Transcript  

Dr Sam Manger  0:00   

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the Traditional Custodians on the lands on which this podcast was recorded, and the Traditional Custodians on the lands and waters on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander Elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people. 

[INTRO] Melissa Billiau  0:20   

The main difference for a woman who’s had a cesarean compared with a vaginal birth is really that they may not return to core exercises quite so early. But other than that, the recovery is not too dissimilar, and I do encourage women to be quite slow with returning to those higher impact exercises. 

Dr Sam Manger  0:33   

Hi, I’m Dr Sam Manger, a GP, and your host of this series, The Clinician’s Guide to the First 2000 Days, brought to you by the Queensland Government through Health and Wellbeing Queensland.  

Prevention across the first 2000 days offers an opportunity for healthcare professionals to support generational health improvements, but preventative health will only be successful if it is done with confidence and empathy and an evidence base.  

Over the course of this series, I will be talking to some of Queensland’s leading experts to explore how they discuss preventative health and how to create meaningful change for the next generation. Let’s get started. 

Today I’m talking to Dr Sarah Thomas and Melissa Billiau on women’s postnatal physical and mental health. Dr Sarah Thomas is a registered psychiatrist at the Mater’s Katherine House, the State’s first dedicated inpatient facility for new mothers experiencing perinatal mental health challenges. Melissa Billiau is an Advanced Pelvic Health Physiotherapist with over 12 years’ experience. She’s the clinical lead in a primary health clinic at Ripley Satellite Hospital.  

Thank you both for joining me, Sarah, Melissa.  

Dr Sarah Thomas  1:45   

Thank you for having us.  

Dr Sam Manger  1:46   

Let’s start with a bit of core knowledge, good old physiology. Melissa, what physiological changes occur in a women’s body immediately after childbirth, and how does the postpartum hormonal state affect a woman’s muscles, joints and overall strength and ability?  

Melissa Billiau 1:59   

Really good question. I’ll sort of split it up into hormonal effects and then more of the musculoskeletal effects. So hormonally, there’s a really big change that happens in that early postnatal period. So, throughout the pregnancy, levels of oestrogen and progesterone are significantly high, but once the baby is born, these levels do drop quite dramatically, which has a significant effect on the mum.  

These levels usually drop around that day three, day four, postnatally, and is one of the big contributors to those big, uncontrollable emotions that can be seen at that time. The low levels of oestrogen and progesterone will continue throughout that fourth trimester, so really right up until 12 weeks, postnatally, but actually can even go a lot longer, particularly for mums that are breastfeeding or exclusively pumping.  

These low levels of oestrogen contribute to low mood, anxiety, vaginal dryness, pain with resuming intercourse, musculoskeletal changes, you know, the list could go on and on. So, they’re very, very significant throughout this time. Other changes that happen, in that physiological changes that happen, in that early postnatal period are, of course, the big musculoskeletal changes. You know, mum has had a growing abdomen throughout the pregnancy, which then drops once baby is delivered. Those abdominal muscles that have been stretched throughout that time, obviously have to regain their tensile strength. They have changes to their posture, including increased lumbar lordosis, the weakening of glutes often happens, a weakening of the hamstring muscles, on and on.  

So quite significant changes that happen throughout that time. Throughout the pregnancy, our pelvic floor muscles have undergone a significant strain with baby sitting right on that area, and then, obviously with vaginal birth, they’ve undergone a very significant stretch, up to, I think 300% has been recorded, increased length of the muscles. So obviously, with a vaginal birth, there is that added stretch, and in some cases, trauma to these muscles and also the nerves in that area that can contribute to a weakening and a dysfunction of these pelvic floor muscles. We have very good evidence to support pelvic floor muscle training throughout the antenatal and the postnatal period to improve this, which in turn improves symptoms in bladder and bowel and sexual function.  

Dr Sam Manger  4:12   

Yeah, great. And we’ll get back to management a little later, because that is critically important. How we can help women recover from that, as you say, fairly significant period of their life. And as you highlighted there, this diffuse role that can happen both musculo-skeletally but also psychologically. And this brings us really, to your area of expertise, Sarah. You know, the two sides of the same dice that is the complex human, the mind and the body. What are the changes that we may not be able to see, those that are psychological? How prevalent is perinatal mental ill health and what’s its potential impacts on both mothers and infants? 

Dr Sarah Thomas  4:44   

Perinatal mental illness is probably a lot more common than most people realise. We see postnatal depression in between one in five, to one to seven women. One in five women will develop an anxiety disorder across the perinatal period. Postnatal psychosis will affect one to two women in 1000, and bipolar disorder affects one in 100 people in Australia, and often, women will experience their first episode of a bipolar disorder in the postnatal period.  

