Yoga and the Postnatal Pelvic Floor by Sarah Oxley 2015
Yoga and the Postnatal Pelvic Floor
A woman’s pelvic floor muscles are significantly effected as a result of pregnancy and childbirth
The following piece of work came about for two main reasons. The first is the author’s own personal experience of coping with weakened pelvic floor muscles from 3 pregnancies and births. The second is more professional, in that the author has recently started a postnatal mum and baby group to complement a pregnancy yoga class which she has facilitated for the last 6 years (for the National Childbirth Trust).
The author’s experience of pelvic floor rehabilitation followed the standard NHS route (of which shall be called for the purpose of this piece of work, the ‘conventional route’) as advocated by the present National Institute of Clinical Excellence (NICE) guidelines. Looking back on it, the experience was at times quite emotional and physically invasive. It was also at a time when her yoga practise was not as regular or intelligent as it is now. The author wanted to see if a regular postnatal yoga practise – with a direct aim of healing the pelvic floor muscles –would offer women a more holistic, empowering and enjoyable way of healing their postpartum bodies.
To help answer this, time was spent researching the anatomy of the pelvic floor muscles and how they change and respond to pregnancy and childbirth. From here, research was made into the yoga approach to pelvic floor rehabilitation and this was used to create a little programme for some willing postnatal women to follow over a period of 6 weeks. The author then spent time reflecting on the two approaches (conventional and yoga) using her own experience, along with the feedback from the postnatal women as a source for comparison.
The following piece of work is a write up of all the research carried out prior to running the yoga pelvic floor ‘programme’ and a discussion on how it went and what was found out. Because it is quite a long piece of work it has been split up into sections for ease of reading. It must be emphasised here that this was a very small scale project so the actual validity of the results overall is suggestive only. In addition it is very biased towards yoga and the author is aware that there are other exercise programmes which provide just as much support. However, the findings are pretty interesting all the same and have certainly made a difference to her own understanding of the pelvic floor muscles and personal yoga practise. The sections are as follows: Anatomy of the Female Pelvic Floor, Pelvic Floor Dysfunction and Its Relation to Pregnancy and Childbirth, the NICE guidelines and Conventional Treatment Pelvic Floor Rehabilitation, Postnatal Yoga and Pelvic Floor Rehabilitation and Final Reflection.
- The Anatomy of the Female Pelvic Floor
The pelvic floor is a generic term to describe all the structures which enclose the pelvic outlet. These structures include 6 layers of tissue: skin; subcutaneous fat; two layers of muscles; ligaments (which support the uterus during pregnancy) and connective tissue (Steen et al 2011). The two muscle layers are often described as a hammock which span from the pubic bone to the base of the spine at the level of the coccyx (Day et al 2010). The pelvic floor muscles (PFMS) perform a number of functions which include:
- Supporting and preventing the prolapse (dropping) of the lower abdominal organs of the bladder, vagina and rectum (Berzuk 2007, Forth 2005, Day et al 2010 and Steen et al 2011).
- Allowing us voluntary control of urination and defaecation and assisting in the proper closure of both sphincters.
- Supporting and adjusting to any changes of intra-abdominal pressure (caused by jumping, running, sneezing etc.) – vital for preventing incontinence.
- Stabilizing the lumbar spine – the PFMS work with the deep abdominal and back muscles to stabilise the spine.
- Increasing (or maintaining) sexual satisfaction and sensation.
- Supporting a baby during pregnancy and assisting and enabling childbirth.
The two muscle layers of the pelvic floor are known as the superficial muscles and the deep muscles (pelvic diaphragm). The superficial layer is key in supporting the sphincter of the bladder, vagina, anus and their respective organs. They keep the base of the pelvic floor strong. The deep layer is responsible for supporting the vagina and ‘indirectly’ the uterus (Steen et al 2011). It also provides the main source of strength for the pelvic floor in that it plays a vital role in supporting most of the functioning roles outlined above.
The Superficial Muscles
The superficial layer lies like a sheath along the pelvic outlet underneath the bottom surface of the deep muscle layer (Steen et al 2011). It is made up of a series of muscles which actually form two layers: the urogenital triangle and the urogenital diaphragm. Both layers have muscles which form a triangular shape between the ischial tuberosities (sit bones) and the pubic bone. The urogenital triangle also has a figure of 8 muscular structure which stretches from the pubic bone down to the coccyx.
The Urogenital triangle is the most superficial ‘layer’ of the pelvic floor muscle and includes the following muscles:
- Bulbocavernosus (or bulbospongiosus) muscle – envelops the vagina and the clitoris.
- Ischiocavernosus muscle – extends from the clitoris and runs along the pubic arch to the ischial turberosities.
- Superficial transverse perineal muscle –stretches between the two ischium and passes through the central tendon.
- Anal sphincter muscles.
The Urogenital diaphragm lies in between the pelvic diaphragm and the urogenital triangle and consists of the following muscles:
- External sphincter of the urethra –surrounds the lowest part of the urethra.
- Deep transverse perineal muscle – triangular shaped ‘sheath’ which stretches from the sit bones to the pubic bone.
The Deep Layer (Pelvic Diaphragm)
The deep layer is shaped like a tea-cup, with a narrow base and wider top. It is situated above the superficial layer and consists of 4 muscles; three of them are collectively known as the Levator Ani (LA).
Levator Ani Muscles
The LA muscles are attached posteriorly to the coccyx and the sacrum, laterally to the ischial spines and anteriorly to the pubic bone (Steen et al 2011). They include the:
- Puborectalis – muscle closest to the medial part of the pelvis – starts at the pubis and loops around the rectum like a horseshoe.
- Pubococcygeus – surrounds the puborectalis and makes up the next horseshoe layer of muscle. It attaches along the arc of the ischium via strong tendons and again loops around the rectum.
- Iliococcygeus – surrounds the pubococcygeus and attaches to the ischium towards the posterior part of the pelvis. It forms the last horseshoe layer of muscle and finishes at the coccyx.
Coccygeus Muscle (also known as the Ischiococcygeus)
The coccygeus muscle is located behind and on the same level as the LA; it stretches between the ischial spine, sacrum and coccyx (Calais-Germain 2003), forming a ‘back wall’ of muscle.
The Levator Ani button hole (Urogenital Hiatus)
The insertion points at the left and right side of the pubis forms a muscle free zone running behind the pubis and up to the central tendon known as the levator buttonhole. Within this zone lie the openings of the urethra, vagina and the clitoris (in men it includes the opening of the urethra only). During birth, it allows the vaginal opening to widen for the crowning of the head.
The Central Tendon
The superficial and the deep muscle layers meet and cross each other at a ‘junction point’ called the central tendon (Steen 2011). This area is otherwise known as the perineum or perineal body and lies (in women) at the midpoint between the anus and the vaginal opening. The perineal body is protected by a collection fat, skin and connective tissue but the three do not offer any structural support.
The Functional Role of the Pelvic Floor during Pregnancy and Childbirth
The role of the PFMS are to help support the lower abdominal organs against the force of gravity and intra-abdominal pressure (preventing their prolapse). During pregnancy the role remains the same; the only major (and significant) difference is the change in the amount of weight pressure the muscles support. Right from the start of pregnancy, the uterine muscle fibres start to transform and increase in number (Calais-Germain 2003:57). By the end of pregnancy, this increase of muscle ‘bulk’ will support up to 6kg of extra weight contributed by the baby, uterus, placenta and amniotic fluid (Barton 2004).
Childbirth (Vaginal Birth process)
During childbirth, the PFMS have a big role to play especially during the second stage of labour. In second stage, the baby moves out of the uterus (head first in a straight forward birth) and begins its descent down the vaginal passage (birth canal) and out into the world. The deep PFMS assist this process by turning the baby (like a corkscrew) as it passes through (Steen et al 2011). The corkscrewing action is essential; without it, the baby’s head would not be able to fit through and negotiate the changing diameters of the pelvic cavity. Simultaneously, the PFMS must also be able to release enough to allow the baby to descend through it. If it cannot, there is a risk that the baby will get stuck on route due to the grip of the surrounding muscle. So, the pelvic floor needs to be toned enough to turn the baby effectively and flexible enough to allow the baby to descend.
Once the baby’s head gets to the pubic arch it has reached the point where it can exit via the vaginal opening (perineum). This is the area of the levator button hole (as described earlier). The baby’s head passes directly through here and very close to the central tendon. Once the head is out, the deep PFMS will rotate the shoulders so that they can comfortably move through the button hole and the pelvic outlet. Following this, the top shoulder is born first, and then the rest of the body comes out with the next contraction. With the birth of the baby and the end of second stage the hard work for the PFMS ends
- Pelvic Floor Dysfunction and Its relation to Pregnancy and Childbirth
- Pelvic Floor Dysfunction (PFD)
As mentioned the pelvic floor is a ‘muscular hammock’, which supports the cavity of the pelvis. When the hammock gets distorted (i.e. twisted, over stretched, too tight, over saggy) the pelvic floor muscles are unable to function properly (Ripoll 2015). This in turn, can affect the functionality of the pelvic organs (bladder, vagina and rectum). This is called pelvic floor dysfunction (Aston 2010:90) and the range of conditions which are associated with the term include:
- Stress Incontinence: Accidentally leaking small amounts of urine when you cough, sneeze, bend, lift, laugh, exercise or play sport.
- Urge Incontinence or overactive bladder: Urinating more frequently than necessary and feeling a sudden urgent need to urinate. An overactive bladder tends to hold much less than the norm and will initiate the urge to urinate before reaching its full capacity (the normal capacity of an adult woman’s bladder is 350–500ml).
- Faecal Incontinence: Feeling an urgent need to defecate, leaking faeces, soiling yourself before you reach a toilet or accidentally passing wind.
- Organ Prolapse: This occurs when one or more of the pelvic organs (your bladder, bowel or uterus) become displaced and sag down into the vagina. Symptoms include feeling a bulge or ache in the vagina, finding it difficult to keep a tampon in place, or sensing heaviness, discomfort, pulling, dragging or dropping in the pelvic region.
- Pelvic Floor Dysfunction (PFD) And Childbirth
It is inevitable that the PFMS and their neighbouring structures (including the organs) will undergo some kind of change as a result of pregnancy and birth. Without fail, the PFMS will lose some of their strength as a result of being stretched considerably (Barton 2004). During pregnancy the overstretching occurs as a result of holding up the extra weight of the pelvis and abdominal cavity. During labour, we see it through its need to considerably stretch and release enough to allow the passage of the baby. The muscles of LA (especially on the medial side of the LA button hole) and the central tendon are particularly vulnerable to excessive stretching and weakening. A stretched ‘slack’ pelvic floor is otherwise known as a hypotonic pelvic floor. Studies have shown that a hypotonic pelvic floor can lead to 30% of women postpartum developing symptoms of PFD (Aston 2010). The most common forms are stress and/or urge incontinence, uterovaginal prolapse, cystocele (bladder prolapse), rectocele (rectum prolapse) and dyspareunia – painful sexual intercourse – (Logan 2005; Stables et al 2010). The risk of developing these conditions increases if any of the following factors are also prevalent:
* Pre-existing PFD prior to Pregnancy
It has been noted that woman who enter pregnancy with pre-existing PFD – in the majority of cases stress incontinence – will tend to develop more severe symptoms post-delivery (Chaliha 2009).
