September 27, 2011

The Pelvic Floor, Prolapse and Pregnancy

It is quite ironic that I started this blog prior to the labor and delivery of my son, and now I am in the midst of dealing (and healing!) with pelvic floor problems postpartum. I was originally drawn to this subject matter because so many students discretely approached me about pelvic floor issues. Many had bladder prolapse, and several were still suffering from incontinence months after the delivery of their child.

It was surprising for me to learn that so many women were quietly suffering from pelvic floor dysfunction. My own midwife explained about 20-25% of her clients have some sort of pelvic floor weakness postpartum. So while it is a common issue- it is rarely talked about. I believe this is mainly due to women being embarrassed to talk about the pelvic area. One of our teacher trainees kept referring to this area as “the bathroom muscles.” It is unfortunate that there is such shame, isolation and embarrassment when addressing the powerful area of the body that carried and birthed our babies.

One of the woman I spoke with asked if there was anything she could have done prenatally to avoid the bladder prolapse and incontinence she suffered from. One proactive idea: next time you are at your prenatal or 6 week postpartum visit, ask your care provider to assess your pelvic floor strength and check for pelvic organ prolapse. If your care provider recognizes a problem, it is best to find a physical therapist who specializes in pelvic floor issues and start a rehabilitation regimen. Even if all is well with your pelvic floor it is still important to establish a regular Kegel routine.

Why Should I address this Issue?
The strength and flexibility of the pelvic floor is especially important to address during and after pregnancy mainly because of the effect of the hormones relaxin and progesterone, combined with the weight of the growing fetus, weakens the pelvic floor. If a woman does not maintain a strong, flexible and healthy pelvic floor, she can suffer prolapsed bladder (Cystocele), prolapsed uterus, prolapsed anus (Rectocele), urinary incontinence, back pain and pelvic pain. Even if a woman gives birth by Cesarean section, she will still have carried the weight of her baby for an average of 40 weeks, and the pelvic floor will have experienced some weakening.

My midwife explained to me that during the postpartum stage, the estrogen level drops dramatically- on par with what is experienced during menopause. This drop of estrogen effects the muscle tone and leaves the muscles in a more relaxed state. Decreased estrogen levels can account for some of the hypotonia (low muscle tone) which can diminish the sphincters from fully closing leading to incontinence and a lack of support for the pelvic organs. If the mother is breastfeeding, this low level of estrogen is prolonged until solid foods are introduced to the baby. Once the baby has started on solids, the mother is often breastfeeding less and her estrogen levels start to increase.

Brief Explanation of the Pelvic Floor Muscles.

The pelvic floor is made of two layers of muscles, the superficial layer and the deep layer. The muscles that we focus on when practicing Kegels are part of the superficial layer of the pelvic floor. To help visualize these muscles, you can think of a figure 8 shape. Simplifying this greatly, the bulbospongious muscle is the front loop of the figure eight, which runs from the clitoris to the central tendon (the perineum), and the anal sphincter is the back loop of the figure eight.

The deep layer of pelvic floor muscles are made up of the Levator Ani and Coccyeus muscles and create a bowl shape. These two muscles are the sides of the bowl, or the walls of the lesser pelvis, and support the pelvic organs in their proper alignment.

What is Prolapse of the Organs?
When the normal anatomical position of the pelvic organs slips out of place either into the vagina or presses against the vaginal walls due to a weakened pelvic support of muscles and ligaments, one experiences prolapse of the organs. The extent of severity is measured as 1st, 2nd and 3rd degrees of prolapse.

What Can Be Done During Pregnancy and After Pregnancy to Prevent Prolapse?

There are several ways to help prevent prolapse during and after pregnancy. As I already mentioned, continue to regularly practice Kegels, also maintain a healthy weight and diet (this will lessen the pressure and weight on the pelvic floor muscles), avoid smoking, exercise regularly, and refrain from straining during a bowel movement.

Besides kegel exercises, you can maintain strength and stability in the pelvic floor by also working what I call the periphery muscles to the pelvic floor- the adductors, abductors (inner and outer thigh muscles) and transverse abdominal muscles.

