What a Postpartum Evaluation Looks Like Through the OT Lens

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Transcript

(00:01):

New and seasoned OTs are finding their calling in pelvic health. After all, what's more a DL than sex peeing and poop? But here's the question. What does it take to become a successful, fulfilled and thriving OT in pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs. We are pelvic health OTs. I'm your host, Lindsay Vestal and welcome to the OTs and Pelvic Health Podcast. Thank you so much for listening to another episode of OTs for Pelvic Health podcast. Anyone who is a member of my OTs for Pelvic Health Facebook group knows I love a good case study. I actually did my first case study here on the podcast on episode 31. I heard from so many of you that you love learning that way too.

(01:09):

So I decided to jump on here today and share another case study this in addition to some other case studies on my Facebook group and my forthcoming book that's going to completely feature OTs role and our special perspective on pelvic health. It's going to be nothing but a book of case studies. I hope you check that out. It's going to be published in 2023. There is a survey in the show notes if you are interested in adding some perspective to what you want to see covered on that. If the survey is closed, know that the book is in full effect and it's going to be published very soon. But check that link out in the show notes if you have some thoughts on what you'd like to see in the book. Without further ado, today's case study is all about evaluating a newly postpartum person through the OT lens, and I wanted to share a little bit with you on what a typical evaluation looks like from the OT perspective.

(02:15):

And I have to admit, this is a hard topic for me because the way my brain works, I tend to see all of the nuances and the exceptions for things. Am I the only one? Let me know. Let me know if I'm the only one who sees things that way. I just can't see it any other way. And as OT in pelvic health, I really love treating the client with their individual set of needs, their individual circumstances and their goals. And let's face it, there are always exceptions to the rules and I love it that way. But as we're learning our way around those nuances that a client can present with, there is something so grounding about thinking through a case study that is most typical and that's the point of the case study book that I'm putting together. It's like, let's see what's possible and then we can make the choice to divert from that or not, but at least we need to see what's possible.

(03:20):

And again, if we feel comfortable with what's possible, we can stop focusing on planning and be really, really present with what the client needs throughout their session and be open and comfortable with the exceptions. By the way, I did do an OT and Power Hour on my OTs for Pelvic Health Facebook group all about planning a roadmap around your treatment session based on diagnoses, and I'm going to link to that episode in the show notes. You can even download the actual roadmap that I created and fill it in for yourself using approximate percentages of how to spend your time throughout your first couple sessions. I've received so much feedback that so many of my OT pioneer students are loving this roadmap. So check it out, see if it can help you in your journey as well. So onto the case study, I'd like to introduce Elizabeth, who is a former client of mine and she is eight weeks postpartum.

(04:28):

She was referred to me by her midwife who refers to the functional pelvis. Often Elizabeth had a long labor of about 38 hours. She pushed for three hours and she had a natural tear that was about two or so degrees. Now this is actually the most commonly seen tear during childbirth and it extends through the skin and into the muscular tissue of the vagina and the perineum. She was experiencing urinary frequency. She was peeing about every hour or so. She was leaking urine when she coughed and she was straining excessively during bowel movements. She had not tried having sex with her partner yet, and she apologized profusely in her first session for not doing her kegels enough and for not exercising. Again, her exercise of choice was spinning swimming and the elliptical. She was a pretty anxious person overall about her pelvic floor and particularly about resuming intimacy.

(05:40):

The only discomfort around caring for her baby was around the lack of sleep she was getting otherwise a routine well, as much as you can have one at eight weeks postpartum had been established. Elizabeth was nursing successfully and I remember she was the oldest of a large family. I think she had like five or six siblings and was really comfortable with her role change. Overall, her goals were being interested in being intimate with her husband again, hoping it didn't hurt in her exact words, not leaking urine and being able to exercise again after hearing her birth story and really holding space for it. We talked about the pelvic floor in the holistic system that it's in. But wait, I want to go back for a quick second and mention what I mean by holding space around her birth story. So I've noticed so many clients start repeating some of the things most people ask them about such as, I don't know how long their labor was.

