Let me tell you a little secret about the pelvic floor in the postpartum period…it’s an unsung hero! Issues with the pelvic floor are often dismissed as a “normal” part of having a baby, but that couldn’t be further from the truth. Mommas are already dealing with so many changes during pregnancy and postpartum that preparing them for childbirth and the 4th trimester sets them up for success during a stressful period of life. Here are some steps to help your clients prepare for the postpartum period, healing during the postpartum period, and when to refer to a specialist.
Step 1: Education and Preparation
What happens to the pelvic floor?
Let’s begin by quickly reviewing what happens to the pelvic floor during childbirth. For a vaginal birth, the tissues can stretch up to 245% of its resting length  , which can lead to muscle weakness and laxity. This can contribute to issues related to incontinence and prolapse. Now with a C-section birth, this delivery route is typically shown to have less risk of pelvic floor dysfunction.  However, these women are not necessarily “in the clear” because the pelvic floor, posture, and core muscles still must go through major changes during pregnancy, the start of labor, or any intervention prior to the C-section. It is therefore so important to assess each mother individually while keeping in mind her pre-pregnancy and pre-childbirth pelvic floor history. There are also many treatment options available to aid in the recovery of these issues – read here about an easy-to use, 5-min/day, at-home pelvic floor strengthening device, Flyte.
- Diaphragmatic breathing: Teaching how to use the diaphragm to help with pelvic floor elongation and relaxation can be a key factor to improve childbirth! The uterus is in charge of pushing the baby out with help from mom, and the pelvic floor must be able to open and stretch to allow this to happen (and reduces risk of tearing!). For this, pelvic floor strengthening is not helpful and instead, helping mom tune into her breathing and connecting with the pelvic floor via a mirror or self-palpation can be truly helpful to prepare for birth.
- Pelvic floor and pelvis opening stretches: There are some great stretches that can help facilitate opening of the pelvis and pelvic floor muscles to prepare for childbirth. A few great ones are cat/cow, child’s pose, happy baby pose, deep squats, figure 4, and hip internal rotation stretching – breathing can be incorporated with all these too!
Step 2: Heat vs Ice Postpartum
Ice will be your client’s best friend after delivery to help with pain and swelling to the perineum. She can use any form of ice to get some relief – ice pack or padsicles for 10-20 minutes. She will get the most benefit in the first 24-72 hours after birth. Padsicles are nice because she can still wear it while getting up if the baby needs her.
When can heat be introduced? After the first 24 hours after delivery, a sitz bath or a warm bath are fine to start using, but keep in mind where she is at in her healing (any signs of infection?). The body’s natural inflammatory phase is a normal part of healing (and she might still feel swollen down there!), so we don’t want to ice too much to slow down the healing process. Heat is ok to use at the right time.
Step 3: Constipation Management
The first bowel movement after childbirth can be intimidating for a new mom! The thought of pushing again on healing tissue that is already so sensitive is scary. Helping your client prepare for this can help reduce their fear and anxiety.
- Squatty potty: Helps to open the muscles around the bottom to improve ability to pass a bowel movement. When paired with proper diaphragmatic breathing, it can be a game changer!
- Essential oils: If your patient feels comfortable, a couple of drops of their favorite essential oil (peppermint, for example!) in the toilet bowl can help them focus on their breath and relaxation while having a bowel movement
- Water: Drinking plenty of fluids avoids dehydration that can harden stools
- Gentle, short walks for exercise: Improves motility in the gut!
- Eat foods with fiber: Fruits, veggies, and whole grains – helps to normalize bowel movements
- Stool softeners or laxatives: May be needed, refer to a doctor if necessary
Step 4: Drink up!
Just as noted in step 3, water is so important! Improving a momma’s hydration postpartum helps with tissue healing, overall recovery, constipation, fatigue, headaches, reduces muscle cramps, and reduces swelling. If she is breastfeeding, increasing her water can help produce more milk for her baby. And lastly, water is so vital to the overall health of the mother and the changing needs of her body in the postpartum period.
Is she still struggling to drink water? Maybe offer some lemon/lime or fruit to add some extra flavor!
Step 5: Posture! Posture! Posture!
Although posture can seem like a low priority, good posture can lead to better healing postpartum. The forward hunched position moms are constantly in with feedings and changings can lead to various aches, pains, and fatigue. Improving their posture can impact physical health, reduce these pains/complaints, and improve overall comfort. It’s also a great way to allow their core to heal and being working for them!
Reminders of good baby holding positions are helpful to not compromise a momma’s posture. A good baby carrier can be so helpful with this! Make sure it fits her and the baby just right, with equal straps on each side, low, and high to distribute the baby’s load evenly on her body.
