It's incredible how much our bodies evolve after pregnancy and childbirth. As a parent and a pelvic floor physical therapist, I truly appreciate the physiological and biomechanical changes in my body, especially my pelvic floor, since the birth of my children. But as an athlete (or a former athlete, I should say), it's so easy to be tough on myself and wish my pre-pregnancy body magically re-appear. When I have these thoughts, the PT in me has to step in quickly to keep things in perspective. Realistically, it takes at least a year before most new birthing parents start to feel like they are a fraction of their former physical selves. Unfortunately, pelvic health services in the US continue to be an afterthought for our postpartum population. In countries like France, postpartum people receive 10 to 20 sessions of government-subsidized la rééducation périnéale, (or "perineal re-education") that is the cornerstone of French postnatal care. On the flip side, we typically get one six-week postpartum appointment here in the US. That's it! Unless there are any huge concerns like an infection or bleeding, you are generally cleared to return to all your pre-pregnancy activities. Most new parents, especially first-timers, have no idea what to expect regarding their postpartum recovery. It's incumbent on them to educate themselves on caring for themselves and when to ask for help. 

What can you expect at your first Pelvic floor therapy appointment?

Working with a Pelvic floor therapist can be powerful in offering the support every new parent needs in healing their bodies. I recommend scheduling an appointment shortly after that six-week postpartum check with a midwife or gynecologist. Expect to work with your therapist in a private room at your first appointment. It can be tough to talk about really sensitive topics around poop, pee, and sex, so know that your therapist will be prioritizing providing a safe and compassionate environment where you can share more about what you've been going through. Your therapist will ask questions about your physical goals, give a short anatomy lesson and do a physical exam. They'll look at your posture, watch you move, test your strength and even see how you breathe. An internal vaginal and/or rectal exam is usually done at the end if needed, and that gives them more specific information about how your pelvic floor muscles are working. By the end of that first appointment, you should walk out with a game plan on how therapy can help you and what you can start doing at home.

The first step in figuring out whether or not you might need pelvic floor therapy is recognizing what healing properly postpartum looks like–and what you don't have to live with. So, for all the new mothers and birthing parents, here are the top five things you should know about your postpartum pelvic health and what you can do about them. 

What is the pelvic floor and what happens to the pelvic floor after birth?

The pelvic floor muscles are a group of muscles that connect the tailbone in the back to the pubic bone in the front of the body. They help with bowel, bladder, and sexual function and form the supportive bottom layer of the core.

With postural changes and trauma that occur during pregnancy and childbirth, these pelvic floor muscles are directly impacted, resulting in various symptoms. Here is a breakdown of the five most common things every postpartum person should know about their pelvic health.

1. After your doctor gives you the thumbs up, sex should not hurt.

Plain and simple! Painful sex, or dyspareunia, is persistent genital or pelvic pain before, during, or after sex. The most common reasons for this are:

Low estrogen levels: Estrogen and progesterone levels drop immediately after delivery allowing milk production. Over time, these hormonal changes can cause symptoms similar to menopause, such as decreased libido and vaginal dryness. This can lead to friction, irritation, and pain during sex.

Scar tissue: It is normal for the body to create scar tissue after c-sections, episiotomies, perineal tears, and tail bone fractures. However, they can have a pulling effect on the connective tissue surrounding the muscles in the pelvic floor and pain during sex. Massaging scar tissue can reduce pain. 

Involuntary muscle spasms: The pelvic floor muscles (independent from scars) can develop involuntary spasms in response to trauma. With scar tissue restrictions and involuntary muscle spasms, women will typically report deep pelvic pain during or after sex that can even refer to the abdomen or hips. 

2. No amount of peeing when you cough, sneeze, or exercise is necessary.

Postpartum urinary incontinence typically comes in three forms: Stress, urge, and mixed incontinence. Stress urinary incontinence (SUI) occurs when you leak urine after you forcefully laugh, cough, sneeze, jump, run, or lift weights. Urge Urinary Incontinence (UUI) occurs when a sudden urge to urinate, and accidental leakage occurs before getting to the bathroom (even though the bladder may be nearly empty). UUI is also referred to as having an 'overactive bladder.' Mixed Urinary Incontinence (MUI) combines both SUI and UUI. Incontinence in the postpartum population can result from anatomical changes to the bladder and urethra from the weight of the baby. Studies using ultrasounds have shown that the angle between the bladder neck and the urethra increases, producing a larger bladder neck opening. This structural change can cause urine leakage even with minimal exertion. Incontinence can also occur due to hormonal changes that cause increased pelvic floor elasticity and decreased bladder support. Mechanical trauma to the pelvic floor from instrument-assisted deliveries like forceps, episiotomies, and perineal tears can result in scar tissue muscle or nerve injury and limit how well the muscles function. If peeing when you laugh stops being funny, it's never too late to work with a PT to address it.

