Postpartum Care

The most important need for a healthy postpartum woman is education. Women and their partners have expressed their desire to learn competence in caring for their babies. Newborn care is the major education point, especially for first-time mothers. These new moms need reassurance that they can care for their babies. This education must include basic newborn care such as bathing and circumcision care to more complex education such as when to call the doctor. Education should also include safe sleep practices and shaken baby syndrome. There is much information, and it can be overwhelming. Giving resources for the woman to refer to at home may be useful (Mayo Clinic Staff, 2023).

It is also important to teach the mom about self-care. The woman should be taught to rest because sleep is difficult with a new baby. It is also important to teach the woman to walk to prevent VTE. The nurse must teach the patient about the signs and symptoms of complications that can occur in the postpartum period, even though the complications can be scary. The maternal morbidity and mortality rates are too high in the United States, in fact, they continue to exceed those of other high-income countries (Gunja et al., 2024). In the United States, in the year 2022 alone, there were about 22 maternal deaths for every 100,000 births (Gunja et al., 2024). Over 65% of maternal deaths occur within the first year after childbirth (Gunja et al., 2024). The most common causes of maternal mortality include (Gunja et al., 2024):

• Severe bleeding
• Cardiovascular conditions
• Coronary conditions
• Cardiomyopathy
• Venous thromboembolism (VTE)
• Hemorrhage
• Infection
• Mental health conditions
• Preeclampsia and eclampsia
• High blood pressure

ACOG looks at the "fourth trimester," which is the 12 weeks following delivery. During this time, a woman is tasked with recovery, adapting to changing hormones, and learning to feed and care for her newborn (Tully et al., 2017). During this fourth trimester, many women experience common challenges, often including pain, fatigue, depression, difficulties navigating breastfeeding, lack of sexual desire, and incontinence, and may consider this normal and, because of this, choose not to seek care (Tully et al., 2017). Women should not suffer during this time and should receive appropriate care. Because more than 65% of all maternal morbidity occurs after delivery, ACOG believes that women who gave birth should be monitored closely for those first 12 weeks (ACOG, 2018a).

Every woman who has given birth should be educated about signs and symptoms to look for that could indicate a potential complication. The woman should be told to get emergency help for (Mayo Clinic Staff, 2021):

• Chest pain
• Shortness of breath
• Seizures
• Thoughts of harming self or baby

The patient should be instructed to call their provider if they have (Mayo Clinic Staff, 2021):

• Bleeding that soaks through a pad in an hour or blood the size of an egg or larger
• An incision that is not healing
• A temperature of 100.4°F or higher
• A red or swollen leg that is warm and/or painful
• A headache that does not get better after taking medication
• A severe headache with vision changes

Pain is another problem that postpartum women may experience that can interfere with the woman's ability to care for herself and her new baby. Pain can also increase the risk of postpartum depression and should be managed (ACOG, 2021). Women who have had a vaginal birth may experience uterine cramping, which can increase with each delivery and perineal pain, which can be severe with a laceration or episiotomy. These women may also have hemorrhoids. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually effective at treating cramp pain. Ice packs, topical sprays, and creams can help with perineal and hemorrhoidal pain. Women who have had a cesarean section will have abdominal pain. Multimodal pain management, including nonpharmacologic and pharmacologic therapies, is important. There is a variation in the types and level of pain women experience during the beginning of the postpartum period (ACOG, 2021). For postoperative cesarean pain, standard oral and parenteral analgesic medications, including acetaminophen, NSAIDs, and mild opioids, should be used first (ACOG, 2021). Stronger opioids should be reserved for use when the other medications do not relieve pain. It is also important to educate the woman that opioids can pass through breastmilk and sedate the baby. Acetaminophen, ibuprofen, and ketorolac are acceptable pain medications for breastfeeding infants. The length of prescribed opioids should be as short as possible for treating acute pain (ACOG, 2021).

