I am 2 weeks in to my new practice, and absolutely loving it! I was fortunate this past week to be a guest on the podcast series, Real Talk with the Pelvic Docs. Jenny LaCross has been a friend for a few years (we connected when she was in her residency program), and she’s doing amazing things for the pelvic health community! It was such a pleasure to talk with her about my experiences with pregnancy, childbirth and my own postpartum recovery. You’ll also hear more about my journey to private practice and my hopes and dreams for the future! I hope you enjoy this podcast as much as I enjoyed recording it!
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.
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!
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.
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?
Happy Pelvic Pain Awareness Month! I do plan to post a few blogs on pelvic pain over the course of this month, I promise, but I wanted to quickly share with you a few events I am going to be a part of over the next month!
First, next Wednesday, May 15th, I will be the special guest at a FREE pelvic health education event hosted by PLS Yoga and Wholeheart Psychotherapy, “Women’s Pelvic Health: Key Considerations for Health and Wellbeing for Women Living with Pelvic Pain” The event will run 7-9 pm at 6 Lenox Pt NE in Atlanta! If you are struggling with pelvic pain, please join us for this incredible evening!
Next, on Sunday June 2nd my colleagues and I will have a booth at the Mama Bear Fair, hosted by Dr. Jamie Michael’s chiropractic clinic in Smyrna! Fitting, as this is just 2 weeks before my due date (I did tell you all I was expecting another baby girl, didn’t I?) Stop in between 3-6pm to chat with me about prenatal/postpartum care and pelvic health! RSVP for the event via Facebook!
I hope to see some of you at these events! Please feel free to be in touch if you have any questions!
About 2.5 years ago, I had the incredible opportunity to join Herman & Wallace Pelvic Rehabilitation Institute as a Faculty instructor for the Pelvic Health Series. This was an absolute dream come true for me, as I completely love teaching and had always dreamed of teaching continuing education in pelvic health. (Seriously… as a new grad, I remember asking an instructor at a course what advice they had for someday becoming an instructor. Funny story is that I now co-teach with that very instructor!). Teaching in pelvic health has been such a incredible blessing for me– not only do I get to travel across the country and help other clinicians learn to treat my most favorite population of patients, but I also get the opportunity to co-teach with inspiring and incredible experts in pelvic physical therapy.
This past September, I had the opportunity to teach with Sara Reardon, PT, DPT, WCS, BCB-PMD, who is not only an incredible clinician, but is also hilarious, down-to-earth, and passionate about women’s health. One night at dinner, Sara, Darla Cathcart, and I had a long conversation about pregnancy, childbirth, the postpartum period, and becoming moms. At one point, I think all of us had tears in our eyes, as we shared our own journeys, challenges we/our family/our patients have had, and our hopes for making everything better. After that chat, I just knew I needed to interview Sara here so all of you have the opportunity to learn from her and feel her passion! I hope you enjoy this interview! Please feel free to leave any questions or comments below!
If you would like to see Sara’s work, check her out at www.thevagwhisperer.com. Here, you will find information about seeing Sara in-person, her online therapy options, mentoring options, and her instagram/blog presence!
Happy New Year!
If you want to see all of our expert videos in one place, be sure to check out my youtube channel! This video as well as the others can be found here!
Last week, one of my favorite things to happen in the clinic happened again. A sweet patient I had been working with over the past few months came in to her session, and as soon as we closed the door, she exclaimed, “We had sex and it didn’t hurt!” As a pelvic PT, there is nothing better than sharing in the joy of the successes of your patients. Treating sexual pain is close to my heart, particularly because this was one of the reasons I became a pelvic PT to begin with. “Treating Sexual Pain” was actually the focus topic for my small group mentoring program this month, so I thought it would be fitting to highlight a common treatment tool/strategy used in pelvic PT to help people experiencing painful penetration.
What are vaginal trainers?
Vaginal trainers are tools used to help to desensitize the muscles and tissues of the canal. They are often helpful when a person is wanting to participate in penetration activities, and is having difficulty doing so due to pain. Vaginismus is a particular diagnosis that refers to painful vaginal penetration due to muscle spasm. Women experiencing vaginimus in particular can be very good candidates for this type of treatment program. That being said, trainers can also be helpful for people with pelvic pain in performing self-manual treatment to the pelvic floor muscles, or for other vulvar pain conditions. Trainers also come in rectal variations, and some patients benefit from these as well depending on their primary complaints and goals.