Is she breastfeeding? Make sure she has adequate support of her baby and her shoulder. Offer tips on bringing the baby up to her during a feeding session versus her dropping her shoulder down and slouching. For example, propping up her arms, back, and even feel with towel rolls, pillows, or a stool to help her maintain a good posture.
Extension exercises can be very helpful. Here are a couple easy beginners: Shoulder rolls , overhead reaches, mini-cobra, cat/cow, and even some neck stretching.
Step 6: Postpartum Self-Care is Important! Postpartum Self-Care is Possible!
Reminding a mom to take care of herself might feel like an impossible task to her with everything else she has on her plate. Gentle reminders that “we don’t just bounce back in 6 weeks” can help to set the standard to honor her body’s changes and gradually progress towards her goals based on what her body is ready for at that moment. Reduce mom-guilt and improve her own healing, physically and mentally, with these few tips:
- Sleep: Yes, sleep will help improve energy, your mood, and your focus (mom brain is totally real!)
- Eat: Don’t forget to eat a balanced diet to feel better overall.
- Get out of the house: Go outside for a walk on a nice day, or if the weather is not so great, motivate yourself to nix the Amazon order and go for a Target run!
- Gentle exercise: Gentle dynamic stretches for the spine, neck, hips, etc. can begin early postpartum without harm. This can help moms feel less fearful about returning to movement, avoid future or further injury, and reconnecting to the body often feels really good!
- Have fun: Reconnect with a friend and schedule time to get together – you will be amazed at how re-charged you feel!
- Take pictures: Taking pictures of that new baby can bring so much joy and happiness and remind a new mom how special this time of life really is.
Step 7: When to See a Specialist
It’s important to be aware of some of the signs and symptoms associated with pelvic floor dysfunction. If your client is not getting better with your recommendations, know when to refer them to a specialized doctor or a pelvic floor physical therapist.
- Heaviness, fullness, pressure, or ache in the vagina – can get worse throughout the day or even after a bowel movement
- Seeing or feeling a “bulge” out of the vagina or rectum
- Difficulty starting or stopping the urine stream
- Constipation or the feeling of incomplete emptying
- Leaking with activities (coughing, laughing, sneezing, bending, lifting, exercise, etc.)
- Urinary urgency and frequency
- Pain with urination
- Pain with intercourse (if resumed) or tampon insertion (if menses has returned)
- Muscle spasms in the pelvis
- Pain to C-section scar or visible adhesions and scar tissue formation
- Complaints of pelvic, pubic, hip, lower back, or sacroiliac joint pain, etc.
- Leaking of stool, inability to hold gas
- Not making it to the bathroom in time
- Urinary tract infection-like symptoms without a positive urine culture
- Feeling core weakness or noticing a bulging of the belly’s midline with certain activities
If your client is wanting to return to an exercise program, be sure to recommend them to get the appropriate screening done for readiness to reduce the risk of injury physically and mentally. A pelvic floor physical therapist is ideal in this screening process to determine if the client is ready to resume their pre-pregnancy exercises (i.e. running, jumping, etc.) without an increase or cause in the above listed pelvic floor dysfunctions.
Looking for an at-home treatment for your clients with pelvic floor weakness? Read about Flyte and how it has been shown to improve the benefit of Kegel contractions 39x more than doing them on our own! And check out the article “5 reasons why every postpartum plan should include Kegels”.
- Svabík K, Shek KL, Dietz HP. How much does the levator hiatus have to stretch during childbirth? BJOG. 2009 Nov;116(12):1657-62. doi: 10.1111/j.1471-0528.2009.02321.x. Epub 2009 Sep 1. PMID: 19735376.
- Blomquist JL, Muñoz A, Carroll M, Handa VL. Association of delivery mode with pelvic floor disorders after childbirth. JAMA. 2018;320(23):2438. doi:10.1001/jama.2018.18315
About the Authors
Leah Fulker, PT, DPT, has treated a wide variety of pelvic floor conditions including stress urinary incontinence, urge incontinence, overactive bladder (OAB), pelvic pain, and prolapse. Since achieving her Doctorate in Physical Therapy in 2012, she realized the need for pelvic floor physical therapy and began her certifications in 2014. She has aided in the recovery of many of these conditions during her career. At Pelvital, Leah is the Customer Care Manager and leads the Ask a PT program. You can reach her through their website www.flytetherapy.com and click on Ask a PT.
Shravya Kovela, PT, DPT, OCS is a pelvic floor physical therapist and orthopedic clinical specialist. After receiving her Bachelor of Arts at the University of Virginia, she went on to Emory University for her DPT. She completed her orthopedic residency at The Jackson Clinics in northern Virginia and began treating numerous pelvic floor conditions shortly afterwards. She is passionate about increasing awareness of pelvic floor conditions. At Pelvital, Shravya is the Business Development Manager where she leads clinician outreach.