Pelvic Floor Physical Therapy – How can it promote healing during the Fourth Trimester?

Written by Sarah Blecher, SPT

For decades, the medical field has normalized the after effects of childbirth such as pelvic pain and urinary incontinence, but it begs the question, is this normal? Picture this: You bring a little human into the world after nine months, you are in awe of just how precious they are. You forget your pain and labor and you go home to your newly expanded family.

After a few weeks, you’re in some discomfort or pain but brush it off because you just gave birth, no big deal. You wear large pads and underwear for the next six weeks as your vagina tries to figure out how to recover. At around six weeks postpartum you have your first check-up with your OB-GYN ¹ and they give you the “clearance” to resume normal physical activity and intercourse. Most of the time, this six-week check-up is completed without a pelvic exam. With the physician’s blessing, you start returning to normal exercise without knowing if you are doing too much or too little and you attempt to have sex again. You find that sex is painful as you try anything to enjoy intimacy with your partner. What’s worse, and to your embarrassment, you find yourself leaking while jogging or lifting weights. You turn to your girlfriends or OB-GYN and their common response is to use more lube, drink a glass of wine, or do some kegels. Is that what you and your body need though?

Before you become pregnant these were non-issues and then BOOM – postpartum – you pee a little when you sneeze, cough, laugh, or jump and now sex is no more enjoyable due to pain. A study showed that women who experience urinary incontinence at three months postpartum will continue to experience it twelve years postpartum. ² Most physicians don’t know, or don’t refer, to a Pelvic Floor Physical Therapist who is trained and specially certified to examine and treat the muscles of the pelvic floor, which are altered postpartum. As Physical Therapists are the musculoskeletal experts, I decided to meet with Dr. Lacy Kells PT, DPT, who owns Fayetteville Pelvic Health and Wellness, to ask some questions about what women can do postpartum and how Pelvic Floor PT can help during the fourth trimester. The following is a transcript of our Q&A session.

First, tell me about what is Pelvic Floor Physical Therapy?

Pelvic Floor Physical Therapy (PFPT), is orthopedic PT with more knowledge of pelvic floor structures and nerves that are involved in the pelvic floor. It’s not an island unto itself, it’s not scary. I think it made me a much better orthopedic PT when I took the pelvic floor classes because it’s this huge piece of the puzzle that we didn’t get much of in PT school; I certainly didn’t get any of it in my clinicals. It was a fantastic outpatient PT clinic, but this is just ignored and so I was missing a big chunk of the muscles and nerves and how the body is connected; I was just ignoring it until I went to some of these classes. Pelvic PT is not just zeroed in on the pelvic floor; it is a component of the bigger picture, but we specialize in these scary topics of incontinence, constipation, pregnancy, postpartum (PP) things that other people don’t want to touch because it freaks them out even though the pelvic floor is a small part of it, but you have to look at the bigger picture. I spend a very small part of my time in people’s vaginas. The beauty in this is that we have the tools to look there and sometimes that is the missed piece but that is not all of it; I treat head to toe every day.

When it comes to treating the pelvic floor directly, what is involved in the evaluation and examination?

I always start with an external exam, my general ortho exam. If it is warranted, then I will do an internal exam, but it is just like any other body part. First, you observe: does it look normal, is there edema, erythema, what do the structures look like, can the muscles work (a kegel and bearing down), then we do neuro testing: using a q-tip for sensation testing, sometimes we have to do sharp and dull testing just like anywhere else, but I usually only use a q-tip. Then, I assess for muscle tenderness and tension in the superficial muscles, so I’m basically feeling down each side of their labia. I do an internal exam with just one finger and your assessing the same thing of muscle tension; you have them contract, relax, and manual muscle testing. Its all the same things we learned for every other body part, but you have a finger in the vagina or rectum. You’re able to feel pudendal nerve, the coccyx and mobilize that, especially rectally. You can feel obturator internus vaginally. It is really the best way to feel if it is the problem because you have these patients with hip or low back pain, and you have worked on everything externally so maybe that is the missing piece. You go in and get on obturator internus and they say, “that is my pain,” which is great because then you can go ahead and address that. You cannot address low back pain and ignore the pelvic floor because pelvic floor muscles connect to the sacrum which is connected to the lumbar spine.

How do you “retrain” muscles of the pelvic floor?

