By Laura Ward, PT, DPT, MTC
As a physical therapist (also known as a physiotherapist) who specializes in women’s health physical therapy and treating the pelvic floor, I was particularly interested in the blog post from The Subtle Mummy about her "broken vagina." First, I really enjoyed Zoe’s blog -- the humor and her honesty made me think of my own birth story and all of my patients who have told me a similar story. It also made me want to give her a hug. I really wish Zoe had had more information going into her birth and postpartum -- and I’m not talking about people oversharing their horror stories -- I’m talking about pelvic floor health information.
Zoe’s description of having three pelvic floor "holes" is very accurate. But she left out the three major functions of our pelvic floor. The first one is to just be there and help hold everything up. The second is to contract and lift, also known as a Kegel. This closes the sphincters of our urethra and our rectum (ie, like when you stop your pee mid-stream). The third is to bulge or “bear down.” This allows us to urinate, defecate, and push out a baby.
Being aware of theses muscles and each of their tasks is helpful for everyone (yes, even men have pelvic floors), but especially in pregnancy. You want to be able to contract the pelvic floor to continue to support your body as your baby gets bigger, assist with continence, and overall support. You also want to be able to relax your pelvic floor, which will help you prepare for a vaginal birth.
There is a tool used in pelvic floor physical therapy called biofeedback. This device lets you know what your muscles are doing. It reads the natural electrical activity our muscles have and it can give you the feedback of contracting and relaxing your pelvic floor muscles. It is also safe to use in pregnancy. One of my favorite things to do with pregnant patients is to practice birthing positions with biofeedback to see which position they are the most relaxed in, in order to help plan for birth. Shorten et al’s study found that birthing positions may affect the health of your perineum (the area between your vaginal opening and anus). The study also found that side lying positions had the highest rate of intact perineum (no tears) after vaginal delivery. Another study by Walker et al found the patients who used a side-lying position with birth had “significant reductions” in assisted vaginal delivery and perineal trauma as compared to patients who delivered in the traditional position (supine, on your back).
This is not to say that everyone should go and birth in the side-lying position. There are several other positions to consider for birth and it's important to learn about the many variations as well as talk with your doctor or midwife about your options. But this also means it is important to know how your pelvic floor muscles work and how to control them!
Another point in Zoe’s story that I want to address is her scar tissue. Her doctor told her the scar tissue would hopefully tear with another birth - yikes! Physical therapy can assist with breaking up scar tissue by teaching relaxation and using self-scar tissue release to help ease the discomfort of scar tissues from perineal tears and episiotomies.
Zoe did mention seeing a physio “trainer” that did educate her on dilators to help assist with stretching her pelvic floor muscles. This is very true. Dilators are a tool that can be used for a circumferential stretch of the pelvic floor and vaginal muscles. But on occasion, this technique is not enough to help with scar tissue pain. This is the time to see a women’s health physical therapist or physiotherapist who can help break up the scar tissue.
Zoe's use of dilators may have helped her with the birth of her second child. Some evidence suggests that perineal stretching during pregnancy (especially your first pregnancy) can help with the pain after your vaginal delivery. The jury is still out (evidence still conflicting) on whether stretching beforehand helps to decrease tears, but it has been shown to help decrease pain afterward (Eogan et al).
One thing to touch on, which Zoe did not mention, is the importance of breathing. More specifically, diaphragmatic breathing. The diaphragm and our pelvic floor have a unique working relationship together. The diaphragm and the pelvic floor are bound together structurally and functionally by both fascial and muscular connections. Julie Wiebe, PT, described it appropriately as a piston. As you inhale, your diaphragm drops down and your pelvic floor relaxes. As you exhale, your diaphragm will push up and your pelvic floor reflexively contracts. By practicing this specific breath it can help to restore your overall pelvic health, and assist with making your pelvic floor contractions more automatic.
I appreciate Zoe for sharing her story. So many women out there believe that a "broken vagina" after a vaginal birth is normal and just something they have to deal with and eventually "get over." It is not. There are many health care providers out there who are willing and able to help. I encourage you to learn about pelvic floor health before and after pregnancy, and to seek out appropriate help when needed. And please, keep sharing your stories so we can let everyone know that a "broken vagina" isn't normal -- and can be fixed!
Shorten, A., Donsante, J., & Shorten, B. (2002). Birth position, Accoucheur, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth. Birth, 29(1), 18-27. doi: 10.1046/j.1523-536X.2002.0015.x
Walker, C., Rodriquez, T., Herranz, A., Espinosa, J. A., Sanchez, E., & Espuna-Pons, M. (2012). Alternative model to birth to redcue the risk of assisted vaginal delivery and perineal trauma. International Urogynecology Journal, 1-8.
Eogan, M., Daly, L., O’Herlihy, C.(2006). The effect of regular antenatal perineal massage on the postnatal pain and anal sphincter injury: A prospective observational study. Journal of Maternal-Fetal and Neonatal Medicine, 19(4), 225-229.
Chaitow, L & Jones, R. (Eds) Chronic Pelvic pain and Dysfunction 2012 Elsevier Churchill Livinstone.
Laura Ward, PT, DPT, MTC