Physical Wellness
Physical Wellness
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The 4th Trimester
You've researched everything possible to be prepared for your pregnancy and birth, but what about postpartum? The 4th trimester refers to the first 12 weeks following birth. This period is filled with many changes for both you and your baby. This page here is all about physical recovery and self-care for you, Mama.
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Material on this page is adapted from a Herman and Wallace continuing education course: "Self-Care for Postpartum Mothers" ©2013
Ergonomics for New Mothers
Ergonomics for New Mothers
Many activities associated with taking care of your baby, from diaper changing to car seats, is done in a forward leaning position. As a result of this, coupled with overstretched abdominal and pelvic muscles from pregnancy and delivery, your lower back may be feeling painful and tired. Knowing the best way to carry, lift and feed your baby can help keep your body in its best shape.
Lifting your baby
Lifting your baby
Before picking up your baby, gently pull in and squeeze your lower stomach muscles (like zipping up a pair of jeans). Bend at the hips as you lean over, keeping your back straight. Pick up your baby and hold them close to your chest. Exhale as you stand up.
Managing Equipment
Managing Equipment
Babies don't travel lightly—carrying a heavy changing bag on the same shoulder can cause stress and pain to the muscles in your arm, neck, and back. When possible, use a backpack style bag to distribute weight more evenly across you body.
Feeding your baby
Feeding your baby
Taking a moment to arrange your posture before feeding your baby can increase comfort. Place a pillow on your lap to avoid leaning forward before bringing your baby to the breast or bottle. When finished, gently stretch your neck/shoulders by looking to either side and gentle rolling.
© 2013 Herman & Wallace
Breast and Nipple Care
Breast and Nipple Care
Breast Health
Benefits of Breastfeeding
Benefits of Breastfeeding
Breastfeeding may aid with physical recovery for the mother and protect against infant diseases including gastroenteritis, respiratory tract infections, asthma, and sudden infant death syndrome (Sponseller et al., 2021; Pitonyak, 2014).
Breastfeeding is associated with improved mother-infant attachment and decreased effects of postpartum depression (Sponseller et al., 2021).
Nipple Care
Nipple Care
Discomfort and pain with breastfeeding are common within the first few weeks of postpartum. Meeting with a lactation specialist early on can promote positive engagment in breastfeeding for you and your infant. Use of a baby-safe nipple cream and hydrogel pads applied to the nipples directly after feeding can help you to overcome mild pain and discomfort with breastfeeding. Use of nursing bras, breathable clothing, and only water to cleanse the nipples and breasts when bathing can protect the natural oils produced by the breast to naturally moisturize the nipples during this time (Jacobs et al., 2013). Additionally, it is recommended to change nursing pads frequently to prevent bacterial or fungal infections.
Pain with Breastfeeding
Pain with Breastfeeding
Persistent pain associated with breastfeeding is a more pressing matter. In fact, 1 in 5 women report persistent pain at two months postpartum (Berens et al., 2016). Pain that is persistent may be due to a variety of factors including infant oral-motor skills, positioning of yourself and the infant during feeding, or infection/rash surrounding the breast tissue. It is important to closely observe breasts that are reddened or abscessed to prevent further injury to the surrounding tissue. If you continue to experience excruciating pain, cracked, or bleeding nipples due to breastfeeding, schedule an appointment to work with a lactation consultant or breastfeeding specialist as soon as possible.
Lactation Support with Occupational Therapy
Lactation Support with Occupational Therapy
Breastfeeding is a primary co-occupation that occurs between the mother and baby. Pizur-Barnekow and Erickson (2011) define co-occupations as any activity that requires shared physicality, emotionality, and intentionality during meaningful engagement. During breastfeeding, the mother engages in both feeding and self-care to maintain phyiscal health of her breasts. Simultaneously, the infant is engaged in eating and self-regulation. Each of these life skills and activities are defined as occupations in the Occupational Therapy Framework (OTPF; AOTA, 2020),
Occupational therapy has a unique role in working with the breastfeeding dyad (mother and baby) by conducting feeding assessments, modifying positioning, forming new routines to support breastfeeding, providing social support through therapeutic use of self, and educating mothers on strategies to promote latch and nutritional suck (Sanders & Morse, 2005; Pitonyak, 2014).
Practitioners are forging this specialized practice area for occupational therapy by securing continuing education in lactation support. Research has indicated that mothers who participate in holistic breastfeeding support programs led by an occupational therapist experience an improved sense of competence, self-worth, psychological well-being, and greater personal health (Sponseller et al., 2021).
Notable OT practitioners who have developed services, information, and materials to support the role of OT in breastfeeding promotion include Marissa Yahil, MSOT, OTR/L, CBS, IBCLC and Darian Roberts, MS, OTR/L, CLEC, IBCLC, NCS co-founders of 'The Lactation OT'; Jeanne Pichoff, LOTR, IBCLC owner of 'Flourish Pediatric Therapy and Lactation'; and Dr. Carlin Reaume, OTD, OTR/L, MAEd, PMH-C, PCES with 'Supported Mama' which provides holistic transitional services for matrescence.
