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Body After Childbirth — Explaining Those Aches and Pains

Sketch by Whitney Waller

Let’s face it–carrying, on average, a seven pound baby in your belly is no easy feat. Coupled with your extra weight gain, swelling, varicose veins. . . feeling uncomfortable is putting it mildly. But then, you push that baby out and new aches and pains come to light, some of which stay around for months, even years. Breezy Mama turned to Ginger Garner MPT, ATC, PYT, ERYT500 to answer our readers most common complaints. From aching tailbones to incontinence to swelling–see what causes these ailments and what you can do to feel like yourself again.

One woman is still very swollen (so much so that a wedding ring won’t go on), though she gave birth four months earlier. Is this normal or is it a sign of something else?

No, swelling such as she describes does not sound normal.  My first response is to turn to differential diagnosis. Meaning, a medical practitioner needs to determine if there is an underlying cause of concern for her swelling. A few preliminary questions she should ask herself are:

  • Is it related to eating or what she eats?
  • Is it related to activity?
  • Is it weight related?
  • When is the swelling worse?
  • What is her blood pressure?
  • Does she have headaches?
  • Does she have leg pain?
  • What are her dietary or nutritional habits?

Eating processed foods, which are typically loaded with sodium, sugar, and other food additives could contribute to the swelling; however, I would suggest she see her physician or practitioner to determine the root cause of the problem. If it is related to eating or food, then she could have an allergy or may need to cut out processed foods high in salt and sugar.

On the other hand, if the swelling is unrelated to food or has no pattern, this is a more concerning reason to seek immediate medical attention.  Swelling could be a sign of longstanding chronic issues such as heart disease, lymphatic drainage, blood clots (which can be fatal) or other problem.  In her case, I would suggest seeing her physician, midwife, or other health care provider immediately since she may be unsure of the root cause – or if she has associated headaches or leg pain (which could be associated with deep vein thrombosis or cardiovascular disease).

A reader has had carpel tunnel in her past pregnancies, but after her most recent pregnancy she still has it, though she gave birth months ago. Will it go away?

Carpal tunnel syndrome is included in a category of injuries or dysfunction called repetitive stress syndrome.  Although in pregnancy, carpal tunnel syndrome can be caused by edema, or swelling of the carpal tunnel, which entraps the median nerve as it travels through the wrist.  Nonetheless, pregnancy creates a situation of repetitive stress to the area, and it is not uncommon for many syndromes or dysfunctions to continue long after pregnancy.  Low back pain, neck pain, shoulder pain, carpal tunnel syndrome, as well as systemic illness such as gestational diabetes, can all persist in the postpartum.

The reasons are not always well understood, but with carpal tunnel syndrome, excess weight, edema (swelling), repetitive stress such as computer keyboarding, gaming, or other hobbies or recreational activities that place the tunnel of the wrist in a smaller, compromised position, can all contribute to chronic carpal tunnel syndrome.  If the person has an occupation (caring for a newborn included) that requires repetitive activities of the wrist, fingers, or hands, coupled with the pregnancy related cause (typically edema) of carpal tunnel syndrome-then it is perfectly feasible that carpal tunnel syndrome could become a nagging problem long past pregnancy.

Additionally, sleep and postural habits influence development or resolution of carpal tunnel syndrome (CTS).  For example, sleeping with the wrist fully flexed or extended (in an extreme range of motion in either direction) creates a situation of repeated microtrauma which can cause CTS by compressing or closing down the carpal tunnel. As a result, CTS causes numbness, tingling, feelings of hot or cold, altered sensation, loss of strength, and even paralysis in the first three fingers of the hand.

A physical therapist or occupational therapist is the medical professional who specializes in treatment of carpal tunnel syndrome.  If she has persistent CTS, I would strongly recommend she seek a referral for PT or OT immediately.

One mother’s tailbone hurts 28 months after giving birth to her second child–is this normal?

Unfortunately, yes, tailbone is common in pregnancy and postpartum. However, no, it is not a normal condition and should be treated.  She should seek out a physical therapist or referral to a PT who specializes in women’s health (it means they have received specialized training past their normal 6-8 years of education) in order to treat pelvic pain, which includes tailbone pain.

Pain in the tailbone, or coccyx, can be attributed to several causes.

During labor, it is not unheard of for the tailbone to be fractured, especially if the woman vaginally births a large baby, or the baby has a large head.  The baby must clear both the pubic symphysis and the tailbone, and if his/her head is too large – either the pubic symphysis, the tailbone, or any musculoskeletal or ligamentous connection will be injured.