So, as Melissa discussed, following childbirth, there is a dramatic drop in oestrogen and progesterone, which does lead to drastic mood swings and can predispose to developing symptoms of depression and anxiety. This is what we see when people talk about the baby blues. Often starts around day two to day three, and often women will experience uncontrollable crying sadness.  

They can have significant disruption to their sleep outside what is expected of having a brand-new baby, and women can feel, often quite disconnected from themselves and their baby. Generally, this resolves within two weeks, but if it persists more than two weeks, we start thinking more about, is this a postnatal depression?  

Dr Sam Manger  5:56   

So, you said there one in five can suffer from sort of postnatal anxiety and depression, and depression, and then obviously, smaller rates for the more severe mental illnesses. Is there a flip of that where there’s some women who get better mental health?  

Dr Sarah Thomas  6:08   

Yeah, so there are some women who have preexisting mental illness who actually see an improvement in their symptoms throughout pregnancy. I would say that they’re generally not the people that are referred to me. A lot of the women that I’m seeing are women who, unfortunately, have ceased their psychiatric medications because of the pregnancy and have experienced a significant deterioration in their mental state secondary to this. So, it’s what we see a lot of unfortunately.  

Dr Sam Manger  6:37   

So, what’s your approach to assessment for these women, and are there screening tools we can use for postpartum depression or anxiety or the other psychiatric conditions you mentioned. 

Dr Sarah Thomas  6:45   

Yeah. So, the most commonly sort of used screening tool within the Australian healthcare system is the Edinburgh Postnatal Depression Scale. This is a 10-item questionnaire that asks women to rate their feelings over the past seven days and is scored for a total score out of 30. This looks at symptoms of postnatal depression and anxiety and should be completed the first booking visit and should be repeated in the second trimester. This is usually done by the midwives and obstetricians, but also GPs are able to do this. These tools should be repeated at least once in the postnatal period, around the 6 to 12-week mark, and should be repeated again later on in the first postnatal year. It’s important to note that these are screening tools only, so if women are screening positive on a screening tool, they should be referred for further assessment. That assessment should be completed, usually by a GP in the first stages, but can also be completed by psychologists, psychiatrists and other trained mental health professionals, depending on the settings in which these women are being seen. 

Dr Sam Manger  7:43   

Excellent. Are there culturally specific tools that one can use for First Nations people that also screen for these things?  

Dr Sarah Thomas  7:48   

Yeah. So, there is a specific tool that’s been developed and validated for use with the First Nations population, which is the Kimberley Mums Mood Scale, that’s freely available online, and the Edinburgh Postnatal Depression Scale has been translated into a number of different languages, which, again, is available freely online.  

Dr Sam Manger  8:08   

Excellent. That’s great. Thank you. And does the Edinburgh tool also include sort of risk to self, risk to child, within the questions, or is that something we should add on top?  

Dr Sarah Thomas  8:17   

So, the final question, question number 10, asks specifically around risk to self if women answer positively to that question at all. So, the Edinburgh will ask for a response out of four different responses and is a score between zero to three. If a woman scores one, two or three around the question for self harm, they should have further assessment prior to leaving the office in which they have completed their screening tool in the postnatal period, we need to ask specifically around any thoughts around harming the children.  

Dr Sam Manger  8:46   

Yeah. Okay. Very important. Thank you. So, if there are symptoms of postpartum depression or anxiety, what are the strategies, components of management, and who else should we be involved? You mentioned we might start with the GP as an initial assessment, which makes absolute sense. So, what’s the wider team and what’s the management part of this? 

Dr Sarah Thomas  9:04   

So, management will really be guided by the severity of the symptoms, but also the support and resources available within the network that a woman is in. So as with all mental illnesses, we always like to focus on the practical supports to start with, as well as sort of the biological care of these people. So, ensuring adequate nutrition, sleep, although difficult with a baby, encouraging women to sleep as much as they can, as well as limiting their use of substances and exercising when safe to do so for mild to moderate cases. Psychotherapy is the first line treatment for both depression and anxiety. There are a number of perinatal psychologists, but also public services which women can be referred to for specialist perinatal psychology support that can be accessed with a mental health care plan at no charge to women for moderate to severe cases. Often, women will require psychotherapy plus medication, that medication depending on the condition to be treated that we have a number of medications which are safe to use in breastfeeding. For specialist advice, or for very severe cases, specialist advice should be sought. And we have an increasing number of perinatal psychiatrists in Brisbane with the advent of Katherine’s House. But I would suggest GPs to all phone for advice if you’re not sure what to do in rural and remote areas, there is the EPIM service, which is a tele psychiatry service for perinatal and infant psychiatrists for women living outside of the metropolitan areas as well. 

