Postpartum Checks, Pelvic Exams, and Incontince with Renee Knowles
January 20, 2021 at 6:06 AM
Compiled by our Senior and Women's Health Physiotherapist Renee Knowles. To book an appointment with Renee, or read her Meet the Team profile CLICK HERE.
Whether you've a little one on the way, or they've already arrived, a meeting with a Women's Health physio at Auckland Physiotherapy will help you understand how to keep (or return) your body to its best physical state, and what can be done to avoid or treat any pain and discomfort.
What problems can we treat?
The team of Women's Health physios can treat a wide range of symptoms that women may experience:
- Urinary urgency/frequency (Overactive Bladder Syndrome)
- Urinary incontinence (stress or urge)
- Faecal incontinence
- Sexual or pelvic/vulval pain
- Pelvic organ prolapse
- Other pelvic pain, vulvodynia, vaginismus (often associated with sexual pain)
- Recovery post perineal trauma during delivery – scaring, pelvic floor weakness etc.
Obstetric (ante or post natal):
- Spinal and pelvic pain – sacroiliac joint dysfunction, symphysis pubis dysfunction (SPD)
- Rib pain
- Shoulder, arm and wrist pains
- Recovery post Caesarean delivery
- Rectus Abdominis Diastasis (separation of the tummy muscles)
We also treat other associated musculoskeletal injuries that may arise during pregnancy or postnatal e.g. knee pain, shoulder pain etc.
What are some of the major signs of a weak pelvic floor and the supporting muscles?
Common symptoms include increased urinary urgency and frequency, which can also come with urgency and/or stress incontinence episodes. It is rare, but some women can experience a loss of faecal control if certain muscles and the anal sphincter have been affected. Often women can also experience low back pain and/or pelvic pain. This pain can also coincide with heavy or dragging sensations that may occur in the lower back or abdomen, if there is descent of the pelvic organs. Sometimes the pelvic floor muscles can be weak, tight or overactive, but can also elicit pain on sexual intercourse due to active trigger points. Whatever the symptoms you may have, it is important to see a Women’s Health physiotherapist if you are concerned.
Why should you not ignore your symptoms and seek treatment?
Firstly, I want to reassure women that research has shown that 1 in 3 will experience some form of urinary incontinence post-partum, therefore you are not alone at all. Often women find the symptoms embarrassing or they just simply don’t have the time as a new mother to see a professional.
It is quite common for pelvic floor weakness to take its time to become symptomatic though, and therefore women don’t realise that they may have a silent issue developing and may have symptoms down the line. The NICE guidelines have established that conservative therapy with pelvic floor muscle training should be offered to women during their first pregnancy and post-partum, as prevention and treatment.
What treatments do we offer?
We can provide manual therapy and rehabilitation for back/neck/pelvic pain (PGP/SPD)/sciatica/carpal tunnel syndrome, dry needling, pregnancy and postnatal massage, Clinical Pilates, preparation for labour, abdominal re-training following C-section or Rectus Abdominis Diastasis, pelvic floor re-training, bladder retraining for overactive bladder, internal manual therapy, and rehabilitation post hysterectomy and other pelvic floor surgery. Guidance for return to sport and exercise is also included within this, along side our running assessment and strength and conditioning team.
What does a pelvic floor examination involve?
A Women's Health internal examination is a helpful part of the treatment process and will allow full assessment of your pelvic floor symptoms and concerns. It will allow the physiotherapist to assess your pelvic floor region, ensure that you are correctly performing a pelvic floor muscle contraction, and also provide a guide to your treatment programme.
If you consent, a vaginal examination will take place in a private treatment area where your privacy will be fully maintained. The examination will involve:
- Observational check of your pelvic region
- An abdominal and neurological screen
- Internal examination of the pelvic floor (vaginal and/or back passage)
- Contraction of the pelvic floor muscles and assessment of how they maintain this contraction when you cough.
- Further muscle and soft tissue analysis
You may opt out of the examination and assessment at any point. After the assessment your physiotherapist will explain their examination findings, formulate a specific treatment plan, and ensure your full understanding to achieve a successful outcome.
If you have any questions or concerns regarding this examination please speak to your physiotherapist who will be happy to discuss any issues with you.
