Postpartum Pelvic Floor Considerations
Top Contributors - Jess Bell, Kim Jackson and Carin Hunter
Defining the Postpartum Period[edit | edit source]
The postpartum period has been divided into three phases:
- The initial / acute phase which covers the first 6 to 12 hours after birth
- The subacute phase which lasts between two and six weeks
- The delayed postpartum phase (follows the subacute phase and can last up to 6 months or longer)
The effects of birth are usually felt most during the first 12 weeks postpartum. These initial 12 weeks are also known as the fourth trimester. However, in reality, childbirth can impact a mother’s pelvic health for much longer than just the fourth trimester. Thus, pelvic health should be a key focus during the postpartum period as the pelvic health foundations established during this period can have a long-term impact on mothers.
The Fourth Trimester[edit | edit source]
During the fourth trimester, tissues are still healing and the body is "finding its new self". During the first two to six weeks in particular, the body experiences significant changes in terms of:
- Genito-urinary recovery
- Emotional state
Changes in the later postpartum period tend to be very gradual and pathology is not common. Because of these physical and emotional changes, it is important that women do not overstrain or exert their tissues. Instead, the focus should be on:
- Restorative practices
Expectations for Recovery[edit | edit source]
It may be necessary to discuss recovery expectations with women. Savage suggests that having a wellness action plan can help expectant mothers and their families to be proactive and prepare for their physical and emotional needs after the birth of their baby. However, it is important to note that many women in the fourth trimester will have to plan:
- Their return to work
- Getting strong enough to manage everything on their own
Discharge from Obstetric Care[edit | edit source]
Many women will be discharged from the care of their midwife or obstetrician after their six-week follow-up unless there is a specific medical concern. These time-frames / standards may vary in different countries.
At the point of discharge, not all women will be given a comprehensive examination of their pelvic floor. However, when it is safe and appropriate, a women's pelvic health physiotherapist can provide this evaluation as needed. This is often around the five- to six-week mark once bleeding has stopped. It is also possible to teach clients how to perform a self-examination of their vulva and perineal region with a mirror.
The rest of this page will discuss six specific areas that pelvic health physiotherapists can review with their clients prior to the six-week assessment to enhance their pelvic health.
Normal and Abnormal Experiences[edit | edit source]
According to Finlayson et al., many women do not feel prepared for the physical and psychological impact of childbirth or for their postpartum recovery. The following sensations / experiences are considered normal in the first six weeks:
- Body may still be in “birthing” mode (ie. open, soft ligaments)
- Connective tissue / soft tissue healing takes at least six weeks
- The stability system (i.e. inner core) is often compromised and needs retraining
- The vulva / vagina will likely look and feel different after a vaginal birth
- Clients may express that they feel like their bottom is falling out
- Pelvic heaviness or pressure
- Discomfort or pain in hips, low back, pelvis, perineum
- A jiggly / jelly-like belly
- Doming or tenting in the abdomen when trying to sit up or lift things
- It may be challenging to control urine, stool or gas loss
- Dryness or sensitivity in vaginal tissues (this can persist due to hormonal changes)
- A sense of living in an unknown / different body
After six to eight weeks and certainly by 12 weeks, these sensations will usually have self-resolved. There should be no ongoing incontinence / leaking or a sense of instability etc. Women who continue to experience these sensations should be encouraged to see a pelvic health physiotherapist.
Perineal and Vulvar Care Practices[edit | edit source]
More than 85 percent of women are estimated to experience perineal trauma during childbirth, most commonly an episiotomy or tear. Associated complications include pain, discomfort, infection, persistent pelvic pain, dyspareunia, pelvic floor weakness, urinary incontinence, sexual dysfunction, depression and unstable mood.
