Are you struggling with bladder control after having your baby? The bladder can have a bit of a rough time during labour. It can be ignored and not emptied and subsequently overdistended or stretched. It can be pushed and squashed by the descending baby, it can be filled due to IV fluids, affected by hormones and medication and it can be irritated by a catheter or surgery. As a result of all this, some women present with a complete loss of bladder control after childbirth and this can cause a lot of distress at a time when emotions are already high and exhaustion is present.

Three main types of urinary incontinence

There are three main types of urinary incontinence that may occur immediately postnatally.

Stress urinary incontinence (where urine leaks due to the inability to compress and shut the urethra during an increase in abdominal pressure – such as with a cough), urgency urinary incontinence (where urine leaks in response to an overwhelming urge to reach the toilet) and overflow incontinence.

1. Stress urinary incontinence is very common in the postnatal population – it is thought around one third of postnatal women experience stress urinary incontinence. Often (but not always) it is due to a weakening of the pelvic floor and an inability of the pelvic floor muscles to generate the required, or timely, force closure of the urethra. Urine subsequently leaks during a raise in intra-abdominal pressure, such as with a cough, sneeze or jump.

2. Urgency urinary incontinence is also very common postnatally. This is where the urge to urinate overrides the ability to maintain control and urine escapes. The bladder lining has become more sensitive and overreacts to the filling bladder.

3. Overflow incontinence occurs when the bladder is not emptying properly. Postnatally this is called Postpartum Voiding Dysfunction (PPVD). This may happen due to an obstruction eg postnatally a swollen perineum following a tear or episiotomy or because of overdistension of the bladder which prevents complete emptying and results in regular urine loss.

Overflow Incontinence can occur postnatally and is a warning sign for Postpartum Voiding Dysfunction. This is when a postnatal woman is unable to fully empty her bladder. This may be very apparent – she just can’t wee, or less so – she is managing to pass urine but it is slow, hesitant, small in volume, she keeps having to go back to do more and there may be regular incontinence.

Either way, this is not good news for the bladder. With this condition the bladder is at risk of overdistention (overfilling and stretching) which can lead to a chronically dysfunctional bladder down the line.

PPVD is more likely in those women who have had an instrumental birth, such as forceps, an epidural, a prolonged labour, first-time mums, caesarean section and/or perineal trauma.

After delivery of a baby, the bladder is usually monitored to ensure the woman passes urine within 6 hours of delivery or 6 hours after catheter removal. The volume is measured to make sure it is an appropriate amount (normally over 150ml). If there is no urine or only a very small amount within 6 hours, the woman may require an in/out catheter to drain the urine and is then monitored further. Occasionally an indwelling catheter is required for 24 hours or longer to protect the bladder from overfilling and allow it to recover. The exact protocol is dependent on your local care provider.

What you need to do if you suffer from a complete loss of bladder control after childbirth

The good news is that the bladder, perineum and pelvic floor are normally all great at getting better. For PPVD it is important that you flag up any concerns to your Midwife or Doctor as soon as possible as you will need to be monitored and checked regularly. You may require timed voiding (going to the toilet at a set time) moving forwards and subsequent help and advice.

For stress urinary incontinence and urgency urinary incontinence there is much conservative treatment that can be accessed easily through the NHS or Privately. Ask for a referral to a Women’s Health Physiotherapist. Here you will be assessed and guided through the appropriate muscular rehabilitation, given advice about fluid and bladder control techniques, advised on how to move forwards with general exercise and taught perineal care as appropriate.

Although postnatal incontinence issues are common, they are not normal and as such should not be ignored. If you’re suffering with a complete loss of bladder control after childbirth, make sure you seek treatment. There is a lot that can be done with excellent success rates. If you have any questions, please do not hesitate to email me at erica@hertfordshirewomenshealth.co.uk.

You can also read our blog post on what you can do to improve your pelvic floor if you’re struggling with incontinence after childbirth.

It astounds us how incontinence after childbirth and leaking is often seen as a normal part of motherhood. We believe that it is time to put a stop to this archaic way of thinking.

We’re making it our mission to tell women everywhere:

YOU DO NOT HAVE TO PUT UP WITH THIS SHIT.

Sometimes, literally!

Urinary and faecal incontinence are, sadly, much more common than you would think, and it is so important to be aware of what you can do to support yourself.

The strength and function of your pelvic floor is hugely impacted by pregnancy and birth – from the weight of a growing child to the exertion, and potential tears and interventions, of a vaginal or caesarean delivery.

Once your baby has arrived, your pelvic floor may not be able to sufficiently support you. And when these muscles are struggling, there is more chance that you will experience leaking, pain and feelings of heaviness or dragging.

What is stress incontinence?

