All About the Pelvic Floor
The pelvis and the pelvic floor are the key parts of the body when we are speaking of pregnancy and birth. Although this is pretty well known, we don’t always pay attention to the importance of pelvic floor muscles, mostly because of a lack of information.
When I was studying my postpartum doula training with Childbirth International, I came across a Tedx talk by a women's health physiotherapist on the course readings. She made it so clear how attention shifts from the mother to the baby after giving birth. How babies have many routine checks in the first year, but mothers have only one or two. How some problems have never been discussed and considered the ‘normal’ of motherhood. That made me think a lot because it is so true. That was around the same time when I met Aygül, who is a physiotherapist that specializes in pelvic floor. I listen to the same things, but more extensively, from her. I have also done readings about this topic and I talk about it in detail in my education sessions.
We had an interview session with Aygül and she answered some of the basic questions about women's health physiotherapy and the need for it during pregnancy and after birth. I asked her the questions that are important for pregnant mothers and mothers who have given birth. Her contact details are at the end if you would like to reach her to learn more.
Ayşegül Boz Baltacı (ABB): First of all, very briefly, what is the pelvic floor or women’s health physiotherapy?
Aygül Köseoğlu Kurt (AKK): Pelvic floor muscles form a crucial group of muscles within the pelvic bone, playing a significant role in our bodies. These muscles contain openings for the urethra, vagina, and rectum, leading to the outside world. That's why our pelvic floor muscles are key to both our bathroom habits and our sexual health. We, as pelvic floor physiotherapists, or, in other terms, women's health physiotherapists, specialize in treating pelvic floor dysfunctions and preventing these types of problems through rehabilitative care.
A critical part of our job is teaching patients how to strengthen their pelvic floor muscles, how to relax them, and generally how to maintain health in this area.
ABB: You mentioned pelvic floor dysfunctions, what are these dysfunctions?
AKK: Urinary incontinence, urgency, frequent urination, difficulty emptying the bladder, feeling like there's still urine in the bladder after urination, being able to feel even small amounts of urine, getting up at night to use the bathroom, leaking urine when laughing, sneezing, coughing, or doing physical activity, difficulty holding stool, fecal incontinence, involuntary passing of gas, constipation, difficulty with bowel movements, feeling like you can't completely empty your bowels, pain during intercourse, lack of sexual desire, pain in the pelvic region, urinary tract infections, and organ prolapse are among the pelvic floor dysfunctions we often encounter in our clinic. Underactive or overactive pelvic floor and a lack of coordination can be the reasons for these dysfunctions. To determine which category you fall into, a physical examination is essential.
ABB: What can you say about women’s need for pelvic floor physiotherapy during pregnancy and postpartum?
AKK: I can wholeheartedly say that I could talk for hours about why pregnant women and postpartum women might need a pelvic floor physiotherapist and why they do. But if I were to summarize, the pelvic floor is a muscle structure that undergoes various stresses at different times, from childhood toilet training to menopause and beyond. What kind of stress, you might ask? Well, there is childhood potty training, the onset of menstruation during adolescence, sexual intercourse, pregnancy, childbirth (whether vaginal or cesarean), weight fluctuations, and menopause—all of which can cause biomechanical and emotional stress on the pelvic floor at different times. However, the literature indicates that the most significant biomechanical pelvic floor trauma occurs during pregnancy, childbirth, and menopause.
Talking about pregnancy and childbirth, increased intra-abdominal pressure during pregnancy, the uterus pressing against the bladder, and the relaxation of the pelvic floor muscles in preparation for birth can all lead to pelvic floor dysfunction. Regardless of the mode of delivery, childbirth tends to cause even more trauma to the pelvic floor. Studies show that vaginal birth results in pelvic floor problems in 27% of cases, while cesarean birth leads to problems in 12% of cases. However, two-year follow-up studies indicate that the mode of delivery doesn't have a protective effect on preventing pelvic floor problems.
It's documented that there's a significant decrease in pelvic floor muscle strength starting from the 20th week of pregnancy and lasting until the 6th week postpartum. This loss of pelvic floor muscle strength, leading to dysfunction, affects 46% of women postpartum, according to statistical studies. This means that almost one out of every two women reading this blog who have given birth is at risk. From this, it's clear that regardless of the mode of delivery, every woman who has given birth should at least consult a pelvic floor physiotherapist once, even if she has no issues, to get advice and a risk assessment for pelvic floor health.
ABB: So, do you think pregnant women can do anything for pelvic floor health during pregnancy?
AKK: Of course, it's not just me saying this. Science has proven it. Pelvic floor muscle exercise training is recommended as the first step in treating and preventing pelvic floor dysfunction because it has a low risk of harm during pregnancy. It's been shown that starting pelvic floor exercises no later than the 20th week of pregnancy has a significant impact on maintaining pelvic floor health during pregnancy and after childbirth. So, it's advised to start pelvic floor-protective exercises as soon as possible. But the critical question is, who should be doing these exercises, how often, with how many repetitions, at what intensity, and for how long?
