Women's Health Physical Therapy in the Postpartum Period: More Than Just Kegels - Presented By: UNMC
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Women’s Health Physical Therapy in the Postpartum Period: More Than Just Kegels Presented By: Shannon Roth, PT, DPT Board-Certified Women’s Health Specialist Certified Lymphedema Therapist Pregnancy and Postpartum Corrective Exercise Specialist May 18th, 2021
Learning Objective: The audience will be able to: 1) Describe the anatomy and functions of the pelvic floor musculature 2) Explain the relationship of the pelvic floor with deep core musculature 3) Summarize the various symptoms and conditions that a Pelvic Health/Women’s Health Physical Therapist (PT) can address in the postpartum period
Anatomy of the Pelvic Floor
Musculature
• The pelvic floor
muscles live at the
bottom or the under
surface of the pelvis
• Sling from front to
back
• Sling from side to
side
• Consist of 3 layers
https://www.pelvicexercises.com.au/wp-content/uploads/2012/05/Pelvic-floor-muscles-op.jpg
Anatomy of Pelvic Floor
Musculature
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSPZb8b8s0i84SEhpYGw5jfJMyj0i3ZkpLVXg&usqp=CAU
Anatomy of Pelvic Side Wall
Piriformis
Piriformis
Obturator internus
Pelvic
floor
https://www.kenhub.com/en/library/anatomy/obturator-internus-muscle
https://www.practicalpainmanagement.com/sites/default/files/imagecache/lightbox-large/ppm/p1101_herrera/herrera_fig01.jpg
Nerves Surrounding the
Pelvis
https://memyselfnlifecom.files.wordpress.com/2016/12/dorsal-nerve-of-the-clitoris-1.png
https://media.springernature.com/original/springer-static/image/chp%3A10.1007%2F978-1-4939-6554-0_19/MediaObjects/307030_1_En_19_Fig1_HTML.gif
Nerves Surrounding the
Abdomen & Pelvis
Inguinal
ligament
https://www.mmc.nl/verwijzers/wp-content/uploads/sites/40/2017/09/ann-surg-results-fann.pdf
https://www.nysora.com/wp-content/uploads/2018/07/82_Cx04-787x1024.jpg
https://static.practicalpainmanagement.com/sites/default/files/imagecache/inline-image-wide/images/2014/08/04/Screen%20Shot%202014-08-04%20at%2012.07.26%20PM.png
https://evidencebasedbirth.com/wp-content/uploads/2018/02/On-back-in-stirrups-1024 x483.png
Functions of the Pelvic
Floor Muscles
• Help us to maintain
continence
• Play a role in sexual
function and arousal
• Support our pelvic
organs such as the
bladder, uterus, and
rectum
• Provide postural
stabilization and are
considered a core
muscle group
http://holisticfamilydoulas.com/wp-content/uploads/2020/03/pelvic-floor-image.jpg
Canister System
• The pelvic floor, deep
back muscles
(multifidi), diaphragm,
and deep abdominal
muscles (the
transverse
abdominis) all work
together to provide
postural stabilization
http://mariskaodendaal.co.za/wp-content/uploads/2020/05/4c71e61567c43f85663c0b9d36b010e4.jpg
Pelvic Floor – Diaphragm
Piston Relationship
• The diaphragm and
pelvic floor
coordinate together
with our breathing
https://global-uploads.webflow.com/5f921ea5cf0058796a47ee47/5f921ea5cf0058535547f38f_D%20BREATHING%20COMPOSIT%20(1).pngWomen’s Health Physical
Therapist
• Women’s Health or Pelvic Health
• Licensed PT with specialized training in the
evaluation and treatment of the pelvic floor
• Specialized training
• Women’s Health Physical Therapy
Residency program
• Continuing education courses and
certification courses
• Mentoring from other pelvic health PTs
• Completing a women’s health clinic rotation
while in PT schoolRelevance of Musculoskeletal Changes in Pregnancy to Postpartum http://2.bp.blogspot.com/-exEozTpt3qU/U2vbJhwkdUI/AAAAAAAAAfE/tkMjjoCxmSM/s1600/posture_during_pregnancy.jpg https://images.squarespace-cdn.com/content/v1/5ac65c733c3a537dfcfee198 /1542148835371-WGSW52W6KEASTKK70WKE/ke17ZwdGBToddI8pDm48kFdaLkorAW_sV92IWMgZ_VpZw- zPPgdn4jUwVcJE1ZvWEtT5uBSRWt4vQZAgTJucoTqqXjS3CfNDSuuf31e0tVEu1Zi5hMaOsSD1RKO2aOUPoHXkmw773NYAnXP9EPfCZd1lH3P2bFZvTItROhWrBJ0 /pregnancy+and+pain.png
