understanding medical realities

The midwives are between my legs. My baby is on my chest, her dad beside me. It’s been some time since I delivered the placenta. But since they are still down there, I start to realize something is wrong.

“Did I tear?”

“Yes, a little bit, but we’ll stitch you up.”

After twenty-six hours of unmedicated labor, I get a shot of local anesthetic in my perineum. Yet I still feel the tugging of the stitches, together with the stinging of my nipples from my baby trying to nurse and the sharp uterine contractions as she suckles. It’s a lot of sensation to track at once.

I’m not experiencing the elation and tears I expected I would. I’m relieved and starting to feel worried. It’s taking them a long time to stitch me up, which tells me it’s pretty bad. When I ask how many stitches, they say that they didn’t count. When I ask exactly where, they say, “Everything’s going to be okay.”

I’m not satisfied with this answer. I have mapped every centimeter of my own body through years of dance, yoga, bodywork, and sitting meditation practice. I want to know exactly what is happening. I can’t feel much, so I want them to help me fill in the gaps, but there is so much going on. My parents arrive. “What’s the baby’s name?” they ask.

I feel totally unprepared to answer that question. All I can think is, What happened to my body?

Many women tell me that they had absolutely no idea that what they experienced during birth or are experiencing postpartum was even possible. As a birth educator, one of the biggest questions I face is how much to tell pregnant women about what can potentially happen during and after birth. I don’t want to scare anyone. At the same time, I do want to save women the despair and disillusionment of experiencing symptoms that they have never heard of and had no idea were possible. In most cases, it is not just the pain of the actual dysfunction or injury that troubles women—it is the feelings of confusion and isolation.

While nothing can take away the pain of an injury, the suffering can be minimized when a woman has sufficient information and some context for what happened to her. In this chapter, we’ll go over some medical realities that are common after childbirth. While they are common, they are not normal. The bad news is that there are some possible physical outcomes of childbirth that require special attention and rehabilitation, and may take time to heal. The good news is that while many practitioners, from doctors to physical therapists, may say that it is just something to manage or live with, or to take a “wait and see” approach, there is a lot of healing that you can do to return to healthy function and feel whole again that does not include surgery. While you may feel broken, it is not permanent. Some bodies take longer than others to repair, but your birth outcome is not a life sentence, and you are not alone. It may take more time than feels fair or convenient, but healing is possible.

ANTICIPATE THE SIX-WEEK CHECKUP

After giving birth, most women will see their doctor or midwife once or twice in the following days. Then, several weeks will pass with no professional support at all. During this time, as women are getting to know their babies, they are also experiencing the profound aftereffects of their birth experience. The medical realities of this period can come as a surprise to many women. To make matters worse, women generally don’t talk to each other about these realities.

Typically, the six-week postpartum doctor’s visit will only clear women for returning to exercise or having sex. What they leave out is most everything else. Hemorrhoids, structural pain, incontinence, pain at stitching, prolapse, and emotional distress are a few of the symptoms included in the range of “normal.” Often women who are given the go-ahead to exercise and make love don’t feel remotely ready for either. Many women are offered the birth control pill or antidepressants at their postpartum checkups; some of my clients have been offered both at the same time. While some women may want or need one or both of these medications, using hormonal treatment for every kind of symptom, including physical injuries, is a mistake. This practice reflects the brokenness of the medical model that isn’t equipped to look at the whole picture, but instead divides our experience into pieces and parts. Most obstetricians are not trained to evaluate the structural or biomechanical health and integrity of the pelvic floor—but physical therapists are. Unfortunately right now, referrals to physical therapists are the exception rather than the rule, so each woman needs to advocate for herself to receive this important piece of health care.

I have heard from many women that their postpartum checkups took less than ten minutes. To remedy possible confusion and get a thorough evaluation, I recommend that women go to a postpartum physical-therapy, holistic pelvic care, or STREAM session in addition to their six-week checkup with a doctor or midwife. Don’t be afraid to ask your doctor for a referral even if everything seems okay. That way, you can ask all the questions you may have and get a clear picture of how the healing process is going from someone whose expertise is pelvic health. It is the therapist’s job to take you through a thorough assessment, answer your questions, and ask you any questions that may have been overlooked.

Unfortunately, with the way our health-care system is set up, many birth doctors don’t have much follow-up with their patients. When they make interventions during labor and birth, whether it’s anesthetic, forceps, or vacuum delivery, episiotomies or doing repairs, they don’t have long-term follow-up with women to see how their lives have been affected. I attended a birth as a doula where the doctor pulled the baby out with forceps. In order to use forceps, there is almost always an episiotomy, or vaginal incision, to make more room for the instruments. In this particular birth, the incision extended into a tear through the whole pelvic floor. The doctor looked over at me, shrugged, and matter-of-factly said, “The rectal sphincter popped, but we just sew it back up.” I knew that this doctor would probably not see this woman again, so he most likely would not know what the future ramifications of this intervention would be for her.

Statistically, 75 percent of women will experience some kind of pelvic-floor dysfunction after a childbirth that includes a mechanical intervention, such as forceps or vacuum extraction. I know from working with women in my office and from personal experience that it can take years to recover from the aftereffects of these kinds of injuries. The problem is that they are not categorized as injuries. If they were, women would be referred to physical therapy routinely after birth.

