Aim: To explore how fertile women with symptomatic pelvic organ prolapse after vaginal delivery
 experience their daily physical active life.

An inductive, text-driven approach was taken, selecting thread posts from an internet forum written by 33 women. The data presented in this article stem from a larger empirical data that explored fertile women's experiences of symptomatic pelvic organ prolapse (sPOP) after vaginal delivery (VD). Data were processed using qualitative content analysis. The data consisted of chains of questions and answers or comments on the topic of sPOP, posted on an online forum by fertile women who had experienced sPOP after VD.
 	
All materials published on the forum are public and no password is required to read thread posts. However, registration is required for writing own posts and communicating with other members. Prior to the data collection, the forum’s web operations manager and management team were contacted and informed verbally and in writing about the study. Written consent to undertake the study was obtained from the operative manager. Moreover, an information letter with details about the study’s aim and structure and about confidentiality, the voluntary nature of and right to withdraw at any time without explanation was sent to the forum manager to be published on the forum’s website.

The theme “Ruined active life” showed that many of the fertile women experienced that their active lives were ruined because of unexpected physical limitations caused by sPOP. They found themselves balancing being a parent and being disabled because of sPOP. Bothersome symptoms like vaginal heaviness, fullness, soreness and pain were aggravated by many basic daily activities, generating fear that any action involving physical activity might worsen the situation. The women were extremely scared that doing daily household chores and parenting, e.g. lifting and carrying the baby or using a carrycot, might aggravate the symptoms. Moreover, this fear restricted women from playing active games with their older children, such as helping them onto a swing, teaching them to ride a bike, and jumping on a trampoline. All these restrictions led to feelings of being inadequate mothers, resulting in frustration, sadness, anger, uncertainty and a growing sense of hopelessness.
Another substantial result of this study addresses sports activities. For many fertile women, sports activities had played an important role before delivery, and now sPOP restricted them from it. The realisation that they could not continue engaging in sports at the same level of athletic performance as before delivery led to intense grief, anxiety and frustration. For instance, women had to give up running and high-intensity training. Some of them did not dare to participate in any activities at the gym. One of them had to quit her job as a training instructor. Giving up favourite activities that were a part of the women’s identity caused an identity crisis, leading to depression. They often expressed that they “just wanted their life back”, demonstrating an inability to accept the new situation. Discussions concerning exercise and safe workouts were very common in the thread. Women were desperate to find information and sought advice from healthcare providers regarding lifestyle changes and how to adjust physical activity in relation to sPOP. However, it was found to be difficult to access satisfactory, unambiguous information. Instead, information was inconsistent, unclear and difficult to understand. Although some healthcare providers were considered helpful and kind, unfortunately they lacked knowledge, which led to useless advice being given which often was not in line with the information that the women had found out by themselves from independent sources. For instance, one woman was encouraged to continue with life as usual and with exercises such as doing sit-ups in spite of her complaints about aggravating her symptoms by physical activity. The woman was told that “nothing would fall out” and in any case if it did happen she was in no danger. Moreover, the fertile women who sought professional help expressed that normalisation of sPOP as a condition was common among healthcare providers. On the contrary, women did not perceive the symptoms of POP as normal or natural, and the attitude of healthcare professionals was experienced as humiliating and discouraging and caused feelings of not being taken seriously. This led to mistrust, disappointment, frustration and criticism of healthcare professionals and the system.

The fertile women in this study experienced failure to carry out their parental responsibilities, both physically and emotionally. Fear that activities such as lifting children or playing active games with them might worsen the symptoms led to emotional imbalance. This worry has reasonable grounds, owing to an assumption that increased load to the pelvic floor in the form of elevated intra-abdominal pressure (IAP) contributes to development of POP. It has also been shown that IAP increases during brisk walking and as a result of carrying things in a front carry position, which is used by postpartum women to carry their babies in car seats (1). 
One of the main findings of this study was psychological suffering due to an inability to participate in high-intensity exercise, since for some women, exercise was a part of self-esteem and a natural part of life. It is well established that physical activity has positive effects on health. Moreover, moderate or vigorous physical activity such as brisk walking, cycling, tennis, swimming and running has been shown to reduce depressive symptoms postpartum (2). Some of the fertile women in this study suffered from anxiety and depression and would probably have benefited from participating in physical activity. However, they felt unsure about what kind of physical activities they could resume without worsening their symptoms and became disappointed when they faced a lack of understanding and competence among healthcare professionals in terms of advising suitable exercises. Likely recommendations regarding leisure-time physical activity for postpartum women with depression without sPOP must differ from those with sPOP. One such physical activity that might be suitable for women with sPOP is basic Pilates exercises, which does not raise IAP and, for instance, is safe to recommend for women after POP surgery (3).

This study demonstrates that sPOP has a significant impact on fertile women’s active life. sPOP restricts daily and sports activities and affects the ability to fulfil everyday parental duties. In addition, the lack of information from healthcare providers regarding suitable physical activities adds more emotional stress and worsens the situation. It is of the utmost importance to acknowledge this problem. There is a need to develop guidelines for management of sPOP after VD, including information regarding safe lifting techniques and suitable exercises.

Coleman, T. J., Hamad, N. M., Shaw, J. M., Egger, M. J., Hsu, Y., Hitchcock, R., .. Nygaard, I. E. (2015). Effects of walking speeds and carrying techniques on intra-abdominal pressure in women. Int Urogynecol J, 26(7), 967-974. doi:10.1007/s00192-014-2593-5
Craike, M. J., Coleman, D., & Macmahon, C. (2010). Direct and buffering effects of physical activity on stress-related depression in mothers of infants. Journal of Sport & Exercise Psychology, 32(1), 23-38.
Coleman, T. J., Nygaard, I. E., Holder, D. N., Egger, M. J., & Hitchcock, R. (2015). Intra-abdominal pressure during Pilates: unlikely to cause pelvic floor harm. International Urogynecology Journal, 26(8), 1123-1130. doi:10.1007/s00192-015-2638-4