Author: Laura Plankis, PT, DPT
In 2016, there were 3,945,875 childbirths.2 Each delivery was unique, as every mother and child are different. Of these millions of deliveries, 68.1% were vaginal deliveries and 31.9% were cesarean deliveries.2 Some women may have delivered in a hospital, others at a birthing center, some at home, and maybe even a few in a car. New moms may have opted for an epidural for pain management whereas others chose to be unmedicated. Some women may have had family and friends surrounding them, others may have had doctors and nurses, and others may have hired a doula. There are many differences between deliveries, and often times women consider the best ways to prepare for the event. However, physical therapy is rarely a part of that plan!
The aches and pains of pregnancy
One study found that 68% of women experience low back pain during part or all of their pregnancy.4 Another study reported that 50% of women experience moderate to severe pelvic pain. 5 Many women also experience hip pain, mid back pain, and generalized feeling of weakness or instability – among other things. These are all signs that in addition to advancing pregnancy, there may be musculoskeletal issues contributing to symptoms. These underlying problems may impact labor and delivery. One goal of physical therapy towards the end of pregnancy is to prepare the mother’s body for baby’s arrival, as well as to learn pain management strategies to use in the delivery room. This may include assessing and treating the muscles and soft tissue surrounding the pelvic girdle, pelvic floor muscles, and increasing core stability. Additionally, treatments will involve educating women on laboring positions that would be best for their unique anatomy. For example, a woman dealing with a herniated or bulging disc during pregnancy will want to opt for positions with decreased forward bending in order to decrease pain and decrease risk of further injury.
Prepping the pelvis
An important component of a vaginal delivery is the feto-pelvic relationship7, or the relationship between the fetal head and the shape of the women’s pelvis. Although the fetal head can not be addressed with physical therapy treatments, the pelvic girdle can be treated in order to improve this relationship. During labor the fetus starts moving downward, engaging into the pelvic inlet.7 For this to occur, the mother’s pelvic bones, sacrum, and ilium change position to make more space. 7 Then, at the end of the labor and delivery process, the fetus moves through the pelvic girdle ending in expulsion, or delivery. During this time, the sacrum and tailbone need to move outward creating more room at the pelvic outlet for the baby to pass through.1 If there is stiffness of the SI joint, sacrum, or coccyx this may not be successful, which could result in tissue injury for the mother or failure to progress for the fetus. At the end of pregnancy, a specially trained physical therapist can assess your pelvic girdle for dysfunction and can teach you positions for labor and delivery that can further promote the feto-pelvic relationship. For instance, rotating your legs out can help open the pelvic inlet, which is required for the fetus to engage. 1 Then, rotating your legs inward can help open the pelvic outlet, which is required for delivery. 1 A physical therapist can also instruct in positions during labor and delivery for pain management. After a formal evaluation and assessment of contributing factors to the women’s pain, a detailed outline can be made to help the mother determine what positions will be safe and effective for her during labor. This may include options such as being in quadruped, or on hands and knees, to decrease “back labor”. 7 Positions may also be recommended to prevent injury, such as sidelying. Research has shown that 66% of women who deliver in this position do not experience perineal tearing. 8
Learning to breathe
Physical and mental coping techniques are another realm of treatments that can be offered to woman at the end of their pregnancy. Breathing techniques are a great coping strategy; however not all women are instructed in appropriate diaphragmatic breathing. The diaphragm moves 5 cm upward with advancing uterus size; therefore breathing patterns can drastically change during pregnancy. 3 This changes shape of the rib cage, which affects breathing coordination during pregnancy. A physical therapist can help ensure you are using your diaphragm appropriately, which in turn can be used for pain management. Physical therapists are also trained in manual trigger point release, which has been shown to reduce pain, increase maternal satisfaction with pain management, and decrease use of medicine for pain management. 8 Massage techniques are another tool that can be used to decrease anxiety, improve maternal emotional experience, and improve management of labor pain. 8 These skills can be taught to someone who will be accompanying the woman in the delivery room during a physical therapy session.
What about c-sections?
It is also helpful to see a physical therapist prior to a cesarean delivery. A cesarean delivery may be scheduled for medical diagnoses such as placenta previa, fetal malposition, or maternal pelvic abnormalities – among other things. A cesarean delivery may also be unplanned, following an unsuccessful attempt of a vaginal delivery. Both can result in pelvic floor dysfunction, abdominal dysfunction, and/or low back pain. It is important to learn abdominal and pelvic floor muscle activation techniques prior to cesarean to improve healing following delivery, and prevent onset of new pain.
There’s PT for that.
As you can see, a physical therapist can help in many ways to improve the labor and delivery process. If you have signs of musculoskeletal dysfunction, such as pain or weakness, it is important to see a physical therapist to learn ways to manage these issues. Your physical therapist will outline a plan of care to not only address the problem, but also to educate you on ways to minimize further injury during labor and delivery. If you feel your pregnancy has been a breeze with no aches or pains, come see a physical therapist around 37 weeks gestation to learn coping techniques and ways to prevent injury during labor and delivery.
Physical therapists at all four locations are trained in prenatal treatment. Call today to schedule your appointment!
- Calais-Germain B, Pares NV. Preparing for a gentle birth: The pelvis in pregnancy. 2009, English translation 2012. Healing arts press: Rochester, VT
- Cdc.gov. (2018). FastStats. [online] Available at: https://www.cdc.gov/nchs/fastats/births.htm [Accessed 4 Jun. 2018].
- LoMauro A, Aliverti A. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818213/. Published December 2015. Accessed June 4, 2018.
- Low back pain during pregnancy. Egyptian Journal of Medical Human Genetics. https://www.sciencedirect.com/science/article/pii/S0104001416300276. Published November 25, 2016. Accessed June 4, 2018.
- Malmqvist S, Kjaermann I, Andersen K, Økland I, Brønnick K, Larsen JP. Prevalence of low back and pelvic pain during pregnancy in a Norwegian population. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/22632586. Published May 2012. Accessed June 4, 2018.
- Nikolajsen L, Sorensen HC, Jensen TS, Kehlet H. Chronic pain following cesarean section. Acta Anaesthesial Scand. 2004; 48: 111-116
- Simkin P, Ancheta R. The Labor Progress Handbook: Early interventions to prevent and treat dystocia 3rd edition. (2005) 2011. Wiley-Blackwell Publishing Ltd.
- Soong B, Barnes M. Maternal position at midwife-attended birth and perineal trauma: is there an association? Birth. 2002; 32(3): 164-169
- Alexander-Tanner, R. (2018). https://www.nytimes.com/2017/05/11/well/family/well-illustrated-childbirth.html. [image].
- Amato, P. (2018). https://www.familyeducation.com/pregnancy/week-40-pregnancy/you-are-39-weeks-4-days-pregnant. [image].
- Hegewald, M. and Crapo, R. (2018). https://www.semanticscholar.org/paper/Respiratory-physiology-in-pregnancy.-Hegewald-Crapo/a2000ff80d1e61337f0bba24b512fdeba02750c7. [image].
- http://en.hesperian.org/hhg/A_Health_Handbook_for_Women_with_Disabilities:Labor_and_birth. (2018). [image].