The myth is that it is all about the kegels. Very often it is the opposite, you have to actually train the muscles to relax first. Pelvic floor muscles can be weak because they are tense. Think of length tension relationships. If the muscles are resting with the fibers already overlapped, and they are sitting like that all the time, then when you go to contract them with a kegel it is this little baby contraction because the muscle fibers cannot overlap more than they are. You go to stretch them with intercourse or at the OB-Gyn during an exam and it hurts because that is a lot of stretch. A lot of women are leaking, not because the muscles are weak, but because they are tight. So, we must get those muscles to come back down to the lobby. Think of the pelvic floor as an elevator, a kegel is taking the elevator to the third floor. A happy pelvic floor then returns to the lobby while resting, and you should be able to go from the lobby to the basement which is a bulging of the pelvic floor, so when you poop or push out a baby, the pelvic is meant to descend and go down even further than when resting. That is where we have to start with retraining – with breathing and bulging. I don’t use a lot of probe biofeedback. I think it can be helpful, however, studies have shown that it’s a lot more helpful for relaxation (down training). For me, I have a yoga background and I feel that I have had good success skipping biofeedback, except in select cases. Teaching people to properly breathe by using my finger on their perineal body, I ask, “do you feel my finger on your perineal body” (between the vaginal opening and anus), then telling them “push my finger away”, then they use their own finger and push it away and they can go home and practice that. It is a lot of relaxation techniques. Then I move into the strengthening phase, which is your kegel. I prefer tactile cues – I will insert my finger and use tapping to wake up the muscles or tell them to not let me pull my finger out of the vagina. We use tactile biofeedback and it will become part of their home exercise plan. They can use their finger, a mirror, or their partner’s finger. During intercourse is a good time to practice because you have the feedback and can squeeze and hold with the vagina; the mirror is good for visual cues. The beauty of my job is that I can also work all the other muscles that feed into pelvic floor strength such as transversus abdominis (TA), glutes – gluteus medius, and multifidus. I almost always start with latissimus dorsi because of all the fascial connections to the sacrum.

How can physical therapy help during pregnancy and postpartum?

Contrary to popular belief, pregnancy should not be painful. Ideally women would come in during pregnancy and be comfortable because they have a PT and get a tune up. When and if you start to waddle, I advise to strengthen the glutes or work on posture by getting that thoracic spine moving. Little tweaks to try and keep the body moving better in preparation for delivery. I also teach women things to help with delivery like perineal massage, breathing, activation of TA and pelvic floor, and relaxation. Many women don’t know how to push, honestly, I didn’t know how to push for my first delivery but remember if that pelvic floor cannot move down to the basement then it is going to be hard to push a baby out if those muscles are stuck up on the third floor all the time. A couple techniques I use for patients are: relaxing the pelvic floor (PF) prior to delivery, asking for the mirror to see how the PF moves as you are pushing, and telling them about better positions for pushing, that the hospitals sometimes don’t tell you about. Those are the big ones for pregnancy.

Postpartum, is so essential and so maddening because we don’t get our hands on a fraction of people who really need it. The one thing I wish PP women had in those first couple weeks is the knowledge of how to breathe, to make the abdominal wall and pelvic floor move. Think of breathing like a piston, as you breathe in to your belly, diaphragm drops down, abdominal wall expands, and PF gently bulges away from the body. On exhalation, it’s the opposite; diaphragm rises, abdominal contracts, and PF lifts. Knowing how to do a belly breath, the PF is moving, if you have a C-section the abdominal wall is gently moving, and you could be rehabbing yourself day one by doing something that you have to do anyways – breathing. Cesarean and perineal scar massage, we should all be doing that after our scars are healed in the first few months. After you deliver, the abdominal wall has no idea what it is supposed to do, its been stretched for the past nine months and most of us have a separation. If you don’t have someone to help you retain those muscles, put their hands onto TA or look at your PF, most of transition back into normal lives. We exercise and things are not working ideally which leads to issues like diastasis recti, hernias, we pee on ourselves, have back pain, or have an urgency pee. These things could be prevented if women had access to PF PT post-partum. Even just one visit, you see your OB then they refer you to your PT who can then educate you on scar massage, breathing, and when or what type of exercises are appropriate. If it were standard of care, we would be so empowered as women to at least know more about our PP bodies. When I show most women my pelvis model, they all are in shock of “wow, that’s what that looks like.” Just educating women of the PF and the muscles is a game changer because education is power.

