How Can Doulas Improve the Musculoskeletal Health of Childbearing Women?

This handout was used during two recorded lectures for a local group of Doulas.  I have posted them here as a resource for others.  I hope you find them useful.  Recordings (reference # 5 and 6) can be downloaded or listened to in the same location as the journal club recordings.

• https://www.freeconferencecall.com
• Top right corner – “log in”
• Access code – 436790
• Dial-in number – (209) 647-1000
• Subscriber PIN – 883352
• Choose the date you want to access – you can playback or download in several formats.  If you want to save it to your computer you click “wav” and choose “save” – name the file and choose the location to save it.

Doulas have a unique position

·        Ability to interact with healthy women who are interested in being healthy

·        Prenatal and post partum visits

·        Many opportunities but 2 very important

• Avoiding long term low back pain (LBP) and pelvic girdle pain (PGP) associated with pregnancy and delivery 
• Maximizing the function of the pelvic floor muscle (PFM)

How many women have back pain during pregnancy? (Wang 2004)

·        49% to 76% during pregnancy, 1.8 to 3.5 million per year

·        10% to 30% will have decreased function

What conditions predict LBP? (Wang 2004, Wu 2004)

• Previous LBP – non pregnant, pregnant, and menstrual
• Low socioeconomic class
• Weak evidence: second, third, fourth pregnancy, heavy fetus

So what?  Implication of LBP and PGP in pregnancy

• 20% have pain so sever they avoid another pregnancy
• 1/3 report sever limitations in activities of daily living
• 3 months postpartum (Figeurs 2004, Schytt 2005)
• 23 to 57% headaches
• 30% neck and shoulder pain
• 28 to 51% LBP
• 26% leg pain
• 21% urinary leakage
• 21% carpal tunnel syndrome
• Continued LBP after delivery (Albert 2001, Larsen 1999, Mogren 2006)
• 6 months – 30 to 43%
• 18 months – 37%
• 2 years - 8.6%
• 12 years – 86% some amount of LBP after pregnancy

Types of prenatal and post partum LPB and PGP (Stephenson 2000, Sapsford 1998)

Postural LBP

·        Symptoms

o       Ache across the low back

o       Worst with long standing

o       Sway back

·        Treatments

• Pelvic tilt
• Round back to stretch muscles
• Heat and massage to low back
• Strengthen abdominal muscles
• Pregnancy brace

Sacroiliac pain

·        Symptoms

• Shooting buttock pain, radiating down the leg, sciatica
• Pain with single leg stand and rolling in bed

·        Treatments

• Avoid uneven postures, miniskirt movements
• Stretch tight buttock muscles
• Heat and massage to buttock
• Sacroiliac belt

Pubic symphysis strain

·        Symptoms

• Pain localized to pubic symphysis
• Pain with single leg stand, walking, climbing stairs, and rolling in bed

·        Treatments

o       Same as Sacroiliac joint pain except heat and massage to inner thigh muscles

Coccyx dysfunction

·        Symptoms

• Pain localized tailbone pain (in the buttock crack)
• Increased with sitting

·        Treatments

• Avoid slouched sitting
• Use tailbone cushion
• Heat and massage to buttock

When to suggest further treatment

·        Pain that limits function is never normal

·        If the client is unable to care for her child or continue working because of pain

Physical therapy treatment of pregnancy and post partum pain

·        Beth Shelly Physical Therapy 

·        There are many skilled orthopedic PTs in the Quad Cities

·        Must have a prescription from a healthcare practitioner

·        Covered by most insurances

Labor position modification for musculoskeletal conditions

Condition	Positions to avoid	Recommended positions
Disc herniation / bulge	Lumbar flexion (rounded back) ·        Squatting ·        Semi-sitting ·        Litotomy with legs bent to chest	Lumbar extension (arched back) ·        Semi-reclined with lumbar roll ·        Side lying ·        Hands and knees
Spinal stenosis (arthritis) Spondylothiesis (spinal fracture with severely arched back)	Lumbar extension (arched back) ·        Standing	Lumbar flexion (rounded back) ·        Squatting ·        Leaning forward over ball ·        Side lying (may need to choose non painful side)
Sacroiliac dysfunction	Uneven positions ·        Walking during the first phase ·        Semi sitting with legs unsupported or unevenly supported ·        Side lying ·        Lying on back	Even, supported positions ·        Hands and knees ·        Semi-reclined with legs evenly supported with pillows or persons
Pubic symphysis	Legs widely spread apart or uneven ·        Squatting ·        Side lying with legs far apart and uneven ·        Semi sitting or reclined with legs unevenly supported	Legs closer together and even ·        Hands and knees ·        Side lying with legs comfortably apart and even ·        Semi sitting or reclined with legs supports, even and not too far apart
Tailbone dysfunction	Pressure on tailbone ·        Semi-sitting ·        Lithotomy	Any position where the tailbone is free to move ·        Side lying ·        Squatting ·        Hands and knees ·        Upright kneeling ·        Standing

Pelvic floor muscles (PFM) during the childbearing year

·        Lack of information – survey of women one day post partum – 46% received no information about Kegels (McLennan 2005)

·    One year post partum

• 23% still leaking urine

• 6.8% leaking feces
• 24% having painful intercourse  

·        80% of vaginal deliveries show evidence of nerve trauma (Dolan 2003)

·        Urinary leakage should be resolved by 3 months post partum (Rogers 2007)

·        15 million Americans

 

So what?

