Fiona McMahon PT, DPT, PRPC
Believe it or not pelvic floor physical therapy has been around for a very long time. In fact, while digging through some old boxes from childhood, I found the pelvic floor exercises my mother had been given bedside nearly 40 years ago in Aberdeen, Scotland after she delivered me and my twin sister. That said, postpartum pelvic floor therapy has not been an expected part of post birth recovery in the United States up until very recently. It’s kind of wild considering the athletic endeavor of pregnancy and birth whether it be a vaginal birth or c-section birth, that we are not given immediate referrals to physical therapy to allow us to recover completely as we make the leap to motherhood. To state the abundantly obvious, our bodies go through tremendous changes during pregnancy, labor, and delivery. Not to mention, shortly thereafter you are expected to literally carry a tiny (but surprisingly heavy) human around with you as you go through your day-to-day life. It’s a lot and it can be even more with postpartum symptoms like weakness, pelvic pain, incontinence, back and upper extremity pain. That’s where pelvic physical therapy can come in to make life just a bit easier.
When to Start Pelvic Physical Therapy
Most people will want to start their pelvic floor therapy shortly after their 6 week OBGYN check up. You will be cleared for exercise and sex, but oftentimes, you’ll feel weak, won’t know exactly where to start, or be fearful of hurting yourself. Additionally the idea of penetrative sex so shortly after giving birth can feel completely overwhelming. These feelings are common. This is where pelvic physical therapy can come in handy. From addressing pain to safely reintroducing exercise, pelvic physical therapy can make knowing where to start far less overwhelming.
What about before the 6 week check-up? You certainly can come to pelvic physical therapy prior to your 6 week check-up, however we are much more limited on what we can do. Before 6 weeks we do not prescribe aggressive exercises or do internal pelvic exams. For folks that do come in, we often work on posture and body mechanics to minimize aches and pains while lifting or breastfeeding your baby. My honest piece of advice is if you are feeling relatively well, the 6 weeks before you can come into pelvic physical therapy is an excellent time to focus on resting (when you can), bonding with baby, and taking it easy. Allowing yourself to rest can lower your stress levels and allow your body to do the metabolic work of recovery so you are ready to take off when you come in at the 6 week mark.
Now, I am sure there are a fair number of you reading this blog with a pit in your stomach wondering if it is too late to come to pelvic pt. It’s not. I see loads of patients who are years out from their births. The pelvic floor is a muscle and muscles are trainable. What is important is that you come in when you are ready.
What Happens in Postpartum Pelvic Therapy
There is no one size fits all approach in postpartum physical therapy. As you may have noticed when comparing your pregnancy and birth story with other mothers, everyones’ experience is different, not to mention their postpartum goals. Protocols and one-size fits-all rehab, fails to recognize the individual needs and goals of new mothers. It is a disservice to provide one-size-fits-all rehab. Our lives, our goals, our bodies are all so wonderfully different from each other. Your goal may be to run a marathon or it may be to get up off the couch without leaking urine. Both goals are excellent but require vastly different therapeutic approaches. That said, (Fiona steps off of her soap box) there are some things that most pelvic floor therapists will want to look at when they first meet you.
Pelvic Floor
Call in Captain Obvious. Your pelvic floor physical therapist will want to look at your pelvic floor. But what are they looking for?
The pelvic floor includes the muscles that live between your pubic bone and your tailbone. Think of the area that makes contact with a bicycle seat. These muscles are responsible for stabilizing our pelvis, regulating waste (both pooping and peeing), sexual function, and supporting your pelvic organs. The pelvic floor is clearly a muscle group that we all have an interest in working well. These muscles do a tremendous amount of work during pregnancy and stretch substantially during birth. Sometimes we sustain tears or episiotomies within our pelvic floor during delivery. It is not uncommon for your pelvic floor to need a little TLC after birth.
We examine the pelvic floor in a couple ways. The first is an external evaluation where we see how the pelvic floor contracts and relaxes as well as assessing the state of healing of any scars from tears or episiotomies if present. The next step, especially if someone is having pelvic pain is a test called the q-tip test. The q-tip test involves using a q-tip to gently touch the inner lips (labia minora) to assess for sensitivity. The results of this test can be really helpful in determining if your pain is purely musculogenic or if there are hormonal contributions to your pain. Based on the results we will decide whether or not we need to collaborate with a physician/ physician extenders for extra support.
