Effect of Childbirth on the Pelvic Floor And Physical Therapy

In 2010, the specialty area of Women’s Health was recognized on a national level at the Combined Sections Meeting of the American Physical Therapy Association (APTA), at which 60 newly certified Women’s Health Clinical Specialists (WCS) were acknowledged for their achievements.

Advanced and in-depth study of anatomy, including internal muscle assessment, physiology, evaluation, and treatment, is highly recommended for therapists who specialize in this area.

Effect of Childbirth on the Pelvic Floor

Neurological Compromise

Stretch and compression of the pudendal and levator and nerves occur during labor as the baby head travels through the birth canal; this stretch can be as much as 20% of the total length of the nerve. This compromise to the nerve tissue is most intense during pushing(the second stage of labor), through the completion of vaginal delivery.

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Muscular Impairment

Extreme stretching of the pelvic floor tissues is inherent in the process of labor and vaginal delivery in the female body. Recent research simulations specific to the biomechanics of childbirth are adding to the understanding of these impairments.

Muscle injury during vaginal birth diminishes the maximal closure pressure of the pelvic floor complex, which makes the muscle complex more vulnerable to increased intra-abdominal pressure and changes force transmission to the distal vagina, possibly leading to prolapse.

The pelvic floor musculature may also be torn or incised during the birth process. Additional soft tissue trauma can occur as a result of forceps use, necessitating suturing throughout the musculature and into the vaginal vault.

Episiotomy

An episiotomy is an incision made in the perineal body. It is automatically considered a second-degree laceration according to the following classification of perineal lacerations.

• First degree—only skin
• Second degree—includes underlying superficial muscle layer
• Third-degree—extends to the anal sphincter
• Fourth-degree—tears through the sphincter and into the

Rectum, possibly into the deeper muscular layer of the pelvic floor. Although episiotomy is common, occurring in 33% to 54% of vaginal deliveries, there is no strong medical evidence supporting its use. In fact, outcomes with episiotomy are worse in some cases, including pain with intercourse and extension of the episiotomy into the sphincter or rectum.

Anal sphincter defects were linked with fecal incontinence in the postpartum period as many as 6 months after delivery in a study done by the Pelvic Floor Disorders Network. There is a consistent agreement in the literature that episiotomy is closely associated with forceps-assisted delivery;

additionally, if epidural anesthesia, forceps, and episiotomy are all utilized during labor and delivery, the risk of anal sphincter tear is even greater. Pregnant women have many questions about labor in general and episiotomy in particular; the clinician can provide education and support for the patient as she explores her options with her physician.

Electric stimulation may be added postpartum to modulate pain and to stimulate muscle contractions, respectively. Ultrasound may be helpful in cases of poor episiotomy healing and painful scar tissue.

Potential Structural and Functional Impairments during/after Pregnancy

1. Musculoskeletal pain and muscle imbalances from faulty postures
2. Poor body mechanics related to lack of knowledge, changing body size, and physical demands of childcare
3. Lower extremity edema and discomfort from altered circulation and varicose veins

Pelvic floor dysfunction, including urinary or fecal incontinence

• organ prolapse
• hypertonus
• poor episiotomy healing
• poor proprioceptive awareness and disuse atrophy

1. Abdominal muscle stretch, trauma, and diastasis recti
2. Potential decrease in cardiovascular fitness
3. Lack of knowledge of body changes and safe exercises to use during and after pregnancy
4. Lack of physical preparation (strength, endurance, relaxation) necessary for labor and delivery
5. Lack of knowledge of appropriate positioning for optimal comfort in labor and delivery
6. Lack of adequate postpartum rehabilitation

Plan of Care/Physical therapy Management

1. Develop awareness and control of posture during and after pregnancy. Stretching, training, and strengthening of postural muscles and Posture awareness training can help.

2. Learn safe body mechanics. Body mechanics in sitting, standing, lifting, and lying as well as transitions from one position to another Body mechanics with baby equipment and childcare activities. Positioning options for labor and delivery instructed by Physical therapist And Nursing Staff.

3. Develop upper extremity strength for the demands of infant care. Resistive exercises to appropriate muscles will Help to increase the strength of the upper extremities.

4. Promote increased body awareness and a positive body image. Body awareness and proprioception activities Posture reinforcement like Postural re-education is a very powerful aspect during pregnancy for sure.

5. Prepare the lower extremities for the demands of increased weight-bearing and circulatory compromise. like Use of elastic support stockings, Stretching exercises, Toning and resistive exercises to appropriate muscles will helpful. this step can be followed before the pregnancy is there, so it will be so effective during and after pregnancy.

6. Develop awareness and control of the pelvic floor musculature. Awareness of isolated pelvic floor muscle contraction and relaxation Train and strengthen for muscle control, integration with Routine life and daily activities.

7. Maintain abdominal function and prevent or correct diastasis recti. Monitor diastasis recti often by the therapist and suggest Diastasis recti exercises and Safe abdominal-strengthening exercises with diastasis recti protection.

8. Promote or maintain safe cardiovascular fitness. Safe progression of aerobic exercises under therapists' guidelines.

9. Learn about the changes in pregnancy and birth. it is necessary to give Patient/family instruction Refer to other disciplines as indicated.

10. Learn relaxation skills. Relaxation and breathing techniques like Jacobson's relaxation, yoga is mostly supine are instructable with fewer precautions. the patient can perform it at home once she learns and can perform it correctly.

11. Prevent impairments associated with pregnancy. Education about potential problems of pregnancy Teach prevention techniques and appropriate exercises are a must.

12. Prepare physically for labor, delivery, and postpartum activities. Strengthen muscles needed in labor and delivery, and train responses Teach comfort measures for labor and delivery.

13. Provide education on safe postpartum exercise progression also guidelines on Postpartum exercise.

14. Develop awareness of treatment options for pelvic floor dysfunction such as prolapse, incontinence, or hypertonus is sometimes becomes much more helpful than it looks.

Suggested Sequence for Exercises after Pregnancy

1. General rhythmic activities to “warm-up”
2. Gentle selective stretching for postural alignment and for perineum and adductor flexibility
3. Aerobic activity for cardiovascular conditioning (duration/intensity may need to be individualized)
4. Postural exercises; upper/lower extremity strengthening and individualized abdominal exercises
5. Cool-down activities
6. Pelvic floor exercises
7. Relaxation techniques
8. Labor and delivery techniques
9. Educational information
10. Postpartum exercise instruction (e.g., when to begin exercises, how to safely progress, precautions) because the patient may not be attending a postpartum class. Include education regarding body mechanics relative to child care.