Why Should Everyone See a Pelvic Floor Physical Therapist Postpartum?
Let’s start with what the pelvic floor is!
The pelvic floor is a group of muscles, ligaments and connective tissue that attach to the bones at the base of the pelvis and form a hammock. The pelvic floor consists of three layers of muscles including muscles of the pelvic wall (piriformis and obturator internus) which are deep hip rotator muscles (this is important because it shows the connection between hip function and pelvic floor function). The pelvic floor muscles have the 5 S’s of function including;
Support
Sphincter control
Sexual function
Sump pump (diaphragm and pelvic floor working together)
Stability, and they play a role in posture and breathing as the pelvic floor is the base of the deep core system.
The pelvic floor should be able to contract and relax and work in coordination with the respiratory diaphragm. The pelvic floor should be able to do so in a timely manner based on the demands of the activity (ie. difference demands on the pelvic floor with running versus walking) but this automatic process does not happen when there is dysfunction and often needs re-training postpartum.
Image used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM)
Image used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM)
What are 4 things that happen during pregnancy that make everyone need Pelvic Floor Physical Therapy postpartum?
Everyone focuses so much on how the birth was in deciding if they need to see a pelvic floor physical therapist postpartum. Or they focus on symptoms such as peeing your pants (urinary incontinence) when they return to activity. Both of these examples are great reasons to see a pelvic floor physical therapist but there are so many other reasons that go overlooked.
For example, just having been pregnant is enough of a reason to need to work with a pelvic floor physical therapist postpartum. Yes, that means everyone who is postpartum should work with a pelvic floor physical therapist. This is because the postural changes that occur during the 9 months of pregnancy have a major effect on your body function postpartum. As your posture changes due to the growing baby your body learns new ways to compensate (different muscles activate and shorten in response to body changes) and we need to re-train this posture and pattern postpartum to optimize your musculoskeletal function, pelvic floor function and for injury prevention. Here are some examples of how these postural changes impact function.
During pregnancy your thoracic spine becomes stiff and loses mobility. This can make your neck and low back compensate and by becoming too mobile. Your thoracic spine mobility impacts your pelvic floor as your pelvic floor and your respiratory diaphragm (which lives at the base of your thoracic spine) work in conjunction with one another. In order to have a pelvic floor that works well you need to have a thoracic spine that moves well. (See Image below).
Image used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM)
3. During pregnancy and postpartum your ribs and diaphragm get stuck in inhalation. Your diaphragm sits at the base of your rib cage and thoracic spine and your diaphragm gets shoved up, making your thoracic spine and rib cage stiff, making it harder to get a good breath, making it harder to properly use your core. Your rib cage remains expanded (anyone notice a larger bra size postpartum?) and you can get stuck in inhalation. The diaphragm gets flattened and shortened in the back and can become a postural stabilizer rather than functioning as a primary muscle of respiration. This is one reason it is so important to restore rib mobility and breathing during postpartum pelvic floor physical therapy as your breathing affects your pelvic floor. (See image above).
4. During pregnancy your abdominals lengthen! Your abdominal muscles stretch over the course of your pregnancy while the baby grows inside you. Once you give birth your abdominal muscles are still stretched out. The abdominal muscles can also become imbalanced, meaning they are not activating in a timely pattern that is supportive to your deep core system. In response your back muscles tighten and overcompensate. In postpartum pelvic floor physical therapy we need to retrain your abdominal muscles to strengthen/shorten and coordinate closer to their pre-pregnancy length and function and help the back muscles to stop compensating. You need your abdominal muscles to be working well in order to not have back pain!
Image used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM)
I could keep going! I haven’t even gone into the pelvic floor changes and pressure on the pelvic floor that happens from the growing baby. But you get the point that everyone needs to see a pelvic floor physical therapist postpartum, no matter what they are experiencing. Instead of asking “do I need to see a pelvic floor physical therapist postpartum?” the question you need to be asking is with your pelvic floor physical therapist; “how many sessions do you think I will need?” Once we change this mindset culturally we will be in a much better position to support postpartum women.
What can pelvic floor dysfunction look like postpartum?