(06:52):

Did they get an epidural? How long did they push? You kind of see them go into that replay mode and not really telling the story as perhaps they might want to. So if I notice this, I gently ask if there's anything else about their birth that they want to mention, the emotional story, perhaps the fact that the birth didn't go as planned or that the thought of getting a c-section was going to happen or that she really thought a c-section was going to happen or that she didn't exercise her own advocacy when a student anesthesiologist performed the epidural even when she said she would prefer someone else. Those things that are often untold because we think others wouldn't want to hear them. Now, these are the things that can be considered traumatic to our clients, and I think having a conversation around them, those topics can be so healing for them.

(08:02):

I definitely encourage holding space for that in your pelvic floor sessions. Okay, so back to the pelvic floor in the system. This is when I introduced the role of the diaphragm and the breath with the pelvic floor. Now I do this for several reasons. I already want them to know that we're going to be focusing on so many more things other than the pelvic floor, even though that's why the client is here and I sort of get their buy-in on that right from this initial conversation as I help the client develop their own body literacy around whole person pelvic health. It also helps because when we transition to the internal work, I use breath queuing to evaluate her muscles. So already having some familiarity with these concepts are so helpful. I'll weave in relevant stats such as how many people experience urinary incontinence or if relevant, how many have prolapse now think that ease them from feeling the burden that they're the only one in the whole wide world to have experienced.

(09:15):

These things are so helpful. Now this is a pretty common feeling, so I like to put them at ease as quickly as possible. So this is about halfway through my initial evaluation, which is we're into about minute 45 now of a 90 minute session. My evals are 90 minutes. I usually have my pen down during this time because I want to maintain eye contact and set the stage for how different of a practitioner I am. I will listen to them. I'm going to offer client-centered care and weave in just the right amount of education in order to help them already start to feel that they're in charge. They're starting or continuing a journey of really understanding their body, a part of the body they likely didn't know much about beforehand. I then give them an idea of what to expect throughout the duration of our session.

(10:17):

A postural assessment, an assessment of functional tasks like standing at a counter, picking something off the floor, squatting, reaching, rotation, walking. We then transition to lying down where I check their diaphragm and their abdominal wall. I explained that we could transition to an internal exam if they're comfortable with that. Even though my paperwork explained that we may do it in the session. I always ask at least two or three more times in the actual session I mention what the internal exam would actually provide us, but that it's not at all necessary. In fact, if I'm getting clues that they would not be comfortable with it or have a history of trauma, I don't do this the first session I just mentioned that if they're comfortable, we could do it in future sessions, but we get so much information from all the other work we're going to do together.

(11:16):

Now listen, I am a firm believer that just because we have the ability to do an internal exam doesn't mean we should. In fact, the more and the longer I'm in this field, I find the less internal exams I'm actually doing. Very often the pelvic floor is the reactor and not the driver and addressing the reactor first is not getting to the heart of the issue and in my experience can actually cause more nervous system, which is not at all helpful for the pelvic floor. So in Elizabeth's case, we actually decided to do an internal exam and in her exam I discovered she was overactive on her right side, which was actually the same side that she tore and she was underactive on the left side, which felt a little bit more like a longer standing muscle state. For her, the right side, it felt more like a reaction to the tear.

(12:20):

She had non-optimal breathing coordination. She had a difficult time elongating or relaxing her pelvic floor with the inhale and was contracting more of her rectum than her clitoral muscles. When I did her abdominal wall assessment, she was oblique dominant. There was a history of straining with bowel movement and her diaphragm felt quite low in her torso. Now I find this pretty often with my postpartum clients, especially for those who have had a long second pushing phase. I also noticed that her scar was still quite tender. We reviewed perineal care and I asked her if she felt comfortable with doing some scar massage. We reviewed how to do it and I also asked if she could imagine when and where she could do this work during the week. So this type of work is not like just squeezing in a few clamshells on the living room floor with the entire family around.

