It all starts with your pelvic floor — and we’ll tell you everything you need to know. (Spoiler: We’re going way beyond Kegels.)
You are not destined to pee yourself for the rest of your life after having a baby.
It’s a common refrain — or perhaps, more aptly, a warning — spoken to pregnant people: Have a baby and get ready to welcome a life of compromised continence, among other undesirables. The underlying assumption being that childbirth dooms you to a busted pelvic floor and that’s just how it is.
Well, good news, that’s a big fat NOPE.
Now, there are many physical sacrifices a body will go through to grow and birth a child. And sometimes, because of pregnancy, childbirth-related trauma, or other existing conditions, the effects of childbirth will remain with the birth person well beyond the postpartum phase. Possibly for life.
However, for most uncomplicated vaginal and cesarean deliveries, the idea that you’ll forever pee yourself when laughing or coughing is a myth — and a harmful one at that. You won’t be peeing constantly, or don’t have to be, with dedicated treatment to your pelvic floor.
See, the pelvic floor is like any other muscle in your body (but way cooler because it handles a sh*t ton of superpower work). Get past the whole “it’s-connected-to-your-vagina” squeamishness, and you’ll start to see that it reacts, recovers, and deserves attention just like, say, a bicep or a knee.
“The pelvic floor is an extremely important piece of our bodies, especially for women,” says maternal pelvic health specialist Ryan Bailey, PT, DPT, WCS, founder of Expecting Pelvic Health in New Hampshire. “Everyone should be acquainted with it, even before getting pregnant.”
With that said…
Your pelvic floor is, in short, incredible. It sits like a hammock within your perineal area, connecting to your bladder, urethra, vagina, anus, and rectum. Your bladder, bowels, and uterus rest on it, and crisscrosses front-to-back and side-to-side from your pubic bone to tailbone.
It can move up and down; control the opening and closing of your urethra, vagina, and anus; and it contains a rich network of connective tissue and fascia.
In other words, it’s a BFD. You engage your pelvic floor when you pee, poop, have sex, orgasm, stand up, sit down, exercise — just about everything. And it’s massively affected by the weight of pregnancy and the trauma of vaginal birth (or pushing before an unplanned C-section), as it stretches, elongates, and experiences soft tissue damage.
1. Postpartum incontinence is normal — but only for a limited time
Given the journey your pelvic floor has been on with pregnancy and delivery, it will be weak post-birth. Because of that, you may have trouble holding in your urine, particularly when you laugh or cough, for up to six weeks postpartum, says Erica Azzaretto Michitsch, PT, DPT, WCS, co-founder of Solstice Physiotherapy in New York City.
If you sustained an injury, or had a second-degree tear or more, you may experience incontinence for up to three months postpartum. “Do we want it to happen? No,” says Bailey. “But it’s likely.” If there is no tearing or direct injury to the pelvic floor, “there shouldn’t be any peeing of the pants” by three months.
2. It’s very rare for you to be ‘loose’ after having a baby
The idea that you’re “loose,” isn’t just an offensive, sexist fear. It’s clinically incorrect! “Very rarely is someone ‘loose’ after birth. Your pelvic floor tone is actually higher,” explains Kara Mortifoglio, PT, DPT, WCS, co-founder of Solstice Physiotherapy in New York City.
The pelvic floor muscles elongate during pregnancy and they are stretched with birth. As a result, “the muscles usually tighten up in response,” after birth Mortifoglio says. Extended pushing, tearing, stitches, and/or an episiotomy only increase the tension, with additional inflammation and pressure to the area.
3. Perineal pain is common, but that doesn’t mean it’s OK
There are many different types of perineal pain a person may experience during pregnancy and postpartum. According to Bailey, any pain that lasts longer than 24 hours during pregnancy — even if it only happens with a particular movement — is unacceptable and deserves attention. Postpartum, the timeline is trickier given the number of variables.
It’s safe to say that after you’ve healed and are starting to resume normal(ish) activities, anywhere from weeks to several months after baby, persistent pain and discomfort should not be disregarded.
Talk with your OB-GYN and/or head straight to an accredited pelvic floor therapist specializing in pelvic health. (Indeed, there are PTs who specialize in the pelvic floor, just as other PTs specialize in shoulders, knees, or feet. More on this below!)
4. Kegels are not a one-size-fits-all solution
Now, for the biggest surprise of all: Kegels are not a magic fix. In fact, they can do more damage than good, especially if that’s the only way you are engaging your pelvic floor.
“If you have a little stress incontinence, and are told to, ‘Go do Kegels,’ that’s inadequate,” says women’s pelvic health specialist Danielle Butsch, PT, DPT, of Physical Therapy & Sports Medicine Centers in Connecticut. “A lot of people need to down-train, not up-train. You need to loosen up the tissue and do some manual work [to relax it]. You don’t need [patients] Kegeling away.”
She adds, “Even when Kegels are appropriate, we’d never say, ‘Just do Kegels.’ We don’t treat anything else like that.”
