Last week, we discussed common physical changes that occur during pregnancy (changes in the musculoskeletal, cardiovascular, gastrointestinal, and integumentary systems). But postpartum, it all just goes away on its own, right? Not exactly. In the case of birth trauma, specific interventions and care should be standard of care to make sure all of mom’s parts get working again as well as possible (check out yesterday’s post for a bit more info). And in the case of all postpartum bodies, let’s have a conversation about how the physical changes of pregnancy and childbirth could be better addressed to more effectively put mom back together after the amazing work she has done carrying and birthing a child (or children!). It is a disservice to the hard-working mothers of this country to not facilitate their physical recovery postpartum and an equal insult to their resiliency and intelligence to think that by “sparing” them knowledge of the honest risks of physical trauma or changes, that we are “avoiding scaring them unnecessarily.” We’re tough enough to have babies, y’all. We’re tough enough to get the whole picture of what comes with it. Besides, I swim in a fishbowl where I see the worst of the physical injuries and you know what...? It made me feel more prepared for what could possibly lie ahead for each of my three pregnancies AND I have never (never, never, ever) met a woman who doesn’t believe that their child was worth whatever price paid. They just would also have liked to know the potential cost before getting to the checkout line, and to be sure that every woman in their place gets the right owner’s manual for their own bodies—not just for their new baby
Consider that preventive care measures are gaining ground in the healthcare discussion, purported to be better for us health-wise and better for the wallets of whomever is paying for our healthcare. Now consider the fact that approximately 80% of women in the United States give birth each year, urinary incontinence affects 13 million Americans, and 85% of these 13 million are women. Hmmmm...sounds like we may have a connection, here. It has been stated elsewhere that pregnancy is the single greatest risk factor to developing urinary incontinence in one’s lifetime and, based on the previous series of stats, we can assume that nearly 9 million of the women in the US with urinary incontinence have had at least one child in their life. Can anyone think of a better window in a woman’s life where targeted preventive services could have a massively magnified effect decades later (in improved quality of life, decreased prevalence of incontinence, decreased cost of interventions to manage and treat incontinence, etc.)?
Every woman I talk to has a first-hand account of the significant effects of pregnancy, labor and delivery on the female body. Yet in our clinical experience, women tell us that they were rarely well-prepared for the physical after-effects of pregnancy and childbirth, which can have a profound impact on not only physical health, but on emotional and mental health as well. Postpartum pelvic floor and musculoskeletal dysfunction (including urinary incontinence, sexual dysfunction, low back pain, abdominal pain, and pelvic pain) are very common; in fact, it is estimated that 75% of women in the first 6 months postpartum report urinary incontinence, and for a portion of women, resuming regular sexual activity can take 6 months or longer after childbirth. It appears to us that insufficient time and resources are dedicated to informing and training women to better prepare for, prevent and manage these issues, thus women have no expectation that they will need to make this a priority in their postpartum recovery.
Complicating things, many of these issues are often disregarded as “normal;” “well, you had a baby...what do you expect?” If that statement means, “you had a baby...do you actually expect that your body will still work? That you will be able to pick up your baby without your back hurting? Chase them at the playground without leaking? Get it on in the bedroom (or wherever! & this is assuming all the other elements are in sync—emotional, sleep, etc.— but that’s another post, altogether!).” My answer is yes, Yes, HECK YES I expect to and deserve to be able to do all of that and more without a problem. When necessary, I have worked hard for that to be the case, but it all started by not accepting the opposite of these expectations as the “normal” for which I should settle. It is our hope that by spreading the word on postpartum health and recovery, women can find tools and resources to seek help as needed, and to ultimately influence both discourse and practice patterns regarding perinatal health in the US.
Part 2 of our discussion turns more specifically to some of the anatomical structures affected by pregnancy and birth, and how function can be adversely affected postpartum. You may want to briefly review some of the common musculoskeletal system changes that occur during pregnancy:
These changes don’t uniformly or automatically resolve after your baby has made his way into the world. If they resist, they can cause problems in a woman’s ability to do all of the things she needs to do in a day.
Understanding the implications of pregnancy, labor and delivery on a woman’s musculoskeletal system requires understanding the role of muscles that make up our “core” (see figure below). These include the transversus abdominis (the deepest layer of abdominal muscle), the multifidi (deep back muscles that run vertically along our spine), the diaphragm (our primary breathing muscle), and the pelvic floor. Effective function of our trunk—of our whole bodies, actually—relies on the interconnection between these muscles, and the nerves and connective tissue (fascia) that work with them.
Why is this important? When these four muscles are working well, we can move and play with our kids and enjoy life without having to worry about bladder and bowel control, pain, or support of our pelvic organs. The muscles should turn on in anticipation of movement to give us the core support that we need, like a team coming together in a huddle before every big play. Often, whether due to pregnancy-related changes, delivery trauma or even pre-existing injuries, the coordination, strength, and timing of this muscle activation is affected.
Consider labor and delivery for a moment. Let’s face it—no matter how natural a process, childbirth is a decidedly physical process! Whether your labor and delivery were uncomplicated or you encountered a whole host of unexpected events, your body underwent a monumental physical experience, which had the potential to impact muscles, fascia and nerves. During a vaginal delivery, injury to the pelvic floor, including perineal tearing, episiotomy and nerve stretch or compression, can contribute to postpartum urinary and fecal incontinence, problems with gas control, sexual function, pain and pelvic organ support. With a cesarean delivery, lasting incisional pain is common, and it has the potential to disrupt the pre-play core muscle “huddle” discussed previously by changing how the abdominals engage. Failure of any key players, the transverse abdominals or pelvic floor for example, to show up for the huddle, can cause or exacerbate low back and pelvic girdle pain, as well as contribute to problems with urinary incontinence with activities like coughing, sneezing, laughing and lifting.
In addition, the hormonal changes of pregnancy that create increased laxity or loosening of the ligaments and joints in the body are still around postpartum if a woman is breastfeeding. The demand for muscle control is heightened as a result, and if the muscles aren’t up to the challenge (i.e. too weak or uncoordinated), problems arise.
With all of the changes that take place in pregnancy and postpartum, it’s important to take time to care for your body, and to advocate for comprehensive perinatal care. Help us spread the word on this, too! You don’t have to wait years to get the help you need! Talk with your doctor about anything you’re facing that doesn’t seem quite right. He or she may then refer you to any number of professionals who want to help women recover from pregnancy and childbirth. Speaking for me and my colleagues, physical therapists specializing in obstetrics and the rehabilitation of the abdominal wall and pelvic floor want to take a seat at the table. I truly believe we can and should make a change in how we (and our healthcare system) approach postpartum recovery to ensure all women are well cared for during this important time! Are you with us?
Jessica McKinney, PT, MS Founder, Share MayFlowers
Julie Fox, PT, MS Physical Therapist, Marathon Physical Therapy and Sports Medicine
Amy Boutry, DPT Physical Therapist, Marathon Physical Therapy and Sports Medicine