Breastfeeding is an occupation that the Centers for Disease Control and Prevention (CDC) estimates that approximately 84% of mothers engage in after childbirth (CDC, 2024). While lactation support professionals including Certified Lactation Counselors (CLCs) and International Board-Certified Lactation Consultants (IBCLCs) are the ideal professionals to assist postpartum mothers and babies in their initial breastfeeding experiences, many nurses have the training to assist the postpartum mother and child dyad.

Providing breastfeeding guidance and support as a nurse means teaching postpartum mothers comfortable positions, how to assess for a proper latch, how to and how long to breastfeed for in a single session, what tools and supports can be used to improve baby’s position and milk intake, and what cues to watch her new infant for, that might indicate the child is hungry and wants to feed. Because every baby is different, even postpartum mothers who have breastfed a child before could benefit from the hands-on breastfeeding assistance at the bedside.

OTs can support breastfeeding mothers as well during this transitionary period and support the formation of new routines around this occupation. A lack of time, lack of awareness about available supports, and stress can all contribute to breastfeeding mothers not meeting their mothering and personal goals (Sponseller et al., 2021). OTs can support mothers in creating routines and habits that ease their transition to breastfeeding.

A pilot study with 14 mothers, explored if OT services, provided in an individual and group format, could successfully assist breastfeeding mothers at lactation centers to accomplish personal wellness goals while continuing to breastfeed their child (Sponseller et al., 2021). The study indicated that after OT interventions, mothers experienced an increased sense of competence and self-worth, improving their psychological well-being and confidence in addressing their needs and the needs of their infants and families (Sponseller et al., 2021). OTs can also support breastfeeding mothers by addressing their ergonomic concerns, including concerns related to the physical discomfort experienced by some women while breastfeeding (Barbic et al., 2021).

Alana is a 39-year-old woman who just had her first baby at 35 weeks gestation. After 16 hours of labor, Alana had a cesarean section to deliver her twin sons. She is exhausted and tearful because one of her babies is in the Neonatal Intensive Care Unit (NICU) for difficulty breathing.

Alana tells you that she has not had much experience with babies and is worried about how she will care for these babies. Her medical history is negative, except for some mild anxiety that she says comes and goes over time. When you first speak to her about postpartum depression, she expresses that she could not possibly get postpartum depression because she has wanted and tried for a baby for many years and could not be happier.

Is Alana at risk for postpartum depression?

Alana is at risk for postpartum depression. Any woman is, but at her age, with twins, these being her first babies, an unplanned NICU stay, and her having a history of anxiety, all increase her risk of developing postpartum depression.

How can you educate Alana about postpartum depression?

It is important to teach Alana that postpartum depression does not mean she is unhappy with having her babies. It is a postpartum condition caused by changing hormones and sleep deprivation and it can happen to any woman. It does not signify that she is not a good mom. The nurse must give her resources for when she goes home if she develops postpartum depression. It may also be helpful to educate Alana when her partner is also present to hear the information.

As has been discussed earlier in this course, during the “fourth trimester”, a woman must navigate recovery and learn to feed and care for her newborn, all while adapting to their fluctuating hormones (Tully et al., 2017). This is such an exciting but equally stressful, even daunting time in a woman’s life. Just as a lack of quality sleep, inadequate diet, and deficiency of exercise can affect one’s mental health in “normal” conditions, the postpartum period can be especially impactful for these women.

Postpartum depression (PPD) can significantly impact the well-being and mental health of both women and their children. Mothers who experience PPD can have difficulties engaging in meaningful occupations and activities. This occupational disruption can impact their ability to care for themselves and their newborns. Nurses, as well as OTs, can support new mothers in finding resources, helping them adapt to changes, fostering self-care, perseverance, and flexibility during this vital role transition (Barbic et al., 2021).

