#32 “Push Like You are Pooping” with Dr. Q, PT

We are thrilled about this episode. We’ve been talking about this. Dr. Q has been on our list since the beginning of us putting together like our dream podcast list, and we have her here today. I’m going to let her introduce herself in just a second, but I wanted to give you a heads-up. We have Justine’s alter ego in the room with her really ridiculous sounding voice. So, you’ve been warned that she sounds a little rough. She feels fine, but when you hear the half man, half somebody else on this call, then that’s Justine. So, we are super excited to have Dr. Q here. We are going to talk all things pelvic health, pushing, saving the pelvic floor. This is an area that I have gotten passionate about in the last few years.

If you’ve taken our physiologic birth class, you’ve heard me tease out pelvic floor, pelvic health stuff. But what I love about this today and what I’m excited about today is for us as nurses to start thinking outside of just the labor room. Because while that day is so important and yes, it influences the future of their lives, there’s a lot that happens coming into the labor room and then there’s a lot that happens when they leave our labor rooms and leave the hospital. My guest is Dr. Q, you see some of that. So, I think we need to start thinking bigger picture spectrum of health.

What does health and walking away complete look like and intact look like when we send them out of the hospital? So why don’t you just introduce yourself and then we’re going to jump into some questions, but we’re so excited to have you here. We’ve been itching about it. Ooh, yes.

You’re so sweet.

I can’t wait to talk to her.

I’m very grateful to be invited and I love how open you all are to including this information. Of course, I’m bias. I think it’s super important, but I know for a lot of people, this is probably one of the first times we’re hearing about this, so I’m happy to be here. My name is Q, like the letter, short for Quozette. I have a doctorate in physical therapy, so I have a clinical doctorate for that. I did my undergrad at San Diego State University and I did my doctorate at Chapman. I’ve been a therapist for I guess going on eight years now. My first almost three years was in orthopedics. Most of my training during school was in orthopedics. After about three years of doing that, I switched over to doing pelvic health full-time and I haven’t looked back.

Within the first year of me doing pelvic health full-time is when I stumbled into the birth world because of how much disparity and difficulties people are having in postpartum. Well, when I was new in my career, pregnancy as an orthopedic therapist was one of the most frustrating things for me to teach or to treat. I was just intimidated by it. I was like, “Well, isn’t this all going to go away once you’re not pregnant? So what do you want me to do about it?” Little did I know there’s tons we could do for it. Then when I made the leap into pelvic health full-time, I really didn’t love working with postpartum. I was like, “Oh, my gosh. It’s picking people off of the floor and just trying to help them get their life back.”

It can be sad but also fulfilling, but it takes a lot of patience and everybody’s coming in at a different starting point, whether it’s six weeks, six months, six years, right? Once you’re postpartum, you’re always post-partum. I just got really frustrated with those outcomes and that’s when I started talking to more doulas and following more midwives and looking into, “Well, what’s going on in the birth spaces that people are coming from and why aren’t the OBs referring?” A lot of our referrals come from word of mouth or friends of a friend who happened to benefit from therapy. So, I just got really frustrated with that. So, I tried a different route and I took a postpartum doula training.

I don’t offer the services because with what time, but I learned a lot about how to support somebody through that transition non-clinically, which then I think really helped me reshape the clinical parts of postpartum rehab. That actually to me helped make the work a lot more grounded. Long story short, I ended up taking a child birth education class. So, it really did just spiral. But in any case, I am a physical therapist specializing in pelvic floor dysfunction and I teach child birth education to work with a ton of doulas. I do doula trainings, podcasts, whatever, to get this information out. So, thank you for the opportunity.

Amazing. What does a normal day look like for you? What does a pelvic health physical therapist look like? What do they do? We have no frame of reference otherwise.

So I feel like I’m part physical and part psychologic therapist.

Totally.

Maybe cognitive behavioral therapist. So, for me, I work 10-hour days, so I work three 10-hour days and a half day on Monday, which is why I’m able to record this morning. But that looks like a full day is I think 13 patients from start to finish. We do 45 minutes a session. I don’t use any aides. Aides are unlicensed. Usually, they’re students or interns, and we use instead PT assistants or codas. We have some OTs, so I use OT assistants and they’re licensed. So, we take a lot of the same CE courses. We mentor them a lot. So, you’re looking at 13 patients a day. Some of those, I’m coaching with the assistant, depending on if they have time. A lot of that I would say is follow-ups. I think we cap it at four new patients a day just for our mental sanity and capacity.

Yeah, 45 minutes with each person asking them about the most intricate and vulnerable parts of their day, their bladder habits, their bowel movements, their sexual health or their sexual life, their reproductive health, their menstrual cycles, their birth experiences, their traumas, their surgeries. We do treat people with penises, so we do treat male anatomy just as much as female anatomy, because everybody has a pelvic floor. So, we might see some prostatitis, some pain with ejaculation, erectile dysfunction, those things. So, in terms of variety, it’s all there, but I’m pretty much on autopilot getting my patient, getting them back, asking them how they’re doing. They undress if we’re doing internal, always with consent.

Then we might do some hands-on. I’m a very heavily manual therapists, so I do a lot of orthopedic manual therapy, myofascial therapy, visceral manipulation, especially for people with a lot of abdominal or pelvic pain or congestion. Very helpful to do some visceral work with them. So, yeah, it’s hands-on, hands in sometimes depending on what we’re working on, lots of education, exercises. Then once we’re done and we either progress or review what they need to be working on, whether it’s retraining their bladder, looking at their bowel routine for constipation, pelvic floor exercises, we work on their treatment plan and then on to the next. Then it’s pretty much a circle, a cycle like that.

So, I think every three to four patients, I take a 15-minute break to drink some water, get a snack, go to the bathroom, try to take my own advice about health care. Then it’s chunks of three or four patients. Then of course, there’s charting. So, we take insurance. We’re one of the only practices in our area in Southern Los Angeles, I guess we’re in South Bay, LA and Long Beach, we’re one of the only practices that takes insurance, so we are charting as well.

Oh, that’s a lot.

It’s an autopilot type of thing, but because we get so much variety and because I’ve been doing this for a while, it’s help as many people as you can, get as many people in the door as you can, and make sure that they understand what they’re here for and that they feel like there’s a benefit to it. That’s pretty much it. It’s straight up patient care, front to back.

Love it. How would someone know that they needed somebody like you?

Well, if you think about the functions of the pelvic floor and the systems that they work with, pretty much anybody with bladder issues, bowel issues or sexual dysfunction or reproductive difficulties, whether that’s pain with intercourse. We treat patients who are dealing with fertility issues. I wouldn’t say we treat the fertility issues per se. There is plausibility that some of the techniques we use can help with fertility, but that is obviously going to be taken with a grain of salt depending on the research that you look at, because nobody wants to be the Guinea pig when it comes to fertility, right?

