct that.

SPEAKER_04

From the inside, pressing backwards and out to the sides. Hold that point of stretch for up to two minutes. Okay. Because that will help increase the elasticity of the perineal tissue. So this is not pelvic floor muscles that we're stretching. The pelvic floor muscles are much higher up inside. It's the soft tissue at the entrance at the skin.

SPEAKER_05

But it's still all connected and will help reduce that coma to the perineal region, which is between the vagina and the bottom.

SPEAKER_04

Exactly. So there are some situations where you shouldn't do that. So we should always talk about the risks and who should and should not do it. So if you have any vaginal bleeding during pregnancy, we recommend don't do that vaginal perineal massa or placenta previa or severe high blood pressure during your pregnancy. Or if you have any active infection in the vagina at the time, like thrush. Yeah. So under those circumstances, no, don't do the perineal massage. But for the majority of women it will be perfectly safe and you can have confidence that it may well help prevent some trauma to the perineum.

SPEAKER_05

Yeah. A couple of other things that I might think to be as a caution to do that might be if you're at risk of preterm birth or if you've ruptured your water. Absolutely. Yes. But it would probably be best to just discuss it with your health professional anyway, wouldn't just to check if there's anything you're missing that might be a recommendation against doing it. But aside from that, it sounds like a really great thing to do.

SPEAKER_04

Yes, because we do have some evidence that it actually can be effective.

SPEAKER_01

Yeah.

SPEAKER_04

So anything you can do yourself gives you that sense of control over preventing injury.

unknown

Definitely.

SPEAKER_04

And that's a good thing.

SPEAKER_05

Yeah. How about in labour? Is there anything that we as health professionals in labour can do to help reduce the risk of peroneal trauma?

SPEAKER_04

There is some evidence for various things that the woman or the carers can help with during labour, such as applying warm compressors to the perineal area, so warm wet towels to improve the blood supply and help the woman relax the tissue. Doing that perineal massage during labour. So that would obviously be the midwife or the health carer who does that. And for the woman, it can help relieve discomfort and pressure and perhaps excessive force on the perineal if she's leaning forward, so uh kneeling or on all fours, hands and knees, or leaning over a beanbag. Yep. And that can also help if you're feeling back pain during labour because of the position of the baby. So there are a couple of things that you can do to help reduce the pressure and the risk of the perineal injury.

SPEAKER_05

Yeah, great. That's really good to know. And I I feel like this is relatively new evidence because we're really trying to incorporate these practices more.

SPEAKER_04

Absolutely, because we're aware of the trauma that can occur and it can be long-lasting for some women. And of course, when we say trauma, we mean both there's physical trauma to the tissues and there's also psychological trauma. So that might be your future episode addressing those in detail.

SPEAKER_05

Definitely, yeah. That's a big topic, you're right, Helena. And but in terms of trying to reduce trauma to the pelvic floor and the perineum. The tissues, yeah. The tissues, this is really important. Yes. Empowering women.

SPEAKER_04

Indeed. And of course, there can be injury to the pelvic floor muscle during birth as well, which is a form of trauma to the pelvic floor muscles. They can overstretch and maybe have micro-tears. Now, we may not be able to prevent that, and it can be due to factors outside our control like size of the baby, position of the baby, speed of second stage labour, some of the other factors beyond our control. So if that occurs, then we would obviously provide care postnatally to help the pelvic floor muscles recover and compensate for any trauma that did occur to the muscle during birth. And remember that our body and our muscles have a great capacity to recover. So we have trauma in other areas of the body and injuries to muscles, and they do recover with good care. So we should always feel there's a recovery pathway.

SPEAKER_05

It's very rarely not able to be recovered. Correct. Yeah.

SPEAKER_04

And it's very rarely complete. So even if there is a tear or a separation, it's filled in with connective tissue, which occurs in other injuries of the body. We're not left with nothing. While we talk about a gap in the muscle, that gap is actually filled in with connective tissue. So it's not as if the pelvic floor muscle is floating freely.

