What are your pregnant and postnatal clients not telling you?

The past couple of years have put additional stressors on pregnant and postnatal women. By being aware of this, and displaying extra sensitivity, you can help your client regain her physical and emotional wellbeing, writes women’s health expert Dianne Edmonds.

As a physiotherapist working in a private practice located inside an obstetric GP clinic in Western Australia, I (and my colleagues) noticed the following issues since the onset of community transmission of Covid in WA in 2022.

• A client taking a deep breath and feeling it in her chest a few weeks after having Covid, and a cough for only 2 days, but this feeling lingering
• Pregnant client with morning sickness early in pregnancy develops Covid, and the coughing and vomiting combined cause stress urinary incontinence so she now needs to wear a pad
• Pregnant clients putting up with back and pelvic pain for a few months before coming in for an appointment, so their pain is more severe
• Early postnatal client develops Covid and is coughing, impacting her recovering pelvic floor
• Fewer post natal women coming in for early pelvic floor assessment after a difficult vaginal delivery
• Fewer post natal women who have had stitches coming in for treatment of their scar tissue, which may mean some women who are having pain with sexual intercourse are not presenting for treatment in the early postnatal months 

Towards the end of 2021 there was a return in confidence after a number of lockdowns, so more post natal mums were coming in for ‘return to fitness’ checks. This year that trend has reduced, which may impact upon their return to fitness and training postnatally.

Wide ranging impacts on health

There has been widespread discussion about the impact of the stresses caused during the pandemic on all aspects of health. For some women during pregnancy and after childbirth, this has resulted in restricting their access to services including gyms and training facilities intermittently during a time when they would benefit highly from working with fitness professionals.

Some women have experienced heightened pain and symptoms associated with physical problems after childbirth, including pelvic joint pain, pelvic pain and pelvic organ prolapse. This has been noted by health professionals working in this area, particularly pelvic health physiotherapists. Click here to read ‘Stress and the core: the hidden effects on the pelvic floor’)

There has been widespread discussion about the impact of the stresses caused during the pandemic on all aspects of health

Is there another hidden cost of the pandemic impacting women’s health? The effect of Covid has interrupted people’s usual health care routines in wide ranging ways. Physiotherapists throughout Australia are experiencing more cancelled appointments due to illness and caregiving responsibilities by women’s and pelvic health clients. Women may then delay treatment or put their pelvic health lower on the list, although in many clinics telehealth, which was introduced in 2020, remains an option.

Fiona Rogers from Pelvic Floor Exercise says “That’s possibly changed the game somewhat, because telehealth does give accessibility to a lot more women who may not have been able to get physically to the clinic for whatever reasons, from distance to travel or difficulty getting out of the house. There has been that explosion in online telehealth and programs, which I think probably has made a big difference and made it more accessible to women.”

Your awareness matters

As a fitness professional, if you are aware that your training clients have not been accessing the ‘ideal’ services, talk to them to uncover their story and listen out for red flags that then prompt you to ask more questions, such as:

• Have they seen a women’s and pelvic health physiotherapist?
• Have they had Covid? If so, did they experience coughing and for how long?
• Did they have any lingering cough, which may increase the risk of stress urinary incontinence?
• Do they have pain or awareness of weakness or symptoms in their body that they have been ignoring?

Encourage referral

Competing demands mean that women often prioritise other things before their own health, and when symptoms are personal and embarrassing in nature, such as pain during intercourse or leakage of urine, they often don’t reveal this.

Women often prioritise other things before their own health

As you build your relationship with your clients, consider ways in which you could, sensitively, ask them how they really are, and encourage referral to your local women’s and pelvic health physiotherapist if they haven’t seen one yet. If they tell you that they had to cancel their appointments and haven’t been back, encourage them to make an appointment.

If your pregnant or postnatal client has had Covid and experienced coughing, then the downwards force from repeated coughing is an additional risk factor to their pelvic floor. If the cough is lingering, with reports that Covid coughs can do so for months, then this is an additional stress on their pelvic floor.

Provide education on the pelvic floor

Sam Kirker from Iron Sisters Personal Training, located in a rural town in the north of WA, uses handouts to help her clients develop an understanding of their pelvic floor as the first step of awareness.

“I use handouts because I think it’s important that women do their pelvic floor exercises properly – and in my experience most women don’t know how to do this. They will do them but hold their breath, brace their tummy muscles. I teach them the steps of awareness of being able to lift their pelvic floor, keep their glutes relaxed, not over-tightening their upper abdominals or holding their breath.

I also suggest they count the number of breaths they can do while lifting their pelvic floor or that they use a watch for the seconds, as I find when they count they tend to hold their breath more. Using handouts is a good starting point as they can always refer back to it.”

Use pelvic floor protection principles

The Ten Step guide from the Pelvic Floor First website (click here to view) includes some tips for pelvic floor protection for pregnant and postnatal clients in areas including:

• exhaling with effort 
• taking care with fatigue 
• focusing on good form.

Regular reminders on these tips are important for your clients, particularly if they have had a break from training during pregnancy or are postnatal, in which instances fatigue levels can vary depending on the amount of sleep they are getting and the demands of looking after a baby.

Modify programs as needed

Pregnant and postnatal client programs specifically target the needs of these clients due to the changes in their body from pregnancy and birth. Clients who have had Covid and have been in isolation may not be as far along on the path of recovery as they would like to be. Some clients may have avoided going out to reduce their risk of contracting Covid, and if they have experienced heightened stress during this time, physical symptoms may be present in their body as a result.  

