If you're an avid reader of articles about topics like pregnancy or general pelvic health, you're probably somewhat familiar with the term "Kegel." There's a reason the word pops up a lot — Kegels are a common exercise recommended to strengthen the pelvic floor during pregnancy.
Why does the strength of the pelvic floor matter during pregnancy? And are Kegels really a must for all pregnant people? In this article, we're answering these questions and pulling in the perspective of a pelvic floor specialist so you have all the information you need to consider an exercise routine during pregnancy. Here are the biggest takeaways up front:
- The pelvic floor is a group of muscles and ligaments that wrap around the pubic bone to keep all of your pelvic organs (the uterus, vagina, bladder, and rectum) in place.
- When the pelvic floor is too tight or too loose, that can lead to uncomfortable side effects — during and after pregnancy.
- During pregnancy, the added weight of the expanding uterus puts a lot of stress on the pelvis. If the pelvic floor isn’t balanced in its strength, that can cause more discomfort during pregnancy and increased risk of incontinence after pregnancy.
- While research examining the effects of pelvic floor exercises (aka Kegels) show mixed results, the main benefit they seem to provide is helping with incontinence during and after pregnancy. That's why many healthcare providers and pelvic floor specialists strongly recommend them.
"The hardest part about addressing pelvic floor dysfunction is that 99% of the time, we are unaware of the incredible work these muscles are doing every day. So, it takes coaching to understand how to activate and relax these muscles," says OB-GYN and Modern Fertility medical advisor Dr. Eva Luo, MD, MBA. "I wish pelvic floor physical therapy could be better incorporated into one's fertility journey: prior to pregnancy, during pregnancy, and after."
Keep reading as we cover everything from the anatomy of the pelvic area to how to do the perfect Kegel.
So, what is the pelvic floor?
Think about your pelvic area. Within bodies assigned "female" at birth, that area houses the uterus, vagina, bladder, and rectum. The pelvic floor, or pelvic muscles, are a group of muscles and ligaments that essentially act as a hammock, wrapping around the pubic bone to keep all of those organs in place. Like many other muscles in the human body, flexibility is an important part of pelvic floor health. You don’t want a pelvic floor that is too loose, but you don’t want it to be too tight either. A pelvic floor that is too tight can result in pelvic floor dysfunction.
Signs of pelvic floor dysfunction include:
- Frequent urination, difficulty releasing urination, pain with urination, and a stop and go cadence to the flow of urine
- Straining, or pain due to straining with bowel movements, including constipation
- Leakage of urine or stool, also known as incontinence
- Unexplained lower back pain, or ongoing pain in the pelvic region, including the genitals and rectum
- Pain during sexual activity
When the pelvic floor is too loose, it can result in uterine prolapse. When this happens, the uterus begins to sit lower, out of its natural position. Signs of uterine prolapse include:
- A sensation of pressure or heaviness in the pelvis
- Uterine tissue sitting in the vaginal canal, or the outside of the body
- Vaginal discharge that's unusual or higher in volume
- Pain during sex
- Bladder infections that recur frequently
- Constipation or issues with urination including frequent urination, a sudden urge to urinate, or involuntary leakage of urine
By retaining the correct flexibility to hold the pelvic organs in place, the pelvic floor helps to ensure that they function effectively.
What does the pelvic floor have to do with pregnancy?
As we mentioned earlier, the pelvic floor has the very important job of supporting all of the pelvic organs and making sure they stay in place. When a birthing person becomes pregnant, the pelvic floor has an additional job, supporting the uterus while it has a growing baby inside of it. Understandably, pregnancy puts quite a bit of strain on the pelvic floor effectively weakening it.
"The pelvic floor muscles, which are the muscles in the bicycle seat area of the body, have many roles, all of which are challenged in pregnancy!" explains Stephanie Stamas, PT, DPT, PRPC, ATC, a pelvic health specialist and the founder of Chelsea Method. "One of their main jobs is to support the weight from above. The pelvic floor will gradually decrease in strength and tone as the baby, placenta and uterus increase in size and weight."
