The early weeks and months after giving birth are a blur. Sleep deprivation, adjusting to new challenges, learning new skills – as beautiful and awesome as this time is, it’s an accomplishment just to make it through each day.
Which is why it’s a big ask to advise a new mother at 6 weeks postpartum to not only get to appointments with the paediatrician, the obstetrician or midwife, the GP for immunisations and the Child Health Nurse, but to also see a specialist Women’s Health Physiotherapist as well. Surely attending all of these other appointments are adequate to get the all clear to return to exercise?
In reality, the vast majority of what goes on in these appointments is actually centred around the health and well being of your newborn baby. In general (and I’m sure there are exceptions to this), the only check ups that are involved in this for the mother are:
- A screening test for Postnatal Depression
- A conversation about birth control and family planning
- A check of the healing stitches (either perineal/vaginal or from a Caesarean section) if there are concerns
- A pap smear if it’s due
Again, there may be exceptions to the rule, but I haven’t come across anyone who has had their pelvic floor muscles assessed at this check up, or had a plan put in place for gradual, individualised return to exercise.
And that’s to be expected – these musculoskeletal assessments and exercise prescriptions are not the domain of obstetricians, midwives and GP’s. Their specialities are delivering babies and ensuring that mother and baby are medically well. These are instead the domain of physiotherapists who have done post-graduate training to specialise in Women’s Health and Continence.
So, why should you prioritise this extra check up at this already-hectic time?
Here are five things that a specialist physiotherapist can help you with at a postnatal check
1. Pelvic floor muscle assessment
The pelvic floor muscles are the muscles that form a sling at the bottom of the pelvis, and they are responsible for keeping our bladder and bowel from leaking, holding in our pelvic organs, supporting our lower back and pelvis, and maintaining optimal sexual function. Pretty important roles, it’s not a muscle group you want to neglect!
If you’ve had a vaginal birth, the pelvic floor muscles have had to stretch up to four times their normal length to allow the baby to be born. The muscles may have torn or been cut, but even if they are intact, they have still undergone the equivalent of a significant sporting injury and need adequate rest and rehabilitation.
If you’ve had a caesarean birth – I’m sorry to say you’re not completely in the clear! Research has shown that long term, it’s the pregnancy that is the main risk factor for pelvic floor muscle dysfunction, due to the weight of the growing uterus directly down on the muscles and the hormonal changes that occur.
At a postnatal assessment, the physiotherapist will assess your pelvic floor muscles. This may be off-putting to some people – but it doesn’t necessarily have to be done via a vaginal examination. A screening test can be done with an ultrasound through your lower tummy, which shows the physiotherapist how well you can elevate and relax those muscles – and you, the patient, can see this on the screen too, which is great for feedback and learning.
A vaginal examination, however, is the gold standard and a lot more information can be gained such as pelvic floor muscle strength, tone and the presence of pain or a vaginal prolapse. This more thorough examination is even more highly recommended if you wish to return to impact exercise or weight training, or have any symptoms of pelvic floor dysfunction, such as:
- Bladder or bowel incontinence
- A feeling of vaginal heaviness
- Any pain in the vaginal area
2. Abdominal muscle assessment
The presence of a Rectus Abdominis Diastasis (RAD) will be determined, which means whether or not your ‘six-pack muscles’ and the connective tissue in the midline, has returned to normal after being stretched in pregnancy.
This stretching of the two muscle bellies apart from each other is completely normal if you carry a baby to full term, so if this was assessed immediately after delivery, we would expect the muscles to still be sitting apart from each other and be quite weak in the midline.
For most women, it should be enough in these early weeks to encourage optimal healing with relative rest and avoiding activities that cause repetitive increases in abdominal pressure, such as:
- Sit ups
- Heavy lifting
- Chronic coughing and sneezing
- Straining to open your bowels
But did you know that research has shown that natural healing only occurs in the first 8 weeks? If the tissue in the midline isn’t back to being thick and strong by that stage, you will need to do specific exercises to rectify it. The physiotherapist can put a program in place for you at this appointment if you need it.
3. Musculoskeletal assessment
The physiotherapist will ask you about any current or past pain or injury to any joints or muscles. The most common complaints in these early weeks are:
- Pelvic girdle pain (pain in the pubic bone or buttock region)
- Back pain
- Wrist pain
Early diagnosis and management of these issues is essential to stop them becoming chronic problems.
4. Bladder and bowel function screening
Many women experience bladder or bowel dysfunction during and in the early weeks after pregnancy. The physiotherapist will ask you questions about:
- How much you’re drinking
- How often you’re opening your bladder and bowels
- Whether you feel an urgent need to get to the toilet
- Whether you have a history of pain with intercourse
- Whether you experience any urinary or faecal leakage
And a whole lot more questions that will make you question why any of us specialised in this area! Honestly – we are so immune to the fact that we talk about wee and poo and sex all day!
These may be embarrassing issues to discuss, but it’s so important that someone asks these questions and probes into whether there are any early signs of dysfunction. Prevention is better than cure, and if we can pick up anything at this stage that isn’t quite right, we can help you to put in place a plan to optimise it again before it becomes a bigger issue.
5. Return to exercise plan and goal setting
Everyone has different postpartum goals regarding return to exercise and activity. One woman might want to run a half marathon in four months time, another woman may wish to be pain free when caring for her newborn baby and two toddlers.
Whatever your goals are, it is important to discuss them with a specialist physiotherapist and work out how achievable they are, and what needs to happen to safely achieve those goals.
We want nothing more than to help all women live active lives. But postnatal rehabilitation needs to be viewed like building a house – the foundations need to be strong before you start building the walls and roof on top otherwise you will always have issues down the track. This assessment will test where you’re at with your core strength and your ability to transfer load effectively when you do abdominal muscle exercises, high impact exercises, loaded weights exercises etc – whatever it is that you individually want to achieve.
In this way, it is a very individual approach to postnatal exercise – there is no ‘recipe’ that you should be able to achieve a certain level of activity at a certain number of months postnatal. We can never assume that one woman’s muscle activation, hormonal changes, and birth trauma are the same as the next woman.
So, the take home message is that although there are many common issues that affect women in the short and long term after childbirth – incontinence, vaginal prolapse, back pain etc – there are things that can be put in place to help to prevent and treat these issues. You don’t need wait for problems to occur or to worsen, you can be proactive by seeing a specialist Women’s Health & Continence Physiotherapist in the early months after delivery.