To Kegel or Not to Kegel? That is the Question!

Every few years, the Kegel exercises come under attack. Practicing Kegels is often cited as the cause of difficulty during the pushing stage of birth, due to bearing down against contracted rather than relaxed pelvic floor muscles. This increases resistance to fetal movement, potentially damaging soft tissue, as well as stressing maternal cardiac reserve and the fetal heart. So, a call goes out to stop doing Kegels. But, Kegels were invented for a reason, and contracting the pelvic floor during birth is not it.

So, to kegel or not to kegel? Two things help us understand how to answer the question of whether or not – and when – to do Kegels. One is history (ever a useful tool) and the other is identifying the anatomy and physiological functions of the female pelvic floor.

1) History

Hands and knees is mechanically efficient for mom's body to "cradle" the fetus.

Hands and knees is mechanically efficient for mom’s body to “cradle” the fetus.

 

First thing, a quick peek at evolution. The pelvic floor did not originally support the contents of the abdomen. Starting out as 4-legged creatures, our pelvic floor originally served more as the back door.

Sacrum & Coccyx at top. Pubis at bottom. Evolution position.

Sacrum & Coccyx at top. Pubis at bottom. Evolution position.

Thus, the opening and closing of outlets were primary functions, and support of abdominal contents was largely a job for the Transverse Abdominals.

We could rock into an upright posture (squatting or sitting on our “sitsbones”), allowing gravity to assist in downward emptying of abdominal contents. When we relax our skeletal muscles, the involuntary muscles and neuro-motor emptying pathways proceed unfettered.

Squatting

Squatting

Once we discovered we could stand on our feet and still reach much of the fruit in the trees, a fast transition to upright (in evolutionary terms) placed strain on movement and support in the pelvis, spine and hip joints. Reviewing all the details involved in the ensuing adaptations is another story for another day. Suffice it to say, supporting the abdominal contents was not included in the original design of the pelvic “floor.”

Fast forward to the end of the 19th Century when birth began moving into a clinical setting and women were routinely placed on their back for labor and birth.

Pubis at top. Sacrum and coccyx at bottom. Supine position.

Pubis at top. Sacrum and coccyx at bottom. Supine position.

Yes, this slowed down the process and made it more painful. Thus, the next steps emerge in the early 20th Century: “Twilight Sleep” and increased forceps birth.

For a good understanding of this era, I recommend the following 1916 article:

  • Haultain FWN and Swift BH. The Morphine-Hyoscine method of painless childbirth or so-called “Twilight Sleep,” British Medical Journal, 1916 Oct 14;2(2911):513-5. Full text here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2354830/pdf/brmedj07070-0003.pdf

  • The reader can also learn more about Twilight Sleep and its adaptations in the U.S. by entering “twilight sleep childbirth” into the PubMed search field.

Next: Urinary incontinence! Or, the reason Kegels were invented.

So, what was the product of placing women on their backs, putting them into a semi-conscious state, amnesia of events, and sometimes dragging the baby out of the vagina with forceps? Likely, increasing incidence of pelvic floor dysfunction. However, additional factors also influence maternal pelvic floor outcomes, including the Valsalva maneuver during pushing, and instrumental birth. Who invented “pushing” anyway? Male doctors.

  • For more on such matters, I recommend the reader examine Sheila Kitzinger’s work. She is a renowned British anthropologist who studied, wrote and spoke on global birth customs throughout her life.

Pushing, or bearing down, occurs naturally during coughing, sneezing, emesis, forced exhalation (as when a tennis player grunts while hitting a ball), urination, defecation and – when occurring without analgesia – parturition (birth). Identifying the “best” way to push remains illusive. What is the goal? Speed, damage control, fetal outcome? The Cochrane Library concludes only that maternal preferences and medical imperatives should guide the method of pushing.

  • Lemos A et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2015 Oct 9;10:CD009124. doi:10.1002/14651858.CD009124.pub2.

And, what about organ prolapse? How does that figure in here? Is weakness in the pelvic floor muscles a cause? It is becoming more clear that, even in the absence of trauma, genetic factors play a significant role in the occurrence and severity of pelvic floor dysfunction. There is great variability in how connective tissues respond to stress and stretching. A good recent account of one possible gene avenue is this article:

  • He K, Niu G, Gao J, Liu JX, Qu H. MicroRNA-92 expression may be associated with reduced estrogen receptor β1 mRNA levels in cervical portion of uterosacral ligaments in women with pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 2016 Mar;198:94-9. doi: 10.1016/j.ejogrb.2016.01.007. Epub 2016 Jan 11.

