Pelvic health

Getting comfortable and turning over in bed with pregnancy related pelvic girdle or lower back pain

Basic pelvic floor strengthening exercises

Pregnancy-related pelvic girdle pain (PGP)

• Pregnancy- related PGP is common but it is not normal or expected during pregnancy
• The sooner it is identified and assessed, the better it can be managed
• Around 1 in 5 pregnant women experience discomfort around the pelvic area during pregnancy (PGP)
• PGP occurs more commonly in second or further pregnancies
• Different women experience different symptoms, and these are more severe in some women than others.

What is Pelvic Girdle Pain?

Pelvic girdle pain is a term used to describe pain in the joints around the pelvis, lower back and hips. Common points of discomfort can include the pubic bone at the front, below the tummy or across one or both sides of your lower back (as shown in the shaded area in the diagram below)

Diagnosis is made based on certain signs and symptoms including:

• Pain in all or some of the areas shaded in the diagrams below
• Difficulty walking
• Pain when standing on one leg (e.g. climbing stairs, dressing, or getting in or out of the bath)
• Pain and/or difficulty moving your legs apart (e.g. getting in or out of the car)
• Clicking or grinding in the pelvic area - you may hear or feel this
• Limited or painful hip movements (e.g. turning over in bed)
• Difficulty lying in some positions (e.g. on your back or side)
• Pain during normal activities of daily life
• Pain and difficulty during sexual intercourse.

What can I do to help?

• Wear supportive footwear such as trainers
• Use a rucksack over both shoulders instead of a bag on one shoulder
• Shorten your stride length if required
• Be as active as possible within your pain-free limit. This may mean adjusting your activity or doing smaller bursts of activity
• Try avoiding activities that aggravate your pain
• If people are offering help, take it! This may be with getting some shopping or some household chores
• Try to keep your knees together when getting in and out of the car. If you are not driving, you can use a carrier bag under your bottom to help rotate your body
• Place a pillow between your knees when sleeping on your side and, when turning over, keep your knees together as much as possible
• Try getting into bed or turning over in bed via hands and knees
• Do your pelvic floor exercises and low abdominal exercises as advised by your physiotherapist
• Swimming may help, but the breaststroke kick may aggravate your pain
• Take the stairs one at a time (lead with your less painful leg when going upstairs, and when going downstairs lead with the more painful leg)
• If you need to use crutches, then a small rucksack may be helpful to help carry things
• Consider alternative positions for sexual intercourse such as side-lying or kneeling on all fours.

What should I avoid?

Where possible, avoid activities that make the pain worse, which may include:

• Standing on one leg
• Bending and twisting to lift, or carrying a toddler or baby on one hip
• Crossing your legs
• Sitting on the floor
• Sitting twisted
• Sitting or standing for long periods
• Lifting heavy weights (e.g. shopping bags, wet washing, vacuum cleaners and toddlers)
• Vacuuming
• Pushing heavy objects like supermarket trolleys
• Carrying anything in only one hand
• Don't take up any new high-impact sporting activity.

Contact information and self-referral

Pelvic Health Physiotherapy Department, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH

Tel: 01737 231688

Information adapted from POGP booklet - Pelvic girdle pain and other common conditions in pregnancy: 

https://thepogp.co.uk/_userfiles/pages/files/resources/23697pogppelvic_girdle_pain.pdf

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450, Email: fchc.enquiries@nhs.net,Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS093  Publication date: April 2025

Diastasis Rectus Abdominus or DRA (abdominal separation)

DRA is a common occurrence in pregnant women and nearly all women will have DRA at the end of pregnancy to make room for your growing baby. For most, it will resolve within 8 weeks of having your baby without any intervention, but for approximately 1/3 of women it might not resolve by itself.

What is DRA?

The rectus abdominis muscle runs from the bottom of the ribcage to the pubic bone of the pelvis and is split into two halves connected by a connective tissue called the Linea Alba. DRA is a condition where the left and right sides of the rectus abdominis muscle spread apart as the linea alba widens and stretches. It is sometimes known as Rectus Abdominis Diastasis or divarification recti.

What are the signs and symptoms?