In many cases, the six-week checkup is supposed to be the beginning of a recovery phase after birth, but more often, it signals the end of midwifery or doctor care. I see women week in and week out in my practice suffering from pelvic-floor dysfunction who feel abandoned by their birth practitioners. They are too embarrassed to ask their primary-care physicians about fecal incontinence or painful sex, and often their problems remain unaddressed. If they do share that something doesn’t feel right, often the doctor or midwife simply says everything is fine and will get better over time. To arm and empower you, some of these issues are outlined and defined in what follows, so you will have a better idea of what to look out for and talk about with your health-care professionals.

THE FOUR DOMAINS OF PELVIC HEALTH

We arrive at the birth altar with the same body that has carried us to this point. Every moment we have lived—though our minds may have forgotten, may not have been present, or may have been anesthetized—our bodies were there. Your body never left you and is a trustworthy living record of all you have experienced. Therefore, the body has all of the organic intelligence and the keys to your healing. After a lifetime of conditioning that tells us we can think our way into answers and understanding, our first step after giving birth is to come back into deep contact with our body.

The next step is to befriend our bodies and learn to listen to their signals. Listening to the language of our bodies is an ongoing process, but it brings us into direct relationship with the parts of ourselves that know what we need in order to heal. Rather than looking outside for answers, we become our own inner authority, our own inner doctor. We begin to understand what we actually need, rather than what we think we need. There is no greater tool for mothering than an authentic connection to our own sensations, emotions, and the truths communicated through them.

Although we may want to know why things happen, we may never know the exact reason for why we are injured, why we tore, why our abdominal muscles separated, or why everything seemed totally fine and now is not. There is rarely one discrete cause for one discrete symptom; there are constellations of moments that converge to create particular outcomes. Unraveling those constellations to connect the dots of one’s story is part of our evolution as humans, women, and mothers.

When it comes to pelvic health, there are four domains that hold the key to our healing. Most medical and health-care professionals are trained to look at just one or two of these areas. But when we take all four into account, we have a powerful combination to accurately address pelvic-floor symptoms in a meaningful and lasting way.

You may feel great in three of the areas, but the one you haven’t considered could be the root cause of whatever your symptom is. These four basic elements of health are biomechanics, biochemistry, emotions, and scar tissue. I first learned about the model of the four domains (see fig. 29) from my mentor, Ellen Heed, PhD. She developed this model to serve the needs of women who had painful sex from pelvic-floor scar tissue after giving birth. The key to your health, healing, and self-understanding lies in your understanding of these four domains.

Fig 29: The Four Domains of Pelvic Health

Biomechanics

You can think of biomechanics as posture and flexibility. How you stand affects the position of your pelvic floor. Pregnancy and childbirth often exaggerate the postural tendencies that you already had. If you already had a swayback, you may notice that your lower back curve gets even more pronounced. If you rounded your upper back and pushed your thighs and hips forward, you may find yourself doing this even more. We live in the field of gravity. Posture determines whether the impact of gravity is working for us creating a sense of life and buoyancy, or against us creating a sense of heaviness and descent. Your genetics play a part in your flexibility; the way you move and hold yourself is in part a result of the density or stretchiness of your connective tissue. When your spine has its natural lumbar curve, your pelvic organs have a little shelf on your pubic bones. If you have a pronounced curve in your low back, your uterus may get pushed onto your bladder, in turn pushing your bladder too far toward your vaginal canal. If you are tucking your pelvis and flattening your buttocks, the bladder and uterus lose their shelf of support and this can contribute to pelvic-floor dysfunction like prolapse and incontinence.

Biochemistry

Biochemistry describes the internal environment of your body. It’s mostly influenced by your diet and nutrition, but it is also influenced by exposure to pollutants, what you take into your body through food, and how that food is absorbed. Are your tissues hydrated? How is your blood moving? What medicines have you taken in the past or present? Have you had prior surgeries and been under anesthesia? What kind of anesthetic did you use during birth? Is there inflammation in your system? Inflammation causes biochemical changes in tissues that irritate nerves and cause pain.

As mentioned in chapter 6, postpartum women need healthy saturated fats, adequate hydration, and whole foods to rebuild what was lost in pregnancy and childbirth. Collagen- and mineral-rich foods are two elements common to indigenous diets that are specific to postpartum women. For all women, but especially women with less connective tissue density, saturated fats from grass-fed cream and butter and other animal protein are imperative to giving the body the basic building blocks to strengthen organ tissue and ligaments, and return them to a robust and stable structure.

In proper Darwinian fashion, the body will take whatever it needs from the mother to make the highest-quality breast milk possible for the baby. In order to heal well after childbirth, it is crucial that women have sufficient nutrient density to nourish both themselves and their babies, especially if added healing is needed. Maintaining even blood-sugar levels by eating three balanced meals with two snacks will also help ensure that a woman is getting the building blocks she needs to recover.