Dr Sam Manger  10:40   

Excellent. You summarise those three core pillars, the lifestyle, social factors, the psychotherapeutic factors, and obviously the pharmaceutical or medication factors. And I think it’s worth saying, and I can have some anecdote here as a GP, that there is a lot of hope there, because treatment is quite effective, and women can get a lot of relief and improvement of their mental health. So, it’s important to highlight that with the social part as well. Do you find it quite important to support women in a sort of peer support or social connection, or women’s group or community sort of element? Is that often a part of your management plan? 

Dr Sarah Thomas  11:14   

Most definitely, we know that being at home with a newborn and a young baby can be incredibly isolating, and so having women increase their social connections often through mother’s groups is a quite an easily accessible way to access that social support. There are also a number of organisations that do peer support, specific mental health support. Peach Tree is one of my go-tos. They run a number of different programs, and they are a lived experience, peer workforce, so very helpful at supporting women.  

Dr Sam Manger  11:45   

Fantastic. That’s Peach Tree for the listeners out there. And what about the third wheel here, dads? So, I’m a dad. I’m a dad of three, so I had to throw this question in. So, what about the new pressures on dads? Because obviously there’s a huge amount of going on for the mother and the child. But what about those changes, pressures on Dad, the changes to the relationship dynamics and the role that the partner can play in supporting this whole process? 

Dr Sarah Thomas  12:09   

Dads are often forgotten a lot in this space, which is something that we’re trying to change, and we know now that up to 1 in 10 fathers will experience postnatal depression. Unfortunately for dads, really their experience of parenthood begins with the birth of the baby. They haven’t really had the same experience of preparing for delivery of the baby like the mums have, so it’s often a bigger adjustment for fathers once baby is here.  

Dads often are having to go back to work a lot earlier as well, so they have to very quickly adjust to the new roles and responsibilities within the household but also juggling parenting and returning to work quite quickly. Dads also will vary a lot in their confidence in handling the baby, and often will be quite anxious in feeding, bathing, settling baby, but they should be encouraged to do so, because we know the benefits of having dad involved in caring for the baby, not only for building that bond with dads, but also the benefit of that on baby’s brain development.  

Dr Sam Manger  13:05   

Yeah, absolutely, I think is it, do we know much about the, sort of, role of oxytocin in this? Because, as you highlighted, the mother has the whole pregnancy to, feel and get used to the idea of the baby, and there’s that bonding, hormonal connection that’s going as well as the sort of psychological bonding, and that builds with breastfeeding and continued support, but with men, that’s not around so much, and it takes us, sort of, 6-12, months to really feel a sort of deeper bond, potentially.  

Dr Sarah Thomas  13:30   

Yeah, it often will take fathers a lot longer to develop that bond and attachment with their baby, which is why we encourage dads to be involved as much as possible, including helping with feeding where possible, but all of the tasks of looking after the baby, not only to help their bond with a baby, but also to help out their partner as well. 

Dr Sam Manger  13:51   

Yeah, absolutely. And it’s good to somewhat normalise that process. You highlighted before, the key pillar there of lifestyle determinants and lifestyle approaches, and there’s significant evidence things like physical activity and diet and sleep can improve mental health and physical health, and so when we consider that lifestyle behaviours can impact this so significantly. Let’s get a little bit of context. Melissa, if we can about when we can use these approaches safely, what are the typical timelines for postpartum recovery, and how soon can a mother safely return to exercise after different types of birth, whether it’s vaginal delivery or C sections.  

Melissa Billiau  14:23   

Yeah look, it’s really different for every single woman, and it depends on their experiences, you know, physically during pregnancy, even before pregnancy, and what sort of things they were doing at that time as to how they can recover. You know, that early period in the first sort of couple of weeks after having bub it’s really about adequate rest, and not necessarily about doing anything in particular, but actually being forced to lie down and rest their body and allow their body to heal in the best place it can. You know this is particularly important for women who have laboured and birthed vaginally.  

But then for women who have had a cesarean, you know that supine rest is really very, very beneficial. It’s important to, you know, reduce the physical pressure on the perineum, especially if there has been a tear there with stitches, we want to avoid friction and pressure there while it’s healing. It also helps to reduce the swelling and the inflammation that can occur in that area, particularly if we’re just sitting all the time, as opposed to if we can lie flat, we really allow that to flow and get flushed out throughout the lymphatic system much better.  

