By Amy Fearn
In the previous blog, we learned about the pelvic floor muscles (PFM) and discussed some of the changes that take place within the PFM during pregnancy. In this blog, we’ll look at delivery, the postnatal period and returning to exercise.
Delivery and the Postnatal Pelvic Floor
Increased load on the PFM during pregnancy and their considerable stretching during delivery, massively reduces the amount of support the pelvic floor can offer during the postnatal recovery period and beyond. A woman’s first vaginal delivery not only causes damage to the muscles, but also nerves and fascia contained within the PFM and it’s thought that future deliveries contribute further damage. The effect of pregnancy hormones on connective tissues during pregnancy is thought to persist for up to 5 months postnatally and for 4 months after breastfeeding, meaning joints and structures such as the PFM remain vulnerable. Other factors, such as mode of delivery and maternal age can also affect the PFM, so let’s have a look more closely at some of these.
A recent Guardian article reported that the number of women aged 45 and over giving birth, was at the highest level since records began. But with increasing gestational age, unfortunately, comes an increased risk of PFM-related injuries. The levator ani muscles, which make up the largest layer of the PFM, are essential in supporting the pelvic organs and maintaining urinary and faecal continence.
Levator avulsion, the partial or total disconnection of the levator ani muscles from their insertion points on the bony surface of the pelvis, is strongly associated with maternal age and increases to over 50% at 40 years of age, compared to less than 15% at 20 years of age with a vaginal delivery. The number of women suffering from levator avulsion injuries also increases from 20 to 40% for first vaginal deliveries at age 35 or over, as does the frequency of anal sphincter injury.
Signs and symptoms of a levator avulsion include symptoms of pelvic organ prolapse, particularly those associated with coughing, sneezing, squatting or heavy lifting, and no improvement in PFM strength following 8-12 weeks of intensive (and correctly executed) PFM strengthening. If any of this sounds familiar, your first port of call should be a WHP to confirm diagnosis, begin conservative management and discuss suitable treatment strategies.
Type of Delivery
Research has shown that vaginal births are by far one of the biggest factors in developing PFMD, with 1 in 2 women having some degree of pelvic organ prolapse and symptoms of bladder or bowel dysfunction. During the second stage of labour, the PFM and nerves need to stretch to allow baby to progress down the birth canal. An assisted vaginal delivery, especially with forceps, can significantly increase the risk of both faecal incontinence and partial or complete levator avulsion. In addition, assisted deliveries require an incision (episiotomy) in the perineum (the space between the vagina and anus), to expand the vaginal opening, causing further trauma to the perineum and PFM.
PFM exercises aren’t necessary after a caesarean, right? Think again. A caesarean delivery following active labour can still cause damage to the levator ani muscles of the PFM and won’t necessarily prevent PFMD. That, and the effects of pregnancy hormones and the additional weight placed on the PFM during pregnancy are the same, regardless of delivery. So, however baby enters the world, PFM training during the postnatal period remains essential. Postnatal PFMD can happen for many reasons, including:
- Overstretching of nerves
- Collagen type
- Baby’s weight
- Size of baby’s head
- Maternal age
- Perineal trauma
- Long second stage of labour (>2 hours)
- Constipation and active daily living
There’s an awful lot going on with the PFM after having a baby! But don’t despair, there’s plenty you can do to restore or manage your pelvic and abdominal health, and safely make the transition back to exercise.
Postnatal Recovery and Exercise – Weeks 1-6
Less is more where PFM rehabilitation is concerned. Many women are so preoccupied with getting back to their pre-baby bodies that they completely overlook rehabilitation of the PFM and the fact that their body requires care and rest, not an immediate return to pre-pregnancy activities. Research has shown that the PFM can take 6-12 months (no, that’s not a typo) to regain its full tensile strength, so rushing back to exercise too soon can put you at greater risk of injuring your PFM. During these early postnatal weeks, you can gradually start to build awareness of the PFM through simple actions such as postural awareness, diaphragmatic breathing and gentle PFM exercises, provided any tearing or episiotomy is healing well.
Gentle exercise such as walking can gradually be added, increasing the duration of activity in line with what your body will allow.
