Post-partum check-up: I have the ok (to do what? Return to “normal” activities?). But should I?

Most women go through pregnancy with multiple doctor appointments, scans, blood and other tests. They see their OBGYN every 4 weeks during pregnancy.  They give birth, leave the hospital relatively quickly and return home.  Now what to do?

You will visit your health care provider four to six weeks after birth for a brief check-up to insure that the vaginal area and/or the c-section scar is healed.  You may be screened for postpartum depression - common during this period of time. If all is well, you will be told it’s ok to have sex and to exercise. Really??? Should I get back to my bootcamp training, cross-fit, running? Great questions.

The American College of Obstetrics and Gynecology updated, post-partum guidelines state, “​postpartum care should be an ongoing process, rather than a single encounter… all women should have contact with their ob-gyns or other obstetric care providers within the first three weeks postpartum.” 

This means you should see your doctor before 6 weeks postpartum to ensure healing is on-track.  So… a 3-week and 6-week postpartum visit is two appointments. Now wait a minute - when you were pregnant you had many appointments during  9 months of pregnancy!  Since you will have fewer interactions with your healthcare provider(s) postpartum, maybe you can use some additional information and assistance to guide the “fourth trimester” - your post-partum recovery.

SEX

Although sex may be the last thing on your mind, remember that the vaginal area should be healed prior to engaging in sex. Generally, this is the case for most women six-weeks after delivery.  However, if you had a traumatic delivery, i.e. the use or forceps or a vacuum, you may have suffered a perineal tear.  Perineal tears are graded from 1 to 4 with 1 being the least severe.  See below for the definitions of each grade:

• 1st  Degree: Laceration of vaginal epithelium or perineal skin only

• 2nd Degree: Involvement of perineal muscles, but not the anal sphincter.

• 3rd Degree: Disruption of anal sphincter muscles

• 4th  Degree: Disruption of anal sphincter and anal epithelium

A grade 1 or grade 2 tear usually heals well.  Grade 3 and 4 tears are larger, and may take longer to heal.  These tears can result in pain, urinary or fecal incontinence. However a grade 1 or 2 tear can also be painful.  Scar tissue is laid down during the first three weeks of healing and  it can be stiff, rigid, and uncomfortable. Gentle massage by a pelvic floor PT can help alleviate scar-restrictions and allow pain-free intercourse.  A pelvic floor PT may recommend the use of a vaginal dilator, to help stretch the area.  

Hormones play an important role postpartum.  After delivery, estrogen and progesterone levels drop dramatically.  The hormone drop causes the breasts to fill with milk for breastfeeding.  However, a drop in hormones can also cause vaginal dryness.  Estrogen is important for the vagina, because it keeps the tissue thick and elastic, allowing the area to accommodate a penis or toy. Here are some things to consider: 

1. Ask your OB about topical estrogen cream.  Cream can help during the post-partum and breastfeeding period

2. Try natural moisturizer(daily) such as: olive oil, coconut oil.

3. Use a lubricant during sex, both on yourself and your partner/toy.  Brands we recommend: Slippery Stuff, Sliquid H20, Sutil.

4. Remember - foreplay is very important!  From start of foreplay to orgasm, men need five to seven minutes on average, but women need an average of fifteen to twenty minutes.  

EXERCISE 

During pregnancy, the following changes occur in your body: 

1. Progesterone increases, allowing ligaments in your pelvis to relax.  The pelvis widens to allow the baby to move through.  This softening of  the ligaments also allows the pelvis to open up during childbirth.  Ligaments support your organs and with increased laxity, you are at risk for prolapse ( organs descend in the pelvis). 

2. Abdominal muscles stretch and weaken.  As the baby increases in size, the abdominal wall stretches.  When muscles are stretched, they are not as strong as they would be if they were in a normal resting state. 

3. Rib cage widens and expands.  As the baby becomes larger, all of the organs get squished and displaced within the abdominal cavity.  To allow more room, the rib cage expands in size…hence why your bra may feel tight! 

During the postpartum period, this is what happens:

1. Progesterone will continue to stay elevated as long as you are breastfeeding. If you are not breastfeeding or stop breastfeeding, it will take time for hormonal levels to return to normal levels. Essentially this means that the pelvis may stay wider than pre-pregnancy, but it may also be unstable due to the ligamentous laxity.

2. Abdominal muscles may separate during pregnancy, a condition called “rectus diastasis”, meaning the tissue between the rectus abdominis muscles is stretched out. Almost all women have some rectus diastasis postpartum.  It will usually resolve itself, but if you do vigorous abdominal exercises too soon, it could worsen the separation.

3. Rib cage will stay somewhat expanded post-partum.  If takes about three months for the uterus to return to pre-pregnancy size, at which time the ribs should return to normal.  

GUIDELINES FOR EXERCISE

Now that you understand what is happening to your post-partum body, it may be more helpful to guide your postpartum return to exercise.  Remember that the baby was growing for 10 months, so it will most likely take ten months to one year to feel “back to normal”. 

• First 6 weeks: Listen to your body and rest as much as possible.  You will be sleep deprived, and still healing so don’t push yourself too hard. 

• 6 weeks- 3 months: If the doctor says you are healing well; you can start to do a bit more.  Consider longer walks, add some hills.  Start with low-level Pilates and yoga moves to get your muscles firing.  If you go straight to vigorous cardio, it won’t be effective because your muscles are still weak and abdominals are stretched out.  It is important to get these muscles working prior to intense cardio.

• 4+ months: When lower level Pilates and yoga start to feel good, consider progressing to full classes of yoga, Pilates or strength training.  Consider starting to jog again.  Begin with an interval program first, i.e.  jogging/walking. Then  slowly progress to running.  If you are leaking, feel heaviness/pressure, or have pain, you may not be ready yet for this activity.  

If you continue to have leaking, pressure, or pain, visit a pelvic floor PT to understand what is going on.  Pushing through it on your own will usually make symptoms worse.  Remember that everyone is different, so the recovery timeframe is different for everyone. 

Remember to consult a pelvic floor PT for the post-partum rehab program that will make you feel your best!