Mirjam Lukasse of the University of Tromso in Norway and colleagues have completed interesting and relevant research among women who have experienced childhood sexual abuse and pregnancy. In a longitudinal cohort study based on data from the Norwegian Institute of Public Health, nearly 5000 women were questioned about childhood abuse and feelings about pregnancy. Between 18 and 30 weeks of gestation and again 6 months postpartum, subjects were sent questionnaires to assess associations between childhood abuse and women's fears about childbirth or preference for cesarean section (c-section) during pregnancy. In the study, 21% of the women reported experiencing childhood abuse. Women who were abused reported a significantly higher rate of fear of childbirth when compared to women who did not report abuse (23% and 15%, respectively.) Subjects who reported abuse were also more likely to state a preference for a c-section during the second pregnancy (6.4% versus 4%.) 

The same author was the primary researcher on an article summarized as the following: "Abuse in childhood is associated with increased reporting of common complaints of pregnancy." The authors point out that clinicians need to consider the issue of childhood abuse when working with pregnant women who have multiple complaints or increased challenges from typical complaints in pregnancy. In a similar updated article, Lukasse and colleagues describe the relationship between sexual violence and pregnancy-related symptoms. You can access the full text article by clicking HERE. Prior or recent severe sexual violence is correlated in this research with suffering from equal to or greater than 8 pregnancy-related symptoms. Symptoms include backache, fatigue, constipation, pelvic girdle dysfunction, nausea/vomiting, edema, headache, urinary dysfunction, pruritus, and others. 

Let's address the potential value of this information. Most of us who work in pelvic rehabilitation also treat women who are pregnant or who may become pregnant. While assuming that a woman who has significant pregnancy-related symptoms has been abused is not appropriate, considering that she has a history of abuse may be helpful to the patient. A woman who is experiencing abuse while pregnant may feel especially vulnerable as she considers how to care and provide for her child. Knowing how to ask questions in a respectful and clear way can be extremely helpful. The website "Survivors of Childhood Sexual Abuse" has a page of helpful language and strategies for the primary care provider who is engaging in a conversation about abuse. If you scroll down to the bottom of the page in the link you will find a printable summary of how to sensitively ask questions about abuse. Consider utilizing this information for an upcoming article review or inservice to staff or colleagues. Sharing statistics with patients and developing the habit of asking all patients about abuse can help to normalize the discussion so that patients feel safe enough to reach out when able.

As reported in Physical Therapy, the tendency to catastrophize may not be a stable one, as women demonstrated measurable changes across time during pregnancy and during the postpartum period. Pain catastrophizing, as described in this article, is "...an exaggerated negative orientation toward noxious stimuli." In this research, 242 women were assessed using the Pain Catastrophizing Scale during weeks 19-21, weeks 34-37, and at 6 months postpartum. You can learn more about the Scale by clicking here. The Disability Rating Index was also utilized at 6 months postpartum to assess physical ability. 

What the researchers found is that most of the women (57.9% ) did not catastrophize during any of the test scoring, while 10.3% reported catastrophizing during all test events. The remaining number of women had variable test scores towards pain catastrophizing, and they also reported higher levels of postpartum lumbopelvic pain as well as higher levels of activity restriction when compared to the women who did not catastrophize. Lumbopelvic pain included self-reported pain in the low back, anterior or posterior pelvis.

The authors point out that other research has correlated catastrophizing about labor with increased pain intensity during labor, and decreased social functioning and physical ability in the postpartum period. While other studies mentioned have reported a consistent response towards catastrophizing, this study identifies variation in catastrophizing that occurs for some women over the course of pregnancy. 

Pregnancy related pelvic girdle pain is a considerable issue for women that creates significant loss of function. An update on pelvic girdle dysfunction from Kanakaris et al can be found here by opening the link to the free full access text to the right of the Pubmed abstract. They report that the incidence of pregnancy pelvic girdle pain ranges from 4-76% in the literature depending on the definition utilized. 

Britt Stuge, PhD, PT, of Norway and colleagues recently published an article in the Physical Therapy Journal. The article includes a new tool that physical therapists can utilize to assess function in female patients who have pelvic girdle pain. 

The tool is called the "PGP" for "pelvic girdle pain" and was designed for use in the pregnancy and post-partum period.  20 of the questions refer specifically to activities and 5 questions are about symptoms. This is a rather specific tool and it was designed for use in the clinic or for research.

Wendy Sword, Professor in the School of Nursing at McMaster University, and her colleagues have recently published a study in which they looked at the relationship between mode of delivery and risk for post-partum depression. An interesting correlation that the authors found shows that having urinary incontinence in the first 6 weeks after childbirth doubles the risk for having post-partum depression. In McMaster University's post about this research, it is pointed out that up to 20% of new mothers experience post-partum depression, and this can interfere with the mother's self-care, with bonding between the mother and child, and with the care needed by the infant. Early detection and treatment of post-partum depression is critical.

In this research, 1900 new mothers were studied, up to 1/3 of them had c-sections as the mode of delivery. At 6 weeks post-partum, nearly 8% of the mothers had post-partum depression. The depression was not identified as being related to one mode of child delivery over another. The 5 strongest predictors of post-partum depression were identified as: 1) mother's age less than 25, 2) mother requiring hospital readmission, 3) non-initiation of breast-feeding, 4) good, fair, or poor self-reported health by the mother, and 5) urinary incontinence. 

Dr. Sword recommends that providers ask patients about continence status early in the post-partum period, as patients may be embarrassed to bring it up, and also because incontinence is often dismissed as a common issue post-partum that will likely improve. When patients are referred to rehabilitation for continence issues, we often find that the symptoms have persisted for years, sometimes decades, unfortunately. During our marketing visits and education of the community, we can also encourage patient providers to send the patients to rehabilitation as early as possible. It is often at the 6 week appointment that the patient can be screened for such concerns, and this is when many of our referrers are comfortable sending a patient in for a check of the pelvic muscles.  

On April 18th, a group of German and Italian researchers published this article on the impact of episiotomy on pelvic floor dysfunction. The paper found that "Episiotomy appears to be a protective factor for women's wellness. Women who had episiotomy and who experienced perineal symptoms have a better psycho-physical health status in the 12.79 months follow-up."

Available for download is a 15 page PDF of "Impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study". The PDF contains research highlights (including Abstract, Background, Methods, Results and Conclusion)