Therapy for Management of Childbirth Perineal Tears and Post-Partum Pain
Childbirth is a transformative event in a woman’s life. The onset of motherhood presents a unique set of physical, emotional and psychological challenges. The post-partum phase can become even more challenging when the new mother experiences perineal or genital tract trauma as a result of childbirth. Gynecological pain imposes physical limitations on the new mother, making child-care, sitting, walking and other activities of daily living (ADLs) extremely difficult and painful.
Perineal tears as a result of childbirth trauma are common with spontaneous vaginal birth. 1 Research has shown that as many as 85% of all women will experience some kind of perineal tearing during childbirth. 1 Lacerations of the perineum are defined and graded according to the structures that have been torn or injured. A classification system (see Table 1) was first described by Sultan 2 and adopted by the International Consultation on Incontinence and the Royal College of Obstetricians and Gynaecologists in 2007. 3
The most common lacerations in spontaneous childbirth are first- and second-degree tears. 1 Risk factors for genital tract trauma and perineal lacerations include forceps delivery, baby weight over 4000 g, shoulder dystocia, malpresentation of the baby, prolonged second stage of labor, Valsalva pushing and older mothers. 4-9 Third-degree and fourth-degree tears are not as common but are associated with episiotomy. 1 Risk factors for third- and fourth-degree perineal lacerations include the low-squatting birth position, vacuum extraction, median episiotomy and oxytocin augmentation. 10
Perineal tears are not only a major source of pain for new mothers but they also are associated with increased risk of infection, dyspareunia, urinary stress incontinence, fecal incontinence, anal flatulence, scar tissue, pelvic adhesions, swelling and bruising of the perineum and possible damage to the pudendal nerve. 11,12 In clinical practice, we find that women who experience gynecological trauma during childbirth also report difficulty with prolonged sitting while breastfeeding, pain with walking, pain with positional changes and inability to wear certain types of clothing.
Depending on the severity of the tear, perineal stitching may be required to promote normal tissue healing and function. 13,14 While first-degree tears may either be sutured or left to heal on their own, more severe tears typically require suture repair. 13 Following laceration and repair, scar tissue and adhesions form within the perineum and pelvic floor muscles. Although a normal part of the healing process, scars and adhesions can impede normal pelvic floor muscle strength, flexibility and function. In order to restore control over urination, defecation and sexual function, the resultant perineal scar tissue and pelvic floor muscle strength must be normalized in new mothers. 15
Physical therapists trained in women’s health and post-partum care use a multitude of manual therapy techniques to help women regain a pain-free lifestyle after childbirth. Women’s health physical therapists incorporate intra-vaginal and intra-rectal pelvic floor muscle stretching, soft tissue massage, scar mobilization, trigger point release, myofascial release and pelvic floor muscle strengthening.
Modalities such as ultrasound and transcutaneous electrical nerve stimulation (TENS) have commonly been used in physical therapy for the treatment of scar, perineal and muscle pain. 16 However, new research has shown that in addition to traditional modalities, low-level laser therapy (LLLT) can play an important role in the rehabilitation of post-partum women with scar pain, soft tissue injuries, myofascial pain, trigger points and tendonitis.
LLLT is the direct application of infrared light over injured tissue, creating the effect of photo-stimulation in the cell. The emitted light stimulates the cell’s mitochondria to become more active and produce more energy in the form of adenosine triphosphate (ATP). This increase in ATP is then used to facilitate the metabolic processes of DNA and RNA synthesis, enzyme synthesis and the synthesis of other products needed to restore balance and homeostasis in the injured cell. The increase in ATP energy production allows the cells and tissues to regenerate, repair and proliferate. The pain and tissue healing properties of LLLT are listed in Table 2. 17-23
The energy coming out of the laser creates a unique healing opportunity within the tissues. Treating patients with low-level laser light energy adds energy and vitality to targeted injured tissues thus unlocking their healing potential.
The laser used in the following case study was the ML830 by MicroLight Corporation (having three Gallium-Aluminum-Arsenide diodes driven by 30 milliwatts of power) that produced a combined energy output of 3 joules of energy per 33 seconds of treatment time and able to reach tissue depths of up to 5 centimeters with no heat production. 24 This is referred to as a “cold laser” since it produces no heat in the treated tissue. This property allows the laser to be used directly on injured and compromised tissues such as scars, wounds and metallic plates. Since LLLT has minimal side effects, it is an ideal modality for women who are not candidates for pain medication—such as women who are breastfeeding.
LLLT laser has been recently cited in the literature for the treatment of scar tissue. Research by De Paiva et al demonstrated that scars treated with LLLT were more malleable, had 50% lower pain scores and reduced scar thickness compared to the controls. 25
The following case report describes the successful physical therapy treatment of a patient following surgical repair of a fourth-degree perineal tear. The purpose of this case study is to demonstrate the effectiveness of a conservative treatment approach combined with LLLT for the management of pelvic pain following childbirth perineal tears in post-partum patients. The treatment approach described in this article was developed by the lead author.
The patient was a 33-year-old Hispanic female who presented status post sphincteroplasty (anal sphincter repair) following the birth of her first child. While delivering in a supported low-squat position, the patient sustained a fourth-degree perineal tear. The attending midwife performed the initial perineal repair.
Ten days following the primary repair, the patient required a secondary repair, performed by an obstetrician/gynecologist. In the months following the revision repair, the patient reported having one-to-three incidents of fecal incontinence per day. To address the fecal incontinence, the patient underwent a sphincteroplasty 20 months following childbirth.