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Childbirth Injuries
PT Products Magazine. July 2009
Heather Jeffcoat, DPT
You had the perfect pregnancy. Everyone in the delivery room told you the delivery went smoothly. At your six-week checkup, your doctor tells you that everything looks great. So, how long will this incontinence last? And when will this pain go away?
Pelvic pain is an often neglected problem, that many women experience after childbirth. However, when pain persists beyond the first few weeks, patients are often hesitant to mention it to their healthcare providers. Oftentimes when they do, they are told “it will get better with time” and no further support is provided.
This pain can persist for weeks, months and sometimes years. That is a long time to wait, especially if the pain is preventing you from returning to exercise, playing with your little one, or even enjoying intimacy with your spouse. There are several potential sources of persistent postpartum pelvic, vaginal or rectal pain. These include scar tissue hypersensitivity, peripheral nerve injury or entrapment, joint injury or pelvic floor muscle spasm.
After delivery, estrogen levels drop and progesterone levels stay high. This is especially the case if your patient is breastfeeding. This hormonal influence causes dryness of the vaginal tissues. In this case, the solution might be as simple as recommending a water-based lubricant for your patient and instructing them to increase their water intake.
Immediate vaginal muscle and skin pain or discomfort is also expected, especially if tearing occurs during the delivery. This can be managed, in part, with frequent ice packs to the perineum. Performing Kegel exercises will also promote healing by increasing local circulation.
Keeping the area clean with the use of a perineal irrigation bottle and sitz baths will reduce infection and further assist in the healing process. Additionally, use of a doughnut cushion provides relief for perineal wound pain in some patients by reducing pressure on the perineum when they are sitting.
Finally, keeping bowel movements soft will minimize stress on any sutured and healing sites, thereby minimizing pain. This is generally addressed through a prescription such as Colase, increasing water intake and possible dietary modification.
In another scenario, women may experience immediate, central pubic pain during their vaginal delivery. This could be due to a sprain or separation of the pubic symphysis joint, termed a diastasis pubis. Peripartum pubic separation is reported in the literature as having an infrequent occurrence in as few as one in 521 deliveries.(Musumeci, 1994) When this separation occurs, the patient will experience pain over the pubic sympysis joint, sacroiliac joints, buttocks and/or thighs. The patient will report extreme difficulty and pain with turning in bed, transitioning from a seated to standing position, getting in and out of a car, or with weight-bearing activities.
Later sequelae may include bladder dysfunction (Snow, 1997). Early intervention includes providing the patient with a pelvic brace for external support and temporary use of an assistive device, such as a rolling walker. Symptoms usually resolve in 4-6 weeks, however some patients require advanced manual techniques to restore normal alignment, reduce muscle spasm, and instruction in stabilization exercises that will strengthen the area without causing further pain.
Coccydynia may occur during the peripartum period, as a result of direct injury to the coccyx or coccygeus muscle. These women will primarily complain of pain with sitting. Instruction on proper posture and use of a specialized wedge cushion are important first steps to reduce direct pressure on the coccyx. Oftentimes, pelvic floor muscle spasm is associated with this diagnosis and may require further intervention, such as direct massage and stretch of the levator ani muscles or coccyx mobilization.(Maigne, 2006;Maigne, 2001)
Patients may additionally report vaginal scar pain, either from an episiotomy or natural tearing. The severity of the pain can range from pain and sensitivity at rest, to pain with tampon insertion or intercourse. For some women, the pain is so intense that they minimize or avoid these activities all together. Teaching perineal massage over the scar is a helpful initial intervention. Additional stretching and muscle work to the pelvic floor may also be required if increased tone present.
Nerve injury or entrapment is another potential source of pelvic pain. The reported incidence is 0.92% of live vaginal births (Wong, 2003), but is generally thought to be much higher. The positioning of the mother may create nerve compression or ischemia. It has been reported that the semi-Fowler-lithotomy position or excessive hip abduction and external rotation are common positions linked to nerve injury. These positions may contribute to femoral mononeuropathy during uncomplicated, vaginal deliveries (al Hakim, 1993).
