Postnatal Prolapse
Postnatal prolapse
by Emma Green
Pelvic organ prolapse (POP) is a common and often distressing occurrence in the postnatal period, affecting around half of women who have had a baby. It can take a physical and emotional toll on new mums during a vulnerable stage. The information here is designed to help you understand prolapse, and what can be done to manage it. It’s important to seek help if your prolapse symptoms are impacting your ability to exercise or care for your baby (or other children in your family).
What is prolapse?
Prolapse occurs when one or more of the pelvic organs (bladder, uterus, bowel) descends into the vagina.
It may feel like:
A vaginal bulge
Lump
Heaviness
Dragging
‘Something coming down’
‘Something coming out’ of the vagina
Some women may be able to feel or see (with a mirror) the bulge
Sometimes, prolapse is accompanied by bladder or bowel symptoms such as:
Urinary or faecal incontinence (bladder or bowel leakage)
Difficulty emptying your bladder or bowel
Feelings of incompletely emptying your bladder or bowel
Recurrent urinary tract infections
What are the types of prolapse?
Anterior Wall Prolapse
o The bladder or urethra move downwards into the front wall of the vagina
o This is the most common type of prolapse
o Previously referred to as cystocele or urethrocele
Posterior Wall Prolapse
o The rectum moves towards the back wall of the vagina
o Previously referred to as rectocele
Apical Prolapse
o The uterus and cervix descend into the vagina
Prolapses are graded by severity from 0 (no prolapse, and very rare even in women who haven’t had babies) to 4 (most severe).
Why does it happen (what are the risk factors?)
Vaginal birth is the leading cause of prolapse, due to changes to the pelvic floor muscles or the ligaments/fascia that support the pelvic organs. Some other risk factors include:
The use of forceps
The use of ventouse (vacuum)
Active pushing (second stage) >150 minutes
3rd or 4th degree tear
While each subsequent pregnancy and vaginal birth increases risk of prolapse, it is the first vaginal birth that carries the greatest risk. Though less common, prolapse can still occur in women who have only had caesareans (c-section delivery), or who have never even been pregnant.
There is also a genetic component to prolapse – if your mother/sisters/grandmother/aunts/cousins (especially on your mother’s side) have had prolapse, then you may be more likely to experience prolapse.
How do I know if I have a prolapse? How is it assessed?
The best way to assess a prolapse is by an internal vaginal examination. Your physiotherapist can take some measurements to assess the type of prolapse and its severity, which will help guide treatment options. They can also assess your pelvic floor muscle function, as optimising pelvic floor muscle function is one component of managing prolapse.
In addition to looking directly at the pelvic area, your physiotherapist may also consider the way you breathe and move, and the strength/mobility of the muscles around your back, abdominal wall and pelvis.
1 in 2 women who have had a vaginal birth will experience some degree of prolapse
How can I manage a postnatal prolapse?
Pelvic floor muscle training is one component of conservative prolapse management. Research suggests that individualised pelvic floor muscle training program can reduce prolapse symptoms and improve quality of life. However, weak pelvic floor muscles are not the sole cause of prolapse, so strengthening them is not the only answer. It is important to have an individualised assessment, so you know you are doing the best exercises for you. Sometimes when a woman has a prolapse, her pelvic floor muscles will tip into ‘protect protect protect’ mode and they actually need to learn how to relax too.
Avoiding constipation is another key component. Straining on the toilet can put a lot of pressure through the pelvic organs and worsen prolapse symptoms. Your physiotherapist will ask questions about your bowel function in your initial assessment, and may suggest modifications to your diet, fluid intake or defaecation technique to reduce straining. https://www.thepelvicstudio.com/blog/defecationtechnique
Horizontal rest reduces the effects of gravity on the pelvic area and reduces the stretch on the fascia supporting the pelvic organs. Even 10-15 minutes resting on your back or side (not just reclined) a couple of times per day will help. If you are breastfeeding, you may find learning to breastfeed in side lying helps you get more horizontal rest. https://www.thepelvicstudio.com/blog/breastfeedinginsidelying
Consider a vaginal pessary. Your physiotherapist may suggest trialling a vaginal pessary, which is a medical-grade silicone device inserted into the vagina to give support to the pelvic organs while your postpartum body is recovering.
Talk to your doctor about whether vaginal oestrogen might help. During the postnatal period, women have low levels of oestrogen. Oestrogen plays an important role in the strength and elasticity of the pelvic floor muscles and connective tissues, so using vaginal oestrogen can improve the integrity of these structures and improve prolapse symptoms.
Strengthen the muscles around the pelvis. Having strong muscles on the outside of the pelvis can reduce the load on the pelvic floor muscles. Your physiotherapist may prescribe specific exercises to do at home, or suggest you join our small 4:1 exercise rehab classes (side note: these classes are also a great way to connect with other mums, some of who may also be experiencing prolapse).
Minimise heavy lifting/pushing/pulling. We get that it’s impossible to care for a baby (+/- other kids) without some amount of lifting/pushing/pulling. But as much as practical, especially in the early months, try to take the load off. This might look like:
Dividing heavy loads
eg do two (or more) trips to/from the car, rather than bringing in all the groceries and baby gear at once. Take a few wet towels from the washing machine to the washing line at a time.
