Is this subject too taboo?
When I started my studies for physiotherapy I never thought that I was going to be where I am today. I used to think this job was meant to help people with back pain, broken bones and sport injuries. Isn’t that what physiotherapists spend their precious time on?
I have been following the Luxmama activities for some time now and have also been reading all your comments, and I realised that you as parents now know that your beloved kids also sometimes need physiotherapy, especially around that dark, dreary winter time marked by the dreaded bacterial outbreaks in day-care centers. I wish I knew that during the first year of my university studies.
Fortunately, I discovered pediatric physiotherapy in my second year of university. I enjoyed working with and around children and decided to have a trainee-ship in a maternity hospital to learn more about handling new-born children. That was the time when I was thrown in at the deep end. Not only was I surrounded by crying babies but also and in particular by pregnant women, sexual pain, perineal tearing, incontinence, aching breasts and so much more. I was literally shocked!
Young and ignorant as I was, I had no idea of what happens after the first rush of happy hormones wear off after giving birth. From the movies we learn that giving birth is painful, exhausting and is really really hard, but nobody speaks about why it is so painful. Why is nobody talking about what happens to the pelvic floor during the pregnancy, childbirth and following weeks and months?
In the era of Shades of Grey, when nothing seems unspeakable, unfortunately, the pelvic floor and its injuries like perineal tearing is still a taboo topic. A study (1) says that 93.5% of primiparae (women giving birth for the first time) suffer a perineal tear at delivery. Moreover, 32% to 64% of women world-wide are affected by urinary incontinence (2). Women who experience damage of the perineal structures have pain, social and psychological problems in addition to problems with their pelvic floor (incontinence or organ prolapse) (3).
Women of all ages need to be enlightened. The sooner the better. That is the reason why it is so important to talk about these potential challenges and to prevent them.
Today, I am a physiotherapist specialized in gynaecology, urology and… whoop!… paediatrics.
I want to give you more information about topics like the pelvic floor, doing sports during pregnancy and perineal tears, so that the unpleasant side of delivery is no longer a taboo subject. Women, and men, need to know that there is a way to resolve urinary incontinence, so you can focus more on other more positive sides of being a mum.
The Pelvic Floor
The pelvic floor is the area between the pelvic bones at the very end of our trunk. Roughly speaking you can imagine a bowl of muscles resting between your pubis (the bone close to the bladder), your coccyx (the bone which hurts a lot if you fall on your bum) and your ischial tuberosity (the bones which you sit on).
On the one hand the function of the pelvic floor is it to guarantee continence and to avoid organ prolapse. This security must be given at any moment, also in pregnancy. On the other hand, the muscles must be able to relax when we go to the toilet to voluntarily empty the bladder or the rectum (4). The pelvic floor must hold against the pressure which can result from sneezing or coughing or carrying the baby in the uterus. So, the muscles contract and they lift the vagina and the anus to regulate the push. To sum up, strong pelvic floor muscles are needed (5).
The pelvic floor undergoes changes due to the hormonal and mechanical changes during pregnancy (6). In this context we speak about the weight of the uterus pushing on the pelvic floor (7), the Body Mass Index of the mother before the pregnancy and at the moment of the delivery, but also the weight of the fœtus. The heavier the baby is, the more weight is pushing on the structures of the pelvic floor (8).
The production of the hormones Oestrogen, Relaxin and Progesteron is higher during pregnancy, which influences the pelvic floor and the urogenital organs (9). The effect of those hormones is a loss of stability of the ligaments and muscles, particularly the muscles of the uterus, the bladder and the urinary tract. This results in an inefficient closing mechanism and therefore in urinary incontinence (7). Incontinence is described as an involuntary loss of urine or faecal matter (13). This can be felt during physical activities such as sneezing, coughing or lifting the baby (10).
Physical activity and sports contribute to the production of catecholamine, which helps to guarantee the functionality of the closing mechanism of the urinary tract and safeguards urinary continence (11).
Several other risk factors during pregnancy and delivery can impact the pelvic floor negatively. These include as for example the second stage of birth, smoking habits and epidural anaesthesia (6).
In addition to the slacking of pelvic floor tissue during pregnancy, strains and tears of the perineal structures (vessels, muscles, connective tissue) cannot be ruled out (12).
There are already studies which can prove the positive effect of pelvic floor exercises to prevent incontinence while researchers continue trying to find even more solutions against perineal tear, too.
I would love to accompany you and your friends in your re-education of the pelvic floor. There is no reason why we should live with incontinence after an experience as wonderful as becoming a mum.
About the Author
Carmen Glod is a physiotherapist specialized in urogynecology and paediatrics. She is luxemburgish and studied in Germany. Talking about the pelvic floor is her passion. Her aim is to break the taboo around pelvic floor injuries and incontinence.
She is working in the Cabinet de Kinésithérapie Mélodie Hermant. 121C route d’Arlon 1150 Luxembourg. Tél.: +352 263899
Don’t hesitate to get in touch!
(1) Samuelsson, E., Ladfords, L., Lindblom, BG., Hagberg, H. (2002). A prospective observational study on tears during vaginal delivery: occurrences and risk factors. Acta obstetricia et gynecologica Scandinavica, 81(1), 44-9.
(2) Milsom, I., Altman, D., Lapitan, MC., Nelson, R., Sillen, U., Thom, D. (2009). Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ Prolapse (POP). Committee 1.
(3) Handa, VL., Blomquist, JL., McDermott, KC., Friedman, S., Munos, A. (2012). Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstetrics & Gynecology, 119(2 PT 1), 233-9.
(4) Ashton-Miller, JA., DeLancey, JO. (2007). Functional anatomy of the female pelvic floor. Annals of the New York Academy of Science, 1101, 266-296.
(5) Nyangoh, TK., Bessede, T., Zaitouna, M., Peschaud, F., Chevallier, JM., Fauconnier, A., Benoit, G., Moszkowicz, D. (2015). Anatomy of the levator ani muscle.
(6) Bozkurt, M., Yumru, A. E., Sahin, L. (2014). Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwanese Journal of Obstetrics & Gynecology, 53(4), 452-458.
(7) Chan, S. S., Cheung, R. Y., Yiu, K. W., Lee, L. L., Leung, T. Y., Chung, T. K. (2014). Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study. BJOG: An International Journal of Obstetrics & Gynaecology, 121(1), 121-129.
(8) Bozkurt, M., Yumru, A. E., Sahin, L. (2014). Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwanese Journal of Obstetrics & Gynecology, 53(4), 452-458.
(9) Chen, B., Wen, Y., Yu, X., Polan, ML: (2005). Elastin metabolism in pelvic tissues: is it modulated by reproductive hormones?. American journal of obstetrics & gynecology, 192(5), 1605-13.
(10) Schumacher, S., Müller, SC. (2004). Belastungsinkontinenz und Mischinkontinenz. (electronic version). Der Urologe. 43, 10, 1289- 1300.
(11) Thyssen, HH., Clevin, L., Olesen, S., Lose, G. (2002). Urinary incontinence in elite female athletes and dancers. International urogynecology journal and pelvic floor dysfunction, 13(1), 15-7
(12) Memon, HU., Handa, VL. (2013). Vaginal Childbirth and pelvic floor disorders. Women’s Health, 9(3), 265-77.
(13) Haylen, B. T., Ridder, D., Freeman, R.M., Swift, S. E., Berghamans, B., Lee, J., Monga, A., Patri, E., Rizk, D. E., Sand, P. K., Schaer, G. N. (2009). An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the Terminology for female pelvic floor dysfunction. Neurology and Urodynamics, Version 17, 10-17.