Totally.

Anyways, so yeah, I would say pretty much if you have anything going on with trying to empty your bladder, whether there’s pain, difficulty, bleeding, hemorrhoids, constipation, straining on the toilet, feeling like you’re not completely evacuating. Those are all things that we work with and look at, because when you think about what those parts of our bodies have to do, they’re excreting. I know it’s a bunch of nurses listening to this, so we’ll use the big words. We are excreting or emptying those hollow organs and those contents have to pass through a very important layer of muscles called your pelvic floor. When somebody says pelvic floor dysfunction, that can mean weakness. That can mean lack of endurance or coordination.

That can mean pain or overactivity. Whenever there’s a change in a muscle long term, then you start to transition into dysfunction where now the muscle is not behaving the way that it should. So, there’s pain or symptoms or difficulty with any of the systems that it works with. So, I think that’s a long way of saying treat everything, overactive bladder, stress incontinence, urgent incontinence, urinary frequency, nocturia, so waking up more than once a night to empty the bladder, feeling like you can’t make it, constipation, straining on the toilet, rectal pain, pregnancy, postpartum, and all the fun stuff that comes with that.

So, prolapse, diastasis. I mean I don’t think anybody wouldn’t benefit from coming in at least once in their life. So, that’s the hard part of answering that question is how do you know you need a therapist? Don’t we all need a therapist? I mean even mentally, if we all had access, wouldn’t that be nice to just have somebody in your corner?

Totally.

So who would benefit? Everyone who needs consistent therapy, that depends on what you’re experiencing.

So transitioning to our world, the birth world and honing in on that and your work, what are some of the injuries that you see that we have no idea happen? That I teased out at the beginning that I think we are on autopilot even when we’re pushing. I do have some frame of reference for this and I do see clients postpartum, but most labor and delivery nurses are never going to see their patient again. They’re going to have zero idea what happened in their postpartum experience. So, I think it’s important for us to know what are some of the things that you’re seeing maybe as a result of their birth.

So, I would say one of the most obvious to me but probably not to nurses is hip injuries or pelvic girdle issues. I’m not speaking about all facilities because I don’t know how all facilities work, but specifically a lot of facilities that require somebody to push on their back and full lithotomy, full hip flexion, a lot of external rotation and abduction of the hips. Depending on how long second stage is and depending on how aggressively either partner on one side, nurse on the other side are supporting the limbs, the legs, you can have some femoral nerve compression, you can have some femoral acetabular impingement, so hip impingement, which is a joint issue or maybe even a labral tear.

So, that I would say is something that is commonly not discussed, because depending on the severity again of how long they had to push for and if the baby got stuck and they had to change positions midway, there’s a lot of other factors obviously, but just the sheer requirement of that positioning during trying to create so much force for pushing a baby out, it’s a lot of pressure on the joints. So, sometimes we’ll see, like I said, those hip injuries, but also with the pelvic girdle because the pelvic girdle itself is the innominates fused together in the front by the pubic joint, the two SI joints in the back.

So, when there is asymmetries in that from, again, an imbalance in the posturing and the prolonged pressure on the hips with pushing, you can see some pubic synthesis dysfunction, pelvic girdle pain either in the pubic area and the groin or sacroiliac dysfunction or pain, which is pain. People will say their low back or maybe their tailbone, but it really is like that SI joint. Anytime anybody says, “I have tailbone pain,” I ask them to point with one finger, where do you feel the pain? Not majority of the time, but a substantial amount of times, they’re not actually on their coccyx, right? They’re like on their sacrum or their lumbar spine. So, just trying to differentiate that.

But those I would say are the more obvious ones to us and that might not be obvious to nurses because you’re trying to get the baby out. It’s nobody’s fault necessarily. I did have one patient who at one point during her pushing, the nurse abducted her leg a little bit quickly and she felt a pop. It blew my mind. We don’t use metrics. I’m trying to convert in my head. I want to say it was a 30-millimeter pubic synthesis separation and she was in a wheelchair for a year. So, I won’t name the hospital and this was I think her second baby, but yeah, couldn’t walk, couldn’t stand up after the kids. So, there’s a lot that happens I think to the pelvic girdle in terms of the joints and the hips in terms of the joint and the nerves there.

Then of course, there’s the injuries to the pelvic floor. I mean you all know about perineal tearing, grades one through four, but then there’s also maybe some nerve traction there, some nerve injuries. So, anytime a nerve is on prolonged stretch, there’s ischemia, hypoxia, you’re not getting blood to those tissues. So, you might have increased risk of tearing, but also a change in the sensation. So, sometimes people have a difficult time achieving orgasm in postpartum. So, they might have delayed or dampened sensations with erection, arousal, and climax. They might not even be able to achieve climax, or if the nerves are sensitive or irritated, they might have pain with orgasm or after intercourse. So, that’s another thing that I think is less commonly understood. What else?

Nerve injuries, tearing. Ig try not to scare anybody. I don’t want to fearmonger your people and be like, “Everything goes wrong in there,” but I do appreciate you saying it is hard because you’re in there with a certain purpose. When I teach childbirth and when I educate patients, I always say nurses are humans. They’re on a shift. Their responsibility is to keep you safe. They have a license to protect. They have things that they have to document, and you don’t know how many other people are in labor when you are. You don’t really know until you’re there and try to acknowledge and level with the fact that everybody’s doing hopefully their best. You want to at least believe that at a baseline, right? But yeah, this is a grain of sand in their hole.

They were pregnant for hopefully at least 9 to 10 months before they came into that point, and they have these expectations. They’ve been working really hard. A lot of my patients who are in therapy from 20 weeks pregnant or even before that were lucky and they’re in here in their first trimester. They are putting a lot of effort into achieving an experience that is positive and to them is going to be one of the best days or hopefully best days or biggest days of their lives. To the staff, it’s another shift. It’s just how can we do this safely, efficiently? It’s not always patient-centered unfortunately and sometimes it can’t be depending on the risk associated, but for the most part, I definitely think that it’s a very brief but significant time in somebody’s journey.

If we just think a little bit more about what happens when they leave the hospital, maybe that will start the wheels turning of how can I change my approach to this by just being more informed of what can happen and how to help her. I do have to say just changing the hips though, I know people are going to ask, “Well, how do we not do that?” Give the hips a break. If they’re pushing for more than 45 minutes, take some pressure off of the front of the hips by coming out of that flexion until the next push, right? Jiggle the legs a little bit to get some blood back, especially if they’re on anesthesia. You have to almost go back to baseline thinking about anatomy and tissues. How do tissues get damaged?

