Common Vs. Normal: Dispelling Postpartum Myths
Black leggings, the demigod
If you’ve ever been to a trampoline park, you’ll likely see two things: Hoards of ferrel children jumping and flipping around like banshees, and a band of mothers standing on the sidelines. If you happen to witness the ever-so-rare mom jumping on the trampoline with her kids, there’s a high likelihood that she’s sporting black leggings and/or a panty liner to hide and disguise any leaks that might happen. Research would tell us that approximately 26% of women leak urine postpartum, and that those who have a vaginal delivery are twice as likely as those who deliver via cesarean section to experience these symptoms. (Thom and Rortveit, 2010)
We all stand on the sidelines and joke about peeing our pants, our “mom butt”, feeling like our insides are falling out of us, how sex is so different after having kids, or about our “kangaroo pouch”, as if it’s a rite of passage into motherhood. However, just because you and everyone else around you is dealing with these things, that doesn’t make them normal and it certainly doesn’t mean that they can’t be fixed. Keeping reading as I shed some light on some of the most common things people experience after giving birth, and I’ll give you some practical steps to work toward improving or resolving your symptoms:
Urinary Incontinence
There are several different categories of urinary incontinence, but the kind that we generally think of postpartum is stress incontinence. Stress incontinence is the involuntary leakage of urine when there is increased pressure placed downward on the bladder. Some may only notice symptoms during a forceful cough or sneeze, or while running or jumping. Others may notice their symptoms are triggered by things as simple as standing up from a chair, or rolling in bed. At the end of the day, the pelvic floor muscles are only part of the clinical picture for people dealing with stress incontinence. Often, there are postural changes, muscular imbalances, and abnormal firing patterns of muscles in the core that also contribute to symptoms.
There is level 1, grade A (very strong!) evidence that pelvic floor muscle training (PFMT) is effective in treatment of stress urinary incontinence. Long-term success at resolving SUI with pelvic floor muscle training ranges from 41%-85%. (Bo and Hilde, 2013) This study focused solely on training of the pelvic floor muscles—I would argue that had they looked at results for expert-guided pelvic rehabilitation to address additional postural changes, muscular imbalances, and muscle firing patterns to help you better manage pressure onto your bladder, the results would be even more superior.
Mom Pooch & Mom Butt
After giving birth, lots of us notice a little “pooch” just above our pubic bone that just won’t go away, no matter how much we exercise or watch what we eat. Likewise, many women notice that their rear end disappears after going through pregnancy and giving birth. Both of these issues are biomechanical phenomena.
Mom Pooch. One of the first postural changes we see in women during pregnancy is that the pelvis will roll into an anterior pelvic tilt to accommodate the growing uterus. Excessive time spent in that anterior tilt, accompanied by the stretching of your abdominal wall due to the growing fetus, causes a pooching of the lower abdominal wall in the postpartum period. Yes, of course, for a period of time there’s a bit of excessive skin and usually increased accumulation of fat. However, more often than not, that look of “just needing to lose 10 more pounds” at one-year postpartum is because your pelvis is stuck in an anterior tilt and lower lower abs just can’t do their job and support you. Not all core work is created equally when it comes to correcting this issue. Guidance from a pregnancy + postpartum corrective exercise specialist can help you correct your posture, get your pelvis moving better, and re-train your deep core muscles to fire better to get rid of that annoying pooch. There are other subtle nuances that need addressed as well, typically including addressing any increased pelvic floor tension, and how you manage pressures down into your core canister.
Mom Butt. As mentioned above, in pregnancy, your pelvis rolls into an anterior pelvic tilt. In response to this, you get a pseudo-butt. The pelvis rolling into an anterior pelvic tilt causes the bum to stick out a bit more, giving it the appearance that you’ve had the coveted BBL (Brazilian Butt Lift) while you’re pregnant. If your bottom was actually getting plumper and rounder, however, it wouldn’t just disappear after giving birth—Yet, that’s what most women experience. With your pelvis sitting in an anterior pelvic tilt for such a long time throughout pregnancy, the glute muscles actually get stretched, and often weakened. As soon as baby comes out, and we’re hit with the severe sensation of weakness and instability in the core, trunk, and hips, and we often grip our bottom and clench our butt cheeks under us to hold us together. What do we call small, flat, weakened, clenched butt cheeks? Mom butt.
