Bladder Control
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‍Women who have one baby are nearly three times more likely to leak urine and wet themselves than women who have not had a baby.
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Why does having a baby make you wet yourself?
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When the baby moved down through the birth canal (the vagina), the canal was stretched.

The nerves and muscles (called the Pelvic Floor Muscles) that help keep the bladder closed were also stretched. Even if you had a caesarean to deliver your baby, pregnancy itself can lead to pelvic floor problems over time.

This can leave the muscles weak so that they are not able to keep the bladder from leaking. This leaking can happen when you cough, sneeze, lift or exercise.

Is this leaking likely to go away by itself?
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The leaking is not likely to go away unless you take steps to prevent future damage and begin to exercise your pelvic floor muscles to help them get your strength back. As you get older, your pelvic floor muscles will tend to get weaker.

If you don’t get the muscle strength back after each baby you have, you are more likely to start wetting yourself. Following menopause, there is also a higher risk that you will wet yourself.

How do my waterworks work?
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The bladder itself is a hollow structure surrounded by muscle. The bladder fills up slowly from the kidneys. You should be able to hold on until there is about 300-400ml inside the bladder.

The bladder closing muscles are called the pelvic floor muscles. When you are ready, the pelvic floor muscles relax and the bladder squeezes the urine out. Then the cycle begins again.

What do my pelvic muscles do?
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‍The diagram below shows where the pelvic floor muscles are.

These muscles do a number of things, such as:

- Help to close off the bladder, the vagina (birth canal) and the back passage (the anus).
- Help to hold the bladder, the uterus (womb) and bowel in their proper place.

What happens if my pelvic floor muscles are weak after birth?
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- You might leak urine when you cough, sneeze, lift, laugh or exercise.
- You might not be able to control your wind.
- You might feel a sense of urgency when you need to empty your bladder or your bowel.
- You might not have proper support for your bladder, your uterus or your bowel.

When one or more of your pelvic organs (bladder, womb, bowel) sags down into your vagina, this is called pelvic organ prolapse. Prolapse is very common and happens to half of all New Zealand women. If you have a feeling of ‘something coming down’, you might have a prolapse.

NB: one in ten women in New Zealand have surgery for prolapse, but half of women actually have a prolapse.

See your doctor if you are not sure about this.


Pelvic Floor Muscles
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How do I exercise my pelvic floor muscles properly?
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‍To begin, sit leaning against a back support (wall or bed). When you do a proper pelvic floor muscle squeeze you should:

- Squeeze, lift and hold as if you are trying not to pass wind.
- Feel the pelvic floor lift. At first the movement that you feel may be very small. If your muscles are very weak, you may feel very little at all.
- Make sure that you do not have any downward movement of your pelvic floor when you try to do a squeeze and lift.
- The lower part of your tummy muscles should gently pull in as you squeeze and lift your pelvic floor muscles.
- You might like to use a hand mirror to see your pelvic floor working, if you feel comfortable doing this.
- Tighten, lift and squeeze your pelvic floor muscles before every cough, sneeze and lift. You should try to do this for the rest of your life. This is called ‘The Knack’.
- Straight after the birth of your baby, you should follow the simple exercise plan below for about six weeks.
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Pelvic Floor Exercise
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1. A proper pelvic floor squeeze should lift up and hold hard. Pelvic floor exercises should be done slowly – you need to concentrate.
2. Every squeeze should be done as strongly and tightly as you can!
3. Squeeze, lift and hold for three seconds, three times.
4. This is ONE SET.
5. Try to do THREE SETS each day.

As pelvic floor muscles get stronger, you can hold your squeeze for longer. You should aim to hold a long squeeze up to the count of ten. It may take some weeks before you can hold for the count of ten. Start with whichever number you can manage to do. This might be any number from one to ten.

Once you can hold on for longer and are more confident you can add in some quick short holds – squeeze as hard and as quickly as you can.

If you are unsure about whether or not you are using your muscles correctly, see a pelvic floor physiotherapist.


Getting ‘The Knack’
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‍You should squeeze up and hold before you cough, sneeze or blow your nose and before each time you lift anything. This braces your pelvic floor and protects it. The lower part of your tummy should squeeze, lift and hold as well.

When you feel that your vagina has recovered from the birth of your baby (some time after three weeks), you might like to place a clean finger gently into your vagina. As you squeeze up hard, see how many seconds that you can hold the squeeze. Now see how many of these long squeezes you can do, one after each other with a short rest between each. Filling in the table on page 7 might help you to watch your progress more easily.

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Keeping track of your progress
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Use the table to keep track of your progress.
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How can I remember to do my exercises?
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The hardest thing about pelvic floor exercises is remembering to do them. It will be easier to remember if you do one set of exercises (or use ‘The Knack’) each time that you do a certain thing. During a shower or bath is a good time to practice your exercises. Choose from the list below which times you think would work best for you.
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- After you have finished going to the toilet.
- When you wash your hands.
- When you have a drink.
- When you change the baby.
- When you feed the baby.
- When you have a shower.

