Pelvic floor in pregnancy: care and exercises

Welcome, mum! In this article I'd like to talk to you about a very important subject that affects many women during pregnancy and birth: the pelvic floor. As you know, the pelvic floor is a structure of muscles and connective tissue that supports the organs of the pelvis, such as the bladder, the uterus and the rectum.

During pregnancy, the growth of the foetus and weight gain can put a great deal of pressure on the pelvic floor, which can lead to problems such as urinary incontinence and pelvic organ prolapse. What's more, birth can also have a significant impact on the mother's pelvic floor health.

In this article, put together by our team of midwives using the latest scientific evidence, we are going to look at how pregnancy and birth can affect the pelvic floor, what preventive and treatment measures exist for these problems, and how you can look after your pelvic floor before, during and after pregnancy to maintain your quality of life and wellbeing. As a midwife, my aim is to share my experience and knowledge with you so that you can enjoy a healthy pregnancy and birth without complications related to the pelvic floor. Let's begin!

What is the pelvic floor made up of?

The pelvic floor is made up mostly of the levator ani and coccygeus muscles, such as the paired puborectalis, the pubococcygeus and the iliococcygeus. The muscles of the urethral and anal sphincters are also part of this structure. The endopelvic connective tissues sit above these muscles and connect to the side walls of the pelvis and the sacrum.

On the outer and lower part of the pelvic floor is the perineal membrane, which includes the bulbocavernosus, transverse perineal and ischiocavernosus muscles. The innervation of this area comes from segments S2, S3 and S4 of the spinal cord, which merge to form the pudendal nerve. This nerve innervates the external anal sphincter, while the levator ani muscles, the coccygeus muscles and the urogenital diaphragm appear to be innervated by a direct connection of S2, S3 and S4 nerve fibres.

What happens to the pelvic floor during pregnancy and birth?

Science suggests that the biological mechanisms of pelvic floor injuries during pregnancy and birth are not yet fully understood. However, it is thought that stretching, compression or tearing of the nerve, muscle and connective tissue due to pregnancy and birth contributes to these injuries. Neuromuscular function and support of the pelvic organs are essential for your body to work normally.

During birth and vaginal delivery, the descent of your baby's head can stretch and compress the pelvic floor and the associated nerves, which can cause demyelination and denervation (problems).

Studies suggest that most pelvic floor injuries resolve during the first year after birth; in some cases, evidence of denervation injury can be seen up to five or six years after birth. Denervation injury can accumulate with increasing parity, and it is not known why some women recover neuromuscular function after birth and others show evidence of permanent damage.

Always bear in mind that the levator ani muscle complex is essential for pelvic floor function, and losing its function can lead to widening of the urogenital hiatus and descent of the pelvic organs.

How do I know if my pelvic floor is weakened?

There are several symptoms that may indicate weakness in the pelvic floor. Some of the most common include:

1. Urinary incontinence: Involuntary loss of urine when coughing, sneezing, laughing or making a physical effort.
2. Urinary urgency: A sudden, intense need to urinate.
3. Difficulty emptying the bladder: A feeling that the bladder has not emptied completely after urinating.
4. Pelvic organ prolapse: Descent of the pelvic organs such as the uterus, the bladder or the rectum.
5. Pain or discomfort in the pelvic area or during sex.
6. Loss of bowel gas or stool.

If you experience any of these symptoms, it is advisable to consult a healthcare professional, such as your midwife, a physiotherapist specialising in the pelvic floor or a gynaecologist, to receive an appropriate diagnosis and treatment.

If you would like to know what the weekly symptoms are on the wonderful journey of pregnancy, I invite you to visit our pregnancy calendar, where we talk about the different sensations, your baby's development, tips, and much more! This will help you feel safe and supported on this beautiful journey. Access the Happymami pregnancy calendar here.

What things damage the pelvic floor?

Parity consists of several components (pregnancy, labour, birth), each of which can contribute to the development of pelvic floor disorders. The following sections review the evidence on the role of each component.

Pregnancy and the pelvic floor

During pregnancy, urinary incontinence is more common than before pregnancy due to pelvic floor impairment. Between 7% and 60% of women report urinary incontinence during pregnancy, with the highest incidence of incontinence during the second trimester.

And although these symptoms resolve in most women after birth (70% of mums) or after the postpartum period, between 11 and 23% of mums still have incontinence 12 months after birth. One positive note is that the severity of incontinence decreases in the first year after birth, with a substantial reduction in both the frequency of incontinence episodes and in other measures of severity.

Incontinence in pregnancy and the pelvic floor

Women who suffer from incontinence during pregnancy appear to have a higher risk of postpartum urinary incontinence symptoms due to a previously weakened pelvic floor, compared with women who have not experienced incontinence during pregnancy.

