By Kierra Daves, DPT

Pregnancy is an exciting and evolving transitional period. What begins as roughly the size of a poppy seed develops into an approximately 5 to 8-lb bundle of joy. It’s a given that the woman’s body has to go through changes to accommodate the growing fetus and to prepare for delivery once the time comes. But what is equally as important is what happens afterward.

Pelvic floor physical therapy intervention is effective in addressing joint instability, weakness and pain that can result from pregnancy and remain as the woman transitions into the postpartum phase. The key is movement. A pelvic floor physical therapist works with the postpartum patient to first identify the areas of impairment and the patient’s goals. The physical therapist will assess breathing patterns, postural alignment, core strength, pelvic floor muscle (PFM) function and hip flexibility and strength.

Intra-abdominal pressure (IAP) management is often the start of intervention as it is common to activate accessory musculature for respiration due to upward movement of the diaphragm in response to the growing uterus during pregnancy. Another tendency is to perform the Valsalva maneuver, breath holding, while performing both light and strenuous activities. This tendency places the patient at risk for a hernia, prolapse and hemorrhoids. Proper IAP management training via diaphragmatic breathing and avoidance of the Valsalva maneuver significantly reduces these risks and is a form of treatment that can be quickly adopted into a daily routine with behavioral changes.

As the fetus grows during pregnancy, the center of gravity moves anteriorly, resulting in increased lumbar lordosis. The additional weight overloads the knees and ankles, resulting in increased pressure within the midfoot due to flattening of the arch, possibly leading to leg cramps. The core becomes weakened due to the expansion. The lining between the rectus abdominis muscle, termed the linea alba, becomes weakened, resulting in a separation of the musculature also known as diastasis recti. As a result, the core is unable to provide stability to the spine, also contributing to back pain.

The aforementioned postural imbalances can potentially lead to weakness in the major hip muscles, especially the glutes, and tightness within the anterior and inner thighs. Pelvic floor physical therapy intervention can address these imbalances and impairments by first providing education on modifications to promote better alignment and exercises to stretch tight muscles such as the hip flexors and adductors and strengthen the weakened core, glute and intrinsic foot muscles.

The pelvic floor’s bony structure can be thought of as a bowl at the center of the body. The pelvic floor muscles and ligaments are present to reinforce this bowl and provide support, as if they were a hammock, to the pelvic organs. During pregnancy, the pelvic floor muscles can become excessively lengthened to accommodate the changes taking place within the body, resulting in weakness. This places the woman at an increased risk for prolapse and urinary incontinence as the muscles are no longer capable of providing adequate support to the organs or maintaining sphincter closure. This can result in the pelvic organs descending into the vaginal canal and unintentional loss of urine or stool, especially with activities that involve an increase in IAP such as sneezing, coughing, jumping and lifting.

To strengthen the weak pelvic floor, the physical therapist will first ensure there’s a proper understanding of pelvic floor muscle (PFM) activation. This entails contracting the pelvic floor and performing a Kegel without breath holding or use of accessory muscles: the core, glutes and hip abductors. The therapist would then progress to strengthening the slow and fast twitch muscle fibers to increase vaginal wall stability and reinforce sphincter closure and further progress by incorporating functional activities into the treatment.

Tension can build up within the PFM over time due to stress, trauma and behavioral habits such as stomach gripping, gluteal clenching and suppressing the urge to urinate for extended periods longer than four hours. The tension can lead to pain, urinary hesitancy, urinary urgency and painful intercourse. A pelvic floor physical therapist can assist in addressing these symptoms by performing pelvic floor relaxation exercises, manual therapy with the use of dilators or a pelvic wand, biofeedback for muscle re-training and education on stress management techniques to promote relaxation within the body.

The body is truly one big chain. Changes that occur during the stages of pregnancy and into postpartum should be considered and addressed. A pelvic physical therapist can be an effective resource in providing education, treatment and tools that can lead to an optimal quality of life.

Kierra Daves, DPT, is with Holy Cross Health.

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