Understanding Postpartum Pelvic Pain in Fourth Trimester

By: Courtney Edgecomb, DPT

Postpartum Pelvic Floor Physical Therapy is increasingly utilized to help new moms recover from pregnancy and delivery.

Is pain normal after giving birth? Of course that is an extremely open-ended question and I would get different answers from almost every single mom (and from each of her pregnancies). But it is hard to tease out what is normal and what is not, and a new mom is going to want some answers if she is experiencing pain after childbirth. You may have heard of the “common” pains expected from delivering a precious little one, such as:

Vaginal or perineal pain
Tender or sore breasts
Headaches
Muscle soreness
Back pain
“After pains” (contractions)

Generally in the first 6 weeks, these symptoms should dissapate and your OB will clear you to return to exercise, sex, etc. at your next check-up. However, you still might not be feeling better after 6 weeks or are experiencing a different pain that isn’t on the list above. If this is the case, hopefully you are able to bring these concerns to your OB at your 6 week check up. Yet it’s possible you found it hard to talk about, or you didn’t get the full answer; and you may leave underwhelmed and still confused about your pain. This is probably the last thing you need while caring for a newborn. So let’s go through why postpartum pain occurs, which symptoms can manifest, and what treatment options can help.

Hormonal changes:

After delivery, your estrogen levels drop dramatically and remain that way for many months if you are also breastfeeding. One of the many important roles estrogen plays in the body is to regulate tissue health, especially that of the vagina. When the vagina does not have the appropriate amount of estrogen, it can decrease lubrication and thickness of the tissues. In turn, this creates a thinner, weaker, dryer, and more sensitive tissue. Now if you were wondering why sex hurt after your OB cleared you at the 6 week check-up, this is your answer. It’s like rubbing sandpaper together, OUCH! As your tissues become more irritated and pain increases, it will likely make the muscles surrounding them very irritated as well. I’ll get into that below.

C-section:

This is a MAJOR surgery. A woman’s body was already going through enough to carry a baby, and then an incision is made into the abdomen and placenta to deliver her baby. There are a lot of layers to get to the baby and all of them have to heal after being cut and sewn back together. Scar tissue forms as the body naturally heals, but it doesn’t align properly with the tissues around it and it isn’t as elastic either. Try moving with a large incision over the abdomen and you might feel stuck, tight, or just a blast of pain. As the scar tissue continues to form, it can grab onto the tissues nearby and keep everything from moving like it did before. Your body will want to move from somewhere else and overtime it could lead to pain as muscles and joints aren’t used to it.

Episiotomy or Perineal Tearing:

Scar tissue occurs as a result of an episiotomy or perineal tearing, very similar to after a C-section. The surrounding area becomes tight, sticky, and sensitive. Your vagina is already healing from labor itself, but now it is healing from and injury and stitches as well. This recovery can vary dramatically from woman to woman, but it is not normal to still have pain 6-8 weeks later. An episiotomy or perineal tear can cause painful intercourse, difficulty sitting, difficulty exercising, itching, burning, or sensitivity.

Diastasis Recti:

During pregnancy, the rectus abdominus muscle (think 6-pack) splits in the middle at the piece of connective tissue holding it together called the linea alba. This allows for the belly to expand while the baby is growing. It naturally closes after delivery, but 1 in 3 women will still have a separation greater than 2 centimeters after 6 weeks. This separation makes it very difficult for your core muscles to work effectively and you will have to make up that somewhere else. Your hip flexors, low back, gluteals, or pelvic floor will be working overtime and eventually hit a limit. Sometimes, that limit is hip pain, back pain, buttock pain, or pelvic floor dysfunction (more on that below).

Pelvic instability:

Weakness, laxity, and changes in posture and center of gravity have a huge impact on a woman’s pelvis during pregnancy, childbirth, and postpartum periods. Not only do hormones affect the vaginal tissues as I mentioned above, but they also affect the pelvic girdle so that a woman’s body can adjust for her growing baby and prepare for labor. Relaxin is primarily responsible for this change as it helps to increase the laxity of ligaments that support our joints. Basically, the ligaments around your hips loosen so your pelvis can expand. This is great for labor, but not so great when the loss of stability leads to pain. Your hip and pelvic joints are not supported as much by ligaments, sometimes causing a separation in joints including:

The acetabulum: where your thigh bone meets the pelvis on each side,
The sacroiliac joint: where the base of your spine meets the pelvis in the back,
The pubic symphysis: where the pubic bone comes together in the front.

