Following the Tissues: The Clinical Reasoning Behind a Complex Pregnancy Case Study

What do you do when a pregnant client presents with tailbone pain, SI joint dysfunction, painful intercourse, and persistent uterine cramping – but nothing quite explains the full picture?

In this fascinating case study, Lynn walks through the clinical reasoning behind treating a first-time pregnant client whose symptoms continued to evolve over multiple visits. As the pieces slowly came together, an unexpected finding challenged assumptions and reinforced the importance of following the tissues rather than chasing symptoms.

This episode explores how careful assessment, respectful hands-on treatment, and clinical curiosity uncovered a restriction that could have had significant implications for both comfort during pregnancy and preparation for birth.

Key Takeaways from this Episode:

• Why persistent tailbone pain and painful intercourse may be connected to much more than pelvic floor muscle tension.
• How following tissue restrictions over multiple treatment sessions can reveal the true source of dysfunction.
• The relationship between the sacrum, uterine support structures, and changing symptoms throughout pregnancy.
• Clinical reasoning behind treating complex pregnancy presentations while respecting the safety of both mother and baby.
• Why stepping back and reassessing the entire kinetic chain can change the direction of treatment.

Clinical Application

Sometimes the biggest breakthroughs come from listening to what the tissues are telling you rather than forcing a diagnosis to fit the symptoms. This case is a powerful reminder that pregnancy-related pain often requires ongoing reassessment, thoughtful clinical reasoning, and 

If you enjoy complex case discussions that challenge your thinking and help refine your clinical reasoning, you won't want to miss this one.

Frequently Asked Questions

Why does tailbone pain happen during pregnancy?

Pregnancy tailbone pain can result from changes in pelvic alignment, ligament tension, muscular guarding, and altered mobility of the sacrum and coccyx. This case demonstrates why evaluating the entire pelvic system may provide more answers than focusing on the tailbone alone.

Is painful intercourse during pregnancy always caused by tight pelvic floor muscles?

Not necessarily. While pelvic floor muscle tension may contribute, this case illustrates how restrictions involving connective tissues, uterine support structures, and pelvic mobility may also influence symptoms.

Why is reassessment important throughout pregnancy?

As pregnancy progresses, tissue tension, biomechanics, and symptom patterns continually change. Regular reassessment helps clinicians refine treatment as new findings emerge and supports better clinical decision-making.

Where can I learn more?

Download the Institute for Birth Healing’s FREE Pregnancy Pain Treatment Guide to learn more about working with the pregnant body.

About The Speaker

Lynn Schulte, PT is a pelvic health physical therapist with more than 30 years of experience helping practitioners understand the biomechanical, myofascial, and nervous system influences affecting pregnancy, birth, and postpartum recovery. Through the Institute for Birth Healing, she teaches evidence-informed continuing education courses focused on practical techniques that help clinicians achieve meaningful outcomes for their clients.

Connect With Lynn

Have a comment or question about today’s episode? Message Lynn on Instagram or Facebook, or Email Lynn.

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Transcript

Speaker: [00:00:00] Hello everybody, and welcome to this episode. Today I have a very interesting case study with you that I'm excited to share with you. This is a first-time mom who is pregnant, and she, uh, when she came to see me she was only 13 weeks pregnant. And she was complaining of tailbone pain, and, uh, she sits at a computer all day so that made it worse, so she actually quit that job.

She's actually a massage therapist as well. Um, she is complaining of, um, discomfort in her left sacroiliac joint. Um, when she's sitting and the tailbone hurts, she's like, "It feels like it's off to the left." Uh, she also complains of pain with insertion and thrusting. And, um, she was also having, um, uh, she said when she was laying on her back she feels a cold sensation and numbness in the front of her thigh, but if she rolls over it goes away.

Um, if she keeps her knees bent up, that doesn't happen, so there's something interesting going on there. [00:01:00] And, um, she was also having a lot of crampiness in her belly, and her midwife's starting to get worried. She's planning on having a home birth with a midwife, and the, the midwife's starting to get a little bit concerned about the crampiness, so she's wondering if she should, uh, send this client to go get an ultrasound to see what might be going on internally.

