Common Soreness and Pains That Can Be Felt After Giving Birth

Unless you are a miraculous human being – without doubt you will have a degree of soreness and inflammation down below after a vaginal birth and possibly soreness around the tummy are too.  Depending on the mechanics of how the birth followed you may have pain in your pelvis, low back or around your pubic bone too.  Going to the toilet may be a very uncomfortable time in the early stages.  Here are some simple ways to help relieve any soreness and inflammation in the first several days after giving birth.

The first and most obvious is to take what ever pain medication has been prescribed by your doctor for the level of pain you have. This varies between people and your Doctor will advise and prescribe what you need.

Another very effective pain relief tool during the early stages of recovery is ice. There are different options for its application. The one many women prefer is the frozen sanitary towel. Take clean water, soak a large sanitary towel in it and freeze it. Ideally we advise using the sanitary towel for about 15 minutes or until it is melted and no longer giving relief. (No longer advised as can become warm and moist increasing chances of infection). Then gently dry the area by gently patting with a towel, then lying on the towel with no underwear for about 10 minutes.  This is a gravity offloaded position as well as allowing the area to dry out which is also an important healing component.

For the first couple of weeks post birth gravity is not your friend. If you sit directly onto your vulva most women find it too painful so an easy way around this is to sit in a way that doesn’t place any direct contact onto the vulva. Either by sitting in a side seated or on one bottom sitting. Using a towel rolled up from the ends to allow space for the vulva. Or using a donut cushion (can buy inflatable donut rings as pic from Amazon).

When sitting on either the towel or rolled up cushion we advise not to sit for too long as gravity will cause pooling of liquid in and around the vulva causing more discomfort. Where possible especially in the first week spend more time lying down rather than sitting down, as the swelling and bruising subside so will it become easier to sit for longer periods and directly onto the vulva itself.

While we do not want to over exert a very fatigued and (depending on whether you have torn or had an episiotomy) damaged pelvic floor; using the muscles can be like a pump action which gently pushes out the fluids gathered.  Gentle pelvic floor squeezes where you try to “stop passing wind” and then relax. You can aim to try repeat this 3-5 times several times through the day.

We do not advise practicing these pelvic floor contractions without a check from a Womans Health physio first if you have been told you had a Grade III or Grade IV tear or Prolapse during the Birth.

Your breasts go through a number of changes from pregnancy to birth to postpartum.  Below shows a pic of the normal breast anatomy and then the changes you can expect will be discussed.

When you are pregnant your body changes your breasts to start preparing them for feeding your baby. Some of these changes include:

• increase in breast size and tenderness
• changes in colour, size and sensation of nipples and areola
• bigger & more noticeable Montgomery glands (raised bumps on areola)

Usually after about the 16th week of pregnancy the breasts are able to start producing milk. This may result in colostrum (the nutrient dense first milk you produce) leaking from the nipples. It may be noticeable through clothing or merely just coat the nipple and areola.  Your breasts and nipples will grow in the last few weeks of pregnancy as the milk producing cells enlarge. This can lead to feelings of being overly full and uncomfortable.

As mentioned earlier the first milk you produce is colostrum which is nutrient and energy dense as a new born only has a very small stomach. Some women like to harvest the colostrum, freeze it and save it for after birth.  This should be discussed with your gynaecologist first and is generally done after the 37th week.

After giving birth your hormones drop rapidly and severely.  Your colostrum gets diluted with your mature milk that comes in generally around 2-4 hours after birth.  If you are breastfeeding or pumping there may be several problems that you may encounter on your journey. With all issues the key is to address your individual needs or problems so we always advise seeing a lactation consultant to help along your journey but here are some basic guidelines you can follow for the treatment of some of the more common conditions.

Nipple main is a common reason for stopping breastfeeding early.  Nipple pain or discomfort is very common in the first few days of breastfeeding however if it is persisting beyond that it needs to be reviewed.  There are many causes and the  nipple pain can be accompanied by trauma such as abrasions, fissures or cracks as well as bleeding and scabs.

