Now imagine you are told all this pain, leakage, and weakness is a “normal” part of your postpartum journey. It can be isolating and scary, and leave you with more questions than answers.
Most women (and men!) hardly know what their pelvic floor does, let alone feel comfortable talking about it. But it is a vital part of our function, supporting our bowels, bladder, and sexual activity. And it is especially crucial during the “fourth trimester” immediately following childbirth, which is where the system often fails new moms.
This is when physical therapy can have a strong impact — during a time of healing, hormonal shifts, and altered body mechanics when new mothers might be particularly vulnerable. Pelvic health physical therapy during that fourth trimester can empower them with the skills they need to feel confident and protected. Physical therapists can offer guidance on when to return to therapy should their problems persist. We can give them the same care and support they had during their pregnancy.
Our goal has been to have a more open conversation surrounding pelvic health, to destigmatize the topic, and empower women on their postpartum journey.
In our own journey to help healing mothers, we facilitated a program at our hospital to see new moms during their inpatient postpartum stay. After all, most patients who have had simple abdominal surgery automatically are referred for physical therapy; why not new moms? Postpartum care is not just important, it is crucial.
Typically, new moms stay between two to three days postpartum, and we see them the day or two after delivery. We are pelvic floor physical therapists who work in an outpatient center attached to the hospital, so we are able to bounce back and forth easily. In our current program, we have two-to-three hours reserved during different times of the week to see these patients. Most often we see patients who had cesarean deliveries, experienced more severe perineal tears, or who have given birth to multiples.
We start by chart reviewing all new mothers, with attention to medical history and their birth notes to see if there was any trauma or labor complications. When we first started the program, we next would call the resident obstetrician for verbal orders to see our patients. After a few months of building a good rapport with the physicians and registered nurses, we have been fortunate enough to receive standing orders for our patients, only calling the obstetrics team with complex patients. As any inpatient physical therapist knows, the nurses are invaluable. We talk to them prior to seeing patients, gathering important information about the patient’s pain and activity levels, and gaining some insight into their healing journey since delivery.
Our sessions differ a little bit from traditional mobility inpatient physical therapy. We go in expecting to talk to them about their bowels, bladder, and body mechanics since most are ambulating independently. For our subjective examination, we ask about past deliveries and current pain levels. We also discuss voiding and bowel movements, asking about issues such as straining, pain, and incomplete emptying. Our mothers who have had a cesarean delivery, in particular, listen up at this and tell us if they have been worried about having a bowel movement or if doing so has been painful.
For the objective exam, we perform a general movement assessment, including bed mobility, transfers, standing activities, and gait. Adding the pelvic floor to that, we look at quality of breathing, transverse abdominis recruitment, and pelvic floor muscle recruitment.
Patients often are used to using accessory muscles to breathe during pregnancy, because the organs shift in the abdomen as the baby grows, causing the diaphragm to compromise on its own movement pattern. To address this, we start teaching them gentle diaphragmatic breathing. We talk to them about the importance of managing pain, cramps, and scar tissue as well as helping them to void and have a bowel movement without straining. In some cases, new moms have difficulty voiding after delivery, and addressing diaphragmatic breathing and toileting posture has helped those patients avoid having to use a catheter.
These discussions lead into the topic of intra-abdominal pressure, and we have found that some patients tend to perform the Valsalva maneuver with movement. In most cases, we can easily manage the increased pain that comes with holding their breath and “bracing” during movement by using breathing techniques. We discuss exhaling and contracting the pelvic floor or transverse abdominis (as long as it is pain-free) with functional mobility. Teaching them to breathe more effectively and efficiently has been beneficial to their pain management.
Along the same lines, we also discuss the benefits of abdominal binders to support healing in the abdomen and help with diastasis. We teach them how to don and doff the device, and how and when to wear it. We remind our patients that abdominal binders are not “waist trainers” or shapewear meant to help them “get their figure back,” as those would interfere with the breathing exercises we’ve taught them, impede their core strength recovery, and could even cause harm.
Does this seem like information overload for someone already overwhelmed by new motherhood? We give all patients a postpartum packet that discusses everything we have taught them. The packet also contains information on body mechanics for holding and carrying a baby, indications that they should follow up in outpatient physical therapy for pelvic health, and the clinic phone number if they have questions. Patients get a lot of information during their stay, and our hope is that having it all written out will give them better retention and confidence when they return home.
In the time we have been doing this program, we have had some growing pains, but we are constantly changing to meet the needs of this patient population. We are incredibly proud of the service we are providing to these postpartum mothers, we appreciate the support of the obstetrics team, and we hope this will become a more common practice in all hospitals.
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source: apta