The main symptom to be aware of is doming (bulging) of your abdominal muscles which you may notice in tasks such as sitting up from lying or when you return to exercise. You can measure the gap between the abdominal walls using your fingers. Gently place the fingers into the gap, anything up to 2 cm (approx. 2 fingers width) is within normal range. You may have a DRA if:

• The gap at your midline is more than 2 fingers width.
• The gap at your midline does not shrink as you work your abdominal muscles harder.
• A visible small bulge or dome protrudes at your midline.

Other symptoms may include:

• Lower back pain
• Pelvic pain
• Pelvic floor dysfunction (for example, urinary or bowel incontinence, frequency or urgency to go).

Recommendations:

• During the first 8 weeks it is important not to overload the muscles while your body heals and recovers. Don't be afraid of movement or exercise, just keep within a range that is comfortable for you
• Avoid unnecessary lifting where possible and especially heavy objects
• Avoid exercises which cause your abdominal wall to bulge out/doming on exertion until you have further support from your physio such as sit-ups. If you notice it happens when getting out of bed, try rolling onto your side first and use your arms to help push you up
• Start off slow with return to exercise and gradually build in exercise whilst monitoring for symptoms
• Bowel management is important! Avoid constipation and straining by staying hydrated, including lots of fibre in your diet and by sitting in the right position on the toilet (see below).

• Step one: Put your feet on a stall or step so your knees are higher than your hips.
• Step two: Lean forwards and put your elbows on your knees
• Step three: Bulge out your abdomen and straighten the spine or you could try making a 'moo' sound (like a cow) to create abdominal pressure to help the poo come out.

Exercises

It is important to strengthen both the pelvic floor and deep abdominal muscles first: these can be done in any comfortable position e.g. lying, sitting, standing or while walking.

The Pelvic Floor Muscle Exercise - Concentrate on tensing the muscles you would use to stop yourself from passing wind and/or to stop yourself from passing urine. Hold for up to 10 seconds and repeat 10 times as able. Try completing 10 fast squeezes where you tighten and release continuously without holding in-between.

The Pelvic Tilt - Lie on your back with your knees bent up or go onto all fours. Engage the pelvic floor (as above). Push the small of your back down so that it flattens onto the bed. Hold this position for a few seconds, then release and repeat.

Hip Twist - Lie on your back with your knees bent up. Engage the muscles of the abdomen and pelvic floor (as above). Allow one leg to slowly drop out to the side as far as is comfortable and then bring it back in - don't allow the pelvis to tilt to the side during this movement. Repeat on the opposite leg. Repeat alternating legs, the whole time keeping your tummy and pelvic floor braced to stop the pelvis rocking from side to side.

100's or Flaps - Lie on your back with your knees bent up. Engage the muscles of the abdomen and pelvic floor (as above). Raise your arms off the sides of the bed and flap the arms quickly up and down 100 times. Keep breathing throughout (try to breathe in for 5 flaps and then out for 5 flaps) and try to hold the pelvis and tummy as still as you can throughout the flapping movement.

Start off small with a goal that is achievable for example, completing 10 repetitions of each exercise every other day. As you feel able, you can increase this amount of progress your activity levels. Remember building up muscle strength is a slow, gradual process, but no-one else can strengthen your muscles for you, so keep going to achieve the results you are looking for!!

Your Pelvic Health physiotherapist can help support you further with progressing exercises and return to sport if required.

Exercise images owned by: Wibbi (https://wibbi.com)

Contact information and self-referral

Pelvic Health Physiotherapy Department, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH

Tel: 01737 231688

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450, Email: fchc.enquiries@nhs.net,Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS094  Publication date: April 2025

Advice for pregnant women

What is carpal tunnel syndrome?

Carpal Tunnel Syndrome (CTS) is the name given to the squashing of the nerve as it passes through the carpal tunnel at the wrist.

The tunnel is made up of small hand bones on the bottom and a strong ligament over the top. Muscles, tendons, blood vessels and nerves lie in the tunnel going into the hand.

Will it go away?

Your symptoms should go away after six weeks following the birth of your baby as the hormones and fluid levels return to normal and you lose the weight gained in pregnancy. However, while breastfeeding, these hormones stay at higher levels in the body, so it may take some women longer than others to find the symptoms settle.

Why in pregnancy?

