The purpose of this blog is to outline pelvic floor training, rehab & management for women before, during, and after pregnancy. This covers the anatomy and function of the pelvic floor, cues to best activate it, various positions to work it, and ways to progress to higher level movements.
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This is a practical review of the current information on pelvic floor training for women around pregnancy. This is not specific advice, and you should speak with your doctor or a pelvic floor physical therapist for specific advice on your needs.
Anatomy & Function
Our abdominal region is multiple areas and layers of muscles across it. It can be thought of much like a cylinder, with a front, sides, back, top and bottom. The front is made up of the abdominal muscles, the sides are made up by the obliques, the back by the spinal extensors, the top is made by the diaphragm, and the bottom by our pelvic floor. The pelvic floor muscles lay in and around the pelvic girdle, creating a dome like shape.
Our pelvic girdle is formed by two innominate bones meeting our sacrum. This connection creates a strong bony framework for the muscles and ligaments to utilize.
The muscles that make up the pelvic floor lay across the the bottom of the pelvic girdle, making the floor of the abdominal cavity. Due to the shape of the pelvic girdle, our pelvic floor has a funnel shape, with two primary gaps in it for the uretha and anal cavity. The pelvic floor has a range of functions, most notably regulating bowel and bladder control, involvement with sexual function, and pressure management in the abdomen.
When these muscles contract, they elevate up, lifting the abdominal content that is resting upon them. When these muscles relax, they depress, bringing down the abdominal content that is resting upon them.
As pressure management is a major function of the pelvic floor, it has a coordinated motion with breathing. During inhalation, our diaphragm contracts and lowers, which will push our abdominal organs down. During inhalation, our pelvic floor will normally relax, allowing it to lower and give more space for our organs to move down. In contrast, during an exhalation, the diaphragm will move up, and the pelvic floor will contract, moving up our abdominal content. This creates a relative net neutral pressure system.
If the pelvic floor contracts and resists descending during inhalation, it will have increased pressure to resist, something important we will discuss more soon.
Why You Should Train The Pelvic Floor
During pregnancy, women may experience incontinence, increased abdominal pressure, and back and pelvic pain. After birth, many of these issues may persist.
Training the pelvic floor muscles can help reduce issues with leakage, improve support of the pelvic and abdominal muscles, and help in reducing back and pelvic pain for women preparing for pregnancy, pregnant women, and postpartum women.
How To Do Kegels
In doing a kegel, your goal is to get the pelvic floor muscles to contract, which is something a lot of people struggle with. When you contract, you should feel it, and when you relax, it should relax and you should be able to tell.
It’s just like when you contract your bicep, you should feel it contract, and when you stop, you can feel it relax. To help with feeling this, here are a few different cues you can think about as you try:
Firstly, squeeze like you’re trying to stop the flow of urine. This will help to get more the anterior pelvic floor and urinary sphincter contracting.
Secondly, squeeze like you don’t want to pass gas. This will help to get more of the posterior pelvic floor and anal sphincter contracting.
The third is to pretend there’s a ruby at the edge of your vagina and you’re going to try and draw it in. This will get more of the deeper pelvic floor muscles and not the sphincters.
You can experiment with each of these and even try doing sets with different focuses as these are each beneficial. You may not notice a big difference between the cues at first, but as you get better at contracting your pelvic floor, you’ll be able to coordinate contracting different parts of the pelvic floor.
Now when you go to do the kegel for the first time, it can be beneficial to work on coordinating a contraction with your breathing. To start the movement, take a deep breath in and try to relax, and then as you exhale, perform the kegel and contract your pelvic floor. Try to hold the contraction for 3-5 seconds, and then relax and take a deep breath in again. Over time as you get better with kegels, you can start contracting while inhaling and holding the contraction for 1-2 breaths at a time.
Now let’s talk about a few common mistakes when executing kegels.
First one, squeezing your glutes. Since people often struggle in contracting the pelvic floor, they commonly will contract other muscles around the pelvis, such as the glutes. If you’re sitting and see that you get a bit taller when you contract, then you’re likely squeezing your glutes. You can use a mirror for feedback on this and work on not raising up, or try putting your hands on the sides of your glutes and feel for it.
Second one, squeezing your adductors. Much like the glutes, since the adductors are close to the region, people will commonly contract them as well. You may notice your legs coming closer together, which would suggest you’re contracting them. You can put your hands on your adductors and feel for them being relaxed while you’re doing your kegels.
Third one, doing a crunch or squeezing the abs. Just like the last two, the abdominals attach onto the pelvis and in an attempt to contract the pelvic floor, people will often end up contracting them, sometimes even doing a crunch. You can put your hands below and above your belly button and feel for if they’re contracting and try to minimize it.
Fourth one, performing a valsalva or excess bearing down. In an attempt to get the pelvic floor muscles to contract, sometimes people will hold their breath and contract a lot of abdominal musculature. To minimize this, use the cues from earlier and focus on having a more relaxed abdomen while doing pelvic floor contractions. You can try placing your hands on your stomach again like with the crunch situation.
Working on these is beneficial to learn how to coordinate and improve your control of your pelvic floor.
Changing the position in which you perform a kegel can be beneficial. Firstly, when you change the relative orientation of your body – such as from laying on your stomach to sitting upright – you change the amount of pressure the pelvic floor has to work against. Secondly, certain positions may be more or less comfortable during different time points during pregnancy. Thirdly, as you improve with control, certain positions will be more accommodating to progressing towards more functional tasks.
