As with the introduction of any new exercise while pregnant, it is recommended that you consult with your physician before beginning this exercise program. It is important that you are aware of any symptoms that would signal stress to you or your baby, such as feel nauseous, dizzy, light headed, short of breath, or reaching a heart rate above 140 bpm. If you feel any of these symptoms listed above, discontinue your exercise program and consult with your physician if the symptoms continue. The Hab It team commends you for working toward a healthy pregnancy with increased body awareness! [Read More]
Understanding the muscles that will be supporting your growing uterus and the postural changes that can occur as your pregnancy progresses will give you an opportunity to remain pain free, to work toward an easier delivery, and a quicker recovery. To achieve this understanding, it is important to have a good visual of your anatomy as you progress through pregnancy. The most important area that undergoes significant changes throughout the different stages of your pregnancy is your pelvic “basket”. This basket has the bony stability of your two pelvic/hip bones as borders on the sides, and your tail bone in the back. It is the soft tissue of your transverses abdominus (TA) muscle that encircles the front of your pelvic basket and the soft tissue of your pelvic floor muscles that close off the bottom of the basket.
These two soft tissue areas of your pelvic basket are the most stressed throughout your pregnancy. To help you further identify these two areas, simply place your hands on your hip bones to feel the bony borders. As you roll your hands across the front of your pelvis, you will feel the muscular area that is your transverses abdominus muscle. This muscle is able to stretch through the length of its fibers as your pregnancy progresses, offering support to your growing belly as well as to your low back. It is important to recognize that you maintain the ability to activate your TA throughout your pregnancy even as it stretches. In fact, maintaining good tone in your TA muscle plays a big role in a pain free pregnancy, and easier delivery, and sets you on the right path to a healthy recovery.
Now that we have felt your transversus abdominus muscle at the front of your pelvic basket, we will work to find the bottom of your pelvic basket. If you place your hand on your pubic bone and roll your hand just beneath this bony landmark, you now can feel the soft tissue of your pelvic floor. The muscular and connective tissue that makes up your pelvic floor spans this open area, extending back to your tail bone and spanning the area between your two sit bones. The expectation is for your pelvic floor to cradle and support your bowel, bladder, and uterus, as well as to control the passage of solids, liquids, and air from your body. This significant responsibility is shared by the 4 layers of muscular and connective tissue that make up your pelvic floor.
The most superficial layer of your pelvic floor is your anal sphincter, a circular muscle that controls your anal opening. The second layer is your urogenital triangle, which is a triangular group of muscles that sit up closer to the pubic bone and are primarily sexual in function. The third layer is your urovaginal sphincter that forms a figure 8 around your vaginal and urethral openings. The final and deepest muscle layer of your pelvic floor is your levator ani, which is often described as a sling or a hammock. This muscle connects from your pubic bone back to your tail bone and when it contracts, it pulls hard on these attachments to draw that sling or hammock muscle to a tighter position, higher within your pelvic outlet. This muscle action not only works to support your three pelvic organs, but it also squeezes tight on the urethra that extends from your bladder down to your urethral opening.
Your pelvic floor is truly the base of your pelvic basket, with little to no bony support. Because of its position it is challenged by gravity, any weight carried within your abdomen and pelvis, and any increase in intra-abdominal pressure. Beyond these variables, simply the anatomy of having three openings within this relatively thin tissue increases the probability of pelvic floor dysfunction which can lead women to accidental urine leakage (incontinence) or inadequate support of one or more of your pelvic organs (prolapse).
Pregnancy and childbirth are additional challenges for the muscular and connective tissue of your pelvic floor. It has been reported that your pelvic floor muscles can stretch up to three times their original length during late-term pregnancy and delivery. This is logical as every extra pound that you carry within your abdomen and pelvis is an extra pound that your pelvic floor must support throughout your pregnancy. It is this direct stress on the pelvic floor that often produces symptoms of occasional urine leakage during pregnancy when these strained muscle fibers lose their ability to fire effectively. These incontinence symptoms most often increase in the third trimester when your baby and your uterus undergo the most rapid growth, placing more pressure on your pelvic floor muscles and your bladder. The stress on the pelvic floor tissue increases as women approach delivery, requiring their pelvic floor to stretch to its limit and often beyond resulting in tearing of the muscles. If cesarean delivery is required, it is the transversus abdominus muscle that is compromised, requiring separation of these muscle fibers as well as an incision of the uterus itself.
