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Blog posts tagged in Pregnancy and Postpartum

The eve of my daughter’s 5th birthday has me reminiscing about my first pregnancy. I had recently surrendered my ACL on a ski slope and was contemplating surgery when I got confirmation I was pregnant. A seasoned surgeon had told me if I just wanted to return to running and not ski or do cutting sports (without a brace, anyway), I would probably be fine; so, I chose to forego the surgery and was running again 7 weeks later. Being my first pregnancy, I was not sure how hormones would affect my knee stability without an ACL or if the impact was safe for me and the baby or if my doctor would approve of my exercise choice of running. After all, pending ligamentous laxity from hormonal changes made running without an ACL seem risky while pregnant; but, runners tend to be, well, stubborn, when it comes to being able to run.

Deghan et al (2014) discuss the hormone relaxin and its effect on bone, muscle, tendon, ligaments, and cartilage. Interestingly, relaxin actually plays a role in the healing and remodeling of certain tissues in the body such as muscle and bone. However, the article also emphasizes how relaxin has been shown to reduce the integrity of the ACL and put female athletes at risk for injury. Lucky for me, that hormone couldn’t have its way with my knee since the ACL was already gone!

A study in the British Journal of Sports Medicine just published online October 4, 2015, encourages running and other high-impact sports before pregnancy to decrease the risk of pelvic girdle pain. The patients engaging in such exercises prior to being pregnant showed a 14% lower risk of having pelvic girdle pain during pregnancy. Out of 4069 women, 12.5% of the 10.4% of women who experienced pelvic pain were non-exercisers pre-pregnancy. The women who exercised 3-5 days per week and participated in high-impact aerobic exercise prior to being pregnant had less pelvic pain while pregnant.

Postpartum perineal injuries can cause pain and dysfunction for a short or an extended period of time. Pelvic rehab providers are in a position to educate women about the immediate and long-term management of perineal pain. A 2015 study by Manfre et al. assessed the response of cortisone cream application to the perineum in the immediate postpartum period. The study was a randomized controlled trial involving 27 subjects with each subject serving as her own control. Three different treatments were given over a 12 hour period: corticosteroid, placebo, and no treatment. (The hydrocortisone cream was at 1% in an alcohol-based cream, the placebo was a non-medicated acetyl alcohol-based cream.) The cream was applied by an investigator who placed the cream on a Witch Hazel pad. The participants and the researchers were blinded to the type of cream applied, and the applications were randomized and took place within the first 12.5 hours after birth. Perineal pain levels were assessed immediately before cream application, and at 30 and 60 minutes after application. Using a visual analog scale (VAS), the symptom of pain was assessed and compared to baseline. In the study, the authors report that in the immediate postpartum period, women in their institution were often prescribed medication ranging from ibuprofen to hydrocodone. Topical medications, ice packs, heat packs are also mentioned as available treatments. Other pain medications or cold packs were available during the study; no other topical creams were utilized.

Results indicated that the participants responded positively to both creams with significantly more pain reduction than the no treatment group. The authors propose that both creams provided a soothing effect by providing moisture to the tissues, creating a protective barrier, and preventing friction and irritation. Because the placebo emollient cream was not significantly more expensive than the hydrocortisone cream, the article suggests using hydrocortisone on the postpartum perineum due to the medication’s potential beneficial anti-inflammatory effects. Also of note was that ice packs were used by less than half of the women in the study, and when ice was used, it was only during the first four hours after birth. One reason for the low frequency use of ice was thought to be the difficulty in maintaining ice application on the perineum.Manfre 2015

Because the pelvic rehab provider is in an optimal role as educator for pain reduction strategies, this study provides some interesting information to share with other birth providers and with patients. Learn more about postpartum patient care at Care of the Postpartum Patient, available in Seattle this March.

Diastasis of the Rectus Abdominis Muscle (DRAM) is the separation of the two rectus abdominis muscles along the linea alba and is very common during and after pregnancy as the rectus abdominis and linea alba stretches and thins. Patients with DRAM are often sent to seek non-surgical management for DRAM from a physical therapist (PT). Typically these patients are either at the end of their pregnancy or adjusting to round the clock care of an infant. They can be sleep deprived, and have a full schedule of doctor’s appointments, having difficulty finding childcare, making attending PT somewhat challenging. Furthermore, they may have difficulty finding the time for a home exercise program (HEP). As PT’s we often struggle with making sure to give the patient exercises that will accomplish the goal of improving DRAM, however, making sure the HEP is not so extensive or time consuming that it becomes unmanageable. Is something as easy as abdominal bracing with exercise effective for reducing DRAM in post-partum women? A recent study published in 2015 in the International Journal of Physiotherapy and Research explores just this topic(Acharry).

