The pelvic floor muscles elongate during pregnancy and are stretched with birth. As a result, after birth “the muscles usually tighten up in response,” Mortifoglio says.
It’s a common refrain — or perhaps, more aptly, a warning — spoken to pregnant people: Have a baby and get ready to welcome a life of compromised continence, among other undesirables. The underlying assumption is that childbirth dooms you to a busted pelvic floor and that’s just how it is.
You are not destined to pee yourself for the rest of your life after having a baby.
It all starts with your pelvic floor — and we’ll tell you everything you need to know. (Spoiler: We’re going way beyond Kegels.)
“The pelvic floor is an extremely important piece of our bodies, especially for women,” says maternal pelvic health specialist Ryan Bailey, PT, DPT, WCS, founder of Expecting Pelvic Health in New Hampshire. “Everyone should be acquainted with it, even before getting pregnant.”
Get past any “it’s-connected-to-your-vagina” squeamishness, and you’ll start to see that it reacts, recovers, and deserves attention just like, say, your biceps or knee.
See, the pelvic floor is like any other muscle system in your body (but way cooler because it handles a sh*t ton of superpower work).
However, for most uncomplicated vaginal and cesarean deliveries, the idea that you’ll forever pee yourself when laughing or coughing is a myth — and a harmful one at that. You won’t be peeing constantly, or don’t have to be, with dedicated treatment to your pelvic floor.
Now, there are many physical sacrifices a body will go through to grow and birth a child. And sometimes, because of pregnancy, childbirth-related trauma, or other existing conditions, the effects of childbirth will remain with the birth person well beyond the postpartum phase. Possibly for life.
And it’s massively affected by the weight of pregnancy and the trauma of vaginal birth (or pushing before an unplanned C-section), as it stretches, elongates, and experiences soft tissue damage.
In other words, it’s a BFD. You engage your pelvic floor when you pee, poop, have sex, orgasm, stand up, sit down, exercise — just about everything.
It can move up and down; control the opening and closing of your urethra, vagina, and anus; and it contains a rich network of connective tissue and fascia.
Your bladder, bowels, and uterus rest on it, and the muscles in your pelvic floor crisscross front-to-back and side-to-side from your pubic bone to tailbone.
The pelvic floor is actually a group of muscles that sits like a hammock within your perineal area, connecting to your bladder, urethra, vagina, anus, and rectum.
1. Postpartum incontinence is normal — but only for a limited time
Given the journey your pelvic floor has been on with pregnancy and delivery, it will be weak post-birth.
Because of that, you may have trouble holding in your urine, particularly when you laugh or cough, for up to 6 weeks postpartum, says Erica Azzaretto Michitsch, PT, DPT, WCS, co-founder of Solstice Physiotherapy in New York City.
If you sustained an injury or had a third- or fourth-degree tear, you may experience incontinence for up to 3 months postpartum.
“Do we want it to happen? No,” says Bailey. “But it’s likely.” If there is no tearing or direct injury to the pelvic floor, Bailey mentions “there shouldn’t be any peeing of the pants” by 3 months.
Incontinence after delivery is more common if you experience incontinence during pregnancy, and about half of people experience incontinence while pregnant.
Most people will see the issue resolved within 3 months, but if your urine leaking lasts longer than 3 months, don’t be alarmed. In fact, 31 percent of people who delivered a baby still experienced incontinence 6 months after delivery.
That being said, even people who deliver without any tearing can still have postpartum incontinence, and people who didn’t have issues with leaking pee during pregnancy might have it after delivery.
Risk factors for postpartum urinary incontinence include:
vaginal birth
a large baby
incontinence during pregnancy
smoking
operative vaginal delivery, like the use of forceps
You should discuss any issues you’ve had with urine leakage during your postdelivery care appointment. While it is typical for a bit of time, prolonged incontinence may warrant additional review and treatment.
2. It’s very rare for you to be ‘loose’ after having a baby
The idea that you’re “loose,” isn’t just an offensive, sexist fear. It’s clinically incorrect! “Very rarely is someone ‘loose’ after birth. Your pelvic floor tone is actually higher,” explains Kara Mortifoglio, PT, DPT, WCS, co-founder of Solstice Physiotherapy in New York City.
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The pelvic floor muscles elongate during pregnancy and are stretched with birth. As a result, after birth “the muscles usually tighten up in response,” Mortifoglio says.
Extended pushing, tearing, stitches, or an episiotomy only increase the tension, with additional inflammation and pressure to the area.
3. Perineal pain is common, but that doesn’t mean it’s OK
The perineum is the area of your body between the anus and vagina. This area can experience a lot of changes and a lot of trauma during pregnancy and childbirth.
There are many types of perineal pain a person may experience during pregnancy and postpartum, and it’s not uncommon that a pregnant person will experience pain in this area during these months.
In fact, 77 percent of pregnant people report low back pain, and 74 percent of pregnant people report “pelvic girdle” pain, or pain in the area that connects the pelvis to the legs. (This includes the perineum.)
After delivery, these numbers drop a bit: 52 percent of people experience low back pain after delivery and 41 percent experience pelvic girdle pain after delivery.
Weight gain, changes in posture, and hormone changes can all increase pain during pregnancy, especially in the low back and perineum.
According to Bailey, any pain that lasts longer than 24 hours during pregnancy — even if it only happens with a particular movement — is unacceptable and deserves attention.
But any severe, sudden pain during pregnancy or after delivery deserves medical attention quickly. Weakness, fever, or vomiting signal you need emergency attention.
