Advice and exercise following childbirth

The pelvic floor is a group of muscles that form the base of the pelvis. It is a sling of muscles from the pubic bone at the front of the pelvis, to the tailbone at the base of the spine (diagram 1). 

The pelvic floor helps to: 

• close the front and back passages to help avoid the leaking of urine, faeces or wind 
• support the pelvic organs and abdominal contents 
• enable sexual function.

Your pelvic floor muscles will have been lengthened and stretched by pregnancy and delivery. This process depends on your own natural tissue strength, other medical conditions, pregnancy and delivery. Most postnatal women will have some degree of symptoms related to pelvic floor dysfunction, although most get better with time and exercises.

Pelvic floor exercises help to restore strength, muscle tone and control. Pelvic floor muscle exercises are safe to do if you have had perineal stitches (or a caesarean), and can help to relieve swelling and discomfort and encourage healing. 

If you have had a urinary catheter inserted, wait until this is removed before starting pelvic floor exercises. 

Contracting your pelvic floor

Sit comfortably with your knees slightly apart. Imagine trying to stop yourself passing wind and urine – the feeling is that of a ‘lift and squeeze’. This is a pelvic floor contraction. 

Aim to complete your pelvic floor exercises five to six times a day in the next 12 weeks, and then reducing to three times a day. 

Pelvic floor exercise one

Long hold contractions for strength and endurance: 

• Lift and tighten the muscles around your back passage, vagina and front passage. 
• Hold this contraction as long as you can. 
• Rest for four seconds and repeat the contraction as many times as you can. Build up to a maximum of ten seconds and repeat up to ten times.
• Record how many seconds you contracted for _____ .

Pelvic floor exercise two

Short contractions for coordination and timing: 

• Lift and tighten the pelvic floor, and hold for one second before releasing the muscles. 
• Repeat this, tightening and relaxing steadily as many times as you can up to a maximum of ten times.
• Record how many contractions you managed _____.

Do not stop and start your urine flow when going to the toilet, this is not a recommended form of pelvis floor exercise.

The perineum is the area of skin between the vagina and the anus. Underneath the skin are muscles, connective tissue and nerves that are important in supporting the back passage. 

When your baby is born, his or her head stretches the opening of the vagina, and the skin inside and surrounding the vagina. During this part of the birth, it is common for women to receive a tear in the skin, the inside of the vagina (vaginal wall), or both.

What are the different types of tear?

There are different types of tear, which are classified by the depth of the tear and which parts of the skin and muscle are affected. 

The most common tears are first- and second- degree tears. Less common are third and fourth-degree tears. 

A first-degree tear is a superficial tear to the skin or a graze inside the vagina. 

A second-degree tear is deeper and can affect the vaginal wall, skin and muscle. You are likely to require stitches to help healing and prevent bleeding. 

A third-degree tear involves the muscles of the anal sphincter (rectal muscle). 

A fourth-degree tear involves these muscles and extends into the anus or rectum (back passage).

What is an episiotomy?

An episiotomy is a cut made to the perineum at the time of delivery. An episiotomy may be performed by a doctor or a midwife to help with the birth of your baby, sometimes to prevent a larger tear during delivery. Episiotomies are more common in births with ventouse (vacuum suction) or forceps are required. 

If you need information on third or fourth-degree tears in other languages, please visit the RCOG website: https://www.rcog.org.uk/for-the-public/browse-our-patient-information/care-of-a-third-or-fourth-degree-tear-that-occurred-during-childbirth-also-known-as-obstetric-anal-sphincter-injury-oasi/

Following the birth of your baby, the vaginal and rectal areas will be examined by a midwife or doctor to assess your perineum. If you have had a tear or an episiotomy you may need stitches; this will be discussed with you. If you have had a third or fourth-degree tear you will be taken to theatre for stitching by a doctor. 

Following the repair of a third or fourth-degree tear the doctor may prescribe antibiotics to reduce the risk of infection. Laxatives are also commonly used to ensure easy passage of soft stools whilst the muscles are healing, and to prevent straining of your pelvic floor muscles. 

• Keep the area of stitches clean and dry. 
• Wash your hands regularly: before and after going to the toilet and changing your sanitary pad. 
• Change your sanitary pad at least every four hours. 
• Avoid using soap or perfumed products. 
• Shower as frequently as makes you comfortable. 
• Gently dab dry after washing, front to back, and do not use any heating devices e.g. hairdryer. 

