Category Archives: C-Sections

Back Pain and Breastfeeding? Here are 5 Tips to Help!

Did you know that last week was international breastfeeding week? I know this event and really, even discussions about breastfeeding can lead to lots of thoughts amongst mamas. Pride, having accomplished something challenging. Sadness, if your breastfeeding journey did not necessarily go as planned. Fear, as to whether your baby is actually getting enough milk and growing the way she should. Joy. Guilt. Happiness. Anger. The list goes on.

I think it’s important that while we recognize that breastfeeding has incredible benefits, we also recognize what is most important– a fed and growing baby and a healthy happy momma. There is so much that goes into the decision a parent makes about how to feed their baby, and it’s important that we help all feel supported and loved– not judged and put down. (Again, let’s build each other up, parents!!)

Musculoskeletal pain postpartum is fairly common. A 2019 study of 400 breastfeeding women found that around 37% experienced neck pain and 22% experienced low back pain. Another 2015 study looked at the experiences of 229 individuals after giving birth. Around 50% experienced back pain and 25% had an onset of back pain at 2 or more weeks postpartum. (This later onset makes a lot of sense to me based on the big changes in movement and positioning that often happen after having babies.)

So, if you are having back pain after childbirth, you’re in good company. I’ll add here that while this is indeed common, it if not normal. This is good news, because it means that we actually have strategies to help this improve.

What can a nursing mama do to help these aches and pains?

1. Be sure you are using good mechanics when you feed your little one. My daughter takes 20-30 min to feed and ate every 2-3 hours after birth (and now, at 9 weeks old, still eats every 2 hours or so during the day–but sleeps more at night!! Yay!). That means that she feeds anywhere from 160-360 minutes each day. That is a long time to be in the same position. So, to minimize aches and pains, aim to sit with support at your back. If possible, find a comfortable place to feed your baby where your body can relax and you aren’t having to work to stay in a good position for feeding. Also, be sure you bring your baby to your breast not your breast to your baby. If you are having to bring your breast to your baby, you’ll inevitably slump down and holding that position for 20-30 minutes makes my back hurt just thinking about it.

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My first little nursling, Emma, after she just finished eating.

These recommendations also hold true for my pumping and bottle feeding mamas. Pumping also leaves you in one position (unless you have one of the new styles of pumps like the Elvie– more to come later on that!!) for a long period of time, so being sure you have a comfortable place to pump and feed your baby is key!

2. Use pillows and cushions to provide support. Remember, 360 minutes in one position each day can be touch. Try using pillows like the boppy, brest friend, or others that support the baby being lifted to the breast. I actually find for my daughter that I like the boppy more when I sit in my glider or recliner, but I prefer the brest friend when I’m sitting in bed (used with a pillow under it for positioning). Right after birth, depending on where I was sitting, I sometimes just preferred using a few pillows, or using a football hold position to nurse. So, try a few options and see what helps you get into the most optimal position.

If you are bottle feeding, using pillows and supports like this can still be helpful to keep you in an ergonomic position and support your baby during your feed.

3. Change it up. When it comes to posture, the current thought is along the lines that there is not one perfect posture per se, but rather variability in posture and movement seems to be important. So, changing up your position to feed can sometimes help. This can mean feeding in a wrap or a carrier (I have yet to master that!), or nursing while lying down (my most favorite!). Sometimes mixing it up like this can make a big difference.

4. Take movement breaks between feeds. This goes along with Tip #3. Movement breaks like this feel amazing to me after nursing my little Mary. The following movement sequence is meant to take you out of the position you’re in to feed, and help restore some variability. Doing a short movement series between feeds like this can really help improve these aches and pains.

Cat-cow: I love this exercise because it allows your spine to move well into flexion and extension. This can feel great when you have been feeding for so long or holding your baby in a slightly flexed position. Pairing this with breathing can be fantastic as well (and helps to get your deep core–including your pelvic floor–involved). To do this, inhale while your back extends and your head comes up. Exhale while you arch your back, tucking your pelvis and allowing your head to drop down.

Wall Angels: This is another of my favorites. This exercise stabilizes your low back while encouraging movement at your shoulders and mid-back. It feels AMAZING if you have been sitting for a while at a computer…or in this case…sitting for a while and feeding a little one!

