We’ve been told we should be able to heal within six weeks after vaginal delivery of a baby, but is this true? And is there a better way to heal?
Anatomy and physiology of the pelvic floor, during pregnancy and afterwards
The physical act of carrying a child and then giving birth has recently been shown under magnetic resonance imaging (MRI) to be as traumatic on the skeletal and soft tissue (pelvic muscles, organs, ligaments, skin) as many endurance sports (4). Besides, vaginal childbirths result in tears in 90% of women (2).
Concepts which have been known for a long time to Sports Medicine and Orthopaedics have not been applied to childbearing and postpartum women yet. When suffering a musculoskeletal trauma, the body starts the physiological processes needed to protect the proximal tissues and initiate repair of the injury. Indeed, inflammation is a natural and necessary mechanism in this process, actually controlling it can allow the body to switch into healing mode sooner (1).
Contrary to what was previously told to mums, current studies show that the imaginary bright line for the six-week OB/GYN follow-up appointment is just the beginning of postpartum recovery. In fact, recovery of connective tissue and complete pelvic floor muscles contractility takes up to 6 months after vaginal delivery. Notably, MRI studies of levator ani muscles (one of the key muscles that hold up the pelvic floor) have shown that the process by which the reproductive tract returns anatomically to a normal non-pregnant state after delivery is far longer than six weeks (4).
Your body is changing, dealing with forces and gravity: Bones, muscles, nerves, hormones and the physics of healing.
By the time you are already back at home with your baby, you may feel your uterus contracting for several days. You may be heating your abdomen with a heat pad, relaxing and taking deep breaths, or even using one of labour breathing techniques. Usually, six weeks after giving birth, your uterus will be back to its non-pregnant size, although the rest of your pelvic organs, muscles may not (yet). If you are breastfeeding, your uterus will heal faster. The hormones that let down your milk also make your uterus contract. If you push yourself too hard in these early weeks, your physical healing will take longer (10). It’s important to rest.
Unfortunately, too often hormonal changes during pregnancy and mechanical injury to the pelvic floor support (direct muscle trauma), cause disruption of connective tissue support and denervation, which are some of the underlying mechanisms for the development of pelvic organ prolapse (5).
You will probably have your first bowel movement two to three days after giving birth. Although, women frequently get constipated after giving birth. That can be the result of being less active and not eating enough fruits and vegetables or not drinking enough water (10).
During the second stage of labour, the uterus pushes the baby out and typically lasts 20 minutes to two hours or longer. Pushing can take a short or a long time. That depends on the position of your baby, the effects of medicines, and how well you can push. Your health care team will help and suggest positions and techniques that will aid you in your pushing efforts (e.g. using your abdominal muscles to push down) (10).
Prolonged pushing for more than one hour during the second stage of labour (known as pushing phase) has been associated with denervation injuries (loosening and rupture of nerves from muscles) to the pelvic floor in women delivering for the first time (primiparous) (5). Surprisingly, it has recently been shown that similar-looking skeletal muscle injuries in MRI at the same anatomical site, but caused by a different mechanism of action (dependent on the forces applied and causing the trauma or during over-stretching), have completely different healing rates (3).
Research shows that, shortly after the trauma, decisions from health caregivers and proactive actions taken by mums can prevent further damage and lessen the extent and duration of the recovery from childbirth. In fact, timely action from mums (preparatory exercises during pregnancy and flexing of pelvic floor muscles right after childbirth) can prevent the retraction of ruptured muscle stumps (gap within the muscle), avoiding larger hematomas (bruises), and subsequently, reduce connective tissue scar size (3).
When things don’t go as expected.
Recent health assessments found that 33 to 79 % of first-time mums experienced unfinished rehabilitation of pelvic organ support when evaluated at various time-points between six weeks and one year postpartum. Moreover, a prospective, observational study found that 35 % of women in unlaboured-cesarian delivery and 37 % in trial-of-labour presented Stage II prolapse (5).
How to get ahead of complications, unpleasant sensations, pain and discomfort.
Your health care team will probably suggest you follow these general tips:
a) Prepare your mind, know the possible outcomes
b) Get fit for the later months of pregnancy
c) Plan ahead
Be aware of common things that can go wrong as well, and how they happen.
Although, pregnant mums (to be) counsel with nurses and doctors about how to care for themselves, reality and statistics show that there is much room for improvement. Eventually, it will take time to recover from labour and birth. The “after birth” period is a special time of adapting to parenthood as well as for physical recovery. Indeed, postpartum healing takes months, not weeks.
“Indeed, postpartum healing takes months, not weeks.”
This period starts at the hospital and continues at home (10). Ultimately, the mobilisation of the skeletal muscles that have been injured should start gradually (i.e. within the limits of pain) as soon as possible. In fact, early mobilisation has been confirmed to best enhance the regeneration phase of the injured skeletal muscle fibres as well as to induce angiogenesis (regrowth of blood capillaries) (3).
