In this podcast interview with Midwife Tanya at The Mother Wit Podcast, you will learn how pelvic floor birth prep works, why Physical therapy needs to be included in birth prep, why quick fixes don't work for the pelvic floor, why I approach things differently, and how you can optimize your pelvic floor for the best birth outcomes.
Tanya is a Certified Nurse Midwife (CNM) who owns and runs a virtual coaching business for women during the prenatal and postpartum period. She is part of their support team during their journey, providing them with education on resources, exercise, advocacy, evidence based advice, and general what if's and how to's.
Tanya and I have been collaborating together for over a year now, and our collaboration started through her online course Thriving After Birth, where she lays out everything a mom needs to know in the very early days postpartum. You can find me in the pelvic floor sections there.
Tanya is such a great asset to our mamas at Flow Physical Therapy and Wellness that you will also see her in the Pelvic Floor Birth Prep Virtual Course. You can check out the course and purchase it here!
1 - How my own journey through pelvic pain led me to become a pelvic floor Physical Therapist
The reason I get asked this question so often is because the gold standard for a true pelvic floor assessment is an internal vaginal exam. In my early years after high school, I ended up moving to LSU in Baton Rouge and changed my major many times, like most people in college. Through my years in Tiger Band and Biochemistry with a minor in Latin, I still did not have Physical Therapy on the mind.
After college, I ended up getting my Masters in Pharmacology through research in the lab on cell cultures and mice at LSUHSC in New Orleans. I ended up writing my thesis on cell targets to prevent hypertension (high blood pressure). It was still not something I could see myself doing.
Then I started getting more into fitness for my own health, and I started having problems. I was having issues with hip and pelvic pain with running and could never figure out what was going on. I was seeing orthopedic Physical therapists and other people who were giving me gray answers. It wasn't until I saw a gynecologist I have a good relationship with who told me the issues are from pelvic floor dysfunction.
I was able to go through the process myself as a patient. I was in a car accident a long time ago as a teenager, where I fractured one side of my hip in three places. It healed but left some limited mobility in that side of my hip, and it pulls on that side of my pelvic floor. That leads to a lot of tension in my pelvic floor, and finding all of the answers to this in my journey made a huge impact for me, and that's what I want to do for my patients.
So after I got my Doctorate in Physical Therapy, I further specialized in Pelvic Health. I love working through both the orthopedic and internal pelvic floor components. I blend both of those so we really address it from all sides.
So we aren't just looking at the hip or just the pelvic floor, but we need to look at both.
Tanya discusses how important it is to find a pelvic floor physical therapist who doesn't just look at the pelvic floor. For example, in the research in knee pain in the postpartum period, people don't realize it's connected to the pelvis and pelvic floor. But our body is a chain, and we are all connected head to toe. It's usually that core and pelvic floor imbalance sending a message to the rest of the body.
Another example I discuss is correcting neck dysfunction in mamas who are pregnant so they can have better spinal alignment and better function over their diaphragm and pelvic floor movement.
We have to be able to look from all points of view. My practice is more holistic, meaning that I look at the whole body so you don't have to see a different specialist for each part of your body, but instead we can put it all together. Using this holistic viewpoint, I have spent the last several years developing a specialist birth prep program in my clinic.
2 - Why we need to include Pelvic Floor Physical Therapy in the birth prep process
To address this, we have to talk about the current healthcare model. You go see your doctor because you have a problem. The doctor tells you what the problem is and makes a recommendation to fix the problem. It's not always that easy when it comes to birth, injuries during birth, emotional trauma, or things maybe not going the way we thought they would go during the birth.
There's a whole missed component in the research about preventing issues or at least optimizing what control we do have in order to mitigate our risk for all these injuries to make our postpartum recovery shrink down in time. Not only does the healing process go faster, but we also have the support of a Physical therapist who is someone that has been with you through the pregnancy who is not just looking at it from the OB or midwife standpoint - such as looking to see if baby is healthy and what medical interventions may be needed.
