Pelvic floor ; function, pelvic floor impairments after pregnancy

Female Pelvic Floor

The female pelvic floor allows for passage of the urethra, vagina, and rectum. This creates less inherent stability when compared to the male anatomy.

Innervation

The pudendal nerve arises from ventral divisions of S2 to S4 in the sacral plexus, as well as direct branches from S3 and S4, and supplies the pelvic floor complex. This dual innervation provides a safeguard against direct damage to the pudendal nerve. The terminal branches are the perineal branch and the inferior rectal nerve, which ends in the external anal sphincter.

Female Pelvic Floor


Function

The pelvic floor musculature has the following essential roles:

Provide support for the pelvic organs and their contents Withstand increases in intra-abdominal pressure Maintain continence (through sympathetic nerve fibers) to the urethral and anal sphincters Sexual response and reproductive function

Effect of Childbirth on the Pelvic Floor Neurological Compromise

Stretch and compression of the pudendal nerve occurs during labor as the baby’s head travels through the birth canal; this stretch can be as much as 20% of the total length of the nerve.3,61 This compromise to the pudendal nerve is most intense during pushing (the second stage of labor), through the completion of vaginal delivery.

Muscular Impairment

Extreme stretching of the pelvic floor tissues is inherent in the process of labor and vaginal delivery. The pelvic floor musculature may also be torn or incised during the birth process. 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 muscle

Third degree—extends to anal sphincter

Fourth degree—tears through the sphincter and into the rectum

Additional trauma can occur as a result of forceps use, necessitating suturing throughout the musculature and into the vaginal vault.

Episiotomy

Although episiotomy is common, occurring in 33% to 51% of vaginal deliveries (with some studies reporting a figure as high as 75%), 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.

PREGNANCY-INDUCED PATHOLOGY

The combined influence of hormones, weight gain, and postural changes of pregnancy contributes to a variety of impairments (in addition to pelvic floor dysfunction that was described in the previous section) that can be addressed with physical therapy.

Diastasis recti

Diastasis recti is separation of the rectus abdominis muscles in the midline at the linea alba. The etiology of this separation is unknown; however, the continuity and integrity of the abdominal musculature are disrupted . Any separation larger than 2 cm or two fingerwidths is considered significant. Diastasis recti may occur in pregnancy as a result of hormonal effects on the connective tissue and the biomechanical changes of pregnancy; it may also develop during labor, especially with excessive breath-holding during the second stage.  It causes no discomfort. It can occur above, below, or at the level of the umbilicus but appears to be less common below the umbilicus. It appears to be less common in women with good abdominal tone before pregnancy. Clinically, a diastasis may be found in women well past their childbearing years and also in men. Routine assessment for this condition is highly recommended and can easily be done in conjunction with abdominal strength testing. Back pain commonly occurs because of the postural changes of pregnancy, increased ligamentous laxity, and decreased abdominal muscle function.

Incidence

Back pain is reported by 50% to 70% of pregnant women at some point during pregnancy30,47; this condition contributes to lost work days and decreased functional ability. In addition, symptoms may continue in the postpartum period, with a prevalence in up to 68% of women, for as long as 12 months after delivery.

Characteristics

The symptoms of low back pain usually worsen with muscle fatigue from static postures or as the day progresses; symptoms are usually relieved with rest or change of position. Women who are physically fit generally have less back pain during pregnancy.

Interventions

Low back pain symptoms can be treated effectively with many traditional low back exercises, proper body mechancontinued ics, posture instructions, improvement in work techniques, along with superficial modality application. The use of deep-heating agents, electrical stimulation, and traction is generally contraindicated during pregnancy.

Female Pelvic Floor


Sacroiliac/Pelvic Girdle Pain

Characteristics

Sacroiliac pain is localized to the posterior pelvis and is described as stabbing deep into the buttocks distal and lateral to L5/S1. Pain may radiate into the posterior thigh or knee but not into the foot. Symptoms include pain with prolonged sitting, standing or walking, climbing stairs, turning in bed, unilateral standing, or torsion activities. Symptoms may not be relieved by rest and frequently worsen with activity. Pubic symphysis dysfunction may occur alone or in combination with sacroiliac symptoms, and includes significant tenderness to palpation at the symphysis, radiating pain into the groin and medial thigh, and pain with weight bearing. In addition, excessive separation and translation of the bone may occur. One study reported a four times greater incidence of posterior pelvic pain than low back pain in pregnant women.

Interventions

Pelvic girdle and sacroiliac symptoms are treated via modification or elimination of activities that may further aggravate sensitive tissue, stabilization exercises, and the use of belts and corsets to provide external support to the pelvis.

Activity modification

 Daily activities should be adapted to minimize asymmetrical forces acting on the trunk and pelvis. For example, getting into a car is done by sitting down first, then pivoting both legs and the trunk into the car, keeping the knees together; side-lying is made more symmetrical by placing a pillow between the knees and under the abdomen, and sexual positions are altered to avoid full range of hip abduction. Single-leg weight bearing, excessive abduction and sitting on very soft surfaces should be avoided. In addition, caution patients to avoid climbing more than one step at a time, swinging one leg out of bed at a time when getting up, or crossing the legs when sitting.

Exercise modification

 Exercise must be modified so as not to aggravate the condition. Avoid exercises that require single-leg weight bearing and excessive hip abduction or hyperextension

Varicose Veins

Varicosities are aggravated in pregnancy by the increased uterine weight, venous stasis in the legs, and increased venous distensibility.

Characteristics

Varicosities can present in the first trimester, and are more prevalent with repeated pregnancies. They can occur in the lower extremities, the rectum (hemorrhoids), or vulva. Symptoms usually include heaviness or aching discomfort, especially with dependent leg positions; intensity may become severe as the pregnancy progresses. In addition,  pregnant women are more susceptible to deep vein thrombosis.

Interventions

Exercise modification

If there is discomfort, exercises may need to be modified so that minimal dependent positioning of the legs occurs.

External support

 Elastic support stockings should be worn to provide an external pressure gradient against the distended veins, and the woman should be encouraged to perform lower extremity exercises and to elevate the lower extremities as often as possible

Joint Laxity

Significance

All joint structures are at increased risk of injury during pregnancy and during the immediate postpartum period. The tensile quality of the ligamentous support is decreased, and therefore injury can occur if women are not educated regarding joint protection. There is much controversy regarding the impact of postpartum hormone levels; however, elevated levels have been found 3 to 5 months after delivery. This may persist even longer if the woman is nursing. Many patients are aware of persistent symptoms in conjunction with the menstrual cycle.

Interventions

Exercise modification

 Teach the woman safe exercises to perform during the childbearing year, including modification of exercises to decrease excessive joint stress.

Aerobic exercise

 Suggest nonweight-bearing or less stressful aerobic activities such as swimming, walking, or biking, particularly for women who were relatively sedentary before pregnancy

 

Nerve Compression Syndromes

Causes

Impairments from conditions such as thoracic outlet syndrome (TOS) or carpal tunnel syndrome (CTS) may be caused by one or more of the following in pregnancy: postural changes in the neck and upper quarter, fluid retention, hormonal changes, or circulatory compromise. Overall, women are three times as likely as men to experience carpal tunnel syndrome

 

Interventions

Typical protocols include postural correction exercises, manual techniques, ergonomic assessment, and modalities. Splints may be used in the treatment of carpal tunnel syndrome. Carpal tunnel surgery in the pregnant population is rare, as symptoms generally resolve soon after delivery; a longer course of the problem has been noted in women who breastfeed.

 

 

 

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