Whether it’s your first child or you’re a seasoned mother, the days, weeks and months following the birth of a baby can feel like a rollercoaster for many women.
While you may be impatient — or not! — to return to the gym and to your training program to regain a sense of normalcy, it’s important to remember that pregnancy and childbirth are significant events, and that you should give your body adequate time to heal after birth.
Just like proper rest and recovery are needed after running a marathon, tearing your ACL, or breaking your arm, it’s just as essential after pregnancy and delivery.
If you’ve had a vaginal birth, you may have experienced perineal tearing, obstetric anal sphincter injury or levator avulsion. While these conditions are common, they can certainly affect a mother’s ability to return to exercise with confidence after birth. As such, they require adequate management with the help of a qualified professional.
While perineal tears are the most common complication of vaginal childbirths — affecting approximately 85 percent of women  — as a pelvic health physical therapist, I have seen many women who have undiagnosed obstetric anal sphincter injury and undiagnosed levator avulsion.
In some cases these women have tried to resume their pre-pregnancy exercise programs, and experience a loss of confidence due to uncomfortable symptoms associated with their birth injury.
What Is Perineal Tearing?
The perineum is the area between the vagina and the anus. During childbirth, this area stretches and in many cases, the perineum tears. There are four degrees of tearing and the degree is determined by how far back the perineum has torn and how deep into the anus.
- First-degree tear: Injury to perineal skin and/or vaginal tissue, but no muscle.
- Second-degree tear: Injury to perineum involving perineal muscles but not involving the anus.
- Third-degree tear: Injury to perineum involving the anus.
- Fourth-degree tear: Injury to perineum involving the anus and the rectum.
First degree tears usually require little or no stitches and recovery is quick with minimal discomfort. Second degree tears require stitches, can be uncomfortable and take a few weeks to heal.
Third and fourth degree tears are classified as obstetric anal sphincter injury (OASIS) and require surgery to repair the anal sphincter. Women with OASIS have a higher risk of developing bowel control problems, bowel urgency and pain; and recovery can take several months.
If you have had third- or fourth-degree tearing, it is important that you consult a pelvic health physical therapist for assessment if you aren’t already working with one. To know how to find a pelvic health physical therapist, click here.
Perineal Tearing & Return To Exercise
Women with minor perineal tearing may be able to return to exercise soon after delivery, however those with OASIS may not. There is no simple answer for when women can return to exercise after birth injury, and will be based on each unique woman’s experience.
In the early stages, you can work on diaphragmatic breathing and transversus abdominis muscle training, however pelvic floor training needs to be approved by the pelvic health physical therapist first. In some women with OASIS, the pelvic floor muscles can become hypertonic, so additional pelvic floor training may aggravate symptoms.
Initially post-birth, I recommend very gentle pelvic floor contractions to improve blood flow and to decrease pain and swelling. After six weeks, I introduce a pelvic floor strengthening program focused on building the anal sphincter muscles. This involves pelvic floor activations with an anal cue (for example, visualise a tampon in the anus, and tighten the anus around the tampon and pull it up towards the tailbone).
If you experience fecal incontinence or difficulty controlling wind when training, it’s likely to be a sign that the exercise is too difficult for you right now, and should be revisited at a later time when your anal sphincter muscles and pelvic floor muscles are stronger.
Levator Avulsion & Return To Exercise
Levator avulsion is tearing of the pelvic floor muscles and can be unilateral, bilateral, partial thickness or full thickness. When the pelvic floor muscle tears, the structural integrity is compromised and women are more likely to develop pelvic organ prolapse — when the connective tissue supporting the internal organs is insufficient, and the organs descend in the pelvis — along with bladder, bowel or sexual dysfunction .
If you have levator avulsion, you can struggle to return to exercise because of your compromised pelvic floor musculature, and experience an assortment of pain including back pain, pelvic pain and coccyx pain. It is important, however, that you do build up strength in the remaining pelvic floor fibers and the surrounding muscles.
A pessary can be very useful for providing the pelvic organ support you need, so work alongside your pelvic health physical therapist and gynecologist to find the right solution for your particular needs.
A gradual return to exercise with a focus on all the core muscles during training is essential. In the initial stages after birth injury, your remaining pelvic floor muscles are likely to fatigue easily as well.
If you experience pain, loss of bladder or bowel control, or feelings of pressure during training, cease the exercise and work with your coach to find an easier alternative.
Many women with birth injury may experience feelings of hopelessness.
As a fitness professional, you can empower your clients to find alternative forms of exercise that can help them recover physically and emotionally.
Be on the lookout for the following symptoms in your client, and ask them to tell you if they experience any:
- Difficulty controlling wind
- Loss of bladder or bowel control
- Feelings of pelvic pressure
If your client experiences any of these symptoms, stop the exercise they’re performing, as it’s likely to be too difficult for them right now. Find an easier alternative, and revisit the initial exercise at a later time, when your client is stronger.
Utmost care must be taken when progressing clients with OASIS to ensure that they are not bearing down during exercise. Fitness professionals should always work alongside a pelvic health physical therapist when working with a client who has an OASIS.
Note from GGS: To find a pelvic health physical therapist in your area, search one of the following websites.
- Australian Physiotherapy Association
- Canadian Physiotherapy Association
- Chartered Society of Physiotherapy (United Kingdom)
- Physiotherapy New Zealand
- Section on Women’s Health, American Physical Therapy Association
If nothing comes up in your area, a general Internet search using one of the following terms: pelvic health, pelvic floor, women’s health physical therapist, or women’s health physiotherapist and the name of the city will provide some leads. In the U.S. use the term physical therapist. Outside of the U.S., use the term physiotherapist.
- Kettle C & Tohill S. Perineal care. BMJ Clinical Evidence. September 2008; 1401. https://www.ncbi.nlm.nih.gov/pubmed/19445799
- Dietz HP, Moegni F, Shek KL. Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound in Obstetrics & Gynecology. December 2012; 40(6): 693-8. http://onlinelibrary.wiley.com/doi/10.1002/uog.11190/full
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