Breastfeeding and Pelvic Organ Prolapse

Is weaning the best option when a mama has incontinence or prolapse?

Birth, it is a magical time where we finally meet the newest love of our life. Unfortunately, the birthing process sometimes leads to less than magical side effects like incontinence (leaking of urine when we laugh, cough, sneeze, jump or lift or a strong urge to go all.the.time) and maybe even pelvic pain or pelvic organ prolapse. For many moms that are breastfeeding they are given two options: 1) deal with it until you decide to stop breastfeeding or 2) wean your child. Since I’m feeling feisty today I’m going to put it bluntly, both of those options are steamy pile of BS. And since I like to back up my feistiness with research, here’s why you deserve better:

Relaxin and estrogen are not the enemy

Doesn’t increased relaxin and decreased estrogen weaken the tissues of the pelvic floor? Well, kind of. Prolactin, can block the production of estrogen. And it’s true, a decrease in estrogen can weaken the pelvic floor musculature but this is most commonly seen with the hormonal shifts of menopause, not postpartum. Relaxin has also been shown to decrease by three days postpartum so it is unlikely that relaxin is causing the pain or discomfort.

Many mamas who supplement also experience similar issues so emphasizing the hormonal effects of breastfeeding at the expense of looking at the bigger picture can lead to insufficient care for new moms. For a long time breastfeeding and hormones have been blamed but there is new information coming out about the importance of nutrition, methylation (liver support), the gut microbiome and even sleep quality as it relates to pelvic pain. All of this to say, it isn’t just breastfeeding but everything going on around you that can affect what’s going on down there.

Prolapse, incontinence and pelvic girdle pain are all signs of mechanical dysfunction

Often times mama who have prolapse or incontience also have hip and/or low back pain, diastasis recti and even pelvic pain. These are all signs of a mechanical problem. Mechanical problems are often best treated, well, mechanically. This is where a professional trained in pelvic floor rehabilitation and functional movement excels. A proper evaluation of the pelvic floor looks at you, the mama, as whole. If you aren’t sure what to expect, here’s a great article on what to expect at Your First Visit to See a Pelvic PT. The evaluation often includes your history, a movement exam (including how you are breathing, your posture, etc), specific tests to look for both stability and mobility, myofascial palpation (do you have tenderness in the abdomen, pelvis, buttocks or even the thighs), and the pelvic floor exam once you feel comfortable. This whole-body approach will help your provider determine the mechanical cause(s) of prolapse, pain, discomfort or incontinence in order to treat the entire system.

Breastfeeding and Pelvic Girdle Pain - Are they related?

There was longitudinal study out of Norway that followed over 10,000 women that showed breastfeeding has a small beneficial effect on pelvic pain and should be encouraged rather than discouraged.

The Catch: Lactational Atrophic Vaginitis

Atrophic vaginitis is dryness and inflammation of the vaginal tissues generally seen in post-menopausal women but can sometimes cause symptoms in lactating moms due to excessively low estrogen. Signs of lactational atrophic vaginitis include pain during sex, decreased sex drive, vaginal itching or dryness, frequent UTIs, irritation with clothes and an increased urge to urinate.

Although lactation atrophic vaginitis is caused by decreased estrogen, there are solutions that can help manage this discomfort! The management of atrophic vaginitis is different than the management of prolapse, pelvic pain or incontinence as it may include hormone replacement in the form of topical estrogen (see OB/midwife for appropriate recommendations), botanical therapies and self-help measures. Botanical therapies may include moderate amounts of phytoestrogens like soy, oats, sesame seeds, barley, apples, carrots, lentils and pomegranates. Self-help measures include using water-based lubricants to help moisturize the tissue or Vitamin E oil or hyaluronic acid suppositories.

There are many factors that influence postpartum recovery. It is important to figure out what influences you individually. For some moms, they need more emotional support or self care time, others benefit from attention to nutrition, improved sleep (yes, difficulty sleeping is closely related to pelvic pain) some are in pain from physical complications related to their birth and labor experience. If any provider undermines your confidence in feeding your child by stating breastfeeding is the only cause of your pain or discomfort, you are allowed to fire them. Each mama is different and it is important to enlist the appropriate support team to look at the whole picture. Along with you, that team may include a chiropractor or physical therapist trained in pelvic floor rehab, your OB or midwife, nutritionist or a functional medicine doctor. It’s important for the team to work together WITH YOU to determine the root cause of your incontinence, prolapse and/or pelvic pain.