As with all breast conditions it is important to determine the root cause of the issue. However there are some key strategies to implement:

• get help early!  The earlier the intervention the better the outcome
• the most important thing is to ensure the baby’s attachment is correct, when the attachment is correct the entire areola is in the mouth and your nipple will rest comfortably against the baby’s soft palate at the back of the mouth
• flattened, wedged, lipstick shaped or white nipples can be a sign of poor attachment where the nipple is being pinched & rubbed against the hard palate
• try different feeding positions to reduce pain
• feed with the unaffected side first (unless having any blockage or mastitis issues)
• wash your hands before handling breasts to minimise bacteria and change nipple pads (if you’re using them) with each feed (especially in warm humid countries)
• break the suction on the nipple instead of pulling baby straight off
• keep the baby feeding as long as they want – if you shorten the feeds to “rest” the nipples it does not help & may affect your supply
• wear a cotton bra to let the breast breathe or no bra if possible

If the nipples are already damaged or cracked the evidence is a bit more conflicting but some general advice to follow:

• washing and drying the nipples more frequently
• warm water compresses before feeding
• applying purified lanolin to the nipples (if irritation occurs stop use)
• if pain is persistent and or there is any discharge get checked to ensure there is no infection
• temporarily expressing until pain subsides with gradual reintroduction of breast feeding
• laser therapy to the nipple can be done by a Women’s Health physio and for some can give significant relief

A milk blister occurs when your nipple closes over a milk duct opening, becomes inflamed and milk fills up in the area behind it. They look like a small raised bump on your nipple and can be white or yellow.  They can look like a tiny line of toothpaste or small crystals.

Do not pop as can lead to infection. Try the following to help remove a milk bleb or blister.

1. Try applying vinegar to the milk bleb with a cotton wall ball placing it against your nipple inside your bra.  The vinegar helps to dissolve calcium so can help relieve the blister
2. Try a warm wet compress before feeding for a few mins which will help loosen the skin so when the baby nurses the skin opens and releases the bleb 
3. Try a saline soak of 2 teaspoons of epson salts with 1 cup of water and dip a flannel in the mix and hold on the area for a few mins 
4. Try applying olive oil to the milk bleb with a cotton wall ball placing it against your nipple inside your bra between feeds which can help to loosen the skin and release the bleb.
5. Encourage breastfeeding as the baby will help apply pressure gently to the bleb helping it to release or have a go at gently manipulating or massaging the area around the bleb after a warm wet compress to help it release 
6. If it appears inflamed or infected try applying an antibiotic cream to the area in a tiny amount applying after feedings 
7. If none of the above succeed then you can see your Doctor who may be able to help by releasing it with a sterile instrument (do not try this at home yourself).  

Depending on the reason for the engorgement will determine the treatment. If you are struggling with recurrent engorgement & oversupply we strongly recommend seeing a lactation consultant to assess your individual needs. However there are some general guidelines you can follow:

• self massage of the boobs – see post video for some massage techniques to try
• frequent and effective feeding or pumping/expression at regular intervals (roughly 8-12 times/day)
• warming the breasts with hot flannels or hot packs before feeding to help getting the milk flowing
• cooling the breasts with frozen cabbage leaves or cool packs
• wear a good fitting nursing bra
• expressing a little milk to relieve discomfort
• there are certain over the counter pain medications that are safe to be taken during breastfeeding discuss with your doctor
• other treatments such as ultrasound & lymphatic massage for pain relief
• if symptoms do not improve or if you develop any fever or flu like symptoms then consult a doctor

The milk making glands in your breasts are segmented and bunched together somewhat like an orange.  Then narrow tubes carry the milk from the glands to the nipple, these are called ducts. When a blockage in the ducts occurs it can lead to a build up of milk behind the blockage.  Signs of a blocked milk duct include one or more of the following:

The overall health of the mother is unaffected but if the blockage is not treated quickly it can lead to mastitis.

An Abscess is a painful build up of pus in the breast caused by an infection.  They are more common than previously believed.  If the pain does not improve with any of the treatments then do not leave it without getting medical help.  Ideally we would advise seeing a breast doctor who will be used to dealing with these situations and know what to do.  They sometimes will prescribe antibiotics and or may even need to drain the area.  If you are unable to get an appointment with a Breast Doctor then do make sure you see your usual Doctor asap to get help.

