Postpartum Pelvic Floor Therapy: What Nobody Tells You at the Six-Week Check

The six-week visit is a safety check. It confirms that the uterus is involuting, that a caesarean or perineal repair is healing, and that there is no infection. It is short, it is usually not an assessment of muscle function, and almost nobody asks how you are urinating, emptying your bowels, or feeling during sex. So women leave assuming that whatever is still happening is simply the cost of having a baby.

It is not. Common is not the same as normal, and "give it time" is not a treatment plan. Most of what I see in the first postpartum year responds well to skilled care, and it responds faster when it is addressed early rather than after five years of avoiding trampolines.

What is worth getting assessed

• Leaking urine with a cough, sneeze, laugh, run or lift — at any volume, at any point after delivery
• Heaviness, dragging or pressure in the vagina, especially by the end of the day
• Pain with intercourse, with a tampon, or at the scar of a tear or episiotomy
• A belly that still domes or bulges along the midline, or a core that does not feel like it switches on
• Constipation, straining, or difficulty controlling gas or stool
• Caesarean scar tightness, numbness, pulling, or a shelf of tissue above the scar
• Low back, hip or tailbone pain that started during pregnancy and never left

The part of postpartum recovery that gets ignored

Research published this year found that the more severe a woman’s postpartum pelvic floor symptoms were, the more depressive symptoms she reported and the lower her self-esteem. That will not surprise anyone who has had to plan their day around a bathroom, or who has stopped wanting to be touched because it hurts. These symptoms are not only physical, and treating them is not vanity or perfectionism. It is a real part of postpartum mental health.

Nobody should have to accept leaking, pain or heaviness as the price of becoming a mother.

What a postpartum assessment actually involves

The first visit is a full hour, one-on-one. We start with the history — your birth, your symptoms, your bladder and bowel patterns, what you want to get back to. Then I look at how you breathe, how you move, and how your abdominal wall and pelvic floor respond to load. I assess posture, hips, ribcage and scar tissue, because the pelvic floor does not work in isolation.

I also use real-time ultrasound imaging to see your deep abdominal muscles and pelvic floor working on screen. It shows objectively whether you are lifting or bearing down, whether the transversus abdominis is engaging, and how wide the gap at your midline is in millimetres rather than fingers. It is a useful teaching tool too — most women understand their contraction in one session when they can watch it.

An internal examination is the most accurate way to assess pelvic floor strength, tone and coordination, and it is always optional. If you do not want one, or are not ready, we work with external assessment and imaging and revisit the question later. Your consent is not a formality here.

Treatment is rarely just Kegels

Plenty of postpartum pelvic floors are not weak — they are tight, guarded and poorly coordinated, particularly after a difficult delivery or a painful scar. Squeezing a tight muscle harder makes symptoms worse. That is why the assessment comes first. Depending on what I find, treatment can include down-training and breathing work, manual therapy for scars and tender tissue, graded pelvic floor and core retraining, pressure management for lifting and carrying, bladder and bowel retraining, and a return-to-running or return-to-lifting plan that is actually progressive.

When should you start?

Gentle breathing, scar care and early pelvic floor work can begin in the first few weeks. Most women come in between six and twelve weeks postpartum. But there is no expiry date on this — I regularly treat women who are two, ten or twenty years out and get excellent results. If you are reading this with a toddler or a teenager, you have not missed your window.

Postpartum care in North Jersey

Our clinic is in Upper Montclair, a few minutes from Montclair, Glen Ridge, Bloomfield, Verona, Cedar Grove and the rest of Essex County. Every appointment is a full hour with me, not shared with other patients, and babies are welcome in the treatment room.