Supine, or laying on your back, is a common position that is used for early pelvic floor training since the position takes load off the pelvic floor. For those pre and post partum, it can be a great starting position.
In contrast, for many pregnant women, it can be a position where they are not comfortable for long durations of time, so other positions are often used or recommended.
Sitting is usually comfortable and one that can give women a lot of feedback about execution, but it can also be too challenging.
Left side lying is a great position to work the pelvic floor for many women. Since our abdomen isn’t pressing downwards as much on the pelvic floor in this position, it reduces the load that is challenged on it. It’s also generally a comfortable position, particularly for pregnant women who are further long in their pregnancy.
Quadruped can be a progression from left side lying as it’s one where we also are able to get a relative unloading on the pelvic floor, but it loads other parts of the pelvis, low back and abdomen more.
From quadruped you can progress to more vertical positions such as tall kneeling, half kneeling, or sitting. Since these positions bring the load of the abdomen back over the pelvic floor, they can be much more challenging but are beneficial to work towards.
Following these, you can progress by getting into standing positions, whether with feet symmetrical, staggered, or in a split stance. These continue to be more upright, but often take away support from either a chair or legs around the pelvis which can slightly reduce the demand. These positions also increase the opportunity for incorporating more movement options.
Since your goal is to eventually be able to maintain control during all activities, you can then begin progressing your kegel by adding in movement.
A good starting point is trying to do pelvic tilts in whatever position you were previously doing kegels. Think about trying to tilt your pelvis forward and back while maintaining your kegel contraction. Do a contraction, tilt your pelvis forward and back, then fully relax and reset. If you handle that well, then try out these other options.
If you were initially quadruped, you can try rocking forward and back on your hands and knees, getting some upper and lower body motion involved. Start off by contracting your pelvic floor, then rocking back and coming forward, and then resetting. You can work up to multiple reps per contraction over time.
If you were initially in side lying, you can try out doing some side lying leg raises and or side lying arm raises. You can contract your pelvic floor, raise your leg and or arm up, then bring it back down, fully relax and reset and repeat. You can work up to multiple reps per contraction over time.
If you were initially in sitting, you can try transition from sitting to standing, having a contraction in sitting, standing up, aiming to maintain that contraction and then sit back down and relax. Over time you can work up to doing multiple reps of sit to stands per contraction.
From here, you can begin progressing these by making them more challenging, doing more complex movements, adding in more load, etc. Eventually you’ll want to be able to include a kegel contraction while doing standard exercise, like squats, lunges, etc.
For example, in a sumo deadlift, you can set up with the bar in front of you as normal, get down into the starting position, take a breath and let it out, perform the kegel contraction, then lift the bar, return it back down, and relax and reset. Again, over time as you build more ability with managing the contraction and the pressure, you can work up to multiple repetitions per contraction.
Parameters for Pelvic Floor Exercises
When you first start off doing pelvic floor muscle training, you will likely find that you struggle in contracting the area and can’t hold the contraction for very long. Your goal is to increase the strength of the contraction, and the length of time you can hold it. Commonly people will try to train them too frequently, such as multiple times per day every day.
Sometimes this may be helpful if someone struggles in just getting a contraction, but if you can contract them consciously, then you want to work them like other muscles. To do this, we want to use two different styles of workouts.
The first is more endurance oriented. Find a position where you’re comfortable to do them and focus on trying to hold the contraction for 3-5 seconds on exhales. Repeat this for 5 – 15 repetitions based upon fatigue. Rest for 2-3 minutes and then repeat for another 2-4 sets. Then you can repeat that pelvic floor workout every other day, giving yourself a day off to rest and recover.
If you are able to perform multiple sets of 15 forceful contractions, then you’d want to start looking to progress these. To progress it, you can either begin holding each contraction for a longer time, such as holding it for a full breathe cycle. Or you could now begin progressing the positions and incorporating resistance as discussed earlier.
If you’re able to hold the contraction while doing regular exercises, then you can start working on including the contraction while executing a repetition of a movement, then relaxing and resting between repetitions.
The second type of pelvic floor workout is more strength and power oriented. Everything is very similar as before, but this time we are performing shorter and more powerful contractions. You can set up in the same positions as before, but now you’ll perform a stronger contraction for 1-2 seconds, and then relax for up to 5 seconds and then repeat.
The goal is to increase the strength and power for higher effort load activities. Over time you can progress these like the previous, working up in number of repetitions, then progressing by doing them in different positions, then into movements.
You can perform both endurance and strength and power oriented workouts in the same week. You should find that as you perform pelvic floor training that you are having less symptoms over time, such as reduced leakage. If you are not seeing improvement, you should consult with your physician or a pelvic floor specialist physical therapist.
Pelvic Floor Training Summary
Pelvic floor training is very beneficial for women around pregnancy. Since the pelvic floor will have a greater amount of load placed upon it during pregnancy and birth, training it to improve its strength, endurance, and power is important. Through appropriate cueing, we can ensure we optimize the activation of the muscles and coordination of them. Change the positions you perform kegels in by your need to begin with and then to progress the movements over time. Introduce different movements as you improve to improve the functional usage of these muscles.
If you’d like more information on this topic, we have two podcasts that discuss these topics:
Urinary incontinence and pelvic floor training with Dr. Sarah Haag.
Rehab and management of issues around pregnancy – before, during, and after with with Dr. Meryl Alappattu.