For Health Practitioners

Pelvic Pain After Pregnancy

Pelvic Pain After Pregnancy

Pelvic Pain After Pregnancy

Around 1 in 4 women have some pelvic pain at 3 months after having a baby. That’s common. As many causes of these pains naturally improve, only around 1 in 10 women still have pain by 8 months after the
birth.  

What causes pelvic pain after having a baby?

Pregnancy and birth involve a wide variety of changes to your body, posture, pelvis, vagina and hormones. These changes are both essential to life and challenging, especially for some women.

Postural changes and pain from muscles, ligaments and joints

Pelvic pain from muscles, ligaments or joints (pelvic girdle pain) is common during pregnancy. There is more information about this here. Often this pain improves once the baby is born. However, sometimes pelvic girdle pain persists after delivering your baby, or begins after having a baby.

Many of us have mild postural imbalances present from our early years. Our posture is the way we sit and stand. These imbalances may have caused us minimal problems before pregnancy, but are aggravated with the heaviness, pressure and looser ligaments of pregnancy and the birth process.

Elasticity of the vagina, the birth process and vaginal prolapse

During pregnancy and especially during vaginal birth, the vaginal tissues stretch substantially. This is the bodies way of preparing for and allowing vaginal birth.

If you have delivered your baby vaginally, there will be some changes to how your tissues and organs are placed within the pelvis. For some women there are no symptoms, whilst others will have mildly to very bothersome symptoms. This can include pelvic pain, painful sex, urinary or faecal incontinence, a sensation of heaviness or ‘dragging” in the vagina, especially during or after lifting, and when coughing or sneezing.

Image: Diagram of pelvis with (right) and without (left) Symphysis Pubis Dysfunction.

Vaginal tissues that stretch easily make a vaginal birth easier. However, these tissues don’t always return completely to normal after the birth, and vaginal prolapse may be more likely.

Vaginal tissues that are less stretchy, where the baby is larger, or where instruments (forceps or vacuum cup) are needed to deliver the baby all make some pelvic or pelvic pain afterwards more likely.

 A vaginal delivery that occurred normally, but where the birth stretched the pubic symphysis (the pelvic joint right in the middle of the front of the pelvis) can also cause pelvic pain (and pelvic instability).

Episiotomy and vaginal tears

Unfortunately, some tearing of the vagina is a natural part of childbirth. Every woman’s experience will be different, varying from very minor to extensive tearing. Sometimes an episiotomy is necessary to protect the bladder and bowel. This is where the health practitioner caring for you makes a cut where the vagina meets the vulva (the perineum). An episiotomy makes more more space in the vagina for the baby during delivery and reduces the risk of more severe tearing that could damage the bladder or bowel.

Small tears (Grade 1 or Grade 2 tears) usually heal well within the first 6 weeks after birth. Larger tears (Grade 3 or Grade 4 tears) need careful management involving an Obstetrician. They can be associated with ongoing pain and sometimes require surgery. More severe tears are supported by extra rehabilitation support in the public health sector, which includes subsidised post birth care and medical review. Grade 1 or 2 tears usually heal on their own or with some advice and guidance from your women’s health physiotherapist.

Pudendal neuralgia after vaginal birth

The pudendal nerve passes through the pelvis to the clitoris and vulva. Pressure from the baby’s head and stretching of vaginal tissues during birth stretch the pudendal nerve, especially when the baby’s head fits tightly in the pelvis or delivery of the baby required instruments (forceps or vacuum cup). This can cause numbness or a tingling feeling in the clitoris or vulval skin, which is usually mild, but can sometimes be severe, felt on one or both sides of the vulva or vagina. If this pain is severe after the birth, make sure that you discuss this with a gynaecologist and ask whether the pain could be pudendal neuralgia. There is more information about Pudendal Neuralgia, here.

The hormones of breastfeeding:

During breastfeeding levels of estrogen in the body are low. This allows the breast to make milk for the baby, but also means that the vaginal skin can be thinner or drier. The hormones of breastfeeding can contribute to pain by keeping the ligaments soft and loose.

Getting Better

Pelvic or lower back pain after having a baby is common, but not normal, and certainly something that can be improved. There are many simple things you can do yourself, but make sure you also tell your health practitioner about your pain, particularly when you have your 6-week check-up.

Image: Diagram of front and back of the pelvis indicating the pubic symphysis and Sacroilliac Joints.

If you are still experiencing sacroiliac joint pain (pain at the back of the pelvis, usually on one side) or symptoms of Symphisis Pubis Dysfunction (sharp / stabbing pain in the centre front of your pelvis), then this should be discussed with your treating health practitioner at your 6 week check-up.

