Pregnancy and postpartum are times of incredible change. While many people focus on prepping the nursery or packing the hospital bag, one of the most important players in this journey is often the most overlooked: the pelvic floor.
Understanding the functional changes in your body is the first step toward a confident recovery. It’s time to move beyond the idea that “leaks and pressure” are just a normal part of motherhood, and look at how we can actually support the body through and beyond this transition.
What is the pelvic floor?
Most women have heard that they should do Kegels during and after pregnancy. A Kegel is a contraction of the pelvic floor muscles. These muscles get a lot of press related to pregnancy because of the important role they play in supporting the pelvic girdle through all the hormonal and mechanical changes that occur in the body during this season!
Positioned like a hammock from pubic bone in the front to tailbone in the back, the pelvic floor is a group of muscles that supports the internal organs including the bladder and uterus. It also includes the sphincter muscles, which close and open the urethral and anal openings — relaxing to let urine and stool void when at the toilet.
Key functional changes during pregnancy
To understand why this support system is so vital, we have to look at how the body manages shifting demands. It isn’t just about muscles stretching; it is a complex recalibration driven by hormones, load, and the demands of a growing baby.
- Hormonal changes: Beginning in the first trimester, the body produces higher levels of relaxin, a hormone that increases the flexibility of ligaments and connective tissue throughout the pelvis. This is necessary for birth, but it also means the pelvic floor muscles have to work harder to compensate for reduced ligamentous support — especially as pregnancy progresses.
- Increased load and pressure: As the baby grows, the downward pressure on the pelvic floor increases significantly. By the third trimester, the pelvic floor is managing substantially more load, especially in upright positions — standing, walking, lifting — than it was before pregnancy. This is why symptoms like leakage or heaviness often worsen with activity as pregnancy progresses. It is also why holding back urine may be easier when coughing/sneezing if you are lying down, but more difficult when upright.
- Coordination changes: The pelvic floor doesn’t work in isolation. It’s part of the core — a pressure management system that includes the diaphragm, deep abdominal muscles, and the muscles of the hips and back. As posture shifts during pregnancy, the center of gravity moves forward, the lumbar curve increases and the coordination of this whole system is affected. Muscles that were working well together may start to fall out of sync.
- Postpartum recovery: After birth, whether vaginal or cesarean, the pelvic floor enters a recovery phase. Tissues may be stretched, bruised, or healing from tears or surgical incision. Hormonal shifts (including the drop in relaxin) mean the ligamentous support begins to return, but muscle strength and coordination don’t automatically follow. It is also important to note that for those who are breastfeeding, hormones continue to be in a state of flux. The hormonal profile associated with milk production can cause tissue laxity to persist for as long as you are nursing. This gap between tissue healing and functional recovery is exactly why postpartum pelvic floor physical therapy can make such a meaningful difference.
As the posture/weight distribution changes in the pregnant body, these support muscles must work harder in a “gravity dependent” position like standing and walking. For example, holding back urine may be easier when coughing/sneezing if you are lying down, but more difficult when upright.
Signs and symptoms of pelvic floor dysfunction during pregnancy
During pregnancy, what’s common, what’s not, and when to see a PFPT
One of the questions I hear most often is some version of: “Is this normal, or should I be worried?” The honest answer is that many symptoms during pregnancy and postpartum are common — meaning a lot of people experience them — but that doesn’t mean they should be ignored or accepted as just part of the deal.
READ MORE: In this companion blog — Debunking Pregnancy Myths — we explore three common myths about pregnancy and explore how physical therapy can empower expectant mothers with evidence-based solutions for a healthier pregnancy.
What can be expected during pregnancy (and often improves with the right support):
- Occasional leakage with sneezing, coughing, or laughing, especially in the third trimester or early postpartum weeks
- A sense of heaviness or pressure in the pelvis by end of day, particularly later in pregnancy
- Mild urgency or frequency as the bladder adjusts to a growing uterus
- Some discomfort at the perineum or tailbone during pregnancy as the joints and ligaments accommodate the baby
- Fatigue in the core and pelvic region, especially with prolonged standing
These are common experiences, and they often improve with proper pelvic floor training and support — which is why early evaluation can be so helpful, even if symptoms feel mild.