Relevance of Musculoskeletal
& GI Changes in Pregnancy to
Postpartum
diaphragm
Dome shape
position of
diaphragm
https://www.mom365.com/~/media/Mom365/Blogs/Images/Posts/lmann/2012/6/22/pregnancyorgansjpg.ashx
https://www.teachpe.com/wp-content/uploads/2019/07/breathing-mechanics620.jpgRole of Women’s Health PT in the Postpartum Period Body mechanics education and functional mobility C-section specifics Musculoskeletal issues Urinary incontinence Constipation Pelvic/abdominal pain Prolapse management Safe return to physical activity/exercise
Body mechanics education
and functional mobility
Bed mobility
Stair negotiation Transfers
Walking Lifting/carryingC-section Scar
Scar massage
techniques
Early mobility
considerations
right after delivery
to reduce scar pain
Core muscle
activation
Scar pain
http://acuclinic.com.au/pocit/LUSCS-Layers1.pngMusculoskeletal Issues
Sacroiliac joint
Low back pain
pain
Pubic
Thoracic pain
symphysis pain
Muscle
Diastasis recti
weakness
Hip pain
https://www.rcog.org.uk/contentassets/d956bf46a08143ed8a4e52aa6789669a/pelvic-girdle.pngAbdominal Muscles
Linea alba
•Linea alba: meshwork of
connective tissue
•Inter-rectus distance
(IRD): linear distance
between the medial
aspects of the rectus
abdominis muscles
•Definitions around
normal IRD cluster
around 2 cm but there is
no consensus in the
literature for optimal IRD1
https://antranik.org/wp-content/uploads/2011/10/muscles-of-the-abdominal-wall.jpgDiastasis Rectus Abdominis
(DRA)
•Prevalence
•27-33.1% during
pregnancy2,3
•60% at 6 weeks postpartum2
•45.5% 6 months postpartum2
•32.6% at 12 months
postpartum2
•100% of women have a DRA
at 35 weeks of pregnancy and
separation persists in 40% of
women at 6 months
postpartum4
https://yourpaceyoga.com/wp-content/uploads/2018/08/Diastasis-600px.jpgDiastasis Rectus Abdominis
Linea alba
Linea alba
https://i.pinimg.com/originals/29/c0/6a/29c06a9fe301b23e039007bf313c1916.jpgDiastasis Rectus
Abdominis
• Many ways to assess
• It's not all about
closing the gap
https://www.jospt.org/doi/pdf/10.2519/jospt.2016.6536
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQLIakWOtwmr-T1gRcxOkKXM38SwFDbvNtaiw&usqp=CAU
https://www.pamelamorrisonpt.com/2015/02/23/9-finger-diastasis-recti/Urinary Incontinence
• Types5
• Stress urinary incontinence: compliant of
involuntary loss of urine on effort or physical exertion,
or on sneezing, coughing or laughing
• Urge urinary incontinence: complaint of involuntary
loss of urine associated with urgency
• Mixed urinary incontinence: symptoms of both
stress and urge urinary incontinenceUrinary Incontinence
• Pelvic floor examination
• Surface biofeedback training
• Functional progression
• Supine, sitting, standing
• Squats, lunges, jumping,
jump rope, running
• Box jumps
https://www.cmtmedical.com/wp-content/uploads/2020/08/Emyo-with-Monitor-100-200-Together-Low-Res -365x365.png
https://www.cmtmedical.com/wp-content/uploads/2012/11/Pathway-MR-15_5522-365x365.jpgConstipation
Bowel log/diary Behavioral strategies
Toileting
Breathing techniques
posture/position
Pelvic floor
Abdominal massage
coordination/training
Dietary
recommendations
https://images-na.ssl-images-amazon.com/images/I/61hPHqgn4cL._AC_SL1000_.jpgPelvic/Abdominal Pain
• Dyspareunia
• 21.2% 6 months
postpartum6
• 17-36% 6 months
postpartum7
• Perineal lacerations
• Obstetric anal sphincter
injury/tear
• 3rd and 4th degree
tears
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRWobthRg3wvGwx8jzIqzB0HMMguL0hjvIGlQ&usqp=CAU
