Although there are many books and information on what to expect while you are pregnant, there is considerably less information on what to expect after childbirth. Many women recognize that their bodies will change but the degree of pelvic floor disruption is commonly underestimated.
Beyond stretch marks…
During pregnancy, there is a substantial increase in abdominal pressure that transfers down to the pelvic muscles and connective tissue. With vaginal delivery, the pelvic muscles are stretched over 3x its original length and often connective tissues are torn even when there is not a superficial break to the vaginal skin.
Along with this comes some disruption to the nerves in the area. Furthermore, having a cesarean delivery after an attempt of a vaginal delivery has not been found to be particularly protective of this. This damage may lead to disruption of normal bladder and bowel function, pelvic organ prolapse, and scarring that is sub-optimal for sexual function.
Shortly after delivery…
Women may not have good control of their bladder. Although some women may not be able to effective empty their bladder due to nerve disruption and swelling that necessitates the use of a catheter, the majority of women have urinary leakage beyond their control.
Women get better control of their bladder with time as their body remodels but as many as 1 in 3 women can have urinary incontinence 6 months after their first delivery.
Those who delivered vaginally particularly with the help of forceps or a vacuum are more likely to have urinary symptoms but a cesarean delivery does not completely protect women from this.
Similarly, bowel function is often disrupted. Many women suffer from severe constipation soon after childbirth. It is important to use stool softeners or laxatives to avoid straining as this can lead to more pelvic floor damage when the tissues are still healing.
In a recent national study, 18% of women had bowel leakage at 6 weeks after delivery. At 6 months postpartum, there was accidental bowel leakage in 7.6% of those that had a cesarean section, 8.2% in those that had a vaginal delivery, and 17% in those that had a vaginal delivery with a 3rd or 4th degree tear.
Having a sphincter tear at delivery doubled the odds of bowel leakage and should be addressed appropriately.
Pelvic Organ Prolapse in Women
During pregnancy, pelvic organ prolapse has been noted to be present in close to 48% of women.
Often the feeling of a bulge and heaviness is equated with the baby “being low,” but after delivery this sensation can be persistent. Prolapse or a bulging of vaginal tissues is similar to a hernia and is very common immediately after delivery with a decrease in time. This risk increases with more deliveries, larger babies, a vaginal delivery requiring forceps or vacuum assistance, and in women who deliver at an older age.
As the pelvic floor remodels after delivery, it is important that there is not much added pressure with constipation or heavy lifting that could increase the severity of the prolapse
There are dramatic changes in a woman’s hormone levels after delivery. Particularly with women who breastfeed, there is decreased estrogen to the vagina which can lead to thinning of tissues and decreased elasticity, similar to a menopausal state. Wound healing can be slower in those that are breastfeeding. Women may feel vaginal dryness and have pain with sex.
Overall, about 90% of women resume sexual activity by 6 months after delivery. However, a recent study estimated 36% of women reported pain with sex and there was no difference whether the woman had a cesarean delivery, a vaginal delivery, or a vaginal delivery with large tears. Poor wound healing, scarring, or nerve disruption may have caused this, and women may benefit from an evaluation.
Reducing Pelvic Floor Symptoms after Childbirth
The pelvic floor takes about 6 months to remodel after delivery and this is a crucial time to assist recovery and allow for optimal healing.
Some lifestyle modifications include:
- Emptying the bladder at regular intervals
- Increasing fiber or using stool softeners to avoid straining with having a bowel movement
- Avoiding high impact exercises or heavy lifting beyond the baby particularly soon after delivery
- Doing pelvic floor muscle exercises (“Kegel”exercises) regularly
Speak with Your Delivering Provider
If you suffer from pelvic floor symptoms, you are not alone. It is important for you to discuss this with your obstetrician or midwife. They will do an initial assessment and you may benefit from the use of vaginal estrogen supplement and/or a referral to a physical therapist or a urogynecologist/reconstructive surgeon for further evaluation and treatment.
About Andrea Crane, MD, FACOG, FPMRS
Dr. Andrea Crane is a board certified urogynecologist and female pelvic reconstructive surgeon at WakeMed with interests in comprehensive pelvic reconstruction, da Vinci® robot-assisted sacrocolpopexy, and sacral neuromodulation. Her training includes evaluation and treatment of childbirth trauma, advanced pelvic organ prolapse, urinary and fecal incontinence, mesh complications, and sexual dysfunction.
Learn more about urogynecology in Raleigh, NC, and schedule an appointment today.