Physiotherapy

Pre/Postnatal Health

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PRENATAL

Pelvic Health

Physiotherapy

Pregnancy is a time of firsts, joy, and excitement. Women look forward to the first time they will feel their baby move, and anticipate the potential pregnancy-related symptoms that they might experience. However, many do not know how to prepare their pelvic floors for their pregnancy, labour and delivery, and postnatal stage. It is a topic that is not brought up enough, yet should be the standard of care in every pregnancy journey. 

The Influence of Pregnancy on the Pelvic Floor


As a pregnancy progresses, there is a natural increase in the demand placed on the pelvic floor. This occurs due to the growing baby bump, pregnancy-related weight changes, and modified activity of adjacent muscles. Essentially, these muscles have to work harder during pregnancy, making it more important than ever to know how to properly connect to this area. 

 

If a woman’s pelvic floor becomes overworked and tired, or does not have the necessary strength throughout pregnancy, she may experience certain pelvic health symptoms.

The Influence of Pregnancy on the Pelvic Floor


As a pregnancy progresses, there is a natural increase in the demand placed on the pelvic floor. This occurs due to the growing baby bump, pregnancy-related weight changes, and modified activity of adjacent muscles. Essentially, these muscles have to work harder during pregnancy, making it more important than ever to know how to properly connect to this area.  
If a woman’s pelvic floor becomes overworked and tired, or does not have the necessary strength throughout pregnancy, she may experience certain pelvic health symptoms.


For a detailed explanation on the influence of pregnancy on the pelvic floor, and common symptoms explained, click here. 

Common Pelvic Health symptoms related to Pregnancy:

  • Urinary incontinence when laughing, sneezing, coughing, or exercising 

  • Urinary frequency/urgency

  • Urinary retention/incomplete emptying 

  • Pelvic floor heaviness/pressure

  • Pelvic varicose veins

  • Constipation

  • Diastasis Recti Abdominis

  • Pain with sexual intercourse (dyspareunia)

  • Pain in the perineum/rectal region

  • Lower abdomen pain

  • Low back, pelvic, sacroiliac joint, tailbone or hip pain

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Prenatal Pelvic Health Physiotherapy 

 

Our Pelvic Health Physiotherapists are highly specialized and passionate in helping women optimize their pelvic health during pregnancy, labour and delivery, and the postnatal stage. The initial assessment will include completing a detailed health questionnaire, which will enable your Physiotherapist to better understand your goals, symptoms, and health concerns. The physical exam will involve the assessment of the muscles, ligaments, tendons, and connective tissue of the abdomen, pelvis, hips, sacroiliac joints, low back, and thorax. With your consent, an internal examination of your pelvis and pelvic floor muscles may be performed. An internal examination enables your Pelvic Health Physiotherapist to examine anatomical changes, symmetry to a contraction, muscle tone, and painful areas¹,². However, if an alternative is required, many external techniques can be performed to determine the root cause of your symptoms. 

What does Treatment involve?

Treatment is always tailored and specific to each individual. Your Physiotherapist will evaluate your health history, the physical exam findings,  and your functional goals to determine the best course of treatment. Options may include:

Prenatal Pelvic Health:

 

  • Bladder health management 

  • Constipation management 

  • Pelvic Organ Prolapse management

  • Targeted manual therapy of the myofascial system 

  • Pelvic floor muscle downregulation and relaxation

  • Pelvic floor muscle strengthening and training to optimize function during pregnancy 

  • Motor control training and strengthening of the deep core musculature

  • Motor control training and strengthening of the abdominal wall, hips and thorax

  • Discuss appropriate maternity belts and other supportive devices 

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Labour and delivery prep:

  • Perineal massage

  • Education regarding optimal positions for labour and delivery

  • Breathing mechanics and techniques to optimize pelvic floor relaxation 

  • Education regarding how your birth partner can assist during labour and delivery 

  • Pain management strategies 

  • Discuss movement strategies in the event of a Cesarean birth

Postnatal stage prep:

 

Postnatal Pelvic Health Physiotherapy

Once a woman has given birth, her focus naturally shifts towards her new role as a mother and soaking up those newborn cuddles. During this time, she may notice some unexpected physical symptoms, such as a feeling of pressure in her pelvic region, urinary leakage when she sneezes, or weakness in her abdomen. Unfortunately, she might think ‘well, my friends warned me this would happen, I guess this is my new normal’, and go on trying to ignore her symptoms.
 

