I remember the exact moment of excruciating pain when the well-meaning L&D nurse cranked back on my leg. I told her it hurt worse, but she misunderstood me. And she kept cranking. The pain was unbearable. And I was in too much agony to be able to voice any protest. So I kept pushing. My baby was crowning. I was about to meet him. I pushed through the pain.
The nurse thought I was just talking about my son’s crowning, which was true, it DID hurt far worse than my first two. But the reason it hurt so much more – was because it was also severely damaging my hip, not to mention increasing pelvic floor tension and closing down the pelvic outlet.
It was excruciating, and I’ll never forget it. My now reconstructed hip won’t let me. It’s a constant reminder of a catastrophic injury and over 3 years of chronic, debilitating pain – that was entirely avoidable. I don’t wish that kind of pain or disability on anyone, and this post is one of many dedicated to helping other women avoid the injury I experienced.
The take home message is, leave her legs alone.
During birth you are at risk for hip labral tears, especially if someone is is manipulating your legs. So labor and delivery (L&D) nurses, birth partners, and other staff, keep your hands off a mom’s legs.
No pushing the legs back during birth, no grabbing the foot or leg and pushing. It not only increases the risk of hip damage. It also closes down the pelvic outlet (contrary to popular belief that it opens the outlet) and increases perineal tension, which exponentially raises the risk of tearing.
If you want to learn the hard science on better birth positions, read this post from Evidence-Based Birth: Birth Positions: The Evidence.
In a previous post, I also discuss The Importance of Early Intervention in Labral Tears.
Pregnancy brings with it a bevy of physiological and hormonal changes. They greatly influence orthopaedic health, not to mention psychoemotional well-being. However, what has historically been overlooked is the risk at which the acetabular hip labrum and related structures are placed during pregnancy, labor, delivery, and the postpartum. Hip labral tears are debilitating and painful, preventing normal ambulation, ADL completion, or participation in any recreational activity, including sex. Tears can also lead or contribute to pelvic pain, with the average time of injury to diagnosis being an average of 2.5 years. This delay in diagnosis can put mothers at high risk for developing chronic pelvic pain, and yes, put them at higher risk for a labral tear, among other serious disability.
Several theories have been posited as to why pregnancy and being a new mom brings a higher risk of hip labral tears. Increased joint laxity (hyper mobile joints) has been widely debated but is generally accepted as a plausible mechanism in back pain, sacroiliac joint dysfunction, pubic symphysis dysfunction, or related pain. Increased (axial) loading through the joint combined with joint laxity are thought to be compounding factors. These changes alone could explain the presence of a prenatal tear, says researchers Brooks et al (2012).
Unavoidable changes in joint structure and function during labor and delivery also place mothers at higher risk. This means screening for hip joint intra-articular pathology is vital in the clinical setting. Further, forces applied externally during labor can be responsible for hip labral tears. Brooks et al (2012) found 4 of 10 women (all with labral tears) reported a specific incidence during labor, such as a pop, twist, or sudden sharp pain in the hip, that led to their diagnosis of hip labral tear. The range of motion that is most often forced in the hip during labor is flexion and internal or external rotation, combined with abduction. This looks like pushing the legs out to the side and up to the chest. This is commonly done in the delivery room and it should be stopped. It applies torque at the hip joint and can commonly be done by a birth assistant (husband, relative, or health care professional).
What Can We Do?
This problem raises the importance of interdisciplinary interaction in maternal health care since “differential diagnosis of anterior hip, groin, and pelvic pain spans many health care specialties from gynecology to general surgery to musculoskeletal medicine and orthopedic surgery.” The cost that these injuries exact on the healthcare system is ENTIRELY AVOIDABLE, if we would consider these solutions:
- Hand’s off a mom’s legs during delivery. No touch unless she asks for your help. And when she does, do NOT push back or pull her legs out to the side or up to her chest.
- Prenatal and postpartum pelvic physical therapy should become the norm during pregnancy and postpartum. It should be offered to every mother without charge in order to address pain and identify any issues that can cause bigger problems down the road. Pre-existing conditions of the hip and pelvis, such as femoral torsion, femoracetabular impingement (FAI), hip dysplasia, shallow acetabulum, and lumbopelvic instability or failed load transfer can all contribute to the incidence of, and increased risk for, hip labral tears. These could be addressed during pelvic physical therapy, which would offer a great cost savings down the road.
- Screening mothers at highest risk for hip joint pathology and special tests to target the hip labrum and related structures should be considered a regular part of prenatal and postpartum care. Hunt et al (2007).
Since over 80% of women give birth in the United States during their lifetime, the vast majority of women are at risk for hip labral tears. Universal screening and education for hip joint preservation should be made available, through women’s health PT, as part of national agenda to improve birth and maternal health. This would be an excellent start to stem avoidable and preventable pain, injury, and disability for women worldwide.
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About the Author
Ginger has spent 20+ years helping people (mostly moms!) with chronic pain as a physical therapist, athletic trainer, and professional yoga therapist. Ginger is the author of Medical Therapeutic Yoga, now in its 4th foreign translation, founder of ProYogaTherapy Institute, codirector of Living Well Yoga in Healthcare, and most recently ran for State Senate in NC.