There is little free space left in the carpal tunnel as the nerve passes through. Any change in the tunnel will lead to the symptoms you are feeling.

During pregnancy many hormonal changes occur. There is an increase in the amount of hormones in the body, which means that the body will retain a lot of fluid. (You may feel your hands and feet are swollen.) The extra fluid will settle in the tunnel, putting more pressure on the nerve and squashing it.

As you gain weight during your pregnancy, the nerve can be squashed further, which may also increase your symptoms.

What are the symptoms?

Symptoms usually start in the night when you are woken up with 'cramps' in the hand, which require 'shaking out'. You may feel burning, tingling, numbness and pain in the hand, and sometimes the arm. Usually both hands are affected, but you will find that symptoms in your dominant hand are a little more severe than the other hand.

These symptoms are first noticed at night because we sleep with our wrists in a bent position. This lessens the space in the tunnel even more, but as symptoms continue, you may feel the tingling and numbness during the day as well.

Some people may have weakness of the thumb muscles. This means that holding the toothbrush or a phone can become more difficult.

How is it treated?

Sleeping and getting rest is very important, especially in preparation for labour and giving birth. Therefore, the aim of treatment is to manage the symptoms. This can be done in the following ways:

1. Make a fist and open and close it quickly. Do this for about 30 seconds to increase circulation. If you can, try and elevate the hand and elbow above the shoulder, supported on a pillow.
2. Try bathing your hands in alternate bowls of warm and cold water to help reduce the pain (Do not use ice or hot water if you have difficulty feeling the temperature of things for example, diabetic neuropathy).
3. Massage the fluid back up in the direction of your elbow. This will help to circulate the fluid back into the body.
4. Try the following stretches, these help improve circulation of fluid.
5. If you have wrists splints, use them at night. These will keep your wrist in a better position and maintain the space in the tunnel. Most of all, it will help you sleep better.
6. Avoid any heavy lifting as this will cause the tendons to swell and further reduce space within the carpal tunnel.
7. Pace yourself with hand actions or positions that make your symptoms worse (e.g. ironing, driving).

Exercise images owned by: Wibbi (https://wibbi.com)

Contact information and self-referral

Pelvic Health Physiotherapy Department, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH

Tel: 01737 231688

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450, Email: fchc.enquiries@nhs.net,Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS097  Publication date: April 2025

Introduction

Many people (about 1 in 100) have trouble in controlling their bowels. This can include passing faeces or stools (pooing) at the wrong time or at the wrong place (also called faecal or anal incontinence). You may get a sudden urge to empty your bowel that you feel you can't control and have to rush to the toilet or be unable to hold in wind.

This problem can be caused by injury to the anal sphincter muscles (muscles around the anus/back passage) in childbirth, anal surgery, pelvic floor dysfunction, the ageing process and constipation.

If you have any of the following, consult your doctor as soon as possible:

1. Bleeding or pain from the back passage
2. A feeling that your bowel is never completely empty
3. Dark or black stools
4. Unexplained weight loss.

Anal Sphincter exercises to aid bowel control

Anal Sphincter exercises, when done correctly, can build-up and strengthen your muscles to help you improve your bowel control.

To begin

Sit comfortably with knees slightly apart.  Squeeze the muscle around the back passage as if stopping yourself passing wind.  Try squeezing and lifting the muscle as tightly as you can, you should feel the back passage tighten and pull up away from the chair.

Do not hold your breath when exercising.

Slow holds

Squeeze the muscle and lift as tightly as you can. Hold for up to 10 seconds, relax for 10 seconds, and repeat as many times as you can, up to a maximum of 10 times.

Fast squeezes

Pull up the muscles as quickly and tightly as possible and then relax.  Repeat as many times as you can up to a maximum of 20 times.

Sub-maximal

Squeeze and lift your sphincter muscles, up to about half of their maximum squeeze. Try to hold this for as long as you are able (up to 20 or 30 seconds). Repeat two or three times. Aim to increase the time you are able to hold. You can also try these in standing or walking.

Repeat these exercises three times a day.

The St Mark's hospital 'Holding on Programme'

As with many bodily functions, you can retrain your bowels. The following programme can teach you to hold on when you need to empty your bowels. Your rectum (where you store poo), your sphincter muscles (around your back passage), and your confidence need retraining to help you overcome this problem. This can take time, so be patient.