Biochemistry also includes hormones. As described in chapter 5, after delivering the placenta there is a steep drop in progesterone and estrogen as the body shifts toward healing and milk production. While pregnant, your placenta was making these hormones; after delivery, your ovaries have to kick back into gear. Sometimes thyroid, adrenal, or pituitary imbalances appear after giving birth. If you have a history of hormonal imbalance, which could manifest as painful periods, fertility challenges, or depression, or have been on the pill to regulate symptoms, you want to take care to have blood work done so that you can confirm that your body has returned to making the hormones that you need. Likewise, if you have a history of depression or anxiety, and feel these states activated, make sure to ask for an evaluation from your doctor so that you can feel safe, secure, and stable. You may need to seek out a naturopathic doctor or a specialist in functional medicine to get the tests you need.

Emotions

Emotion plays a role in healing most tangibly when women have had either preexisting trauma or birth trauma itself. Whatever is happening at the time an injury is sustained is an important factor for healing that injury. The domain of emotion also includes our ability to self-regulate, to care for, and to soothe ourselves when experiencing the unknown or during times of difficulty.

It’s impossible to talk about post-birth medical realities without taking into consideration the very specific emotional, spiritual, and psychological nature of pelvic-floor dysfunction. Women use words like broken, damaged, and even eviscerated to describe how they feel. Because these injuries are typically invisible and occur in territory that is rarely explored, they remain untreated, but not unfelt.

Some of us may have shame that prevents us from exploring or seeking care for these injuries. Many women don’t want to explain to their partners how they are feeling because they don’t want their partners to see them as damaged or unlovable. They don’t want their partners to avoid sex with them and view them as damaged. One client shared, “I can’t think of anything less appealing than him knowing that my bladder is falling out of my vagina. Why would I want him to know that? He can’t feel it while I am on my back. I prefer to leave it that way.” Feeling damaged in the pelvic floor can make some women consciously or unconsciously want to avoid sex, creating confusion when there is no language to describe their injury’s location or sensation, or a total fear of communicating their physical reality to a partner.

Many women have never met anyone who has openly discussed the symptoms they are feeling. Walking around in daily life with organs that feel like they are falling out, or with bumpy and rough skin where it was once smooth, or with a fear of wetting our pants or pooping in them creates a nonstop internal commentary, with the symptom always present in the background. It can make women avoid many behaviors and situations they would normally participate in, from running to sitting with open legs to having sex.

Emotions play a key role in memory formation. Disentangling the emotion from the physical injury is often a key piece of healing, and is why working only with the biomechanics isn’t always effective.

Scar Tissue

To understand scar tissue, we first need to understand connective tissue, or fascia.

Fascia is the wrapping of the body. If you think of an orange and peeling back the skin, underneath it, the whole orange remains intact because of the pith, the white part. Divide the orange in half and it will remain intact because of the deeper layer of pith. Then, when you divide it into fourths and eventually individual pieces, each will be wrapped, all the way down to each piece of pulp. The body is similar; if you were to remove our skin, we are wrapped in a sheath of connective tissue. Then each muscle group, each muscle, and finally each muscle fiber is also wrapped in layers of this gauzelike tissue. What we want is for these layers to be able slide over each other. When we experience muscle knots, often it is wadded-up connective tissue that is not sliding easily. When it lets go and softens, what is inside the wrapping can reorganize. The body-wide web of fascia is connected to everything else in the body, which explains why, when touched in one area, we can feel a connection to another area in our body.

This tissue is made up of several kinds of fiber, including collagen and elastin fibers. Elastin fibers make fascia pliable and elastic, as the name suggests. Collagen fibers make the tissue resilient, strong, and dense. We all have a different ratio of elastin and collagen fibers in our connective tissue, due mostly to genetics. More elastic tissue will stretch farther without tearing but will have a harder time coming back together when torn. Collagenous tissue won’t have as much give and may tear more easily, but it will lay down collagen fibers to repair itself faster.

Scar tissue isn’t on the radar of most health-care providers, yet it is a key player in many women’s pelvic-health issues. Over 80 percent of women come through childbirth with some kind of scar tissue in their pelvis. Scar tissue looks and feels like a brittle chaotic spider web, with crisscrossed fibers and little pebbles or rocks inside it. It can also feel like stringy rope or be very dense and thick, like rubbery calamari. Imagine layers of plastic wrap smashed together, almost impossible to peel apart without tearing. Tissue that was once fluid, glistening, and pulsing in rhythm with breath and blood circulation becomes dehydrated, immobile, and unable to pulse at the same rhythm as the rest of the organism. Healthy fascia has a certain ratio of collagen fibers to elastin fibers, but scar tissue has a disproportionate amount of collagen fibers to bind where it was cut, torn, or damaged.

Scar tissue can be formed from birth tears, stitched repairs, C-sections, episiotomies, forceps or vacuum deliveries, babies being stuck in certain positions for long periods of time in the pelvis, the force of the pushing phase, or expulsion itself putting specific pressure on tissues in the pelvis. Women often have preexisting pelvic scar tissue from gynecological procedures, surgeries, miscarriages, abortions, endometriosis, or sexual abuse.

Scars are physical artifacts of trauma. Often emotions come up when scar tissue is touched for the first time. Gentle, persistent touch will allow the scar to begin to let go. It is normal for there to be sensitivity and numbness. Often, there is tingling and vibration as sensation begins to return to the area of the scar. It is important to touch the scar non-aggressively and allow the tissue the time it needs to soften. Understand that scars that are not tended to can potentially grow, forming more adhesions, which can affect circulation, organ placement, and even posture.