SPEAKER_05

Yeah, that's good to know and and important to picture. I suppose one logical thing that one might think is that because of the load and the pressure of the baby on the pelvic floor and the perineum during a vaginal birth, that a way to protect the pelvic floor might be a cesarean section. What's the evidence for that? And is that a complete protection of the pelvic floor? What are your thoughts?

SPEAKER_04

No, it's not a complete protection. So it's important that when women are making that decision about their birth, that they're aware it is not a guarantee for complete protection. There might be other reasons that are important for a cesarean, but having it as a pelvic floor protection prevention is not guaranteed. So we know, as we discussed before, the strongest risk factor for developing incontinence postnatally is having some incontinence before your first pregnancy. So you can't prevent that by a cesarean. And then there are the effects of pregnancy on the pelvic floor, as we've discussed. So even if you have an elective cesarean, your pelvic floor has still been under the load and the hormonal influences and stretching for the length of the pregnancy. So there's still going to be some effect of that, which can't be prevented with a cesarean. So a cesarean may offer partial protection against developing incontinence and pelvic organ prolapse postnatally. But whether it protects against fecal incontinence is less clear. And that protective effect may be lost over time as other factors contribute to development of fecal incontinence for some people. Like age. That's right. So even the partial protective effect on incontinence may also be lost over time. And with repeated cesareans, it may be by the time you've had three elective cesareans, your risk of incontinence is the same as someone who's not. Okay. Yes.

SPEAKER_05

That's because of that load of the pregnancy.

SPEAKER_04

Three pregnancies, yes. So you do lose that protective effect over time, even with multiple cesareans. The protection from a cesarean appears to be stronger against prolapse than it is for incontinence.

SPEAKER_05

Okay.

SPEAKER_04

Yeah, so that that's something to take into consideration. So if you have other risk factors for prolapse, such as your connective tissue or family history, or other reasons that need to be considered, then you may have a stronger protection against developing prolapse with the caesarean than you have for incontinence.

SPEAKER_05

And by prolapse we mean the lowering of the pelvic organs.

SPEAKER_04

Yes, the loss of support to the pelvic organs from the ligaments and the muscles that help keep them in their correct position. So if the ligaments or the muscles or the connective tissue stretches or even tears, then that organ, if you think of the bladder or the uterus or the bowel, it's got no support from underneath. So the scaffolding has been compromised. And because of gravity, the fact that we're on two legs, things fall down. Yes. So without the support underneath and to the sides, tethering the organ, it will drop. And the sensation you feel then is a sensation of heaviness or bulging. So any of the three organs can drop or prolapse. So it could be the bladder prolapsing, it could be the uterus, it could be the bowel, it could be a wall of the vagina. So loss of any of those connective tissue supports can lead to that bulging or dropping in any part or, as we say, compartment of the pelvic floor. Mm-hmm.

SPEAKER_05

Okay. That's good to know. So cesarean section can prevent a prolapse in some circumstances. To an extent, yes. And it will obviously prevent trauma to the perineum in that birth because we're having a an incision through the abdomen instead. Yes. But it can't necessarily prevent urinary incontinence completely because of that pressure on the pelvic floor with the pregnancy. That's right.

SPEAKER_04

And particularly if you have that risk factor of having incontinence pre-pregnancy, it can't reverse or undo previous risk factors. And then you have the load of pregnancy as well.

SPEAKER_05

And we did talk a little bit about those specific risk factors like high in impact sport, perhaps, for urine continence.

SPEAKER_04

Yes, although it's likely that that as a risk factor goes away when you stop doing the high impact. So it's reversible. Correct.

SPEAKER_05

What are some of the other risk factors that might alert you to needing to be more in tune with your pelvic floor and be more proactive?

