By: Liz Simons, DPT
Almost every woman who has had a baby will say that their ‘body is never the same’. Pregnancy is tough. Growing and birthing a child (whether vaginal delivery or C-section) comes with its own physical and emotional obstacles – weight gain, hormonal shifts, fatigue, emotional lability – rarely does a postpartum body just “bounce back,” to a pre-pregnancy body as we see rampant on social media. This supports the stigma that has existed for a long time – that ‘childbirth is natural and issues experienced in postpartum women should be accepted as a common part of the process of becoming a new mom and motherhood’. The focus of care is often on the new baby, and there is very little focus on the care of the healing mother who just went through this major life event, which has left her body forever changed.
Education = Empowerment
Being educated on signs and symptoms to lookout for in the postpartum period should start during pregnancy, not a few weeks postpartum. It is never too early to educate mothers on what to expect and how to better understand what their bodies are going through with pregnancy, labor and delivery. Simply learning about your pelvic floor muscles and abdominis core muscles and how they function by seeing a pelvic floor physical therapist can drastically change both your pregnancy and postpartum care experience.
During the postnatal period, women can struggle with diastasis recti, weak pelvic floor muscles, pelvic organ prolapse, perineal scar tissue, C-section scars, altered pelvic girdle alignment and postural dysfunction that can manifest into various symptoms, including muscle imbalance, dysfunction, incontinence and pain. These issues are often ignored since women are busy adapting to motherhood and many health care professionals tell you that it is normal. The weeks following the birth of a baby is a critical time period for healing.
The changes that occur to the body in the peripartum period can last for decades if left untreated and can result in suboptimal movement strategies, poor breathing patterns, persistent weakness and pain, as well as an increased incidence of bladder and bowel incontinence later in life.
How can postpartum physical therapy help?
Seeking physical therapy treatment postpartum can help to restore musculoskeletal function of the core and pelvic floor, get the body working in sync again and help moms to feel strong and safe moving within their “new” bodies. With proper screening and guidance, the patient can address their postural, pelvic floor, and abdominal muscle changes and have a successful return to a pain free lifestyle, optimizing wellness and musculoskeletal function. Below is a comprehensive list of issues that a women’s health/pelvic floor physical therapist can help with:
- Cesarean management and scar massage
- Perineal scar management and scar massage
- Diastasis recti rehabilitation
- Abdominal splinting instruction
- Pelvic floor awareness training and strengthening
- Organ prolapse treatment and management
- Dyspareunia or painful intercourse
- Pain with sitting/coccydynia
- Urinary urgency, frequency and incontinence/dysfunctional voiding
- Bowel urgency, frequency and incontinence
- Pelvic girdle pain
- Shoulder/elbow/wrist/hand pain
- Postural training and movement awareness
- How to move with your baby
- Self-care techniques to manage aches and pains
- Breastfeeding positioning and ergonomics
- Mastitis manual breast drainage
- Guided return to exercise
The muscles of the pelvic floor sit at the base of the pelvis, and provide support for the abdominal contents above, and are important in the management of intrabdominal pressure changes that occur with functional tasks like lifting, or coughing, laughing, sneezing; they play an integral role in bladder and bowel function as well as sexual function. These muscles are dynamic and interact with the entire body – making sure they are working properly and are balanced is vital to postpartum recovery and healing.
When should moms seek out support for a women’s physical therapist?
A physical therapy assessment is much different than the postpartum 6 week check up exam. The six-week exam from your OBGYN health care provider largely just checks on the healing process of the uterus and vaginal canal, and (hopefully) a mental health check in on the new mother, but not much beyond that. Here you get the ubiquitous “you’re free to exercise and have sex” clearance – but what does that really mean? Healing and the experience of postpartum is so individualized; what works for one, may not work for another. Although PFPT is increasing in awareness, many OBGYN’s do not recommend physical therapy treatment plans or fully understand how helpful it can be, thus you are left feeling like your concerns about back pain, heaviness sensation in the vagina, urine leakage with sneezing and pain with intercourse is to be expected and considered “normal.” In 2018, the American College of Obstetricians and Gynecologists (ACOG) released a new paradigm of postpartum care, “to optimize the health of women and infants, postpartum care should be an ongoing process, rather than a single encounter, with services and support tailored to each women’s individual needs” and pelvic floor physical therapy made the list as a component to the postpartum care plan! Recognizing the need for care beyond the quick 6-week check is a major win for moms everywhere.
