27/02/2024

Care Health

Prioritize Healthy life

Should Everyone Who Gives Birth Get Physical Therapy?

Should Everyone Who Gives Birth Get Physical Therapy?

At the busy county hospital where I did my medical residency, we cared for patients with every imaginable problem. But one part of treatment was always the same: As soon as it was deemed medically safe, a physical or occupational therapist would visit each and every patient. In the intensive-care unit, a physical therapist might assist a patient into a sitting position at the edge of the bed. An occupational therapist might help her relearn how to hold a fork after weeks of being fed by a tube. On the general-medical and surgical wards, at least one or two patients could always be found walking the long hallways with a walker or cane, a strong and amiable physical therapist keeping pace beside them, casually asking crucial questions: “Are there any stairs in your home?” “Who does the laundry and cooking?” “Who will be around to help you?”

But there was one area of the hospital where physical and occupational therapists weren’t involved in patient care: the maternity ward. In many hospitals, this is still true. Although I now work in outpatient OB-GYN care, my colleagues in Labor and Delivery confirm that PT/OT doesn’t have a large presence there. Amy Willats, a nurse-midwife in the San Francisco Bay Area, told me that she orders physical therapy for new mothers only in rare circumstances—“when someone is in so much pain, they can’t walk to the bathroom.” As for occupational therapy, she said, “it’s not even on my radar.”

Some physical and occupational therapists want this status quo to change. They believe that everyone who gives birth should receive a PT/OT evaluation prior to discharge, with the same goal as for any other hospitalized patient: to prepare them to move around safely and comfortably at home. I remember how easily, in the chaotic world of the hospital, I could overlook the quiet work of physical and occupational therapists. But the extra layer of attention and care they provide could help millions of new mothers recover faster—and may even save lives.

Pregnant women and new mothers are, in a sense, different from other hospitalized patients. Doctors tend to think of them as healthy young people undergoing a normal, natural process, one that should require serious medical intervention only occasionally. This is how my patients tend to see themselves too—and most of them do go on to live normal, if changed, lives. By this philosophy, what new mothers need isn’t intensive rehab, but a brief period (one or two days) of observation, some education about how to feed and care for their baby, and then a timely discharge home, with a single postpartum visit a few weeks later. Indeed, this laissez-faire approach is the standard of care in many U.S. hospitals.

But as the U.S. faces a surging maternal-mortality rate, with more than half of maternal deaths occurring after delivery, physicians are now in wide agreement that the standard of care needs to change. Pregnant women in the U.S. are not as young as they once were. Pregnancy and childbirth can present grave dangers—particularly when a woman already has underlying health conditions. A vaginal delivery is an intense physiological event that involves the rapid expansion and then contraction of the musculoskeletal system, along with dramatic shifts in hormones, blood volume, and heart rate. A Cesarean section is a major surgery that involves cutting through layers of skin, fascia, and muscle—and that’s if everything goes perfectly.

Rebeca Segraves, a Washington State–based doctor of physical therapy specializing in women’s health, told me she was struck early in her career by the realization that women undergoing a C-section did not receive routine postoperative PT. She was used to performing inpatient evaluations for patients recovering from relatively minor illnesses and surgeries, such as pneumonia, gallbladder removal, and prostatectomy. But after a C-section, she says, a PT evaluation “just wasn’t the culture.” She set out to change that.

For most people, if the phrase postpartum physical therapy calls to mind anything at all, it’s pelvic-floor PT. In the early 2010s, American women living abroad introduced U.S. audiences to the French practice of perineal “reeducation,” a comprehensive exercise regimen prescribed for every postpartum mother and subsidized by the French government, designed to retrain the muscles of the pelvic floor after birth. Since then, U.S. researchers and the popular press have documented the widespread and devastating effects of urinary incontinence, pelvic-organ prolapse, and chronic pelvic pain—issues that can be overlooked or dismissed at the postpartum visit.