(13:24):

You need privacy for this type of work. Clients often aren't thinking through logistics around when and where they can do this type of non-traditional home exercise program. So I find strength as an OT in the ability to use task analysis and remove the barrier to entry by helping them carve out a strategy around optimal conditions to do the work. Now, we weren't getting very far with her understanding of pelvic floor elongation when she was lying down. So I had her get dressed, which is way more comfortable for the majority of our clients anyway, and we practiced this while sitting on a physio ball. This gave her amazingly accurate feedback at her pelvic floor and she's got one at home. So I'm really hoping that she does this and easily recreates it at home and kind of develops more and more aha moments because it does take time to recreate elongation of the pelvic floor.

(14:27):

It's often a non-familiar feeling for a lot of our clients. We played around with a ton of cues because pelvic floor softening is not easy for people, right? We hear so much about Kegels and lifting and tightening the pelvic floor that many of our clients simply don't have a frame of reference. For the reverse Kegel, she had limited rib cage mobility. So we did some gentle things that were also very downregulating for her nervous system, such as thread the needle, some gentle foam rolling work to open it up. I had her check in with her breathing and her pelvic floor response all throughout these exercises mentioning that she may not always feel it as it's such a new sensation for her. I'm very clear with her that my goal for this first session is to improve her proprio reception of her pelvic floor coordination and movement.

(15:26):

I also revisit the urinary frequency she reported and she didn't share. This was a concern for her, but we talk about optimal pelvic floor function. We talk about that as down the road because eight weeks postpartum is still pretty early. I want her to do less and less of just in case peeing because early on when baby falls asleep on you and your bladder is screaming, most of us once we experience that once or twice, we just don't want to feel that again. So we're often peeing just in case right before we feed baby or anticipate that baby might fall asleep on us. So I'm sort of planting clues for her now. I'm planting clues for her now so that she can get an idea of where I expect her growth to go over the next couple months, and I want her to pay attention to the cues her bladder is sending her a bit this week.

(16:20):

Does she remember what it feels like for her bladder to have an urge? How about what it feels like to be full? Again, working on body literacy and interoception, we're going to focus on this more in future sessions if she doesn't start to see this change. But she's so early on in her postpartum journey that I like to start with gentle awareness and interceptive work. In terms of leaking with coughing, this comes often back to coordination, and since we know she has both overactive and underactive pelvic floor, we start connecting with the breath. So I spend some time with her on how the elongation of the pelvic floor will help her with bowel movements. We review optimal toileting posture and how the breath can help relax the pelvic floor. I also wanted to make sure that we touched on her fear of painful intimacy. I shared with her what to expect in terms of norms that over time it should be less and less painful each and every time her partner try penetration.

(17:24):

We talk about the importance of healthy lube being open to sex being different now that she's had a baby and exploring sexuality first by herself. There's no rush. There's no rush to jump back into it with her partner in terms of her worrying about not kegeling and not exercising yet. Well, we talked about that too, right? We talked about how Kegels may not be right for her anyway and that she may not even have to worry about doing them. So there was no reason to feel behind or guilty. I weave in what we found with her exam that her right side was overactive, her left side was underactive, and then we're going to focus on coordination and release first, and then we're going to get the pelvic floor working together in terms of exercise and her desire to get back at it. Well, we spent some time going over how time and space for healing postpartum can help her on her journey to getting back to spinning and swimming and elliptical and waiting for those activities for now doesn't mean she's going to be behind in the future.

(18:28):

We worked on a gradual return to exercise program, which began with gentle walks in her neighborhood and swimming. I told her we would absolutely get her back to all the things she loved, but wanted to give her a rationale to consider how waiting and a thoughtful reentry was beneficial versus thinking she missed the boat and that she wasn't going to get fit Again. I hope that this case study was helpful for you. It was a portrayal of a very typical postpartum evaluation through the occupational therapy lens, and I hope to see you for my next episode. Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to ig, Facebook, wherever you post your stuff. And be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health Podcast.