While it is not always known what causes a milk duct to get blocked it is usually due to insufficient drainage of a duct.  This can be due to tight clothing around the breast (eg a tight poorly fitted nursing bra); long periods between breast feeding or the baby not attaching well. In the case of the difficult attachment seeking the help of a lactation consultant is really going to help. The key thing is to remove the blockage so here are some general guidelines you can follow:

• try getting your baby to feed more frequently on the affected side
• try different positions, if possible pointing the baby’s chin towards the lump
• avoid wearing tight clothes or bras
• certain anti-inflammatories ie ibuprofen
• cold compresses over the breast (try frozen peas wrapped in a towel) or purchase an icepack from the local pharmacy
• massage the affected area before and during feeding or pumping gently but firmly trying to work the lump towards the nipple
• temporarily expressing after feeding
• Women’s Health Physios can help with providing ultrasound therapy to the blocked duct combined with lymphatic drainage which often helps to break down the blockage and clear it out

Mastitis is where your breast becomes swollen, hot and painful and may be accompanied by infection. It occurs most frequently in the first 6 weeks postpartum but can occur at any point during lactation and sometimes in women who are not breastfeeding or men. Mastitis generally affects one breast at a time, you may have a swollen wedge-shaped lump or hard area in your breast usually accompanied by a fever (>38.5C/101.3F).  You may also present with flu like symptoms of aches, chills & fatigue.

Mastitis may result from blocked ducts and or engorgement. If left untreated it can lead to a breast abscess. Mastitis can worsen rapidly and needs careful & immediate treatment. If the mastitis is a result of blocked ducts or engorgement and is an ongoing issue we strongly encourage seeing a lactation consultant to determine what specific issues need to be addressed.

Other causes for mastitis include: damaged nipples; infrequent or missed feedings; poor attachment; rapid weaning; oversupply of milk; pressure on the breast (eg from a poor fitting bra as well as maternal stress, fatigue or illness. While the cause needs to be determined and addressed on an individual basis here are some evidence based guidelines to follow:

• Effective milk removal – either via increased frequency of feeding on the affected side or ensuring the latch is correct or using a pump
• pain can interfere with the let down reflex, if this is the case start feeding on the other side until the let down occurs and then switch
• Certain over the counter pain medications such as ibuprofen are deemed safe to take during breastfeeding but should be discussed with your doctor or pharmacist before commencing
• Position the baby with either the nose or chin pointing towards the blockage to try and help drain it
• Massaging during the feed to help get the milk flowing ensure to massage from the blocked area towards the nipple
• If feeding, once completed, try expressing or pumping any remaining milk out of the breast
• Lymphatic drainage towards the ducts can also help along with appropriate application of ultrasound therapy
• Resting as much as able
• If the symptoms are not improving in 12-24 hours or if you’re unwell then a course of antibiotics is advised

If symptoms are not improving then further tests may need to be done to determine what the cause is or to rule out other issues.

This is usually down to the position you are breastfeeding.  Your shoulders should not be protruding forwards and your head bending down.  Try to support yourself with cushions and pillows and position yourself as shown below. 

Once you have decided you wish to cease breastfeeding and your supply and routine are well established it is advised to slowly reduce the number of feeds/pumping sessions as stopping too quickly can lead to engorgement and or mastitis.  Your body will continue to produce milk as long as there is demand. So reducing length of feeds/pumping and dropping a session will help you wean. After you have stopped you may still leak for a while after if something triggers your let-down reflex.  If you are struggling have a chat to your doctor as there are some medications which may help to cease breast milk production.

The tail bone known as the coccyx can be a common source of pain postpartum it is  known as Coccydynia. The coccyx is a small triangular shaped arrangement of bone at the end of the spine. It serves as a very important attachment point for the muscles of the pelvic floor.

Despite it being a small area it can be a very debilitating condition. It can be caused by the huge change in hormones experienced during and after pregnancy as the body softens ligaments and allows more movement around the joints to prepare for birth. Another common cause of coccydynia is trauma during childbirth, for example where the baby’s head passes over the tailbone and causes injury or in the case of an instrument assisted birth (especially with baby in a face up position) can result in a bruised or fractured tail bone.

Depending on the severity of pain or possible mechanism of injury your doctor could suggest some diagnostic tests such as x-rays or CT scans. However the most common method for diagnosis is a physical examination with thorough history taking. The examination includes an external palpation of the tailbone and if required an intra-rectal examination.

