By Melinda Fontaine, DPT, PHRC Walnut Creek
I recall being eight months pregnant treating other pregnant women or new moms. I would always hear, “How are you still working full time on your feet?” I still think the most honest answer is, “Pure luck”. Every pregnancy is different, and there are a lot of things that are out of your control. We all do the best we can to take care of ourselves, which means staying informed and making healthy choices. The other common response I gave to people was, “I work with a great group of women who specialize in caring for pregnant women, so I am very well taken care of.” I wouldn’t undervalue the importance of having a support group during pregnancy. My colleagues were there to listen to my musings and complaints about pregnancy, give me advice, and treat my aches and pains. I am very lucky to have such vast experience with pregnancy professionally because I knew what to expect and how to prepare myself physically and mentally. I am also very unlucky to have such vast experience with pregnancy professionally because I know about all the worst case scenarios! The possibilities of what can happen during pregnancy are endless, but I’d like to share some of the knowledge that helped get me through my pregnancy with minimal freak-outs and discomfort.
Build Core Strength
When I first found out I was pregnant, I did two things for myself: I signed up for prenatal Pilates and I bought compression stockings. The Pilates classes were to strengthen my core in a safe, effective, and fun way. I knew that a strong core would support me while I carry a baby. The deep core muscle, transverse abdominus, wraps around one’s midsection like a corset. It is responsible for supporting the low back and hips, which becomes increasingly important as the hormone relaxin starts to make joints looser and the belly starts to pull forward. Pelvic girdle pain or low back pain affects 72% of all pregnant women1, and a strong transverse abdominus is the first defense. There are many exercises to strengthen this muscle, but I chose Pilates because I thought it would be fun and safe. My instructor was very knowledgeable about the special needs of a pregnant body and knew how to modify exercises and teach perfect form. My biggest fear about starting a new exercise regimen, especially when pregnant, was trying to keep up with the group, doing something wrong, not being corrected, and ending up injured. I also kept up my old exercise routine at the same intensity as before I was pregnant until my body started to tell me to take it easy. In healthy women with uncomplicated pregnancies, it is generally safe to do so2, but always listen to your body and your doctor. The American College of Obstetrics and Gynecology recommend moderately intense exercise for 30 minutes a day on most or all days of the week. Exercise during pregnancy has been associated with lower risk for diabetes, depression, hypertension and preterm birth3. In some cases, the increasing weight of the pregnant belly, the hormone relaxin, and underlying pathology will overpower the core muscles, and external support may be needed to alleviate pregnancy related low back pain. A sacroiliac joint belt hugs the bones of the pelvis and supports the pelvic girdle and sacroiliac joints. A maternity support belt lifts and hugs the belly to reduce abdominal and back discomfort.
Wear Compression Stockings
The compression stockings help minimize swelling and circulate blood from the feet back to the heart. During pregnancy, the volume of blood increases and the walls of the veins soften and expand. This leads to fluid collecting in the feet and legs, especially in women who spend a lot of time on their feet. For all people, pregnant or not, who spend a lot of time standing during the day, such as myself, compression stockings with light to moderate compression can help to counteract the effects of gravity and help legs feel more energized. Maternity compression stockings exert about 15 mmHg of pressure and are comfortable (although sometimes hot in California in the summer). Try different brands of knee highs or full length stockings to see what you find comfortable. I wore Juzo.
Avoid Constipation and Hemorrhoids
As pregnancy progresses, different signs will appear such as morning sickness or that dark line in the middle of your abdomen. So many changes could possibly happen that I can’t list them all. One guarantee is that the pregnant body produces more progesterone. Progesterone is the hormone responsible for relaxation of smooth muscle, such as that in your digestive system, and decreased motility in your stomach and intestines. This means that food travels through your system slower and can lead to constipation. Too much straining with constipation can lead to hemorrhoids. I recommend drinking plenty of water and eating a high fiber diet. I put my feet up on a stool when I sit on the toilet to have a bowel movement because this is the most natural way to poop. After all, most of the world poops and has babies in the squatting position to put the pelvic muscles on slack and allow the pelvis to open. I can’t tell you how many people are in love with their poop stools after they try it. Put one in your house, and everyone, young and old, male and female, will benefit. Here is a link to the one we have in our clinic in Berkeley. I also avoid holding my breath and bearing down to poop. All that pushing puts a lot of downward pressure on the pelvis and can lead to hemorrhoids, prolapse, or nerve injuries. This is such a common problem that some prenatal vitamins even have stool softeners in them. If you still struggle with constipation and/or hemorrhoids, talk to your physical therapist or doctor about other ideas.