Recognizing the changes that your body goes through during pregnancy and the further trauma that the tissues undergo with vaginal or cesarean delivery highlights the importance of strengthening the muscular tissue of your pelvic floor and your pelvic basket as you progress through pregnancy. Consistent exercise of all the muscles of your pelvic basket will help to ensure efficient communication between the nerves and muscles as they change in length and experience increased strain. Keeping the communication between our nerves and muscles primed will not only help throughout your pregnancy but will also help those muscles recover more quickly following delivery. Common symptoms that women experience following delivery as their muscles work to recover are urine leakage, prolapse of one or more of their pelvic organs, pelvic floor pain, low back pain, and/or hip pain. All of these symptoms can be the result of ineffective muscle activation or inadequate muscle strength following the trauma of pregnancy and delivery. Preparing your body with appropriate strengthening exercises for your pelvic floor and your entire pelvic basket as well as learning how to find and hold optimal posture can help to prevent the muscle dysfunction that can cause these symptoms.
In the next few paragraphs, we will describe specific exercises that can safely be performed during pregnancy to work the front, back, sides, and of course, the floor of our pelvic basket. This exercise instruction will be followed by a section highlighting the most common postural mistakes made both during pregnancy and following delivery. All of these exercises as well as postural positioning are preventative measures you can take to give yourself the best opportunity for a pain free pregnancy, an easier delivery, and a quicker recovery. [Read Less]
1. Pregnancy side lying kegel (8 reps/day)
To perform a 2-Step Kegel sequence in the side lying position (this is the best starting position during pregnancy) follow these instructions. Begin by positioning yourself on your side with your head placed on a pillow or your hand. Bend your knees to 90 degrees, with one leg directly on top of the other. Your shoulders, hips, and ankles should all be in line, with your knees bent out in front.
In this position, first perform a Kegel contraction by tightening your pelvic floor as if to stop the flow of urine or the passing of gas. Hold this Kegel contraction as you begin to elevate your pelvic floor up into your pelvic outlet. Imagine there is a string attached from your belly button down to your pelvic floor and you are attempting to pull it up. Keep pulling that "string" up for a full 8-count. (You will feel your belly button draw in as you work to pull your pelvic floor higher. This is your transversus abdominus coordinating along with your pelvic floor contraction.)
At the count of 8, release your hold, relaxing your pelvic floor down, allowing yourself to take in a deep breath and release, relieving all muscle tension. Now, follow with 4 quick flicks or quick Kegel contractions. With this action, you are only tightening the muscles around the openings of your pelvic floor as if you don't want to pass any urine or gas. These are quick contractions with a quick release to a rhythm of "tighten, relax, tighten, relax" and so on for four quick flicks. These quick flicks isolate the sphincter muscles of your pelvic floor so your back shouldn't move and your legs should remain in the same position (bent at 90 degrees) as when you started the exercise.
You have just been instructed in one complete Kegel sequence, consisting of a pelvic floor elevation followed by 4 quick flicks. As a women's health physical therapist, I recommend you perform eight complete 2-Step Kegel sequences each day to maintain good tone in your pelvic floor muscles. You do not have to perform all eight at once. You may find that your muscles fatigue too quickly to perform eight in a row, so you may benefit more from performing groups of Kegels throughout your day. Keep in mind, the key to successful rehabilitation of the pelvic floor is not quantity but consistency!
Further information on the 2-Step Kegel:
Performing a sidelying kegel is recommended because it allows your pelvic floor to work free from the pull of gravity. However, once you feel comfortable with activating these muscles, you want to progress to performing the 2-Step Kegel sequence in sitting and standing positions. These positions are more functional because most of our daily activities are performed in sitting and standing. They are also more difficult as you now have to work against the pull of gravity and you also have to work to hold neutral spine. This neutral spine position ensures appropriate extension of your tail bone because your pelvic floor will pull on this attachment when it contracts. Setting a solid anchor for your pelvic floor to pull against is important to achieve maximum pelvic floor control. You can also refer to the last exercise in this instructional write up for further guidance on finding your neutral spine posture.
