Pelvic Floor Education Before Birth

birth first trimester pelvic floor pelvic floor education prenatal education Oct 19, 2022

Melissa Dessaulles, BScPT, BScKin, Pelvic Health and Kimberley Johnson M.S. and PhD candidate focusing on perinatal and pelvic health to discuss birth related pelvic floor trauma and the association with higher rates of perinatal mood and anxiety disorders, and how a lack of pelvic floor focused education may be associated with greater distress following pelvic floor trauma and its sequelae. 


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[00:00:00] This episode is a collaboration between Melissa Desaulles of Mommy Berry's Physiotherapy and the Pelvic Floor Project.


[00:00:56] Melissa: As a physiotherapist that works with pregnant and postpartum women, [00:01:00] I see many themes and hear some of the same comments over and over. Nobody told me. Why don't we hear about this? I wish I would have known. I'll be honest and say some days I find myself hitting my head against the wall wondering how we are going to fill these gaps in care that exist for the perinatal population.

[00:01:23] Then along comes Kimberly Johnson, a fifth year PhD student whose research is focused on psychology and pelvic health in the perinatal population. Her most recent publication highlights the physical and emotional struggles that postpartum women experience with the current lack of information and guidance and how this is improved when women are provided with an understanding as they go into birth and come out with their eyes wide open. The findings of her study demonstrate that prenatal pelvic floor education is a key aspect, in not just reducing risk of [00:02:00] postpartum pelvic floor trauma, but also mitigating distress if it does occur. If you're pregnant or postpartum yourself, or you are a care provider that works with this population, this is a must listen, and then I challenge you afterwards to take one small step towards putting this research into practice.

[00:02:19] Now, without further ado to talk about all of this, I can't wait for you to meet Kimberly Johnson. All right, Kimberly, I as always, I'm really looking forward to this conversation because I as a clinician and as a physio, you start to see so many patterns with your clients, especially the perinatal clients. And you see some of the same things over and over again. But we need people like you who are doing the research to be able to have a voice. Cause I think sometimes otherwise it's hard to know what to believe and what's true. And so when I saw some of your recent work being shared on Social media, I thought, I can't wait to talk to this [00:03:00] lady. I hope she says yes to me. And she did. So thank you so much for being here.

[00:03:04] Kimberly: Yeah, I'm excited to chat as well.

[00:03:06] Melissa: So, you're a doctoral student in psychology. You have a special focus on pelvic health, right?

[00:03:14] Kimberly: Mm-hmm.

[00:03:14] Melissa: And you've recently done some really important research on looking at birth related pelvic floor trauma. Yeah. And that, you know, that association with higher rates of mood and anxiety and mood disorders and anxiety. And I would love to talk about that today and just kind of some of the findings, what brought you to this area. And why don't you start by just telling us a little bit about who's Kimberly Johnson? Who, who are you, and why this interest in this?

[00:03:46] Kimberly: Yeah, so I am a fifth year PhD student in clinical psychology. I'm at the University of Utah. My second year of graduate school, my daughter Juniper was born. Prior to that I was already in the health [00:04:00] psychology specialty track. So I was really focused on adaptation and coping at the intersection of physical and mental health. So looking at people who'd experienced, you know, various types of physical injuries, conditions, et cetera. So lo and behold, I had the opportunity to live out my own research and clinical interests when my daughter was born, and I experienced a birth injury.

[00:04:22] So this is something that I was wholly unprepared to deal with. I had, I was a type of pregnant person who did all the things, or so I thought, you know, I did all their research. I even took a, you know, I took a very comprehensive birth class, read all the books. Nowhere in all of this preparation did birth injuries and pelvic floor trauma come up outside of like minor perineal tearing that I was told was no big deal and would heal very quickly.

[00:04:51] So my own injury was a levator in a muscle evulsion. So that's where a pelvic floor muscle actually tears off the bone and it is [00:05:00] a non-repairable injury. So it's, it has some pretty potentially significant implications. And for me, that also resulted in pelvic organ prolapse. So two injuries that I didn't even know were possible in the context of childbirth and had pretty life shifting implications for me as someone who had been a professional athlete prior to graduate school, and was still a very active person. I love trail running, backpacking, all the things. So to experience an injury and then be given what I now know are non evidence-based recommendations, like, don't lift any more than 10 pounds. Is there anyone who can help you hold your baby? Like, what a thing to be told in this sensitive postpartum period. So to say I felt broken is you know, not an understatement.