Beware of Incontinence
Instead of, or in addition to, struggling to get waste out, some pregnant women struggle to keep waste in. I’m referring to incontinence (or leaking) of urine, feces, or gas. In pregnancy, this is most common due to the pelvic floor being asked to do too much work. (There are other possible causes as well, so talk to your physical therapist.) Besides doing its usual tasks of supporting the pelvic organs and pelvic girdle and maintaining sexual function and continence, the pelvic floor is asked to hold up an extra 7 lbs of baby, 1 ½ lbs of placenta, 2 lbs of enlarged uterus, and 2 lbs of amniotic fluid. Something’s gotta give, and when it’s your pelvic floor, you end up leaking. Often this improves after delivery, but it is not a normal part of pregnancy or being a mom. It is an indication that something is not working right, and it should be evaluated. The pelvic floor may be too weak or too strong, which brings me to my next point…
To kegel or not to kegel
Another guarantee while you are pregnant is that you will undoubtedly hear from someone, “Do your kegels”. To be honest, this kind of makes my skin crawl because you can’t blindly prescribe any one exercise to every woman. Kegels are a strengthening exercise. I wouldn’t tell a person with a strong pelvic floor to do kegels any more than I would tell a competitive weight lifter to run a marathon. Not only is it not necessary, but it may also be harmful. A pelvic floor that is too tight could lead to incontinence, retention, urgency, frequency, or pain. Doing kegels could make these symptoms worse, your pelvic floor may need to be lengthened before it is strengthened. On the other hand, a weak pelvic floor could really benefit from kegels to decrease incontinence and prolapse and improve ease of delivery. It is impossible to tell which kind of pelvic floor someone has without a manual exam from a physical therapist, so take the advice to “do your kegels” with a grain of salt.
Expect Changes
Another common pregnancy tip for the 2nd and 3rd trimesters is to avoid lying on your back. This is sound advice, especially as the baby gets larger. The weight of the baby can press on the vena cava (a large vein in your abdomen responsible for returning blood to your heart). This can make mom start to feel lightheaded and can be serious if it is not corrected quickly by changing positions. The increasing size of a pregnant belly also stretches the muscles of the abdomen. Sometimes, the recti abdominis (or 6-pack muscles) can separate creating a soft part in the middle of your belly above or below your belly button called a diastasis. I avoid doing sit-up type exercises that would further stress and pull apart these muscles. Diastasis is very common during pregnancy and is more likely if your belly grows quickly or if you have had multiple pregnancies. It can go away on its own after delivery, or you may need a physical therapist to teach you how to correct it. Lastly, carrying around extra weight in the front of your body means that the muscles in the back of the body have to work overtime to keep you standing upright. The gluteals (buttocks) are one such group of muscles. If these muscles feel tight, painful, or uncomfortable, getting a massage or rolling them out on a foam roller can feel really good. Wearing sneakers with good arch support will also support muscles further up the leg by creating good alignment, and they give added compression at the foot, in addition to the compression stockings discussed above.
Take a Class
At the end of about 40 weeks, the baby will be born. Sometime before then, I recommend taking some sort of childbirth class. There is no one right way to birth a baby. As a mom, you have many choices to make. It is hard to make decisions during delivery because you are physically and emotionally exhausted. Learn as much as you can about what to expect before, during, and after delivery, and think about your preferences. That being said, you cannot control what is going to happen and you may make changes to your preferences in the moment. Some things to think about include: where will you deliver, vaginal or cesarean, who will be with you, what are your pain management options, who will cut the umbilical cord, will you vaccinate, who will be your Baby’s pediatrician, will you circumcise, will you try to breastfeed. I also find it comforting to know a little about labor and delivery including how to know when you are in labor, what does labor consist of, when will you start pushing, what will happen after the birth, what tests will be provided to the baby after birth, etc. If you are birthing at a facility, take a tour.