I know you would probably love to be in control of your pelvic health and have a plan so I’m excited to offer a complimentary 15 Minute Healthy Mama Strategy Session or you can schedule an appointment today. I look forward to hearing from you and if you have questions, don’t be afraid to reach out and ask!

References:

1. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13118?fbclid=IwAR0g9BcZRjxZjUA-rpXpWykvR_gWeDzF7-nNd78k7OA9_e4gp6ZF5UJNCa4

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307380/

3. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(86)92068-4/fulltext

4. https://www.ncbi.nlm.nih.gov/pubmed/12867914

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

Perineal Massage during Pregnancy & Delivery

Perineal massage is massaging of the pregnant mama’s pernineum (area around the opening of the vagina). Perineal massage is most effective at stretching the perineum to help mentally and physically prepare for labor in first time mamas. Often times perineal massage is recommended starting the last month of pregnancy and ideally starting earlier at week 34. Perineal massage is recommended 1-2 times per week for 5 minutes each time. As much as we all want to think that more is always better, research actually shows that 1-2x a week is the happy medium and there are no added benefits of doing it more frequently.

How To Perform Perineal Massage

First, talk to your provider to determine if it is safe for you to perform perineal massages. Some contraindications include rupture or leaking of membranes, spotting/recurrent vaginal bleeding and indications that the womb may not be structurally normal. Once you get the green light, decide if you want to perform the perineal massage or if you want your partner to help. Next, wash your hands and trim your fingernails!

Once you’re physically ready, find a comfortable position that allows you to reach your perineum. For some this is squatting on a chair with your knees spread or using a stool to support one leg while other fortunate people are able to reach simply by sitting propped up. The position doesn’t matter as long as you are comfortable. Next up, pick your lubricant of choice making sure you have enough but not too much (a rough guess is ~1 tsp but to each their own). Start by massaging the lubricant into your perineum and using your thumb and index or middle finger, insert your fingers into the vagina up to the first knuckle.

Once inserted, gently massage and stretch the vaginal walls apart (sides and towards the anus). You can press your fingers away from each other and hold the position while breathing and relaxing the muscles. Now, the goal of perineal massage is to GENTLY stretch the perineum so while there may be pressure, please do not go to the point of pain! To prepare for labor if there is pressure or discomfort, you can also practice breathing and progressive relaxation to help.

Benefits of Perineal Massage

Perineal massage prior to labor may reduce the likelihood of episiotomies and perineal trauma that requires stitching during childbirth. There were no differences in likelihood to have first, second, third or fourth degree perineal tears.

Perineal massage during the second stage of labor by a healthcare provider resulted in fewer mamas having third and fourth degree tears and more women with intact perineums.

For mamas who have birthed before, there was a significant reduction in pain at three months postpartum.

This one isn’t backed by research, but using perineal massage as a feedback tool can be a great way to help you connect and communicate when done with your partner. Often times the partners are overlooked during pregnancy and massage can be a great tool to help them feel connected and helpful to their partner.

Lubricants, Because They Ain’t All the Same

Lubricants serve a dual purpose as they make perineal massage more comfortable (hello, not stretching dry skin) and also hydrate the tissue. But not all lubricants are the same. Here are a couple of my go-to lubricants for all things perineal health:

1. Coconut oil - I prefer Skinny & Co. as their coconut oil is cold-processed and doesn’t lead to altering the vaginal flora like other highly processed coconut oils

2. Good Clean Love - organic, water-based lubricant that is free of petrochemicals, parabens, or glycerin

3. Desert Harvest - 100% all-natural aloe-based lubricant

Got questions? Don’t hesitate to reach out and ask! I hope you find this info helpful, and I can’t wait to hear from you!

References:

1. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005123.pub3/full?highlightAbstract=withdrawn%7Cperineal%7Cperin%7Cmassage%7Cmassag&fbclid=IwAR1TbGsOxDXoqG8eaRMOsCM56v9mmDyD2YrI1wiHnaHvF_tbUAbcWoVz6m0

2. https://www.aafp.org/afp/2014/0301/p335.html

3. https://www.cochrane.org/CD006672/PREG_perineal-techniques-during-second-stage-labour-reducing-perineal-trauma

4. https://www.ncbi.nlm.nih.gov/pubmed?term=16437520

5. https://www.ncbi.nlm.nih.gov/pubmed/11368136
   

HELP! My Baby Wants to Snuggle and Hates Being Put Down

While pregnant you probably read every article on the internet on all the gadgets and goodies you need once the baby arrives to make sure you have a baby registry that sets you up for success. The best crib, bassinet or co-sleeper? Check. The best carseat? Check. Information on the best butt paste and breast pumps were readily available. Information on what to expect in those first few weeks? Yeah…not so much. Now that you just had the baby you may find yourself in a whirlwind of emotions asking yourself, “is this normal” and thinking, “nobody told me this was a thing”.