Next time you need to open your bowels:

• Sit on the toilet and try to hold on for one minute before opening your bowels. Don't forget to take a watch / clock in with you. As this becomes easier, gradually increase the hold time to five minutes. Do not worry if you are unable to do this initially but keep practising
• When you have mastered this, repeat the above but increase the hold time to 10 minutes before opening your bowels. This stage is harder but remember you are on the toilet and therefore safe from mishaps and accidents
• Once you can delay opening your bowels for 10 minutes, you should try to hold for 10 minutes whilst off the toilet, but still in the bathroom. As you feel more confident you should gradually move further away from the bathroom. Maybe sitting on a chair just outside the bathroom, then on your bed in the bedroom a little further away. As your muscles are now becoming stronger you should be able to hold on for 10 minutes and as you feel more confident, increase the distance between you and the toilet. Gradually you will find that you can increase the distance and the time away from the toilet.

This may take some time to master, but the more practice you have at both your sphincter exercises and the holding on programme, the sooner you will improve. It takes time for muscles to get stronger and you will need to exercise for several months before the muscles gain their full strength.

Get into the habit of doing the exercises with things you do regularly - brushing your teeth, answering the phone, after every toilet visit.

If you are unsure that you are doing the exercises correctly, look at the area in a mirror either sitting up slightly in bed or squatting over a mirror, you should see the anus close as you squeeze it. If you are unsure, you can ask your pelvic health physiotherapist.

Use your muscles when you get the sense of urgency or if you are about to leak.

Other tips

• Most people will find that the strongest urge to open their bowels is 20 to 30 minutes after eating breakfast. This is due to the food entering an empty stomach and setting off an automatic reflex called the 'gastrocolic reflex' which moves the stool down the rectum towards the anus.  It can be helpful to spend some time sitting on the toilet at this time to see if nature takes its course and you are able to empty your bowels before your day starts, which might avoid issues with your bowels later in the day.  It is important that you relax and don't rush. Do not be tempted to try and push or strain if the urge to empty does not come.
• Being overweight puts more pressure on the muscles that help provide control at the back passage.
• You may find that avoiding drinks with caffeine in them (for example coffee, tea, energy drinks and Coke etc.) may help your bowel urgency. Caffeine can speed up the transit time through the bowel and make bowel urgency worse.
• A loose stool is always harder to hold, we aim to have a stool that is a type 3 or 4 on the Bristol stool chart. If your stool is loose you may want to look at your diet to see if you can change this. This is a helpful resource if you wish to explore this further: https://www.bda.uk.com/foodfacts/home.

Consistently completing your exercises is key to keeping the sphincter muscles strong.  It is important to include these into your daily routine to prevent the condition re-occurring in the future.

Contact information and self-referral

Pelvic Health Physiotherapy Department, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH

Tel: 01737 231688

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450, Email: fchc.enquiries@nhs.net,Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS095  Publication date: April 2025

If you have sustained a perineal tear or had an episiotomy (cut to the perineum) during childbirth, it is helpful to conduct perineal soft tissue massage from 6 weeks after the birth of your baby, to help the scar tissue to heal in the best possible way. This massage can help to smooth down lumpy scar tissue and can decrease pain and stimulate normal sensation in the area. This will help you to accept any changes in your body, become familiar with your body, and give you confidence in resuming sexual relations and intercourse again.

You should not begin perineal massage until soft tissue healing is complete, which is usually at 6 weeks. Do not perform massage if you are having any complications with the wound and its healing, or if you have a vaginal infection, genital herpes or thrush.

How do I perform perineal massage?

• Prepare: Begin by washing your hands and making sure you have short fingernails. Perineal massage can be completed by yourself or by your partner if preferred.
• Position: It can be done whilst having a bath, or in relaxed postures like resting on the bed supported with pillows at your back and your legs bent up.
• With what: Natural oil such as almond, coconut or olive oil (If not allergic) or intimate lubricant.

Technique:

It can be performed daily and takes about 5-7 minutes to complete. There are images below to orient you to the correct anatomy and images to support the following steps.

