Do you have pain or heaviness in your pelvis? Does it feel like your insides are "falling out"? Does it feel like your vagina is full, as though there's something stuck inside it?
These symptoms can all be signs of pelvic organ prolapse, a condition in which one or more pelvic organs drop lower in the pelvic region. Prolapse is closely associated with the pelvic floor: the muscles, ligaments, and other connective tissues that support the pelvic organs from below.
Many postpartum people struggle with pelvic floor complications, including prolapse symptoms, after delivery. If you’re postpartum and struggling with symptoms of prolapse or other pelvic floor disorders, know that you aren't alone. Postpartum pelvic floor problems are common, but this doesn’t mean they have to become your new normal.
There are treatment options that can help you heal your pelvic floor and reduce those symptoms. Let’s explore the importance of pelvic floor health for people living with postpartum prolapse and discuss the strategies you can use to regain and maintain optimal pelvic floor function.
Postpartum Recovery & the pelvic floor
The pelvic floor forms the bottom of the pelvic cavity: it consists of muscles, the connective tissue between them, and the nerves and blood vessels that feed those muscles. These tissues play a critical role during pregnancy and delivery (yep, even if you deliver via C-section!), so it's important to understand how they work.
Here are the key jobs the pelvic floor does for us throughout our lives:
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It helps maintain continence so you don’t urinate, pass gas, or have a bowel movement when you don’t want to.
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It allows for sexual activity: the pelvic floor is important for arousal and orgasm in people of all genders.
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It’s critical during labor and delivery, particularly for those who deliver vaginally.
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It acts like a “sump pump” of sorts, helping to move lymph fluid out of the pelvis and further through the lymphatic system.
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It supports the pelvic organs and stabilizes the pelvic joints during dynamic activities like walking or balancing.
This final job of supporting the pelvic organs is particularly relevant in the context of pelvic organ prolapse. The internet is full of scary information about this condition (especially severe prolapse), which often leaves birthing people feeling anxious and isolated. Good news: there are plenty of options to treat prolapse and manage the symptoms it can cause. Let’s learn more about it!
Pelvic Organ Prolapse After Childbirth
Pelvic organ prolapse (POP) is a common condition in people with vaginas, including postpartum folks. Up to two-thirds of women may experience it in their lifetime, although some people may never have symptoms.
What is POP?
Pelvic organ prolapse is an umbrella term for the descent of pelvic organs into a lower position inside the pelvis. POP occurs when the pelvic floor muscles and vaginal walls are weakened and unable to fully support the organs. This lack of support allows the pelvic organ(s) to descend and press against the walls of the vaginal canal.
POP may involve the bladder, rectum, lower intestines, and/or uterus. There are many subtypes of POP, each named for the organ(s) involved:
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Cystocele, or bladder prolapse
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Rectocele, in which the rectum pushes against the vaginal walls
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Uterocele, or uterine prolapse
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Vaginal enterocele, in which the intestines push against the vaginal walls
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Vaginal vault prolapse (sometimes shortened to "vaginal prolapse") in which the walls of the vaginal canal descend downwards
Prolapse can occur in other areas of the body, too. For example, anyone with a pelvis can experience rectal prolapse, in which the rectum starts to descend through the anal opening. For the purposes of this article, though, we're focusing on prolapse that occurs in the vaginal canal.
People with symptomatic pelvic organ prolapse often describe a feeling of heaviness, fullness, or bulging inside the vagina or pelvis. Some people describe feeling as though they have “an egg inside the vagina” or like they are “sitting on a golf ball.” These sensations may be worse when the person is upright (standing, walking, etc.) because gravity is pulling downward on the organs.
Why does prolapse after birth happen?
Vaginal childbirth is the biggest risk factor for developing POP. While it's not the only cause of prolapse, it's certainly the most well-known. As your baby passes through your vaginal canal during delivery, it can stretch and strain the supportive structures there. If you have several vaginal deliveries or if your birthing team needs to use forceps or a vacuum to assist delivery, the risk of POP increases.
Compared to people who give birth vaginally, the risk of developing POP is lower among those who have a C-section. You might think, “If vaginal delivery stresses my pelvic floor so much, why don’t I just have a C-section?”
Well, when it comes to postpartum pelvic health, no form of childbirth is perfectly protective. C-sections carry their own risks, and they don’t guarantee you’ll be POP-free after childbirth. Pregnancy itself can put strain on your pelvic structures, particularly as your baby grows and exerts more pressure on your pelvic floor.
Pelvic organ prolapse in the postpartum period, regardless of delivery method, is really common! A 2014 study of 202 postpartum people, including those who'd had C-sections, assessed their pelvic health about 1 year after delivery. The researchers found that most study participants had some degree of prolapse:
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89% had some uterine prolapse
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90% had some bladder prolapse
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70% had some rectocele (descent of the rectum against the vaginal walls).
