The diaphragm, pelvic floor, & core in the postpartum body are an interesting topic that we are addressing everyday in the clinic, working with pregnant & postpartum moms. The interaction between these three structures in our body are important, and we want to look at them holistically and functionally how these structures affect our body. If you’re a new mama, struggling to understand the aftermath of pregnancy, and are looking to better understand how you can get back to doing the things you love by healing your body, you’re in the right place.
Postpartum Functional Anatomy
When we talk about these three structures - the diaphragm, pelvic floor, & core, we look at how they play a role in our body’s function. We call this functional anatomy. What this means is that we are not just pulling out these structures individually without considering how they work together and how they might be impacting various parts of your body as you go about your daily routines.
We think of these three structures collectively, as the abdominal canister, a word we often use in pelvic health physical therapy. To break this term down a bit more, visualize with me: the diaphragm sits on the top, the pelvic floor sits on the bottom, and the structures that sit in the middle (or the core) include structures like the transverse abdominis, the internal obliques, & in the back the multifidus muscles of the spine. These structures form the abdominal canister.
Breath Work as the Foundation
The key to the efficiency of this canister is proper breath work. We as pelvic PTs are all about breath work. There are two phases to breathing that I am sure you are familiar with, inhale & exhale.
During inhale, the pelvic floor and diaphragm move downward. The pelvic floor is lengthened and the diaphragm is shortened. If we are achieving a good inhale, we should visually see expansion at the chest and the ribs moving outward in the front, back, & sides in this sort of 360 degree motion. Inhales drive the sympathetic part of the autonomic nervous system, meaning it’s the inhales that, if we are not careful, can really drive us into a “fight or flight” state. If you are upset, or feeling anxious, we tend to take quick & shallow inhales - ultimately driving use into that “fight or flight” response. We, of course, want to avoid this state.
During proper exhale, you are supporting the parasympathetic nervous system, or the “rest and digest” system. The diaphragm & pelvic floor are both moving upward into a resting state. At the end of exhalation is when the diaphragm is at its most lengthened position. I often encourage my clients to emphasize going all the way to the end of their exhale so that they can’t get any more out - this sort of stretches the diaphragm (just like we stretch our hamstrings). We want to promote the diaphragm to move through its entire range of motion to benefit its mobility and function, which is why entire exhalation is so important.
Want to learn more about the importance of breath work? Check out my blog post here to learn more.
Exhalation Methods for Treatment
There are a couple of different ways that we can use the exhale phase to benefit us and our goals. In the clinic, I focus on more of a “passive exhale” if I am looking to work on the autonomic nervous system and achieve more of that “rest and digest” environment within their body. We work on taking nice, deep inhales and relaxing, slow flowing (but emptying) exhales. A good rule of thumb is to think of inhaling for 6 seconds & exhaling for 6 seconds. Both phases are very slow and controlled, which is very beneficial for supporting your nervous system if you are feeling stressed or anxious.
The second exhale pattern I have clients focus on is called a “forced exhale.” You can think about it as breathing out with sound. This forced breathing pattern will help to engage the core muscles, and also the pelvic floor. We sometimes use this as a training tool to help our clients meet their body where it’s at if they are struggling to consciously activate these muscles on their own. It can also be very beneficial to use during activities such as lifting car seats, going up & down stairs, carrying groceries, and getting in and out of bed. These functional movements can be a bit challenging, especially postpartum, so a good rule of thumb is to utilize the “forced exhale” to support the core appropriately.
The Three Diaphragms
Moving into more detail about the 3 diaphragms in the abdominal canister, we have the upper diaphragm, which is the throat or glottis. The mid diaphragm, which is the respiratory diaphragm up under our ribcage. Lastly, we have the pelvic floor, which sort of forms the bottom part of the canister. It’s important that these 3 structures are not only connected, but that they are in good alignment so that communication is efficient between them.
Oftentimes, postpartum moms will sit in more of a forward head posture, which happens a lot because we are caring for an infant. We’re looking down at them, cradling the baby, nursing the baby, and many more actions that drive our head down into a forward head position. If this is the position we are in when trying to breathe or restore function, our diaphragms are not going to be able to communicate very well. We need to work on posture to create safe positions to practice our exercises & support good alignment of the 3 diaphragms and restore efficient pressure between all of the structures within the abdominal canister.
It’s also important to support your body through the healing process of postpartum. One issue that often occurs is diastasis recti. This is something a lot of new moms are concerned about and if they are not applying the appropriate pressure within the abdominal canister, it makes it difficult for the diastasis recti to heal back together. Restoring proper posture and communication between these 3 diaphragms can help the body to heal in postpartum.
