Pelvic Floor Care Is Routine in Germany—Here's What I've Learned

 Naomi Kaye Honova Profile Photo
By Naomi Kaye Honova | Updated on Jan 16, 2024
Image for article Pelvic Floor Care Is Routine in Germany—Here's What I've Learned

For many women, knowledge about their pelvic floor and its workings often comes too late, or not at all. However, the costs of ignoring pelvic pain and other issues of the pelvic region can be high. Incontinence, severe diastasis recti, and prolapse are some long-term complications that can develop if left untreated—complications that most women would be willing to do anything to avoid.

My introduction to the importance of pelvic floor health happened naturally during my pregnancy in Germany when I learned of Ruckbildungskurs, a German insurance-subsidized postpartum pelvic floor class that is generally recommended for women somewhere between 4 and 12 weeks after giving birth. 

Postpartum coverage in Germany was a revelation. In addition to the class, which allowed me to either bring my baby along or attend via Zoom, I also had access to the services of a midwife, who does postpartum house calls and could address any pelvic floor muscle issues I was having. And it was all covered by insurance. 

Coming from the United States, this level of care and focus on pelvic floor health came as a big surprise. After years in both countries, I’ve found that Germany tends to prioritize preventative care, which includes pelvic floor health. It made a big difference for me. The exercises I learned and the tips for how to reduce full-body and pelvic strain in everyday life came in very handy, and I still use much of the advice in my post-postpartum life today.

Many of my American friends had a very different experience. In the United States, many women don’t have access to pelvic floor preventative care and treatment, or they don’t know how important it is to pay attention to this area until they are already dealing with unpleasant side effects. 

Until all people have access to the same resources we have in Germany, it’s important to educate yourself about pelvic floor health so that you can take prevention and treatment into your own hands, including advocating for further care and treatment when you need it.

Getting Reacquainted With Your Pelvic Floor

Before you can work on protecting and optimizing your pelvic floor for pregnancy, you first have to understand what the pelvic floor is and how it works. 

Pelvic floor muscles refer to the muscles sitting at the pelvis’s base, supporting the organs in the pelvic region. These organs include the uterus, bladder, and bowel. Suffice it to say, it’s a critical group of muscles, and these muscles come under a lot of stress during pregnancy and birth. 

If your pelvic floor is struggling under the strain of growing a baby or after giving birth, you may experience pelvic floor and lower back pain, leaking and incontinence, uterine prolapse, and sexual issues. But it’s not all inevitable doom and gloom. This is one of those pregnancy and postpartum symptoms that can be both prevented and treated with a little extra TLC. 

Protecting Your Pelvic Floor Starts in Pregnancy

The pelvic floor is frequently overlooked during pregnancy since it doesn’t become the obvious star of the show until labor. But pelvic floor work early on can make a big difference when it comes to any issues during pregnancy and postpartum. Daphna Ross, a physical therapist who specializes in women’s health and pelvic rehabilitation, says that “women can and should seek out pelvic floor treatment anytime in their pregnancy, especially if any particular issues come up.” 

“Learning how to contract, relax, and bear down your internal pelvic floor muscles prior to birth can improve confidence for many people who are giving birth,” explains Noa S. Goodman, a physical therapist with a specialization in pelvic floor rehabilitation. “If someone has shame around the pelvic floor, self-touch, and sex, it can be difficult to coordinate these muscles all of a sudden during birth, especially if the person has impaired sensation due to an epidural.” 

Here are some of the best things you can do during pregnancy to get your pelvic floor into top shape:

  1. Start practicing Kegels: Kegels and other special pelvic exercises1 , like supported squats and belly breathing, can help you strengthen these muscles to both support your growing belly and to prepare for labor. If you’re struggling with these moves or have any concerns, consider consulting a pelvic floor physical therapist who can provide further tips and assistance.

  2. Don’t skip out on gentle exercising: Other forms of movement, especially things like yoga and swimming, can also benefit your pelvic floor during pregnancy as they help develop more flexibility and strength. 

  3. Pay attention to your bathroom habits: “Constipation makes you strain your pelvic muscles, so it’s really important to avoid constipation for pelvic floor health,” says Lynn Darbyshire, a registered midwife in both Germany and the United Kingdom. The best ways to keep constipation at bay are getting exercise, staying adequately hydrated, eating enough fiber, sitting in the proper position on the toilet, and not delaying a visit to the bathroom when you feel the urge to go.