In the early-mid 20th Century, much less was understood about how genetics, physical training, postural sway and practice protocols might affect these matters. In 1948, Dr. Arnold Kegel, an American gynecologist, published on a non-surgical method of toning the pelvic floor in order to help women control incontinence following childbirth. By exercising the pubococcygeus muscles (PC muscles or sphincters) of the pelvic floor, he found that women could reduce their likelihood of experiencing bladder problems after pregnancy and birth. Here are the two publications that give rise to calling these exercises “Kegels.”

  • Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948 Aug;56(2):238-48.
  • Kegel AH. The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure. Ann West Med Surg. 1948 May;2(5):213-6.

Keep these factors in mind: The experiments leading to publication included measurement of the strength of contraction of these muscles. Several devices (balls, cones and devices that read muscle strength) were developed to provide tactile aid in contracting and releasing the PC or sphincter muscles, and continue to be used today by physiotherapists. These actions are aimed at squeezing the detrusor (or urinary flow mechanism) to prevent incontinence with weak or relaxed sphincters.

What about the issue of organ prolapse? How does that tie in? Over time, the term “Kegel” has also come to refer to tightening the levator muscles (the sling-like muscles that lift the pelvic floor). This action is the opposite of what happens when bearing down. Which nicely brings us to the second topic:

2) Anatomy and Functions of the Female Pelvic Floor

There are three rings of muscles and four muscle actions that govern the opening and closing of the bony structures and soft tissue of the pelvic floor. The overall bony shape of the pelvic floor is similar to a baseball diamond, as seen in the first graphic.

Pelvic outlets, lithotomy position.

Pelvic outlets, lithotomy position.

 

The three rings are – from outside to in:

  1. Gluteals, transverse perineals and ischiocavernous that create two triangles of the pyramidal bony structure and create a rigid fence when contracted or a mobile structure when released. The deep rotators, including piriformis, and the pyramidalis also function to close the pelvic outlet.
  2. Levator and diaphragm muscle that lift and close the pelvic floor and/or support the contents of the abdomen by contracting when the woman is vertical.
  3. Sphincter muscles that squeeze and release the three orifices: urethra, vagina and anus, closing and opening these outlets.

The four muscle actions are:

  1. Contraction – tightening the muscle as in strength training. Can be done to shorten muscle (concentric) or as muscle extends (eccentric). Muscles can shorten approximately half their resting or relaxed length. Contracting muscle against resistance increases cardiovasculature and improves delivery of nutrients and oxygen, as well as improving innervation and awareness of motion.
  2. Release/Relaxation – letting go of contraction, allowing muscle to rest, relax or be stretched.
  3. Stretching – muscles can be lengthened approximately a third of their resting length by applying leverage to the bony structures the muscle controls. Stretching is also affected by genetic factors regarding elasticity of the connective tissue within and attaching to muscle and bone.
  4. Bulging or Distending – Some muscles can extend beyond their stretching range by pressure from the diaphragm, often termed “bearing down.” Both the Transverse Abdominals (TA) and pelvic floor muscles do this during parturition (efforts to expel the baby). The TA tighten in a distending position to assist in the emptying of the abdominal contents and the pelvic floor extends beyond the bony structure defined by the sit bones (ischial tubersoities) on either side of the vagina. To get a sense of how this occurs, I recommend two things: first, cough hard enough that you can sense the action of TA and pelvic floor; second, next time you take a poop, sense how your body is working. It is the same for parturition, although the target is the vagina rather than the anus and the voluntary assisting effort needed is much more intense. Two practices help prevent damage to the pelvic floor. One is following the urge to push and the other is to “labor down” when their is no urge, when the mother needs to rest a bit during pushing. Avoiding, as much as possible, the Valsalva maneuver (holding the breath while pushing) reduces strain on maternal cardiac reserve and the fetal heart.

An excellent way to get a sense of how the pelvic floor functions in birth is to view the 1974 Brazilian film, Birth in the Squatting Position. Here is the link:

https://www.youtube.com/watch?v=ZHHHcIZEi9U&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DZHHHcIZEi9U&has_verified=1

So, do we do Kegels? Yes, but we also release/relax, stretch and learn the coordination of bulging/distending these muscles. After birth and as we age, we also do them as a method of recovery and because we are upright animals who have to support the contents of the abdomen. Learning to sit in an anatomically neutral position in a chair and many other healthy postural habits – not to mention understanding our genetic factors regarding elasticity – will also help us maintain a healthy pelvic floor. But these ideas are another story for another day.

 

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