Last winter a patient of mine, who we’ll call Sarah, shared her birth story with me. She was in the hospital laboring with her first child and everything was progressing as planned. Sarah started to develop strong urges to push and instinctively started to bear-down. The nurse in the room noticed what she was doing and told her to stop. She wanted the doctor to be present for the delivery. Unfortunately, the doctor was not close by and Sarah ended up suppressing her urge to push and waiting almost 20 minutes for the doctor to arrive. When the doctor arrived, he then coached her on when to push. Happily, Sarah delivered a healthy baby.

The thought of Sarah not being allowed to push when she had a strong instinct to sounded peculiar to me. I decided to do some research and look into the literature to find out what the best practices are with regards to coached pushing and uncoached maternal pushing.

As mentioned in Melinda Fontaine’s blog on labor and delivery, the second stage of labor is the time between complete cervical dilation and the birth of the baby. It is accompanied by frequent and regular contractions with an urge to push. There are two approaches the medical team can take at this point, coached pushing or maternal pushing.

1) Coached pushing is when the medical team “coaches” the mother on both when to push and how to push. Commonly in the USA, once full cervical dilation is reached, the woman is instructed to lie on her back and to immediately begin pushing. She is coached to take a deep breath at the onset of a contraction and to hold it while bearing down as strongly as she can for approximately 10 seconds.1 This is repeated with each contraction until the baby is born.

2) Maternal pushing, also known as “uncoached pushing,” is when the woman is encouraged to wait until she feels an urge to push before initiating bearing-down efforts. This urge may not be immediate after full cervical dilation is reached as it can take up to 1-2 hours before the woman feels an urge.1 Only when she does feel an urge to push is she encouraged to bear down. She is not instructed to take a deep breath and hold it while bearing down. Maternal pushing promotes the woman’s spontaneous urge to push; the medical team is there for support rather than direction.

To understand the relative merits of these two approaches, it is important to understand what is actually happening in the second stage of labor. It turns out that there are two phases in this stage. The first phase is called the “latent” phase and it lasts from complete cervical dilation until the woman begins active pushing.1 During the latent phase the fetus passively descends the birth canal. Women may not feel an urge to push during this phase and in the maternal pushing approach they are encouraged to rest and conserve their energy instead. Pushing right away, which is what happens in the coached pushing approach, does not allow the fetus to passively descend, nor does it give the woman time to rest and conserve energy. The second phase is called the “active” phase. As the baby’s head reaches the pelvic floor muscles, a reflex is triggered and the woman starts to feel an urge to bear down, actively pushing the baby out.1 However, not all women will feel this urge, and so the beginning of the active phase can also be recognized from when the baby’s head becomes visible at the vaginal entrance.1

From this, it seems as though the latent phase could be an important part of the birthing process. Research on what happens during “spontaneous” delivery provides more information about the physiology of natural childbirth. For example, in spontaneous deliveries, women tend to choose up-right positions for giving birth, instead of lying on their backs.1 When these women have an urge to push, they tend to wait for the contraction to build to a threshold of uterine pressure ≥ 30 mmHg before initiating pushing.2 They then tend to push approximately 3-4 times during a contraction for an average of 5 seconds, followed by several breaths for approximately 2 seconds each. The women in the study did not choose to hold their breath while pushing.1 It was also found that women do not always bear down with each contraction and the intensity of bearing-down varied. As the second stage of labor progressed, the intensity of bearing-down increased.2 This is very different from routine coached pushing, which includes breath-holding and bearing-down as hard as the woman can for 10 seconds.

So, coached pushing involves encouraging the woman to behave differently from how they would have in a spontaneous delivery – but is this a bad thing? The research mentioned above goes on to suggest that holding the breath and bearing-down for 10 seconds can contribute towards short- and long-term pelvic floor and urogynecological impairments.1 Delaying pushing efforts until the active phase begins (as in maternal pushing) results in optimal use of the woman’s energy, has no detrimental effects towards the woman, results in improved fetal oxygenation, and can reduce the incidence of C-section births.1 Lying flat on the back and hold the breath while pushing can cause a decrease in the baby’s heart rate, resulting in decreased oxygenation.1

They conclude that while coached pushing may result in a shorter second stage of labor, the benefits of maternal pushing may outweigh this time saving.