3.Safely working on your post-baby belly is essential to support your spine and abdominal muscles.

The pressure of the growing uterus on the abdomen can cause the 'six-pack' muscles (the rectus abdominis) to separate sideways. When the abdominal muscles move apart, the uterus, intestines, and other organs only have a thin band of connective tissue right through the middle of the abdomen (the linea alba) to hold them in place. Because the influx of pregnancy hormones causes the linea alba to soften and weaken, the belly sticks out. This condition is referred to as Diastasis Recti. Why is it important for you to know if you have diastasis recti? Separated muscles are weak and cannot do their job of supporting the spine and abdominal organs efficiently. Without learning how to engage the deep abdominal muscles properly, symptoms can worsen, so you need to rehabilitate the entire group of core muscles carefully.

4. Protect your pelvic organs by treating pelvic organ prolapse.

During pregnancy, hormonal changes soften the pelvic floor's supporting structures, making them more elastic. These muscles can quickly weaken, resulting in a condition known as pelvic organ prolapse (POP), the descent of the pelvic organs like the bladder or uterus into the vagina. Factors that can increase the risk of POP include traumatic delivery, chronic constipation, pelvic floor muscle weakness, being overweight, and having more than one baby. Most women and birthing people will describe prolapse as a 'bulging sensation' in the vagina, especially after standing for a long time or difficulty inserting or retaining tampons. Strengthening your pelvic organs with the help of a PT or exercises you can do at home. 

5. You can treat your scars.

After c-sections, perineal tears, and episiotomies, Scar tissue formation is a normal part of the healing process. However, what often gets overlooked are the problems scarring creates after the 6-week postpartum follow-up. When scar tissue forms, it lays down in a haphazard pattern, sticking to the fascia (connective tissue) and organs in the abdomen. This pulling creates a crushing effect that can impact the bladder, colon, and uterus, resulting in constipation, urinary frequency, pain with sex, low back pain, and pelvic pain. Massage can reduce scar tissue and minimize discomfort.

Recognizing that these are all issues that you do not have to live with means you are already on the right track. The next steps include some simple things you can begin to adjust in your everyday routine.

• If you have leakage, any pelvic pain, or weakness in your core or pelvic floor, ask for help. Talk to a friend, connect with new parent groups, speak candidly to your OBGYN or midwife, and ask for a pelvic floor PT referral. These aren't symptoms you should live with. If you're several months or years postpartum, you are not alone, and it's not too late to get the support you need to heal fully.

• If you have pelvic pain, focus on learning how to stretch and relax your pelvic floor muscles. As important as it is for these muscles to be strong, it is just as important for them to be soft, pliable, and pain-free. Child's pose, deep squats, and pigeon stretch are great exercises to help this. Here is an excellent video of pelvic floor stretching exercises that you can check out.

• If you had a perineal tear or a c-section, massage your scar. Massaging helps to improve blood flow, reduce tension and decrease pain. Here's how to start. Using your finger or medical devices like a pelvic wand or vaginal dilator vaginally can be very effective for perineal and episiotomy scars. Intimate Rose ® is a fantastic resource for safe, self-treatment tools. 

• If you have pelvic organ prolapse or diastasis recti, work on learning how to strengthen your pelvic floor and core. The key is learning how to work these muscles properly while doing different activities that mimic your daily life. Working with a Pelvic PT on this can be very helpful, but you can also check out trusted resources like 'POPUp: An Uplifting Guide' created specifically for people with prolapse.

• If you have constipation, use a squatty potty or a footstool when using the toilet. This facilitates a healthy toilet posture, improves your bowel health, and reduces pelvic organ prolapse.

In the meantime avoid…

1. • Straining when using the toilet. Bearing down and holding your breath to use the restroom can make prolapse or diastasis recti worse.

1. • Doing Kegels if you are having pain with sex or if Kegels are painful. If you are experiencing this pain, you most likely have a muscle spasm in your pelvic floor muscles, and trying to strengthen them would be counterproductive.

1. • Doing high-impact exercises less than 12 weeks postpartum. There is almost six times more risk of developing pelvic floor dysfunction with high-impact exercise than low-impact exercises. So steadily building strength as your postpartum body heals is key.

Ann Nwabuebo, PT, DPT, PRPC is a Doctor of Physical Therapy and the founder of Body Connect Physical Therapy in Philadelphia, PA. She specializes in treating pelvic health and chronic pain conditions for all genders. As a mother and someone with a history of pelvic pain, she is interested in working with the prenatal and postpartum population. She is a strong proponent of wellness and prevention and strives to empower her patients throughout their childbirth journey.