It’s important for coaches working with pregnant and postpartum women to understand the birthing process and the implications it may have on a client’s body and her return to exercise, as well as the emotional and psychological impact of the experience.

In this article, you will learn about the technical details of the birthing process, vaginal and Caesarean deliveries, including potential interventions and complications. We will also discuss topics like post-delivery bleeding, mental health, and postpartum depression.

With this information, a coach can be prepared to support a client’s postpartum recovery, while also recognizing when it’s necessary to refer her to other health professionals.

Types of Delivery

There are two types of delivery: vaginal and Caesarean section (also called “Caesarean” or “C-section”). A C-section birth can be planned (elective) or unplanned (non-elective, emergency).

A planned, or elective, C-section is planned ahead of time. In an unplanned (emergency) C-section, the plan was to have a vaginal birth, but the delivery ended up requiring a C-section due to an unexpected turn of events. The idea of having a vaginal or C-section delivery can evoke a range of different emotions in women, depending on their personal experiences, beliefs, values, and priorities.

For example, some women hope to have a C-section as they believe they are less likely to experience the pain of childbirth, have pelvic floor dysfunction, or incur vaginal tearing as a result. Other women feel very strongly about having a vaginal delivery, as they believe it’s more natural and beneficial for both the mother and the baby.

Both types of delivery come with a unique set of potential complications, and regardless of the type of birth your client has, you should aim to be non-judgmental, supportive, and compassionate — particularly if the birth did not go as anticipated.

Vaginal Delivery

Birth will be different for every woman, but early signs of labor can include strong and regular contractions, release of the mucus plug (“show”), rupture of the amniotic sac (“water breaking”), lower back pain, menstrual cramp-like pain, and bowel urgency or loose bowels.

Stages of Labor

There are three stages of labor. The first stage of labor is usually the longest stage. In this stage a woman begins experiencing regular and strong contractions that last for more than 30 seconds and are at least five minutes apart. During contractions the uterus is tightening, which causes the cervix to dilate. The first stage is complete when the cervix is completely dilated at 10 centimeters.

The second stage of labor begins when the cervix is fully dilated and ends with the birth of the baby. This is when the baby is moving through the vagina as the woman is “pushing” the baby out with contractions.

The third stage of labor is the delivery of the placenta, which occurs after the baby is born.

Assisted Birth

There are two main types of assisted vaginal deliveries, namely forceps and ventouse (vacuum). These instruments are used during birth to help deliver the baby, and are often required when labor has been long and is not progressing.

Forceps resemble metal salad tongs. They cradle the baby’s head to guide the baby out of the vagina. Ventouse, or vacuum, is a suction device that features a cup with a handle. The cup fits over the baby’s head, a vacuum is created, and the baby is pulled out during a contraction and push.

It is important to note that women who have assisted births have a higher risk of pelvic floor dysfunction including prolapse, incontinence and pain; forceps deliveries also have a higher risk of levator avulsion, a tear of the pelvic floor muscles.

Episiotomy

An episiotomy is a procedure performed during labor where a small cut is made to widen the woman’s vagina to assist with the delivery of her baby. This may be recommended when the baby develops fetal distress, or if an equipment-assisted birth is necessary, or if a C-section is not appropriate (e.g., if the baby’s head is already moving down the birth canal). A small, diagonal cut is made from the back of the vagina and directed down and out to one side. After delivery, the cut is stitched together using dissolvable stitches.

Women who have had an episiotomy will typically experience pain around the cut for two to three weeks, particularly when sitting or walking, and may experience stinging pain when urinating.

Perineal Tearing and Obstetric Anal Sphincter Injury

Sometimes during birth, women can sustain tears to their perineum or in some cases, further into their anal sphincter and rectum. There are four degrees of perineal tears:

  1. First-degree tears: Small, skin-deep tears which heal naturally or may require some stitches.
  2. Second-degree tears: Deeper tears affecting the muscles of the perineum. These are usually repaired with stitches immediately after birth.
  3. Third-degree tears: Deeper tears that involve the anal sphincter muscles.
  4. Fourth-degree tears: Tears extending further up the anus into the rectum, with complete tearing of the anal sphincter.

Third- and fourth-degree tears are classified as obstetric anal sphincter injuries (OASIS) and require surgery after birth to repair the torn muscles. If you are working with a woman who has had third- or fourth-degree tearing, it is important to refer her to a pelvic health physiotherapist for assessment if she isn’t already working with one.