The pelvic floor also helps to provide stability for the pelvis and lower back. During pregnancy, a hormone called relaxin jumps in to keep the ligaments relaxed (hence the name) — but that also makes it harder for the body to maintain a stable core.
Finally, the pelvic floor also "acts as a suction pump to prevent blood from pooling in the genitalia, which can feel like heaviness in the labia and around the vagina," Stamas says. (Side note: This suction is why the pelvic floor muscles contract during orgasm.) When you're pregnant, the blood volume pooling in the pelvis increases — and varicose veins can develop in the pelvis, groin, and legs.
For all of these reasons, a weak pelvis during pregnancy can cause:
- Lower back pain
- Groin/hip pain
- Pelvic pain
- Pubic bone pain
- Increased pelvic heaviness
- Pain during sex
- Urinary incontinence
That last bullet, urinary incontinence, is a common symptom of pregnancy. The bladder is positioned under the uterus — and as the uterus grows along with the baby, so does pressure on the bladder. This particular symptom usually goes away on its own a few weeks after giving birth as the body heals from the pregnancy and birthing journey, but the issue can show up months or years after delivery.
- Uterine prolapse: When the uterus sits lower than its natural position.
- Cystocele: This is when the bladder begins to sag due to a lack of support from the pelvic floor. This can feel like a bulge within the vagina.
- Pelvic nerve damage: Prolonged labor, prolonged pushing, or a difficult laboring process can cause the nerves in the pelvic floor to become damaged, resulting in bladder incontinence.
- Physical injury: A vaginal delivery (with increased risk for operative deliveries, including forceps or vacuum delivery) can result in physical damage to the pelvic floor and anal sphincter muscles.
If pelvic floor is so important before, during, and after pregnancy, do healthcare providers ever assess strength before conception? "During labor, so much change occurs with the patient and baby that an assessment prior to labor is just not accurate," explains Dr. Luo. "Pelvimetry used to be something that was assessed and some patients were recommended to have C-section due to these pelvic measurements. Due to the fact that labor is such a dynamic process, pelvimetry has fallen by the wayside." Dr. Luo adds that pelvic floor strength will typically only come up if someone describes significant pelvic floor discomfort or back pain during pregnancy.
Can pelvic floor exercises during pregnancy help?
The research examining the efficacy of pelvic floor exercises during pregnancy focus on the role they play in reducing incontinence. One 2020 Cochrane review that looked at forty-six trials on the subject, covering over ten thousand pregnant and postpartum women, found the following:
- Pregnant women who were not experiencing urinary incontinence and engaged in proactive pelvic floor therapy experienced a lower rate of incontinence later in pregnancy, as well as a slightly lower risk at 3-6 months postpartum.
- Pregnant women who were already experiencing urinary incontinence did not see an improvement after engaging in pelvic floor therapy in late pregnancy, or up to a year after giving birth.
The researchers concluded that within mixed groups of pregnant women (who do or don't experience incontinence), there may be a benefit to beginning pelvic floor therapy that extends from late pregnancy into six months postpartum. However, they also noted that a number of factors, including problems with study size and design, made the data a bit rocky to rely on.
All that said, physicians generally do recommend pelvic floor exercises during and after pregnancy — and pelvic floor specialists strongly advise them.
What pelvic floor exercises can you do during pregnancy?
Dr. Luo explains that she recommends Kegels during pregnancy, which she says is a term "used interchangeably to describe the muscles that control your urethra (think about the muscles that you squeeze when you experience the urge to urinate) and exercising the pelvic floor."
More specifically, Stamas recommends Kegels during the first and second trimesters and reverse Kegels in the third. A lot of us might be familiar with the former, but why the latter? "I’ve worked with too many moms that did a ton of Kegels during their pregnancy and ended up with a tight pelvic floor that worked against them during labor," says Stamas. "Pushing in labor is an opening of the pelvic floor muscles so they can get out of the way. If you’ve only practiced closing, it can be hard to know how to do the opposite."
Here's how to do a Kegel, which Stamas called "a close and lift motion":
- Gently draw your tailbone toward your pubic bone without moving your pelvis.
