The pelvic floor muscles form a muscular hammock at the base of the pelvis, supporting the bladder, uterus, and bowel. During pregnancy, they bear the increasing weight of a growing uterus that can reach over four kilograms at term, on top of the weight of amniotic fluid and placenta. They are also subjected to hormonal softening from relaxin, which loosens ligaments and connective tissue throughout the pelvis to prepare for birth. The combination of mechanical load and hormonal laxity makes the pelvic floor particularly vulnerable during pregnancy, and the consequences of neglecting it, urinary incontinence, prolapse, and pelvic pain, can persist for years postpartum.
The Evidence for Pelvic Floor Training in Pregnancy
A Cochrane review by Woodley et al., updated in 2020, evaluated pelvic floor muscle training during pregnancy and the postnatal period. The review found that training during pregnancy reduced the risk of urinary incontinence in late pregnancy by 29 percent and in the first postnatal year by 22 percent, compared to no training or usual antenatal care. The NICE antenatal care guideline recommends pelvic floor exercises throughout pregnancy, and the RCOG and Royal College of Midwives both emphasise their importance as standard antenatal care. Despite this, studies consistently show that a minority of pregnant women perform the exercises correctly and at the required frequency.
How to Perform Pelvic Floor Exercises Correctly
The most common error in pelvic floor exercise is contracting the gluteal muscles, thighs, or abdomen instead of, or alongside, the pelvic floor. A correctly executed pelvic floor contraction involves drawing up and squeezing the muscles around the urethra, vagina, and anus simultaneously, as if stopping the flow of urine and preventing passing wind at the same time. There should be no visible movement of the abdomen, buttocks, or thighs. The breath should be maintained throughout: many women mistakenly hold their breath during contraction, which increases intra-abdominal pressure and counteracts the lift.
Frequency and Progression
The most studied protocol involves three sets of eight to twelve contractions daily, with each contraction held for six to eight seconds and followed by an equal rest period. This should be performed throughout pregnancy and restarted as soon as comfortable after birth. As the pelvic floor strengthens, the hold duration and number of contractions per set should increase progressively, as with any muscle training. A pelvic floor physiotherapist can provide real-time biofeedback to confirm correct technique, which is particularly valuable for women who are unsure whether they are performing the exercises effectively.
- Begin pelvic floor exercises as early in pregnancy as possible: do not wait for leakage or symptoms
- Perform three sets of ten contractions daily, holding each for six to eight seconds, then releasing fully
- Check you are breathing normally throughout the contraction: breath holding generates downward pressure that counteracts the exercise
- Add a "brace and lift" before activities that increase intra-abdominal pressure: coughing, sneezing, lifting, and rising from a chair
- Consider a session with a pelvic floor physiotherapist to confirm correct technique: doing the exercises incorrectly provides none of the benefit and can occasionally worsen symptoms
Sources
- Woodley, S.J., et al. (2020). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews, 5, CD007471.
- NICE. (2008, updated 2021). Antenatal care (NG201). National Institute for Health and Care Excellence.