[00:05:50] Melissa: Yeah. Mentally and physically, right?

[00:05:52] Kimberly: Yeah. Like, yeah, exactly. I really, I truly felt like my life was over because so much [00:06:00] of what I'd envisioned felt suddenly off the table and you know, I had this vision for motherhood and this experience that I was living, and they were just, there was just such a strong mismatch between the two and I was kind of scrambling to reconcile that. Scrambling to, rewrite my own narrative, make, you know, figure out what this meant for me both then and long term.

[00:06:21] So I would say that I was squarely in the trenches for about nine months. And then slowly started to find my way out. And as I did, I started to become really, really passionate about changing some of this for the better so that fewer people feel as alone and broken as I did. Because not only is there this major injury that you're coping with during a critical window, a known critical window in the lifespan, a perinatal period but it's also really stigmatized and it's a taboo topic. And you know, and I actually, you know, have had some pretty significant physical injuries. You know, when I was bike racing, I at one point fractured my [00:07:00] C2 and was lucky enough to not have any long-term neurological damage. But the point of comparison is that I never felt the need to hide that injury or make up stories so people would know what happened. And I had this sense that like I couldn't talk about my pelvic floor injury because it's just taboo, right? We don't, in society, generally talk about breaking our vaginas in the same way that we talk about breaking another bone or so.

[00:07:24] Melissa: Out of curiosity, Kimberly, were you already attached to a physical therapist, like a pelvic health physiotherapist? Like was that on your radar or was that something that you learned about after the injury?

[00:07:35] Kimberly: No, so it was very much on my radar as something that I should be doing. I'd actually already planned to set up an appointment, you know, around six weeks postpartum with a pelvic floor PT. I saw a PT during pregnancy for a little workshop on kind of core and pelvic floor considerations in pregnancy. But looking back, it was not a, like a birth prep course, it was more of like [00:08:00] posture things to do to manage pregnancy related pain, you know, pelvic floor considerations during pregnancy. So I obviously, in retrospect, wish it would've been, I would've done more birth specific prep, uh, because even with that class, birth injuries were not discussed and were not on my radar. So yeah, I had already planned on doing up, you know, six week check-in with the PT and I'd always assumed it would be kind of like a, okay, everything's looking great, you're good to go. That was not the case for me, unfortunately.

[00:08:29] Melissa: So then you kind of, you know, you're going through your recovery, you're starting to understand how the muscles are, you know, related to some of your symptoms. You're starting to draw the parallels between some of the other injuries you've had before as an athlete. You start realizing, wow, there's some missing information here. And so I'm a researcher, I I have questions and I know how to look into this. Is that kind of, you know, the path and then, yeah, tell me a little bit more, because [00:09:00] I, I wanna start talking about the recent research we've done. So I wanna know kind of, yeah, how does that lead to your recent work?

[00:09:07] Kimberly: Yeah, so I started in my own kind of recovery and rehab process. I started, you know, digging into the research, trying to see what was there, and I was pretty shocked to see a really major gap in evidence-based information, especially from kind of the psychosocial side of things. There's a fair bit and growing in the PT world, you know, talking about, I think there's increasing knowledge in the value of PT in managing birth injuries and recovering, but I just could not find much at all in terms of the psychological implications and coping and recovery there. And I found for me personally, that the mental and emotional aspects of this were as salient as the physical and from talking with others, that was a consistent theme that I saw. Specifically kind of bridging to this research question, when I started looking at - there was [00:10:00] a sense of really being blindsided. It's a consistent sense of like, how, how was this never talked about? How was the first time I learned about this when I experienced this injury? And I found out that I had prolapsed because I was googling the symptoms and trying to figure out what was going on with my body versus having been informed during pregnancy. Like we are informed of so many other things that happen at far lower rates really. And so, I started to become interested in coping and adjustment in the context of birth and injury more broadly. And this, this idea of kind of the value of information in reducing distress was one of, was the first, uh, research questions I really tackled in the form of a submitted manuscript.