Stress incontinence is leaking when under pressure – such as sneezing, laughing or jumping, and around a third of new mums experience this during their first postnatal year. It could be just a few drops, or it may be enough to leak through clothing and cause severe embarrassment. Stress incontinence can have a real impact on women’s lives if it is not brought under control, in fact there is a clear link between continence and postnatal depression, so it is vital to seek help if this is something you are currently struggling with.

Why am I suffering from stress incontinence?

There are certain factors that mean that some people are more susceptible to stress incontinence than others. If you suffered with incontinence during your pregnancy, particularly earlier on in the first or second trimesters, you are more likely to experience it postnatally too. If you had a long pushing stage, a 3rd or 4th degree tear or an instrumental delivery, you are also more likely to experience postpartum incontinence issues.

How long will incontinence last after childbirth?

It really is different for everyone. Some people find that within a few days they don’t have any issues but, for some women, it can last months or even years. If you are still experiencing issues by the 6-week mark it is advisable to discuss this with your GP and ask for a referral to a Women’s Health Physio, if left untreated, it could cause you problems for the rest of your life. Please remember that this is not something that you simply have to live with and with the right support you can regain control.

What can I do to help prevent postnatal incontinence?

At the hospital when you have your baby you are likely to be given a leaflet that talks about pelvic floor exercises. Pelvic floor exercises or ‘kegels’ are proven to help reduce incontinence after childbirth and are a useful tool in restoring your pelvic floor postnatally. However, they are just one piece of the puzzle and you need all of the other pieces in order to build up a full picture of pelvic floor health.

Before we delve into the many other ways that you can improve your pelvic floor function, first let’s make sure that you can kegel properly.

Kegels aren’t everything, but they’re a good place to start…

How to kegel:

Pelvic floor health isn’t just about strength and it is very important to remember that the release of these muscles is just as important as the contraction. As with any muscle, in order to contract effectively, your pelvic floor needs to be able to release effectively too.

The way you breathe is also crucial to perfecting this exercise and your breathing should be relaxed throughout and not forced or restricted in any way. Your pelvic floor moves up and down with each breath you take – as you inhale, your belly should move outwards slightly, and as you exhale it should move slightly inwards. Your ribs should also move as you breathe, make sure you are not just breathing into your belly.

You can make your pelvic floor contraction more effective by coordinating the movement with your exhale. As you exhale, let your pelvic floor naturally lift and then add in a gentle contraction, like you are trying to pull a piece of spaghetti up your bum! Make sure you are not squeezing your bum muscles, tensing your shoulders or holding your breath. It might not feel like much is happening at first, especially if you have recently given birth, but as you gain strength you will get more sensation.

As you inhale visualise your pelvic floor releasing.

Be sure to release fully in between every single contraction.

The long-term aim is to hold the contraction for 10 seconds and repeat that 10 times.

You can do this exercise 3 times a day.

Is that all I need to do?

As mentioned before, this is only the beginning! How you use your body for the rest of the day is just as important as doing your pelvic floor exercises.

Here are some top tips for looking after your pelvic floor:

1. Consider your posture

When the rest of your body aligns well with your pelvis, your pelvic floor will function better. You want to have your rib cage stacked on top of your pelvis and your pelvis stacked above your ankles to allow everything to function as it should. Pelvic floor health is a full body issue. Everything is connected! Which means that your feet, legs, ribcage and head all have an impact on your pelvic floor. Tension and imbalance anywhere in your body can make a difference to what is happening in your pelvis, so you need to look carefully at your posture, your alignment and the way you are moving day to day.

2. Address your toilet habits

Constipation can cause straining which leads to a lot of problems for the pelvic floor. Make sure you are drinking enough water and eating enough fibre. The angle your legs are at when you poo can also help to reduce straining – think of a toddler squatting to poo in their nappy. Buy a squatty potty or similar so that when you are on the toilet your knees are higher than your hips and you are less likely to need to strain.

3. Move!

All low impact exercise is pelvic floor exercise. Going for a walk every day and being active in your life will ensure your pelvic floor switches on and does a better job of supporting you. When you sit too much, your pelvic floor tightens and then cannot contract as effectively.

4. Coordinate your breath with movement

As you’re aware, when you breathe out your pelvic floor lifts and contracts. Like with any muscle, we build strength by loading it and adding movement. The pelvic floor is not an isolated muscle, it works as part of your whole-body system and should be worked as such. Movements, like squats, can be coordinated with the breath to create a great pelvic floor work-out – simply inhale as you squat down, exhale as you push back up.

5. Exhale on the effort

This is a useful phrase to keep in your mind when you are picking up something heavy, like a baby! If you breathe out, it will help you to control the pressure that is created.

6. Release your pelvic floor

There is always a huge focus on the strengthening of your pelvic floor, but it is important to make sure you are releasing these muscles enough too, especially if you sit a lot.