Picture this scene - you are wrapped in a nice and cozy, warm blanket constantly being rocked to sleep with music always playing. That seems pretty freakin’ fantastic, right? Well, not so long ago that is where your baby was at while in the womb. Being rocked back and forth in a pool of amniotic fluid, wrapped in the warmth of your body listening to the sweet sound of your heartbeat. Now that they made their great escape, everything is different. It’s cold, they are no longer wrapped and rocked to sleep and they have this newfound freedom to move while noises and lights are different and really really loud and bright. The only thing that isn’t new is the comfort of you. Of course they want to snuggle up and be next to their protector; you’re the only thing they recognize in this new world! It is not only common but it is normal in those early days for babies to want and need to be held. They are not trying to be spoiled or manipulate you, they are simply seeking the same comforts they had while on the inside—a steady heartbeat, warmth and the gentle sound of your breath.

Just because it’s normal for babies to need to be snuggled, it doesn’t mean it is always easy. I remember those sleepless nights, questioning if I was doing anything right and calling friends before the crack of dawn for support and guidance. The best thing I did was focus on my personal needs (and wants). I focused on breathing, gentle movement, snuggles, and filling my cup emotionally and with quality nutrition.

Lying-in during the co-regulation period can be a huge stress reliever in those early days as it takes away the unrealistic expectations that you “should” be out and about showing off the baby. The baby won’t know if she met Great Aunt Susie Q at 2 days or 2 months, but she will recognize and sense your stress levels if you’re anxious about going out. If you aren’t ready to leave the house, don’t! Lying-in gives you an amazing opportunity to support your needs and desires while also working to build a relationship with the newest member of your family. Skin-to-skin helps keep the baby warmer, stabilizes blood sugar levels and even helps regulate breathing. This can lead to better bonding, less crying, decrease in postpartum depression and maybe even better sleep for both of you (no promises)! With skin-to-skin you may be thinking, but what about visitors? That’s the glorious part about being a new mom, you can say no. For me personally, if you want to visit but don’t want to see me wearing nothing but a tank top or nursing bra, you may want to wait a month or so.

Once in the recovery period, it’s great to continue skin-to-skin and also get up and start moving around more. One way to ease back into your new reality is to take the babe with you. Go out and walk with your baby. She still wants and needs all the snuggles so baby wearing is a great option to allow you to get up and get back to moving.

Last, but certainly not least, it takes a village to raise a child. There is great strength in asking for help. As Doula-Extraordinaire, Jenny Anderson in Bend, Oregon said, “Postpartum is a tricky, cloudy, and confusing time. Connecting with your community, and asking for help from lactation experts, doulas, therapists, doctors, family, and friends is a sign to the world that you recognize your own boundaries and that you are not expected to do all of it alone. You are mama. Not a mama AND a lactation expert AND a doula AND a therapist AND a doctor AND a maid AND a gourmet chef AND … AND … AND ….You are perfect as a mama, with a powerful support system.” I can tell you that raising my daughter through the early days wasn’t easy but it was definitely easier with the help of friends and late-night texts, early morning calls, food delivery, laundry and housecleaning support from my mom and an amazing lactation consultant who came to my house along with my own chiropractor and acupuncturist. The support is around you, it’s just important to ask for what you need.

And mama, you’ve got this! If you are in the area, I’d love to set up a free 15 minute Healthy Mama strategy session call to discuss how we can help you create the postpartum you want.

XOXO- Dr. Lauren

Pubis Pain aka “Lightning Crotch” or Pelvic Pain During Pregnancy: Part 2

Part 2 - Managing pubic symphysis dysfunction through exercise

Not sure what pubic symphysis dysfunction is or the causes? Check out Part 1 for more information!