Studies have shown that mums who have more than one baby (three deliveries or more) increase their risk of developing PFD with each birth (Forth 2005:29, Steen et al 2011, and Barton 2004). It has been indicated that the most damage will usually occur after the first delivery and even if full function is reclaimed, there will be weaknesses in the pelvic floor that will buckle more easily under the pressure of further pregnancies and labours (Chaliha 2009, Sultan et al 1994 cited in Steen et al 2011: 694).
Women who are older (35 years +) when they have their children are at greater risk of postnatal PFD (Forth 2005, Steen et al 2011).
- Particular Events of Pregnancy and Childbirth Which Contribute to the Weakening of the Pelvic Floor Muscles
The following section goes into a little more detail about how pregnancy and childbirth contributes to the development of a hypotonic PFM and PFD. Not all women suffer by any means, but it is worth having an idea of which events (both physiological and medical) can cause problems for the PFMS.
Physiological Changes during the 9 months of pregnancy
Pregnancy hormones help to make physiological changes within the body in preparation for the birth. For example, the fascia of the pelvic floor becomes much more elastic and mobile. After childbirth these changes should fully reverse, but for some women (especially if the fascia underwent a lot of strain and pressure throughout pregnancy and childbirth) the reversal will not easily happen. Weakened fascia can contribute to the development of the postpartum stress and faecal incontinence. It can also be contributing factors to an organ prolapse (Steen 2011).
Pregnancy hormones can also change the ‘geography’ of the pelvic floor area. For instance, it has firstly been noted that the bladder can become more mobile and change its position in the pelvis (Herbert 2009, Steen et al 2001). Secondly, the growth of the uterus can adjust the position of the bladder and the rectum and in some cases, cause compression and distension. Thirdly, postpartum, the uterus takes up to six weeks to return to its former size, and may shift position as a result of the stretching of the supporting ligament structure during pregnancy. All these potential shifts are important to note as pre-pregnancy, all the pelvic organs are arranged in such a way that they help to support each other within the bony pelvic cavity (Calais-Blandine 2003). Any changes to this optimum arrangement may negatively affect the ability of the pelvic floor to function well.
Incidence of Tearing During Childbirth
As mentioned earlier, the area of the central tendon will suffer unavoidable loss of strength and tone as the baby’s head crowns (Calais-Blandine 2003). As with the deeper pelvic floor muscles the central tendon must stretch and release in order to allow the baby’s head to pass through the vaginal opening. Sometimes, if it cannot release enough, the strain and pressure of the area will cause tearing. The severity of a tear is classified by the type of perineal injury and the tissue layers which are involved (Steen et al 2011).
- First Degree: involves the skin of the perineal body only.
- Second Degree: involves the posterior vaginal wall, subcutaneous fat, perineal skin layer, superficial muscles (namely the bulbocavernosus and transverse perineal) and deep muscle of the pubococcygeus). This is very common in first time mothers.
- Third Degree: involves the same layers as described in the second degree tears and also includes the anal sphincter (which are also categorised according to their severity).
- Fourth Degree: involves all the above and the whole anal sphincter complex.
The weakening and/or injury to the central tendon can significantly affect the pelvic floor muscles. A first or second degree tear has been linked with the occurrence of stress incontinence postpartum (Steen et al 2011). Third degree tears (and above) are closely linked with the development of faecal incontinence postpartum (Steen 2011 and Chaliha 2008). It is also important to note that the incidence of tearing can contribute to the formation of scar tissue and neurological damage (discussed later).
Changes in the normal physiology of labour (prolonged pushing/instrumental deliveries)
For a nulliparous mum the time spent ‘pushing’ usually lasts for up to two hours in a straight forward vaginal birth. It makes sense that the longer she spends pushing the more strain is placed on the PFMS. Studies have shown that mums who push for three hours are more at risk of weakening the LA muscles (the main supportive muscles of the pelvic floor). Once weakened the risk of postpartum organ prolapse and stress incontinence increases significantly (Chaliha 2009). At the moment NICE guidelines recommend that nulliparous women should push no longer than three hours and multiparous women, two hours before intervention. Usually, before the respective times are reached, an instrumental delivery by forceps or ventous will be suggested. Although it may save a mum from the trauma of prolonged pushing, this intervention (in particular forceps) still increases the risk of postpartum PFD, due to the fact it can cause neurological damage (see below). Studies have also shown that the use of forceps is linked with acute anal sphincter damage (Steen et al 2011, Chaliha 2008, Forth 2005 and Barton 2004).
It must also be noted here that a forceps delivery is usually accompanied with an episiotomy. An episiotomy is a medical incision which involves all the tissue layers of a second degree tear. Studies are inconclusive on just how influential an episiotomy is in the development of PFD (Ewing et al 2005, Steen 2011 and Chaliha 2009). What is clear is that a medio-lateral incision can damage the Levator Ani muscles and is associated with a significant reduction in pelvic floor strength post-delivery (Sartore et al. cited in Steen et al 2004) as well as a contributor to anal sphincter damage (Barton 2004:224).
Development of Scar Tissue
Any damage to the pelvic floor musculature (whether it be from general weakening and stretching or damage by tearing or medical interventions) can result in the formation of fibrous scar tissue. Scar tissue will affect the overall contractility and elasticity of the muscles (Steen et al 2011) as the ability of the pudendal nerve to innervate the area can be compromised as a result (damaged muscle is less ‘pliable’ than healthy muscular tissue). Any part of the muscle which is not successfully innervated may not function well and this will undoubtedly contribute to the development of some kind of PFD. Women who have more than one baby can potentially develop more fibrous scar tissue which again, can increase the potential risk of developing PFD.
The PFMS are innervated by direct branches of the sacral and pudendal nerves; both are susceptible to damage during pregnancy and childbirth (Forth 2005). The pudendal nerve and its peripheral branches are particularly vulnerable due to its position in the pelvic cavity. During childbirth the baby’s head passes alongside the ischial spines; a point which is also occupied by the pudendal nerve (Chaliha 2009; O’Dell 2008; Forth 2005). If the baby’s head compresses the nerve on route it can become damaged. Other factors which have the potential to cause neurological damage (which have been discussed) include the overstretching and weakening of the PFMS; the formation of fibrous scar tissue; the occurrence of tears and/or the use of an episiotomy; and an instrumental delivery. Any nerve damage can contribute to stress, urinary and faecal incontinence; firstly, by reducing sensory or voluntary awareness of the muscles and secondly, by slowing down the reactive ‘speed’ of the sphincter muscles. Nerve damage can also contribute to the incidence of organ prolapse (O’Dell et al 2008). For many cases this is temporary but in some the damage is permanent (Kaoor and Freeman 2008 cited in Herbert, Snooks et al cited in Barton 2004).
- The NICE guidelines: The Conventional Treatment Pelvic Floor Rehabilitation
- The NHS Guidelines For Postnatal Pelvic Floor Rehabilitation
The current National Institute for Health and Clinical Excellence (NICE) guidelines recommend that most PFD problems postpartum are the result of a hypotonic pelvic floor and can be rectified by re-toning and strengthening the PFMS. The conventional approach to pelvic floor rehabilitation therefore involves a pathway which aims to build back this strength and tonality and may include all or some of the following: pelvic floor exercises, physiotherapy and surgery.
Pelvic floor Exercises
The practise of PFEs (otherwise fondly called Kegels) are the first and often only step in ‘fixing’ PFD. NICE (2015) advocates that preventative measures are as (if not more) important as recovery work. It is therefore recommended that women do pelvic floor exercises (PFEs) throughout their pregnancy as well as postpartum. Current guidelines advise that a pregnant woman’s assigned midwife should provide information about PFEs at the 10 week check-up. NICE suggest performing 8 ‘lift and squeeze’ (contractions) 3 times a day, alternating between slow and fast contractions. This combination aims to target the muscles of both the superficial and deeper layers of the pelvic floor. The guidelines do not specify how the pelvic floor exercises should be done; that is left to the discretion of the health care professional. There is, however, a minefield of resources which women can easily access online or in books. There are also commercially available electrical and resistance vaginal trainers which act on the same principle as the lift and squeeze.
After a period of 3-6 months postpartum, any women who are finding that their PFM exercise regime isn’t working have the opportunity of seeing their GP in order to get extra help.
A trial of supervised pelvic floor muscle training of at least 3 months’ duration should be offered as first-line treatment to women with stress or mixed UI.
A referral to a specialised physiotherapist usually results from this visit. The physiotherapist will spend time making sure that the pelvic floor exercises are being performed properly and monitor progress over a 3-6 month period. If no sign of improvement is made then there is usually the offer of a referral to a gynaecologist.
Currently in the UK the use of electrical stimulation is not advised as a source of treatment in pelvic floor rehabilitation. Electrical stimulation is when a vaginal probe is placed near the pelvic floor muscles. The muscles are encouraged to contract by being stimulated electronically which will increase tone and strength over time. In France, where it is used routinely, it has been considered quite successfully in ‘getting the pelvic floor muscles back into shape.’ However there are authorities who state that electrical stimulation is not as effective as other treatment techniques (Day et al 2010). It is of course possible to buy electrical stimulators/toners from a number of sources (as mentioned earlier).
Surgery is the option offered for women who for whatever reason cannot re-strengthen their PFMS through PFEs. For most postpartum women they will have surgery to fix stress incontinence and/or an organ prolapse:
Stress incontinence – Tension Free Vaginal Tape:
This is where a special form of nylon tape is looped around the urethra midway between the sphincter of the urethra and the bladder itself. If the procedure is successful it will prevent the patient from passing urine in an uncontrolled way post operation.
Organ Prolapse Repair
The surgery which is most commonly performed is a posterior repair which focuses on the supporting tissues between the vagina and bowel (rectocele) aiming to remove any ‘bulges’ in the vaginal wall by tightening the muscles around the area. Other repairs may involve tightening the tissues between the bladder and the vagina (cystocele) or the uterus and the vagina (uterovaginal prolapse).
Limitations of the Conventional Route
The author’s experience of pelvic floor rehabilitation pretty much followed the route described above. After the first two pregnancies PFEs were practised. With these alone, the author managed to reclaim a healthy functionality in the PFMS after the first, but after the second, there was always a permanent weakness (which showed up during exercise, coughing and/or sneezing harshly). After the third, PFEs did not work for her at all. The author suffered with severe stress incontinence; any activity which involved a fair amount of laughing, jumping or running needed to be supported with a ‘TENA Lady.’ She also struggled with simple tasks such as going to the toilet – emptying the bowels became a problem and almost an obsession- all very embarrassing and life changing. Eventually she did pluck up the courage to see the GP and was referred to a physiotherapist. Over a 3 month period, the author was instructed to repeat the PFEs and had a monthly appointment to ‘see how it was going.’ After the 3 month period, the physiotherapist decided that continuing the exercises would be ‘pointless’ and she was referred to see a gynaecologist. He diagnosed stress incontinence and a rectocele (posterior prolapse) and recommended surgery. The author went on to have a TVT fitted to cure the stress incontinence and a posterior repair to ‘fix’ the rectocele (see Appendix A for the full story of her experience). At the time, it seemed the right course and there was no reason to have any cause for concern in taking this route. However, as a result of embarking on a yoga teacher training course (one of the best decisions the author has ever made) and the additional research completed for this piece of work, it has become quite clear that the conventional route has limitations and these will be discussed next.
