Epidurals and Perineal Tearing?

In recent weeks, it seems we’ve been asked this question more and more frequently by our pregnant clients. It’s overwhelming to try to take in all of the information about the risks and benefits of medical interventions during labor and delivery, and even more challenging when there is only a small number of high quality academic studies available to guide our choices.

An individual’s risk of perineal tearing during vaginal delivery is based on a myriad of factors, some under our control (such as birthing position and the use of hands-on perineal support techniques) and others not (such as the size of the baby and speed of delivery).  The choice to have epidural anesthesia is also dependent on a patient’s medical history, personal values and prior experiences, and often the duration and intensity of labor. However, more and more of our clients are basing this choice, at least partially, on whether an epidural will change their risk of perineal tearing with delivery.

Many studies attempt to separate the effect of variables such as the use of an epidural on risk of perineal tearing. The most recent analysis (Pergialiotis 2014) combined the data from 22 studies with a total of 651,934 subjects. Its conclusion was that those with epidural anesthesia had a 1.95 times greater risk of perineal tearing than those who did not. However, another large single study of 61,308 women showed that in its subjects, the increased risk of tearing with an epidural was not present when the analysis controlled for the fact that more first time mothers choose an epidural, and a first vaginal delivery is also more highly associated with perineal tearing. 

Take away: One study shows that epidurals increase the risk of tearing. Another says that the reason more tearing occurs with epidurals is that more first time moms choose epidurals and first vaginal deliveries are already associated with a higher risk of tearing. 

That’s a lot of statistical analysis to digest, but the short story is that, as with many things in medicine, it is almost impossible to draw definitive conclusions. However, we can definitively say that there has not yet been a study that shows that epidurals decrease the risk of perineal trauma with birth - only that it may increase it or not affect the outcome at all. Our advice to clients is to make choices regarding anesthesia based on other important risks or benefits, but to avoid using risk of tearing as the single deciding factor.  

Are Planks Safe?

The internet is a fantastic resource for many of life's questions. However, when it comes to how to strengthen your abdominals when you have diastasis recti (DRA), there seem to be more questions than answers. One of the most common questions our patients ask is whether it is safe to plank with a DRA. 

Like many questions about health and fitness, the answer is "it depends." We should instead be asking ourselves what we're trying to accomplish with a plank, or any other abdominal strengthening exercise.

If a patient comes to us with a DRA, our goal is to improve the ability of the deep abdominal muscles to hold the two sides of the separation together when she moves through her day. Over time, we hope that consistent, appropriate exercise will improve the tension and thickness of the ligament that runs down the middle of the abdomen (the linea alba) to keep the gap closed in the long term. 

With any strengthening exercise, we have to provide a challenge to the muscle we are targeting to cause it to change in strength. As strength improves, the difficulty of the exercise must also increase to provide a new and appropriate challenge. Exercises that are too easy will not cause any increase in strength, and exercises that are too challenging will cause compensations in the surrounding muscles and bypass the weaker muscle we are trying to target. In the case of a DRA, an exercise that is too challenging will cause the person to compensate by holding their breath, bulging their abdominals, and actually widening the separation in the moment. 

A plank is safe for you if you can do it while using your deep abdominals to generate good tension in the linea alba, while breathing and with good form throughout your body. 

So, when a patient comes to us for guidance in a strengthening program to treat DRA, we need to determine whether any exercise (plank or not) is the appropriate challenge. For many, we need to start simply by practicing recruiting the deep abdominals in positions such as hands and knees, sitting, and standing. For others, we start with a plank or even planks with moving arms or legs. The key is determining what their abdominals look like when they are performing the exercise; all of these patients may be equally challenged by their respective exercises but start at vastly different points. 

Most people need an outside opinion on how their abdominals are performing during an exercise, and even using a mirror may help you determine objectively what your body is doing. If you are unsure of which exercises are right for you, we strongly recommend consulting with a qualified postpartum physical therapist or exercise instructor. 

Postpartum Abdominal Binding

Our postpartum clients often ask us about abdominal binders, and whether they are a safe and effective way to regain abdominal function after birth. Many cultures have a long history of abdominal wrapping in the immediate postpartum period; modern products and programs have popularized the practice and advertise it as a way to correct abdominal separation (diastasis recti) that often occurs postpartum. We acknowledge the wisdom and importance of long-standing traditions, but also recognize that some practices are not right for the majority of postpartum moms. 

