As a urogynecologist, I mostly see women with bladder leaking and pelvic organ prolapse.  But did you know that I also see women who have recently delivered a baby? The pelvic floor goes through amazing changes during pregnancy and delivery. During a vaginal delivery, the muscles stretch over three times their baseline length; this is over 200% more than when you are not pregnant! Consequently, the muscles and nerves may not work well after delivery. When you add on swelling and tearing, healing the postpartum perineum can require some extra attention.

Healing with postpartum physical therapy

Most postpartum women don’t need to see a urogynecologist but there is some thought that all women should see a pelvic floor physical therapist after delivery.  This is to “re-educate” your perineum and helps with bladder leaking, leaking stool, and painful intercourse.  10-20 sessions are a standard part of postpartum maternal care in France.  While this is not standard care in the US, many insurances will cover it.  Because I am invested in my own pelvic floor working optimally (and I like to try the things that I recommend to other women), I saw a pelvic floor physical therapist during and after my pregnancies. And even though I know how all of this works, it was super helpful.

Postpartum urogynecology

I see postpartum women who are having problems with leaking, prolapse, fistulas, or poor wound healing. Leaking urine is common after delivery and happens in 20-30% of women. Trouble with controlling bowel movements can also happen and is more likely when you have had a large tear or episiotomy. Pelvic organ prolapse happens in less than 10% of postpartum women. Fistulas after delivery are rare in the US but do happen.  Wound healing issues are common after delivery. Infections can happen and even when everything is healing well, the area is often very sensitive. 

There are postpartum perineal clinics in the US that are solely dedicated to healing this area of the body after a delivery.  A great example is the postpartum clinic at the Univeristy of Michigan. These clinics see women that are having perineal issues after delivery but focus on third or fourth degree lacations after delivery.  The primary focus of the clinic is on education- how to clean and care for the perineum and how to promote good wound healing.  Physical therapy is frequently recommended when the wound has healed.  And they make sure to screen for postpartum depression and breast feeding issues.  I love the idea of these clinics- I know there are many more women who could benefit from being seen and aren’t being sent my way. These clinics should be part of standard care.

Factors that impact the healing postpartum perineum

Estrogen

This is a time of low estrogen levels.  Breastfeeding lowers estrogen.  Birth control can lower estrogen levels.  Breast feeding and having the right birth control are so important but this lowered estrogen can impact how the vagina and vulva heal and how they feel. It may help to know that these factors are temporary. Adding in some vaginal estrogen can also be helpful.

Microbiome

The vaginal microbiome changes after delivery and the amount of lactobacilli in the vagina are much lower.  This results in a higher pH, a different bacterial mileu, and can result in different vaginal symptoms. This too is temporary and will improve over time. There is ongoing research to determine how to best treat this change. In the meantime, be sure to eat a healthy diet.

Muscle function

Your muscles may be out to lunch.  Delivering a baby vaginal can do a number on the pelvic musculature and nerves.  It takes time for the pelvic floor to recover and it is not completed 6 weeks after delivery.  Improvement can continue for over 6 months.  Be patient and make sure you have a medical team that is supporting you during this time.

What to do if you are having problems healing postpartum

If you have a new baby, you may be having pelvic floor problems like pain and leaking. These issues can make your new life with your baby harder than it needs to be. Start by checking in with your obstetric provider. Be direct and tell them what is happening. There is a lot to discuss in these visits so be sure to prioritize your concerns. They will be able to get you on the right path!

1. Nygaard IE.  Pelvic floor recovery after childbirth. Obstet Gynecol 2015l125(3):529-30.