Pelvic Floor Therapy AKA Perineal Re-education - What's It All About?
More adventures in my French healthcare experience!
I had been told early in my pregnancy by my OBGYN that I would have the option to receive “la rééducation périnéale” post birth. Huh? I learned that the word “education” can be used in French like the word “training” is used in English, and that "la rééducation périnéale” is known more commonly as “pelvic floor therapy” in the United States. All women who give birth in France are given the option to receive subsidized therapy with a midwife.
My mom and grandmother had reported bladder problems after pregnancy, and many American women I know joke about trying not to pee when they sneeze or cough. Some friends at the gym had laughed about not feeling like they could jump rope anymore. I thought this was a price paid with admission to motherhood, but the French had a different attitude about it.
I had so many questions about it, but my doctor kept me focused on the current task at hand – a healthy pregnancy. “Well, we’ll see if you need it and cross that bridge when we get there,” my OBGYN stated plainly. I thought about how I currently dribbled pee (TMI?) occasionally while pregnant, and anticipated this experience being in my near future.
At my six week follow up post-birth, my OBGYN assessed my pelvic floor strength. The assessment felt similar to a cervix check. “Okay, squeeze my fingers”, she said. I tried closing down on her fingers as best I could but felt embarrassed by how little control I had over them. “Hmmm, try one more time.” I did, and she said, “Okay, you need some work. But good, you already know how to use your lower and upper pelvic floors!”. I half smiled as if in agreement...yet had no idea what she was talking about. In retrospect, I must have engaged different muscles without knowing it! She gave me a prescription for ten sessions and sent me on my way.
A few weeks later, I was in my midwife’s office. “So! We will see how much re-education you need and decide how many sessions to do”, said Lena during my first appointment. “You might need only 7, or you might need more than 10. We will find out!”.
Lena was a wonderful woman in her thirties, cute and blonde, with a few children of her own. She had been recommended to me by my hospital, and I had grown to trust her throughout our professional relationship. She had given me one-on-one childbirth and labor educational sessions (subsidized by the healthcare system) that included topics such as pain control, breathing, labor positions, breastfeeding, what to expect out of a natural delivery and a c-section, and more. She had been to our home twice after giving birth, where she assessed my bleeding, blood pressure, and general health as well as weighed our bébé and checked in with our family unit to see how we were adjusting. She was as integral to our pregnancy and post-birth care as any other healthcare professional.
The first appointment felt a little awkward simply because I didn’t know what to expect. However, I was comforted by the fact that I already knew my midwife, she already knew our son (who came with me to nearly all appointments), and I had already been to her office many times. As a new mom, it was also wonderful to go to an office that had a bathroom big enough for a stroller, a changing table, and a baby bouncer in the office (which our little one used multiple times during my sessions).
This first session, Lena welcomed me with her warm smile and her French-accent I had grown to adore. “Hello et ça va? How are you? Your bébé is getting so big!”.
Lena asked me a few questions about my sleep, eating, breastfeeding, and overall health. She also asked about pain, intercourse, and any problems going to the bathroom.
After our brief conversation, I removed my clothing from the waist down and slid onto her exam table. I held bébé in my arms, as I had tried putting him in the bouncer and he began crying. Lena calmy said “You may feed him, as you want” and adjusted the table so I could feed him comfortably, yet laying back in a way that Lena could assess me. “Is it okay?” she asked, motioning to my perineum and seeking permission before assessing me (she asked every session, even up to the last one). “Yes, thank you!” I said, still not knowing what to expect.
Lena was professional, kind, patient, and thorough in her explanation of what she was doing and what I should do. “Now, close like you stop pee-pee”, she said in her friendly accent. “Good. Now hold for 5, 4, 3, 2, 1.”
“Wow, that was hard,” I marveled. “You’re doing great,” she said. “Now, squeeze the sides of your pelvic floor.” Ummm… what? I thought. I have no idea how to do that, but I tried imagining the sides of my pelvic floor closing in on her fingers. I was sweating with effort. “Okay. Good job. Now hold for 5, 4, 3…”. I exhaled before she could finish. “Whew! Sorry, I lost it!” I said.
She asked me to try to push her fingers left and right. One side was obviously much weaker than the other, and Lena stated that bébé’s head was likely on that side of the pelvis during pregnancy. This could have resulted in weakened muscles on that side. I found it fascinating!
We moved on to the floor of the pelvis (who knew there was multiple sides of the pelvic floor?!?! It seems obvious now but I had no idea at the time). “Okay, now, close like you are holding gas,” she instructed. “Good, now hold.”
The exercises had already seemed complicated to me, as I had little experience controlling these muscles. However, her next instructions challenged me further. “Now, we will move all together. You will breathe in and stop pee-pee. Then, you will breathe out but pull your pelvic floor up, like a zipper. You will use all muscles, the sides and bottom. Okay?”. I nodded, and we tried a few times.
“Okay, all done for this session,” she said. I had sweat dripping down my knees and onto her table, and bébé was still in my arms where he had fallen asleep after feeding. She helped me off the table and I apologized for the large sweat spot. “It’s normal,” she said, and explained that hormonal changes likely also contributed.