Simple things you can do yourself

Simple things can be very effective, and the best thing is that you can start them straight away. There is no need to wait to see your health practitioner.

For Pelvic Girdle Pain (pain from muscles, joints and ligaments)

  • A great place to start is our pelvic pain in pregnancy page. This includes activity modifications that avoid aggravating the problem that you can use after pregnancy too.
  • Gentle stretches of your gluteal (buttock) muscles help relieve pain and tightness in your lower back due to irritation of the sacroiliac joint during birth. You can find pictures of these stetches here.
  • Tenderness behind your hips improves with lying on the floor and rolling a tennis ball or spiky ball between you buttocks and the floor.
  • Where possible, avoid holding your baby on one hip as the baby’s uneven weight can aggravate postural changes and pelvic girdle pain
  • Avoid very low and hard-to-get-out-of couches, if at all possible. If your chair is low, then sitting on pillow will make sitting more comfortable. Using lots of pillows under your arms or on your lap or using a special breast-feeing pillow makes feeding your baby easier.  

Avoid walking too far, especially when holding the baby carrier or pram. Short walks are less likely to aggravate your pelvis or cause the “heaviness” sensation that often accompanies prolapse.

Avoiding Constipation

This is particularly important because constipation often means straining at the toilet. This puts pressure on healing vulval and vaginal tissues and can worsen vaginal prolapse, pudendal neuralgia and most types of pelvic pain.

Constipation is common after birth because this is a time when we tend to drink less, eat a different diet, exercise less and using pain medications. It is also a time when the nerves to the pelvis have been stretched and need time to recover.

The best ways to avoid constipation are to drink plenty of water and fluids, to include plenty of fibre rich foods such as fruit, vegetables and grains in your diet, and to gradually increase the exercise in your day. Sitting on the toilet with a small foot stool (or a roll of toilet paper under each foot if no stool is available) puts the rectum (bowel) in a better position for easier bowel movements. Taking a bit longer while on the toilet and relaxing help too, although this isn’t always easy with a new baby to care for.

Light exercise stimulates your bowels to open. If you have pain, this can be difficult so start small. Even a 5-minute walk twice a day is a good start, and great for the bowels.

Some people have very slow bowels, and common treatments to avoid constipation aren’t enough. If so, ask your health practitioner, or a pharmacist, which medications or supplements are best when breast feeding.

Pelvic Support Garments

These are garments you can wear to reduce pain and increase mobility, either during or after pregnancy. They work by reducing the painful movement in the joints and supporting the pelvic organs. If you are already seeing a pelvic physiotherapist, you can ask them about pelvic support garments. If not, you can order them yourself online from Australian company, Everform at everformwear.com.au.

Examples of suitable garments for use after pregnancy include the:

  • Serola Belt for Sacroilliac Joint Pain. These can be worn over clothes., or the
  • Everform Pregnancy Support Shorts or Leggings. These are worn under clothes and have built in pelvic support for pain relief in people with sacroiliac joint or pelvic girdle pain.
  • Active Recover Postpartum Support Shorts. These are helpful for recovery after caesarean or vaginal birth. They are particularly beneficial where there are perineal tears, vulval swelling, uterovaginal prolapse, abdominal muscle laxity (called diastasis recti) or incontinence.

 

A private health insurance rebate is available for these products with most private insurance plans, but it’s always best to check with your individual plan.

 

Working with a Pelvic Physiotherapist

A Women’s Health Physiotherapist

Keeping active during and after pregnancy is crucial not only for your physical health, but also for your emotional and psychological wellbeing. A women’s health physiotherapist can guide your choice of exercise and activity. They are skilled in thoroughly assessing your needs, and managing pelvic pain, incontinence or vaginal prolapse symptoms.

Once a women’s health physiotherapist has diagnosed your problem, they will prepare a pelvic strengthening and stretching program especially for you to do at home. Sometimes they recommend group pilates sessions, or special exercise classes for women who have given birth. Other treatments include massage of scar tissue and tight muscles, teaching you the correct way to strengthen your pelvic floor and core muscles without aggravating pain, and how to relax your pelvic floor if these muscles are tight.

Remember that your GP can prepare a Care Plan to cover some (but not all) of the cost to see a pelvic health physio, even if you don’t have private insurance.

You can find a women’s health pelvic physiotherapists near you, look at Find A Health Professional.