And when I evaluated her, I worked mainly on her pelvis the first session because she was only 13 weeks pregnant, and I found her coccyx and her lower sacrum were really hard, especially on the left side. And as I held that sacrum in my hand, I actually felt a drawing up on that left-hand side that went all the way up to the cranium.

So I just held the cranium, and then that left-side sacrum kind of released and relaxed and, and came down. And, um, and [00:02:00] then I worked, um, you know, because she was only 13 weeks pregnant, I really just didn't do much with the uterus at this time and just tried to focus in on the pelvis and the pelvic floor.

She was tighter on the left side, um, pelvic floor muscles, but both sides with the coccygeus really. And, um, and so, uh, I didn't want to do the pelvic mobilizatio- or the, I'm sorry, the uterine mobilizations because I just felt there's crampiness going on. I tuned into it. I worked with it energetically. And I, what I, um, my sense when I tuned into the uterus, and I remember telling her this after her first session, I said I feel like your baby's okay, but there's something going on with your uterus.

And, um, and so I had her, um, uh, wait a couple of weeks to come in, and she did say when I saw her [00:03:00] again almost less than like three weeks later, um, she's now 16 weeks pregnant, uh, she reported that the pain was gone for four to five days, and then it came back, but the pain feels different. So something's happening with her pelvis.

Uh, we made some good adjustments to her pelvis that helped her out, but she's still having some, uh, crampiness in her uterus and everything. Um, she had a lot of pain in her left SI joint, uh, the fo- the previous week. And, um, what I found this time seeing her was that her uterine mobility felt pretty restricted.

Her right round ligament was very restricted and n- not able to mobilize anything that, that y- ligament would just not move inferiorly along the, like, at the labia. So I worked in the inguinal canal and helped to restore a little bit more mobility to that right round ligament. [00:04:00] I also released the right uterosacral ligament.

Um- And, and just felt like there was some restriction because she's only 16 weeks. I, I did just gently really work with the uterus on the bladder at this point in time, and there was a l- a big restriction with that. And I did do some internal work this time, and I found some bilateral levator ani muscle tension, some coccyx- coccygeus were tender bilaterally and tight.

But the left side endopelvic fascia felt a lot tighter. And, um, and again, just feeling into whatever's happening with the uterus, um, the position of the uterus to the sacrum doesn't feel normal and happy. And, um, and so I instructed her to do some inversions. And, um, and [00:05:00] then she, she went home and, and I again saw her, uh, four weeks later.

And, uh, she's now 20 weeks, and her tailbone pain is back. She's doing inversions, which she feels is really helping with that round ligament. She's waking up at night to pee, and she feels some pelvic pains when she's doing it. She says sex is still super uncomfortable and is just off the table right now.

It, um... She said she did try it, but it was burning during and after, and her pelvic floor just felt cranky afterwards. And her right... So when I went to treat her this time, her right side ILA felt really hard, and, uh, the coccyx was still to the left. Her bilateral round ligament, I released that, the right broad and uterosacral ligaments.

Uh, there was an anterior rotation of her left ilium that I noted, and she, um, did have that trauma from childhood that I felt was kind of being [00:06:00] held in her right ILA of the sacrum. Um, and w- it did bring up an event in her childhood that we dealt with. And, um, again, I left that session going, "The uterus feels off, but the baby feels fine."

And, um, and so now, and, and I did assess her fundal height, you know, at that 20-week mark. It was at the l- the level of the umbilicus, so I'm like, "Okay, she's tracking there." Um, she comes back to see me the following week, and she's saying she's getting numbness in her left thigh in sitting and in standing.

And, um I felt like her, um, when I assessed her uterus, it felt like there was a pretty good mobility to it, um, because I was just, like, at the top of the fundus, and it, that was moving and, and doing okay. [00:07:00] Um, but there did seem to be a connection between the sacrum and the uterus, and, like, the, the lower third of the sacrum just felt really hard as I was working with her, and the tailbone too.

And I did do some side-lying release work on her b- uh, broad ligaments bilaterally. And then after I got done working externally, this is where it gets interesting, guys. I went to go internally, and I was just following her bowel back, and I didn't notice this in any of the other... I did internal work one or two sessions ago, and I didn't notice anything.