What should you tell your physiotherapist before a pelvic exam?
It is very important that you inform your physiotherapist if any of the following apply:
- You may be pregnant
- You have had a baby recently or have had recent pelvic surgery
- You currently have any vaginal infection
- You have recently received radiotherapy
- You have an allergy to latex or any gels
- Your cultural/religious beliefs do not allow this type of examination
- If you have ever seen your doctor with a complaint of pelvic pain or other problems around the pelvic area
- You are menstruating
When do we recommend women have one?
After your 6-week check with your obstetrician, we can then assess the pelvic floor function also. However, if you have concerns before that stage, or you are in pain we are happy to see you.
Women's Health physiotherapists will often perform an internal examination every 4-6 weeks, to check that your muscles internally are getting stronger and doing their job properly again. It may be more than that if we have other muscle concerns, scaring or trigger points that are causing pain and dysfunction in the muscle system.
What exercises can you do to treat existing issues or prevent future problems?
There are many forms of exercise you can do before and during pregnancy to help prevent and treat musculoskeletal pain, and pelvic floor dysfunction. Firstly, Pilates-based exercise, continuing cardiovascular activity and specific strength exercise that your body is used to is advised. Pregnancy can feel like a marathon at times so the fitter you are before pregnancy, the better you may generally feel during pregnancy and afterwards.
There are sound guidelines that support exercise during pregnancy (e.g. The Royal College of Obstetricians and Gynaecologists and Sports Medicine Australia). Women must ensure they have been cleared to exercise, and a physiotherapist or trainer with specific qualifications in exercise in pregnancy can help guide you.
Looking after your pelvic floor muscles is essential to help prevent leakage from the bladder and bowel ante and postnatal, to help safeguard from prolapse and may improve your sexual function. It is quite important to know that you are doing these correctly and that they are actually appropriate for you.
What exactly should it feel like doing these exercises to make these techniques effective?
An effective pelvic floor contraction should feel as if you are stopping wind and then urination. It should be a squeezing together movement and then a lift forwards and upwards at the same time. Visualisation can be very helpful here. For example, small marbles squeezing and lifting in the openings, visualising a lift going up, or holding in a tampon. Often you will feel the lower abdominal wall of muscle coming into the contraction at the end also.
Pelvic floor muscle exercise, or Kegel's, include endurance based holding and also faster contractions due to the ratio of slow twitch and fast twitch muscle fibres e.g 10 x 10 second holds with and 10 x on and off. It is integral that you don't just brace your abdominals, buttocks and inner thighs, and ensure you keep breathing. Learning to activate the muscles before coughing, sneezing, and lifting in functional day to day activities is very important for functional carryover.
On the other end of the spectrum, sometimes pelvic floor exercises may not be what you need and can make symptoms worse – e.g. for overactive pelvic floor muscles. We recommend booking for a complete assessment.
What forms of exercise do we recommend post-partum (and what to avoid)?
The first thing to understand postpartum is what your body has been through. Hormones and the growth of your baby has affected a lot of the soft tissues and therefore how your joints function. This can have a significant effect on the stability system of the body.
For the first 6 weeks, take it easy, let your body heal, and the soft tissue recoil without overloading it. Avoid heavy lifting for the first 6 weeks. Pelvic floor and transversus abdominis muscle activations as above and with pelvic tilting in different positions is a nice starting point. Walking for cardio with gentle progressions then moving onto other non-impact cardio e.g cycling, cross trainer from 6-8 weeks. No oblique or front abdominal exercises should be performed until you have a good deep transversus abdominis activation.
Rectus abdominis diastasis can occur in up to 80% of women in the third trimester. It is therefore very important to avoid sit-ups, planks and heavy loaded exercise or running/impact work until it is almost closed. Research has shown that there is a strong correlation between abdominal muscle weakness, rectus abdominis diastasis and pelvic floor dysfunction/incontinence.
Return to impact exercise is often the most common topic women are concerned about. Some of the hormones that influence soft tissue laxity during pregnancy can remain in the body until 6 months after you stop breastfeeding. Therefore, the effects and vulnerability to the pelvic floor can continue up until this point. Research is now saying to avoid any impact exercise for the first 6 months at least post-partum.