By Cara McDougall, Reg. PT

If you are pregnant, don’t think that leaking urine, having constant pelvic pain and abdominal separation are ‘just what happens’.  Plenty can be done during pregnancy and after delivery to help these issues.

MYTH #1: UNSAFE EXERCISES IN THE PRESENCE OF A DIASTASIS RECTUS ABDOMINIS

Many, if not all, women experience a diastasis rectus abdomens (DRA) during pregnancy, which is defined as a stretching of the linea alba fascia between the left and the right vertical strips of rectus abdominis muscles. In fact, one study found that 100% of women had a DRA in their third trimester, and that 35-39% of those women still have a DRA at 6 months post-partum(1).

The significance of a DRA is that the presence of this stretched and thinned connective tissue compromises the myofascial tension that the inner core is able to generate and maintain, in order to most efficiently and effectively stabilize the spine and pelvic girdle and control intra-abdominal pressure (IAP) . A woman may notice that her belly bulges or tents when she sits up from a lying position or with exercise for example.

Until recently, the status quo regarding correcting a DRA had been to avoid certain activities believed to create excessive IAP and strain on the already stretched linea alba. Under this regime, activities such as sitting up in bed from a lying position or doing crunches at the gym were thought to be potentially injurious or at least  responsible for prolonging the separation. Furthermore, until recently, many had presumed that certain activities such yoga, were safe for pregnancy and DRA.

However, recent studies that have measured IAP have revealed that pressure generated by activities of daily living and exercise actually varied widely between participants. The wide variation has been said to likely be due to factors such an inadequate form,disordered muscle recruitment, and breath holding. Furthermore, some very surprising values of IAP were found for previously assumed benign or safe activities. For example , in one study participants generated more IAP during downward dog than a crunch (2,3). The importance of considering IAP is that how women perform particular movements can elevate IAP above what their inner core can resist.

This latest research indicates that labelling certain movements or activities as “unsafe” may not be doing our moms-to-be justice; but rather highlights the fact that each woman needs to be individually assessed and educated on how to engage her inner core in a functional manner to generate appropriate levels of IAP. Therefore, recent research has revealed that the pressure created during certain movements has much more to do with how a person is executing the movement, versus the activity or movement itself.

MYTH #2: IT’S NORMAL TO LEAK URINE WHILE PREGNANT

Stress urinary incontinence is defined as the unintentional loss of urine with any kind of increased IAP, for example coughing, sneezing, laughing, jumping, or squatting. In the case of unintentional urine loss, the pressure or the force exerted by the detrusor (bladder muscle), exceeds that of the internal and external sphincters, thereby allowing urine to escape. Although it is relatively common, indeed one study suggested as many as 41% of pregnant women experience urinary incontinence, it is NOT normal (4).

One long term, 12 year prognostic study found that onset of SUI during pregnancy or within the first three months post-partum was very predictive of SUI 12 years later. Indeed, they found that 42% of women reported SUI 12 years after their first delivery (5). Thus, it is important that SUI be recognized as a  pathological condition; one that can be corrected in most situations with proper pelvic floor muscle training.

MYTH #3: NOTHING  CAN BE DONE TO RELIEVE PELVIC GIRDLE PAIN (PGP) DURING PREGNANCY

Pelvic girdle pain is “pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints…may radiate to the posterior thigh and can also occur in conjunction with or separately in the pubic symphysis…endurance capacity for standing, walking and sitting is diminished…exclusion of lumbar spine causes…reproducible by specific clinical tests” (6). Commonly cited causes of pelvic girdle pain include biomechanical factors, hormonal factors, parity, and genetics. Incidence in pregnant women is approximately 20% (7).

Contary to the belief that nothing can be done to help relieve, diminish, or abolish PGP, there is actually a lot that can be done. Research advocates that individualized treatment programs be created, focusing on stabilizing exercises that enhance lumbar spine and pelvic control and stability (8). With proper assessment and treatment, prognosis of PGP can be remarkably good. One study found that 90% of women who had experienced PGP during pregnancy, and sought treatment for it, were reportedly symptom free 18 months post-partum (9).

Similar to the evidence for pelvic floor physiotherapy and stress urinary incontinence, there is such strong evidence for the treatment of PGP from a physiotherapy perspective, that the Canadian Physiotherapy Association and the Society of Obstetricians and Gynecologists of Canada have another joint policy statement stating that core stability training with a physiotherapist is recommended to prevent back and pelvic pain during and following pregnancy.

If you are pregnant, and are experiencing a diastasis rectus abdominis, stress urinary incontinence, or pelvic girdle pain (PGP), contact a pelvic floor physiotherapist today!

References

1. Fernandes da Mota el al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum , and relationship with lumbo-pelvic pain. Manual Therapy 2015, 20: 200-205.

2. Cobb WS, Burns JM, Kercher KW, Matthews BD, Norton HJ, Heniford BT. Normal Intra-abdominal Pressure in Healthy Adults. Journal of Surgical Research . 2005 (129);. 231-235.

3. O’Dell KK, Morse AN, Crawford Sl, Howard A. Vaginal Pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines. INT Urogynecol J. 2007; 18: 1481-1489.

4. Sansawang B, Sansawang N. Stress urinary incontinence in pregnant women: a review of prevalence, pathiophysiology, and treatment. Int Urogynecol J. 2013 Jun;24(6):901-912.

5. Viktrup L, et al. Obstet Gynecol2006; 108:248-54.

6. Vleeming et al. Eur spine J 2008; 17(6):794-819.

7. Verstraete, EH et al. ObGyn 2013 5(1): 33-43.

8. Vleeming A, Albert H, Ostgaard H, Sturesson B, Stuge B. Eur Spine J 2008 (17):794-819.

9. Rost, CC et al. Spine 2004. Nov 15; 29(22): 2567-72.