For example, if you had a tight quad, would you just keep strengthening it? Of course not.
“Sometimes you need to strengthen, but sometimes you need to stretch. Your pelvic floor is no different, it’s just hard to get at,” she says. “It’s so frustrating. Women are told to do Kegels. And then, if that doesn’t work, they’re given bladder sling surgery. When there’s actually a whole huge area in between those two options, and that’s where [pelvic floor] physical therapy resides.”
5. Sex should not be painful after you’ve recovered
Bottom line, you need to be ready. And when “ready” is, is entirely subjective. “People feel so much pressure [to resume sex after having a baby], but everyone’s experience is extremely different and everyone heals differently,” Azzaretto Michitsch says.
Aside from hormone-related dryness (a definite possibility), tearing and/or an episiotomy can impact recovery time and comfort, and scar tissue can cause intense pain with insertion.
All of these situations can and should be addressed by a pelvic floor physical therapist. “The pelvic floor has to relax in order to allow any sort of insertion,” Azzaretto Michitsch says. It’s also involved with orgasm. “If the pelvic floor muscles are very tight or have high muscle tone, you might have more trouble orgasming. If the muscles are not as strong, insertion wouldn’t be a problem, but climaxing could be,” she adds.
6. Warning signs can be silent
Pelvic floor damage or weakening of the pelvic floor muscles do not always manifest the same way. Only in extreme cases will you see a hernia or feel a prolapse when wiping.
After about six weeks postpartum, book an appointment with your OB-GYN if you have any of the following symptoms:
- a feeling of heaviness in your perineal area
- pressure in your perineal area
- the feeling of sitting on something when you sit but nothing is there
- leaking after peeing
- difficulty urinating
- sustained constipation
- difficulty passing a bowel movement even when it’s soft and not compacted
7. Pelvic floor physical therapy is intimate but shouldn’t be invasive
I know, I know, I know. A pelvic floor PT will want to work on your pelvic floor through your friggin’ vagina and that is all kinds of weird/scary/intense. It’s the biggest hurdle to the pelvic floor being talked about and treated like other muscles in your body.
In case you’re concerned, however, know this: It’s not like a clinical exam. There is no speculum nor flashlights.
“The most invasive we get is one finger worth of assessment,” Butsch says. That way, “we can assess both how strong you are and how long you can hold a contraction — your power and endurance — and we also assess how well you are able to relax.”
Manual therapy will involve finger insertion, but a pelvic PT can also work with you on physical exercises, visualization techniques, and body movement/posture based on your needs.
8. You can see a pelvic floor therapist before there’s a problem
If you had shoulder surgery, would you go home afterwards, DIY your recovery, and only see the doctor one time six weeks after? Of course not. You’d recoup for a week or two and then begin a rigorous course of physical therapy.
“People who run a marathon have more care than women after [childbirth],” Bailey says. “Everyone should seek a pelvic physical therapist [after birth] because of the huge amount of change. It’s amazing how much our body changes over 40 weeks. And in a matter of hours or days after birth, we’re completely different again. Not to mention some of us having had major abdominal surgery [with a cesarean].”
Azzaretto Michitsch agrees: “Go to pelvic floor therapist and ask, ‘How am I doing? How’s my core? My pelvic floor?’ Ask the questions you want to ask, especially if your OB-GYN isn’t answering them. These things can all be addressed. There’s no reason not to seek help if you’re unsure.”
That said, while pelvic PT should be available to every postpartum patient (like it is in France), it’s not always available due to insurance coverage, so some patients would need to go out of pocket. Talk to your medical provider and see what works for you.
Real moms share their own experience with their pelvic floor recovery.
“I went into physical therapy for my back issues (thanks, kids) and found out the main cause of all the pain was the pelvic floor. Nothing like doing Kegels while someone has a finger up there. But about four months later I am doing so well and don’t have nearly as much pain as before. Who knew you didn’t have to pee every time you sneezed? I always thought that came with having kids.” — Linnea C.
“My recovery after my son was born in 2016 was really rough. I had trouble walking for several weeks, couldn’t do much physical activity for months, and really didn’t feel back to myself until about a year postpartum. When I got pregnant with my daughter in 2018, I found a new provider who told me she would have referred me to pelvic floor physical therapy and that I probably would have benefited. My daughter was born in February this year and my recovery this time has been so much better.” — Erin H.
“I didn’t know I had pubic symphysis dysfunction with my first until the end, when my specialist saw how much screaming pain I was in trying to roll over during an ultrasound. That explained so much! It was a searing, ripping sensation that only eased a little with pelvic floor physical therapy postpartum. Had I known what was happening, and that it was not normal to be in that kind of pain, I’d have done things differently.
— Keema W.
Mandy Major is a mama, journalist, certified postpartum doula PCD(DONA), and the founder of Motherbaby Network, an online community for postpartum support. Follow her at @motherbabynetwork.com.