Written by: www.physiotherapyclinic.com.au
What happens during Pregnancy
The pelvic floor and endopelvic fascia undergo changes during pregnancy, influenced by the major hormonal shifts taking place, and the new musculoskeletal demands on the body. We are talking about three main hormones, relaxin, oestrogen and progesterone.
Relaxin peaks in the first trimester, allowing connective tissue (ligaments, fascia and muscles) to stretch and lengthen. This stretch gives the pelvis the mobility needed to open the pelvic inlet, making room for the baby to engage in the pelvis, and the pelvic outlet to allow the baby to exit the pelvis and be born. Oestrogen and progesterone slowly rise and peak in the third trimester, similarly aiding the pelvis to open for delivery.
Oestrogen and progesterone drop rapidly once the placenta is delivered, and these hormones stay low throughout the breastfeeding time frame. When we are low in oestrogen, our connective tissue including ligaments, muscles, fascia and blood vessels lack elasticity, and thus the ability to “bounce back” which may contribute pelvic organ prolapse and incontinence. Vuval skin can be drier and weaker which might be noticeable returning to intercourse after having a baby. (we are not saying stop breastfeeding to get your oestrogen back, but its good to know as oestrogen returns, function improves).
What can happen to the pelvic floor and endopelvic fascia during vaginal delivery
Vaginal delivery may contribute to pelvic floor dysfunction.
This can occur from a number of variables.
1.Length of time in second stage: If the mother is in second stage of labour ( ie: pushing stage) for more than two hours, it is a known risk factor for pelvic floor dysfunction, for two reasons. One: The long sustained stretch on the muscles and fascia can leave them elongated and weak. Two: The long sustained stretch also happens to the nerves that supply the pelvic floor and bladder, and this stretch can inhibit the nerve from working effectively. Poor neural function can contribute to early incontinence and pelvic floor weakness.
2.The deep layer of the pelvic floor muscles (the levator ani) themselves can tear during birth which of course lends them to be less functional. Tearing can also occur through the superficial pelvic floor or perineum and into the anal sphincter. Once again, this trauma needs healing time and rehabilitation.
If the mother has had a delivery that includes any of the above components, it is possible, but not definite, that she may have sustained an injury that needs rehabilitation. Remembering the role of the pelvic floor is to support the continence mechanisms in our body, support our pelvic organs and helps sexual function.
What do we (physiotherapists) assess post birth and how to we manage what we find?
As a physiotherapist working in women’s health, we like to assess our post natal women at six weeks post partum regardless of their delivery!
The factors discussed are alarm bells for pelvic floor dysfunction, but given that sometimes pelvic floor weakness is silent in terms of symptoms, we like to see our clients anyway. In particular if a women is wanting to return to exercise. We love exercise, all types of exercise, we love helping people exercise the way they want to exercise. But some exercise will place more load on the pelvic floor and pelvic organs than others - and we want to make sure all mums have pelvic floors ready to absorb the load!
Depending on the findings of our assessment, we will likely set a rehabilitation program, design a return to exercise plan, and where necessary fit aids called “pessaries” to stabilise pelvic organ prolapse.