Whenever I talk to mothers (and fathers) about toilet training toddlers I always start with the suggestion that learning how to go to the toilet is a REALLY big task! Sure, we now do it on autopilot (most of us at least), but let’s look at all the steps involved in being able to successfully do a wee in the toilet:
- You have to be aware of the urge to urinate
- You have to recognise that urge in enough time to allow you to make it to the toilet
- You have to find your way to the nearest bathroom
- You have to be able to remove your clothing and underwear
- You have to be able to shift your body weight onto and off of the toilet
- You have to have the neural control required to release the urine from your bladder
- You have to have the ability to sense when your bladder is fully empty
- You have to have the manual handling skills to tear the toilet paper from the roll and wipe your perineum
- You have to be able to stand up from a seated position
- You have to be able to re-dress yourself
- You have to be able to remember to flush the toilet and wash your hands.
Phew! It’s no wonder toddlers take a while to get the hang of it! Ask my three-year old – she’ll tell you!
Learning to wee? There’s more to it than you think.
So what’s my point here? Well, toileting is a really complicated task. There are several body systems and processes at play in mastering the cognitive and physical elements within it, and it also requires us to integrate those systems and processes to work together. Which is why it takes us so long to learn how to do it as toddlers – and why we tend to have so many accidents.
Frequently, I come across parents who are frustrated at how long it’s taking their child to toilet train. I find encouraging them to remember the enormity of this task – all 11 points listed above – helps shift their mindset around their child’s toilet training.
Which brings me to the topic of postnatal incontinence and pelvic floor dysfunction.
This is a common issue impacting on many postnatal women. Most recently given the less confronting title of “leakage”, postnatal incontinence has the potential to dramatically impact on a woman’s life. It can lead to issues with embarrassment, low confidence and self esteem, it can lead to women ceasing or reducing their favourite social, recreational and sporting activities, it change how they see themselves as a woman. At the extreme end, it can lead to serious mental health conditions such as depression or social anxiety. It’s difficult to feel free, spontaneous, athletic or sexy when you’re worried your pelvic floor is going to let you down. There’s such a stigma about incontinence in our society that it’s rarely spoken about out loud, and when it is, it’s almost always spoken on in diminished terms “leakage”, “light bladder leakage”, “LBL”.
Just like toilet training a toddler, dealing with adult incontinence also requires us to step back and look at a range of body systems and processes. Unfortunately the common understanding by the general public is that this issue is just related to weak pelvic floor muscles, which is not entirely true. Certainly the functional capacity of the pelvic floor musculature has a huge role in regaining and maintaining continence. But what else is there to consider?
Our overall posture: How we stand or sit throughout the day impacts on the length and function of our body’s postural muscles – many of which have connections with the pelvis and the pelvic floor muscles. Imbalanced postural muscles can impact the way our pelvic floor muscles function.
How we breathe: did you know the diaphragm (the muscle under your lungs) is designed to work in unison with the pelvic floor? To maintain good ‘intra-abdominal pressure’ they should work together – when the diaphragm contracts downwards the pelvic floor should relax downwards. When the diaphragm relaxes up, the pelvic floor should lift up. By the time we reach adulthood so many of us have developed poor breathing patterns, and we’ve lost our ability to breathe properly, or connect our breath with our pelvic floor.
What we eat and drink: A common tactic used by many women to address incontinence is to simply reduce their fluid intake. This is a huge no-no as it means the bladder becomes used to only holding small amounts of urine. Over time, it can lose it’s capacity to stretch to it’s previous size. To maintain good continence, we want the bladder musculature as functional as possible. Also, were you aware that caffeine is a stimulant for the bladder? Sometimes eliminating coffee from our diet can be a big piece of the puzzle.
Our habits: Going to the loo ‘just in case’, or because your friends are; ‘holding on’ because you want to avoid public toilets while away from the house; how about running the tap while you pee to avoid the embarrassment of someone hearing your stream on urine? We women have terrible habits when it comes to toileting – but honestly, it’s probably not our fault, it’s something we have drilled into us from an early age as young girls. The problem is, when our toilet habits become habitual or situational, it means we lose that important mind-body connection between our brain and our bladder. When we lose that connection, we lose the trust in our own bodies, and that has a huge impact on continence.
Poor toileting habits early in life can lead to continence issues down the track.