The most important thing to know is that each mama is unique in her needs. For that reason, it is important to see a chiropractor or physical therapist with additional training in pregnancy and postpartum to find out what your specific needs are. With that being said, there are some general guidelines. Y’all know by now that I love mamas to stay active during pregnancy but there are some exercises that are best modified or temporarily taken out when you have SPD.

The ‘Don’ts’ of exercising with pubic symphysis pain (exercises to avoid with lightning crotch):

• Don’t over-stretch

  • Yes, it is possible to over-stretch, especially during pregnancy when relaxin and progesterone are helping muscles and ligaments relax in order to prepare for birth. If you are doing yoga or pilates, it’s a great idea to not push mobility at the end of any pose as this can increase your risk fo stretching too much and destabilizing the pelvis

• Limit single leg movements for a few weeks (2-3 weeks) and slowly add them back in your routine to see if you can manage the load. If not, that’s OK…you can take them back out. If they do not increase or cause pain, it’s a great idea to add them back!

  • This includes taking out lunges, bulgarian split squats, pistol squats, warrior pose, assault bike, and step ups as all of these exercises are one-leg dominant and can increase shearing on the pelvis.

  • Here’s the catch…some mamas actually benefit from single leg movements with a little modification. If you notice that deep lunges cause pain, you can modify it! First, try to change the position of your feet by bringing them closer together. You may notice that by bringing your feet closer together decreases your pain but still lets you use those muscles. This is great! You can strengthen this area and then try to increase the distance between your feet as you get more comfortable. The next thing you can change is the depth or how far down you go into the lunge. If a full lunge causes pain, try to lunge at half depth or a quarter of the depth. If you are able to do these without pain, that’s great - you should continue to do them! Our goal is never to exclude the movements you love but to work with them to see what can work with your body at this time.

• Use caution with traditional “core” exercises 

• Traditional core exercises like sit-ups and crunches focus on activating one or two muscles independently of the core system (diaphragm, pelvic floor and all abdominal and back musculature). Working these muscles can actually pull on the pubic rami and increase pain. Core exercises like the plank are advanced and require full pelvic/core stability and joint centration (the pelvic floor and diaphragm should be aligned). It is common for mamas to compensate during this movement as their natural gravity shifts and this compensation can lead to increased pelvic and low back instability.

• Watch deep squats or sumo squats

  • I love deep squats because the bottom of a squat is when the pelvic floor is most relaxed (hello benefits in labor) BUT that stretch can be too much with pelvic pain. If you notice pain with deep squats OR after deep squats, it’s okay to take them out.

• Adductor stretch or adductor machines 

  • The adductors are connected to both the inner thigh and the pelvis and can definitely play a role in pelvic pain. Like most everything, it is best to figure out if the adductors need relaxed or strengthened. If you are constantly stretching and they don’t feel better, they may actually need strengthened! Vice versa, if you’ve been working hard to strengthen the adductors but they continue to be sore, you may need to calm the signal from the brain to down regulate this pain. The best way to know this is to see a professional who can guide you in what your body currently needs.

• Fast/explosive movements 

  • We want to continue moving during pregnancy but fast and explosive movements require the musculature around the pelvis to respond quickly and when there is pain this reaction is often slower. It is easier to compensate and not utilize the appropriate muscles to create the force to stabilize.

Exercises that may improve pubic symphysis pain

• Focus on posture and pelvic alignment

  • As you stand and walk your diaphragm should be aligned with your pelvic floor — this is a neutral spine. If you drop into too much anterior or posterior pelvic tilt this can increase pain/pressure on the pubic region. So one easy exercise to stand in front of a mirror and focus on finding that neutral spine.

• BREATHE

  • As we inhale, our pelvic floor gently descends and relaxes and as we exhale it gently lifts and contracts. This is a normal progression with diaphragmatic breathing that naturally helps to activate the deep abdominal muscles and stabilize the pelvic region with the breath

• Balance strength and mobility

  • All movements should be slow and intentional to start to focus on maintaining task-specific pressure (that’s the amount of support/brace/natural tension you need to create to stabilize the body). This intention trickles down to balancing strength and mobility so we aren’t over-stretching or strengthening a muscle that does not have its full range of motion.

