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.
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.
- 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.
- 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