Urinary incontinence and pelvic organ prolapse are two of the most common pelvic floor disorders associated with pregnancy. Both conditions can negatively impact a pregnant individual’s quality of life.
Most notably, these disorders may hold them back from sticking to a regular workout routine due to fear (that exercising may worsen their symptoms), shame (of losing control of their bladder), or a complicated mix of both. This, in turn, prevents them from reaping the many physical and mental health benefits seen with leading an active lifestyle during pregnancy—from a lower risk of gestational diabetes to improved mood.
So, as a Certified Personal Trainer or a Certified Prenatal and Postnatal Fitness Specialist, you may wonder: “What can I do to help?” Well, that’s what this article is for. Continue reading to learn how to confidently help your pregnant client optimize their pelvic floor health while still staying within your scope of practice.
What Do the Pelvic Floor Muscles Do (in People with Vaginas)?
The pelvic floor comprises muscles and connective tissue (including fascia) that sit inside the pelvis. The pelvic floor muscles perform two major functions:
- Provides support for the pelvic organs: The pelvic organs include the vagina, uterus, bladder, urethra, and rectum. You can think of the pelvic floor muscles and connective tissue almost like a hammock, essentially a support structure that helps keep these pelvic organs suspended and “in place” inside the body.
- Helps to constrict the urethra, vagina, and anal canal: The appropriate contraction and relaxation of the pelvic floor muscles enable bladder and bowel control (i.e., control over peeing, pooping, and passing gas)—and can also result in more enjoyable sex (think: vaginal contractions during orgasm). And perhaps more relevantly, pelvic floor muscles support the growing baby’s weight during pregnancy, plus vaginal delivery during childbirth.
How Does Pregnancy Affect the Pelvic Floor Muscles?
Pregnancy affects the pelvic floor muscles through:
- Hormonal changes: To allow a baby to pass through the birth canal more easily, the body releases increased amounts of “pregnancy hormones,” like relaxin, to soften the muscles and ligaments, especially in the pelvic area. This, in turn, contributes to “looser” pelvic floor muscles.
- Increasing pressure: As the uterus expands to accommodate the growing baby, more pressure bears down on the pelvic floor muscles, which are often not strong enough to deal with the additional load.
Unfortunately, pregnancy-induced hormonal changes and increasing pressure often translate into pelvic floor dysfunctions.
Take urinary incontinence, for instance. Research shows up to 58% of pregnant individuals may show incontinence signs by week 30.
And while it’s challenging to obtain accurate estimates of the prevalence of pelvic organ prolapse, findings from vaginal examinations note that the condition affects as many as 25% to 65% of individuals with vaginas.
Optimizing a Client’s Pelvic Health During Pregnancy
Thankfully, ample evidence highlights the effectiveness of pelvic floor muscle training during pregnancy in lowering the incidence of urinary incontinence and pelvic organ prolapse post-birth. But what does “pelvic floor muscle training” entail, exactly? And how can you coach a client through it? Find out below.
Step 1: Screen for Pelvic Floor Dysfunction
First things first. Make sure your client is medically cleared to exercise (get them to have their healthcare provider fill out the medical clearance form!)
Beyond that, it’s also a good idea to screen your client for any existing pelvic floor dysfunction before developing a new training plan to optimize their pelvic health during pregnancy.
You can do so by asking them if they:
- Unintentionally leak urine when exercising, playing sports, laughing, coughing, or sneezing?
- Need to get to the toilet in a hurry, and sometimes not make it there on time?
- Constantly need to go to the toilet?
- Find it difficult to empty their bladder or bowel?
- Have a prolapse (e.g., a bulge or feeling of heaviness, discomfort, pulling, dragging, or dropping in the vagina)?
- Experience pelvic pain during or after sex that involves vaginal penetration?
While it’s not within your scope of practice to diagnose and/or treat pelvic dysfunctions, you could develop an exercise program that accounts for any pelvic floor concerns. And you’ll learn how to do that in steps two through four.
Step 2: Introduce Pelvic Floor Exercises
Contrary to popular belief, strengthening the pelvic floor muscles cannot be done solely through “contraction exercises,” like Kegels. Instead, like other muscles in the body, the pelvic floor muscles operate best when they’re able to release fully after a full contraction.
That’s why you’ll need to coach your client through a combination of “contract exercises” and “relaxation exercises”:
- Contract exercises: Examples include the Kegels, quick flick Kegels, heel slides, and toe taps
- Relaxation exercises: Examples include the happy baby pose and diaphragmatic breathing
If your client has difficulty “finding” (i.e., activating) their pelvic floor muscles initially, get them to contract the muscles they would squeeze to stop urine flow or prevent passing gas. Try to have them isolate the pelvic floor muscles without contracting the abdominal and gluteal muscles.
Step 3: Teach the “Connection Breath”
Under normal circumstances, increased intra-abdominal pressure while lifting is beneficial; it helps increase the rigidity of the core, improving overall stability and power, enabling the lifter to move greater loads while minimizing the risk of injury.
But this doesn’t apply to pregnant individuals.
More specifically, increased intra-abdominal pressure can place additional stress on already-weakened pelvic floor muscles, skyrocketing the risk of urinary incontinence and pelvic organ prolapse, amongst other pelvic floor dysfunctions.
