A very common question among pregnant women is ‘How do I keep my pelvic floor and core muscles strong during pregnancy?’
In this blog, Women’s Health Physiotherapist Taryn Watson delves into exactly what and where the core muscles are, whether it’s safe to exercise them during pregnancy, and how this can be done.
Firstly – what is The Core?
To a Women’s Health Physiotherapist, ‘The Core’ is a term to describe the supporting muscles deep inside the trunk, the Pelvic Floor (PF) Muscles and the Transverse Abdominis (TA) Muscle.
Despite popular belief, your six-pack muscle (more correctly termed the Rectus Abdominis or RA) is not technically your core. Neither are the two layers of obliques underneath this. Think about the core of an apple – is it simply everything between the top and the bottom of the apple? No – it’s the inner, deeper part. It’s the same with our abdomen.
The outer muscles are ‘power’ muscles and help to move your trunk. While very important, they do not have the same supportive function for the pelvic organs and the spine as the deeper core does. In fact, while the pelvic floor and the transverse abdominis muscles have an upward, inward movement when contracting correctly, the six-pack and obliques can create a downward force in the abdomen, which, unless used correctly in synergy with the deeper core, can contribute to common gynaecological issues.
The upward and inward action of the ‘core’ and having optimal support in these muscles is very important for you in pregnancy and beyond. Having a well-functioning pelvic floor, working in synergy with the TA, helps to prevent common issues such as:
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The pelvic organs descending (known as pelvic organ prolapse)
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Bladder and bowel leakage (called incontinence)
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Back and pelvic pain.
Having core muscles that are able to be correctly contracted, and just as importantly relaxed, will help you to get through your pregnancy without pain or dysfunction in the pelvic area.
Is it OK to do core exercises while pregnant?
You may have heard it said that abdominal muscle exercises are ‘unsafe’ in pregnancy or that doing abs exercises while pregnant will increase the risk of significant abdominal muscle separation. These are myths! You absolutely can exercise your core, including your abdominal muscles, during pregnancy.
A more correct version of this myth is 'you are likely to need to modify your abs exercises during and after pregnancy’. You may also need to modify the way you exercise your pelvic floor. But it’s important to understand that this doesn’t mean avoiding using these important muscle groups during your pregnancy.
The abdominal muscles are at a mechanical disadvantage as the baby grows, and the two sides of the ‘six pack’ muscles stretch apart from each other. This will likely mean that certain exercises, for example, plank variations and pull-ups, would become more difficult and may need to be substituted for an alternative.
Also, a pregnancy phenomenon called ‘supine hypotension’ (which means low blood pressure when lying flat on your back) means that common abdominal exercises like sit-ups and bicycling would need to be substituted as well.
In a nutshell - you'll need a new repertoire of some potentially less ‘well-known’ abs exercises to replace the sit-ups, the bicycles, and the burpees for a while. Examples may include ‘bird dog’ and other four-point kneeling options, side plank variations, standing or kneeling trunk rotations, and long lever-resisted arm exercises.
What are the benefits of exercising your pelvic floor during pregnancy?
Pregnancy can increase the risk of urinary incontinence, in particular ‘stress urinary incontinence’ where bladder leakage occurs on pressure increases like coughing and sneezing. This is likely due to the combination of the increased weight of the baby and the pregnancy hormones creating more laxity in the supporting ligaments and connective tissue in the pelvis.
The good news is that several studies have shown that regular pelvic floor exercises done during pregnancy can prevent or reduce bladder leakage during and after pregnancy.
Also, importantly, there is research indicating that doing pelvic floor exercises through pregnancy might aid in labour, with positive outcomes such as preventing prolonged pushing or reducing the need for assistance like forceps. This is interesting, as it’s likely to be less about the improved strength and endurance of the pelvic floor and more to do with the increased ability and awareness to relax the pelvic floor during the pushing phase of labour. This highlights the importance of having an individualised pelvic floor assessment done, which can identify those women who have tense pelvic floor muscles and need to focus their programming on practising full relaxation.
How do I exercise my pelvic floor muscles during pregnancy?
Pelvic floor muscle exercises are done by squeezing and lifting this sling of muscles inwards and upwards as if stopping wee or wind or lifting a tampon inside you.
Transverse abdominis co-activation is usually very beneficial, and this can be done by adding in a gentle in-draw of the lower tummy, like doing up a low button on a pair of jeans.