Here are some helpful exercise suggestions to encourage release of your pelvic floor:

FASCIAL RELEASE

Take a fascia release ball, if you don’t have one, you can use a soft football, and sit on the ball, so your knees are facing forward and your legs are behind you. Sit for two minutes to give the tissue around your sit bones time to soften.

CAT COW

This is a gentle stretch for your pelvic floor. On all fours, in the position of the cat cow Yoga pose, consider the space between your sit bones. When you exhale, try to round your back into a cat position and imagine you are drawing your pubic bone towards your ribcage – notice how the space between your sit bones changes and gets smaller. As you inhale, release back into a flat back and notice again how your sit bones widen and create more space.

Repeat 10-times to really find the movement in your pelvic floor.

GLUT RELEASE

Standing up against a wall, take a spiky ball (you could also use a tennis ball) and massage it into your bum cheek. Your pelvic floor and gluts are really connected and releasing the gluts can help to reduce pelvic floor tension. Look for a tight spot at the top of your bum cheek, this is your piriformis which runs from your lower back to the inside of your hip and is often an area of tension.

We have a range of online and St Albans based classes (COVID restrictions permitting!) to help mums of any age with incontinence after childbirth. Get in touch for more information on our specialist Pilates classes, a great way to improve your pelvic floor health and reintroduce yourself to postnatal exercise.

Sorry to say this, but… please don’t!

It isn’t easy to be told that you should stop doing something that is so intrinsic to your physical and mental wellbeing. Many women we meet, see running as an amazing release and a core part of looking after their mind and body. But please remember if you’re running with incontinence, it doesn’t have to be forever. But it’s best to stop whilst you have the symptoms.

What to do if you are struggling with incontinence

There is so much you can do to ensure that your pelvic floor is supporting you effectively. Sometimes it just requires a few weeks of focusing on other types of exercise to encourage your core to support you more productively. Once you know that a few simple movements are easily do-able, you can go back to doing what you love – jogging, jumping and skipping without the wet pants!

Running heavily impacts your core. Each time your heel strikes, a huge load moves through your body and, if your pelvic floor is struggling, this really needs to be addressed.

Einstein gave the definition of insanity as “doing the same thing over and over again and expecting different results”. And, forgive us for saying this, but we see a lot of people who fall into this bracket!

Many women think that incontinence will get better as their children grow up, but this is rarely the case. If anything, our pelvic floor health tends to decline with age. As we hit menopause and oestrogen levels drop, pelvic floor trouble becomes prevalent, in fact over 50% of women over 50 have a degree of prolapse.

Increasing your understanding of the way you use your body and growing your knowledge of what you can do to help it, can only be a positive thing.

If you would like more guidance of what is and isn’t advisable in this area, the ‘Returning to Running Postnatal Guidelines’ are an excellent starting point. These guidelines were written by two women’s health physios who were frustrated by the frankly abysmal postnatal guidance that was previously available, and they are applicable to all women, whatever age your baby is.

Here are some important recommendations from the guidelines:

• Individualised care is important, if you can visit a women’s health physio it is highly recommended. Rather than generalised advice, you will be able to understand exactly what is happening in your pelvic floor.
• It is not advisable to run before 3-months postnatal under any circumstances, and if you are experiencing any symptoms of pelvic floor dysfunction then you shouldn’t be running at all, no matter how old your baby is.
• Symptoms of pelvic floor dysfunction can include urinary/faecal incontinence, urinary / faecal urgency, heaviness, pressure, bulging or dragging in the pelvic area, pain during intercourse, obstructive defecation, bulging of the abdominal wall, abdominal separation and lower back pain.

When it comes to pelvic floor health, you should always err on the side of caution as any stresses to this area can have lasting a impact on the way your body functions.

* Other risk factors for returning to running include hypermobility, breastfeeding, previous pelvic floor conditions or issues/pain in the pelvis and lower back, obesity, a caesarean birth or perennial scarring and vaginal bleeding that isn’t related to your menstrual cycle.

Our top tips on getting yourself ‘running ready’:

1. Sleep

It is difficult to say this to parents, as sleep is at such a premium for everyone, but please be kind to yourself and, if you are sleep deprived, do not feel under any pressure to get back to exercise. Sleep is absolutely vital to allow your body to recover from both physical and psychological stress. There is a clear link between increased injury risk and sleep deprivation in athletes (Milewski et al. 2014). Sleep deprivation lowers your general health and increases stress levels as well as impairing maximal muscle strength (Biggins et al. 2017, Knowles et al. 2018). If you aren’t getting 7-9 hours a night, it is more than okay not to be pushing yourself physically.

