You know I love getting some other perspectives on this business of pelvic floor dysfunction and it isn’t just because I’ve run out of things to say (even though it has been a while since I have posted a blog!) The Christmas rush has definitely taken its toll and hence the lack of recent communication. But recently at the Continence and Women’s Health Christmas break up a physio Meggen Lowry, who has set up some great classes for the pregnancy and post pregnancy clients, mentioned that she would be keen to be a guest blogger and so here it is…and I think it is a fascinating insight into some observations she has made over the years in a multi-cultural maternity ward. It is long – but very worthy of a pre-Xmas read.
As a rehabilitation physiotherapist, I often become involved with clients after they have sustained an injury or developed a disability. 5 years ago I made a commitment to reserve a few hours of my professional time and energy each week for preventative health initiatives, and I realised that the child-bearing year is an exciting time to enter someone’s life and it’s a time when women tend to be most receptive to health education. Five years of weekend work on a maternity ward has been a culturally enriching experience. I’ve had the privilege of observing the way that different ethnic groups welcome a new baby into the world.
On a maternity ward, a physio assesses how a woman’s body has coped during her pregnancy and delivery, and provides education about how to best rehabilitate her body postpartum. At times, this means respectfully challenging a woman’s cultural beliefs about how to manage her early postnatal recovery. In many foreign cultures, family members sit at the bedside around the clock, tending to the needs of the mother and her baby so that she can completely rest. This practice can last for several months. Many times I’ve had to plead for the blessing from a traditional Chinese grandmother for her daughter to get out of bed the day she has given birth. Similarly, some Indian women observe the tradition of remaining in confinement for 40 days postpartum to avoid pollutants and infection. With a little tactful education, they tend to come round to the idea that walking in the corridors is safe and actually good for them.
In Sudan, some women kneel over a fire to purify the birth canal. Sudanese immigrants sometimes substitute a fire for a hair dryer or a hot water bottle. After respectfully acknowledging these traditions, I can usually convince them that heat will further inflame a swollen perineum, and in fact intermittent ice packs are ideal in the first 72 hours. Traditional Samoans and Philippinos believe that tightly binding the mother’s abdomen for up to one month will facilitate uterine contraction and prevent internal organs from “falling out”. They too can be educated about the pros and cons of abdominal binding, and tend to accept my individualized assessment and prescription of abdominal support braces based on the size of their rectus diastasis and the quality of their abdominal wall stability.
The cultural belief system that is most misinformed, and most difficult to change, is that of Anglo-Saxon Australians, who assume that the sooner a woman returns to her normal domestic duties and sport after giving birth, the better she has coped with the pregnancy. This is a misconception that is not only unfair to perpetuate, it can be outright dangerous.
It seems like every few months the media champions another celebrity ‘super-mum’ for making a speedy post-natal recovery and jumping straight back into her strenuous personal training regime within weeks of giving birth. Just last week my friend referred to his sister, a dairy farmer and mother of three, as “a machine” because she was back to throwing bales of hay and milking cows the day after she gave birth to her son. Recently at another friend’s baby shower, a pregnant guest boasted that she is still going to CrossFit, but has cut down from 4 minute planks to 1 minute planks and now only lifts 15kgs overhead. A circle of friends praised her with admiration. If she were my client, it would have been my duty of care to inform her that heavy lifting in pregnancy, even when pain-free, places her already strained pelvic floor muscles under extra pressure and will likely “bulge” it downwards and weaken it. I’d have told her that the tissues that connects her 6-pack muscles might divide further if she repeatedly overstrains them, and this will make it harder to get her body back into shape in the long run.
But this advice is often not well received, particularly by mothers of toddlers, and nobody likes a know-it-all offering unsolicited health advice at a Sunday afternoon social event. So I bit my tongue. Instead I invited her to try my safe exercise in pregnancy class for free.
