Case Study, One Patient: Two Births
In the summer of 2021, I had the pleasure of writing a blog on a patient who was 9 months postpartum with her first baby. To recap: she delivered her baby vaginally and experienced perineal tearing during the birth, which took a longer time to heal than expected ~8 weeks. This contributed to her leaning to one side while sitting, nursing etc. in order to avoid putting pressure on that area. She continued to sit like that for several months after the tear had healed. At that time, she was experiencing low back, hip, and tailbone pain. She was also noticing urinary urgency while wearing her 20# baby in a front carrier, and noticed mild urinary incontinence when she started running at about 6 months postpartum.
We worked together for 5 sessions, with each visit addressing some component of postural awareness, deep core activation and connection to her pelvic floor and abdominals, spinal and hip strengthening, as well as manual therapy to release any tension in the pelvic floor, most notably in the area where there was scar tissue present at the perineal region. The patient was able to return to running without leaking as well as total relief of her hip and low back pain by the end of this course of treatment.
Fast-forward to fall of 2022, when the patient returned to our clinic - pregnant with her second baby, midway through her second trimester! She had complaints of a few drops of urinary leakage when sneezing, squatting down to pick up her toddler, and when she had a full bladder. She also noted the sensation of heaviness and pressure at her pelvic region. From here we talked about the importance of postural awareness - especially with the baby growing and her body adjusting for this change in center of gravity. We practiced optimal breathing patterns while lifting her toddler from the crib and floor to reduce any back or hip discomfort, as well as further strengthening and connection to her deep core. She did well with this strength training over the next few sessions. Around 33-35 weeks we shifted focus to optimize her hip mobility, as this is where she was feeling limited. This was also good timing to reassess her pelvic floor and practice lengthening (the opposite of tightening!) of the pelvic floor. This was also a great time to practice different breathing patterns, especially in different positions, to optimize her hip and pelvic mobility for delivery.
There were some hiccups along the way in the last few weeks of her third trimester including: fatigue from being sick, low fluid and being monitored in the hospital with regular ultrasounds, but the patient was still able to get in a virtual appointment at 38 weeks to review as much birth prep as we could! This included:
- Things to bring/ask for in the birthing suite
- What to work on over the next few days/weeks until she went into labor
- Perineal massage and how this can be beneficial
- Birthing positions - why and how certain positions can assist in baby’s progression
- Pushing preparation/techniques with breathing
- Immediate postpartum tips
- Considerations for if she had pubic symphysis pain or an epidural
This was the last session we had before she had her baby! She had been doing so much work leading up to that point, that she was able to tune into a lot of the positions and breath patterns without much thought when laboring. We met again virtually for her two-week virtual postpartum session- which we find to be such a valuable session since a lot can happen between your delivery and 6-week postpartum visit with your OB. This visit generally includes guidance in regards to postural changes with nursing, when and how to start movement, and what breathing patterns to adopt when caring for a new baby and in this case a toddler as well. It is also a good time to check for diastasis rectus abdominis.
At this visit I learned that the patient delivered her baby vaginally, sustaining a tear in the same spot she tore with her first, though with much more efficient healings. She did not have an epidural, and noted that her baby progressed down much quicker than her first, and she pushed for much less time. Her baby was also smaller than her first. Overall her complaints at this two week visit were tailbone and sacral pain from sitting and lying down on an angle to nurse frequently. We discussed strategies and modifications to support her nursing schedule and to reduce prolonged pressure to that area.
When I saw the patient again at 6 weeks postpartum - in-person this time - she had some mild complaints including some tightness at her perineum where she tore, and some lingering tailbone and sacral pain from nursing. Now that the patient’s tearing had healed, we started adding in supportive movements to reduce the pressure to the tailbone. This included movements such as cat-cow, inner thigh stretching, and hip mobility stretches., We also developed a plan to avoid sitting to nurse as much as possible. She also did well with the addition of some glute releasing and manual scar tissue release to the area where she tore.
At her 10 week follow up, the patient noted continuously reducing symptoms at her tailbone, but noted it felt like her shoulders were feeling pulled forward and rounded due to the consistent nursing position. We worked on some chest opening stretches and breathwork, as well as some strengthening progressions. She was feeling really ready to get moving and mentioned her goals of returning to running in the spring and summer. It is so important to start a specific lower body strengthening program to lead into running, and slowly integrate impact exercises to be sure your body is ready to put all those parts together to run. The patient has been working on this and is gradually improving her single leg strength and endurance. Our next session will add some gentle impact (hopping-type) exercises to get her body prepared to shock-absorb adequately, so that her whole system responds well to this, including her pelvic floor!
I really wanted to highlight this case to not only show the different outcomes in this patient’s births (there will always be many variables to this), but also to touch on the fact that just because there are challenges with a first birth, it does not mean they will reoccur in a second or third birth. Plus this case highlights what support looks like in parts of pregnancy, delivery, and postpartum periods. Guidance and support throughout your pregnancy can go a long way, even if you’ve already gone through a birth, there is always more to learn!