Complications of tears or episiotomy can have an immediate or longer-term impact and they may affect:
- Urinary or bowel elimination
- Newborn care
- Activities of daily living
The following can be beneficial for perineal / vulva care immediately postpartum:
- Padsicles (chilled or frozen sanitary pads) and herbs can be used to decrease perineal pain and reduce swelling
- Air-drying the area from time to time to promote healing and reduce the chance of irritation or infection
- Nutrient-dense food choices and adequate hydration to promote healing
Healthy and Pressure-Free Bowel Movements[edit | edit source]
Constipation is a common condition for postpartum women causing pain, discomfort and straining. The risk of postpartum constipation is increased by:
- Pain around an episiotomy
- The effects of pregnancy hormones
- Haematinics used in pregnancy, such as folic acid and iron salts:
- These may be given to prevent anaemia and to ensure normal foetal development
Strategies to encourage healthy and pressure-free bowel movements immediately postpartum include:
- Using a squatty potty
- Not straining
- “ILU” massage over the abdomen (i.e. a massage making the letters I,L and U) See below.
- Supporting the perineum manually
- Food and drink choices
The following videos provide additional information on the squatty potty (left), bowel motions postpartum (centre) and the ILU massage (right).
Postpartum Abdominal Wall Support[edit | edit source]
After childbirth, the abdominal muscles are able to return to their role as primary stabilisers of the spine. However, these muscles are often stretched or overstretched during pregnancy. It is, therefore, important to discuss abdominal wall support with clients during the first six weeks postpartum to:
- Facilitate healing and provide support
- Using an abdominal wrap
- Restore balance
- Alignment and diaphragm above the pelvic floor
- Manage pressure
- Avoid compression on the belly that puts strain on the pelvic floor or diaphragm
- Postures and positions
- Diaphragm and rib position
- Breathing style
- Pelvic floor
- Clothing (belts, baby carriers)
- Self-perception (waist trainers, sucking in)
- Reconnect to the core
- Gentle reactivation, re-awareness
- Providing a check for diastasis recti
- Regain motor control and pelvic floor coordination
- Simple movements in supine such as alternating bent knee lifts or a simple clamshell
- Teaching the knack
- The knack is when you pre-contract the pelvic floor muscles before a cough or a sneeze or other pressure generative event
- It acts as a brain-body strategy to help avoid leaking urine
- Progressively retraining with a focus on function
Resuming Penetrative Intercourse[edit | edit source]
Various studies have looked at mothers’ experience of intercourse during the postpartum period:
- Connolly et al. found that 57 percent of women resumed intercourse at 6 weeks, 82 percent at 12 weeks and 90 percent at 24 weeks postpartum
- Barrett et al. found that 89 percent of women resumed intercourse within six months of giving birth
- 83 percent of women experience sexual problems in the first three months after childbirth compared to 64 percent at six months
- Pre-pregnancy sexual problems were found in 38 percent of women
- Dyspareunia in the first three months after birth was associated with vaginal deliveries and a history of dyspareunia
- There was no association between dyspareunia and delivery type at the six month follow up
- Korzeniewski et al. found that women usually resumed intercourse during the early postpartum period, during which time there was a high prevalence of sexual health problems
It is beneficial to advise women that intercourse should not be painful and if it continues to cause discomfort, they should get help. They should then work on increasing pleasure if that has been affected by birth.
Activities of Daily Living[edit | edit source]
Women should be encouraged to be mindful of their pelvic floor when they participate in activities of daily living. Mothers are often involved in:
- Prolonged lying
- Prolonged sitting
- Floor activities
Strategies to assist with these activities include encouraging mothers to:
- Engage the pelvic floor when exerting themselves
- Monitor for pain or discomfort
- Try doing a task different ways
- Keep activities varied
- Aim for left / right symmetry and balance
- Use props, rolls, pillows, wedges and stools
- Visualise what is happening in the pelvic floor in different positions or during movements / tasks
- Limit being in prolonged static positions
- Hold and carry a load close to the centre of gravity
References[edit | edit source]
- Romano M, Cacciatore A, Giordano R, La Rosa B. Postpartum period: three distinct but continuous phases. J Prenat Med. 2010;4(2):22-5.
- Afolabi I. Postpartum Pelvic Floor Considerations Course. Plus , 2022.
- Paladine HL, Blenning CE, Strangas Y. Postpartum care: an approach to the fourth trimester. Am Fam Physician. 2019;100(8):485-91.
- AAMCNews. Baby Notes: The Fourth Trimester. Available from: https://www.youtube.com/watch?v=APczZl9bJ1E [last accessed 18/1/2022]
- Savage JS. A fourth trimester action plan for wellness. J Perinat Educ. 2020;29(2):103-12.
