What you need to know about childbirth with pelvic pain

By Elizabeth Akincilar-Rummer

As we learned in a recent previous post by Stephanie Prendergast, the vast majority of women are not well informed when it comes to their pelvic floor, pregnancy and childbirth. In fact, 93% of women felt like they were insufficiently informed about their pelvic health! Unlike the rest of the population, many of our patients tend to be more informed and better educated about their pelvic health even before they step into our office. Because so many of them have struggled to find qualified providers to treat their pelvic pain, they’ve often had to do their own research and educate themselves about their pelvic floors in order to find an effective treatment.

Although our patients are typically much more informed that the average person, they still come to their physical therapy appointments with lots of questions. At PHRC, we feel it is crucial that our patients have an excellent understanding of their pelvic health. We take considerable time and effort to be sure our patients have all the information and resources they need to understand their pelvis. Between our blog, our website, and our book, Pelvic Pain Explained, we have a lot of great resources to offer our patients so they can become fully fluent in all things pelvis! However, there are some questions that are very difficult to find answers for. Most often, this is due to the limited number of providers that specialize in treating pelvic pain combined with a lack of research. One of these questions that is lacking a reliable answer to is the effects of pregnancy and childbirth on women who either have a history of pelvic pain or are currently suffering from pelvic pain.

The most common questions I get from my female patients of childbearing age suffering from pelvic pain are related to pregnancy and childbirth. Questions such as, “am I going to be able to get pregnant?” or, “am I going to be able to have a vaginal delivery?” are very frequent. Undoubtedly, these are understandably concerning questions, but the answers often pleasantly surprise my patients. It’s not as bleak as many of them think.

There is very little or no data on the effects of pregnancy and childbirth for women with pelvic pain, particularly pudendal neuralgia. To try to shed some light on this topic, I recently interviewed Dr. Mark Conway from Nashua, New Hampshire, to get his recommendations with regards to pregnancy and childbirth for women that currently suffer with, or have a history of pelvic pain and/or pudendal neuralgia. Dr. Conway is currently a gynecologist and pelvic surgeon, although he practiced obstetrics for nearly 25 years. Additionally, he is an international expert on pudendal neuralgia and pudendal nerve entrapment.

Q: Can pudendal neuralgia or other pelvic pain syndromes affect a woman’s fertility?

A: With regards to pudendal neuralgia, the only limitation to fertility is if the woman is unable to have intercourse. However, there are other ways to conceive, such as intrauterine insemination (IUI) and in vitro fertilization (IVF). Women suffering from pelvic pain due to endometriosis can experience fertility challenges secondary to endometriosis, if untreated. Additionally, if women are suffering from pelvic pain due to prior pelvic inflammatory disease, this can also lead to fertility challenges because of scarring and/or damage to the fallopian tubes.

Q: Are there any precautions during pregnancy for a woman with a history of pudendal neuralgia or pelvic pain?

A: Women suffering from pelvic pain due to endometriosis tend to feel better during pregnancy. Although there is no data concerning pudendal neuralgia and pregnancy, my observation is that many patients with pudendal neuralgia often feel an increase in their symptoms during pregnancy.

Q: Would you recommend completely resolving pudendal neuralgia or other causes of pelvic pain before getting pregnant?

A: For women with pudendal neuralgia, it really depends on their level of functionality. If their function is high, it is really up to the patient. If their function is low, she may want to consider focusing on the treatment for the pain first. If the patient is older, she may want to focus on the pregnancy, but if younger, she may want to focus on treating the pelvic pain first. For women with endometriosis or prior pelvic inflammatory disease, the disease should be treated prior to conceiving. For women with localized vulvodynia, it’s probably better to treat it prior to pregnancy because it could be successfully treated with a vestibulectomy.

Q: Are there any precautions during labor and delivery for women with a history of pudendal neuralgia or other pelvic pain syndromes?

A: There are no studies examining women with pudendal neuralgia and childbirth. However, I would recommend a Cesarean section for women with a history of pudendal neuralgia. This is because once a nerve is injured, it is more prone to re-injury. The pudendal nerve stretches significantly during a normal vaginal childbirth. The data shows that the majority of women have an increased pudendal nerve latency, due to injury to the nerve, following vaginal childbirth; however, most recover. Women who have already had trauma to the pudendal nerve prior to childbirth will likely not fair as well after vaginal childbirth versus those who have not had prior trauma. I would also recommend a Cesarean section for women who have localized vulvodynia, particularly if it is their first birth.

Q: If a women with pudendal neuralgia wants to attempt to have a vaginal delivery, do you have any recommendations during delivery? Are there particular positions that are better? Any effects from an epidural?

A: I would recommend trying to make the delivery as easy as possible. I would strongly recommend against an assisted delivery, either with forceps or vacuum. I would recommend limiting the second stage of labor to two hours to limit the time the head of the baby is pressing against the perineum. In this case, the woman may want to opt for an episiotomy to expedite the delivery. Additionally, in general, an epidural tends to prolong labor, including the second stage of labor. As far as positioning goes during labor, I would recommend whatever position that expedites the second stage of labor. For women with pelvic pain due to pelvic floor dysfunction, I would recommend against an episiotomy to prevent further damage to the pelvic floor musculature. Theoretically, it may be helpful for these women to get an epidural, as it may be helpful in preventing central sensitization in women who were already suffering from pelvic pain prior to the pregnancy.

Q: Do you recommend pelvic floor physical therapy prior to childbirth?

A: Yes, I recommend pelvic floor physical therapy to all of my patients suffering from pelvic pain.

Q: Do you recommend pelvic floor physical therapy after childbirth?

A: Yes, if my patient has pelvic pain after childbirth I recommend pelvic floor physical therapy six to eight weeks postpartum.

Q: What are the chances that previously resolved pudendal neuralgia will recur after childbirth?

A: There is no data on the effects of pregnancy on pudendal neuralgia, but theoretically, a woman is at a higher risk for a return of symptoms due to the potential damage to nerves and muscles during pregnancy and childbirth.

Q: Is a woman with a history of pudendal neuralgia or other pelvic pain syndromes at a higher risk for pelvic organ prolapse?

A: No, I am not aware of any correlation.

Q: Is there any chance that childbirth could improve pelvic pain symptoms?

A: Women with endometriosis often feel better during pregnancy and breastfeeding, but the symptoms of endometriosis often return within one to two years after childbirth, if untreated. It has been proposed that pelvic floor hypertonicity may improve after childbirth. Dysmenorrhea and dyspareunia due to vaginal stenosis may also improve after vaginal delivery, although these are clinical observations only.

See, it’s not as dismal as some may have thought! You CAN get pregnant, you CAN deliver a baby either vaginally or via C-section, and your pelvic floor CAN recover following childbirth, with the help of a great pelvic floor PT, of course!! 😉

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.