They don’t have enough blood and they’re stiff because they’re not moving, right? Twenty-four hours of bedrest, you’re already looking at the onset of muscle atrophy. So, imagine being in a certain position for several hours during labor and then trying to push this baby out and putting all this pressure on your joints. So, motion is lotion, and as much as you can, try to let people move and shift and listen to their bodies.

Well, and I think this is very much a system-wide issue with hospital birth as far as how we’re just trained and taught. We just don’t know better. Once we know better, we can do better. I’m thinking of these nurses listening and thinking, “Okay, so what I’m hearing is that we need to change positions regularly.” My question for you is how regularly and giving the hips and even potentially the pelvic floor a break by shifting the weight, jiggling, thinking about circulation, or even I think about nursing 101 as skin breakdown.

We don’t ever have to deal with pressure, ulcers in L&D, but other places they do. So, if they’re on their butt for two hours, they need to shift weight. I’m also thinking, okay, but how do we this in a way that is subtle enough working with a team that maybe isn’t as educated as these nurses are going to be after this episode? Any strategies for that?

Yeah, I mean, if you’re looking at just general guidelines, we should be moving at least every 45 to 50 minutes. Going about an hour, not moving intuitively, you don’t sit and watch a Netflix show and not move for an hour. I mean, you might, but something falls asleep, something goes numb, and you’re like, “Oh, no, got to shift my weight.” So, I would say a good baseline is at least every 45 to an hour. Now, that depends on how active labor’s going.

So, I think a good starting point would be if most nurses started training on physiology of labor and the science of how that works uninterrupted and then being more judicious about the things that you add to that process to help speed it up or augment, looking at ways to do that that is person oriented as well as physiologically aligned with what the body’s trying to do, which the physiology of labor essentially comes down to somebody being in a very primitive state, like a primal sense of it’s your nervous system. Your nervous system is telling your body to do something very specific, and it cannot focus on that if you are not feeling supported or if you are not feeling heard or validated because of what that does to oxytocin.

If whatever I just said in the last 10 seconds flew over your head, let’s start there. Let’s have you understand what I just said. So, that you understand what you’re training medically is for and who it serves, and then you can be more judicious about who you’re applying that to when you’re in the L&D room. I can’t tell nurse how to do their job because I know that they know how to do their job and there are factors that they’re looking at. Don’t ask me the last time I took vitals, first of all. I get that there’s a method to everything too. I’m not anti-medicine obviously, but I think where things get muddy is that you lose sight of what that person’s body is going through and what their nervous system is trying to acclimate to. All the input to that person’s system, their brain is trying to process.

If you don’t understand what that physiologically looks like and you don’t know how to support that and not just how to support it, but how to switch gears, maybe we should try a new position or I know you said you wanted to do this unmedicated, but your body language, I could tell that you’re not here. You’re not able to rest. You’re not able to listen to your body. Do we want to consider some pain management options? So, we’ll talk about epidurals later, I’m sure, but there are people who pigeonhole themselves into thinking their birth is going to go one way. When they don’t get that, they have no other options because they didn’t think about any other options.

So, my whole thing is if you’re the nurse in the room and you have this toolbox, it’s not so much what should you add to that to do things better? It’s how can you look at what you have and be more careful with what you select and offer to that person? Are you able to explain it in a way that they hear you and understand why you’re offering that that is right free of coercion, free of negative language, that feels more like empowerment and not fearmongering? I think that’s where that starts, because once you have that, then you understand how all of this affects the pelvic floor because nobody’s going to relax their pelvic floor to help a fetus descend through the pelvis and push it through the birth canal when they’re in constant fight or flight because they feel like they’re in a ton of pain.

Nobody’s listening to them. They cannot get comfortable. It’s been 48 hours. They can’t feel half of their body because the epidural worked on the left side but not the right, but they can only get the heart rate when they’re on the left side, so they can’t move. I’m telling you, I’ve heard it all. So, there is no one size fits all. A lot of this comes with time and experience and wisdom and listening to other more experienced nurses or birth workers who have seen all the ways labor can go. So, you understand you can’t force a square into a circle. Just because we know Pitocin works doesn’t mean we have to use it with everybody, right? That’s a big thing I know nurses are taught.

Then the last thing I would say is understanding physiology, but understanding pain, which was supposed to be my topic at a specific conference later this summer. But pain being the “fifth vital sign” and nurses being taught that we don’t want that. We want to make it go away. Pain is just not something we want our patients to have to deal with because it gets in the way of things. But pain is more than a symptom or a sensation. It is an experience. Pain doesn’t exist until your brain goes, “Yeah, that hurts. That doesn’t feel great.” That’s why people who have spinal cord injuries or nerve damage can’t feel certain things or their muscles don’t behave the way they’re typically supposed to.

So, when you’re not able to help support somebody in their processing of pain by either educating them on what’s going on with their body and giving them the options of how to manage, you’re going to set them up already for just an uphill battle of, “Well, it hurts. I don’t know what you want me to do about it.” Then to not offer let’s change positions or do you want an ice pack or do you want me to dim the lights or do you want to stand up? Should I get the birth ball? I don’t know. There’s so many things you could do that I’m never going to sit here and be like, “Here’s the method. Here’s the algorithm.” There is no algorithm. Look at your person, not your patient, your person. How are they managing? Are they able to make eye contact? Are they clenching their fists at every contraction?

Are they holding their breath? All of those things that we do when we’re nervous and anxious, that’s not what the body needs to birth a baby. So, I don’t know. I think for nurses, go back to basics, right? Before you even add all the pelvic floor stuff, I could teach you how to do a Kegel in 10 seconds. I could teach you how to push a baby out in 10 seconds. If you have difficulty with that, there’s some other stuff to unpack about maybe your bladder habits, your bowel routine, and all that, your reproductive history. But learning how to use that in the arena of L&D, that’s on you. That’s to look at. What’s standard, what’s working, what’s not working, and what are your outcomes and are you satisfied with those?

Well, thank you for teasing out both our physiologic birth class and physiologic coping, whether you knew it or not, which is happening in Cancun in two months, because that is entirely-

Cancun.

… the whole point. I know we’ll have to talk about it.

Oh, wow.

That really is the entire point of where physiologic birth started and even talking about pelvic floor and pelvic health and fascia and ligaments and what’s happening down there and then also, what is the physiology of pain and how do we help them cope and give nurses a toolbox to understand what’s happening in the body and in the nervous system. That’s why we’re bringing a psychologist, all of that. So, with that being said, you mentioned education that you could educate someone to push in 10 seconds. I would love to hear your take on if you were educating us nurses, what do you want us to say when we’re teaching someone how to push?

