Integrate Pelvic Floor Muscle Techniques into Your Checkup Routine and See a Massive Difference
We live in a culture that minimizes how physically difficult it is to give birth. Our culture tends to glorify movies stars that get their postpartum bodies back before they leave the hospital. We can change that perception with good old-fashioned education. The six-week postpartum checkup sets the tone for the new mom’s recovery and what is said, done and recommended will change the course of a woman’s life forever. I believe that we can improve maternal outcomes, reduce pain and make a difference in postpartum recovery if we learn a little bit more about what the “new mother” is experiencing physically by asking the right questions — and not just tell them this is the normal recovery.
Midwives, family physicians, doulas, OB/GYNs and physical therapists are in a unique position to make the most impact. The pelvic floor muscles, the core and the bones of the female body get very little attention at the six-week postpartum check. The tips I share here will change that and help you to supercharge your six-week postpartum checkups.
Childbirth has been compared to running a marathon, but there is one big difference: for a marathon you train and for childbirth you don’t. Childbirth can leave women debilitated for years and the six- week checkup is an opportunity for you to make a difference.
Here’s the Truth…
Women are injured during childbirth and are not getting diagnosed properly:
- 77% have persistent low back pain (Mannion, 2015)
- 49% have urinary incontinence (Mannion, 2015)
- 29% of mothers experience pubic fractures (Miller, 2015)
- 41% have pelvic floor tears (Miller, 2015)
- 24% of women still have painful sex 18 months after having a baby (McDonald, 2015)
- 53% of postpartum women have a Diastasis Rectus Abdominis (Coldron, 2008)
- Only 1 in 4 women are able to do a Kegel correctly (Kandadai, 2015).
You are probably going to have one of three responses to the above statistics:
- “I already know that and have implemented programs and taken steps to address this in my practice.”
- “Wow. I am aware of some of the challenges that women face after childbirth, but I had no idea that women experienced all of that.”
- “Really??? That is incredible!! I need to do something to help?”
Or you may have a combination of all three reactions. Regardless of your reaction, I think it is safe to say that we can all do more to address these statistics within our practice and help our patients who have recently given birth.
I absolutely love hearing the stories of triumph of new mothers and seeing the joy they express talking about their new child. Simultaneously many are in real pain and it brings out the compassion in me to get them back to health as soon as possible.
If you want to make a huge difference in your patient’s postpartum time period, there are 8 steps to consider:
Tip #1: Access and evaluate the pelvic floor muscles before giving advice or referring them out.
Every healthcare provider that works with new moms, and women in general, needs a good understanding of the pelvic floor muscles (PFMs). There are nuances to the function of the PFMs that need to be taken into consideration before making recommendations. Women and postpartum women experience trauma, incontinence and/or organ prolapse, and blanket recommendations can do more harm than good. You must check the PFMs for strength, endurance, coordination, scar tissue, trigger points, spasms, tone and nerve damage. I am strongly recommending that you check out their PFMs properly before sending them for additional therapy or recommending Kegels, bladder or prolapse surgery. A speculum push goes right past the PFMs; therefore, with this type of exam you may miss many things. All you need to do is simply insert your index finger into the vagina and feel around for what is going on in the PFMs. Use your index finger to access all the PFMs. Once she is cleared and there’s no pain, then proceed to the speculum part. If there’s pain with a digital exam, postpone the speculum part of the exam. Tissue healing is still occurring at the six-week mark and you may need to see your patient again to see if she is healing properly and before doing a typical pap smear.
I cannot tell you how many times women ask: “Why didn’t my doctor, midwife, nurse tell me about this?” “Why wasn’t I told that this could happen?” “Why do I hear it from you?” Patients will lose faith in you and not go back to see you, causing you to not only lose a patient, but revenue and future referrals. So check these muscles first and don’t forget to test for organ prolapse. This type of testing is often overlooked. The important thing is to master evaluation and accessing the PFMs so that you can truly make a difference in your patient’s life.