Lactation-Specific Continuing Education for Therapists (OT, SLP, and PT)
OT, Feeding Therapy, and Lactation Support
A concierge wellness service designed to support you as you transition into motherhood.
Vulvo-Vaginal Health
Vulvo-Vaginal Health
Episiotomy
Episiotomy
An episiotomy is the name given to a cut the doctor may make in the perineum during birth; you may also tear naturally in this area. Some women have little or no discomfort while others may still be quite uncomfortable at their postpartum check-up, due to scar tissue adhesions. Regularly completing scar massage in the perineal area may relieve some of this discomfort.
Episiotomy Massage
Episiotomy Massage
For best results, you should massage your scar regularly at home. Wash your hands well and keep your fingernails short.
Apply lubricant to the vaginal opening and to your thumb
Insert the tip of your thumb (to the first knuckle) in to the vagina
Gently press downward towards your tailbone
Hold for 30-60 seconds with gentle pressure, no pain
Move a little to the left. Again apply gentle downward pressure for 30-60 seconds
Repeat to the right side
Finish with a gentle sweeping movement, from left to right for 30-60 seconds
Lochia
Lochia
Vaginal discharge post-birth is called lochia. It is similar to menstrual blood and may contain small clots at first. Over the following weeks, it should turn brown, fade to yellow/white, then stop around 6 weeks postpartum. Use sanitary napkins and change them regularly—avoid use of tampons in the first weeks after delivery.
When to Call
When to Call
You should call your doctor if you experience the following:
Itching, burning, redness, or swelling in the vaginal region or surrounding a c-section scar.
If you consistently pass large clots (marble to golf ball size).
If your lochia has been brown/white and suddenly turns back to red.
© 2013 Herman & Wallace
Dyspareunia
Dyspareunia
Some women find they are ready to resume intercourse quite soon after childbirth, while others may find it takes much longer. Following an episiotomy, tearing, stitches or with ongoing pelvic pain, your sexual interest can be diminished. It is important to listen to your body and decide what is right for you. Remember that for some women, it can take 6-12 months before feeling comfortable and confident to resume penetrative sexual activity.
A study completed by Tully and colleagues (2017) reported that more than half of the women surveyed following a postpartum visit received insufficient information regarding postpartum sexuality and contraception. Participants stated that an emphasis was placed on selecting and initiating contraception by their provider, rather than an open discussion about their current issues and future goals such as wanting additional children (Tully et al., 2017). This inadequate guidance opens the door for care coordination among healthcare professionals, including occupational therapists. The Occupational Therapy Framework defines sexual activity as an activity of daily living, describing this as engagement in "the broad possibilities for sexual expression and experiences with self or others (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse" (AOTA, 2020). An OT can work collaboratively with the postpartum mother to determine what outcomes regarding sexual activity are desired, then implement effective interventions to address the unmet needs.
Only resume penetrative intercourse when your pelvic floor, abdomen and vagina are pain free. Explore other forms of intimacy that do not involve penetration, such as massage or manual stimulation.
Natural lubrication of the vagina may take a few weeks after giving birth to return. If you are ready to resume intercourse, consider liberally applying a lubricant in and around the vagina to increase comfort during penetration.
Take it slow! It is important to be in control of the depth and rate of penetration during your return to intercourse. Positions that are free of pressure on your breasts and abdomen may be more comfortable, such as you being on top or lying with your back to your partner.
© 2013 Herman & Wallace
Pelvic Floor Recovery
Pelvic Floor Recovery
Your pelvic floor is made up of a group of muscles that support the intestines, rectum, bladder, urethra, uterus, cervix, and vagina. During pregnancy, these muscles are put on stretch and may take awhile to return to normal after delivery. This means that everyday activities such as going from sitting to standing, coughing, or sneezing may be painful due to the muscles responding more slowly. Strengthening these muscles post-birth can help to reduce future incontinence or organ prolapse.
Try it out!
Try it out!
Lay on the bed or floor with knees bent in a comfortable position. Stay relaxed.
Take a deep breath in and as you exhale, let your lower tummy and pelvic floor muscles relax and soften.
Now take another deep breath in—as you exhale, imagine you are closing the openings to you pelvic floor (imagine halting the flow of urine or stopping gas). Keep breathing and lift/squeeze your pelvic floor up and in.
Keep breathing and hold this for a count of 5 seconds.
Let everything relax.
Start with 5-6 repetitions of this exercise 1-2 times per day. You can begin to practice them sitting or standing once you feel comfortable.
© 2013 Herman & Wallace
© 2013 Herman & Wallace
Pelvic Floor Recovery with Occupational Therapy
Pelvic Floor Recovery with Occupational Therapy
One theoretical approach used by occupational therapists called the Biomechanical frame of reference focuses on improving strength, endurance, and pain (McMillan, 2011). This approach can be used to address pelvic floor dysfunction by providing education to mothers about the structure and function of these muscles and to provide training on how to strengthen and rehabilitate these muscles (Groetken, 2020). According to the Occupational Therapy Practice Framework (AOTA, 2020), education is a primary intervention that occupational therapists use to support meaningful occupations. This allows practitioners to work directly with their clients to develop an individualized program which addresses their unique needs and to educate clients on a home exercise program that fits into their daily routines without disrupting their occupations.