Unfortunately, many pregnant women or new mothers tend to rely on YouTube videos, childbirth books, or advice from people who aren't physiotherapists, to address pelvic floor issues. However, just as you wouldn't start taking medication without consulting a doctor, you shouldn't attempt pelvic floor exercises based on videos or suggestions without consulting a pelvic floor physiotherapist. During my career, I've seen many cases where pelvic floor exercises done with the wrong dosage and technique either worsened symptoms or provided no benefit at all. I've even had clients who, thinking they were doing pelvic floor exercises correctly for years, ended up doing unsuitable exercises, wasting time, and unfortunately, worsening their pelvic floor health. So, I highly recommend stepping away from the "just do Kegels" mindset and seeking advice from a pelvic floor physiotherapist to get an exercise prescription tailored for you. Because pelvic floor exercises are much more than just Kegels.
ABB: Something I know as the consequences of interventions, but I want to ask you: Do interventions such as episiotomy or cesarean section increase the need for pelvic physiotherapy in the postpartum period?
AKK: In defining the risks associated with childbirth-related pelvic floor problems, it has been reported that vaginal birth presents a greater risk for early pelvic floor issues compared to cesarean birth. However, as I mentioned earlier, studies have shown that this risk equalizes over a two-year follow-up period, indicating that the mode of delivery does not create a significant difference in the long-term occurrence of pelvic floor problems. Additionally, factors such as a second stage of labor lasting more than an hour, the need for an episiotomy, the use of assistive equipment during delivery, the baby's birth weight, and the number of births are all documented risk factors. From this, a woman preparing her body for childbirth, learning what to expect during labor, and working with a doula can reduce the risk of episiotomy, assistive device use, and prolonged active labor—all of which are modifiable risk factors for potential pelvic floor problems. Therefore, regardless of the mode of delivery, the best investment a woman can make in her pelvic floor health is to meet with a doula and a pelvic floor physiotherapist before giving birth.
This is crucial because sometimes the mode of delivery can change based on medical indications, which is a natural part of the process. Also, as mentioned earlier, the mode of delivery does not offer a clear advantage over the other for pelvic floor health in the long run. What is certain, however, is that the support and skills we gain before and during childbirth are invaluable in preserving our pelvic floor health.
ABB: What do you think are the reasons that women generally do not know about the need for pelvic physiotherapy after birth?
AKK: I want to answer this question with some striking numbers. Scientific data shows that women who report urinary incontinence within the first three months after childbirth have a 76% chance of experiencing incontinence 12 years later. This is a startlingly high rate. Additionally, 23% of women who experience pelvic floor problems postpartum tend to isolate socially and face emotional issues such as depression, anxiety, and stress. However, sadly, it's reported that 70% of women with urinary and/or fecal incontinence complaints after childbirth have never discussed their symptoms with healthcare professionals. Although the reasons for this can vary from one society to another, my personal experience and observations suggest that after childbirth, women tend to prioritize their babies over themselves. This leads to delays in seeking treatment for their complaints. Unfortunately, these delays can often cause the symptoms to grow like a snowball, negatively impacting the success of our treatment. In some cases, delays in finding the right team or person to consult can also postpone treatment. In this context, families need to support women postpartum, recognizing that a mother's physical and mental well-being can also impact the baby.
ABB: What are the life-long benefits, or, in other words, what do you miss out on when you don’t see a pelvic floor physiotherapist after giving birth?
AKK: The good news is that there's nothing life-threatening, but this is a situation that can significantly reduce your quality of life. You don't necessarily need to have a problem to consult with a pelvic floor physiotherapist after childbirth. We, as women, are all at risk of experiencing pelvic floor problems at some point in our lives. That's why it's incredibly valuable to have a pelvic floor check-up, conduct a risk analysis, and take preventive measures. Starting preventive approaches early can reduce the likelihood of experiencing pelvic floor problems in the future and decrease the severity of symptoms by approximately 40%. The preventive steps and exercises you take now can help protect your pelvic floor health in the long term.
ABB: Last question: when should people book an appointment with you? Which week in pregnancy and how many weeks after birth?
AKK: For pregnant women, I recommend starting to seek support from us to protect their pelvic floor health before reaching the 20-week mark. In the postpartum , they should consult with us as soon as possible. The first rule of pelvic floor physiotherapy is patient education, and we don't necessarily need to meet face-to-face for the initial consultations. The first steps in early pelvic floor health protection include learning how to carry the baby, which maneuvers to use when getting out of bed, and what to be mindful of while defecating and urinating. Don't expect sessions with heavy exercise; even teaching proper breathing techniques is incredibly valuable during this period. Assessing for diastasis recti in the early phase and addressing it during the tissue healing process is a good step for your future pelvic floor health.
ABB: How could they reach you?
AKK: You can reach me by email at aygulkoseoglu@gmail.com, on my Instagram @aygulkoseoglu, or on my website at www.aygulkoseoglu.com.