Your Obstetrician/Gynaecologist

Each woman, each baby and each birth are different, and sometimes birth can result in larger vaginal tears, damage to the bowel or bladder, or problems with a caesarean section scar. If this happens, an Obstetrician or Gynaecologist experienced in repairing these conditions should be consulted. They will work together with your physiotherapist and your normal general practitioner to ensure you have best care possible.

A Psychologist

The birth of a baby is a big event for anyone, regardless of whether the birth was vaginal, involved instruments such as forceps or a vacuum cup, or where your baby was delivered by Caesarean section. Birth trauma is more related to how you felt during your birth than the type of birth you had. Whether you felt respected, listened to and part of the decision-making process during the birth of your baby can all affect how you feel. You may have expected or hoped for a certain and particular birth experience, and ended up with a different experience, despite careful planning and the best of intentions. Sometimes things happen quickly during labour and delivery, often for good reasons, and you may not have felt you had enough time to adjust to changed plans.

After the birth, and during your time at home, you may have questions about your experience. The health practitioner who was with you during the birth is a good place to start, as they will be aware of your situation. A psychologist can also help by talking about your expectations, the events around the birth of your child, psychological distress, or chronic pain. A sexologist can also help if you have unresolved pelvic pain, or trauma that impacts on your sexual relationships.

Could my pain be a sign of something dangerous?

Vaginal tears usually heal well, but there are a few things to look out for.

Sometimes vaginal tears become infected. If so, the area around the tear becomes more painful or swollen. This skin around the tear may look read, and you may have a fever. Infection in the uterus can also cause fever, pain and feeling unwell.

If you have any of these symptoms or are unsure, it is best to contact the health practitioner who cared for you during the birth straight away.

Wise choices for returning to exercise after having a baby

Returning to exercise after having a baby is important for so many reasons. Research shows that exercise has a wide range of physical, mental and emotional benefits. If pelvic pain, prolapse or incontinence is limiting your daily activities and making it difficult to return to exercise, please consider seeing a women’s health physiotherapist. This is beneficial for all people who have delivered a baby, but even more important if you have pelvic pain, incontinence or vaginal prolapse that still bother you 6 weeks after your baby was born. They can guide you to the best exercises for your needs.

If all is going well, and you don’t have pelvic pain, incontinence or vaginal prolapse, then the following advice from a women’s health physiotherapist will probably suit you:

  • Soon after the birth. Pelvic floor strengthening exercises can start as soon as you are able to do so after delivery, especially if you have already learned how to do these correctly. If you aren’t sure how to do pelvic floor exercises, as your health practitioner for advice, or ask them to arrange for you to see a women’s health physiotherapist. These exercises should be repeated several times per day. Start with 2 sets of 10-12 pelvic floor lifts, 3 times each day. The easiest way to start these exercises is to do them when you are lying down. Once you can do the exercises lying down, you can progress to doing them when sitting up, and later on when you are standing up. Vaginal birth involves a big stretch for the vaginal tissues and the nerves to the pelvic floor muscles. By doing these exercises you help the brain, the nerves, the pelvic muscles reconnect with each other. Remembering to lift up your pelvic floor just before you cough, sneeze, or lift your baby helps protect your pelvis too. This is sometimes called ‘the knack’.
  • The first 3 weeks after birth: Remember to lie down for a rest regularly to allow the pelvic floor muscles and any surgical stitches to heal. Lying down takes away the pressure of gravity present when you stand upright on your feet. When resting, it is important to get up regularly too, maybe every 60-90 minutes during the day. This reduces the chance of blood clots in the legs. When in bed it is helpful to do foot and ankle exercises, point and stretch toes to keep calf muscles active. Writing the alphabet with your big toe will make sure you’ve moved those muscles well. If you have had a caesarean birth, then continuing to use the compression stockings until you are more mobile will give you extra protection against blood clots in the legs.
  • Building up your strength: As you are able to, you can return to light walking. While it is good to gradually walk longer distances, how far you walk will depend on your pelvic pain and your energy levels. Pushing yourself hard at this time isn’t always beneficial. Again, a women’s health pelvic physiotherapist can guide you.
  • Running and impact sports: It is best to avoid running or impact sports until at least 12-24 weeks after the birth. Your pelvic floor and core muscles need time to recover, heal, and strengthen before the rigours of high impact exercise.

If you are a keen exerciser, you might enjoy some of the low-cost, evidence-based online recovery programs for after childbirth. Some examples of these include:

References

Exercising throughout your pregnancy (2012). Clapp, J MD, Cramm, C MD. Addicus Publishing.

Factors associated with persistent pain after childbirth: a narrative review – PMC (nih.gov)

The Royal Women’s Guide to 3rd and 4th Degree tears Fact Sheet

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