Practice
Something that might not be covered in a typical birth class is practicing pushing and finding good positions for you during labor. I do this with all of my patients who are preparing for delivery. A large number of women don’t know how to push a baby out on their first attempt. Good pushing involves a soft relaxed pelvic floor to allow for easy passage of the baby and a strong abdominal contraction to increase the pressure in the abdomen above the baby and help push baby down and out. The most effective pushing position for each woman is different and some positions will not be possible after an epidural. Curling up as if doing a sit- up could help increase abdominal pressure to bear down. Being in an upright position such as squatting uses gravity to help the baby come out. Hands and knees can also be a nice way to labor without the weight of the baby on your back. Use a chair, bed, or partner to lean on as well. Try multiple positions ahead of time and see which ones feel comfortable to you, so you will have some ideas to try during labor. For more information on labor and delivery, stay tuned for future blog posts.
Veteran Moms: Do you have any other tips you would like to add to this list?
Warmly,
Melinda Fontaine, DPT
Melinda is a native of Concord, California and is part of our Berkeley team. Melinda earned her bachelor’s degree in exercise biology from UC Davis and her doctorate in physical therapy from Simmons College in Boston. When she’s not at PHRC, you’ll find her either dashing around in her running shoes or cooking up delectable meals in her kitchen. She’s famous for her killer baked chimichangas and her inability to stick to a recipe.
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Are you unable to come see us in person? We offer virtual appointments!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
References:
Bergström C et al. (2014). Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation. BMC Pregnancy and Childbirth,14, 48. doi:10.1186/1471-2393-14-48
American College of Obstetrics and Gynecology (ACOG). (2002, reaffirmed 2009). ACOG Committee opinion number 267: Exercise during pregnancy and the postpartum period. Accessed July 2015 via the web at: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Exercise-During-Pregnancy-and-the-Postpartum-Period
Domingues M R, et al. (2015). Physical activity during pregnancy and maternal-child health (PAMELA): study protocol for a randomized controlled trial. Trials, 16, 227. doi:10.1186/s13063-015-0749-3
Pregnancy weight gain: What’s healthy? Mayo Clinic. Accessed July 2015 via the web at http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy-weight-gain/art-20044360?pg=2
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
My wife is pregnant, and she wants to make sure she does what she can to be healthy before the baby comes. That being said, I really appreciate you sharing some insight on pelvic tips that my wife can try out. I definitely think these stretches and things are going to help her a ton. Thanks for sharing this with me.
Hello Bennett,
Unfortunately, we cannot suggest specific advice without an evaluation. It just would not be in the best interest of the patient. We highly encourage your wife to consult with a local pelvic floor therapist who can assess her presentation, and begin treatment if necessary.
Best,
Admin
Thanks for your sharing. I know that feeling. To prepare a newborn baby is important so the mother should take part in a class to know more information
Just a quick question on the “avoid lying on your back” point. What is the ideal position to just hang out in, while pregnant? Obviously lying on the stomach is out, so the side is all that is left. But, should I try to avoid lying down as much as possible and pick another position instead? I’m currently 18.5 weeks into my second pregnancy and have a minor diastasis from my first pregnancy, so I want to avoid making it worse. Any advice is appreciated! Thanks!
Author Melinda Fontaine says:
“Side lying, especially left side lying is ideal for resting lying down. Sitting is also OK if that is comfortable for you. Your diastasis should be alright in either position, just avoid using your abs to curl-up, like in a sit-up.”
This is some really good information about pregnancy. My best friend just told me that she is pregnant. I am so happy and I want to help her get through her first pregnancy well. I like that you talked about being aware of inconsistencies. That does seem like a good thing for her to be aware.