Post-birth body care. Queen Mary s Hospital outpatient physiotherapy department. Our phone number hrs

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1 Do you need further help? If you have any of the following concerns then please do contact your women s health physiotherapist for further advice and treatment: If you are having any problems with your bladder and bowel function If you are unsure whether you are exercising your pelvic floor and abdominal muscles correctly If you have resumed sexual intercourse/activity and are experiencing any pain or discomfort If you have any symptoms of pelvic organ prolapse a dragging, heavy sensation felt vaginally usually more evident towards the end of the day or with prolonged standing or lifting. Queen Mary s Hospital outpatient physiotherapy department Post-birth body care Our phone number hrs Jo Fordyce Clinical physiotherapy specialist in women s health physiotherapist Rebecca Bennett Senior women s health physiotherapist September 2014 For those who have given birth vaginally and by caesarean section Living our values Excellent, Kind, Responsible, Respectful

2 Perineal care If you have had a vaginal birth, the perineum (area between your legs) may be feeling rather sore in the first few days. There are a number of things you can do to help the healing process and improve your comfort. Make sure you have adequate pain relief (speak to your GP or midwife), but do be aware of the potential of pain medication to cause constipation (see below for advice) In the early days, a gel ice-pack wrapped in a clean towel or a cold sanitary pad placed in your underwear for 10-15minutes two-hourly may help to relieve pain and swelling Try to avoid prolonged sitting where possible lying on one side may be more comfortable and you can breastfeed in this position too (ask your midwife or health visitor for help with this) You can use a special cushion called a valley cushion to relieve pressure when you are sitting you can hire them from the NCT: Do not use a ring cushion to sit on this may make you more uncomfortable Keep the perineal area clean and dry- change your maternity pads often, always wipe from front to back after using the bladder or bowel, wash the area gently with warm water from the shower head going from front to back after using the toilet and dry the area carefully by patting not rubbing. When opening your bowels, place a clean sanitary towel over the front part of the perineum and apply some gentle upward pressure for support Try and get as much rest as possible when the baby is sleeping, try and rest yourself this will help you heal more quickly and help with your emotional health Start pelvic floor muscle exercises as soon as you have passed urine naturally do not worry if you have stitches - this will improve circulation and promote healing. Bowel function Opening your bowels after having a baby can sometimes be difficult due to any tissue damage that may have occurred during birth and also due to medications you may have taken, especially painkillers. It is very important to avoid constipation so make sure you drink plenty of water (2-3litres) and eat a healthy, fibre-rich diet. You may also need to take medication to improve your bowel function speak to your GP or health visitor about this.

3 Position for opening your bowels Lean forward Keep your back straight Bring your legs apart Rest your forearms on your knees Elevate your feet on a little step (knees higher than your hips Pelvic floor muscle exercises Your pelvic floor muscles (PFM) are a sling of muscles extending between your legs from your tail bone to your pubic bone, at the front of your pelvis. As their name suggests, they form the floor of your pelvis. The urethra (urine tube), vagina (birth canal) and the rectum (back passage) pass through the pelvic floor muscles. The main functions of the PFM are: 1. To support your pelvic/abdominal organs 2. To help maintain continence of bladder and bowel 3. To enhance sexual function Technique for opening your bowels: Don t hold your breath when trying to open your bowels. Sit on the toilet as described above, relax your shoulders and breathe normally. You may find it easiest to breathe in through your nose and our through your mouth Use your abdominal (stomach) muscles to push. Make your abdominal muscles bulge outwards to make your waist wide. Now use these abdominal muscles as a pump to push backwards and downwards into your bottom. Keep up the gentle but firm pressure. The final part is to relax the back passage. Many people with constipation actually tighten the back passage when they are trying to open their bowels instead of relaxing. The pelvic floor muscles may become stretched and weakened due to both pregnancy and the birth process. Exercising these muscles can prevent problems such as leakage of urine, as well as helping you to hold on before reaching the toilet to reduce symptoms of pelvic organ prolapse.

