I wrote this paper as part of a Maternity Massage Certification.
In an age where “kegal” is in the vernacular, there is shamefully little talk about the epidemic of pelvic pain amongst women. The pelvic floor and its complexities are not well understood and the result is needless suffering. With more research and education within the medical community, better treatment can be taught to physical and massage therapists. With these sort of treatments being offered to women in a more widespread fashion, a variety of pelvic issues could be avoided.
Birth trauma is defined as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant. The birthing woman experiences intense fear, helplessness, loss of control, and horror.” (Beck, 2004, p. 28) This kind of trauma is very common in the western birthing world. Penny Simkin, founder of the Prevention and Treatment of Traumatic Childbirth, claims that “between 25 and 34 per cent of women report that their births were traumatic” (2014). Anywhere from 1 – 9 per cent of those women go on to develop post-traumatic stress disorder (Simkin, 2014), though as many as 34% may suffer some symptoms (Beck, 2009, p. 190). Women often reported those feelings as being a result of treatment from hospital staff (Beck, 2009, p. 191). However, the sudden and physically stressful interventions that women have during hospital births also plays a major role (Beck, 2009, p 192).
Muscles of the pelvic floor are the recipients of a lot of that trauma. One large study of the UK showed that 85% of vaginal births will result in perineal trauma (Johanon, 2000, p. 250). It is part of the body’s core and many functions are wrapped up in the complicated web of muscle. The urethra, vagina, and anus are all nestled into those muscles. They form a hammock that holds in those pelvic organs. Weakness in those muscles can cause prolapse in both the vagina or rectum. This points to a need for heavier focus of care and maintenance on those muscles, especially through the pregnancy and birth process when they are stretched, torn, and sometimes cut.
Studies show that antenatal perineal massage, performed by self or partner, can reduce risks of trauma and intervention. The risk of trauma requiring sutures and episiotomy was significantly reduced in women giving birth for the first time (Beckmann and Garrett, 2006, p. 159). The frequency of massage was shown to have an effect, reducing suturing in primagravitas women by 10%, to 17% for those who massaged an average of 1.5 times a week (Dame, et al, 2008, p. 480). Both Beckmann and Garrett (2006) and Dame, et al (2008) found that pelvic pain was reduced in women who had given birth in the past, especially when massaging as frequently as 3.5 times a week. Perinatal massage during labor has mostly been shown ineffective, particularly when laboring in supine. However, when administered during left lateral lying, perineal trauma was reduced (Herbruck, 2008, p. 177)
Pelvic floor exercises, often known as Kegals, are theorized to help reduce birth trauma when performed prenatally. Dias, et al ( 2011) found no significant outcome change in delivery in a study carried out on low income women in Brazil. In fact, another study of Brazilian women showed that pregnancy did not significantly reduce the pelvic floor muscle strength at all (Caroci, et al, 2010, p. 2432). Antenatal exercises were also shown to be ineffective at reducing levels of urinary incontinence after birth (Mason, et al, 2010, p. 2784). However, according to The Joanna Briggs Institute, there is strong evidence to show pelvic floor exercises can reduce incontinence when undertaken both ante- and postnatally (2011, p. 379). This not-for-profit research group based out of Australia, looked at 21 studies about the effect of pelvic floor exercises on urinary incontinence after childbirth and analyzed all of the results together. They recommended that in order to be successful, women needed to have more than two instructional sessions and that the design of the program needed to take the demanding and exhausting nature of the postpartum period into account such that the exercises are easily incorporated into the daily routine (The Joanna Briggs Institute, 2001, p. 380).
Sexual dysfunction is also a component of birth trauma. Women report a wide range of symptoms, including low libedo, pain during intercourse, reduced frequency of orgasm, and decreased vaginal lubrication (Ratfisch, et al, 2010, p. 2640). According to Klein, et al (1994, p. 117), sexual functioning at three months postpartum is best for women who had intact perineum or suffered only natural tears. Women who underwent episiotomy or suffered 2nd degree perineal tears were significantly more likely to report at least one sexual dysfunction when compared to women with an intact perineum (Ratfisch, et al, 2010, p. 2646). When one considers that a cadaveric study of the vascular tissue in the vulva found that bulbs of the clitoris are located in the perineum (Yang, et al, 2005, p. 770), the implication becomes that when the perineum is ripped severely or cut during labor, those bulbs may be cut severed. This would certainly have a significant impact on a woman’s sexual functioning during the healing process.
Manual therapy for chronic pelvic pain using the Thiele technique has been shown quite effective in a small study (Montenegro, et al, 2010, p. 982). The thiele technique is a five minute massage of a muscle from origin to insertion. The results were quite promising, since little has proven effective in abating chronic pelvic pain (Montenegro, et al, 2010, p. 981). Though chronic pelvic pain is defined partly as being unrelated to pregnancy for the purposes of the this study, the muscle group involved in birth trauma is shared, so we can potentially take some information from this. The women in Montenegro’s (2010, p. 982) study suffered tenderness in the ani levator muscle particularly. Pundental neuropathy, which is often caused by prolonged stage two labor and is correlated with incontinence, causes weakness in the levator ani (Herbeck, 2008, p. 174). It stands to reason that transvaginal massage of the pelvic floor by a practitioner could assist with many of the symptoms associated with birth trauma.
Although in most places, special licensing or training is required to perform internal massage – and for good reason – it seems clear that perineal massage can be utilized in all stages of the birthing year to provide comfort and support. When so many vital functions literally hang in the balance of such an often over-used and under-talked-about part of the body, women need as many vocal advocates for pelvic health as possible. Some studies (Eogan, et al, 2006) talked about issues getting women to participate or carry out the perinatal massage or pelvic floor muscle exercises reliably. Moving towards a scenario with more training for practitioners will lead to more practitioners vocally offering pelvic floor work and education. While it doesn’t erase the legacy of birth trauma that exists in our culture, it is a step in the right direction to positive pelvic health for many demographics.
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