Considerations of Musculoskeletal Harm Reduction During Labor and Birth

In Pregnancy/Postpartum by Molly Bachmann1 Comment

By Molly Bachmann PT, DPT, PHRC San Francisco

When you reflect on major athletic moments or professional accomplishments in your life, you likely remember the days, weeks, months or maybe even years of training your body and mind for that event. The evaluations from medical professionals and coaches helped you identify which drills to run, what food to consume, and provided you with the motivation necessary to score that winning goal or complete that one additional pirouette that leaves the audience in “awe.” You may remember the extra course work you learned from on the side while working 40 hours a week to boost your resume to get your seat at the table you’ve always dreamed of sitting at. All of those hours of preparation and building the right community helped you to succeed.

 

When it comes to labor and birth, we should be thinking of preparation as a necessity for not only nesting and adjusting to the idea of bringing in a new family member, but also for our bodies. Just as we emphasize injury prevention on the field or burn out prevention in the workplace, we should be emphasizing injury prevention in labor and birth, rehabilitation in early postpartum and community centered care for new parents to reduce stress and poor health outcomes. Physical therapy can play a huge role in helping you prepare. 

 

In thinking about birth through a biomechanics lens, it is essential that we have a conversation about birthing positions. In the United States, most pregnant people who give birth in hospital settings will do so lying on their backs with legs up in the air. This is called the dorsal lithotomy position. According to research, this may not be the most appropriate position for all pregnant people especially when thinking about the musculoskeletal system.

 

Laboring and birthing in the dorsal lithotomy position demonstrated:

  1. Increased need for perineal sutures
  2. Increase patient reports of severe pain
  3. Increased rate of episiotomies
  4. Higher rates of instrument assisted deliveries
  5. Increased risk of extremity nerve injuries due to prolonged positioning at end range
  6. May prohibit sacral nutation which is required for opening the pelvic outlet

 

When compared with the dorsal lithotomy position, side-lying showed: 

  1. Least likely to cause perineal tearing
  2. 66% of pregnant people gave birth to an intact perineum
  3. Avoids compression to joints reducing pain
  4. Helpful for patients pregnant for the first time and for those with larger newborns
  5. May slow a precipitous labor

 

Birth in a quadruped (on hands and knees) position showed:

  1. Less need for perineal suturing as opposed to dorsal Lithotomy
  2. 61% birthed with an intact perineum
  3. May be helpful in reducing orthopedic pain

 

Lastly, squatting can help to:

  1. Shorten the 2nd stage of labor
  2. Reduce need for oxytocin to stimulate labor
  3. Reduce rate of episiotomies and severity of perineal lacerations

 

If we can use effective and personalized exercise/therapeutic programs to prepare people for more positive outcomes prior to a total knee replacement, we can do the same in birth spaces. Having a good understanding of how to breathe properly during birth, how to lengthen your pelvic floor muscles, appropriate hip flexibility and strength, can all help to reduce musculoskeletal injury. Preparation as well as critical analysis of which positions are best for you can help to achieve healthier outcomes for you and the baby. As you prepare for birth, it’s important to consult with your birth work team and physical therapist as they can help you to identify an appropriate individualized program as well as which positions may be best for you and your body.

 

 

References:

AL;, De Jonge A;Teunissen TA;Lagro-Janssen. “Supine Position Compared to Other Positions during the Second Stage of Labor: a Meta-Analytic Review.” Journal of Psychosomatic Obstetrics and Gynaecology, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/15376403/. 

B;, Shorten A;Donsante J;Shorten. “Birth Position, Accoucheur, and Perineal Outcomes: Informing Women about Choices for Vaginal Birth.” Birth (Berkeley, Calif.), U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/11843786/. 

Golay, Jane, et al. “The Squatting Position for the Second Stage of Labor: Effects on Labor and on Maternal and Fetal Well‐Being.” Wiley Online Library, John Wiley & Sons, Ltd, 2 Apr. 2007, onlinelibrary.wiley.com/doi/abs/10.1111/j.1523-536X.1993.tb00420.x. 

Simarro, María, et al. “A Prospective Randomized Trial of Postural Changes vs Passive Supine Lying during the Second Stage of Labor under Epidural Analgesia.” Medical Sciences (Basel, Switzerland), MDPI, 8 Mar. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5635775/. 

Soong, Barbara, and Margaret Barnes. “Maternal Position at Midwife-Attended Birth and Perineal Trauma: Is There an Association?” Birth, vol. 32, no. 3, 2005, pp. 164–169., doi:10.1111/j.0730-7659.2005.00365.x. 

Walker C;Rodríguez T;Herranz A;Espinosa JA;Sánchez E;Espuña-Pons M; “Alternative Model of Birth to Reduce the Risk of Assisted Vaginal Delivery and Perineal Trauma.” International Urogynecology Journal, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/22297706/. 

Wong CA;Scavone BM;Dugan S;Smith JC;Prather H;Ganchiff JN;McCarthy RJ; “Incidence of Postpartum Lumbosacral Spine and Lower Extremity Nerve Injuries.” Obstetrics and Gynecology, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/12576251/. 

 

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $85.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

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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.

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