IMPLICATIONS OF THE “40 DAY LIE-IN” FOR POSTPARTUM WOMEN

Submitted by Christine on April 30, 2008 - 1:31am

All those who treat women for disorders of pelvic organ support are informed by medical science and therefore subject to the same faulty paradigms that have followed gynecology down through the ages. Flawed models engender unsound practices such as the “40 day lie-in” currently being promoted by Australian neurologist Susan Mathers, MD.

As explained by physical therapist Melinda Cooper, “It takes around this time for the pudendal nerve to re-innervate the pelvic floor following parturition. She (Dr. Mathers) demonstrated that neurological growth hormone was secreted in large amounts and had the effect of ‘bathing’ the axons of the pudendal nerve to facilitate their recovery. Curiously, (or is that tragically) in high context societies such as our own where women do not have post-partum ‘lie-in’ period and where women are expected to birth babies and return to running the household and possibly work within this period of pudendal nerve regeneration, it is not surprising that POP presents.” Cooper states that all postpartum women in her practice are encouraged to follow a 6 to 8 week program that includes minimum weight bearing activities/positions such as standing, walking, and sitting; learning to breast feed lying down; pelvic floor muscle training immediately post-partum; and not lifting anything heavier than the baby.

According to Cooper, “The presence or absence of POP is unrelated to lactation as its aetiology lies in the physics of forces, resistance and transference of loads. POP in the post-partum period is due to excessive forces applied during parturition. POP can occur in women who have never been pregnant – it is as a result of force in a direction that exceeds the resistant force. Aetiology is similar to the mechanisms involved in developing inguinal or hiatus hernias and spinal disc prolapses.”

The concepts of force, resistance, and load transference have no meaning outside a framework of accurate skeletal anatomy. The causes of spinal disc prolapse and pelvic organ prolapse are indeed similar, but for reasons that obviously evade Cooper. Orthopedic medicine has long since proven that prevention of herniated lumbar discs relies upon the natural self-locking mechanism of the bipedal pelvis1.

DeLancey, Ashton-Miller (see previous blog), and co-authors have demonstrated something of great importance to the study of pelvic organ support even if the significance of their findings appears to evade them2. These researchers demonstrate that ‘vaginal force closure’, or how tightly the front vaginal wall closes against the back vaginal wall, increases 92% when a woman moves from the supine to the standing position. This mechanism is also dependent upon the self-locking pelvis at the core of natural human posture.

The temporary effects of vaginal birth on the pudendal nerve were described decades ago3,4 and that neuroactive steroids, particularly testosterone, help its regeneration has also been discovered by other researchers5. Considering that the rhythmic secretion of testosterone, as well as the flow of the rest of our hormones, is regulated by the master circadian clock located inside the mammalian brain6, which in turn is regulated by natural cycles of light and dark7, it might give one pause before suggesting that a newly postpartum woman spend 6 to 8 weeks in bed.

It would be interesting to see Dr. Mathers' anatomical descriptions of the pudendal nerve and whether she portrays it within the broader context of the bipedal pelvis. The central portion of the pelvic floor is innervated by direct branches coming off the spinal cord at the 2nd through 4th sacral vertebrae (S1-S4), by the inferior rectal branch of the pudendal nerve, or by a combination of the two8. This would be the area most stretched by the fetal head and also most responsible for vaginal sphincter closure. The more lateral portions of the pelvic floor are innervated on their top aspects by S4 and on their underside by branches of the pudendal nerve9. All of this suggests that the pudendal nerve shares innervation of the pelvic floor with the direct spinal branches.

The portions of the pudendal nerve at the level of the pelvic floor exist between the sacrospinous and sacrotuberous ligaments. Orthopedic studies have thoroughly demonstrated that with pelvic nutation (see Saving the Whole Woman, 2nd edition) these ligaments tighten to stabilize both the pelvis and its contents10. A theory that attempts to facilitate postpartum regeneration of the pudendal nerve by keeping the pelvis in its counternutated position has no basis in biomechanics. Rather, it is risking development of prolapse by destabilizing the dynamics of pelvic organ support.