As I got dressed, she explained the process. “We grade all the sides of the pelvic floor, and once you reach 5 of 5, you graduate!”. The whole session had only lasted thirty minutes. I was still waiting for my “carte vitale” to come from the government (my health insurance card), so I paid for the session out of pocket (55 euros) and received a form to submit for reimbursement. Later, I would receive 21 dollars reimbursed from the government, and the rest from the mutuelle (private health insurance offered by my husband’s company, common in France).
Lena gave me a prescription for a tool she described like a “wand”, and advised me to bring it to each appointment (though she said if ever forgot it, not to worry, we could still make progress without it). I could easily schedule all of my appointments online, keeping in mind the requirement to wait at least 48 hours between sessions to allow the muscles to recover.
The next time appointment, I brought the tool. Lena called it the “sound”, which I found confusing (I later found out she was saying “sonde”, which also means “probe” or “catheter” in French). It looked like a small metal wand, the size of a large tampon, that would make therapy more efficient. It gave out intermittent electrical impulses which would stimulate the muscles to contract (if you’ve ever used a tens unit for physical therapy after a sports injury, you can picture this!). I had picked it up from the pharmacy before my second visit. I laughed at the name of the contraption in French, which had the word “banana” in it (a good description for the tool!).
I handed the tool over to Lena who sterilized it and plugged it into a handheld device. After requesting permission, she placed it inside my pelvic floor and began increasing it’s electric strength until I could feel the impulses. Lena coached me to contract my pelvic floor at the same time as the tool. We went through the same exercises as the prior visit.
I explained to Lena how difficult it felt for me to control these muscles. “It’s normal,” she said (a phrase I learned the French use to say both “it’s expected” and “it’s no problem”). “You are already doing as well as some women do on their fifth visit!”.
I was told to expect mild soreness, and it felt similar to having very mild period cramps for about 24 hours following therapy.
On one of my next visits, I told Lena about a pain I had in my right side. It had been there for weeks, but I assumed I would be told to stretch and rest (which I was already doing) and that it would eventually go away (this is what I would have expected my American providers to tell me, whether that’s fair or not).
I felt it when I turned over on my side in bed, and sometimes I braced myself when I stood from sitting. I attributed it to my second week post pregnancy when I carried bébé for a few hours as I walked to my covid booster appointment. I stubbornly didn’t ask for help carrying him, and I could tell afterwards that I had done too much.
As soon as I told Lena about it, she told me we would switch our form of pelvic therapy and that if there was another area irritated in the pelvic region, it would prevent the typical therapy from being productive. I learned that one of the ligaments near my uterus was inflamed; I basically had a pulled muscle.
She pulled out a machine called the Winback (you can read more about it here). It sends electrical impulses to the body, helps it naturally repair itself and even stimulates collagen production. When I learned this, I said to Lena, “I wish you could use this all over my entire body!”, to which she replied “Me too!”.
The machine heats and sends electrical impulses to a ligament through a wand. Lena massaged it into my stomach, and it felt amazing; I had instant relief. I nearly fell asleep during the therapy. After my appointment, I send this text to my mom and a girlfriend as I explained the procedure: “One more awesome thing about pelvic floor therapy! I think I might be in love with my midwife haha. I felt so much relief.”
After another session using the machine, I felt enough relief that we returned to the typical pelvic floor therapy. I remember being amazed at how in tune Lena was with my movements. She could instantly tell when I was using any part of my pelvis; if I let go of the tool too soon or if I used one part of my pelvic floor instead of the area she had directed me, she pointed it out instantly. “Ah, see how you engaged the bottom floor but then lost the top?”, or “Never forget to close the pelvic doors”.
Each session I imagined that she had a visual representation of my pelvic floor on her hand held device which was plugged into the sonde (how else can she tell exactly what I’m doing?). On the last session I asked to see it. To my surprise, it was a basic screen that showed the intensity of the electrical impulses…that was it. She was able to fully understand what my pelvic floor was doing just by holding the tool in place. Amazing!
As therapy progressed, so did the difficulty of the exercises. Every session included contracting the front, sides, and bottom of the pelvic floor, but gradually we moved to more complex movements, such as engaging the abs along with the pelvic floor and using the entire pelvic floor in unison. I learned how to protect myself from injury during weight lifting or exercise by scooping the pelvic floor up into my body rather than bearing down.
I noticed a huge difference in my pelvic floor health from my first visit onwards, with a significant improvement in urinary symptoms and more comfort lifting heavy things (like my 17 pound bébé, or my stroller up the two flights to our Paris apartment).
On my seventh visit, Lena assessed me again. “Good, grade 5 of 5,” she said and began flipping through my chart. Her eyes grew big when she looked at the grade she had given me when I first arrived (of which I have forgotten). “Wow, what an improvement! I am so proud of you!” she gushed. She told me it was my last visit, and that if I wanted to try to continue therapy I could engage my pelvic floor after each time I used the bathroom. She also told me to practice engaging my abs and pelvic floor before picking up anything heavy, while running, and during any exercise.
I left that appointment feeling light and strong. I was so grateful for getting inexpensive (and later, fully reimbursed) care from an expert. I had a strong pelvic floor that I fully believed was now stronger than it had been before I was even pregnant. I had avoided the incontinence and embarrassing leaks that so many people had told me would be a part of my future. I felt somewhat guilty, yet very thankful, that I was living in France for the birth of our son so I could partake in the perineal re-education that treated and prevented further bladder problems.
Vive la France!