What’s more, while perineal pain isn’t unusual, you shouldn’t ignore it. It’s safe to say that after you’ve healed and are starting to resume normal(ish) activities anywhere from weeks to several months after baby, you shouldn’t disregard pain and discomfort.
Talk with your OB-GYN or head straight to an accredited pelvic floor therapist specializing in pelvic health. (Indeed, there are PTs who specialize in the pelvic floor, just as other PTs specialize in shoulders, knees, or feet. More on this below!)
4. Kegels are not a one-size-fits-all solution
Now, for the biggest surprise of all: Kegels are not a magic fix. In fact, they can do more damage than good, especially if that’s the only way you are engaging your pelvic floor.
“If you have a little stress incontinence and are told to, ‘Go do Kegels,’ that’s inadequate,” says women’s pelvic health specialist Danielle Butsch, PT, DPT, of Physical Therapy & Sports Medicine Centers in Connecticut. “A lot of people need to down-train, not up-train. You need to loosen up the tissue and do some manual work [to relax it]. You don’t need [patients] Kegeling away.”
She adds, “Even when Kegels are appropriate, we’d never say, ‘Just do Kegels.’ We don’t treat anything else like that.”
For example, if you had a tight quad, would you just keep strengthening it? Of course not.
“Sometimes you need to strengthen, but sometimes you need to stretch. Your pelvic floor is no different, it’s just hard to get at,” she says. “It’s so frustrating. Women are told to do Kegels. And then, if that doesn’t work, they’re given bladder sling surgery. When there’s actually a whole huge area in between those two options, and that’s where [pelvic floor] physical therapy resides.”
5. Sex should not be painful after you’ve recovered
Bottom line: You need to be ready. And what “ready” means is entirely subjective. “People feel so much pressure [to resume sex after having a baby], but everyone’s experience is extremely different and everyone heals differently,” Azzaretto Michitsch says.
Pregnancy-related issues can impact sexual arousal and comfort postpartum. These include:
trauma from childbirth
tearing
episiotomy
pelvic floor dysfunction
operative vaginal delivery, such as the use of forceps
Healing from tears or episiotomy is usually complete in 6 weeks but may take up to 3 to 6 months. During that time, sex and penetration may remain uncomfortable or painful.
But a whole host of other issues can also cause low sexual arousal or pain, and they may have nothing to do with the physical toll of pregnancy and delivery.
Common causes of postpartum sexual issues include:
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hormonal changes of the vagina, especially if you’re breastfeeding
infections
sleep deprivation
adjustments to life with a baby
new or changing stressors
interpersonal relationship issues
postpartum depression
All of these situations can and should be addressed by your OB-GYN and a pelvic floor physical therapist. “The pelvic floor has to relax in order to allow any sort of insertion,” Azzaretto Michitsch says. It’s also involved with orgasm.
“If the pelvic floor muscles are very tight or have high muscle tone, you might have more trouble orgasming. If the muscles are not as strong, insertion wouldn’t be a problem, but climaxing could be,” she adds.
All people should have routine postpartum care no later than 6 weeks after delivery. Some people may need to be seen sooner, especially if you’re experiencing issues that are impacting healing and daily life. The first postpartum appointment should be no later than 12 weeks after delivery.
6. Warning signs can be silent
Pelvic floor damage or weakening of the pelvic floor muscles do not always manifest the same way. Only in extreme cases will you see a hernia or feel a prolapse when wiping.
After about 6 weeks postpartum, book an appointment with your OB-GYN. If you have any of the following symptoms, be sure to bring them up:
a feeling of heaviness in your perineal area
pressure in your perineal area
the feeling of sitting on something when you sit but nothing is there
leaking after peeing
difficulty urinating
sustained constipation
difficulty passing a bowel movement even when it’s soft and not compacted
7. Pelvic floor physical therapy is intimate but shouldn’t be invasive
I know, I know, I know. A pelvic floor PT will want to work on your pelvic floor through your friggin’ vagina and that is all kinds of weird/scary/intense. It’s the biggest hurdle to the pelvic floor being talked about and treated like other muscles in your body.
In case you’re concerned, however, know this: It’s not like a clinical exam. There is no speculum nor flashlights.
“The most invasive we get is one finger’s worth of assessment,” Butsch says. That way, “we can assess both how strong you are and how long you can hold a contraction — your power and endurance — and we also assess how well you are able to relax.”
Manual therapy will involve finger insertion, but a pelvic PT can also work with you on physical exercises, visualization techniques, and body movement and posture based on your needs.
8. You can see a pelvic floor therapist before there’s a problem
If you had shoulder surgery, would you go home afterward, DIY your recovery, and only see the doctor one time 6 weeks after? Of course not. You’d recoup for a week or two and then begin a rigorous course of physical therapy.
“People who run a marathon have more care than women after [childbirth],” Bailey says. “Everyone should seek a pelvic physical therapist [after birth] because of the huge amount of change. It’s amazing how much our body changes over 40 weeks. And in a matter of hours or days after birth, we’re completely different again. Not to mention some of us have had major abdominal surgery [with a cesarean].”
Azzaretto Michitsch agrees: “Go to pelvic floor therapist and ask, ‘How am I doing? How’s my core? My pelvic floor?’ Ask the questions you want to ask, especially if your OB-GYN isn’t answering them. These things can all be addressed. There’s no reason not to seek help if you’re unsure.”
Many women can also benefit from seeing a pelvic floor therapist before giving birth as well.
That said, while pelvic PT should be available to every postpartum patient (like it is in France), it’s not always available due to insurance coverage, so some patients would need to go out of pocket. Talk with your healthcare professional and see what works for you. If you’re looking for someone in your area, start here or here.
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