Fascial injuries that occur during pregnancy, labor, & delivery at the level of the pelvic floor are also common. There certainly could be traumatic injury through a vaginal delivery, but also during a cesarean section. Restoring the pressure within the abdominal canister is super important to promote healing of these muscular and fascial structures of the pelvic floor as well.
Putting it All Together
So, how does this all work together?
First, we want to look at the muscular structures themselves, including the abdominals, diaphragm, psoas, TFL, paraspinals, & multifidi. During pregnancy, as the baby grows inside of you, they are pushing and putting pressure up on the diaphragm, out on the core, and down on the pelvic floor. This is why it is so critical that we focus on these three areas to restore function in the postpartum phase, especially if someone is having negative issues following pregnancy.
Typically, if a postpartum mom is having problems, they are either going to have a core imbalance, ineffective diaphragm, or ineffective or overworked pelvic floor contributing to their symptoms. We also look beyond the canister itself, looking at structures above and below because a lot of times that’s where symptoms are going to arise. In the end, it is typical these 3 primary systems within the abdominal canister that are going to be the drivers of whatever dysfunction you are experiencing.
The Circle of Dysfunction
I developed this diagram below to help you sort of visualize how all of these systems work together in a postpartum body. It also helps me to go through the steps in my brain depending on what I am seeing in front of me with my patients in the clinic.
Notice the center of the diagram. If we have a core imbalance & an ineffective diaphragm and pelvic floor, that’s going to equal poor stability. If you are experiencing dysfunction of central stability, that is going to result in an overworked (and tight) TFL to help you stabilize your pelvis, and a tight psoas, resulting in a rib flare because it is working hard to stabilize you at the spinal level. The tight psoas results in a rib flare because the muscle itself originates in the back of the diaphragm in the lower spine. As it “swings” around to the front, if there is tension in the psoas muscle, it is going to throw your ribs forward - rib flare.
If we follow the arrow down, we see that because we have a tight TFL & psoas, and a forward rib posture, we now have decreased core control and poor diaphragmatic movement. Remember, the diaphragm sits right under the ribs like an umbrella. If the ribs are forward, the diaphragm also gets tipped forward, and now you have poor diaphragmatic movement and the pelvic floor also can’t respond appropriately.
Check out my blog post here to learn about one of the key components of your core system - the transverse abdominus muscle.
If you continue to follow the arrows, you can see how these structures just result in coming full circle, one thing leading to another and then circling back. The postpartum body, without proper intervention, becomes stuck in the state of unhealthy movement patterns and dysfunction.
Being a Catalyst for Change
When I am looking at a client in the clinic, I first visualize this circle of dysfunction and start to ask myself what kind of symptoms they’re having and try to figure out what point on the diagram I can jump in. I look to see where I can start to be a catalyst for healthy change so that all things work together like they’re supposed to.
Almost every time I am working with a new client, I start with breath work. Breathing is foundational and restorative, but it’s important to keep in mind that everybody’s breath pattern is a little bit different. With that being said, it’s important to keep in mind that my role is to be a catalyst for healthy change to support the client somewhere on that circular wheel of dysfunction.
Sometimes, that healthy change begins to happen rather quickly, but it definitely depends on the individual. It can also take some time to see results of healthy change for others as well, again, everyone’s treatment and progression is 100% individualized. I often remind my new moms that it can take up to a year for postpartum recovery and before they start to feel like themselves again.
Ready to jump in on your postpartum recovery journey? Check out this video here, where I take you 4 gentle movements to promote postpartum healing.
Moving Toward Healing
Let’s finish up with some key points to keep in mind. First, we don’t want to leave those dysfunctional movement patterns in place with our postpartum moms because healthy change is much less likely to happen. As pelvic PTs, we are always looking for what the client is currently doing to be driving or supporting these dysfunctional movements. We look to see how we can jump in to start to change that dysfunction to help your body to restore itself.
At the end of the day, we are looking for healing, we are looking for restorative movement, and we want to start to instill those automatic movements & automatic motor patterns so that the body starts to do the right thing without having to intentionally think about it.
Trust me, it will happen. It is very important that we as pelvic PTs, help to develop a good exercise program for you that emphasizes repetition to start to build in that automatic piece to help get you moving and back to feeling like yourself again.
If you'd like to watch the video associated with this blog post, check out the link here.