When to Start Pelvic Floor Therapy During Pregnancy
Understanding Pelvic Floor Therapy
What is pelvic floor therapy?
Pelvic floor therapy is a specialty niche of physical therapy or occupational therapy trained in the pelvic region. Pelvic floor therapists are specialized to treat from your diaphragm to your feet. Examples of things we often treat include urinary leakage, urinary urgency and frequency, constipation, pain with sex, hemorrhoids, diastasis rectus abdominus, pelvic organ prolapse, and any type of prenatal or postpartum pain (round ligament, abdominal, tailbone, low back, cesarean scar, etc).
Pelvic floor therapists attend doctorate level graduate school, but receive very little education on the pelvic floor in their didactic portions of their curriculum. Therefore, most pelvic floor therapists spend a lot of time in specialty continuing ed courses.
Benefits of pelvic floor therapy during pregnancy
Not only can a pelvic floor therapist help make your life/pregnancy much less miserable by treating the many aches and pains that come along with pregnancy, but they can also help you prepare for your birth – both vaginal and cesarean.
A few examples of things pelvic floor PTs can help with before birth to optimize birth include:
Teaching you how to push
Pain management strategies to utilize during birth
Positional recommendations for the 1st and 2nd stage of labor to open the pelvic inlet and outlet
Safe and effective core exercises to begin postpartum
Additionally, any pain is a sign of dysfunction and possibly restriction in the pelvis that could inhibit the progression of labor. Pregnancy related pain we often see includes:
Pelvic girdle pain (back of the pelvis)
Round ligament pain (sharp/stabbing pain when you go from sitting to standing or rolling over in bed
Lightning crotch (also very sharp/stabby)
Pubic symphsis pain (very similar to round ligament pain)
Pain with sex (likely coming from the pelvic floor)
Role of pelvic floor therapy in preventing complications
Pelvic pain and low back pain are often signs of dysfunction in the pelvis; this can be pelvic floor restriction or a rotation of the pelvic girdle backwards/forwards.
Not having proper alignment in the pelvic girdle/low back can be a causation of failure to progress during labor or a breech baby, which can lead to an unplanned cesarean birth, so ensuring proper alignment of the pelvis and minimal restriction in the abdominal muscles during pregnancy prior to delivery is ideal.
Please note that seeing a pelvic floor therapist during pregnancy does not guarantee a smooth vaginal delivery if that is the goal, but definitely helps.
Differences between pelvic floor exercises and therapy
“Pelvic floor exercises” typically means kegels – a pelvic floor muscle contraction. During birth, you want your pelvic floor muscles to relax or get out of the way, not contract and restrict the progression of birth.
Pelvic floor therapy is a much more specialized and one-on-one style of treatment. Not only are kegels not an effective treatment strategy for pregnancy, if you are experiencing pain, urinary issues, or constipation, it will likely make your symptoms worse. A good pelvic floor therapist will be able to get to the root of your symptoms and give you specific exercises and strategies to treat whatever it is you are experiencing in an optimal way to prepare you for your birth.
Timing of Pelvic Floor Therapy
When to start pelvic floor therapy during pregnancy
Starting pelvic floor therapy as soon as possible during pregnancy is ideal. In a dream world, our pregnant patients start seeing us in the first trimester about once/month given there is no pain or other signs of dysfunction like leakage, etc.
The frequency of pelvic floor visits aligns nicely with the frequency of your other provider – starting at once/month and increasing frequency as your pregnancy goes along. We like to begin our birth prep session around 30 weeks. IF our patient is having a healthy pregnancy and is still symptom free, we recommend 3 birth prep sessions every other week beginning at week 30 and ending at week 36. We practice this way because 37 weeks is considered early full terms, and want our patients that do deliver around this time frame to have adequate time to practice what we go over in these sessions and ask any questions they have.
Signs you need pelvic floor therapy during pregnancy
Signs you need pelvic floor therapy during pregnancy include any pelvic floor dysfunction and/or any low back/pelvic pain.
Pelvic floor dysfunction includes:
Urinary symptoms (leakage, urgency/frequency, pain with urination)
Bowel symptoms (pain with BMs, constipation, hemorrhoids)
Prolapse - read more about pregnancy with existing prolapse here
Pain with sex - early sign of pelvic floor dysfunction
Low back pain/pelvic pain examples include:
Low back pain
Pelvic girdle pain
Pubic symphysis pain
Round ligament pain
Chronic pelvic pain
Deep pelvic pain
And….. if you want to optimize your birth, you need pelvic floor therapy.
Can pelvic floor therapy be started in the first, second, or third trimester?
Pelvic floor therapy can be started in any of the trimesters. Ideally earlier, but if you start experiencing pain or symptoms in the third trimester and/or want to prepare for a vaginal birth, it’s never too late. There will always be benefits!
How pelvic floor therapy changes throughout pregnancy
If started in the first trimester, we can build a solid core strength foundation before your body starts changing too much and address any pain that is occurring.
If you start in the second trimester, you still have time to build a solid core strength foundation, but your body is changing rapidly so it might be more challenging to connect with your core. We will ensure adequate mobility and address any pain or dysfunction that might be occurring because of a growing uterus. In the third trimester we will begin working towards your specific birth plan and prepare you for postpartum.