Given this research, why do women continue to be coached in the USA?  There are multiple barriers with instituting maternal pushing throughout the country. The main obstacles include nurses’ lack of trust in the evidence presented, resorting to old habits by the medical team, and physician resistance to new protocols – but also the patients’ desire to deliver the same way as they did with previous births.1

 

Sarah plans to have more children, however after discussing the literature findings with her, I doubt she will deliver the same as she did the first time.

Please feel free to share your birth story or delivery tips in the comment section below.

 

1. Osborne, Kathryn, and Lisa Hanson. “Labor Down Or Bear Down.” The Journal of Perinatal & Neonatal Nursing 28.2 (2014): 117–126.
2. Roberts, J, and L Hanson. “Best Practices In Second Stage Labor Care: Maternal Bearing Down and Positioning.” Journal of Midwifery & Women’s Health 52.3 (2007): 238–245.

By Lorraine Faehndrich

Persistent pelvic pain can, and often does, have an emotional component.  The pelvis is a part of the body that for many reasons tends to hold emotion, and when that emotional component is addressed alongside the physical components of pelvic pain it can be an effective combination.  

 

If you’re suffering with pelvic pain, or you work with patients who are, you are very likely already aware of the connection between mental and emotional stress and physical tension and pain.  Most of us have experienced that connection in one way or another in our lives.  Whether through an occasional tension headache or backache, or just increased tension in the places we tend to carry it (neck, shoulders, low back, etc).

 

When I say that pelvic pain can have an emotional component, I’m not referring to some abstract connection between the mind and the body, and I don’t mean that the pain isn’t real physical pain, or that pelvic pain sufferers are to blame for their pain.  There is actually a very real physiological connection between emotional energy and the muscles, nerves and fascia in the body.

 

How Emotions Can Contribute to Chronic Pain

 

Emotions are energy that is meant to move through our body in response to events in our lives.  In this way, they help us process, learn from, integrate, and let go of our experiences.

When emotions are flowing in this way, they not only help us move through stressful experiences more easily, they contribute to our health and wellbeing, and they don’t create physical tension or chronic pain.

 

Problems arise when our emotions are suppressed.  This can happen when the brain learns (usually through negative or traumatic early experiences) that certain emotions are a threat to our wellbeing.  When that happens, our brain and body will protect us from those emotions by unconsciously suppressing them, and they do that by stopping emotional flow.

 

There are two primary ways the body can stop the flow of emotional energy.  

 

1. Tensed and contracted muscles:  Muscles can tense in response to certain emotions to stop their flow.  In this way they protect us from feeling the emotions that our brain has learned are threatening to us in some way.  For example, it’s common for men to learn that it’s inappropriate to cry, or women to learn that they shouldn’t express anger.  Those emotions then get “buried” or suppressed in the body.  Chronically contracted muscles can hold back that emotional energy, over time impacting circulation, nerves, fascia, and surrounding tissue.  The neck, shoulders, jaw, back and pelvis are common places to hold emotion in the body, and the muscles there can be contracted for years before we end up with chronic pain. (Our bodies are actually pretty resilient that way.)

 

1. Restricted breathing:  Similar to contracted muscles, shallow breathing or holding the breath between the in-breath and out-breath, inhibits the flow of emotional energy.  If you have a hard time taking a full deep breath, this can be why.

 

Both of these mechanisms are unconscious.  We’re not aware of the emotions themselves, nor that we are suppressing them, until we bring our conscious attention to our body and begin to observe what’s going on.