4 These exercises can be started as soon as you have had your baby, even if you have had stitches. Gently exercising these muscles can help reduce soreness, tightness and swelling around the perineal area. They can be done in any position that is comfortable for you. If you have a catheter in place, wait until it is removed and you are able to pass urine normally before starting these exercises. Technique for Pelvic Floor Muscle Exercises Sit or lie comfortably and relax the muscles of your thighs, buttocks and abdomen Tighten the muscles around your back passage as if you are trying to stop passing wind At the same time, imagine you are trying to stop the flow of urine in mid-stream You should feel a squeeze and lift Pelvic Floor Muscles are made of fast and slow twitch muscle fibres, therefore they need to be able to activate quickly and strongly, but also have good endurance to support the weight of your pelvic organs throughout the day. To do fast squeezes, quickly tighten and lift the muscles around your back and front passage as firmly as you can, and release immediately. You should feel a sensation of letting go. To do longer holds, slowly tighten and lift the muscles around your back and front passage. Hold for as long as you can (up to 10 seconds), and then let go and rest for 5 seconds. You should feel a definite sensation of letting go. If this doesn t happen, reduce the time you are holding for. How much and how often? Research shows that you need to do PFM exercises at least three times a day to make a difference to the muscles. A good starting point is to repeat 10 short and 10 long (up to 10 seconds) contractions three times a day. But the more you do them, the stronger your muscles will become! You can do these exercises in any position start by doing them lying down and then progress to doing them in sitting, standing and even when you are walking. It is hard to remember to do them so try and use a trigger to remind you while you are waiting for the kettle to boil, while you are feeding the baby are good times to do them. Abdominal (stomach) muscle exercises Your abdominal muscles are very important in supporting your back and abdominal organs. During pregnancy, the abdominal muscles stretch and lengthen to accommodate the growing baby. At some point during pregnancy, the outermost muscle (called the rectus abdominus) separates down the centre to allow the baby to grow. This is a totally normal part of pregnancy, and once the baby is born, the gap between the two parts of the muscle can be felt. By about four weeks post birth, this gap should be around 2cm at the widest point (at your navel).

5 You can feel it if you do a gentle curl up and move your fingers side to side around your navel. With time this gap will close up until you can t feel it anymore. However while this is occurring, it is important not to overwork your abdominal muscles. The exercises below are a good starting point to help these muscles knit back together. Working your deep abdominal muscles: the core muscles The deepest layer of abdominal muscles (the transversus abdominus) go around your body and work like a corset to support your back and abdomen. These muscles work at a low level (around 30%) so they can help support you while you are upright. To activate the transversus (stomach) muscle: Lie on your back or side with your knees bent, relax your stomach muscles Breathe in through your nose and as you breathe out, draw in your lower abdomen, thinking about drawing your navel towards your backbone (spine) Hold this for five seconds whilst continuing to breathe normally, and then relax Repeat this 10 times, making sure your back and pelvis do not move Gradually try and increase the time you hold to 10 seconds do this five times a day Try and activate your pelvic floor muscles at the same time they tend to work together You can then try these exercises on hands and knees, or when sitting, or standing The most important time to activate these muscles is when you are doing physical tasks such as lifting your baby. You can start this exercise as soon as you feel comfortable after having your baby. Progressing your abdominal exercises: The following exercises can be started once you can activate your core and pelvic floor. 1) Pelvic Tilt Draw in your abdomen as in the previous exercise, pull up with your pelvic floor muscles and flatten your lower back into the bed/floor as your pelvis tilts. Hold this position for five seconds, then relax. Repeat four or five times, aiming to build up to 10 times holding for 10 seconds. You can do this exercise when sitting or standing.