Prolapse is common. 50% of women who have had a vaginal delivery will experience prolapse in their lifetime.
Genetics most certainly play a part in determining tissue quality, but we ought not underestimate the extent to which a woman’s daily activities, exercise routine and muscle recruitment influence the integrity of her pelvic floor. Delivering a baby vaginally or via C-Section involves stretching, tearing and/or cutting through different types of tissue. We cannot deny the science of tissue healing. Skin heals the fastest of all tissues, and at 3 weeks a skin wound has only regained 20% of its final tensile strength. Skin and muscle enter the remodeling phase at 3 weeks. Neural regeneration occurs at 6-8 weeks. Evidence supports introducing early strength training after 8 weeks, and if a torn muscle was properly rested and protected initially, it can regain approximately 80% of its tensile strength at approximately 12 weeks. That last 20% is the hardest to get back and pushing it too hard and too fast can predispose a woman to incontinence and prolapse. Retraining endurance takes even more time, patience and body awareness.
On the maternity wards post-partum women are encouraged to rest a great deal, particularly in the first week, and are prescribed a program of walking, stretches and gentle exercise for their pelvic floor & transversus abdominis for their first 6-8 weeks. But what about after that? If I had a dollar for every time a patient who has had an injury or a surgery has asked me “when can I return to running?” or “how long before I can start lifting weights again?” I’d have a lot more to play with than I do now!
The healing process can most certainly be compromised by putting the tissues under strain before they have developed sufficient structural integrity. Similarly, it can be enhanced by introducing the right loads to the tissues at the right time to promote better protein synthesis and cross linkages in the collagen that is laid down when healing is occurring. First comes rest, then comes gentle loading of the damaged structures, then comes reassessment, then technique perfection, then additional loading, then context specific training.
Going out on my own and establishing Next Step Physio this year has given me the opportunity to innovate with a model of care that promotes wellness and empowers people with the education they need to build or rebuild their own bodies from the core outwards. Every woman who starts my post-natal rehabilitation class begins with ‘bronze’ level exercises in her first class, and only when her technique is perfected, and we’re both confident that her postural muscles appear to be handling the load, does she progress to silver, gold and perhaps ultimately platinum exercises. We don’t attach timeframes to milestones and nobody asks “when can I…?” anymore. With this model, my clients are assured that if their body has the potential to perform high-level exercise without pain or strain, it will be achieved by progressing through the exercises taught in the class. If they have inherited poorer quality tissue (like me!), they can decide if the risk outweighs the benefits, and they’ll have discovered a whole range of exercises along that journey that are more suitable for them.
I’ve been up and running for 6 months, delivering a suite of exercise classes for different ages and stages of the lifespan in community halls in Windsor and East Brisbane. Next year I’ve decided to take one leap further and bridge the “us and them” divide in the exercise industry. In January I’ll move my East Brisbane classes out of a community hall and into Quany’s gym; a new members gym run by a couple of positively genuine young men who are keen to foster a two-way channel of cross-professional education. Only good things can come from fitness professionals working alongside health professionals. Bring on 2015!
All Next Step Physio classes are claimable on private health insurance. Visit www.nextstepphysio.com for more information.
Thank you Meg for your blog and all the best for your venture in 2015. I totally agree about the importance of connecting with the fitness industry. There are only so many Women’s Health Physios and there are many more women exercising at gyms, learning and performing pilates and doing yoga – and we need to somehow get that message out there about the correct progression of exercise following the birth of a baby and ensure women are pacing themselves appropriately.
I am now on holidays and the sound of the waves and sea breezes will be lulling me to sleep tonight. In case my great intentions of being more productive with the writing this holiday fall over and I just lie in the shade of an umbrella on the beach and read a NOVEL (now there’s a novel idea!), I’ll take this opportunity to wish all my followers, patients, friends and relatives a very happy Christmas and this year give everyone, especially your kids, an extra special hug…..do it right now!
My lovely Crofts