Trainers generally come in graded sizes, often ranging from very small (think pinky finger) to large. There are several different companies that make trainers, and I’ll share a few of the different types here:
Silicone Dilators/Trainers: These are smooth silicone, and bend and move very easily, so they are what I consider to be top-of-the-line trainers. Soul Source and Intimate Rose are two companies that sell these trainers. Both are great, but I do really like how smooth and soft the intimate rose dilators are. These are a little pricey, so range from $18-50 per trainer $80-200 for a set. (As an aside, Intimate Rose was actually designed by a pelvic PT, Amanda Olson, DPT, PRPC. Amanda has excellent resources on her website, including this great video providing a breathing exercise for pelvic pain)
Plastic Dilators/Trainers: These are hard plastic, so they do not move and bend the way silicone trainers do. However, they do tend to be on the cheaper side. Vaginismus.com sells a trainer set including 6 sizes with a handle for about $45. The Berman Vibrating Set includes 4 sizes and often sells on amazon for less than $25. Syracuse Medical also makes a set without handles that is solid plastic, and those trainers are sold individually ($10-20 each) or as a set ($45-80).
How do you decide which to pick?
Well, it depends on a lot of things. Some of my patients prefer to go the cheapest route possible, so for them, it makes sense to get the $25 Berman set off of amazon or the $45 Vaginismus.com set. For others, they really like the softness and bendiness of the silicone sets, so they feel comfortable spending a little more for that type of set. Some sets come with varying sizes, so it is important to pick one that has the sizes you (or your patient) needs to accomplish their treatment goals. Usually, I sit down with my patients, show them a few different sets, then allow them to pick the set they feel the most comfortable with.
Wait…Trainer or Dilator? What’s in a name?
So, you’ll see these terms used interchangeably quite a bit, but honestly, I think the name really does matter. The term “dilator” never really settled well with me…because…well…dilation is a fairly strong word. Dilation refers to passive opening. I think pupil dilation. I think cervical dilation (although one could argue that is not totally passive!). Honestly, dilation is not what we are aiming for when it comes to the pelvic floor muscles. Trainer on the other hand, is an active term. It requires participation, focus, involvement. It is not a passive process, but rather, is an active journey. And that, my friends, is what utilizing trainers to improve penetration should be.
Getting started with trainers
A word of advice- please do not try this on your own. I have had so many patients who become discouraged, sore, or get worse from using trainers without the guidance of a pelvic PT. If you are struggling with sexual pain, and you would like to try trainers, please please please make an appointment with a pelvic PT who can evaluate you and guide you in this process.
Once my patients purchase their trainer sets, I have them bring the trainers to the clinic. We then will use them together in the clinic before they begin using them as part of their home program. I have a few rules when it comes to trainers:
We are gently introducing a new stimulus to the vagina; therefore, we do not want to do anything that leads to the body guarding and protecting by pain. So, when people use trainers, all discomfort should be 2/10 or less, and should reduce while we are using the trainer. (Note: Some very well-intending clinicians will give advice to “insert the largest dilator you can tolerate and leave it there for 10-15 min.” Tolerate is a very strong word, and I find this approach tends to lead to a lot of pain as well as fear and anxiety associated with the treatment.)
We cap out at 10-15 minutes. I encourage patients to set a timer when they start, and whenever that timer ends, to go ahead and end their session. This keeps the session reasonable in time commitment, and also avoids over-treating the area.
We avoid setting “goals” for the sessions or the week. The goal of using trainers is to gently provide graded exposure to the muscles and the tissues, to allow relaxation and opening without anything being threatening or painful. Our muscles are impacted by many different things, so many patients will find that the size of trainer they use or the level of insertion that happens can vary based on the day, week, etc. So, for this reason, we avoid setting a goal to accomplish, but rather, just aim to spend time focused on breathing, relaxation, opening, and gentle desensitization.
So, how do we use the trainers?
My approach to using trainers is strongly influenced by my friend and mentor, Darla Cathcart, PT, DPT, WCS, CLT. Darla was my clinical instructor back when I was getting my doctorate 10 years ago, and her approach to using trainers is gentle, progressive, and based in our understandings of muscles and neuroscience. (As an aside, Darla recently started teaching for H&W and I could not be more excited!! We taught our first class together a few months ago, and we will be teaching together again in 2019!! She is the absolute best, and is actually currently doing her PhD research on women with vaginismus. I’ll try to share more as she gives permission to do so in the future!)