6 2) KNEE ROLLING Engage your lower abdomen, gently lower both knees to the left as far as comfortable before bringing them back to the centre. Relax. Draw in your abdomen, and this time repeat the exercise to the right. Do this three to five times each side. 3) Head Lift Lie on your back using a pillow under your head if required. Take a breath in and as you breath out draw in your deep abdominal muscle, pull up with your pelvic floor and gently lift your head and shoulders off the floor, hold for three seconds, lower and relax. Repeat five times, building up to 10 repetitions. Support your neck with your hands if necessary. Try and do these exercises three times a day if possible. Posture, back care and lifting Being a mother is a very physical job! When your baby arrives, the physical stresses of being pregnant are replaced with the physical stresses of looking after a new baby lots of lifting, bending and carrying. As your body is trying to recover from being pregnant, which can take some months, it is very important that you take care of your body, particularly your back, to avoid overstraining. Getting in and out of bed: While your abdominal muscles are regaining their tone, you may find it easier to get in and out of bed using a similar method you may have used whilst pregnant:. To get out of bed: Bend both knees and roll over on to your side moving your shoulders and hips together Bring your legs over the edge of the bed so that your feet are on the floor Push your upper body into sitting by pressing down on to the bed with your upper hand. To get into bed, do the reverse. Feeding the baby: Take some time to find a comfortable position in which to feed your baby you spend a lot of time doing it so it will be worth your while! Ideally use an upright chair that has support for your arms Try to sit right back into the chair you may find a rolled up towel in the curve behind your waist helps keep you upright

7 Make sure you have the baby on a firm pillow (e.g. a feeding pillow) remember, bring baby up to the breast / bottle, not the other way around You may need a support under your feet, either a little stool or upside down washing up bowl Don t forget that you can always breastfeed lying on your side Lifting and bending: Try where possible always to work at waist height so you can keep an upright posture. This applies to changing, dressing and bathing the baby. Never leave your baby unattended on a high surface. You will find that you are lifting your new baby many times each day, so good technique is vital: Bend your knees, not your back Keep the load as close to you as possible at all times Activate your core stabilising and pelvic floor muscles whenever you lift Avoid lifting and twisting move your feet instead In the first few weeks after having your baby, try to avoid heavy lifting (e.g. baskets of washing, heavy shopping bags). This is especially important if you have had a caesarean section lift nothing heavier than the baby for 6 weeks. Returning to general exercise In the first six weeks after birth, the most important exercises are: Pelvic floor muscle exercises (as above) Gentle core stability exercises (as above) Gentle walking, gradually increasing your intensity as you feel able start with 10 minutes and slowly increase the time/distance. Remember, if you are walking with your pram, maintain a tall posture and keep your hips to handles (i.e. don t stick your bottom out when you walk!). If you are walking with the baby in a sling, limit your walk to around 20 minutes to avoid overstraining your back. Swimming can be started once all vaginal bleeding has stopped, and any stitches or scars have healed sufficiently this may be at least six weeks. Specific post-natal exercise classes can be a great way of exercising safely and effectively. Classes such as post-natal pilates or post-natal fitness classes are a great place to start getting back into shape. For a list of local classes, please ask your physiotherapist. We recommend that you don t start any impact exercise, such as running, until at least three months post birth. This is to allow your body to recover from being pregnant, and to allow you time to increase your core stability and pelvic floor muscle strength. Do bear in mind that women recover from pregnancy and birth at different rates so pace yourself and listen to your body. If you are not sure when to return to general exercise discuss it with your GP at your post-natal check.

8 Returning to sexual activity Research suggests that only 50% of couples have returned to sexual activity three months after the birth of their baby, so there is no hurry to resume sexual intercourse after birth! It is important that the experience is a positive one for both partners so take things slowly and gently and be openminded. Here are some practical tips: Make sure you find a comfortable position if it doesn t feel good, change it! Take time to relax and unwind before having penetrative sex Especially for the first few times, using some lubrication (replens/ Sylk) may make resuming sexual intercourse more comfortable Make sure you empty your bladder before and after having sex It may take a few attempts before sex feels normal again don t be afraid to experiment with different positions Rest and relaxation Having a new baby can be very demanding, both physically and psychologically. So it is important to have some time for yourself to relax each day. At least for the first 6 weeks, try to sleep when your baby is sleeping or just lie down even if only for minutes. You will quite naturally want to focus your attention on your baby, but it is important to have some you time resist the urge to do housework, make dinner, check s when the baby is asleep!