However, your body still tries to create stability by tightening up surrounding muscles and changing your posture. You’ll get a double whammy if those surrounding muscles were weak in the beginning. All these changes can lead to hip pain, back pain, tailbone pain, pubic pain, buttock pain, and possibly pelvic floor dysfunction. Are you seeing a trend? For some, this will resolve once you welcome your precious newborn, but for others the pain continues into postpartum. Don’t worry, we are almost to the part about how you get better.

Pelvic Floor dysfunction:

First of all, what is the pelvic floor? Well if you have read any of our other blogs or have done prior research, you may have a good idea already. If not, I’ll explain it anyway. The pelvic floor is a group of muscles that are shaped like a bowl in the bottom of the pelvis that control urinary, sexual, and bowel functions and help support the pelvic organs. Pregnancy and childbirth puts extra demand on these muscles due to the weight of the baby, postural changes, pelvic support when ligaments become lax, and pushing during child labor. So as I mentioned above, when the limit is reached after working overtime, pelvic floor dysfunction. AKA Vaginal pain, perineal pain, tailbone pain, low back pain, pelvic pain, anal pain, painful intercourse, painful urination or bowel movements, pain while sitting or exercising. The pelvic floor can lead to an array of situations due to very tight muscles and trigger points. Although I am focusing on pain in this blog, I do want to note that pelvic floor dysfunction can also present as urinary urge or frequency, straining to urinate, pelvic organ prolapse, constipation, or incontinence. So don’t count yourself out if pain isn’t necessarily your primary complaint.

Connective tissue dysfunction:

This typically goes along with everything I have already talked about, but it is worth noting as it becomes a critical part of treatment with many of these conditions. Connective tissue makes up the layers of soft tissue between your skin and muscles called fascia. It helps to hold muscles, nerves, vessels, etc. in their place and is surrounded by lubricating fluid so your body moves with ease. However, that fluid can become sticky or the fascia can tighten up along with the muscles attached to it. Everything begins to rub and becomes irritated, then increasing pain responses due to the nerves within all of thee layers. So as hormones affect tissues; a c-section creates scar tissue; compensation patterns form due to diastasis recti, pelvic instability, or pelvic floor dysfunction; the connective tissue layers change in response. Fascia needs to be treated as well so that proper movement, nerve function, and blood flow can be restored.

Nerve irritation:

So as we have discussed above, your body and posture undergo many changes in response to carrying a baby. One more condition this can lead to is nerve pain, which most commonly involves the sciatic nerve or pudendal nerve due to their pathway and innervation in the pelvis. Compression or stretch on the nerves – as a result of all of the above – is a typical culprit for nerve pain including burning, shooting, stabbing, tingling, numbness, itching, or sensitivity. This pain may be in the buttocks, lower back, lower abdomen, back of the legs, front of the hips, groin, perineum, or vulva. And it can linger while postpartum because nerves do not heal as fast as other tissues and the nervous system has a complex interaction with chronic pain. There is also a chance that labor could have injured or stretched nerves while the baby passes through the vaginal canal. Scar tissue from a c-section, episiotomy, or perineal tearing can restrict the mobility of surrounding nerves and create burning, shooting, painful intercourse, itching, etc.

Take home message:

All new mom’s can benefit from an evaluation with a pelvic floor PT as every woman’s body responds differently to pregnancy and labor and delivery. However, we still have a few tips that most new moms can safely use to help along their recovery. Stay tuned to next week’s blog for more information!

Want more information?

Check out PHRC Cofounder Stephanie Prendergast ‘s interview with Katie Lowes on the Katie’s Crib Podcast!

…and Stephanie’s interview with Dr. Elliot Berlin on the Informed Pregnancy Podcast!

Check out Pelvic Floor Physical Therapist Sara Reardon’s (aka the Vaginal Whisperer) recent Ted Talk on Pelvic Floor PT!

Resources

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.