Please let your midwife or general practitioner (GP) know if: 

• Your perineal area becomes hot, swollen, smelly, weepy or very painful. 
• Tears which have been repaired begin to open. 
• You develop a temperature and flu-like symptoms. 

These may be signs of an infection and could need attention from a medical professional.

The perineal area is sensitive and can be painful after delivery. You can use some simple techniques to reduce your discomfort: 

• Sit on soft surfaces, pillows or lie on your side. 
• Sitting on a towel that has been rolled up into an upside down ‘U’ redirects the weight through your sitting bones rather than your perineum. 
• Use an ice pack wrapped in a towel, or a sanitary pad covered in water and cooled in the fridge or freezer, on the tender and swollen part of your perineum for 10 minutes. Ensure a clean, dry layer is between the ice and your skin. You can repeat this process three to four times a day for the first few days. 
• Gentle pelvic floor exercises can promote healing and reduce pain by increasing the blood supply to your perineum. These exercises are described earlier in the leaflet. 

The postnatal ward team can advise you regarding pain relief medication in hospital and on return home.

Following a vaginal or caesarean birth it is important to pace your activities. It is recommended that for the first six weeks you do not lift anything heavier than your baby. During this time you are encouraged to accept all the help that is offered and to avoid any strenuous activity, such as lifting, prolonged standing or vacuuming.

During the time you are less mobile following your caesarean birth you are encouraged to do gentle exercises to prevent problems with your chest and circulation: 

• Breathing exercises: Take three to five deep breaths, expanding your lower ribs as you inhale, every hour. 
• Circulation Exercises: Move your feet forwards/backwards/in circles 10 times every hour. 
• During the first few days if you cough or sneeze, lean forward and support your stitches with your arms crossed over a pillow or small towel to make this more comfortable. 
• Try and sit out in a chair as often as is comfortable throughout the day.

Caesarean scar management

Gently massage an emollient type moisturiser into and around the scar, once the scabs have dropped off, two to three times a day for two to six months. This can be followed up by the use of either a silicone gel or silicone sheet for two to six months. These will help reduce water loss through the scar and excessive scar formation. On-going scar problems may benefit from specialist scar massage therapy.

Due to pain and discomfort it may be initially uncomfortable to pass urine or open your bowels. It is important to give yourself plenty of time, ensure you are comfortably positioned, and to avoid straining. To reduce stinging, you can pour water over your perineum as you urinate. 

If you have not passed urine within six hours of delivery (or catheter removal), have no sensation to pass urine, or feel you are unable to pass a good volume of urine you should inform your Midwife. 

If you are unable to avoid the leakage of urine (on the way to the toilet or on coughing/sneezing/changing position) you may need to see a member of the Women’s Health Physiotherapy team.

To open your bowels, position yourself on the toilet so that your knees are raised higher than your hips using a small footstool or books, then lean forward and take your weight through your arms (see diagram 3). 

This position can help to pass stools more easily. It may also feel easier if you hold a clean sanitary towel or tissue over any stitches when you are trying to pass the stool if you are experiencing any discomfort. Avoid straining on the toilet to minimise the pressure on your pelvic floor muscles. 

Getting in and out of bed

Getting in and out of bed correctly will reduce the strain on your back and abdominals (figure 4): 

• Sit on the edge of the bed. 
• Rest down on to your elbow. 
• Put your head on the pillow. 
• Swing both legs up onto the bed To get out of bed, do the same in reverse. 

Lifting

Avoid heavy lifting for the first six weeks. If you do lift, to make it as safe and comfortable as possible you should: 

1. Stand with your feet shoulder width apart. 
2. Bend your hips and knees, keeping your back straight. 
3. Gently pull in your lower tummy muscles and tighten your pelvic floor prior to lifting. 
4. Hold the load close to your body. 
5. Use the strength in your legs to stand up.

Breastfeeding 

Aim to sit upright in your chair with your feet raised on a pillow or foot stool and your lower back well supported. Try not to stoop whilst feeding; bring your baby up to you rather than lowering yourself to your baby. You can also feed lying on your side or sitting upright in bed, providing your head and neck and baby are well supported. 