Back to trainers, I encourage people to start with the smallest trainer (or for some, I may recommend a different size based on what I noticed with the exam). First, I encourage creating a comfortable environment to use the trainers– this means calm lighting, comfortable space, pillows to support legs and torso so that muscles can relax, and sometimes even a nice candle or soft music. We begin with placing the smallest dilator at the opening of the vagina, then slowly insert until the person feels discomfort (2-3/10) or guarding. When this happens, we stop moving, and they take slow long breaths focusing on relaxing and opening the pelvic floor muscles. They can then gently (like with 25% force) contract and relax the pelvic floor muscles, aiming to completely let go and rest the muscles. If the tenderness/guarding they felt resolves, they continue to slowly insert the trainer and repeat this process until the trainer is completely inserted. If at any point the discomfort does not reduce, we then will back the trainer out a little bit and rest/breathe there for a minute, then try again. If it still does not reduce, then the body is giving a cue that it is ready to take a break from trainers, and we go ahead and stop the session.
Once the trainer is completely inserted, we add movement. This can include turning the trainer side-to-side, or pressing it right, left or down. We avoid turning or pressing the dilator toward the pubic bone as the bladder and urethra live there, and they don’t generally like being mashed on. We can also move the trainer slowly in and out, stopping again during this process if anything is uncomfortable and repeating the steps above.
One that size trainer is completely comfortable, we move on to the next size and repeat the process. This continues until the 10-15 minute session ends, and then wherever we are, we stop for the day. We can add modifications in to trainer sessions, and this will depend on the particular patient. Sometimes this includes partner involvement with trainers or it can include visualizations or imagery to aid in the process.
With this slow, graded, and gentle approach, I find that most patients can do very well and this can be an excellent treatment to help them achieve their goals! I hope this was helpful in better understanding an approach to this treatment! If you are a patient and think you may benefit from using this approach, I would strongly recommend discussing this with your physician and seeking out a pelvic PT to help you guide the process!
If you are a pelvic PT, feel free to share any additional tips or recommendations you have for trainers in the comments below!
Exercise has so many incredible benefits for overcoming pain, optimizing cardiovascular health, and facilitating psychological well-being. Unfortunately, for many struggling with pelvic floor dysfunction (whether it is in the form of pelvic pain, urinary/bowel dysfunction, or pelvic organ prolapse), thoughts of exercise and fitness are often accompanied by fear. Fearthat moving incorrectly will lead to a worsening of their symptoms. Fearof a set-back. Fearof creating a new problem. Finding an exercise program that will not only be safe, but actually aid in a person’s recovery and pelvic floor health is a fine art. Seeing a skilled pelvic floor physical therapist can be a good step in finding an individualized exercise program, but many may not have the luxury of working with a professional.
Recently, I did some research to help a few my patients find on-demand options for guided fitness that were pelvic floor friendly. I am grateful to have such an incredible community of pelvic health professionals to learn from and learn with, and I wanted to share these fantastic resources with you here. As always, please know that what works well for one person may not work well for another, thus, an individualized assessment is always the best option to determine the most appropriate exercise program for you.
For those with pelvic pain or pelvic floor tension (often the case in cases of pelvic pain, constipation, overactive bladder):
Creating Pelvic Floor Health with Shelly Prosko- Part A: Pelvic Floor Muscle Relaxation.“30 minute practice of releasing the pelvic floor muscles through pelvic floor awareness, visualization and breathing methods, during mindful movements and yoga postures.” Shelly is an incredible physiotherapist from Canada, with a practice specializing in using yoga interventions to help people with pelvic floor dysfunction. Shelly was kind enough to offer blog viewers 10% off her combined package using the discount code: ClientDiscount10
FemFusionFitness by Brianne Grogan– Brianne (also a physical therapist) has an excellent youtube channel, with several playlists offering movement options for those dealing with pelvic pain or pelvic floor tension. Her “Painful Sex” series includes 2 30-minute yoga sequences emphasizing pelvic floor relaxation, and it’s free!
For those with pelvic floor weakness (often the case–but not always! in situations like urinary incontinence, pelvic organ prolapse, diastasis rectus, fecal incontinence):
Mutu System: This is an excellent post-partum recovery program. Very helpful for those with pelvic floor weakness or diastasis rectus after having a baby. This is often my “go-to” for people having these problems that are unable to travel to see a pelvic PT. She does a great job at encouraging appropriate referral for further evaluation as well.
Fit2B: This is an online program with options for purchasing specific programs or for membership. It has a postpartum series, diastasis recti series, prenatal workshop, and foundational courses. I have had patients use this program who really enjoyed it.
Your Pace Yoga by Dustienne Miller:Dustienne has expanded her video library to include videos such as “Optimizing Bladder Control” which includes sequences to support pelvic floor engagement through yoga.
Pelvic Exercises by Michelle Kenway: Michelle has done excellent work creating videos and ebooks on safe exercise progressions for pelvic floor muscle weakness, prolapse, bowel dysfunction and surgical recovery. Check out her excellent videos here.