If started in the third trimester, we work on any of your specific goals including pain or birth prep, and get you ready for the postpartum period too. There is not as much time to work on core strengthening, but exercises can typically be given to work on at home.
Benefits of Early Intervention
How early pelvic floor therapy improves birth outcomes
Early pelvic floor therapy can optimize so many things not only birth related, but also pregnancy and postpartum related too.
If started early enough, we can ensure adequate core strength for pushing which translates to postpartum.
We can prioritize pelvic alignment, which also decreases the likelihood of low back pain. Proper pelvic alignment greatly affects the pelvic floor muscles as well. If the bony anatomy is “off”, the muscles will be too.
We can address pelvic floor function which not only helps with pushing but also decreases the likelihood of pain with sex, urinary issues, constipation or prolapse.
Reducing the risk of prolapse and incontinence with early pelvic floor therapy
Prolapse and stress incontinence are both pressure management issues with pelvic floor coordination. Contraction/relaxation is usually either not happening or happening at the wrong times.
Beginning pelvic floor therapy early in pregnancy allows you to connect to your pelvic floor and understand how to contract and relax it appropriately. Doing this prior to all of the changes that occur later in pregnancy is very beneficial as it can be more challenging to feel these muscles and understand the coordination piece of the pelvic floor later in pregnancy.
Benefits of starting pelvic floor therapy before pregnancy
Did you know you don’t have to be postpartum to begin pelvic floor therapy?
We actually treat all ages, including pediatrics. Pelvic floor issues such as leakage, prolapse, and pain are not exclusive to pregnant/postpartum women and often start prior to pregnancy. Many athletes actually experience urinary incontinence in power sports such as volleyball.
Additionally, we can help with achieving pregnancy! That’s right – I am a fertility trained therapist that can help with fertility struggles by addressing the scar tissue, lymphatic flow, pelvic organ restriction, and blood flow of the uterus and ovaries. This non-invasive technique is truly life changing and so cool to see how it helps patients along their fertility journies.
How pelvic floor therapy helps with pregnancy discomfort (back pain, pelvic pain)
Low back pain, pelvic girdle pain, and pubic symphysis pain can all be the consequence of muscle dysfunction.
Glute weakness can result in pelvic girdle issues which often feels like low back pain that does not radiate
Core weakness can result in low back pain that does radiate
Adductor tension can result in pubic symphysis pain
Addressing muscle imbalances/deficits will help alleviate this pain and discomfort and ultimately help with your birth and postpartum recovery. If there’s one thing I wish pregnant women knew it’s that pregnancy doesn’t have to be painful.
Postpartum Pelvic Floor Therapy
When to continue pelvic floor therapy after childbirth
We typically like to begin seeing our patients at 2-4 weeks postpartum. This allows us to begin working on any pain right away, address any mid back restriction (no matter how you feed your baby this is bound to happen), and being restrengthening the core musculature.
This visit is especially beneficial for the post cesarean mamas, as we are able to begin working around the scar on sensitivity and upper abdomen for any restriction.
After that visit we pause until after 6 weeks postpartum and then resume. After 6 weeks we are able to do more treatment, movement, and a more thorough exam.
Pelvic floor recovery postpartum
Okay this is a hot topic — and I have a few hot takes.
Hot take number one— postpartum return to exercise and return to intercourse should be more along the lines of 12 weeks rather than 6.
Clearance for those activities happens at 6 weeks because of the status of the uterus and incisions, NOT because of the pelvic floor. While those tissues might be ready for activities, your pelvic floor likely isn’t, especially the more intense modes of exercise like running, HIIT, and CrossFit.
I do think gentle exercise like light core strengthening and walking is beneficial before 12 weeks.
My point: return to exercise looks different for everyone and shouldn’t be a one-size-fits-all approach to return at 6 weeks.
Pelvic floor therapy for postpartum incontinence
There are two main types of incontinence we see postpartum.
Stress incontinence
Urge incontinence
Stress incontinence occurs more often with laughing, jumping, coughing and sneezing and is more common after a vaginal birth.
Urgent incontinence occurs more with getting to the bathroom or hearing running water and is more common after a cesarean birth.
Stress incontinence occurs more often because of core coordination, while urge incontinence occurs more often because of pelvic floor tension.
Both are very common and very treatable, we see this all the time postpartum. Don’t let any provider tell you this is your new normal!
How to maintain pelvic floor health after pregnancy
Outside of seeing a pelvic floor therapist for individualized treatment, I have four recommendations to maintain a healthy pelvic floor postpartum:
Aim for daily bowel movements
Shoot for 60 to 80 ounces of water per day
Manage stress
Participate in a mode of exercise you enjoy
Each of these things alone is so beneficial for your pelvic health but practicing them together is very beneficial.
If you are pregnant and looking to start pelvic floor physical therapy: good news! We are currently taking new patients with prolapse in Rockwall, Canton, and Sulphur Springs. If you are interested in scheduling an appointment, please request an appointment here and someone from our team will reach out to you to get you scheduled.