When programming what to do in an exercise session for the pelvic floor, it is important to understand that one size does not fit all. Your program would really depend on what your ‘focus areas’ are from an individual assessment. What can you already do well, and what do you need to work on? For example:
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Full relaxation
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Strength
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Endurance
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Getting the ‘timing’ right before an increase in pressure (like a cough or sneeze)
Here is an example of what might be given as a home exercise program for a pregnant woman:
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Hold the muscle on for 10 sec, then relax for 10 sec. Repeat this 6 times in a row
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Bring the muscle on quickly, and then let go (1 sec on/1 sec off). Repeat this 10 times in a row
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Finish with 4 ‘fake coughs’ with the pelvic floor coming on and staying on during the cough, and letting go afterwards
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Do this program 2-3 times in a day
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Do this in a variety of different positions
Common mistakes to avoid
Many women are just handed a brochure or verbally taught pelvic floor muscle exercises, and research shows that about half of women would be inadvertently contracting the core in the wrong way.
Common mistakes include:
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Overusing the abdominal muscles and bearing down into the pelvic floor instead of lifting it upwards. This obviously wouldn’t be helpful for an existing prolapse!
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Failing to relax the pelvic floor muscle after contracting it. Many people make this mistake and end up with a tense, possibly painful pelvic floor muscle, which may in turn lead to difficulties with birthing vaginally.
This is why it is essential for your pelvic floor muscles to be individually assessed and an individualized program to be put in place. Book your pelvic floor muscle assessment at FitRight HQ here.
What is the best way to have my pelvic floor muscles assessed?
There are physiotherapists, like those at FitRight HQ, who specialize in pelvic health and can do pelvic floor muscle assessments. They can be done in two different ways, one more invasive than the other, but one that gives a lot more information than the other.
1. Real Time Ultrasound
This ultrasound goes on your lower abdomen and looks downwards towards the bladder. When you contract your pelvic floor muscles correctly, the base of the bladder should lift upwards on the screen. We can assess how long you can hold, how well you can relax, and how well you can activate it in different positions like lying, sitting and standing.
It cannot, however, assess strength, tone, pain or prolapse. All of these things are very important to note if you already have symptoms such as bladder leakage or vaginal heaviness.
It is usually good to use as a screening check for those with no current problems who want to proactively know if they are using their muscles correctly, for those who would rather not have a vaginal examination, or as a visual learning tool in conjunction with a vaginal examination.
2. Vaginal Examination
A vaginal examination to check your pelvic floor muscles is the gold standard and will give you a terrific amount of feedback about the way you’re activating your muscles, how strong they are, how well-supported the bladder, bowel and uterus are, how at-risk you are of vaginal prolapse etc.
If you wish to be empowered to make exercise choices that are very specific to your own body and personal risk profile and to know that the pelvic floor exercises that you’re doing are definitely being done in the most effective way possible, this is definitely the optimal way to be assessed.
It involves a short (5-10 minutes) assessment with the therapist's gloved fingers palpating inside the vagina. It shouldn’t hurt, and there are no speculums used like in a pap smear. During pregnancy, you may choose not to have any non-essential vaginal examinations done for the safety of the baby. However, there is no evidence to show that a vaginal exam would pose a risk to the baby, and many women continue to be sexually active during pregnancy.
How do I include pelvic floor and ‘core’ exercises in my workouts during pregnancy?
Once you’ve been given a program from your physiotherapists, isolated pelvic floor exercises can be done multiple times a day in different situations. How about trying to remember to do a set of them:
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When you brush your teeth
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When you’re in the shower
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When you lie down in bed at night
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When you’re waiting for the kettle to boil
They can be done pretty much anywhere that you can properly focus on them and get through a whole set for 1-2 minutes. Which is why doing them at the traffic lights might not be ideal…!
The pelvic floor can be incorporated into modified ‘core’ exercises during your workout too, with the use of ‘The Knack’ (a pelvic floor pre-contraction before an increase in pressure). For example, some of the ‘core’ exercises mentioned above, such as ‘bird dog’ or straight arm band pull, can have a pelvic floor contraction included during the movement (and then a relax afterwards).
There is a whole section in FitRight’s online membership platform with examples of ‘Core Workouts’ for pregnancy.
Summary
In summary, it is important to keep globally strong during pregnancy, and this includes keeping your core (pelvic floor and abdominal muscles) strong. It is not unsafe for the mother or the unborn baby to do abdominal muscle exercises during pregnancy, but they may require modification while they are on stretch and at a mechanical disadvantage! There is very good evidence for pelvic floor muscle training during pregnancy, and including this as part of a more global ‘core muscle’ workout is ideal.