I hope these resources are helpful! Did I leave anything out? If you have other wonderful home exercise options that are “pelvic floor friendly” please let me know in the comments below!
“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?
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!)
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).
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.
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!
I spent my first few years of practice going deep into the pelvis… and my most recent few years, desperately trying to get out. Now, I know that may seem like a strange statement to read coming from me, the pelvic floor girl. But bear with me. I love the pelvic floor, I really do. I enjoy learning about the pelvis, treating bowel/bladder problems, helping my patients with their most intimate of struggles. I like to totally “nerd out” reading about the latest research related to complex nerve pain, hormonal and nutritional influences, and complicated or rarely understood diagnoses. However, the more I learned about the pelvic floor, the more I discovered that in order to provide my patients with the best care I can possibly provide, I needed to journey outside the pelvis and integrate the rest of the body.
You see, the pelvic floor does not work in isolation.
It is not the only structure preventing you from leaking urine.
It is not the sole factor in allowing you to have pleasurable sexual intercourse.
It is not the only structure stabilizing your tailbone as you move.
It is simply one gear inside the fascinating machine of the body.
And, the incredible thing about the body is that a problem above or below that gear, can actually influence the function of the gear itself! And that is pretty incredible! One of the patients that most inspired me to really start my journey outside of the pelvis was an 18-year-old girl I treated 4 years ago. She was a senior in high school and prior to the onset of her pelvic pain had been an incredible athlete– playing soccer, volleyball and ice hockey. Since developing pelvic pain, she had to stop all activities. Her pain led to severe nausea, and was greatly impacting her senior year. When I examined her, I noticed some interesting patterns in the way she walked. With further questioning, she ended up telling me that a year ago, she experienced a fracture of her tibia (the bone by her knee) while playing soccer. She was immobilized in a brace for about a month, then cleared to resume all activity. (Yep, no physical therapy). Looking closer, she had significant weakness around her knee that was influencing the way she moved, and leading to a compensatory “gripping” pattern in her pelvic floor muscles to attempt to stabilize her hips and legs during movement. So, we treated her knee (She actually ended up having a surgery for a meniscal tear that had not been discovered by her previous physician), and guess what? Her pelvic pain was eliminated. BOOM. If you want to read more about her story, I actually wrote the case up for Jessica McKinney’s blog and pelvic health awareness project, Share MayFlowers, in 2013.
So, what else is connected to the pelvic floor? Here are a few interesting scenarios:
Poor mobility in the neck and upper back can actually lead to neural tension throughout the body– yes, including the nerves that go to the pelvic floor. (I’ve had patients bend their neck to look down and experience an increase in tailbone pain. How amazing is that?)
Being stuck in a slumped posture can cause a person to have decreased excursion of his or her diaphragm, which can then put the pelvic floor in a position in which it is unable to contract or relax the way it needs to.
Grinding your teeth at night? That increased tension in the jaw can impact the intrathoracic pressure (from glottis to diaphragm), which in turn, impacts the intra-abdominal pressure (from diaphragm to pelvic floor) and, you guessed it, your pelvic floor muscles!
An ankle injury may cause a person to change the way he or she walks, which could increase the work one hip has to do compared to the other. This can cause certain muscles to fatigue and become sore and tender, including the pelvic floor muscles!
Pretty cool right? And the amazing thing is that this is simply scratching the surface! The important thing to understand here is that you are a person, not a body part! Be cautious if you are working with someone who refuses to look outside of your “problem” to see you as a whole. And if you have a feeling in your gut that something might be connected to what you have going on, it really might be! Speak up!
As always, I love to hear from you! Have you learned of any interesting connections between parts of your body? For my fellow pelvic PTs out there, what cool clinical correlations have you found?
Have a great Tuesday!
Wanna read more? Check out this prior post on connections between the diaphragm and the rest of the body!
If you didn’t know, December 1st was a day that all PTs came together to share with the public all of the benefits of seeking PT! My colleague, Stephanie Prendergast, founder of the Pelvic Health and Rehabilitation Center in California, wrote an amazing blog post on why someone should get pelvic PT first. I thought it was great (as you know…I post lots of Stephanie’s stuff), and Stephanie gave me permission to re-blog it here. So, I really hope you enjoy it. If you aren’t familiar with Stephanie’s blog, please check it out here. You won’t regret it.
On another note, I will be teaching a live webinar Thursday 12/10 on Pelvic Floor Dysfunction in the Adult Athlete. I really hope to see some blog followers there! Register for it here.