Tip #2: Do not routinely tell your patient to do Kegels at their checkups.
You should know that Kegels don’t always work especially if there’s scar tissue from an episiotomy, forceps or vacuum-assisted delivery. Kegels also won’t work if there are trigger points, hypertonicity or poor pelvic floor coordination. What’s even more astonishing is that Kegels can make leaking worse.
Many times the scar tissue needs to be dealt with first and then—and only then—will the pelvic floor muscles respond to Kegels. In this case, a Reverse Kegel is in order.
A 2015 study showed that 1 in 4 women are unable to do Kegels. So if you are prescribing Kegels make sure your patient knows how to do a Kegel correctly and also prescribe the number of reps and sets. Remember Kegel exercises are medicine. Find the right dosage! By the way, I use at least 20 different types of Kegels and a dozen or more different types of Reverse Kegels. If you want to go deeper into learning how to prescribe pelvic floor exercises, that’s great! Having the right knowledge about what is really going on in the PFMs will supercharge your patient’s/client’s healing.
Tip #3: Evaluate the pelvic floor muscles for scar tissue, internal pelvic floor tears, poor healing, and granulation tissue.
Assessment of scar tissue can be performed internally in the vagina or externally on the perineum. Remember that even superficial perineal tears can lead to pelvic floor dysfunction and pelvic pain because scar tissue disperses. Scar tissue in the pelvic floor muscles can lead to incontinence and pelvic pain.
I recommend you tell your patient to gently massage their scars by using their fingers. Have them massage the scar where it is the tightest or most restricted. This goes for Cesarean scars as well as perineal. Chances are if there’s pain or scar tissue in the pelvic floor muscles your patient should not be doing Kegels until the pain is resolved. Instead they should be performing a Reverse Kegel and stretches that help to relax the scar.
Tip #4: Check for Diastasis Recti Abdominal Separation (DRA).
Diastasis Recti Abdominal Separation (DRA) occurs when the rectus abdominal muscle separates at the linea alba. Typically this condition begins in pregnancy and does not spontaneously come back together once the baby arrives. A DRA puts your patient/client at a higher risk for incontinence, pelvic pain, organ prolapse and sexual pain and it is simple to test for at the six-week checkup and before. Even at bedside.
I believe that a DRA separation even as small as one finger can cause problems and pain for the new mom. DRA is more of a concern if your patient has pelvic floor muscle dysfunction and is complaining of leaking, pelvic pressure or pelvic pain.
To check for DRA check to see how many fingers you can place horizontally at the navel, 2 inches above and 2 inches below. Your fingertips are parallel to your patient’s waist. You are testing at the linea alba, and there should be no gap. If more than two fingers fit into the abdominal gap, then this patient needs help to restore the core. Check every patient including women who have had Cesarean births. If DRA is present, this patient will need:
- A corrective abdominal exercise,
- A postpartum belt to help support the abdominal muscles while they heal.
- Biomechanical instruction such as to log roll out of bed, avoid forward flexion and bend from the knees to pick up baby and items off the floor.
Tip #5: Check their pelvic bones. Palpate the coccyx, sacrum and pubic bones for pain and tenderness.
Often overlooked but a big trigger for postpartum pain are bone strains and fractures. Tears in the pelvic floor muscles can pull on the pubic bone and cause pubic bone fractures. The pubic bone houses the Pubococcygeus muscles, and special care should be taken to screen this bone for fractures or separation. Furthermore the pubic bone can separate during childbirth and lead to issues with walking and turning in bed, causing excruciating pain. These women need to be belted right away to hold the pubic bone in place and enhance lumbar pelvic stability. A sacroiliac joint belt like the Serola belt can help bring relief and stability to the pubic bone. If you suspect a fracture, send right away for imaging. If there’s a fracture, a belt may not help and actually may cause more pain. The coccyx can get injured, strained or fractured during childbirth and should be screened, and if pain is out of the ordinary, send your patient out for X-rays.