Postnatal Recovery and Exercise – Week 6 and Beyond
So, you’ve had your 6-week check and have been given the all clear by your GP to resume exercise, it’s time to sign up for that half marathon or get back to your favourite HIIT class, right? You can probably guess what my (short) answer is…
There’s limited research on postnatal rehabilitation and a lot of contradictory advice. The celebrity culture of seemingly bouncing back two weeks after having a baby is both misleading and not at all representational. Your body needs time to recover from delivering your baby. Your hormones need time to settle. On top of this, you’re probably not eating consistently or getting enough sleep. When you’re tired, your core is fatigued and your muscles, including your PFM, don’t function optimally.
The best starting point after your 6-week check is to go for a Mummy MOT or book in for a postnatal check with your local WHP. This is the only way to diagnose and treat the early signs of PFMD that you might not be aware of and which might otherwise cause problems in the future if you choose to embark on a strenuous postnatal exercise regime. Many women stop doing their postnatal PFM exercises when they start to see an improvement, but it’s important to continue to help prevent future weakness caused by factors such as lifestyle and menopause. Some factors that might delay your return to impact exercises, such as running, include:
- Any pre-existing PFMD, including pelvic organ prolapse
- Lower back or pelvic pain
- Pre-existing hypermobility
- Caesarean section
- Perineal scarring or delayed healing
- Maternal fatigue and poor diet/nutrition
Tips for getting ready to exercise again
The PFM and abdominal muscles work closely together to provide lumbar and pelvic stability, but after pregnancy, everything is out of sync. The abdominals and PFM are stretched and weakened and require re-educating to regain their functionality and strength. Attending a series of postnatal Pilates classes can be a great way to start to strengthen the entire core unit in preparation for more intense exercise in the future, as well as improving overall mobility, flexibility and joint stability.
So, you’ve been doing your PFM exercises. Your core is getting stronger and more reactive. You’ve had your 6-week check and been for a postnatal check with your local WHP. You’re feeling good and you’re ready to get back to impact exercise. Let’s get you started with some simple movements taken from the latest Return to Running Postnatal Guidelines.
You should be able to carry out the following movements without pain, leaking, heaviness, dragging or bulging in the perineum or abdominal wall midline before you commence any impact exercise such as running. Build up to each of these movements gradually, rather than trying to do them all at once.
- Walking for 30 minutes, then gradually increase duration, pace, stride or incline
- Single leg balance, build up to 10 seconds each side
- Single leg squat, build up to x 10 each side
- Jogging on the spot for 60 seconds, start by running through your feet without lifting them, then gradually increase the height
- Forward bounds x 10, starting with small steps and gradually increasing the size, then increase the energy until you’re bounding and landing without symptoms
- Hop on the spot x 10 each side, start by standing on one leg, raising to tip toes, then lowering gradually then gradually increase impact up to a full hop
- Single leg running man x 10 each side, start with small range of motion then gradually increase
A combination of abdominal and PFM training and re-education together with the above movements should provide a good starting point for returning to impact exercise postnatally.
It’s worth remembering that everyone’s journey back to exercise will be different and some women will bounce back more quickly than others. Take things one day at a time and focus on the basics, like breathing, PFM training and correct core activation. Work towards resolving other issues, such as stress, constipation, sleep, diet and daily activities. Above all else, listen to how your body feels and adjust your postnatal exercise accordingly. If it doesn’t feel right for you, then it probably isn’t the right thing to do. Tomorrow is another day.
- The PFM support the pelvic organs and works with the abdominal muscles to provide pelvic and lumbar stability
- PFMD can happen at any time in life and for a variety of reasons
- Correct recruitment of the PFM often requires guidance from trained professionals
- Physical and hormonal changes during pregnancy have an impact on the PFM
- Stretching of the PFM during vaginal delivery can damage nerves, muscles and fascia, with older women being more at risk of injuries such as avulsion
- PFM training is essential, regardless of how baby is delivered
- Postnatal recovery in the first instance should focus on breathing and gentle PFM activation and relaxation, followed by re-education of the core unit
- It is recommended to seek advice from a WHP following the 6-week check
- Exercise following the 6-week check should follow the latest guidelines and be re-introduced gradually
- Everyone’s journey back to exercise is different, it’s important to listen to your body and not try to do too much too soon
Amy is a qualified Adore Your Floor Coach with Adore Your Pelvic Floor. She is also a qualified Pilates Instructor, Pre and Postnatal Fitness Instructor and Massage Therapist, and the founder of Little Mamma Wellness, a new postnatal wellbeing service in Manchester.