Scratching the Surface

There’s no doubt that the human body experiences many changes during pregnancy and birth. The time after birth can be just as challenging, if not more, for new mothers. The postpartum period varies in length from person to person but can typically last anywhere from 6 weeks to 12 months. Some of the changes that occur postpartum will return to their prepartum state, however other changes are permanent and result in a new normal for mothers. Here we will discuss some of the more common changes, although we are just scratching the surface and more changes are possible.

Physiological Changes to Expect Postpartum 

Endocrine System

• There is a rapid decline in estrogen and progesterone immediately following birth. This allows prolactin to stimulate milk production in the breasts. Suckling from the infant will trigger the release of oxytocin which allows release of the milk. If the mother is not breastfeeding, prolactin will drastically reduce within 2 weeks.
• It is important to remember that during pregnancy, elevated levels of reproductive hormones will increase the amount of a hormone called relaxin. This creates more laxity in the soft tissue and ligamentous structures throughout the body. Although hormones will reduce to their prepartum state, this laxity may persist. This is why it may be important for postpartum mothers to participate in strengthening programs or Pelvic Floor Physical Therapy when cleared by their Physician.

Cardiovascular System

• The main changes that occur postpartum include an elevated heart rate and increased risk for clotting and DVTs (Deep Vein Thrombosis) due to blood loss during birth. If mothers had blood pressure issues during pregnancy, this can also affect the cardiovascular system postpartum and may require continuous monitoring and increase in post-delivery activity precautions.

Reproductive System

• The Uterus will return to its prepartum size roughly 6 weeks after birth. This process is called involution.
• Lochia is a vaginal discharge that occurs after birth. Lochia can start out as a bright red color, turn to pink and then eventually white. This should last anywhere from 3 to 6 weeks. If lochia persists, is excessive, or turns back to a red color this can be indicative of excessive activity.
• The Menstrual cycle can take 7 to 9 weeks to return in non-lactating mothers, however in mothers who are breastfeeding this may take up to 12 months. Ovulation may or may not occur with the first few menstrual cycles. Due to the inconsistency in menstrual cycles, symptoms similar to PMS can vary and be unpredictable.
• The breasts may become engorged after birth. It is important to take care of the breasts and monitor for pain or soreness. This may indicate a clogged milk duct or if concurrent with a flu-like symptoms (i.e fever, chills, body aches) can indicate infection, such as mastitis.

Gastrointestinal System

• Constipation occurs for reasons attributed to the pregnancy itself, labor and delivery, and also hormonal changes. Food and fluid restriction during delivery can alter a woman’s bowel movements. Painful and irritated perineal tissue can also interfere with a mother’s ability to evacuate bowels. Hormonal changes that occur after birth can contribute to normal bowel function, therefore considering all of these factors it may take a couple weeks to return to normal.

Urinary System

• The bladder retains more water and loses muscle tone after childbirth. Therefore, new mothers retain more fluid during and after birth. This retention can lead to infections such as UTIs. If the bladder or urethra are damaged during birth this can also affect a mother’s urinary function. Finally, due to the anatomical changes that occur during and after birth, the pelvic floor muscles may be lengthened and weak which can contribute to incontinence. Incontinence is a common condition experienced by new mothers but can be addressed with Pelvic Floor Physical Therapy.

Musculoskeletal System

• Lengthened abdominals – Postural changes related to pregnancy can result in lengthened and weakened abdominals. Abdominal muscles will regain tone a few weeks after birth, however weakness may persist. This is especially true in the population of mothers who had a c-section due to the compromised abdominal tissue. Mothers are also at risk for developing diastasis recti.
• Lengthened and weakened pelvic floor – Similar to the abdominals, anatomical and posture changes related to pregnancy and also active labor contribute to pelvic floor lengthening. A lengthened and weak pelvic floor can lead to many conditions such as incontinence, pelvic pain, bowel changes, prolapse, and many more.
• Scar and/or scar tissue – Incisions made during labor and delivery can result in scarring and scar tissue. Abdominal incisions made during cesarean deliveries will result in scars at multiple layers of tissue. During vaginal birth, the Obstetrician or midwife may decide to perform an episiotomy, which is a surgical incision made through the skin, fat, and superficial perineal muscle layer. It is typically performed to widen the vaginal opening and avoid tearing, however if not performed tearing may still occur. No scar heals the same, but there are interventions to promote scar healing.

