Everything You Need to Know

Congratulations on your new baby! The postnatal period can feel like an ocean of feelings and waves of emotions. There can be joy, exhaustion, uncertainty and everything in between as you adjust to life after birth. 

At around six weeks postpartum, you will usually have a follow-up appointment with your midwife. This is an important opportunity to check how you are healing, talk about how you are feeling and reflect on your labour and birth experience. Your midwife can also help identify whether you need any additional support as you navigate this new chapter, whether this is your first, second, third or fourth child.

But what happens after this visit?

This is where many women tell me they begin to feel a little lost. Perhaps you have been told that everything is healing well and that you can start exercising again. Or maybe you have been advised to work on your pelvic floor strength.

But what does that actually mean for your body?

How should you perform pelvic floor muscle training? How do you know whether your pelvic floor needs strengthening in the first place? What exercise is appropriate to start with? And how do you safely work towards the activities and exercise you enjoyed before pregnancy?

This is where a postpartum pelvic health assessment can help.

In this blog, I’ll take you through what happens when you come to see me for a postpartum visit as an advanced practitioner in pelvic health, what we can assess together, and how you can prepare for your appointment.

Let me talk you through the visit! I really want to emphasize that I want this to be your safe space. 

1. History taking 

We’ll start by having a conversation about you. 

I’ll ask about your pregnancy, labour and birth, how your recovery has been so far, and whether you are experiencing any symptoms such as pain, heaviness, leaking, changes or issues in bladder or bowel function, or difficulties with intimacy now or previously. This will be an important conversation as it provides insight into the pelvic floor and your recovery postpartum. 

We’ll also talk about your general health, previous pregnancies or injuries, your current activity level and if this is having any impact on the pelvic floor, and, importantly, what you would like to get back to. Whether your goal is to feel comfortable on a walk, return to the gym, start running again, or simply feel more confident in your body, this helps me understand what matters to you. It also allows me to provide a more specific plan for you to return to physical activity and exercise.

All of this gives me a clearer picture of your recovery and helps guide the rest of your assessment.

Most importantly, there are no silly or embarrassing questions here!

2. Assessment plan

At this point I will provide a plan for the session which usually includes the following steps.

Step 1: 2D Transperineal Ultrasound

The purpose of this assessment is to visualise HOW you contract and relax your pelvic floor muscles.

Using ultrasound, you will be able to see your pelvic floor working in real time. We can look at how you perform a pelvic floor contraction and, as part of the functional assessment, explore sustained and repeated contractions as well as your ability to fully relax between contractions.

I commonly perform this assessment in both lying and standing, as this allows us to observe how your pelvic floor behaves in different positions.

For many women, actually seeing the pelvic floor move on the screen can make it much easier to understand what a pelvic floor contraction should feel like and whether you are performing it as intended.

Heads up! I’ll be writing a separate blog dedicated to 2D transperineal ultrasound, where I’ll take a closer look at the available evidence, what this assessment can help us evaluate and, equally importantly, what it cannot tell us.

Step 2: Pelvic Floor Examination

The assessment is performed lying on a therapist treatment table rather than in a gynaecological examination chair. You will be provided with a towel to cover yourself, and I will explain each part of the assessment before we begin so that you know what to expect.

The assessment starts with a visual examination of the pelvic floor area. I will look at the skin and any scars that may be present, as well as observe what happens when you contract and relax your pelvic floor muscles, cough and gently bear down.

A more detailed assessment of the pelvic floor muscles can then be performed using one finger inserted into the vagina. This allows me to assess the resting tone of the muscles and how well you can contract and, equally importantly, relax your pelvic floor. I will also assess whether there are any noticeable differences between the left and right sides.

Pelvic floor muscle strength is commonly assessed using a 0–5 scale, but strength is only one part of the picture. We also want to understand how well you can control and coordinate your pelvic floor muscles.

You may therefore be asked to perform some fast contractions. Here I am looking at how effectively you can repeatedly contract and relax the muscles while maintaining good technique and coordination. A heads up, these can be difficult to perform postpartum.

What if my pelvic floor feels weak?

Depending on when you come to see me after giving birth, some pelvic floor muscle weakness may be expected. Recovery takes time, and improvements in muscle function can continue over the following months.

