Pelvic floor recovery after birth

The six-week check is not a clearance certificate

Ask most women what happened to their pelvic floor after birth and you get a version of the same story: somebody mentioned exercises, there was a leaflet, the six-week check came and went, and the leaking either settled or quietly became something to live with.

NICE’s guideline on pelvic floor dysfunction does not work that way at all. It does not mention six weeks. What it gives instead are risk factors, and supervised programmes measured in months — three or four of them — run by a physiotherapist and reviewed at least twice. If nobody has offered you that, this page exists to tell you what to ask for.

What raises the risk, and why it is worth knowing

NICE lists the labour factors plainly: an assisted vaginal birth with forceps or ventouse, a vaginal birth with the baby lying face up, an active second stage lasting more than an hour, and injury to the anal sphincter. Alongside those sit two pregnancy factors that surprise people because they have nothing to do with how the birth went: being over thirty when you had the baby, and having given birth before.

Three of those — assisted birth, face-up birth and anal sphincter injury — trigger a specific recommendation. NICE says to consider a three-month programme of supervised pelvic floor muscle training during postnatal care for women who had any of them. Not a leaflet. A programme, supervised, for three months.

Symptoms change the answer, and the wording

If you are leaking urine when you cough, laugh, sneeze or exercise, the language in the guideline gets stronger. For stress or mixed urinary incontinence, NICE says to offer a supervised programme of at least three months. Offer, not consider. That distinction is worth quoting at an appointment.

Heaviness, dragging or a bulge is a different recommendation again: consider a supervised programme of at least four months for symptomatic prolapse that does not extend more than a centimetre beyond the hymen on straining. Note that the threshold requires an examination. Nobody can tell you which side of it you are on from a description, which is precisely why the answer to prolapse symptoms is a referral rather than a longer exercise plan.

Leaking wind or stool is anal incontinence, and it is the symptom most under-reported and least worth waiting out. RCOG says women with anal incontinence are referred to a specialist team and that treatment exists — physiotherapy or, less often, surgery. Six to eight in ten women with a third or fourth degree tear have no long-lasting complications once it is repaired and healed, but if you are not one of them, that is information, not a verdict.

Supervised means supervised

NICE says these programmes should be run by a physiotherapist or another professional with appropriate expertise, and that supervision includes assessing whether you can actually perform a pelvic floor contraction and a relaxation, then tailoring the programme to what you can do. That second half matters more than most people realise. A pelvic floor can be too tight as well as too weak, and if pain is your main symptom, squeezing harder is capable of making it worse.

The phrase to use with your GP is pelvic health physiotherapy. In the UK your GP can refer you. If you cannot perform a contraction at all, NICE suggests considering biofeedback, electrical stimulation or vaginal cones alongside the training — another reason an unassessed leaflet is not the same intervention.

Doing them in the meantime

Long squeezes held as long as you can but no more than ten seconds, then relax. Short quick squeezes until the muscles tire. Build up to ten repeats of each, at least three times a day. Keep breathing, and do not pull your stomach in. You can do them lying, sitting or standing, and with practice, anywhere. The UK Chief Medical Officers say to start as soon as you can after birth and continue daily; NICE says to keep going throughout life, because long-term training keeps working.

The separated stomach muscles nobody warns you about

It is common for the two muscles running down the middle of your stomach to separate during pregnancy, usually by about two finger widths, because the growing womb pushes them apart. The separation usually returns to normal by the time your baby is eight weeks old. If the gap is still obvious then, the NHS says to contact your GP: you may be at risk of back problems, and a physiotherapist can give you specific exercises. In the meantime, avoid sit-ups, planks and high-impact exercise, and avoid straining on the toilet and heavy lifting.

Three months is when to go back

The pelvic floor is stretched to roughly two and a half times its resting length during a birth, and recovery of the muscle and connective tissue is thought to be maximised somewhere between four and six months. But the number to hold on to is three: women with persistent incontinence at three months postpartum are significantly more likely to still have it at five years. Three months is not the point at which to accept it. It is the point at which to make an appointment.