It’s amazing to think of how much our bodies evolve after pregnancy and childbirth. As a pelvic floor physical therapist (PT), I truly appreciate the physiological and biomechanical changes that have occurred in my body since the birth of my children. But as an athlete (or a former athlete I should say), it’s so easy to be tough on myself and wish for my pre-pregnancy body to magically re-appear. When I have these thoughts, the PT in me has to step in quickly to keep things in perspective. Realistically, it takes at least a year before most new moms start to feel like they are a fraction of their former physical self. Unfortunately, since postpartum pelvic health services in the U.S. are an afterthought (versus being the standard of care, as in most European nations), it is incumbent on new moms to be well educated on what to expect in their postpartum recovery. Hence this post!
So, for all the moms out there, here are the top five things that you should know about your postpartum pelvic health!
1. Sex should not hurt!
Plain and simple! Painful sex, or dyspareunia, is persistent genital or pelvic pain before, during, or after sex. The most common reasons for this are:
Low estrogen levels: Estrogen and progesterone levels drop immediately after delivery allowing milk production to occur. Over time, these hormonal changes can cause symptoms similar to menopause such as decreased libdo and vaginal dryness. This in turn can lead to friction, irritation and pain during sex.
Scar tissue: It is completely normal for the body to create scar tissue after c-sections, episiotomies, perineal tears and tail bone fractures. However, they can have a pulling effect into the connective tissue surrounding the muscles in the pelvic floor and as result, pain during sex.
Involuntary muscle spasms: The pelvic floor muscles (independent from scars) can develop involuntary spasms in response to trauma. With scar tissue restrictions and involuntary muscle spasms, women will typically report deep pelvic pain during or after sex that can even refer into the abdomen or hips.
2. NO AMOUNT of peeing when you cough, sneeze, or exercise is normal!
Postpartum urinary incontinence typically comes in two forms: Stress and urge incontinence. Stress urinary incontinence (SUI) occurs when you leak urine after you forcefully laugh, cough, sneeze, jump, run, or lift weights. About 66% of women with SUI also experience urge urinary incontinence (UUI), which occurs when there is a sudden urge to urinate and accidental leakage occurs before getting to the bathroom (even though the bladder may be nearly empty). UUI is also referred to as having an ‘overactive bladder.’ Incontinence in the postpartum population can result from anatomical changes to the bladder and urethra from the weight of the baby and size of the uterus. Studies using ultrasound have shown that the angle between the bladder neck and the urethra increases, producing a larger opening of the bladder neck. This structural change can cause urine leakage even with minimal exertion. Incontinence can also occur due to hormonal changes which cause increased elasticity of the pelvic floor and decreased bladder support. Pelvic nerve and/or muscle injury from vaginal delivery can cause mechanical trauma especially after obstetric procedures such as forceps, episiotomies, and vacuum assistance
3. Safely working on your post-baby belly is important
The pressure of the growing uterus on the abdomen can cause the ‘six-pack’ muscles (i.e. the rectus abdominis) to separate sideways. When the abdominal muscles move apart, the uterus, intestines, and other organs only have a thin band of connective tissue right through the middle of the abdomen (i.e. the linea alba) to hold them in place. Because the influx of pregnancy hormones causes the linea alba to soften and weaken, the belly ends up sticking out. This condition is referred to as Diastasis Recti. Why is it important for you to know if you have diastasis recti? Separated muscles are weak and cannot do their job of supporting the spine and abdominal organs efficiently. Straining with heavy lifting and routine exercises (like sit ups, push-ups, and front planks) can make this issue worse, so care needs to be taken with movements and exercises to correct it.
4. Protect your organs!
During pregnancy, hormonal changes soften the supporting structures in the pelvic floor making them more elastic. Coupled with the weight of the baby, these muscles can easily weaken resulting in a condition known as pelvic organ prolapse (POP). POP is characterized by the descent of the pelvic organs (i.e. bladder, rectum, cervix, and uterus) into the vagina. Factors that can increase the risk of POP include traumatic delivery, chronic constipation, pelvic floor muscle weakness, being overweight, and having more than one baby. Most women will describe prolapse as a ‘bulging sensation’ in the vagina, especially after standing for a long time, and/or difficulty inserting or retaining tampons.
5. Treat your scars!
Scar tissue formation after c-sections, perineal tears, and episiotomies is a normal part of the healing process. However, what often gets overlooked are the problems scarring creates after the 6-week postpartum follow-up. When scar tissue forms it lays down in a haphazard pattern, sticking to fascia (i.e connective tissue) and organs in the abdomen. This pulling creates a crushing effect that can impact the bladder, colon, and uterus, resulting in issues like constipation, urinary frequency, pain with sex, low back pain and pelvic pain.
So, what’s a girl to do?
Just by recognizing that these are all issues that you do not have to live with, means you are already on the right track! The next steps include some simple things you can begin to adjust in your everyday routine. These are some simple Do’s and Dont’s for you to consider.
1. Strain when using the toilet. Bearing down and holding your breath to ‘poop’ or ‘pee’ can make prolapse or diastasis recti worse.
2. Perform kegels if you are having pain with sex or if Kegels are painful. If you are experiencing this pain then you most likely have a muscle spasm in your pelvic floor muscles and trying to strengthen them would be counter productive.
3. Do exercises like sit ups, front planks, push ups, or heavy lifting if you have a prolapse or a diastasis recti. If you are not strengthening your muscles correctly these exercises could worsen your symptoms.
1. Learn how to properly train your pelvic floor muscles to contract and relax fully. As important as it is for these muscles to be strong, it is just as important for them to be soft pliable and pain free!
2. Use a squatty potty or a stool when using the toilet. This facilitates healthy toilet posture to ease constipation.
3. Massage your scar. You can use coconut oil or essential oils (like lavender or tea tree oil) to gently massage your c-section scar. For perineal and episiotomy scars, using a crystal wand or dilator intra-vaginally can be very effective, but this does require the guidance of a licensed PT.
4. Ask for help! Talk candidly to your OBGYN and ask for a pelvic floor PT referral. These PT treatments include hands-on work to help release scar tissue and muscle spasms in-and-around the pelvic floor, and improve pelvic floor and core stability.
Wishing you happy pelvic health!
Ann Udofia, PT, DPT
Ann is Doctor of Physical Therapy and the co-founder of Body Connect Health & Wellness, a holistic physical therapy center in Washington D.C. She specializes in pelvic health PT (for women and men) and advanced manual therapy services. As a mother of a 2 year old and a 4 month old, she has a particular interest in treating pelvic and chronic pain issues in the pre and post-partum population.