Pelvic floor muscles are a sling of muscles forming a muscular support at the bottom of the pelvis. They are vital for controlling continence, child birth, pelvic and hip stability, and sexual function. Many people wait until they have problems before incorporating exercises into their daily routine. This blog discusses the function of the pelvic floor and looks at the principles I use to teach rehabilitation exercises which can be done during pregnancy, in the post partum period and for any other time in a woman's life.
What is the pelvic floor?
The pelvic floor muscles is a group of muscles that form a sling around the front (urethra), middle (vagina) and back (anus) passages. These muscles are called coccygeus (ischiococcygeus), levator ani (iliococcygeus and pubococcygeus), as well as deeper sphincters and the perineal body. They all work closely together to create a strong sling.
Pelvic floor functions:
- Continence - controlling the contraction and relaxation of the bladder and anal sphincter.
- Child birth - firstly bearing the weight of the baby and secondly, to allow for the expansion required for vaginal birth.
- Pelvic and hip stability - as you can see from the images below there is very close proximity of the deep hip and pelvic muscles such as obturator internus and piriformis (which control hip internal and external rotation respectively).
- Sexual function - these muscles create the orgasm.
The pelvic floor muscles receive innervation from the pudendal nerve and lower sacral trunks S3-S5.
How to activate your pelvic floor muscles?
The most important part of completing pelvic floor exercises is the technique. To correctly active these muscles you need to 'squeeze and lift' the sling of muscles around your front, middle and back passages. Often squeezing without the lifting leads to a bearing down of your pelvic floor.
Like most other muscles, the pelvic floor responds well to progressive strength training. Initially start by mastering the 'knack' of a squeeze and lift without activating your gluteal or abdominal muscles. It is also important to continue breathing normally and avoid holding or drawing in your breathe. This technique can be performed in lying, sitting or standing.
Lying down will be the easiest as there is less gravity on your pelvic floor. Once the technique has been established build up the repetitions to about 10-15 repetitions.
- To always switch on and let go with control.
- Don't allow your muscles to fade out during the hold.
- Allow just as much rest break as activation time.
- If you can't feel the letting go or feel that the strength of the lift is reducing, your muscles are most likely fatiguing so have a rest.
- Only progress one variable at a time:
- Length of hold
- Number of repetitions
- Position of exercise.
Phase 1: You're in the cognitive learning stage learning about technique.
Learn to switch on your pelvic floor and slowly build up your endurance (length of hold) and repetitions until you are able to comfortably hold up to 10 seconds.
- Pick a posture which feels right for you - lying on your back, side, sitting, standing.
- SQUEEZE AND LIFT the muscles around your FRONT, MIDDLE & BACK PASSAGES.
- The lift needs to stay up... don't hold it so long that your contraction drops off without your control.
- The length of rest is the same if not longer than the time of contraction. You're pelvic floor is a muscle - give it time to recover.
- You have to continue to breathe normally - NEVER HOLD YOUR BREATH.
- Its also a good idea to avoid starting the contraction by breathing in.
Phase 2: You're going to progress the exercise into a functional position such as sitting and standing.
Changing the posture changes the load of gravity on the muscles. In sitting you can feel the support of the surface you are sitting on. This is a great way to get some proprioceptive feedback about your technique. I often say in sitting 'Squeeze and lift equally from front to back, lifting off your underwear...'
Here are some starting positions for phase 1 and 2.
Phase 3: You're now loading the exercise to increase complexity.
Add in arm or leg movements such as floating your arms above your head or performing a squat on a swiss ball. When it comes to feeling the pelvic floor muscles contract, there is not a lot of space allocated in the brain to 'feeling them' and especially when compared to our ability to detect movement in our big limb muscles. So adding in a slow squat or arm movement will a) add more complexity through increased load, and b) add more complexity through concentration and awareness.
Phase 4: Build it into your daily routine.
Progress to a normal exercise routine and try to involve your pelvic floor during your strength or floor based exercises. You might try doing them in part of your weekly workouts or even just practice them every time you're blowdrying your hair if you're still working on sustaining a contraction in standing. Find an activity that allows you to perform these exercises at least 3 times a week if not more.
