The moment you give birth marks a significant milestone in your life that you will always remember and the feeling of overwhelming joy after having a child is indescribable. However, this ecstatic moment can be quickly overtaken by the realization of the physical changes that your body has undergone since there are often several unanticipated changes that come with pregnancy and delivery.
At FYZICAL Therapy & Balance Centers, our pelvic health physical therapists can help you on the road to recovery after pregnancy and delivery. Each female body is unique and undergoes multiple changes during this time. Our pelvic health physical therapists will create an individualized plan of care to relieve symptoms and train the muscles to function properly. We also believe that proper education is imperative for all pelvic health patients to fully understand the musculoskeletal changes that have occurred and why physical therapy is important for recovery.
Pregnancy - The 4 B’s
- Belly changes
- Back pain
- Bladder control
- Bowels / constipation
The abdominal wall is made up of three layers of abdominal muscles which consist of the superficial rectus abdominis, internal and external obliques, and the deepest layer, transverse abdominis. Strong fascia called linea alba makes up the midline which can become stretched and separate with the growth of your “baby belly”. During this time, you may notice some “doming” or bulging around your belly button during pregnancy called a diastasis recti, which is most apparent after delivery.
During pregnancy, hormonal changes will occur to prepare the pelvis for vaginal delivery. According to the Society for Endocrinology, relaxin is the hormone that is produced by the ovary and placenta. Relaxin works to relax the ligaments in the pelvis so that they soften and widen the cervix in preparation for delivery. This can increase the likelihood of mechanical dysfunction of the pelvic girdle (i.e., sacroiliac joints (SIJ) and pubis) which can create pain and cause difficulty in movement such as walking, getting up from a chair, and rolling over in bed.
A multinational study conducted by Jill Boisonnault, DPT, et al. studied 869 pregnant women from the United States, United Kingdom, Norway, and Sweden. Pelvic girdle pain and/or low back pain were reported by 70-86% of the women in the study. With the help of physical therapy treatment, 68-87% of women reported a positive effect from the treatment.
Bladder control is also a common issue during pregnancy. This occurs due to the hormonal changes in the first trimester, the growth of the baby, and the downward pressure on the bladder and pelvic floor muscles. According to a study by Morkved and Bo et al., 48% of women leaked urine during their first pregnancy if they did not perform pelvic floor exercises in comparison with 32% of women who did. Additionally, three months post-delivery, the women who did not receive physical therapy had a 32% incidence of urinary incontinence compared to those who did receive physical therapy who only had a 20% incidence. Bowel changes such as constipation and straining to have a bowel movement can also occur during pregnancy.
Postpartum – The 4 P’s
Pelvic Floor Weakness
The Pelvic Floor is a group of multiple small muscles that provide the sling of the perineum and attach from the pubic bone in front to the coccyx in the back. This group of muscles is responsible for 4 normal body functions:
- Supporting the bladder and organs
- Sphincter control
- Sexual function and arousal
- Supporting the trunk as part of the core muscle group with the abdominals, multifidi, and diaphragm
During vaginal delivery, the muscles will stretch and weaken during pregnancy if appropriate exercises are not performed. A study performed by Viktrup et al. found that 92% of those who are still incontinent at 12 weeks, will still be incontinent at 5 years without intervention. Wilson et al. noted that 5-7 years after delivery 45% of women have some degree of incontinence.
Post-delivery pelvic floor exercises should be implemented to regain control of the pelvic floor muscle group. Tightening the pelvic floor muscles means drawing “up and in” this sling of muscles in the perineum. The number of how many reps and sets you should perform depends on multiple factors, which is why FYZICAL creates individualized treatment plans. Depending on your ability to hold the contraction effectively, good timing, recruitment, and holding ability your physical therapist may adjust the number of exercises to best fit your needs. Our pelvic health physical therapists will evaluate your conditions and set up an at-home and in-clinic plan of care. The goal is to help you regain full control of your pelvic floor muscles when you pick up your baby, cough, laugh, exercise, weight lift, and even jump to prevent any leaking.
Perineal Tearing
The area of tissue surrounding the vaginal opening is called the perineum. Tearing can occur during delivery with the severity will be dependent on several factors. How quickly your baby’s head was delivered, the position your baby was in on the presentation, how many pregnancies you have had, and other genetic factors may all impact tearing. Tears can be painful, especially when resuming sex and other regular activities. FYZICAL’s pelvic health physical therapists can treat the scar tissue with several techniques designed to reduce the adhesions and painful tissue to help facilitate pain-free sexual intimacy again post-delivery.
Prolapse
A prolapse is the downward movement of the pelvic organ, most commonly the bladder, below its normal position in the vaginal cavity. However, other organs can also prolapse such as the rectum bulging through the posterior vaginal wall or the uterus dropping down in the vagina. During the initial postpartum period, they may be at their worst but can improve as the hormonal balance is restored. One vaginal delivery increases the risk of prolapse by 4 times, and 2 or more deliveries increase the risk by 8.4 times as stated by Mant et al. In a study performed by Hagen and Stark et al., it was found that 50% of women that have delivered a baby had some degree of pelvic organ prolapse.