It is also important to remember that postpartum recovery is not only about the muscles. Pregnancy and childbirth also affect the connective tissues that contribute to pelvic support, and these tissues need time to recover and adapt too.

This is why your assessment is always considered in the context of where you are in your postpartum recovery, your symptoms and what you want to return to doing.

Step 3: Rectal Assessment

A rectal assessment can provide additional information about pelvic floor muscle function and strength, as well as the support of the posterior vaginal wall. This can be particularly relevant if you are experiencing difficulties with bowel movements, such as problems emptying your bowels.

As we move through the different parts of your assessment, I will always explain what we are going to do and why before we do it. This gives you the opportunity to ask questions or let me know if you have any concerns.

You are always in control of the assessment. You can ask me to pause or stop at any time, ask questions, or discuss what we are finding together. Nothing has to be performed simply because it is part of the assessment.

My aim is for you to understand not only what I am assessing, but what the findings mean for you and your recovery.

Standing Assessment

Yes, a standing assessment is also part of the visit!

This can be particularly important if you experience symptoms such as heaviness, leakage or a sensation of bulging during everyday activities. After all, many of these symptoms occur when you are upright and moving around, and an assessment performed only while lying down may not always capture what is happening in your daily life.

For example, when attempting to contract your pelvic floor while standing, you may unintentionally strain or bear down. This can result in a downward movement of the pelvic floor rather than the upward movement we would expect during a correctly performed pelvic floor muscle contraction.

Sometimes, a small adjustment to your technique can make a surprisingly big difference!

Bringing It All Together

The entire visit takes almost an hour, and my aim is to meet you where you are in your postpartum recovery and support you from there.

If you arrive feeling uncertain or worried about your pelvic floor, I hope you leave with a clearer picture of your current pelvic health and function. Most importantly, I want you to have a better understanding of your pelvic floor, how it works, what we found during your assessment and what this means for you moving forward.

The goal isn’t simply to tell you whether your pelvic floor is “strong” or “weak”. It is to help you understand your body and give you a clear direction for the next stage of your recovery.

At this point, I will provide you with an initial care plan based on your assessment, your symptoms and your goals. This may include pelvic floor muscle training (if needed), general advice on exercise and physical activity, or more specific guidance if you have a particular activity or sport you would like to return to.

The plan is individual to you, your recovery and where you want to go next.

Follow-Up

A follow-up visit is often recommended and plays an important role in evaluating your progress and adjusting your care plan as needed.

As you gradually increase your exercise and physical activity, you may notice symptoms that were not present during your initial assessment. If this happens, we can explore when and why these symptoms occur and discuss how your exercise may need to be modified. This could include adjusting the frequency, intensity, time or type of exercise (check the previous blog discussing these variables in returning to exercise).

Your follow-up may also include a reassessment of your pelvic floor muscles. This allows us to evaluate changes in areas such as strength, relaxation, coordination and overall pelvic floor function, rather than focusing on strength alone.

Most importantly, the follow-up gives us an opportunity to see how you are progressing towards your individual goals and to decide together what the next step should be.

Finally, 

Think of It Like Assessing Any Other Part of the Body

It may help to think about a pelvic floor assessment in a similar way to how we would assess a knee after an injury or a shoulder that isn’t functioning as it normally would.

We wouldn’t simply look at a knee and say, “It needs to be stronger, start exercising it.” We would first want to understand what is happening. We might assess movement, strength, control, symptoms and how the knee responds to different positions or activities.

The same clinical reasoning can be applied to the pelvic floor.

Rather than assuming that every pelvic floor needs to be stronger, I want to understand how your pelvic floor is functioning. Can you contract it? Can you fully relax it? How is the coordination? Are there differences between sides? What happens when you cough, strain or stand? And, importantly, how does all of this relate to the symptoms you are experiencing and the activities you want to return to?

This is why your postpartum pelvic floor assessment involves several different steps

Thank you for your time,

Mary-Lou Richards leg. naprapat, Advanced Practitioner in Pelvic Health, Bäckenbotten, kvinnors hälsa 

Hela Kvinnans Klinik

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