Delivering babies, whether that's vaginally or via c-section causes changes to our pelvic floors, our cores and more broadly can affect the body as a whole. The big hormone fluctuations, stretching of tissue, increases in body weight, postural adaptations and overall deconditioning we go through during pregnancy all play a role in how our bodies recover in the postpartum period. When bodies undergo the rapid physiological changes that pregnancy brings as well as the potential injury that we can incur during labor and delivery, women can be left with things like hip or back pain, urinary or fecal incontinence, pain with intimacy, urinary/bowel issues, core weakness and pelvic pain to name a few.
We know that taking a proactive approach to the things mentioned above can put us in the post position to not only have a favorable and desired birth experience but to be able to recover and heal the best - avoiding symptoms immediately afterward and years to come.
We want to cover today the pelvic floor and core anatomy changes that occur during pregnancy, the pain complaints seen in the pelvic floor after birth, what rehab looks like in the postpartum period and specific things you can do at home to take the best care of your pelvic floor.
The pelvic floor is a group of skeletal muscles that live on the bottom of your pelvis. They act as a sling or a hammock, suspended from either side of your pelvis and tailbone. While anatomy is slightly different in males versus females, we all have a pelvic floor and generally the job of the pelvic floor is the same in every person! This article dives deep into birthing individuals, but you can read more here about male pelvic floor health!
Because the pelvic floor is skeletal muscle (the same as our bicep or our quad muscle) this means we have control over it. We should be able to voluntarily contract and relax this muscle. The name of a pelvic floor contraction is called a “kegel”. What makes the pelvic floor different from other muscles in our body is that it does have input from our autonomic nervous system (subconscious control). It is important to make this distinction because when it comes to rehabilitating this part of our body, we need to make sure we address both the conscious and the subconscious sides!
The pelvic floor has 5 main functions or jobs that it is responsible for. You can watch a video here with a more in depth explanation of it. Understanding the roles of the pelvic floor gives us a better idea of when it needs some help!
Sphincteric Control: The pelvic floor acts as valves to open and close the holes. Holes include our urethra, our anus and our vaginal opening. A healthy pelvic floor should be able to open allowing things to exit when we want and to close, keeping things like urine, gas or fecal matter in when we want. Issues with this function include urinary incontinence or fecal incontinence, constipation, urinary hesitancy, decreased flow rate, vaginal flatulence (queefing) fecal smearing and urinary retention.
Support: our pelvic floor acts as a hammock or sling, helping support the organs that live in our pelvis. These organs include our bladder, uterus/cervix, rectum and our small intestines. When we have a malfunction with this job we can see things like pelvic organ prolapse, heaviness, inability to retain a tampon, and leakage.
Stability: It also supports our pelvic bones and our lumbar spine, providing stability to our pelvic and backs. Its attachments to our bones play into a bigger picture when it comes to posture and support. Chronic back pain, hip pain, SI joint dysfunction, pubic symphysis pain and tailbone pain are all common complaints when this job is not being done correctly.
Sexual Health: our pelvic floors are a part of the bigger team that allow for both men and women to become aroused, achieve an erection and have an orgasm. In females, the pelvic floor houses the clitorus. A strong and mobile pelvic floor provides adequate lubrication for intercourse and supports the clitoris for arousal and orgasms. The pelvic floor should be mobile to allow for things to penetrate (vaginal or rectally) without pain as well! When we have issues in our pelvic floor, it can manifest itself in pain with intercourse, pain with ejaculation or orgasm, inability to orgasm, persistent arousal, erectile dysfunction and premature ejaculation.
Sump Pump - The pelvic floor works with our deeper core to provide stability and postural support to our abdomens. It works hand in hand all day to balance pressure in our body. When we have issues with this job we see things like hernias, diastasis recti, hemorrhoids, bloating/distension in our bellies, poor core strength, and declining posture.
While we do know the general complaints listed above with the pelvic floor, we can see more specific issues manifest in the postpartum period. Understanding common complaints and why they manifest can be helpful to understand what is normal and when to get help.
Vaginal Birth Considerations
The pelvic floor muscles are stretched more than 3x their length during a vaginal birth. When we look at all other tissues in the body, tissue failure or rupture happens when stretched just 1.5x their length! One of the biggest and most common birth injuries women endure is perineal tearing (the area between the vagina and the anus). Grade 1 and grade 2 tearing is typical, sometimes requires stitches and most women heal naturally within a few weeks. Grade 3 and grade 4 tearing is more severe, resulting in injury to the pelvic floor muscles/sphincters, requires surgical intervention to fix and can lead to long term issues with things like fecal incontinence and prolapse.