There are some over the counter anti-inflammatories that can be purchased or some more advanced anti-inflammatories on prescription from your Doctor.  If breastfeeding make sure they are safe to take.

If sitting is painful then you can try kneeling in the early stages as often the pain is not a problem in this position.

Or you can purchase a wedge seat which can offload the area taking pressure of the tailbone.  Ring shaped donut cushions are not recommended for long periods of sitting after birth as it can cause fluids to pool in your vulva (vagina lips). There are several makes of the wedge cushion. The make of the wedge cushion in the pic is Comfysure.

If there is pain on a bowel movement it is important to ensure constipation is not an issue worsening the problem and the pain. See our section on ‘Constipation’ for detailed strategies to help relieve constipation.

These simple positions can help with offloading the area and pain relief.

You may have experienced lower back pain in pregnancy and it has continued after birth or you may find low back pain starts after giving birth.  For some lower back pain was present before pregnancy and has worsened through pregnancy and after birth.  Learn about why lower back pain occurs and treatments you can take to relieve the pain.

Heat can be applied to the lower back and give relief.  You can use a hot water bottle or there are heat packs that are available to heat up in the microwave.  Pharmacys also offer a stick on heat patch which activates when you fold the patch before applying and the effect can last a couple of hours so can be worn while moving around.

Pain relieving patches that you can apply to the lower back come in different types.  Some contain herbal relieving remedies or Tiger Balm and others contain medications that require prescription.

There are also pain relieving gels that you can rub on the sore area which some people find helpful and can be bought from the pharmacy.

Regards pain medications its best to only use when pain acutely bad rather than get into the habit of taking regularly.   Simple Paracetamol or Anti-inflammatories are the best options to try first.  If you feel more pain relief is required then seek the help of your Doctor who will be able to prescribe higher doses pain relief meds or if feels the need to refer you on to a Spinal Consultant for a review.

Generally just moving helps lower back pain.  Often for those who sit around it makes the back pain worse and if you do not exercise and move your body becomes deconditioned and then if you start trying to move again the back pain will start. Try and walk more – gradually increasing each time how far you walk.

Also try our Recovery Workouts (see Recovery Workouts Section) which concentrate on moving your body safely again with simple exercises.

These simple stretches can help relieve lower back pain by doing gentle movement to the joints and of the muscles which may have become tight and in spasm.  If you feel muscle soreness when stretching that is normal.

Specific types of Ab Curl Exercises help to shorten the Rectus Abdominal 6 Pack  Muscles that have been stretched during pregnancy and also restore their thickness as they are shown to become thinner having been stretched.  This helps the rectus abdominis to also create a tension back again between the chest bone and pubic bone which then helps to form a strong front outer core.  This can then help prevent compensation and strain taken on the back muscles.  These Ab curl exercises can start early after birth.  See our ‘Pelvic Floor & Core Activation’ Section to learn how to do this safely and correctly.

Ensuring sufficient fibre & fluid intake and adhering to the advice in our ‘Constipation’ section will help to not irritate the haemorrhoids.

A frequent cause of pain and frustration in the postpartum period is upper back and shoulder pain.  These are highly correlated to handling, caring for and feeding a baby,  but can be triggered off by straining a muscle or group of muscles during childbirth.

This pain can present in a number of different ways feelings of muscle fatigue, burning sensations, dull aches all the way through to sharp and consistent pain if in acute spasm.  It can often be exacerbated by lifting, feeding or carrying your baby or spending longer periods of time on the computer/phone.

If you are breastfeeding, feeding with a bottle, pumping or a combination you are going to be doing it for hours.  This is a new type of posture for your body to cope with and if staying in not ideal postures for long periods of time then your muscles and joints in your upper back and shoulders will start to speak out.  Often resulting in feeling sore and in pain.   First of all make sure that you change your postures and do not just keep the same posture for feeding or pumping all the time.

Below shows how to try and correct your feeding position to help keep these issues at bay.

Holding the pumps in position is definitely not an ideal situation for long periods of time.  Some tips:

• Invest in good nursing tops that do the holding of the pumps in place for you
• Position yourself comfortably not sitting forwards and hunched over
• Invest in pumps that fit inside your bra and do not need you to stay in one position.  Do be aware that these pumps tend to not be as strong so best to alternate with a pump machine that connects to the boobs that is strong enough to effectively draw out the milk.

