Peripartum Physical Therapy Panel

A group discussion with OB-GYN Dr. Jeanne Sullivan and physical therapists providing peripartum physical therapy

Dr. Sullivan joins three Denver area physical therapists for a peripartum physical therapy panel discussion. The group reviews physical therapy goals for their patients who are getting ready to or recently have given birth. The doctors discuss when postpartum mothers can return to their pre-birth exercise plans, Kegels and so much more.

Panel audio: peripartum physical therapy

Jump to each panel section

• Goals of peripartum physical therapy
• Pelvic floor musculature education
• A social justice perspective
• A postpartum six weeks plan
• Pregnancy exercises
• Tweaking pelvic floor physical therapy
• Delaying postpartum exercise
• Phases of tissue healing postpartum
• Postpartum exercise, from high load to Pilates
• Pelvic organ prolapse
• Kegels
• Managing diastasis recti
• Constipation prevention & management
• C-Section and instrument-assisted delivery problems
• Preventive pregnancy physical therapy
• Perineal tear physical therapy
• Return to sexual function
• Painful sex & nervous system regulation
• Research supporting perineal massage
• Physical therapy for C-section scars

Dr. Jeanne Sullivan: We are starting our optimization of the peripartum period talk, so first we’re going to introduce our panel. I am Dr. Jeanne Sullivan a general OB-GYN at CU East Denver, formerly Rocky Mountain OB-GYN.

Dr. Niki Popper: I am Niki Popper, a Doctor of Physical Therapy at Popper PT in Greenwood Village.

Dr. Becca Campbell: I am Becca Campbell also a Doctor of Physical Therapy at Popper PT with Niki, as well as at Integrated Physical Therapy of Littleton.

Dr. Cami Hatch: I am Cami Hatch, a Doctor of Physical Therapy, and I have my own private practice in LoHi.

 

Dr. Jeanne Sullivan

Perfect, so we’ve got our crew. We wanted to come together for this talk not only to promote activity and exercise surrounding pregnancy but more specifically to review the optimization of the peripartum period from several qualified and licensed physical therapists. For the purposes of this talk, peripartum refers to immediately before, during and after delivery.

We also wanted to say that for this discussion we may be using pronouns like “she,” “her,” “hers” and terms like “mother” or “mom” as a generalization. This is truly for the sake of smooth conversation. We recognize that not all birthing persons will use these pronouns or titles and we support inclusive care for all birthing persons.

As an OB-GYN, we know that exercise and pregnancy for the average person is extremely low risk but also high reward. Benefits include: higher rates of vaginal delivery, meaning lower incidence of cesarean delivery and instrument assisted delivery; we have lower incidence of excessive gestational weight gain, gestational diabetes, gestational hypertensive disorders, preterm deliveries, low birth weight; and we do know that there is a great impact on peripartum mental health with physical activity and exercise, decreased rates of postpartum depression, AND there are NO studies to show that exercise decreases lactation ability.

So, really low risk to exercise. We also know that many people in and after pregnancy experience abdominal pain, back pain, hip pain, leg pain, urinary issues, pain with sex and issues with bowel movements. Of course, there’s a reward: you get a cute baby afterward. But this is really how we’re going to move into our first talking point.

Goals of peripartum physical therapy

Dr. Jeanne Sullivan

I just wanted to start by asking the question for each of us: What are our goals as a provider when someone comes to us in the peripartum period? And so, I’ll go first.

As an obstetrician my goals are very simple: healthy mom and healthy baby. Of course, when someone comes to me peripartum I want to evaluate for things that can harm both mom and baby. And once those are ruled out, then we can move to symptom control and talk about reassurance. At our practice we always strive to use evidence-based medicine to guide our decision-making processes.

But it’s really important to acknowledge that obstetrics is a unique area where study design can be very difficult due to the ethical ramifications when you’re not only looking at mom but also baby. This means that sometimes we don’t have those extremely high-powered, randomized control studies that a lot of other areas in medicine do have. So with those recommendations you can land in a gray zone where there’s not always evidence, and things are very gray or unclear. This is when both the provider and patient experience can lead the plan.

It is very important for us to acknowledge and say that if truly we’re in an area that we don’t have clear guidelines and if there are reasonable options, we should review the pros and cons and weigh the patient’s goals and thoughts. I try to remember that each person presents with their own goals, background and understanding, but many times the patient’s primary goal is uniquely and singly the birth experience.

I absolutely wish to make this a pleasant, fun and memorable experience. But as an OB, the bottom line is: My job is to keep mom and baby safe. Looking past the birth experience, and I think a few of us have talked about this before, many people come to us in the postpartum period and say they were so focused on the birth but they didn’t prepare for the recovery. So that’s really why I wanted to do this discussion with you guys, so we can optimize this.