But Segraves is arguing for postpartum PT/OT that goes beyond the pelvic floor. Segraves has developed an approach called “enhanced recovery after delivery” (ERAD), essentially a training program for OB-GYN departments and hospital-based PT/OT staff that encourages an evaluation for every woman after childbirth. ERAD includes an assessment of body mechanics and cardiopulmonary function, gait retraining, infant lifting and lowering techniques, and (in the case of C-section) incision-protection training. Crucially, a therapist also monitors the woman’s bodily responses—such as pain and vital signs—while she practices these simple home activities in the hospital.

Segraves believes that these interventions could be lifesaving. Warning signs of the major postpartum killers—including preeclampsia, stroke, hemorrhage, and infection—sometimes manifest right away, but in many cases they don’t appear until a woman returns home, where they may go unrecognized. The more attention paid to new mothers in the hospital—particularly while they’re moving around, Segraves argues—the more likely providers are to catch these warning signs.

As an example, Segraves told me about a patient she met a few years ago who had suffered a third-degree perineal laceration (a particularly severe birth injury) during a vaginal delivery. At the time, Segraves was primarily focused on providing physical therapy after C-sections, but her team advocated for this woman to receive a PT evaluation prior to discharge. When the woman tried to stand and walk, her blood pressure shot to a dangerously high level. Ultimately, the patient was transferred to the ICU and diagnosed with severe preeclampsia.

Anecdotes like these make a powerful case for universal PT/OT for new mothers. But as yet, there’s no proof that it could affect postpartum outcomes on a large scale. To get this kind of evidence, Segraves will need a clinical trial. So far, she told me, she’s gotten a grant to study physicians’ and therapists’ attitudes toward routine postpartum PT/OT.

Her research is in the early stages, but my conversations with maternal-care specialists suggest that attitudes are mixed. Olga Ramm, a urogynecologist in the San Francisco Bay Area, told me she worries that PT/OT for all pregnant women could be hard to implement universally, “because so much of it really depends on that interpersonal relationship and connection between the patient and the therapist.” Funding is an issue too: Physical and occupational therapists are licensed professionals whose services aren’t cheap, and many hospitals are already strapped for cash and staff. Adding a PT/OT evaluation for every hospitalized patient “seems like a fairly expensive way” to bolster postpartum services, Ramm said. Willats, the nurse-midwife, agreed. “The way we educate people should change,” she said. “We don’t necessarily need a different group of people to do that education.”

Then again, physical and occupational therapists may be uniquely positioned to do this work. Unlike doctors, who are usually trained to think about patients as sick or healthy, PTs and OTs are interested in how a person’s body serves her in her daily life—what Segraves calls “roles and routines.” This means seeing a new mother as someone who is about to return home in a changed body, who will need to lift, rock, and soothe a newborn; perform heavy chores such as cleaning and laundry; and perhaps breastfeed that newborn, whose kicking feet land right on a fresh C-section scar. PT/OT is about helping her adapt to all of these changes with intention and care.

Doctors and patients tend to think of physical therapy as primarily a set of rehab exercises that help a patient recover from an injury. But another way to view PT and OT is as an opportunity, inside the overwhelming world of the hospital, for a skilled professional to see and treat the patient as a whole person. Segraves told me the story of a young woman with a high-risk pregnancy and a prolonged hospital stay, during which baby gifts from friends and family piled up around the room. After several agonizing weeks, she delivered a stillbirth by C-section. A few days later, Segraves watched as an occupational therapist sat by the patient’s side, helping her fold all of those tiny newborn clothes, tucking them neatly back into gift bags for her to take home. At that moment, Segraves said with a touch of awe in her voice, the young woman was “more functional than any of us had seen her up to that point.”

When I consider this story, I can’t help but recall the therapists strolling the hallways of my residency hospital, asking my patients questions I’d never bothered to address—about their home, their life, their “roles and routines.” Really, the questions they were asking were much deeper—and exactly the ones that are central to new motherhood: How will you manage in this new body, this new life? Who will you be?