Women who are carrying a baby can expect a lot of changes when it comes to the pelvis and pelvic floor.

As a pelvic floor physical therapist, Lindsey Karamihalis helps pregnant patients deal with the pain that can accompany pregnancy and that does accompany labor and delivery.

Karamihalis (pronounced kara-MI-hal-is) practices at Novant Health Rehabilitation Center in Shallotte, North Carolina and is building a program at Brunswick Medical Center.

We asked her about the physical changes pregnant women can expect during the second, third and fourth trimesters (the first 12 weeks after giving birth) and how even one visit with a pelvic floor therapist can help prepare women for an easier labor and delivery.

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What physical changes does a pregnant woman experience, particularly during her second through fourth trimesters that pelvic floor therapy could help with?

When you’re pregnant, your abdomen is expanding, which can put more pressure on the lower back. Pregnancy-related pelvic girdle pain (PGP) and symphysis pubis dysfunction (SPD) can occur because of the widening of the pelvic bones. You might experience pelvic pain because of the muscle compensation patterns and increased stress on the pelvic region – a result of a body that's changing very quickly.

Urinary incontinence is a possibility during pregnancy because you've got increased downward pressure on your organs. If you think about a baby growing in your abdominal cavity, you can see there's more pressure and more weight over the bladder. That pressure can cause urinary leakage.

Diastasis recti is something else pregnant women should be aware of. Also known as diastasis rectus abdominis or diastasis, it’s when the fascia that connect the rectus abdominis muscles – the abs – separate during and after pregnancy. Nearly every mom will have some sort of diastasis when she gets into that late third trimester.

The condition can cause low back pain, constipation, urine leakage and hernia. There are specific exercises you can do for it.

Pelvic organ prolapse (POP) is another condition resulting from increased pressure on your organs. Those organs can sometimes even come through the pelvic floor muscles externally. It’s important to be aware of the signs and symptoms of POP for earlier intervention. Feelings of pressure or heaviness in the pelvic region are often the first signs.

How does pelvic floor therapy address those things?

We use body mechanics to show you effective ways to move your changing body, while minimizing discomfort. Things like getting in and out of a car or your bed, going from sitting to standing, how to pick an object off the floor.

If you are experiencing low back, hip or pelvic girdle pain, there are stretching and mobility exercises that can help keep the body happy and moving. Strengthening exercises can be helpful for second and third trimester, too. Cues like “bring the baby with you” can be helpful for taking pressure off the low back and activating your deep core muscles.

If you're having pain in the pubic area, there are different support braces I can suggest to help manage that pain.

We also give women tools they can use when they're in labor. We can educate them on different positions for labor that help facilitate the opening of the pelvis. We show them how to tap into their body’s natural instincts to deliver a child; the biggest thing is learning to let go and use the breath to generate pressure. Don’t be afraid to make some noise, either. There are tools you can use such as birthing stools, exercise balls and mirrors to help facilitate labor.

Some women will tear at the perineum – the area between the vulva and the anus. Or, their doctor will make space surgically (for the baby) by cutting the perineum. We can teach you how to do perineal massage, which allows you to prep those tissues, getting them to relax and creating more space for the baby.

You mentioned teaching women to use their breath. I didn’t realize a pelvic floor therapist would even deal with breathwork.

Oh, it’s a huge part of what we do with pregnant patients. You can use your breath as a tool to manage pain and pressure on the pelvic floor during pregnancy and especially during labor.

There is such a close correlation between the breath, the diaphragm and the pelvic floor. They’re all connected. And just understanding that relationship can be huge.

Who comes to see you, and how do they find you?

Nowadays, more women are getting pelvic floor therapy as a pre-emptive measure – before they have pain or any symptoms. I applaud that. But most commonly, people are coming to me because they do have symptoms.

Anything else you cover with patients?

We cover cardiovascular fitness. We give women that encouragement that physical activity is good, but tell them there are ways to exercise that feel, and are, safe when you’re pregnant.

I can help patients develop an exercise program – whether that's walking, yoga, water aerobics, Pilates, whatever you enjoy – that will help you stay physically active and recover more readily from childbirth.

I notice you haven’t mentioned Kegels, which I thought were a big part of pregnancy pelvic floor therapy.

There can be a place for Kegels in pregnancy, but they’re not appropriate for everyone. If an expectant mom comes in with a history of pelvic pain or painful intercourse, Kegels would not be my first go-to.

Can pelvic floor therapy help make a vaginal delivery easier?

Absolutely, but it can also help with a C-section, too. (I should note that if you’re having a planned C-section, perineal massage does not apply to you – but everything else I’ve mentioned is applicable.)

When should a woman plan to see a pelvic floor therapist?

I recommend coming during the second trimester, although patients are welcome anytime throughout their pregnancy.

I’ve seen people who are years postpartum for a first visit, and the overwhelming consensus is that they wish they’d known about it sooner. It can be so beneficial to go to even one pelvic floor physical therapy visit just to get the knowledge.

You’ll need a referral from either your physician, midwife, physician assistant or nurse practitioner. Insurance coverage for PT is based on each individual’s plan. It’s best to contact your insurance company to confirm coverage.

If a woman comes for just one visit during her pregnancy, what can she expect?

We’ll look at activity modification, body mechanics and adaptive equipment that’s specific to each person’s routine and changing body. I’ll give you tools for dealing with back, hip or pelvic girdle pain in the form of mobility exercises and stretches that are great for any expectant mom. We’ll talk about prep for labor; offer positioning ideas during labor including movements that open up the hips; discuss managing discomfort and pain with the use of simple tools like pillows, braces, wedges and exercise balls.

I’ll give you ideas for how you can position yourself for a good night’s rest; discuss perineal massage, if it's applicable; and teach you how you can do it at home yourself. I hope to offer a space where expectant moms can feel comfortable to ask any question they may have.