“I wish I had been better prepared for postpartum healing.”
“I wish I had learned more about postpartum recovery… what it actually looks like.”
“I wish I knew how to navigate recovery if you experience symptoms… you don’t realize until you’re going through it, you wonder if it’s normal or requires more attention…”
Postpartum Recovery & The Pelvic Floor
Talk to any mom you know, and you’ll find that going through postpartum recovery for the first time can come as a major shock.
Childbirth is physically traumatic, even under the best circumstances. Our bodies literally open and allow new life to pass through. After birth, our bellies are squishy and empty. Our organs are all out of place. We might have stitches in places that should really never see a needle. We might have a scar running across our lower belly, which means every move we make has to be calculated and gentle. Basic tasks and physical activities like sitting down, using the toilet, walking, and even sneezing might all be really, really uncomfortable. Everyone around you pats your hand and says, “take it easy, it will get better”.
And it does get better. The bleeding subsides. Our core strength slowly returns and abdominal muscles strengthen. We get on with our new life as a parent. We might still have leakage, or feel pressure and heaviness at the pelvic floor, but we are often told to “give it more time” before we worry. In a healthcare system that typically only schedules one women’s health postpartum follow up visit at 6-8 weeks after birth, the “wait and see” approach can be scary and isolating for a new mom experiencing new symptoms of pelvic floor dysfunction.
What if we knew more about what possibilities to expect and where to turn for support in our recovery? Would that knowledge make the whole experience less stressful and traumatic?
A recent study by Johnson et al. evaluated how women felt about the information they received about postpartum recovery when they were pregnant, and compared these results with how traumatic, distressing, or impactful the participants felt their postpartum symptoms were. Prior studies have shown that people who report having inadequate information during childbirth are more likely to perceive it as a traumatic experience. With 2 out of 3 new moms reporting distressing symptoms after birth, including urinary and fecal incontinence, stress incontinence, pain with intercourse, sexual dysfunction, lower abdominal pain, and/or vaginal pressure or bulging discomfort, and other pelvic floor issues, researchers wanted to know if more education before birth would make birth-related pelvic floor trauma and its sequelae (PFTS) less of a traumatic experience.
Knowledge is Power
Results show that those who reported the largest gap between expectation and reality showed the biggest association between pelvic floor and mental health symptoms. The more satisfied people felt with their prenatal education about postpartum recovery, the less likely they were to feel distressed about pelvic floor symptoms after birth.
So what does this mean? For one, it debunks the idea that birth-related injuries and pelvic floor problems are “too scary” to talk about with pregnant people. Just as with so many other aspects of pregnancy and health in general, more knowledge helps us feel empowered in our choices and ready to address any issues that arise.
What Moms Wish They Knew
One of the most common themes that emerged from this research is that most moms wished they’d had more complete information about pelvic health considerations for pregnancy and birth, particularly during the pushing stage of labor. As one mom reported, “I wish I had learned about breathing techniques to protect my pelvic floor during the pushing stage.” Many moms also wished they had better preparation for postpartum healing and pelvic health concerns. Another mom said, “I thought Kegels were just for pushing out the baby!”
Given that 92% of postpartum moms reported a discrepancy between expectations and experience, let’s lay out a few of the details here to help bridge that gap. If you’re currently pregnant, you may want to use this information to start a conversation with your healthcare provider about your personal birth and postpartum risk factors and recovery plan.
Birth & Bowel Movements: Pushing!
Most of the time, we want the pelvic floor to be strong, supportive, and flexible. The two times in life we need those pelvic floor muscles to fully release and even stretch (up to 300% during delivery) are during birth and bowel movements. Pelvic floor exercises are extremely important during this time. It’s worth practicing when you poop, and in the weeks leading up to delivery – especially if it feels strange at first!
Pushing during labor is a physiological process. You will likely feel a strong urge to push as your uterus does most of the work for you, and your conscious pushing efforts will be more effective if you wait for the natural urge to feel strong. The pressure may feel lighter with an epidural, but the same breathing strategies still apply.
Try it: Start with an inhale as you relax your pelvic floor. Begin to exhale slowly as you partially close your glottis or make a low groaning sound. Allow that extra downward pressure to travel all the way into the pelvic floor, and practice relaxing the muscles around the pelvic floor. The key here is to push down slowly, and without holding your breath. The low groaning sound will help slow you down and allow some pressure to build so that each push is as effective as possible.