The Limitations of Pelvic Floor Exercises (Kegels).
The first concern relates to the way PFEs are taught. From what the author has experienced, read and from what other women have told her, it has become evident that PFEs are not always taught in a way which respects the anatomical function of the pelvic floor (and its relationship to neighbouring muscles). As Aston (2010) states, there is an indication that health professionals do not have a proficient knowledge in pelvic floor anatomy to enable them to support women and their postpartum pelvic floors sufficiently.
For starters, the pelvic floor has a close working relationship with the respiratory diaphragm. The two work together to support the changing pressure of the abdominal sac; the diaphragm from the top and the pelvic diaphragm from below. As Sabel (cited in Dowdle 2010) poetically defines, “if you can picture the hammock of the pelvic floor in your mind you can begin to work with the breath to feel that hammock moves with the breeze……it moves in a dance with the diaphragm. When we breathe in, the diaphragm moves down and so does the pelvic floor; when we breathe out, they both move up.” So, in essence, the body performs its own PFE – drawing the muscles in and up on the exhalation. On the inhalation the muscles gently stretch and move downwards.
The instructions given to women (by well-meaning health professionals) rarely embrace this relationship and instead instruct ‘normal breathing’ or worst still, make no mention of breathing at all. For postnatal women this is not very helpful. To reverse the effects of childbirth (i.e. stretching and opening of the vaginal passage to allow the baby to pass through), the muscles need to be encouraged to ‘close’ inwards again. The most sensible way to achieve this is to ‘build’ upon and work with its natural in and upwards movement with the exhalation. Due to the way conventional PFEs are taught, the women will not think to do this and more often than not, will work against the natural movement and flow of the muscle. Consequently, they may develop difficulties making any satisfactory connection with the muscle at all.
Conventional PFEs also tend to ignore the functional relationship between the PFMS and the transverse abdominals (TA). The TAs work closely with the pelvic floor to support the internal organs of the body; the activation of one feeds into and directly supports the action of the other. The two muscles should not be activated separately but as a joint unit. Unfortunately this is exactly the way many women train their PFMS and not only their TA but the rest of the abdominal muscle group. There is an ongoing trend that for the PFMS you should do this ‘box’ of exercises and for the abdominals you should do another. This is not so much a problem if the PFMS are trained on their own. If the abdominals are trained separately then they can weaken the PFMS. Being a bigger power ‘house’ their activation can significantly push the PFMS downwards. If done persistently, the PFMS will eventually weaken and droop (Calais-Blandine 2003 and Forth 2005), as they will be unable to withstand the pressure of the downward force over time. In addition, due to our cultural obsession of gaining a flat tummy as soon as possible postpartum, women have the tendency to prioritise collective abdominal training over pelvic floor rehabilitation. This can potentially make matters worse. Ironically, this whole approach will not help women achieve the flat stomach which they crave and will certainly not develop a strong, healthy and functional core.
As well as the respiratory diaphragm and the TA, the pelvic floor also works in partnership with other muscles including the iliopsoas, rectus abdominis, oblique abdominis, multifidus (a deep muscle located along the back of the spine), gluteus, small hip muscles, biceps femoris and the adductors. These muscles have attachments on the bony pelvis so have the potential to influence the functionality of the pelvic floor. For example, healthy gluteus counteract the opposite pull of the PFMS (Bowden 2015). If they become weak, the PFMS can assert too much force which can lead to the pelvis being pulled out of its optimum alignment (see below for details). A pelvis which is out of alignment will negatively affect the ability of the pelvic floor to function properly. Ultimately, some form of PFD may result as a consequence. Ideally, the gluteus needs to be responsive enough to keep the ‘tug of war’ relationship between the two evenly weighted. With conventional PFEs little thought is given to including balanced ‘exercises’ which embrace all the muscles mentioned above and most women (unless they are knowledgeable in such areas) will be unaware of their connection and influence on the functionality of the pelvic floor.
Of course, just as imbalances in the neighbouring musculature can negatively affect the PFMS, imbalances in the PFMS themselves will in turn affect their own functionality and that of their neighbours. It has already been mentioned that a healthy pelvic floor muscle is one which can apply an equal amount of release and activation. The problem with PFEs is that they serve to strengthen weak PFMS only. For a postpartum woman (who has developed a hypotonic PFM) this is of course very welcome and the PFEs are relatively successful. If the focus stays on tightening the muscles only, there is a danger that the pelvic floor will become hypertonic (too tight). If this happens, it will (itself) push the pelvis out of its optimal alignment. Hence, it can clearly be seen that all of our muscles have a complicated relationship which is quite finally tuned and intricately balanced.
So, what exactly is the optimum alignment of the pelvis? According to authorities like Kent (2006 cited in Dinsmore-Tuli 2014), O’Dell (et al, 2007) and Bowman (cited in Crawford 2015), the best position of the pelvis (for optimum pelvic floor health) is when it has a slight anterior tilt. This anterior tilt allows the pelvic organs to rest on the bony support of the pubic bone and puts them in a position where they are supported by the PFMS, the pubic bone and intra-abdominal pressure. Interestingly, when the pelvis is aligned this way, the sacral end of PFMS actually form a back wall rather than a ‘floor’ of support (as many of us visualise in our minds). This takes gravity out of the picture enabling the PFMS to support more effectively – which makes a lot of sense. A less optimum position for the pelvis is a more posterior tilt. Here the sacrum is shifted backwards and the tailbone tucks under. At this angle the pelvic floor can no longer support from the ‘back’ becoming more of a ‘floor’ again. The pelvic organs ‘tip’ away from the pubic bone making them unstable. At this angle the PFMS have to work harder (and against gravity) to re-stabilise the organs. This can cause over gripping and excessive muscle tension. Eventually the PFMS become tight and weak (rather than floppy and weak). Studies show that both scenarios can cause the development of some form of PFD (Kent 2006, Bowman 2015).
Most women (myself included for a very long time) are under the impression that a tight pelvic floor is the only way to avoid PFD postpartum (as this is the advice that is generally given out). For instance, after the author’s surgery, she distinctively remembers being told to practise ‘kegels’ every day for the rest of her life to prevent the prolapse from returning! The truth of the matter is that yes, a strong pelvic floor is good up to a point; it must, however, have a certain amount of length and flexibility to enable it to effectively function (Dowdle 2010, Bowman cited in Crawford 2015, Ripoll 2015).
In the light of the above, it can be fair to say that if the PFEs are done in isolation as the conventional methods tend to promote, there is a strong likelihood that they will not work long term or they will contribute to further problems down the line. It is human nature to give up on something if you feel it isn’t working for you. It stands to reason that if postpartum women practise PFEs with no result, then they will give up on doing them in the end. The author can empathise with this strongly as there were certainly times when she thought ‘what is the point?’ When you cannot feel any improvement after religiously taking ‘time out’ to practise, it makes you lose faith. The simple fact that you may be doing the exercises unintelligently does not cross your mind and why should it? If you are not given all the necessary facts to start with, then of course you will not have all the information to perform the PFEs effectively.
Limitations of Surgery
This particular concern is very close to the author’s heart as she had two lots of surgery to ‘cure’ her pelvic floor problems. Surgery has the potential to fix the source of the problem. Indeed, looking back the surgery was considered to be very successful. The stress incontinence was completely eradicated and the rectocele was repaired. The author was indeed ‘fixed’ from a medical point of view. However, this fix only tightens the muscles up through clever ‘needle’ work. As Champion (2015) advises, any surgical repair cannot strengthen the muscles. They remain in a weakened state unless targeted with appropriate exercise and rehabilitation.
Also surgery (like poorly taught PFEs) is localised to the problem area only. As already mentioned, the pelvic floor and neighbouring muscles do not work alone and are influenced by each other and the surrounding structures (i.e. skeletal, tissues and organs). Any imbalances will influence negatively or positively how the muscles will function. So, although surgery will smooth over the cracks, in time it may not be enough to keep the problem at bay long term and the issue may return. Going back to the author’s experience, she was unaware that she may have had an unstable pelvis and excessive lordosis at the time of surgery. This is not 100% certain, as it was only 6 years later that she became aware of it (as a result of the YTTC). We have already seen that a pelvis which is out of alignment can cause pelvic floor problems. The author therefore wonders if it was actually a problem at the time of the surgery, firstly why it was not diagnosed and secondly (if it had been an issue), could she have gone down another route which avoided surgery completely and at the same time deal with the muscular imbalances which may have contributed to her PFD – hence providing more of a ‘long term’ solution.
Emotional/Mental limitations of The Conventional Approach
Aston (2010) states that “postnatal women are at high risk of developing PFD and are in a very vulnerable position.” Many women who find themselves developing stress incontinence or other PFD problems are often shy about seeking help from their GP or health professional. Many women will suffer in silence and allow themselves to accept that it is an inevitable consequence of childbirth. Again, this problem is not helped by the fact that many health professionals are not in a position to give out appropriate advice. As we have already seen, if the prescribed PFEs do not bring the result the women hope for, it may inspire them to give up practising them and avoid seeking extra support.
As well as the possible issue that women are shy about seeing a GP, ‘time’ or their perceived lack of time is another factor which prevents women seeking help. Women will ‘brush’ their own health and emotional issues aside due to the demanding pressures of looking after one or more children and balancing home and work life. We take parenting duties very seriously and will put our needs at the bottom of the ‘pile’ (Aston 2010). This is quite simply human nature and something which is almost impossible to change. However, it is needs to be acknowledged and embraced when trying to help such women who have pelvic floor issues. It was certainly a factor in the development of the author’s own PFD problems over the three pregnancies. If it hadn’t been for a very good friend pushing her, she may not have made the trip to the GP at all.
- Postnatal Yoga and Pelvic floor Rehabilitation
In the search for how yoga can help postnatal women the author found inspiration in the work of Dinsmore-Tuli (2006, 2008) and Freedman (2014). She also attended a mum and baby teacher training course (with Yogagro) and other relevant workshops (run by TeachYoga.com). She used all that she learnt to help her create a 6 week mum and baby course. A small selection of new mums (at least 6 weeks postpartum) were invited to join the course. The details of the programme and an outline of typical class can be seen in Appendix B. Over the course of the 6 weeks regular feedback was requested verbally or by email, to check in on how they were feeling about their pelvic floor and ‘core awareness.’ General feedback was also requested so that the author could get a sense about what the mums thought about the classes overall. As babies were involved it did become a little hit and miss in terms of what we could achieve during each session. Therefore handouts were given out so the mums could practise at home (see Appendix C). The author also kept a diary for her own use as a way of recording any feedback or comments received during the classes themselves.
Outline of the Results
- Out of all the participants who returned verbal and/or written feedback an improvement of 30-40% in their pelvic floor awareness and strength (by the end of the 6 week course) was recorded.