Why is Diastasis of the Rectus Abdominis Muscle (DRAM) important?

Women with DRAM tend to have a higher degree of abdominal and pelvic region pain(Parker). Also women with DRAM may be more likely to have support related pelvic floor problem such stress urinary incontinence, fecal incontinence, or pelvic organ prolapse. The linea alba and rectus abdominis play an integral role in maintaining the anterior support of the trunk, these structures work together with pelvic girdle, posterior trunk muscles, and hips in maintaining stability when we shift weight (or transfer load) such as with standing, squatting, walking, carrying, and lifting. Therefore postural stability may be impaired with these daily tasks. Lastly, the abdominal muscles and fascia protect and support our organs so women with DRAM may have compromised support and protection of visceral structures.

Is DRAM common?

Pregnancy is the most common cause of DRAM and studies widely range from 50-100% of women experiencing DRAM at end stage pregnancy. Natural reduction and greatest recovery of DRAM usually occurs between day 1 and week 8 after delivery. Various ways exist to diagnose DRAM. The gold standard for diagnosis is computed tomography but is sometimes considered impractical due to expense. Clinically a separation of 2.0-2.7cm or “two finger widths” of horizontal separation at the umbilicus or 4.5cm above or below while performing a hooklying (supine with knees bent) abdominal curl up is considered pathological separation.

Infertility is often times a very sensitive subject for couples who are struggling to conceive. In the US, there are approximately 6.7 million women who are facing challenges with getting pregnant. (CDC 2006). In 2015, a ten-year retrospective study examined the efficacy of manual physical therapy to treat female infertility and discovered significantly positive outcomes.

The study looked at data collected from 2002-2011, which included approximately 1,392 patients treated for infertility. It specifically included those with single or multiple causes for infertility that involved: 1) elevated FSH (follicle stimulating hormone) of 10 mIU/ml or higher 2) fallopian tube occlusion 3) Endometriosis- when the lining of the uterus grows outside of the uterus causing significant pain, abnormal bleeding, infertility 4) Polycystic Ovarian Syndrome (PCOS)- a condition that affects female hormone regulation at times producing multiple follicles that remain as cysts in and around the ovary 5) Premature Ovarian Failure (POF)-loss of ovarian function before a woman is 40 years old and 6) Unexplained Infertility (Rice, 2015)

Patients were treated using an individualized physical therapy treatment plan that was named the CPA (Clear Passage Approach) protocol. This protocol was tailored to meet the individual needs of the patients and to treat specific sites of restrictions and immobility within each patient’s body. Treatment included integrated manual therapy techniques focused on minimizing adhesions and decreasing mechanical blockages in order to improve mobility of soft tissue structures. Visceral manipulation was also used to help restore normal physiologic motion of organs with decreased motility.

Does prior training in pelvic floor muscle exercises contribute to a woman’s ability to contract the pelvic floor shortly after childbirth? Researchers aimed to study this question and other variables in a prospective observational study involving 958 women. Within one week of childbirth, and in the hospital setting, participants were instructed by a physiotherapist (specializing in pelvic floor) to contract the pelvic floor in a supine position. Confirmation of a contraction was determined by visual observation of the perineum moving inward. The women were also asked by a physiotherapist if they had prior knowledge or experience with pelvic floor muscle training, and if not, the women were briefly instructed in the location and function of the pelvic floor muscles. The women who had some knowledge of the pelvic floor muscles including exercise experience “…were asked if they considered themselves able to perform correct…” pelvic muscle contractions.

