The 4th Trimester: Postpartum Pelvic Pain is Common but Not Normal

In Pregnancy and Postpartum Pelvic Health by Courtney EdgecombLeave a Comment

By: Courtney Edgecomb

 

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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