- Most also noted that they saw an improvement in their abdominal strength, overall posture and gait.
- Many described the feeling of ‘coming back together’ again and of losing the sense of having a gaping hole in the middle of their bodies.
- Positive comments were made about how the asanas had improved their strength, flexibility and balance.
- The author noticed a change of attitude of clientele towards their bodies – an element of acceptance and kindness as well as a sense that their bodies were not made up of separate parts.
- The author got a wonderful sense that the clients felt ‘safe’ to talk about their experiences from all perspectives (e.g. conversations could range from stress incontinence to ‘waterbed’ tummies to when you should wean the baby).
Discussion of the results: Conventional versus Yoga
As already outlined the conventional approach to pelvic floor rehabilitation highlighted the following limitations.
- PFEs are mainly taught in a way which ignores their anatomical function in the body; they focus on strengthening work only and ignore their relationship with the rest of the musculo-skeletal system
- Surgery (like PFEs) fixes the ‘local’ problem and does not accommodate the ‘bigger picture.’
- The conventional approach is not always sensitive to the emotional needs of any woman who is suffering from pelvic floor issues.
From what the author experienced herself in comparison to what she discovered through facilitating the mum and baby classes, an intelligent yoga practice does have the potential to overcome these limitations – its main strength being the fact that it is a holistic practise which basis its whole foundation on the power of the breath (our life force). Yoga wisdom understands that the respiratory system is the control centre of the body; “the breath is the string that ties all other practices together in a cohesive whole” (Stiles 2000:17). The act of breathing connects all movement. If it is held, it negatively affects the functionality of our bones, muscles and connective tissue. When it is ‘fluid’ it brings life and functionality to all these ‘structures’ (Hately 2006). Yoga wisdom understands that the breath is the key to a healthy, strong and functional body. It also promotes our health beyond the physical, assisting in our mental, emotional and spiritual well-being. It is this wisdom which gives yoga the ‘edge’ when it comes to postnatal (and pelvic floor) recovery. The following discussion will outline the theory behind the wisdom and how it was practised in the mum and baby classes.
The Breath and the Body
It has already been mentioned that the pelvic floor has a working relationship with the respiratory diaphragm. This relationship forms part of a larger ‘dance’ between other muscles and structures which contribute to our ‘core stability.’ The respiratory diaphragm is the centre point of this dance. It has connections (fascial) with the abdominals (transverse and obliques), the psoas, lower and upper back (postural) muscles. When the diaphragm moves these muscles respond and move as well – just as the pelvic floor moves. Yoga science understands that effective breathing, helps with the relationship between all these muscles and their fascial connections. In essence, effective breathing is the key to building a mobile but strong responsive core (which includes a functional pelvic floor). This can be further enhanced through the practise of accessing the bandhas (energetic locks).
Bandhas powerfully enhance the respiratory system; they change breathing into an internal exercise (Stiles 2000). When they are “accessed via our physical anatomy” they create muscular balance, strength and mobility along the midline of the body (Hatley 2006). Any postnatal mum, particularly in the first few months after the birth, will struggle to connect to this midline – at worst she feels as though she has a gaping hole from the middle of her trunk all the way down to the pelvic outlet! Relevant pranayama and bandha practise can help to close this ‘hole’ and so provide the perfect way of healing and rehabilitating the pelvic floor and the rest of the core in a safe and ‘body –friendly’ way.
Mula Bandha (root lock) is the yoga equivalent to a PFE or ‘kegel’; it is sourced around the area of the pelvic floor muscles. Just like a PFE its action is concentrated around the central point of the pelvic floor (i.e. the mid-point between the pubic bone, coccyx, and ischial tuberosities), drawing the muscles inwards and upwards. The main difference is that it respects the anatomical relationship between the pelvic floor and the respiratory diaphragm. Mula Bandha is activated on the exhale, coinciding with the natural inward and upward movement of the pelvic floor muscles. This action reverses the flow of downward-moving energy (apana) and in doing so ‘lifts’ any ‘dragging’ or ‘drooping’ feeling in the uterus and vagina (Dinsmore-Tuli 2014). On the inhale, Mula Bandha is released, again going with the natural movement of the muscles. Because Mula Bandha respects this, it works the PFMS in a balanced way. Consequently there is little danger of over working or tightening the muscle. In addition Mula Bandha can only be accessed when the pelvis is in neutral which supports the correct position of all the other structures (and neighbouring muscles) of the pelvic floor (meaning that the muscle remains functionally supported).
Appropriate pranayama and Mula Bandha practise formed the start of every class (either before or after baby massage). The mums were first taught the Full Yogic Breath. Once they were comfortable with this Mula Bandha was integrated into the breath (creating the Healing Breath or Reverse Breathing – see appendix B for details). The practises were done in a supine position to encourage neutrality of the spine and the optimal opening of the chest and shoulders (to assist with posture). The following comments (made by the mums), display how much they could connect with their pelvic floor using these two breathing practises.
“Working with the breath helped me to sense where the muscles were; it also provided me with a focus and a pattern of when to ‘lift and release.”
I found the healing ‘lift’ breath really helpful. It was really hard at first to get a sense of lifting the pelvic floor to different ‘levels’ but doing it with the breath really helped. Not only was it easier to ‘find’ but it gave me a structure to follow – knowing when to lift and when to release. It also felt more natural and normal to lift on the exhale. I find that I am automatically lifting and squeezing if I sneeze or cough as I am so used to engaging it on the exhale – it has become a habit – a useful habit!”
“I couldn’t feel my pelvic floor at all at the start. However, linking it with the breath helped me to get a sense of where it was and I now know I am getting the right muscles.” I love the lift sequence as I can sense that my pelvic floor is getting stronger as I can hold the lift more easily on the different floors.”
Mula Bandha is the first of three main primary bandhas; the other two are Uddiyana Bandha (abdominal lock) and Jalandhara Bandha (throat lock). In addition to these we have two secondary bandhas: Hasta and Pada Bandha. For postpartum women, exploring Mula, Uddiyana and Pada Bandha are the most helpful to begin with.
Uddiyana Bandha is located where the transverse abdominals (TA) links with the lower muscle fibres of the internal obliques and the multifidi muscles. Together they span from the pelvic girdle all the way up to the ribcage. The multifidi in fact follows the entire spine from the sacrum right up to C2 where Jalandhara Bandha is accessed. The muscles work together acting like a girdle supporting and compressing the trunk of the body. The lower point of the TA attaches at the pubis of the pelvic girdle and at its upper point the lower ribs, interweaving with the diaphragm (again, explaining how the respiratory diaphragm is so influential to creating core stability). Going back to its lower point, the TA feeds into the pelvic floor, linking Mula and Uddiyana Bandha together.
Uddiyana Bandha is activated at the end of the exhalation following the activation of Mula Bandha. This creates a vacuum effect where the muscles draw into the midline of the body. Working in this way there is no danger of the abdominal muscles pushing the pelvic floor downwards (as Mula Bandha is always initiated first). For postnatal mums, once they were comfortable with finding Mula Bandha, we practised connecting the two. Again the practise was done in semi-supine through the Full Yogic and the Healing breath. Once this felt comfortable Uddiyana Bandha was further explored with a practise entitled ‘abdominal compression’ (Blandine Calaise 2003) or Supta Uddiyana Bandha (Dinsmore-Tuli 2006). This is a slightly stronger practise which helps the mums to further connect to the ‘vacuuming affect’ of Uddiyana Bandha (still linked strongly to the breath). Much of this practise was encouraged at home as well as during the class. Combining the two practises helped to give the mums a sense that their bodies were ‘reconnecting’ (as shown in the comments below).
“It is a wonderful feeling; it does feel like there is a vacuum in your tummy which is sucking everything in.”
“It made me laugh by saying that we should think of the vacuum hose attachment when trying to visualise the action of the pelvic floor and the abs! It does kind of work – that feeling that you are drawing – sucking – everything in and up.”
“The post-natal physio that we were given in my post-natal class had separate exercises for pelvic floor and abs, twice as many exercises to forget to do. This links them together, as intended by nature, as your core.”
“After my c section I felt my abdominals were really far apart when I started to reconnect to them with my breath I felt my diaphragm come together. I am more aware of them now and when I take a deep breath in and out I engage my pelvic floor and connect with my abdominals.”
“It never occurred to me that breathing helped give you a flat stomach and a healthy pelvic floor –it is so good to be able to ‘feel’ the muscles again. I have been so numb since the birth and it felt as though my body was an alien – not mine.”
Anatomically the pelvic floor has fascial connections with the adductors which in turn have fascial connections with the lower leg muscles of the peroneus and the tibialis posterior. The latter two attach to the bottom of the feet and act as stirrups where they help lift the arches (Hatley 2006). This marks the area of Pada Bandha (foot bandha) and because of its connections with Mula Bandha, it makes sense to practise it along with the other two primary bandhas. Accessing Pada Bandha teaches the mums that the core is not only supported around the trunk but from other areas of the body – in this case the feet. They get a sense that the PFMS form part of a bigger muscular chain which together help support the stability of the whole body – a notion far removed from the isolated practice of conventional PFEs. The mums learned to access Pada Bandha again in supine along with Mula and Uddiyana Bandha through the Full Yogic or Healing breath.
“I can feel that sense of when I push into the balls of the feet I can feel my inner thighs work and that moves all the way to the groin area and yes if I concentrate I can feel it in the pelvic floor …………”
The comments made by the mums clearly show that they could connect with their pelvic floor and core through the combination of the breath and bandha work. From here, the mums could move away from accessing the bandhas in a supine position and explore them in other yoga positions (asanas) – sitting, kneeling, standing and ‘semi’ inverted. As Freedman (2014) and Dinsmore-Tuli (2008) state, appropriate yoga asanas, encourage a healthy range of movement in the body, which promote good posture, spinal alignment and muscular health (tonality, flexibility, balance and strength). For example, Malasana (squat) allows Mula Bandha to be accessed with a good pelvic alignment. At the same time, it has the capacity to condition the muscles of the gluteus –one of the muscles which balances out the action of the PFMS. Most of the yoga postures practised in the classes were chosen because of their capacity to support the core and of course the pelvic floor. Below are some comments made by the mums about their experience of practising asanas.
“It (yoga) stretches me out and gives my posture a reset, and gives me simple exercise I can use if I need to stretch something out through the week.”
“I love the way it opens up my shoulders and eases my lower back pain.”
“I feel like a new woman after yoga.”
“Practising yoga postures reminds me to think about my pelvic floor and abs before I do anything –breathe, lift and move – it has almost become a daily mantra!”
The last comment above is particularly interesting as it links strongly to something that Freedman (2004) highlights in her writing. The combination of breath and bandha work (integrated in the practise of yoga asanas) give women the tools to take it ‘off the yoga mat and into their everyday lives.’ Using their knowledge, they can use the breath to generate the right degree of engagement to support any activity from lifting the baby to coughing or sneezing.
I can feel my pelvic floor in different positions now since doing yoga. This has really helped me when I have been in situations where I think I lose ‘control.’ The other day for example, I was putting shopping in the car boot and felt a sneeze coming – I remembered my yoga, breathed out, pressed through the feet and lifted – no embarrassment!