All women was asked to complete three pelvic muscle contractions in a row and were assessed visually using a score of 0 (no movement of the perineum), 1 (weak movement), or 2 (strong inward displacement/lift of perineum). The physiotherapist gave feedback if the women completed a correct, insufficient, or incorrect contraction. Further verbal instruction was provided to those who could not adequately contract, and a re-assessment was completed with a quantification of any change in ability to contract. After providing feedback on pelvic muscle contractions, 73.6% of the women were able to perform a better contraction. In 500 of the 958 women, no inward displacement of the perineum was observed. Additionally, a significant number of the women (33%), believed that they were doing a contraction correctly but in fact were not. Another interesting point is that women with urinary incontinence before or during pregnancy had more knowledge about pelvic floor function and training.

Although in this study, 47.8% of the participants were able to perform a pelvic floor muscle contraction shortly after giving birth, “Knowing about the function and location of the pelvic floor was a positive predictor for being able to complete a pelvic floor muscle contraction.” Interestingly, having prior training in pelvic muscle exercises was not predictive of being able to complete a contraction. The value of assessing the ability to contract the pelvic floor is evident in this study, and with methods that are quick, easy, and non-invasive, women can be empowered with an improved ability to improve performance of a pelvic muscle contraction which is necessary for an effective pelvic muscle training program.

Dr. Susane (Susie) Mukdad is the founder of Healing Hands Physical Therapy, Inc., located in Willow Springs, IL.

Being a new mom is such a blessing, a new chapter in a woman’s life filled with joy, happiness, and many surprises! But giving birth can also bring about many changes in a woman’s physical, emotional, and social health. Increased level of sex hormones can result in physiological, cognitive, and musculoskeletal changes. These fluctuations continue to occur after birth, placing a new mom, who is now faced with many physical and emotional challenges at risk for burn out. In addition, new moms have to worry about their careers and relationships, suffer sleep deprivation, and the availability for support from their family and friends all of which can affect a new mom’s self-esteem, mood, and most importantly parenting ability.

According to a recent CDC survey, approximately 8-19% of women experience postpartum depression. In most cases, this occurs during the first 3 mo postpartum.

Guidelines for the management of 3rd and 4th degree tears were updated and published last month by The Royal College of Obstetricians & Gynaecologists. The purpose of the guidelines are to provide evidence-based guidelines on diagnosis, management and treatment of 3rd and 4th degree perineal tears. These types of tears are also referred to as obstetric anal sphincter injuries, or OASIS. The authors acknowledge an increased rate of reported anal sphincter injuries in England that may in part be due to increased awareness and detection of the issue. In terms of classification of anal sphincter injuries, the following is recommended (note the different levels at grade 3:


- 1st degree tear: injury to the perineal skin and/or the vaginal mucosa
- 2nd degree tear: injury to the perineum involving the perineal muscles but not involving the anal sphincter.
- 3rd degree tear: injury to the perineum involving the the anal sphincter complex
- Grade 3a tear: Less than 50% of the external anal sphincter (EAS) thickness is torn.
- Grade 3b tear: More than 50% of the EAS thickness is torn.
- Grade 3c tear: Both the EAS and the internal anal sphincter (OAS) are torn.
- 4th degree tear: Injury to the perineum involving the anal sphincter complex (EAS and IAS) and the anorectal mucosa.

Pelvic rehabilitation providers commonly treat a variety of conditions associated with peripartum pelvic girdle dysfunction. This list of conditions includes coccyx pain, and a recent study aimed to identify risk factors which may lead to coccyx pain in the postpartum period. Dr. Jean-Yves Maigne, who is well known for providing foundational research on the topic of coccyx pain, and colleagues completed a case series of 57 postpartum women presenting to a specialty coccydynia clinic. Dynamic x-rays were taken to assess mobility of the coccyx, and data about delivery methods were collected. (A control group of 192 women were comprised of women who also presented to the clinic but who had coccyx pain from other causes.)

The authors found that the women reported immediate postpartum pain in the coccyx with sitting. Instrumentation was a common finding in regards to the patients’ deliveries. 50.8% of the deliveries utilized forceps while 7% were vacuum-assisted. An additional 12.3% of the deliveries were spontaneous and were described as “difficult.” A subluxation of the coccyx was observed in 44% of the women who developed coccyx pain after childbirth as compared to 17% of the controls. A fractured coccyx occurred in 5.3 % of the women. Body mass index (BMI) of more than 27 and having 2 or more vaginal deliveries was also associated with a higher prevalence of a subluxation of the coccyx.

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