  4. Perfect your posture: Switching to an exercise ball for sitting or desk work, using a standing desk when possible, making sure to relax your shoulder and back muscles every so often, and generally paying attention to your posture are all great for protecting your pelvic floor during pregnancy.

Don’t Forget Your Pelvic Floor During Labor 

While your pelvic floor muscles are involved throughout pregnancy, they jump into action during labor when they stretch between 200-300%2  to help your baby make their exit. But even while they’re doing all of this work, there are things you can do to assist and increase the chances for a positive recovery. Below are some examples you can focus on in advance before giving birth.  

  1. Pay attention to your breathing: In order for your pelvic floor to stretch like a slinky, it also has to be fully relaxed. “Learning how to breathe through the intense pressure in the perineum prior to birth prepares the person giving birth so there is reduced fear, reduced likelihood to clench or contract, and improved ability to allow the tissue to stretch during labor,” Goodman says. 

  2. Give perineal massage a try: Perineal massage, laboring upright, and the use of warm compresses or laboring in water can all potentially reduce the risk of tearing3  during a vaginal birth. “Severe tearing can impact the muscles connecting to the anus, which can then affect bowel movements after giving birth,” Darbyshire says. 

  3. Think about your labor positions: Active positions during labor can also help prevent strain on the pelvic floor. If you and your birth team are okay with it, try not to lay flat on your back during the pushing phase.

If things don’t go entirely according to plan, that’s okay and expected. Just remember that if you encounter any difficulties like a third- or fourth-degree tear or a forceps or vacuum-assisted birth, make sure you schedule a visit to a pelvic floor physical therapist early in your postpartum period. While studies have shown that C-section births generally have a lower incidence7  of pelvic floor muscle issues, you shouldn’t ignore this area in your recovery as problems can still pop up. 

During Postpartum, Pelvic Floor Care Is Key

The first step to caring for your pelvic floor after giving birth is an easy one: prioritize rest4  in the initial weeks after childbirth. This helps the pelvic floor muscles recover and prevent prolapse (or prevent pre-existing prolapse from worsening). Some other things to keep in mind:

  1. Let someone else do the heavy lifting: Avoiding heavy lifting and straining is one of the key elements of giving the pelvic floor time to recuperate. 

  2. Get back to your pelvic floor exercises: Starting back on some gentle specialized pelvic floor exercises5  is helpful for recovery. Your postpartum pelvic floor routine can include things like pelvic tilts, hip flexor stretches, and Kegels while lying on your belly and side. While you should be able to start these up again shortly after giving birth, check in with a practitioner to make sure you are safe to do so. 

  3. Wait for the green light to get it on again: Give your pelvic floor time to recover by avoiding sex, at least until you’re cleared, which generally happens during your initial postpartum exam several weeks after giving birth (4-6 in the U.S.). Once your doctor gives you the go ahead, if you experience pain or discomfort, this is absolutely a postpartum pelvic floor issue6  and you should bring it up to your practitioner.

  4. Look into posture and everyday movement training: Practicing standing up straight and picking up some techniques for the best way to hold your baby, push a stroller, and other tasks can help reduce pelvic floor strain.

When in doubt, see a specialist who can give you further tips as well as conduct more thorough assessments and treatments. While treatment for lingering pelvic floor issues varies, it can involve digital internal exams to pinpoint specific weaknesses and assess the general condition of your muscles, external checks for issues like diastasis recti and hernias, or more physical therapy-type exercises. 

In the New Mom Chaos, Don’t Forget Yourself

Like many other new parents, after I gave birth to all of my babies, I initially found it hard to focus on my own needs. I was so involved with my baby and how he was doing. Between endless feeds, diaper changes, and sleep deprivation, it was challenging to pay attention to and prioritize what was going on with my pelvic floor. 

But from experience, I can tell you that it’s incredibly important—and worth it—to take a little step back from caring for your new baby to care for yourself. Your body deserves the best possible recovery. I’m grateful to be living in a place and time where pelvic floor issues are losing a lot of their former stigma and people are getting the information and help they need, from preventative care to active treatment. By taking classes and getting support, I feel much more empowered to advocate for my own health and needs, and I hope that someday everyone who goes through pregnancy and birth can feel the same way.

Pregnant woman holding her stomach on a bed with a plant in the background

Want evidence-based health & wellness advice for fertility, pregnancy, and postpartum delivered to your inbox?

