By Dr. Ann Croghan, PT, DPT, CLC, and CAPP-OB trained with introduction by Stephanie Prendergast, MPT
A few months ago I shared a link to an article I was interviewed for in Men’s Health Magazine about postpartum sex on our PHRC Facebook Page. I was disappointed there was not better coverage about postpartum pelvic floor physical therapy in this article since that was the bulk of my interview. Postpartum care in the US leaves a lot to be desired and my post mentioned this. Pelvic floor physical therapist Ann Croghan chimed in, commenting on an antenatal and postpartum program that sounds too good to be true:
Since Ann and I connected back in April, the American College of Obstetrics and Gynecology release a position paper regarding a “4th Trimester” and regarding the need for improved postpartum care. Pelvic floor physical therapy only received a brief mention but I suppose we should be grateful it was mentioned at all. Ann and Sarah Hudelson have created a program that should be in every hospital in the United States and available to all postpartum women. The ACOG Guidelines are a start to improve postpartum care, pelvic floor physical therapists need to continue to advocate for ourselves and the work we do. I suspect Ann and Sarah’s story will inspire you the way it did me, check it out.
Inspiration behind program: The inspiration for this program came out of a really poor birthing experience that I had with my first child when I lived in Denver. I was already practicing as a pelvic PT and I had completed one class for CAPP-OB certification through the SoWH. When I took the Fundamentals in Pregnancy and Postpartum class, I was thinking why don’t we have PTs on the L&D floor? This question continued with me as I moved my way through an uncomplicated pregnancy. When I was 34 weeks GA, the midwife group I was working with informed me that my baby was in a breech presentation. They referred me to an acupuncturist, a chiropractor, pool, and a lot of inversions. I was grateful for the interventions by the chiropractor, but I was confused as to why a PT wasn’t included. I ended up doing everything recommended as well as including a PT co-worker for some of the “pelvic balancing” that the chiropractor was doing. Ultimately, my baby never turned and I refused to consent to cesarean until I had labored for >12 hours and decided that I had no other option.
I was shocked at the lack of support that I had in the antenatal period, but even worse was the amount of pain and lack of support in the postpartum period. My recovery from my cesarean birth was a long process. My external obliques were torn during the surgery, so it hurt to have my baby on my stomach to nurse. Her little feet would hit my incision and pain would almost make me pass out. Pain and a drop in my blood pressure prevented me from getting out of bed by myself and the only help I had was from my husband. A nurse even commented to me “Wow, you really are taking your time” when I was trying to engage my TrA and log roll to sit up in bed. The next few days were filled with pain, tears, asking for help and not receiving. “Why can’t PT come help me” was a question I asked the nursing staff and physicians. They all said, “PT doesn’t work on this floor”. And why not was all I could think. Why not?
When I made it home, five days later, I was still in significant pain with mobility, with gas, with urination, with bowel movements. Luckily, I am a pelvic PT and knew right away that NONE of this was normal. I went and saw of few of my pelvic PT friends and felt 50% better in a few weeks. It would take me 18 more months to feel 90% better with the help of my own knowledge and with the help of my PT friends.
Two months into my maternity leave and postpartum recovery, I decided that this system needed to change. So I moved to Salida, CO in order to work for a small hospital where I knew the community would be supportive of a change. That leads me now: four years postpartum from my cesarean birth and 18 months postpartum from my VBAC baby. I have worked to establish a mom supported culture at HRRMC and in the home birth community. My program is supported by physicians, nurses, midwives, and moms because we all know that this is what’s best for moms and for families.
What is the program: The physical therapy department had an existing pelvic physical therapy program started in 2008 by Sarah Hudelson, PT, DPT. I started the physical therapy obstetric program October of 2014 after the poor birthing experience. The program started with inpatient visits to all women who had a cesarean birth and quickly progressed to all births! We then added on a standard 6 week postpartum visit and, more recently, a standard 3rd trimester visit. We will see any woman who is having dysfunction, but the standard visits were designed to attempt to improve patient outcomes.