The fact is, while these symptoms are incredibly common, they do not have to be the new normal, and should be addressed. Studies demonstrate that women who undergo pelvic floor muscle training notice significant improvements in their pelvic floor symptoms compared to those who do not ³,⁴. Moreover, Pelvic Floor Physiotherapy has been shown to help prevent certain common postnatal symptoms, such as stress urinary incontinence, with lasting effects⁵. 

Some pelvic health symptoms that are noticed later in life may have originated in the postpartum stage. So, if you are out there reading this, and have older kids, we’re talking to you too.

What causes Pelvic Health Symptoms?


Pelvic health symptoms may originate when the the pelvic floor muscles are not activating enough and are hypotonic (too relaxed), or if they are working too much and become hypertonic (too tight). In either state, the muscles are unable to activate and relax properly, affecting their ability to carry out their daily functions.


It is common to see hypertonic or hypotonic pelvic floors postpartum due to the impact of pregnancy on the pelvic floor, labour, vaginal, and Cesarean births. 

Common Postnatal Pelvic Health Symptoms

  • Urinary Incontinence 

  • Urinary frequency/urgency

  • Urinary retention/incomplete voiding

  • Fecal incontinence

  • Constipation

  • Pressure/heaviness in pelvic region

  • Pelvic Organ Prolapse

  • Pain with intercourse

  • Pain in perineal/rectal region

  • Perineal scar pain

  • Ceasarian Birth Scar pain/stiffness

  • Tailbone pain (coccydynia)

  • Low back or hip pain 

  • Diastasis Rectus Abdominis (Ab separation) 

Hugging a Pillow

What does Treatment involve?

 

Treatment is always tailored and specific to each individual. Your Physiotherapist will evaluate your health history, the physical exam findings, and your functional goals to determine the best course of treatment. Options may include:

  • Education regarding your symptoms, condition, assessment findings, and treatment plan

  • Bladder retraining

  • Constipation management and bowel retraining

  • Targeted manual therapy of the myofascial system

  • Pelvic floor muscle downregulation and relaxation

  • Pelvic floor muscle strengthening and training 

  • Motor control training and strengthening of the deep core musculature

  • Motor control training and strengthening of the abdominal wall, hips and thorax

  • Perineal scar mobilization and management 

  • Cesarean birth scar mobilization and management 

  • Postural education and retraining

  • Diastasis Recti Abdominis retraining

  • Pelvic Organ Prolapse management strategies 

  • Functional retraining of the neuro-muscular system to achieve movement and activity goals

  • Liaising with your other healthcare professionals to achieve holistic and comprehensive treatment outcomes 

 

Pelvic Health

Diastasis Recti Abdominis

What is Diastasis Recti Abdominis (DRA)?

Diastasis Recti Abdominis (DRA) is defined as a horizontal separation of 2 muscle bellies of the rectus abdominis (the 6 pack muscles in the abdomen). This occurs when the linea alba, which is the white connective tissue that runs down the center of the abdomen and connects the rectus abdominis, expands against pressure, creating space between the muscles. This pressure could be the result of an increase in intra-abdominal pressure, such as if we hold our breath to lift something heavy, or some direct mechanical pressure from the abdomen, such as during pregnancy. 

It is important to know that some degree of DRA is found in 100% of women at 35 weeks of pregnancy.(15) It is one of the body’s way of adapting to the growing bump. That said, a DRA during pregnancy does not mean that a woman will have a DRA postpartum. 


DRA’s are also found in men, women who haven’t been pregnant, and children.


A DRA could occur above, at, or below the belly button, or in all 3 of those regions.
 

