Back in the stirrups again, I leaned back as I waited to see my doctor for my 8-week postpartum follow-up.
I had a c-section, and aside from the removal of my staples at 1-week postpartum, the only time I’d talked to any doctor since the hospital was when I cried to my new baby’s pediatrician about sleep deprivation and breastfeeding woes.
I’d been to so many appointments before the birth of my baby with eagerness and anticipation, but now I had my healthy baby strapped snuggly in her car seat carrier with me. This felt like one more appointment to check off before I moved into my new motherhood normal.
After my OBGYN ensured everything was healing as it was supposed to, let me cry (again), and headed toward the door, I quickly mentioned I was also having some sharp pelvic pain. She stopped short of leaving and said, “Oh, let’s get you a referral to physical therapy, there’s no reason you should have to be dealing with that kind of pain.”
“Oh, OK,” was all I said. But inside I thought, “I figured this pain was just part of the whole giving birth thing.”
Like me, many women think pain, leakage, or other issues are just part of the process and don’t mention it to their doctors for any number of reasons, including embarrassment. This can, unfortunately, be reinforced by others dismissing symptoms as “normal” or saying things like “well, you did just have a baby.” The expectation for women to “bounce back” quickly to their pre-baby selves, not to mention go back to work within 6 to 12 weeks, contributes to women feeling like they need to toughen up and deal with it, rather than speak up and ask about it.
The expectation for women to ‘bounce back’ quickly to their pre-baby selves contributes to women feeling like they need to toughen up and deal with it, rather than speak up and ask about it.
I spoke with two physical therapists, both moms themselves, who specialize in the pelvic floor and postpartum physical therapy—Katie Weingartz, PT, DPT, and Karen Munger, MSPT. Both helped answer some common questions about postpartum pelvic floor wellness and shared why it is so essential to our health before, during, and even long after you give birth. As Munger said to me, “So much preparation goes into the baby and very little for the moms.”
What exactly is my pelvic floor and why is it important to my health?
Weingartz explained that our pelvic floor is like a hammock that holds a number of important elements in place. Specifically, the pelvic floor is responsible for four key areas:
- Sphincter–the circular muscles that control gas and hold in waste (AKA poop and pee)
- Sexual–lubrication, arousal, penetration, vulvar care, pain syndromes, nerve impingements
- Support–collections of connective tissues, muscles, ligaments, and bones that hold things in place structurally. For example, your body supporting the baby growing inside you.
- Lymphatics–pumping and regulating fluid flow through the whole body, but particularly here in the pelvic region
So, yeah, it’s pretty darn important. Some countries, like France, actually recognize it as a medically necessary part of postpartum healing, and the government has even subsidized “perineal re-education” that helps strengthen a new mother’s pelvic floor. I’m conflicted about how much I want the government up in my pelvis, but it would be nice to feel informed enough to make my own choice about pelvic floor therapy.
How do I know if I need postpartum pelvic floor physical therapy?
Your six to eight-week appointment is to ensure your body is healed on the inside, but you’ll want to bring up any questions with your doctor or midwife, even before your appointment, as most postpartum physical therapy begins with a referral (and is usually covered by insurance).
“First-time moms especially don’t always realize what is normal and what requires more attention,” says Munger. Typical postpartum symptoms that can be helped by physical therapy, according to Munger, are diastasis recti (separation of your abdominal muscles), pelvic or tailbone pain, urine leakage when you cough, sneeze, or laugh that doesn’t improve, and bowel incontinence.
Additionally, since women often wait for intercourse until after their six to eight-week check with their doc, they won’t know if they have pain during intercourse until after the appointment, leaving the onus on them to follow-up if it doesn’t get better. (If you’re having pain during intercourse, you’re not alone—keep reading.)
“The most obvious and most urgent matter that needs a physical therapy consult is a separated pubic symphysis,” says Weingartz. “Although that sounds scary, it’s empowering to know what to look for.” The inability to walk without pain–as in you need a walker to walk–is a major indicator. The pelvis has cartilage keeping it together right in front of your bladder. It naturally changes from hard (like the bridge of your nose) to jelly during pregnancy to get ready to expand the pelvis to allow the baby’s head to go through during birthing. Sometimes, it doesn’t go back into place and causes severe pain.