Our mental health: It’s a two way street – continence issues can increase the likelihood of mental health problems, such as depression and anxiety, but these conditions can also impact the prevalence of continence issues. When we experience depression, anxiety or social phobia, our habits and lifestyles change – which means that every one of those four areas listed above can be impacted. It changes our posture, our breathing, our nutrition and our habits. All of which can lead to pelvic floor difficulties.
Did someone say vicious cycle?
So you can see that treating pelvic floor issues is about so much more than just strengthening those pelvic floor muscles. The list above is by no means exhaustive either. But it’s enough evidence to be able to say that addressing incontinence and pelvic floor dysfunction requires a truly holistic view of the individual involved.
The good news is there’s so many wonderful health practitioners out there who can support you if you need help with this area. incontinence is not something you have to live with. It can be treated, but for best treatment, you need someone who is going to look at the whole you – not just your pelvic floor. Search around for a Women’s Health OT (like me), or a Women’s Health physiotherapist, those of us who specialise in this area know that taking an integrated approach is the best, and only, answer.
Until next time, be well.
Cheers, Sarah xx
ps. If you want to know more about how to restore your pelvic floor function after having a baby, make sure you check out my Body Mind Baby postnatal wellbeing program. This 10 week online program covers a wide range of physical and emotional challenges faced by new mothers – with information and simple, practical strategies you can implement in your everyday life to positively impact your wellbeing – you can check it out here.
Working in the postnatal wellbeing field, one of the most common questions I get from new mums is this:
What type of postnatal exercise is safe for me, and what exercises should I avoid?
It’s a difficult question to answer in a blog post – because the answer will be different for each woman. What is and isn’t considered to be safe will depend on several factors, such as the woman’s level of fitness before and during pregnancy, the type of birth she had (vaginal or Caesarean), whether she had a traumatic birth, or perhaps an episiotomy or perineal tear, how well her pelvic floor is restoring to full function, whether she has an abdominal separation (diastasis recti) and how severe it is, how much rest she’s currently getting at the time, whether she had significant blood loss during labour which might have affected her iron levels….
The list goes on and on, because the factors are very diverse, which is why in my clinic I always undertake a detailed initial assessment for each new Mum who comes to see me for rehabilitation.
But I know this isn’t possible for everyone, so I’ve put together a list of the five most important moves for new mothers to avoid.
When looking at this list it’s important to remember that these restrictions aren’t FOREVER! I know some women might see the list and become frustrated or demotivated, but please remember that by sticking to the guidelines now, you’re likely to recover from your pregnancy and delivery much quicker, which will enable you to get back to the fun stuff a lot sooner – and with less ongoing problems (such as embarrassing leakage issues in Body Attack!)
So the following moves are best avoided for the first several weeks (or months) until such time that you are fully healed from pelvic floor issues, diastasis recti, back pain, and C-section surgery. Remember that every woman heals at a different rate, so to be really sure you should seek advice and support from a women’s health OT, women’s health physio, or a fitness trainer with excellent training in postnatal wellbeing.
The top five types of exercises for new mothers to AVOID
Exercises that put lots of strain on the belly – such as crunches, sit ups, or double leg lifts. These all increase the “intra-abdominal pressure” in the torso, and can worsen an abdominal separation or increase pelvic floor dysfunction.
Sit ups aren’t the only way to work those abs!
High impact activities
Running, jumping, bouncing on a trampoline, jumping jacks, burpees, box jumps, skipping, Body Attack classes. These also put increased pressure on the pelvic floor musculature, which can lead to or worsen incontinence.
Box jumps can be too high impact for many postnatal women.
Heavy overhead work
Such as lifting heavy weights over your head – again can result in increased intra-abdominal pressure, plus, if you don’t have good core control – which is common post pregnancy due to weakened abdominals, there is a danger of lower back injury.
Weight training is great for postnatal women, but it should be modified for each individual’s needs.
Moves where your legs stretch apart from each other at speed
Splits, sumo squats, skiing type movements, mountain climbers, jumping jacks, kickboxing – place additional strain on your pelvic floor muscles and ligaments
Save the star jumps and interpretive dance for a few months down the track.
Moves where your belly is hanging down – such as planks. Now this is a bit of a controversial one, as lots of new mums and trainers like to use planks, because they know they shouldn’t be doing sit ups (see point 1!). But it’s best to use caution with planks early on, and to make sure that if you’re going to do them, that you’re able to properly engage your abdominal muscles, to prevent poor form and potential back pain.
Planks are great – but make sure your core is ready for them.
Right, so what CAN I do??