Reach and Roll: This exercise is a good one to get some movement in your shoulders and thoracic spine. Keep your pelvis “stacked” and your knees and hips bent to 90 degrees to encourage movement through your upper back.

Child’s Pose: This is a nice position to open your hips, lengthen your spine and extend your shoulders. As a bonus, a wide-kneed child’s pose also encourages lengthening of the pelvic floor muscles, so this is a favorite exercise of mine for individuals with pelvic floor overactivity or pelvic pain. **If you are fairly early postpartum, you may not want to lengthen your pelvic floor this way. So, in your case, consider keeping your knees together rather than wide.

5. If pain persists, seek help! This could mean seeing a lactation consultant if you are needing help positioning your baby. It could also mean seeking an evaluation with a physical therapist who has experience working with people postpartum (usually, this primarily includes pelvic health PTs). While back pain can be very aggravating, it is often very treatable. We usually see good results for people experiencing this, very quickly.

I hope this helps some of my fellow nursing mamas! If you have any questions or comments, feel free to reach out!

Have a wonderful weekend!

~ Jessica

Early Recovery After Caesarean Birth

6 weeks ago, we welcomed our second daughter into the world. Mary Lynn was 6 lbs 10 oz of squishy, adorable, babyness. And she came into the world via a Caesarean birth. And it was amazing. And hard. But good.

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In the recovery room right after Mary’s birth!

C-sections come with challenges, just like vaginal births do, and for me, these challenges included a significant blood loss that led to me fainting on the second day, a super low blood pressure due to a response to the epidural that contributed to the fainting but also meant going off of my epidural pain meds really early, and nerve pain that lasted for about a month after Mary was born. (We’ll y’all more about that another time.)

Since I am living the early postpartum life, I thought it would be fun to do a series of posts on my own rehabilitation journey (since, in many ways, each of my births has been a mini-case study for myself!).

So, let’s talk Cesarean rehab in the first 6 weeks!

Moving well after major abdominal surgery

I love when people imply that birthing via Cesarean section is somehow “the easy way out” compared to birthing via the vagina. Hello people, this is major abdominal surgery! All mommas get birthing badges– let’s support each other in our journeys, right?!

Initially after a Cesarean, movement alone can be challenging. Standing up from a chair. Rolling over in bed. Lying down in bed. But the good news is that with some easy tips, this movement can become much easier. First, as you are moving, bending, standing, etc. remember to “blow before you go.” This easy to remember phrase comes from my friend and colleague, Julie Wiebe. This means, begin to exhale before you initiate a movement. Breathing like this with movement helps to control pressures within the abdomen and pelvis, so it can significantly help you in your movement after having your baby- both in terms of ease but also in protecting your pelvis and abdomen.

When standing up from a chair, remember, nose over toes. Scoot to the edge of the chair first. As you go to stand, lean forward first. This puts your body weight over your legs and helps take the burden away from your core.

When you lie down or get up from lying down, channel your inner log. So, when you lie down, first sit on the edge of the bed. Slowly lift your legs onto the bed, then lower the rest of the body down, using your arms for support. If you need to roll over, bend your knees, then roll your body as a unit- like a log. Reverse these steps for getting up out of bed.

Abdominal Binders and Compression Underwear? It depends. It may be worth considering  using an abdominal binder for the first few weeks after your birth, progressing to wearing compression underwear or shorts(ie Spanx, SRS recovery shorts, Core shorts). These types of garments provide support to the abdomen and can be incredibly helpful for moving and walking around after your surgery. The flip side with compressing the abdomen is that it can impact how well you can move your ribcage and can influence pressure mechanics within the pelvis. So, if you are already struggling with pelvic organ prolapse or urinary leakage, or if you pushed for a period of time before having a Caesarean birth, it may be worth talking with a pelvic floor PT prior to utilizing this during your recovery. Generally, the compression underwear/shorts provide more support to the pelvic floor and abdomen, so they may be a little better with pressure modulation than the binder. For me personally, the binder and compression undies were amazing! They took away my nerve pain, and helped me move much better. I chose to wear these sporadically during the day (a bit on, a bit off), and practiced breathing well with my diaphragm during the times the binder was off.