• Work the glutes and adductors in synergy through movement

  • Banded monster walks

  • Glute bridges with band around knees and yoga ball or block in-between knees

  • High Bear or low bear: with bands around knees and yoga ball or block in-between knees —> if you are able to do this and looking to advance the movement without doing a bear crawl, you can simply lift and hold one arm or one leg at a time

  • Hip Hinge or banded good mornings

  • 90/90 or Shin box flow: this is a movement where slow and intentional movements are best

• Work all of the core together

  • Box squats: i mentioned earlier that deep squats may not be beneficial but shortening the range of motion to the point before there is pain can be extremely helpful in pelvic pain and keeping pelvic mobility with core stability

  • Side bridge

  • Bird dog with pelvic floor focus and focus on breathing and elongating spine

  • Dead bug with focus on crossover

Part 3: Labor and Delivery considerations for pubic pain

Mama, if you are struggling with pubic symphysis pain or any pelvic pain, I understand the frustration, anger and fear that comes along with it. I believe that no woman should have to suffer through pregnancy or postpartum in pain. Call 331-307-7110 to schedule an appointment today or book online. Not ready yet? That’s OK, schedule a free 15-Minute Healthy Mama strategy session today to discuss your options.

Symphysis Pubis Pain aka “Lightning Crotch” or Pelvic Pain During Pregnancy: Part 1

Part 1 - What is pubic symphysis dysfunction and what causes it?

Symphysis pubis pain is unaffectionately known as lightning crotch. It's that feeling that 20% of pregnant women know all too well—the sharp and sudden pain deep in their pelvis. The feeling of their pelvis shearing, pain that can stop a mama mid-step or leave her gasping for air trying to roll over in bed. Affecting 1/5 of all pregnancies, it's important to know what it is and what to do if you are one of the mamas affected.

What is the pubic symphysis?

The pubic symphysis is a cartilagenous joint that connects the left and right pubic rami. The pubic symphysis helps transfer weight during normal activities like walking but also helps to stabilize the pelvis.

During Pregnancy, the pubic symphysis opens and expands in order to make more space for the baby to descend. With the help of hormones, the average pubic symphysis widens 3mm (30-40% of normal) during pregnancy and up to 20mm during labor. This widening is extremely beneficial to allow the baby to rotate, the pelvis to open and the baby to descend. 

What are the signs and symptoms of symphysis pubis dysfunction (SPD)?

SPD can present in many ways from a mild twinge of pain to a debilitating pain. Here are a list of ways pubic symphysis pain can show up:

• Sharp or shooting pain at front of pelvis, vagina, rectum or pelvis (hello, one of the causes of lightning crotch)

• Pelvic/pubic radiating to upper thigh/groin

• Throbbing or deep achy pain around hips, low back, lower abdomen or perineum (between vagina and anus)

• Pain with transferring weight from one leg to another - pain with walking, standing on one leg, climbing stairs, getting in/ out of the car or bed and rolling over in your sleep

• Clicking or popping sound of pelvis accompanied with pain or discomfort

• “Pregnancy waddle” to avoid pain
  

What causes pelvic pain during pregnancy?

Like most of women’s health care especially around pregnancy and postpartum, we do not know the cause of SPD. Realistically, there is not one cause but instead SPD is related to a variety of factors and it’s important to find the root cause for yourself. However, here are some theories as to the links/causes of pelvic pain during pregnancy and postpartum:

1. Prior pelvic trauma 

2. Hypermobility

Whether you have a connective tissue disorder like Ehlers-Danlos Syndrome or are just generally bendy, excessive mobility in the pelvis can lead to increased instability.

3. Pelvic joints not moving properly (unequal muscle pull), bony misalignment 

As we naturally progress throughout pregnancy we alter our general posture including the angle of our pelvis. Changes in biomechanics along with added weight and gravity can lead to increased pressure in the pubic region

4. Baby positioning 

Those kiddos can be an adventure before they even make it Earth-side. If a baby is posterior, asynclitic or transverse, it may lead to increased pressure or pain on the pubic bone. For ideas to help baby positioning, check out the free download “Optimizing the Pelvis Through Pregnancy” or check out Spinning Babies or Miles Circuit.

5. Repetitive motion

If your occupation, hobbies or past fitness routines were one-sided, this may be shown in muscular imbalances that can lead to uneven force transfer and mobility/stability. 

6. Hormones

During the 1st trimester there is an increase relaxin and progesterone. This helps increase joint laxity to allow for the opening of the pelvis. The studies are inconclusive but this increase in relaxin may be related to SPD.

Stay tuned for Part 2- Managing pelvic pain through exercise and mindset

Part 3 - Labor and Delivery Considerations with pelvic pain