POSTPARTUM CASE STUDY: Graciously Active Mother of 4 

All Content, Blogs, Case Studies

POSTPARTUM CASE STUDY: Graciously Active Mother of 4 

Introduction: The client is a 37 old healthy active woman who worked part-time as a fitness instructor, ran marathons and half marathons prior to motherhood. I included her as a case study as she demonstrated the profound power of a single session of Institute for Birth-Healing techniques. I also felt that our history of working together multiple times over the last 5 years allowed an increased connection, trust and rapport that offered us both confidence in trying the IBH Postpartum Protocol techniques. 

Client Characteristics: Client is 7 weeks postpartum from the birth of her 4th child. Her first son was born vaginally via a traumatic hospital birth 12/8/2016. We met and initially worked together during her second pregnancy (vaginal delivery of son 04/26/2019), during and after the pregnancy of her 3rd child (Traumatic cesarean delivery of daughter 01/23/21 at 37 weeks due to chorioamniotic separation) and during and after her 4th pregnancy (VBAC delivery 04/30/22 @ 41 weeks). For her 4th birth she delivered unmedicated, on her hands and knees, in the hospital, without interventions or reported complications.

She was motivated to have a VBAC delivery. She delivered 2 of her other children at 41+ weeks and was nervous about finding a provider that would support her in her birth, but ultimately found a very supportive OB-Gyn that she felt comfortable and confident with. 

Her primary postpartum pelvic health complaint was pelvic heaviness and the goal of safely returning to prior activities. She was stationary biking twice a week for 20 minutes and walking up to 30 minutes daily at the end of her pregnancy as well as when she presented to postpartum physical therapy. She began implementing breathing and gentle pelvic floor muscles immediately postpartum per our work together during her pregnancy.

Examination Findings: 

Observation: forward shoulders and posterior translation of her rib care with a posterior pelvic tilt and reduced recruitment of her abdominals. 

General listening: pulling to the R posterior pelvis

Energy Assessment: open birthing pattern

Thoracic Assessment: wide infrasternal angle (110 deg) with pulling into the chest noted bilaterally, reduced posterior to anterior mobility at lower thoracic segments 8-12

Abdominal Assessment: doming of her abdominals with activation observed during bed mobility

  • Diastasis recti: 3 cm wide above the umbilicus with soft end feel, 2 cm at the umbilicus with soft end feel and 1 cm diastasis with soft end feel below the umbilicus; approximation was minimal along the length of the abdominals.
  • Oblique and Recti with reduced mobility at R obliques and R>L lower abdominal fascia
  • Lower abdominal fascial restriction R>L
  • Bladder and Uterine Mobility: restrictions noted for side to side to the L, rotation L for uterus, superior mobility of both bladder and uterus, compression for both uterus
  • Pubovesical ligament release: R side restriction
  • Broad ligament release: R side restriction
  • C/S scar tissue release: R side restriction

Assessment of Pelvis- Supine

  • ASIS 45 deg force: within normal limits/ unremarkable
  • Sacral assessment for hardness: R>L 
  • Sacral tilt with base higher towards head: R side high
    Sacral spring: reduced mobility R side
  • Sacral correction R side
  • Sacral sheer correction R ILA moved from R to L
  • ischium/ilium release/rebalancing posterior ASIS & ischiums
  • Pubic bone
    • L tenderness
  • Pubic rami between legs: L side firm and tender

Assessment of Pelvis-Prone

  • Sacral rotation mobility R side stiff
  • Inferior glide mobility reduced R side
  • ILA mobility reduced R side
  • Ischium anterior spring reduced B
  • ischium/ilium rebalancing with PSIS and ischiums with 6 different ways 

Assessment of Ilium-Side lying (Unremarkable)

Internal Assessment

  • Perineal body with reduced mobility in the left posterior quadrant
  • Pelvic floor muscles 4 quadrants
    • Strength 2/5 R upper 3/5 R lower and 3/5 L upper and 3+/5 L lower
    • tone/tenderness-reduced tone on R, no tenderness
    • Spring coccyx and coccygeus-reduced mobility R with increased R sided tone
  • Urethra 
    • bulging energetically-yes
    • quality of tissue- boggy
    • spacing side to side- slightly to the L of center
  • Bladder assessment
    • Length of urethra- short
    • Distance from vaginal wall more noted to the L side
    • Bladder repositioning midline
  • Bladder to cervix with minimal space
  • Cervix with slight positioning to the R with reduced mobility to the L

Treatment: 

