Summary

The present study was undertaken to produce a detailed specification of a programme of massage, controlled breathing and visualization performed regularly by birth partners, from 36 weeks gestation and assisted by a trained professional, following hospital admission during labour and birth. As current research on massage interventions for pain relief in labour is poorly characterized, we began by undertaking a feasibility study on an established massage programme [Goldstone LA. Massage as an orthodox medical treatment past and future. Complementary Therapies in Nursing & Midwifery. 2000;6:169–75]. The intervention was designed in light of experimental findings that repeated massage sessions over 14 days increases pain threshold, by an interaction between oxytocin and opioid neurons [Lund I, Yu L-C, Uvnas-Moberg K, Wang J, Yu C, Kurosawa M, et al. Repeated massage-like stimulation induces long-term effects on nociception: contribution of oxytocinergic mechanisms. European Journal of Neuroscience 2002;16:330–8]. A 4 week time-frame was selected to coincide with a physiological increase in maternal pain threshold [Cogan R, Spinnato JA. Pain and Discomfort Thresholds in Late Pregnancy. Pain 1986;27:63–8, Whipple B, Josimovich JB, Komisaruk BR. Sensory thresholds during the antepartum, intrapartum, and postpartum periods. International Journal of Nursing Studies 1990;27(3):213–21, Gintzler AR, Komisaruk BR. Analgesia is produced by uterocervical mechano-stimulation in rats: roles of afferent nerves and implications for analgesia of pregnancy and parturition. Brain Research566:299–302, Gintzler AR, Liu N-J. The maternal spinal cord: biochemical and physiological correlates of steroid-activated antinociceptive processes. In: Russell JA, Douglas AJ, Windle RJ, Ingram CD, editors., Progress in Brain Research. Volume 133. The Maternal Brain. Neurobiological and Neuroendocrine adaptation and disorders in pregnancy and postpartum. Amsterdam: Elsevier Science, 2001. p. 83–97]. The main objective was to measure the effects of the programme on maternal pain perception during labour and birth. To detect any effect of massage during labour, on maternal cortisol and catecholamines, cord venous blood was taken to measure plasma concentrations following birth. Twenty-five nulliparous (N) and 10 multiparous (M) women participated in the study. Cortisol values were similar to published studies following labour without massage but pain scores on a Visual Analogue Scale (VAS), at 90 min following birth were significantly lower than scores recorded 2 days postpartum [Capogna G, Alahuhta S, Celleno D, De Vlieger H, Moreira J, Morgan B, et al. Maternal expectations and experiences of labour pain and analgesia: a multi-centre study of nulliparous women. International Journal of Obstetric Anaesthesia 1996;5:229–35]. The mean score was 6.6. Previous studies suggest that a reduction from 8.5 to 7.5 would significantly reduce pharmacological analgesia in labour [Capogna G, Alahuhta S, Celleno D, De Vlieger H, Moreira J, Morgan B, et al. Maternal expectations and experiences of labour pain and analgesia: a multi-centre study of nulliparous women. International Journal of Obstetric Anaesthesia 1996;5:229–35]. 1991;

Complementary Therapies in Clinical Practice Vol 12, Issue 3, August 2006, Pg 222-23 – abstract

doi:10.1016/j.ctcp.2005.12.006

Summary

Pregnancy-related pelvic girdle pain (PRPGP) has a prevalence of approximately 45% during pregnancy and 20–25% in the early postpartum period. Most women become pain free in the first 12 weeks after delivery, however, 5–7% do not. In a large postpartum study of prevalence for urinary incontinence (UI) [Wilson, P.D., Herbison, P., Glazener, C., McGee, M., MacArthur, C., 2002. Obstetric practice and urinary incontinence 5–7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284–300] found that 45% of women experienced UI at 7 years postpartum and that 27% who were initially incontinent in the early postpartum period regained continence, while 31% who were continent became incontinent. It is apparent that for some women, something happens during pregnancy and delivery that impacts the function of the abdominal canister either immediately, or over time.

Current evidence suggests that the muscles and fascia of the lumbopelvic region play a significant role in musculoskeletal function as well as continence and respiration. The combined prevalence of lumbopelvic pain, incontinence and breathing disorders is slowly being understood. It is also clear that synergistic function of all trunk muscles is required for loads to be transferred effectively through the lumbopelvic region during multiple tasks of varying load, predictability and perceived threat. Optimal strategies for transferring loads will balance control of movement while maintaining optimal joint axes, maintain sufficient intra-abdominal pressure without compromising the organs (preserve continence, prevent prolapse or herniation) and support efficient respiration. Non-optimal strategies for posture, movement and/or breathing create failed load transfer which can lead to pain, incontinence and/or breathing disorders.

Individual or combined impairments in multiple systems including the articular, neural, myofascial and/or visceral can lead to non-optimal strategies during single or multiple tasks. Biomechanical aspects of the myofascial piece of the clinical puzzle as it pertains to the abdominal canister during pregnancy and delivery, in particular trauma to the linea alba and endopelvic fascia and/or the consequence of postpartum non-optimal strategies for load transfer, is the focus of the first two parts of this paper. A possible physiological explanation for fascial changes secondary to altered breathing behaviour during pregnancy is presented in the third part. A case study will be presented at the end of this paper to illustrate the clinical reasoning necessary to discern whether conservative treatment or surgery is necessary for restoration of function of the abdominal canister in a woman with postpartum diastasis rectus abdominis (DRA).

Journal of Bodywork and Movement Therapies, in press
doi:10.1016/j.jbmt.2008.05.003