Pelvic floor muscle injury in labour

Recovering after 3^rd and 4^th Degree Tears

Unfortunately, during birth, women can experience perineal tearing. The perineum is the area between the vaginal opening and the back passage. A woman can suffer from varying degrees of tearing, with some short term, but also long term effects on pelvic floor function. This can include bowel and bladder issues or ongoing pain. The worse of these tears are called 3rd & 4th degree perineal tears are also known as Obstetric Anal Sphincter Injuries (OASIS), because the perineal tear extends into the anus.

The varying tears are grouped according to the extent or length of the tear:

• First degree tears — small skin deep tears which heal naturally
• Second degree tears — deeper tears affecting the muscles of the perineum. These are usually repaired with stitches.
• Third degree tears — deeper tears that involve the anal sphincter muscles.
• Fourth degree tears — tears extending further up the anus into the rectum

Some long terms effects of perineal tears and OASIS can include:

• bowel urgency
• difficulty controlling wind
• difficulty controlling bowel matter
• painful sex

What can I do if I have suffered from a perineal tear?

After 6 weeks, and once the perineal area has healed you can begin to do some exercises to strengthen the area and reduce or prevent anal incontinence. You will usually have a pelvic floor or women's health physio helping and guiding you along the way, and they will teach you the following exercise types. Mind the anus chat to come!

Pelvic Floor Exercises with an Anal Cue

These anal sphincter muscles need to be retrained as part of your pelvic floor, because the perineal injury can cause them to become lazy or switch off. It is easy to focus on this part of the pelvic floor sling. Lying on your back with a neutral pelvis

• Breathe in to relax your pelvic floor down.
• Breathe out as you squeeze and lift your pelvic floor muscles focussing on the anus being pulled up towards your lower back.
• Breathe in to relax the pelvic floor muscles back down.
• Repeat 10 times.
• Repeat another set in active neutral sitting.
• Repeat another set in active neutral standing.

Pelvic Floor Elevator with an Anal Cue

You need to be able to control these muscles at different points so that you are able to control your wind and bowel movements and prevent accidental leaks or accidents. Visualise your anal canal (from your anus to your rectum to the centre of the dimples in your lower back) as 3-storey building with an elevator in it.

• Tighten your anus and pull it up a third of the way — bring the elevator from Ground Floor to Level 1.
• Tighten your anus further and pull it up two thirds of the way — bring the elevator to Level 2.
• Tighten your anus as much as you can and pull it up all the way — bring the elevator to the Roof.
• Slowly release the elevator down to Level 2, then Level 1 and back down to Ground Floor.
• Repeat 3 times.

Anus Quick Flicks

You need your anal sphincter muscles to get stronger in their fast-twitch fibres and especially down at the exit, to help you overcome or manage bowel urgency. Visualise the anus at the exit of your bottom as a circular muscle. Imagine trying to pull up a pea through the anus just 3 mm and back out again.

• Do 10 quick flicks as fast as you can in a pulsing manner as you tighten the circular anus closed and release again.

I need more help...

If you have suffered from a perineal tear after birth, it is important to see a trained women's health physiotherapist as she can help prescribe even more specific exercises, as well as help you to heal from the injury faster.

Women's health physiotherapists at The Fix Program physios will help you recover from any birth issues, and perineal tears often require gentle scar tissue massage to release the tissues and muscles that can tighten up after tears. If you are experiencing any bowel issues, your women's health physiotherapist will help you overcome these issues.

Research shows physiotherapy for just 2 months can significantly improve anal sphincter control and strength to minimize or prevent any wind or fecal incontinence. Your physiotherapist will also discuss important bowel habits advice with you and prescribe you individualized exercises.

Why does my period make my back and pelvis hurt?

To understand why the back or pelvic hurts during a period, we need to understand the menstrual cycle and the changing levels of hormones. The menstrual cycle is made of a few main phases.

• The first phase, which is menstruation, begins on the first day of your period. During menstruation hormones, oestrogen and progesterone, are relatively low.