When you see a pelvic health practitioner, they will do an extensive intake, asking you questions about your preconception self, your pregnancy, labor and delivery experience, as well as an in-depth conversation on how your bladder and bowels are functioning, if intercourse is painful and ask about any other aches and pains. After the intake, a pelvic health PT will assess your whole body: your posture, how you are breathing, check your abdominal wall for diastasis recti, and with your consent, will do a gentle internal vaginal and/or rectal muscle assessment to determine how your pelvic floor muscles are functioning (if you are not ready for an internal assessment, some of this can be determined externally). Things that are assessed are the following: can you contract and relax your PFM, can you perform a bulge or push out (what you do when you pass gas, have a BM or push out a baby through the vaginal canal), is there any scarring or tenderness within the vaginal vault, and determine how are the PFM healing; if you had a C-section, the scar will be assessed – how is it moving, is it tender, does it bring up a lot of emotion or birth trauma to touch this scar? Physical therapy can work on restoring balance between the muscles of the pelvic floor via internal muscle stretching and help to improve scar mobility which ultimately leads to less pain and discomfort with walking, sitting and penetrative intercourse. A PT who specializes in women’s health should assess your strategies for movement to see if there are any faulty patterns that could be contributing to your pain/discomfort, or help to instruct you on how to best align and use your body to prevent pain or dysfunction or to rehabilitate whatever the current issue may be. It is important to remember, women do not have to live in pain and/or feel limited in their ability to move and use their body just because they have had a child. Seeking help for issues and/or educating yourself on how to support the healing process postpartum should be an inherent part of the process of motherhood.
How are the core muscles impacted?
Learning about and training your core system – which is comprised of the diaphragm (muscle of breathing), the transverse abdominus (deep, stabilizing abdominal muscle) and the pelvic floor – can set you up for better postpartum outcomes. Physical therapy can educate you on this core system, bringing awareness to the nuances of movement via (re)training your breath and working on the activation of the abdominals and pelvic floor muscles together. This coordinated effort will help to support healing as well as improve function, increase strength and prevent/rehab aches and pains and maintain/regain continence and/or prevent further prolapse symptoms. It is recommended to seek out PFPT during pregnancy, however, if you don’t make it to PT prior to pregnancy, going after birth will be that much more important. Body mechanics shift so much while a baby is growing in pregnancy and learning how to set the body up for success postpartum is key to healing. More often than not, women need to be taught how to re-train their bodies to function in a more coordinated pattern, one that optimizes synergistic muscle relationships and allows for better support of the trunk and pelvis. Holding your baby, feeding your baby and wearing your baby take up a ton of time postpartum and can be very challenging on the body. This can lead to neck, back, shoulder, forearm and wrist pain. Not only is a good women’s health PT assessing your PFM and abdominals, but the education you receive can help prevent and rehabilitate issues related to the physical aspect of caring for your child.
Guidelines on return to fitness postpartum are so generalized and vague – so many women struggle to understand their capacity for exercise postpartum. While some women can in fact tolerate more high intensity training soon after birth, others are not quite yet able to push their child up a hill in a stroller without feeling some pressure in their vagina or pain in the abdomen or low back. There is no one size fits all approach; learning to understand your body and how to safely exercise can be done with some guidance. A woman’s health and pelvic floor PT can help you to determine what you can and cannot tolerate and create a plan to get you working safely towards your goals.
Physical Therapy for all Women
Women should be encouraged to prioritize themselves in the postpartum period. Although this isn’t the case for many moms, seeking the advice and expertise of a pelvic floor physical therapist can offer moms a plan on their road to recovery. Even if you do not experience pain after birth, you should still check in with a Pelvic Floor Physical Therapist to understand more about your body, how to take care of yourself and learn about other tools that are available in case you may need the support down the road.