The Postpartum Diaries Part 2: Second, why did nobody tell me about this?

Author: Kara Schuft, PT, DPT: Doctor of Physical Therapy, Business owner, and Blog Contributor. Specializing in chronic pain, pelvic health and peripartum care. Passionate about health literacy and conversation around our changing bodies throughout the lifespan. Learn more about Kara here.


So glad you decided to join me again! Hopefully your interest is piqued after last week’s talk about navigating postpartum weakness and incontinence. If you missed it, you can read it here. Today it’s all about dealing with pelvic pain.  Remember, that every person and their experience is different. This is meant as a conversational starting point to think about some of the ways your body has changed, and how to help if you are experiencing pain after childbirth. This is a mix of my own personal experience as well as of those of the many women I have had the pleasure of working with as a physical therapist.

Why didn’t anybody tell me about this?

Or maybe they did? I, for one, was grossly unprepared for dealing with the fact that things just didn’t feel RIGHT after having a baby. Both times (though I was more prepared the second time) things were painful. Remember, no matter how you deliver, having a baby is like an Olympic event for your pelvis. Things shift around and settle differently. Labor  is both work and painful in and of itself so it can be very frustrating to have to deal with postpartum pain. Pain can occur for any number of reasons:

  • Pain with having a bowel movement postpartum

  • A scar from a C-section

  • Stitches if you had tearing or an episiotomy during a vaginal delivery

  • Pelvic pain because the pelvis has shifted or you experienced a pubic symphysis separation (I'm so sorry!)

  • Pain during sexual intercourse

  • Pain when you have a postpartum pelvic examination by the OBGYN

Ok, What do I do about it?

I’m going to give you some things to think about. However, if you are dealing with pain for longer than two months, the best person to talk to is going to be your doctor or OBGYN because you might need a pelvic floor physical therapy referral. But more about that later. Let’s tackle these one by one:

Having a bowel movement postpartum: I promise, it will be all right. But having a bowel movement after having a baby can be painful at first for some people. Many women also have to deal with hemorrhoids that develop both in pregnancy and with pushing during labor. Here are some ideas for managing that.

  1. You were likely prescribed a stool softener to use - if you were, use it.

  2. Drink plenty of water - chances are you are having no problem with this because breastfeeding can make you SO THIRSTY!

  3. Eat plenty of fiber.

  4. Do not strain. I know this is hard, but if you are dealing with constipation, really try not to strain when you are having a bowel movement. It stresses the muscles of the pelvic floor, cam make hemorrhoids worse, and is just bad mechanics.

  5. Speaking of straining, do you know there’s actually a better way to go to the bathroom? Squatting is actually much easier on the body and allows for less straining when having a bowel movement. I will often encourage people to have a small footstool next to the toilet to put their feet on. I promise I’m not intending this to be product placement, but this link below is my new favorite instructional video on pooping mechanics:

Scar pain: There can be pain with a c-section scar or stitches in the pelvic floor if there is a tear or episiotomy. A C-section scar is typically located horizontally above the pubic bone. Another site is within the pelvic floor itself because there can be some tearing of that tissue as a baby passes through the vaginal canal. When tissue is cut or tears, it is a natural and normal response in the healing cycle to lay down new healthy cells. That tissue starts to scar down or get tighter as it heals up. However, it’s important for the scar that forms not to get too tight. If the tissue tightens down a lot it can become a source of pain.

  1. Physical therapist perform and teach what is called scar tissue mobilization. This would be after the skin has completely closed up and healed which is 6-8 weeks postpartum for most people.

  2. You can perform your own scar tissue mobilization by trying to move the scar around with your fingers. On a C-section scar you can do little circles or start to gently stretch the tissue around the scar. For a scar in the pelvic floor muscles sometimes women need to use their finger or a dilator to help stretch that tissue. 

  3. Whether you, your partner, or your physical therapists helps to mobilize your scar, it is usually not comfortable. Scar tissue is notoriously tight and difficult to move if it tightens down enough. When you break through that stiffness it can hurt, but afterwards it feels much better. 

Musculoskeletal pelvic pain: We have some large bones in the pelvis. There is a bone on either side made up of the ilium, ischium, and pubic bone collectively referred to as the innominate. Then there is the sacrum. Having a baby can cause these joints to become a little loose and for things to shift around. This can result in pain when you move, bend down, try to step up a curve, walk, or shift in bed. This is best solved by a physical therapist.

  1. One of the first things to do is stabilize the joints. Sometimes women wear a sacroiliac joint belt (SIJ belt or SI belt for short.) This is worn tight around the pelvis to bring extra support to the pubic symphysis and sacroiliac joint. 

  2. The next step is to work on the person's own muscular support. A physical therapist can help you slowly strengthen the muscles that support the SI joint. Mainly hip muscles. Getting stronger through the hips and core will allow a person to have less reliance on the SI belt if they are using it for extra support. 

  3. A physical therapist can also do some mobilizations to manually adjust the bones of the pelvis. Sometimes they have gotten out of alignment so a PT needs to help to realign the bones. This can provide a significant amount of relief. 

Pelvic Floor pain: Ok, here's the thing. After having a baby, the pelvic floor itself needs to do some healing after delivery. Having intercourse again, or having an OBGYN examination can be painful for many reasons: the muscles of the pelvic floor can tighten down a little too effectively, there could be a tight and painful scar from any tearing, and the way the bones of the pelvis can move and settle could result in pain. Again, this is often best solved by physical therapy.

  1. A physical therapist can check for any muscular tightness of the pelvic floor. They can stretch it and teach you how to stretch the tissue at home.

  2. One important factor is learning how to relax the pelvic floor. Often we learn that Kegels, or a pelvic floor contraction is a good thing to do, however, when there is pain, usually we need to learn how to relax and release the pelvic floor. Again, a PT can help teach you how to do this. 

What else can be done about it?

I’m so glad you asked! If you are having pain longer than two months and you have been cleared by an OBGYN or midwife, then you should see a physical therapist who specializes in the pelvic floor. They would: 

  1. Check your bony alignment - is the pelvis stable? 

  2. Size you for a stability belt or SI belt if needed

  3. Give you specific exercises to help strengthen your pelvis and pelvic floor

  4. Teach you scar tissue mobilization 

  5. Teach you how to stretch the muscles of the pelvic floor so that they are not too tight

  6. Instruct on relaxation of the pelvic floor to prevent future tightness

In Oregon, many insurances allow for direct access where you can go straight to a physical therapist without seeing your doctor first. However, typically OBGYN’s, Midwives, and other providers are more than happy to refer you to a physical therapist when needed. Don’t delay, see us today!

Join me next week for The Postpartum Diaries Part 3: Breastfeeding: the good, the bad, and the hungry