As a women’s health physiotherapist I often feel disappointed how our society takes pregnancy and childbirth for granted. I guess because we are surrounded by pregnancy daily and we are all a product of it somehow we ‘normalise’ this extraordinary ability and generalise that women should bounce back to their pre pregnancy stature, strength and stability weeks after pushing an 8lb+ baby through the birth canal or having abdominal surgery to deliver the baby. We somehow forget the major physical changes women’s bodies go through during this time.
Without going into too much detail, consider about 40 weeks of muscle and fascia getting more and more stretched to allow foetal growth. Ligaments becoming lax to allow more pelvis movement and carrying another 30lbs of weight give or take. During the delivery process if you are one of the lucky few who is able to give birth to a baby without the pushing phase exceeding 40 minutes, having no episiotomy or tearing and no assisted help, believe it or not you too will have muscle, fascia and neural compromise.
But for most ladies this dream birth plan goes out the window as you are faced with hours of pushing, episiotomies, forceps or vontouse delivery and cesarean section. This leaves the pelvic floor and abdominal muscle, fascia and nerves injured. If not correctly treated and strengthened this will most certainly lead to incontinence which is an involuntary loss of urine, gas or stool. There is a host of other symptoms also associated post-natally that gets brushed under the carpet. The list includes pelvic organ prolapse, pain during sex, back,hip,groin and vulvovaginal pain, diminished or absent orgasm, urinary frequency, urgency, or constipation and difficulty evacuating your stool and having a hard time with exercise to mention a few. There is an attitude of acceptance that these symptoms are ‘what to expect’ and somewhat ‘normal’ after you have a baby.
In addition, a very common abdominal issue that arises with pregnancy and doesn’t matter what method the baby was born by is something called a “diastasis recti.” A diastasis recti is a separation of the rectus abdominus or “six pack” abs from their central tendon. The ab muscles run down the front of our tummy and almost always separate to accommodate the growing baby. Most separations will return to normal up to 6-8 weeks post baby however some women will experience an increased gap that can actually get worse instead of better due to the demand of daily life, poor posture and an incorrect exercise regime. This can be very stressful for a woman, and has been linked to incontinence, back pain postpartum and promotes poor self image.
It is not as simple as asking a new mother hours after delivering their baby ‘make sure to do your kegal exercises’ and assume they will and know how to do a pelvic floor exercise. In fact, according to one study, 83% of college educated women do not know about the pelvic floor
muscles and the role they play in pregnancy and delivery. Studies show that 40% of women who are told to do their kegals by their healthcare providers aren’t doing them correctly, so it would seem that verbal instruction isn’t enough. Women need to be assessed internally for any muscle dysfunction. If and when the dysfunction is managed, only then should they be shown how to do a pelvic floor contraction. It is simply not enough and ineffective to verbally talk through the contraction. These muscles are deep, you cannot see them so there is clearly no way to ascertain their functionality or strength without palpation.
France is perhaps the country that is the most advanced in the care of post-partum women. In France, it’s the standard of care for every new mom to receive physiotherapy after she delivers a baby. Specifically, after giving birth, women are prescribed 10 to 20 sessions of physiotherapy designed to strengthen and rehabilitate the muscles of the pelvic muscles. In addition to these initial appointments focused on the pelvic floor, 10 additional visits are prescribed that are primarily aimed at treating the abdominal wall for diastasis recti issues.
The main goal of the program is to prevent postpartum incontinence and pelvic organ prolapse, and to restore sexual function—all major factors in a woman’s health and well-being. France’s postpartum rehab program is proven. Studies show that the implementation of this aftercare significantly reduces incontinence and pelvic pain at nine months after giving birth.
Slowly inroads are being carved out in Ireland as some Gynea, GP’s and PHN are starting to prescribe postpartum physiotherapy. But, there is still much work to be done to get the word out so that adequate recovery/rehabilitation guidance becomes the new norm here in Ireland. Education must be engaged during the ante natal stage and the wool removed from women’s eyes going into the delivery stage. Information, preparation and acceptance are vital for women before they deliver their baby.
I believe it would be beneficial for all new moms to have their pelvic floor evaluated 6 weeks post-natal. This kind of early intervention can help address any concerns and ultimately enable women to return to functional and active lives while possibly preventing future pelvic floor dysfunction.
A post-natal physiotherapy appointments should consist of:
A detailed subjective history: This part of assessment is as important as the physical. It can take sometimes the whole initial appointment to speak through symptoms as it may be the first time a woman has actually opened up about how she is feeling. Following the initial chat, all areas from obstetrics history and pelvic pain to diet and exercise are discussed at great length.
Musculoskeletal Examination: This includes an assessment of structure, muscles, tissue. An internal manual evaluation of the pelvic floor muscles to identify how the pelvic floor contraction is performed, what grade of power and endurance there is. The manual assessment also palpates problematic muscles and scar tissue.
Diastasis Recti Examination: Studies show that more than 50% of women have a diastasis recti after pregnancy. Standard exercises, Pilates, and Yoga can make this problem worse and should only be introduced after the diastasis recti is addressed. Specific exercise, lifestyles changes and sometimes binding can be appropriate initially.
As women, we need to make sure we don’t lose sight of how important our own health and happiness is. It is important not to accept the symptoms that have happened after you have had a baby but to take the steps necessary to get back control of your body mind and life.
Laura Ward MISCP, B.Sc (physio) Women’s Health