You know, the pelvic floor, as we said, is already a very weakened and stretched area, and the amount of weight down through that area, even if we’re just standing for long periods of time is really quite significant, let alone if you’re including holding a baby and trying to settle a baby. So, using that network around you is very, very important to allow mum to have that break. As we go on throughout the recovery time, after a couple of weeks, should start feeling a little bit better, and the pain from birth is starting to ease, and the swelling is starting to get better, and mum may want to then start engaging in a little bit more physical activity, which is wonderful, and we really encourage that, just being mindful that, you know, as we start to re engage in exercise, it is really gradual, and listening to the body is really important.  

So, as a very general guideline, I’ll say sort of around two to four weeks. You could start doing some short walks, maybe around the block, maybe, you know, 10-15, minutes. But really, you know, tuning in to how your body is feeling, and if there’s any of those signs of vaginal heaviness or pressure or bulging, then that’s the indication that you’ve done enough, and it’s time to go home. And the best thing you can do when you get back home, as we said before, is to go and lie horizontal, maybe even with your legs elevated, or a pillow under your bottom, just to allow all of that pelvic area to have a really good rest.  

And that only has to be for 10-15, minutes, but can have a significant effect on the recovery as we start to get back into exercise throughout this early time. Of course, we’ve spoken about the pelvic floor muscles as well that are really important to be doing regularly and it’s, you know, coming into these two to four weeks, it is about starting to rebuild up that strength now. So, working the muscles a little bit stronger and adding in, you know, holds or pulses throughout this time is very effective for regaining that strength and functional activation. 

We also include exercises, just low-level exercises for your back pain and thoracic pain that might be occurring with holding baby all the time and those sorts of things just recovering from being pregnant as well. So, this is all very important.  

In this early time, after around six weeks, we start to see that things are starting to feel much, much better. And you know you’re feeling like you want to do a bit more, generally speaking. And we progress those exercises very gradually, but building them more into gravity load, adding more core exercises in at that time, increasing walking distance gradually, but still being very mindful of not doing anything high impact. We don’t want jumping at that stage. You know, running at that stage is probably a little bit too much. And just as always tuning back in and reflecting again, you know, how is the body recovering, and how is the body feeling?  

And obviously, any of those signs of, you know, might not even be heaviness anymore, it might be signs of incontinence. Are those symptoms that actually, that’s too much, we need to bring that back. You know, the main difference for a woman who’s had a cesarean compared with a vaginal birth is really that they may not return to core exercises quite so early. But other than that, the recovery is not too dissimilar, and I do encourage women to be quite slow with returning to those higher impact exercises, even for a cesarean delivery 

Dr Sam Manger  18:39   

Stay with us. We’ll be right back to continue our conversation. 

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Dr Sam Manger  19:10   

And now back to the conversation.  

You mentioned some really important principles there, the first being rest, which can be quite hard to any human to accept at certain periods of their life. As much as we may know we need it or want it, it’s still hard to stop sometimes. So that’s to be encouraged, normalised, supported, celebrated, especially in those first couple of weeks.  

Then you mentioned around the two, four-week mark, there’ll be probably an organic sense that people can start moving more freely, and that’s where you can start bringing holds and walking, and a few basic exercises, like you mentioned, core exercises, but we’re going to avoid the high impact exercises. You mentioned another principle there, which is really important is around tuning in, that listening to the body, that listening to the whispers of the body. Super important, something we can all learn from. So that’s that’s a great sort of idea. When do you think, you mentioned the high impact might come a little bit later. Is there an average for, is that sort of 12-week mark?  

Melissa Billiau  20:01   

Yeah, look, it’s a real, very generalised guideline, but yes, around that 12-week mark is when we tend to see some of the hormones maybe starting to increase again. And we think, you know, you’re looking at a little bit more of a safer recovery time from musculoskeletal tissues, perineal tears, cesarean scars should be relatively healed and strong at that time, but this is all assuming the woman has that background exercise tolerance and is able to progress into that very, very safely as well. So, we always recommend having a pelvic health physiotherapist review to allow that sort of really specific guidelines on how that recovery should commence and re engaging of high impact exercise. But yes, as a general rule, we will say around that 12 weeks is when we can start to consider re engaging in those higher-level activities. 

Dr Sam Manger  20:50   

And what are signs that may either indicate that things are going well or they’re not going so well? So, you mentioned there around potential incontinence might sneak in or may not resolve. So, what are some signs that we need additional support, particularly regarding C sections or perineal tears or pelvic floor strength you measure incontinence or the various other concerns a woman can have?  