• In the second phase, also known as the follicular phase, FSH (or follicle-stimulating hormone) is released, which causes immature eggs to develop. These follicles cause a lot of oestrogen to be produced, and the lining of the uterus thickens, for a possible egg to be embedded.
• The third phase in ovulation, and is when a mature egg is released from the ovary. It is triggered by an abrupt rise in LH (or luteinising hormone). At ovulation, the cervix moves higher and its opening widens. The release of the egg and the movement of the cervix is why some women experience cramps or aches at ovulation, and why some women experience ovulation spotting. After ovulation, the egg enters the fallopian tube and moves along the uterus.
• The fourth phase, also known as the luteal phase is when oestrogen production drops and progesterone increases. This further thickens the uterine lining to allow for a fertilized egg to embed. If fertilization doesn't occur, the egg breaks down, and progesterone levels drop, which disintegrates the uterine lining, in preparation for a period. This drop in progesterone is why some women experience mood swings, bloating, tender breasts or tiredness.

During the period, the broken-down lining of the uterus flows down through the cervix and out of the vagina. When you have a period, the uterus swells and expands and can become almost double the size and weight (pictured below).

Understanding the anatomy of the pelvis can help us understand why the back and pelvis can hurt during a period and during this time when the uterus is so enlarged. Here are some explanations:

• Firstly, the uterus is suspended in the pelvis to the sacrum (pictured below), which is the triangular bit of bone between your lower back and your tailbone. You can feel the top part of your sacrum, where the dimples in your lower back are. These ligaments are called the uterosacral ligaments. When the uterus swells, this puts pressure on the uterosacral ligaments, which can then create a dragging feeling, heaviness or pain on the sacrum and tailbone.

• Secondly, to push the uterine lining out through the vagina during menstruation, the uterus muscle contracts, and if it contracts sharply, it can make you feel strong cramps. Hormone-like substances called prostaglandins trigger these contractions, and prostaglandins are also involved in pain and inflammation processes. If a woman has high amounts of prostaglandins, she can have more severe menstrual cramps.
• If a woman has endometriosis, cells that resemble the lining of the uterus exist on other places within her pelvis, such as on her bladder, bowel, or vaginal walls. These cells can be triggered with a period and cause more pain and inflammation, which is why women with endometriosis tend to have more severe period pain.
• Sometimes the uterus isn't aligned neutrally within the pelvis, and this can contribute to pain that may be one-sided or to pain in the lower abdomen. The uterus may be tilted to the side or it may be tilted forwards. Visceral mobilization to re-position the uterus well inside the pelvis by a trained women's health physiotherapist can help bring back alignment to the uterus and surrounding tissues.
• Often the pelvic floor muscles can cramp because of the contracting uterus and vagina. This can also contribute to an increased perception of period pain, because not only is the uterus contracting, but the pelvic floor and pelvic wall muscles go along for the ride. Over time, these muscles can become stuck in a tight position from overworking for many months or years. Because these muscles also attach to the pelvis, tailbone and lower back they can add to your lower back or pelvic pain. Pelvic floor release techniques by a trained women's health physiotherapist can release these tight muscles, which can in turn reduce the overall pain during periods.

If you have period pain or lower back pain or pelvic pain, try seeing a women's health physiotherapist, as very often, having some physiotherapy can significantly reduce or completely eliminate your pain. Their treatment techniques can help with other menstrual symptoms such as spotting, irregular cycles, long cycles, and research is now showing the benefits of physiotherapy for fertility as well.

Join an online class  from the comfort of your home - Katrina the principle physio at The Fix Program has designed a series of pregnancy exercise programs that will help you immensely. 

12 easy nutrition tips to ease endometriosis and pelvic pain

Last month, I wrote about how hands-on women's health physiotherapy is effective for women who suffer from endometriosis. This month I cover some practical nutrition tips to manage the pain and symptoms associated with endometriosis. This is information I provide as a Women's Health Nutrition Coach to my patients with endometriosis.

In endometriosis and chronic pelvic pain conditions, there is often a repetitive inflammatory process occurring within the pelvis. Pain is often a cardinal symptom of inflammation and, without getting too technical, the presence of something called "cytokines" in the body suggests inflammation. Interestingly, research shows the presence of several inflammatory cytokines in women with endometriosis.

