Pregnancy is a natural process....that being said it is extraordinary what happens to the body to produce, carry, deliver, and take care of a baby. We know that things like bladder and pelvic floor pressure, back pain, and ankle swelling are events to look forward to as the baby grows. However, there are so many other things that shift in the body to accommodate a growing fetus. There is a 50% increase in blood volume in the body to support the uterus and growing fetus with a 30-40% increase in cardiac output. Hips rotate externally to as the belly grows larger, which puts more pressure on the low back that is already increasing in lordosis. Intestines and other organs are displaced, which will affect bowel movements and can lead to constipation. The hormone progesterone can cause ligaments to relax as well as the esophageal sphincter, increasing the chance for joint pain and heartburn, respectively. There is also a chance for the separation of the abdominal muscles in a condition called diastasis recti and even an umbilical hernia. I have attached a link demonstrating the effects of a growing fetus to the woman's body below as well as a video of a woman in her 3rd trimester walking. Physical Therapists can educate women on how to perform perineum stretches to prepare for a vaginal delivery.
Video of growing fetus: https://www.youtube.com/watch?v=y72ULL0bLHU
Video of Pregnant woman walking: https://www.youtube.com/watch?v=FiLAbgLvs24
Pregnancy is one thing, but labor and delivery is another. Whether the baby is delivered vaginally or via cesarean section, the recovery by some mothers can be swift in a matter of a few weeks or take several months to years. Here in the United States, postpartum physical therapy is not standard protocol for new mothers despite substantial research determining its importance. In fact, the US system for new mothers is appalling with the highest mortality rate amongst the industrialized nations with the CDC estimating some 700 deaths per year. The CDC also estimates that 60% of those deaths could have been prevented with better access to medical care. There is also significant evidence that minority groups, women of color and younger mothers are at greater risk for death (1). Some things that women might endure during labor and delivery include: long labor with pushing and pelvic floor pressure from the fetus, vaginal tearing, episiotomy (the cutting of the perineum to allow more room for the fetus), and negative reactions to the epidural. Some women elect to have a cesarean section or due to fetal and/or maternal distress, one is necessary. This requires cutting through the abdominal wall, the peritoneum, and then the uterus. These tissues are spread, the amniotic fluid drained, and the fetus is removed from the uterus. The mother is then stitched back up and scar tissue takes weeks to fully form between all of the layers. Below is a link to observing a cesarean section incision on a live patient, so please be aware of the graphic nature of the video.
Now that we have discussed the effects of pregnancy as well as labor and delivery, let's now discuss postpartum challenges that many women face. Immediately following delivery, women who have torn vaginally or who had to have an episiotomy require stitching. A fundal massage of the uterus is also recommended to help the uterus return to its previous size and location (known as involution) as well as decrease the risk of hemorrhaging and painful cramping. After the placenta has been delivered, then the woman will undergo 6 weeks of peurperium- where the uterus sheds blood, mucous, and remaining amniotic fluids. The bright red blood is called lochia, and the color will decrease in intensity to pink and eventually a lighter yellow color. The pressure from late term pregnancy, several hours of labor as well as vaginal delivery cause weakness of pelvic floor muscles which can allow for incontinence. If the mother has undergone a cesarean section then she has several restrictions to maintain to maintain the integrity of her incision. This includes not lifting heavier than the baby for the first 2 weeks, significantly limiting housework, excessive stair climbing, and exercise beyond walking. It is recommended that women wear a binder postpartum to help with abdominal support.
Those are the more immediate effects of labor and delivery. When a woman has her 6 weeks check-up, usually the ObGyn recommends that the mother can return to intercourse and progress exercise, and general resumption of life. This is where I find many of my patients feeling lost and confused. They might not feel ready to return to intimacy with their partners because they are experiencing pelvic floor pain from tearing, are still experiencing incontinence, or are just not sure what to make of their body at this stage. A sudden drop in estrogen and progesterone causes a chemical shift in the brain and leads to a jumble of emotions which makes the mother question her ability to be a good mother, affects how well she sleeps on top of an already disturbed sleep cycle, and gives her a general sense of helplessness. "Baby Blues" lasts up to 2 weeks postpartum, but true postpartum depression requires a clinical diagnosis and usually lasts several weeks postpartum. Having an adequate support system is vital for new mothers and I wish the US healthcare system did more in regards to this. As a Women's Health PT, I feel that the work I do is vital in postpartum care.
Women's Health PT is more than just Pelvic Floor PT
Seeing a Women's Health PT within the first few weeks following birth has demonstrated time and time again effective in minimizing pain, improving pelvic floor functioning, scar tissue manipulation, decreasing and closing diastasis recti, improving core and lumbopelvic strength as the body recovers. Other benefits include postural stability for neck and shoulders as the infant increases in size and breastfeeding positioning changes, lifting education and return to exercise to help the new mother understand where to start and avoid injury due to hormonal changes that affect strengthening and stability. The new mother is also seeing the PT on a consistent basis, which provides an ally to communicate with the ObGyn if there are any red flags or symptoms of undiagnosed postpartum depression. Though I understand the importance of recognizing my skills as a PT that encompasses evaluating and treating the pelvic floor, I dislike using the term "Pelvic Floor PT" to describe what I do to treat my postpartum patients because it implies that I'm only evaluating their pelvic floor. In truth, I am doing visceral manipulation to help close diastasis recti and improve lymphatic drive for bowel function, performing joint mobilizations to the hips that have become tight over the last several weeks of pregnancy to improve gait, and educating my patients in what to expect and to not feel defeated when they feel overwhelmed. For women who are breastfeeding, I can help them when they experience mastitis or are having trouble with their milk letting down. Sleep positioning is another important aspect of following up with a PT for the mother's comfort and ability to rest and recover. A recent study demonstrated the correlation of utilizing Physical Therapy and self-esteem of postpartum women (2). We are not just someone the new mother can vent to, we are professionals that have solutions to problems and referral resources available, as well as someone to objectively look at their progress because it's sometimes hard to see when life is overwhelming. So, yes, pelvic floor therapy is a large part of helping the new mom recover to help teach her how to reeducate her pelvic floor and improve scar tissue mobility, but that's not all I do.
Postpartum Physical Therapy has gained traction over the past decade since I have become a Physical Therapist. This is very encouraging, but I still see so many women go without supportive therapy following her delivery. Women usually have to request to be sent to a Pelvic Floor PT from her ObGyn. Some states and insurances in the US require a referral from a doctor to see a Physical Therapist, which can delay proper care the new mother requires. Some ObGyn's tell the new mom to "just do kegels" and things will improve. If you have been reading this blog post and have had a baby, you would know that "just doing kegels" can be damn-near impossible when you aren't even sure what's going on with your pelvic floor and you're peeing yourself with every laugh and sneeze. We have a long ways to go in the US for pregnant and postpartum care, and I hope I can be part of that effort one patient at a time.
2. A Review of the Effects of Physical Therapy on Self-Esteem in Postpartum Women With Lumbopelvic Dysfunction
Crockett, Katie L. et al.Journal of Obstetrics and Gynaecology Canada , Volume 41, Issue 10, 1485 - 1496