2. Fitness

Your fitness needs to be considered as low fitness levels will make running more difficult. It is really important to ensure you have a safe and appropriate build up to exercise. Our Centred Mums in Motion online pilates classes are all about building up your fitness in a safe and individualised way. The structure of our classes depends on your birth experience, the way your body works and the pace at which you are able to progress. Everyone is different and there is no hurry!

3. Breathing

It is important to establish a good breathing strategy to allow your core to work in the most effective way. In order for your body to function as its best, there needs to be synergy between your diaphragm, abdominals and pelvic floor. You should build up to pushing your breath by starting at a slow pace that allows you to have a conversation while running.

4. Psychological status

If you are having problems with your mental health, exercise can be a great way to support yourself. But, if your body isn’t quite ready to add running into the equation, it is worth being aware of other coping strategies. Relaxation, mindfulness and lower impact exercise like Pilates are great ways to look after your mental state. Speaking to a therapist or counsellor, can also make a real difference.

5. Supportive clothing

A 2019 study showed that supportive underwear could be almost as effective as pelvic floor muscle training – although this wasn’t in relation to high impact exercise, it is definitely worth considering whether you can gain extra support from your pants! A professionally fitted sports bra will also give you increased support and ensure that your breathing is not restricted by your

clothing. It is important to make sure that your leggings are not over-tight around the waist and causing extra pressure by bearing down on your pelvic floor.

6. Supportive footwear

It is common for shoe size to change during pregnancy, so you may find that you no longer have a good fit in your pre-pregnancy running shoes. You can get your gait analysed to ensure you have the support you need from your footwear.

7. Breastfeeding

Whilst breastfeeding shouldn’t put you off returning to running, it is worth taking your breastfeeding status into consideration when planning to exercise. It is important to ensure that you are making your pelvic floor health a priority and that means staying educated about the risks. Breastfeeding keeps your hormones from returning to their pre-pregnancy state, meaning lower levels of oestrogen and the possibility of increased relaxin levels. The overall hormone levels when breastfeeding, and up to 3 months after weaning, can increase the risk of developing an injury or dysfunction, including prolapse or pelvic floor dysfunction.

8. Scar mobilisation

No matter what kind of birth you had, if you have any scarring – either due to a caesarean, episiotomy or tearing – it is really useful to consider scar mobilisation to prevent the potential pain and restriction that scarring can cause. Everything in your body is connected and changes in the tissue around your scar can impact the function of tissues and structures throughout your whole body. Following a caesarean birth; your digestive, urinary and reproductive systems can all be impacted by your scar. (Comesaña et al. 2017). Scar mobilisation or scar massage can reduce inflammation and fibrosis; and improve tissue remodelling. (Benjamin et al. 2008; Bouffard et al. 2008). We regularly refer clients to www.scarworktherapy.com and have only ever had fantastic feedback about their effect on a caesarean scar.

9. DRA

Specialist pelvic health physios agree that it is important to regain functional control of your lower abdominal wall before you start running. It is vital to be able to control the pressure created in the abdominals (IAP) before you add any extra load due to the impact this could have on the pelvic floor. Although not widely researched, abdominal separation should definitely be considered due to potential risk of pelvic floor dysfunction. When exercising, you need to be able to maintain your ability to control IAP and avoid doming in the abdominals.

10. Weight

If you are overweight, this can also increase the load on your pelvic floor. If you have a BMI >30, you are considered at a higher risk of pelvic floor related symptoms (Pomian 2016), and it is advisable to opt for low impact exercise, to help reduce the load on your pelvic floor. Due to pelvic floor impact, and the increased risk of musculoskeletal injury (Nielsen et al. 2013), it is recommended that weight management is addressed before you return to running. There are many ways to address your weight before you begin running, and you will never regret taking good care of your pelvic floor.

The Returning to Running Guidelines have set a series of markers to assess whether you are fit to return to this high impact exercise. These should be able to be done without pain, dragging, heaviness or incontinence before you return to running.

• Walking for 30 minutes
• Single leg balance for 10 seconds
• Single leg squat – 10 repetitions each side
• Jogging on the spot for 1 minute
• Forward bounds – 10 repetitions
• Hop in place – 10 repetitions each leg
• Single leg ‘running man’: with bent knee and opposite arm and hip flexion/extension – 10 repetitions each side

To build up strength for running it is also a good idea to be able to do 20 reps of the following exercises:

• Single leg calf raise
• Single leg bridge
• Single leg sit to stand
• Side lying abduction

As mentioned above, building up to running is extremely important. We highly recommend using a tool like the Couch to 5k app to allow you to build up slowly and ensure you are not experiencing any negative effects from your running programme.

If you’re running with incontinence, we strongly encourage you to see a Pelvic Health Physio for more support if you feel you need it, or if you are experiencing ANY of the symptoms mentioned in this blog post.