Handling your incision

Initially, your main focus here is keeping your incision clean, and monitoring it to make sure it is healing well with no signs of infection. Around 6 weeks, if you are cleared by your physician, you can begin to gently mobilize the tissue around the scar and aim to desensitize the scar. I usually start above and below the scar, before working on the scar itself. You can perform gentle massage to the tissue above and below the scar and gently stretch the skin in all directions above and below the scar. You can also gently desensitize the scar by touching it with your fingers or a wet cloth, and gently rubbing across the scar in all directions. We can mobilize this scar tissue further, but we are going to talk about this in a future post as this post is focusing on the early period of healing.

At this time, you can also begin applying silicone gel or silicone strips to help soften your scar and prevent hypertrophic or keloid scars. Silicone is considered a gold-standard treatment for the prevention or treatment of hypertrophic scars. While most of the research regarding silicone is of poor quality with significant bias, evidence does tend to suggest a positive benefit. My first Caesarean did lead to a hypertrophic scar, so I began applying silicone gel to my scar once cleared by my OB to do so, around 4 weeks after Mary’s birth. I’ll report back on the difference between this new scar and the old one (See, mini case study!).

**I also have to note here that my colleague, Kathe Wallace, has a fantastic book that details some recommendations for scar tissue management after Caesarean. Kathe also offers a free abdominal scar massage guide at her website, which is a fantastic resource!

Exercise in the Early Postpartum Period

If I could give you one piece of advice on this early postpartum period, it would be to relax. Give yourself a break. Allow yourself to recover and heal. I find that so many people want to jump into too much, way too soon, and unfortunately, this can be more harmful than it is helpful. Remember, you just did something incredible. You just had major surgery. You deserve to rest. 

When we think about exercise during this initial period of healing, we are going to start very gently. Here are a few things you can get started on:

  • Walking: I’m not talking about going and walking several miles. During the first few weeks, it’s best to really rest, and give your body time to heal. Getting up, walking around the house as you feel comfortable can be very beneficial.  As you continue to heal, during the next few weeks, you can increase your walking. So, this may include some outings and short periods of walking between 2-4 weeks. Between 4-6 weeks, you can generally consider a leisurely walk in your neighborhood or a longer outing. The key here is to listen to your body. Rest when you need to, but gradually move to increase your endurance. After you see your OB for a postpartum visit around 4-6 weeks, and you are cleaned to do so, you can continue to gradually increase your walking as you are feeling comfortable.  Are you antsy to jump back into running? Zumba? Bootcamp? Pilates? Don’t. We’ll get there. But let’s rest right now.
  • Breathing: You all know I am fairly obsessed with the diaphragm. 4 years after this post was written, I still think it’s one of the coolest muscles in the body. The diaphragm works in coordination with the pelvic floor muscles, deep abdominal muscles and deep low back muscles to provide support to the abdominal organs, modulate pressure in the thorax and pelvis, and provide dynamic stability to our spine and pelvis. Slow breathing, aiming to expand your ribcage and relax your abdomen as you inhale, then slowly exhaling your air can be incredibly beneficial to re-establishing these normal functional relationships.
  • Gentle Pelvic Floor Muscle Activation & Relaxation: First, my biggest recommendation would be to SEE A PELVIC PT before and during your pregnancy so you really know your current function and can have an individualized plan to get the most out of your muscles and your body. I encourage people to discuss their delivery with their OB, and ask about beginning gentle pelvic floor and abdominal exercises. The timeline for starting this will depend on the specifics of your delivery, and we want to be smart when activating muscles that have been cut. When your provider is on-board with you starting, I like to pair gentle pelvic floor and abdominal wall activation with breathing. This looks like this:
    • Inhale, expanding your ribcage, relaxing your abdomen and your pelvic floor muscles.
    • Exhale and gently draw in your pelvic floor muscles, allowing your lower abdominal muscles to also gently draw in. Aim for a “moderate” effort to allow activation of the muscles but not overactivate them.
    • Then, relax your muscles again as you inhale, repeating this cycle.
    • Aim to do this for a minute or two, twice each day.

Stay tuned as we continue this journey over the next few weeks and months! What have been your challenges after childbirth? For my fellow health care professionals, what else do you like people to know immediately after a caesarean birth?

Have a great week!