  • First appointment:
    • GOALS: 
      • Correct open birthing pattern
      • Restore optimal pelvic girdle mobility
      • Restore optimal length-tension relationship of pelvic floor muscles to reduce complains of pelvic heaviness and restore core stabilization strategies
      • Restore optimal resting position and mobility for pelvic organs
      • Normalize abdominal wall myofascial restrictions to restore midline tension and load transfer through midline with reduced diastasis recti depth and width
      • Facilitate balanced and confident recruitment of core and pelvic floor muscles
      • Reduce pelvic heaviness sensations
    • TECHNIQUES:
      • ABDOMINAL
        • Oblique and Recti release
          • Reduced mobility at R obliques 
          • R>L lower abdominal fascia
        • Lower abdominal fascial release
        • Bladder and Uterine Mobility: restrictions noted for side to side to the L, rotation L for uterus, superior mobility of both bladder and uterus, compression for both uterus
        • Pubovesical ligament release: R side restriction
        • Broad ligament release: R side restriction
        • Cesarean scar tissue release: R side restriction
      • Pelvis- Supine:
        • 2 step common birth pattern correction
          • Sacral correction R side
          • Sacral sheer correction R ILA moved from R to L
        • Sacral spring: reduced mobility R side
        • Ischium/ilium release/rebalancing posterior ASIS & ischiums
        • PB (pubic bone) Bilateral side
        • PB and ILA and PB and ischium along 45 angles bilaterally
        • Pubic rami B between legs L side
      • Pelvis-Prone 
        • No treatments as treatments done in supine
          • Sacral rotation mobility R side stiff
          • Inferior glide mobility reduced R side
          • ILA mobility reduced R side
        • Ischium anterior spring reduced Bilateral
        • ischium/ilium rebalancing with PSIS and ischiums with 6 different ways 
      • Ilium-Side lying=Not treated 
      • Internal Assessment
  • Perineal body reduced mobility to the left posterior quadrant
  • Pelvic floor muscles 4 quadrants
    • Strength 2/5 R anterior 3/5 R posterior and 3/5 L anterior and 3+/5 L posterior
    • Tone/tenderness-reduced tone on R, no tenderness
    • Spring coccyx and coccygeus-reduced mobility R with increased R sided tone
  • Bladder assessment
    • Bladder repositioning midline from the L
    • Internal sphincter 
    • Anterior vaginal wall on side of bladder with mobility of fascial tissue anterior and onto pubic shelf
          • Bladder to cervix and should have space- minimal space
  • Cervix 360 mobility-slightly R reduced mobility noted to the L
        • Pelvic floor muscles
          • Released with ischium compression
        • Rectal fascial release
          • Sweep along rectum out of vaginal opening 
        • Perineal body scar tissue release into L posterior quadrant
        • Anal sphincter release
      • Recheck of pelvic floor muscle strength in 4 quadrants
        • Strength 4/5 R upper 4/5 R lower and 4/5 L upper and 4/5 L lower
      • Core activation protocol
    • HOME PROGRAM EXERCISES: 
      • 360 breathing with focus on posterior and lateral costal expansion vs abdominal
      • Pelvic floor and transversus abdominis with breath in supine hook lying, sitting and standing
      • Blow as you go intra-abdominal pressure management with bending, lifting and increased perceived exertion
      • Lateral weight shifts using adductors and abductors to balance pelvis in weight bearing
      • Yoga inversions (Puppy pose) mid and late day for pressure management as needed

Post Treatment: At the conclusion of her first visit she reported and demonstrated:

  • No pain at rest or with activity
  • No pain with intercourse
  • No pelvic pressure
  • No urgency or frequency for urination
  • Pelvic floor strength 4/5
  • Ability to generate tension through linea alba with <1 finger width, shallow firm end feel at abdominal midline

Outcomes: 

  • She was seen for a total of 1 visit implementing IBH Postpartum Protocol.  We then followed up in the clinic for 2 additional visits for general hip girdle strengthening, core stabilization and to begin returning to running progression with walk/run intervals.  
  • She was reporting increased coordination with weight shifts, breathing and Kegels and was implementing blow as you go during the day with lifting and bending tasks to help minimize pressure and facilitate her pelvic floor and deep abdominal muscles. She was amazed at the profound change in a single session especially reflecting on prior postpartum care with slower progress. At the conclusion of her care, she reported:
    • Comfort and enjoyment while running up to 20 minutes total of running (10 repetitions of run 2 minutes, walk 1 minute) total
    • Able to care for 4 children without pelvic pressure present at end of day
    • Feeling stronger throughout her core with faster progress to return to her nonpregnancy/postpartum wardrobe 4 months sooner than with her 3rd child.

Assessment: She demonstrated increased mobility of bony, soft tissue and visceral structures that she presented with:

  • Common birthing pattern at sacrum
  • Reduced mobility of R >L abdominal and oblique fascia
  • Diastasis recti above and at umbilicus
  • Reduced bladder and uterine mobility
  • Sacrum was firm with reduced mobility R>L
  • Liver and stomach elevated with wide infrasternal angle
  • Pelvic floor muscles 2/5 to 3/5 strength with less anterior recruitment than posterior
  • Urethra and bladder bulging and slightly L of midline
  • Cervix and uterus slightly R relative to bladder

Closing Summary: My client came in with the knowledge, motivation, respect and body awareness of a past physical therapy client.  She participated in PT during her pregnancy and has done pelvic PT postpartum for all her children. She worked at her home program activities and engaged in the clinic based manual therapy techniques.  While motivated, she was very gracious with her healing process and subsequently did not show regressions in progress that she had with her previous postpartum recoveries.  I was amazed at how well the techniques from the IBH Postpartum Course changed her symptoms even though the treatment protocol was implemented early on in my learning journey and prior to taking the IBH Advanced Healing course. It was also helpful to have the familiarity of her prior postpartum recoveries to serve as a relative control measure as well as establish trust and comfort for both of us. 

Lynn Schulte

Leave a Reply