A scoping article by Barbic et al., (2021) reviewed research on risk factors for PPD and interventions related to the scope of OT. The study found evidence to support the role of OT in assessment and treatment of PPD. OT assessments may be more sensitive to changes in functioning and occupational performance that occur as a result of having a child, a life-changing transition (Barbic et al., 2021). Results of the study showed OTs can provide interventions that address clients’ needs, including considering their cultural and societal environment and home needs. OTs can also support the emotional and cognitive transitions related to child-rearing (Barbic et al., 2021). This can occur through leading group therapy sessions that incorporate mindfulness and psychosocial support for mothers experiencing PPD (Barbic et al., 2021). OTs can also support engagement between mother and child, provide psychoeducation, and partner with mothers and families to understand their lived experiences and provide them with hope and encouragement, thereby improving healthy development and postpartum recovery (Barbic et al., 2021).

As early as 1946, the need for physical therapy (PT) in postpartum care was recognized. A program was initiated at Station Hospital located in Fort George Meade, Maryland, to provide obstetrical patients with beneficial postpartum exercises (Harvey, 1949). There is moderate evidence that postpartum women are at risk for pelvic floor, abdominal, hip, and back impairments following pregnancy and delivery (Simonds et al., 2022). Evidence shows that PT effectively treats these impairments; however, in the United States, physical therapists maintain a primarily peripheral role in providing postpartum care (Critchley, 2022). There is an increasingly supported recommendation to include physical therapy within 6-8 weeks following delivery as a standard of care.

It is estimated that by 2050, 43.8 million women are expected to experience pelvic floor symptomology (Dieter et al., 2015). While most pelvic floor dysfunction (PFD) spontaneously resolves within a few months following delivery, it is reported that 25% of American women suffer from pelvic floor disorders, with 20% requiring surgical intervention during their lifetime (DeLancey et al., 2024).

PFD is a public health issue impacting many women after giving birth. The female pelvic floor is made up of layers of muscles and connective tissues that support and aid the functions of the reproductive system, bladder, and rectum. During pregnancy, the pelvic floor is subjected to compressive and strenuous forces and must open and expand to give birth (Burkhart et al., 2021). The uterus enlarges to accommodate the growing infant, which increases pressure on the pelvic floor. Trauma to the pelvic floor can result in PFD and fecal incontinence (Burkhart et al., 2021). PFD can range from pelvic girdle pain and stress incontinence to prolapse and can pose distressing lifelong consequences, greatly affecting quality of life (DeLancey et al., 2024; Simonds et al., 2022).

One study that included 255 women in the United States aged 18 to 45 who had given birth to at least one child, aimed to explore the influence of PFD on women’s occupations and to examine how severely PFD impacted their lives (Burkhart et al., 2021). The study found that PFD symptoms limited women’s occupational performance and negatively impacted their perception of daily life (Burkhart et al., 2021). This study highlights the need for OTs to support women experiencing PFD. OTs use their skillset to provide musculoskeletal rehabilitation in addition to individualized treatment and education that addresses functional deficit areas (Baker et al., 2017). Specifically, OTs can address postnatal coping strategies, maternal attachment, and musculoskeletal dysfunction of PFD through manual therapy and even electrical stimulation (Podvey, 2018).

OTs can address pelvic floor rehabilitation and address lifestyle modifications (Jundt et al., 2015). The numerous symptoms associated with PFD can impact an individual’s ability to perform occupations related to (AOTA, 2020):

• Self-care
• Managing a home
• Sexual activity
• Work
• Rest and sleep
• Social participation
• Leisure activities

A PT examination for PFD may consist of internal and external evaluations to evaluate muscle tone, strength, coordination, and pain (Critchley, 2022). PT interventions for PFD are designed to strengthen, relax, and facilitate proper pelvic floor coordination (Critchley, 2022).

