Preparing for Birth and Postpartum with Pelvic Health Physical Therapy

Devon Dinegar PT, DPT

Why choose pelvic health physical therapy to prepare for birth and postpartum?

During pregnancy, birth, and throughout the postpartum period, your body goes through many changes. Pelvic health physical therapists specialize in the pelvis but are trained in treating the entire body. Not only does your pelvis experience changes from pregnancy through the postpartum period, but posture, walking patterns, and body mechanics also change during this time. Pelvic health physical therapists can help you understand your changing body, identify any impairments, manage symptoms, and learn to move your body efficiently throughout these various stages.

Preparing for Birth

Birthing Position Considerations

There are many factors when considering birthing positions such as comorbidities during pregnancy/labor, fetal complications, having an epidural, your comfort level, and your OBGYN/midwife’s training.

Birthing positions can be divided into two categories: gravity assisted, positions where gravity is helping the baby drop and pass through the birthing canal; and non-gravity assisted positions.

Gravity Assisted Positions

  • Standing
  • Lunging
  • Squatting
  • Sitting on birthing stool
  • Kneeling (on both knees)
  • Half kneeling (kneeling on one knee with the other foot in front)

Gravity assisted positions can be helpful to open the pelvic outlet during labor to promote lowering of the fetus, as well as during delivery to allow the fetus to pass more easily through the birthing canal. These positions may not be appropriate if the birthing person or fetus are in distress and require constant monitoring, or if an epidural is given and proper support is not available to the person giving birth.

Non-Gravity Assisted Positions

  • Laying on your back – Lithotomy position (common birthing position): on your back with head of the bed slightly lifted, feet on stirrups
  • Laying on your side
  • On all fours (hands and knees)

Non-gravity assisted positions are common if an epidural has been administered, or there is not adequate physical support to sustain a gravity assisted position, including but not limited to pillows/wedges and trained hospital personnel. These positions also allow physicians to monitor the status of the person giving birth and the fetus. These positions may be necessary if the fetus is in distress or if the person giving birth has high blood pressure or other medical conditions that may require constant monitoring. Even if you get an epidural, there are always options to optimize your positioning for your birthing experience.

Ask your OB-GYN or midwife, what positions their patients typically give birth in and why. Also be sure to ask what equipment will be available when giving birth (ie. birthing ball, wedge, peanut, birthing bar, birthing stool, etc.). This can be a great opportunity to discuss which positions may be most beneficial for you during labor and delivery.

Breathing and Pelvic Floor Muscle coordination for pushing

The diaphragm and the pelvic floor work together to manage pressure in the upper body. The pelvic floor makes up the “floor” of the trunk while the diaphragm, which sits under the ribcage, acts as a “roof” of the pressure system. Diaphragmatic breathing or belly breathing helps with pelvic floor muscle relaxation and improving pelvic floor muscle length needed for delivery. In addition to having good pelvic floor muscle relaxation and length, the pelvic floor muscles will need to actively lengthen during the pushing phase of delivery. The pelvic floor muscles should be able to “bulge” or bear down without straining or holding your breath to effectively push during delivery. Breathing and pelvic floor muscle function and coordination are key components that are assessed and taught during prenatal pelvic health physical therapy.

Doulas

Doulas are trained professionals who provide physical, emotional, and educational support to people prior to, during, and after childbirth. Doulas also act as an advocate for people going through labor and delivery. Doulas can be a great addition to your healthcare team to ensure your needs and concerns are heard and implemented into your labor and delivery experience. Studies have shown doula supported births are associated with 22 percent lower odds of preterm birth and those who had doula support had lower odds of cesarean deliveries of full term births(Kozhimannil, 2016). Another study found that continuous support (from a doula) has been associated with higher Apgar scores in newborns and overall higher satisfaction by mothers with the birthing process (Sauls, 2002).

Typically, a doula will meet with the expectant birther at least twice before the birth, they will offer continuous assistance throughout labor and birth, and will visit the birther at least twice postpartum.

Birthing Resources

Preparing for Postpartum

Checklist of items you may want to take with you to the hospital

  • Squatty potty
  • Loose fitting clothing
  • Adult diapers
  • Sanitary pads
  • Breast pads (whether you decide to chest feed or not)

Postpartum Recovery Timeline

Everyone in the postpartum phase recovers at their own pace – there is not a one-size-fits-all “timeline”. However, every body requires time for tissue healing. For the first 2-4 weeks, be sure to eat nutritious foods, rest, and listen to your body. At 4-6 weeks you can start to incorporate gentle pelvic floor contractions (kegels) to increase blood flow to the pelvis to promote healing. Be mindful to pair kegels with breathing out, and relax fully when breathing in between contractions. If kegels are painful, do not do them until cleared by your medical provider. Hold off on high intensity exercise until 10-12 weeks postpartum. For guidance on exercise progression, schedule a consultation with a pelvic health physical therapist!