Even though there are a lot of ways that we may accumulate scar tissue, we can also dissolve it. Both movement and heat can contribute to the dissolution of the scar tissue. The body then flushes with blood, lymph, and hydration and is able to carry away the collagen fibers that are no longer needed, replacing them with healthy, new structures and enabling reorganization to occur. That means that scars can become elastic and pliable and even completely disintegrate.

Castor oils packs are the most effective way to begin the process of reorganizing scar tissue. Start by saturating organic cotton flannel strips with castor oil and placing them over the affected area—the abdomen or perineum. Place a hot-water bottle over the soaked strips and let it sit for about twenty minutes. Then, massage the castor oil into the scar tissue for a few minutes, until it is absorbed. Do this every day, or at least most days, for a minimum of three weeks.

If the scar tissue is internal, you can soak an organic cotton tampon in organic castor oil and place it inside your vagina for twenty minutes. After you remove the tampon, use your fingers or a wand or dildo to work on the scar tissue internally. Do this every other day, rather than every day. Women can be sensitive to castor oil inside their vagina, and using castor oil every other day helps avoid sensitization for most women. It is also helpful to work with a professional who may be able to get angles that are hard for you to reach yourself, to assess the trail of the scar, and to provide instruction, so your full experience can be guided.

SOME OF THE MEDICAL REALITIES

After giving birth, I experienced the following symptoms and medical realities: incontinence, diastasis, tearing, and prolapse. My own healing process required years of dedicated exploration and trial and error, as well as major life changes. I had no idea what factors were contributing to my recovery. I felt profoundly broken. For months I could not sit or nurse my baby from an upright position. I could not walk well so I had to minimize trips outside. I was isolated, living far away from my language, my country, and all that was familiar. The pain from the scar, which did not heal correctly, contributed to a downward spiral of problems. I was not producing enough breast milk from all the stress, and was fighting against supplementing with milk from other sources. My lower back and sacroiliac joints hurt all the time. My hip joints felt loose, like they might just keep meandering farther and farther away from each other, until they walked off in separate directions. My organs felt like they were about to fall onto the ground. I went from someone who was having sex almost every day while I was pregnant to someone who couldn’t conceive of having sex at all. When I decided to try despite my body’s aversion to engage sexually, it was incredibly painful and reinforced my feelings of being damaged and that something was seriously wrong. Worse yet, everyone I asked for help—my midwives and lactation consultants—acted like nothing was that bad, that it was all “normal.” Deep down I knew, as many women do, that everything was definitely not normal—common, perhaps, but not normal. Yet I still had no idea what to do about it.

First, I had to understand exactly what was going on, and it took years to parse out the various factors that were contributing to my pain and dysfunction. Below is a glossary with detailed definitions of each issue. While I hope that you experience none of the symptoms that I did, I want you to have the information so that, if you do encounter one of them, you are able to recognize it and get the help you need.

Incontinence

Incontinence is the medical term describing involuntary leakage of urine or feces. Urinary incontinence is when urine escapes the bladder. Peeing, even if just a little bit, when jumping or coughing or sneezing is called stress incontinence. Not being able to hold it when your bladder is full or just feeling like you have to urinate all the time is called urge incontinence. Urinary incontinence is common, but it is not normal. For many women, it glides under their radar. When I ask women who come to see me for structural bodywork how their pelvic floors are doing, most give me a bit of a confused look and say fine. A bit later, they might say, “Well, actually, I have to really concentrate, squeeze my legs together, and hope for the best every time I cough.” But since no one has ever asked them the question and their symptoms are not that bad, they just accept it as normal. Many women would never think of jumping rope or getting on a trampoline after having a child, but they have adjusted their lifestyles without noticing it. It’s easy to understand why. Raising children, working, managing relationships, trying to get in some exercise—they all trump taking real stock of unseen symptoms until they are so blatant that they are impossible to ignore. Simply put, we get used to living with the little inconveniences.

For the first few days after giving birth, it’s normal to have a little bit of leakage. But if incontinence continues beyond those first few days, it doesn’t typically get better on its own. Most people presume that if they have incontinence it is because their pelvic floor is too weak. They are told to do Kegels but not taught how to do them properly. In fact, about half the time, incontinence is caused by pelvic-floor muscles that are too tight, in which case, even a properly executed Kegel will not help. Scar tissue can also be a contributor to incontinence, as it can pull on the bladder or urethra, and other connected structures.

Continued incontinence requires the help of a physical therapist or sexological bodyworker who can help with hands-on work, breathing, and movement exercises.

Diastasis

A diastasis is a separation of the muscles of the outermost abdominal wall, the rectus abdominis (see fig. 30). The rectus abdominis is the six-pack muscle group that begins at the mid-ribs and attaches at the pubic bones—most people just call them “abs.” They are divided in half down the middle by connective tissue called the linea alba. During pregnancy, with the weight of the baby putting pressure on the abdomen and stretching the abdominal wall, these muscles can separate and spread apart. After giving birth, the muscles can stay separated. The separation can occur anywhere between the sternum and the pubic bone. It is measured in fingertips’ width distance that can fit into the separation, usually at three points along the linea alba—two above the navel and one below. It’s most common that the biggest separation occurs by the belly button. It’s normal to have one or two fingers’ distance just after giving birth. Less important than the size of the diastasis is the density of connective tissue of the individual woman. It is possible to have a diastasis and still have full function and integrity in the linea alba.