_____________________

References

1) Vleeming et al Movement, Stability & Low Back Pain – The essential role of the pelvis. Churchhill Livingstone 1997

2) Morgan D et al Does vagina closure force differ in the supine and standing positions? American Journal of Obstetrics and Gynecology 192 1722-1728 2005

3) Snooks S Injury to innervation of pelvic floor sphincter musculature in childbirth The Lancet September 8, 546-550 1984

4) Smith A Hoskell G Warrell D The role of pudendal nerve damage in the aetiology of genuine stress incontinence in women British Journal of Obstetrics and Gynaecology 96: 29-32 1989

5) Melcangi R Garcia-Segura L Mensah-Nyagan A Neuroactive steroids: State of the art and new perspectives Cellular and Molecular Life Sciences DOI 10. 1007/s00018-007-7403-5 2007

6) Karatsoreos I Wang A Sasanian J Silver R A role for androgens in regulating circadian behavior and the suprachiasmatic nucleus Endocrinology148:11 5487-5495 2007

7) Karman B Tischkau S Circadian clock gene expression in the ovary: Effects of Luteinizing hormone Biology of Reproduction 75 624-632 2006

8) Brubaker L Saclarides T The Female Pelvic Floor – Disorders of function and support F.A. Davis Company 1996.

9) Ibid

10) Gracovetsky S The Spinal Engine Springer-Verlag 1988

Comments

granolamom

April 30, 2008 - 7:00pm

well, I do agree that postpartum women should not have to consider it a luxury to look after themselves for a few weeks (months?), and should not feel pressured to resume taking on a complete workload soon after childbirth.
and I do agree, that especially in light of this pudendal nerve thing, that pp women really do need to stack the odds of complete healing in their favor.
but bed rest??

they don't even recommend that for acute back pain anymore. it just isn't what a body needs to recover/prevent an orthopedic/structural problem. not only does it put the pelvis in a position conducive to developing a prolapse, but it isn't good for digestion (who needs constipation postpartum??), respiratory function or blood flow. and NOT good for the mood either.

that said, I am all for new moms napping when their baby naps, and resting as needed.

I didn't look up all the references, but does she have any studies that show that the '40 day lie-in' is effective in reducing the incidence of pp POP? honestly, it would surprise me.

louiseds

April 30, 2008 - 8:38pm

Hi Christine

I would like to investigate this lying in thing a little further with Melinda before dismissing it entirely. I agree with Granolamom and you that there is something affirming a woman's need to go easy for a while after birth. Let's just find about some more about what she is saying before dismissing her advice. I think you will find that we have a lot of common ground, and that building on that common ground will lead to better understanding by all of us, if informed people listen carefully to each other, particularly where their expertise is different from ours, and the level of understanding of each other's recommendations can be limited by that lack of sophisticated understanding of the other person's field.

eg, I was amazed to read Mary O'Dwyer's book, My Pelvic Flaw, and to read about how comprehensive the treatment of pelvic flaw conditions is these days, far better than the 1980's. I think that WW would endorse most of these treatments. I think the book has a major, fundamental problem though, which would prevent me from recommending it as a good reference or guide for women. This illustrates to me how an author can have so much useful stuff to say, much of which is very beneficial to the reader, but which shows a lack of understanding of the body, as you and I would see it. I will talk about this elsewhere, as it is not strictly on topic for this blog entry of yours.

Let's also wait until we hear from Helena Frawley, Melinda Cooper's colleague, and find out what she has to say.

Let's get them to talk to us. It is a pity we are so geographically distant. I hope to be able to talk face to face with some of these Australian researchers if I can get to the other side of Oz at any time. It is less than satisfactory trying to understand each other via text only, and while we do it all in text, via Blogs, Forums and email, I think we have to be extra thorough in our attempts to communicate clearly and listen to each other very carefully, lest the messages be misunderstood or misconstrued.

Cheers

Louise

babygotback

May 22, 2008 - 10:50pm

I am trying to understand this article, and I am sure I will reread it again with a dictionary nearby, but I am confused.

Am I to understand that the 40-day lying in and pampering mom that happens in some countries is not helpful to humans as we might think? Practically speaking, I can imagine that the extremes are the problem. A woman generally feels quite good getting up and getting about at her will, but when pressured to stay in bed or pressured to get out comes the trouble. I am speaking so simply, and hoping not to miss the boat. I have been teaching natural childbirth for several years and in this method, we teach that a woman who has all her faculties and has been able to birth according to her own wits (i.e. not being told to push or to be in unnatural positions or subject to unnatural timing or outside pressures) has the strength and health to get right up and walk out of a hospital with her baby and get on with life as she feels able, to be able to trust her instincts and senses. On the other hand, it is easily discovered by any post partum mom early on in rebounding from the huge experience of birth that if she is overly strained physically by a lot of activity early on, she will bleed unnecessarily much and lose more blood than is needful. It is a sign she is overly exerting herself at home, usually trying to pick up household activities or lifting older children a lot.