So, what you typically say, which I know, is hold your breath and bear down like you’re having a bowel movement. Hold your breath and push like you’re pooping. So, the first thing I would say is maybe not lead with hold your breath. So, we’re going to have that cue of exhale or vocalize as you push, the moaning, the low tone sounds to help the pelvic floor relax. The thing about holding your breath and bearing down, first of all, is that a lot of people are constipated and they don’t know it. Whether that is because of digestive issues, whether that is because of dehydration, and constipation doesn’t just mean you’re not going regularly, because regular is one to three times a day to three times a week.

That’s a very broad range, but that’s very limiting advice because some people already struggle with that. They have difficulty with their bowel movements, especially during pregnancy when hormonally constipation is so common. So, holding your breath and bearing down, what it does is it creates a very significant downward pressure in the abdomen and pelvis, which is necessary, but it doesn’t guarantee that the pelvic floor is relaxing or lengthening. So, again, if you think physiologically, what is a contraction, right? It’s the uterine muscles squeezing to create a downward pressure, well, to first dilate the cervix, but then eventually, once you’re at 10 to create that fetal ejection reflex. All that pressure that builds up at the top of the funness is now pushing the baby down.

Your pelvic floor is the hammock underneath. So, if your pelvic floor is clenching and squeezing and doing a classic Kegel or Kegel, which most people know about, but up to 47% of people are doing wrong. They weren’t taught during an internal exam. They’re not actually relaxing. They’re fighting that downward pressure and creating a situation where you have the uterus trying to push the baby down and the pelvic floor holding the baby in. So, when you hold your breath and you create that pressure, but you create a contraction, nothing’s going to really happen. So, we can stop with the holding of the breath unless the baby’s already at station, I don’t even know, probably beyond zero, because at that point, the pelvic floor is already stretching.

If their heads creating that ring of fire with crowning, holding your breath and bearing down and doing a Kegel is not going to Kegel that baby back up, right? Physiologically, that’s really difficult to do. So, I always used closed glottis or breath holding. So, holding the breath while pushing during the last stages of second stage labor, because that’s when maybe you’re exhausted. You only have two to three more pushes. You can see the hair. Just go for broke, just do it, get it done. Fine, hold your breath. But when you start pushing like that and it can take up to 45 minutes, an hour, hour and a half and beyond, you’re going to tire out faster.

Statistically, holding your breath creates so much hypoxia to both the person giving birth and the fetus that it’s just associated with more complications and more fatigue because you’re not getting that turnover of oxygen. It’s a marathon, not a sprint. So, we could start by differentiating breath holding as a great technique for the end versus the only technique to use from the beginning. The other thing is a lot of people will clench their abs to push the baby down, which for some people works, but some people reflexively contract their pelvic floor when they squeeze their abs. There’s no rhyme or reason to it. Sometimes it’s just the sports that you like to play as an adult.

Maybe you have a chronic cough or asthma or bronchitis and you just have a high tone abdominal wall, so you’re just dominant in your abdominal muscles. So, that can either create excessive pelvic floor tension in some people, so they’re flexing their ab. I think some nurses even tell people to, if they’re on their back, lift their head up to create more trunk flexion, which again, it creates flexion, it creates pressure, but is it promoting pelvic floor relaxation? Because again, the pelvic floor is just the barrier. It’s underneath everything. It’s the barrier to the outside world. So, we say you are not necessarily pushing the baby out. Your uterus is, which is part of you. So, yes, you are pushing the baby out. Your pelvic floor isn’t. Your pelvic floor just has to get out of the way.

So, what I taught at the conference last year, my topic was push like you’re pooping in quotes, because I don’t say that. Push like you’re pooping. A guide to second stage labor from a pelvic PT perspective is inhale your belly or inhale to make your belly like a balloon. As you exhale, focus on making your belly bigger and just see what you notice at the pelvic floor. In the clinic, sometimes I’ll have people roll up a towel roll just like a hand towel or a face towel and sit on top of it like it’s a bike seat. So, they have some feedback underneath them between their sit bones. When they inhale, I tell them that the pelvic floor is the bottom of a balloon. When you take a deep breath and you let your diaphragm flatten down, which helps your lungs expand to fill with air, your abdomen should expand and your pelvic floor should drop.

Then as you’re exhaling that breath, your focus is on keeping the abdomen big, which is very counterintuitive, because we’re all taught to suck it in and have a flat, solid abdominal wall, which is aesthetically pleasing, I guess, but also not functional or realistic. It’s hard for people to conceptually do that. So, inhale belly big, exhale belly bigger hopefully creates a lengthening and a dropping of the pelvic floor. If you feel like you are about to pass gas or pee, you’re probably doing it correctly. Now, if you exhaled and your pelvic floor pulled up and if you’re sitting on that towel roll, you feel that that lift, that’s not wrong.

It’s just not efficient for pushing because isn’t holding your breath and getting the pelvic floor to contract actually really helpful if you are lifting a really heavy bag of groceries or a stroller out of the trunk of your car and you don’t want to pee your pants? So, there’s a time and the place for that motor pattern. Pushing a baby out in second stage labor is not one of those situations. So, relaxing and lengthening the pelvic floor is really the goal. How you get someone to do that is by queuing them to think about their abdomen like a balloon, and using their breath and their diaphragm to create that pressure during a contraction because the uterus is going to push the baby down.

Hopefully, your exhale with the belly big and expanded creates a softening and a lengthening of the pelvic floor. So, that’s in a nutshell what I would prefer to be said in L&D. Whether or not the patient gets it in that moment, again, because they’re so over stimulated, depending on what’s going on and how long it’s been, it might not land and that’s okay. But that’s why I always tell people, you can come to therapy while you’re pregnant. You don’t have to wait until after you run the marathon to get some care, right?

Yup. So, I’m the patient. How would you teach this to the patient? What’s your spiel? I’m so scared to start pushing. Help.

I would ask people to think about what it feels like to hold gas in or to not want to pass gas in a crowded elevator or something full of people. That tension and that pressure, I want them to feel it. Teaching pushing is more teaching proprioception. You’re not really teaching one strategy. You’re teaching somebody how to identify what their pelvic floor is doing when they’re exhaling, when they’re holding their breath, and when they’re flexing their abs or trying to bear down. If they feel that sensation of, “Oh, I clenched, I didn’t want to fart,” then that’s not a good strategy for them.

So, I’ll say something different. I’ll switch it up. I’ll say, “Okay, what if we try as you exhale, you make your belly bigger, and instead of holding your breath, really exhale like you’re blowing out some birthday candles or you’re letting out a deep sigh?” I’ll change the way that they’re trying to exhale, because the pelvic floor and the glottis, which is up in the neck, they’re opposite ends of the same canister, which is our trunk. So, when you’re closing one end, the other end is responding and vice versa. When you squeeze the pelvic floor, something’s going on with the glottis. So, you can create pressure from above and below, which is really great for heavy lifting, for high impact activities like jump squats and all of that CrossFitters.