- Imagine trying to pick up a blueberry with your vagina.
- Think of stopping the flow of urine.
- Imagine your urethra (the tube your pee comes out of) as a straw and try sucking up through that straw without moving your pelvis.
Stamas adds that incorporating Kegels into other movements when you experience pain or leaking (like going to the bathroom) rather than simply doing a bunch of isolated contractions per day "is a great way to train the pelvic floor with the other deep core muscles for a greater impact." She also says that the best way to know if you're doing Kegels "right" is to feel for pelvic muscle contraction.
Now for reverse Kegels. Stamas says to learn how to do them by watching how your pelvic floor moves (unclothed) in the mirror. "The mirror allows us to visually see what we’re doing and fine-tune our skills," she explains. "It’s also something we can take into the hospital to help guide our pushing!" Here are the steps you can take to practice:
- Lie down on your back with your legs open so you can see your perineum (the area between your vagina and anus).
- Take a deep breath in and see if your perineum opens with the inhalation.
- On the next inhale, try to tighten and then relax your perineum. See the differences in the mirror.
- Keep practicing until you’re able to visually see your perineum going downwards.
Are pelvic floor exercises recommended for everyone during pregnancy?
"I would not recommend Kegels for anyone with an already tight pelvic floor, especially if they’re not having any pain or incontinence issues," Stamas says. "I would start with retraining lengthening of the pelvic floor (reverse Kegel) first, and then work on strengthening through the entire range of motion of the muscles." Stamas recommends that if you experience painful sex, periods, or constipation, this could be the result of a tight pelvic floor — in this case, she recommends seeing a pelvic floor specialist to help with reducing your symptoms.
Are pelvic floor exercises recommended before pregnancy?
"If you’re already feeling weak, or experiencing back pain, hip pain, groin pain or pelvic pain, these symptoms can be exacerbated in pregnancy," explains Stamas. "You can still address those symptoms during pregnancy, but it’s easier to treat the body prior to all the hormone shifts." She adds that she's seen related symptoms in hundreds of clients who've never given birth before — and these clients also benefited from lengthening the pelvic floor through exercises (like reverse Kegels).
What other exercises can be beneficial during pregnancy?
According to the American College of Obstetrics and Gynecology (ACOG), exercising during pregnancy carries a few benefits, including:
- Less back pain
- Less constipation
- A possibly lower risk of gestational diabetes, preeclampsia, and C-section delivery
- Stronger heart and blood vessels
The World Health Organization recommends 150 minutes of moderate-intensity exercise for people who are pregnant or postpartum and don't have any preexisting conditions. You can use the “talk test” to determine your intensity level. If you can talk, but not sing during your activity, you’re at the correct level. ACOG says to avoid contact sports, sports that put you at risk of getting hit in the stomach (e.g., ice hockey, boxing, soccer, basketball), skydiving, any activities that could result in falling, hot yoga, scuba diving, or anything done about 6,000 feet. Walking, water workouts, stationary biking, and modified yoga or Pilates are safe for pregnancy.
Exactly what type of exercise is recommended during pregnancy depends on your routine before pregnancy. "If you were a runner prior to pregnancy, unless you were specifically told by a provider due to pregnancy reasons that you need to modify, go and continue running," says Dr. Luo. "However, if the most amount of exercise you did prior to pregnancy was sitting on the couch pressing the remote, pregnancy may not be the time to train for a marathon."
The bottom line on Kegels during pregnancy
Pregnancy puts a lot of stress on the pelvic floor when you're pregnant, which commonly leads to urinary incontinence. Doing Kegels (and reverse Kegels) may help you maintain better bladder control and overall pelvic health during and after pregnancy.
If you're experiencing issues that could be related to your pelvic floor, like pelvic pain or incontinence, consider reaching out to your OB-GYN and a pelvic floor specialist like Stamas. You can find a list of providers in your area right here!
This article was medically reviewed by Dr. Eva Marie Luo, MD, MBA, OB-GYN at Beth Israel Deaconess Medical Center and Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.