‍Red stick-up dots can help you to remember your exercises. You can get these at your newsagency. Stick these up in a couple of places around the house. They can remind you to do your exercises each time you see them.  For example:
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‍- Near the toilet button or behind the toilet door.
- Near where you keep the tea or coffee.

You could ask your partner or a friend to help remind you to do your, pelvic floor exercises.
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Remember to brace your pelvic floor every time you are going to cough, sneeze or lift(this is called ‘The Knack’).
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Remember – you need to do your pelvic floor exercises for the rest of your life!!


Back to sex after the baby
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‍Your pelvic floor muscles not only play a part in bladder and bowel control, they also help with sexual function. They will help you feel your partner and help with sexual responses. Hormone changes during breastfeeding can cause the vagina to be dry, even if you are aroused, causing discomfort. The use of vaginal lubricant can help.  If you had stitches after the birth of your baby, this may cause pain when you first try to have sex. If you are worried about getting back to sex or would like advice about any of these problems, see yourG.P.or pelvic floor physiotherapist. This is an important part of getting back to normal after the baby that is often missed - but you should not feel embarrassed asking for advice.


What can I do to avoid constipation?
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Constipation can lead to pelvic floor stretching.

To avoid constipation:

- Drink plenty of fluid per day, especially if you are breast feeding.
- Eat high fibre foods e.g. whole grains, fruit, vegetables, seeds, nuts, legumes.
- Eat a wide variety of healthy food options.
- Talk to your GP or pharmacist about using a fibre supplement e.g. Metamucil or psyllium husks.
- Vegetables and lentils or pluses are all high in fibre. Try to eat 5 different vegetables every day.
- When you sit on the toilet, keep your feet flat on the floor, lean forward from the hips with a straight back and a relaxed tummy.
- Relax your pelvic floor, bulge the lower part of your tummy forward.
- Gently push keeping your tummy bulged forward, hold the push, then relax.
- Repeat – push, hold and relax.


How can I be sure that I have good bladder habits?
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It is normal to:
- Go to the toilet about 6-8 times each day. Try not to go “just in case”.
- You should pass about 300-400ml each time you go to the toilet.
- It is OK to get up once each night to pass urine. Try not to just go because you have to get up to the baby.

‍Try to:
- Drink at least two litres of fluid each day.
- Some drinks can cause urgency (sudden desire to go to the toilet, with a fear that you may not get there in time). This includes: caffeine, fizzy drinks, artificial sweeteners.

‍You should ask for help if you notice any of the following:
- Any leaking of urine.
- Needing to rush when you need to go to the toilet.
- Not being able to hold on when you want to go.
- Leaking urine on the way to the toilet.
- Burning or stinging inside when you pass urine.
- Having to strain to start the flow of urine.


Summary

What can I do to prevent these things from happening?
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- You can start some pelvic floor exercises.
- Make sure that you have good bladder and bowel habits.
- Keep your body weight within normal limits.
- Only do pelvic floor safe exercise when getting back into shape after having your baby.
- Visit pelvicfloorfirst.org.au for advice on safe exercise.

‍Here are some hints to help you:
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- You should try to avoid downward movement of your pelvic floor during exercise and daily activities.
- Avoid constipation.
- When you need to open your bowels, you can support your vagina with your hand to try and stop it from overstretching as you bear down.
- Use ‘The Knack’ for every cough, sneeze or lift.
- If your pelvic floor muscles feel weak, try crossing your legs tightly together before each cough or sneeze.
- Try to avoid any heavy lifting (even at the gym) or bouncing exercises like jumping jacks until your pelvic floor is strong.
- Even if you have a problem with wetting yourself, you should keep on with gentle exercises, walking or swimming.

If you have trouble with your bladder or bowel, do not despair! Incontinence is common and with the right advice and help you can make a big difference and the chances of cure are good. Remember to take care of yourself both before and after baby is born.

Need help?
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To find out how to best manage your incontinence:
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- Speak with your healthcare professional. This might be your GP, your specialist, your midwife or a pelvic floor physiotherapist.
- Many local hospitals have continence advisors. Please phone the continence helpline for a contact list. They can also provide you with the name of the physiotherapist nearest to you who has a special interest in helping women with pelvic floor problems.
- Receive free information leaflets on a range of continence subjects.
- For all of the above phone the Continence Helpline 0800 650 659 or go to www.continence.org.nz

‍Discuss continence with your health professional. You should ask each of your health professionals how any aspect of your care during your pregnancy, delivery or post-natal period could affect your bladder and bowel control (e.g. epidural, induction, repair of episiotomy or tears). Consider this information when making any decisions regarding your pregnancy, delivery and after-care.

‍Contact the Continence Helpline on 0800 650 659
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‍Email info@continence.org.nz
P.O. Box 254, Waiuku 2431

Written by: Pauline Chiarelli
University of Newcastle

The content of this booklet has been provided by the Commonwealth of Australia, (c) 2011