Abdominal Care
Abdominal Care
Diastasis Rectus refers to a partial separation of the stomach muscles during pregnancy. It often occurs during the last weeks of pregnancy, and for most women it will resolve by 8 weeks postpartum. However, in some cases, the muscles do not come back together on their own and you may need specialized exercises to re-train this muscle group.
© 2013 Herman & Wallace
© 2013 Herman & Wallace
Checking for Diastasis Rectus
Checking for Diastasis Rectus
Lying on your back, place two fingers on your tummy at the level of your belly button.
Lift your head and neck off the bed, using your fingers to feel for any separation in the abdominal muscles.
If you are unsure, talk with your provider or seek out a certified therapist to clarify a diagnosis.
Exercises
Exercises
Complete the following exercises laying down on a bed or yoga mat.
Side Support
Side Support
Use both hands on either side of your abdomen, a towel, or a scarf to gently pull towards the middle, providing support.
Take an inhale, then as you exhale, use your muscles to draw your lower tummy in to your spine while also lifting your head/neck off the bed.
Breathe in again, then slowly lower your head/neck and relax your muscles.
Repeat 5 times.
If you experience pain or fatigue, consult with a therapist for proper technique and to ensure this exercise is right for you.
Pelvic Tilts
Pelvic Tilts
Place your thumbs on your lower ribs and your fingers on your hips.
Breath in, then exhale & gently draw your lower tummy towards your spine.
Gently tilt your pelvis up towards your ribs while keeping your back on the bed or mat.
Hold for 3 seconds, then relax.
Repeat 5 times.
If you experience pain or fatigue, consult with a therapist for proper technique and to ensure this exercise is right for you.
Knee Drops
Knee Drops
Breath in, then exhale & draw your lower tummy towards your spine.
Slowly lower your right knee out to the side, only as far as is comfortable. Slowly bring it back to the center.
Relax your muscles and repeat to the other side.
Do 3 reps on either side, alternating right and left.
If you experience pain or fatigue, consult with a therapist for proper technique and to ensure this exercise is right for you.
When completing exercises, be sure to breath throughout the duration of each movement. Do not hold your breath.
When completing exercises, be sure to breath throughout the duration of each movement. Do not hold your breath.
© 2013 Herman & Wallace
© 2013 Herman & Wallace
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References
American Occupational Therapy Association. (2020). Occupational therapy practice framework (4th ed.). American Occupational Therapy.
Berens, P., Eglash, A., Malloy, M., & Steube, A.M. ABM Clinical Protocol #26: Persistent Pain with Breastfeeding. (2016). Breastfeeding: A guide for the medical profession, 978-986.
Groetken, Paige. (2020). "Occupational Therapy's Role in Pelvic Floor Rehabilitation". Occupational Therapy Capstone Presentations. 20. https://red.library.usd.edu/ot-capstone/20
Herman, H. & Wallace, K. (2023). Self Care for Postpartum Mothers. Herman and Wallace pelvic rehabilitation institute. https://hermanwallace.com/products?gclid=CjwKCAiAioifBhAXEiwApzCztu3p6i7nvnPkhe7
Jacobs, A., Abou-Dakn, M., Becker, K., Both, D., Gatermann, S., Gresens, R., Jochum, F., Kühnert, M., Rouw, E., Scheele, M., Strauss, A., Strempel, A. K., Vetter, K., & Wöckel, A. (2013). S3-Guidelines for the Treatment of Inflammatory Breast Disease during the Lactation Period. Geburtshilfe und Frauenheilkunde, 73(12), 1202–1208. https://doi.org/10.1055/s-0033-1360115
McMillan, I. (2011). The biomechanical frame of reference in occupational therapy. In E. A. S. Duncan (Ed.), Foundations for practice in occupational therapy (5th ed., pp. 179-194). Elsevier Ltd.
Pitonyak, J. S. (2014). Occupational therapy and breastfeeding promotion: Our role in societal health. American Journal of Occupational Therapy 68, 90-96. https://doi.org/10.5014/ajot.2014.009746.
Sanders, M. J. & Morse, T. (2005). The ergonomics of caring for children: An exploratory study. American Journal of Occupational Therapy, 59, 285– 295.
Sponseller, L., Silverman, F., & Roberts, P. (2021). Exploring the role of occupational therapy with mothers who breastfeed. The American Journal of Occupational Therapy, 75(5). https://doi.org/10.5014/ajot.2021.041269
Tully, K., Stuebe, A., & Verbiest, S. (2017). The fourth trimerster: A critical transition period with unmet maternal health needs. American Journal of Obstetrics & Gynecology, 217(1), 37-41. http://dx.doi.org/10.1016/j.ajog.2017.03.032
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