Melissa Billiau  21:12   

Yeah, I think the really big signs in those early periods like we spoke about, is those vaginal heaviness symptoms, those pressure feelings are really important to listen to and take a break from and get further advice as needed, which might be a GP or a physiotherapist. Of course, any signs of incontinence is really important that’s getting looked at and getting referred really early on, as soon as possible. Even urinary frequency or urgency should be, you know, addressed, as well as any sort of bowel issues.  

If there’s any feacal urgency, particularly if there was any element of a third- or fourth-degree tear, where the tear has developed into that anal sphincter, it’s important that we’re really asking the patient about those symptoms and getting those looked at really early on, you know, from other warning signs. I guess, in terms of the recovery of a cesarean tear or a perineal tear, we need to be asking those infection questions as well, making sure there’s no untoward pain or signs of odour or any personal signs of infection in that area, and getting those addressed as soon as we can. 

Dr Sam Manger  22:18   

So, fever, general unwellness, as you say, pain, discharge, increasing and so on. Are there any, you mentioned kegel exercises before? So are there any specific movement recommendations or exercise recommendations that seem to be sort of perennially true or pun intended, I suppose, but the, is that can be helpful regardless of where a woman’s at. So, are there specific pelvic floor muscle exercises you would just recommend, pretty much for most people?  

Melissa Billiau  22:18   

Yeah, absolutely. So really quite early on, you know, even in the hospital, if everything was going well, once the catheter is removed, if a woman does have a catheter, it’s great to start some gentle movement in that area of the pelvic floor muscles. And that might be just really gently, sort of trying to engage and squeeze the muscles around the back and the vagina and then letting it go. And this can help with, you know, blood flow and swelling in that area, which, of course, helps to promote healing. And it’s not doing, you know, 10 repetitions, five times a day, or anything like that, but just a couple every now and then, just to keep that area moving can be really beneficial in that early time, as I said, after a couple of weeks, we’re then starting to really more focus on the strength side of things.  

And then we might be adding in quite structured regimes, which might look like, you know, exercises, try and do them three or four times a day, that the regularity is really important. They’re a small muscle group, but they need to be exercised regularly. And adding in those holds.  

And we often use bub’s age as a bit of a guideline as to how long you might be holding for. So, if bub is one week old, we encourage the woman to try and hold the muscles for one second. And as bub is two weeks old, we hold the muscles for two seconds working up towards 10 repetitions in a row is a very good guide. Usually around that three, four-week mark, we sort of add in those stronger pulses where it’s more of a try and like, squeeze lift, let go, squeeze lift, let go, which is more around those side of coordination of the muscle.  

Dr Sam Manger  24:12   

Yeah, fantastic. And as you say there, there’s sort of, rather than being regimented or too strict around doing it X number of times a day, it’s when opportunity arises, by the sounds of it. So, you know, you might be boiling a kettle, or you might be doing something like that. Now’s the time for my exercises and so make it a part of your life.  

Melissa Billiau  24:29   

Yeah, absolutely. But it can often be the thing that gets forgotten about too, as busy mums are busy looking after a new bub and… 

Dr Sam Manger  24:36   

Of course, sleep deprivation.  

Melissa Billiau  24:38   

Oh, yeah.  

Dr Sam Manger  24:40   

So are there any resources you would often recommend around that, Melissa, specific to exercises? And then Sarah I’ll ask you about mental health resources. But is there often you find handouts or reliable resources, or even, dare I say, reliable YouTube channels that may be a pelvic floor physio set up or things like that? 

Melissa Billiau  24:57   

Yeah. I mean, we really are so fortunate with the increased availability of digital resources that are around now. A lot of the handouts that we use are from the Continence Foundation of Australia website, and they’re all online so women can access them themselves or Pelvic Floor First is another very reputable website, which goes through guidelines on recovery back into exercise with a weaker pelvic floor and gives ideas on what exercises are suitable at different stages of the postnatal period.  

There are a number of apps on our smartphones, and if you put in just a simple search of postnatal recovery or postnatal workout, there will be a stack that come up. Empowered Motherhood is a program by an Australian physiotherapist and includes pregnancy safe workouts and postnatal workouts. And of course, as you said, good old YouTube absolutely has some not so bad guidelines on recovery and little routines of what women can do in those early postnatal periods just to start moving, which is so important.  

Dr Sam Manger  25:58   

Yes, it’s interesting, YouTube has a bit of a bad rep, but the reality is, there is some bad stuff on there, a lot of cat videos, but it’s also, there are some very qualified physiotherapists, for example, who do set up channels and do make some reasonable recommendations. So, if we can filter those for our patients a little bit, that can be helpful.  

