Women’s Health Physical Therapy in the Postpartum Period: More Than Just Kegels

Presented By:Shannon Roth, PT, DPTBoard-Certified Women’s Health SpecialistCertified Lymphedema Therapist

Pregnancy and Postpartum Corrective Exercise Specialist

May 18th, 2021

Learning Objective:

The audience will be able to:

1) Describe the anatomy and functions of the pelvic floor musculature

2) Explain the relationship of the pelvic floor with deep core musculature

3) Summarize the various symptoms and conditions that a Pelvic Health/Women’s Health Physical Therapist (PT) can address in the postpartum period

Anatomy of the Pelvic Floor Musculature

• The pelvic floor muscles live at the bottom or the under surface of the pelvis

• Sling from front to back

• Sling from side to side

• Consist of 3 layers

https://www.pelvicexercises.com.au/wp-content/uploads/2012/05/Pelvic-floor-muscles-op.jpg

Anatomy of Pelvic Floor Musculature

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Anatomy of Pelvic Side Wall

https://www.kenhub.com/en/library/anatomy/obturator-internus-musclehttps://www.practicalpainmanagement.com/sites/default/files/imagecache/lightbox-large/ppm/p1101_herrera/herrera_fig01.jpg

Piriformis

Piriformis

Obturator internus

Pelvic floor

Nerves Surrounding the Pelvis

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Nerves Surrounding the Abdomen & Pelvis

https://www.mmc.nl/verwijzers/wp-content/uploads/sites/40/2017/09/ann-surg-results-fann.pdfhttps://www.nysora.com/wp-content/uploads/2018/07/82_Cx04-787x1024.jpg

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Inguinal ligament

Functions of the Pelvic Floor Muscles

• Help us to maintain continence

• Play a role in sexual function and arousal

• Support our pelvic organs such as the bladder, uterus, and rectum

• Provide postural stabilization and are considered a core muscle group

http://holisticfamilydoulas.com/wp-content/uploads/2020/03/pelvic-floor-image.jpg

Canister System

• The pelvic floor, deep back muscles (multifidi), diaphragm, and deep abdominal muscles (the transverse abdominis) all work together to provide postural stabilization

http://mariskaodendaal.co.za/wp-content/uploads/2020/05/4c71e61567c43f85663c0b9d36b010e4.jpg

Pelvic Floor – Diaphragm Piston Relationship

• The diaphragm and pelvic floor coordinate together with our breathing

https://global-uploads.webflow.com/5f921ea5cf0058796a47ee47/5f921ea5cf0058535547f38f_D%20BREATHING%20COMPOSIT%20(1).png

Women’s Health Physical Therapist• Women’s Health or Pelvic Health

• Licensed PT with specialized training in the evaluation and treatment of the pelvic floor

• Specialized training

• Women’s Health Physical Therapy Residency program

• Continuing education courses and certification courses

• Mentoring from other pelvic health PTs

• Completing a women’s health clinic rotation while in PT school

Relevance of Musculoskeletal Changes in Pregnancy to Postpartum

http://2.bp.blogspot.com/-exEozTpt3qU/U2vbJhwkdUI/AAAAAAAAAfE/tkMjjoCxmSM/s1600/posture_during_pregnancy.jpg

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Relevance of Musculoskeletal & GI Changes in Pregnancy to Postpartum

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diaphragm

Dome shape position of diaphragm

Role of Women’s Health PT in the Postpartum PeriodBody mechanics education and functional mobility

C-section specifics

Musculoskeletal issues

Urinary incontinence

Constipation

Pelvic/abdominal pain

Prolapse management

Safe return to physical activity/exercise

Body mechanics education and functional mobility

Bed mobility

Transfers

Lifting/carryingWalking

Stair negotiation

C-section Scar

Scar massage techniques

Early mobility considerations

right after delivery to reduce scar pain

Core muscle activation

Scar pain

http://acuclinic.com.au/pocit/LUSCS-Layers1.png

Musculoskeletal Issues

Low back painSacroiliac joint

pain

Pubic symphysis pain

Thoracic pain

Diastasis rectiMuscle

weakness

Hip pain

https://www.rcog.org.uk/contentassets/d956bf46a08143ed8a4e52aa6789669a/pelvic-girdle.png

Abdominal Muscles

•Linea alba: meshwork of connective tissue

•Inter-rectus distance (IRD): linear distance between the medial aspects of the rectus abdominis muscles

•Definitions around normal IRD cluster around 2 cm but there is no consensus in the literature for optimal IRD1

Linea alba

https://antranik.org/wp-content/uploads/2011/10/muscles-of-the-abdominal-wall.jpg

Diastasis Rectus Abdominis (DRA)

•Prevalence

•27-33.1% during

pregnancy2,3

•60% at 6 weeks postpartum2

•45.5% 6 months postpartum2

•32.6% at 12 months

postpartum2

•100% of women have a DRA

at 35 weeks of pregnancy and

separation persists in 40% of

women at 6 months

postpartum4

https://yourpaceyoga.com/wp-content/uploads/2018/08/Diastasis-600px.jpg

Diastasis Rectus Abdominis

https://i.pinimg.com/originals/29/c0/6a/29c06a9fe301b23e039007bf313c1916.jpg

Linea alba

Linea alba

Diastasis Rectus Abdominis

• Many ways to assess

• It's not all about closing the gap

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQLIakWOtwmr-T1gRcxOkKXM38SwFDbvNtaiw&usqp=CAUhttps://www.pamelamorrisonpt.com/2015/02/23/9-finger-diastasis-recti/

https://www.jospt.org/doi/pdf/10.2519/jospt.2016.6536

Urinary Incontinence

• Types5

• Stress urinary incontinence: compliant of involuntary loss of urine on effort or physical exertion, or on sneezing, coughing or laughing

• Urge urinary incontinence: complaint of involuntary loss of urine associated with urgency

• Mixed urinary incontinence: symptoms of both stress and urge urinary incontinence

Urinary Incontinence

• Pelvic floor examination

• Surface biofeedback training

• Functional progression

• Supine, sitting, standing

• Squats, lunges, jumping, jump rope, running

• Box jumps

https://www.cmtmedical.com/wp-content/uploads/2020/08/Emyo-with-Monitor-100-200-Together-Low-Res-365x365.pnghttps://www.cmtmedical.com/wp-content/uploads/2012/11/Pathway-MR-15_5522-365x365.jpg

Constipation

Bowel log/diary Behavioral strategies

Toileting posture/position

Breathing techniques

Abdominal massagePelvic floor

coordination/training

Dietary recommendations

https://images-na.ssl-images-amazon.com/images/I/61hPHqgn4cL._AC_SL1000_.jpg

Pelvic/Abdominal Pain

• Dyspareunia• 21.2% 6 months

postpartum6

• 17-36% 6 months postpartum7

• Perineal lacerations

• Obstetric anal sphincter injury/tear

• 3rd and 4th degree tears

https://cdn.shopify.com/s/files/1/0259/5343/5720/products/v_want-clear_590x.jpg?v=1614111644https://hopeandher.com/products/vaginal-dilator-sethttps://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRWobthRg3wvGwx8jzIqzB0HMMguL0hjvIGlQ&usqp=CAU

Pelvic Organ Prolapse

Definition: The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff scar after hysterectomy)5

Symptoms:

• Vaginal bulging

• Pelvic pressure/heaviness

• Back ache

• Splinting/Digitation

https://www.advancedgynecology.com/wp-content/uploads/2020/08/Advanced_Gynecology_Blog_Image_-_Types_of_Pelvic_Organ_Prolapse_-_August_2020.jpghttps://media.springernature.com/lw685/springer-static/image/art%3A10.1007%2Fs10439-021-02755-6/MediaObjects/10439_2021_2755_Fig1_HTML.png

Conservative PT Management of Prolapse

Pelvic Floor Muscle Training

Body Mechanics

Training

Constipation Management

Core Muscle Training

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http://www.athletespotential.com/uploads/2/4/7/3/24730224/breath2_orig.png

Conservative PT Management of Prolapse

• Gripping of upper abs

• Pressure down on pelvic floor

• May contribute to urinary leakage and/or prolapse symptoms

https://dianeleephysio.com/education/butt-grippers-back-grippers-and-chest-grippers/

https://www.alignforhealth.com/uploads/1/0/3/5/10350371/core-activation_orig.jpg

Safe Return to Exercise/Physical Activity

• Guidance on safe return to desired exercise or physical activity

• Running

• Weightlifting

• Jumping activities

• Group classes

•Return to Running Guidelines

• https://www.absolute.physio/wp-content/uploads/2019/09/returning-to-running-postnatal-guidelines.pdf

• Tom Goom, Gráinne Donnelly and Emma Brockwell

Optimizing Postpartum Care• American College of Obstetrics and Gynecology

(May 2018, Committee Opinion)

• "To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs"

• "The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being"

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References1. Chiarello CM, Mcauley JA. Concurrent Validity of Calipers and Ultrasound Imaging to Measure Interrecti Distance. Journal of Orthopaedic and Sports Physical Therapy. 2013; 43(7): 495-503.2. Sperstad JB, Tennfjord MK, Hilde G, et al. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016;50: 1092-1096.3. Bouissanault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther. 1988; 68(7): 1082-6.4. Fernandes da Mota, P. G., Pascoal, A. G., Carita, A. I., & Bø, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy, 20(1), 200–205. https://doi.org/10.1016/j.math.2014.09.0025. Petrou, S. P. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International Braz j Urol, 36(1), 116–116. https://doi.org/10.1590/s1677-553820100001000326. Alligood-Percoco, N. R., Kjerulff, K. H., & Repke, J. T. (2016). Risk Factors for Dyspareunia After First Childbirth. Obstetrics and gynecology, 128(3), 512–518. https://doi.org/10.1097/AOG.00000000000015907. Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women's sexual health after childbirth. BJOG: An International Journal of Obstetrics and Gynaecology, 107(2), 186–195. https://doi.org/10.1111/j.1471-0528.2000.tb11689.x8. Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women's sexual health after childbirth. BJOG: An International Journal of Obstetrics and Gynaecology, 107(2), 186–195. https://doi.org/10.1111/j.1471-0528.2000.tb11689.x

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