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Pelvic floor musculature education

Dr. Niki Popper

I think we’ll probably all have somewhat of a similar answer, but ultimately, I think pregnant people take classes on how to deliver their baby, how to care for their baby, and oftentimes how to breastfeed. But there is very little education that happens about the changes that occur to the musculoskeletal system in pregnancy, which are far reaching and have big implications for a lot of those common problems that you talked about.

Our goal, regardless of whether a patient is symptomatic or not and regardless of the time that they’re presenting to us in the peripartum period, is to educate them on basic anatomy of the pelvic floor musculature to understand what’s normal. Simply put, when it comes to sexual, bowel and bladder function, if there is difficulty keeping things in or getting things out, those are signs of potential pelvic floor muscle dysfunction that warrants seeing a pelvic health PT. Educating patients on what to look for, how to know if they might need some help, and then how to understand what pregnancy is going to change so that they can have a framework to make decisions about how and when they should initiate exercise and what types of exercise will be most beneficial, is our overarching goal.

One of the things that’s complicated for patients in this period is that there’s no one-size-fits-all. It’s really dependent upon their goals, their current lifestyle, job requirements, and any current pelvic health or musculoskeletal concerns. How we’re going to initiate certain exercises for the pelvic floor depends largely on those variables and should be individualized. But there is an overall framework with which everyone can work from to make those kinds of decisions.

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A social justice perspective

Dr. Becca Campbell

I would second a lot of what Niki said. Ultimately, I came to pelvic health because I looked at it as a social justice issue in a way, where there are a lot of normalized parts of the peripartum experience that I think we now know should maybe not be normalized. I think it’s really hard to be an advocate for oneself if you don’t know what normal is. If you are coming to one of us, and like Niki said, we’re giving you a “tour de pelvis” if you will, and you’re learning all about what things should look like and how they should feel relative to bowel, bladder and sexual function, it’s a lot easier to know when something goes wrong. Then you can be your own advocate and seek care for that before it becomes a bigger problem.

A postpartum six weeks plan

Dr. Cami Hatch

And maybe just to add on in terms of goals in the perinatal period, using physical therapists as resources for all the other alternative providers – doulas, midwives, lactation consultants – I always have a lot of those resources. It’s also important to create a plan in that early postpartum period, when patients often feel like they’re left alone. I like to leave people before delivery with a thorough plan for six weeks, whether it is physical or even mental health, which is another provider who is helpful to have on hand.

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Pregnancy exercises

Dr. Jeanne Sullivan

I mean all of those things are so related – making sure that we’re getting our patients engaged with the full picture. When we’re all talking about exercise and pregnancy, we often will start out with the general things, like in pregnancy we don’t want anyone to be doing high collision activities because, of course, the belly can get bumped and something could also happen to mom that could affect the baby. We don’t want people to be lying for long periods of time flat on their back. Short periods are actually probably just fine, so when someone is doing a lot of workouts that involve floor work, many times their bodies are going to tell them when they need to move. But you know, a full 40 minute workout on their back is not going to be what we recommend. But really, just monitoring how they are coping with their exercises; if it’s something that causes them to not be able to talk through the exercise, then that’s probably too intense for their current state.

So we have a lot of exercises that we are just fine and we encourage leading up to pregnancy and in pregnancy: walking, stationary cycling, aerobic exercises, dancing, resistance, stretching, water aerobics if people especially are having a lot of hip and back pain. And we have a whole list of symptoms to pay attention to that say you should stop your exercise, such as preterm contractions or bleeding. Of course, we don’t expect you [our PTs) to go through each possible exercise, because I’m sure that’s hundreds. But there are exercises during pregnancy that you’ll find are really high value exercises, and after delivery as well.

Dr. Cami Hatch

A lot of it depends on what they were doing before pregnancy. If this is someone who had a really high activity level – a lot of lifting, running and/or impact – then they don’t necessarily need to stop during pregnancy. They can carry on with some adjustments and modifications, while being mindful of symptoms. I think it just kind of depends. If it’s someone who was not exercising before pregnancy, we can use that time to actually initiate an exercise program. I would say I get the most benefit out of resistance training, which is supported in the research. We will always work with the person and individual symptoms, and if it’s something new, ease them into it slowly.

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Variances in pregnancy workouts

Dr. Niki Popper

I agree with Cami. This varies depending on the person, of course, but there are some hard and fast rules. If any type of exercise is leading to pain, for example, pubic symphysis pain or pubic bone pain, it is important to modify that exercise as pushing through that type of pain can make the problem much worse. Pubic symphysis dysfunction often happens early in the pregnancy when the hormone relaxin is at its peak around 8 to 10 weeks gestation. Patients can have this type of pain well before they are “showing.” Many movement patterns could make this condition worse, so it’s ideal to intervene as early as possible.

With that example, anything that’s asymmetrical like lunges, single leg work, down to the way you put on pants (if you’re standing or hopping on one foot), that could lead to increased pubic symphysis dysfunction. That’s definitely not a pain that we want anybody pushing through. That could make it worse. That goes for almost any kind of pain – If it is back pain, round ligament pain, any kind of pain – that’s a sign that the system is not working properly. Same with leakage. If something is causing someone to leak urine, air, gas or bowel, that is too high of a load for the musculature or the system doesn’t know how to work in coordination to protect the pelvic floor, the abdomen and the body. We want to make sure that any kind of exercise is not causing those types of symptoms.