[00:10:44] But yeah, I had my, I guess it was my third year, yeah, in my third year of graduate school. So when my daughter was almost a year old I, I, what's the right word, I won a departmental fellowship that gave me some small [00:11:00] funding to start a research study. So that's where all this data came from. It was pretty cool to see how quickly this data was actually able to be collected which to me shows the need, right? It shows how many people have been impacted by this and how many people are invested in seeing this change. Especially cuz I couldn't actually pay a whole lot as a graduate researcher with small amount of funding. So it was a lot of people's, you know, generous time that they volunteered to fill out fairly comprehensive surveys. But within, you know, six months I had about 300 people that had completed surveys and were excited about this work.

[00:11:37] Melissa: Okay. I wanna go into that and I, I, I, I wanna pull out some of the statements that were in your introduction. So I think some of the things that kind of formed your question, and, you know, one of them you just touched on, so this is what it says kind of in the introduction of your paper. "Recent research has found that significant pelvic floor trauma in the context of vaginal delivery is [00:12:00] much more common than previously believed and has been described as a hidden epidemic."

[00:12:04] So what you, you know, kind of what you were just talking about is, you know that this is actually more common than I think, women assume they're alone and they're the only one going through this. But, you know, once you start talking, you'll hear a lot of Me too. Me too. Me too. Right?

[00:12:18] Kimberly: Mm. Yeah. Yeah. And you know, a lot of these injuries aren't visible in the, in the way that perineal lacerations are, and so they often get missed and dismissed leaving people with, you know, really bothersome pelvic floor symptoms and not a lot of clarity. Which I think is another contributing factor in the distress as well.

[00:12:38] Melissa: Absolutely. I did one of my episodes, I don't even remember the number off the top of my head. It was done with a urogynecologist and she was talking about that, the clinical practice guidelines do suggest that every woman has like a vaginal and rectal exam to be able to assess what, what significant, like the tear significance and [00:13:00] what grade, cuz most women are very vague in what they know about their body. Yeah. But she said most often these guidelines aren't really adhered to. Most women aren't assessed to know kind of what they're up against. Yeah.

[00:13:13] Kimberly: Yeah. And in the, you know, I, this wasn't in the paper. I haven't published this data yet, but you know, even in the data I collected, a lot of people, even those who experienced, you know, perineal trauma as well as the more quilt birth injuries weren't even given information on the grade of their tear or information around the injury or how to heal it. And this was even in kind of the most common or most frequently discussed form of injury.

[00:13:37] Melissa: Absolutely. Another statement that I pulled out of your introduction: "People who report inadequate information during childbirth are more likely to experience as as traumatic." So I think kind of exactly, it goes with the unknown. I don't, I don't understand. Therefore, my mind's left to race and make up stories. Right.

[00:13:55] Kimberly: Exactly. Yeah. And that finding is not in the context of birth injuries, but just [00:14:00] childbirth in general. You know, where we look at people who come out of childbirth and, you know, having experienced it as a traumatic event. Yeah, information is important and feeling like you are given choices, information, able to make informed decisions has been really key, and a lot of other dimensions studied.

[00:14:17] Melissa: Absolutely. And then pelvic floor trauma is associated with higher rates of postnatal depression scores and often carry long-term health and quality of life impact. So something you were noticing yourself and just like this doesn't just go away at your six month checkup, or this doesn't just go away when your baby turns one, right?

[00:14:38] Kimberly: Yeah, exactly. Especially because you know certain injuries are managed long term versus healed in a six week period, for example. And so especially when you feel unprepared to deal with this, you have inadequate resources. You're forced to turn to Google. It's really scary and really isolating.

[00:14:56] Melissa: Yeah. So given some of this information that you were drawing [00:15:00] from, like what you found, just looking at what's out there in the literature, looking and noticing your experience, I'm curious to know, so what, what was the question you formulated? What did you set out to, to investigate?