“I notice that I find myself automatically lifting my pelvic floor and abs before I pick up my baby or the car seat – I guess it is coz we do it in class every time we breathe out in postures – it’s really helping my back.”
The Breath and the Mind
The conventional NHS approach to pelvic floor health brought to our attention that a woman’s emotional well-being and state of mind is not always appreciated. The truth at the end of the day is that PFD, if left untreated, can lead to social isolation, embarrassment and a reduced quality of life (Aston 2010, Steen et al 2011). During a yoga practice the breath becomes the ‘bridge’ which connects the mind with the body, encouraging a sense of mental stillness and calm. This gives us the space to soften our ego, and treat ourselves with love and compassion. The author found that the classes brought out the best in the mums – a sense of comradeship and complete support for one another. It became a haven for mums to talk about anything and everything – from their pelvic floor, to how much sleep they had had the night before. The power of yoga to do this is very hard to put into words but is very visible to watch and absorb. Yoga gives you permission to be you and gives you the strength to admit when things are not right and a safe haven to explore it. Of course on a more practical level, it helps women get out with their babies and do something for themselves – eradicating feelings of isolation and loneliness which are common in the first few months after the birth.
I feel safe talking about anything……..the atmosphere in the class is one of friendship and sympathy. I don’t tell lies when I go to yoga
“I ……. love the time I spend with my baby and the other ladies.”
“It is good to talk to other people who are going through exactly the same thing as you – makes your feel sane and normal. I can talk about my body bits – it’s cool! Girls together.”
“It is so so nice to hear other experiences and know that you are not the only one going through something.”
“I always feel centred after yoga – calm and relaxed.”
“Yoga helps me to feel connected to me and other mums – it’s like being in a very special club.”
- Final Reflection
The aim of this little project was to show how an intelligent yoga practise can offer postpartum women a safe and holistic way of regaining a healthy and functional pelvic floor. The author feels that the results from the mum and baby classes demonstrated that this was achieved.
“Link the breath (appropriate pranayama) with appropriate bandha and mudra practice and you have the perfect ‘recipe’ support women through pregnancy, childbirth and post-natal recovery.
An intelligent yoga practise has the potential to heal and nurture – it helps us to understand and accept who we are physically and mentally at all stages of life. Yoga is a natural friend and companion to women throughout the whole journey of pregnancy, childbirth and beyond. It is not a magical wand, but it offers solutions on how we can achieve better overall health. The wisdom of yoga – the power of the breath to nurture the body at all levels (the physical and the non-physical) – is a wonderful gift. On a physical level we have seen how yoga (and the breath) supports the elements which contribute to a healthy functional pelvic floor – the importance of good spinal alignment; the relationship between the pelvic floor and the neighbouring muscles and systems and it honours the simple fact that for the pelvic floor to be healthy, it needs strength, tautness and a degree of length and flexibility. On a non-physical level, it was pretty clear how supported the mums felt emotionally and how they had become more sensitive, self-accepting and compassionate towards themselves. As yoga wisdom understands, the more compassionate we are to ourselves, the more we are to others (including, of course, our children). Without realising it yoga can turn us into better parents.
The conventional approach to pelvic floor rehabilitation in comparison is not wrong by any means. It is however, delivered in a way which is somewhat reckless and substandard. Unfortunately, as a result, many women will needlessly suffer from PFD, simply through a lack of understanding of their own bodies. The key point here is that any pelvic floor rehabilitation must embrace the bigger picture. It must embrace the simple fact that the pelvic floor is an integral part of the whole body. The conventional approach has the potential to do this but fails (in the author’s opinion) through a combination of poor facilitation and management.
Yoga of course (as mentioned in the introduction), is not the only exercise system which offers a more ‘intelligent’ way of rehabilitating the pelvic floor post birth. Pilates is another way and actually grew out of the essence of yoga (amongst other disciplines). The Pilates system is underlined by 5 basic principles: concentration, the breath, girdle of strength, flowing movements and relaxation – many elements we recognise in yoga. Its philosophy on pelvic floor and core care is very similar. As a teacher of any discipline it is undoubtedly good practice to get to know what else is out there, as you may find something which will enhance your own health and self-practise. The more you discover for yourself, the more you can help others.
To Conclude: Final Thoughts and Authors Postscript………..
For the author this piece of work made her realise just how much she was out of touch with her body during her child bearing years (all 13 of them)! Re-living the experiences of trying to get the pelvic floor back brought home just how a lack of body awareness and knowledge can greatly influence ones overall physical and mental health.
The last two years of the yoga teacher training has completely changed her bodily relationship. She is now in the position where she can honestly say that she is more intimately aware of her pelvic floor! She regularly incorporates the ‘Healing Breath’ and includes bandha practice in pranayama and posture work. She has also recently incorporated Mudra (Seal) work with Sahajoli and Ashwini Mudra (Dinsmore-Tuli 2008) for a more intricate practise. Things are certainly not perfect but she now feels like she is following the right road. Yoga and yoga alone has done that and the author will be forever grateful that it has become an important part of her life.
It was unexpected that this project would unfold quite the number of limitations of the conventional route that it did. This saddened the author a little, as so many women will go through a similar experience to what she did. They may not reach the stage of surgery, but the highs and lows of doing PFEs, learning to love a TENA lady, feeling embarrassed about asking for help and most importantly, putting up with a medical care system which is failing them, is pretty prevalent. On a more positive note, the simple fact that the author did experience what she did, really helped her facilitate the mum and baby classes. She found, that not only could she really empathise with the mums and their experiences, but she was in a position where she could give realistic, practical and heartfelt advice. This made the whole experience feel authentic, spiritually rewarding and worthwhile.
Aston B (2010). Postnatal Pelvic Floor Dysfunction: Conservative Treatment and Management Options. Journal of Family Health Care 20 (3) pp 90-92
Barton, S et al (2004) Physiotherapy in Obstetrics and Gynaecology. Oxford. Butterworth Heinemann, pp 205-245
Berzuk (2007) A Strong Pelvic Floor: How Nurses Can Spread The Word. The Association of Women’s Health, Obstetric and Neonatal Nurses. 11 (1) pp 55-60
Calais-Germain, B (2003) The Female Pelvis: Anatomy & Exercises. Seattle. Eastland Press
Chaliha C (2009) Postpartum Pelvic Floor Trauma. Current Opinion in Obstetrics & Gynaecology. 21 (6) pp 474-479
Champion (2015) Mind the Gap: Diastasis of the Rectus Abdominis Muscles in Pregnant and Postnatal women. The Practising Midwife. May 8 (5) pp 16-20
Crawford N (2015) Stop Doing Kegels: Real Pelvic Floor Advice for Women (and Men). http://breakingmuscle.com/womens-fitness/stop-doing-kegels-pelvic-advice-for-women, accessed February 2015
Day J et al (2010) Recovery of the Pelvic Floor after Pregnancy & Childbirth. British Journal of Midwifery. January 18 (1) pp 50-53
Dinsmore-Tuli, U (2014) Yoni Shakti. A Woman’s Guide to Power and Freedom through Yoga and Tantra. London. Yoga Words.
Dinsmore-Tuli, U (2008) Yoga for Pregnancy and Birth. Oxon. Teach Yourself Books
Dinsmore-Tuli, U (2006) Mother’s Breath: A Definitive Guide to Yoga Breathing, Sound Awareness Practices during Pregnancy, Birth, Postnatal Recovery and Mothering. London. Sirtaram and Sons
Dowdle H (2010) Building Strength in the Pelvic Floor. http://www.yogajournal.com/article/health/ accessed February 2015
Ewing et al (2005) Obstetric Risk Factors for Urinary Incontinence & Preventative Pelvic Floor Exercise: Cohort Study & Nested Randomised Controlled Trial. Journal of Obstetrics & Gynaecology. August 25 (6) pp 558-564
Freedman F, B, (2014) STEP-BY-STEP Yoga for Conception, Pregnancy, Birth and Beyond. London. Lorenz Books
Forth (2005) The Anatomy, Structure and Function of the Pelvic Floor Musculature, its interaction with Transversus Abdominis, and the Implications for Clinical Practice. Journal of the Association of Chartered Physiotherapies in Women’s Health. Autumn no 97, pp 27-32
Herbert, J (2009) Pregnancy and childbirth: The Effects on the Pelvic Floor Muscles. The Nursing Times. 105 (7) pp 38-39
Kent C (2006) Why Kegels Don’t Work. http://wholewoman.com accessed February 2015
Logan K (2005) Incontinence and the Pelvic Floor. British Journal of Midwifery 13 (6) pp 374-7
NICE (2015) Antenatal Care: Routine Care for the Healthy Pregnant Woman. Clinical Guideline 62. London. NICE.
O’Dell K et al (2008) It’s Not All About Birth: Biomechanics Applied to Pelvic Organ Prolapse Prevention. Journal of Midwifery & Women’s Health. January/February 53 (1) pp 28-36
Ripoll E (2015) The Painful Saga of Pelvic Floor Dysfunction http://choicespc.net/the-painful-saga-of-pelvic-floor-dysfunction-/ accessed February 2015
Stables D, Rankin J (2010) Physiology in Childbearing. Bailliere Tindall Elsevier, Edinburgh
Steen M, Roberts T (2011) The Consequences of pregnancy and birth for the pelvic floor. British Journal of Midwifery. November 19 (11) pp 692, 694-698
Stiles M (2000) Structural Yoga Therapy. India. Goodwill Publishing House
Dinsmore-Tuli, U (2006) Mother’s Breath. London Sitaram and Sons
Freedman F, B, (2004) Yoga for Pregnancy Birth and Beyond. London. Dorling Kindersley Ltd
Llewellyn-Thomas J (2006) Yoga for Mother and Baby. London. Octopus Publishing Group
Appendix A: The Authors personal experience of Pelvic Floor Rehabilitation over Three pregnancies and births.
I first got a sense of my pelvic floor after the birth of my first child. I imagine that it is the first time any woman starts to show an interest in this area. At that point in time my yoga practise was not very deep or knowledgeable – I enjoyed going to classes especially during my pregnancy. I have to add that I did not go to antenatal yoga; I simply continued on with my regular teacher (who I must admit got a little nervous with my stubbornness to attend as regularly as I could). After the birth, my yoga classes became a thing of the past and was overtaken by the thrill and extreme relentless task of looking after a baby. I did exercise my pelvic floor muscles by performing the well-known Kegel exercise. I remember sticking post-stick notes around the doors of the house with a PF on them and a big smiley face. Every time I saw the note; I performed a kegel. This worked for me; I ‘got’ my pelvic floor back to good working order. Soon I forgot to practise them as much as I should have and just over a year later, I fell pregnant again.