Besides all of the postural changes that happen to every woman postpartum here are some examples of what more specific pelvic floor dysfunction looks like. In a research study by Palmieri et al, they found that almost half of postpartum women experience pelvic floor dysfunction1. However, please remember you don’t have to have one of these symptoms to benefit from working with a pelvic floor physical therapist postpartum because likely everyone has generalized postpartum weakness and postural changes from pregnancy.
Stress incontinence: leaking urine with sneezing, coughing, laughing, jumping, running or any other activity.
Urinary urgency/frequency
Pelvic heaviness (Pelvic organ prolapse)
Pelvic girdle pain/pubic symphysis pain
Hemorrhoids, fissures
Constipation and straining with bowel movements
Painful sexual intercourse
SI joint pain
Scar pain or scar immobility (c-section, perineal tearing or episiotomy)
Tailbone pain
Low back/Hip pain
Diastasis Recti (If a Diastasis is not healing we have to look at the entire deep core system which includes the pelvic floor to determine where the issue in pressure management is).
Image used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM)
What you really want to know! How pelvic floor physical therapy can help!
While all pelvic floor physical therapists have a different approach I am going to give you my approach to postpartum pelvic floor physical therapy.
First I start with a whole body external manual assessment where I use techniques from the Institute of Birth Healing to assess changes in the body from pregnancy and the birth process. For example some of the things I assess are:
Rib cage mobility
Thoracic mobility
Breathing/diaphragm function
Pelvic mobility and alignment (assessing if you are in an open birthing pattern)
External pelvic floor muscle assessment
C-section scar assessment
Assessment of core core strength
Assessment of hip strength and mobility
Diastasis Recti assessment
General posture assessment
A movement assessment
Second, and always pending consent and patient comfort I will do an internal pelvic floor muscle assessment. During an internal pelvic floor muscle assessment I am assessing the pelvic floor muscles to see if they are too tight or too loose, if they are strong or weak, if they can coordinate with your breathing, if they have good endurance and if they can do quick movements. If there is a scar from tearing or episiotomy I will assess the scar and scar tissue mobility. I am also assessing the pelvic floor muscles to see how they respond to you activating your deep core and if you are managing pressures and transferring load appropriately so there is less risk of prolapse. If there is concern for pelvic organ prolapse then a standing internal pelvic floor assessment is done to take gravity and functional movements into the assessment.
Once we know all of this information from the assessment we start a specialized treatment plan. This can look like exercises (which often consist of exercises from my Postpartum Corrective Exercise Specialist training) and manual techniques to release tight tissues and restore mobility.
What happens if the pelvic floor goes untreated?
The problem likely gets worse or lasts longer. Think of an injury somewhere else in the body. The longer you have the injury the longer it takes to treat and then longer it takes to heal. The sooner we get treatment often the quicker we heal and the less dysfunction occurs from compensation.
Should I wait until I am done with having babies to start pelvic floor physical therapy?
No! Please, please, please do not wait until you are done having babies to see a pelvic floor physical therapist. Ideally you would start to see a pelvic floor physical therapist before you became pregnant so we know your baseline.
Oh no I am 5, 10, 15 years postpartum! Is it too late to start pelvic floor physical therapy?
It is never too late to start! Let me say that again, it’s never too late to start! The changes that occur during pregnancy can last if we don’t treat them and retrain the system to optimize function. We can still assess your pelvic floor and see if you are in an open birthing pattern and optimize your movement patterns to optimize your pelvic floor function no matter how long ago you had children. In my opinion a pelvic floor physical therapist should be thought of as someone who you are going to be in a lifelong relationship with. Sometimes you need to see us more frequently. Sometimes you might just need a check in once in a while (hello hormones and menopause). But never think it is too late to start!
What’s even better than working with a pelvic floor physical therapist postpartum?
Working with a pelvic floor physical therapist during pregnancy! What’s even better than working with a pelvic floor physical therapist during pregnancy? Working with a pelvic floor physical therapist prior to conception and or when trying to conceive.
References:
Palmieri, Stefania, et al. “Prevalence and severity of pelvic floor disorders in pregnant and postpartum women.” International Journal of Gynecology & Obstetrics, vol. 158, no. 2, 4 Dec. 2021, pp. 346–351, https://doi.org/10.1002/ijgo.14019.
All images above used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM).