During pregnancy and in the postpartum, gravity and weight gain exert remarkable pressure through the muscles of the pelvic floor and the perineum.  Additionally, the baby’s size and movements can affect the integrity of pelvic structures.  Altered length/tension relationship in the muscles or ligaments, which occur as a natural result of pregnancy and birth, whether or not a woman has had a C-section, can create a situation of long standing pelvic pain – which includes either coccyx or pubic symphysis pain.

Pelvic pain can create difficulty with intercourse, elimination, bowel and bladder function, incontinence, and contributes to low back and sacroiliac joint dysfunction and malalignment.

A Breezy Mama reader had a pretty traumatic delivery with her first child. Her baby was posterior and she pushed for so long that it caused her to have pubic symphysis dysfunction where her pubic bone wouldn’t stay in place and if she moved weird it would literally be knocked out of joint. What can be done for this?

First of all, I am saddened to hear of her experience and want to relay my thoughts and wishes for her recovery – and for a better birth experience in the future, should she choose it.

Second – pubic symphysis dysfunction can occur as a result of labor and delivery, but it also commonly occurs during pregnancy.

What she is describing is a subluxing (partial dislocation that spontaneously resolves) or dislocating pubic symphysis, which is extremely painful and debilitating. It prevents a woman from walking, standing on one leg to even complete simple tasks like putting on pants or getting into a car, and it can make sleeping impossible – since she cannot roll over without compressing or subluxing the joint. Each time the pubic symphysis subluxes or dislocates, microtrauma is caused – which can lead to longstanding pelvic pain that creates difficulties like I mentioned in the previous case.

That being said, there are conservative interventions that a women’s health physical therapist can use to treat pubic symphysis dysfunction.  If surgical stabilization is not needed, which hopefully is not the case, then conservative management includes a course of physical therapy which should address lumbopelvic stabilization, or strengthening of the core muscles which support and stabilize the low back and pelvic region.

These muscles have been defined in research through (Richardson et al 1999 and others) as the cylinder concept.  The cylinder is made up of the respiratory diaphragm (on top), the pelvic floor (on the bottom), the transversus abdominis (the main trunk stabilizer and deepest layer of abdominal muscle), and the multifidi (in the low back).  Cylinder strengthening must be addressed; however, therapy must also include what is called regional synergistic strengthening.  This means the hip rotator muscles and surrounding musculature must also be addressed (through stabilization and strengthening exercises) along with the cylinder – in order to dynamically stabilize the pubic symphysis.  Lastly, normal length/tension relationship in the pelvic connective tissue can be addressed through flexibility, soft tissue mobilization techniques, and manual therapy. The good news is – women’s health PT offers many therapies which can relief her pain and treat her pubic symphysis dysfunction.

The therapy can be undertaken safely during pregnancy and at any time during postpartum.  I consider postpartum to last not just months, but for up to 2 years after giving birth.  It takes the body more time to recover and rehabilitate from giving birth than it does to gestate.

One reader asks, “Ever since I had my baby, I have the urge to urinate, but when I actually sit down on the toilet, nothing comes out. What is this?”

This is most likely a condition called urge incontinence.  If she is stress incontinent (meaning sneezes and coughs or lifting causes “leaks or accidents”, then she is likely also urge incontinent – which essentially means in order to prevent stress incontinence accidents, she goes to the bathroom more often. But in doing that she creates a situation of a hyperactive bladder, or hyperactive detrusor muscle which controls the bladder.  Then – unfortunately – she ends up with 2 types of incontinence. Both are very treatable with physical therapy.

However, if the urination issue is from a blockage or neuropathy, then PT cannot help – and invasive intervention is required.  So it is important to determine if the urge to urinate without actually urinating is coming from a systemic issue such as a bladder infection, a blockage, or nerve damage- OR if it is coming from genuine urge incontinence.

Fortunately – usually it is simple urge incontinence – but it isn’t fun because if they are – the primary symptom or sign is constantly feeling like she has to urinate.

A mother of two has problems with her sciatic nerve, as well as her tailbone hurting—are the two related?

Absolutely.  The sciatic nerve runs through an outlet in the pelvis which houses muscles (and other tissue) that connect one side of the pelvic to the other.  In effect, the ligaments, muscles, and other connective tissue (like fascia) act as a sling – holding up internal organs and preventing them from prolapsing (or literally falling out). Even the fascia of the low back is connected to the pelvis, which means that sciatic and tailbone pain can eventually cause back or even hip pain.

There are many causes for sciatic nerve pain, which is described in different ways – it can be described as sharp, dull, searing, diffuse, radiating, hot, cold, tingling, or burning – and it typically starts in the buttock and can run all the way into the foot, causing numbness, pins and needles sensations, and even paralysis.  Some of the causes can be attributed to lack of flexibility in structures such as the piriformis (a muscle that attaches the hip to the pelvis and in a large portion of the population, houses the sciatic nerve) or hamstrings, loss of cylinder or synergistic strength (as described above), poor posture, acute injury or trauma, nerve damage or trauma, prolonged sitting and slouching, impingement from sitting in a poorly constructed chair or vehicle seat, or you guessed it, pregnancy.