Often, the anal sphincter muscles need specific assessment and strengthening. Your client may complain of fecal incontinence, difficulty holding in wind, or bowel urgency. Many women who experience OASIS will have difficulty with normal activities of daily living, including sitting and moving about, and may not be able to return to gym or exercise for at least eight weeks.

Levator Avulsion

Levator avulsion is a tear of the pelvic floor muscles, which can be unilateral, bilateral, partial tearing or complete tearing. The tear occurs at the pubic insertion of one of the pelvic floor muscles, pubococcygeus. Levator avulsion occurs in at least one in five women, and the risk increases with age of first birth and the use of forceps [1,2].

Levator avulsion is rarely diagnosed at birth, and is usually detected by a skilled pelvic health physiotherapist or a skilled urogynecologist, or via imaging such as 3D ultrasound or MRI. Generally a woman will complain of a “loose” vagina, incontinence, prolapse, or painful sex.

If you suspect a client may have a levator avulsion, refer her to a pelvic health physiotherapist for assessment.

Women with levator avulsion do need to continue to exercise, however they will need more expert management to ensure the symptoms do not worsen with certain loaded exercises.

Caesarean-Section Delivery

A Caesarean or C-section is the delivery of a baby through a surgical incision in the abdomen and uterus. It involves the use of an epidural or spinal anesthesia, and in some critical cases, general anesthetic.

Unplanned (Non-Elective, Emergency) vs. Planned (Elective)

An unplanned C-section is a C-section where labor may or may not have begun, and a vaginal birth is planned, but due to a variety of factors during the pregnancy or labor, a C-section is required. An unplanned C-section may also be referred to as an non-elective C-section or an emergency C-section.

While many unplanned C-sections are emergency C-sections, not all unplanned C-sections are emergent. That said, an unplanned C-section, emergent or not, can feel chaotic and frightening for women, as they are generally unprepared for a C-section. They often occur at the end of hours of labor, when exhaustion has set in. Many women may feel disheartened that their birth is ending in an unplanned C-section. Some may feel an immense sense of relief and joy that their baby was delivered safely, but many experience feelings of failure and may feel disappointed, distressed, or traumatized.

A planned or elective C-section is agreed upon in advance and usually occurs prior to labor. These usually occur at 39 weeks and are often done when the baby isn’t presenting head-down, if the woman has had a prior C-section, or for other medical reasons. These are usually calm and slower, and women are often more prepared with all steps explained to them prior to the surgery.

C-Section Procedure

Anesthetic will be administered as an epidural or spinal block (with an epidural, generally an epidural catheter is left in the woman’s back, whereas a spinal block is just one shot of medication). Some women may experience back pain after surgery. The procedure generally takes between 30 and 45 minutes, and the baby is delivered in the first five to 10 minutes. An incision is made in a slight curve along the bikini line, usually at about a length of 14 to 18 centimeters [3].

The surgeon then manually separates the linea alba and abdominal muscles. The bladder is pushed down or moved to one side, and a small cut is made into the peritoneum (the membrane which lines the abdominal cavity). Next, a small horizontal cut is made into the uterus, and the baby is lifted out. To the mother, this typically feels like a strong tugging sensation. After delivery, the incision is closed layer by layer using dissolvable stitches.

C-Section Recovery

Women who have had a C-section will typically stay in the hospital for two to three days in the U.S. and up to five days in other countries. A woman’s Caesarean birth and recovery experience depends on individual factors including:

  • Birth circumstances
  • Previous level of fitness
  • Pain threshold
  • Care taken during recovery
  • Support at home
  • Timeliness of pain medication

The experience of pain varies among women. Some experience severe pain, discomfort, and inability to do anything, while others may only experience mild discomfort with exertion. For some women, pain is stabbing and intermittent; for others it is a dull ache. Generally, sudden movements can cause sharp pains. Women who have had a difficult labor that ends in a C-section may experience pain in many areas. Pain typically decreases over the first five days, and most women no longer need pain relief medication by seven to 10 days after birth.

Women may experience feelings of numbness, puffiness, itchiness, tightness, and sharp twinges at the site of the scar. Some women also report feeling like their insides are falling out of the site of the incision. These feelings gradually dissipate with time.

When working with a client who has had a C-section, encourage her to massage her C-section incision scar on a daily basis starting at six weeks, after her six week check-up. You may refer her to a pelvic health physiotherapist who can assess the scar and teach her self-massage techniques.