Jessica

Sex After Baby- 4 Reasons Why It Can Hurt and What To Do About It

“Ok, TMI…but is everyone having sex again? We tried last night and OMG it was awful! So painful!!”

I clicked on the thread in one of my Facebook moms groups, and slowly looked through the comments, hoping to see words of encouragement, support, and most importantly, solid health advice. 

“I know, me too. I just try to avoid it as much as I can.”

“What is sex? LOL”

Then, I began my comment, “Hi, I’m a pelvic PT and also the mom to a 6 month old. I’m so sorry you’re hurting. It’s so important to know that pain is not something you have to live with. There is help out there…”

Why is painful sex after childbirth so overlooked in healthcare? Why do so many women feel like they just have to live with this as a normal “consequence” of having a baby?

This past fall, I went through the craziest initiation process to join one of the most exclusive clubs out there: Motherhood. It has been an incredible and humbling journey for me, especially as a health care provider who specializes in helping women with problems they experience while pregnant and postpartum. Becoming a mother has allowed me to experience and witness first-hand many of the challenges women face after having babies.

Pain during sexual activity is extremely common after childbirth (Note: I said common…NOT normal). In fact, a large study of over 1000 women found that 85% experience pain during their first vaginal intercourse postnatally. At 3 months postpartum, 45% still were experiencing pain and at 18 months postpartum, 23% were still experiencing pain. Let that sink in. When a mother’s baby is 18 months old, 1 in 5 mamas had pain during sex! And the sad thing is that pain during sexual intercourse is SO treatable!! So, let’s get down to business…

Why could sex hurt after a baby? 

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  1. Perineal Trauma from Childbirth

    Spontaneous tearing and episiotomies are very common during vaginal deliveries. In fact, this study looking at 449 women who had at least 1 delivery found that only 3% of them did not have any tearing/episiotomy. Many women are able to heal from tears without problems. However, for some women, these injuries can become sources of pain, especially during sexual intercourse. This is especially true with more severe tears extending into the external anal sphinctor and rectum (grade 3-4 tears). This study found that women who had tears extending into the anal sphinctor were 3-4 times more likely to have pain during intercourse at 1 year postpartum compared to their counterparts. Perineal scars can be very sensitive and move poorly in some women leading to persistent discomfort which can last for years after the baby is born when it is not treated (but guess what? It CAN be treated!)

  2. Hormonal Changes

    Anyone who has had a baby can attest to the crazy hormonal fluctuations that happen during pregnancy and postpartum. One of my very best friends warned me about this telling me that she cried every day for the first week after the baby was born. Guess what? So did I. These crazy hormones can also impact what is happening down below, especially in breastfeeding mamas. Basically, the hormonal changes lead to decreased estrogen in the vulvar tissues often causing thinning and dryness. This is why breastfeeding is associated with painful sexual intercourse early on postpartum. Now, if you are reading this and you are a nursing mama like myself, should you stop to fix your sexual discomfort? Not necessarily. This study found that although nursing was associated with dyspareunia at 6 weeks postpartum, the association was eliminated by 6 months. Meaning, stopping nursing won’t necessarily fix the problem (so don’t let this be your deciding factor in the decision to breastfeed your babe).

  3.  Tender Pelvic Floor Muscles

    The pelvic floor muscles themselves can become big sources of sexual discomfort if they are tender, shortened or irritated after childbirth. Perineal trauma and hormonal changes can lead to tenderness in the pelvic floor muscles, but the muscles can also stand on their own. Many people believe that C-sections protect the pelvic floor muscles from having problems, however, we have to remember that the pelvic floor are one member of a team of muscles (including the deep abdominal muscles, low back muscles and respiratory diaphragm) that work together to provide support and stability to the pelvis. That could be partially why C-section mamas are actually 2-3 times more likely to experience more intense pain during sexual intercourse at 6 months postpartum.