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Tweaking pelvic floor physical therapy

Dr. Niki Popper

There’s a lot of hard and fast statements about abdominal exercises and what is safe. The ultimate risk for diastasis recti (DR), prolapse and any kind of urinary or bowel dysfunction all links back to increased intra-abdominal pressure, like a valsalva maneuver. For example, even with DR you can safely crunch if you know how to do it while managing abdominal pressure. That is a simple statement for a complex task. Probably every pelvic PT is starting with an assessment of how their patient is breathing and what their abdominals and pelvic floor muscles do while they’re breathing. We’re teaching the importance of exhalation with exertion so that we can decrease that pressure. If someone is lifting weights but they’re too heavy to breathe through that exercise, they could make a DR or prolapse worse or create incontinence. There are some nuanced recommendations around breathing. But in general if it hurts, if you can’t breathe, if you can’t keep a neutral spine, or if you’re leaking, you need a modification.

Dr. Becca Campbell

I think the assumption is often,

Oh I went into pregnancy super fit already and I’ve been doing these things, so they must be safe for me to keep doing.

But that may lead to overload or not knowing how to change or alter or modify the exercises that you’re currently doing to accommodate for that increase in intra-abdominal pressure, because there are more things going on in there in the moment when you’re lifting those same loads. We can see a change in coning or doming within a single session by just tweaking how someone breathes, or their body mechanics, or the timing of the muscle patterning. And those are things that, like Niki said, are very person-to-person dependent and hard to just give a blanket statement for. But know that’s a really big component of how we support people through exercise.

Dr. Jeanne Sullivan

You guys kind of broached on this a little bit with asymptomatic patients. Are there ones that you guys would say, You know what, maybe this person should see a physical therapist early in pregnancy? Especially being in Denver, we have a lot of athletes. Just your thoughts on who we should maybe be giving this information to, especially when they’re highly motivated to keep exercising in pregnancy, which is great.

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Delaying postpartum exercise

Dr. Cami Hatch

My biggest one would be runners. Perhaps cross fitters and athletes in sports, just because the recommendation for return to running in that postpartum period is 12 weeks. And once they get that clearance from you, people come to me all the time, OK well I got cleared last week from the OB and I’m going to start running. I think if we, as PT’s can see them through the pregnancy period, we can do a lot of education around the “why” of why it’s 12 weeks. And we can work on all of those, like connecting to the core muscles, managing pressure, working on pelvic floor contraction and relaxation. And that can usually make things a little bit easier in the postpartum period. They have a plan, they understand where their timeline is, and we’re preventing any further injuries later down the line.

Dr. Sullivan

I think the timeline you mentioned is really important. We as obstetricians evaluate patients at 6 weeks postpartum because that is when the female reproductive organs should have gone back to their pre-pregnancy state, or the uterus should have fully involuted. That’s a time when often bleeding patterns change, and people’s milk supplies will likely be where they’re going to be. So it’s a great time point for us to say, “Ok the uterus is back to normal, things have healed well.” Given the perineum has physically had time to heal after a tear, we may say after looking at the incision, “Ok, it should be safe if you resume intercourse.” But that is a very individualized assessment. So even if your OB-GYN says at your 6 week visit your uterus is back to normal, we as OB’s can definitely do better at making sure to reinforce that everyone has a different timeline for exercise, bowel function, bladder function and sex.

Dr. Cami Hatch

Yeah, during that first six weeks, maybe they’re not doing a lot of physical activity. So there’s also that period of building back muscles in order to be able to tolerate high intensity activities, which takes about four-six weeks depending on the person.

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Phases of tissue healing postpartum

Dr. Niki Popper

I would add that I often talk about phases of tissue healing for my patients. I’ll use a scab as an analogy, which isn’t perfect but it works to explain what’s going on. We know that for about the first two weeks after delivery you’re going to be in an inflammatory phase of healing. That’s as if you just cut your arm, your arm is bleeding, you need a Band-Aid on top of it to stop it from bleeding; you don’t have scab formation yet, so you’re just going to protect that skin and keep it clean. That’s how I view those first couple of weeks postpartum: you might need to ice your perineum, we want you resting, establishing bonding and feeding, and treating yourself as if you had an injury or tissue insult. If you had a tear or incision, that is a tissue injury.