My second pregnancy was harder and by six months I did look like ‘Mr Greedy’ out of the Mr Men books. My friends used to call the bump ‘the tornedo’ as when I had my back to them I didn’t look pregnant at all. When I turned round, however I had a bump which (and I quote) they quite rightly used to say was ‘almost the size of you Sarah. How on earth are you managing to stay upright?’ Looking back the strain that my body was enduring must have been huge. Although I still exercised, my yoga practise and regular classes had petered out due to the demands of looking after a toddler and being so huge for most of the pregnancy. As it turned out, the labour was a difficult one too. The baby had decided that it was going to lie posteriorly rather than towards the front. This position means that the birth is usually longer and more painful as the baby usually has a harder time getting through the pelvic cavity if it is back to front. I, indeed had a very long and painful labour. It didn’t help that the baby had managed to get into a position where it was irritating the sciatic nerve. I remember thinking very clearly, the contractions are fine; my leg however is really, really hurting. The baby did eventually do the magic turn and was born vaginally. Ironically, after a tortures first stage, the second stage was over in minutes. Thirteen years later and I still bear the scars. I have a very unhappy sciatic nerve which flares up regularly and for the first 4 months after the birth I was affectionally called ‘peg legged.’ My pelvic floor, understandably took a little longer to get back to any normal function. For a while, I couldn’t do anything which involved running up the stairs, or playing with the kids without a good deal of pre-planning (i.e. making sure I went to the loo as last minute as possible, wearing a TENA lady). It was during this time I began to understand that a weak pelvic floor was not only a physical problem but it was also an emotional one too. The feeling of embarrassment and abnormality was there all the time. I remember going back to the gym and attending a circuit class. One of the stations was ‘jumping jacks.’ I remember fearing that station completely knowing full well that I couldn’t do a jumping jack without losing control. I adapted the move, I had to, but I remember feeling unaccomplished and a failure. I mean I was quite capable to doing a jumping jack, my pelvic floor, however, had other ideas. For the first time ever I began to hate what I had become. I was in my eyes a damaged flabby woman, with stretch marks and no bladder control. Still, being a glass half full person, I eventually accepted that if you wanted to have children you have to pay the price – emotionally and physically. I got very good at blanking out all the sad areas of my life I did not want to acknowledge. I had begun to see my body as something which I had to fight with to get back and I did with relentless trips to the gym. Eventually, after nearly a year, my persistence with the kegels and my obsession with exercising to try and get my body back enabled me to get some control back. I still though, had some weakness there which I accepted as part of the deal after having had two healthy babies. Indeed didn’t my friends keep telling me, that this was to be expected? Look at the size of you look at the size of your babies at birth. You should expect that you will be and feel differently afterwards. It is part of being a mother.
My third pregnancy, came at a time when the first two children were older. The youngest had started full time school, so I guess it was a cross road of my life. I either found something to occupy my days now the kids are both at school or I had another baby. I chose to have another baby! The pregnancy was a little easier; the bump was very similar in size to my first baby. I think another important aspect which helped was the fact that I had no stubborn toddlers to carry around when they got tired which meant that my body was not being contorted into different shapes which were probably not very healthy for my spine or pelvic floor. This time, I had the luxury of being able to attend an antenatal yoga for pregnancy class. The birth was a calm homebirth and I can almost say that I enjoyed the experience – almost! The only part which didn’t go to plan was the fact that baby c was so keen to come into this world he did it too quickly, with both shoulders coming out at the same time. After the head, each shoulder is meant to come out one after the other not proudly as one. This was the straw that broke the camels back in terms of my pelvic floor recovery. After my third, my poor body and pelvic floor were in terrible shape. No amount of kegels brought them back to a state where (with a bit of planning I could cope with everyday life). In addition, my stomach muscles struggled to knit back together and my whole skeleton felt like someone had unscrewed it to a point that it was almost falling apart. I had physiotherapy over the space of a few months but it didn’t work. I was referred to a gynaecologist who calmly told me that I not only had chronic stress incontinence but I also had a posterior prolapse (a condition where weakness in the support tissues between the vaginal and the bowel causes a bulge in the back wall of the vagina). A prolapse can make emptying the bowel difficult as it changes the shape of the rectum (often meaning that you have to go several times before feeling empty). In addition sex can be uncomfortable and painful and wearing a tampon becomes impossible as it always feels as though it is going to fall out. I had all those symptoms and had buried them away telling myself this was something I had to put up with; after all I had had three pregnancies now. To stop the stress incontinence, repair the organ prolapse and the diastasis recti, I had two operations. Recovery was long but at the time the operations worked for me. Six years on and I am still free of stress incontinence and organ prolapse but am also aware that unless I take my pelvic floor health seriously both problems can potentially come back.
After the operation I continued the kegels as instructed but never really got on with them. I often forgot to do them as well. I continued to try and strengthen my abdominals but really struggled to ‘feel’ anything and certainly couldn’t get rid of the bulge! Things changed when I started the yoga teacher training course. Over the months, I gradually learned about the importance of the bandhas and correct alignment. After lots of practice and perseverance I finally understood what it meant to have a sense of connection and bodily awareness. My posture began to change for the better and I started to get the sense that I could activate my core properly. Most importantly it felt natural and fluid and completely right. I am still on the road to self-awareness and discovery but with each step I take I am learning more and enjoying the new relationship I have with my body.
Appendix B: Summary of the Postnatal Yoga Programme
Typical Class Outline:
Opening 5-10 minutes: introductions and discussion about anything which the clients wanted to talk about with regards to their home yoga practice or life with a baby
Baby Massage 10-15 minutes: baby massage became an important element of the class. Most of the time it was completed towards the start, when the babies were most accommodating. Sometimes it was done at a different time in the class if necessary.
Breath Awareness/Bandha work in Supine 5 minutes:
The practice of full yogic and healing breath was done during each class with an emphasis on accessing Mula, Uddiyana Bandha and Pada Bandha
|Full Yogic Breath ² ³ ⁴ ⁵ ⁶
|· In supine position move through diagrammatic, thoracic and clavicular breath||· During pregnancy babies take up a lot of space in the body; the diaphragm gets squashed and accustom to not working fully. Full yogic breath re-conditions the diaphragm helping it to work to its full capacity.
· Starts to reconnect the pelvic floor diaphragm with the diaphragm and transverse abdominals
· Opens and relaxes the chest muscles helping to re-align the position of the shoulders and improve posture by waking up the upper postural muscles (serratus anterior, mid trapezius). This helps to bring the ribs back into alignment helping to set the foundation for good postures and bandha connection.
|Healing Breath or Reverse Breath ² ³ ⁴ ⁵ ⁶||· Practised in a supine position. Begin with full yogic breath. Once a good rhythmic flow is established begin by actively engaging the perenium area on the exhale (Mula Bandha)
· Once Mula Bandha action can be felt on exhale, work can be done to strengthen it by using the 3 floor ‘lift’ sequence. IN: EX engage the perenium, IN hold, EX lift in and up to the next level (feeling the TA engage), IN hold, EX lift in and up to the 3rd level. IN hold, EX release back down to the ground floor
|· Teaches mula banda and a gentle Uddiyana Bandha connection with the breath
· Re-traces in reverse the birthing breath
· Resettles the pelvic organs in non-pregnant places
· Begins to connect and tones with the pelvic floor and the abs. This link is especially important for postnatal women to nurture because it goes a long way to reducing the risk of organ prolapse
· Strengthens the pelvic floor muscles and encourages length and flexibility.
· Continues to teach good posture.
|Supta Uddiyana Bandha ¹ ² ³
|· Begin supine, with the knees bent and feet flat on the floor.
· Spend a few moments practising full yogic breath.
· IN: expand the side and back ribs
· EX: try to maintain the expansion of the ribs all the way to the end of the exhalation
· IN: expand through the ribs and back/front body
· EX: keep the expansion of the ribs.
· Continue this action and feel the abdominals stretch and vacuum in up and back creating an ‘hour glass’ figure.
|· Help move all the structures of the pelvic floor including the organs back into their pre-pregnancy position. Described in Blandines book; The Anatomy of the pelvis. This is not a wholly yoga practise but the second part (abdominal decompression) is very similar to the essence of Uddiyana Bandha
· Teaches diaphragmatic breathing
A series of supine, kneeling, standing postures were done each week with the aim of moving the spine in all four directions and incorporating the activation of the core muscles when relevant. The tables below outline what postures were incorporated and why.
|Poses to Support the Engagement of All the Bandhas
1) Engaging Pada Bandha ⁹
Lie in a supine position with the feet flat on the floor. Place cushion/brick between the inner thighs. Move pelvis in neutral, connect with the PFMS and TA using the breath and activating the feet and inner thigh connection
2) Supine chataranga ² ⁹
Lie in supine with the knees bent and feet flat on the floor. Pelvis is in neutral; engage PF and TA through full yogic breath. Connect with pada bandha (press all 4 points of feet into floor, hug inner thighs to sink femur head into the sockets). Bend elbows so upper arms are by the side of ribs; forearms are perpendicular to floor, flex the wrists – palms face the ceiling. Activate hasta bandha by stretching the fingers; imagine pausing something up towards the ceiling. Feel connection with upper arms (triceps) and under armpits.
3) Cat/Cow/Ardho Mukha Svanasana (AMS) ² ³ ⁴ ⁵ ⁹
On all fours move through Cat/Cow and then into AMS placing the emphasis on pressing evenly into the grounded parts of the body; lengthening the tailbone and sides of the waist; activating the bandhas; feeling the front ribs move inwards.
|· Continues to build awareness of the connection between Pada bandha and Mula Bandha and Uddiyana Bandha
· Teaches how Hasta bandha is connected to the upper postural muscles.
· To learn good foot to pelvis connection and good hand to shoulder girdle connection to build an awareness of how good alignment helps the accessibility of the bandhas.
|Pelvic Stability and stabilisation /release work for muscles around the pelvis (e.g. gluts, adductors, hip stabilisers
1. Apasana and variations ² ³ ⁴ ⁵
2. Pelvic Tilt and Thrust ⁴ ⁷
3. Supta baddha konasana and variations ⁴
4. Setu bandha and variations ⁴ ⁸ ⁹
5. Urdhva Prasarita Padasana ⁴
6. Vaparti kapari ⁴
7. Windscreen Wipers (similar to Jathara Parivartansana) ⁷
8. Thread the needle ⁴
1. Sukasana with variations ² ³
2. Janu Sirsasana ² ⁷
3. Log pose ⁷
1. Cat (Majariasana) ² ³ ⁵ ⁶ ⁸
2. Vyaghrasana (tiger)² ³ ⁵ ⁶
3. Sunbird sequence ⁸
4. Hip stretch with wall plus groin stretch ⁷ ⁸
1. Bhujanganasana ⁹
2. Shalabhashana ⁹
3. Vimanasana (variation of shalabhasana) ⁶ ⁸
Wall standing postures
1. Psoas stretch with squats on block ⁹
2. Standing Lunge with wall ⁷ ⁹
3. Utkatasana (bottom against wall and/or hands against the wall) ² ³ ⁷
4. Parsvottanasana with wall ² ⁷ ⁹
5. Parsvakonasana ⁷
6. Utthita Trikonasana (Triangle Pose) ⁶ ⁷
7. Ardha chandrasana ⁷
8. Dog up the wall ² ⁷
1. Tadasana (and variations with props) ⁷
2. Utkatasana (sitting and standing variations) ⁷
3. Standing lunge with chair ⁷
4. Virabhadrasana ² ⁶ ⁷
5. Uhitta trikonasana ⁵ ⁶
6. Prasarita padottanasana ⁷
7. Malasana ⁴
Vrksasana ⁷ ⁸
|The following postures all contribute to practising engagement of Mula and Uddiyana Bandha. They are a combination of release, align, strengthen and stretch work with an emphasis on core stability and pelvis stabilisation.