When mom’s get that 6-week check up and the “all clear” from the OB, do they even look at the PF?

Yes and no. OBs are super important to the medical field, but they are not trained in muscles of the pelvic floor and how those muscles are supposed to properly work. We, as PTs, are the movement experts specializing in muscles and movement coordination. They are specialized in ruling out scary stuff making sure baby is safe and getting you through delivery safely. You are only getting their perspective on if the scar is healed, are you bleeding, and does your vagina look happy – then ‘good’. Women are missing a big piece of everything. When I had my son, I wasn’t practicing PF PT, I didn’t know what to ask and I was too exhausted to even think about it. They had to cauterize my perineal tear 3 times because the stitches weren’t healing, over the course of several months. I remember at my 6-week checkup, my OB asked me if it hurts when I have sex, and I was so in my own head. I knew I had PP depression at this time, but I never really gave her a direct answer. She assumed I was already having sex at this point, and had I said “no” she probably would have said well you can go ahead and start and that would have been it. I have women tell me all the time, “I have told my doctor it hurts, I’ve told them 3 times” and the OB just says “well you had 3 kids or you have a baby now and It’ll get better.” Well, it might not unless you have someone who knows what tools to give you. And OBs are not trained to do that and that isn’t their fault, it doesn’t make them bad at their job, it is just outside their scope of practice. Just like delivering a baby is outside my scope, but they go hand in hand. It makes sense we should be working together.

What are some red flags new moms should be looking out for that tells them to seek out their OB or another professional?

Certainly pain with intercourse is not normal, pain with vaginal exam like at your 6-week follow-up, if you are peeing on yourself, painful bowel movements, difficult bowel movements, or constipation are all red flags. If you are still having pain at the c-section or abdomen when you are working out or picking up baby then there is something going on in the muscles that needs to be addressed. Back pain, or mid back pain, often happen while nursing, but even if you are not nursing you are still holding your baby in a position that can stress the body. Why suffer if you don’t have to; those are the PT red flags.

When it comes to seeing a PF PT, how does insurance work, is there a barrier to access?

I removed my barrier of referral by going cash based. It was terrifying. I got really sick of not being able to treat the whole person. I hate when a patient comes in with a script for pelvic pain, but they also have fibromyalgia and a history of headaches. They come in with an awful headache and its hard to justify to insurance that I need to treat their headache in order for everything to calm down and relax. I cannot manage the pelvic pain because I need to address the headache. I have to either not treat the headache or not bill for it and then I get in trouble with my clinic because I only billed 2 units. I got really frustrated with insurance dictating how to treat my patients; if you have a patient with pelvic pain for years, they will not get better in just six-weeks. This is probably a year of therapy for some of these PF patients because they are more complicated. With cash based, you don’t need a referral to see me and can see me for as long and as often as you want, treating whatever is bothering you. For insurance to pay for it, it requires a physician referral, but they might not cover all diagnoses such as dyspareunia (painful intercourse) because many insurance companies might not think its worthy of treatment. This is where you have to get creative with how you code and you basically cannot use sex as a goal, even if that is the patient’s goal. The physician will then have to make something up like pelvic weakness to refer the patient because insurance doesn’t want to pay for wellness; they just slap a bandaid on the problem. It could save the insurance a lot of money if a patient doesn’t have ten years of pelvic pain that will take you two years to treat. Instead, they could have come in postpartum for a wellness check and we teach them all the things I mentioned previously, and they have no pain. I am seeing more moms in the community because I provide some free classes, so I have more new moms contacting me just to check things out and make sure its all good to return to orange theory or body pump or whatever because they don’t want to do it wrong or end up like their mother who has urinary incontinence.

That’s a great Segway into my next question of how do you suggest postpartum women get back into exercise safely?