  4. Because Babies are Hard

    I had to add this one in. It’s important to remember than normal sexual function should include sexual desire, arousal, and orgasm. New mamas are exhausted, feeding sweet little babies around the clock, settling into a new routine whether they are returning to jobs or caring for their babies at home,  sleep-deprived from often waking up multiple times a night, changing diapers, and worrying constantly about helping these little babies survive and thrive. And honestly, it can be really hard for many moms to have the same level of sexual desire and arousal that they had prior to having their babies (at least until life settles down– or I’m told–when the babies go to college LOL). When a woman experiences sexual desire and arousal, there is natural lubrication and lengthening of the vaginal canal, and this step is so important in having enjoyable sexual activity. Sometimes, when this step is skipped, women are more likely to experience discomfort with vaginal penetration.

So, what can be done to help?

Realize it is not normal. Don’t just deal with it. And check-in with your Obstetric provider.

The first step is seeing your OB or midwife to make sure everything is ok medically. She should evaluate you to make sure everything is healing the way that it should be healing and that nothing else is going on that needs to be managed medically. I have had patients who have had difficulties healing after tears and needed some medical help to encourage their tissues to heal the way they needed to. I have also worked with women who had underlying infections contributing to their pain, that of course, needed to be treated to move forward. This is not a step you should skip, so don’t be bashful! Tell your doctor what is going on.

Don’t be afraid to use a little help.

I get it. You never had to use lubricant before, and it’s annoying to have to use it now. But guess what? It can make a HUGE difference in reducing discomfort from thin or dehydrated vulvar tissues after babies! So, if you don’t already have a good one, go pick out a nice water-based lubricant to use. Some of my favorites for my patients are Slippery Stuff and Sliquid. I am also a big fan of coconut oil (but make sure to know that using it with condoms can cause condom breakdown).

If you are having difficulty with sexual arousal and desire since having your baby, and you feel comfortable with it (I know, some women don’t!), try using a small vibrator to help with improving sexual arousal and promoting orgasm. Many sex therapists I work with encourage couples to consider using this on days when they need a little assistance attaining the arousal they need.

Educate your sexual partner and empower them to help you

It can be so helpful to include partners in this process. Show them this blog post, so they can understand what could be going on, and empower them to help you! For some women having difficulties with arousal, having their partner do something like clean up after dinner and put the baby to bed so they can have time for a quiet relaxing shower can be just the ticket to helping them become more sexually aroused to decrease sexual discomfort. If you are having problems with painful perineal scars or pelvic floor muscles, consider including your partner in your medical or physical therapy visits so they can understand what you are experiencing. Many pelvic PTs (like myself) will often educate partners in methods to help with decreasing pain , and even in treating the pelvic floor muscles/scars (if both people feel comfortable and on-board with this!).

Go see a pelvic PT!

If you have tender pelvic floor muscles or painful scars, all the lubricant and sexual arousal in the world is not going to fix the problem. Working with a skilled pelvic floor physical therapist can be hugely beneficial in identifying where and what the problem is, and helping you move forward from pain!

A skilled physical therapist will spend time talking with you the first visit to understand your history (including specifics of your delivery), and will perform a comprehensive examination, head to toe, to see how your body moves, where you might not be moving as well as you could be, and how you transfer force through your body. They will also perform an examination of the abdominal wall (especially important for C-section mamas), and an internal vaginal examination of the pelvic floor muscles. Based on this examination, they will be able to work with you to develop a plan to help you optimize the function of your body and get back to a happy and healthy sex life!

This is first in likely a few series of posts I will be doing on postpartum specific problems. I hope you all enjoy! Please please please reach out if you have any questions at all!

Have a wonderful week!

Jessica

 

Painful scars? Yes, you can do something about it!

 

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I can’t help it. Every time I think scar, I think… Scar (and yes, I used to have a much better picture of Scar from The Lion King for you…but I had to remove it in my attempt to make sure I’m not violating anyone’s copyright laws!)  I was going to try to think of some funny way to explain why scars and Scar are the same… but I can’t… I relate it to the 50,000 times I have watched The Lion King... so I’ll leave it at that.

Scars can be a big pain though– literally! I have treated women who even after several years cannot tolerate pressure on a c-section scar. Men who have nice huge abdominal scars that ultimately contribute to problems with constipation. And moms who have discomfort near their perineal tears every time they have sexual intercourse.  The truth is that scar tissue is often something skilled physical therapists will evaluate and treat as part of a comprehensive program in men and women with pelvic floor dysfunction(and really, with any type of problem!). And the best part– treating scar tissue can make HUGE differences!

So, what is a scar? 