· Apasana relaxes the lower back, mobilises the pelvis, mobilises the hips and stretches the inside of the thighs
· Pelvic tilts help to find Mula and Uddiyana Bandha; massages sacroiliac joint
· Supta Baddha Konasana mobilises the pelvis and the hip joints (including SI joint); strengthens and stretches the inner thigh muscles; teaches inner thigh to pelvic floor connection; strengthens the core muscles
· Setu Bandha mobilises the knee and hip joint, stretches the leg muscles, strengthen adductors and glutes; conditions the hip flexors and corrects pelvic misalignment.
· Urdhva Prasarita Padasana mobilises the knee and hip joint, stretches the leg muscles, conditions the hip flexors and corrects pelvic misalignment.
· Vaparti kapari (with the use of a couple of bricks) helps to bring the pelvis into neutral making the bandhas easier to access. Highlights any misalignments of pelvis.
· Windscreen Wipers internally rotate the hips and stretches the side of the body – enhances pelvis stability
· Thread the needle stretches the piriformis muscle
· Sukasana (pelvic stabilisation sequence). This sequence will help stabilise the sacral joint and relieve any pain as well as continuing the hip and pelvic mobilisation work.
· Janu Sirsasana stretches the hamstrings, glutes, lower back, conditions the hip flexors
· Log pose stretches the piriformis and helps to stabilise the pelvis
· Cat provides relief for pelvic girdle, lower back pain, mobilises, aligns, strengthen and stretches the entire pelvic girdle region.
· Tiger encourages a cross-angle stretch; helps connect with transverse abdominals
· Sunbird sequence: as in 2. Also stretches and tones the hips flexors.
· Bhujanganasana strengthen the lower back muscles; stabilise the SI joint.
· Shalabhashana strengthens the lower back and abdominal muscles
· Vimanasana strengthens the backs of the thighs and the deep buttock and lower back muscles;
Wall supported standing postures
· Psoas stretch helps to lengthen and release the hip flexors; teaches you to engage the outer gluts and the hamstrings; strengthens the front of the thighs
· Standing lunge teaches pelvis stabilisation and core activation.
· Utkatasana/Parsvottanasana/Parsvakonasana aligns and strengthens the quadriceps, adductors abductors and track the knee, hip and ankle alignment; teaches correct engagement of inner and outer spiral (stabilise the legs); strengthens core; with the hands on the wall, the shoulder loop is worked; with the back of the pelvis into the wall pelvic stability and alignment is worked; stabilise the pelvis especially in the sacroiliac joint; helps you to work the legs properly whilst standing;
· Parsvottanasana teaches correct action of the shoulder loop (stabilises the upper postural muscles); also teaches correct activation of the feet to leg to pelvis connection
· Trikonasana/Ardha Chandrasana strengthens and stretch the hips, legs and the spine
· Wall Dog is a good way to finish the standing sequence because it helps to re-align the spine, relieve any tension and pain in the lower back and helps improve posture; emphasises opening the chest and the shoulders strongly and can be used to teach engagement of the mid traps and SA
· Tadasana helps teach good posture and the correct action of the legs in all standing postures
· Utkatasana helps to work the thigh adductors and assists with pelvis and hip stability. Assists the good function the hip joints
· Standing lunge extends the hips, strengthens the quads, and stretches the hip flexors and upper postural muscles
· Virabhadrasana stretches the spine and groin; strengthens the outer hip, leg and abdominal muscles; strengthens the buttock and leg muscles. Stabilises the muscles of the hips
· Trikonasana strengthens and stretchs the hips, legs and the spine
· Padottanasana stretches the hamstrings, adductors, mobilises the pelvis and the lower back. Also provides a gentle inversion
· Malasana helps to release and lengthen the pelvic floor muscles to avoid them becoming overtight. Trains the gluts
· Help strengthen the awareness of the core
· Strengthen the legs and improves balances
· Strengthens and opens the shoulders
Supine: Pranayama as above
1. Flapping Fish ⁹
2. Bhujangasana ⁷ ⁸ ⁹
3. Shalabhashana ⁸ ⁹
4. Vimanasana (variation of shalabhasana) ⁸
1. Chakrasana and variations ⁸
2. Low/high dolphin ⁹
3. Rabbit ⁹
4. Tiger sequence ² ³ ⁵ ⁶
5. Plank and variations ⁴
· Flapping Fish targets the serratus anterior, one of the stabilising muscles around the shoulder blade. Prone positions also help the uterus go back to its pre pregnancy position (Calais-Germain 2003)
· Bhujangasana strengthens the back and uses the legs to initiate space in the sacroiliac joint
· Shalabhashana strengthens the lower back and abdominal muscles, hamstrings and glutes. Creates space and stabilises the SI joint.
· Vimanasana strengthens the backs of the thighs and the deep buttock and lower back muscles
· Chakrasana coordinates the core with the breath, lengthen the hips flexors, mobilises the spine and warms up the body.
· Dolphin, Rabbit, Tiger & Plank help to connect to Mula Bandha and Uddiyana Bandha to create internal heat. They also fire up the upper postural muscles of the mid traps, serratus anterior muscles which help to stabilise the ribs and the shoulder girdle which in turn will help access to the bandhas.
- Calais-Germain, B (2003) The Female Pelvis: Anatomy & Exercises. Eastland Press
- Dinsmore-Tuli, U (2014) Yoni Shakti. A Woman’s Guide to Power and Freedom through Yoga and Tantra. Yoga Words.
- Dinsmore-Tuli, U (2008) Yoga for Pregnancy and Birth. Teach Yourself Books
- Dowdle H (2010) Building Strength in the Pelvic Floor. http://www.yogajournal.com/article/health/ accessed February 2015
- Freedman F, B, (2004) Yoga for Pregnancy Birth and Beyond. London. Dorling Kindersley Ltd
- Freedman F, B, (2014) STEP-BY-STEP Yoga for Conception, Pregnancy, Birth and Beyond. Lorenz Books
- Fishman L, Saltonstall E (2008) Yoga For Arthritis. Norton & Company
- Stiles M (2000) Structural Yoga Therapy. Goodwill Publishing House
- Voyce E (2014-15) Series of Therapeutic Workshops
Appendix C: Selection of Handouts Used In Classes
PELVIC FLOOR CHECKLIST J
Use the following checklist to ascertain the strength of your pelvic floor:
Do you worry about leaking when you laugh?
Do you avoid running, jumping, or chasing after a bus unless you are wearing a TENA lady?
If you have young children do you have to plan any chasing activities so you are prepared to a ‘whoops’ moment (i.e. make a quick toilet trip or pop a TENA lady on)?
Do you leak urine when you cough, sneeze or exercise?
Do you cross your legs when you sneeze?
Do you have trouble holding back wind?
Do you know the location of every toilet in Aylesbury?
Do you use the bathroom at more than nine times a day?
Do you use the bathroom just in case every time you’re about to leave the house, even if you just went 10 or so minutes ago?
Have you altered any physical or social activities because of your bladder?
To you just feel that things are not the same as they used to be, your bladder is more finicky or your pelvic floor does not feel as toned as it did before you had your baby (ies).
If you answer yes to any of the questions above, you may be experiencing pelvic floor weakness. Begin practising Mula Bandha regularly and use this checklist to mark any improvements or changes as the weeks go by.
YOUR PELVIC FLOOR
The main functions of the pelvic floor muscles are to support the pelvic organs, keeping everything up and in. They also work to allow us to have voluntary control of urination and elimination and are at the heart of a healthy sex life!
In order to get the most out of your pelvic floor rehabilitation, it is important that you get to know your pelvic floor a little more intimately. The pelvic floor muscles look very much a hammock which stretches across the area of the lower pelvic cavity. The hammock is made up of two layers of muscles: the superficial layer (which lies like a sheath along the bottom of the pelvis) and a deeper cup-shaped layer (narrow at the bottom; wider at the top) which lies within the pelvic cavity.
The superficial layer includes the following muscles: the bulbocavernosus, the ischiocavernosus, the transversus perineum and the anal and urethral sphincters. Together they form the shape of a triangle with a figure of 8 in the middle (between the pubis and the coccyx). Along the line of this figure of 8 lie the three openings of the anus, the vagina, the urethra.
The deeper layer consists of the muscles of the levator ani and the coccygeus (not shown but is located at the same level and behind the levator ani). The levator ani is the main muscle which supports the uterus and the vagina and so needs the most attention after childbirth.
Both the superficial and the deep muscle layers meet and cross each other at a ‘junction point’ called the central tendon. This area is otherwise known as the perenium or perineal body (a term which you may already be familiar with).
Pelvic Floor During Pregnancy, Childbirth And Now
It is not just the process of childbirth which puts a strain on your pelvic floor. The nine months of pregnancy puts a lot of ‘weight pressure’ on the muscles which can weaken them especially towards the end of the third trimester.
During childbirth the pelvic floor had two roles; the first was to help turn the baby’s head so that it could pass through the bony pelvic cavity; the second was to release enough to allow the baby to pass through ‘itself’ via the vaginal passage and out into the world. Both roles can potentially weaken the pelvic floor. The second role, in particular, significantly stretches the muscles of the vagina. During ‘crowning’ (at the end of second stage), the ‘central tendon’ or perenium (the area where the deep and superficial muscles cross and meet), would have also undergone a lot of strain. For any readers who have had the unfortunate experience of ‘tearing,’ this was the result of the tendon ‘caving’ in under this pressure. For any who had an episiotomy, the doctor or midwife would have had major concerns for this tendon. An episiotomy is performed to help avoid a serious 4th degree tear which is when the tear stretches from the vaginal opening right down to the anus.
As a consequence of all of the above, it is quite normal to feel like you cannot ‘find’ or ‘connect’ with the pelvic floor area, especially in the first few months after the birth. It is therefore very important to spend some time giving your pelvic floor some ‘one to one’ attention so that you can bring it back to its former pre-pregnancy glory. You may not believe me, but with a little patience, commitment and perseverance you will get it back and hopefully improve or avoid the following conditions:
- Organ prolapse
- Painful sex or loss of sensations
- Painful periods
- Loss of core awareness, strength and stability
Starting the Journey
At the moment, you may feel like you have a huge internal space or hole (a vacant space left by your baby). You may feel like you cannot feel your pelvic floor or your abdominal muscles. Don’t despair, once you find your breath you will begin to connect with the pelvic floor. From the breath we can start the practise of Mula Bandha and with both together you can literally start to ‘knit’ yourself back together again. Even if you have not just had your baby both practises are a good way to sustaining and improving the health of these muscles.
