From the Guidelines
The best next step in managing this postpartum patient with coccydynia is to initiate conservative treatment, including oral NSAIDs such as ibuprofen 600 mg every 6 hours, as recommended by recent guidelines 1. The patient's presentation is consistent with coccydynia, a condition characterized by pain in the coccyx region that commonly occurs after vaginal delivery, particularly with instrumentation such as forceps. Her symptoms of low back and buttock pain that worsens with sitting, along with exquisite tenderness over the coccyx without erythema, are classic for this diagnosis. Conservative management is the first-line approach as most cases resolve within weeks to months. The patient should be advised to:
- Avoid prolonged sitting when possible
- Use proper posture
- Apply ice packs to reduce inflammation
- Consider using a donut cushion for sitting to reduce pressure on the coccyx If symptoms persist beyond 4-6 weeks despite conservative measures, further evaluation with imaging and consideration of local corticosteroid injections may be warranted. Physical therapy focusing on pelvic floor relaxation techniques could also be beneficial if symptoms persist, as recent studies have highlighted the importance of addressing mechanical injury and tissue laxity in the postpartum period 1. It is essential to prioritize the patient's quality of life and address any potential long-term consequences of labour and childbirth, such as pelvic organ prolapse or incontinence, which can be associated with forceps delivery 1.
From the Research
Diagnosis and Assessment
- The patient's symptoms of exquisite tenderness to palpation over the coccyx following a forceps-assisted vaginal delivery after epidural analgesia removal are consistent with coccydynia 2, 3, 4.
- A thorough medical history and physical examination, including palpation of the coccyx and assessment of coccygeal mobility, are essential for diagnosis 2, 5, 6.
- Imaging studies, such as lateral X-rays of the coccyx, may be indicated to rule out other potential causes of pain 2, 6.
Treatment Options
- Conservative management is the initial treatment of choice for coccydynia, and may include:
- Rest and avoidance of exacerbating activities 3, 6
- Medications, such as NSAIDs, for pain management 6
- Use of a coccyx cushion or seat cushioning to reduce pressure on the coccyx 3, 4
- Physical therapy, including manual therapy and pelvic floor physical therapy 5, 4
- Local injections of anesthetic or corticosteroid into the painful structures 2, 6
- Surgical intervention, such as coccygectomy, may be considered in refractory cases or in patients with evidence of advanced coccygeal instability or spicule formation 2, 3, 6.
Specific Considerations for Postpartum Patients
- The patient's recent forceps-assisted vaginal delivery and epidural analgesia removal may be contributing factors to the development of coccydynia 2, 3.
- A multidisciplinary approach to management, including input from obstetrics, physical therapy, and pain management specialists, may be beneficial in optimizing the patient's care 5, 4.