The 3rd trimester visit is newer, started in 2016, and is slowly growing. I had another baby in September of 2016, so we have recently picked our efforts back up in 2017. Since we have a small tight knit community, our mothers have been good about spreading the word on this program. One month ago we were able to get this 3rd trimester visit standardized with one of the two physician practices where they have a referral paper in the mother’s 3rd trimester packet. We, the physicians and PTs, are hoping that this helps remind them to refer. This visit(s) includes: what happens in normal birth from an orthopedic/PT perspective, pelvic balancing, uterine balancing (after 36 weeks GA), and a labor and positioning visit where moms can bring a birth partner. We then write up a letter with our recommendations for labor and birth, send one with the client, one to the nursing staff at the hospital, and one to the physician. Our goal is to avoid orthopedic injury, decrease perineal tear rate, decrease primary cesarean rate, educate mothers on pain relieving techniques/positions in order to avoid epidural use, and improve maternal mental health. We are tracking our outcomes for orthopedic injury, tear rate, primary cesarean, and epidural use. Hopefully we will be able to present some of these statistics at CSM in 2019 or 2020.
The inpatient visit is structured around basic biomechanics, isometric activation of TrA and pelvic muscles, prolapse prevention with bowel mechanics and discussions around lifting baby, addressing any surgery or tearing she may have had, a list of common but not normal symptoms she may experience that she should get help with if they come up, and she is assessed for a DrA. All the moms are fitted with a binder, which we know is controversial, but we felt like it was the best option for our inpatient PTs in order to help them make decisions on care.
The 6 week follow-up visit is mostly standardized, with the majority of physicians remembering the referral. In this visit, we do a basic pelvic muscle assessment and intake and make our recommendations from there. One piece that has been interesting about this 6 week visit is the amount of mothers that present with some issue with breastfeeding. In our small town, there are not many places to refer out. I found myself not able to fully help them meet their breastfeeding goals and I was making positional recommendation based on their dysfunction (prolapse, tear recovery, cesarean scar pain, coccydynia, etc) and these suggestions were not always protective of their breastfeeding relationship. With the help of the Chaffee County Breastfeeding Coalition, I became a Certified Lactation Counselor and opened my own lactation company to see clients privately for lactation support. I can also answer questions during my PT session related to breastfeeding and positioning. I found that pelvic PTs, and PTs in general, can be perfect providers for lactation support. But that is another topic for another time!
How you got it going: I started with speaking with the labor and delivery nurse manager about PT care of the post-surgical patients and discussing the role that PT has in caring for moms post-surgical (ie: post cesarean). The nurse manager and I discussed the role PT has with all orthopedic surgeries and how these surgeries were no different: they required mobility, isometrics, swelling, and pain management. We then went to the OB services meeting and discussed PT seeing all cesarean birth moms day one post op with the physician staff. We decided to make PT a standard visit. This was key in the success of our program. With PT being standard, the physicians don’t have to write an extra order. The box is already checked on physician visit note. I feel like programs that give the physicians or the nursing staff a checklist of when to use PT will fail because the PTs should be the ones deciding if a person should be seen or not seen, not other medical professionals. I then tried the inpatient PTs on the basics on our program including basic evaluation of DrA. We then also trained the nursing staff on the role of the PTs on the labor and delivery floor so they would know what to expect of us. The physicians, nurses, and moms loved the visits from PT so much that in two months all births had a standard PT visit. From there, we attended all OB service meetings to normalize our role on the labor and delivery floor. After a year we introduced our 6 week postpartum follow up. In 2016/2017 we then introduced our 3rd trimester visit utilizing the “Save the Perineum” campaign and a goal to reduce the primary cesarean rate. We are still working on growing the 6 week and 3rd trimester visit and we still attend the OB service meetings. I’m very active on our social media as well as offering a free postpartum recovery classes in order to continue to grow our community interest and community referrals. This program is a labor of love and is not without hard work and significant effort.
Our care providers, both physicians and nurses, are amazing. They have trusted this process and have been supportive of my dream. I am so thankful for their support and advocacy.
