"I was having pain and I couldn't balance, I couldn't jump, I couldn't follow any exercise classes," recalled Germain, 31.
"I would either pee my pants or I felt like my pelvic floor was falling out of my body."
Urinary incontinence — the loss of bladder control — had affected the Ottawa nurse prior to and after the birth of her eldest son, now 3 1/2. But after the birth of her younger son, now 14 months, Germain's postpartum recovery proved far worse.
The boy had a broken clavicle, and use of a vacuum as well as an episiotomy were required during the natural birth. Now, it wasn't just incontinence that was an issue: Germain experienced significant pain in her pelvic floor, the muscles which hold the uterus, vagina, bowel and bladder in place.
Stress urinary incontinence occurs due a lack of support from the pelvic floor, according to the Canadian Continence Foundation.
It can also be caused by damage to the sphincter muscles, which prevent the bladder from leaking urine when there's excess abdominal pressure. Triggers in these instances could be coughing, sneezing, laughing, lifting or jogging.
Frances Stewart, nurse continence adviser at Women's College Hospital in Toronto, said there's no genetic predisposition to having incontinence. And there's no evidence that having a C-section improves a woman's chances of avoiding it.
Many women will experience some stress incontinence in pregnancy because of the weight of the uterus — but it won't occur after birth, she noted. What's more, Stewart said there can be other reasons for leaking urine, like an overactive bladder.
Many new mothers may be unaware that pregnancy and childbirth — especially complicated deliveries — and obesity are all risk factors for stress urinary incontinence, which is more common in women, according to CCF.
Even after some four decades working in the field, Stewart said the subject of incontinence is still "in the closet."
"Doctors don't want to talk about it because they just say: 'Oh well, it's normal after you've had babies.'
"It's not till (women) start talking amongst their friends and realize that they're not alone in this — that they can't jump on the trampoline anymore and they can't run for the bus."
Since last November, Germain has been working with pelvic floor physiotherapist Monate Praamsma of Core Connections Physiotherapy in Ottawa.
To conduct an internal exam, Praamsma said they typically wait after mothers have been given clearance by doctors or midwives during the six-week post-delivery checkup to ensure the pelvic floor, internal organs and tissues have sufficiently healed.
"We can see the moms to check exactly what's happening in their pelvic floor. We want to see: 'Can they actually recruit those muscles properly? What's the tone like? Is there any pain internally?'"
Even if women aren't experiencing leaking right away, Praamsma said they're still able to see them early on to work on postural training and diaphragm breathing. Moms also learn how to recruit their core by using proper body mechanics for breastfeeding, lifting and carrying their babies.
Prior to delivery, Praamsma said much can be done to help women prevent urinary incontinence by learning how to correctly activate their pelvic floors.
"A lot of people don't do it properly," she said.
"They start squeezing their bottom, they start squeezing their inner thighs, they squeeze all of their stomach muscles. That doesn't provide a good contraction and support for the bladder.
"Learning how to recruit other key muscles in their core like the deep abs, the deep back muscles and the diaphragm, we can do that all beforehand. It's a great session for the women to learn how to prepare for labour."
Praamsma said contracting muscles to stop the flow of urine or passage of gas are good ways for women to visualize isolating their pelvic floors.
Germain said she has learned better control in contracting her pelvic floor muscles and the importance of co-ordinating exercises with proper breathing techniques.
"I know if I have to cough, then I squeeze in my pelvic floor and I hold it in and then I cough."
In addition to performing Kegels (pelvic floor strengthening exercises), Stewart said it's also important for mothers to avoid getting constipated.
"When your bowel is full it pushes up against your bladder and it can make you incontinent," she said.
"It also causes patients to strain, and of course, a lot of straining can enhance incontinence. It can also give them a prolapse, a herniation of some area of the pelvic floor."
If conservative management like Kegels, limiting fluid intake and bladder training don't work, Stewart said surgery is "the definitive cure."
However, no surgical correction or big intervention can be done until they've finished their childbearing years, she noted.
"There is help, and they shouldn't think they're going to be incontinent for the rest of their lives — because they're not."
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