Tory Toogood has been a pelvic health physiotherapist for 20 years. She works in private practice and spends some of her time teaching Masters of Physiotherapy students at Flinders University. She is passionate about helping women maintain the ability to engage actively throughout their lives and to have enough physical strength and fitness to do the things that they love doing.
It was a lived experience that influenced her to work in the area, having been an athlete. Her career started as a musculoskeletal and sports physiotherapist. “I was sure I was going to be a sports physio,” Tory says. “But as I was working and then had a family, I saw the gaps in knowledge, awareness and in comfort in talking about issues related to bladder and bowel control.
Issues to do with pelvic health are so personal and private, but at the same time they're almost universal.” Tory Toogood
HOW DOES BEING PREGNANT AND GIVING BIRTH IMPACT A WOMAN'S ABILITY TO BE CONTINENT?
Pregnancy comes with enormous hormonal changes and weight distribution changes, as most women will gain between 10 to 15 kilograms. On a smaller frame this could be an additional 20 or 25 per cent of body weight, normally happening over only six months. It's a very dramatic change in weight in a short period
of time. Most of the weight is concentrated in the abdomen and within the pelvis, on top of the pelvic floor and the bladder.
There is also an increase in progesterone (a type of hormone). Progesterone relaxes the smooth muscles to help manage all the extra blood that is flowing around, to help this little life form get all the energy and nutrients and waste removal that the baby needs. Progesterone helps manage blood pressure in the first trimester by relaxing the walls of the blood vessels. It also means that your bowel wall relaxes.
This can tend to make you constipated, so you may not be as regular as you were. If you're constipated, you may strain to empty your bowels and that puts a lot more pressure on your pelvic floor muscles and can cause some stretching and damage if it goes on too long.
Giving birth results in significant stretch to pelvic floor muscles, or to surgery on the abdomen. This level of stretching, or of stitches and surgery creates changes in how the muscles usually work, which can affect continence.
WHAT ARE SOME THINGS THAT WOMEN SHOULD LOOK OUT FOR THAT CAN AFFECT CONTINENCE?
Movement is important to consider, so include regular exercises to suit your body and pregnancy. However, certain strenuous movements can contribute to excessive load on the pelvic floor and on the supports for the bladder, which may cause some loss of urine.
Be aware of the sort of activities that you're doing. Whether that's heavy lifting or substantial exercise, which puts more pressure on your pelvic floor muscles. Then if your pelvic floor muscles aren't quite strong enough, the extra weight of the baby and uterus, combined with the activity, might be a bit more than the muscles can cope with. So, specific strengthening would help manage that and ensure a return to more vigorous activity when the muscles are performing better.
If you've got any issues or concerns, it’s well worth addressing that before childbirth so you have strategies in place. Know how to seek support that is around you, from the midwives or the birth team.”
Vomiting from morning sickness can also have quite an impact on the pelvic floor, because it is usually so forceful and again, may be frequent.
There are many messages to drink a lot of water but it's not often that I'll see somebody under 60 who doesn't drink enough. If you are overloading your system with too much water, that can be an issue, in terms of going to the toilet often and electrolyte imbalances such as sodium levels.
I say to every patient, as you feel comfortable, tell your friends, speak to the women that you're with, family members, that they don't have to put up with this. Know that you are not alone, and that help is available. Being continent or finding a continence product (that works well as an interim measure) have such an impact on women's ability to participate.
in life, whether it's participating in sport, whether it's feeling comfortable to leave the house, even to be able to work, to be able to volunteer, to be able to socialise or to be able to care for other people. We need to recognise that there is so much work and contribution that women make and much of it falls to her being physically capable and not being restricted by feelings of discomfort around the perineum or in the vagina, or by issues with the bladder or bowel.
WOMEN EXPERIENCE AFTER GIVING BIRTH?
There can be several different ways that you could be incontinent of urine
- A little bit of urine may come out when coughing, sneezing, bending over and reaching out. This is because when you create more pressure on your tummy and if pelvic floor muscles are not well coordinated or strong enough, there may be a little leak of urine
- Very early on after giving birth, due to the stretch of the delivery, there may be a little bit, almost unnoticeable, loss of urine. If that's persisting after the first few days, speak to your healthcare professional as this needs to be investigated. There may be a nerve problem or something else
- With bladder urgency, it should be investigated what the mother is drinking and how often; whether you are either not drinking enough or drinking too much. If that is okay, a care provider may do an ultrasound to check that the bladder is emptying properly.
Constipation can also occur. Providing support to the pelvic floor for the first bowel movement after childbirth is important.
You can ask yourself, am I feeling:
- Urgency to empty my bladder or bowel
- Leakage on the way to the toilet
- Leakage when coughing or sneezing, or from vomiting during the pregnancy
- Not feeling my bladder or bowel is fully empty after going to the toilet.
The aim is to feel that you can contract the pelvic floor muscles, that you could stop or prevent the flow of urine. So regular check-ins with your physiotherapist before the pregnancy or during the pregnancy is valuable.
WHAT ARE SOME WAYS TO MANAGE INCONTINENCE FOR PREGNANT WOMEN?
The number one thing is pelvic floor muscle training and in particular strength training of these muscles. It is supported by a lot of research. This way you can
- Better understand where these muscles are in the body
- Do a controlled, correct pelvic floor muscle squeeze and relax
- Hold this squeeze for long enough, or being able to do it quickly and in a coordinated fashion
- Make sure that there is adequate strength, endurance and coordination in these muscles.
Look at bladder habits, for example relaxing and taking your time on the toilet, waiting for a good urge before going to the toilet, fluid intake and perhaps make some changes. This could include some bladder calming strategies or bladder training, for example deep breathing and pelvic floor contractions to control urgency.
Diet is important too. If you are constipated it tends to impact the bladder as well as the pelvic floor muscles. Make sure you have a balanced diet which includes a variety of fibre and follow good bowel habits, for example not ignoring the urge to use your bowels, getting to a good toileting position leaning forward with elbows on knees and tummy relaxed and not straining.
WHAT ADVICE WOULD YOU GIVE TO WOMEN WHO'VE JUST FOUND OUT THAT THEY ARE PREGNANT?
If you have questions or concerns, or if something hurts, it's worth checking out to see what you can do about it. If you know that you can do a good pelvic floor muscle contraction and can also relax your muscles well and can practice your pelvic floor exercises every day, you're going to be in a really good position for your post-natal period or after childbirth. It's always nice if there's a physiotherapist you've already met, somebody you already trust.
It makes it much easier to discuss new problems. If you have any concerns around your bladder, bowel, vagina or ability to have sex, a pelvic health physiotherapist is a good person to see.
WHERE CAN WOMEN SEEK SUPPORT IF THEY ARE EXPERIENCING INCONTINENCE?
- The Continence Foundation of Australia is a very important source of
information and has a Service Directory to help find a pelvic health physiotherapist near you - Call the Continence Foundation of Australia’s National Continence Helpline on 1800 33 00 66 for free
and confidential advice and information from a Nurse Continence Specialist, including information on your local pelvic health physiotherapist - Speak to your birth healthcare professional (your doctor or midwife) is often a good first step to find local support and services
- Your hospital may have a Nurse Continence Specialist who will be able to provide support and access to the Physiotherapy Department.