What’s next: At this point our biggest task is to continue to increase participation in the 3rd trimester visit and the 6 week visit. Our physicians are working on trying to find a way to prompt those visits, and I think we are almost there! My 3-5 year goal is to have PT be more involved during birth. There are a few physicians that will text or call me and ask me questions about mother positioning if labor is not progressing. What I want is the ability/availability for PT to be a part of the birthing team during the labor and delivery. My 5-8 year goal is lift our VBAC ban and improve maternal care from this standpoint. I see myself as a birth advocate, and I want for the women in our community to know they have a choice in how they birth. We are improving this by empowering women to make choices in their own position during labor and delivery; this will soon be followed by being able to make the choice to VBAC or have a secondary cesarean birth. Another goal that I have involves our lactation support and how PT is utilized for lactation support, but, again, that is a topic for another time!
Our goal is to present our program in four different poster presentations for CSM 2019 in D.C. We then hope to present the entire program with all of the data at CSM 2020 in Denver. Hopefully we are accepted!
Feedback: Here are some notes from our supporters!
“From helping relieve back and pelvic pain during pregnancy to helping women feel normal again after delivery, pelvic PT has been very beneficial for my OB patients. Pain, incontinence, and dyspareunia seem to be symptoms women think are normal after having children – until they go see a pelvic specialist and find out they can get better. Patients often realize that these taboo topics are very common among other women and feel empowered to improve their symptoms and talk with other women about what should be considered normal during pregnancy and after having children.” – Dr. Vanna Irving MD with practice specialty in OB/Gyn
“Our perinatal physical therapy program is unlike anything I have ever had the pleasure to work with, even at much bigger urban hospitals. The service that Ann and Sarah provide empowers women to approach childbirth with confidence having created a personalized plan for both labor and delivery. Not only does it give them practical tools to both relieve pain and prevent injury, but it also follows them after birth to ensure their recovery is without chronic problems like incontinence and pelvic pain. I refer all my pregnant patients to them.” – Dr. Daniel Lombardo MD with practice specialty in OB/Gyn
“The HRRMC pelvic floor physical therapists have not only given our moms the tools to recover well postpartum, but have equipped our nurses with safe, productive labor and pushing positions for our laboring moms. I am relieved to know that we are doing everything we can to prevent long-term problems that can result from pregnancy and childbirth. Our pelvic floor PT program is a success and a great service to our childbearing population in Salida.” – Tracey Hill, RN, BSN, MS
“The OB PT program was absolutely essential for my second pregnancy as well as my postpartum recovery with both of my babies. I suffered third degree tears with both of my babies and I believe I wouldn’t have the recovery and healing that I had without pelvic PT. The care I received from Ann was above and beyond what one would expect of a medical professional and I am forever grateful to have been referred to her initially. It is so evident that she is genuinely concerned with the well being and full recovery of her patients. She has a true gift. My hope is that pelvic PT becomes more widely used as a norm as I feel every single woman could benefit from it postpartum.” – Local Salida Mom
Congratulations to Ann and Sarah for their work and program! They are bringing pelvic floor physical therapy to it’s well-deserved place and helping tons of women. We thank Ann for sharing her story and ideas on how to create similar programs in our own geographical areas!
Women can find pelvic floor physical therapists through the American Physical Therapy Association’s PT Locator.
Additional Reading and Podcasts:
Why all postpartum women need physical therapy
Katie’s Crib Podcast with Stephanie Prendergast
Babes and Babies Podcast with the Vagina Whisperer Sara Readon
Informed Pregnancy Podcast with Stephanie Prendergast
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
This is absolutely amazing and what I am working toward at my OP clinic/hospital! It is so encouraging to read about this program’s success. It gives me hope for the moms in this country as pelvic floor therapists continue to blaze a trail forward to improve quality of postpartum care!
Great work Ann and Sarah! I can’t wait to hear more about it at CSM.
Yes! Thank you ?
Great story and very inspirational!