TREATMENT
As with most issues, prevention is better than cure!  Ideally you would start some upper body strength exercises while pregnant or before. However there are a few at home treatments which can help significantly:

• Ergonomics: Get your positioning correct! For everything from phone and computer use to breastfeeding, picking up and putting down the baby as well as bathing, changing and playing.
• Heat: a hot pack over the achey tired muscles can help relax and ease them off. Ensure its not too hot as you don’t want to burn yourself
• Ice: for a more numbing effect try an ice pack but take care to not leave it too long or you may get an ice burn
• Massage: deep tissue release can be very effective in temporarily relieving tired and achey muscles
• Exercise: there are many exercises that can be done to help in the longer term.  Take a look at our brief introduction to upper body and shoulder work outs to start you off. Have a chat to your physiotherapist about how to progress these on!

As with any condition postpartum if you are uncertain or your symptoms are not improving then seek out a healthcare professional to help.

The pelvis is made up of three bones. This circle of bones is shaped like a bowl with a hole and it has three joints. The joint in the front, which joins the front pubic bones together is known as the pubic symphysis (PS). It is the most stable joint in the pelvis.

Pain from the pubic symphysis is generally felt in the front part of the pelvis, right at the joint, just above the genitals.   It can radiate outwards into the hips (on one or both sides), into the groin and and/or genitals.

There can be a couple of reasons for developing this pain after birth.  During pregnancy your hormones change significantly and the pubic symphysis softens allowing it to be mobile for the baby to pass through the pelvis through the birthing process. As a result muscles and tendons surrounding will compensate increasing their workload and then become fatigued and tired and can result in spasm leading to pain.

Sometimes it may be the case that you have had your legs pushed apart to help with the birth and this can then cause the 2 sides of your pelvis to move apart pulling on the already softer pubic symphysis joint.

The key to successfully managing Pubic Symphysis Pain is to try and avoid activities that make the pain worse and at the same time build strength around your pelvis.  Things that make pain worse are often causing a shearing like force over the joint.

Some good pointers to help stop this joint shearing stress therefore stop the pain from happening:

1) Reduce step size when walking

2) Go up and down stairs one step at a time

3) Try pillow between knees when sleeping

4) Keep Knees Together When:

• • Moving from one position to another
  • Getting out of a car
  • When having sexual intercourse
  • When getting out of bed or off the sofa – see video below

If the pain is very severe on weight bearing and walking try to take some rest and put your feet up.  If need to walk then try using some crutches to help offload the area and relieve the pain hopefully helping it to settle down.

Refer to the Section ‘Pelvic Floor & Core Activation’which will help to engage your core pelvic floor muscles.  These muscles will help provide support around your pelvis reducing the effect of stresses on your pubic joint area.   Learn easy ways of how to activate them now.

First they will take a thorough history from you and do a full examination of your posture, strength, flexibility and pelvic floor core strength.  They will then be able to determine the issues that are causing the pain.  They will advise you on lifestyle modifications and then devise an individualised treatment plan which may include the following:

• Hands on treatment which when done correctly can be highly effective at relieving pain
• Custom designed exercise programme to be followed at home which will help address the issues relating to strength – some of the exercises that are commonly recommended are below
• Different modalities like hot and cold treatments or sometimes electrical pain relieving devices may be prescribed
• Various taping techniques or prescription of a bump belt support – which will be determined during your exam where the physio will take you through some specific functional stability tests.

Exercise can be of great help as we try and strengthen up the muscles surrounding the pelvis as the pelvis is the attachment site for 35 different muscles.  Some of these important muscles that provide support are the gluteal buttock muscles and adductor inside thigh muscles.  Our Symphysis Pubis Pain Relieving Exercises are shown below.  Try practicing these exercises every day to help relieve your symptoms.  If you start feeling the pain on any of the exercises do not push further into the exercise but try to do in non pain producing range. Ie. if squeeze the pillow or ball between knees if you start feeling the pain stop there and release – do not continue the squeeze through the pain.  With time you should be able to squeeze more without the pain starting.  If you feel you need more supervision and help then seek the help of a physio.