Maternal age and the pelvic floor

As women get older and have children, the risk of problems in the pelvic area increases, such as urinary incontinence and pelvic organ prolapse caused by greater weakening of the pelvic floor. One study has shown that women who give birth vaginally after the age of 30 are more likely to need surgery to treat these problems than women who have children before the age of 30.

Baby's birth weight and the pelvic floor

Some studies suggest that a higher birth weight for the baby may be related to a greater risk of pelvic organ prolapse caused by weakening of the pelvic floor, but it is not clear whether there is a link with urinary incontinence.

For example, a study of women who had given birth 20 years earlier showed that the risk of pelvic organ prolapse increased by 3% for every 100 grams of increase in the baby's birth weight. However, no link was found between birth weight and urinary incontinence. In addition, another study found that women who were born weighing more than 4000 grams had a 50% higher risk of having urinary incontinence problems in the future.

Pelvic floor pain in pregnancy

Pain in the pelvic floor during pregnancy is a common complaint that affects many women due to the physical and hormonal changes that occur at this stage. This discomfort is usually related to the baby's weight gain, the growth of the uterus and the relaxation of the ligaments caused by hormones, especially relaxin.

Among the most frequent symptoms are:

• A feeling of heaviness or pressure in the pelvic area.
• Sharp pain when walking, standing up or changing position.
• Discomfort when making an effort, such as coughing or sneezing.

To relieve the pain, these strategies can be followed:

1. Gentle exercises: Carrying out controlled movements, such as Kegel exercises, which strengthen the muscles of the pelvic floor.
2. Postural changes: Avoiding standing or sitting for a long time, alternating positions to reduce pressure on the pelvis.
3. Complementary therapies: The use of physiotherapy specialising in the pelvic floor or accessories such as pelvic support belts can be a great help.
4. Adequate rest: Resting with your legs raised to reduce pressure on the pelvis.

If the pain persists or significantly affects your quality of life, it is important to consult a healthcare professional for an appropriate assessment.

How to look after your pelvic floor during pregnancy

Caring for the pelvic floor during pregnancy is essential to prevent discomfort and prepare yourself for a healthy birth. These muscles support the weight of the uterus and take an active part during labour, so keeping them in good condition is key.

Recommendations for looking after your pelvic floor during pregnancy:

1. Strengthening exercises: Practising Kegel exercises regularly helps to tone the muscles of the pelvic floor. These consist of contracting and relaxing the muscles as if you were trying to stop the flow of urine.
2. Avoiding excessive effort: Reducing activities that involve carrying weight or making sudden movements that could weaken the pelvic floor.
3. Postural hygiene: Keep an upright posture and avoid crossing your legs when you sit down to improve circulation and reduce pressure.
4. Bowel care: Avoiding constipation by eating a diet rich in fibre and keeping hydrated to prevent unnecessary effort when going to the toilet.
5. Consult a physiotherapist: A specialist professional can guide you through specific exercises and make sure your pelvic floor is in optimum condition for birth.

Looking after your pelvic floor will not only help you during pregnancy, it will also make postpartum recovery easier, preventing problems such as urinary incontinence or prolapse.

How can you strengthen your pelvic floor during pregnancy?

Doing exercises to strengthen the pelvic floor muscles during pregnancy can help reduce the short-term risk of urinary incontinence in women who had no previous incontinence problems. However, it has not been established whether these exercises offer long-term benefits.

An analysis of several studies found that pregnant women who did these exercises had a significantly lower risk of urinary incontinence between three and six months after birth compared with those who did not do them. It is important to note that most of the studies included women who had not given birth before.

In studies that assessed women six or more months after birth, no significant effect was observed, and a trend was noted towards a lower rate of urinary incontinence in those women who did not do the pelvic floor strengthening exercises.

In addition, it is important to bear in mind that postpartum pelvic floor exercises can be harmful for some women, since if they have suffered injuries to the levator ani muscle complex during birth, an exercise programme may be contraindicated in the initial phase of recovery from the injury.

When should you start pelvic floor exercises in pregnancy?

Exercises for the pelvic floor muscles done during pregnancy help to reduce the short-term risk of urinary incontinence in women with no previous incontinence, but a long-term benefit has not been established.

In addition, there is no specific recommended routine for starting pelvic floor exercises. A randomised trial found no reduction in urinary incontinence in postpartum women who did supervised pelvic floor exercises for 16 weeks.

How long does the pelvic floor take to recover after birth?

The recovery time with pelvic floor exercises depends on each individual case. Bear in mind that these are beneficial exercises, but ones that do deliver results in the long term. So keep up this routine over time, because over time pelvic floor exercises will strengthen your pelvic floor and you will notice their positive effects.