The tailor position with prolonged epidural anesthesia has also been suspected in femoral and sciatic nerve traction injuries(Ley, 2007). The position of the fetus or prolonged pushing can also put adverse tension on nerves. A common site for compression is the obturator nerve (Massey, 2008). Injury to the pudendal nerve and external anal sphincter injury is associated with occiput posterior presentation at birth and with forceps or vacuum-assisted deliveries (Tetzschner, 1997) (Tetzschner, 1995).
Finally, surgical lacerations have the potential of creating peripheral nerve injury as well. When nerve input is disrupted in this area, the result is often pelvic pain and/or incontinence.
There is a common phrase repeated in medical and PT offices, “I do Kegels, but they don’t work”. A study published in the early 1990’s looked at the performance of Kegel exercises after brief verbal instruction.(Bump, 1991) The results showed that 51% of women were performing a Kegel incorrectly at this level of teaching. Worse yet, 25% of women were performing them in such a way that could actually worsen their incontinence.
The first item to consider is, does your patient perform a Kegel properly? This is an essential first step in reducing or eliminating incontinence conservatively. When performing a Kegel, your patient should only see the anus and vaginal opening lift and close. They should not see or feel the muscles in their inner thighs or gluteal area contract or their abdominal muscles bulge out. There are various types of biofeedback for the pelvic floor on the market. These range from inexpensive Kegel Exercisers to computerized biofeedback units which provide real-time feedback of pelvic floor and accessory muscle performance.
The use of conservative therapy and pelvic floor muscle biofeedback is supported in numerous studies.(Hay-Smith, 2006)(Di Benedetto, 2008) However, depending on the severity of the incontinence and any additional contributing factors (for example, prolapse or pelvic pain), the total duration of their therapy may require more than 6 weeks to completely eliminate their symptoms.
References:
ACOG, 2005. Your pregnancy and birth. Washington, DC: Meredith Books.
Al Hakim M,. Katirji B. 1994. Femoral mononeuropathy induced by the lithotomy position: a report of five cases with a review of literature. Muscle Nerve 17:4 466.
Babayev M., Bodack M.P., Creatura C. 1998. Common peroneal neuropathy secondary to squatting during childbirth. Obstet Gynecol 91:5 830-832.
Haslam, J., Laycock, J. Therapeutic management of Incontinence and Pelvic Pain.
Therapeutic Management of Incontinence and Pelvic Pain. 2nd edition. Halsam and Laycock.
Ley L., Ikhouane M., et al. 2007. Neurological complication after the “tailor posture” during labour with epidural analgesia. J Gynecol Obstet Biol Reprod 36:5 496-499.
Massey E.W., Cefalo R.C. 1979. Neuropathies of Pregnancy. Obstet Gynecol Surv. 34:7 489-492.
Ronchetti I., Vleeming A., et al. 2008. Physical characteristics of women with severe pelvic girdle pain after pregnancy: a descriptive cohort study. Spine 33:5 145-151.
Snow R.E., Neubert A.G. 1997. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv 52:7 438-443.
Stephenson, R., O’Connor, L. 2000. Obstetric and Gynecologic Care in Physical Therapy. New Jersey: Slack, Inc.
Tetzschner T., Sorensen M., et al. 1995. Pudendal nerve damage increases the risk of fecal incontinence in women with anal sphincter rupture after childbirth. Acta Obstet Gynecol Scand 74:6 434-440.
Tetzschner T., Sorensen M., et al. 1997. Delivery and pudendal nerve function. Acta Obstet Gynecol Scand 76:4 324-331.
Wong C.A., Scavone B.M., et al. 2003. Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstet Gynecol 101:2 279-288.
Bump, et al. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991 Aug;165(2):322-7
Carriere, B., Feldt, C.M. 2002. The Pelvic Floor. New York: Thieme.
Di Benedetto, P., Coidessa, A., Floris, S. Rationale of pelvic floor muscles training in women with urinary incontinence. Minerva Ginecol. 2008 Dec;60(6):529-41.
Hay-Smith, E.J., Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005654.
Stephenson, R., O’Connor, L. 2000. Obstetric and Gynecologic Care in Physical Therapy. New Jersey: Slack, Inc.