Ideally, your doula or postpartum-care provider would manually check you for diastasis ten days to two weeks postpartum, so you would know to diligently wrap your belly and start the breath for length exercises. It is difficult to manually check for yourself; however, if you are lying down and lift your head, and your belly makes a cone shape or you see something bulging at the midline, then you probably have a diastasis. In that case, make sure to ask your practitioner or even a friend to check you.

Fig. 30: Diastasis

Diastasis is most common in women with a very strong abdominal wall, such as rock climbers and triathletes. It is also common in yoga practitioners who backbend frequently while pregnant.

How to check for a diastasis:

1. Lie down with your knees bent and feet flat.

2. Have a friend kneel to your right. Have them place the four fingers of their right hand horizontally on the midline of your abdominals just below your ribs. They need to press down gently to feel where the linea alba is and how big the gap is in a resting position.

3. Next, lift your head up.

4. What happens to their fingers? Does the gap close, does it stay the same, or does it widen?

5. Repeat this process in three places—just below the ribs, just above the navel, and between the navel and the pubic bone.

A one-finger gap after a baby is okay. Any more than that will require targeted breathing exercises and, potentially, splinting. Knowing the three numbers will help you track your progress. You can check every week to see if the gap is closing.

There are specific movements for diastasis recovery, the most important of which is the diligent recruitment and entrainment of your transverse abdominis, your corset muscles, together with pelvic-floor activation. You want to lift your pelvic floor as the belly moves toward your spine, without tucking your pelvis. This movement is explained in the breath for length in chapter 4. The most comprehensive method for diastasis recovery is the Tuppler method, which combines targeted movement exercises together with abdominal splinting, and can be started whenever you discover you have one.

An intact abdominal wall protects soft organs. When the abdominal wall splits, there is potential for hernia. A diastasis can contribute to lower back pain, as well as an overall feeling of physical and emotional instability and vulnerability.

Tearing

As your baby comes through the birth canal, there is a tremendous amount of stretching that needs to happen. Sometimes the tissues don’t have enough time to stretch sufficiently, or they are tight to begin with, and the skin or muscles tear. Tearing is measured in degrees. A first-degree tear is when the skin of the vagina, labia, or perineum tears. Often first-degree tears don’t require stitches, but it’s helpful to keep your legs together for ten days to two weeks, so the tissues continue to come together and don’t re-tear. A second-degree tear goes through the skin and the underlying pelvic-floor and vaginal muscles. A third-degree tear goes through the skin and the muscles, all the way to the front of the anal sphincter. A fourth-degree tear goes all the way through all those layers as well as through the back of the anal sphincter, damaging rectal nerves. Second-, third-, and fourth-degree tears all require skillful layer-by-layer stitching to reconstruct and reconnect the tissues.

The stitching is done when the tissues are highly engorged. So when the swelling goes down, it is common that the texture of the tissue has changed or that things are not as symmetrical as they were before. It can be very disconcerting to feel that things are not at all back to normal, functionally or visually. The perineum can be bumpy rather than smooth. The introitus, or vaginal opening, can be asymmetrical, rather than round and even. Many women aren’t sure how they looked or felt before, but they know that things are different after birth. For this reason, I recommend that all women take photos of their vulvas. I have even heard of a woman who took a picture of her vulva to the birth, so if she needed a repair, her midwife or doctor would know how she looked originally and help to return her as close as possible to how she was.

Tearing can be confusing because symptoms don’t always correlate with the degree of tear. For instance, a second-degree tear can lead to more complications than a fourth-degree tear. This has to do with your particular connective-tissue density, how well you are able to rest during healing, how well the repair was done, and your past sexual and health history. I have worked with women who experienced fourth-degree tears but had such great repairs that, together with ample rest and recovery, they experienced no pelvic-floor dysfunction. I have also worked with women with second-degree tears experiencing prolapse, urinary incontinence, and painful sex. Each woman has her own story and requires the right treatment for her own unique circumstances.

Importance of Energy Channels

In Chinese medicine, the channels that energy runs through are called meridians. It is along these meridians that acupuncture and acupressure points are found. In Ayurvedic medicine, the “little rivers” of energy are called nadis. When we are in radiant health, these nadis are so clear that energy runs through them unobstructed. We feel a glowing warmth and pulsation throughout our body.

As mothers, we are vessels for beings to move from spirit into human form. As a result of being the conduits for this transition, our physical bodies go through profound changes. So do our energetic bodies. Our energy circuitry is shaken when we give birth. Imagine a pan that has layers of residue at the bottom and needs to be soaked for a long time before you can thoroughly clean it. Hot water and soap have to soften the layers before you can scrape them loose. Each of our own inner worlds has some residue. In Indian philosophy, this residue is composed of samskaras. Samskaras are lingering past impressions of life events that remain with us, coloring our vision of the present, making us who we are, and creating our temperament.

