Recovery Advice After Birth

• Bladder Care

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  During labour and after birth you should;

  1. Pass urine regularly every 2-4 hours. If any concerns please speak to your midwife.
  2. Drink small amounts of water regularly rather than having a large amount all at once.
  3. You may be asked to complete a diary of what you are drinking and urinating (this may be something your birth partner can help with assisting you to complete.)

   

  After birth:

  1. Should have passed urine within the first 6 hours after giving birth, or once you have had your catheter removed. It is important that the first time you urinate is measured by the midwife.
  2. To help pass urine, sit on the toilet seat and relax. It may help to run some water or gently tap over the bladder.
  3. Some have difficulty fully emptying their bladder after giving birth, which can lead to long term issues if not identified. In this case your health care provider might advise you have a catheter for a short period of time to allow your bladder to rest and recover.

   

  It is important to tell your midwife if;

  1. The sensation to pass urine is reduced. You can set a reminder to urinate every 2-3 hours to help with this.
  2. If you have difficulty emptying your bladder.
  3. If you have not been able to pass urine for 6 hours after birth or catheter removal.
  4. If you have been leaking urine particularly when standing or moving around.

• Pain Management and Wound Care

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  Pain and swelling around your vagina is common for up to 7 days after birth.

  Taking regular pain medication or placing a cold pack or maternity pad between layers of underwear for periods of 10-15 minutes may help with this.

  You may find some positions more comfortable than others, for example lying on your side with a pillow between your legs, or when sitting placing a rolled up towel in a 'U' shape under your thighs.

  If you have a caesarean wound, support it when getting in and out of bed, coughing or when opening your bowels, by using a rolled towel to apply gentle pressure. You may also find it more comfortable to get out of bed by rolling on to your side first and using your arms to push up. It's also helpful to gently massage your scar once it has fully healed.

  It's important that you keep your stitches clean and dry for both perineal or caesarean wound. Avoid long hot baths in the first 2 weeks, only have short baths or showers.

  You should also avoid using any soaps or perfumed products directly on the area. Plain water is best. Pat the area dry rather than rubbing.

  If you notice any signs of infection like a foul smelling discharge, excessive itching, increasing pain or swelling, you should contact your midwife or GP.

  It is safe to return to sex approximately 6 weeks after birth as long as the wound has healed, although you should only return to sex when you feel ready. It can be helpful to use a water based lubricant.

• Posture and Positioning Following the Birth

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  Following birth: it’s important to look after your back.

  If changing your baby, try to use a surface at waist height. If you are using the floor or a bed to bath or change your baby then kneel down. This will avoid you stopping.

  When feeding your baby use a supportive chair or sit well in the bed. If breastfeeding, bring the baby to your breast and use pillows so that you are not bending forwards. If sitting in a chair make sure your feet are well supported on the floor and the baby is well supported and can’t fall.

• Pelvic Floor Exercises

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  It is recommended to do daily pelvic floor exercises during pregnancy and after birth. This will help prevent symptoms of Pelvic Floor Dysfunction such as bladder and bowel leakage or prolapse.

  Your pelvic floor exercises or ‘Kegels’ can be performed in any position. Find one which is comfortable for you. You may find lying or sitting easier if your muscles feel weak and try standing when they are stronger.

  Imagine that you are trying to stop yourself passing wind and urine at the same time. You can also think of squeezing tight in the vagina. You should feel your pelvic floor muscles ‘squeeze and lift’ inside. Don't hold your breath or clench your buttocks. You may feel a gentle tightening in your tummy, which are your deep tummy muscles working to help the pelvic floor.

  Pelvic Floor Exercise Programme

  Your pelvic floor exercises should include long squeezes and short quick squeezes.

  Long Squeezes

  • Squeeze and lift your pelvic floor muscles tight, hold and release.
  • Repeat your long squeezes, with a rest in between each, until you feel that your muscles are tired. 

  Short Squeezes

  • Quickly squeeze and lift your pelvic floor muscles and immediately relax and lower them.
  • Always let the muscles fully relax before the next squeeze.