Image 4:
Exercises to Strengthen the Muscles of the Pelvic Floor

Pelvic floor PT may also include manual PT, biofeedback techniques, and electrical stimulation. The 2019 Cochrane review demonstrated that women who received pelvic floor PT were 5 to 8 times more likely to eliminate urinary incontinence than women who received general education, motivational phone calls, lifestyle advice, or no interventions at all (Critchley, 2022). It is, however, important to see a PT who is trained specifically to treat PFD.

Diastasis recti abdominus (DRA) is a common consequence of pregnancy and childbirth, where the linea alba widens and the rectus muscles separate. DRA is reported to occur in 60% of people, with the separation naturally decreasing within eight weeks post-delivery (Cleveland Clinic, n.d.). Studies have found, however, that 45% of women exhibited DRA at six months postpartum and 33% at 12 months postpartum (Critchley, 2022). DRA often causes a bulging or “pooch” of the lower abdominal region and can lead to negative self-perception and body image, possibly leading to depression (Critchley, 2022).

Image 5:
Diastasis Recti Abdominis

PT approaches may involve bracing, strapping, movement and biomechanical education and specific, safe core strengthening exercises. It is important to consult a PT as many of the core exercises that first come to many women’s minds may actually make DRA worse. This includes many yoga or Pilates-based movements.

Low back pain is a common experience for many women following delivery. However, it is not uncommon for women to also experience pain in their thoracic spine, hips, and pubic symphysis. Pain in the sacroiliac joints, lumbosacral region, pubic symphysis, or any combination of these joints has been termed pelvic girdle pain(Fiani et al., 2021).

It has been estimated that almost half of all pregnant women experience pelvic girdle pain, with 8-10% continuing to have pain for one to two years postpartum (Fiani, et al., 2021). Many of the biomechanical and hormonal changes that occur during pregnancy lead to abdominal and hip weakness, tightness in the lumbar musculature, and joint instability.

PT assessment is important to develop an appropriate treatment plan to address the above impairments. Manual therapy including joint manipulation, stretching, dry needling, and core and hip stabilization exercises have all been proven to be effective in treating back and pelvic girdle pain in postpartum patients, with strong evidence of significantly higher improvements when manual therapy and stabilization exercises are used in conjunction as part of a treatment plan (Simonds et al., 2022).

Education on proper biomechanics following delivery is also a key PT intervention. Despite the weakness, back tightness, and pelvic instability that occurred following delivery, the postpartum woman is now lifting more than previously, carrying heavy baby carriers, bending over cribs, and changing tables more frequently. This can also lead to increased stress on the neck, thoracic spine, and shoulder girdle.

Women are often advised to return to exercise and activity as early as 6 weeks postpartum, despite significant physical and physiological changes that have occurred over the past nine to ten months (Schulz et al., 2023). Schulz et al. investigated 33 studies, with most stating that return to sport postpartum can begin once “medically safe” and around 6 weeks postpartum. Additionally, most recommended engaging in 150 minutes of moderate-vigorous physical activity per week after 6 weeks, but the type of exercise was non-specific (Schulz et al., 2023).

According to Schulz et al., it was reported that many general physicians do not feel they have the education and adequate training in postpartum exercise prescription (Schulz et al., 2023). As a result, many women are left to their own devices and aggressively go to aerobic gym classes, Pilates classes, or engage in running as a means to lose weight.  Just as it is common to use PT in the post-operative or post-injury populations to return to higher-level activities, PTs can help optimize recovery and assist a postpartum woman in safely returning to sport.

PTs can help develop a graduated return-to-exercise plan for the postpartum patient that corresponds to a time- and criterion-based approach, similar to a return-to-running program following injury. A proposed outline for postnatal performance is described by Selman et al. (2022), which recommends beginning light exercises of postural work, initial safe core and pelvic floor exercises, and household walking at 0-2 weeks postpartum. Exercise guidelines and strengthening recommendations gradually increase on a weekly basis based on the ability of the patient, pain, and demonstration of appropriate healing.