Ask and check to assess their current levels of:

• core control
• pelvic floor fitness
• flexibility in their body
• energy.

Programming may need to be modified if your client has experienced a setback in any of these areas due to experiencing Covid or a period of isolation. 

Give your clients pelvic floor testing tips

When a client has an effective pelvic floor contraction, ideally having seen a women’s and pelvic health physiotherapist, they can learn ways to test their own pelvic floor fitness in response to training.

I try to empower them to understand what they are looking for and why

Angelina Lee, a physiotherapist with PhysioForward who works with women returning to fitness postnatally, suggests testing the pelvic floor before training, to see the endurance and quality of a maximum hold. Most clients will max out around 30 seconds, but this gives them a ‘baseline’ with which to compare following training. They are encouraged to do this before starting a new class or returning to running, as it enables them to subsequently see the effect of training on their pelvic floor. Following the class, or run, the client repeats the max hold (in the same position as the initial test), and if it isn’t as ‘good’ (i.e. long) as their baseline effort, they are advised to repeat the pelvic floor maximum hold exercise you to three times a day over subsequent days to see how long it takes for them to return to the baseline hold duration.

Angelina also instructs her clients to self-monitor for any symptoms or warning signals in their bodies; “I try to empower them to understand what they are looking for and why, and to keep a diary so they can reflect on what may have overloaded their system” she says.

Encourage awareness of warning signals 

This is an area that you will focus on for all your pregnant and postnatal clients, but for some clients you will also need to take into consideration the additional effects of Covid and isolation. For these women, you may need to exhibit extra sensitivity when it comes to seeking feedback on the sensations they experience during training. This may only be necessary in relation to specific parts of the training program you have prescribed them. Warning signals include:

• loss of form due to reduced concentration or fatigue, muscle weaknesses or imbalances
• any feeling of pressure or heaviness in the pelvic floor
• feeling that their pelvic floor or any other area of their body is vulnerable 
• feeling that the pelvic floor is dropping down during an exercise
• breath-holding during training
• back or pelvic joint pain or back ache
• excessive fatigue.

Ask them how they really are 

Being pregnant or postnatal during the pandemic may mean that some of your clients have experienced higher levels of stress hormones during their pregnancy, which may have affected their physical and mental health.

Kylianne Farrell, founder of Move for Mental Health and a Gidget Foundation Ambassador, reported that there had been a 70% increase in requests for help from pregnant and postnatal women during the pandemic, highlighting the need to build the strength of support systems for women.

Some women will need additional support and referral to dedicated services, but you can also have a role in this support system, connecting with your clients when they see you for training.

Catherine Birndorf, MD, a reproductive psychiatrist and co-founder, CEO and medical director of The Motherhood Centre of New York, talks about “looking women directly in the eyes and asking them how they really are”. She suggests pausing and sitting with the discomfort, to allow women permission to really say how they are, not just give a quick response. She is the author of What No One Tells You: A Guide to Your Emotions from Pregnancy to Motherhood.

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Resources to educate your clients

Pelvic floor

Pelvic Floor health for expectant and new mums’ booklet (previously known as The Pregnancy Guide) https://www.continence.org.au/resource/pelvic-floor-health-expectant-and-new-mums

Pelvic floor First resources:
http://www.pelvicfloorfirst.org.au/pages/pelvic-floor-resources.html

10 step guide to putting your pelvic floor first · Pelvic floor friendly exercises · Pelvic Floor First

Women’s, Men’s and Pelvic Health Physiotherapy – Australian Physiotherapy Association

Mental health

Beyond Blue Pregnancy and new parents (beyondblue.org.au) 

COPE COPE: Centre of Perinatal Excellence

The Gidget Foundation Gidget Foundation – Perinatal Anxiety and Depression

What No One Tells You: A Guide to Your Emotions from Pregnancy to Motherhood: Sacks, Dr. Alexandra, Birndorf, Dr. Catherine: 9781501112560: Amazon.com: Books

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Look after yourself

With the awareness of what your clients may have been experiencing comes the awareness of the toll of the pandemic on your own health and wellbeing. There has been acknowledgement of this in a number of professional circles, and you know for yourself how challenging it has been since the pandemic started. You can relate to your clients’ stories on the effects of isolation, changes in plans, holiday and event cancellations and training schedules. This enables connection and your understanding, as you work with them in their training programs.

As the author John C Parkin has written, ‘In the dance of life, pull down your own oxygen mask first, then take a deep breath and help everyone else. They’ll thank you for it, believe me.” 

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REFERENCES & FURTHER READING 

Stress urinary incontinence

Stress incontinence – Symptoms and causes – Mayo Clinic

Incontinence & Bladder Weakness | Jean Hailes

Still Coughing After COVID? Here’s Why It Happens and What to Do About It (msn.com)

Pelvic Pain: 5 minutes with Dr Patricia Neumann · Pelvic Floor First

Pelvic floor exercises: Pelvic Floor Exercise

Working your pelvic floor · The pelvic floor · Pelvic Floor First

How Pelvic floor Muscle Exercises Help Birth and Recovery | Women’s and Men’s Health Physiotherapy (wmhp.com.au)

Dianne Edmonds

A physiotherapist based in an obstetric GP clinic, Dianne has a passion for improving the standards of women’s health nationally, starting when she was national Chair of the physio group now titled WMPHP, from 2002 – 2007. She has assisted The Continence Foundation of Australia in developing freely available resources for pregnant and postnatal women.