 

To give you an idea of the impact that these patterns can have over time, you can do a little experiment.  Contract your bicep – nothing too intense, just gently engage the muscle.  Now imagine keeping it contracted like that for a full 24 hours.  Now imagine multiplying that by weeks, months, or years.  At some point, this is going to get uncomfortable, and eventually it will be painful.  And the pain is not going to stop until you relax your muscle.  Now, if you’re consciously engaging your muscle it’s not so hard to stop.  Or if it’s engaged because of a physical issue, a physical and occupational therapists can help you retrain and relax your muscle.  

 

But, if your bicep were contracted in order to hold back emotional energy that your brain is protecting you from feeling, the only way to permanently relax it would be to learn how to allow that emotional energy to flow.   Otherwise, no matter what you do physically to relax and strengthen the muscle, that protective pattern is going to keep kicking in.

 

In other words, in order to relieve the pain, you need to re-learn how to be with your emotions – and more than that, how to show your brain that that is actually a safe thing to do.

 

Chronic tension in the pelvis can be part of a long-term habitual and unconscious pattern of blocking emotional flow in the body, and the first step of unraveling it is awareness.

 

How pelvic floor physical and occupational therapy and mind body healing can work together to relieve pelvic pain

 

As a mind body coach my goal is to help my clients become aware of their unconscious protective patterns (mental and physical), so they can learn how to consciously choose to feel their emotions and allow them to flow.  When the brain no longer perceives emotions as a threat, because it has been retrained to recognize that they are actually safe to feel, the muscles can relax.

 

(Remember, flowing emotions don’t cause chronic pain, suppressed emotions do.)

 

Depending on the level of negative early experiences or trauma a person has been through this can take varying degrees of time and support.  But it all begins with awareness, re-connecting to the body, and a willingness to be present with sensations – a little at a time, in a way that feels safe and supported.

 

And what I have seen is that physical and occupational therapy can help tremendously with this process!  Especially if the physical and occupational therapists is aware of the potential emotional component of the physical pain, and actively creates an environment where it is safe to allow emotions.

 

Creating a Safe Space for Emotions

 

If emotions start to move, or release, as a result of physical and occupational therapy, it is a great opportunity to learn how to be present with the sensations of those emotions and process them in new and healthy ways.

 

When the patient and practitioner work together to create a safe environment, emotional energy can flow and contribute to the healing process.  On the other hand if the environment feels unsafe, emotions can be suppressed and can hinder the healing process.

 

How to Allow Emotions to Flow

 

If you are already working with a pelvic floor physical and occupational therapists, and you suspect there may be a mind body component to your pain, here are some tips for working with that during your sessions and during any home practice that you’re doing – like stretching, using dilators, massage, etc.

 

1. Intend:  Set your intention to allow and be present with the sensations of your emotions in your body as they arise.  Simply being aware that emotions may come up and at the same time willing to feel them is a huge step in the right direction.  When you have that intention, you’ll naturally be more aware and welcoming of any emotional sensations that do arise.  

 

1. Breathe:  During your sessions (and during any home practice) maintain a gentle continuous breath into your low belly.  You don’t have to do this perfectly at all!  The idea is to stay present in your body and allow any emotions that may come up to flow.  If you notice you’re holding your breath or your breathing has gotten shallow again, simply bring your breath gently down into your low belly.

 

1. Track Sensations:  Keep your conscious attention on the sensations in your body paying particular attention to sensations that seem connected to emotions.  If you notice any emotional sensations like heaviness, dense or sinking feelings, tightening in your chest or belly, tingling or swirling, hot or cold; or you feel tears or anger swelling up, be curious about the sensations, allow them, and keep breathing.  You don’t need to understand why you’re having the emotions.  For now, just being willing to be present with the sensations of them is more than enough.

 

1. Maintain Good Communication:  Don’t push through anything that feels uncomfortable. Stay in communication with your PT.  If anything hurts, feels uncomfortable or overwhelming – physically or emotionally, let your therapist know.  Learning how to honor your body and go at it’s pace can go a long way to creating the safety you need to be able to feel on an emotional level.  

 

1. Get Support:  Consider getting support from a mind body coach or therapist who can teach you how to start feeling emotions in your body as they surface.   A mind body practitioner can help you process emotions in new healthy ways that won’t contribute to physical tension and pain.

