How I Support Women Through Pelvic Health Physical Therapy

As a pelvic floor physical therapist, I treat many postpartum women. But I wasn’t aware of postpartum depression until I worked with one patient a few months ago. While evaluating a 33-year-old mother for excruciating postpartum pelvic pain, and urinary incontinence, she was on the verge of tears while describing extreme fatigue and lack of attachment with her baby.  She said she felt guilty and afraid that she couldn’t be a good mother, which is why she opened up to me about what she was feeling. I realized that it would be challenging to see any improvement in pelvic pain until her depression gets better.[1]

Postpartum depression is one of the dark sides of pregnancy no one talks about much, but approximately 1 in 8 women experience symptoms of postpartum depression in the 

United States, such as loss of appetite, sleep deprivation, feelings of inadequacy as a parent, crying, irritability, and inability to care for their baby or themselves.[2]

Most people talk about the good, fun-loving aspects of pregnancy, and, by all means, it can be one of the most joyful times in many women’s lives. However, this isn’t every woman’s truth; all women around the globe experience pregnancy differently. Some difficult situations during pregnancy could exacerbate the possibilities of having depression that are stressful life events, complex health diagnoses, socio-economic crises, and prior history of depression. [3]

Figure 1: Stats retrieved from https://www.cdc.gov/reproductivehealth/depression/index.htm#Postpartum

Although I could provide limited talk therapy during her sessions, I urged her to consult an expert for her postpartum depression. While as a physical therapist I am trained primarily to assess pain and movement deficits in the human body, working with this new mother inspired me to add mental health screenings for my postpartum patients. While it might seem unusual to include a mental health screening in a physical therapy evaluation, working with this patient emphasized how closely pain and depression can be interrelated Thus, improving depression can leads to a greater prognosis in pain and vice versa. Research about postpartum depression shows that pain itself could be one of the causes of depression, so chances are that your postpartum patients with pain could also be depressed. [4]

I have had positive outcomes in my practice by including the Edinburgh Postnatal Depression Scale[5] at least during the initial visit and after that as needed. This test is a patient-report depression symptoms questionnaire to improve the detection and management of postpartum depression. The test is quick and easy; for most women, with ten short questions about how the patient has felt in the last few days. It takes less than five minutes to complete. Mothers scoring more than 12 or 13 are likely to be depressed and should seek medical attention. My patient scored 14 so I referred her to her doctor for further clinical evaluation to confirm the diagnosis and establish a treatment plan. At her last physical therapy visit, her Edinburgh Postnatal Depression Score was zero, and her pelvic pain was occasional and minimal.

I was happy to see her become more physically and mentally stable. Although depression is common in pregnant and postpartum women, there is a lack of appropriate screening and assessment at multiple levels. The United States Preventive Services Tasks Force recommends depression screening in pregnant and postpartum patients. However, most patients haven’t been asked about the screening by other health disciplines.[6]

Including mental health screening during physical therapy services appears to improve overall rehab prognosis while helping to avoid the consequences of undiagnosed postpartum depression. Several studies are under development directed at investigating a multifaceted approach to this complex disorder. In the meantime, educational and screening initiatives can help with early diagnosis and prevent adverse events that may otherwise occur due to unrecognized postpartum depression.[7]

[1] IsHak, W. W., Wen, R. Y., Naghdechi, L., Vanle, B., Dang, J., Knosp, M., … & Louy, C. (2018). Pain and depression: a systematic review. Harvard review of psychiatry, 26(6), 352-363.

[2] Dennis CL, Brown JVE, Brown HK. Interventions (other than psychosocial, psychological and pharmacological) for treating postpartum depression. Cochrane Database Syst Rev. 2019;2019(11):CD013460. Published 2019 Nov 5. doi:10.1002/14651858.CD013460

[3] Patel, M., Bailey, R. K., Jabeen, S., Ali, S., Barker, N. C., & Osiezagha, K. (2012). Postpartum depression: a review. Journal of health care for the poor and underserved, 23(2), 534-542.

[4] Von Korff, M., & Simon, G. (1996). The relationship between pain and depression. The British journal of psychiatry, 168(S30), 101-108.

[5] Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry, 150(6), 782-786.

[6] Centers of Disease Control and Prevention: https://www.cdc.gov/reproductivehealth/depression/index.htm#Postpartum, retrieved on 1/27/23. 

[7] Halbreich, U. (2005). The association between pregnancy processes, preterm delivery, low birth weight, and postpartum depressions—the need for interdisciplinary integration. American journal of obstetrics and gynecology, 193(4), 1312-1322.

Author: Khushali Trivedi, PT, DPT, MS

Author Bio: Khushali Trivedi, PT, DPT, MS, is a Ph.D. student at Texas Woman’s University and works at Holsman Physical Therapy and Rehabilitation in New Jersey. She is a women’s health activist, and she is fighting for healthcare equality through VediKh Care (NGO).