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.
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.
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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