A lot of women don’t want to hear that they need to dial it down first before you can get back where you left off. I have actually worked with several crossfit coaches which has been a game changer because they then send their new moms to me. I have one patient send me the weekly crossfit workouts and I go through via text to modify the workouts, even though they have a postpartum program, but it’s not created by a PT, its done by a coach, and some of these women are still not ready to complete certain exercises. They will get there but right now they need modifications. They trust me and feel better about going to the gym because they have a coach to push them at the gym but then they have me as an expert in movement. Its been really nice for the coaches to be aware and learn more about tailor programs to postpartum moms. I want women to be safe to do exercises as long as they want but if their abdomen is puffing out during a workout, that’s not great. Doming or tenting while performing a “core” exercises is saying that rectus abdominis or obliques are being over used. The main issue with that, especially during the postpartum period is that you already have an abdominal separation, the linea alba (the center fascia between the six pack muscles) is weak, so that will potentially make it worse and put you at risk for a hernia, back pain, or pelvic floor dysfunction. We want to make sure TA is engaging primarily and we can teach coaches to look for this, so that if someone is doing a v-sit and it looks like a puffed-up pooch then they can modify by keeping their feet on the floor. It’s amazing because people just have no idea. Many coaches are unaware of this and people get in trouble because they push themselves past where they are really capable of going.

An article I read made a statement that if you have urinary incontinence or organ prolapse when you’re an older adult then you are still living in a state of postpartum, is that true?

Well, yes. Once you are postpartum, you’re always postpartum. None of these conditions are things that you cannot work on and improve. Even if you’re 60 and peeing on yourself, you can still make it better, you just need the resources to do it. Organ prolapse we can work on, except grade 3 or 4, then that might require surgery. But we can always strengthen the muscles. There is no reason you must live like that; there is not a magic number where you’re just stuck with these problems from now on. You might be postmenopausal, and hormones play a role in this too, but there is no reason it shouldn’t be addressed.

So, should senior nursing facilities (SNFs) teach people to retrain their pelvic floor or educate on it?

Yes, they should. I am cash based so I don’t deal with medicare. When I was at my previous clinic, I would have older women come in all the time and say, “Oh honey, I’m 80, I don’t know why I’m here, my doctor just wanted me to come.” Their always surprised with how passionate I am about this and they just seem so reluctant to address it. But they get better and tell all their lady friends about it. I think it could be really helpful in SNFs but you have to think, if you have dementia or if you’re too weak to get up and get to the bathroom it may not be the place. For other people, if they just knew what a kegel was or how to make those muscles work or even how to properly breathe, and if PTs could incorporate that into treatment, then it could be helpful. I think it is a ways off though because we are still fighting to get postpartum moms better care and physical therapy.

There is the concept of the Fourth Trimester that’s hit the market, what is the basis of this?

It’s basically for baby and mom. It’s baby trying to figure out the world; needing to be fed and held. For moms, it’s this concept of you don’t snap out of this as soon as this baby pops out. Especially here in the US, you’re discharged from the hospital in 24-48 hours with practically no education, and then good luck! The baby needs to see the pediatrician in 3 days and you can go back to work when you are ready. Some moms go back at six-weeks. Your body and hormones are not regulated in any means after delivery. So, that fourth trimester is your body still trying to recover from birth for those next few months. I tell many moms it takes a year to really recover after birth and that might be conservative in reality. Especially if you continue nursing, or have PP depression, or multiple children. I think it’s a concept that is trying to change how things are done. If you look at European countries, they are giving moms months of maternity leave and a lot more time to heal and we don’t do that here. Bringing awareness to the concept that just because the baby is out does not mean you’re good to go. Your body needs more time to rest and recover and get back to homeostasis. Its 2019 and we are in this pathetic, awful place. We have so many advances in the medical field and we are making women suffer because of how our society is and has been. It’s okay to seek help from a therapist if you’re depressed, to sleep when the baby sleeps, to allow people to help you, or to not leave the house. Allow yourself grace to recover and be present in this fourth trimester.

When would you first implement an exercise in the postpartum period?

Well right off the bat, they can work on their breathing for the first few days. If they are feeling like it, they can begin the TA activation of drawing that muscle in towards the spine. Those muscles need to work regardless of whether you had a c-section or vaginal delivery. There is no danger of using them because you’re rolling in the bed, and walking. You’re activating the core with movement, so why not properly do it. I will also tell them to start kegels to get blood flow to the area to help with healing and swelling. If they have pain, then stop the kegels because they actually need relaxation techniques. That’s the first 6-weeks postpartum. From there we can do more foundational exercises like working on glutes, multifidi, TA progression, and pelvic exam if they want. They can walk after the first few days as well. Many women are scared to just move, so they will come to me only with questions and giving them that permission to move is what they needed, and they will feel so much better once they move.