With a small number of exceptions, we do not recommend this practice for our clients, as it can adversely affect the pelvic floor (and the core in general) and does not show long term efficacy in correcting diastasis. For women following cesarian birth, gentle compression with a Baby Belly Band, snug camisole or high-waisted underwear can be beneficial to reduce soreness and speed healing. However, this compression should be discontinued within the first two months postpartum.

Explaining why this occurs requires an understanding of the “core.” The core is composed of the diaphragm, lumbar muscles, abdominals and pelvic floor, functioning together in one closed system. A good image is one of a soda can – the system is closed, meaning that pressure generated in one location affects other sides of the “can.” If a woman wears an abdominal binder wrapped tightly in the center of the core, it increases pressure upward and downward. The diaphragm is no longer able to expand as far to allow filling of the lungs with air, and pressure is increased downward onto the pelvic floor (the bottom of the can). In most postpartum moms, the pelvic floor is weakened after pregnancy and birth, and many experience urinary incontinence and pelvic organ prolapse. Women with diastasis recti are even more likely to have these symptoms of pelvic floor muscle weakness. If excess downward pressure is generated downward on the pelvic organs (bladder, uterus and rectum), the pelvic floor cannot adequately oppose it. For a woman who is already experiencing urinary leaking, pelvic or vaginal heaviness, or other symptoms of pelvic organ prolapse, wearing a binder will only worsen those symptoms. For women who are not experiencing those symptoms, they may notice them upon wearing a binder.

Simply put, wearing an abdominal binder may change the shape of the abdomen and size of an abdominal separation while someone is wearing it, but it does not actively train the abdominals and pelvic floor in relationship to the core as a whole. For long-term recovery and function, exercise and re-education of the core muscles is the most effective treatment. We recommend working with a physical therapists or exercise professional who specialize in postpartum recovery.

How Big Will My Baby Be?

Are you pregnant and concerned about your ability to birth a "big baby?"

In late pregnancy, ultrasound and other methods are used to try to estimate a baby's size at birth. We hear a lot of our pregnant clients worrying about their ability to birth their baby vaginally, especially those who have been told that their baby may be on the larger end of the spectrum. 

But how accurate are these estimates, and how does the information affect choices surrounding birth?

The medical community generally defines a large baby as over 8lb 13oz. Statistically speaking, fewer than 8% of babies born in the US meet this definition. 

A new study surveying 1,960 new moms found that four out of five of the mothers who were warned that they might have a big baby did not, in fact, give birth to a large infant. However, those mothers were almost twice as likely to have medical interventions such as labor induction, and almost twice as likely to have a planned cesarian birth.

A 2012 study showed that simply being told the estimated birth weight of a baby caused a significant increase in the percentage of cesarian births when all other variables were controlled. 

The American College of Obstetricians and Gynecologists (ACOG) has published guidelines stating that suspecting a large baby is only "rarely" an indication for a planned cesarian birth. These guidelines say that doctors should only offer a cesarian to women with a baby predicted to weigh over 11 lbs at birth.

As we learn more about the role of womens' past experience, fears, and preconceptions on the processes of labor and birth, it's important to recognize the effect of the large volume of information that women receive during pregnancy. While technological advances and the ability to collect more data can be helpful, anxiety regarding a baby's size may influence how an expecting mother approaches vaginal birth or considers elective cesarian birth. 

Psychotherapy for Irritable Bowel Syndrome

A recently published systematic review and meta-analysis showed that cognitive therapy, hypnotherapy, mindfulness, behavioral therapy and dynamic psychotherapy all showed benefits against the symptoms of Irritable Bowel Syndrome (IBS). This high-quality study showed that these therapies were significantly effective when added to standard care, with the benefits remaining at 6 and 12 months. See the full text article here. 

This study is an important reminder to physical therapists, doctors and patients that the management of abdominal and pelvic dysfunction is often most effective with more than one provider. If you are suffering from IBS, talk to a provider you trust about a multidisciplinary approach to manage the aspects of your symptoms beyond the gastrointestinal and musculoskeletal systems!


Pregnancy and Pelvic Floor Exercise

In our daily work with expecting mamas, we are constantly reminded that pregnancy is a time of information overload. Advice comes from all directions - family, friends, doctors, midwives, doulas, class instructors, books, magazines and the internet - and many women and their partners simply don't know how to make sense of it all.

