Why Postpartum Athletes Need Early Rehab

As a physical therapist who creates protocols for in-hospital postpartum care, I know the many physical challenges that birthing people can face as they recover from childbirth. If you’re a serious athlete, these challenges can feel particularly overwhelming as you grapple with a body that may barely be capable of walking to the bathroom.

Take a mom and professional athlete who I treated at a level 1 trauma center that delivered 500 babies a month. I entered her hospital room just one day after her baby was born, after she had requested to see a PT as soon as possible.

 “My OB-GYN was just here before you came,” she told me. I could tell she was upset but she continued. “She told me that I was going to have a really long recovery.”

I typically provided physical therapy to patients within a day or two after c-section on the maternity unit. However, this mom had delivered vaginally and sustained a grade 3c perineal tear. This meant that during her childbirth, she tore through her skin, perineum, and the anal sphincter muscles that were responsible for controlling gas and stool.

“Did your doctor say anything else?” I asked. She looked at me. “No. That’s why I wanted to see you.”

I’m so glad she asked about PT asap after childbirth — it's something too few postpartum individuals realize is an option. The benefits can lead to a quicker, smoother recovery.

Why Postpartum Rehab Should Start Earlier than 6 Weeks

I started my career in orthopedics, cancer, and women’s health. As I built my practice, I spent part of my time in operating rooms and worked with surgeons to develop rehab protocols for patients who benefited from an active recovery. 

Among my caseload, I was seeing athletes with such regularity that caused me to consider how the current standard of care did not suit them.

Athletes were not the patients that could wait 6 or more weeks to be treated. For their mental health and physical function, they needed to start a rehab program much sooner than that. 

Part of my coaching to surgeons, especially OB-GYNS, was that 6 weeks was way too long for anyone to wait for rehab. Given what we knew in orthopedics, I recognized that we needed to develop active solutions in pelvic health, especially for athletes whose identity was tied to their fitness.

I sat across from the mom who was nursing on her side in a fetal position with her hips bent. She later told me that it was the only position she felt like she could be in because she didn’t want to hurt anything. She was afraid to have a bowel movement and she could feel herself leaking urine when she walked. When I visually examined her stitches and pelvic floor muscles, she asked if she was performing the contraction I asked her to do because she could not feel it. She was not.

By this time, her husband was doing skin to skin with their daughter. She said to me, “I feel guilty for saying this,” looking at their newborn, “but all I can think about is how this will affect my activity. I feel like I should be caring more about my baby.”

Postpartum Athletes Need Encouragement & Education

Dr. Sarah Boyles, MD, FACOG, URPS is a urogynecologist, board certified in Female Pelvic Medicine and Reconstructive Surgery who has a passion for working with athletes in her Portland, OR, practice.

“Telling someone it’s going to take a really long time to heal is not as supportive as it could be. With athletes…the stakes are even higher because they really see their body as a tool…they use it in ways that most of us don’t,” Dr. Boyles explained. “The thing that’s interesting about athletes is that they’re thinking about everything: ‘What scar tissue am I going to have? How is it going to affect my muscles? How am I going to be able to work in my sport?’ It’s important to their identity and their mental health.”

I considered my patient, a professional athlete with a grade 3c tear who had to advocate for herself to be seen by a physical therapist in the hospital after birth. Given the nature of her injury and her profession, healing on her own without a specific plan was not an option. As a women’s health therapist, it was common for me to work closely with urogynecologists just as I did with orthopedic surgeons. We held the same values of starting rehab earlier than the standard of care which was commonly 6 weeks or later for many pelvic health patients. 

I asked Dr. Boyles, “How soon should patients be referred to your clinic after a 3^rd or 4^th degree tear?”

“Within a couple of weeks…anyone who has a 3^rd or 4^th degree tear, a long labor, an operative delivery, a big baby, older moms – all of those people should see physical therapy or occupational therapy,” said Dr. Boyles. “When you’ve had that kind of tear, there are a lot of things that can happen under the surface that you’re not seeing. The perineal laceration you can visualize, but there can be microtrauma to the levator muscles. The levator muscles can actually avulse and pull off the pubic bone. You can get fractures to the pubic bone. There’s a lot of edema. All of those things can take a very long time to heal. They can take 6 months. Athletes need to know what trauma they’ve had, what muscles are working, and what muscles aren’t working.”