Samskaras are part of our karmic inheritance, our particular circumstances that we have to negotiate in this lifetime. Rites of passage like pregnancy and birth function like the hot water and soap to soften and loosen all that is hardened in our nadis. All that is calcified into habit and obstructs our ability to truly see, truly know, and truly love can be shaken loose, so we are free to make new choices. This kind of change is not always welcome. We are accustomed to our habits and ways of seeing the world. What is shaken loose is not always what we want to look at, yet ultimately, this rite of passage has the potential to clear the nadis and, as a result, lead us to a deeper sense of freedom and a clearer expression of who we are, in body, mind, and spirit.

Years after giving birth, my midwives told me that I had had a second-degree tear. But when I was receiving bodywork, both my practitioner and I felt that the scar tissue extended into my anal sphincter, which was not severed but had definitely been affected. I couldn’t sit well or walk for two months. I was experiencing fecal incontinence, painful sex, and excruciating lower back and pelvic pain. Because the other women I knew who had fourth-degree tears were doing better than I was, I assumed that I must have had a fourth-degree tear also. As I later found out, my body had rejected the suture material used by my midwives to repair the tear. I have low-density connective tissue and had been a vegetarian for twenty years, which I believe contributed to my stitches reopening. Not only did my body naturally have less collagen to form healing bonds in the tissues, but I also wasn’t eating mineral- and collagen-rich foods to help support new connective-tissue repair.

It’s not surprising that I had difficulty producing enough breast milk to feed my child when so much energy was being taken up by the healing process. My body was recruiting everything it had to repair, and the confusing symptoms only added to my stress levels. Like many women, I had no guide or map to find my way through this territory.

Prolapse

Prolapse happens when the bladder, uterus, or rectum fall below their ideal position in the body, resulting in a feeling of bulging or heaviness (see fig. 31). Women with prolapses say things like “I feel like my insides are falling out,” or “It feels like there is something between my legs that wasn’t there before,” or “I feel like there is an egg sitting in my vagina.” The technical term for a bladder prolapse, when the bladder falls down from behind the pubic bone and into the vaginal canal, is cystocele. A rectal prolapse, when the rectum is caving toward the back vaginal wall, is called rectocele.

Fig. 31: Prolapse

The following can contribute to prolapse:

• Extended pushing phase in childbirth

• Mechanical delivery (birth assisted by forceps or vacuum extraction)

• Multiple deliveries

• Loose connective tissue/hypermobility

• Premature return to high-impact exercise

• Root energy concerns such as moving, lack of financial stability, lack of tribe or community, family deaths

• Vegetarian diet

While tears are rated in degrees, prolapses are rated in stages. These ratings are relative. The size of each woman’s organs and the length of her vaginal canal differ, so there can be a big range between a stage-two and stage-three prolapse. If the organs are slightly below their original position, it is considered a stage-one prolapse. If the organs are lower down with less ligamentous support holding them up, it is a stage-two prolapse. Farther down the canal and visible at the entrance of the vagina is a third-stage prolapse. A fourth stage is when the organs are actually coming out of the vagina.

Why do some people experience prolapse and others don’t? There is no easy answer. Statistics show that labor interventions like forceps and vacuum extraction greatly increase the risk of prolapse. We also know that an extended pushing phase as well as pushing with a full bladder contributes to the incidence of prolapse. With each push, all of the organs are pushed downward, and when repeated again and again, it increases the likelihood of their becoming dislocated from their optimal positions. Similarly, women having a second or third child are more likely to experience prolapse. Women who have more elastic, stretchier connective tissue are more likely to prolapse. I also see many women who did not have a prolapse immediately after birth, but they returned to running and intense exercise before their body was ready, which resulted in a prolapse. Avoiding a prolapse is one of the main reasons to stay in bed during the sacred window.

Living with prolapse can be very frustrating. In addition to it being very disconcerting to feel something sliding down from its right place, there seems to be a “two steps forward, one step back” quality to working with it. For many women, it seems like there is no rhyme or reason to the prolapse—one day it’s better; the next day it’s worse, without being able to trace much of the reason why. Women report feeling better one day on a walk, and then the next day, they are just resting and feel the prolapse lower again, when not even affected by gravity.

All women should know that while they are nursing, their body is still secreting the hormone relaxin, which contributes to looser ligaments. While you are still nursing, be especially patient with your healing process and stay positive about how well your treatment is going. As a strategy to correct prolapse, I recommend you fortify your body first and wait until after you stop nursing before making any decisions about surgery. The statistics for success in surgical repairs for prolapse are not encouraging. It can be very tempting to go the surgical route, especially when symptoms seem like they are not improving or are improving at a snail’s pace, but there are no quick fixes for prolapse. That said, a stage-four prolapse, when the organs are outside the body, will require surgery.

Uddiyana bandha kriya, as described in chapter 11, is one of the most effective ways to heal a prolapse. The strong abdominal suction actually lifts the organs up. If you already have experience with inversions, then headstand can be very effective at treating prolapse; combine headstand with uddiyana bandha for a maximal effect.