For the first two weeks, we want to protect that tissue. It’s not a hard and fast rule, like the clock strikes midnight and you’re on the next phase of healing. But, approximately two weeks after delivery, we could equate that healing phase to seeing scab formation on a cut. As the body is starting to lay down some new collagen fibers, that tissue is starting to reorganize and will be able to withstand more load. Once you have a scab forming, you probably don’t need your Band-Aid anymore but you could still sluff the scab off and potentially create some bleeding. That’s a perfect example of if you are walking or exercising postpartum and you have increased bleeding, that’s a sign that exercise was probably too hard on the uterus. We want to monitor how much you’re bleeding to understand if it’s correlated with exercise. It is normal to still be bleeding in that time frame, but if the exercise you’re doing is causing increased bleeding, that’s a sign that you pushed too hard for the phase of healing you’re in.

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Postpartum exercise, from high load to Pilates

Dr. Niki Popper

When folks are closer to that six, eight and then into the 12 week marker, we’re really starting to see those fibers get more organized. People start to feel better, usually the tissue is not as red and swollen, the OB tends to clear them from pelvic rest and it’s safe to return to exercise. That is a critical window where I find a lot of patients exercise too hard, because they don’t have the knowledge of how to gradually build back up again and how to monitor their tissues for what is safe.

What we’re doing in that period really depends on what their goal is. If their goal is to run a marathon, I’m going to have them doing much higher load exercise at that time. If their goal is just to be pain free and just heal normally, I’m going to be doing more Pilates-based exercises and just match the exercise to their goals. But we really don’t want to see folks loading that tissue at a high impact until 12 weeks, in general – that’s like running, jumping, HIIT workouts – because of the phases of tissue healing.

Dr. Becca Campbell

I really like to use a framework for returning to any kind of impact loading, which allows it to be a little more individualized, based on, Can we practice these precursors to running, for example? We have a return to run protocol, which is what I’m referencing. It’s a way for us to test the waters with certain movements that are close to running but not quite doing the actual thing to see if they have any increased bleeding, like Niki mentioned, or other things that are telling you that your body’s not quite ready for what you’re doing yet, which might be incontinence or it might be pelvic pressure/ heaviness, which could signal that you’re in prolapse land or getting there. I think a bigger, more empowering part of the process is just teaching someone how to listen to what their body is telling them and translate it into:

OK, is this me being fatigued because I’m out of practice, or is this me needing to have a conversation with my body about how I should dial this back because I’m not quite there yet?

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Pelvic organ prolapse

Dr. Jeanne Sullivan

I think you all each mentioned it, so trusting a woman’s symptoms to help guide where they are at with their recovery. And what we’re trying to prevent is, of course, dysfunction. So having pain or inability to do those things that we are looking for in the recovery: peeing, pooping, having sex, getting back to your normal exercise routine. Then also you mentioned pelvic organ prolapse. That can be the front wall of the vagina coming down, which is typically the bladder; that can be the uterus coming down in the middle; and then the back wall of the vagina sometimes can protrude through and that’s typically really the intestines, but most commonly the rectum. These are things that long, long term we see in a lot of people who have had children, whether or not via C-section or vaginal delivery – but with vaginal the risk is higher. But we can see especially in some of our really, high intense exercise people or athletes we see it sooner – I mean people sometimes in their 30s and 40s. So we are talking about optimization but some of this is also prevention and stopping before things go wrong.

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Kegels – a hot topic!

Dr. Jeanne Sullivan

One thing I did want to ask – I have a lot of patients who ask about thoughts on Kegel exercises. Would one of you want to talk about how and when you should initiate Kegels – or if?

This is a hot topic!

Dr. Cami Hatch

A Kegel exercise is the conscious contraction of the pelvic floor muscles at the base of the pelvis. While we can consciously contract and relax these muscles, most of the stress that they’re getting actually comes from the whole system. Having that connection with those muscles is important during pregnancy and postpartum. As far as doing Kegels all day long, which was commonly recommended, that’s not typically necessary, especially if there is any sort of pain presentation: pelvic pain, low back pain, pain with sex, even leaking sometimes because the muscles are a little bit too tight. We’ll assess to see where their tone and coordination is at and kind of take it from there. But as a general recommendation, you don’t need to be doing 90 Kegels a day (that was what my mother was told do).

Old school Kegel advice

Dr. Becca Campbell

Yeah, that is the old school advice: Kegels all day long, all the time. I think maybe you had mentioned, Cami, that relaxation is very important with a lot of these exercises, and that was something I don’t think was stressed enough.

And not to imply that there isn’t a time and a place, but I think of it more as if you are trying to reestablish a connection to a muscle. Maybe you don’t have any volitional control postpartum. You might train something in isolation for a short time just to reestablish a connection. But because the pelvic floor is part of a larger system, I think Kegels do the most good for folks when they’re in the context of where they need them in their everyday life – or an exercise that they really enjoy doing. So, making sure that that piece of the system is firing – you know, when somebody is in a lunge or a squat or what have you – is a pretty important piece of the puzzle.

Doing the right type of Kegel

Dr. Niki Popper

Great answers. I agree. When it comes to Kegels, I think a lot of people don’t realize that there are two types of muscle fibers in the pelvic floor: There’s fast twitch fibers and slow twitch fibers. If we do need to be doing Kegels, it can be helpful to know which type of Kegel to be doing, as a blanket statement wouldn’t necessarily apply to everyone.