In prenatal and postnatal yoga class, we often include poses to target these muscles groups. Poses such as:
-squeezing a block between the thighs for downward facing dog, utkatasana (chair pose), tadasana (mountain pose) and uttanasana (standing forward bend)
-opposite limb extension
-strapping thighs and pushing outward into the strap
-prenatal and postnatal abdominal -specifically transverse abdominal exercises

The transverse abdominus is the inner most muscle. It arises from the lower 6 costal cartilages, the lumbar fascia and the iliac crest. The fibers of the transverse muscles run inward towards the midline. You can think of this group of muscles as a natural corset, helping to stabilize the torso and maintain internal abdominal pressure. Unlike the other three abdominal muscles, the transverse abdominus does not move your spine. You flex this muscle to pull in your belly.

Transverse abdominus muscles can be toned using an exercise involving deep slow exhalations of the breath. The pregnant mom comes on to her hands and knees. While trying to maintain a flat back, she inhales and releases the muscle tone of the belly and then exhales contracting the transverse and rectus abdominus. Many women want to “cat/cow” in the exercise, and it is more effective to avoid undulating the spine. Another way to think about this exercise is to imagine that with each exhalation you are tightening a corset around your middle, and drawing their baby closer to your spine.

Symptoms of Prolapse Organs
* A feeling of heaviness or pressure in the pelvis
* Pain in the pelvis, abdomen or lower back
* Pain during intercourse
* A protrusion of tissue from the opening of the vagina
* Recurrent bladder infections
* Unusual or excessive discharge from the vagina
* Constipation
* Difficulty with urination, including involuntary loss of urine (incontinence), or urinary frequency or urgency

What Can Be Done After Pregnancy to Repair the Situation
There are several options for repair depending on the severity of the pelvic floor issue.

* Pelvic floor exercises or electrical implants – These may help to strengthen your pelvic floor muscles if your prolapse is minor.
* Vaginal pessary – This is a plastic ring put inside your vagina to prevent any loose vaginal skin from coming down. It can be an effective and comfortable alternative to surgery, but does not work for everyone. With regular checking it may work for many years.
* Laparoscopic surgery – This is an operation using keyhole instruments. The pelvic floor is repaired through a number of small cuts in your abdomen rather than through your vagina.
* Burch colposuspension – This is an abdominal operation to lift the bladder. If your bladder has prolapsed, especially when you also have problems with leaking urine, this may be the best treatment.

All of these alternative treatments may be improved by hormone replacement therapy (HRT) or by using hormone creams, called oestrogens. These help by increasing the blood supply to your pelvic organs.

Commonality of the Problem

It is estimated that at least half the women who have had more than one child have some degree of genital prolapse (although only 10-20% complain of symptoms)

From the women I have talked to, there is little discussion postpartum about pelvic floor prolapse with their OB/GYNs or Midwives. Interestingly, an article came out last year in the New York Times, highlighting that in France “all new mothers are entitled to 10 free sessions of pelvic floor rehabilitation, followed by abdominal workouts. The sessions, which are paid for by the French government, include electric stimulation devices and computer games that aid in post-birth recovery.” (2) So if your care provider does not bring this subject up, it may be up to you, the new mother, to inquire about the state of your pelvic floor.

This is a message from one of my students. “Stress incontinence after complete recovery from vaginal birth (e.g. several months) is not something you should have to accept as part of the effects of birth on your body. Get evaluated and if your stress incontinence cannot be address with physical therapy (as was my situation) review your surgical options. I “put up with” the condition for two long years thinking that I could kegal my way back to normalcy. I wish I had been more aggressive about treatment options earlier on.

Where to find Treatment

Pelvic floor rehabilitation may not be the specialty of all physical therapist. I would recommend researching specifically for a PT that has a strong background in that area.

In the NYC area, I would recommend:
* Pamela Morrison at Pamela Morrison Physical Therapy P.C (This is the PT I have been working with. She is on the UWS and is fabulous! A real no-nonsense woman!)
* Isa Herrera at Renew Physical Therapy
* Amy Stein at Beyond Basics Physical Therapy





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