- Spelke B, Werner E. The fourth trimester of pregnancy: committing to maternal health and well-being postpartum. R I Med J (2013). 2018;101(8):30-3.
- Queenie Physio. How To Self-Check Your Vagina! #shorts. Available from: https://www.youtube.com/watch?v=fhiVYX4DUGE [last accessed 18/01/2022]
- Finlayson K, Crossland N, Bonet M, Downe S. What matters to women in the postnatal period: A meta-synthesis of qualitative studies. PLoS One. 2020;15(4):e0231415.
- Lopes G, Leister N, Riesco ML. Perineal care and outcomes in a birth center. Texto & Contexto - Enfermagem. 2019;28:e20180168.
- Shoorab NJ, Taghipour A, Mirteimouri M, Roudsari RL. Social recovery: a neglected dimension of caring for women with perineal trauma in Iran. Iran J Nurs Midwifery Res. 2020;25(4):333-40.
- Frilasari H, Saudah N, Prameswari VE, Azizah YN, Suhita BM. Nutritional pattern and healing of perineum wound on postpartum period. Journal Of Nursing Practice, 2020;3(2):172-80.
- Ratna Sari R, Yunola S, Anggraini H. Relationship of parity, knowledge and anemia status with perineal wound healing in postpartum mothers at PMB Bukit Sangkal Palembang Working Area in 2021. Science Midwifery. 2022;10(2):580-6.
- Leeds Teaching Hospitals NHS Trust. Caring for your perineum after the birth of your baby. Available from: https://www.youtube.com/watch?v=e88EHQwNobY [last accessed 18/1/2022]
- Turawa EB, Musekiwa A, Rohwer AC. Interventions for preventing postpartum constipation. Cochrane Database Syst Rev. 2020;8(8):CD011625.
- Mohammed BS, Helegbe GK. Routine haematinics and multivitamins: Adherence and its association with haemoglobin level among pregnant women in an urban lower-middle-income country, Ghana. Basic Clin Pharmacol Toxicol. 2020;127(1):21-9.
- Bloom Integrative Health & Movement. Postnatal Tips: Pooping after baby. Available from: https://www.youtube.com/watch?v=Q0BvNW_pBxE [last accessed 18/1/2022]
- Bridget Teyler. SEX AFTER BIRTH | FIRST PERIOD AFTER GIVING BIRTH | POOPING + PEEING. Available from: https://www.youtube.com/watch?v=868g5csQN-M [last accessed 18/1/2022]
- ECO Physiotherapy. #19 The I love you massage. Available from: https://www.youtube.com/watch?v=JTOkKVlBHzk [last accessed 19/1/2022]
- Swanson S. Abdominal muscles in pregnancy and the postpartum period. International Journal of Childbirth Education; Minneapolis. 2001;16(4):12.
- Sigurdardottir T, Steingrimsdottir T, Geirsson RT, Halldorsson TI, Aspelund T, Bø K. Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial. Am J Obstet Gynecol. 2020;222(3):247.e1-247.e8.
- Live Core Strong. Postpartum Belly Wraps: Frequently Asked Questions On How To Use A Postpartum Belly Wrap. Available from: https://www.youtube.com/watch?v=thDPPG-PNhg [last accessed 18/1/2022]
- Coast Sport. Identifying Abdominal Separation (Diastasis Rectus Abdominis/DRAM). Available from: https://www.youtube.com/watch?v=ETqg8q_oGyA [last accessed 18/1/2022]
- Michelle Kenway. How to Control Bladder Leaks and Get 'The Knack'. Available from: https://www.youtube.com/watch?v=cSBd7tn0SeI [last accessed 18/1/2022]
- Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J. 2005;16:263-7.
- Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women's sexual health after childbirth. BJOG. 2000;107(2):186-95.
- Korzeniewski R, Kiemle G, Slade P. Mothers’ experiences of sex and sexual intimacy in the first postnatal year: a systematic review. Sexual and Relationship Therapy. 2021;36(2-3):219-37.
- Proactive Pelvic Health Centre. Postpartum Dyspareunia (Painful Intercourse). Available from: https://www.youtube.com/watch?v=BM4r2SU1YRk [last accessed 18/1/2022]