Pregnancy, Labor, and Delivery with Vulvovaginal Pain

By Melinda Fontaine

Julia called me yesterday to ask some questions about pelvic pain and pregnancy. She was 38 weeks pregnant and getting ready to give birth. She had a history of some pain with intercourse prior to getting pregnant and was surprised to feel some vaginal pain at her last OB appointment as well. Julia wanted to know if her pain meant she was going to have trouble giving birth in a few weeks or difficulty recovering. Her doctor was unable to answer her questions.

Julia is not alone. Vaginismus and provoked vestibulodynia (two diagnoses that create vulvovaginal pain) are present in 5% and 12% of women respectively. Women with vulvar or vaginal pain get pregnant and have babies and don’t know what to expect. While we never truly know what to expect during a pregnancy or delivery, let’s discuss some possibilities.

How will clinician’s treat me?

Obstetricians, midwives, and ultrasound technicians should be familiar with pelvic pain conditions. However, since taking a sexual history is not commonly part of the intake for these clinicians, women will need to disclose this information and have a discussion about their pain. Pelvic pain is often linked with anxiety about different parts of the pelvic exams as well as delivery. Good communication with your providers can reduce anxiety about pregnancy and delivery and help them provide the care you need.

How to talk to your clinician:

Ask about your biggest fears – how will your provider reduce risks and handle complications?
Confirm that you have control over the situation and that the provider will stop a pelvic exam if you say so
Ask the provider to go extra slow
Ask the provider to explain exactly what they will do before they do it
Request that you insert the vaginal ultrasound transducer yourself if needed
Ask if you can keep some of your own clothes on during exams or delivery
Request a position that makes you most comfortable
Ask your practitioner to utilize maternal directed pushing during delivery
Ask what to expect during your recovery from childbirth

Will my baby be affected?

Babies born to women with vulvar pain have the same Apgar scores and perinatal mortality as those born to women without pain. Babies of women with vulvar pain also showed no difference in the rate of miscarriages, stillborns, and preterm births. These babies are more likely to be born by cesarean section, induced labor, or vacuum assisted delivery.¹

How will I be affected physically?

Women with vulvar pain prior to delivery are more likely to have vulvar pain after delivery.² Vaginal delivery is safe even after vestibulectomy and is not associated with more perineal tears.¹

Can I prevent a perineal injury?

Tears in the perineum are a fear of every child bearing woman, but especially those with a history of vulvar or vaginal pain. There is no data that says these women are at higher risk for perineal injury, but there are a few things women can do to help their perineum during childbirth.

Perineal massage is stretching of the muscles around the vaginal opening during the last few weeks of pregnancy. It reduces the risk for an episiotomy, and may decrease the risk for large tears, especially in first time mothers.
A warm compress on the perineum, massaging the vaginal opening during labor, and “hands on” support on the perineum during delivery of the head each decrease the risk for significant tears. “Hands on” support means that the practitioner assisting the delivery puts pressure on the perineum with their hand as the baby’s head is delivered.
A mother’s position during delivery can have an effect on how easily she gives birth. If you think about it, most of the world squats to give birth (or to have a bowel movement for that matter) because it makes the pelvis want to open and takes advantage of gravity.

http://www.borcad.cz/birthing-bed-ave-birthing-positions/

Squatting, for example with a squat bar, has been associated with greater comfort, fewer episiotomies, and shorter second stage of labor.¹ Side lying or hands and knees provide similar advantages.⁴

Maternal pushing is letting the mother decide when to push based on her urges. This type of pushing is better than coached pushing for protecting the pelvic floor.

How can I manage my vulvovaginal pain during pregnancy?

The medications that patients take for vulvar pain may be risky for the unborn baby, so patients and doctors need to reevaluate the risks and benefits to each medication when a woman becomes pregnant. Discuss if pain relieving medications, topicals, or herbs can safely be used during pregnancy. Using a specifically placed warm or cool compress can reduce pain. Mindful meditation, acupuncture, and pelvic physical therapy also help control pain.

Can I go to pelvic physical therapy during and after pregnancy?

Many women with vulvar or vaginal pain go to physical therapy. Physical therapy treatment can be very helpful and safe with a few modifications for pregnancy. Internal therapy is also safe and effective when the pregnancy is low-risk. If sexual intercourse is safe, then physical therapy is considered safe. Physical therapy for women with vulvovaginal pain very rarely includes kegels, instead it is often aimed at releasing tension and regaining muscle length. Physical therapy also helps discomfort during the postpartum period. Internal work is usually resumed at least 6 weeks postpartum after the obstetrician or midwife has cleared the mother for intercourse. Here is how pelvic PT helps women who are pregnant or postpartum.

Conclusions

Pregnancy and delivery with vulvar or vaginal pain is safe for babies
Women with vulvovaginal pain are more likely to have a Cesarean section, but are not more likely to have complications during a vaginal birth
There are ways to manage vulvar pain during pregnancy and delivery
Physical therapy can be safe and effective during and after pregnancy

I told Julia the same thing I would tell other women with vulvovaginal pain who are pregnant or considering pregnancy: It is possible to have a normal pregnancy and delivery with no ill effects for you and your baby. Your pain does not mean that you will have increased difficulty birthing the baby. There are ways to manage the discomfort you may feel with vaginal exams or other parts of the pregnancy, delivery, and recovery. A physical therapist is a valuable part of your pain management team while trying to conceive, during pregnancy, and postpartum.

References

Rosenbaum T and Padoa A (2012) Managing pregnancy and delivery in women with sexual pain disorders. J Sex Med 9:1726-1735
Nguyen RH (2012) A population-based study of pregnancy and delivery characteristics among women with vulvodynia. Pain Ther 1:2
Van Kampen M, et al. (2015) The efficacy of physiotherapy for the prevention and treatment of prenatal symptoms: a systematic review. Int Urogynecol J 26: 1575-1586
Bazi T, et al. (2016) Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion. Int Urogynecol J doi 10.1007/s00192-016-2993-9
Osborne K and Hanson L (2014) Labor Down or Bear Down: A strategy to translate second-stage labor evidence to perinatal practice. J Perinat Neonat Nurs 28.2:117-126

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.