When there is an initial injury (and yes, a surgical incision is an “injury”), the body goes through three phases of healing: Inflamation, Proliferation and Remodeling. Through this process, the body creates scarring to close up the initial injury. Scars are composed of a fibrous protein (collagen) which is the same type of tissue that is in the tissue the body is repairing (i.e. skin, etc).  The difference, however, is that scars are not quite organized the same way as the tissues they replace, and they don’t really do the job quite as well. (i.e. scars are much more permeable to UV rays than skin is). Scars can form in all tissues of the body– even the heart forms scar tissue after someone has a heart attack (myocardial infarction).

How do scars lead to problems? 

After the inflammation and proliferation stage of healing, comes the remodeling. This stage can take months to years! During this time, the body is slowly adapting and changing the scar to the stresses on the tissue. Have you ever noticed that some scars initially are pink and raised and then over time become light/white and flat? That’s remodeling.  Ultimately, there are a few major reasons why a person might develop pain from a scar:

  • Adhesions: Scars are not super selective when it comes to tissues they adhere to. So, sometimes, scars will adhere to lots of tissues around them and this pull can lead to discomfort.
  • Sensitivity: Scars can become very sensitive for a variety of reasons. Sometimes, small nerves can be pulled on by the scar which can lead to irritation. Other times, people themselves will have a significant amount of fear related to the scar. This fear, can often make people avoid touching the scar, and that, along with what we know about how our brain processes fear and pain (See this post, this one, and this one), can lead to a brain that is veeerrrryyy sensitive to the scar. Along with this, muscles near scars can become tender and sensitive. This can occur due to the scar pulling on the muscle or due to the sensitive nerves in the area.
  • Weakness/Poor Muscle firing: So, we know that when our tissues are cut, the muscles around the tissues are inhibited (have you ever seen someone after a knee replacement? It can be quite a bit of work to get those muscles to fire immediately after surgery). That’s why it’s important to get the right muscles firing and moving once a person is safely healed. Moving the right muscles improves blood flow too which promotes healing.
  • Changing Movement: Painful scarring can lead to altered movement. We can especially see this with postural changes after c-sections or other abdominal surgeries, but movement patterns can change with scars all around the body. We also know that abnormal movement patterns over time can lead to dysfunction and pain.

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What can we do about it? 

There are several ways physical therapists can help decrease pain from scars. Can we actually break-up/melt/eliminate scar tissue? I don’t really think so– honestly, scars are made from strong material and truly breaking up the scar is typically something that has to be done surgically– but most of the time, that is not necessary. We can decrease pain from scars by:

  • Improving the mobility of the scar: Gentle techniques to massage the scar and the tissues around the scar can facilitate blood flow to the area and decrease some of the pulling on the tissues around it. There is a thought as well that scar tissue massage can disrupt the fibrotic tissue and improve pliability of the scar (basically, help the scar organize itself a little better, and ultimately move better), and help to promote decreased adhesions of the scar to the tissues around it. Unfortunately, there really is not a lot of great research out there about scar tissue massage. However, this review published in 2012 found that 90% of people with post-surgical scars who were treated by scar massage saw an improvement in either the appearance of the scar or their overall function–which is very promising!
  • Desensitizing the scar and the nervous system: This is where I think we can make huge changes–both by improving someone’s worries/fears about the scar (calming the nervous system) and by slowly desensitizing the scar and the skin around the scar to touch. This is a slow process, but over time, many people who initially can barely tolerate pressure on the scar can be able to easily touch and move the scar without discomfort.
  • Promoting movement: So, we talked about how muscles can become inhibited or tender after a surgery? Part of improving scar tissue related pain is helping the muscles around the scar move well and learn to fire again. This can include some soft tissue treatment to the muscles to reduce the tenderness of the muscles, but ultimately leads to learning to use the muscles again in a variety of movement patterns. Movement is amazing for the body and can not only improve blood flow, but decrease pain too!

Wanna learn more? 

Several of my colleagues have written wonderful information about scar tissue! Check out this great, article and free handout by Kathe Wallace, PT on abdominal scar massage! My colleagues at the Pelvic Health and Rehabilitation Center have also written a few blogs on scars, which you can find here and here.

Have a great rest of your week!

~ Jessica