But for something like prolapse prevention, we’re going to be a little bit more in tuned to what those endurance fibers are doing – how they’re able to support the overall core. And then for someone who’s having stress incontinence – leakage when they cough or sneeze – that’s going to be more fast twitch muscle fibers. So, it is important that if someone is practicing Kegels, that they’re practicing the right type and that they do know how to turn those muscles off. Because if folks are walking around with a tense pelvic floor, and then there’s a load that comes down on that pelvic floor, if it’s already in a full state of contraction, it probably won’t have enough gas left in the tank to support them, whether that’s preventing leakage or protecting them from prolapse.

Doing fewer Kegels

Dr. Niki Popper

So, I’d say more often than not, at least in our practice, we are telling people to do fewer Kegels. And there’s definitely a misconception that if you’re pregnant, you’re going to end up with this really weak, loose pelvic floor. A lot of our pregnant patients come in and they’ve all of a sudden increased how many Kegels they’re doing. And that really doesn’t support their overall goals especially in the third trimester when we really want to be helping those tissues to relax, to just move out of the way as the uterus contracts to deliver the baby. So I am fairly opposed to Kegels in the third trimester. In general, I never just have someone do seated Kegels or lying down Kegels; it’s always going to be functional. We want you to Kegel and exhale as you get up from a chair, Kegel and exhale as you roll over in the bed. And those are things I teach people to start on day one, or as soon as they can.

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Managing diastasis recti

Dr. Jeanne Sullivan

For other prevention strategies – Kegels are most commonly talked about for control of things that could fall out – for the condition diastasis recti, which is a condition that is hard to diagnose in a very objective way, but subjectively a lot of patients report that because of their rectus muscles moving more laterally or out they feel that the belly kind of out pouches more or pushes out sometimes, looking in the mirror feeling like they look like they’re bloated although they may not feel bloated. I think we have a lot of patients who come in during pregnancy saying,

My sister had this, I’m so worried it’s going to happen to me – what can I do in pregnancy and after?

Dr. Cami Hatch

I think a lot of it comes down to pressure management in pregnancy and learning how to manage the pressure. During pregnancy the rectus is going to separate because it has to grow. So the separation is not so much the concerning part as being able to control the pressure in the abdomen and use the core correctly – timing issues were mentioned earlier – and then how that all goes together based on their specific goals.

I do think it can be better managed in the postpartum period if you’re really working on it during pregnancy.

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Diastasis recti physical therapy

Dr. Niki Popper

There are a lot of studies that show when physical therapy is initiated, that diastasis recti can improve faster, it can be less symptomatic, less impactful. We know that there are a lot of PT interventions that are really, really helpful for diastasis recti.

I think something that’s really tangible for people – especially in the OB’s office – I know when I had my kids after my ultrasounds the ultrasound tech or whoever was in the room almost always would offer their hand to me and pull me up like in a crunch to get up from the supine (lying on the back) position. And that’s a perfect time for patients and providers to look and see if they spot any of that doming, especially since the abdomen is probably already exposed. So even if someone lifts their head, and they see that the middle of the abdomen is pushing forward in a bread loaf type shape or a tent type shape, that’s a sign that pressure is not being managed properly – that internally there’s tissue pushing on that loosened connective tissue. And if you repetitively do that type of movement, you’re going to make it harder for those muscles to come back together again postpartum.

That’s a great time to say, “Hey, try to exhale as you do that, or try to do a little pelvic floor contraction – think about if you were holding back gas or trying to stop your urine flow. Can you do that and exhale at the same time as you sit up? Do we see as much of that doming?” Or maybe there’s no time for that and you just say, “Hey, a better way to get up right now that would be universally safe for your abdomen would be to roll on your side. So you’re not having to activate those muscles. But we don’t want to create fear that all those movements are bad, because you have to do that type of motion especially postpartum – breastfeeding, maneuvering in bed – it’s really hard not to engage your rectus abdominus (outer abdominals). Ideally we’re teaching people really early on in little snippets how to do little things to manage it. I would say “blow as you go” for me is like the most important thing. Exhale as you move.

Dr. Becca Campbell

I think as a paradigm shift, we’re trying to move toward being less limiting. And if we can change how someone does something so they can keep doing the thing the way they’re already performing, that’s ideal. Instead of saying outright, “Avoid this, this and this.” That also feeds the narrative that you are like a little delicate flower to where if you sit up wrong, something horrible is going to happen to your body. I think we all know that the female system is a heck of a lot stronger than that. But, we do also have the opportunity – if we try a bunch of different things and the load is just too great for the system to manage safely – to teach ways around it or compensations or things to do instead. But that tends to be my second attempt if I can’t do it the other way first.

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Constipation prevention & management

Dr. Jeanne Sullivan

A really sneaky thing, in terms of whether it’s diastasis or prolapse or what have you, that I want to mention is constipation prevention and management.