Community Stories:
Julia

Julia had her third child in Holland, a vaginal birth after two cesareans. She had the help of Kraamzorg, a Dutch system of maternity care that included a nurse who came six hours a day to wash clothes, cook, help with her two older children, and make sure she was resting. After those initial eleven days, Julia’s husband went out of town. She was feeling so energized from the help of the nurse and the difference in recovery between the vaginal birth and the cesarean births, that she resumed all her regular activities of cooking, lifting, and taking her kids to and from school. The return to these activities so soon resulted in a second-degree bladder prolapse that she didn’t have immediately after birth. Frustrated, she realized that she still needed to rest, and shortly thereafter she sought out holistic pelvic health care.

Women have also had great results with vaginal steaming in working with prolapse. The herbal steam flushes and tones the tissues, increases blood flow, and encourages the organs back upward.

Bleeding after Birth

For the first two to six weeks following birth, your uterus will continue to cleanse itself and you will experience bleeding. The bleeding, called lochia, should decrease over time. If you pass a clot larger than your fist in the first few days, you should contact a medical professional. Over the course of your healing, the bleeding will become spotting and will eventually end. If, in that time, the bleeding slows down or stops and then starts again or becomes bright red again, your body is signaling that you are doing too much and need to rest more.

In between when the lochia slows and your period returns, many women have greatly benefited from the practice of vaginal steaming to allow the uterus to be fully cleansed and to create more tone and resiliency in the vaginal tissues.

Eventually your period will return. It is possible to ovulate within six weeks of giving birth, meaning it’s possible to start menstruating within two months of giving birth, or to have Irish twins. Yes, even if you are breastfeeding exclusively, you can get pregnant.

The return of a woman’s menstrual cycle after having a baby can vary from three months to two years. For women who have experienced birth injuries or birth trauma, periods can be especially painful. Many women experience an exaggeration of symptoms with their period—abdominal muscles feel weaker, pelvic tone feels less accessible, and prolapsed organs feel lower than normal. Periods can feel like mini-births and reactivate the trauma or symptoms that occurred during birth. What can a woman do about this?

Just knowing that this is common can be a relief. Also, if you are trying to heal a prolapse, but you are still nursing and are experiencing heavy or painful periods, be patient. It will take time, but don’t lose hope! These shifts allow you to become more attuned with your body, helping you realize how to shift your diet and choice of exercise in order to support the different phases of your cycle.

To this day, I feel a difference in my pelvic-floor tone and organ position between my period and ovulation (follicular phase) and between ovulation and menstruation (luteal phase). When I am in the follicular phase, I am able to do more rigorous exercise and a stronger yoga practice while maintaining a sense of my core. When I am in the luteal phase, I opt for slower, yin-style yoga practice and less intensive workouts, so I feel my pelvic floor and organs are supported. This would be an attuned way for us as women, even those without pelvic-floor problems, to modulate and potentiate our energy throughout our menstrual cycles. Most of us have never been taught to respect the different energies and physical shifts that happen throughout our cycles. Most of us have trained ourselves to be as productive as possible and try to continuously operate at our maximum. When we are young, we feel we can get away with anything, pushing ourselves at every phase of our cycle. But as we get older, imbalances show up more frequently when we fall out of sync with our biology. Giving birth often serves as a deeper awakening to these feminine rhythms, and dealing with birth injuries even more so.

MY OWN MEDICAL REALITY

Postpartum recovery was the first experience in my life that proved to me what I had always believed but had never really felt in my own body—true healing involves all the layers of our human experience—physical, emotional, sexual, relational, and spiritual. One year after giving birth, I returned to the United States to try to get some health care that I understood. Without so much as a pelvic exam but upon hearing about everything I was going through, the doctor I went to told me I needed a full pelvic-floor reconstruction. Since I had chosen a home birth precisely because I valued my own body’s ability to birth and heal without intervention, the idea of surgery and more stitching was terrifying to me. I couldn’t even fathom exactly what that meant. How do you reconstruct a pelvic floor without creating even more scar tissue? And yet, I had no idea what I should do to address all the symptoms and uncomfortable sensations I was experiencing.

I returned to Michele Kreisberg, a holistic pelvic-floor physical therapist whom I had seen before I gave birth. She gave me the first hopeful news: in spite of all my symptoms, I was not the worst case she had ever seen, which was my biggest fear. She believed there was a lot that I could do before pursuing surgery, which was a last resort for me. That visit was the beginning of the journey that resulted in this book.

I threw myself headfirst into figuring out how I was going to get better. I began to suspect that this dearth of information was something that many women must experience. I traveled to Asia to learn about and experience another way of treating postpartum women. I moved to Thailand for four months, where I had access to inexpensive, organic food as well as affordable childcare. I put my daughter in preschool for the first time and invested in thrice-weekly Thai massage treatments at the local hospital. I returned to a meditation practice and a yoga practice made possible by the space created while my daughter was at school. I began to feel relief from my lower back and sacroiliac pain. This is also when I met Ellen Heed, who became my mentor. She was visiting to teach the anatomy portion of a yoga teacher training I was coleading. When I told her about my symptoms, she told me that she was conducting a study on pelvic-floor scar tissue in postpartum women. She asked if I would be willing to be a part of her study, to be documented through photos and videos in exchange for sessions.