During pregnancy, alterations in gait (walking), weight gain, edema, loss of strength and flexibility, and pressure from the baby’s position which affects dynamic pelvic alignment – can all contribute to this type of pain.  A physical therapist with special training in prenatal and postpartum women’s health can address her pelvic pain, through methods similar to the ones mentioned in the last case, but also including manual therapy to readjust the spine or pelvic, soft tissue mobilization techniques such as massage and myofascial release – which can all help resolve her issue.

Incontinence after birth is very common. Many women can’t laugh to hard or do a jumping jack for fear they will urinate. Is Kegels the only option for strengthening this?

There are many options for training the pelvic floor, other than Kegels.   Kegels originate from the physician Dr. Arnold Kegel in 1948.  However –

As a physical therapist specializing in women’s health through medical yoga therapy, I can tell you that yoga has taught pelvic floor strengthening, or Kegels, for thousands of years.  Pelvic floor strength is addressed in yoga through what is called mula bandha (moola bahn-duh).  However traditionally taught as 100% contractions of the pelvic floor with breath holds (historically created by and generally practiced by men), women need a different approach.

The pelvic floor can be strengthened in any of the following ways:

  • EMG Biofeedback – I used this many times in my women’s health practice.  It helps women visualize where the pelvic floor is and how to use or contract it.  By using internal sensors or electrodes, a woman can literally see on the computer screen – how strong (or weak) her pelvic floor is – this provides an incredibly reliable method for solving incontinence issues. A physical therapist specializing in women’s health can carry out these tests and the therapy using EMG.  Learn more about women’s health PT at http://www.womenshealthapta.org/plp/index.cfm
  • Medical Yoga – A prescribed medical yoga practice for mula bandha, which I teach in a gender specific format for women – which includes no breath holding and training the pelvic floor through use of yoga postures, breathing, imagery that includes three specific techniques. Find a medical yoga therapist at http://www.professionalyogatherapy.org/Find+A+Therapist
  • “Elevator” lifts – working from a mild pelvic floor contraction to 100% contraction and back down again.
  • Quick flicks – lifting or contracting the pelvic floor quickly and at 100% of a maximum voluntary contraction followed by a quick release.  This method helps women prevent accidents if they perform a quick flick right before sneezing, coughing, or lifting.
  • Long holds – practicing lifting the pelvic floor and holding for up to 20 seconds at a time.
  • Sexual intercourse – yes, even! A woman can strengthen (and learn to use) her pelvic floor by contracting it during sexual intercourse, which produces a squeezing affect around your partner’s penis. Of course, learning to use the pelvic floor also lends itself to a more simulating (and educational) experience.
  • Vaginal weights – These are inserted while in a variety of positions, starting with laying in supine (flat or reclined on back) and moving to sitting, standing, and walking or doing light housework, in order to strengthen the pelvic floor and provide constant biofeedback and input.  The weights begin very light and increase in weight as a woman’s pelvic floor becomes stronger.  The goal is to retain the weight while breathing, and to move up in weight as you get stronger.

About Ginger Garner MPT, ATC, PYT, ERYT500: Ginger is a practicing licensed physical therapist (MPT), licensed athletic trainer (ATC), advanced level experienced yoga therapist and teacher (ERYT500), certified Pilates instructor (CPI), and Ayurvedic Counselor (ALT). If you have any questions please contact Ginger Garner at ginger@gingergarner.com.

For more information on Ginger, please visit her websites at: http://gingergarner.com/physical%20therapy.html and http://gingergarner.com/about.html

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Comments

  1. Wow! This is the most comprehensive post on the problems after childbirth I’ve ever read. Thank you so much, Ginger and Breezy Mama! I’ll be sharing this everywhere!

  2. More information on incontinence, symptoms, therapies and treatments can be found at http://www.nafc.org. The National Association for Continence is the world’s largest and most prolific consumer advocacy organization dedicated to public education and awareness about bladder and bowel control problems, voiding dysfunction including retention, nocturia and bedwetting, and pelvic floor disorders such as prolapse.

    Check out our blogs! http://nafcpowderroomtalk.blogspot.com/ or http://bladderbreak.wordpress.com/

  3. Thanks Kristen and Stacey for your post – I was revisiting this article in planning a lecture on the bladder and women’s health at the Mountain Pose Medicine and Yoga Symposium – and saw your comments again, realizing I had forgotten to answer them in this forum.
    Thank you for your inputs – and for the resources as well. I appreciate your work and hope to hear from you again in the near future.

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