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A Pelvic Floor Physical Therapist Shares the Common Signs of Prolapse After Birth

Learning the signs of prolapse after birth is essential, as it’s critical to catch prolapse sooner than later during postpartum recovery.

During pregnancy, labor, and delivery, immense strain and pressure is put on the pelvic floor. For some, their pelvic floor literally can’t handle the pressure and begins to descend, causing the infamous “bulging” feeling within the vagina.

What is pelvic floor prolapse?

The pelvic floor is responsible for helping to support the pelvic organs (bladder, bowel, and uterus) and keep them in place.

Pelvic organ prolapse is the symptomatic descent of one or more of the anterior vaginal wall (that supports the bladder), the posterior vaginal wall (that supports the bowel), and the apex of the vagina (cervix/uterus) or vault after a hysterectomy.

Different kinds of medical terminology for prolapse exist. You may hear other terms like a cystocele or bladder prolapse, a rectocele or bowel prolapse, and uterine prolapse.

New medical terminology requires a woman to have symptoms and increased movement of the vaginal walls for prolapse to be diagnosed.

The overall prevalence of POP (pelvic organ prolapse) varies significantly depending on the definition used and ranges from 3% to 50%.

What causes prolapse after birth?

During pregnancy, hormonal changes promote connective tissue stretching and softening to allow room for the growing baby.

The additional ‘give’ in the connective tissue can affect the degree of pelvic support. The baby’s weight and the (healthy) overall weight gain also increase the pressure on the pelvic floor.

During a vaginal delivery, the pelvic floor stretches, allowing the baby to pass through the birth canal. Those who have spent time in the ‘pushing phase’ of labor usually have a degree of pelvic floor stretch, even if their birth results in a C-Section.

Many factors contribute to prolapse, including:

  • The duration of the active ‘pushing’ stage of birth. A second stage that lasts longer than ninety minutes is associated with increased pelvic floor changes.
  • The use of forceps in delivery is associated with an increased risk of pelvic floor muscle avulsion, where the muscle is “torn away” from the bone, which results in an increased risk of the anterior wall and uterin prolapse
  • Episiotomy or tear and the degree and direction of that tear. Larger tears are associated with increased pelvic floor changes.
  • The birth weight, size, and position of the baby at birth.
  • Genetics. 
  • The coordination of our pelvic floor muscles and the ability to relax the pelvic floor.
  • The use of epidural and the pace at which baby passes through the birth canal.
  • The use of antenatal perineal massage.
  • Postpartum pelvic care.

How is pelvic organ prolapse diagnosed?

The best way to receive an accurate diagnosis of pelvic organ prolapse is to have an internal vaginal pelvic floor assessment by a pelvic floor physiotherapist. Ultrasound assessments to diagnose prolapse are not as accurate as internal vaginal assessments. 

What are the common symptoms of prolapse?

Common physical symptoms women complain of associated with prolapse include:

  • A ‘bulging’ sensation in the vagina
  • A sensation of ‘falling out’
  • A heaviness or dragging sensation within the pelvis
  • Lower back pain
  • Difficulty initiating/completing a bladder/bowel motion
  • Needing to support the vaginal wall (usually with a finger) to pass a bowel motion
  • Incontinence or leakage from the bladder or the bowel
  • A deep thudding sensation/pain with sex

How do I prevent prolapse during pregnancy?

You can do many things to support your pelvic health during pregnancy. Ensuring healthy bladder and bowel habits, particularly avoiding constipation (we know this isn’t always possible) and adopting good toilet posture, is helpful.

Modifying your exercise according to the phase of your pregnancy and the support of your pelvic floor is key. 

The best things you can do to support your pelvic health in preparation for vaginal birth are:

1. Get your pelvic floor muscle co-ordination checked by a pelvic floor physiotherapist

One in three women who have never had a baby find it very challenging to relax their pelvic floor during increased intra-abdominal pressure and downward pressure on the pelvic floor.

An inability to relax the pelvic floor muscles during birth is associated with increased obstructed labor and birth-related pelvic floor changes.

Therefore, knowing how to relax the pelvic floor muscles during a downward push on the pelvic floor during pregnancy may support you during birth. 

2. Practice perineal massage

Antenatal perineal massage significantly reduces perineal pain, fecal incontinence, and anal sphincter injury. Perineal massage for birth preparation is different from postpartum perineal massage.

Women are suggested to commence pregnancy with a perineal massage from about 34 weeks pregnant. A water-based lubricant or perineal massage balm is recommended for comfort.

To practice perineal massage, first find a comfortable position.

  • Gently insert a thumb into the vaginal about three to five centimeters
  • Press down and outwards on the perineum until you feel a gentle stinging sensation
  • Press for about two minutes, moving the thumb slightly to the left and right
  • Relax and repeat once (two rounds of two minutes of massage)

For pregnancy preparation, it is recommended that you perform this massage at least twice per week and optimally three to four times per week. One session of a longer massage of about ten minutes has also been effective.

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Some pelvic physiotherapists and midwives offer perineal massage for birth preparation.

How do I help prevent prolapse after birth?

Postpartum pelvic care is about striking a delicate balance between rest and gentle movement that promotes whole-body recovery. Postpartum pelvic care includes:

  • Laying down occasionally during the day decreases the pelvic floor load.
  • Avoiding heavy lifting in the early weeks postpartum when possible. Allowing others to support you has significant benefits.
  • Reconnecting to your deep core and pelvic floor and gradually returning to exercise. Check out Taryn Gaudin’s YouTube for deep core and pelvic floor connection practices.
  • Knowing your body intimately – a pelvic floor physiotherapist can offer you tailored guidance. You can start pelvic floor recovery days after birth – you don’t need to wait weeks.
  • Recent studies have found one of the most protective aspects of postpartum pelvic floor recovery is for women to return to their pre-pregnancy weight within six months of birth.

The most important thing is listening to your body. Knowing the symptoms of prolapse and slowing down if/when you feel symptoms is key. If you know a particular activity aggravates symptoms, modifying your activity can be extremely helpful.

Lifestyle modifications don’t need to be forever. They may only be required while you recover from birth.

Should I worry about prolapse?

I commonly see women feeling highly anxious when they have signs of ‘prolapse’ in their early postpartum weeks when these changes are normal and part of this phase in our journey.

Instead of feeling like we should ‘bounce back’ and expecting new mothers to ‘do it all’, we could embrace this phase for what it is. In embracing a gentler postpartum, women would take time to recover from the inside out by nourishing their bodies and meeting their needs first.

This doesn’t mean that new mothers are incapable of carrying their baby, moving their body in gentle and nourishing ways, or that women need to be ‘scared of doing too much’ in this phase.

If women tune into their body and their baby, moving with the rhythm that this postpartum period invites, they can more naturally go about their days in ways that are positive for pelvic health. 

Pelvic health prolapse can be a confronting and worrying diagnosis. It is important to remember that postpartum recovery continues well after the fourth trimester. Most women continue to have significant pelvic health improvements in the first twelve months after birth, which can last well beyond twelve months.

It may feel easier to ignore prolapse symptoms, which might place you at risk of worsening symptoms. Finding a pelvic floor physiotherapist that can support you in your journey to optimize your pelvic health and harness your body’s amazingness can help.

In my book, Body Conscious Woman, I share extensively about whole-body health during pregnancy, birth, postpartum, and motherhood.

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