  How Often Should I do Pelvic Floor Exercises?

  Try and repeat this programme 3 times a day. Build up to do 10 long squeezes for 10 seconds, then 10 short squeezes. You may need to start with little and often until the muscles get stronger.

  Build up your exercise programme over the following weeks and months. You should notice the exercises getting easier in around 3-5 months.

  Once improved continue to practice them once a day to maintain the improvement. You may find the NHS squeezy app useful to support you with your daily pelvic floor exercises.

  The Squeezy App

  

  Everyone across Norfolk & Waveney will be invited to download the NHS endorsed Squeezy App to support you with your pelvic floor exercises during and after pregnancy.

  Squeezy is an app that will send daily reminders for you to complete your pelvic floor muscle exercises. It contains visual aids to help you know when to squeezy and relax, and counts repetitions for you so you don’t have to. Squeezy also allows you to track your symptoms so you can see when you may require further assistance or tailoring of your exercise programme.

  If you would like to download your squeezy app for free please contact the team on nwicb.perinatalpelvichealthservice@nhs.net with your name, date of birth, address, and which Norfolk & Waveney NHS hospital you are booked under to receive your maternity care.

• Your Stomach Muscles

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  Your stomach muscles run from the bottom of your ribcage up to your pubic bone and are connected by ligaments.

  These ligament increase in width during pregnancy to accommodate your growing baby. They may remain stretched and weak for some time after birth.

  You may get the feeling of a gap between your six pack muscle. For most people this will improve within 8 weeks after birth.

  However, if after 8 weeks you can fit more than two fingers in-between the six pack muscles and you experience a visible bulge, especially when going from lying to sitting this is called diastasis recti of the abdominal muscles.

  If you have diastasis recti of the abdominal muscles you should take care to reduce the bulging of your abdominal muscles when moving, lifting or carrying heavy objects or when exercising.

  • Avoid sit ups and abdominal exercises that make the abdominal muscles bulge.
  • Avoid straining with constipation.
  • When getting in and out of bed roll on to your side first and push through your hands.
  • Start gentle core strengthening exercises (as per video and companion guide).

  Should these symptoms continue beyond 8 weeks after birth speak to your GP and they may refer you to physiotherapy for support.

  Essential Advice & Exercises Afterbirth

• Healthy Bladder & Bowel

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  Having a healthy bladder and bowel can help you avoid Pelvic Floor Disfunction (PFD). 

  Eating & Drinking 

  Try and drink 6-8 glasses of water a day. Other drinks such as milk, herbal (caffeine free) teas, diluted squash and juices are also OK sometimes. This helps you to stay hydrated. If you don’t drink enough, your poo can become hard and difficult to pass.

  If you are experiencing symptoms of urgency and frequency with weeing try to limit the caffeine that you drink (coke, coffee, and tea).

  Eating a balanced nutritional diet will help your poo to be soft and formed.

  Weeing

  When using the toilet, sit down to wee, don’t hover! Sit in a relaxed position and lean forward with your feet apart. This will help your bladder to empty fully. Remember to give your bladder time to empty. When you have a newborn baby or small children you may often hurry off the toilet before you have completely finished. This can lead to you needing to go back again or leaking after.

  Cut out ‘just in case wees’. After birth, over the following weeks and months, teach your bladder to hold again, aiming for going every 2-3 hours. Try to avoid going just because you are going out the door! This can cause bad habits.

  Check your urine. If it is dark, cloudy, smelly or blood stained make sure to tell your midwife or GP. During pregnancy you are more likely to get urinary infections and a health professional can check this for you, but also rule out other causes. 

  Pooing

  Use a footstool to poo. Placing a stool or toddler step under your feet can ensure you are in a more relaxed squat position. This will help pass your poo more comfortably.

  Listen to your bowel. It is important to make time to poo when your body tells you it needs to go. If you miss the ‘call for stool’ it can then be harder to open your bowels. 

  Don’t strain, this can weaken the pelvic floor muscles further. If you are finding your poo is too hard and difficult to pass, discuss treatment options with your health professional.