1. Begin by inserting the thumb (palm down) into the vaginal opening a small distance (approx. 1 inch).
2. With a sweeping action, massage down gently but firmly along the lower tissues as if between the 3 o'clock, 6 o'clock and 9 o'clock positions on a clock face (ie in a U-shape). You can spend 1-2 minutes performing this.
3. Then push downwards with your thumb at the 4-5 o'clock position until you feel a mild stretch. Hold the stretch for 30-60 seconds. Then move your thumb across to the 6 o'clock position and perform the same stretch for 30-60 seconds.
4. Repeat the stretch again at the 7-8 o'clock position.
5. Additionally, you can roll the scar tissue between your thumb inside and your finger outside for 30-60 seconds.
6. Finish off the session with another 1-2 minutes of sweeping massage between the 3, 6 and 9 o'clock positions.
7. Do not massage forcefully as this could cause bruising or swelling. It should not be painful. Use of a mirror to see what you are doing can be helpful.

When should you stop perineal massage?

Stop massaging and contact your GP if you experience any of the following:

• Excessive redness (a little redness from where you have been massaging is normal).
• Bleeding or swelling.
• Scar feels a lot warmer than the skin around it.
• Site of scar is more painful than normal.
• Any discharge from the site of the scar.

Further information:

Recovery from perineal tear or cut. Link : pi-perineal-tears-poster-colour.pdf

Contact information and self-referral

Pelvic Health Physiotherapy Department, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH

Tel: 01737 231688

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450, Email: fchc.enquiries@nhs.net,Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS098  Publication date: April 2025

Massage techniques help improve alignment, suppleness and flexibility of scar tissue and nearby soft tissue. This may help with posture, movement, and discomfort, as well as the look and feel (sensitivity) of the scar.

Always wait for an incision or tear to fully heal before beginning massage - this is usually after about 6 weeks of healing. Do not massage over areas of broken skin.

How do I massage caesarean scar tissue?

Prepare: Begin by washing your hands. A warm bath or warm compress may help to increase blood flow or relax the area.

Position: You can be in any position you find comfortable including lying or semi-sitting (use pillows if required) but massage is usually easiest when the skin is flatter.

With what: For comfort and lubrication you can use natural oils such as almond, coconut or olive oil (if you are not allergic). You can also use Bio oil (from a local chemist) or non-perfumed moisturising cream

Technique:

Below are 3 techniques you can use for caesarean massage. Try a combination of these techniques for between 5 and 15 minutes, 3-7 days per week, until your scar feels as smooth and comfortable and non-lumpy as possible. It is never too late to do scar massage - even if your scar is years old.

These techniques should not be painful but may cause a slight pulling or tingling sensation around the scar which is normal.

You do not need to wear gloves as shown in this picture as long as your hands are clean.

Note: Every scar is different, and this image has been created for educational purposes.

When should you stop C-section massage?

Stop massaging and contact your GP if you experience any of the following:

• Excessive redness (a little redness from where you have been massaging is normal).
• Bleeding or swelling.
• Scar feels a lot warmer than the skin around it.
• Site of scar is more painful than normal.
• Any discharge from the site of the scar.

Further information:

Recovery from C-section. Link: Recovery from C-Section | POGP

Contact information and self-referral

Pelvic Health Physiotherapy Department, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH

Tel: 01737 231688

References:

• Arung W et al. Pathophysiology and prevention of postoperative peritoneal adhesions. World of Gastroenterol. 2011; 17(41): 4545-4553.
• Majchrzycki M et al. Kinesiotherapy in women after gynaecological surgeries. Przeglad Menopauzalny. 2012; 11(6): 510-513.
• Agha R et al. A review of the role of mechanical forces in cutaneous wound healing. Journal of Surgical Research. 2011; 171(2): 700-708.
• Wasserman et al. Soft tissue mobilization techniques are effective in treating chronic pain following Caesarian Section: A multicentre randomised clinical trial. Journal of Women's Health Physical Therapy. 2018; Sep - Dec; 42(3): 111-119.
• Wasserman et al. Chronic Caesarian Section scar pain treated with fascial release techniques: A case series. Journal of Bodywork & Movement Therapies. 2016; 20(4): 906-913.

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450, Email: fchc.enquiries@nhs.net,Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS096  Publication date: April 2025