Delivery Methods

The two delivery methods for giving birth include vaginal birth or cesarean delivery (C-section). Cesarean deliveries may be planned or unplanned, depending on the mothers’ condition during pregnancy or previous pregnancies. The postpartum period can vary depending on delivery method or other complications that may have occurred before, during, or after birth.

General Precautions and Considerations Postpartum

Episiotomy or tearing – This can increase postpartum pain and result in greater precautions for activity and vaginal entry postpartum. Perineal scars can also affect urinary and bowel voiding strategies.

Pelvic Floor and Abdominal Weakness – These muscles need adequate time to recover after labor and delivery, therefore excessive strain should be avoided in the initial postpartum period. The muscles may regain some tone on their own, however many times they require strengthening and posture retraining which can be addressed with PT intervention

Diastasis Rectus – This is simply a separation of abdominal tissue in the middle of the abdomen. Diastasis can change the way the abdomen looks aesthetically and also contribute to core weakness. This can all be addressed with Physical Therapy intervention.

Vaginal entry with tampon or intercourse – New moms should refrain from vaginal entry, including tampon insertion and intercourse, until about 6 weeks postpartum or per Physician recommendations. This also avoids risk for infection in those with scars.

Precautions and Considerations After Cesarean Delivery

Decreasing activity levels – It is important to decrease activity levels after birth, especially with cesarean delivery due to the multiple incisions in the abdomen. The scar needs time to heal and should not be stressed with heavy activity.

Avoiding valsalva – Increasing intra-abdominal pressure excessively or too frequently can also compromise recovery and healing of the incision.

Incisional pain – Pain can be worsened with tight clothing, excessive stretching, or excessive activity levels. It is important to protect/splint during activities such as functional tasks and coughing.

Lengthened and weak abdominal wall with incision – Weakness may contribute to other musculoskeletal pain and impairments with functional tasks. Strengthening is put off for roughly 6 weeks after delivery.

Bleeding and clots – This can occur up to 6 weeks after delivery, however increase in bleeding or pain and a fever should warrant a call to the Physician.

Lifting precautions – Usually, mothers are prohibited from lifting more than 10 lbs to avoid excessive intra-abdominal pressure or stress on the healing scar.

Postpartum Conditions That Can be Addressed with Physical Therapy

A lot of changes that happen during pregnancy resolve some time after birth. However, there are postpartum conditions that persist and can be treated with Pelvic Floor Physical Therapy. Some of the conditions that can be addressed with PT include:

• Incisional pain and sensitivity
• Diastasis recti
• Incontinence
• Constipation
• Pelvic Pain
• Prolapse
• Pelvic Floor Dysfunction
• Levator ani avulsion
• Pain with intercoure or tampon insertion
• General weakness and conditioning

Pelvic Floor Physical Therapy is typically not recommended until 6 weeks postpartum unless cleared by their Physician sooner. Even if a new mother doesn’t experience pelvic symptoms in the postpartum period, it is strongly encouraged to get evaluated by a Pelvic Floor Physical Therapist to assess the integrity of the abdomen and pelvic floor.

Summary

There are many more changes that occur in the postpartum period, which can last anywhere from 6 weeks to 1 year. Ultimately, everyone’s experience is unique and recovery is not linear. Some changes may persist and that’s ok! This period of recovery can be challenging for new moms, on top of caring for a newborn. Having a supportive team of family and Physicians can only benefit during this period. Don’t be afraid to inquire about Pelvic Floor Physical Therapy to further assist this journey.