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Postpartum Pain & Incontinence Part 1: Posture


What's a Mama To Do?

I remember when my midwives told me I would have to give up exercising, even brisk walking, for 6-8 weeks after my baby was born. I scoffed at the recommendation; I was a personal trainer with a degree in exercise science and surely this was advice for more sedentary moms. Little did I know, it would be months before I could walk without pain, let alone exercise. Three years, three physical therapists, a chiropractor, and many hours of self study on postpartum physical issues later, I am finally able to say confidently that I am healing, and I am eager to impart what I've learned about postpartum recovery to other moms.

The more I work with families, the more I hear that my experience is not uncommon. I hear from women who have had incontinence issues for years since their baby was born. Others complain of low back pain, hip pain, and even pelvic pain that just won't go away. It begs the questions, why is this happening to so many women and what can we do about it?

I believe that for many women, the main causes of postpartum chronic pain and incontinence are:

  1. Improper postpartum posture and imbalanced musculature from pregnancy, exacerbated by the rigorous physical demands of parenthood. These demands include but are not limited to lifting and carrying an infant, and/or older children; babywearing with a carrier for extended periods of time; breastfeeding in sub-optimal positions; carrying diaper bags, car seats, etc.; leaning over cribs, changing tables, strollers....

  2. Not knowing when postpartum pain or discomfort are within the realm of normal, and thus neglecting to seek help. When these issues go untreated, they can lead to longer term damage and chronic inflammation.

Assuming that your postpartum physical imitations are not due to severe pregnancy or delivery complications, addressing posture and correcting your muscle imbalances can help a lot! By working on postural alignment, learning (or re-learning) proper body mechanics, and strengthening some of the muscles that become overstretched during pregnancy, you can give your body a much needed break from repetitive overuse injury, as well as improve the ability of your pelvic floor to function properly. If your pain or incontinence issues are more severe (prolapse, a broken tailbone, pubic symphysis dislocation, etc.), or you have had these issues for more than a few months, seeking out professional help from someone who specializes in postpartum issues may also be of benefit. 

Postural Alignment: The leg bone's connected to the hip bone...

When we have proper posture, our musculoskeletal systems are able to work efficiently and in harmony; when there is a small deviation in even just one joint, it can compromise the entire system. That's why I employ a multi-point check system for postpartum posture: 

Feet → Hips/pelvis → Ribs → Neck/shoulders 

Most moms tend to have similar posture during pregnancy and postpartum. Carrying a heavy load in front of our bodies-- whether it be a pregnant belly or a child-- causes us to shift our weight back, usually via mid-upper back extension. To compensate for that motion, most people then squeeze the bum and tuck the pelvis under, shifting the hips forward. This posture leads to several problems. 

  1. Mid-upper back extension stretches your rectus abdominis muscle (your "six pack" muscle), which is already overstretched from pregnancy. All women experience some degree of separation in this muscle during pregnancy and the muscle needs to be put in a shortened position in order for the fibers to reconnect; upper back extension makes that process much more difficult.

  2. Posterior pelvic tilt (tucking your bum under) puts your gluteus maximus (largest butt muscle) and pelvic floor in a sub-optimal position, resulting in weakness and even deactivation of those muscles. Not only do you wind up with "mama flat butt syndrome" as I call it (low bum definition), the smaller muscles of the hip and low back have to take over, causing them to become inflamed and overly tight.

  3. Shifting the hips forward causes you to hang into your hip flexors, causing overuse of those muscles and further deactivating your glutes (the hip flexors are glute antagonists).