Not only is this a huge passion of mine because I see the impact, but it's also incredibly rewarding to go through the journey with my moms. I've been working with a mama for over a year through her pelvic pain prior to getting pregnant. When she got pregnant, I was one of the first people she told she was pregnant, and she wanted to continue working with me through the pregnancy, and now she's about to have the baby. I am awaiting the picture of her and the baby, which is one of the coolest parts of working with this population.
3 - Why quick fixes aren't the answer to pelvic floor problems
Tanya explains that quick fixes don't tend to involve those of us who are very hands on - high touch, low tech. That is where we see amazing outcomes, but because we aren't selling a quick fix, no one is willing to put in the effort to do the quality research we need to prove this, so we are always left a little in this gray zone where we only have the data in front of us but not this big giant clinical trials.
That is also true for physical therapy not being a quick fix. You don't come for an initial assessment, and then all of your problems are fixed from the one session. When we are talking about muscles, joints, ligaments, nerves, and even hormones, they don't respond that fast. It's not the same as getting a pharmaceutical option for the issue.
4 - Optimization during pregnancy
Tanya says she also starts helping people with postpartum while they are still pregnant. You can't just detach and say we will take care of you postpartum once you have a baby in your arms.
If we didn't make the right choices that are right for each person, like select the team that's appropriate, we may have missed out on a crucial moment to optimize our postpartum care and well being.
A lot of that in my practice comes from listening to my moms. I cannot count anymore how many times I have heard a mom who is newly postpartum say, "I wish someone would have told me." They almost feel angry because now they have this issue, and they are working backwards through it in their mind. They begin searching google, talking to friends and colleagues, and feel like they missed all of this preparation that was right under their nose.
I've heard that so many times, I took the research into my own hands and pulled data and evidence based treatment approaches from labor, biomechanics, activities to promote baby moving down, exercise research, physical therapy research. All of this has gone into my treatment approach for someone who wants Birth Prep during pregnancy.
This is also the biggest reason I will get a call - a mom is newly pregnant in the late first trimester and wants to know what she should do to prep for her birth.
5 - Why I approach things differently than most pelvic PT's
Part of that reason is because insurance does not cover wellness. All birth prep would be considered wellness, and insurance has dictated that wellness is not worth covering, only sickness later on unless they can prove there is a medical diagnosis. Even then, some of the codes and types of treatments will come back denied without the patient knowing on the front end because not all treatment codes commonly done in a PT clinic are covered even though "physical therapy" is labeled as covered.
My clinic model does not let insurance dictate treatment, and we do not go by the insurance so my patients can have the most quality pelvic health without important parts of the sessions being left out because they aren't covered.
6 - Pelvic floor Physical Therapy during pregnancy versus postpartum
In general, I'm going to start with the person in front of me, meaning I believe in giving the highest quality care for what you are here at the clinic for today. If I'm just seeing you for the first time postpartum, we might spend a lot more time of the initial session going over your medical background history, including your pregnancy and birth. All of that matters to develop proper assessments and treatments.
On the flip side, for someone that I have been working with during the pregnancy, I am able to see how the pelvic floor changes throughout the pregnancy. An example is the mom I mentioned previously. I was able to see the state of her pelvic floor through her injuries, through conception, and how it changed into the third trimester. It followed the research. Her pelvic floor was initially more tense because of some low back and hip problems. As the pregnancy progressed, the pelvic floor lengthened out, which is exactly what we know happens from research due to the musculoskeletal changes.
Since I know her history and findings from her pregnancy so well, we don't have to spend as much time in the postpartum assessment going over what she did in the pregnancy and what her pelvic floor was like, what her aches and pains were, etc. We can start from the birth and pick up where we left off. Plus, she has already been taught how to do a lot of the foundational exercises and rehab from the pregnancy, so she already understands these concepts that we will begin postpartum.
