After her first pregnancy, Angela gave birth to a beautiful 7 lb, 3 oz, baby girl. More than six months after leaving the hospital, baby was healthy and thriving, however, the same couldn’t be said for Mom. Mentally, she was full of joy over being a mom, but physically…well, physically, she just didn’t feel right.
For one thing, every time she laughed or coughed, she leaked urine. Her first attempt at going for a run after giving birth had ended in so much leakage, that she was anxious that she might never be able to run again. Before attempting the run, she had told her Ob/Gyn about the leaking issue at her six-week follow up appointment. Her doctor’s response was she had just had a baby, a little leaking was normal, and to do Kegels.
Then her doctor cleared her for resuming sex and exercise, which brings us to the other reason Angela “wasn’t feeling quite right.” Before baby, she and her husband had had a great sex life, now, however, for Angela sex was painful.
After two more appointments with her doctor, and being told that everything was fine, Angela figured she had better start getting used to her new “normal.” Painful sex, no more running, and “moderate” incontinence. “Oh well, I guess it’s all part of having kids,” she thought.
Angela is one of millions of new moms who believe that postpartum pelvic floor symptoms are all part of a new normal they must learn to live with. And its no wonder as in general, their complaints are dismissed by both the medical community and society.
The reason I decided to write this post is to let you know that Angela’s symptoms and the host of other symptoms new moms can face after pregnancy and delivery are far from “normal!” In fact, the vast majority of common postpartum issues can be helped by a physical therapist who specializes in postpartum and pelvic floor rehabilitation.
Common Postpartum Pelvic Floor Problems
When a woman goes through a pregnancy and delivers a baby, her pelvic floor muscles, fascia, and nerves are put through the wringer. And that’s during an uncomplicated and normal pregnancy and childbirth!
Incontinence, which is basically an involuntary loss of urine, gas, or stool, is one of the more common postpartum issues new moms face. It’s a problem that results from damage to pelvic floor muscles, nerves, and supporting fascia. And, it’s a problem that’s generally widespread in the United States. According to a 2001 to 2008 National Health and Nutrition Examination Survey, more than half of women more than 20 years old in the United States experience some type of incontinence.
But, besides incontinence, there’s a host of other common symptoms women can experience as a result of pregnancy and childbirth. The list includes: back, groin, hip, vulvovaginal, tailbone or pelvic floor pain; pain during sex, diminished or absent orgasm, urinary frequency, urgency, or retention (retention is difficulty starting your urine stream), constipation and difficulty evacuating your stool, and having a hard time with exercise.
In addition, a very common abdominal issue that arises with pregnancy is something called a “diastasis recti.” A diastasis recti is a separation of the rectus abdominus or “six pack” abs from their central tendon. The ab muscles run down the front of our tummy, and sometimes to accommodate the growing baby, they will separate from their attachment. This causes abdominal weakness, and has been linked to incontinence and back pain in postpartum women.
Plus, if there is any vaginal tearing or there is an episiotomy performed during a vaginal delivery, this can also cause future issues with pelvic floor muscles. From an anatomical standpoint, a third or fourth-degree tear has gone deep enough into the tissue to tear muscles in the pelvic floor. Remember, these muscles are important for continence, sexual health, and support of pelvic organs and joints. Just as a hamstring tear or rotator cuff tear needs PT, the pelvic floor muscles also need proper rehabilitation.
Pelvic floor physical therapy can easily treat many of these issues, and it can help even if years have gone by since a woman has given birth. Ideally, however, if a problem has persisted for three months postpartum, it’s time to get help.
But sadly, the majority of new moms have no idea that PT can help them. In fact, most don’t even know what their pelvic floor is or what it does, let alone what it might be doing to cause their problems. In fact, according to one study, 83% of college educated women do not know about the pelvic floor muscles and the role they play in pregnancy and delivery.
The reason new moms are so in the dark about the role their pelvic floors play in postpartum recovery/rehab is that the United States is far behind in it’s postpartum care and treatment. Other countries, like France, Denmark, and the U.K. are much more attune to this health issue.
Let’s take a look at France, which is perhaps the country that’s the most advanced in this area. In France, it’s the standard of care for every new mom to receive PT after she delivers a baby. Specifically, after giving birth, women are prescribed 10 to 20 sessions of la rééducation périnéale. Translation: “PT designed to strengthen and rehabilitate the muscles of the pelvic floor.” Toward that end, physical therapists or as they’re referred to in France, “kinestherapeutes” use both manual internal techniques and biofeedback to strengthen and rehabilitate a new mom’s pelvic floor.