You can see how this sort of posture could lead to low back pain, hip pain, and/or incontinence issues. Putting the main core and pelvic floor muscles at a disadvantage can really mess you up over time! Below is a picture of one of my clients, Jaime, who very generously agreed to be my posture demonstration. Note that her alignment shown here is her natural postpartum posture and that she has had some issues with hip tightness/discomfort.

jamie_before_small

I worked with Jaime using the multi-point check system, which works as follows: 

  1. Feet hip distance apart and toes pointing forward.

  2. Hips/pelvis un-tucked and even. Unwind your pelvis by pretending there is a string attached to your tailbone. Someone is pulling that string from above and slightly behind you. If you place your thumbs on your iliac crests (the bony pieces on the front of your hips), you will feel them move downward as your tailbone moves back and up. If you like anatomical terms, you would be moving from posterior pelvic rotation toward anterior pelvic rotation. Many people falsely believe this will cause lordosis (low back hyper-extension)-- lordosis is actually more caused by incorrect mid-upper back alignment (see next check point). Finally, check that you are not leaning into one hip or the other. Your weight should be centered over both feet.

  3. Ribs drawn together. All postpartum women have some degree of abdominal separation, called diastasis recti. I'll talk more about that in a video below, but this "check point" is especially important postpartum because it draws the abdominal muscles toward each other, allowing them to heal properly. Most women, even prior to pregnancy, walk around with their upper backs extended and "nips to sky" as I like to call it. When you are pregnant, you are somewhat forced even further into this position to make room for your lungs as your baby pushes them upward. Draw those lower ribs down and together, which will then bring your mid-upper back into neutral alignment and reduce lordosis.

  4. Neck/shoulders relaxed! As parents, we put enough stress on our neck and shoulders with carrying babies and bags, breastfeeding, stress.... Whenever possible, do a good old fashioned shoulder roll. Bring the shoulders up toward your ears, then roll them back and down, drawing your shoulder blades together. Drop your ear to one shoulder, then the other. Make sure you're all loosey-goosey. *Note that this motion does appose the rib motion of down and together in front, so make sure you don't undo that check point.*

  5. This isn't a checkpoint per se, but I want to emphasize that no one should be sucking in her stomach all day. It's something almost all women have learned to do thanks to our society's obsession with being thin, but it really is harmful to your postural health. If you think of your core as a balloon, when you squeeze one part of it, the rest of the pressure has to go somewhere. When you suck in your "mummy tummy," that pressure is going to go into your pelvic floor, rendering it useless, and also into your ribs, making it harder to draw them together and downward. The good news is, as you strengthen your core correctly, your post-baby belly may gradually shrink.

Below you can see Jaime's "before" photo again, with a post-check point photo next to it.

Jaime Before & After

At first glance, they look similar. But if you look closely at her hips and mid-back, as my friend and owner of Fierce Mama Fitness, Alexis, put it, they're in different zip codes! She looks (and reports feeling) much more comfortable after re-aligning her posture.

The one nice thing about the postural checkpoints is that they work no matter what position you are in. Some things to specifically focus on include:

  • When seated or squatting, your pelvis should be slightly more un-tucked (rotated anterior) than when standing, BUT it is imperative that you then draw your rib-cage together and down over your hips or you will be putting a ton of pressure on your low back. It's not the same as leaning forward! It's a rib cage rotation, not a movement from the hips.

  • When lying down, I find it can help to reach your legs out from the hips a couple times (imagine someone is pulling on each ankle) to allow your pelvis to relax into a neutral position without your ribs popping up.

  • When bending over, UN-TUCK that pelvis! Bend the knees a bit and draw those ribs together. This position tends to be hardest for parents to remember, especially if they're desperately trying to ninja away from a baby sleeping in a crib.

  • When baby wearing, especially on your front, the most common thing to lose is the ribs drawn together. Your body tries to go right back pregnancy posture. Don't let it happen! Keep that pelvis un-tucked and those ribs together and rotated down over your hips.

  • When breastfeeding or bottle feeding, relaaaaaax those shoulders and neck please. It helps baby relax too!

Happy recovery! For more on exercises that can help these postural checkpoints "stick" and restrengthen over-stretched postpartum muscles, see Part 2: Exercises. For more on local providers who specialize in postpartum physical issues, see Part 3: Where to Get Help.