Well firstly, remember, these guidelines are only to be in place until you’re HEALED! So please don’t fret, or get impatient! It’s best to grade your workouts down a notch for a few months to make sure you heal fully, and start gradually building back up. Please don’t jump back in full-bore, and risk exacerbating a condition that hadn’t quite healed, or creating a brand new problem.
Things that are great in the early months (after six week check up) include:
Walking : Seriously this is the best – on your own, with a friend, or grab the pram and take bubs around the block – use good form and walk mindfully – don’t just stroll, really think about your stride, your posture and your breathing. Keep upright, shoulders back and down, core “on” while walking – especially when pushing a pram!
Pilates: My absolute favourite – you can choose from mat or equipment classes –Just make sure you let your instructor know you are postnatal. Everything in Pilates can be modified or replaced, so if your instructor doesn’t alter any exercises for you, think about how much knowledge they have – don’t be afraid to ASK them about what post-natal training they’ve done! Mums and Bubs classes are great as they are tailored for post-natal women.
Yoga – another great low impact option. Again, let your instructor know you are postnatal, be gentle with your body and don’t push too far into any pose. Remember you may still have some amounts of relaxin running through your body, which keeps your ligaments more prone to over-stretching. Also, avoid hot or bikram yoga if you’re still breastfeeding.
Weights – weights are a fantastic way to build strength and fitness back up after baby, they’re also a great way to address potential muscle imbalances that arise in new Mums. It’s best to avoid group classes until you’re healed and I recommend booking some one to one sessions with a trainer to check your form and set up a program if you’re not familiar with weight training.
Finally, a word on instructors and group fitness classes:
As I mentioned earlier in the article, don’t assume your instructor or trainer has any knowledge about working with postnatal clients. There are so many amazing trainers out there. But unfortunately many of them don’t have specialised training in working with pregnant and postnatal clients. There’s a lot happening in the postnatal body, and recovery can often take a lot longer than we think it will. There’s also a lot going on ‘inside’ our body that we can’t see, which we should be mindful of when it comes time to get back to exercise. So always ask your trainer what postnatal training and qualifications they have, and ask them to talk about how they will adapt a program for you. If you’re not happy with their response – find another trainer! You only get one body, so make sure you find someone who’s going to help you look after it!
Also, let’s just chat about group fitness classes. Quite often group classes will have up to 30 – or even more – people in the class. So it’s difficult for a trainer (even one who knows you are postnatal) to watch you carefully and remind you of all the modifications. So there’s a lot of responsibility on the postnatal woman (ie. You!) to make sure you know your restrictions when it comes to these classes, which often feature lots of the movements I mentioned above. Also, be particularly cautious of energy in group classes. When something is super fun and inspiring, it can be quite easy to get “dragged along with the crowd” and attempt moves that are outside of your comfort zone, or to feel like you’re not doing enough and want to measure up to everyone else.
My final piece of advice…
Just be patient, take these first few months to really get to know and respect your body, and do the right thing by it. Trust me – your body will thank you for it down the track – and hopefully never let your pelvic floor fail during Body Attack!
Until next time, keep well.
Cheers, Sarah xx
ps. If you’d like to know more about how best to regain strength and function while recovering from pregnancy and childbirth, check out my Body Mind Baby online postnatal wellbeing program, our next program begins on May 2. Register before April 22 to take advantage of our early bird pricing – just $117 down from $147.
Women ask me the BEST questions!
Since I moved into this field of pregnancy and postnatal wellbeing, the funniest thing has been happening – I now get asked all manner of questions I never thought I’d be asked when I started my OT career.
In one-to-one appointments, group Pilates classes, Facebook forums and even at fancy-pants awards dinners, women start asking me the most awesome questions whenever I tell them what it is that I do.
Here’s a few of the questions I’ve had in just the past week – and my answers.
Q: “I just realised that since I started Pilates, I haven’t needed to wear a Tena-lady anymore when I go running – could that be due to the Pilates?”
A: Yes!! Pilates is awesome! (ps, this lady was talking about Pilates with another instructor – who is clearly awesome – so I’m not blowing my own trumpet here!)
No Tena Lady required!
Q: “If I had a pelvic organ prolapse, would I know about it?”
A: Not necessarily, there are different stages of prolapse, and in the early stages the prolapse is still contained within your body – it’s not until the late stages that “things pop out” of your body – so if something doesn’t seem quite right with your lady parts – get it checked out by your gynaecologist or women’s health physio.
Keep those pelvic organs right where they should be!
Q: I had a C-section, do I still need to worry about pelvic floor rehab?