 

Because of the nature of pelvic floor physical and occupational therapy most therapists will already be creating a welcoming and safe environment for their clients.   But if there’s anything else you need to support your staying present with the sensations in your body don’t hesitate to ask.  Most of my clients find that their physical and occupational therapistss are more than happy to support their mind body work when they do.    

 

If you’re a physical and occupational therapists or other bodywork practitioner, simply being aware of and creating space for this mind-body-emotion connection, and the potential for emotions to surface can be a great benefit for your patients or clients that do have an emotional component to their pain.  

 

It’s All Connected

 

We tend to think of the mind, body, and emotions as separate things, but they are not actually separate.  They are all part of one being that is us.  The mind, body, and emotions are inextricably linked, and supporting any one of them inevitably supports the others, creating the optimum conditions for healing and relief.

 

If you’d like to learn more about a mind body approach to relieving pelvic pain – sign up to receive a free Mind Body Alchemy Kit at www.radiantlifedesign.com or register for Lorraine’s upcoming free class, Say Goodbye to Pelvic Pain, accessible by phone or online from anywhere in the world.

 

Regards,

Lorraine Faehndrich

Lorraine Faehndrich is a Women’s Mind Body Mentor and Pelvic Pain Relief Coach specializing in the relief of female pelvic and sexual pain.  Through her company Radiant Life Design, she empowers women with the skills and information they need to understand the connection between their mind and body, allow their emotions, access their inner wisdom, and go on to live radiantly healthy joy-filled lives!

 

By Stephanie Prendergast

 

Vaginal pain. Burning with urination. Post-ejaculatory pain. Constipation. Genital pain following bowel movements. Pelvic pain that prevents sitting, exercising, wearing pants and having pleasurable intercourse.

When a person develops these symptoms, physical and occupational therapy is not the first avenue of treatment they turn to for help. In fact, physical and occupational therapistss are not even considered at all. This week, we’ll discuss why this old way of thinking needs to CHANGE. Additionally, we’ll explain how the “Get PT 1st” campaign is leading the way in this movement.

We’ve heard it before. You didn’t know we existed, right? Throughout the years, patients continue to inform me the reason they never sought a physical and occupational therapists for treatment first, was because they were unaware pelvic physical and occupational therapistss existed, and are actually qualified to help them.

Many individuals do not realize that physical and occupational therapistss hold advanced degrees in musculoskeletal and neurologic health, and are treating a wide range of disorders beyond the commonly thought of sports or surgical rehabilitation.

On December 1st, physical and occupational therapistss came together on social media to raise awareness about our profession and how we serve the community. The campaign is titled “GetPT1st”. The team at PHRC supports this campaign and this week we will tell you that you can and should get PT first if you are suffering from a pelvic floor disorder.

 

Did you know that a majority of people with pelvic pain have “tight” pelvic floor muscles that are associated with their symptoms?

 

Physical therapy is first-line treatment that can help women eliminate vulvar pain

Chronic vulvar pain affects approximately 8% of the female population under 40 years old in the USA, with prevalence increasing to 18% across the lifespan. (Ruby H. N. Nguyen, Rachael M. Turner, Jared Sieling, David A. Williams, James S. Hodges, Bernard L. Harlow, Feasibility of Collecting Vulvar Pain Variability and its Correlates Using Prospective Collection with Smartphones 2014)

Physical therapy is first-line treatment that can help men and women with  Interstitial Cystitis

Over 1 million people are affected by IC in the United States alone [Hanno, 2002;Jones and Nyberg, 1997], in fact; an office survey indicated that 575 in every 100,000 women have IC [Rosenberg and Hazzard, 2005]. Another study on self-reported adult IC cases in an urban community estimated its prevalence to be approximately 4% [Ibrahim et al. 2007]. Children and adolescents can also have IC [Shear and Mayer, 2006]; patients with IC have had 10 times higher prevalence of bladder problems as children than the general population [Hanno, 2007].