Your privacy is important to us. By subscribing you agree to our Privacy Policy and Terms & Conditions.

Expectful uses only high-quality sources, including academic research institutions, medical associations, and subject matter experts.

  1. Parents Editors"Pregnancy Exercises to Strengthen Your Pelvic Floor"Aug 10, 2023https://www.parents.com/pregnancy/my-body/fitness/the-best-pelvic-floor-exercises-during-pregnancy/.

  2. Liesbeth Westerik-Verschuuren, Marjolijn Lutke Holzik-Mensink, Marleen Wieffer-Platvoet, and Minke van der Velde "Sexual Aspects of the Female Pelvic Floor" Midwifery and SexualityMar 10, 2023, pp. 113–123https://link.springer.com/chapter/10.1007/978-3-031-18432-1_10.

  3. Royal College of Obstetricians and Gynaecologist"Reducing your risk of perineal tears"https://www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies-in-childbirth/reducing-your-risk-of-perineal-tears/.

  4. World Health Organization and USAID"Postnatal Care for Mothers and Newborns"Apr 1, 2015https://www.who.int/docs/default-source/mca-documents/nbh/brief-postnatal-care-for-mothers-and-newborns-highlights-from-the-who-2013-guidelines.pdf.

  5. Pelvic Health Physiotherapy Team"Pelvic Health Physiotherapy Post Natal Information and Exercise Sheet "May 2, 2022https://www.esht.nhs.uk/wp-content/uploads/2021/01/0894.pdf.

  6. American Pregnancy Association"Sex After Birth"https://americanpregnancy.org/healthy-pregnancy/first-year-of-life/sex-after-birth/.

  7. Barca, J. A., Bravo, C., Pintado-Recarte, M. P., Asúnsolo, Á., Cueto-Hernández, I., Ruiz-Labarta, J., Buján, J., Ortega, M. A., and De León-Luis, J. A."Pelvic Floor Morbidity Following Vaginal Delivery versus Cesarean Delivery: Systematic Review and Meta-Analysis"Journal of clinical medicine, vol. 10, no. 8Apr 13, 2021, pp. 1652https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070303/.


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Updated on Jan 16, 2024

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Pelvic Floor Care Is Routine in Germany—Here's What I've Learned

 Naomi Kaye Honova Profile Photo
By Naomi Kaye Honova | Updated on Jan 16, 2024
Image for article Pelvic Floor Care Is Routine in Germany—Here's What I've Learned

For many women, knowledge about their pelvic floor and its workings often comes too late, or not at all. However, the costs of ignoring pelvic pain and other issues of the pelvic region can be high. Incontinence, severe diastasis recti, and prolapse are some long-term complications that can develop if left untreated—complications that most women would be willing to do anything to avoid.

My introduction to the importance of pelvic floor health happened naturally during my pregnancy in Germany when I learned of Ruckbildungskurs, a German insurance-subsidized postpartum pelvic floor class that is generally recommended for women somewhere between 4 and 12 weeks after giving birth. 

Postpartum coverage in Germany was a revelation. In addition to the class, which allowed me to either bring my baby along or attend via Zoom, I also had access to the services of a midwife, who does postpartum house calls and could address any pelvic floor muscle issues I was having. And it was all covered by insurance. 

Coming from the United States, this level of care and focus on pelvic floor health came as a big surprise. After years in both countries, I’ve found that Germany tends to prioritize preventative care, which includes pelvic floor health. It made a big difference for me. The exercises I learned and the tips for how to reduce full-body and pelvic strain in everyday life came in very handy, and I still use much of the advice in my post-postpartum life today.

Many of my American friends had a very different experience. In the United States, many women don’t have access to pelvic floor preventative care and treatment, or they don’t know how important it is to pay attention to this area until they are already dealing with unpleasant side effects. 

Until all people have access to the same resources we have in Germany, it’s important to educate yourself about pelvic floor health so that you can take prevention and treatment into your own hands, including advocating for further care and treatment when you need it.

Getting Reacquainted With Your Pelvic Floor

Before you can work on protecting and optimizing your pelvic floor for pregnancy, you first have to understand what the pelvic floor is and how it works. 

Pelvic floor muscles refer to the muscles sitting at the pelvis’s base, supporting the organs in the pelvic region. These organs include the uterus, bladder, and bowel. Suffice it to say, it’s a critical group of muscles, and these muscles come under a lot of stress during pregnancy and birth. 

