Breathing and the Pelvic Floor
To explain why we can't blanket recommend breathing exercises to 'improve core function', let's look at what the core’s function is Job number keep your insides from falling out.
In a postpartum individual, a loss of function here might be a hernia. In which case you
most certainly would not recommend breathing exercises. This person would require surgery.
Breathing exercises *might* make up part of post-surgery rehabilitation in this case but again, not to improve function. For someone who's had abdominal surgery, breathing exercises might offer safe first step back towards movement and the benefits would probably be mostly psychological, giving them a feeling of readiness to get back into doing other things.
Job number 2, facilitate breathing. If a postpartum individual is struggling to breathe…hospital.
But have you just tried breathing?
We tend to hear a lot about 'faulty' breathing patterns
during pregnancy. This language is unhelpful. Breathing patterns are altered
they literally must be to carry a baby to full term. This is not a bad thing;
this is the body cleverly adapting in pregnancy. Most people find that they
readopt their previous motor patterns after birth.
Would some coached breathing exercises be useful for this?
Who knows? It would be down to whether the individual enjoyed them and felt any benefit to them. It might feel nice to take some deep breaths now you're not full of massive baby, but this is going to be individual.
Job number 3, keep us upright.
If a postpartum individual is struggling to stay upright…hospital.
That would be very concerning.
Job number 4 (and the one most people are interested in/need help with) facilitate movement.
This is quite a big topic because we don't have concrete evidence that individuals who have given birth have 'weaker' cores or pelvic floors than those who haven't. Yet the narrative around postpartum bodies is that they are broken and weak.
Many postpartum individuals have absorbed the idea that their body is now shit and useless and this psychological aspect can have a huge knock-on effect on to how capable and 'strong' someone feels in movement.
To recommend any kind of exercise to someone in this situation you would need to know more about them the approach needs to be completely individual.
What do they currently feel like they can't do and what do they want to be able to do?
If they want to get stronger, then what do you want to get stronger for?
How will they know they are stronger?
If a postpartum individual was completely terrified of getting back to movement, especially in the case of a caesarean, you might recommend breathing exercises for much the same reason as mentioned after a hernia operation. Psychologically, this might give them the confidence boost they need and demonstrate to them that their body can do more than they thought it could. It might be a gradual step towards other movements.
If you are early postpartum, breathing exercises, walking and stretching are recommended because they are generally safe and require no more exertion than your day-to-day life with a new-borns.
I am not saying breathing exercises are useless, in fact I've identified a few scenarios where you might use them.
Best case scenario, breathing exercises will give you a sense of calm, much like meditation. If you're taking deeper breaths that usual, you might even get a nice stretch in a few muscles.
The benefits are much more psychological than physical for the postpartum individual.
Worst case scenario is they won't make you feel anything.
But will breathing exercises improve 'core function', no. That unfortunately is not substantiated by scientific evidence. We do not a body of evidence to recommend anything specific to a broad population of people.
Postpartum individuals are not a homogeneous group who all need the same thing. If we don't have the evidence, then we are misleading people. If someone does breathing exercises expecting a result that we don't have evidence for, that's misleading them. And most of the time, the individual is blamed for 'not doing it if right' if they don't get the desired outcome or they will be told their body is dysfunctional.
The term core function is too VAGUE and too broad to have any meaning unless applied to the unique individual in their circumstances.
On to the pelvic floor.
This is a huge topic and I'm only going to speak from the lens of pregnancy and postpartum. Pelvic floor is a complex system and has multiple functions. 'Pelvic floor dysfunction' is related to a variety of pain syndromes and symptoms it's an umbrella term. Prior to recommending any treatment, you'd need to know which part of the pelvic floor is causing the complaint.
Types of common urinary incontinence
Stress incontinence urine leaks with pressure (happens in second and third trimester as baby gets bigger)
Urge incontinence sudden urge to pee
Persistent incontinence caused by a mixture of underlying problems or changes like pregnancy or injury
Overflow incontinence consistent dribbling due to bladder not emptying properly
Mixed incontinence more than 2 of the above
A postpartum individual could also fall into the following categories
* No previous UI before pregnancy, UI symptoms in late pregnancy and after pregnancy
Previous Ul before pregnancy, Ul symptoms in through pregnancy, maybe even getting worse than before, and after pregnancy
Either of the above with sign of prolapse
During pregnancy, the pelvic floor is subjected to increased pressure, meaning it is not able to do its job of 'shock absorber' as well. This can be a separate issue to existing UI symptoms.
Combined, this can make things feel a bit uncertain down there.
TO pee or not to pee.
Maximal squeeze pressure is reduced during pregnancy but by how much can depend on where the individual sits based on what I just said (type of UI, was it existing etc).
Most postpartum individuals find an improvement in the first few weeks of recovery without any intervention, again this will depend on what category they fall into.
When it comes to leaks, if this doesn't improve over time, research points in the direction of surgery and even medication if the issue lies with the bladder contracting when it shouldn't.
The problem with studies on pelvic floor exercises is they are often mixed interventions (using pelvic floor exercises alongside things like breathing exercises, electric stimulation, aerobic exercises, education on the pelvic floor) and are done on women with mixed UI symptoms.
Although randomised control trails do sometimes report an improvement in symptoms in some cases, which intervention was it?
Or did the pelvic floor just get a chance to do its job in lots of different everyday situations leading to an improvement in over all function?
They are also extremely small sample sizes which means we can't make broad
recommendations based on the results.
Most review papers and meta-analysis conclude that evidence from RCTs is of low quality and more studies are needed in order to make any recommendations.
Also, many of the results are self-reported data from the individuals. Did these individuals increase their self-efficacy and confidence with their UI and get braver to try new activities, meaning they felt like their UI was no longer impacting their quality of life and THEREFORE FELT BETTER ABOUT IT?
WHO KNOWS? We need more research on specific UI scenarios to know for sure.
Again, breathing exercises are recommended because they are deemed safe and can't make the problem worse, it's more of a 'might as well try' situation because it's also cheap and accessible.
Anyone with lungs can do them. Convenient.
If breathing exercises form the first step towards movement for the client who has very negative thoughts towards their body and is scared that they might leak everywhere if they even think about exercise, then you might recommend it to this individual.
The reason it is important not to mislead people by saying an exercise can do something that it can't is because it may delay them in seeking surgery or medication which could help them.
When fully informed, many people like to try different exercises first before going down the surgery route because not many people want to have a surgical procedure because of the impact it can have (taking time off, recovery periods etc). But it's important that the choice to things in this order is theirs and not from the wrong information.
Both urinary incontinence and perceived loss of 'core function' are both hurdles for the postpartum individual and can act as barriers towards exercise and getting on with everyday life.
Sometimes, as personal trainers, if we focus too much on the hurdles and not on what the individual wants to be able to do, then we can make these issues bigger than they need to be.
Psychological factors and how a postpartum individual views their body post birth play a key role in their health and well-being. The way we talk about core muscles, pelvic floor and other body changes really matters and that's why informing people about what exercise can and can't do is vital.
Focusing too much on pelvic floor 'dysfunction' instead of talking about very normal changes to how the pelvic floor works could make someone's symptom worse, as there's often a neurological element to urinary incontinence.