While there are some factors that are out of our hands when it comes to tearing in pregnancy, we do know that there are a few things we can do that can lower our risk for grade 3 or 4 tearing. One thing we cover in pelvic floor PT and birth prep is self perineal mobilization.
Whether you sustain a tear to the tissue or not, many times the pelvic floor itself will go into a spasm or a shortened state in reaction to the great stretch it undergoes. The muscle is guarding itself after the injury of birth. Muscle guarding in the pelvic floor can cause pain with sitting, heaviness, changes in urinary/bowel health.
Pelvic organ prolapse is seen in over 50% of women who undergo vaginal births. Due to the high stretch rate of our tissues as babies are birthed as well as weakness in the muscles, our pelvic organs sit in new positions after birth. This leads many women to experience in early days after baby a significant heaviness in their vaginas or feels as though they are sitting on something. Women who require instruments (forceps or vacuums) to birth their babies have a higher rate of prolapse than those who do not.
C-section considerations
Many people that undergo a c-section feel like they are spared from pelvic floor dysfunction due to the mode of delivery and unfortunately, we find this is not the case. Many times after a c-section, the pelvic floor muscle will still spasm/guard due to the loss of stability and change to the abdomen or sump pump mentioned above. We also think this due to the injury/deconditioning that it went through during the time of pregnancy. Either way, we see that many c-section moms can experience incontinence and pain with intercourse due to lack of mobility and stiffening of the pelvic floor muscles.
C-section scarring is another issue women can experience after birth. The incision itself can become very fibrotic, limiting the movement of the tissue involved. This can manifest itself in pain, aesthetically can cause what's called a “c-section shelf” which inhibits the ability of muscles to contract as well as they can experience bladder issues like urgency/frequency due to scarring down of the bladder.
As stated above, the process of birth is a huge injury to our tissues no matter how the baby gets here. We believe that all tissue should be allowed a time period of rehab after injury and birthing a baby is no different.
Seeing a pelvic floor physical therapist after you deliver your baby should be considered standard care for all women. You can read more here about what you could expect from your first visit with a pelvic floor PT.
Rehab includes an in depth assessment of your posture, hip/spine mobility, external and internal assessment of your pelvic floor, diastasis recti screening and prolapse check. After the evaluation, a customized rehab plan to address the things found at the evaluation is put into place to help you. This could include hands on treatment to help decrease muscle guarding or scar mobilization. Breathing and connection techniques are taught. Progressed core strengthening alongside time appropriate exercises for full body strength is also a part of a comprehensive postpartum rehab plan. Rehab will also include making sure you are able to return to intimacy and intercourse pain free.
While there is no cookie-cutter approach to return to fitness and each body is different, we do have some general timelines we can lean into when understanding progression and time of recovery. Below is a general overview of rehab for a woman after delivering a baby. It is prudent to also remember that most women report feeling “back to normal” 1 year to 18 months after baby. While that doesn't mean you have to wait that long to get back to moving, we do know this can be a long road as our bodies heal and as our new babies grow and change as well.
Whether you are looking to get back to formal exercise or not, we do know there are daily habits all women can focus on for overall pelvic floor health and recovery postpartum.
Daily Habits for Pelvic Floor Health
Bladder health and our rhythms with sitting on the toilet to pee go hand in hand with a healthy and thriving pelvic floor. The first thing we suggest is getting on a good peeing schedule of emptying your bladder every 3-4 hours. Women that go more often than this have what is called “urinary frequency”. There are many factors that can increase our voiding times. Simple fixes are first, stay hydrated. Dehydrated urine can cause our bladder walls to be irritated which can increase our signals to pee. We suggest starting with at least half your body weight in ounces of water daily. Ideally your urine is clear each time you pee. If your urine is yellow or darker brown, you need to increase your water intake.
Stop “power peeing” or pushing your pee out. Early on postpartum, we want to avoid excessive pressure downward as our tissue heals. Make sure you give yourself adequate time to sit on the toilet, relax and breathe as you pee. You should not need to push your pee out.
A perineal bottle or a bidet is suggested early on postpartum for cleaning after going to the bathroom to avoid angering your tissue below with wiping.