A: Yes, definitely. It’s not just birth that puts strain on the pelvic floor. Nine months of your little baby bouncing up and down on that collection of muscles will definitely stretch and strain the pelvic floor. Rehab is always recommended after pregnancy – no matter what type of delivery, it may just be a different level of rehab.
Pelvic floor rehab is for all women, no matter what type of birth you had.
Q: What’s the minimum amount of time to wait between pregnancies, from a physical recovery perspective?
This is a tricky one, and we really need to look at it from a functional perspective, rather than on a timeline. It would definitely be advised to wait until any diastasis recti (abdominal separation) is healed and core strength is restored, ditto for pelvic floor difficulties. So you need to be physically “put back together” in order to give your body the best chance of staying strong during your next pregnancy and recovering again post-pregnancy. But women also need to consider how well their hormonal levels have rebalanced, and how well their nutritional stores have recovered. If women are still nutritionally and hormonally depleted when they conceive again, then this will put an added strain on their body during that subsequent pregnancy. This would differ for every woman. I dare say many women don’t get back to being fully functional and balanced before getting pregnant again, even if a year or two has passed since they gave birth, and this can lead to increased risk of further and more pronounced dysfunction through the second pregnancy.
Ready for baby number two?
So there you have it – just a few of the conversations I have with women every day! I truly have an awesome job.
Now over to you. Do you have a burning question? Feel free to shoot me an email and I’ll do my best to respond anonymously on my Facebook page in a Q&A post.
Alternatively, you could always join my Body Mind Baby program, which begins in Adelaide on Thursday, March 17. Find out more about it here, or call me on 0432 420 846 if you want to chat about it in person.
Until next time,
Be well and live your best life.
Cheers, Sarah xx
So – let’s talk incontinence!!!
I came across this article yesterday on the Women’s Running Magazine facebook page and it got me fired up.
So, so, so fired up.
In case you missed it, it’s a story from a running blogger named Steph, about her little quirks that make her #uncool. Here’s what Steph wrote:
A campaign was launched last week with the title and theme of #WeAreAllUncool. The idea is to celebrate that we all have quirks, habits and differences that make us unique. Sometimes these traits lead us to feel vulnerable and embarrassed about our shortcomings. We should not have to apologize or feel ashamed.
Steph goes on to talk about the fact that she wears a sanitary pad every time she runs or works out, because she has a postnatal continence problem.
I wear granny underwear under my running shorts—even spandex—because I pee my pants on every run and workout since having my son 9 months ago. I have to wear a maxi pad to help avoid soaked pants post-run. It leads to a super-hot look when I’m rocking light-colored spandex.
Now I don’t know Steph at all. I don’t know her story of her pregnancy and labour and I don’t know what she’s been doing in terms of pelvic floor rehab. She’s clearly very fit and healthy and is an elite level runner, so I’m presuming she has great coaches and (hopefully) a top-notch physio on hand. But the reality is, she has a serious continence issue.
Now I’m not setting out to shame Steph – not at all. In fact, I think it’s remarkably brave of her to put this out there in the public arena, and opening up this conversation is always good. So many women would simply keep this to themselves and pray that no-one else finds out. So kudos to you Steph, for your bravery!
But here’s my issue, and this is what I got fired up about.
There is no context around this article. And there is no call to action for other women who may be experiencing the same problem.
I applaud Steph for bringing this issue to light. Truly I do, because it’s a serious and extremely common concern for many women, particularly those who have had children.
But I wish that Steph – or Women’s Running Magazine – would have gone a step further and talked about what she’s doing – or could do – to address this issue.
Is she doing pelvic floor rehab? She’s still only 9 months postnatal, so really she’s still in recovery phase.
Did she consider taking time off from running to get this issue resolved before she started running again?
Does she have a great women’s health physiotherapist she’s working with to get this under control?
Or did she have a severe tear which has led to significant perineal damage and the resultant incontinence?
I don’t know, but I wish there was a little more context around her frank admission, in order to give all of her readership a little more food for thought.
Instead, what we got was several other women telling their stories of incontinence, and Women’s Running facebook page replying with “Don’t worry ladies, it is so common. It feels better knowing it happens to everyone!”
I think the basis of the #WeAreAllUncool campaign is great (though I think it should be renamed #WeAreAllCool) – it’s about embracing our uniqueness, diversity and all the little foibles that make us human. That is totally cool. It’s cool to be different. In fact, it’s completely freakin’ awesome and it’s what makes this big, wide, crazy world a great place to live.