Specific programs have been designed to regain pelvic floor strength and reduce prolapse, in conjunction with positioning. Additionally, in some cases, a simple device has been used to support the prolapse. One item typically used is similar to a tampon applicator and helps to give support to the bladder during the recovery stage. This device is like using a brace on your ankle to support a sprain during healing.
Physical therapy treatment will often include setting up a home program, training on how to lift and carry your infant properly to speed up recovery, education about returning to exercise/running, and biofeedback training. Biofeedback is a device that allows you to see what your muscles are doing which will help to facilitate retraining, good control, and strength. The biofeedback will either be a handheld device or a complex computerized system.
Painful Sex- Dyspareunia
As mentioned previously, scar tissue can cause pain during sex after having a baby. Sometimes there are other muscular and nerve generators of pain during sex. Pelvic health physical therapists can help determine the musculoskeletal driver of your pain and work with you to reduce it. At FYZICAL, we offer several treatment approaches such as myofascial and muscle release, scar tissue techniques, exercises, stretching, laser therapy, relaxation breathing, and mindfulness. We believe in a collaborative and holistic approach to treating patients with pelvic floor conditions. Our trained pelvic health therapists have extensive knowledge and experience in pelvic health which will allow them to effectively address our patients’ issues. Painful C-section scars can also be treated with myofascial techniques, laser therapy, specific massage techniques, and dry needling after 6 weeks of natural healing.
Diastasis Recti (DR) is a separation of the rectus abdominis and the linea alba. This looks like a “pooch” that protrudes above or below the umbilicus. A specific program of abdominal and core strengthening can be used for treatment, along with avoiding certain movements that would strain the abdominals and potentially cause them to worsen. Additionally, back pain is associated with weak abdominal support.
Perform a Self-Test to See if You May Have a Diastasis Recti
- Lie down on the floor without a pillow with your knees bent up.
- Place your fingers just above your belly button.
- Lift your head up off the bed and feel with your fingers if the abdominals are flat in the middle, or if there is a “gutter” just above your umbilicus which your fingers sink into it. The gap can be as small as one finger or could be up to six fingers wide.
- To be considered a Diastasis Recti it must be at least two fingers wide.
What to Do for A Diastasis Recti
See a Pelvic Physical Therapist immediately to start a program designed specifically for you.
- Avoid sitting straight up while getting out of bed. Instead, roll on your side to get out of bed while using your arms.
- Avoid lifting anything heavier than your baby.
- Avoid any exercises that make your belly “dome” outwards more (most likely to occur with sit-ups, running, double leg lifts, and crunches).
- Possibly consider a belly band for heavy activities such as cleaning bathrooms and pushing a stroller. Ask your Physical Therapist for additional recommendations.
How to Begin Exercise
Everyone is eager in the post-natal period to get back to looking good and feeling healthy. Returning to exercise varies for each person and we highly recommend working with a physical therapist to ensure you are ready to start your weight training program, interval training, or running. They will consider your current pelvic floor strength, bladder control, prolapse, and abdominal separation as well as changing hormones, breastfeeding, and other medical concerns.
All these changes that occur in your body are completely normal and with the combination of pelvic floor rehabilitation, education, and home exercises you can significantly decrease your postpartum symptoms. Pelvic Floor Physical Therapy will work to help you return to full activities.
Contact FYZICAL Franklin by calling (828) 369-7878 to begin our Pelvic Health Program designed to help you gain control of your bladder and pelvis so that you can feel better and return to the activities you love!
By:
Dr. Ruth Jenkins, PT, DPT, COMT, CMTPT/DN
National Director of Pelvic Health & Wellness
References:
1. Annelie Gutke 1, Jill Boissonnault 2 3, Gill Brook 4 5, Britt Stuge. J Womens Health (Larchmt). 2018 Apr;27(4):510-517.doi: 10.1089/jwh.2017.6342.Epub 2017 Aug 23.The Severity and Impact of Pelvic Girdle Pain and Low-Back Pain in Pregnancy: A Multinational Study.
2. Siv Morkved, Kari Bo, Berit Schei, Kjell Asmund Salvesen. Obsteric Gynecology.2003 Feb; 1010 (2) : 313-9.doi:10.1016/s0029-7844 (02) 02711-4 Pelvic Floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized control trial.
3. L Viktrup 1, G Lose. Int Urogynecol J Pelvic Floor Dysfunct. 2000 Dec;11(6):336-40.doi: 10.1007/s001920070002.
4. Wilson, P.D., Herbison, P., Glazener, C., McGee, M., MacArthur, C., 2002. ICS Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284–300] Obstetric practice and urinary incontinence 5–7 years after delivery.
5. Mant J, Painter R, Vessy M, Br J Obstetrics and Gynecology. 1997; 104:579.Epidemiology of Genital prolapse: observation from the Oxford Family Planning Association Study.
6. Suzanne Hagen 1, Diane Stark Cochrane Database Syst Rev. 2011 Dec 7;(12):CD003882.doi: 10.1002/14651858.CD003882.pub4. Conservative prevention and management of pelvic organ prolapse in women.