Childbirth is the most significant risk event for pelvic floor dysfunction in a woman's life. Vaginal delivery subjects the pelvic floor muscles, connective tissue, and pudendal nerve to substantial stretch, compression, and potential direct trauma. Studies using MRI imaging after vaginal birth have documented visible pelvic floor muscle tears in a significant proportion of women who had clinically uncomplicated deliveries. One in three women who give birth vaginally will experience urinary incontinence, one in ten will experience pelvic organ prolapse requiring intervention, and a meaningful proportion will experience sexual dysfunction related to pelvic floor changes. Early and appropriate rehabilitation substantially alters this trajectory.
When to Begin Rehabilitation
Gentle pelvic floor contractions can and should be commenced within the first 24 to 48 hours after birth, once the initial acute discomfort allows. This applies after both vaginal and caesarean births: caesarean section does not protect the pelvic floor from the effects of pregnancy itself, and scar tissue from the uterine incision benefits from early gentle movement. The first contractions will be weak and may be barely perceptible, which is expected. The goal in the first week is simply to re-establish the neural connection to the muscles rather than to build strength. Sustained strength training can progress from the second to sixth week depending on recovery speed and clinical guidance.
The Evidence for Postpartum Pelvic Floor Training
The Cochrane review by Woodley et al. found that women who undertook supervised pelvic floor muscle training in the postpartum period had significantly lower rates of urinary incontinence at 12 months compared to those who received no training or standard care. The effect was greater when the programme was individually supervised rather than based on leaflets alone, consistent with research showing that a substantial proportion of women perform the exercises incorrectly without feedback. A physiotherapist-led pelvic floor assessment at six to eight weeks postpartum is recommended by several international obstetric bodies and is standard care in countries including France, where women receive 10 sessions of postpartum perineal rehabilitation as a standard maternity entitlement.
Return to Exercise: The Important Caveat
The postpartum period is often a time when women feel pressure to return to their pre-pregnancy body quickly, and to resume pre-pregnancy exercise habits. The evidence strongly cautions against returning to high-impact exercise, running, or heavy resistance training before the pelvic floor has adequately recovered. The POGP Return to Running guidelines recommend a minimum of twelve weeks postpartum before running, provided specific pelvic floor and strength benchmarks are met. Returning to high-impact exercise too soon is one of the most common causes of postpartum pelvic organ prolapse and worsening urinary incontinence.
- Begin gentle pelvic floor contractions within 24 to 48 hours of birth, even if they feel imperceptible at first: re-establishing neural connection is the first goal
- Progress to 10 sustained contractions held for 8 to 10 seconds, three times daily, by four to six weeks postpartum if recovery allows
- Do not return to running, jumping, or heavy lifting before twelve weeks postpartum and not before completing a pelvic floor readiness assessment
- Request a referral to a pelvic floor physiotherapist at or before your six-week postnatal review: self-discharge from maternity care without pelvic floor assessment is the norm but should not be
- Symptoms to report immediately rather than accept as normal: any urinary or faecal leakage, a feeling of heaviness or bulging in the vagina, or pelvic or lower back pain that does not improve in the first two to three weeks
Sources
- Woodley, S.J., et al. (2020). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews, 5, CD007471.
- Groom, T., et al. (2019). Returning to running postnatal: guidelines for medical, health and fitness professionals managing this population. Physiotherapy, 107, 1-12.