Podcast Summary: Dr. Chapa’s Clinical Pearls – "Perform PFMT Antepartum?"

Host: Dr. Chapa
Episode Date: October 15, 2025
Main Theme:
Exploring the evidence and recommendations surrounding pelvic floor muscle therapy (PFMT) initiated during pregnancy (antepartum) to reduce the risk and severity of peripartum and postpartum urinary incontinence.

Episode Overview

This episode responds to a community question (from listener Laura) about whether pelvic floor muscle training (PFMT) should be started during pregnancy, or if it should wait until postpartum. Dr. Chapa reviews the physiology of urinary incontinence in the peripartum period, explains current evidence and practical recommendations, discusses different types of PFMT (including strengthening and relaxation), and provides actionable protocols for clinicians and patients.

Key Discussion Points & Insights

1. Prevalence and Timing of Urinary Incontinence

• Urinary incontinence is not only postpartum: Both stress urinary incontinence (SUI) and overactive bladder (OAB) symptoms often begin during pregnancy, sometimes as early as the first trimester (03:10).
• Prevalence stats:
  • SUI during pregnancy: 30–70%
  • OAB (with or without leakage): About 60%
    “These are not limited to postpartum! ... That’s pregnancy, one of the joys of the beautiful condition.” (15:35)

2. Physiology and Types of Issues

• Mechanisms:
  • SUI relates to physical changes, such as the uterus leaving the pelvis or increased pressure from a growing baby, causing leakage when sneezing or coughing.
  • OAB can be both neurogenic (overstimulation of detrusor) and due to “hypertonus” (excess tension) of the pelvic floor (05:15, 18:40).
• High vs. Low Pelvic Floor Tone:
  • Low tone (weak muscles): Stress incontinence
  • High tone (overactive muscles): Can actually worsen OAB symptoms after delivery

3. PFMT (Pelvic Floor Muscle Therapy)

• PFMT ≠ Only Kegels:
  “Not all pelvic floor therapy is to make you Kegel. Some pelvic floor muscle therapy is to help you relax.” (10:43)
• Pelvic floor exercises can be both about squeezing/strengthening (for SUI) and learning to relax (for OAB, vaginismus) (19:20).
• Relaxation-based PFMT is particularly helpful for patients with high-tone dysfunction.

4. Clinical Evidence on Antepartum PFMT

• Who benefits most:
  • Best evidence for women who are baseline continent, especially primigravidas (first-time pregnancies).
  • Unclear benefit if there is already pre-existing incontinence.
• Protective Benefit:
  • Starting PFMT in the first trimester can statistically and clinically reduce postpartum incontinence (both stress and urge types).
  • Protective benefits persist for up to a year postpartum, especially if exercises are resumed in the immediate postpartum interval (21:40).
• Evidence base:
  • Referenced an October 2025 narrative review from the Green Journal and the 2020 Woodley Cochrane meta-analysis.
• Supervised vs. Home Exercise:
  • A single session with a pelvic floor therapist for education is advised, followed by home exercises, which are similarly effective (12:07, 22:35).

5. Practical PFMT Regimens

• Woodley “8-3-3” Rule (from Cochrane Review):
  • 8 contractions per set
  • 8 seconds per contraction
  • 3 sets per day
  • 3 days per week
  • For 3 months (25:47)
  • “Man, that’s a lot of work!” (25:47)
• Weighted devices:
  Good for biofeedback, but not mandatory; ensure safe, non-porous products
• Simplified routine:
  Even “alternating closing and relaxing, about 10–15 reps per set,” is beneficial.

6. Realistic Expectations

• Relative risk reduction, not elimination:
  “You can’t tell them that you’re not gonna get incontinence. This is about relative risk reduction, not elimination of risk.” (26:52)
• Set appropriate expectations for outcomes.

7. PFMT and Related Interventions Postpartum

• Continue PFMT after birth, especially after perineal trauma (OASIS).
• Severe persistent symptoms (beyond 6 months):
  • For SUI: Consider surgical management (midurethral sling), not necessarily restricted to women who are done with childbearing, although tradition persists (28:39).
  • For OAB: After behavioral and PFMT, can consider medications after ~6 months, but caution with botulinum toxin if breastfeeding (30:22).

Notable Quotes & Memorable Moments

• Setting the scene with humor:
  “...if you pass a mini watermelon through the vajayjay, obviously you’re going to have some neuromuscular effect, some neuronal perineal nerve stretching.” – Dr. Chapa (02:37)
• On misconceptions:
  “Pelvic floor therapy isn’t just Kegels... Some pelvic floor muscle therapy is to help you relax.” – Dr. Chapa (10:43)
• On practical benefit:
  “There is protective benefits to the pelvic floor if you start pelvic floor therapy early in the first trimester, and it helps reduce postpartum urinary incontinence of both types.” (20:58)
• On realistic advice:
  “This is all about relative risk reduction, not elimination of risk.” (26:52)
• Protocol humor:
  “That pelvic workout – I’m not talking about sex. Alright? Although sex is a pelvic workout. But, but we’re talking about pelvic health.” (21:25)
• On product selection:
  “Make sure that they are good quality. Make sure that they are not porous so that you don’t trap bacteria in there.” (26:15)

Key Timestamps

• [03:10] – SUI and OAB begin during pregnancy, not limited to postpartum
• [10:43] – Not all PFMT is just Kegels; relaxation is also a focus
• [15:35] – Prevalence statistics for urinary incontinence in pregnancy
• [20:58] – Direct quote from Green Journal narrative review supporting early PFMT
• [21:25] – Woodley Cochrane protocol details
• [25:47] – 8-3-3 rule explained
• [26:52] – Emphasis on risk reduction, not elimination
• [28:39] – Surgical management for persistent SUI
• [30:22] – OAB treatment, breastfeeding considerations

Practical Takeaways

• Screen all pregnant patients—even in the first trimester—for urinary symptoms and educate about pelvic floor muscle health.
• Recommend pelvic floor muscle therapy antepartum, especially for baseline continent, first-time pregnancies, to reduce postpartum incontinence.
• Emphasize both strengthening and relaxation, tailoring exercises based on patient’s symptoms (high vs. low pelvic floor tone).
• Supervised education is helpful, but most benefit can be achieved with standardized, at-home PFMT.
• Use realistic counseling: Exercises reduce risk, don’t eliminate it.
• Persistent, severe symptoms postpartum may require medical or surgical intervention, with shared decision making.

Summary in a Pearl:
Starting pelvic floor muscle therapy during pregnancy—not just after delivery—has clear, evidence-based benefits in reducing both types of postpartum urinary incontinence. It’s best for women without baseline symptoms, easily implemented at home after education, and should be tuned to both strengthening and relaxation depending on individual findings.