In the office, I mention it every time and I apologize to all of my patients.

Other panel members

Agreed! They talk about this every day. And I think you should talk about poop every day because it’s such a huge thing that if it’s not well managed, the trickle-down effects in terms of any kind of vulnerability in the system is going to be made worse by that situation.

Dr. Niki Popper

I’m so glad you mentioned it. Yeah, it’s a low hanging fruit, like that’s one of the first things to ask and address, and there are a lot of ways to improve that.

Dr. Jeanne Sullivan

A lot of safe things that you can do with your regular diet but also medications in pregnancy that are actually data supported.

Dr. Niki Popper

Yes, like dates.

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C-Section and instrument-assisted delivery problems

Dr. Jeanne Sullivan

I think maybe we should talk a little bit more about the unfortunate things that can sometimes happen with deliveries. We can’t always have a vaginal delivery, there are many reasons that vaginal delivery is contraindicated for patients, though that is still the rare scenario. But we have patients who have C-sections and patients who also have instrument assisted vaginal deliveries like vacuum or forceps.

For instrument assisted deliveries, there are risks with having that type of delivery – although it often expedites delivery, which can be important if the baby is not doing well or for a couple of other reasons! Many times, we have higher order perineal lacerations, which are cuts that happen between the vagina and the anus.

We also know that’s very common in any sort of vaginal delivery, medicated or unmedicated, but the larger lacerations – the third- and fourth-degree – are ones that the anal sphincter can be damaged. Of course, no one wants to have any sort of incontinence. If someone has not had these anal sphincter injuries, but they have had, say a forceps assisted delivery, what are your thoughts on initiation of pelvic floor physical therapy? Or would you recommend waiting until someone has a symptom?

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Preventive pregnancy physical therapy

Dr. Niki Popper

I definitely am a big proponent of preventive based referrals. I think in an ideal world, every pregnant person would be referred to physical therapy during and afterwards. So, I think anyone, ideally, would be at least told that this is out there. There are a lot of common things that happen after delivery: tears are really common, diastasis recti is really common, prolapse is pretty common too. While it might not be available to everyone – although there are a lot of insurance based pelvic PTs, there’s a lot in this area – at least just knowing that if you’re experiencing those things there are pelvic health physical therapists that can help you.

We have a nice opportunity to have a little more air time with our patients. We have long appointments, so it’s a really good opportunity for us, especially early in the postpartum period, to just be looking for signs of infection, just as a secondary provider to help check blood pressure, assessing all of the systems. Getting that early is a great way to prevent some of these statistics that we’re seeing about maternal fetal health in this country.

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Perineal tear physical therapy

Dr. Niki Popper

In terms of the perineal tear specifically, icing is a huge thing that we’re telling people to do. It seems in the hospital that goes on, but then so many people go home and just don’t think about icing that tissue. So regardless of the stage of tear, that can be iced for the first couple of weeks or even longer. That can make a tremendous difference, and that’s such an easy thing to do. Once that tissue has healed from the infection standpoint, which would likely be your OB clearing you probably around six weeks, then we can initiate lots of stretching and relaxation exercises to help that tissue to move again and also massage techniques to break up that scar tissue. That’s regardless of the stage of the tear. I think a stage 3 or 4 absolutely should be referred to PT every time. Ideally, I’d like to see everyone referred, but I know that’s not how it all works.

We know that the likelihood of having incontinence or dysfunction is going to be much higher with those higher degree tears. What we tend to see with the lower stage tears is pain with intercourse. And that can lead to a whole cycle of problems. Then also urinary dysfunction, because that’s where those fast twitch muscle fibers are. So if there’s a lot of scar tissue on the fast twitch fibers, we could see incontinence because they’re not able to contract enough. We could also see incontinence because they’re not able to have proper fiber alignment and be relaxed enough to contract when they need to.

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Return to sexual function

Dr. Cami Hatch

I also think that we have the luxury of guiding people through the nitty gritty of getting back to sexual function in general. We are very uniquely positioned providers to give people stepping stones back to what they were doing before. I think of it like exercise, to be honest. That infrastructure has changed a little bit, and it’s not all of a sudden you’re clear and then you go for gold. There’s a lot of in between. I, like Niki, am huge on the preventive piece. Even if it’s one visit where we talk through exploring your scar site: “How does it feel when you move it this direction or that?” Showing you some basic techniques to help to free that up and make it more comfortable for you, and also identify if you think that there’s something more going on that you need some help with. That can be really, really powerful, and giving people a place to talk about it and problem solve. We walk through different positions you can try for penetrative sex and a whole slew of things that I feel fall through the cracks quite a bit in terms of what’s happening in that immediate postpartum period.