Everyone’s postpartum recovery is different, give yourself grace through your postpartum journey. Remember that growing a baby takes nine months, recovery takes time too!

Urination and Bowel movements postpartum

Urination following both vaginal and cesarean deliveries may be difficult. In the case of a vaginal delivery, you may feel as though you need to urinate but find it’s challenging due to a change in bladder position and lack of pressure on the bladder now that the baby has been delivered. You may also experience pain or burning during urination from vaginal tearing. During a cesarean, anesthesia may be used and a catheter inserted into the urethra. Once the catheter has been removed, urinating may feel delayed, incomplete, or uncomfortable. Interestingly, after a c-section you may notice having a reduction in lower abdominal pressure after urinating due to less pressure from the bladder being applied to the uterus.

If you’ve had a vaginal delivery, the idea of having a bowel movement after delivery can be scary!

Tips for having a successful first pee and poop after giving birth

  • Drink plenty of fluids
  • Use a squatty potty: placing your knees slightly higher than your hips will help to relax your pelvic floor muscles necessary to urinate or defecate
  • Listen to running water
  • Use a straw to blow bubbles in cup of water: this will increase pressure in the abdomen needed to release urine or stool

Caring for Perineal Tears

If you’ve delivered vaginally, you may have some perineal tearing. The perineum is the space between the vaginal opening and the anus, and is susceptible to tearing when stretched. You may be at greater risk for perineal tearing if you had an instrument assisted delivery with a vacuum or forceps or if delivery was less than 20 minutes or greater than 2 hours, due to either rapid stretching of the tissue or gradual stretching over a long period of time. Your delivering doctor will stitch the tears. You will need to wear pads or adult diapers for bleeding that may occur for days, or weeks afterwards. Some blood is okay, but if you notice increased pain, heavy bleeding, fever, sweating, or nausea, call your doctor – the wound may be infected.

To heal from perineal tears, the body will do most of the initial work! For the first 4-6 weeks, the best thing you can do for your body is rest, eat nutritious foods and make sure that the wound is being kept clean by changing pads regularly. At your 6 week postpartum check, your doctor should check the perineum for any signs of delayed healing. If you are cleared to return to activity, but are still having discomfort at the perineum, pelvic physical therapy can be a great next step.

Your pelvic health therapist will first educate you on your pelvic floor and help to identify where you are specifically feeling discomfort. They will also teach you desensitization techniques to reduce discomfort at the perineum. Desensitization is a method to reduce your body’s response to touch. After vaginal delivery, your body may be in protective mode, meaning your muscles will be protectively guarding the area that is in pain, and in the case of perineal tears – that likely means your perineum and/or the surrounding area. In addition to weekly sessions, your physical therapists will give you stretches and exercises to work on at home to reduce sensitivity and increase blood flow to the area to promote healing.

Caring for C-section Scars

For the first 4-6 weeks after having a c-section, the body will initiate the healing process. During this stage, prioritizing rest and having a nutritious diet and monitoring the scar for infection is key. Signs of infection to the incision include increased pain, increased bleeding, fever, sweating, or nausea – if you notice any of these symptoms, contact your doctor as soon as possible. At your postpartum check up with your OBGYN, your doctor should check the incision and if it has healed well, you should ask your doctor about starting physical therapy to work on c-section scar mobility and management. With any scar, scar tissue must form to improve the integrity of the tissues. Scar tissue is vital to the healing process but often gets a bad rap because it can limit movement if unaddressed.

To address scar tissue formation, one may try massaging the scar to help to improve the mobility of the scar and thus the scar tissue underneath to ensure that the scar tissue is not adhering to other body parts. Physical therapists can assess scar mobility and teach you how to self massage the scar to maintain good movement of the scar in all directions. When the scar is moving well, the scar will have better blood flow which is vital to the healing process. Good scar mobility may also improve movement of the trunk, and reduce pain associated with movement.

It is never too late to have PT for your c-section scar, even if you are several months or years out from having a c-section.