[00:15:16] Kimberly: Yeah. So one pretty kind of salient experience that shaped the specific research question was a conversation which turned into a series of conversations that went similarly with providers, you know, ranging from urogynecologists to midwives to OBGYNs where I asked, you know, why, why do you think it is that this isn't really discussed during pregnancy? You know, why are so many people coming out with these injuries, feeling blindsided, and probably the most consistent answer across providers I got was, well, you know, we can't entirely prevent something like this, and so we don't wanna scare people and there's really no point to talk about something that we don't know how to fully prevent so we don't wanna increase distress. And I kind of said, huh, like, that's interesting because I actually think that the lack of information is what [00:16:00] increases distress. And so I started to formulate this question wondering whether, uh, the information itself would serve as a moderator in the association between the experience of birth related injury or pelvic floor trauma and, you know, psychosocial sequela including depression, trauma, symptoms, other measures of adjustment.

[00:16:17] So what's really kind of key to this study compared to other ones is that this isn't saying, you know, in terms of like the value of information, the value of prenatal pelvic floor PT, this isn't actually saying that prenatal pelvic floor PT can always prevent birth injuries. That's something that I wanna make sure, you know, isn't the takeaway from the study because that's not what I studied. It was saying that even when birth injuries happen, those who felt more prepared and aware of these injuries had less distress. So that was my question is, "does the provision of prenatal public floor information reduce distress for those who do experience birth injuries?"

[00:16:56] Melissa: Absolutely.

[00:16:57] Kimberly: Yeah, I kinda give myself a spoiler alert there and yes, it does. [00:17:00]

[00:17:00] Melissa: Oh, and you see that all the time as a clinician, and I'm curious to know then I, I really look forward to talking once we go through some of the details in your study. I really look forward to talking about what you said. Why is this not discussed? Cuz I think that you list a lot of the reasons, and I have a couple reasons that I notice all the time too, that it's, it's not shared. First, can you talk about how did you look at that? So I know you sent out a few questionnaires to different groups of people, and I'm just wanting you to talk a little bit about what that looked like.

[00:17:30] Kimberly: Yeah. So I will also say kind of just upfront that I didn't get kind of as nuanced into this question as I would've if this was the only question I was looking at in the study. I, you know, this initial study that I did was pretty comprehensive and I looked at a lot of variables and I'm, you know, currently in the process of writing other papers. And so, which, you know, which means that anytime you're doing something comprehensive, you can't be really nuanced in everything you look at. Otherwise it's gonna be like a five hour survey. Yes. So, you know, as I was doing these analyses and writing up the paper it highlighted the need [00:18:00] for, you know, really a more nuanced investigation of these questions because really what I asked is, you know, during pregnancy, lemme see if I can scroll down to find the exact question. Yeah. "During pregnancy, did you learn about pelvic health prolapse or birth related injuries? Yes or no?" I asked people to report in kinda a free text way where this information came from. And then looking back, "are you satisfied with the information you received? If not, what do you wish you would've learned?"

[00:18:26] So a really good foundation, but I wish I would've had more because for example, you know, in the free text responses I saw that there was some kind of lumping together of people who were you know, aware of things like perineal tearing versus those who had a really comprehensive understanding of prolapse, pelvic floor function in the context of childbirth, that kind of thing. So I think the fact that we still saw the patterns we did is, uh, means that we would likely see it even stronger if we broke it down into a more nuanced questionnaire, if that, does that make sense?

[00:18:58] Melissa: Absolutely. And I [00:19:00] noticed that, you know, when you talked about kind of what you found, generally the women that had received information were, were happy with, with the fact that they did receive information.

[00:19:09] Kimberly: Mm-hmm.

[00:19:09] Melissa: I couldn't believe some of the numbers though. 64% of participants reported learning about pelvic health, that that's pretty low. 64%. Birth related injuries are prolapsed during pregnancy. But of them, only 20% learned that from their provider or their birth class. Mm-hmm. Most were learning that from friends, social media and doing their own research. And that's definitely something I notice in the clinic as well. I often ask, where are you at? What do you know? I want to know what they're coming in with. And I always say, how do you gather your information? And I would say it's pretty well always social media. Podcasts are definitely getting a lot more front facing, more people are listening to podcasts. But again, you don't always know where that information is coming from. Right, right. Yeah.