But that tension from above and below isn’t something you necessarily want for pushing a baby out. So, I focus on the exhale. I focus on keeping the belly big and creating an expansion as you exhale that I’ll tell people, imagine there’s a beach ball in your belly. When you take a deep breath, the beach ball inflates. As you exhale, you want to keep that beach ball as big as you can, but almost like you want it to push down into your pelvis. So, inhale, inflate the beach ball. Exhale, push the beach ball as big as you can and down into your pelvis. Then if they notice, “Oh, yeah, I feel like I’m going to poop or I feel like I’m going to pass gas,” great. That means your pelvic floor is about to relax and you’re fighting it.

So, once they have that proprioception, that’s when I’ll say, which one do you think you would want to use to push a baby out? So, it’s almost like you have to have them feel whatever they feel initially and then in a direction either that’s opposite of that or facilitating that if they’re doing it properly. The only way to know is to ask them to try it and have them get in their body and explain what they feel.

I’m picturing somebody working with you prior to pregnancy, you telling them that and showing up to the hospital, I’m like, “It’s okay.” I’m not very hopeful to be honest because this is so different from anything that we talk about. What I’m hearing you say is that you want us to breathe out and release our air when they’re pushing. I just hear providers and nurses being like, “No, hold it in. That’s the pressure.” Then I’m also thinking about these epiduralized patients that don’t have the same proprioception necessarily. Some of them may have a little bit of pressure, sensation, but otherwise.

Do you have any tips for us? The nurse in my head’s like, “Oh, okay, cool. This sounds awesome.” Then I’m just realistically thinking there’s such a disconnect. I hope that’s what people are taking away of, “Whoa, we need more education in the medical system. Let’s call you to your hospitals and come in and educate the residents, doctors, and midwives and nurses all together to switch this up a little bit.” That was a lot, but what are your thoughts on some of that?

Well, it’s ironic because after this, I am actually going to the hospital down the street to present to OB residents on the same topic.

Amazing.

So that’s really cool.

Amazing. That’s what needs to happen.

But as for the nurses, yeah, there is a disconnect. I was laughing when you were saying that, because I’ve had tons of patients come back who did come in prenatally, and I’m like, “How did it go?” Majority of the time, they’re vaginal births and the ones that are vaginal, how long did you push for? I don’t like to brag, but most people that I’ve taught how to push, I haven’t kept stats on it, I really should, less than 30 minutes. So, not that faster is better because I’ve had some people push for two pushes and they have a grade four. That’s not necessarily better. So, let’s just asterisk that.

But in terms of efficiency and the ability to push productively without fatigue and exhaustion and distress, the patients that accomplished that have told me, “Yeah, because I ignored everything the nurses told me.” I trained my patients to potentially have to put earmuffs on and say, “They’re going to tell you because that’s what they’re trained to tell you.” If they had kids too, because we all know everybody likes to emotionally dump on everybody who’s pregnant, who’s been pregnant, that might be what worked best for them. So, in their heads, they’re giving you good queuing, but you know your body, we’ve worked on this. You know what positions you like, you know exactly what you’re supposed to feel. Trust that, listen to that, and do what you need to do.

A lot of patients have also told me that they don’t necessarily always say to the nurse, “I’m not listening to you. That’s wrong,” or “I know how to do this better,” or “I was taught by a therapist how to do this properly.” They just do it and here come the nurses with, “Oh, you push really well. You have really pushing mechanics.” They’re like, “Yeah, because I’m not holding my breath like you’re telling me to.” So, in a way, there is a disconnect, and honestly, I already know that. So, I train my patients to advocate for themselves, first and foremost, that they know what their body’s doing, that they practice this. My advice to nurses is go try it. When you happen to have a bowel movement, go sit on the toilet, hold your breath and bear down and see if that works for you. If it does, great.

My follow-up questions are, have you ever dealt with hemorrhoids? Have you ever dealt with prolapse? Do you feel like you’re completely evacuating or do you have to go back to the bathroom several times after that because you feel like something’s still in there? Because that’s your feedback. If you truly are pushing properly and creating softness and lengthening of the pelvic floor, a bowel movement is physiologically the same thing. Instead of the uterus, it’s the rectal walls pushing hopefully what is a solid bowel movement out of your body. If you’re relaxing your pelvic floor, that should feel efficient and pain free and those perfect bowel movements where you just sit and you just sit there. You don’t even do anything, and it just glides out of your body.

You wipe and nothing’s on the toilet paper and you feel like you lost three pounds. Those are the bowel movements that everybody dreams of. If you’re holding your best and clenching your pelvic floor and notice that your bowel movement is coming out in pieces or that you’re having to repeatedly push, I want you to think about what you think your anal sphincter is doing. If that’s your only go-to cue for your patient, then it’s a self-limiting approach. Because if you do that on the toilet and it doesn’t work for a bowel movement, what makes you think it’s going to work for a patient? Now, if it does work for you, that’s great, but you are not your patient.

So, if they have chronic constipation or you see that they have hemorrhoids, there is already some pressure mismanagement going on there. So, just consider the fact that it’s not one size fits all and try it yourself. If you have better understanding of proprioception of your own pelvic floor, you’re going to help other people find it better. Yours doesn’t have to be perfect. Mine’s not perfect. Well, it is, but you don’t have to know that. But I’ve never had children. So, really it’s pretty straightforward, but it is something that you can help somebody understand better when you’ve tried it at least yourself. Imagine trying to teach somebody how to ride a bike when you’ve never done it.

So, use your own pelvic floor and try these strategies that you’re giving your patients and see if it works for you. I know tons of people that have probably already had kids are listening to this. Yeah, I did hold my breath and it did take forever or I did have a grade three tear. I don’t have to say that. Somebody out there is going to be like, “Oh, yeah, that makes total sense. Why would we teach it like that?” Then somebody else is going to be like, “That’s exactly how I did it. My baby was born in five pushes.” Congrats. Your pelvic floor probably relaxed when you did that. If your patient’s not progressing, switch it up, right? It’s not one size fits all.

The problem is that we’ve normalized pushing for two hours to four hours that that’s normal or yeah, it’s going to take a while for you to figure it out. I mean, I say that stuff and we’ve seen that hold your breath and the babies come out sometimes, but I think what I’m hearing here is that it’s more than just getting the baby out, that there’s actual protection of the integrity of their body that we are maybe not doing and causing harm by making that recommendation. What about for epidurals? The patient’s never seen you before. They know nothing. They’re so disconnected from their pelvic floor. They get an epidural. I come in as the nurse and now we’re going to start pushing.