Pelvic Organ Prolapse
Pelvic organ prolapse, or POP, occurs when there is weakness of the pelvic floor and connective tissue attachments to the bony pelvis allowing abnormal descent or herniation of the pelvic organs (uterus, vaginal apex, bladder, or rectum) from their normal position in the pelvis. Most people have never even heard about pelvic organ prolapse. The story is usually something like this. “When I was wiping myself on the toilet I noticed a little ball, like something was falling out of my vagina.” Or, “After I got home from my run it felt like something was falling out of me.” Many women have told me their first inclination when they see if for the first time is to go to the ER, because they’re afraid they have a tumor.
Prolapse of any sort after giving birth is relatively normal. It’s estimated that 35-50% of women will experience prolapse after a first vaginal birth, and that number continues to climb after subsequent vaginal deliveries. Just as with stress incontinence, prolapse is twice as likely in those who have a vaginal delivery versus a cesarean delivery. (Gyhagen et al., 2013)
The thing about prolapse, is most people never even know they have it. As a pelvic floor physical therapist, I’m hardly ever concerned with the stage or degree of the prolapse, and concern myself more with how symptomatic a person might be. I’ve had patients with Stage I (very mild prolapse), who are severely sensitive to it and aware of it all of the time, and patients with Stage III (moderate to severe) prolapse who have no clue that it’s even there.
Prolapse is extremely complicated. In addition to any underlying pelvic floor dysfunction, it is absolutely imperative to address how a person manages intra-abdominal pressure, how they breathe, how they lift, how they move, how they carry themselves, and manage any underlying constipation. The 2013 International Consultation on Incontinence report concluded that there is level 1, grade A (very strong!) evidence to recommend pelvic floor muscle training in the treatment of POP (Dumoulin, 2013). Many of the studies showing improved outcomes with pelvic floor physical therapy had physical therapy regimes with individualized training and vigorous supervision (i.e. online programs just don’t cut it).
Pain with Intercourse
Unfortunately, the myth that it’s normal for intercourse to be painful for women is pervasive, and not only in the postpartum world. The prevalence of postpartum dyspareunia (fancy word for pain with intercourse) is estimated to be 35% (Banaei, 2021). Unlike with stress incontinence and prolapse, women who have a caesarean are more likely to report more intense dyspareunia at six months postpartum (Ellie, 2016)
There are many things that can drive pain with intercourse in the postpartum period. Scar tissue (whether that be in the pelvic floor or abdominal wall), pelvic floor muscle spasm/increased tone, and vaginal dryness from hormonal changes are three major contributors to dyspareunia in this population.
Pelvic floor physical therapists are the experts of choice when it comes to managing scar tissue issues and increased tone in the pelvic floor muscles. As for managing vaginal dryness, there are a wide array of non-hormonal options for vaginal moisturizers and suppositories that help to keep the tissues down there hydrated and happy. Often, women who are lactating can also benefit from a bit of topical estrogen cream applied to the vulvar tissues a few times a week to help with dryness, itchiness, and pain—This is something you can discuss with your midwife or OB.
Questions? Let’s Chat
At Paradigm Pelvic Health & Wellness, we specialize in the examination and treatment of all of the things listed above. Pelvic floor physical therapy is often the intervention most supported by research for management of these conditions in the postpartum period. You don’t have to suffer any longer or watch from the sidelines. Give us a call at (240)-267-2924, or contact us here to start your healing journey today.
References
Thom DH, Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand. 2010 Dec;89(12):1511-22. doi: 10.3109/00016349.2010.526188. Epub 2010 Nov 5. PMID: 21050146.
Bø K, Hilde G. Does it work in the long term?--A systematic review on pelvic floor muscle training for female stress urinary incontinence. Neurourol Urodyn. 2013 Mar;32(3):215-23. doi: 10.1002/nau.22292. Epub 2012 Jul 27. PMID: 22847318.
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013 Jan;120(2):152-160. doi: 10.1111/1471-0528.12020. Epub 2012 Nov 2. PMID: 23121158.
Dumoulin C, Hunter KF, Moore K, et al. Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: summary of the 5th International Consultation on Incontinence. Neurourol Urodyn 2016; 35:15–20
Banaei, M., Kariman, N., Ozgoli, G., Nasiri, M., Ghasemi, V., Khiabani, A., Dashti, S. and Mohamadkhani Shahri, L. (2021), Prevalence of postpartum dyspareunia: A systematic review and meta-analysis. Int J Gynecol Obstet, 153: 14-24. https://doi.org/10.1002/ijgo.13523
Ellie A. McDonald, Deirdre Gartland, Rhonda Small, Stephanie J. Brown. Frequency, severity and persistence of postnatal dyspareunia to 18 months post partum: A cohort study. Midwifery, Volume 34, 2016, Pages 15-20.
