I write this blog because I want to educate women about their pelvic floor.

In my day job, I am used to talking to women one-on-one.  This means that I get a lot of feedback (just like in any conversation), and I can tell if my words are helping them.  A blog is a little different.  I put my words out there and don’t get much direct feedback.  But every now and then, I hear about someone who has been helped by this blog and the information on it.

Most recently, a friend referred her daughter to my site.  Her daughter had just had a baby and was having pain. Her daughter was diagnosed with pelvic floor dysfunction and sent to physical therapy.  She had never heard of pelvic floor dysfunction and was dubious about physical therapy because she did not believe it would help.  She felt isolated and wondered why she was the only person she knew with these issues.  My blog helped her to realize that pelvic floor dysfunction is common, that she was not the only new mom with these issues, and that pelvic floor physical therapy is a legit treatment.

So for all of you new moms out there, let’s talk about the changes in the pelvic floor after delivery.

Most women expect to have some swelling after delivery and some vulvar discomfort.

Having a perineal tear that requires stitches is common.

We learn to use a peri-bottle to clean this area and expect this soft tissue wound to heal quickly.  The first bowel movement is usually painful, but things improve after that.  But we expect all of this to be short-lived and to be completely healed by six weeks after the delivery.  And while the outside may look well healed, this is not the full story.

During a vaginal delivery, the puborectalis and pubococcygeus muscles (two of the pelvic floor muscles) stretch 2-3.5 times their normal length.  How much they stretch depends on how close the muscle is to the vaginal opening.  Muscles closer to the vagina stretch more.  I just want to emphasize that one more time- the muscles stretch 2-3.5 times their normal length.  These muscles more than double their length.  There is no other muscle in the body that can do this.  And the pelvic floor muscles can only do it with the help of the hormones released during pregnancy.

The female body is amazing allowing the nerves to stretch during delivery.  The nerves don’t stretch as much as the muscles fibers- usually between 10-40% of the baseline length.  There is a lot of swelling during a delivery as the baby pushes against the muscles, creating a lot of tissue trauma.  So what does this all mean?

The external tissue trauma can be seen.

But much of the trauma is underneath the skin and can’t be seen.  Up to 30% of the time, there are tears in the anal sphincter muscle that can not be seen.  Imaging studies have shown that there can be swelling in the pubic bone and even fractures in the bone after a delivery.  Who knew that could happen?

The pelvic floor muscles can also swell and can even detach from the pubic bone where they are normally connected.  These changes in the muscle and bone are similar to what is seen in some ultra-marathon runners after a race.  I think comparing a vaginal delivery to an ultra-marathon makes sense.  While it is a normal event, it is also an endurance activity!  We don’t routinely image the bones and muscles after delivery (this is more of a research protocol), so it is rare to know exactly what has happened.  But we do know who is at the most risk of muscle trauma after a delivery.

Some women who have large perineal tears after a delivery, like tears that extend into the anal sphincter muscle or rectum, have more tissue trauma.  Other women who are delivered with forceps or a vacuum also have more tissue trauma.  While any delivery can result in this tissue trauma, it is more likely after difficult deliveries like operative deliveries or those with large tears.

And while everyone assumes things will be healed six weeks after delivery, this is often NOT the case.

The swelling in the soft tissues has usually gone away, but the nerves, muscles, and even bones may still be healing.  Imaging studies have shown ongoing tissue trauma 8 months after delivery.  Nerves heal very slowly and take a long time to regain their function.  So the takeaway here?  There is a lot of trauma that happens underneath the skin.  Healing is often NOT completed by six weeks and may take more than six months.  This is more common after difficult deliveries but can also happen after an “easy” delivery.

In France, all women are offered physical therapy after a delivery.  And in Britain, all women are screened for bladder and stool leaking at their 6-week postpartum appointment.  If any issues are detected, the woman is sent to physical therapy.  We aren’t that systematic in the United States.  Screening is not as common.  Physical therapy is also not available everywhere.  But if you are having any issues, you should talk to your provider.  They will know the available resources.  All of these changes can lead to some dysfunction in your pelvic floor muscles.  And since much of the pelvic floor activity is reflexive, it takes effort ( and often some expert help) to relearn how to use these muscles.

There are other factors that can impact how the pelvic floor feels and functions after a delivery.

  This is a time of big hormone changes.

If you are breastfeeding, your body moves to a state of low estrogen and high progesterone.  Certain birth control (progesterone only forms) will create this state as well or make it more extreme.  While this is normal for your body, this low estrogen state can create some pelvic floor issues.  Incontinence and prolapse may be worse.  There may also be vaginal dryness or discomfort.  You should know these changes are temporary and will resolve when your period returns to normal.  If it is too significant just to wait it out, you can discuss vaginal estrogen with your doctor.

Constipation.

The swelling in the soft tissues has usually gone away, but the nerves, muscles, and even bones may still be healing.  Imaging studies have shown ongoing tissue trauma 8 months after delivery.  Nerves heal very slowly and take a long time to regain their function.  So the takeaway here?  There is a lot of trauma that happens underneath the skin.  Healing is often NOT completed by six weeks and may take more than six months.  This is more common after difficult deliveries but can also happen after an “easy” delivery.

In France, all women are offered physical therapy after a delivery.  And in Britain, all women are screened for bladder and stool leaking at their 6-week postpartum appointment.  If any issues are detected, the woman is sent to physical therapy.  We aren’t that systematic in the United States.  Screening is not as common.  Physical therapy is also not available everywhere.  But if you are having any issues, you should talk to your provider.  They will know the available resources.  All of these changes can lead to some dysfunction in your pelvic floor muscles.  And since much of the pelvic floor activity is reflexive, it takes effort ( and often some expert help) to relearn how to use these muscles.

Lien. Obstet Gynecol 2004

Lien. Am J Obstet Gynecol 2004

Caldwell-Hall. Am J Obstet Gynecol 2018

DeLancey. Obstet Gynecol 2003.

Valsky. J Ultrasound Med 2016.

Kearney. Obstet Gynecol 2006.