Bear in mind that there are professionals who specialise in this subject, both midwives and physiotherapists, who can help you achieve this in the best possible way.

What are the consequences of an episiotomy?

An episiotomy is a surgical procedure carried out during birth to widen the vaginal opening and make it easier for the baby to come out. Although it is a common practice in many places, it has been shown that it can have negative consequences for pelvic floor function.

The mediolateral episiotomy, which is an incision into the levator ani and coccygeus muscles, can affect the function of the pelvic muscles. However, a study in Sweden reported that the mediolateral episiotomy was not associated with pelvic muscle strength six weeks after birth.

It is important to note that there are currently no proven treatments for women who suffer a levator avulsion during birth, which is an injury to the muscles that support the pelvic organs.

A small study showed that women with and without levator avulsion have a similar response to postpartum pelvic muscle exercises. Therefore, it is not common to assess levator avulsion in the postpartum period, since there are no effective secondary prevention measures and it has no clinical value.

Prevalence of pelvic floor damage

Women who have given birth to at least one child have a higher prevalence of pelvic floor disorders, which suggests that pregnancy and birth play a causal role in their development. The rate of pelvic floor disorders increases with the number of births, and it is estimated that 50% of cases of incontinence and 75% of cases of prolapse in parous women can be attributed to pregnancy and birth.

The effect of parity is more noticeable in premenopausal women, while age is an important risk factor for pelvic floor disorders in postmenopausal women. In nulliparous women under 55, the prevalence of urinary incontinence is 6.5 to 18% and that of prolapse is around 0.6%. Several comparative studies have shown that parity and age significantly affect the prevalence of pelvic floor disorders.

For example, a national survey in the United States found that parous women had a higher prevalence of urinary incontinence and prolapse compared with nulliparous women. It was also observed that the prevalence of pelvic floor disorders increased with the number of births and with age. Overall, these findings support the importance of preventing and treating pelvic floor disorders in women during and after pregnancy and birth.

What happens if the pelvic floor is damaged?

Damage to the pelvic floor can have various consequences, including:

1. Urinary incontinence: weakening of the pelvic floor muscles can prevent the urethra from closing properly and cause urine leaks when doing physical activities or making an effort.
2. Pelvic organ prolapse: when the pelvic floor muscles weaken, the pelvic organs (such as the uterus, the bladder or the rectum) can descend and protrude into the vagina.
3. Pelvic pain: weakening of the pelvic floor can cause pain in the pelvic area, especially during sex.
4. Bowel problems: weakening of the pelvic floor can cause difficulty passing stool or faecal incontinence.

It is important to note that not all people with a weakened pelvic floor have symptoms, but if a problem is suspected it is advisable to consult a pelvic floor specialist for an appropriate assessment and treatment.

How can you strengthen your pelvic floor?

As well as pelvic floor exercises, there are other methods for strengthening the pelvic floor, but these will need assessment and implementation by a specialist professional such as your midwife or physiotherapist:

• Biofeedback: This involves inserting a sensor into the vagina that identifies which muscles you are contracting and measures the strength of each contraction. This can be useful if you find it difficult to isolate the pelvic floor muscles during Kegel exercises, and it can also give you an idea of your progress as you manage to strengthen your pelvic floor.
• Electrical stimulation: This involves placing a device in the vagina or anus that delivers a small electrical current which makes your pelvic floor muscles contract. This technique can be carried out together with biofeedback.
• Vaginal weights: Much more common, as they can be bought in pharmacies or online. They are weights that are inserted into the vagina and that you will need to hold in place during everyday activities using your pelvic floor, thereby increasing its strength. Although the evidence supporting this method is limited, some people find it helps them to strengthen their pelvic floor.

Conclusion: the pelvic floor

In conclusion, strengthening the pelvic floor through pelvic floor muscle exercises during pregnancy can reduce the short-term risk of urinary incontinence in women with no previous incontinence. However, the long-term benefits have not been clearly established.

In addition, the evidence on the effectiveness of pelvic floor exercises in women with pre-existing urinary incontinence is limited. It is important to bear in mind that postpartum pelvic floor exercises should be done with caution, since some women may suffer injuries to the levator ani muscle complex during birth. Overall, more studies are needed to determine the long-term effects of pelvic floor exercises during pregnancy and postpartum in the prevention and treatment of pelvic floor disorders.

Pelvic floor bibliography

1. Facog LBM. Patient education: Pelvic floor muscle exercises (Beyond the Basics) . Uptodate.com. . Available here.
2. Handa VL. Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse . Uptodate.com. . Available here: