By Malinda Wright
In mid-April, Fox News Health wrote an article on why postpartum moms need physical therapy. (To see the article click here.) As pointed out in the article, France, Netherlands, and Australia automatically provide postpartum moms with 6-12 pelvic physical therapy treatments. Meanwhile, here in the US postpartum moms are rarely told by their OB/GYNs to attend physical therapy. When a postpartum-related issue is brought up by a new American mom, it’s not uncommon for her doctor to respond with, “Well, you just had a baby.” This statement implies something like “You need to deal with it and eventually it might go away.” To illustrate the importance of pelvic physical therapy for postpartum moms, I would like to discuss Sarah’s case study. You’ll remember Sarah from the blog Coached Pushing vs. Maternal Pushing.
When I initially saw Sarah she was a first-time mom who was 8 ½ months postpartum. Her main concern for attending physical therapy was pain with sex, medically known as dyspareunia. Sarah reported she delivered her baby vaginally. She stated she was in lithotomy position (on her back with her feet in the stirrups, like in the movies) and ready to deliver her baby when she felt a strong urge to push. She started pushing and the nurse had her stop. The nurse would not let her push until the doctor arrived, which was not until 20 minutes later. Sarah reported she pushed once and the baby arrived “fast.” She sustained a 3rd degree tear along the perineum, meaning that she tore from the perineal muscles down to her anal sphincter. Sarah stated she attempted intercourse once, sometime later, but stopped due to severe pain. During her evaluation with me, she described her pain as “like having razors” along the entrance of her vagina. She reported a “hard nodule” right at the entrance, which was painful during sex. Sarah had been unable to participate in sex due to this pain, and had felt discouraged about her plan to have multiple children. She had confided in her friend about her pain and her friend had encouraged her to seek pelvic physical therapy. That’s when she came to see me.
Pelvic Physical Therapy Examination and Assessment
- I checked her abdominal wall for a diastasis recti (separation of the abdominal muscles), because all postpartum women should be evaluated for this no matter what;
- I looked for connective tissue restrictions throughout the abdomen, suprapubic, bony pelvis, and medial and posterior thighs;
- I observed her vulvar tissues for any abnormalities, such as de-estrogenized tissue and hypertrophic scar;
- I palpated her perineum scar, checking for mobility and hypersensitivity;
- I palpated the muscles in her abdomen, medial thighs, buttocks, and pelvic floor for tightness and myofascial trigger points;
- I assessed her motor control of her pelvic floor muscles.
The reason why I assessed these particular components was because I wanted to know whether Sarah’s pain with sex was caused by muscle tightness, trigger points, and/or scar sensitivity. I also wanted to know whether any abdominal wall instability was contributing towards her pelvic floor dysfunction. The pelvic floor can compensate due to transversus abdominis (TrA) muscle weakness and a diastasis recti. Fortunately, Sarah did not have a diastasis recti, and her TrA muscle strength was normal. Her connective tissue was also normal, as was the muscle tone throughout her hips and buttocks.
What I did find with Sarah was scar tissue restrictions along the perineum where the tearing had taken place. The scar tissue was hypertrophic (raised), hypersensitive, and hypomobile (lacking movement). The “hard nodule” she was feeling during sex was this hypertrophic scar. Hypersensitivity to touch along the scar was contributing towards her pain. Guarding from this pain was contributing towards her pelvic floor muscle tightness, eliciting myofascial trigger points, which were then in turn creating more pain and feeding into the pain cycle.
Physical Therapy Treatment Plan
My initial treatment plan with Sarah was for her to come in once a week for 4-6 weeks for a session consisting of scar mobilization (breaking up scar tissue), myofascial trigger point release, Thieles massage, and neuromuscular re-education with emphasis on pelvic floor voluntary relaxation, combined with a home program. This home program initially consisted of perineal massage with scar mobilization and pelvic floor drops. We also discussed proper positioning for bowel movements (because I tell everyone about that), and why kegels were not appropriate for her.
On Sarah’s 3rd visit, I showed her husband how to do scar mobilization, since she expressed a preference for having her husband help. I also educated her husband on perineum massage prior to sex, in order to help decrease the discomfort Sarah was feeling with penetration.
On Sarah’s 4th visit, she reported that she had not been consistently having her husband help with scar mobilizations, and that she was having a hard time reaching the scar herself. We introduced a small dilator to help her with releasing the transverse perineal muscles and softening the scar tissue. In later visits, she reported being very consistent with the dilator.
Sarah completed a total of 11 pelvic physical therapy treatments. I saw her weekly for 6 visits, after which I re-evaluated her and came up with a new treatment plan. She reported a significant decrease in the pain intensity, from 9/10 to 1/10 on the pain scale. I spaced out her treatment to once every 2 weeks, as a result of the improvement in her symptoms, and her compliance with her home program.
On Sarah’s 10th visit, she reported having had sex regularly, however she had felt pain with initial penetration for the first 30 seconds each time. We continued with her treatment plan, and on her 11th visit, Sarah reported having had no pain with sex that week.
Sarah’s symptoms are all too common with postpartum moms, but as you’ve seen in this case study, physical therapy can help resolve these issues, and have a huge impact on a new mom’s quality of life. In my opinion, France, Netherlands, and Australia are doing it right: it’s time we in America caught up.