* The Hab-It: Pelvic Floor dvd provides physical therapist guided kegel sequence instruction with visual and verbal cues as well as thorough instruction in neutral spine positions when working sitting and standing kegel exercise.
2. Pregnancy Hands and Knees TA lift (3x10)
You can feel this coordinated effort as you identify your TA contracting, drawing your belly button up and in, when you work to elevate your pelvic floor as instructed in the 2-Step Kegel exercise. In order to achieve maximum pelvic floor control, you have to be able to produce an effective transversus abdominus contraction. To achieve a safe and effective TA contraction while pregnant, follow the instructions below.
Position yourself on your hands and knees and relax your belly. A side view of your body in a mirror is great visual feedback as you can see the movement of your belly. Activating your TA muscle will lift your belly up from its relaxed position to a tighter position as if being cinched up like a corset. The mirror will allow you to see the movement of your belly, but will also ensure that you see no movement of your hips, back, or upper body. The only movement should be your belly drawing up to a tighter position. Hold each TA lift for a 5 count before releasing and watching your belly drop back down before repeating. You should feel the pressure within your pelvis and abdomen lift up under your ribs with each contraction. If you feel any "bearing down" sensation or any downward pressure within your pelvis, you are activating the wrong muscle group.
*Note the difference between activating your transverses abdominus (TA) versus activating your rectus abdominus (RA) which is associated with diastasis recti. Your TA cinches up your midsection, drawing everything in and up when contracted. Your RA, on the other hand, curls your ribs closer to your pelvis, increasing the downward pressure on your pelvic floor. Performing 3 sets of 10 TA lifts and holds each day will ensure good tone of this muscle throughout your pregnancy and help to achieve a quicker recovery of this muscle following delivery.
3. Pregnancy Multifidi extensions (3x15)
Your multifidi muscles are responsible for giving your tail bone a lift and holding your lumbosacral spine in a neutral position. This neutral spine position holds your pelvic floor muscles at the perfect length with the optimal tension to fire efficiently and effectively. To learn how to activate your multifidi muscles, giving a light tension to your pelvic floor muscles, follow the instructions below.
To begin, it is recommended that you stand so that you have a side view of your body in a mirror to give you good visual feedback. In this standing position, place your hands on your hips, so that you can feel the subtle movement of this exercise, which is a slight rotation of your pelvis. As you activate your multifidi muscles of your low back, you will give a lift to your tail bone. The view that you should see in the mirror is your low back and pelvis rotating into a gymnast posture when you activate your multifidi muscles. It is important to be sure the movement is at the level of your pelvis only and that there is no movement of your legs, upper back or shoulders. Remember that your pelvic floor muscles attach to your tail bone, so that with each multifidi contraction, you are passively increasing the tension in your pelvic floor muscles and then relaxing them repetitively throughout the reps. 3 sets of 15 multifidi extensions are recommended each day to work these stabilizing muscles.
4. Pregnancy Hip Abd-add (3x10)
To begin this exercise, position yourself on your Swiss ball or sit on the front edge of a chair to allow your knees to drop slightly below the level of your hips. This positioning will allow you to roll your pelvis forward so that you now feel pressure on your two sit bones and your pubic bone. This is optimal sitting posture as it rocks you forward to sit on your body's natural tripod and takes all sitting pressure off your tail bone. This is neutral spine when sitting and is the best position to activate your pelvic floor.
From this neutral spine position, place a soft ball or pillow between your knees and squeeze your knees together for a 3 count before releasing the tension. Repeat this 3 second squeeze and relaxation for 10 repetitions before releasing the ball or pillow from between your knees. The second part of this exercise requires you to place your hands on the outside of your knees, providing your own resistance. Contract your deep hip rotators by attempting to push your knees apart against the resistance of your own hands. Provide enough resistance so that there is no movement of your knees. Hold this isometric contraction for a 3 count and then relax. A common mistake in this exercise is to hold your breath while pushing and holding your knees. Remember breath holding increases the pressure down onto your pelvic floor, so be sure to breathe out as you push, allowing yourself to take a breath in on the relaxation phase and then breathe out as you push again. Continue this pattern for 10 repetitions before going back to another set of adductor squeezes with the ball or pillow between your knees. Continue alternating these exercises until you have completed 3 sets of 10 repetitions of each. Again, it is optimal to make this a daily exercise to maintain the efficient firing of these stabilizing muscles throughout your pregnancy and into your recovery following delivery.
