How to Run a Postpartum Pelvic Floor Evaluation as an OT

OTs in Pelvic Health Podcast · 20 min listen

If you're an OT wondering what actually happens in a postpartum pelvic floor evaluation — what you ask, what you assess, in what order, and how you handle the parts nobody taught you — this is one, start to finish.

I'm Lindsey Vestal, an OT in pelvic health, and I founded The Functional Pelvis, the first in-home pelvic floor therapy practice in New York City run by an OT. Most of my caseload was postnatal. Below is a real evaluation from that practice: a client eight weeks postpartum, ninety minutes, and the reasoning behind every decision I made along the way.

"Let's see what's possible. Then we can make the choice to diverge from it or not — but we need to see what's possible first."

I'll admit this is a hard topic for me, because of the way my brain works. I see all the nuances and the exceptions. What I love most about this work is treating the client in front of me — their circumstances, their goals, their particular set of needs. There are always exceptions to the rules, and I like it that way.

But while you're learning your way around those nuances, there's something grounding about walking through a case that's typical. Once you're comfortable with what a session can look like, you stop focusing on planning and start being genuinely present with what the client needs.

So here's one.

Meet Elizabeth

A second-degree tear is the most commonly seen tear in childbirth. It extends through the skin and into the muscular tissue of the vagina and the perineum.

In her first session she apologized profusely — for not doing her kegels enough, and for not exercising.

Holding space for the birth story

Before I get to the pelvic floor, I want to explain what I mean by this, because it matters more than almost anything else in the first session.

I've noticed that clients often start repeating the things most people ask them about. How long was your labor? Did you get an epidural? How long did you push?

You can see them go into replay mode, telling the story the way it gets asked for rather than the way they might want to tell it.

So when I notice that, I gently ask whether there's anything else about the birth they want to mention.

The emotional story. The fact that it didn't go as planned. That they were convinced a C-section was coming. That they didn't advocate for themselves when a student anesthesiologist performed the epidural, even after saying they'd prefer someone else.

Those are the things that go untold, because we assume nobody wants to hear them. And those are often the things our clients experience as traumatic.

Having a conversation about them can be profoundly healing. I'd encourage you to hold space for it in your sessions.

Starting with the system, not the pelvic floor

After her birth story, I introduce the role of the diaphragm and the breath alongside the pelvic floor. I do this for several reasons.

I want the client to know from the start that we'll be focusing on far more than the pelvic floor — even though that's why she came. I'm getting her buy-in on that in this first conversation, while helping her develop her own body literacy around whole-person pelvic health.

It also pays off practically. When we transition to internal work, I use breath cueing to evaluate the muscles, so familiarity with the concept helps enormously.

I weave in relevant statistics too — how many people experience urinary incontinence, or prolapse if it's relevant. It eases the burden of feeling like the only person in the world this has happened to. That feeling is common, and I want to put it to rest as fast as I can.

Why my pen is down

We're about 45 minutes into a 90-minute evaluation at this point.

My pen is usually down during this time, because I want to maintain eye contact and set the stage for how different a practitioner I'm going to be.

I will listen. I'll offer client-centered care. I'll weave in just enough education that she starts to feel in charge — starting or continuing a journey of understanding a part of her body she likely knew very little about.

The shape of the session

Then I tell her what to expect for the rest of our time.

Even though my paperwork explains we may do an internal exam, I ask at least two or three more times during the session itself.

And if I'm picking up any clue that she wouldn't be comfortable, or that there's a trauma history, I don't do it in the first session. I say that we could in future sessions if she wants to — and that we get so much information from everything else we're going to do together.

"Just because we have the ability to do an internal exam doesn't mean we should."

The longer I'm in this field, the fewer internal exams I actually do.

Very often the pelvic floor is the reactor, not the driver. Addressing the reactor first doesn't get to the heart of the issue, and in my experience it can create more nervous system activation — which isn't helpful for the pelvic floor at all.

In Elizabeth's case, we did decide to do one.

What I found

Perineal care, and the logistics nobody plans for

We reviewed perineal care, and I asked whether she felt comfortable doing some scar massage. We went through how to do it.

Then I asked something that matters just as much: could she imagine when and where she would do this during the week?

This isn't squeezing in a few clamshells on the living room floor with the whole family around. It needs privacy.

Clients often aren't thinking through those logistics, and the home program quietly doesn't happen. This is where I find real strength as an OT — using task analysis to remove the barrier to entry, and helping someone build a strategy around the conditions that would actually let them do the work.

When lying down wasn't working

We weren't getting far with her understanding of pelvic floor elongation while she was lying down.

So I had her get dressed — which is far more comfortable for most clients anyway — and we practiced sitting on a physio ball instead.

That gave her remarkably accurate feedback at her pelvic floor. She has one at home, so I'm hopeful she can recreate it easily and keep building those aha moments. Elongation takes time, and it's an unfamiliar feeling for most people.

We played with a lot of different cues, because softening the pelvic floor isn't easy. We hear so much about kegels and lifting and tightening that many clients have no frame of reference for the reverse.

She also had limited rib cage mobility, so we did some gentle work that was downregulating for her nervous system — thread the needle, some gentle foam rolling to open things up. Throughout, I had her check in with her breathing and her pelvic floor response, while being clear that she might not always feel it, because it's such a new sensation.

I was explicit with her that my goal for this first session was to improve her proprioception of pelvic floor coordination and movement.

Her symptoms, one at a time

The urinary frequency. She hadn't raised it as a concern, but we talked about optimal function being further down the road, because eight weeks postpartum is still early.

What I want is less and less just-in-case peeing. Early on, when the baby falls asleep on you and your bladder is screaming, you only need that experience once or twice before you start emptying preemptively — right before a feed, or any time the baby might fall asleep on you.

So I'm planting clues now about where I expect her growth to go over the next couple of months. I want her paying attention to what her bladder is telling her this week. Does she remember what an urge feels like? What about being full?

That's body literacy and interoception. We'll do more if it doesn't shift on its own, but this early I prefer to start with gentle awareness.

The leaking with coughing. This often comes back to coordination. Since we know she's both overactive and underactive, we start by connecting with the breath.

The straining. I spent time on how elongating the pelvic floor will help with bowel movements, and we reviewed optimal toileting posture and how the breath helps the pelvic floor relax.

The fear of painful intimacy. I shared what to expect in terms of norms — that over time it should become less painful each time she and her partner try penetration. We talked about healthy lube, about being open to sex being different now that she's had a baby, and about exploring her sexuality by herself first.

There's no rush to jump back in with her partner.

The guilt about kegels and exercise. We talked about that too. Kegels may not be right for her anyway, and she may not need to worry about doing them at all, so there's no reason to feel behind or guilty.

I wove in what we found on exam — right side overactive, left side underactive — and explained that we're going to focus on coordination and release first, then get the pelvic floor working together.

Getting back to exercise. We spent time on how giving herself time and space to heal would help her get back to spinning, swimming and the elliptical. Waiting now doesn't mean she'll be behind later.

We built a gradual return-to-exercise program starting with gentle walks in her neighborhood, and swimming.

I told her we would absolutely get her back to everything she loves. I just wanted her to have a rationale for why a thoughtful re-entry serves her — rather than believing she'd missed the boat and wouldn't get fit again.

That's a fairly typical postpartum evaluation through the occupational therapy lens.