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25% had two or more types of prolapse
However, here's the important point to remember: 80% of these participants had no symptoms or problems related to their prolapse. This is important: even if you develop some POP after childbirth, it may not cause you problems.
Remember that other factors besides childbirth can increase the risk of developing POP. These include:
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Chronic constipation and straining to poop
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Obesity
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Generalized connective tissue disorders like the Ehlers-Danlos syndromes
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Previous pelvic surgeries
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Performing heavy manual work
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Certain genetic factors
What are the symptoms of prolapse?
The most commonly reported symptoms of pelvic floor prolapse include:
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A sense of heaviness or pressure in the pelvic area or vaginal canal
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A sensation of a bulge, lump, or "something falling out" in the vagina or rectum
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Difficulty emptying the bladder or bowels
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Urinary or fecal incontinence (loss of bladder or bowel control)
Recall that some people with POP may not have obvious symptoms. If you’ve been told you have a prolapse but do not have symptoms, you may still benefit from seeing a pelvic physical therapist to be sure you’re moving in the right direction!
How is prolapse after pregnancy diagnosed?
So how do you know if you have a pelvic organ prolapse, especially if you don't have obvious symptoms? For many people, prolapse will appear during a pelvic exam: your OB-GYN or pelvic health physiotherapist can look into the vaginal canal and watch how your organs respond to pressure. They may ask you to "bear down", pushing like you're trying to pass a stubborn poop: this pressure from above can make POP more visibly obvious.
If you were to use a mirror to look at your own pelvic floor, you might see a bulge coming down toward the vaginal opening (particularly when you bear down). Depending on the severity, that bulge may be very obvious, or it might be hard to see.
Some people have POP that doesn't show itself during a pelvic exam: because you're usually lying down for these exams, gravity isn't pulling down on your organs. When you sit or stand up, however, gravity comes back into play, drawing the organs downward. Many pelvic PTs will check for prolapse in a standing position, too.
It's important to note that it's very difficult to accurately diagnose the type of prolapse (i.e., the specific organs that are descending) from a pelvic exam alone. Unless you're planning to have a surgery to correct severe prolapse, though, it isn't critical to know which organs are involved.
It's more important to understand the severity, or "grade", of the prolapse: how much the pelvic organs are descending. The grade of POP informs what type of treatment is most likely to help. Here's the good news: most people with mild to moderate POP respond very well to non-surgical treatment options, such as pelvic physiotherapy!
What can I do to reduce my symptoms of prolapse after birth?
For people with mild to moderate pelvic organ prolapse, pelvic floor muscle exercises and pelvic physical therapy (aka physiotherapy or PT) are first-line treatments. Pelvic physiotherapy can help you establish pelvic floor strength, coordination, and mobility to better support your pelvic organs. It can also help reduce the symptoms of POP, including the bladder and bowel disruptions prolapse can cause.
Pelvic floor muscle exercise involves much more than “just doing your kegels.” First of all, about 25% of people perform pelvic floor contractions incorrectly without realizing it. Incorrectly performing kegels can actually worsen POP symptoms by increasing pressure on the organs and pelvic floor!
Additionally, your pelvic floor muscles do more than just "squeeze and hold". To function optimally, they must be strong, agile, and coordinated. You wouldn't try to strengthen your arm muscles by just holding a biceps curl all day...so why would you approach your pelvic floor muscles that way?
A pelvic physical therapist has specialized training to help you learn how to do pelvic floor exercise correctly and tailor it to your unique needs. This PT locator tool is a great resource to help you find a pelvic PT near you!
Besides seeing a physiotherapist, what else can help with prolapse after birth?
Here are some other things you can do to reduce the symptoms of POP:
Manage pressure inside your abdomen and pelvis
Certain movements and activities, such as holding your breath while lifting something heavy, can increase pressure on your organs and pelvic floor. Pay attention to your body when performing these common movements:
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Standing up from a chair
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Bending over to pick something up off the floor
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Bearing down to pass a bowel movement
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Exercising
If you notice that you’re holding your breath or straining during any of these movements, try gently exhaling to relieve internal pressure on your pelvic floor.
Improve your bladder and bowel habits
Straining to poop also creates extra pressure on your pelvic floor. Rather than holding your breath and pushing as hard as you can, try the following:
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Place a stool under your feet to elevate your knees above your hips. This squat-like angle aligns your rectum optimally for emptying.
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Inhale through your nose and fill your belly with air. Think: “belly big, belly firm”.
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Exhale and visualize your sitting bones spreading apart: this helps your pelvic floor muscles relax to allow stool to leave your body.
