Taryn fills us in on Recovery From Vaginal Birth, and shares what no one else is likely to tell you!
A vaginal birth is often referred to as a ‘natural birth’, and the general assumption is that you should be able to return to exercise and activity relatively quickly afterwards. After all, you didn’t have surgery like with a Caesarean, so surely the medical all-clear at 6 weeks is enough to get back to the gym?
But, as physiotherapists who work in the area of pelvic health, know, it’s a huge event for a baby to pass through the pelvis, right through the middle of the pelvic floor muscles, and injuries are very likely to occur.
Our bodies are amazing and most women will recover very well from these issues, which are often similar to sporting injuries. However, many women never have their pelvic floor muscles and surrounding tissues properly assessed after childbirth, especially if they have no symptoms, and so they go back to exercise and daily activities without knowing if they are in a high-risk category for future problems like vaginal prolapse.
Possible injuries that can occur during a vaginal birth
Injury can occur to the muscles, the nerves and connective tissue as the baby’s head (or bottom/feet in a breech birth) descends into the pelvis and then through the middle of the pelvic floor. This means that these injuries can also occur in a woman who has had a Caesarean section after going through labour.
If the labour is prolonged, these injuries become more likely because everything is on stretch for an extended period of time.
It is also more likely if the second stage (the pushing stage) is quicker than usual, and the baby passes very suddenly through the pelvic floor without the chance for everything to stretch gradually.
A common injury is to the pelvic floor muscles where they connect at the front to the pubic bone. It is a ‘U shaped’ muscle that goes from behind one side of the pubic bone, around the back of the urethra, vagina and anus, and then connects onto the back of the other side of the pubic bone. These ‘arms’ of the pelvic floor can be so stretched, either by the baby or commonly by forceps, that they can tear away from the pubic bone, which is called a ‘levator avulsion’.
Another area that can be injured is the perineum, which is the skin and tissue between the back of the vaginal opening and the front of the anal opening.
Perineal tearing is graded from 1-4, with first-degree tears being only the skin, second-degree tears involving some of the pelvic floor muscles, and third and fourth-degree tears extending into the anal sphincter muscles. An episiotomy (where a surgical cut is made) is usually the equivalent of a second-degree tear.
Most tears are first or second degree and are unlikely to cause long term issues, with third and fourth degree tears making it more likely that the woman will have difficulty controlling wind or faeces in the future. It is highly recommended that pelvic floor and anal sphincter muscle function should be assessed after any tearing to identify weakness early that can be optimised.
And finally, it is very common during a vaginal birth for the pelvic fascia to be damaged. This is the connective tissue that helps to hold our pelvic organs (bladder, uterus and bowel) in place, and so stretching or tearing of this can lead to the organs dropping down over time. This is called ‘pelvic organ prolapse’.
How physiotherapists can assess and manage vaginal birth injuries
Immediately after a vaginal birth, there is often swelling and pain in the vaginal and perineum. Physiotherapists can help with this, by giving advice on making daily activities like going to the toilet, getting out of bed and sitting on a chair more comfortable, and gently restarting pelvic floor contractions and a walking routine.
At this early stage, some physiotherapists will apply therapeutic ultrasound to the perineal area to help to decrease the swelling.
It is very important to note that in these early weeks as women get back into movement and physical activity, that vaginal heaviness should be noted. This is usually a sign that the pelvic organs are not well supported, and that the woman should take care to decrease the load on that area and spend more time resting in positions where gravity isn’t going to cause downward movements of the organs.
At a postnatal assessment, which usually occurs at 6-8 weeks after birth, a physiotherapist can assess your pelvic floor muscles after giving birth with either a real-time ultrasound machine or with a digital vaginal examination.
This real-time ultrasound can be done through the perineum, which gives a lot of additional information, however with most physiotherapists it is usually done through your lower tummy. It is important to note that if this is the only way you’ve had your pelvic floor assessed, with an ultrasound on your lower abdomen, that birth injuries won’t be able to have been diagnosed. Although it is a good screening assessment to see if you can elevate the bladder base when you contract your pelvic floor, it can’t assess pelvic floor strength, or the presence of a prolapse, or your risk of developing prolapse in the future.
The information that a pelvic health physiotherapist would gain from an assessment that included looking at the perineum and then doing an internal assessment would include a measure called ‘GH+PB’, which assesses how moveable everything is with straining or pressure, and gives an accurate risk profile for whether you’re likely to develop a prolapse.
They would also test to see if there was likely to be a levator avulsion (as mentioned before, this is a tear of the muscle away from the pubic bone), and other pelvic floor measures like strength, endurance and whether you can coordinate it with breathing and loaded exercises.
Management would then involve a very individualised program that is likely to include pelvic floor exercises, advice on return to general exercise, and education on other aspects of your life that can help or hinder your recovery, like how to go to the toilet and lift your children without unnecessary strain.
Some women at this stage might benefit from a support pessary in the vagina, to allow them to get back into movement and exercise without their prolapse worsening.
How to know when you’re ready to increase your exercise after a vaginal birth
It is completely different for every woman as to when they are ready to increase their exercise loads! Beware of recipe recommendations such as ‘at three months do x, and at four months do y’ – because as mentioned previously, every woman will have different birth injuries and recoveries, plus different baseline fitness levels, and the rate of return to exercise will vary greatly between individuals.
Generally, in the first month or two after a vaginal birth, women can safely return to modified exercise such as stretching, gentle core exercises, relatively low load strength work and slowly increasing low impact cardio exercise like pram walking (taking care to monitor for symptoms of vaginal heaviness or pain).
If you would like to know more about exercise in this very early postnatal period, you can see the FitRight video series called ‘The First Six Weeks’, or join the FitRight Mums – Members Only group for a library of graded, low impact exercise programs.
From the postnatal physiotherapy appointment at 6-8 weeks onwards, everyone’s exercise aims, goals and progressions will be very different. This is the time when the FitRight Baby&Me six week exercise courses can be commenced, either Studio, Aqua or Online, which are able to be individualised to suit the participants.
If you’d like to know more about returning to running and high impact sport, please see our blog called ‘What You Need To Know About Your Return To High Impact Exercise After Childbirth’.
Many thanks to physiotherapist Jess Vanson for collaboration on this article.