Pelvic floor health: Why is this important during pregnancy?

As a mother and director of porn for women I have wanted to address the topic of Sex during Pregnancy for a long time and I’m happy to announce that on June 20 I will be releasing an explicit sex documentary about sex and pregnancy featuring adult performer Tiffany Doll & her husband Bruno. In the upcoming weeks, the Erika Lust Blog will host a number of highly experienced women’s health and sexuality professionals to discuss everything around the topic of Pregnancy & Sexuality.

Breaking taboos: What do I need to know about sex in pregnancy?

For many people, sex, intimacy and relationships are an important part of our lives. Pregnancy is a significant time of life and for many women the experience of sex during this time is very different. Current maternity healthcare services provide plenty of information on topics including labour, different types of birth and breastfeeding. These are all very important but sex is rarely talked about, and if it is, the information given is often very limited and focused on heterosexual couples.

There is a stigma around having sex when pregnant. But talking about sex during pregnancy is important to help normalise any fears or concerns – and also to address any myths that you may have read about. Around 63-93% of women complain of problems with sex during pregnancy which is much higher than those not pregnant. There are many reasons for this including the common ‘side effects’ of pregnancy such as nausea, fatigue and back pain, as well as just not feeling in the mood for it.

Which positions are great to reduce or prevent pelvic girdle pain or back pain?

As well as the awkwardness of a growing bump, it may be uncomfortable to have any kind of sex, including penetrative sex, in certain positions. Be experimental and try out new positions – no matter what kind of sex you are having – so that you find something that feels more comfortable for you. The most comfortable positions for all types of sex, particularly penetrative sex, in pregnancy tend to be:

1. Lying side by side facing each other

2. Sitting on top of your partner

3. Missionary – better in the first trimester. After the 19th week, lying on your back can affect blood flow to the mother and baby causing symptoms such as dizziness, nausea and an increased heart rate. This is the body’s natural alarm system kicking in so if you feel any of these symptoms roll onto your left side. Placing a few cushions behind you so that you are sat up slightly should help prevent this.

4. Spooning – great for all trimesters and you may want to put a pregnancy pillow or cushion under your bump for extra comfort

5. On all fours (on your hands and knees) – great especially in the third trimester and if you experience any pelvic girdle or back pain during pregnancy

Around 20% of women experience pregnancy-related pelvic girdle pain (previously known as symphysis pubis dysfunction – SPD) or low back pain. This can have an impact on day to day activities, such as walking, sitting and standing, and can also impact on sex. Try the positions listed above but don’t have your legs too far spread apart as this can aggravate pelvic girdle pain.

Pelvic floor health: Why is this important during pregnancy?

The pelvic floor muscles are an important part of female anatomy and their main job is to control bladder and bowel function, preventing urinary and faecal incontinence. During pregnancy, these muscles can weaken due to hormones, increasing weight gain, and pressure onto the pelvic floor muscles caused by the growing baby.

Pelvic floor problems are common – but definitely not normal. Problems can be due to not just weak pelvic floor muscles but also ‘overactive’ muscles. Healthy muscles that function normally should be able to contract (squeeze) well but they should also fully relax – and some people find this difficult. The muscles should do the right thing at the right time. If the muscles are not functioning correctly, this can lead to problems.

The most common problem related to weak pelvic floor muscles is urinary incontinence and around 1 in 3 women will experience urinary incontinence at some point in their lifetime. This rate increases for pregnant women, particularly in the 2nd and 3rd trimesters. Another shocking statistic is that around 1 in 4 women will have problems with controlling wind or faecal incontinence in late pregnancy. Pelvic organ prolapse (where one or more of the pelvic organs – uterus, bladder or bowel – moves down within the vagina) is also a weakness related problem affecting approximately 50% of women.

‘Overactive’ pelvic floor muscles are often linked to problems including pain during sex, vaginismus (involuntary muscle spasm of the pelvic floor muscles), urgency (rushing to the loo to pee) and frequency (peeing more than normal – but this is very common in pregnancy).

There are sometimes other underlying causes for the problems above so discuss anything new with your doctor or midwife. The type of birth you have may affect your pelvic floor muscles. There is some evidence to show that vaginal childbirth is strongly associated with stress urinary incontinence (urine leakage with coughing, sneezing, laughing or during exercise) and pelvic organ prolapse. There is also a link between an instrumental vaginal birth with forceps and the development of pelvic organ prolapse. During the pushing stage of labour, the pelvic floor muscles are stretched and injury may occur. A vaginal birth will have more of an impact on your pelvic floor but it is important to remember that both a vaginal birth and a c-section carry their own risks and benefits. Whichever birth you have, pelvic floor muscle exercises should be done by everyone.

Pelvic floor muscle exercises (PFME) should be done throughout pregnancy to help keep these muscles strong and therefore prevent or treat any incontinence. Women who start these exercises early on in pregnancy may experience less urine leakage in late pregnancy and in the 4th trimester. There is currently no evidence to say that doing PFME will improve sex during pregnancy but some studies have shown that PFME in the 4th trimester may enhance your experience of sex in terms of desire, arousal, orgasm and satisfaction. The theory is that the exercises help to improve genital arousal and enhance vaginal sensation therefore increasing pleasure and improving orgasms. Other theories include greater self-confidence, improved body awareness and improved body image.

The menopause is the next stage of life where the body goes through a large change and there are muscular and hormonal changes. The pelvic floor muscles may become weaker and the vaginal walls thiner and drier, leading to increased risk of developing pelvic floor problems. This is why continuing with pelvic floor muscle exercises throughout our lifetime is so important. We need to look after these muscles by strengthening them when needed and then maintaining them at that improved level. There is a risk that if you stop the exercises, with time, they will slowly weaken. A good comparison is to compare it to running – if you stopped, all the health benefits would diminish.

Pelvic floor muscle exercises (also known as ‘Kegel exercises’): How do we do them?

As the muscles are inside us and we cannot see them, many people do not know how to do PFME correctly. Sometimes the technique is so wrong that it is actually causing more harm than good. Ideally a vaginal examination should be performed by a specialised pelvic floor physiotherapist to properly asses the muscles.

A common question women ask is whether doing PFME during pregnancy will affect a vaginal birth and prevent the baby from being delivered. The answer is simple: no. In fact, some studies reported that PFME helped with labour and women who did PFME during pregnancy had a lower rate of prolonged second stage of labour (the pushing phase), fewer breech presentations and a lower episiotomy rate.

To work these muscles, squeeze around the back passage (imagine you are trying to stop wind!) and, at the same time, pull up through the vagina (imagine you are trying to stop the flow of pee! – but don’t actually practice this). If you are still unsure of what you are doing, use a mirror and as you squeeze you want to see the perineum (the area between the vaginal opening and back passage) tighten and pucker in.

You should do fast squeezes (aim for 10-20 repetitions with a pause in between each one) AND slow squeezes (where you hold for up to 10 secs, relax for a few seconds, and then repeat as many times as you can until the muscles tire out). This rest period in between each squeeze is important as you need to give time for the muscles to fully relax. Breath normally when you are doing these squeezes. As PFME can be done in any of these positions in pregnancy – side lying, sitting or standing – they can be done in most places at any time. In pregnancy, if you can do these exercises three times per day, that is fantastic – but remembering to do them is the biggest challenge! Some women use a pelvic floor exerciser app such as Squeezy to help remind them – or whatever works for you.

So these are my top tips for sex in pregnancy from a physiotherapist’s perspective – be experimental with sex positions and find something that works for you, especially if you have pelvic girdle or back pain – and get going with your PFME as early as possible!