·        Urinary leakage can result in

• Decreased social activities outside the home or social isolation
• Change in intimacy
• Limited work opportunities – unable to get to bathroom, stress
• Avoidance of exercise or social activities involving exercise activities (dancing and hiking)
• Knowing were every community bathroom is before you go

·        Women with severe urinary incontinence pay $900 annually for incontinence routine care (Subak 2006) similar to osteoporosis, Alzheimer's disease and arthritis (Anger 2006)

·        Urinary leakage is one of the leading causes of admission to a NH

·        Muscle strength is easier to improve when young

Risk factors for perineal trauma, painful penetration, urinary or fecal incontinence, pelvic organ prolapse 

·        Vaginal delivery

• Instrument delivery – forceps
• Abnormal presentation (breech, occiput posterior, deflexed fetal head – chin not tucked in)
• Prolonged active second stage – more than 1 to 2 hours pushing
• Birth weight over 7.7 to 8 pounds
• 4th degree tear (especially for fecal leakage)
• Episiotomy 
• Epidural or other regional anesthesia

·        Chronic increased intra abdominal pressure

• Obesity – BMI over 30
• Chronic cough, asthma, smoking
• Repetitive lifting
• Chronic constipation/straining
• Exercise routines - high impact exercises  

What can be done prenatally?

·        Teach proper PFM contraction – see below

• Women who start exercises started in early pregnancy have a less urinary leakage than those who start them in late pregnancy or post partum
• PFM exercises during pregnancy decrease urinary leakage after delivery (Hay-Smith 2009)
• PFM exercises with stability exercises and education decreased LBP, sick time and increased function during and after delivery (Morkved 2007)

·        Encourage consistant, proper PFM exercise

• Only 17% of Norwegian women performed PFM exercises during pregnancy (Bo 2007)

·        Avoid increase intra abdominal pressure

·        Education about labor and delivery avoidance of modifiable risk factors

What can be done post partum?

·        Teach and encourage proper PFM exercises

• Multiple studies show post partum PFM exercises decrease symptoms and improve function
• At one year post partum success was related to adherence to exercises not degree of birth trauma (Gordon 1985)

·        Restore normal fluid intake and bladder patterns (see below)

·        Avoid constipation and other causes of increased intra abdominal pressure

·        Suggest further medical treatment if symptoms do not improve

Normal fluid intake and bladder pattern

·        Amount of fluid intake:

• 6 to 8  8 oz glasses/ day. 
• Not more than 70 to 80 oz
• Type of fluid intake: minimize irritants (caffeine, alcohol, nicotine)
• Time of fluids: should be evenly spaced throughout the day

·        Total number of voids/day: goal is less than 7/ 24 hours

·        Number of voids per night: 0 to 1/ night under 65 years old

·        Voiding interval: should be 2 to 5 hours between voids, average 3 to 4 hours

·        Amount of urine voided each time:  8 to 12 oz/ void

·        Bladder dairy can be used to record patterns – available a www.bethshelly.com “for patients” scroll down to see other forms.

Teaching PFM exercises

·        Key words to use – pull up and in, pinch your rectum, hold back gas

·        Duration – start with 3 seconds holding, build up to 10 seconds

·        Rest – at least as long as you hold – make sure to rest

·        Repetitions – start with 5 to 10 and build up to 20 or 30

·        Position – start supine, advance to sitting and standing

·        Overflow muscles – do not squeeze buttock or legs, do not hold your breath

·        Functional PFM contraction – squeeze before sneeze and lift

·        Check yourself – place on finger inside the vagina or look at the perineum using a mirror – watch or feel for movement up toward the head  

A word about vaginal pain

·        There are many reasons for pain in the vagina. – it is never normal

·        Women should discuss the symptoms with their health care professional before self treating

·        After medical causes for pain have been ruled out – consider scar adhesion and PFM spasm

·        Both can be treated with physical therapy – massage, dilators, biofeedback, relaxation

Physical therapy for PFM dysfunction

·        This is a very small specialty in PT

·        There is a national directory

·        Treatment is often covered by health insurance

·        Need a medical practitioner prescription

·        Usually improves in 2 months with weekly visits 

·        Includes

• Individualized PFM exercises
• Coordination of PFM with other muscles – abdomen and breathing
• Use of biofeedback to “see” the muscle activity
• Bladder training
• Education on fluids, constipation, posture and body mechanics
• Possibly electrical stimulation, vaginal weights, home trainers

I hope this has been helpful. I am happy to be a resource. Please feel free to email or call.

Beth Shelly, PT, DPT, WCS, BCB-PMD
Doctor of Physical Therapy
Board Certified Specialist in Women's Health
Specializing in Pelvic Health and Lymphedema

Adress - 1634 Avenue of the Cities, Moline, IL 61265

Phone - 563-940-2481

Web site - http://www.bethshelly.com/

Email - beth@bethshelly.com

Blog - www.pelvicpt.blogspot.com