Physical and Occupational Therapy is first-line treatment that can help men suffering from Chronic Nonbacterial Prostatitis/Male Pelvic Pain

 

Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) affects 2%-14% of the male population, and chronic prostatitis is the most common urologic diagnosis in men aged <50 years.

The definition of CP/CPPS states urinary symptoms are present in the absence of a prostate infection. (Pontari et al. New developments in the diagnosis and treatment of CP/CPPS. Current Opinion, November 2013).

 

71% of women in a survey of 205 educated postpartum women were unaware of the impact of pregnancy on the pelvic floor muscles.

 

21% of nulliparous women in a 269 women study presented with Levator Ani avulsion following a vaginal delivery (Deft. relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014 Feb 121: 1164 -1172).

64.3% of women reported sexual dysfunction in the first year following childbirth. (Khajehi M. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015 June; 12(6):1415-26.

24% of postpartum women still experienced pain with intercourse at 18 months postpartum (McDonald et al. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015)

85% of women stated that given verbal instruction alone did not help them to properly perform a Kegel. *Dunbar A. understanding vaginal childbirth: what do women understand about the consequences of vaginal childbirth.J  Wo Health PT 2011 May/August 35 (2) 51 – 56)

Did you know that pelvic floor physical and occupational therapy is mandatory for postpartum women in many other countries such as France, Australia, and England? This is because pelvic floor physical and occupational therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex.

 

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse?

 

Physical and Occupational Therapy can help with Stress Urinary Incontinence

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse? 80% of women by the age of 50 experience Stress Urinary Incontinence. Pelvic floor muscle training was associated with a cure of stress urinary incontinence. (Dumoulin C et al. Neurourol Urodyn. Nov 2014)

30 – 85 % of men develop stress urinary incontinence following a radical prostatectomy. Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months postoperatively. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9).

Physical and Occupational Therapy can help with Erectile Dysfunction

 

Several studies have looked at the prevalence of ED. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years. The prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years.1

Physical and Occupational Therapy can help with Pelvic Organ Prolapse

 

In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone a hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. (Susan L. Hendrix, DO,Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6.)

Pelvic floor physical and occupational therapy can help optimize musculoskeletal health, reducing the symptoms of prolapse, help prepare the body for surgery if necessary, and speed post-operative recovery.

 

Did you know….

 

In many states a person can go directly to a physical and occupational therapists without a referral from a physician? (For more information about your state: https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf)

You need to know….

 

Pelvic floor physical and occupational therapy can help vulvar pain, chronic nonbacterial prostatitis/CPPS, Interstitial Cystitis, and Pudendal Neuralgia. (link blogs: https://pelvicpainrehab.com/patient-questions/401/what-is-a-good-pelvic-pain-pt-session-like/, https://pelvicpainrehab.com/male-pelvic-pain/460/male-pelvic-pain-its-time-to-treat-men-right/https://pelvicpainrehab.com/female-pelvic-pain/488/case-study-pt-for-a-vulvodynia-diagnosis/)

Pelvic floor physical and occupational therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex: https://pelvicpainrehab.com/pregnancy/540/pelvic-floor-rehab-its-time-to-treat-new-moms-right/

Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months in postoperative men following prostatectomy. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9). (Link blog: https://pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

A study from the University of the West in the U.K. found that pelvic exercises helped 40 percent of men with ED regain normal erectile function. They also helped an additional 33.5 percent significantly improve erectile function. Additional research suggests pelvic muscle training may be helpful for treating ED as well as other pelvic health issues. (link blog:https://pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

 

….that you can and should find a pelvic floor physical and occupational therapists and  Get PT 1st.

To find a pelvic floor physical and occupational therapists:

American Physical and Occupational Therapy Association, Section on Women’s Health:

http://www.womenshealthapta.org/pt-locator/

International Pelvic Pain Society: http://pelvicpain.org/patients/find-a-medical-provider.aspx

 

Best,

Stephanie Prendergast, MPT

 

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical and occupational therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.