• Recovering After a Caesarean Section

• Return to Exercise

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  Pregnancy and birth can have a considerable impact on your body. Everyone recovers at a different rate, and you must gradually reintroduce and build your exercise levels.

  It can take up to 9-12 months for your body to fully recover.

  The following advice applies to women and birthing people who have had any type of birth:

  In the first six weeks:

  • Continue your pelvic floor exercises.
  • Gradually increase your walking distance keeping within your comfort levels.
  • Start gentle exercises.

  6-12 weeks:

  Before progressing to do more advanced forms of exercises, ensure any vaginal bleeding has stopped and your caesarean or perineal wound has healed.

  Do low impact exercises and gradually build your endurance and strength. This could be:

  • Pilates or yoga.
  • Swimming or cycling.
  • Cross training or power walking.
  • Light weight training.

  As you build up your exercise it should remain comfortable for you.

  After twelve weeks:

  If you have built up your cardiovascular endurance and muscle strength, you can progress to more advanced exercises, such as;

  • A gradual return to running (the link below should assist you).
  • A gradual increase to the weight you are using for strength training.
  • A gradual introduction to high impact or high intensity training.
  • A gradual increase in the difficulty of abdominal exercises, including sit ups.

  Should you have any of the following symptoms you should stop the exercise immediately, and speak with your healthcare provider and seek a referral to a pelvic health physiotherapist so that you can have a clinical assessment and guidance.

  • Pain.
  • Bulging of the stomach muscles.
  • Concerns with your bladder or bowel.
  • Or heaviness within your vagina when you exercise.

  Return to running:

  If you are considering a return to running, the graphic below will guide you on exercises to consider and includes gradual return to running after birth.

  

  It is important for us to highlight that each person’s road to recovery will differ and the same applies when returning to exercise. There is no expectation following birth to achieve these exact time frames or fitness milestones.

  But if you have built up your strength following guidance below and are ready to return to running at 12 weeks after birth, then using tools like the NHS Couch to 5k App is recommended. This will help you gradually build up your running fitness and endurance.

  Other Useful Links

  Fit For The Future - Essential Advice & Exercises Following Childbirth

  Pilates In Women's Health Physiotherapy

Pelvic Floor Dysfunction (PFD)

Pelvic floor dysfunction (PFD) is a term for a group of related conditions caused by the pelvic floor not working correctly. 

Click the titles below for more information on PFD conditions and the treatments available if you need help.

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• What is Pelvic Floor Dysfunction?

  Pelvic floor dysfunction (PFD) is a term for a group of related conditions caused by the pelvic floor (muscles, fascia and ligaments) not working correctly. These symptoms can include;

  • Urinary incontinence - leaking of urine.
  • Overactive bladder - urgency to go to the toilet often. 
  • Pelvic organ prolapse - descent of one or more of the organs into the vagina.
  • Anal incontinence - accidental bowel leakage.
  • Dyspareunia - discomfort during sexual intercourse.

  Is PFD normal?

  It is quite common to experience incontinence during pregnancy and after having a baby.

  • 40-50% of people in their 2^nd and 3^rd trimesters of pregnancy and immediately after birth have urinary leakage.
  • 25% of pregnant people can also have anal incontinence.

  Although common, it is very important to know that these symptoms should only happen for a short time, should be mild and should go away quickly.

  If you experience any significant pelvic floor symptoms during pregnancy or afterwards, or mild symptoms that do not improve within six weeks of childbirth; then we advise that you seek help. Simple treatments will often improve the symptoms and prevent long term problems.

• Stress Incontinence - Accidental Wee

  Stress incontinence is accidental leakage of urine when you do something that increases the pressure in the tummy. This could include jogging, dancing, jumping, coughing, laughing or lifting your baby.

  Stress incontinence is caused by the pelvic floor not supporting the urethra, the water pipe from the bladder though which you wee, well enough. Many people experience this when they return to activities such as running, exercise or dance classes after they have had a baby.

  Read more about promoting continence with physiotherapy

• Overactive Bladder

  Overactive bladder is when your bladder squeezes and tries to empty without you wanting it to.