It is important that women start moving as early as possible after Caesarean births. Walking improves circulation, which reduces the risk of blood clots and stimulates the digestive system to lessen the chances of constipation. Women are encouraged to begin with ankle pumps and rotations in bed, and to get out of bed on the first day. By the second day, they should be able to walk to the shower and around the room, and by the third day, they should be walking around the ward in preparation for going home.

Post-Birth Bleeding

After birth, regardless of mode of delivery, bleeding and vaginal discharge are normal.

During pregnancy, the volume of blood in a woman’s body rises by 50 percent [2]. When the placenta detaches from the uterus, it leaves open blood vessels, which bleed into the uterus. The uterus contracts to allow for childbirth and delivery of the placenta. The uterus continues to contract, to close these blood vessels, and reduce the bleeding.

Breastfeeding allows the body to produce oxytocin, which also helps the uterus contract. This is why many women feel cramps when breastfeeding. If a woman has a C-section, she may experience more bleeding. If she had an episiotomy or tear, she may also bleed from these areas.

Postpartum hemorrhage, which is excessive blood loss due to the uterus not contracting well after delivery, is not normal. It is common in almost three percent of women [4], and can happen within 24 hours of birth, or even days or weeks later.

Lochia is the excess vaginal discharge women experience after birth. It is made up of blood, bacteria, and tissue from the lining of the uterus. In the first few days after birth, lochia is made up of mostly blood so it should look bright red, like a heavy period. It can come out continuously or intermittently in small amounts.

Each day, the lochia should reduce and become lighter in color. By the fourth day, it should be pinkish and watery, and by day 10 it should have decreased to a small amount of yellow or white discharge. It should stop by day 40 but can stop earlier. Some women experience intermittent spotting for a few more weeks.

Mental Health

After giving birth, up to 80 percent of women experience weepiness and irritability, also known as “baby blues” [5]. After birth, women have significant changes in their hormones, primarily a large drop in estrogen and progesterone, which leads to these baby blues. These feelings often last for a few days, with the worst of it being around the fourth or fifth day after birth. A new mother may feel moody, weepy, tired, or anxious.

Some women experience low moods for a month or more after birth. This is a symptom of postnatal or postpartum depression (PND or PPD), which affects 15 percent of women [6]. Women with postpartum depression may also experience poor sleep, low energy, decreased pleasure, hopelessness, constant negative feelings and thoughts, and inability to cope. If you or your client suspect she is experiencing postpartum depression, advise her to seek help from her general practitioner, as she may require counselling sessions or temporary antidepressant medication.

In cases of traumatic birth, women may develop postpartum post-traumatic stress disorder or P-PTSD, which includes flashbacks and nightmares about the birth, physical reactions like heart palpitations, nausea, faintness when seeing a hospital or hearing about birth. If a client is experiencing postpartum post-traumatic stress disorder, advise her to seek help from her general practitioner and get a referral to a qualified mental health professional.

Summary

It’s important for your postpartum clients to recognize the physical toll their body has undergone during either type of delivery and to adjust physical activity accordingly in the days and weeks after delivery. Psychologically, childbirth is also a time of intense emotion.

Every woman’s birthing experience will be unique. While many have an incredible, exhilarating, and joyful experience, others experience complications that often occur during delivery that could have been predicted in advance. Because of this, your client may have experienced a vastly different delivery than she had hoped for, with physical and psychological implications. Approach this topic with utmost compassion and sensitivity as it’s hard to predict what type of experience your client may have had.

Note from GGS: To find a pelvic health physical therapist in your area, search one of the following websites.

If nothing comes up in your area, a general Internet search using one of the following terms: pelvic health, pelvic floor, women’s health physical therapist, or women’s health physiotherapist and the name of the city will provide some leads. In the U.S. use the term physical therapist. Outside of the U.S., use the term physiotherapist.

References

  1. Dietz HP. Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol. 2007 Mar;29(3):329–34.
  2. Hytten F. Blood volume changes in normal pregnancy. Clin Haematol. 1985 Oct;14(3):601–12.
  3. Ayers JW, Morley GW. Surgical incision for cesarean section. Obstet Gynecol. 1987 Nov;70(5):706–8.
  4. Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 1994-2006. Am J Obstet Gynecol. 2010 Apr;202(4):353.e1–6.
  5. National Institute of Mental Health » Postpartum Depression Facts [Internet]. [cited 2017 Aug 2]. Available from: https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
  6. National Institute of Mental Health » Postpartum Depression Facts [Internet]. [cited 2017 Aug 2]. Available from: https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml

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