Regaining the Confidence to Move

My priority with this new mom was active recovery. She had to experience different positions that would not only help her pelvic floor heal faster but would help her regain her confidence.

By the time my visit with her was over, she was able to lie on her back with her arms stretched above her head, place her legs in a butterfly position while lying down, get on all fours on her hospital bed to do a Cat/Cow maneuver, and comfortably lean back with her knees wider than her hips in child’s pose position – all without pain. She couldn’t believe it.

“I didn’t know I could do any of this.” She stood up and stretched her arms.

I responded, “Most people don’t.”

“Physical therapy is often not started early enough - especially after the kind of surgical repair you had.” I curled my fingers into a ball that she could see. “It may feel intuitive to lay on your side with your hips bent,” I slowly stretched out my hand, “but a strong muscle is a flexible one.”

She nodded, “That makes complete sense.”

After I left her room, I called her surgeon. I introduced myself and thanked the OB-GYN for her referral. I briefed her about my visit, the athlete’s background, her goals, and my recommendations for her rehab plan. She expressed her surprise at my request for her to place an order so that her patient could start pelvic health therapy within the next two weeks. We talked about it. Once I explained the stages of tissue healing and the activity that this athlete would return to, she agreed. “That makes sense.”

What I love about working with athletes in both the outpatient clinic and within the hospital, is that once they find something that works, they tell everyone about it.

Incontinence in Postpartum Athletes

Dr. Leticia Jacquet, MSPT, DPT is the founder of Little Antz Physical Therapy in West Hartford, CT. She is a marathon runner and 16-year veteran practitioner of the Afro-Brazilian martial art form, Capoeira. She had an unplanned c-section and shared her experience of a “recovery that felt endless.”

“Exercises I thought I’d be doing were off-limits. Leaking worsened with running and even sneezing. Attempting martial arts movements felt like my legs might give out. I was miserable, uncertain if I was facing postpartum depression or simply the frustration of failing to regain the strength to do what I loved.”

She continued, “One day at an event, a fellow Capoeira practitioner noticed my lack of participation and reached out to ask about my postpartum journey. That was my first introduction to pelvic floor physical therapy. She shared how it helped her and suggested I tried it. I was blown away by what I learned after my first visit and was even more surprised that pelvic floor PT wasn’t offered to me sooner.”

Dr. Jacquet’s experience was like many athletes who search for a solution after dealing with bladder leaking and other issues way too long. Part of the concern that athletes have is whether they must give up their sport.

Dr. Joselyn Rodriguez, owner of The Pelvic Trainer in Davie, FL, believes there are better solutions in pelvic rehab to keep people active. 

“I was treating a 65-year-old woman who confided in me that she was experiencing leaking with her lifting: overhead press, squats, and deadlifts. We started focusing on her breathing patterns, her core and pelvic floor strength, and her coordination. We had to decrease her weight initially, but then she slowly progressed back to her previous weight and surpassed it as her pelvic floor was better able to manage the pressure.”

Likewise, Dr. Leticia Jacquet now specializes in prenatal/postpartum care and pelvic floor dysfunction in women and children. “I continue to play Capoeira and run leak free.”

Physical Therapy fo All Postpartum Individuals

When I moved my women’s health practice from the outpatient clinic to the hospital, I knew I would miss the joy of seeing my patients through to a full recovery and return to their sport. However, I recognized that I was filling a large gap in pelvic healthcare. Patients in the hospital now had earlier access to active recovery solutions, especially after surgical repair of their pelvic floor muscles, birth, or other conditions that affected their bowel, bladder, and sexual function. 

Dr. Sarah Boyles agrees, “In my dream world, everyone we operate on would get physical therapy. There would be some kind of prehab - teaching people to use their bodies correctly so they’re not bearing down and they’re contracting their pelvic floors at the right time.”

“One of the most important things I tell people is that we do surgery so that you can get back to your activity”, she says. “I don’t want to tell people they can’t do things, yet it’s important to do them correctly. Learning how to move correctly works best with a physical therapist.”