Notably, starting exercises for pelvic floor muscle training (PFMT) during pregnancy appears to decrease the prevalence of urinary incontinence by up to 6 months after delivery in women having their first baby. Besides, PFMT shortly after giving birth is not painful in most women. Indeed, a recent study (8) assessing women immediately after childbirth reported that while perineal pain is highly prevalent during activities of daily living, urinating, and mobilising the bowel, it is not painful during pelvic floor muscle contraction. Certainly, researchers confirm that it would be recommended.
Similarly, it would not be too difficult for healthcare providers to teach women the advantages and the technique of PFMT immediately after delivery, without fear of pain, as shown in that study. Moreover, pelvic floor dysfunction should be explained, and a brief description of the anatomy, functions and possible dysfunctions of the pelvic floor muscles better be exposed (8).
The use of palliative non-pharmacological solutions implies less risk of addiction to painkillers, better neonatal compliance, meaning that mum and baby establish a better connection, and paves the way for a successful breastfeeding experience, and results in faster cognitive and affective development of the baby.
Interestingly, cryotherapy (cold therapy) enhanced by the simultaneous application of compression has shown clear therapeutic benefits. In fact, current research suggests that the sum of compression with cryotherapy ameliorates the extent and speed with which the tissue heals, attenuate oedema, and concomitantly control pain and inflammation (7; 6). This means it improves healing, reduced inflammation, and helped with pain. Furthermore, traditional cryotherapy are affordable and easy to perform for acute musculoskeletal injuries like pelvic trauma after delivery.
Contrary to what has previously been recommended to mums after vaginal delivery, the recovery of the pelvis and complete pelvic floor muscles contractility takes up to 6 months. MRI studies have opened a new window on our understanding of pelvis dynamics after giving birth, and challenge previous medical knowledge and practice.
Child delivery, in first mums in particular, can be physically traumatic for pelvic bones, ligaments, muscles and pelvic organs. Such traumas, researchers currently agree that are not far from those experienced by high-performance athletes. So, therapeutic solutions and preventive measures in childbirth and sports seem to have some common ground.
It is particularly challenging for mums returning home with the baby to take care of and to care for their healing body postpartum. Knowing how to deal with pain and discomfort while applying current measures to alleviate, prevent further damage and heal seem the safest road for mums to follow. One of those solutions may come from, known but not yet generalised, pelvic floor muscle training which has been demonstrated to not be painful as previously thought. Finally, the education of mums to be, including an explanation to women about their anatomy, functions and possible dysfunctions of the pelvic floor can certainly help them to face the potential risks and play an active role in getting better postpartum outcomes.
Dr Rebecca Harwin
Chiropractor & Multi-book Author
1. Dunn, A.B., Paul, S., Ware, L.Z. and Corwin, E.J., 2015. Perineal injury during childbirth increases risk of postpartum depressive symptoms and inflammatory markers. Journal of Midwifery & Women’s Health, 60(4), pp.428-436.
2. Frankman, E.A., Wang, L., Bunker, C.H. and Lowder, J.L., 2009. Paper Presentation. Journal of Pelvic Medicine & Surgery, 12(5), p.231.
3. Järvinen, T.A., Järvinen, M. and Kalimo, H., 2013. Regeneration of injured skeletal muscle after the injury. Muscles Ligaments Tendons J, 3(4), pp.337-45. Scholz, D., Tomas, S., Sass, S. and Podzuweit, T., 2003. Angiogenesis and myogenesis as two facets of inflammatory post-ischemic tissue regeneration. In Vascular Biochemistry (pp. 57-67). Springer US.
4. Low, L.K., Zielinski, R., Tao, Y., Galecki, A., Brandon, C.J. and Miller, J.M., 2014. Predicting birth-related levator ani tear severity in primiparous women: evaluating maternal recovery from labor and delivery (EMRLD study). Open journal of obstetrics and gynecology, 4(6), p.266.
5. Manonai, J., 2017. Pregnancy, Puerperium and Pelvic Organ Prolapse. In Childbirth Trauma (pp. 213-230). Springer London.
6. Markert, S.E., 2011. The use of cryotherapy after a total knee replacement: a literature review. Orthopaedic Nursing, 30(1), pp.29-36.
7. Meyer-Marcotty, M., Jungling, O., Vaske, B., Vogt, P.M. and Knobloch, K., 2011. Standardized combined cryotherapy and compression using Cryo/Cuff after wrist arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy, 19(2), pp.314-319.
8. Neels, H., De Wachter, S., Wyndaele, J.J., Wyndaele, M. and Vermandel, A., 2017. Does pelvic floor muscle contraction early after delivery cause perineal pain in postpartum women?. European Journal of Obstetrics & Gynecology and Reproductive Biology, 208, pp.1-5.
9. Song, M., Sun, X., Tian, X., Zhang, X., Shi, T., Sun, R. and Dai, W., 2016. Compressive cryotherapy versus cryotherapy alone in patients undergoing knee surgery: a meta-analysis. SpringerPlus, 5(1), pp.1-12