If your pelvic floor is struggling under the strain of growing a baby or after giving birth, you may experience pelvic floor and lower back pain, leaking and incontinence, uterine prolapse, and sexual issues. But it’s not all inevitable doom and gloom. This is one of those pregnancy and postpartum symptoms that can be both prevented and treated with a little extra TLC. 

Protecting Your Pelvic Floor Starts in Pregnancy

The pelvic floor is frequently overlooked during pregnancy since it doesn’t become the obvious star of the show until labor. But pelvic floor work early on can make a big difference when it comes to any issues during pregnancy and postpartum. Daphna Ross, a physical therapist who specializes in women’s health and pelvic rehabilitation, says that “women can and should seek out pelvic floor treatment anytime in their pregnancy, especially if any particular issues come up.” 

“Learning how to contract, relax, and bear down your internal pelvic floor muscles prior to birth can improve confidence for many people who are giving birth,” explains Noa S. Goodman, a physical therapist with a specialization in pelvic floor rehabilitation. “If someone has shame around the pelvic floor, self-touch, and sex, it can be difficult to coordinate these muscles all of a sudden during birth, especially if the person has impaired sensation due to an epidural.” 

Here are some of the best things you can do during pregnancy to get your pelvic floor into top shape:

  1. Start practicing Kegels: Kegels and other special pelvic exercises1 , like supported squats and belly breathing, can help you strengthen these muscles to both support your growing belly and to prepare for labor. If you’re struggling with these moves or have any concerns, consider consulting a pelvic floor physical therapist who can provide further tips and assistance.

  2. Don’t skip out on gentle exercising: Other forms of movement, especially things like yoga and swimming, can also benefit your pelvic floor during pregnancy as they help develop more flexibility and strength. 

  3. Pay attention to your bathroom habits: “Constipation makes you strain your pelvic muscles, so it’s really important to avoid constipation for pelvic floor health,” says Lynn Darbyshire, a registered midwife in both Germany and the United Kingdom. The best ways to keep constipation at bay are getting exercise, staying adequately hydrated, eating enough fiber, sitting in the proper position on the toilet, and not delaying a visit to the bathroom when you feel the urge to go.

  4. Perfect your posture: Switching to an exercise ball for sitting or desk work, using a standing desk when possible, making sure to relax your shoulder and back muscles every so often, and generally paying attention to your posture are all great for protecting your pelvic floor during pregnancy.

Don’t Forget Your Pelvic Floor During Labor 

While your pelvic floor muscles are involved throughout pregnancy, they jump into action during labor when they stretch between 200-300%2  to help your baby make their exit. But even while they’re doing all of this work, there are things you can do to assist and increase the chances for a positive recovery. Below are some examples you can focus on in advance before giving birth.  

  1. Pay attention to your breathing: In order for your pelvic floor to stretch like a slinky, it also has to be fully relaxed. “Learning how to breathe through the intense pressure in the perineum prior to birth prepares the person giving birth so there is reduced fear, reduced likelihood to clench or contract, and improved ability to allow the tissue to stretch during labor,” Goodman says. 

  2. Give perineal massage a try: Perineal massage, laboring upright, and the use of warm compresses or laboring in water can all potentially reduce the risk of tearing3  during a vaginal birth. “Severe tearing can impact the muscles connecting to the anus, which can then affect bowel movements after giving birth,” Darbyshire says. 

  3. Think about your labor positions: Active positions during labor can also help prevent strain on the pelvic floor. If you and your birth team are okay with it, try not to lay flat on your back during the pushing phase.

If things don’t go entirely according to plan, that’s okay and expected. Just remember that if you encounter any difficulties like a third- or fourth-degree tear or a forceps or vacuum-assisted birth, make sure you schedule a visit to a pelvic floor physical therapist early in your postpartum period. While studies have shown that C-section births generally have a lower incidence7  of pelvic floor muscle issues, you shouldn’t ignore this area in your recovery as problems can still pop up. 

During Postpartum, Pelvic Floor Care Is Key

The first step to caring for your pelvic floor after giving birth is an easy one: prioritize rest4  in the initial weeks after childbirth. This helps the pelvic floor muscles recover and prevent prolapse (or prevent pre-existing prolapse from worsening). Some other things to keep in mind:

  1. Let someone else do the heavy lifting: Avoiding heavy lifting and straining is one of the key elements of giving the pelvic floor time to recuperate. 