But this time, when I went to just follow her uterus back I ran right into the cervix, which was crazy for being... Like, she's 24, she's 21, one or two weeks pregnant at this point, [00:08:00] and that cervix should be way up. Like, the uterus is up out of the pelvis at 16 weeks, so the cervix should be moving up along with it, but it wasn't.

And I, uh, you know, as I, I just, my fingers went back and I was like, "Whoa, what's that?" And I just gently palpated around, and it was her cervix. And what I felt was that her cervix was actually elongated. And, um, you know, I just, I was like, "Whoa, okay." I was super gentle and super just careful because I've, I don't treat cervixes in pregnancy.

And, um, I was like, "Wow, okay, this just..." As I was sensing into the cervix, I didn't go to the opening, okay? I'm, I'm feeling more along the sides of above the, the os of the cervix. And again, it just felt, like, elongated, [00:09:00] and it felt very hard and like it couldn't move. Not that I was pushing it around much, but, um, I, I was just like, "Yeah, this cervix is..."

You can feel whether a tissue can move or not without actually moving it. So if you're interested in learning that, please come to a live course. I'll show you how to do that. So that's what I was doing, is just kind of sensing into, does this tissue, can it move? Does it like to move? And it was no. And so I realized that, like, okay, I gotta really work on the uterosacral ligaments.

And then I worked a lot on the endopelvic fascia internally on both sides to release whatever I could there. I did a bilateral release of the u- uh, uterosacral ligaments. Um, and everything just kind of softened. And to me, it made more sense, like, 'cause I, I... This whole time I'm like, "There's something going on between your sacrum and your uterus."

And I felt this session, [00:10:00] like, her uterus was moving pretty good. But now that I'm internal, I was like, wow. I think externally I was, like, just on the top of the fundus and just to make affecting movement in the top of the fundus because what I'm feeling internally is the lower half of that uterus is not moving.

And I wasn't really appreciating exactly what was happening externally because I was only getting, like, the tip of the iceberg in the movement. So I did all this, like, really careful, careful work around the cervix and, um, and I wasn't working directly with the cervix. I just wanna clarify that 'cause I don't want people to think like, oh my gosh, she's working on the cervix.

But this was a cervix in need. And, um, by the time I got done with the release work and I, [00:11:00] you know, reassessed things, the cervix was totally up and out of the way. It, it was no longer right along near the, the bowel in there. It had retracted back up to a more normal position internally. And, um, and, and just again tuning into that tissue without moving it or doing much with it, it was much softer.

And, um, and I was just astounded, number one, that I found it like this. I've never encountered it this before. I've never encountered a cervix before without looking for a cervix, especially in pregnancy, because I don't go looking for them in pregnancy. It's not our job to be messing around with the cervixes internally during pregnancy.

And I found by working with the endopelvic fascia and working with the uterosacral ligaments externally or with my external hold really, there [00:12:00] was a softening that happened, and the cervix was able to go back up. Now, the fun piece, so there was a huge, huge shift and change in this, and she stood up and she was...

After I got done, she stood up and she was like, "Whoa, that feels different." She felt more free and lighter in her pelvic space after that session, and her uterus felt more calm. Um, and the next time I saw her, she reported that intercourse was fine. It's much better. Surprise, surprise. Uh, there's... This is the first time that she...

Well, the first time she had intercourse there was no pain. The second time there was a little bit of movement, but then it went away. It didn't linger. Um, she did... You know, she's still dealing with tailbone, is still speaking to her. Her left SI joint isn't happy. And what we did find, um, in this session, which I may have noted in the first session but didn't really follow up [00:13:00] on it, but, um, her left leg has a very significant valgus to it that the right leg does not have, and it's shortening her left leg.

And that is creating this anterior rotation of the ilium. And I think I just got so enamored with, like, what was going on with the sacrum and the uterus the first couple of sessions that I just focused on that. And now on this fourth or fifth session it's like, oh, I think she has a leg length discrepancy that is causing this left side SI joint to, to be cranky because it's, it's un- unstable, unbalanced.