What is Mula Bandha
In yoga working with bandhas helps us to create a strong but mobile core which works fluidly with the breath. The main respiratory muscle, the diaphragm, is anatomically connected with the muscles involved in stabilising the core, so it makes sense that you can develop a better more functional core, practising yoga. There are three main bandhas but for the purpose of this handout we will look at Mula Bandha.
Mula Bandha focuses on the area of the pelvic floor muscles. This makes sense when we look at the translation of Mula Bandha from Sanskrit into English; mula means root and our pelvic floor is located at the ‘root’ or ‘base’ of our spine.
The benefits of practising Mula Bandha (the healing breath) include:
- increasing the stability of the pelvis.
- strengthening the support structure around the pelvic organs.
- resettling the organs into their pre-pregnancy positions.
- strengthening and toning the vaginal passage.
- acting as a starting point for strengthening the core as the pelvic floor is linked directly with the abdominals and the back muscles which together support the spine.
Like the standard kegel, the action of Mula Bandha concentrates on the area around the central tendon and the vaginal opening. With your awareness at this central point, you are aiming to draw the wall of your vagina in and up, just like a ‘lift’ or ‘elevator.’ The movement should feel internal but you will also get the sense that you are stopping the flow of urine and preventing yourself from passing wind. The difference between a kegel and Mula Bandha is that, with the later, the movement is strongly linked with the breath and performed with good postural alignment. As Uma Dinsmore-Tuli (2003) suggests in her book Mother’s Breath, this is a more holistic way of strengthening the pelvic floor muscles.
Step One: Learning to Breathe Again: The Full Yogic Breath
This may sound funny and completely obvious, but your baby took up a lot of space in your body. Your diaphragm (the main breathing muscle) became very restricted towards the end of pregnancy and will need some ‘exercise’ to get it to work properly. Remember, that your diaphragm (your breath), just like your pelvic floor, are key components to developing a strong core. As you practise the full yogic breath (described below) you will start to reconnect and reactivate the pelvic floor and abdominals (even if you cannot feel it at first). As you exhale, watch for a subtle connection of the breath with the pelvic floor and the abdominals – be patient – it will come. Only start the Mula Bandha healing breath (step two), when you feel comfortable with the full yogic breath.
FULL YOGIC BREATH (Step One)
You will notice that you will find the following breath very familiar; you practised it with me during your pregnancy yoga sessions. However, postnatally there is one big difference. Your baby is no longer taking up space within you. You will therefore feel this breath very differently! Don’t be alarmed but do take time to notice where you are feeling sensations. Take your time and practise regularly; take note of the top tips to help you get the most out of the breathing.
This breathe has 3 parts; abdominal, chest and finally collarbone focus.
How to do it
- Lie in a semi supine position, with your feet pressing gently into the mat, knees are pointing up to the ceiling. Your pelvis is in neutral. To find it imagine that your pubic bone at the front is at the same level or slightly lower than the two hip bones. Not sure? Place the heel of the palms on the hip bones and the fingers lengthening down to the pubis; aim to get the fingers at the same level or slightly lower than the hip bones. Try not to exaggerate the lumbar curve
PART ONE: ABDOMINAL BREATHING
- Start to breathe in and out of the nose. Lengthen the exhalation using sighing out the breathe like the ocean waves
- Let the breath move low down to the belly and the pubic bone
- Inhale: allow the belly to expand
- Exhale: allow the belly to sink back and ‘hollow.’
- Watch and visualise how the flow of the breathe moves the abdominals; do you feel a sense that as you exhale the abdominals are drawing inwards slightly. You are starting to awaken your core.
PART TWO: BACK RIBS/FRONT RIBS
- From the comfortable rhythm that you have with the breath moving to the belly, start to expand the in-breath up towards the chest and the ribs.
- Exhale, sending the breath smoothly out of the lungs. Complete several rounds encouraging the breath to expand and separate the ribs as you inhale.
- Inhale again; draw in the breath so that you feel the chest expand – get a sense of the ribs separating from each other and moving apart.
- On the inhale, work to let the belly expand the abdominals and widen and create space between each rib. Think belly, side ribs, back ribs as you ‘move’ the inhale.
- From here get the sense that the back ribs are widening and creating more space.
- From the sideways expansion can you feel the armpits move, creating space underneath; from this space can you feel the tips of the shoulder blades move in towards each other?
- Can you start to feel the breath lifting and expanding the front of the chest (your heart space)?
PART THREE: COLLARBONE
- In the final stage the breath moves from the belly, to the side and back of the ribs, the front of the heart to the collarbone
- Inhale; take a belly breath, move it to the ribs, the front of the chest and watch it go further up to the sternum and the length of the collarbones.
- Exhale; release the breath calmly and smoothly
- Try to get the sense that the top of your heart is opening up and out; the shoulder blades are softening down and inwards; it should feel like your posture is opening and widening.
- Watch the collar bones; do you get the sense they are lengthening away from each other or smiling?
MULA BANDHA/HEALING BREATH (Step Two)
- Lie semi-supine as in full yogic breath.
- Begin full yogic breathing. Inhaling; draw the breath into the belly, side and back ribs, front ribs and chest. Exhaling; let the breath flow from the top of the collarbones back down to the base of the belly. Get to the point where you have a good rhythmic flow.
- As the breathing settles notice the soft hollowing of the abdominals as you exhale, get a sense of your lower back easing down into the mat as the abdominals ‘hollow’ inwards. Begin to encourage this gentle pelvic tilt keeping the buttocks in contact with the mat at all times and letting the lower back soften down into the mat.
- From here on your next exhale, soften the lower back into the mat (pelvic tilt), feel the hollowing of the abdominals and see if you can sense the pelvic floor area move in response. Stay here for a few breaths
- Inhale, exhale: now actively draw the opening of the vagina inwards and upwards as much as you can. If it helps imagine that your vagina is like a dyson vacuum hose lifting in and up, in and up. Get a sense that the poo poo and wee wee hole is lifting in and up as well. Inhale, release and rest for one full breath. Repeat as many times as you wish.
Top tips and progression
- If you are struggling to make a connection try to lift in and up from the poo poo hole first, then the vaginal hole, then the wee wee hole (in that order) until it becomes easy. Think, I am not going to pass wind, let go of this tampon or have a wee. Use visualisations to get a sense of the area you are trying to engage. Be patient; it will come with practise. The action of the pelvic tilt as you exhale will really help you to find the muscles if you are struggling so use it as much as you need to.
- Once you have the above you can concentrate on focusing the drawing in and up (the dyson hose) from the vaginal opening. With practice you will notice that the central ‘lift’ will draw the poo poo and wee wee openings in and up automatically. This is Mula Bandha.
- Once you can feel the vacuum movement comfortably (and can pull the vagina in and up) try leaving out the pelvic tilts. Encourage the pelvis to lie in neutral. This puts the pelvis in perfect alignment and will help the pelvic floor muscles to work effectively. Try doing a few ‘rounds’ before having a break and going back to the full yogic breath.
Part two: The 3 floor lift sequence (Krama or segmented breath)
- Exhale; draw up the muscles of the vagina inwards and upwards. Imagine an inner lift with the power of the vacuum moving up inside towards the cervix.
- On your next inhale, do not release the lift back down, keep it at the level you have ‘lifted it.’ This is the first floor.
- On your next exhale, can you lift your inner lift up to the second floor (closer to the cervix).
- Inhale, hold the lift here.
- On the next exhale, lift it to the third floor or level (right up to the cervix or even your navel).
- Keep the sense of uplift and inwards squeeze as you inhale here. Hold as you exhale.
- Inhale: release and allow the lift to move down the 3 floors back down to the ground floor
- Rest a while, moving back to full yogic breathing for a few rounds before repeating the whole sequence again.
- Complete the 3-stage lift with the pelvic tilts (as described above). Once you are comfortable with the action leave out the pelvic tilts but continue to practise one round of lifting 3 times having a break before repeating the sequence. Remember to keep the pelvis in neutral whilst performing Mula Bandha.
- Once the above is easy gradually perform more rounds of the 3-lift sequence (3 exhales and 3 inhales) before releasing, still keep at least one round of yogic full breathing in-between rounds to recuperate.
- Try to increase the range of your floors aiming to make the lift stronger and higher each time.
DECOMPRESSION OF THE PELVIC ORGANS
Don’t panic – it sounds serious but decompression of the pelvic organs can assist with your postnatal healing. The area of the pelvic floor would have suffered a lot of compression and strain throughout pregnancy and during the birth. This practise will help move all the structures of your pelvic floor including the organs back into their pre-pregnancy position. This is not a wholly yoga practise but the second part (abdominal decompression) is very similar to the essence of Uddiyana Bandha. Uddiyana Bandha follows on from Mula Bandha – both are strongly connected and vital for creating core stability. This practise will therefore start your journey on getting to know your abdominals or centre core. This is quite difficult so please be patient with yourself and take your time getting to know what sensations you should feel.
Part One: Chest Compression
- Lie on you back with the knees bent, feet flat on the floor.
- Spread the arms out so that the elbows are at shoulder height; keep the arms bent so they form a right angle on the floor.
- From here, begin practising the full yogic breath. Get to the point where your breath moves from the belly, side and back ribs and the front of the chest. Really sense the ribs moving out sideways and front to back.
- On the exhale, watch for the action of the ribs moving back to their original position – this is the result of the lungs expelling their air and drawing the ribs inwards as they retract and empty.
- Think: inhale, expansion; exhale, retraction…………………………………
Part Two: Abdominal Compression
- From above, with the next inhale, expand the ribs once again.
- As you exhale; try to maintain the expansion of the ribs. This will be hard to achieve because you are going against the natural pattern of the breath. Be patient – it will get easier.
- Keep the ribcage as open as you can until the very end of your exhalation
- As you inhale, expand the ribs again
- As you exhale, try to keep the expansion of the ribs once again; can you push them even further apart?
- Repeat once more and then rest for a while before trying again if appropriate.
Keeping the rib cage open as you exhale creates an abdominal vacuum. It will feel like a stretch and pull sensation along the line of your abdominals (from the pubis right up to the rib cage). It is this pull which lifts the pelvic organs back into their proper place. The action also engages Mula Bandha without you having to do anything because of the ‘lifting action’ towards the front of the pelvic floor. When you do the action the abdominals will feel like they are hollowing inwards.
It can also be helpful to make either a SSSSSSSSSSSSSSSS or a HHHHHHHHHHHHH as you exhale. Have a play to see what works for you.
Part Three: Taking it further
This is hard again so take your time and don’t worry if you don’t get it to begin with. Once you have a feel for the abdominal compression you can try to direct the action to different areas of the abdomen: the upper layer (above the navel), middle layer (below the navel), and lower level (base of the groin).
- Inhale; expand the ribs. Exhale; direct the compression to the area above the navel
- Release and relax for a full breath
- Inhale; expand the ribs. Exhale; direct the compression to just below the navel
- Release and relax for a full breath
- Inhale; expand the ribs. Exhale; direct the compression to the lower pelvis.
- Release, return to the full yogic breath to relax. Repeat if desired or try again another day
Calais-Germain, B (2003) The Female Pelvis: Anatomy & Exercises. Seattle. Eastern Press
Dinsmore-Tuli, U (2006) Mother’s Breath. London. Sitaram And Sons