Dr. Becca Campbell

And especially with issues around sex, I like to involve the partners as well. Sex is a two way street. The other advantage is not only educating the woman or the person who gave birth but also the person they’re having sex with, especially if there’s a lot of manual techniques that are beneficial or that we feel we need to do, we can teach the partners how to do that, which also kind of plays into return to intimacy – and all those important things around the relationship, which are going to affect every other thing down the line in terms of just overall function and quality of life.

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Painful sex & nervous system regulation

Dr. Niki Popper

One more thing to add, too, is the risk of having painful sex is a nervous system regulation. So when the brain and the nervous system detect threat, in the form of pain, the muscles are going to tense up. Fight/flight mode comes in, and there’s going to be muscle tension. And that’s going to further perpetuate that pain. Because if you’re having pain with penetration and you’re tensing up your muscles, that’s essentially closing the door. We want to be opening the door. If the brain is sensing threat, it’s going to have a hard time relaxing your musculature. And when folks continue to push through painful intercourse, that can really spiral into a bad place where not only is intercourse painful, but then tampon use becomes painful, or it can really get extreme, feeling your underwear can be painful.

So, a lot of treatment for perineal tears, even the small-degree ones, is nervous system regulation – and teaching people how to recognize what their thoughts are around this and what their muscles do in response to that. I think when they’re on our table, that’s a great time to see it. If we see them breathing with their chest rising and falling and they’re clenching their legs together, that’s a great time for some education.

Dr. Cami Hatch

I also want to say just one thing about that, because I see this happen a lot. It’s important to acknowledge that sometimes that muscle memory, especially like you said if people continue to try to muscle through pain, becomes a reflex, like it’s not something they’re intentionally doing. I have a lot of patients who come in and they assume it’s something that they’re doing, or not doing, wrong. It is important to acknowledge that’s not always under your volitional control, but that is absolutely something that we can help you with. And it is very person-to-person dependent how we go about that. But the nervous system is always a piece of the pie.

Dr. Jeanne Sullivan

You know we’re not just dealing with muscles and nerves, but also the tissue. When someone has just had a baby, whether or not they’re breastfeeding but more commonly when they are breastfeeding, we see vaginal atrophy. There is a drop in your hormones: Things get very dry. One thing that we are trying to talk about more is lubrication, foreplay and vaginal estrogen, which is safe for a lot of patients. But also we need to make sure that if it seems like the return to function is slower than average, or triggering or causing these responses or tightening, that we more readily get access to our pelvic floor PTs. And less of, “Oh, well you’ll push through it.” That is not really actually a thing. I think we all can work on capturing it early. But talking about it makes it easier because a lot of women don’t, so that is helpful.

Really any vaginal delivery can cause 3rd- and 4th-degree lacerations. Are there any techniques that you talk to your patients about while they are pregnant to help prevent those higher order lacerations, even if we’re planning for spontaneous vaginal delivery?

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Research supporting perineal massage

Dr. Niki Popper

Definitely. There is research to support perineal massage as being effective and it is a totally risk-free intervention, unless you’ve been placed on pelvic rest which –

Dr. Jeanne Sullivan

– Is not common.

Dr. Niki Popper

There we go! So unless your OB has told you not to put something internally, there’s potential high yield and virtually absolutely no risk to doing perineal massage. So we universally recommend that at 35 weeks. We often start that earlier just so they have the knowledge, but really encourage that tissue being stretched leading up to the time. When you’re touching your own tissue it is a form of biofeedback. So that’s a perfect time to practice a belly breath and see, How does that tissue feel as I breathe?

We want that tissue to descend or move down when you do a big inhale if it’s through the diaphragm, so a big belly inhale, you can feel that tissue move down. That’s really helpful for labor prep, because that’s going to mimic what we want to be doing during contractions and also what we want to be thinking about with pushing. That’s what we’re going to want to be doing afterward to help any tears to heal as well. So, we teach a lot of diaphragmatic breathing for relaxation, perineal massaging. Then there are a lot of different stretches that can be done as well to really target that tissue. Deep squats would be one of those, happy baby, butterfly type stretching. Some of those stretches we might be recommending also to help optimize fetal positioning and to help spine mobility and other problems can be helped by that too.

I also really like to have a handheld mirror for my patients so they can take a look at that tissue. Get a visual on, Ok when you do a Kegel, it lifts; when you release, it drops. Let’s practice now, like a couple of gentle pushes, and see what direction that tissue goes. Because a lot of folks think they’re pushing but they’re actually doing a Kegel, and then they can see that in the mirror. If they have an epidural, especially, or just if they need a little extra assistance, if a mirror can be brought in during delivery, and they’ve already practiced that, they would hypothetically have a lower risk of tearing, if they were better able to relax those tissues if they’ve already practiced that.

Dr. Becca Campbell

I think that is such an empowering thing for people, and it’s really magical to watch the kind of light bulb go off when someone realizes, Oh, when I breathe this way, this thing happens. It’s a form of control that I don’t think people realize they have – and also exploring positions where they may have better command of relaxing. I often like to explain it in terms of,

If your pelvic floor is more relaxed, if you have really good control of that – if the gate is as open as it possibly can be – you have to use less pressure to get baby earthside. It is a win-win for everyone.