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If you need to bear down a bit, exhale as you do so. Letting air out through your mouth and nose helps relieve internal pressure on your pelvic floor.
Avoid sitting on the toilet too long. If nothing is happening within 3-5 minutes, call it quits and get off the commode. You can try again later!
Consider a pessary for extra vaginal support
A pessary is a medical device that you insert into your vagina, a bit like inserting a tampon. It provides structural support for people with more advanced POP. These devices come in all shapes and sizes to match variations in internal anatomy, so you’ll need a professional fitting from your healthcare provider.
Talk to your OB/GYN or pelvic physical therapist; they can help you determine the right product for you. Even if your pelvic PT doesn’t fit pessaries, they can help you find a provider who does.
Ask your provider if vaginal estrogen could help
Topical estrogen creams can help maintain the integrity and flexibility of your vaginal tissues. It’s particularly helpful for peri- and postmenopausal people because the menopause transition causes your local estrogen levels to decrease. Topical estrogen (delivered through the skin via a patch) can also be beneficial for breastfeeding parents who are in a similar hormonal state. Hormones are complex chemicals, so talk to your healthcare provider to see if vaginal estrogen is appropriate for you.
If physiotherapy and other treatments aren't sufficient, you can consider surgery to restore structural support inside the pelvis.
Because surgery comes with its own set of risks and limitations, it is typically reserved for severe cases in which all other methods have failed.
Can I prevent a prolapse from worsening during future pregnancies?
If you know you already have POP and you’re expecting a baby, you’re probably wondering if your prolapse will worsen during delivery. As your baby travels through the vaginal canal, the pressure certainly taxes those tissues.
There is no guarantee that you can prevent prolapse through the methods below. However, these techniques can help you prepare for labor and delivery and support your postpartum recovery, even if you're already living with POP.
Whenever possible, exhale as you push during labor
Holding your breath increases intra-abdominal pressure. Increased internal pressure pushes down on your already strained pelvic floor and organs. Breathing out helps release this pressure, like popping the top on a can of soda.
Take steps to reduce the severity of perineal tears
Perineal tearing is a common result of vaginal childbirth. It injures the pelvic floor muscles and reduces their ability to support your pelvic organs. Some research shows that perineal massage can help reduce the severity of tears if performed starting at 36 weeks of pregnancy and continued until labor. Your pelvic PT, midwife, or doula can teach you how to perform perineal massage at home.
Support your body as you recover after delivery
Consider wearing postpartum support garments, compression shorts, or leggings that cover your abdomen for the first few weeks after birth. Compression can reduce the sensation of pressure in the perineum as it is healing.
Be intentional about how you move your postpartum body
Taking the time to gently build up your pelvic floor and abdominal strength after birth will prepare your pelvic floor to manage the day-to-day challenges of life as a new parent. Support your body now, and it will pay off in the decades to come.
If you think you may have POP, reach out to your healthcare provider and find a pelvic floor physical therapist near you: they can help you learn how to return to activity safely after birth, even if you're living with prolapse after birth.
Remember, you might not need a GP referral to see a pelvic PT!
In most cases, you don’t need to see your physician before heading to a pelvic physical therapist. All 50 states permit direct access to a physical therapy evaluation and some amount of treatment without a physician's referral. Your physical therapist will be able to inform you of any requirements specific to your state.
Some clinics may also require a referral before scheduling you for pelvic PT services, but that’s usually the exception, not the rule. You can find out more about your local requirements by calling your pelvic physical therapy provider and asking what you need to do to get started.
If you are experiencing pelvic organ prolapse or any other problem with your pelvic floor, remember that it is treatable. Your body will continue healing for many months postpartum. As you learn about your postpartum body, take comfort in knowing there are resources for the challenges you’re facing. You’ve got this, mama!
About the Author
Dr. Samantha Spencer, PT, DPT, is a Medical Advisor with Aeroflow Breastpumps. Dr. Spencer is a physical therapist who specializes in pelvic and perinatal care in the Asheville, NC, area where she offers in-home physical therapy to prenatal & postpartum individuals. She also developed the Strong Beyond Birth 28-Day Course to guide and support moms as they return to exercise, and offers virtual consultations to women everywhere.
Information provided in blogs should not be used as a substitute for medical care or consultation.
References
https://my.clevelandclinic.org/health/diseases/9121-sexual-dysfunction
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10729347/
https://pubmed.ncbi.nlm.nih.gov/24737300/
https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/vaginal-tears/art-20546855
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8584327/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709229/
https://my.clevelandclinic.org/health/diseases/22161-urge-incontinence
https://link.springer.com/article/10.1007/s00192-024-05948-4