For accuracy a coccyx X-ray should be done while the patient is in a sitting position. Additional recommendations can include a sitting cushion, icing to the bone, setting sitting limits and avoidance of Kegels.
TIP #6: Screen your patients at their six-week checkups by using the right investigative questions.
Take more time interviewing your patients during the six week checkup. New moms in pain need to be heard and not just told “welcome to motherhood.” Don’t just talk to them about birth control. Ask your patient about bowel, bladder and sexual health. There are key questions that when asked properly will help you to diagnose your patient’s pelvic floor muscle dysfunction and/or pelvic pain. Nurses, doctors, midwives, and doulas are in a unique position to help postpartum women since they see them first and can help to get them the right care and can also advise them properly. There are questions that you can ask your postpartum patient to screen them properly for pelvic floor muscle dysfunction. I cover these key questions in my upcoming webinar because I truly feel that if you know what to ask you can help your patients more quickly.
TIP #7: Don’t give carte blanche to all exercices.
Postpartum women are sometimes desperate to get back into shape—and who can blame them? We all want to look and feel our best. This is a given right. So many times I hear from my patients: “My midwife (or doctor) told me I could go running, jumping and resume all exercise.”
New moms should resume exercises gradually. Sometimes patients get the wrong advice here and put themselves in jeopardy for an injury and further pelvic floor muscle dysfunction and pelvic pain. New moms need time to recover after having a baby, and they need to have good pelvic floor muscle and abdominal strength before resuming impact exercises such as running.
I can’t tell you how many women I treat that suffer pelvic organ prolapse: they resume impact exercises too quickly because their pelvic floor muscles are too weak to withstand all the pressure and pounding. Don’t advise your patients until you have a good picture of what is going on with their pelvic floor, abdominals, bones, and organs. There’s a right way and wrong way to get back into shape after having a baby. If your patients are suffering from urinary incontinence, fecal incontinence, pubic bone pain, or pelvic pressure, they are not candidates for impact exercises.
Tip #8: Don’t tell women that they are cleared for sex without a full examination.
Check your patient’s pelvic floor muscles, perineal tears, episiotomy, and pelvic bones before clearing them for sex. Nothing is more disappointing to a woman than being cleared for sex only to find that it is painful. A detailed physical exam is needed and a talk with your patients about their sexual health. Have they engaged in sex before their six-week checkup? Are they masturbating? Is there pain with rubbing the vulva? Can they orgasm? Do they experience numbness in the vagina? Is there burning or has there ever been burning in the vulva with sex? Make sure to integrate these questions into your checkup routine.
Although many are not trained in evaluating the pelvic floor muscles or nerves, there are several resources I make available to assist you in increasing your skill set.
If you are inspired, driven, curious, or determined to learn more, or inclined to take a deep dive into the details of pelvic floor dysfunction and pain, please be sure to check out my online certificate course Female Pelvic Floor Essentials for Health Professionals. This page will give you an overview of my “current mission.”
Love,
Isa
Glossary of Terms
Cesarean Section (C-Section). A Cesarean section is a major abdominal surgery in which incisions are made through the mother’s abdomen and uterus to deliver her child.
Chronic Pelvic Pain. A pelvic pain condition that persists for longer than three months. It is poorly understood and many times requires a multidisciplinary approach for successful treatment.
Coccyxdynia or Coccygodynia. Pain in the area of the tailbone and its associated structures.
Diastasis Recti. A separation of rectus abdominis muscle at its connective tissue the linea alba. Diastasis recti separation has been correlated with pelvic pain, abdominal trigger points, incontinence and organ prolapse.
Dyspareunia. Painful sexual intercourse which can occur for many reasons including medical or psychological. Dyspareunia is almost always reported by women, but this problem can also occur in men.
Episiotomy. An episiotomy is a surgical incision made at the perineum to enlarge the vagina. This incision can be midline or medial-lateral. It is a common cause of sexual pain and can cause scar tissue in the perineum.
Incontinence. Any involuntary leakage or loss of urine.