That completes our review of pelvic basket strengthening exercises that can be performed throughout your pregnancy. In summary, your pelvic basket has a big job to do in supporting your organs, managing the passing of solids, liquids, and air, not to mention holding up your growing uterus as your pregnancy progresses. By strengthening all the muscle groups of the pelvic basket, you can increase your ability to manage through the symptoms which commonly develop during pregnancy and after the child's birth and make a symptom-free recovery more likely.
5. Pregnancy Posture
These four bony landmarks are the base of your pelvic basket and they also serve as attachments for your pelvic floor muscles. You can visualize how a posture that tucks your tail bone under, moving your tail bone closer to your pubic bone would create slack in your pelvic floor. This loose muscle responds poorly and becomes weak because you are never able to fully activate all of the fibers due to a muscle that is shortened beyond its contractile capabilities.
Unfortunately this tail bone "tucked under" position is quite common for new moms. Its during this time that moms may spend a significant amount of time sitting with your little one, usually in a very relaxed position, tucking their tail bone under for prolonged periods of time. Then, once moms stand, it is common to thrust their hips forward and their tail bone under to allow their baby to lay on their chest or to provide a hip or belly for them to sit on. New moms must remember to simply extend their tail bone, giving it a slight lift to put their pelvic floor muscles at the perfect length/tension ratio where it can fire all of its muscle fibers efficiently and effectively. This highlights how our posture can position the attachment sites for our pelvic floor for optimal function.
Your posture also plays a second role in your pelvic floor function by shifting your pelvic organs forward or back. This effect can be demonstrated by placing your hands on your hips and rocking your pelvis forward and back. Your hands are placed on the sides of your pelvic basket (your hip bones) and by rocking your pelvis, you are tilting your pelvic basket up on its side and back down to its base. Although, as we have previously stated, there is minimal bony support for your pelvic floor, you are able to shift your pubic bone down to a more suportive position when you rotate your pelvis and lift your tail bone. The more supportive position of your pubic bone when you are in neutral spine, takes some pressure off your pelvic floor muscles, allowing them to contract more efficiently which helps to keep you continent as well as give better support to your pelvic organs.
In the previous two paragraphs we have recognized the "tail bone tucked under" position as a common postural mistake, but the opposite extreme, exaggerating the curve of the lower back, can be a significant source of low back pain which can also effect pelvic floor function. During pregnancy, when the weight of your growing belly shifts your center of balance forward, there can be a strain on your lumbar vertebrae, creating an exaggerated lumbar curve. In this position, the extreme extension of your lower lumbar spine, in what can be described as a gymnast's posture, causes excessive boney compression of the lumbar vertebrae. This is a common cause of low back pain experienced during pregnancy and can be treated by finding your neutral spine position that requires your pelvis to be somewhere between the two extremes that we have labeled the "tail bone tucked under posture" and the "gymnast posture"
When you are in t his extreme extended position, activating your transversus abdominus by drawing your belly button up and in can give good support to the joints of your lower spine and pull you into a position of neutral spine which will relieve your low back pain. "Turning on" your transversus abdominus muscle is like tightening up your own corset that will soften your lumbar curve, bringing each individual vertebrae out of the compressed position that can be a significant source of pain and pelvic floor dysfunction.
Now that you have a good visual of why and how posture can affect your pelvic floor muscles, just imagine how important posture becomes as your pregnancy progresses, when you are carrying a new born baby, or when you cough or sneeze. All of these actions increase the pressure on your pelvic floor, so holding optimal posture becomes even more important to assist your muscles. You can take an active role in holding optimal posture throughout your day with some simple steps including: unlocking your knees, lifting your tail bone, and drawing your belly button up and in, to help you find and hold your neutral spine position.
The information that we have provide d in this "Knowledge of Your Pregnancy Body" write up is designed to give you a better understanding of how you can actively contribute to a healthy pregnancy. Having a good visual of your anatomy, instruction in effective strengthening exercises, and an awareness of your posture are 3 important steps you can take to prevent pain and/or dysfunction both during and following your pregnancy. The Hab It team is committed to leading you through a healthy pregnancy and recovery post partum. Cheers to your health!