Avoid “just in case” pees. Going to the bathroom “just in case” or without an urge can disrupt the signals from our bladders to our brains over time. We see this often in new moms who go to the bathroom every time they wake in the night to feed their newborn. If you do not have the urge to go, then don't!
Avoid constipation. Pain medicine from delivery can greatly slow our bowels leaving postpartum women constipated. Having to excessively push to have a BM can increase your changes of things like hemorrhoids or heaviness in the pelvic floor. Staying hydrated and even using stool softeners early postpartum can be a wonderful way to take care of your pelvic floor!
Core-Strengthening Daily Activities
Due to loss of muscle mass during pregnancy and stretching of tissue, performing strength exercises to our cores is imperative for rehab. Due to lack of sleep, babies schedule and general craziness that life brings, it can be very difficult for moms to find space and time to get formal exercise in. Finding ways to sprinkle in exercises throughout the day can be so beneficial to still make gains without the need of getting a gym membership or even lacing up your tennis shoes.
You can read further here on the importance of early exercise postpartum and easy and simple ways to get it in throughout the day and in the comfort of your own home.
Connection Breathing is an exercise we use to allow women to connect and mobilize their pelvic floors and deep inner cores after baby. We suggest in the first 6 weeks postpartum, getting this in 2-3x/day on your back. As time progresses we encourage people to try this in different positions like sitting, standing or hands and knees. Generally we hope all individuals will get this in at least 2x/week for 2 minutes at a time for the rest of their lives! Pairing this exercise with another habit like conditioning your hair in the shower, when you nurse, or when you brush your teeth can be helpful to create space to get this done.
Another wonderful exercise to do day to day is a deep squat. Getting into this position can help stretch and mobilize the pelvic floor muscles. We know that most pelvic floors will be in spasm after labor and delivery, so frequent positions that allow the muscles to stretch can be so helpful. We suggest this goddess pose each day when you are brushing your teeth or maybe when your baby is getting tummy time in.
Lastly, a wonderful daily core friendly exercise that can be added to almost anytime you pick up your baby is “blow before you go.” This is taking the connection breath we discussed earlier and adding to a functional movement.
Before you bend over to lift up your baby or the car seat we want you to first gently blow out of your mouth like you were blowing out candles. We then want you to squeeze and lift your pelvic floor and draw in your tummy. This is a wonderful way to strengthen the core/pelvic floor as well as protect your back/core as you lift heavy items in the early days postpartum.
Since every birth experience is considered an injury or an assault to the core and pelvic floor, a normal amount of symptoms should be expected in the early days. In the first 2-4 weeks bowel/bladder leakage and heaviness can be present while tissues are very swollen, in spasm and angry. Symptoms should get better each day and generally be gone within 2-3 weeks postpartum.
Reaching out to a pelvic floor PT for guidance is indicated if you have any of the following:
How a Professional Can Help
Understanding the rehabbing postpartum takes a village, just like everything else in life. Professionals like pelvic floor physical therapists can be a wonderful place to start to help you heal when dealing with pelvic floor issues like incontinence, prolapse, diastasis recti and other core concerns. They are also going to be your first line of defense to help you progress back to the sport you love. Look here to find a pelvic floor physical therapist near you!
Prenatal and postpartum chiropractors are phenomenal team members to help with hands on work for optimizing alignment, helping with postpartum back/hip pain and creating a space for better nervous system function. They also are going to be able to provide newborn chiropractic care for your infant in the early days as well.
Pregnancy and postpartum personal trainers are a game changer for once you are ready to get back to the gym to help guide you in your exercise goals. Credentialed personal trainers in pre/post natal fitness is paramount to make sure they are educated in helping you during this season of life. We love partnering with trainers who have undergone Brianna Battles certification, Girls Gone Strong and Sarah Duvall's course as well.
Bringing a baby into this world can be a whirlwind, bringing so much joy and happiness, but also can be a time of great change with anxiety, and a sense of loss as well. The changes that your body undergoes can be a stress point for people during this time. We find that taking time to really understand what your body is going to go through, educating yourself on what to expect, being proactive in the things you can control to minimize your risk of injury and being patient in the postpartum return can set you up for the most success.
We believe that creating your pregnancy and postpartum team to best guide you during this time is also a wonderful way to create the outcomes you desire. Finding professionals that you trust to help walk alongside you can be a game changer and allow you to navigate your body's changes in stride!