As pelvic floor physical therapists, we frequently discuss concerns brought to us by our pregnant patients about the safety and efficacy of pelvic floor muscle exercise during pregnancy. With the volume and diversity of information available on this topic, it's easy to see why a lot of women are paralyzed by fear of doing the "wrong" thing.

So what's a mama to do? Our answer, ultimately, is the same that we would provide to any woman who comes to us with signs of pelvic floor dysfunction. It depends. 

Generalizing exercise prescription for any population of people, pregnant or not, will never completely address the needs of any one of those individuals, and may prevent many from getting relief from their symptoms. The state of pregnancy creates common features among many women, but each enters her pregnancy with a unique physical, gynecological and psychosocial history that must be determined by a thorough history and physical examination before any conclusions about the most appropriate type of pelvic floor exercise can be made. 

The most important "rule" about pelvic floor muscle exercise is that it should work to cultivate a strong, flexible and coordinated muscle group. Our best physical function occurs when our pelvic floor muscles can achieve a full range of motion during voluntary contractions and relaxations, respond appropriately to postural demands as a component of the deep core, provide stability and force closure to the pelvic girdle and lumbar spine, and adequately support pelvic organs against intra-abdominal pressure.

During pregnancy, it is very important to practice relaxing into the sensation of pressure and stretch felt at the perineum (see our home page video about perineal massage!). But it's also important that pelvic floor muscles can contract strongly and with good endurance to provide needed stability for the pelvic bones and give support to a growing uterus and pelvic organs (including the bladder). As with all things in life, moderation of all of these factors is the key.

The path to to get to this ideal state depends entirely on where our muscles begin - some individuals will need to work primarily on motor control and coordination, some will need to practice voluntary contractions, and others will need to focus on voluntary relaxation. The reason that our jobs stay so interesting is that every body is unique - so let's treat them that way! 

Don't Blush, Share a Flush!

California is struggling with a historic drought, and even in San Francisco we are feeling the effects! A major source of water use is from toilets, especially old and inefficient ones. As physical therapists who talk about toileting all day, we want to do our part to find ways to reduce water waste. 

But is peeing in the shower the best way to combat water waste? The body is quick to associate the urge to urinate with certain activities and environments. Those of you who have already tried going in the shower may have noticed that after doing it voluntarily a few times, the reaction of your pelvic floor muscles and bladder to getting into the shower is more automatic. The next time, when you don't necessarily want to release your muscles, it might be very challenging or impossible to hold back! The same sort of situation occurs when you train yourself to pee "just in case" every time you leave the house, or rush into the house after your evening commute and go straight to the bathroom. Urinary urge (the need to pee) may eventually become disconnected from your bladder being full, and connected instead to a certain time of day or situation. Habits are easy to build and harder to break, so it's important to prevent problems from the beginning. Ideally, you should be using the toilet only when you have a physiological need.

Our conclusion? If it's yellow, let it mellow! Don't blush, share a flush! 

But maybe think twice before peeing in the shower.

What is a Kegel, Anyway?

The "Kegel" was first described in 1948 by Arnold Kegel, an Assistant Professor of Gynecology at University of Southern California. In his quest to treat "genital relaxation," he realized that the strength of the pelvic floor muscles was an important component. He developed a "perineometer" to measure pelvic floor strength, and coined the term "Kegel" to describe the voluntary contraction of the pelvic floor muscles. 

So really, a Kegel is one man's attempt to describe the "concentric" (shortening) action of the pelvic floor muscles to achieve the goal of lifting and supporting the pelvic organs. He certainly blazed some important trails for the description and measurement of muscle strength, and his discoveries laid a foundation for the successful conservative treatment of many pelvic conditions.

HOWEVER. Kegel is not the last word on pelvic floor muscle activity! Ideas have evolved and the body of evidence-based practice has deepened and widened significantly since the mid-century. A Kegel is no longer the only tool we have in our toolbox, and we understand that this type of exercise may actually not be helpful for many types of pelvic floor dysfunction. A physical therapist trained in the specific evaluation of the pelvic floor muscles will not only evaluate how the muscle can squeeze and hold (a Kegel), but how well it can relax. A Kegel is only half the story, if even that much! What's more, if you would benefit from Kegels, you may need to be doing them in a different position than in sitting or standing! Depending on your strength and endurance, your PT may prescribe pelvic floor exercise that will be more efficient and give better results. 

Kegel AH. "The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure". Ann West Med Surg. 2 (5): 213–6.