In the next few weeks we are going to explain our role as physiotherapists in early postpartum following either a vaginal or caesarean section delivery. We will answer common questions we get asked from new mothers and what you should be doing to take care of your body and why.
Giving birth is one of life’s truly remarkable experiences and pregnancy and delivery (vaginal or caesarean section) are major events that bring about much change to your body and your life. Therefore, it is critical to understand how this process has affected you to enable optimal recovery postpartum and a safe return to exercise.
Pelvic floor muscles (PFM) undergo huge changes during pregnancy and during labour. A pelvic floor program after the birth of your baby is essential to reduce your chance of incontinence and prolapse, increase your sensation with sex, and improve your efficiency with higher impact exercise.
As women it is important to understand the risks and consequences of birth, how to care for your body following delivery, and what you should look out for following birth and returning to exercise in the first few days/weeks after birth.
1. How can your pelvic floor muscles/fascia of the pelvis be damaged during birth?
During a vaginal birth, the pelvic floor lengthens nearly 3 times its normal length to allow the baby to pass through the vaginal canal. Most of the time this happens quite smoothly, but sometimes the muscles of the pelvic floor become thinned (from the prolonged stretch), torn or pull of the bone (known as an avulsion). As the baby’s head moves through the birth canal nerves, ligaments and vascular structures can also become damaged. The PFM become sluggish, weak and lose their ability to control faeces and urine as the muscles heal and recover.
It is not only the muscles that can endure damage during a vaginal delivery, but the fascia and ligaments that support the pelvic organs in the pelvic cavity including the uterus, bladder and bowel. Pelvic organ prolapse is the descent of one or more of the pelvic organs, with heaviness and a vaginal bulge being some of the main symptoms. The prevalence of POP can be up to 50%, yet only 10-20% show to be symptomatic.
The main risk factors following vaginal delivery include a forceps delivery, long second stage (pushing phase), large baby (>4kg), 3rd or 4th degree tears, and episiotomy.
I highly recommend a pelvic floor postnatal check with a Women’s Health Physiotherapist from about 6 weeks after birth. Women who have experienced the following birth risk factors should make this a priority to ensure specific rehabilitation.
2. Following birth - what should you be doing?
Following delivery there should be many health practitioners and nurses around you to assist you with your recovery.
One of the main goals of physiotherapy following a vaginal or C-section delivery is to educate new mothers about the injury, provide early treatment, wound support, advice on normal activities and restrictions in the recovery period, and help commence early muscle rehabilitation to ensure long term function.
With any acute trauma whether it be a hamstring injury on the playing fields, to a broken bone, the normal acute management applies = RICE. This can be applied to the pelvic floor following perineal trauma e.g. tears, episiotomy. We want to make sure that women are not bearing down and placing strain on stitches. We want to provide the area with as much support as we can.
REST – of the pelvic floor muscles. You should usually avoid strong pelvic floor strengthening exercises for the first 24 hours to 1 week. In the first weeks aim for 10 low level, 0 hold regular contractions for circulation/coordination. Use a squeeze to protect the area when coughing, sneezing.
ICE – for the first 24-48 hours. Put a frozen glove finger in a maternity pad, 5-10 minutes every 2-3 hours and following this dry the perineum.
COMPRESSION – Use 1-2 pads with firm fitting underwear. If sitting is uncomfortable fold a towel/s under each thigh and gradually reduce as pain improves.
ELEVATION – Lie on your stomach to with 1 pillow under your head, stomach and two under your hips. This means your pelvic contents is not pressing on your pelvic floor muscles.
Normal activities - Passing urine can become very uncomfortable on the stitches or tender perineum. Use a ural or ural plus cranberry to reduce acidity on the area in the early stages and lean forward on the toilet to direct the urine away from the stitches.