Postpartum Red Flags – Reasons to contact your doctor

  • Signs of infection: Fever, malaise, redness/swelling around wound, urinary urgency/frequency
  • Signs of internal bleeding: rapid drop in blood pressure, lightheadedness
  • Signs of high blood pressure: changes in vision, severe headache, decreased urinary output

Chest feeding and Mastitis

  • Signs of infection: Fever, malaise, redness/swelling around wound, urinary urgency/frequency
  • Signs of internal bleeding: rapid drop in blood pressure, lightheadedness
  • Signs of high blood pressure: changes in vision, severe headache, decreased urinary output

Risk factors for mastitis include:

  • Milk oversupply
  • Change in schedule…reduced removal of milk
  • Poor latch or suck
  • Nipple damage (teething baby, cabbage leaves/cold compresses directly placed on nipple – can cause frostbite and create an open wound for bacteria to enter)
  • Pressure on breast (clothing, scars, poor fitting breast pump)
  • Illness in the chestfeeder/child
  • Stress/fatigue

Physical therapy can help to treat mastitis in just one visit!

A pelvic health physical therapist will take a detailed history, perform an examination and provide manual treatment with your consent, educate you on the use of hot/cold treatment and instruct you on how to perform the hands-on techniques at home.

Improvements should be seen within 24 hours of your PT visit…if there are no changes with treatment and implementation of the home program, contact your doctor!

Core support and stability

During postpartum, you may hear about products for core support and stability. Abdominal braces can be a helpful tool to allow you to feel snug and supported in your postpartum body but it should not be a substitute for core strengthening. An abdominal support band can be especially useful if you are experiencing pelvic or back pain when walking, stair climbing, or after a long day of being on your feet. It’s recommended that you wear the abdominal band only when doing the movements that are painful. If you notice vaginal heaviness during or after wearing an abdominal brace/band, consult a pelvic floor physical therapist – your body may be having trouble managing the forces the band is putting on the abdomen and sending pressure down into the pelvic floor.

Now, let’s talk about how to strengthen the core muscles actively! The transverse abdominis is a deep core muscle that is responsible for stabilizing the pelvis and the low back. The transverse abdominis can be turned on by gently pulling your lower belly/belly button in toward your spine and can be felt if you put your hands on the inside of your hip bones. Here are some transverse abdominis muscle exercises to begin to strengthen and improve endurance to allow you to move without pain and without wearing a belly band:

 

1. Transverse Abdominal (TA) Activation

Lay down on your back with knees bent, as you exhale gently draw your belly button in toward the spine as if you are putting on a tight pair of pants.

This should not be an inhalation but achieved through lower abdominal muscle activation Place your fingers on the inside of your hip bones to feel a slight muscle bulging under your fingertips.

Look out for signs of muscle fatigue and compensations: using your diaphragm (taking a big breath in) or pelvic tilting to achieve the movement, or upper abdominals bulging upwards, or your back arching up away from the floor.

 

Hold TA activation for 5 seconds 10x

Try TA activation in sitting and standing as well!

 

2. Unilateral Bent Knee Fall Outs

Lay down on your back with knees bent, as you exhale gently draw your belly button in toward the spine as if you are putting on a tight pair of pants.

This should not be an inhalation but achieved through lower abdominal muscle activation Place your fingers on the inside of your hip bones to feel a slight muscle bulging under your fingertips.

Look out for signs of muscle fatigue and compensations: using your diaphragm (taking a big breath in) or pelvic tilting to achieve the movement, upper abdominals bulging upwards, or your back arching up away from the floor.

As you maintain TA activation, slowly lower one knee out to the side and return back to starting position.

 

Maintain TA activation for 5-10 “bent knee fall outs” repetitions for 2 sets on each side

3. TA March

Lay down on your back with knees bent, as you exhale gently draw your belly button in toward the spine as if you are putting on a tight pair of pants.

This should not be an inhalation but achieved through lower abdominal muscle activation Place your fingers on the inside of your hip bones to feel a slight muscle bulging under your fingertips.

As you maintain that TA contraction, slowly lift one foot off the floor to 90 degrees (as shown below) and return back to the floor, alternate legs.

 

Perform 3 sets of up to 10 repetitions on each side

Look out for signs of muscle fatigue and compensations: using your diaphragm (taking a big breath in) or pelvic tilting to achieve the movement, upper abdominals bulging upwards, or your back arching up away from the floor.

 

TA March in 90/90 Position

Lay down on your back with knees bent and lifted to a 90 degree angle (as shown below), as you exhale gently draw your belly button in toward the spine as if you are putting on a tight pair of pants while activating your TA, slowly lower one heel down to the floor keeping your knees bent.

 

Perform 3 sets of up to 10 repetitions

This should not be an inhalation but achieved through lower abdominal muscle activation Place your fingers on the inside of your hip bones to feel a slight muscle bulging under your fingertips.

Look out for signs of muscle fatigue and compensations: using your diaphragm (taking a big breath in) or pelvic tilting to achieve the movement, upper abdominals bulging upwards, or your back arching up away from the floor.