Yeah, that’s a tougher one, especially if the epidural did its job and it’s completely wrong. I would still argue that exhaling is the best practice because they could already have to deal with a prolonged second stage labor because they’re anesthetized and depending on when they were anesthetized and how long they’ve been for better or worse horizontal and there’s not a lot of pressure on the pelvis. They’re not getting that yielding of the tissues that you get with physiologic contractions starting far apart and getting closer together. So, it is an uphill battle, but I also think that if the epidural is successful and the pain is controlled, then it sometimes has a great effect. Again, it’s not either/or.

It’s so hard to answer these questions and not subscribe to one method of thinking, but that’s the point, right? If they got it because they weren’t managing pain well and it helped their pain, then the focus I think should be on the exhaling and explaining to them, you’re not going to feel this and I get it, but think about it. When you exhale keeping your belly big, can you imagine your pelvic floor is a balloon or a trampoline that’s just giving and stretching with each exhale versus think about a time you were really scared and you held your breath and you clenched your abs. Do you think your butt hole went relaxed or do you think it tightened up? So, making that connection still, right?

I go back to neuro rehab. Just because somebody had a spinal cord injury and hadn’t been ambulatory for how many weeks doesn’t mean we don’t do therapy, right? We come in and we’re like, “Okay, we know that this nerve was for better or for worse damaged, so here’s how we’re going to work around that.” But I want you to imagine neuroplasticity, early on, even with stroke patients, wiggle your big toe. Even just the act of thinking or imagining what that muscle is doing, there’s something firing. So, even though the anesthesia’s there, as long as it’s doing what it’s supposed to do in that person’s context of their birth experience by managing their pain so they can focus and they’re listening to you and they’re comfortable, then you could still teach it.

You could still teach belly big, belly bigger. You could still give them the examples of you can hold your breath, but I want you to think about if holding your breath actually relaxes your pelvic floor, because for some people, that doesn’t work. But we can try both. We’ll be here for a little bit. With each contraction, we can try and figure out what works best for you. Don’t be afraid to say, “We’ll try this, but if it doesn’t work, let me know and we’ll try to figure it out.”

You don’t have to make yourself look like you’re the expert on pelvic floor, but just even giving them the understanding of have you ever sneezed and let out gas and you’re trying to hold it in, right? That’s the same thing as blowing your nose and trying not to pass gas. Some people are holding their breath and trying not to poop during labor because they think it’s disgusting when we all know it happens.

Totally. Totally.

So it’s that same concept of give them that input of what they’re trying to feel or trying to accomplish and then give them those examples so that they have that connection. Even if physically they’re not feeling those sensations of pressure and stretching, hopefully, that brain wiring is still there somehow.

Well, I’m envisioning this conversation happening before the provider comes in the room when you’re doing your test pushes. This has somewhat become one of my pet peeves with the pushing side of the work that we do is they’re 10 centimeters and the next thing you know, provider’s fingers are inside. Okay, now push. You have a contraction now. Push, push, push, push, push. You’re like, “Whoa, my brain. Hold on.” There has to be a better way.

First of all, that’s stressful on their nervous system. Second of all, then there’s no orientation to any of it. So, in that transition or as you’re anticipating, I actually teach the abdominal breath where you keep your belly out when we are close to complete and not pushing, but just this awareness, because it’s awkward to figure out to breathe out, but your bellies go out more.

Yeah, yeah. It’s counterintuitive for sure.

It is. So, it takes some practice, but what a great time when they’re nine centimeters, nine and a half anterior lip, and you’re like stalling a little before you get the provider there.

Totally. Probably too, I know your question was you just met them, you just walked in and they’re anesthetized. But if you have the luxury of being there for a little bit of the labor and encouraging them to be on the toilet. Why? Because functionally, that’s where we typically relax our pelvic floor. Also, you empty everything, so there’s less stuff in the pelvis, competing for exit routes strategy. So, practicing the breath on the toilet.

Interesting.

Telling them your bladder pushing out your urine or your rectum pushing out your bowel movements while you hold your breath versus when you keep your belly big and exhale, what do you notice? Do you need to pee? Okay, I want you to try this really quickly because this is how I’m going to want you to push this baby out. If it was early enough for them to walk over to the toilet before they get the epidural, then at least they have some form of connection. This is like Hail Mary. You’re throwing everything at the wall and seeing what sticks. The benefit of somebody doing therapy prenatally is exactly this. I could hook them up to an EMG machine. I could do real-time ultrasound to their peritoneum. I could show them what their pelvic floor is doing.

Interesting.

That’s the benefit of the therapy prenatally.

I didn’t know that.

But obviously as a L&D nurse, I can’t refer to somebody right there. You should have done therapy three months ago. We have not hit, but here we are. So, I get that it’s not going to ever be perfect. But yeah, teaching the exhale, understanding why too. If you hold your breath, you cut off circulation. Again, it’s not the wrong way to push. It’s the less efficient and potentially more damaging to the pelvic floor and the pelvic tissues strategy. It’s more exhausting. So, there’s a time and a place for it, but helping your patient understand the differences and think for themselves, how do I have a bowel movement? If you want to use push like you’re pooping, that’s okay, fine.

Why don’t you ask them to think about how they push when they’re pooping and ask them first, “How do you have bowel movement? Do you hold your breath or do you exhale?” They might even tell you, “Oh, I read this,” or “I saw this Instagram post on whatever social media, and it’s said to actually exhale like I’m blowing up birthday candles.” So that’s actually how I have a bowel movement. You can ask them, “Does that work for you? Let’s do that then.” Or if they’re like, “Oh, I hold my breath.” You’re like, “Well, do you feel like you get everything out or bowel movement’s easy for you?” If they’re like, “Oh no, it takes forever all the time,” then I would argue. Okay, now I know for this person that maybe we try a couple practice pushes with the belly big, maybe even on the toilet.

So, that clinical experience and the wisdom of knowing how to read the person before dumping, right? Let’s do it this way. Even that I think gives you a little wiggle room to choose what road you want to go down. Do we focus on breath? If they’re a yogi, ask them, “When you’re doing your yogic breaths or your diaphragmatic breathing, do you think about your pelvic floor? Is that something you ever read about?” Because they might already tell you, “Oh, yeah, I read about that. I’m not sure if I’m doing it right.” Then your job’s a little easier. You’re like, “Okay, so you’ve heard about it, so let’s try this.” So even just that little nugget of sometimes when we hold our breath, we do a Kegel and a Kegel is counterproductive to a baby coming out, right?