Anyway, it's shorter on that right side, so it's tweaking it, causing it to go into more anterior rotation. So we talked about things and, you know, sh- showed her how to stretch that out. And I did give her a heel lift. I am not a big fan. I feel like those are just bandages. But sometimes during pregnancy that's what your clients need.

So we gave her a heel lift that really did balance out her, evened out her pelvis more [00:14:00] side to side. And, um, w- I'll check back in with her when she comes in again. But, um, w- her, uh, sacrum is feeling a little bit better, um, sure. But her- Uh, coccyx is still not happy fully. Um, I did get a, a little bit more softening.

You know, just keep focusing in on, you know, the, the bones and releasing any hardness from the bones, trying to get as much mobility as we can in these tissues, along with the pelvic floor muscles. And, um, I did notice this time again after that last session that her cervix was much higher than last time and much softer.

Um, there was a slight pull to the left and a twist noted, so I did work on the left side uterosacral ligaments and left endopelvic fascia. Um, and, and so she does have a beautiful contraction and relaxation and good give with her urogenital hiatus. So, um, [00:15:00] I am excited for her. I'm just going to see her when she feels like she needs to come back in now.

Um, but, uh, that was wild what I felt with her cervix. And, um, never came across something like that before. And I am not promoting us working on the cervixes, but imagine ... I was sharing this with another pelvic health therapist colleague friend of mine, and she was like, "Wow, Lynn, imagine what her birth would have been like had that cervix not been addressed."

And I was thinking, wow, yes, that, that would have been interesting. I don't know if that cervix would have been able to dilate, um, because it was so restricted and so held down and, and getting elongated. So, like, the cervix was just being anchored in vaginally at a low spot, and the uterus is still growing, but there was this tug-of-war going on.

And, um, that cervix and uterus was not happy. [00:16:00] And, um, her cramping is all gone. She no longer has the cramping anymore. And, um, and I did talk to her midwife to let her know what I found and what's going on, and I will continue to support her throughout her pregnancy. And I'm curious. I, I did tell her, I'm like, "I think you coming in to get this work done, it was gonna be imperative, uh, for your home birth, um, for you to be successful having a home birth."

So, uh, super interesting. And I hope you found this interesting as well and maybe learned a few things. But I am not promoting that we go look for cervixes and treat cervixes during pregnancy. That is not what I'm saying. Um, and yet when you run into one that shouldn't be where it is, that's a cervix in need.

And think about what is happening to that cervix with intercourse. And, um, you know, it's definitely getting more pushed [00:17:00] around. I would never, um, uh, promote us working with the cervix Except for when it's a need like this. And when done, it needs to be done energetically and not, you know, we're not doing full-on mobilizations at all.

We do not ... Like, we could cause a problem with the mucus plug, or something else could happen, and we don't want to have that on our hands. So please, please do not go messing with cervixes in pregnancy. That is not what this episode is about. Um, I just found that this ... I, I think it's important for us to realize that this can happen.

And, um, pain with intercourse, especially thrusting pain with intercourse, to me is a sign the cervix is not happy. There's something going on with that cervix, and, um, in pregnancy, that I think is super important that we, um, help if, if that's an issue. Um, so [00:18:00] I just, uh ... Yeah, I'm curious. I, I wanna talk to other midwives and colleagues and see, uh, their thoughts because I know there's this avoid the cervix at all costs during pregnancy, and I totally get it and totally abide by that except for when the cervix pops into my hand and I'm not even looking for it.

That's a cervix in need. So, um, anyway, I know this is a little bit more controversial and, and some people might, uh, take this the wrong way, and I really would love for everybody to know that when I'm working with the tissues, I am offering the utmost respect, and a lot can be done with the tissues energetically, and that's how I approached this case too.

So everything's fine. Baby's still doing good. She's still growing. She's still pregnant. So, um, I'm, I'm super excited that she came in and that we've been able to work through this for her and make her more comfortable throughout her pregnancy, and I know [00:19:00] that this work is going to help her in her labor as well.

So anyway, that is a very interesting case study. I hope you found it so. And thank you for listening in, and I will see you all on the next episode. Here is to smoother births and faster recoveries. Take care everybody. Bye-bye.