So, can we not say that it is in the extremes that we find the trouble, or is this article, I am supposing authored by Christine, rejecting the idea of lying-in in any form?

Seeking clarification on this important topic...

louiseds

May 22, 2008 - 11:19pm

I think you have made a really good point, Babygotback. I think on the whole women are pretty good at doing things when they are good and ready, but western reality, lifestyles and media conspire to turn us into superwomen who feel they have to *do* a lot to meet their own and others' expectations of them. Let's face it, in a nuclear family with toddlers and preschoolers and Dad going to work each day, there is a lot of responsibility (real or assumed) that falls on new Mums. Also, there are many women who are psyching themselves and training their tiny babies up for daycare, when they return to work a few months hence. There are also a lot of women who cannot go to bed with a sink full of dirty dishes, or a gleaming floor, or folded washing.

I'm not one of them, and while a certain amount of hygiene is important, some women are unable to separate essential domestic chores from optional chores (like sweeping up leaves in autumn, making gourmet meals every night, polishing socks and cleaning windows.)

I think this is another area of life and community that we have lost; the ability to listen to our bodies and let them dictate a bit more (as new Mums), and the collective responsibility that we all have to be a part of the village that raises each child and looks after each Mum when she has new babies.

Likewise, as women we need to carefully assess what we are doing out of need, and what we are doing out of guilt, and be able to justify domestic and family laziness sometimes for the longer term wellbeing of our female bodies. Even *I* have learnt the art of 'selective helplessness' over the last few years, and that is something that I had previously frowned on, after half a lifetime of priding myself on my physical strength, ability and competence!! Now I value my newly discovered skills in the cunning department, and I ensure that I no longer always get the burnt steak!

Cheers

Louise

alemama

May 22, 2008 - 11:54pm

the risk increases with bed rest. One of the more real risks associated with childbirth. I don't think she (the author) is saying do nothing- and I don't really support her hypothesis that POP would be prevented by bed rest after birth- but I like the advice to lift only baby and nurse in bed.

Christine

May 23, 2008 - 8:09am

I think many mothers would go crazy lying around this much, unless they really needed a long vacation. But that’s really beside the point. The point I’m making is that the pelvis itself has been pushed into and living in its most unstable position for WEEKS prior to birth. By this time the baby itself is sealing off the ‘genital hiatus’, but is also holding the pelvis in counternutation. Remember all the completely relaxed ligaments – the immediately postpartum pelvis must look very big indeed! Also, the bladder and rectum have been (mercifully) pushed well into their proper positions by the big baby in the middle.

After birth, there must be significant osseous remodeling to bring the pelvis back to neutral. This can only be done by proper weight loading from above, i.e. sitting and standing with the lumbar curve in place. The breath (intraabdominal pressure) cannot adequately pin the organs into position without this mechanism. This Must be why postpartum prolapse almost always shows up weeks down the line.

Lying in or no lying in – (an old upper-crust English concept, no doubt, but I understand other cultures are known for it too) pp women need to understand the central mechanism of pelvic organ support and how theirs has been compromised, as well as how it is easily restored.

Btw, these are the sorts of marvelous human studies that would serve humankind so well and one would think would’ve been carried out decades ago.

Christine

queenmother

October 1, 2008 - 11:41am

I have been secretly a little angry with my husband for pushing me to do more with the kids right after my second was born, thinking it was because I didn't rest as much that the prolapses developed. But this is really interesting: After my first birth, I had a third degree tear and lots of stitches. The only position I could maintain comfortably was sitting straight up, with my weight evenly distributed on my bottom. (I couldn't stand for long, though.) I had to sit with correct posture because anything else would cause a pulling sensation in my perineum.

After the second birth with only a 2nd degree tear, I was much more comfortable and could sit up in bed to nurse the baby. Standing was pretty uncomfortable again, so I didn't do much of that either time. But my posture was surely atrocious because I was on the couch so much and this time I could comfortably sit in just the position that we are supposed to avoid - leaning back, tailbone tucking under, slouched... A few weeks later I found the cystocele, and a rectocele followed.

Hmmm...
Sarah