Even just starting there and then asking your patient to try it or asking them to show you how they do have a bowel movement. That’s part of the assessment, right? Are they relaxing at bowel or are they not? That’s the fun part of my job. I’m like, “I don’t know what you’re doing.” That’s why telling everybody, “Oh, you have leakage, you have prolapse, you have diastasis. Kegels,” right? That’s not great advice because everybody’s starting in a very different place with their proprioceptive awareness.

I’m envisioning all these nurses. Pre-epidural, early labor, they’re just admitted. They’re like, “I need to go to the bathroom,” and be like, “Hold on, let me give you five minutes of education. Then let’s talk this through on the toilet.” Sit there and talk you through your breathing out and relaxing your pelvic floor. Actually, nurses, you’re seeing this when you’re looking at the perineum without hands in and you’re seeing that both. That’s when you know they’re pushing well. I hear this depending on where I’m at or what the education level is or whatever, but you can know based on that relaxation, that bulge of the pelvic floor. So, the bathroom being a great opportunity when they go pee and a lot of them early on, they’re like, “I think I need to pee.”

They want to. Exactly.

So there’s your opportunity to say, “Let’s talk about pushing before you do, and I want you to try some things and be really aware, because especially knowing you’re planning on an epidural, that you can make that mind-body connection.” I’ve coined this term conscious pooping when I work prenatally with people. We’re going to begin conscious pooping from now going forward so that you can start to create-

I love that.

… that mind-body connection because you’ll lose pieces of it, but your body still knows what to do.

Exactly.

So it’s strategizing with those opportunities that are being presented at the bedside.

Yeah. You’re helping the uterus with its contractions. You’re not fighting against it. Actually, I use the term reverse potty training when I’m doing a lot of defecation mechanics and toileting, we’ll get to this, with people who come off of the epidural and they can’t empty their bladder after. Sometimes it’s because they’re pushing but their pelvic floor’s not relaxing or there could be some nervous stuff going on. But yeah, reverse potty training in a sense that nobody teaches us this, right? We all have our habits from life. This is a different rabbit hole, but hovering over the toilet seat does not help you relax your pelvic floor.

I’ve heard this, I told my mother this.

Power peeing, trying to push it out and get off of the toilet as fast as you can because your kid’s crying in the next room, that might actually narrow the stream. My prostatitis patients or my pelvic congestion, my male patients who have issues with start and stop stream of urine, that could be a pelvic floor issue. Not everything is a bladder issue. Not everything is a pelvic floor issue. There’s overlap, but knowing that about yourself before you go into L&D is rare unless you know a pelvic floor therapist, but you just answer the question, right? Again, if you just walk in there and it’s nine and a half and things are moving, all right, we just got to do what you got to do.

But if you are there during the active process and things are still slower and the person is tolerating pain well, sprinkling in, “Oh, you need the pee.” Okay, let’s do exactly that. You don’t have to bombard them with this information. They could be four centimeters and you’re like, “Try it. Next time you’re on the toilet, try it, and then let’s try it in different positions and let’s see what’s really comfortable for you.” It might take them a while. They’re like, “Oh, now, I get it right.” Some people get it in 10 minutes. Some people get it in 10 visits with their medical history is, especially if there’s trauma or pain or tailbone issues or other stuff going on.

You’re not telling them to push. Let’s be clear, because we don’t want to get nurses in trouble ahead of time, because if doctors hear that they’re pushing prematurely, it is a release of the pelvic floor. It’s a relaxation of the pelvic floor which will potentially likely set them up for that relaxation throughout their labor, which needs to happen in order for the baby to come down into the pelvis, put more pressure on the cervix, et cetera.

Yes. Perfect. Thank you for clarifying. I have to be careful. Words are important. Words are very important. I sometimes start with you don’t push the baby out, your uterus does. Then I make the joke that your uterus is you. So, yes, you are, but you’re not by doing a Kegel, you’re not by flexing your abs. That’s not how babies are pushed through the birth canal. The uterus is a muscle that does that. Your job is to facilitate the downward pressure against a relaxed pelvic floor to aid that progression of contractions, to create the pressure on the cervix, and to help with dilation and eventually second stage labor. So, you’re not pushing. You’re setting up the pelvic tissues.

You’re creating space within the contractions for the person to focus on the experience of the contraction without fighting it, which contributes to dystocia. Somebody’s not handling those contractions well. There’s no way they’re going to be able to focus on the breathing and all this stuff. But sometimes the breathing and the focal point is what gets them to deal with the contractions in a more productive way. So, it isn’t pushing. When I teach pushing strategies, I’m really teaching pressure management. The functionality of that is, like I said, emptying the bladder of the bowels or pushing a baby out or the opposite when you bear down and you clench for heavy lifting or coughing and sneezing. That’s called the knack maneuver.

When you can do that, that’s actually a different skill, a skill that you don’t need for pushing a baby out. So, it’s just understanding that, yeah, active labor could take days. So, if with each contraction I am clenching my pelvic floor and fighting everything because it hurts so bad or because I’m so uncomfortable, I’m ramping up that sympathetic response and I’m releasing more cortisol and adrenaline and completely just derailing the oxytocin process or physiologic labor. So, yeah, tell your OBs, “They’re not pushing. They’re learning how to relax their pelvic floor. We’re emptying the bowels. We’re emptying the water. We’re trying to clear some space here because we have an incoming delivery that’s going to take up a lot of room.”

So, we want everything out of the way. We want all those tissues to stretch, decrease need for vacuum, decrease need for episiotomy. The statistics are there. So, if you want to split hairs over what we’re calling it. Yeah, you’re not pushing, because we’re not 10 yet. We’ll wait for you. I hate that whole anyways, but I get it. Somebody has to catch the baby. That’s fine. But to ask somebody in physiologic labor to not let their body do what it’s supposed to do is really difficult for them. It’s confusing. They feel like they’re doing something wrong sometimes, but yeah, you’re not pushing.

Yeah, you’re facilitating. You’re letting your body do what it needs to do. We joke that it’s like holding the elevator door open, that button to keep it open while somebody rushes to you. That’s all you’re doing with each breath, with each contraction, your pelvic floor. We’re just holding that door open. So, as you get closer to 10 and the baby gets closer to 0, there’s less resistance to the exit route.

I love that. Justine, do you want to jump in? You’ve not said a word. They’re like, “Is she here?”

I’m here. I promise. No, I am just learning a ton. Honestly, the biggest thing that you’ve said that I was like, “Oh” is the pelvic floor needs to get out of the way. So, I just appreciate that statement, because I was like, “Oh, man. Yeah.” I have a question for you. This is on our list of things, and this is a DM I get all of the time. I have a very strong opinion about it and I hope that you back up my opinion, but pushing with a fully catheter in and why we shouldn’t. So, I hope you’re going to tell me-

Oh, I have a strong opinion about that one too. I didn’t know that was the question coming.