Signs that you should seek a pelvic health PT evaluation during pregnancy:
- Incontinence: any leakage of urine, gas, or stool that is interfering with daily activity or causing you to modify your behavior (limiting exercise, wearing pads “just in case”)
- A feeling of vaginal pressure, bulging, or something “falling out” — these can be signs of pelvic organ prolapse
- Pelvic or hip pain that’s affecting how you walk, sleep, or get in and out of a car
- Significant pain with intercourse postpartum, beyond the first few weeks of healing
- Constipation, straining with bowel movements, or difficulty fully emptying the bladder
- Any feeling that your core “isn’t working right” — such as abdominal doming or coning with movement (a possible sign of diastasis recti)
- Postpartum symptoms that haven’t improved, or feel like they’re getting worse, by 6–8 weeks
A note on timing: You don’t have to wait until something is wrong to benefit from pelvic floor PT. Many of my patients come in during pregnancy without any symptoms at all, simply wanting to prepare their bodies for labor and recovery. Starting that conversation early almost always makes the postpartum period easier.
Understanding and engaging your pelvic floor muscles
Learning how to identify and contract and relax the pelvic muscles can be challenging. It’s hard to figure out if you’re engaging a muscle you can’t see, unlike a bicep muscle, which you can look at and know whether it’s flexed or not.
A pelvic health physical therapist can objectively assess the muscle strength, coordination, and endurance to give women feedback on where they’re at, utilizing internal and/or external biofeedback units and analyzing the information they gather.
What to expect at a pelvic floor PT appointment during pregnancy
If you’ve never seen a pelvic health physical therapist before, it’s completely normal to feel uncertain — or even a little nervous — about what an appointment might involve.
Your first visit is primarily a conversation and a thorough evaluation. We’ll talk about your history, your symptoms, your goals, and what’s been going on in your body.
The physical evaluation typically includes an assessment of your posture, movement patterns, and how your core and breathing system are functioning together. When appropriate — and always with your full consent and comfort — this may include an internal examination of the pelvic floor muscles, which is the most ideal way to assess muscle strength, tone, coordination, and tenderness. For many patients, this is the first time they’ve ever had objective feedback about whether their pelvic floor is actually doing what they think it is.
Internal assessment: it is gentle, it is done at your pace, and you are always in control. Many patients are surprised by how comfortable and informative it is. If you’re not ready for that component, we can do a great deal of meaningful work without it.
From there, treatment is individualized. It might include hands-on manual therapy, guided exercises, breathing and pressure management training, education, or preparation for specific goals like labor, return to running, or return to weightlifting. We build a plan around what your pelvic floor actually needs — which may look very different from what someone else needs, even with similar symptoms.
Preparing for labor and birth
As baby’s due date nears, the focus often shifts from keeping the pelvic floor muscles strong to stabilize the pelvis, to training the pelvic muscles to lengthen and relax as the pregnant body gets ready for birth.
Performing perineal massage during the last six weeks of pregnancy can help prepare the perineal tissue for the stretching required during vaginal birth and reduce perineal tearing.
A pelvic health PT can assist with labor/birth preparation, helping women learn how to lengthen the pelvic floor for bearing down (pushing) during active labor. Practicing labor positions ahead of time helps the pregnant woman understand which positions may work best for her body.
Partners are included in the educational process during PT visits as well, learning techniques such as counterpressure that can assist with pain relief during labor. This collaboration between the PT and the birth team, including OB-GYNs, midwives, and doulas, ensures comprehensive preparation for labor.
Physical therapy after childbirth
Can you imagine someone who has had an orthopedic surgery such as a total knee replacement resuming normal activity without the support of post-operative physical therapy? Of course not! Then shouldn’t every woman also receive physical therapy to help with the physical recovery from childbirth?
Many times, the “all clear” to return to exercise at about eight weeks post-childbirth can result in confusion for the mother whose body doesn’t feel ready to resume higher-level activity like weightlifting or running. This is where physical therapy plays a key role in evaluation, education, and exercise prescription.
Whether the baby is born vaginally or via cesarean section, there is muscle recovery and often scar tissue management involved after birth. Problems such as constipation, hemorrhoids, urinary leakage, pressure/heaviness/bulging from the vagina, and painful intercourse are all frequently experienced issues that can improve drastically with pelvic floor muscle and breath training for improved pressure management in the core.
Let us partner with you on your pregnancy journey.
Pelvic health physical therapy addresses the unique musculoskeletal structure of the pelvic floor. Working with a pelvic health specialist before, during and after pregnancy can help you return postpartum to your optimal function and ensure your focus is on the joy of motherhood.
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