We also assess the pelvic floor by checking the muscles internally. What we are looking for is any tenderness or trigger points, prolapse, and how strong/ coordinated your pelvic floor is. All of these elements together can help us paint a clear picture of how to best help you. That said, internal vaginal exams can be intimidating for some, especially those who have had a history of trauma, which can include birth trauma. It’s important to remember that you should never feel forced to consent to any examination or treatment that makes you uncomfortable. You can wait and we can take our time.
Diastasis Recti
Diastasis recti (DR) is the separation of the rectus abdominis ( 6-pack muscles) during pregnancy. We can also see it in kiddos under 3 months as well as some adults who have never had babies but have core weakness, visceral restriction, or postural habits that prevent closure of the rectus abdominis.
DR itself is not abnormal during pregnancy. It becomes a problem when the rectus abdominis fails to reunite after birth. We see most folks with closure of DR by 12 months and many (almost 60%) at 6 weeks. DR can result in feeling weak and unstable in the core, back pain, incontinence, and even pelvic pain. Addressing any DR is a key part of postpartum rehab.
A skilled clinician is a must for diastasis rehab. We want to ensure we are getting to the main factors that are leading to the failure of your DR to close. Posture, strength, and pressure system management all contribute to DR and will need to be addressed in addition to strengthening alone.
Additionally, as our pregnancies progress, the fetus will displace or move our abdominal organs which can lead to areas of tightness or restriction on the back abdominal wall (posterior parietal peritoneum) which can create tension in the front of the abdominal wall preventing closure of the diastasis. Visceral mobilization (VM) can be tremendously helpful to allow closure of DR. It’s important to note not all physical therapists are familiar with visceral mobilization. If receiving VM is something that is important to you in your rehab, remember it is never impolite to ask you PT about their training. Ember physical therapy does provide VM.
Incontinence
“It’s normal to pee a little when you sneeze after having a baby”. This sentence sounds like nails on a chalkboard in my head when I hear it. Dealing with incontinence is a common postpartum symptom but it is not normal and you can benefit a great deal from pelvic floor physical therapy.
Many folks will turn to Kegels as their first line at home remedy, and honestly it is not my favorite strategy. Kegels can sometimes be helpful, but they don’t always get to the true cause of postpartum incontinence.
The first thing we need to think about when we think about incontinence is the mobility of the pelvic floor. Of course a loose and weak pelvic floor will have difficulty maintaining continence, but did you know that a tight pelvic floor will also be weak and have that same difficulty? An analogy of often use is, imagine I send you to the gym and tell you to curl the heaviest weight you can, but I don’t allow you to fully straighten your arm. You can imagine that what you would be able to lift would be substantially less than what you could lift if I allowed you to use the full range of your arm. This is what happens with a tight and weak pelvic floor, it simply does not have enough range to generate the strength it needs. For folks with a weak and tight pelvic floor, exercises like Kegels may make symptoms of incontinence worse. Instead we work on lengthening the pelvic floor to help allow the pelvic floor to have the range of motion it requires to generate enough strength to stay continent. For folks who have a purely weak and loose pelvic floor, we can start with kegels, but incorporating compound movements like squats and lunges can activate your pelvic floor muscles in manner similar to that of a Kegel but also provide other benefits by strengthening more muscle groups.
In addition to your pelvic floor strength and mobility we will also look at how your body jumps and bumps. Many folks will experience leakage with jumping, lifting, and running. If we just strengthen the pelvic floor, and ignore how we manage force when landing from a jump or struggling to lift, we are missing a key part of continence. In addition to traditional pelvic floor therapy for incontinence, you may be surprised to work on plyometrics, weightlifting, and breathwork to help your body better handle the bumps and jostles of everyday life and to reduce the amount of work your pelvic floor has to do.
Painful Sex
Painful sex is another postpartum symptom that is common but is treatable with physical therapy. The technical term for painful sex is dyspareunia and can occur whether or not you have had children. In folks that have had babies the prevalence of dyspareunia is estimated to be 31.4% at three months and 11.9% at 24 months.
Painful sex can occur postpartum due to tenderness around episiotomy scars. Pelvic floor tightness can be caused by either reactive spasm, poor posture, or pelvic floor overwork during and after pregnancy.
Pelvic floor PT for painful sex can include scar massage and desensitization, myofascial release to the pelvic floor, as well as retraining postural and movement practices that result in the pelvic floor becoming tight and painful.
Prolapse
When I speak to new mothers, prolapse tends to be the most fear-inducing symptom that occurs post-partum. Prolapse can be severe or minor and the most severe cases may need surgery. However, conservative management (physical therapy) can be effective in reducing the severity of prolapse and eliminating symptoms all together.