  You might experience the need to rush to the toilet quickly to wee or find you are going for a wee more often than normal. You may wake up at night needing to wee or experience accidental leakage when rushing to the toilet. This can sometimes be a significant leakage of urine which you cannot stop.

  Overactive bladder syndrome is caused by the muscle in the wall of the bladder contracting and squeezing when it should be relaxed. The abnormal bladder muscle contractions in overactive bladder syndrome cause the urinary frequency, urgency and night time weeing.

  Often overactive bladder problems are developed at the same time as stress incontinence, and you may be affected by both conditions.

  Read more about promoting continence with physiotherapy

• Pelvic Organ Prolapse

  Pelvic Organ Prolapse is when your bladder, bowel or womb moves down from their normal position, causing a bulge inside your vagina.

  It is caused by damage to the pelvic floor which normally supports these organs and keeps them in place. The usual symptoms are the sensation of a vaginal dragging or pressure and/or noticing a bulge or lump in the vagina.

  Sometimes you can also develop problems with not emptying your bladder completely when weeing or emptying the bowels and can cause constipation.

  Sexual intercourse may also be affected with discomfort or a sensation of something being in the way in your vagina.

• Returning To Sex After Having A Baby

  Returning to sex after having a baby can be a personal journey which is different for all.

  If you have a perineal wound or stitches it is safe to return to sex approximately 6 weeks after birth if the wound has healed, although you should only return to sex when you feel ready. Remember to consider contraception.

  If you are feeling anxious or find It feels different try the following;

  • You don't have to start with penetration. Foreplay is a good way to find out your comfort levels.
  • Communicate openly with your partner about what you feel comfortable with. Maybe set some boundaries.
  • Use a water-based lubricant.
  • Deep breathing and relaxation techniques can be a good way to reduce discomfort or anxiety.
  • Prepare the vaginal tissues with perineal massage (see relevant section in the having a baby page). This can help to reduce any scar tissue which may cause tightness.
  • Do daily pelvic floor exercises to help regain sensation and improve muscle strength.

• Discomfort With Sexual Intercourse

  Dyspareunia is the scientific name for discomfort during or after sex.

  Discomfort with sex can be caused by various things. It can be due to hormone levels changing, infection, changes in the function of the pelvic floor muscles, or scar tissue after a vaginal tear during childbirth, or mismatching of the vaginal tissues after stitching. It can also be due to the vaginal area remaining more sensitive following birth or infection.

  If you notice any signs of infection like a foal smelling discharge, excessive itching, increasing pain or swelling, you should contact your healthcare provider who can rule out an infection and also refer you to the relevant service. Pelvic health physiotherapy can help if the pelvic floor muscles or scar tissue are causing discomfort with sex.

  Vaginal dryness:

  During pregnancy there are changes in your hormone levels as your body undergoes change. This can cause the vagina to become itchy or sore at times as a result of vaginal dryness. This can be commonly confused with thrush or cystitis but treatments for this will not help and can make symptoms worse.

  It can be common for vaginal dryness to continue in the weeks after birth, and if you are breastfeeding this can continue for longer.

  Low sex drive

  Low sex drive is often referred to as a low libido. Your hormones can not only cause physical changes to the vagina (dryness) which can cause discomfort with sex, they can also cause your sex drive to be quite low, at least in the early days and weeks after birth.

  Understandably many can be anxious about returning to sex or intimacy after giving birth. Whether you have had a vaginal or caesarean birth your postnatal body may not feel like your own, and can cause many to experience low confidence physically. This anxiety and physical recovery combined with adjusting to life with a newborn can disrupt your body's natural lubrication ability.

• Physiotherapy Treatment for PFD

  Pelvic floor physiotherapy, supervised by a specialist physiotherapist, is proven to improve most mild to moderate pelvic floor problems which occur after pregnancy and childbirth. Getting support quickly if symptoms of pelvic floor dysfunction occur is important, as prompt physiotherapy helps to prevent the problem worsening and will often cure the problem.