Now… enjoy this great post by Stephanie. ~ Jessica
Why get PT 1st? Here are the Facts. By Stephanie Prendergast
Vaginal pain. Burning with urination. Post-ejaculatory pain. Constipation. Genital pain following bowel movements. Pelvic pain that prevents sitting, exercising, wearing pants and having pleasurable intercourse.
When a person develops these symptoms, physical therapy is not the first avenue of treatment they turn to for help. In fact, physical therapists are not even considered at all. This week, we’ll discuss why this old way of thinking needs to CHANGE. Additionally, we’ll explain how the “Get PT 1st” campaign is leading the way in this movement.
We’ve heard it before. You didn’t know we existed, right? Throughout the years, patients continue to inform me the reason they never sought a physical therapist for treatment first, was because they were unaware pelvic physical therapists existed, and are actually qualified to help them.
Many individuals do not realize that physical therapists hold advanced degrees in musculoskeletal and neurologic health, and are treating a wide range of disorders beyond the commonly thought of sports or surgical rehabilitation.
On December 1st, physical therapists came together on social media to raise awareness about our profession and how we serve the community. The campaign is titled “GetPT1st”. The team at PHRC supports this campaign and this week we will tell you that you can and should get PT first if you are suffering from a pelvic floor disorder.
Did you know that a majority of people with pelvic pain have “tight” pelvic floor muscles that are associated with their symptoms?
Physical therapy is first-line treatment that can help women eliminate vulvar pain
Chronic vulvar pain affects approximately 8% of the female population under 40 years old in the USA, with prevalence increasing to 18% across the lifespan. (Ruby H. N. Nguyen, Rachael M. Turner, Jared Sieling, David A. Williams, James S. Hodges, Bernard L. Harlow, Feasibility of Collecting Vulvar Pain Variability and its Correlates Using Prospective Collection with Smartphones 2014)
Physical therapy is first-line treatment that can help men and women with Interstitial Cystitis
Over 1 million people are affected by IC in the United States alone [Hanno, 2002;Jones and Nyberg, 1997], in fact; an office survey indicated that 575 in every 100,000 women have IC [Rosenberg and Hazzard, 2005]. Another study on self-reported adult IC cases in an urban community estimated its prevalence to be approximately 4% [Ibrahim et al. 2007]. Children and adolescents can also have IC [Shear and Mayer, 2006]; patients with IC have had 10 times higher prevalence of bladder problems as children than the general population [Hanno, 2007].
Physical Therapy is first-line treatment that can help men suffering from Chronic Nonbacterial Prostatitis/Male Pelvic Pain
Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) affects 2%-14% of the male population, and chronic prostatitis is the most common urologic diagnosis in men aged <50 years.
The definition of CP/CPPS states urinary symptoms are present in the absence of a prostate infection. (Pontari et al. New developments in the diagnosis and treatment of CP/CPPS. Current Opinion, November 2013).
71% of women in a survey of 205 educated postpartum women were unaware of the impact of pregnancy on the pelvic floor muscles.
21% of nulliparous women in a 269 women study presented with Levator Ani avulsion following a vaginal delivery (Deft. relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014 Feb 121: 1164 -1172).
64.3% of women reported sexual dysfunction in the first year following childbirth. (Khajehi M. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015 June; 12(6):1415-26.
24% of postpartum women still experienced pain with intercourse at 18 months postpartum (McDonald et al. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015)
85% of women stated that given verbal instruction alone did not help them to properly perform a Kegel. *Dunbar A. understanding vaginal childbirth: what do women understand about the consequences of vaginal childbirth.J Wo Health PT 2011 May/August 35 (2) 51 – 56)
Did you know that pelvic floor physical therapy is mandatory for postpartum women in many other countries such as France, Australia, and England? This is because pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex.
Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse?
Physical Therapy can help with Stress Urinary Incontinence
Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse? 80% of women by the age of 50 experience Stress Urinary Incontinence. Pelvic floor muscle training was associated with a cure of stress urinary incontinence. (Dumoulin C et al. Neurourol Urodyn. Nov 2014)
30 – 85 % of men develop stress urinary incontinence following a radical prostatectomy. Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months postoperatively. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9).
Physical Therapy can help with Erectile Dysfunction
Several studies have looked at the prevalence of ED. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years. The prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years.1
Physical Therapy can help with Pelvic Organ Prolapse
In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone a hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. (Susan L. Hendrix, DO,Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6.)
Pelvic floor physical therapy can help optimize musculoskeletal health, reducing the symptoms of prolapse, help prepare the body for surgery if necessary, and speed post-operative recovery.
Stephanie grew up in South Jersey, and currently sees patients at Pelvic Health and Rehabilitation Center in their Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.