And Sarah, what about for the mental health side of things? What support systems and resources? You mentioned a few already around peer support, which is fantastic, but for that perinatal mental health period that health professionals can access, or that the public can access. 

Dr Sarah Thomas  26:26   

Yeah, so it’s really important for healthcare professionals to be aware of what’s available in their area, because it does vary even from the north side of Brisbane to the south side of Brisbane, but we are very fortunate there’s a relatively new service available that’s called ‘ForWhen’, it’s a national service, that can be accessed by families, carers and healthcare professionals, and helps navigate people to the right support, really, so healthcare professionals or patients can ring and describe what’s happening for the mum, and they’ll be directed, really, to the right place.  

My two really favourite online resources are COPE, which is the Centre for Perinatal Excellence. It has a wide range of information for both healthcare professionals as well as patients, including a really lovely section for fathers. My other go to resource is PANDA, the Perinatal Anxiety and Depression Australia, which, again, is a fabulous resource for both families and healthcare professionals. PANDA also operates the only national perinatal mental health helpline, which is open for extended hours from Monday to Saturday and is staffed by volunteers as well as trained professionals.  

So again, families, patients as well as healthcare professionals, can ring that helpline. The Gidget Foundation is another really valuable online resource that although they provide tele-health psychology sessions, they also have free online groups which women can join, and these are often peer support led groups, and they have a wide range of them, depending on how old women’s babies are. So again, another really valuable resource. 

Dr Sam Manger  28:02   

That is fantastic. It’s very heartening to hear actually, how many support services there are, especially in that tele-health peer support component, because obviously a lot of people in Queensland are not necessarily based in a major city. They’re based in regional hubs or rural and remotely. And so having those online/digital/tele-health services available, super important. So that’s really great to hear pregnancy and obviously postpartum, the period afterwards, is at very least, a highly special time, and many, I would think, a fairly sacred time of life. And that brings in a wide variety of different beliefs and practices around this period of life, especially from different cultures.  

And Sarah, how do we address sort of cultural beliefs and practices that may influence how people perceive mental health or the postpartum period or pregnancy so that we can make sure our advice is helpful, hopefully valuable, but also sensitive and tailored? 

Dr Sarah Thomas  28:52   

It’s really important for us working within this space to recognise that sort of our western model of pregnancy and postnatal period is often very different to other cultures and how they really prepare for parenthood and manage the postnatal period.  

Often, there is significant stigma attached to mental illness within other cultures, and so often, women will not feel comfortable discussing their symptoms and can often present a lot later than other women that we are seeing, and often with more severe symptoms. So being really mindful around asking specifically what women are experiencing. And often women will not feel comfortable talking about mental health symptoms in front of other family members as well, so that’s something that should always be considered.  

Something that I do see, unfortunately quite often, is the lack of interpreter use as well. So, for anyone working with women of culturally and linguistically diverse backgrounds, interpreters should be offered for every consultation, especially when talking about some of the more complex mental health symptoms, including thoughts around suicide.  

It’s really important that we’re sure that women are understanding what’s being asked of them. The other really important thing, I think, to note is when we’re looking at women and how they are functioning across the postnatal period, for us, what may seem like symptoms of significant perinatal mental illness, including not wanting to really look after the baby.  

Often, within certain cultures, it’s quite normal for the extended family to take over the primary care of the babies, especially in the early stages. And that’s quite normal and expected. Something I saw really commonly in Covid, which I hope we never have this experience again, was with our closed borders, I had a lot of women from different cultures who had significant perinatal mental distress because they weren’t able to have their families over here with them, and that is really devastating for women who can’t have that expected cultural experience of parenting.  

Dr Sam Manger  30:57   

Yeah, another key point there, as you mentioned, is there’s clearly going to be a difference in diversity in beliefs and practices and so important just be aware of that ‘full stop’, and be aware of the potential stigma that may be aligning around, you said, around potentially perinatal mental health concerns. And it would seem to me that “normalising it” with a tool like the Edinburgh tool that you mentioned helps just bring it into routine practice, so it’s not seen as something that they’re being singled out for. This is just part of routine care. We just screen for this, and we check for this, which is a good thing to do. And as you say, using interpreter is absolutely key. You mentioned that sometimes there can be pressure on women, and they may be with a family member, so this is a nuanced question, but do you, as a psychiatric clinician, sometimes ask to see the woman alone if you feel that there may be that element to it? 