In addition to these initial appointments focused on the pelvic floor, 10 additional visits are prescribed that are primarily aimed at treating the abdominal wall for diastasis recti issues.
The main goal of the program, which was instituted in 1985, and is paid for by French Social Security, is to prevent postpartum incontinence and pelvic organ prolapse, and to restore sexual function—all major factors in a women’s health and well-being. And indeed, the absence of postpartum pelvic floor rehab has been linked to long-term issues, such as incontinence and organ prolapse.
France’s postpartum rehab program is proven. Studies show that la rééducation significantly reduces incontinence and pelvic pain at nine months after giving birth.
Here in the United States, a pelvic floor evaluation and PT postpartum is not part of our labor and delivery culture. Typically, as was the case with Angela, once a new mom has been cleared to begin having sex again after her six-week follow up appointment, she’s instructed to do kegels and sent on her way.(Ironically, studies show that 40% of women who are told to do kegels by their healthcare providers aren’t doing them correctly, so it would seem that verbal instruction isn’t enough, women need someone to show them, not just tell them how to do a kegel.)
However, slowly, slowly slowly inroads are being carved out in the U.S. as some doctors are starting to prescribe postpartum PT, women are starting to request it, and PTs are starting to offer it. But, there is still much work to be done to get the word out so that adequate recovery/rehabilitation guidance becomes the new norm here in the U.S.
At PHRC, we believe it would be beneficial for all new moms to have their pelvic floor evaluated after they’ve been cleared to resume sex and exercise. This kind of early intervention can help address any concerns, and ultimately enable new moms to return to functional and active lives while possibly preventing future pelvic floor dysfunction.
How PHRC Treats the Postpartum Pelvic Floor
At our clinics we treat not only incontinence, but also the myriad of other postpartum problems that can crop up. So, when we see a patient, whether it’s for incontinence or another postpartum concern, we work to uncover any and all postpartum issues she may be having.
Toward that end, the initial evaluation for the postpartum patient includes:
Musculoskeletal Examination: This includes an assessment of structure, muscles, tissue, and a manual evaluation of the pelvic floor muscles. We can identify problematic muscles and scar tissue and develop a treatment plan based on our findings.
Diastasis Recti Examination: Studies show that more than 50% of women have a diastasis recti after pregnancy. Patients with diastasis recti are given specific exercises to correct the problem. Standard exercises, pilates, and yoga can make this problem worse and should only be introduced after the diastasis recti is addressed.
Scar mobilization for Cesarean Section, episiotomy, and other vaginal scars: Scar tissue can cause persistent pain and lead to discomfort and pain with intercourse. That’s because scars from childbirth have the possibility to become adhered to nearby structures due to excessive amounts of disorganized collagen produced during the healing process. Scars from a C-section can contribute to urgency/frequency.
So it’s important to mobilize and stretch these scars to allow the skin, muscle, and other tissues of the body to move freely and without pain. Scar mobilization promotes collagen remodeling to increase pliability of the tissues and reduce uncomfortable sensations, such as itching or sensitivity. It is best to start scar mobilization early in the healing process because the tissues will respond quickest during this period.
Six to eight weeks is the standard for tissue healing, given the incision has closed without any problems or infections. However, scar mobilization can help scar tissue and adhesions that are years old. In addition to helping with the scar itself, scar mobilization desensitizes the area surrounding the scar, which may have become extremely sensitive to touch. As part of our treatment, we show patients how to perform the mobilization at home.
Manual PT for concerns of pain with vaginal intercourse or penetration: Postoperative or post vaginal delivery can result in tissue hypersensitivity around the incision or episiotomy scars as well as create myofascial trigger points or tightness in traumatized muscle in and around the pelvis. We work to normalize pelvic floor muscle tone, eliminate myofascial trigger points and decrease tissue hypersensitivity with manual techniques that can successfully resolve pain with vaginal intercourse or penetration.
Pelvic Floor Muscle motor control exercises and training to treat Urinary Incontinence: Most women are told about kegel exercises and most women report confusion about how to do them properly or how often. Treating incontinence involves proper kegel instructions as well as training in other key exercises to eliminate the problem.
I hope I have succeeded in my goal of bringing this important women’s health problem to light as well as showing exactly how PT is a viable solution to the problem. As women, we need to make sure we don’t lose sight of how important our own health and happiness is, especially as we set out to undertake one of the most important jobs on the planet!
If you have any questions or would like to share your story with postpartum pelvic floor pain/dysfunction, and/or treatment, please don’t hesitate to write in in the comment section below.