31: Your Pelvic Floor (Part 2) with Specialist Dr. Mary Ellen

Last week in Episode 30, part one of the pelvic floor series, Dr. Mary Ellen Kramp explained what the pelvic floor is, what happens to it during pregnancy and birth, and what we know about preparing the pelvic floor for childbirth. If you haven’t listened yet, I highly recommend that episode. Today we picked back up in our interview with Mary Ellen to ask her our questions about the state of the pelvic floor after birth. What happens to it, what’s considered a normal change during the healing process, and what’s considered a sign to seek therapy. Spoiler alert: mothers do not need to accept peeing a little every time they laugh as the new normal just because they have given birth before. But I’ll let Mary Ellen explain this and more today in part 2 of the pelvic floor series.

So Mary Ellen, is incontinence normal?

One thing I tell women is, if they normally tend to have stress incontinence they will notice that for a couple of days before their period until about day two or three of their period, their pelvic floor strength just falls in the toilet (weakens).

They talked about that when I took that very first pelvic floor course. During the course, we tested each other's pelvic floor strength the very first day. (That’s one thing we do as pelvic PTs is we learn and then one of us drops trow and hops on the table for hands on learning to practice all the techniques.)

This period of weaker pelvic floor really struck home for me because on day one of this course, I had 5/5 strength in my pelvic floor. And then day four, as I was approaching my period, all of a sudden I'm barely able to contract my pelvic floor! I was like, “What the hell.  Why is my pelvic floor so weak?”.

So if somebody has a tendency to have issues, like throwing out a couple drops of urine when they sneeze, it tends to be more common as your period's approaching since there's a drop that happens in progesterone.

After childbirth, you’ve basically just passed a bowling ball through your pelvis. Hormones are all over the place at this point.  You've had really high progesterone for months and now you're getting a very sudden drop in progesterone. (Just like right before your period.) (Dr. Kramp provides more insight regarding normal verses dysfunctional incontinence in sections below.)

What do you expect right after birth?

When the baby's born, there's this huge drop in progesterone after that placenta is delivered. So pelvic floor weakness just after birth is normal. Plus the pelvic floor gets pretty mushy leading up to birth. Clinically, I can definitely feel a difference in a woman's pelvic floor as she's getting really close to going into labor because the muscles just start feeling softer and softer. 

So with all of these factors, there's already a low tone in the pelvic floor for a woman postpartum. (Think of low tone as muscle readiness.) And, you've now had a baby pass through there. The muscles are kind of going, “Oh my God” because you've also had a head and shoulders scraped across the back of your bladder, your urethra, and across your rectum.  

In addition to the pelvic floor muscles, you also have fascia throughout this area. Fascia is the connective tissue that surrounds and supports everything in your body. It has its own tone as well. Now normally, the fascia has some oomph to help support the rectum and the bladder to help those structures stay where they are, but sometimes with pregnancy or childbirth, supportive tone can get shut off. 

After birth, things can be quite unsupported between the hormones and the trauma.

How long is an average healing process?

The first two weeks or so after childbirth, everything is trying to figure out where it is and what it's doing again. Physicians and obstetricians have said for decades that you need six weeks to recover from birth, and of course it goes far beyond that, but you really shouldn't be having any weird incontinence things after about two weeks. 

A little bit of incontinence here or there in the first days to two weeks, okay yeah, that can happen as everything's really changing and you're bleeding tons and so forth and so on, but everything should be under your full control within two weeks or so. It’s normal for things to still be healing and changing, but if you consistently can't get to the toilet in time, that's not normal.  

What should we be doing postpartum to support the pelvic floor?

Just normal stuff. Taking care of any damaged tissue, gentle contraction to stop the flow of urine, gently relaxing to go to the restroom, etc. 

What are signs that something is wrong?

If you have zero control. Because you should have some control even from the get go, hopefully you have full control. So zero control, that would be a red flag.

In Europe, pelvic PTs see everyone who's given birth and they don't wait this weird 6 week period to start seeing women after childbirth. If there's no control of urine or no control of feces, then yeah I would say that you should seek support and not have to be incontinent for a full six weeks before you go see a pelvic PT.  

What are Kegels (/kay-glz/)?