Dr Sarah Thomas  31:43   

Definitely. I always like to start by asking the women that I’m seeing what they would like. If I’m getting the sense that there are things that I need to talk about with them on their own, I will often ask at the end of the consultation; do you mind if I have a few moments with you on your own? Obviously, that needs to be done really delicately, especially with women who are in domestically violent relationships, so it’s often a very nuanced way of conducting these assessments. 

Dr Sam Manger  32:14   

Excellent. Thank you. So now if we zoom out a little bit from the really important, obviously, the mum and bub and dad’s sort of perspective, and think about us, the health providers and the health professionals who are helping, this can also be, you know, difficult period for us as well to help women through this.  This can be a lot of stress, a lot of, as you say, a nuance to it. So what are some self care strategies for healthcare professionals working with perinatal populations and to maintain our own well being?  

Perhaps, Melissa, we could start with you and then Sarah. 

Melissa Billiau  32:41   

Look, it can be a really challenging time, and it’s obviously filled with a lot of emotion and a lot of prioritisations for looking after bub. And often, you know, Mum can be forgotten about. And I think you know, when we are dealing with these big emotions and these big challenges, you know, if a mum’s experiencing faecal incontinence, for example, then you know she’s very distressed. But you know, as a healthcare professional, I think managing that within a team is sort of the best way and being able to appropriately debrief and, you know, have those collaborations with your team, on those complex patients, on how you can better support them and support each other, which I’m very fortunate to have out at Ripley. 

Dr Sarah Thomas  33:20   

Yeah, as Melissa mentioned, and yourself Sam, working with this population can be incredibly emotive and challenging at times, and we have the benefit of working with families in the highest of highs, but also alongside that, there are the lowest of lows, and it’s really important that healthcare professionals have regular clinical supervision to talk through the difficult cases that they do work with. Some healthcare professionals end up, and I’d say that this is quite common, having their own psychotherapy to cope with the stresses of of this work. We should practice what we preach. It’s incredibly important for us to be really looking after our physical wellbeing and prioritising the lifestyle factors of adequate nutrition, sleep and exercise, and limiting our reliance on unhelpful coping strategies such as substances, including alcohol. 

Dr Sam Manger  34:15   

Don’t go anywhere. Our conversation continues after these messages. 

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Dr Sam Manger  34:46   

And now back to the conversation.  

And that point there, around there’s no shame in needing help yourself is a really key one. It’s to normalise that that actually it’s probably a good thing if most health professionals did have their own person that they connect or relate to, whether it’s a therapist or a peer support network, or another colleague, as you say, or a supervisor or so on, so a key component of all of our health going forwards. 

Dr Sarah Thomas  35:09   

Most definitely, and it helps you be a better clinician.  

Dr Sam Manger  35:13   

Absolutely, the lived experience itself and the reflection as well, crucially important. All right, so let’s start with a little bit of core knowledge, good old physiology. So, Melissa, what physiological changes occur in a woman’s body immediately after childbirth, and how does the postpartum hormonal state affect a woman’s muscles, joints and, of course, therefore, overall function and strength? 

Melissa Billiau  35:32   

Yeah, thank you, Sam. I mean, that’s just such a big question, and there’s just enormous amount of physiological changes that occur in that that woman’s body immediately after childbirth. One of the big changes that occurs is quite a significant drop in our hormonal levels, particularly of oestrogen and progesterone.  

These have been quite high throughout the pregnancy, and then usually around that sort of day three, day four, we get this really quite significant drop in those hormones, which has a number of effects. But often around that time, we can see those big, uncontrollable emotions that can be linked in with those hormones. So those low levels of oestrogen and progesterone continue throughout that fourth trimester, you know, up until 12 weeks of postnatal period. And actually can go for even longer in a mother that is breastfeeding or pumping.  

And this is particularly relevant when we start talking about return to exercise and the effects of these hormones on these on the musculoskeletal system. So, oestrogen within our muscles and our joints allows for an increased collagen content in our connective tissue. This increased collagen provides a lot more elasticity through our muscles and tendons and our ligaments, which is actually really protective for reducing the risk of tearing or damage.  

So, when these oestrogen levels are low in this postpartum period, our muscles have a lot more stiffness to them. And therefore, if we are to go out and engage in sort of higher intensity exercise, they’re a lot more likely to tear in that early period. If we think more about the pelvic organs such as the bladder and bowel and the uterus, they’re a lot more stiff as well.  