What if sex is painful after baby?
Sex after baby can vary so much from person to person and, according to a study published in the BJOG, 83% of respondents experienced sexual problems within the first 3 months postpartum. Hopefully, sex gets better as you try again and continue to heal. The study shows problems lessen over time. But sometimes it doesn’t get better. Pain with intercourse is a common aftereffect of childbirth that can affect your relationship, but it can also be helped with physical therapy.
Vaginal births can include tears and episiotomies that can cause tightness from scar tissue, which can make penetration painful. C-section scarring can also feel tight and uncomfortable. Both can be helped in a few sessions. Other postpartum factors like vaginal dryness, tiredness, and low libido are common barriers women experience in enjoying sex after baby.
Again, it’s important to know you’re not alone and talking about it with your provider or physical therapist can be a first step towards fixing the problem.
I had a c-section, do I need to worry about my pelvic floor?
“It’s important to remember c-sections are abdominal surgery, and you wouldn’t have surgery without adequate rehabilitation,” says Weingartz. “The rectus abdominis muscle gets sliced open to safely birth your baby, so you are at risk of scar tissue immobility.”
This immobility can lead to feeling tension near your incision as you heal and return to your normal activities such as lifting, squatting, or lunging to take care of your infant. Some things you might learn from your physical therapist are proper ways of moving, lifting, and products that can ease some of the strain while recovering and healing from the abdominal surgery. For example, it’s important to leave your car seat carrier in the car or get a stroller for the car seat to easily click into. A recovering mother should not be carrying the heavy car seat.
How long will pelvic floor treatment take?
This varies from person to person, but some issues can be corrected in only a few appointments. For example, Munger shared diastasis recti and urinary incontinence can often be corrected in seven to eight visits. Pelvic or tailbone pain can take longer. She stresses these are common but fixable problems that are important to address.
What could happen down the road if I don’t get help with my pelvic floor now?
You just had a baby, and conflicts of time are a common frustration Weingartz sees from her patients. A mom herself, she understands sleep schedules, breastfeeding, returning to work, or dealing with childcare are all barriers to moms getting the care they need. But she also sees problems from patients later in life.
She shared that scar tissue building up over time can pull or restrict normal movement or normal organ movement inside your body, including adhesions to the bladder or bowel that affect normal urination or defecation.
Prolonged increases in intra-abdominal pressure without proper pelvic floor muscle contractions lead to the poor length of the muscle (too short or too long). Shortened pelvic floor muscles usually cause pain, and long pelvic muscles usually associated with or urinary or bowel leakage. But not always—some lengthened muscles can cause pain, and some shortened muscles cause symptoms of urinary or bowel leakage. A prolapse (organs starting to push or extend out of your vagina) can happen when the pelvic muscles and tissues can no longer support these organs because the muscles and tissues are weak or damaged.
If pelvic floor wellness is so important, why didn’t I learn about it until I had a baby?
Frustration with not being aware or able to access care earlier is a top complaint Weingartz hears from her patients, along with pain being deemed as “normal” with “suck it up” attitudes from others.
Both Munger and Weingartz stressed pelvic floor wellness is something we have to get comfortable with, much like breast health, and talking about it will help other women speak up and advocate for themselves and their wellbeing.
Bladder and pelvic issues can begin well before childbirth. Chronic pelvic pain is the most common referring diagnosis for women’s health services in 15-25% of women age 15-73 worldwide, according to The Journal of Women’s Health Physical Therapy.
Weingartz suggests that the childbearing years are such an important time to start talking to your kids about their bodies and their health too. “You want your kids to know it’s OK to say, ‘Mom, my vagina hurts,’ which can help them feel more comfortable saying the same thing to their own doctor in the future.”
In the years since my own postpartum physical therapy, I’ve often wondered whether I’d still be walking around with an unbalanced pelvis and a whole lot of pain. I’m so happy I spoke up when I did.