https://hopeandher.com/products/vaginal-dilator-set https://cdn.shopify.com/s/files/1/0259/5343/5720/products/v_want-clear_590x.jpg?v=1614111644Pelvic Organ Prolapse
Definition: The descent
of one or more of the
anterior vaginal wall,
posterior vaginal wall, the
uterus (cervix) or the apex
of the vagina (vaginal
vault or cuff scar after
hysterectomy)5
Symptoms:
• Vaginal bulging
• Pelvic
pressure/heaviness
• Back ache
• Splinting/Digitation
https://www.advancedgynecology.com/wp-content/uploads/2020/08/Advanced_Gynecology_Blog_Image_-_Types_of_Pelvic_Organ_Prolapse_-_August_2020.jpg
https://media.springernature.com/lw685/springer-static/image/art%3A10.1007%2Fs10439-021-02755-6/MediaObjects/10439_2021_2755_Fig1_HTML.pngConservative PT Management
of Prolapse
Pelvic Floor Body
Muscle Mechanics
Training Training
Constipation Core Muscle
Management Training
http://www.athletespotential.com/uploads/2/4/7/3/24730224/breath2_orig.png
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTIj5l-Conservative PT
Management of Prolapse
• Gripping of upper abs
• Pressure down on
pelvic floor
• May contribute to
urinary leakage
and/or prolapse
symptoms
https://www.alignforhealth.com/uploads/1/0/3/5/10350371/core-activation_orig.jpg
https://dianeleephysio.com/education/butt-grippers-back-grippers-and-chest-grippers/Safe Return to
Exercise/Physical Activity
• Guidance on safe return to desired exercise or
physical activity
• Running
• Weightlifting
• Jumping activities
• Group classes
•Return to Running Guidelines
• https://www.absolute.physio/wp-
content/uploads/2019/09/returning-to-running-
postnatal-guidelines.pdf
• Tom Goom, Gráinne Donnelly and Emma
BrockwellOptimizing Postpartum
Care
• American College of Obstetrics and Gynecology
(May 2018, Committee Opinion)
• "To optimize the health of women and
infants, postpartum care should become an
ongoing process, rather than a single
encounter, with services and support
tailored to each woman’s individual needs"
• "The comprehensive postpartum visit should
include a full assessment of physical,
social, and psychological well-being"https://image.shutterstock.com/image-illustration/any-questions-text-written-over-260nw-1054528985.jpg
References 1. Chiarello CM, Mcauley JA. Concurrent Validity of Calipers and Ultrasound Imaging to Measure Interrecti Distance. Journal of Orthopaedic and Sports Physical Therapy. 2013; 43(7): 495-503. 2. Sperstad JB, Tennfjord MK, Hilde G, et al. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016;50: 1092-1096. 3. Bouissanault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther. 1988; 68(7): 1082-6. 4. Fernandes da Mota, P. G., Pascoal, A. G., Carita, A. I., & Bø, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy, 20(1), 200–205. https://doi.org/10.1016/j.math.2014.09.002 5. Petrou, S. P. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International Braz j Urol, 36(1), 116–116. https://doi.org/10.1590/s1677- 55382010000100032 6. Alligood-Percoco, N. R., Kjerulff, K. H., & Repke, J. T. (2016). Risk Factors for Dyspareunia After First Childbirth. Obstetrics and gynecology, 128(3), 512– 518. https://doi.org/10.1097/AOG.0000000000001590 7. Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women's sexual health after childbirth. BJOG: An International Journal of Obstetrics and Gynaecology, 107(2), 186–195. https://doi.org/10.1111/j.1471- 0528.2000.tb11689.x 8. Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women's sexual health after childbirth. BJOG: An International Journal of Obstetrics and Gynaecology, 107(2), 186–195. https://doi.org/10.1111/j.1471- 0528.2000.tb11689.x
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