According to Selman et al. (2022) it is recommended that endurance walking can gradually increase to 30 minutes between weeks 5-6 but should be kept below a jogging speed. High-impact activities have been shown to increase intraabdominal pressures and ground reaction forces as much as 1.6-2.5x body weight. Consequently, increased speed and eventual mileage are recommended between 12-13+ weeks post-delivery. Each phase of this recommended protocol should preferably be monitored by a PT who can best make determinations on a patient’s readiness to progress to the next phase and confirm that pelvic floor muscles are contracting and relaxing correctly (Selman et al., 2022).

Sarah, a 31-year-old athletic female, recently gave birth and is now eight months postpartum. A dedicated runner with a passion for competitive racing, Sarah is eager to return to her pre-pregnancy fitness level. However, she faces challenges such as urinary incontinence, rectus diastasis, and low back pain, which have emerged postpartum. These issues hinder her training progress and performance goals.

Sarah presents to a PT with complaints of urinary incontinence during high-impact activities, such as running, as well as visible separation of the rectus abdominis muscles (rectus diastasis). Additionally, she experiences low back pain when her running mileage and pace increase. Despite her athleticism and determination, these symptoms significantly impede her ability to resume competitive running.

Upon assessment, Sarah demonstrates a mild to moderate separation of the rectus abdominis muscles, measuring approximately 2.5 cm in width at the umbilicus. Pelvic floor muscle weakness is evident, contributing to her urinary incontinence during running. Sarah also exhibits lumbar spine hypermobility and weakness in the deep core stabilizers, particularly the transverse abdominis and multifidus muscles. Her pelvic alignment shows anterior pelvic tilt, exacerbating the strain on her lumbar spine during running.

Sarah is diagnosed with:

1. Urinary incontinence secondary to pelvic floor muscle weakness.
2. Rectus diastasis with associated abdominal wall weakness.
3. Low back pain due to lumbar spine hypermobility and core muscle weakness.

A multidimensional approach is adopted to address Sarah's concerns and facilitate her return to competitive running:

1. Pelvic Floor Rehabilitation: Sarah undergoes pelvic floor muscle training focusing on strength, endurance, and coordination. This includes exercises such as Kegels, pelvic tilts, and functional movements to enhance pelvic floor control during running.
2. Core Strengthening: Emphasis is placed on activating and strengthening the deep core stabilizers, particularly the transverse abdominis and multifidus muscles. Progression includes exercises like dead bugs, bird dogs, and plank variations to stabilize the lumbar spine and pelvis during dynamic movements.
3. Manual Therapy: Soft tissue mobilization and myofascial release techniques are employed to address muscle tightness and fascial restrictions contributing to Sarah's low back pain and pelvic malalignment.
4. Postural Education: Sarah receives education on proper posture and body mechanics during running to reduce stress on her lumbar spine and optimize running efficiency.
5. Progressive Return to Running: A gradual return-to-run program is developed, focusing on increasing mileage and pace incrementally while monitoring symptoms and pelvic floor function closely.

Over the course of several weeks, Sarah demonstrates significant improvements in her symptoms and functional abilities:

• Urinary incontinence during running decreases, indicating improved pelvic floor muscle function and control.
• Rectus diastasis narrows, and abdominal wall strength improves, enhancing core stability and support.
• Low back pain diminishes as core strength and lumbar spine stability improve, allowing Sarah to tolerate increased running intensity and duration.
• Sarah successfully completes her return-to-run program and resumes competitive racing, achieving her pre-pregnancy fitness level with confidence and without debilitating symptoms.

This case highlights the importance of comprehensive postpartum rehabilitation in addressing pelvic floor dysfunction, abdominal wall separation, and musculoskeletal issues in athletic females aiming to return to competitive sports. Through targeted PT interventions, Sarah not only resolves her urinary incontinence, rectus diastasis, and low back pain but also restores her athletic performance and achieves her running goals.