So, you know, again, if we’re engaging in those higher impact exercises in that early postnatal period, there’s just that higher risk of a little bit more trauma to that area. So, encouraging that gradual return is really, really important in that time. Other big physiological changes, obviously the most obvious one is increased stretch on the abdominal muscles throughout their pregnancy, and then after birth, those muscles have to return to some sort of state, which takes time and is often something that can be a little bit distressing to mums.  

So, we need to do that really respectfully. The term that’s often used to describe this stretch of the muscles is a DRAM or a diastasis rectus abdominis muscle, and I think often as health professionals, you might hear terms such as the muscles have been torn or there’s a widening or a separation of these muscles. And I think we need to be really careful with how we’re describing what has happened here, because it can be quite distressing for the mum. We know that usually around that six-to-eight-week mark, these muscles will have recovered really, really well. And actually, you know, the functional implications are very low. If there is a slight thinning of that, it’s the linear alba between our sort of six pack muscles that causes that appearance.  

The main effect that we understand now from the evidence that has come out is that it really is aesthetics disturbance, as opposed to anything functional from a low back pain point of view, or any implications with, you know, bladder or bowel health, those sorts of things.  

The other big physiological change is our pelvic floor muscles. They’ve undergone a huge amount of strain, you know, just through the pregnancy alone, with the extra load on that area. And then, of course, if there’s, you know, a vaginal birth, even if a woman has laboured and may not necessarily have progressed to a vaginal birth, the strain on that area is very, very significant. But of course, if a woman has had a vaginal birth and maybe with a perineal tear or an episiotomy, where they cut the tissue, the extra trauma to that area is increased. So, these muscles are really important for protecting our bladder and our bowel function and our sexual function. So, it is important that we’re restoring those muscles to a good level of strength and function after we have bub. 

Dr Sam Manger  39:06   

So, Liss, you mentioned there around the sort of timeline for recovery and building back in some form of exercise, you know, two to four weeks gentle and then up to 12 weeks high sort of impact. Where does sex fall into that category? Because obviously that’s quite important for many people. 

Melissa Billiau  39:21   

Wonderful question. I mean, such an important part of the relationship dynamic, which we know changes quite drastically after you have a baby anyway. And I think penetrative intercourse is certainly one thing we’ll talk about. But I think re engaging that relationship dynamic and making changes where needed to still be intimate with each other, but maybe not necessarily around that actual penetration is really important consideration and using, you know, just cuddling and holding hands and all those sort of nice things that should happen, you know, can happen within a relationship.  

Typically, I guess, if a woman is feeling well, we will say, you know, once, once your vaginal bleeding has stopped, and if you’ve had a vaginal tear, you’ve had it checked for healing and recovery, and those sort of things, which can be around that six to eight week mark, you are safe to resume intercourse. Many women do not feel ready at that time, and really making sure we’re supporting them that actually, that’s absolutely okay.  

And these are conversations you need to have with your partner, and communication is really essential at this time. But when a woman does feel ready, I do encourage them to use a really good lubricant and a good amount of lubricant. It’s quite normal to be a little bit dry just from the hormonal changes, but also just the concern or worry around resuming that intercourse can add to that. And I encourage the mum to be in control that she’s controlling the speed and the depth and making that as a positive experience as possible, and it’s not unusual to feel a bit of discomfort the first few times. But the important thing is that that’s getting better as they continue to engage in intercourse. And if it’s not, then they need to be asking for some further assistance, either from their GP or a physiotherapist. 

Dr Sam Manger  40:56   

And a pelvic floor physio is the right place to go for that as well.  

Melissa Billiau  40:58   

Yeah, absolutely. So a pelvic floor physiotherapist, you know, can help whether it’s an overactive pelvic floor that might be contributing to some of these symptoms, and it might be just teaching the woman to be able to relax those muscles and let go instead of tensing and holding on during that time.  

Sometimes other interventions are required, which might be things like vaginal dilators just can help to passively stretch that area, or sometimes vaginal stimulation using a tens machine, can be really effective if it’s more from a pain response that might be occurring. 

Dr Sam Manger  41:29   

So, thank you so much Melissa and Sarah for joining me today for this very important topic, and thank you for your excellent work. 

Dr Sarah Thomas  41:34   

Thanks very much.  

Melissa Billiau  41:35   

Thank you.  

Dr Sam Manger  41:37   

Today, we’d be talking to Dr Sarah Thomas and Melissa Billiau about the physical and mental health changes that occur for women post pregnancy. 

For more information on today’s topics, visit the Health and Wellbeing Queensland website@www.hw.qld.gov.au. 

If you’ve liked today’s conversation, be sure to subscribe for future episode updates. We’ll see you next time on the Clinicians Guide to the First 2000 Days.