I recently hosted a table for Everybody Physical Therapy at a convention called BabyFest NW. Hundreds of expecting and new moms attended the event. Some women came with their partners, some came with their mothers, and some came with just their baby. A flood of people came to my table throughout the day wanting an obstetrics physical therapist’s perspective on their problems. These are the top four questions I was asked along with a short version of my answers. (Please email me at firstname.lastname@example.org for the long answers.)
1) I was told I have to just deal with the pelvic pain I’ve had during pregnancy. But sometimes I can hardly even walk. Can physical therapy help me?
Yes, physical therapy can help. I often perform an internal pelvic floor exam to determine the source of the symptoms and the appropriate treatment approach. I also look at bony alignment of the pelvis and mobility of each joint within the pelvic girdle in order to determine the need for manual therapy and stabilization exercises. Depending on the characteristics of the pain (nature of the disorder, location, severity, etc.) physical therapy can usually provide some amount of relief if not full resolution of symptoms. Below is a list of complaints I often hear from pregnant and postpartum women that I have found physical therapy to be successful in treating:
- Pelvic pain
- Pubic bone pain
- Tailbone pain
- Pain with intercourse
- Pain with urination
- Pain with bowel movements
- Hip pain
- Neck or back pain
2) I am worried that the pain I experience during pregnancy will lead to a difficult childbirth. Is this likely?
All of the above conditions can make labor and delivery as well as the postpartum period more challenging. I can teach you how to prevent these conditions from getting worse during childbirth and in the months that follow. Obstetrics physical therapy can help decrease your risk of the following:
- Unwanted Cesarean delivery
- Vaginal tearing
- Pelvic organ prolapse
- Urinary and fecal incontinence
- Abnormal scar tissue formation
- Diastasis rectus abdominis
Physical therapy can also help you prepare for caring for your new baby. I can assist you in positioning for breastfeeding and proper body mechanics for childcare. I can also help you make modifications to decrease pain and discomfort during the tender postpartum period.
3) I feel like I have lost control of my bladder. I sometimes pee myself. What can I do?
The pelvic floor muscles are the muscles that help support the pelvic organs (the uterus, rectum, and bladder). As the uterus grows – especially during the third trimester – it presses down on the bladder. The pelvic floor muscles have to be strong enough to support this pressure. Strengthening1 the pelvic floor muscles with Kegel exercises can help maintain bladder control. Unfortunately, studies show that most women perform Kegels incorrectly. So if you notice that despite doing Kegels you still have urinary leakage you may be doing Kegels incorrectly. Or you may need a program to help with coordinating the timing of the pelvic floor muscle contraction to help prevent leakage. Addressing these strength or coordination deficits during pregnancy can help you have a smoother recovery during postpartum.
4) I am worried about tearing “down there” during delivery or having to get an episiotomy. Is there anything I can do to prevent that from happening?
Yes, perineal stretching can help decrease your risk of vaginal tearing or need for an episiotomy. You can and should begin perineal stretching around 35 weeks of pregnancy. I often instruct my patients and their partners on how to correctly do perineal stretching. (Stay tuned for next week’s blog post on correct perineal massage technique during pregnancy…)
Another way to reduce the risk of vaginal tearing is to wait for your body to give you the urge to push during labor.2 When it is finally time for your baby to be born, a wave of adrenaline is released followed by a series of uterine contractions. If this natural physiological process has not yet occurred, or you are between contractions, and someone is yelling at you to “PUSH!” it can be difficult to know what to do. Other people in the room may get excited and want the baby to be born as soon as possible. Focus on what your body is telling you. As Penny Simkin, PT author of The Birth Partner writes, “During the birthing stage, pushing hard might cause too rapid stretching and injury to the mother’s vagina, or too rapid a delivery. The mother can avoid holding her breath at this time by raising her chin and blowing or panting lightly whenever she feels the urge to push.”
Ideally in the weeks prior to the due date, you should have a conversation with the people who will be present for your birth. Tell them your preferences for waiting for your body to naturally bear down and stretch on its own time - and your hopes to reduce perineal trauma in this way. If you have a long labor you may have multiple nurses, obstetricians, and midwives in and out of your room as some may reach the end of their shift while you are still laboring. Some of these people may act like silent flies on the wall while others may play the role of an enthusiastic cheerleader. It is possible that the people in the room during your birth will not be the people you originally planned on having there. If you can have someone you trust such as your partner and/or a doula present with you to advocate for you while you are in Labor Land, it can take a lot of stress off of you during your labor and delivery.
5) How long before I can have sex again after delivering my child?
I know, for some of you this is the last thing you are thinking about. For some of you, it is the first thing that comes to mind when you think of no longer being pregnant. The answer to this question will differ person to person. Of course, you can try to have sex as soon as you are cleared by your obstetrician or midwife. They will often do a 6-week postpartum follow up appointment to make sure that any tearing or other trauma has fully healed. However, it is possible and very common that intercourse will be painful after they give you the green light. Many women have pain beyond this 6-week time period. If women are left untreated they could continue to have pain during intercourse for the rest of their lives. Fortunately, physical therapy can help get you back to feeling like your normal self.
The first postpartum visit I have with each of my patients, I check for presence of scar tissue from vaginal tearing or an episiotomy. If scar tissue is present I instruct her on how to perform scar massage to help desensitize the tissue. A similar scar tissue massage technique can be used to help with recovery from a Cesarean delivery (stay tuned for an upcoming blog post on how physical therapy can help recover from a Cesarean delivery).
In addition to scar tissue, I also check for the presence of a pelvic organ prolapse. Based on what I find, I help guide my patient with the appropriate positioning to reduce discomfort from a pelvic organ prolapse. I also create a customized home exercise program to help regain the strength necessary to prevent the pelvic organ prolapse from getting worse.
The last thing I assess is the stretch tolerance of the pelvic floor muscles. It is very common for women to experience poor stretch tolerance after delivery, which is contrary to what many women expect. Often women expect those muscles to be too loose after delivery but they frequently are too tight. Imagine running a marathon. Although your legs may feel like Jello after the race, it is likely the next day they will feel very tight and all of your muscles feel shorter than usual. Your pelvic floor muscles behave the same way after delivery. When they are asked to stretch (for example during intercourse), they become painful and the woman’s natural reaction is to tense them even more, as if she is guarding to prevent being reinjured. Luckily, regaining good stretch tolerance in these muscles is easy with the proper instruction. Most women notice those muscles starting to feel “normal” within 3 months of consistent stretching as instructed by their physical therapist.