This then begs the question: how can your client better manage their intra-abdominal pressure while still safely and effectively performing exercises (especially on heavy, compound movements like squats and deadlifts)? Answer: by using something called the “connection breath.”
By getting the pelvic floor muscles and the core functioning together again, the connection breath helps keep the stability of the core without creating excessive intra-abdominal pressure.
Cueing the Connection Breath
To cue the connection breath in a pregnant client:
- Make sure your client is in a comfortable position. If your client is far along in their pregnancy, get them to sit on a bench. If not, they could lie on their back (with a towel supporting their lower back) on the floor, with their knees semi-bent.
- Get your client to breathe in with their hands on their belly. As they inhale, have them visualize their diaphragm expanding with air and pushing down toward their pelvic floor muscles. As a result, their pelvic floor muscles should naturally relax.
- Now, get them to exhale. Have them visualize their diaphragm collapsing and their pelvic floor muscles contracting “upwards.” If they’re having difficulties with this, one cue that may help would be to get them to think about grabbing a pea with their vagina as they exhale.
- With practice, the connection breath will likely become like second nature to your client. They’ll unconsciously relax their pelvic floor muscles when inhaling, then contract when exhaling. You can then have them practice the connection breath while weightlifting. This could help them maintain core stability without excessive intra-abdominal pressure.
Here’s an important disclaimer. There is no one specific way for your client to breathe and connect to the pelvic floor during an exercise (e.g., inhale during the lengthening phase, then exhale during the contraction phase). This varies from individual to individual and will be influenced by each client’s situation, plus the type of exercise they’re doing.
Ultimately, you’ll have to get your client to try different variations—like exhaling during exertion, inhaling on exertion, or maybe even exhaling slightly right before exertion—and ask them which helps them lift and feel better.
Step 4: Make Exercise Modifications Where Necessary
The uniqueness of each pregnant individual’s experience with various pelvic floor dysfunctions makes it challenging to give absolute “safe” and “unsafe” lists of movement. That said, some activities may be more likely to lead to symptom aggravation, including:
- High-impact exercises, like running and jumping
- Heavily loaded exercises that encourage “bearing down” (e.g., squats)
- Intense “abs-focused” exercises, especially anything related to crunches
- Weighted exercises performed in a wider stance
By the way: click here for tips on incorporating low-impact workouts into your client’s training.
What to Do if a Client Reports Symptoms
It is important to ask your client to let you know immediately if they feel any symptoms during their training session so that you can adjust their exercise, program, or technique promptly. Examples of what you could do include:
- Decrease the weight: Your client may be able to work more efficiently with a lighter load.
- Experiment with different set and rep ranges: Cutting down on the number of sets and/or reps your client does may eliminate or, at the very least, alleviate their symptoms.
- Try a different breathing strategy: As mentioned earlier, there are many breathing strategies your client could use. Feel free to experiment to find what works best for your client on that exercise.
- Decrease range of motion: Working in a smaller range of motion (e.g., half squats) may help your client feel more in control.
- Change the position of the load: Instead of loading through a barbell, have your client hold a kettlebell lower toward the floor. Or get them to hold two smaller kettlebells instead of just one. Once again, feel free to experiment to find a configuration your client feels most comfortable with.
- Check for excessive intra-abdominal pressure: You could do so by asking your client what they feel in their abdominal wall and pelvic floor during the movement; they shouldn’t feel too much pressure in the region. Another way is to see if they can breathe relatively normally and even have a conversation with you. If they can’t, it’s a sign they’re creating excessive intra-abdominal pressure while lifting.
Remember which configuration works best for your client so that you can replicate it in future sessions.
While mild discomfort and symptoms may be alleviated by exercise and/or program modifications, some signs and symptoms should be a signal to stop. If your client experiences any of the symptoms below while training, get her to stop exercising and call a member of her healthcare team immediately:
- Amniotic fluid leakage
- Vaginal bleeding
- Painful contractions
- Shortness of breath before exertion
- Chest pain
Step 5: Know When to Refer Out
Your pregnant client is still experiencing symptoms of urinary incontinence and pelvic organ prolapse (e.g., pelvic girdle pain, leaking urine during exercise, and “heaviness” in the pelvic region) during training despite your best attempts at modifying their movements.
What should you do now? Ideally, you should refer her to a pelvic health physiotherapist or a urogynecologist.
That said, remember that your client has full autonomy over her body and decisions. So, don’t force an unwilling client to consult a pelvic health expert just because you feel it’s the best course of action.
Your role is to educate your client on pelvic health—and allow them to make their own health decisions.
As a coach, it’s important to recognize that pelvic floor dysfunctions are prevalent in pregnant clients. Fortunately, training could help with lowering the risk or managing the dysfunction. This allows your clients to enjoy their pregnancy with fewer worries.
Of course, it’s always good practice to refer your clients to a pelvic health professional to ensure that their concerns are well addressed, especially when it’s beyond your scope as a personal trainer.
Looking to provide greater value to your pregnant clients? Don’t be afraid to upskill to gain more relevant knowledge on coaching prenatal clients through AFPA’s Prenatal and Postnatal Fitness Specialist Certification.