Low back pain (LBP) and stress urinary incontinence (SUI) are two of the major problems associated with pregnancy and the post-natal period. The research reports a fairly high prevalence of these problems – LBP was reported in 68.5% of women (Wang et al, 2004) and SUI was reported in 42% of pregnant women and 38% of women post-partum (Morkved and Bo, 1999.) In other words, a significant proportion of women in the peri-natal period are suffering from these problems. There is also a growing school of thought that the two problems are intrinsically linked due to the integrated function of the core system. A particularly interesting finding in Groutz’ study of 2004 found that half the women studied reported moderate to severe SUI but that only 15-18% of these women had consulted a medical professional about the problem. So clearly these issues are under-reported, possibly due to society’s prevailing belief that they are “normal” and “to be expected” if you have had children. However, even fairly mild symptoms can have a huge impact of the sufferer’s quality of life.
Why do these problems occur?
Much research has been done in recent years into the function of the deep core muscles. We now understand that effective transfer of load and force through the pelvis to ensure efficient movement requires this core system to be working optimally (Lee, 2004.) The deep core muscles are transversus abdominis, multifidus, the pelvic floor and the diaphragm. They should function as a unit to stabilise the spine and pelvis, ensure an optimal breathing pattern and maintain abdominal pressure and decreased function in one muscle group can adversely affect the other muscles in the unit.
These are the muscles most affected by pregnancy and delivery and we know that they don’t just spring back into place instantly after the baby is delivered. It is thought that it is not just ‘weakness’ in these core muscles but problems with timing and coordination that affect their optimal function (Lee 2004.)Add into this pattern the physical demands on the body involved in looking after a baby – the lifting, carrying and static postures whilst feeding to name just a few – and it is no surprise that the body has to find another way to achieve function, often by using the global (outer) muscle system. It has been proposed by Diane Lee that it is these compensatory mechanisms that may cause the later onset of musculo-skeletal problems and SUI – “my hip’s never been right since I had my children ten years ago”. If the global system is working most of the time to provide stability it can lead to spinal stiffness, increased compression onto the lumbar spine (a key factor in developing disc problems) and an increase in intra-abdominal pressure, putting stress on the bladder and pelvic floor. A study from Wilson et al (2002) surveyed a large cohort of women (4000+) three months post-partum and 5-7 years post-partum. They found a 31.7% new onset rate of SUI at the 5-7 year mark compared to the immediate period post-partum. Clearly this indicates that the core function has deteriorated over time in women who are still relatively young.
What can be done?
One of the most important factors involved in dealing with these problems has to be encouraging women to report these issues in the first place. Once reported they can be reassured that there are many things they can do to resolve their problems in the majority of cases. Referral to a physiotherapist can help in terms of teaching good postural habits for activities such as lifting and feeding, re-training good integrated core muscle function and addressing any musculo-skeletal issues such as pelvic mal-alignment, spinal stiffness or poor biomechanics. There is some evidence that pelvic floor exercises during pregnancy can go some way to reducing the risk of SUI post-partum (Morkved & Bo, 2013) and clinically this seems to hold true. However, although it is vital to educate women on the impact of these exercises there are two important points to note. Firstly, as earlier indicated, we must not think of the pelvic floor in isolation as a deficit in any other aspect of the system will affect its function. Secondly Bump’s research in the early 1990’s indicates that these type of exercises need to be taught correctly to avoid compensatory strategies. The study looked at pelvic floor exercises performed under an ultrasound scan and found that 51% of women were in fact not engaging their pelvic floor muscles but using a compensatory strategy such as holding their breath or engaging their gluteal muscles – clearly reinforcing non-optimal patterns and in some cases increasing the pressure on the pelvic floor. Therefore it is important that women are properly taught these exercises to ensure they are actually doing what they think they’re doing!
The ‘take home’ messages
Ultimately we must encourage women to talk about and report these issues when they first arise. Referral to a physiotherapist should help resolve the problems in most cases, and this is a much easier job if they are dealt with early, rather than trying to ‘unpick’ many years of sub-optimal movement strategies. Most importantly we need to empower women to take control of their health to enable them to function well in their bodies and not, as is so often the case, let their needs go to the bottom of the pile.
1) Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN Low back pain during pregnancy: prevalence, risk factors and outcomes. Obstetrics & Gynaecology 2004 Jul:104 (1)
2) Morkved s & Bo K Prevalence of urinary incontinence in pregnancy and postpartum. International urogynaecology journal and pelvic floor dysfunction 1999 10(6)
3) Groutz A, Rimon E, Peled S, Gold R, Pauzner D, Lessing JB, Gordon D Cesarian Section: does it really prevent the development of stress urinary incontinence? A prospective study of 363 women one year after their first delivery. Neurourology and Urodynamics 2004 23
4) Lee D,The Pelvic Girdle 3rd edition: An approach to the examination and treatment of the lumbo-pelvic region. 2004
5) Wilson PD, Herbison P, Glazener C, Magee M, MacArthur C Obstetric Practice and Urinary Incontinence 5-7 years after delivery. Neurourology and Urodynamics 2002 21
6) Morkved S & Bo K Effect of pelvic floor muscle training during pregnancy and after birth on prevention and treatment of urinary incontinence: a systematic review. British Journal of Sports Medicine 2013
7) Bump R, Hurt W, Fantl J, Wyman J Assessment of Kegel exercise training for stress urinary incontinence. American Journal of Obstetrics and Gynaecology 1991 165