  2. Get back to your pelvic floor exercises: Starting back on some gentle specialized pelvic floor exercises5  is helpful for recovery. Your postpartum pelvic floor routine can include things like pelvic tilts, hip flexor stretches, and Kegels while lying on your belly and side. While you should be able to start these up again shortly after giving birth, check in with a practitioner to make sure you are safe to do so. 

  3. Wait for the green light to get it on again: Give your pelvic floor time to recover by avoiding sex, at least until you’re cleared, which generally happens during your initial postpartum exam several weeks after giving birth (4-6 in the U.S.). Once your doctor gives you the go ahead, if you experience pain or discomfort, this is absolutely a postpartum pelvic floor issue6  and you should bring it up to your practitioner.

  4. Look into posture and everyday movement training: Practicing standing up straight and picking up some techniques for the best way to hold your baby, push a stroller, and other tasks can help reduce pelvic floor strain.

When in doubt, see a specialist who can give you further tips as well as conduct more thorough assessments and treatments. While treatment for lingering pelvic floor issues varies, it can involve digital internal exams to pinpoint specific weaknesses and assess the general condition of your muscles, external checks for issues like diastasis recti and hernias, or more physical therapy-type exercises. 

In the New Mom Chaos, Don’t Forget Yourself

Like many other new parents, after I gave birth to all of my babies, I initially found it hard to focus on my own needs. I was so involved with my baby and how he was doing. Between endless feeds, diaper changes, and sleep deprivation, it was challenging to pay attention to and prioritize what was going on with my pelvic floor. 

But from experience, I can tell you that it’s incredibly important—and worth it—to take a little step back from caring for your new baby to care for yourself. Your body deserves the best possible recovery. I’m grateful to be living in a place and time where pelvic floor issues are losing a lot of their former stigma and people are getting the information and help they need, from preventative care to active treatment. By taking classes and getting support, I feel much more empowered to advocate for my own health and needs, and I hope that someday everyone who goes through pregnancy and birth can feel the same way.

Pregnant woman holding her stomach on a bed with a plant in the background

Want evidence-based health & wellness advice for fertility, pregnancy, and postpartum delivered to your inbox?

Your privacy is important to us. By subscribing you agree to our Privacy Policy and Terms & Conditions.

Expectful uses only high-quality sources, including academic research institutions, medical associations, and subject matter experts.

  1. Parents Editors"Pregnancy Exercises to Strengthen Your Pelvic Floor"Aug 10, 2023https://www.parents.com/pregnancy/my-body/fitness/the-best-pelvic-floor-exercises-during-pregnancy/.

  2. Liesbeth Westerik-Verschuuren, Marjolijn Lutke Holzik-Mensink, Marleen Wieffer-Platvoet, and Minke van der Velde "Sexual Aspects of the Female Pelvic Floor" Midwifery and SexualityMar 10, 2023, pp. 113–123https://link.springer.com/chapter/10.1007/978-3-031-18432-1_10.

  3. Royal College of Obstetricians and Gynaecologist"Reducing your risk of perineal tears"https://www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies-in-childbirth/reducing-your-risk-of-perineal-tears/.

  4. World Health Organization and USAID"Postnatal Care for Mothers and Newborns"Apr 1, 2015https://www.who.int/docs/default-source/mca-documents/nbh/brief-postnatal-care-for-mothers-and-newborns-highlights-from-the-who-2013-guidelines.pdf.

  5. Pelvic Health Physiotherapy Team"Pelvic Health Physiotherapy Post Natal Information and Exercise Sheet "May 2, 2022https://www.esht.nhs.uk/wp-content/uploads/2021/01/0894.pdf.

  6. American Pregnancy Association"Sex After Birth"https://americanpregnancy.org/healthy-pregnancy/first-year-of-life/sex-after-birth/.

  7. Barca, J. A., Bravo, C., Pintado-Recarte, M. P., Asúnsolo, Á., Cueto-Hernández, I., Ruiz-Labarta, J., Buján, J., Ortega, M. A., and De León-Luis, J. A."Pelvic Floor Morbidity Following Vaginal Delivery versus Cesarean Delivery: Systematic Review and Meta-Analysis"Journal of clinical medicine, vol. 10, no. 8Apr 13, 2021, pp. 1652https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070303/.


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