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Common Symptoms of DRA 

 

  • A separation of the rectus abdominis muscle, that may be visible or felt  

  • Low back, pelvic, or hip pain

  • Poor trunk posture

  • Feeling weak through the midsection, unable to activate the core

  • Doming or tenting of the middle of the stomach. This can occur during activities such as lifting, rolling over in bed, or certain exercises 

The Pelvic Floor, the Core, and their role in Diastasis Recti Abdominis 


The pelvic floor muscles sit within the pelvis, attaching to the pubic bone, tailbone, and sitting bones, acting as a hammock to support our organs. In addition to supporting organs, their functions include bladder and bowel control, sexual health, circulation, and, importantly, core strength. 


Given that the pelvic floor is part of our core (along with the transverse abdominis (TA), multifidus, and diaphragm muscles), it plays an important role in the rehabilitation of a DRA. Specifically, this is due to its association with the TA muscle.
 

TA is a broad muscle that is located just beneath the linea alba, connecting to this connective tissue through fascia. When TA contracts (activates), it transmits tension to the linea alba, helping rebuild the strength and integrity of the tissue. 


When the pelvic floor contraction is paired with a TA contraction, there will be a greater TA recruitment (16), which transmits more tension to the linea alba. 


Take home: a pelvic floor contraction creates a stronger TA contraction, creating more tension in the linea alba, helping to further improve the strength and integrity of the tissue and in turn, resolve a DRA.

 

What does Treatment involve? 


Treatment is always tailored and specific to each individual. Your Physiotherapist will evaluate your health history, the physical exam findings, and your functional goals to determine the best course of treatment. Options may include:


●      Education regarding your symptoms, condition, assessment findings, and treatment plan
●      Bladder retraining
●      Constipation management and bowel retraining
●      Targeted manual therapy of the myofascial system
●      Visceral mobilizations
●      Pelvic floor muscle downregulation and relaxation
●      Pelvic floor muscle strengthening and training 
●      Motor control training and strengthening of the deep core musculature
●      Motor control training and strengthening of the abdominal wall, hips and thorax
●      Postural education and retraining
●      Diastasis Recti Abdominis retraining
●      Pelvic Organ Prolapse management strategies 
●      Functional retraining of the neuro-muscular system to achieve movement and activity goals
●      Neuromuscular Stimulation of the Pelvic Floor
●      Liaising with your other healthcare professionals to achieve holistic and comprehensive treatment outcomes 

If you are unsure of whether Pelvic Floor Physiotherapy will help with your symptoms and condition, we highly encourage you to contact us for a 15 minute Free Phone Consultation. One of our specialised Pelvic Floor Physiotherapists will discuss your concerns with you, and help you determine whether this is the best course of treatment for you.

1. Navarro Brazález B, Torres Lacomba M, de la Villa P, Sanchez Sanchez B, Prieto Gómez V, Asúnsolo del Barco Á, McLean L. The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study. Neurourology and urodynamics. 2018 Jan;37(1):269-77. available from : https://www.ncbi.nlm.nih.gov/pubmed/28455942

2. Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP. Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Australian Journal of Physiotherapy. 2005 Jan 1;51(3):167-70.

3. Von Bargen E, Haviland MJ, Chang OH, McKinney J, Hacker MR, Elkadry E. Evaluation of Postpartum Pelvic Floor Physical Therapy on Obstetrical Anal Sphincter Injury: A Randomized Controlled Trial. Female Pelvic Med Reconstr Surg. 2021 May 1;27(5):315-321. doi: 10.1097/SPV.0000000000000849. PMID: 32282525.

4. Dumoulin C, Lemieux MC, Bourbonnais D, Gravel D, Bravo G, Morin M. Physiotherapy for persistent postnatal stress urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2004 Sep;104(3):504-10. doi: 10.1097/01.AOG.0000135274.92416.62. PMID: 15339760.

5. Mørkved S, Bø K. Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one-year follow up. BJOG. 2000 Aug;107(8):1022-8. doi: 10.1111/j.1471-0528.2000.tb10407.x. PMID: 10955436.

6. Navarro Brazález B, Torres Lacomba M, de la Villa P, Sanchez Sanchez B, Prieto Gómez V, Asúnsolo del Barco Á, McLean L. The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study. Neurourology and urodynamics. 2018 Jan;37(1):269-77. available from : https://www.ncbi.nlm.nih.gov/pubmed/28455942

7. Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP. Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Australian Journal of Physiotherapy. 2005 Jan 1;51(3):167-70.