Prolapse is most effectively treated when we not only look at the pelvic floor but above and below it. Prolapse occurs from a combination of stretched supporting connective tissue of the organs failing to support the pelvic organs as well as the pelvic floor failing to support the organs. It seems obvious that we would look first at the pelvic floor when approaching postpartum rehabilitation. Strengthening can be a key component, but so is managing the pressure from above. A prolapse patient who is suffering from constipation may get a program of constipation management to reduce the straining instead of straight strengthening of the pelvic floor.
In addition to improving the pelvic floor’s ability to support the pelvic organs a truly holistic approach will include strength training the reduces how hard the pelvic floor has to work to support the pelvic organs by strengthening the lower body to better absorb shock from everyday activities like walking and jumping as well as strengthening the upper body to reduce breath holding a subsequent pressure on the pelvic floor from activities such as lifting your baby.
But I had my baby years ago, is it too late for me?
Though in a perfect world, we would see every new mother at 6 weeks. It simply doesn’t always happen. Life, schedules, raising a brand new baby gets in the way. Don’t beat yourself up. Life is about priorities and sometimes pelvic physical therapy has to be on the backburner. Seeing folks earlier has its advantages usually resulting in a quicker recovery and less time and money spent at PT overall. That said, I have seen many patients years out from their deliveries do wonderfully in pelvic physical therapy. The best time to come in, is when you are ready and can commit to a home exercise plan and regular sessions.
Next Steps
Pelvic floor issues after pregnancy can feel isolating and embarrassing. I’m here to tell you that you are not alone. Pelvic floor dysfunction affects 1 in 3 people with female anatomy whether or not they have had children. I am fortunate to have been able to walk alongside hundreds of women recovering from pelvic floor dysfunction and there is so much hope.
Schedule a Consultation:
It is so important to make sure you find the right place for you when selecting pelvic floor physical therapy. Experience, treatment philosophy, education, and personalities all vary. There is no one set standard for pelvic floor physical therapy and it is important to find the right match.
At Ember, we offer free 15-minute phone consults to allow you to speak with Fiona prior to scheduling your first appointment.
Call 551- 244-1186 or email Fiona@emberphysicaltherapy to set up your phone consultation.
About Fiona
Fiona has been practicing as a pelvic floor physical therapist since 2015. In 2023 she moved from practicing in a busy pelvic floor clinic in NYC to opening her very own clinic, Ember Physical Therapy in Ho-Ho-Kus, New Jersey. The foundation of her practice is offering individualized, holistic, and compassionate care to allow her patients to reach their goals and return to the fun things in life without worry. Fiona offers private 1:1 treatments with text and email access outside of sessions.
Fiona completed her Doctorate of Physical at Columbia University and continued her pelvic floor and orthopedic training through the Herman and Wallace Institute, The Barral Institute, Th Institute of Physical Art, and The Prague School. She holds the PRPC certification denoting over 2,000 hours of experience and successfully completed the certification exam. She also has been published in Sexology International and has co-authored the physical therapy chapter in the Textbook of Female Sexual Dysfunction and Dysfunction: Diagnosis and Treatment.
Outside of pelvic floor physical therapy Fiona enjoys running, lifting, and yoga. Great books, soft sweatpants, and her family.
Sources:
Bø K, Anglès-Acedo S, Batra A, Brækken IH, Chan YL, Jorge CH, Kruger J, Yadav M, Dumoulin C. International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training. Int Urogynecol J. 2022 Oct;33(10):2633-2667. doi: 10.1007/s00192-022-05324-0. Epub 2022 Aug 18. PMID: 35980443; PMCID: PMC9477909.
Brandi Kirk, Teresa Elliott-Burke,The effect of visceral manipulation on Diastasis Recti Abdominis (DRA): A case series,Journal of Bodywork and Movement Therapies,Volume 26,2021,Pages 471-480,
Gruppe S, Engh ME, Bø K. What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Braz J Phys Ther. 2021 Nov-Dec;25(6):664-675. doi: 10.1016/j.bjpt.2021.06.006. Epub 2021 Jul 21. PMID: 34391661; PMCID: PMC8721086.
Rosen NO, Dawson SJ, Binik YM, Pierce M, Brooks M, Pukall C, Chorney J, Snelgrove-Clarke E, George R. Trajectories of Dyspareunia From Pregnancy to 24 Months Postpartum. Obstet Gynecol. 2022 Mar 1;139(3):391-399. doi: 10.1097/AOG.0000000000004662. PMID: 35115480; PMCID: PMC8843395.