  Therapy Assistant Practitioners

  Therapy assistant practitioners work to support women/birthing people who may be at risk of pelvic floor symptoms or who have mild symptoms based on the self-assessment questionnaire results. They run pregnancy and after birth pelvic floor workshops offering pelvic health advice at the midwifery hubs.

  How Physiotherapy Treatment Works

  Usually, the pelvic floor specialist physiotherapist or physiotherapy assistant practitioner will see you for a number of sessions after assessing the problems you are having. Often these will be face to face initially, with telephone follow ups to check on your progress. There may be further face to face contact if needed to help you.

  A key part of physiotherapy treatment is to offer an (optional) internal examination to guide you on how to correctly do your pelvic floor exercises. The reason for this is that up to 65% of women who practice their pelvic floor exercises are doing them incorrectly and so won’t be seeing improvement with their symptoms. The examination will then help the physiotherapy team to provide you with a specific exercise programme for you.

  Tools such as biofeedback, which are devices which show you how well you are contracting your pelvic floor can form a helpful part of treatment for some people with pelvic floor dysfunction. Electrical stimulation is using little electrodes to stimulate your pelvic floor muscles to contract help you to learn how contract your pelvic floor muscles effectively. The exercises and techniques you learn as part of pelvic floor physiotherapy will often give you lifelong skills to maintain the health of your pelvic floor.

  As well as exercises, your physiotherapist will also help you with lifestyle advice for bladder and bowel health. Physiotherapy treatment may often last for 3-4 months to allow time for the muscles to develop to then see improvement in your symptoms.

  Physiotherapy works, if you stick with it! Evidence shows 3-4 months of physiotherapy will improve urinary or prolapse symptoms. your physiotherapist is there to guide you with advice and your exercise programme, however you have to put the work in to see the benefits!

• Medications for PFD

  Medications can be helpful for those experiencing certain pelvic floor dysfunction conditions such as overactive bladder syndrome - urgency, frequency and leakage of urine.

  For those with constipation or accidental bowel leakage, the use of prescribed laxatives or medications which slow the transit through the bowel can be useful treatments. However, for all these conditions, pelvic floor physiotherapy is usually the most impactful and useful treatment.

• Accidental Bowel Leakage

  Accidental bowel leakage is when you accidently leak wind or poo from your bottom. This is a rarer than urinary incontinence, overactive bladder or prolapse symptoms, but has a bigger impact on quality of life and can be a very upsetting to experience.

  Accidental bowel leakage is usually caused by disruption to the ring of muscles which surrounds your bottom or anus due to tearing during childbirth. This is known as a third or fourth degree tear. Everyone who has a vaginal birth is checked for these types or tears. Sometimes, even if they are repaired well, you can still develop accidental bowel leakage symptoms. 

  Often, you will also develop the need to rush to the toilet to open your bowels if you have problems with accidental bowel leakage.

  Read more about promoting continence with physiotherapy

• What if Physiotherapy or Medications don’t Work?

  Most pelvic floor dysfunction symptoms will improve after supervised pelvic floor physiotherapy. If you are still experiencing pelvic floor problems after completing a course of physiotherapy, then we will recommend that you see a doctor specialising in pelvic floor dysfunction.

  This will be either a urogynecologist, a gynaecologist who specialises in pelvic floor dysfunction problems or a pelvic floor specialist colorectal surgeon, who looks after pelvic floor problems which affect the bowel.

  Your physiotherapist will usually be able to refer you on to the specialist doctor, as all pelvic floor specialists work together in a multidisciplinary team. A small number of patients may need to have operations to treat stress incontinence or pelvic organ prolapse, or to have specialised procedures to help with overactive bladder problems or accidental bowel leakage.

• 3rd and 4th Degree Perineal Tears

  Your perineum is the area that extends between your vagina and the anus. Many women experience perineal tears during childbirth as the baby stretches the vagina and perineum. 1st degree tears are skin deep and usually heal naturally. 2nd degree tears are deeper and affect the muscles of the perineum, these usually require stitches.

  What is a 3rd or 4th degree tear?

  A 3rd degree tear affects the muscles that control the anus, called the anal sphincter. A 4th degree tear extends further into the lining of the anus or rectum. 