Be sure to make an appointment with a pelvic physical therapist if you are having difficulty finding and activating your transverse abdominis, if you are experiencing pain with any of these exercises, or if you are finding these exercises too easy and pain free. Physical therapists can modify and progress exercises that are unique to you and your specific needs.

 

Pelvic Organ Prolapse

Pelvic organ prolapse is when your pelvic organs – bladder, uterus, or rectum is shifted or sitting lower than where it should. It is diagnosed by your gynecologist by doing a physical assessment of the vaginal canal, the doctor will ask you to bear down as if you’re having a bowel movement and movement or descent of the organs will be assessed and measured on a scale from 0 to 4.

The stage of the prolapse is not indicative of symptoms. Someone could have a stage 1 prolapse and feel more symptomatic than someone with a stage 4.

Symptoms of pelvic organ prolapse include vaginal heaviness or pressure, usually after activity or at the end of the day. Symptoms may also include dribbling urine after the urine stream has finished and incomplete bladder emptying.

Pelvic floor physical therapy can be helpful in managing and improving pelvic organ prolapse! A pelvic floor physical therapist can confirm staging of prolapse, measure pelvic floor muscle function, assess your breathing techniques, and assess your movement patterns to create an individualized program to help you to improve pelvic organ prolapse symptoms.

Poor pressure management can be a major contributor to pelvic organ prolapse. Poor pressure management may look like straining to have bowel movements, difficulty altering breathing pattern, or urinary incontinence with movement.

 

Return to sex

Sexual activity and penetrative sex may seem daunting after delivery and you may have even been cleared by your OBGYN at your 6-week check up for all activities, including sex! Pelvic health physical therapists can help to answer questions or concerns about sexual activity after delivery, assess your body and your pelvis/pelvic floor muscles, and treat you to alleviate any pain associated with sex.

Commonly after any surgery or muscle trauma, muscles around the area will protect you by tightening up. In other areas of the body, such as your arm, it’s easy to recognize and correct for clenching by seeing your arm being tense and telling your arm to relax. In the pelvic floor, it’s not always so simple because you can’t see your pelvic floor muscles and you may not be familiar with what a relaxed muscle state feels like. Pelvic physical therapists can help to recognize and treat this common muscular issue by teaching you various ways to reduce tension and improve potential pain during sexual activity.

If you are experiencing pain during or after orgasm it can be a result of a tight pelvic floor and can similarly be treated by a pelvic health physical therapist. An orgasm is a series of muscle contractions, and in an ideal world your pelvic floor muscles contractions during orgasm and relax completely afterward. If there is existing tightness in the pelvic floor prior to an orgasm it may be difficult for the muscles to untighten and relax, which may lead to pelvic pain.

Pain with sex or orgasm doesn’t have to be something you deal with yourself! You are not alone. Pelvic health physical therapists are here for you!

 

Pelvic pain, hip pain, back pain

Pain during the postpartum period is NOT normal! Do not let anyone tell you otherwise! Although pelvic, hip, and back pain are common, they are NOT normal! Pelvic pain may be due to muscle guarding following a vaginal or cesarean delivery. The pelvic and abdominal muscles often work together, and may be over-working in the weeks or months following delivery. Hip and back pain can also be a source of referred pain from the pelvic floor, as many hip and back muscles attach onto the pelvis, close to the pelvic floor muscles. It is also probable that hip and back pain are unrelated to the pelvic floor muscles and should be evaluated accordingly. Regardless of the cause of pelvic, hip, or back pain, or any pain for that matter…it’s advised that you schedule an appointment with a pelvic health physical therapist. A specialized pelvic health specialist will be able to ask pertinent questions related to your pregnancy, delivery, and postpartum to better understand your pelvic/hip/back pain, and will be able to assess your movement, conduct a series of tests, and determine the course of action to get you back to living without pain!

 

Returning to Exercise

Returning to exercise can be daunting in the postpartum phase, even if you have been cleared by your OBGYN at your 6 week follow up. You may not feel completely comfortable or yourself in your new postpartum body and the thought of returning to the exercise you did during pregnancy or pre-pregnancy may feel foreign and scary. Returning to movement does not have to be scary as long as you meet yourself where you’re at. Give yourself grace, allow yourself to move in ways that may seem easy or slow. Exercise will look different for everyone because everyone enjoys different types of movement. Walking can be a great place to start, but if you’re feeling unsure of what your limits may be based on your particular delivery history, pain, or previous injuries, consulting a pelvic physical therapist can be a helpful next step. A pelvic physical therapist can assess functional movements such as walking, squatting, and lifting/carrying, muscle strength, breathing patterns, and generalized fitness to prescribe an individualized exercise program to kickstart your movement/exercise journey!

 

Get help now from a pelvic floor therapist.