So the treatment plan for someone who came during pregnancy or started postpartum isn't going to be different, but it's just going to have a really different feel because you intimately know how they responded to the treatment before.
7 - Preventing injuries
According to what we know from research, the injuries should be a little bit less and healing times should be shortened if they have been doing the work during pregnancy with PT and other birth practitioners.
We can't control everything. Things can come up even with the most optimal birth prep, and you can still have some kind of vaginal tear or things not go the way you planned with an emergency c-section.
BUT there are things in the physical therapy research that we definitely know prevent severe injuries. It is interesting to see that my trends have also followed this research. Working on pelvic health during pregnancy leads to better outcomes postpartum.
Tanya says we can skew the statistics the way we want to see them go even though we can't control everything.
8 - What a Pelvic Floor Physical Therapist brings to birth prep
Yes! I don't teach specific childbirth education because those teachings are better done by people who have trained in each of the fields, and they are pretty abundant online and in the community.
What I haven't seen is specific education on what's going to happen to the pelvic floor, what is supposed to happen to bones of spine and muscles of the abdomen and back, what should you do to prevent these issues to the pelvic floor, and what should you know about the healing of the pelvic floor. This information is not really out there, and it's not easily accessible.
When a mom comes to me, I'm going to do a full musculoskeletal assessment - how she's moving, what her lumbar/thoracic/cervical spine mobility and stability is like, orthopedic motor control - and then we start putting these things together with how the pelvic floor is interplaying. We are going to assess her current issues, clear up these issues that are already present - like peeing too often or leaking. Once those issues improve, we move towards being able to address healthy pelvic floor movement that is required for pushing and optimizing your risk for injuries.
We'll address things like labor positions specific to you, how to relax your pelvic floor, how to push, when to practice kegels, what to do with your body and pelvis during birth, as a few examples.
I have my mamas practice with me because many do not actually understand how to contract their pelvic floor when asked or how to relax it, and we have to get this right to be able to optimize our risk for birth injuries. As many as 1 in 6 women do not contract their pelvic floor correctly when asked to kegel according to the research. But after proper teaching, 78% are able to do it correctly in a short time.
This is a BIG topic of birth prep because bearing down, kegeling at the wrong time, and not being able to relax your pelvic floor is a huge risk factor for vaginal and perineal tearing and spinal injuries during birth.
Tanya states that she has also noticed in her practice when asking people to kegel how much variability there is with using these muscles properly, and it can take some time and explanation with some people.
9 - Pelvic Floor Birth Prep as an addition to traditional childbirth education
Remember this is not Lamaze, The Bradley Method, and I'm not a doula. We are specifically honing in on the musculoskeletal system with pelvic floor physical therapy.
Of course things come up that are not just about muscles and joints - like should I get an epidural - and my job is providing you the education for what these things are and what the benefits and risks are for your pelvic floor and your birth. Then you are armed with the knowledge so you can advocate for your own decisions.
So part of this is also in advocacy - teaching people to be their own advocate. Like asking "Should I have an episiotomy" is a jam packed question. We can give you the statistics and what the current evidence says is appropriate for the use of an episiotomy and why or why not, but it's ultimately you who makes your decisions, and hopefully you are armed with this knowledge before the birth.
I believe in being a support practitioner and making my moms feel comfortable with their decisions and not telling them what they HAVE to do. And if something has gone a little out of the PT scope, I refer out to the rest of the birth team, like Tanya.
10 - Why a team approach makes for the best care
As OB's and midwives, Tanya states they have a responsibility to say that something in their exam is actually a musculoskeletal issue, and that's not in the midwife/OB scope, so let me get you to the Physical Therapist. Likewise, if there is something gynecological going on in the PT office exam, we also refer back a trusted midwife or OB.