Well, I realize I could have emailed this question back when you sent me the list, but this is more of a discussion. Is it standard to remove it? That’s news to me. It’s controversial.

So people will say, “Well, I have to keep it in because then the bladder’s going to get full, then the baby can’t come down because the bladder’s in the way.” That’s why we have the Foley in the first place, with the epidural, et cetera. Then people will say, they will deflate the balloon, but keep the catheter in and push, and then some just leave It. That’s where you see the Foleys coming out, expelling on their own during pushing. It’s just all bad.

Yeah. So, if I’m answering this based on pure biomechanics, I would agree that removing it would be the most straightforward thing to do because the bladder will have been emptied. I’m sorry, that’s the point.

Starting empty. Our bladders don’t instantaneously fill.

Exactly. Then even deflating it and then it is expelling on its own, first of all, that’s a good sign. Well, I don’t know if I should say good, because there could be some urethral hypermobility and some prolapse that’s happening. Let me just say that. So, not that it’s good, but the fact that it might expel on its own is a sign that there’s some relaxation of the urogenital triangle, which is part of your pelvic floor. So, it is counterproductive, I think, to push with something that’s taking up space there and expect it to not budge. So, if you don’t have time to deflate it, I would argue that keeping the balloon full, it could still move and then deflating it. At least when it moves, there’s no resistance.

So, I feel like deflating it would be, in my opinion, probably my preference if I was giving birth, knowing what I know about the pelvic floor, but the amount of pressure that you’re asking somebody to create being enough to forcefully expel a catheter to begin with, get it out of the way. So, just hearing your explanation of “Yeah, but the bladder’s full,” well, take it out when they’re at 10. You’re already gearing up anyway. That’s when you’re all up in there.

Yeah, when you asked earlier about what injuries that we see, I guess it’s not really as much of an injury as it is one of the consequences of being heavily anesthetized is that some people have a change in their urgency or frequency or ability to avoid completely without straining or forcefully peeing because of how long they were on a catheter for, because it took a long time for anesthesia to wear off, and they weren’t able to voluntarily empty their bladder for dates. So, I would argue that yeah, removing it for pushing, if it were me in the bed giving birth with an epidural, I would probably ask you to, knowing that now, because that’s news to me. I never even thought about that if they removed the epidural prior to second stage or during second stage.

I had a doctor say that the pressure of the head, if they’re pushing for a long time with the Foley in, can create necrosis in the urethra. It went that far where I was like, “What?”

Yeah. So, when you have pressure from a baby’s head stretching everything like crazy, there’s traction on the nerves. Nerves and blood vessels travel together. You’re pinching off the little capillaries and you’re putting pressure on the sarcomeres of the muscle fibers. So, you’re not getting your blood and oxygen. Do that for how many minutes. You’re going to be at higher risk for injury, whether it’s a nerve injury or muscle injury. So, if that’s even a possibility, just move it. So, here’s my thing, it doesn’t belong there, right?

Unless you have a medical reason that you need to be cathing or I&O cathing, whatever, that’s not something that everybody’s used to having anyway. So, if the bladder is empty, it’s time to push. It doesn’t belong there naturally. So, get it out of the way. Then afterwards, if they have difficulty emptying, you very skillfully putting them back, right? So there you go. Yeah, that’s definitely something that I’m going to look more into and ask around. I might ask the OBs when I go to the hospital today, “What are we doing with the catheter?” So yeah.

I find that it’s physician preference.

Yeah. We have a local GYN here. We call him the forceps guy. It’s just his preference. I’m like, “Hmm, I can tell you don’t have a vagina, but okay.” So yeah, my team pull it out.

As are we. We’re all on the same team.

Thank you.

I was hoping that.

This was so much fun. For the sake of your time and everybody else’s, maybe if you guys have any questions, you can always send us an email. You can always send us a DM. We can put together more. I feel like this is just touching the tip of the iceberg on pelvic health and how it applies to our job, because it does apply to our job. We can’t ignore the fact that we are dealing with people’s pelvic floors and their pelvises every single day, and that has lasting potential impact. So, while we want to keep you in business, I think that we would love to also help prevent some of the major lifestyle impact that it has and we need to be thinking about that.

So, we just want to thank you for the work that you’re doing because it is so important. I think for us to recognize publicly that you are a part of the birth team and that there are referrals that we can send that we need to be teasing this out. If you’ve listened to my YouTube channel, if you’ve heard me talk about anything physiology, I’m like, “Where is your pelvic floor therapist?” That’s a part of your prenatal team. That and a chiropractor are the two big recommendations that I have prenatally of a way to set yourself up. So, if you’re a patient sneaking in on this episode, that’s going to be my biggest recommendation to you. Now I hope that you can see how beneficial that can be ahead of time to start making those connections with the body.

We as nurses need to start making those connections with our own bodies so that not only we can teach better so that we can have the impact of having healthy pelvic floors. So, again, I think it’s so fun to help expose this audience to your work, and we’re just so grateful for people like you that can follow up when there is impact. I was going to say damage done, but it sounds really dramatic, but that is how it is. Where can they find you? So if they want more, where do they find you?

I’ve been under a rock for the last year, but I’m still in Instagram jail with my original account, but I have made the decision to eventually make a comeback on there. So, we’ll see the timing of that. But otherwise, my website is drqdpt.com. You can contact me through there. There’s a little window that pops up about a newsletter. I don’t really send weekly newsletters, but that’s something on my list. So, email is the best way. Then hopefully in the next few days or whenever I have the capacity, I’ll be back on social media with the same type of handle, DRQDPT. They haven’t given me my old one back.

I guess I’m on TikTok, but I don’t even want to plug that, because that app gives me anxiety and it’s just so wild on there. It’s not very sustainable, but technically, I am on there as well. Then hopefully in the next few months, I’m trying to digitize a lot of my education base, like my childbirth class, create one for providers and put together something for nurses about pain and how to help with pain management during second stage labor, because I realized that that’s a big part of the puzzle as well. I also treat a lot of nurses as patients.

So, if you yourself, like you said, have to stay healthy and optimize your pelvic health, everybody’s heard of the nurse bladder. Some of you don’t pee for six to eight hours a day. I know you’re heavily caffeinated depending on what shifts you’re working, so it’s a thing. Yeah, I love talking about what I do and I’m so happy when people are interested in helping to spread more awareness about it. So, thank you again for having me.

Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram and TikTok.

Now, it’s your turn to go and sit on the toilet and consciously poop, relaxing your pelvic floor, keeping your abdomen out, and focusing in on your breath. So, you can better educate your patients in their pushing strategies. We’ll see you next time.