"A caesarean section is an operation in which a baby is born through an incision (cut) made through the mother’s abdomen and the uterus (womb). The cut is usually made low and around the level of the bikini line. A caesarean section may be planned (elective) if there is a reason that prevents the baby being born by a normal vaginal birth, or unplanned (emergency) if complications develop and delivery needs to be quick. This may be before or during your labour." RANZCOG, (2019).
Pain control – Making sure you have adequate pain control to assist you looking after your new little bub and to be able to move. Discuss in hospital with your midwife or obstetrician.
Movement and lifting – You may find it difficult to move in and out of bed. Avoid using your abdominals by supporting the area when moving, roll to your side when getting up and use your arms to push up into sitting. Albeit not much, your baby should be the heaviest thing to lift over the next few days/weeks.
Posture – Following the surgery you may find it difficult to sit up straight as it pulls on your wound, take your time, take deep breaths in an upright position and slowly work towards better posture each day.
Bowels – It is very common to be constipated early on following a C-section. Take supplements if required and remember not to strain on the toilet.
Wound care - Your midwife and physiotherapist will guide you with the wound care in hospital. Keep the wound clean and dry as it heals. Wearing high underpants and a sanitary pad between the wound and pants will avoid irritation and rubbing on the wound.
Pressure garments – Your abdominals may feel very weak, feeling you have no support for your back. Tubigrip is great for abdominal support and can be fitted in hospital. You will also be wearing TED stockings to reduce your risk of deep vein thrombosis.
Abdominals and exercise – like with any acute injury you need to allow these muscles to heal and recover. You can begin with breathing exercises (which will help to facilitate your abdominals switching on). Your catheter, drip and wound drain (if you have one) will be removed in the first one to two days depending upon your recovery. Once these have been removed, it is important to take a gentle walk every day.
Postnatal exercises are especially important after a caesarean section to get your muscles working again, but take things at a gentle pace. The midwife or physiotherapist will tell you when you should begin them.
3. Early pelvic floor muscle contractions after birth. What to do in the first few days/weeks?
This is a time where there may be an exceptional amount of cuddles, joy and tears! Yet we still cannot neglect our pelvic floor muscles! Following delivery and if you have had any of the risk factors such as tears, forceps, long pushing stage, large baby >4kg, a physiotherapist may check to ensure the woman is not incorrectly putting strain on the stitches instead of protecting them.
As physiotherapists it is vital that we check the pelvic floor muscle contraction. In the first few days you may not see any activation due to pudendal neuropathy (where a nerve in the pelvis is damaged due to childbirth) in which its function should return within a few weeks.
In the early stages (and once catheter is removed in any situation) try do to 10 pelvic floor squeezes when you breastfeed your baby and use the amount of weeks as a guide. E.g. 0 week old baby : 10 low level, 0 hold regular contractions for circulation/coordination. 1 week old baby: 10, 1 sec strong contractions. 2 week old baby: 10, 2 second strong contractions. Make sure there is relaxation of the muscles following the contraction.
Again this is just a guide. Having a thorough assessment with a Women’s Health physiotherapist from 6 weeks will assist in further rehabilitation of these muscles.
4. When I leave hospital what do I do next?
Most women leave hospital with mixed emotions and feelings. This is normal! Always follow up with your GP if you have any questions regarding your recovery and if you are concerned about your emotional wellbeing. In some cases where the trauma to the pelvic floor is extensive they may need to be reviewed by their gynaecologist 3-6 months postpartum.
I highly recommend a pelvic floor postnatal check with a Women’s Health Physiotherapist from 4-6 weeks after birth. For an optimal recovery post pregnancy and birth it is critical to understand how the process has affected you. The physiotherapy assessment enables you to understand the specific areas of the body you need to rehabilitate, especially your pelvic floor muscles to enable a return to normal function, especially when returning to more demanding exercise.
Contact us today on 4454 2309 if you would like to follow up with any of our Women's Health Physiotherapists who can assist in your recovery whether it be a vaginal or caesarean birth.