So, what do pain, inflammation and inflammatory cytokines have to do with endometriosis?

Well, understanding this process provides the basis for why an anti-inflammatory diet is important in managing this disease. Certain foods have been proven to reduce inflammation and these are recommended for women with endometriosis. Knowing this makes it easier to stick with dietary changes, because ultimately you are not just reducing your symptoms but also reducing the growth of the disease. So let's get into the anti-inflammatory foods.

Some general anti-inflammatory foods that you can simply begin to incorporate into your diet and cooking include

• lime zest
• mushrooms (button, oyster, honey-brown, shiitake, enoki)
• sweet potato, onion (be careful with this if you have IBS and are sensitive to FODMAPs)
• Thai spices such as kyeng, dill, kaffir lime, chilli, teaw, sweet basil, pea eggplant
• other herbs and spices that are anti-inflammatory including curcumin (turmeric), ginger, cinnamon, cloves, oregano and sage.

Please bear in mind that every woman with endometriosis is different and a blanket diet cannot be given to every woman. A woman with endometriosis may have other concurrent conditions that would warrant other dietary modifications. This could include irritable bowel syndrome, interstitial cystitis, poly-cystic ovarian syndrome and pudendal neuralgia.

There are some general recommendations that are given for women with endometriosis. These suggestions can include

• ensuring you have clean protein, healthy fats and fibre at every meal

• going gluten-free. More and more research is showing significant improvements in women who stop eating gluten. Gluten ranks as one of the highest toxins for women with endometriosis. Simply going gluten-free without any other changes can be enough to reduce pain significantly.

  Some women can also be sensitive to other grains, but if not, you can enjoy brown rice, buckwheat, quinoa and teff as alternatives.

• limiting soy. Pelvic pain is found to be higher in women who regularly eat soy. If you need to have soy, its best to stick with low amounts of non-GMO, organic, fermented whole soy foods.

• limiting diary. A lot of women with endometriosis have developed sensitivities to dairy. This can be sensitivity to lactose, which is a sugar found in dairy, or sensitivity to casein, which is a protein found in dairy. Dairy can cause inflammation which can lead to pain.

  Simply substitute for non-dairy alternatives e.g. almond or other nut milk, rice milk, coconut milk, coconut yoghurt, coconut cream and coconut ice cream. Grass-fed butter is usually well-tolerated.

• limiting sugars. Processed and refined sugars wreak havoc on the gut. Switch to coconut sugar or pure maple syrup for sweeteners. If you have a chocolate addiction try Loving Earth brand of chocolate instead.

• limiting coffee and alcohol.

• enjoying increased high omega-3 fatty acids. Foods that are high in omega 3 are your powerhouses of anti-inflammatories. They can even be used as an alternative to pharmaceutical NSAIDs!

  For example, flaxseeds/linseeds, walnuts, brussel sprouts, cauliflower and fish such as sardines, salmon, tuna, blue mackerel, gemfish, shrimp

• increasing your vegetable intake. Have rainbow colourful vegetables at every meal, making sure you have lots of green leafy vegetables. Sulfur containing vegetables and cruciferous vegetables help with estrogen detoxification. This is found in broccoli, brussel sprouts, cauliflower, kale, leafy greens and cabbage.

• increasing your fibre intake. This is effective for estrogen detoxification. Simply add chia seeds or flaxseeds to your meals. Your goal here is 35-45g of fibre per day.

• increasing your antioxidants. Foods high in Vitamin C are very effective for reducing inflammation. These can include papaya, bell peppers, broccoli, brussel sprouts, strawberries, pineapple, oranges, kiwi fruit, cantaloupe and cauliflower.

• drinking lots of water and tea. English breakfast and green tea are anti-inflammatory teas.

• taking probiotics. Cycle between 3 different brands of quality probiotics every 3 days for optimal gut health.

So there you have it. Twelve tips to reduce the pain associated with endometriosis. You can start your journey to a healthier pain-free life by adopting these nutritional strategies.

If you would like more personalised nutrition coaching for endometriosis or pelvic pain, you can enquire with one of our women's health physiotherapists at The Fix Program.