This is answering the question of what is in the best interest of the patient. As a Doctor of Physical Therapy, we have to ask the question, "Is this musculoskeletal, or is it not?" That is an answer we should be able to get to with our exam. If things don't add up - like in the case of undiagnosed endometriosis - it's my JOB to get you to the right referral sources who can confirm so we can work together and improve your care from all sides.
Endometriosis can present as significant pain with sex, which is why this person would come to me. However, if the person has not been evaluated by a gynecologist for bacteria and yeast testing, manual exam to make sure everything is in its right place and there are no other pathological reasons for the pain with sex, that has to be done. There are SO many things that can cause pain with sex. If the gynecologist can confirm that those things are all negative, and it likely is endometriosis causing the pain, I can be more sure now we are dealing with just the muscular effects of this disorder and not pain caused by pathogens, cysts, or abnormal pap, for example. And that's proper practice.
Tanya further explains differential diagnosis, a term that encompasses what any healthcare practitioner is trained to do in their scope and something consumers should understand. We take all of the information, and start creating hypotheses, and any information we gather should help to rule in or rule out each of these hypotheses. What you are feeling with your symptoms could be any one of these things. Every piece of information from what you tell us and from the exam helps us knock something off the list.
That is the purpose of the evaluation. Even though you may not receive a lot of treatment yet that day, we cannot properly design a treatment plan without ruling in and ruling out what is going on. With physical therapy, that looks like figuring out if this pain with sex is because of a muscle or muscles in the pelvic floor, or is it because of dysfunction in your lumbar spine or hip? What's the true driver, and what is the victim, and let's answer that question for proper treatment.
11 - How partnerships should be forming amongst birth practitioners
In a perfect world, every mom deserves a referral to a pelvic floor physical therapist for at least one assessment to see what the state of the pelvic floor is and to be sure the mom knows how to use the pelvic floor correctly for birth.
I would love for all of those professionals to work together instead of people feeling like they have to choose. I'm not a doula and do not crossover into that role. It would be wonderful to have the mom work with ALL of these different types of professionals for their birth team and make a really wonderful, comprehensive, robust birth team.
Research shows that the more we have a team and the more you are educated, the more support and empowered the mom feels. Typically when you are more empowered about your birth, the better prepared you are, and the better the outcomes are.
12 - Can you tell us a story or a global concept that you encounter in the healthcare system that you think is just not cool, something that a provider should not do?
Yes! Hearing from my patients who find me anyways because they still have this problem - that when they brought it up to the OB - they were told, "Don't worry about it. It will get better." And then they feel insecure and like it's all in their head.
Months go by way beyond the 6 week postpartum check, and they still have this problem that is now potentially worse. The OB's are trying not to make unnecessary referrals for these new moms if their problems are just going to go away and be labeled as "normal".
What is problematic here is that these problems are in fact NOT normal. Leaking pee postpartum and pain with sex is NOT normal. However if a client is ASKING for a referral to PT, and they are curious about it. Why are they being denied?
Tanya says what is even more problematic is all the people that couldn't find me or didn't later get access to pelvic floor physical therapy when their problem persisted. There are plenty of people with grown children who say, "Oh I just have to live with it" or "I could never jump on a trampoline without peeing on myself." And this is because their provider hinted at or explicitly stated, "This is your new normal." Which is NOT true and not normal.
Pelvic floor physical therapy treatment is actually much more conservative and safer than many other medical options for these problems that moms are being offered way later on, like invasive tests that are uncomfortable, surgery, and medications.
Tanya wants everyone to feel really empowered to build a team for yourself where everyone is on the same page and you are encouraged to see a PT before you have a problem. That is a sign of a really awesome provider.
Dr. Mel is accepting new clients for in person and virtual Pelvic Floor Birth Prep at her clinic in The Woodlands, TX.
Dr. Melissa Thompson, PT, DPT, MTC, PCES, FAMM
Pelvic Health Physical Therapist
Flow Physical Therapy and Wellness
Blog originally written in 2020.
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