Preventing postpartum prolapse: It’s more than just pelvic floor exercises
How does your pelvic floor perform under pressure?
It’s an important question, particularly when it comes to preventing postpartum prolapse of the vagina and bladder leakage. Women’s Health and Continence Physiotherapist, Taryn Watson from FitRight talks about the other aspect of pelvic floor management that mums are often not aware of – the pressures that go through the abdomen and pelvis.
I remember learning early in my pelvic health career that when looking at managing women with prolapse, you need to consider ‘did it fall or was it pushed?’
This means – did the organ (bladder, uterus or bowel) fall down because of lack of support from the pelvic floor or connective tissue
OR was it pushed down from pressure above?
Or very likely – was it due to both?
Working this out then leads the physio to determine how to manage this woman – do we need to focus on optimising the pelvic floor muscles, or change the amount of load through the abdomen, or both?
I’m sure that many women think managing a prolapse or incontinence is all about the Kegels (pelvic floor exercises) and getting a strong pelvic floor, but it’s amazing how often you can change symptoms of leakage and prolapse without changing the pelvic floor strength at all. It’s all about how you breathe and what strategies you use to move.
What causes increases in pressure in the abdomen and the vagina?
Often it’s due to things like repetitive heavy lifting, or doing abdominal exercises like planks or sit-ups. But sometimes it’s lesser culprits, like getting up from a chair, going up stairs, or holding your baby.
Multiple studies have shown it’s not what you do, it’s how you do it.
Intra-abdominal pressure isn’t necessarily the enemy – we need to increase pressure in our abdomen in order to do lots of daily tasks like coughing or getting up from the ground, and we definitely need to increase intra-abdominal pressure to perform tasks associated with sport and exercise.
And the strategy you use to increase this pressure should change according to the level of the task. For example, if you want to lift your 1 rep max at the gym, or you need to lift the edge of a heavy couch to get something out from underneath– yes, you will need to hold your breath.
The main issues occur, however, when this strategy of breath holding occurs repetitively at lower level tasks. If you use a high load strategy for something that is a long way below the highest load you can lift, then this unnecessarily puts a strain on your pelvic floor and pelvic organs and may occur multiple times in a day.
Why do some women hold their breath for low-level tasks?
It may be to do with a lack of general strength. If you aren’t strong enough to do a task, it is possible you do employ these high load strategies and do things like hold your breath to get up from a chair or pick up your baby.
It may be a learnt habit. If abdominal surgery like a caesarean or hysterectomy caused both pain and an interruption to the pressure system, after the surgery you may be inclined to breathe more shallowly and hold yourself more carefully.
Or, if during your pregnancy, you always held your breath to get up from the floor because of the extra weight, you may have continued to use this strategy afterwards.
It’s not that these are wrong strategies in the short term, but variance in the way you move and breathe should return afterwards, and when it doesn’t, this can cause problems, such as postpartum prolapse, in the long term.
Preventing postpartum prolapse…how do I know if I am putting excessive pressure on my pelvic floor?
Check this out yourself, even if you’re not symptomatic for prolapse or incontinence. How much pressure are you exerting during relatively low load activities in your daily life or at the gym? Do you know if you hold your breath with daily activities?
Next time you get up from the ground, lift a washing basket or push a trolley round a corner, try talking while you do it. Does your voice change?
Put your hand on your abdominal wall or between your legs and feel what happens to your pelvic floor and abdominal wall when you sing, cough or shout. Can you feel them going in or do them push out? If they push down and out, knowing that this strategy could set you up for problems, are you able to change this?
So just take this information away with you. Sit-ups are not necessarily the enemy, and in studies, they are often not the movements that cause the biggest changes in pressure. Often it’s the transitional movements that are done accidentally with a bearing down action that cause the biggest changes.
The ideal rehabilitation plan after having a baby or after having gynaecological surgery should be an individual assessment of how your pelvic floor functions, how you breathe and what strategies you use to move.
If you would like to learn more, I would highly recommend listening to the following podcast with Dr Susan Clinton – she is a wealth of knowledge on this topic and she adds a lot more practical information about managing intra-abdominal pressure.
FitRight has been created specifically to provide exercise class options that help to manage and prevent issues like incontinence and prolapse. With our classes for pregnancy, new motherhood and menopausal age, our physiotherapists will help you to get strong in tasks like sit to stand and getting off the floor, get specifically strong in your core and pelvic floor, and learn different ways of breathing and moving during exercise.
A real-life story
I want to put this in perspective for you with the example of a lovely client from my Baby&Me class recently. She was about 3 months postnatal after her second baby and had been seeing me for treatment of a moderate vaginal prolapse that was causing her to be quite uncomfortable while she was caring for her baby and toddler.
At her initial assessment, I realised that with movements like getting up from the bed, coughing and lifting any weight, she was pushing her abdomen out. When she was cued to ‘contract her core’, which she had been doing repetitively in her previous reformer pilates classes, she was actually pushing her tummy out and pushing the prolapse down.
During one of her first Baby&Me classes, I made sure I sat next to her while I instructed the class to do a set of modified sit-ups. I realised that something had clicked – she was pulling her abdominal wall gently in and breathing out while she did it, in a completely different way to before.
I quietly gave her a high five and after class, I checked how she was lifting and coughing too – also completely differently. At her next appointment in the clinic with me, her prolapse wasn’t giving her any symptoms and her pelvic floor was functioning in a much better way.
I gave her a hug and said, “do you realize that you may have just changed the trajectory of your life?”
It’s stupid that such a little thing got me so excited, but I honestly think that the fact that she learnt (in only a few weeks!) how to do a sit up, i.e. how to get up from the bed or the floor, in a way that doesn’t breath hold and doesn’t push her abdomen and pelvic floor out, will stop her prolapse from getting to the point of needing surgery.
To find out more about FitRight or book into one of their physio-led classes, head to the FitRight website. The next round of FitRight classes starts on 25th Feb 2019.
This post is sponsored by FitRight.