Early bed exercises 

Activating your core 

To activate your lower abdominal muscles (transverse abdominals), imagine you are drawing your belly button towards your spine. You can do this during the following abdominal exercises: 

Pelvic tilting 

In lying, sitting or standing: 

• Gently draw in your lower abdominal (tummy) muscles to gently flatten the small of your back. 
• Hold for ten seconds, breathing normally. 
• Relax your muscles gently. 
• Repeat up to ten times. 
• Do this exercise three times per day. Stop if you experience any discomfort 

Knee rolls

• Start lying on your back with your knees bent to 90 degrees, feet flat on your bed. 
• Gently draw in your lower abdominal muscles to gently flatten the small of your back. 
• Keeping your knees together, slowly lower both knees to the right (just as far as comfortable).
• Gently return knees to starting point and relax. 
• Repeat the exercise to the left. Repeat exercise three to five times on each side. 

Following the changes to your body during pregnancy and childbirth, it is important that your return to exercise is graded. When you choose to commence exercise is a matter of personal choice. It is recommended that you start with non-impact activities. 

You can gradually increase your exercise tolerance through a gentle daily walk (building up from five minutes), swimming (once your bleeding has stopped and any wounds have healed) or cycling (as comfortable). 

In this early period is it also recommended that you avoid any abdominal exercises that cause your abdominal muscles to push outwards, point or “dome” (e.g. sit ups or double leg lifts). If your tummy does dome, stop. You may need to contact a Women’s Health Physiotherapist for advice. 

It is recommended to avoid high impact exercise (jumping, jogging or lifting) for approximately three months. This gives you time to strengthen your pelvic floor muscles enough to be able to safely support your bladder so that you do not leak urine when stretching or on impact. 

There may be a local postnatal exercise, yoga or Pilates class near you. These may help with motivation and provide you with a social outlet. 

Sexual activity

Sexual activity may be resumed when you feel ready, the bleeding has stopped and the scar has healed. You may feel the stitches under the skin for up to three or four months. Gentle massage at the vaginal entrance and the area of any repair after a bath or shower make help make you more comfortable. The use of lubricant is recommended for initial return to intercourse, especially if you are breastfeeding. Ensure any lubricants are condom compatible. If you have any problems with sexual intercourse do speak to your doctor or health visitor who may refer you to the postpartum team. 

If you have had a third or fourth-degree tear, a referral will be made for you to be seen by our specialist team in the postpartum pelvic floor clinic approximately eight to ten weeks postnatally. At this appointment, you will see a Senior Women’s Health Physiotherapist and a Senior Midwife. Following this initial assessment, you may see other members of the team such as a Nurse Specialist or Physiotherapist. 

As part of this clinic pathway, a referral will also be made for you to have bowel-related investigations to further assess the repair. These usually involve a scan of your back passage (endo-anal ultrasound scan) when your baby is about 12 weeks old, and pressure tests (anorectal physiology tests) when your baby is about six to nine months old. 

If you would like the opportunity to discuss your birth in more detail, please highlight this to your team. If you go on to become pregnant again, inform your midwife at your booking appointment that you have had a previous third- or fourth-degree tear. This will allow the team to make sure an appointment is arranged for you to discuss your future delivery. 

If you are unable to attend any of your appointments, please reschedule your appointment in advance. 

Urogynaecology Department

Clinic 2 

Lower Ground Floor EGA Wing 

Grafton Way London NW1 2BU 

• Appointment enquiries: 020 3447 9393 
• Nursing clinical enquiries: 07951 674 140 
• Physiotherapy clinical enquiries: 020 3447 6546 (please note this is a voicemail service, please leave a message and someone will call you back) 

Image acknowledgements

This document includes patient information developed by UPMC, which is used by permission. (c) 2016 UPMC. 

Diagram 2: Reproduced from: Royal College of Obstetricians and Gynaecologists. `Care of a third- or fourth degree tear that occurred during childbirth (OASI)’ Patient Information Leaflet. London: RCOG; October 2019, with the permission of the Royal College of Obstetricians and Gynaecologists.” 

Diagram 3: Reproduced and distributed with the kind permission of the co-authors, including Wendy Ness, Colorectal Nurse Specialist. Produced as a service to the medical profession by Norgine Ltd. ©2017 Norgine group of companies.