Kegel. An exercise named after Dr. Arnold Kegel that consists of contracting and relaxing the pelvic floor muscles.
Levator Ani Syndrome. Consists of pain, pressure, discomfort or deep dull ache in the vagina and rectum, including the sacrum and coccyx. Levator ani syndrome can also cause burning or radiating pain into the thighs and buttocks. Pain with sitting and defecation are common complaints. Many times the pelvic floor muscles are in spasms and have multiple trigger points in them.
Pelvic Floor Muscle Hypertonicity. Muscular hypertonicity is a disorder in which muscles continually receive a message to tighten and to contract. This causes excessive stiffness or tightness and interferes with their normal function.
Perineal Tears in Degrees. Tears are rated from 1st to 4th Degree. 1st Degree is tearing of the vaginal mucosa skin at or around the perineal body. 2nd Degree is tearing vaginal mucosa and submucosa through the pelvic floor muscles. 3rd Degree is tearing of the 1st and 2nd Degree tissues and the external sphincter. 4th Degree is all of the above levels of tearing plus the internal sphincter and the lining of the rectum.
Prolapse. This term is used for organs that protrude through the vagina. This condition makes the organ drop into the vagina causing pelvic floor muscle weakness. The uterus, rectum, bladder or urethra can prolapse into the vagina.
Pubic Bone. This bone forms the anterior aspect of the pelvis and hip bones.
Rectus Abdominis. This is the six-pack abdominal muscle; it runs from below the breast bone to the pubic bone. There are two sides, one to the right of the belly button and one to the left that are connective via the linea alba. A separation of this muscle at the linea alba is called diastasis recti.
Reverse Kegel. This exercise is an elongation and relaxation exercise for the PFMs.
Sacrum. The sacrum is a triangular bone at the base of the spine where it is inserted like a wedge between the two hip bones. Its upper edge connects to the last lumbar vertebra, and its bottom connects with the coccyx (tailbone). The sacral nerves exit through small holes in the sacrum.
Sources:
Coady, Deborah, MD, FACOG et al. Chronic sexual pain: a layered guide to evaluation. Contemporary OB/GYN, 2015. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/chronicsexual-pain-layered-guide-evaluation?page=0,1
Coldron Y, Stokes M J, Newham D J, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. April 2008 Manual Therapy. http://dx.doi.org/10.1016/j.math.2006.10.001
Diastasis rectus abdominis & postpartum health. http://dianelee.ca/article-diastasis-rectus-abdominis.php
Herrera, Isa, MSPT, CSCS. (2014). Ending Female Pain: A Woman’s Manual, 2nd Edition. New York, NY: Duplex Publishing. http://www.EndingFemalePain.com
Kandadai P, O’Dell, Saini J. Correct performance of pelvic muscle exercises in women reporting prior knowledge. Female Pelvic Med Reconstr, 2015.
Mannion CA, Vinturache AE, McDonald SW, Tough SC. The Influence of Back Pain and Urinary Incontinence on Daily Tasks of Mothers at 12 Months Postpartum. PLoS One. 2015 Jun 17;10(6):e0129615. doi: 10.1371/journal.pone.0129615. eCollection 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471341/
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McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. First published: 21 January 2015. BJOG: An International Journal of Obstetrics and Gynaecology. http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13263/abstract
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Yi, Johnny MD; Tenfelde, Sandi PhD; Tell, Dina PhD; Brincat, Cynthia MD; Fitzgerald, Colleen MD. Triathlete Risk of Pelvic Floor Disorders, Pelvic Girdle Pain, and Female Athlete Triad. Female Pelvic Medicine & Reconstructive Surgery: September/October 2016 – Volume 22 – Issue 5 – p 373–376. doi: 10.1097/SPV.0000000000000296. http://journals.lww.com/jpelvicsurgery/Abstract/2016/09000/Triathlete_Risk_of_Pelvic_Floor_Disorders,_Pelvic.18.aspx
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