SPEAKER_04

The risk factors for developing incontinence, apart from the that pre-pregnancy one that you might have from childhood or teenage years, are age. So the older we are, the higher our risk. So if you're an older first-time mum, you may have a higher risk. Our own weight, so our BMI, the higher the BMI, the higher the risk of developing incontinence. And the number of births. So the higher the number of births, the increased risk of developing incontinence. So that they are the three biggest risk factors for developing incontinence in a woman's life.

SPEAKER_05

Okay. Yeah. Whether that's through pregnancy or after pregnancy or at the age.

SPEAKER_04

We can't change those. We're all going to age. But the good news is that we can treat incontinence with pelvic floor muscle exercises. It has very high level of evidence and it's the number one recommendation for treatment. So, yes, there are some things we can't pre- prevent, but there's also good evidence-based treatment for the majority of people.

SPEAKER_05

Yeah, that's really good to know, and it very empowering, I think, for people. Yes. Whether it's pre-pregnancy, during pregnancy, or after pregnancy. That's it. One last question. Yes. We did talk about the uh debugging the myth that you can do too many pelvic floor exercises in terms of labour and birth. But is there ever a situation where you would recommend someone do less pelvic floor exercises or that you might be worried that they're doing too much?

SPEAKER_04

The myth that we were discussing before was not so much about the volume of exercise, like the number you were doing, it was that there was a belief that if you did pelvic floor exercises, your muscles would become too tight. So we don't have a number of exercise threshold, if you like, that more than that is too many and less is too few. What seems to work best is an intensive exercise program. So if you're treating weakness in the muscles or incontinence or prolapse, we do recommend an intense exercise program to build up the strength of the muscle. And the two and eight is great. A couple of times a week would be a good guide.

SPEAKER_03

Okay.

SPEAKER_04

For some women, the focus needs to be more on releasing the pelvic floor muscle if they do have increased tension in the muscle or increased tone. So that might have an exercise program that has a slightly different focus, as we're not trying to build strength as the primary goal, we're trying to improve the relaxation and control of the muscle. But we've just done a study on young women who have endometriosis and whether we can improve their pelvic floor muscle control and relaxation by doing pelvic floor muscle exercises, contract and relax, and we found a good effect of that. So learning how to relax your pelvic floor muscle is difficult to do if you don't know how to contract it. So the way to get the better control of relaxation may well be through a contraction program, but not with the aim of increasing strength, but with the aim of increasing control.

SPEAKER_05

So it's really all about identification and control.

SPEAKER_04

Yes. But if you do too few exercise, no matter what your goal is, whether it's strength or relaxation, you're probably not going to achieve much. It's like if we wanted to get fit and we walked halfway around the block occasionally, we're probably not going to get very fit. Or if we wanted to build up muscle strength in the body, you need a certain threshold to load the muscle to achieve the benefit, the training effect. So too few is probably a waste of time. A waste of time. Too many. I don't recall meeting many people who've done too many exercises. Great.

SPEAKER_05

Yeah, that's really good to know.

SPEAKER_04

Because most people don't have time to um To do that much. To do too many. So usually the job is to encourage them to do enough. Yeah. Yeah.

SPEAKER_03

Yeah.

SPEAKER_04

So we work at ways of fitting it into their busy lives. But two and eight is quite manageable.

SPEAKER_05

It's quite manageable, yeah, and that's a really good rule to remember. Fantastic. Thank you so much, Alina. That's a pleasure, Rangy. Thank you. We covered so much in this first part of our episode on the pelvic floor, and we look forward to discussing a bit more about what to expect postpartum and beyond in our next episode. Great, look forward to that. Thank you.

SPEAKER_01

Thanks, Rangy. Every pregnancy is unique. The information provided in today's podcast is for educational and general purposes only. It is not intended to be substitute for professional medical advice. It is important that you always seek the guidance of qualified health professionals with any questions you may have regarding your health, pregnancy, or any medical conditions.