A pelvic floor that doesn’t stretch is more likely to tear (though perineal tearing can’t always be avoided). If you have the time and space to slow down and push with these strategies, you may be able to conserve energy and reduce the severity of trauma to your pelvic floor. Other factors may come into play during delivery – for instance, if you need to push your baby out quickly, you may find yourself holding your breath and pushing hard for more power, and that’s okay! A strong push or two won’t always result in a tear, and sometimes that urgency can be essential for the health of both mom and baby.
Common Risks with Vaginal Birth Deliveries
Perineal tearing is the most common form of birth injury, with up to 80% of first time moms and 40% of second time moms experiencing some degree of tearing during vaginal delivery. Fortunately, most women experience a 1st or 2nd degree tear, which involves the skin around the vaginal opening, or a small amount of perineal muscle, respectively. These types of tears are easily stitched up and generally heal within the first few weeks postpartum. 3rd and 4th degree tears involve more perineal tissue or the anal sphincter muscle, respectively. These types of tears typically require more healing time and follow up care. Pelvic floor physical therapy can improve pelvic muscle strength and coordination as well as continence, improving quality of life.
Even the smallest amount of scar tissue can remain sensitive after the wound heals. Gentle massage to the scar tissue can help desensitize and soften the area, and if pain lingers or affects anything you enjoy (including intercourse) it may be time to seek the support of a pelvic health physical therapist.
Pelvic Organ Prolapse:
If you google it, you’ll probably get a whole lot of scary information about the worst types of pelvic organ prolapse. What you might not find is that prolapse is extremely common in women, particularly after pregnancy, childbirth, and menopause.
Pelvic organ prolapse (POP) occurs when a weakness in the supporting structures of the pelvic floor allows for pelvic organs (bladder, uterus, or rectum, for example) to descend into the vaginal canal. POP is graded by severity, with grades 1 and 2 as the mildest and most common forms. This can occur as a result of pregnancy or childbirth, but it can also come about from other downward forces like chronic constipation or heavy lifting with poor body mechanics.
Here’s the tricky part, though: many people with diagnosable POP have no symptoms, while other people with very mild forms of POP might have all the symptoms, including pelvic pressure, heaviness, urinary incontinence, or the sensation of a bulge in the vagina. It can be hard to tell how “bad” it is just by how you feel, particularly during the first few postpartum months.
For this reason, some new moms may feel dismissed by healthcare providers if their POP is “mild” upon exam. If you’re experiencing symptoms, that’s what matters. Strengthening your pelvic floor and pubic bone (along with practicing the ability to release and remain flexible) can be a very helpful first step towards addressing any pressure or discomfort that may be related to POP. There may be other factors at play as well, such as chronic constipation, postural alignment, and movement mechanics that a pelvic health physical therapist can work with you to address.
Pelvic Nerves and Joints:
Other types of birth injuries can involve pelvic nerves and bony structures. Stinging, burning pain, numbness, or tingling in the pelvic area or lower body that does not resolve after initial healing or worsens with time could indicate that a nerve has been affected. Injuries to the bony pelvis during birth are often more apparent and may be diagnosed while still in the hospital or under initial postpartum care.
Symptoms After Birth
If you’re having symptoms that may indicate a problem with your healing process, such as infection (fever, body aches, chills, malaise, or redness, swelling, or heat at the site of a wound), increased vaginal bleeding, or urgent pelvic pain call your healthcare provider immediately.
Evaluation by your healthcare provider with pelvic floor or functional recovery concerns may be an important step if you are in the earliest weeks of postpartum recovery, as they can rule out more urgent issues and any pelvic floor disorders. For other types of concerns, they may not have the time or training to perform a full movement evaluation such as you would receive from a physical therapist. For this reason, physical therapy after birth is almost always an excellent choice. Speak to your healthcare provider for a recommendation, or seek out a consultation with a physical therapist on your own. In most locations, no referral is necessary before an initial consultation.
Above all, remember that this too shall pass. Your body will continue to heal for many months and even years after pregnancy and birth. As you learn about your postpartum body, take heart in knowing there are resources available for most concerns you may encounter, and that with time you will feel strong and confident again.