How do you market yourself and how do you recommend Pelvic Floor PTs to market themselves?

Because I am doing cash based, I am not marketing to the physicians, I am going to the people because that is what works. The physicians in Fayetteville, don’t seem to know what we really do and seem closed off to it. Even my Ob-Gyn, who delivered my kids and who I have known for years, has never referred someone to me and she knows what I do. She knows me and we talk about it, but she, and other physicians just don’t seem to think people need PF PT. So, what I have done is stepped outside my comfort zone and I try to consistently post videos and information on Facebook and Instagram and also provide free classes to the community. You must give the community more time and things for free to build trust to come to you; that you are the expert in this field. I post a quick 5-10 minute video of exercises or stretches for certain things and it gets buy in from people. And so far, it is really working for me. It is a lot more effort than getting referrals from a doctor’s office, but I had to take the leap to cash based because I believe in this model and that it is better for me as a clinician. I am providing much better care to my patients because there is less focus on documentation and more time truly spent with the patient.

End of Transcript

This interview was an enlightening experience for me as a student physical therapist because it is a topic that is taboo for many people. At Campbell University, we are fortunate enough to have an entire class on the pelvic floor, but it does not happen until third year when we are about to head out on clinical. Dr. Kells lit a fire for me to further my education within physical therapy, to advocate, educate, and promote health and wellness for postpartum women.

The American college of Obstetrics and gynecology (ACOG) issued new recommendations in 2018 that highlighted how health care professionals should promote well-women in this fourth trimester period and how women deserve ongoing care postpartum. ACOG further recommended that women see their physician at three weeks PP and continue follow-up until a comprehensive exam at twelve weeks. This comprehensive exam should be used to refer and make other recommendations for mothers. ³ Well, it’s almost 2020 and this is still not the standard of care.

How do we get to a place where postpartum women are receiving the care they truly deserve? Well it starts with medical professionals realizing that PT is a vital component of the health care team for postpartum mothers. It is also up to PFPT to market themselves more to the public for greater awareness about how they can help postpartum women get back to a place of health and wellness. Women who have knowledge about this issue need to tell their friends and stop allowing it to be hush hush within their friend groups. The normalization of urinary incontinence, anal leakage, and painful sex needs to end. Speak up! There are many studies out there that link urinary incontinence to mortality.⁴ If the problem is never addressed, then you run the risk being an older adult who is trying to rush to the bathroom, subsequently falling, sustaining a fracture, and further increasing your risk of death.⁵

The American physical therapy association section on women’s health, has guidelines specifically for postpartum women that APTA members can access and distribute to patients during the recovery process.⁶ Women also have a way to search for a pelvic floor physical therapist near them, so that they can receive the treatment that helps them recover. As Dr. Kells stated, Physical therapists are movement experts, so stop living in silence about your postpartum discomfort and pain and give yourself grace to recover during the fourth trimester. I plan to speak up about better postpartum care that includes PTs by starting discussions with classmates and the women in my family, while also using social media as a platform to share this interview and educate as many people as I can reach. It’s never too late to make a change.

References:

1. Committee Opinion No. 666 Summary. Obstetrics & Gynecology. 2016;127(6):1192-1193. doi:10.1097/aog.0000000000001481.
2. Macarthur C, Wilson D, Herbison P, et al. Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2015;123(6):1022-1029. doi:10.1111/1471-0528.13395.
3. Women’s Health Care Physicians. ACOG. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care. Accessed November 15, 2019.
4. John G, Bardini C, Combescure C, Dällenbach P. Urinary Incontinence as a Predictor of Death: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(7):e0158992. Published 2016 Jul 13. doi:10.1371/journal.pone.0158992
5. Soliman Y, Meyer R, Baum N. Falls in the Elderly Secondary to Urinary Symptoms. Rev Urol. 2016;18(1):28–32.
6. Neville C, Drummond J, Scheufele L, Wolfe P, Abraham K. Guidelines for SOWH Member Physical Therapist Usage of the Postpartum Recovery Packet from the Section on Women’s Health of the American Physical Therapy Association. 2010. Accessed November 15, 2019.