It was when I was working with Ellen that I began to see a significant change in the majority of my postpartum symptoms. Our sessions addressed the four domains of pelvic health. Together we were able to form a coherent picture of what exactly was going on. I suspected that the scar tissue was extensive, but with her hands following the paths of every scar, it was no longer a guessing game. We could both feel the path the scars traveled.

In one session, my diastasis knit back together. Normally, diastasis is something that is viewed as requiring intensive and almost constant exercises with splinting through tight belly wrapping. In my case, there was a structural imbalance that, when addressed internally, allowed my connective tissue to reorganize and regain tone. During another session, together with an emotional release, my scar tissue softened and the entrance to my vagina was no longer taut and asymmetrical. Sex became a possibility for me again. I could imagine reengaging sexually.

In my case, the most important quadrants of the four domains of health were emotion and scar tissue. I had experienced a traumatic tear during the birth itself, but the majority of trauma came in the postpartum period, when I did not realize how much support I needed or where or how to get it. That was accompanied by the dissolution of my marriage, and it felt like the ground was falling out from underneath me. So our work together was grieving the loss of the partnership that had created this birth and baby, and grieving the confusing birth scenario that reactivated some core internal wounds, and to do this somatically, by actually feeling the territory where the damage had occurred and lived on as active, self-propagating scar tissue. Biomechanics played a role because of my stretchy connective tissue, made stretchier by years of yoga practice. Biochemistry played a role because my long-term diet was missing meat-based collagen sources, so together with breastfeeding, my body didn’t have the key ingredients for repair.

The biggest chunk of my healing was during the work that Ellen and I did together. The next major leap was when I told my daughter’s father definitively that our marriage was not going to work out. Knowing that I was ending my chance at the nuclear family I wanted and also that I might be putting my daughter’s relationship with him at risk, it was a brave move toward self-sovereignty and profound honesty, with my body leading the way. That night, I felt the two sides of my pelvis slide toward each other, hugging back into my sacrum, and I felt my uterus come back to its normal pre-birth tone. Soon after, when my daughter was two years and four months, I weaned her, and that was another leap forward into more access to my life force.

However, as I mentioned in chapter 4, I was depleted on a deep level. Soon after my daughter stopped breastfeeding, because of repeated monthly sinus infections, I went on a kind of bed rest, taking care of only my most basic needs of food, rest, and work, in addition to mothering a toddler. To rebuild that basic life-force energy required time, patience, dedication, and a lot of faith.

It took me six years to return to radiant health, to the place where any little thing would not send me into a downward spiral of allergies, a cold, or fatigue, and where I had a wider palette of activity choices that felt good to my body. As a yoga practitioner and seeker, I am looking for much more than an absence of pain and mediocrity in the way I feel. Being out of pain is not enough. For me, radiant health is a birthright. Full recovery from my daughter’s birth required that I call everything into question about the way that I had structured myself, my identity as a woman, partner, daughter, and mother. It also required me to live what I had been teaching—that true healing requires attention to the interconnected nature of all the layers of who we are.

Know that healing is available to you too. Use this model of the four essential domains of health to get clearer about what is happening in your body, mind, and spirit that is contributing to how you are feeling. I know how hard it is to prioritize your own health when there is so much to take care of and adjust to just day to day. It is every new mother’s dilemma. When we are in the motherbaby unit, it can be hard to even peek our head above water to have perspective and recognize what is going on. With this model, you can simplify what may seem like an overwhelming situation and reach out to get the support you need.

SUMMARY

• There are four essential domains of health that need to be considered when trying to heal any symptom, including a birth injury—biomechanical, biochemical, emotions, and scar tissue.

• Birth injuries are a potential outcome of giving birth, but they are not inevitable nor are they permanent. Healing without surgery is possible in most cases.

• Incontinence is common but not normal. It’s not always caused by weak muscles. It can also be caused by hyper-toned muscles or scar tissue.

• We must be our own advocates for our pelvic health because medical professionals are not always informed about postpartum birth injuries.

Reflections

• Before having a baby, which quadrant of the four essential domains of health was the most stable and healthy for you?

• Before having a baby, which quadrant was the one that called your attention most often?

• Do you have insights on any vulnerabilities that you may have carried into birth that are now contributing to your postpartum healing process?

Practices

• If you have a birth injury, make your own pie chart with the four essential domains of health. In your estimation, what percentage of your symptoms are due to biomechanical, biochemical, emotional, or scar-tissue causes?

• Now that you have a pie chart, you have a better sense of the care you need and the direction to go for your care.

• If your symptoms are mostly emotion- and trauma-related, the best place to start is body-based therapy.

• If your symptoms are mostly biomechanical, the best place to start is physical therapy or holistic pelvic care.

• If your symptoms are mostly biochemical, the best place to start is a naturopathic doctor or holistic nutritionist.

• If your symptoms are scar-tissue related, bodywork and the home protocols, like castor oil packs, vaginal steaming, and self-massage, are your best direction.

• Most likely, your symptoms are a combination of the four. It’s hard to see ourselves clearly, so if you have pursued one of these avenues and it hasn’t worked, you may need an outside eye to help you with your assessment, such as a STREAM practitioner.