Changing baby’s nappy on a change table, so you don’t have to pick them on and off the floor
Getting groceries delivered, or doing click & collect
Consider hiring a cleaner, dog-walker etc if it’s within your means.
Sitting on a fitball and gently bouncing to settle bub, rather than standing and rocking
Ask for help. It can be difficult to reach out for assistance, particularly if sharing how having a prolapse is impacting you feels hard, or if you feel like you are beyond the initial newborn period where offers of help are common. But it’s worth asking, and being direct and specific with your requests eg ‘could you help me lift the pram into the car? I’m trying to avoid doing it on my own at the moment’
Acknowledge the emotional toll of prolapse, particularly in the postnatal period when your body and life are going through so much change. Many women with postnatal prolapse grieve the loss of the postnatal period they anticipated – it’s ok to feel sad if prolapse symptoms mean motherhood isn’t what you expected or hoped for. Consider seeing a psychologist or counsellor alongside your pelvic floor physio.
Know you’re not alone, 1 in 2 women who have had a vaginal birth will experience some degree of prolapse. Sharing your story with other mums (including your own!) can be a great way to normalise prolapse both for yourself and those who may experience prolapse in future.
FAQ:
When will it get better?
Many women who notice a bulge or heaviness in the early days after having a baby find that it gets better over the first 3-4 months as their body recovers. For other women, it may take a year or more to get to a point where prolapse is not always at the front of their mind. Lots of women find that their symptoms improve once their period returns, although it is common to notice fluctuations in symptoms with your menstrual cycle https://www.thepelvicstudio.com/blog/prolapseandyourperiod
There are many women, who, with the help of physiotherapy management strategies, like pessaries, PFMT and exercise rehabilitation, are ultimately symptom free, or find their prolapse resolves. You may have to be more mindful of your pelvic floor (in terms of managing load, avoiding constipation etc) than you were before having kids, and life events such as future pregnancies and menopause may also require careful management. Surgery is an option for women who have a prolapse. Traditionally, the figure for lifetime surgical risk quoted has been 20%, although surgical rates decreased by nearly 40% in the 15 years to 2021 (Mollah & Brennan, 2023). This is likely due to earlier intervention, and better non-surgical options (such as pessaries).
What exercise can/should I do?
We believe that with the right support, women with prolapse can be empowered to work towards doing nearly any form of exercise. We acknowledge the multiple physical and mental benefits of physical activity, especially in the postnatal period, and we are here to help make that happen. Most women with prolapse benefit from doing an individualised pelvic floor muscle training program. It is important to do this under the supervision of a physiotherapist, who can advise on specific aspects of PFMT, such position, repetitions, coordination with breathing etc. Strengthening the muscles above, below and surrounding the pelvis is also important, to support the work of the pelvic floor muscles. Your physiotherapist can advise on these exercises, and may suggest you join one of our small postnatal exercise rehab groups for weekly sessions. Generally speaking, most low-impact exercise (such as swimming, walking, cycling, pilates, yoga) is considered prolapse-friendly, but it is important to listen to your body and modify accordingly. For example, you might find that walking for 30 minutes on the flat is achievable, but walking for 30 minutes pushing a heavily loaded pram up/down a hill leads to prolapse symptoms the next day. You might find yoga helps you relax and be mindful, but need to avoid wide-legged positions.
What should I avoid? Can I run/lift weights?
Certainly in the first 12 weeks after giving birth, we recommend avoiding high impact exercise such as running. As with rehab after any sort of injury, it is all about taking steps and increasing load gradually under the care of an experienced physiotherapist. Your whole body (not just your pelvic floor) has undergone changes during pregnancy that will take time to recover. After the 12 week mark, your physiotherapist can do a ‘return to high impact exercise’ assessment, which looks at your pelvic floor function, as well as your ability to manage load and impact. This assessment can highlight areas of weakness or asymmetry, and your physiotherapist can advise on specific exercises to help you become ready for running or high impact exercise. Again, we believe that with the right support, you can return to the activities you love. There are certainly women with prolapse who still run, jump and play high impact sports – your rehabilitation will be individualised to your goals, with appropriate timeframes and recommendations.
Can I babywear with a prolapse?
Babywearing is a convenient and snuggly way to settle and carry baby, but for some people may exacerbate prolapse symptoms. You may find that it helps to try out different styles of carrier – many women with prolapse find carriers with firm, structured waistbands uncomfortable, and do better with options such as woven wraps, meh dais or onbuhimos which have less structured waistbands. If using a carrier with a structured waist band, try wriggling it lower over the bony parts of your hips, to avoid downward pressure onto your pelvic floor. Carrying baby on your back may place less strain on your pelvic floor compared with front-carrying. This is usually an option from around 6 months, when your baby has developed neck and head control.
Conclusion
Pelvic organ prolapse is a common condition, affecting around of half of women who have had a baby. Physiotherapists can help you manage the prolapse and get back to doing what you love.
If you’d like to learn more about prolapse or postnatal care at The Pelvic Studio, please reach out to one of our friendly team. You can book an initial postnatal assessment via our online bookings page, or by calling 03 6224 7195.