Basically, contracting your pelvic floor. That's a Kegel. It's kind of like what a bicep curl is for the bicep muscle. The pelvic floor is a group of muscles and when you're flexing that group of muscles it’s called a Kegel.

Could you just get on a little caution soapbox about Kegels?  

Kegels are really kind of a fad right now. When you are post birth and trying to figure out where your pelvic floor is again, contracting those muscles is very important.  Figuring out how to contract them and making sure that that's contracting properly is a good thing. However…if you’ve had, say, a second or third degree tear in those muscles, or if you have a lot of restrictions in that area, then the your Kegels can be very non-optimal or dysfunctional.

As a  PT, I never feel like it's fair to be exercising a muscle when there's dysfunction in it. I want to get the dysfunction out first, so that I'm not teaching the muscle how to contract weirdly.  If you're constantly teaching your muscles to contract, and it's doing so in a wonky manner, are you truly helping them? No, you're just strengthening this “wonk-a-doodle” pattern. So in my biased opinion, I like to get those kinks out of the system first. Then, get the pelvic floor to contract most functionally. Because here’s the other issue, the amount of time that you have to contract those muscles is milliseconds. Those muscles can be really strong, but unless they can contract properly in that window- urine is going to come flying out. Half a second too late, and it's too late!

Proper use of Kegels is fine, but if there's an issue somewhere else in your muscles, such as a structure that's not in proper alignment or something not functioning appropriately, then you're practicing incorrect Kegels (not effective). 

Who should NOT do Kegels?

If a woman has pelvic floor pain, Kegels are not what they should be doing. This includes someone who has pain with intercourse, pain with sitting, or pain with standing, etc. In these cases, we don't want to be exercising the crap out of those pelvic floor muscles. That's not what they need to be doing.

Usually, they need to be learning how to relax those pelvic floor muscles and how to not contract them. Often someone is holding these muscles in a contracted position. It’s just like how some people tend to hold their shoulders up really tight or some people tend to clench their jaws.  Some people tend to clench their pelvic floors. I've also found that a significant percentage of those who've had sexual trauma tend to hold really tightly in the pelvic floor.  Those people do not need to be doing a thousand kegels because they really need to be learning how to relax those pelvic floor muscles.

Others contract their glutes or their thighs when trying to contract their pelvic floor. They too would benefit from a pelvic floor therapist. When you're trying to contract the pelvic floor, you should be able to isolate and pull up on those muscles.

What’s your gold nugget advice for pregnant or postpartum moms?

See a pelvic PT when you're still pregnant. See a lactation consultant after you’ve given birth. And, see a pelvic PT again after you've given birth even if you think things are going right, because I see a lot of women who assume or are told that some changes are “normal” that are not. (E.g. “You’ve had a big baby so your new life includes peeing yourself when you laugh too hard or sneeze.”) Just because something happens commonly, doesn't mean you should suffer with it. It means you should seek treatment for it. 

Mary Ellen goes on to say: Just because you've had a baby doesn't mean you need to pee yourself. Just because you've had a baby doesn't mean you need to have pain with sex.  And just because you've had a baby doesn't mean you need to have limited control of your bowels. It's not true. You can get treatment for it. 

Another example is diastasis recti (when abdominal muscles can separate during pregnancy).  Sometimes they come back together and sometimes you need skilled help (some cases require surgery). A pelvic PT can assess the abdominals in addition to the pelvic floor.

Here’s a list of things a pelvic floor physical therapist can help with:

• Prolapse issues 

• Diastasis recti

• Pelvic floor pain

• Incontinence

• And much more!

I am so grateful for Mary Ellen sharing her wisdom on these sensitive topics. If you would like to get in touch with her I’ve included her contact link below. Mary Ellen also teaches other clinicians through her continuing education course, so for any OT or PT pelvic floor therapists reading this I am also including that link.

Links mentioned in the show and article:

Work with Dr. Mary Ellen Kramp in the Washington area at https://thriveagainpt.com/about-us/

Email Mary Ellen personally at: maryellenpt@evolutionmedical.org 

Find Mary Ellen’s courses for professional pelvic floor therapists: https://evolutionmedicalassociates.com/courses/