The campaign encourages us to not be ashamed or embarrassed about who we are and how we are different.
Certainly, any type of urinary incontinence has the ability to make a woman feel embarrassed, vulnerable and ashamed. Which is why I talk about it a lot. Which is why we focus on this exact topic in my postnatal wellbeing and recovery program, Body Mind Baby. Because I don’t want women to feel embarrassed or ashamed if they experience urinary incontinence. I want them to be able to address it and overcome it.
But I don’t want them to celebrate it. And that’s what this campaign is about – celebrating our uniqueness.
I know it may seem like I’m nit-picking here – but I think an issue as important as this shouldn’t be included in a campaign about celebrating our bodies – at least not without context. Because it’s actually not something that should be celebrated. It’s something that should be addressed and treated – because for the majority of women it CAN be treated.
I want women to feel comfortable to be able to talk about the fact their experiencing postnatal incontinence. But I also want them to be empowered enough to say, “I’m not going to accept that – I know there are options available and I’m going to do whatever it takes to fix this issue”.
What I’d like women to know is that “no leakage is normal”. So yes, even if you just leak a “little bit”, even it it’s only when you sneeze, jump on a trampoline or do a star-jump – that is not normal. BUT, in the vast majority of cases it CAN be resolved. So that woman can undertake all those activities again without any leakage. It is possible for the absolute majority of people.
But, recovering from postnatal incontinence takes commitment, time and effort. It also requires a great deal of respect for the body and its healing process, and an avoidance of high impact activities – such as running – until continence issues are resolved. Because if you continue to place lots of pressure on a dysfunctional pelvic floor – it is NEVER going to heal.
But so what? I hear women say. It’s just a “wee bit of wee” and it’s only when I run, and I just wear a pad, so it’s really not a problem. Right? This is what I hear from women an awful lot.
So I always encourage them to think long term. If your pelvic floor is dysfunctional in your 30’s, how’s it going to be in your 50’s? Your 60’s? Your 70’s?
Have you ever worked in an aged care facility? Have you ever seen a grown adult who simply can’t control their bladder or bowels? Did you know that incontinence is a significant factor in many aged care admissions? I’ve spent time working in aged care facilities and I know too well the pained, shamed expression of a woman (or man) who has just wet their pants. It’s tragic and I’m damned sure I’m not going to let that happen to me (at least not without a serious fight).
When I talk to so many women who say their pelvic floor is “mostly okay” as long as they don’t jump, run or do a handstand, I tell them they should be able to do these things without leaking. Most of the time they just brush it off and say it doesn’t really matter. Well I say it does. I want to be able to jump on a trampoline with my kids – and play “Pop, Bang, Go”* with them like I did when I was a kid.
But the most tragic thing, is that when I ask these women if they regularly do their pelvic floor exercises, or actively work on pelvic floor rehab (because it’s not JUST about kegels), the majority of the time they say NO.
So we have a whole bunch of women, who have just a “little problem” but aren’t doing anything about it???
That’s just not on – not in my book.
One of my favourite phrases – and I say it ALL THE TIME, in every single presentation I give, is this:
Just because something is common, it doesn’t mean it’s normal.
In case you’ve never heard me talk about this before, I wrote about it here.
So getting back to this article, (which also reminds me of this article, which I got steamed up about on my facebook page). I truly hope Steph can get her pelvic floor rehabbed. I really do. I’d love for her to be able to run leak-free. And I’d love for her to be able to have more children and to not have this issue again.
I also want for this topic to be opened up to a bigger discussion, on a more regular basis, especially amongst the postnatal community.
But what I really want, is for this issue to stop being “normalised”. What I’d love is for women to be able to feel comfortable talking about this, while at the same time taking control, respecting their bodies’ limitations and doing absolutely everything possible to address the issue. And not just accepting “leakage” as the status quo.
That’s what I want.
Until next time, Be Well.
* for those of you who don’t know, “Pop Bang Go” is a totally awesome handstand game to see who can hold their handstand the longest. I never won as a child. I still don’t win. But it’s all about how you play the game.
ps. If you’re here in Adelaide, and want some support to rehab your pelvic floor and core I’ve got a few options for you.
If you want to work one to one with me, check out my OT Core Restore program here.
Or, if you’re a new mum with a baby under 12 months old, you can join my Body Mind Baby postnatal wellbeing and recovery program. Our next program starts on February 4, 2016, and don’t forget we have a $50 early bird discounts available until January 15.