Positions for medicated delivery & unmedicated

Dr. Jeanne Sullivan

Right, and both of you mentioned positions. So, we do have many patients who deliver unmedicated, which is great – you have your full mobility, your body kind of guides you into whatever position is going to work for delivery. But we do have many that are medicated, and I just want to say, as an obstetrician, epidurals do not mean that you have to deliver flat on your back. We have a lot of different positions that we can use. Yes, sometimes we can’t always do hands and knees if it’s unsafe for the mom to bear that weight. But that’s not always the case. So many of the things that women are practicing for birth – just because you have an epidural doesn’t mean that we can’t do that. I do want our patients to feel empowered – we always have mirrors – but to use the things that they’ve been practicing, which can sometimes help them to feel that they have an ounce of control in a very uncontrolled setting.

Dr. Niki Popper

I think one tip that is often really, really effective if they do end up on their back, is just taking a towel and getting that pelvis just tilted forward a little bit – just sliding something under the pelvis so it can tilt forward so gravity is more on the side of baby coming out, versus having to take an uphill climb, especially if they’re on their back and knees are pushed up to their chest, that’s just the wrong direction for the pelvis to be in. So I’m always saying, If all else fails and this is how you deliver – which it happens and sometimes that’s what your body is calling you to do, and sometimes that’s the best position anyways. But at least we can minimize some of the downsides to that position just with a simple pelvic tilt.

Panel member

Yeah, I like that. It could be like squatting, side-lying, peanut ball is great, lots of movement.

Other panel members

Isn’t there also a little bit of research on side-lying in the presence of medicated delivery that side-lying reduces the severity of tears?

Dr. Jeanne Sullivan

Yeah, babies tolerate that position quite well, so it’s a nice spot to be in.

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Physical therapy for C-section scars

Dr. Jeanne Sullivan

I think a last question that I know a lot of us wanted to address – just because we have so many of our patients who’ve experienced a C-section and will have firmness at their C-section scar – so, what are your thoughts on scar massage? In general, at least from our side, we encourage people to not do it until two weeks, but I’d like your thoughts, because you’re probably seeing a lot of the more severe cases because they’re getting referred to you for that.

Dr. Cami Hatch

There is the tissue healing component that is there, sometimes when there’s a lot of sensitivity, we’ll start with a cotton ball. So you’re not doing aggressive massage right away but you are trying to desensitize that tissue and create that tolerance, if you will, while it’s still healing and then it creates a nice, gradual increase to where you can get a little bit more aggressive once it heals more. Sometimes it even starts with the woman just looking at the scar. Because sometimes there are some of the psychological impacts that come with C-section scars. But it starts where they’re at and goes from there.

Dr. Niki Popper

That’s another time where I’m often giving an icing recommendation, with caution that the skin is usually going to have some sensation deficits, and you can burn yourself with ice. So you have to be careful with the ice. But ice goes such a long way in those first couple of weeks for reducing inflammation, also providing a little bit of desensitization just putting some pressure there. Many people we see I think get like, Out of sight, out of mind. They don’t want to look at it and they might miss something, like signs of infection. We really want them looking at it and that’s going to help the nervous system. Definitely before two weeks we’ll start desensitization for sure. We want to be able to not touch directly on the incision because of the risk of infection, but all around that tissue. That’s going to help bring that sensation back, help that nervous system to recover. Definitely, I teach everyone scar massage – that comes in.

Dr. Cami Hatch

I am a big fan of working in the periphery – making sure we’re not tensioning too much along any plane. But even some light, manual lymphatic drainage above and around the thing is a really, really helpful tool for people. It just starts to reacquaint you with the area that has looked really different and in wildly different ways.

Dr. Becca Campbell

I have a little bit of a divergent perception around scar work. I think it should be a component, absolutely, especially if there is some tenderness. But there is one PT who’s done some research on this and not wanting to have the scar aggressively over mobilized to the point of laxity. Yes, do some scar massage to make sure that it’s not stuck on the tissues below it, and have people work on it to their comfort. Then shift the focus to mobility from below. So you’re learning how to activate the muscles underneath the scar line, you’re giving them rhythmic movements, which is something I do a lot that allows them to expand and open their abdomen. So we’re playing with mobility and making sure that they don’t do anything except massage for four weeks. And then they go to reach for a plate on a really high shelf and all of a sudden they’re having these shooting pains or this mobility restriction. So I always do scar work, but I make sure that it is accompanied by some mobility tools as well, which I’m sure y’all do as well.

Dr. Jeanne Sullivan

That’s just such a common thing about what we all do. When you’re doing one piece, there are still 10 other pieces that you’re trying to do at the same time. This talk is not to replace someone’s physical therapy journey, but it is to help acquaint people with some of the things that can happen, some of the interventions that we can do, and to just open up the conversation so that we all have more resources.