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Post-partum Pelvic Pain
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post-partum pelvic pain

This article covers post-partum pelvic pain and the various reasons women experience it

International Journal of Childbirth Education. December 2008.

Heather Jeffcoat, DPT

You had the perfect pregnancy. Your delivery could not have been any better. At your six-week checkup, everything looks great. So, what’s with all the pain? 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. But how much time? I have had patients that are still experiencing some degree of pain greater than 1 year after childbirth, and some for much longer than that. 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.

Postpartum pelvic pain can occur due to several factors. After delivery, estrogen levels drop and progesterone levels stay high. This is especially the case if your client 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 client and providing general advice to increase their water intake.

Immediate 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. Use of a doughnut cushion provides relief for perineal wound pain in some patients. Finally, keeping bowel movements soft will minimize stress on any sutured and healing sites, thereby minimizing pain.

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. This will lead to pain over this area, sacroiliac joints, buttocks or thighs. The client 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 and Neubert, 2001). Early intervention includes providing the client with a pelvic brace for external support. Oftentimes, these patients require advanced manual techniques to restore normal alignment, reduce muscle spasm, and perform stabilization exercises that will strengthen the area without causing further pain.

Coccydynia is another commonly reported pain after delivery. These women will primarily complain of pain with sitting. Instruction on proper posture and use of a specialized wedge cushion are important first steps. Oftentimes, pelvic floor muscle spasm is associated with this diagnosis and may require further intervention by a physical therapist trained in manual therapy of this area.

Another common type of postpartum pelvic pain is vaginal scar pain, either from an episiotomy or natural tearing. The severity of the pain can range from pain with tampon insertion to pain with intercourse. For some women, the pain is so intense that they avoid these activities all together. Teaching perineal massage over the scar is a helpful initial intervention. With persistent postpartum vaginal pain, scar tissue hypersensitivity, peripheral nerve injury or entrapment, joint injury or pelvic floor muscle spasm may be the cause and referral to a Women’s Health physical therapist would be indicated.

Nerve injury or entrapment is another potential source of pelvic pain. The reported incidence is 0.92% of live vaginal births (Wong et al, 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, 1994). The tailor position with prolonged epidural anesthesia has also been suspected in femoral and sciatic nerve traction injuries (Ley et al, 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 and Cefalo, 1979).

Injury to the pudendal nerve is associated with occiput posterior presentation at birth and with forceps or vacuum-assisted deliveries (Tetzschner et al, 1995; Tetzschner et al 1997). Finally, surgical lacerations have the potential of creating peripheral nerve injury as well. With all nerve injury, when nerve input is disrupted, this can lead to incontinence or pelvic pain.

Women’s Health physical therapists are trained to evaluate and treat pelvic pain before, during and after pregnancy. Interventions such as scar desensitization and mobilization techniques, manual therapy to the pelvic floor and associated muscles, specific therapeutic exercises, modalities to decrease pain and inflammation, pelvic floor muscle biofeedback and patient education are an essential component of postpartum recovery. To locate one in your area, contact the American Physical Therapy Association Section of Women’s Health at This email address is being protected from spambots. You need JavaScript enabled to view it. or (800) 999-APTA, extension 3229.


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.

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I can’t speak highly enough of the theapists at Femina Physical Therapy and how much they have helped me grow, discover, and love my body. I had had painful sex for my entire life, and didn’t know that there was anything that could be done about it. It was at the point where my husband and I were not having sex for MONTHs, because it was just too frustrating, and I hated feeling like I was the ONLY woman out there who had this problem, especially at my age. I finally brought it up to my doctor because I was turning 40 and my husband and I were barely having enough sex to conceive. And she brought up pelvic floor, PT. I didn’t even know this was a “thing”.

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Testimonial by Jackie W.

I was in multiple car accidents a decade ago, and I have been to many physical therapists through the years without success. They found the root of my lower back pain problems and after nearly a decade of barely being able to walk I finally can again without pain. They are also the best pelvic floor pts and the only ones who found the connection between my pelvic floor and lower back problems. If you need help with physical pain, they are your answer.

-- Jackie W., 1/19/17 via Yelp!

Testimonial by Jackie W.

I was in multiple car accidents a decade ago, and I have been to many physical therapists through the years without success. They found the root of my lower back pain problems and after nearly a decade of barely being able to walk I finally can again without pain. They are also the best pelvic floor pts and the only ones who found the connection between my pelvic floor and lower back problems. If you need help with physical pain, they are your answer.

-- Jackie W., 1/19/17 via Yelp!

Testimonial by A.M.

Months after giving birth, it was difficult for me to go from a sitting or lying position up to a full standing position without feeling that I had to remain hunched over until a bit of time had passed to get fully upright. However, after taking Heather’s course, I learned exercises to get my body back to normal. She also showed me correct ways to lift and carry my son as well as put him in/take him out of the carseat and stroller. This class was really beneficial and Heather is a wonderful teacher who made me feel very comfortable.

-- A.M.

Testimonial by A.B.

Before I was referred to Heather Jeffcoat I was living in a nightmare. I had been married to my husband for three years and I was suffering from Vaginismus. That all changed when I visited my OBGYN and she said she knew of someone with a great success rate. To be honest I was hesitant at first because my first doctor had already told me that all I needed to do was order dilators from the internet and I should overcome my problem. She was wrong because I had followed the book on how to use the dilators with absolutely no advancements in my condition. However, that all changed when I went in for my first visit and Heather took the time to explain my condition and how we were going to work together to overcome it.

I remember leaving her office with a glimmer of hope that I could live a normal life. As my sessions continued I began to see immediate results. With only four sessions and a strict dedication to my home programs I was cured of Vaginismus. In the beginning of this process I was made aware that my health insurance company might not cover the costs, which was disappointing but today I can say one hundred percent that it was the best money I ever spent. Now thanks to Heather I am finally enjoying my life to the fullest with my husband. Thank you Heather, I can’t begin to tell you how much I appreciate all that you have done for me. I will never forget it. Those who are suffering from these types of conditions don’t be afraid because she makes you feel so comfortable and the end result is worth it. Good luck to you all and I hope you experience the success I have.
-- A.B.

Testimonial by J.H.

My last appointment with Heather was over 6 years ago but I still think of her every day. I don’t take for granted that I can easily get out of bed, care for my two active and busy young boys, run, play tennis, clean my house, or sit at a desk for several hours at a time. None of these tasks were easy for me before meeting Heather. Eight years ago my car was struck from behind by a tractor trailer that was estimated to have been speeding. I spent 3 years working with different PTs and Drs trying to heal and move on with my life. When I became pregnant and the hormone relaxin that “relaxes” all the joints of the body and the additional weight gain erased all my progress and I was suddenly in a lot of pain again. My OB sent me to Heather for one last try.

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