How to self-assess your pelvic floor strength?
In most cases mothers will have access to a Midwife or Doctor to guide them through the recovery process post-partum. But pelvic floor exercises aren't just used during the child-bearing years. In fact, many athletes who participate in high impact sports will benefit from monitoring and training their pelvic floor. Below are some of the tests I use in clinical practice to determine strength and starting points for exercise.
Duration of pelvic floor contraction in supine, sitting, standing.
This has been covered above but it depends on what position you're in as to how long you'll be able to hold a good quality contraction. The way to measure is to first get the technique of the squeeze and lift and then to count how long that contraction stays at the 'top' without dropping. Count the seconds to get an idea of your duration. Then repeat until fatigue to understand your endurance. From here you can progress the length or number of contractions.
One of the tests for continence is to see what happens when you cough. Positive symptoms may include heaviness or feeling a downward pressure, urinary leakage, farting, or pain.
Start jump test
Before returning to high impact exercise one of the tests you can do to see how your pelvic floor tolerates impact is to do a star jump. If this feels ok, add a cough into the top of the star jump. If this feels ok.... you're doing well :) If not.... you need more time to build up your strength.
What not to do!
- Hold your breath
- Thinking that holding these muscles all day is a good thing.
- Squeeze your abdominals instead of your pelvic floor.
- Squeeze your bum muscles instead of your pelvic floor.
- Hold each contraction until it fails and drops without your control.
- Do the exercises sitting on a open toilet.
- Practice your exercises while weeing.
- Push down on your pelvic floor.
A word of caution.... If you are experiencing symptoms of urinary or faecal incontinence, a sensation of heaviness and weakness and definitely if there is any pain during daily tasks or sexual intercourse - I would strongly encourage an internal pelvic floor assessment with a Continence Physiotherapist, Doctor, Gynaecologist to determine the cause of your symptoms. Not all pelvic floor issues are due to muscle weakness. In some cases there can me muscle trigger points, overactivity and scar tissue from previous tears etc. It's definitely not a 'one size fits all' principle for pelvic floor exercises. Like will all other muscle injuries, you generally benefit from an assessment of the cause of the problem before commencing rehabilitation.
When is it safe to return to exercise after pregnancy?
This depends on what birthing experience you had, the degree of abdominal or pelvic floor injury sustained and the advice of your treatment medical practitioner.
It is generally safe to recommence pelvic floor exercises day 1-2 after giving birth but does depend on your level of comfort, what birthing process you had and what your levels of pain are. Early exercises will assist with regaining your strength, improving continence, and reducing swelling in the perineum.
Following a natural vaginal birth with 0-grade 1 pelvic floor tear you may walk as much as feels comfortable for your body. The best rest for your pelvic floor is horizontal bed rest. Take 30 minutes to lie flat during the day... it goes a long way in your recovery.
Following a grade 3-4 tear or episiotomy you may wish to wait for 4-6 weeks for the tissues to fully heal. In this case you often remain under the care of a obstetrician and will be cleared for exercise around the six week check up. If there are no concerns with your continence (faecal and urinary) then your exercise tolerance is largely dependent on pain tolerance, swelling and bleeding.
Following a natural vaginal birth it is generally recommended that you should not enter into a public pool or spa for six weeks or until vaginal discharge stops.
Following caesarian section you should wait for six weeks before lifting >2kg, driving a car and returning to exercise. This recommendation excludes isometric lower abdominal and pelvic floor muscle contractions and excludes gentle stretches within your range of comfort. You may also walk as far as feels comfortable. The reason there are restrictions on lifting after surgery is to allow for the incision site to heal. Particularly with driving, the reason you won't be covered by insurance is that the wound often makes it too difficult to brake suddenly. So ask yourself the question 'If a child/animal ran onto the road, could you suddenly slam your foot on the break and steer the wheel away?' If the answer is no, don't get behind the wheel. No matter how safe you are, you can't avoid all accidents.
Exercising pelvic floor muscles is becoming more and more incorporated into Women's Health practices and it goes a long way if you know where these muscles are, what they do, and how to switch them on. Good luck and don't forget to 'squeeze & lift'! :)