  Three in every one hundred women having a vaginal birth can develop a 3rd or 4th degree tear. It is more common with a first vaginal birth, occurring in six out of one hundred women compared to two in one hundred women who have had a previous vaginal birth.

  What happens if I have a 3rd or 4th degree tear?

  When a 3rd or 4th degree tear is suspected or confirmed this will usually be repaired in theatre soon after you have delivered your baby. You will need an epidural or spinal anaesthetic and have a catheter in until you feel able to walk to the toilet.

  After the repair surgery you should be offered pain relief, and a course of antibiotics to reduce your risk of infection. 

  Appointments

  You will be contacted by the Physiotherapy team after giving birth and reviewed by them approximately six weeks later in an outpatient appointment to assess your pelvic floor muscles. You will also have an appointment to see a gynaecology consultant in approximately four months’ time.

  Symptoms to be aware of

  Six-eight out of 10 women have no long lasting symptoms after having it surgically repaired and given time to heal. A small number of women may experience difficulty in controlling their bowels or holding wind in. This is called anal incontinence.

  Other symptoms to be aware of after any type of delivery include:
  • A sensation of a lump in the vagina
  • Urgency or leakage of urine
  • Pain during intercourse
  • Pain and/or discomfort around the scar

  What can I do to help me recover?

  Keep the area clean. Wash daily using only water, do not use any product on the area. Change your sanitary pads regularly. Wash your hands before and after you do so and when using the toilet. This will reduce your risk of infection. A clean wound is a healthy wound.

  What do I need to know about my bowels?

  Your stitches should not be affected by opening your bowels. You may find it harder to control your bowels in the first few days after a 3rd or 4th degree tear than compared to before you had your baby.

  It is important to avoid straining and constipation, the following advice can help:

  • Drink at least 2 litres of water every day
  • Eat a healthy balanced diet of both soluble (fruit, vegetables), and insoluble fibre (cereals,
    wholemeal bread, pasta, rice).
  • Laxatives – Can be taken to make it easier and more comfortable to open your bowels, such as a stool softener (lactulose) or a bulking agent such as Fybogel.
  • Sit down relaxed on the toilet when opening your bowels do not hover. The best position to sit in is with your feet on a stool to raise your knees above your hips. Try to relax with your forearms on your thighs whilst keeping your back straight. Bulge your tummy outwards by taking deep
    abdominal breaths. Keep your mouth slightly open and your jaw relaxed. Breathe out. This will help to expel your bowel motion without straining. Take your time, do not rush. When finished pull up your anal muscles to
    encourage closure of these muscles.

  What can I do to improve or prevent bladder or bowel problems?

  It is important to start pelvic floor exercises as soon as you can, ideally the day after your delivery. This strengthens these muscles and helps healing.

  Your pelvic floor muscles help you to control your bladder and bowel by closing the urethra and back
  passage, thereby preventing incontinence. Your anal sphincter muscles form part of your pelvic floor
  muscles. They work to close the anal canal (preventing incontinence of wind or poo).

  Your pelvic floor muscles will not be very strong after birth and you may initially have very little sensation in your pelvic floor, but this should improve the more you practise your exercises.

  Start gently as pain allows for the first few days. Gradually build up on your home exercise programme increasing the number of squeezes and the length of hold as your muscles get stronger.
  See the pelvic floor exercises section for further advice.

  What should I expect with my recovery and return to normal daily activities?

  Every women’s recovery and expectations of what they view as normal activities will differ. After having a 3rd or 4th degree perineal tear you should avoid heavy lifting or strenuous activity for 4-6 weeks. After this you can gradually increase to your normal activities. Listen to your body.

  Recovering from surgery after a perineal tear and caring for your new born baby can be hard. Seek support from family and friends whilst your body gradually recovers and you become more able.

  Some birth experiences may leave women feeling traumatised, distressed, anxious or confused. For some women, the birth they experienced was very different from the birth they hoped to have, which can be hard to come to terms with. You can access midwifery debrief services to talk about these feelings, and to better understand what happened to you during your birth.