[00:19:52] Kimberly: And, and kind of the double-edged sword with social media is on one hand, it's nice that people have access to this kind of information that wouldn't [00:20:00] otherwise as we see from those results. But on the other hand, there is a lot of information out there and not all of it is accurate or evidence-based. So depending on what people find, it can either help or hurt.

[00:20:10] Melissa: Absolutely. So I, I thought that was crazy then that when you start to pull out some of the, those numbers. Yeah, yeah. Yeah. So, okay, so that was that, that was that questionnaire that you sent out? Mm-hmm. .

[00:20:22] Kimberly: Mm-hmm. Yeah. So I looked at, in this study I looked at prenatal reported prenatal pelvic floor education, reported discrepancy between their expectations and their experience. Measures of pelvic floor symptoms and impact, so things like the pelvic floor distress inventory, pelvic floor impact questionnaire, as well as some ratings of, kind of mental health, physical health, and quality of life interference. And then I also included a couple validated measures of depression and trauma symptoms.

[00:20:52] Melissa: Yeah. And this one was really floored me. 92% of the women reported a discrepancy between their [00:21:00] expectations and their experience. 92% reported a discrepancy, and that 42% reported a significant discrepancy.

[00:21:11] Kimberly: Yeah. And it's hard because on one hand, like I know that we can't, you know, as someone who's gone through a childbirth experience, and I think even without hypothetically imagining, imagining, had I even not had a birth injury, there still would've been areas of discrepancy, right? Because you can never fully prepare for what this transition into parenthood will look like. But I think, so I think the key is really like the high percentage of those who reported a significant or extreme discrepancy. Absolutely. Because what that says, you know, that question, the way it was rated was you know, a score of five indicates extreme discrepancy. My postpartum experience is nothing like what I expected. Mm-hmm, so that's, that's pretty significant.

[00:21:49] Melissa: It is. 63% of participants reported pelvic floor symptoms had interfered with their daily life or quality of life. And that at three months, of those that had reported the [00:22:00] pelvic floor symptoms, 40% still were feeling affected at three, like significant impact at three months postpartum.

[00:22:07] Kimberly: Yeah. Yeah.

[00:22:08] Melissa: 56% said that it affected their physical health and 43% saying mental and emotional health affected, yeah. Mm-hmm. So it's, it's, it's interesting to see those numbers. I find that it, it really helps to, because this is definitely a population that I think, especially during this pandemic, are feeling home and isolated.

[00:22:28] Kimberly: Yeah. Yeah. So it's kind of a double whammy. Isolation on top of isolation. And one of the other things that really drew me to this work is that we do know, like, you know, empirically that the perinatal transition period is a really unique and unprecedented developmental, kind of transition point in the lifespan with as much potential for neurobiological, social, emotional, like all the changes that happen are as salient as, you know, these childhood critical windows and adolescences. You know, it's why the term [00:23:00] matrescence exist and why it sounds like adolescence, right? And so you have this really significant life event occurring during a known critical window in the lifespan that's known to shape long-term health outcomes. So if you have a situation like a birth injury that you know, like we've been talking about, is significantly impacting physical health, significantly impacting mental, emotional health, ability to engage in activities of daily living, ability to engage socially, like this isn't just adjustment to an injury that might occur at any point in the lifespan. This is potentially changing the whole trajectory, which is part of why I care so much about positively impacting this.

[00:23:39] Melissa: Oh, absolutely. And I think that too, I noticed some of the, you know, some of the conclusions that you were drawing were just, you know, there were some of the things you were noticing that the bigger, the discrepancy between the expectation and experience, the stronger the association with like psychological symptoms so that, you know, I think, you know, basically that, [00:24:00] the less you feel prepared for, the harder that is mentally and emotionally after, right?

[00:24:06] Kimberly: Yeah. Yeah. And as a reminder, like the, this whole sample is, are those who experienced birth related pelvic or trauma? So, perceived discrepancy served as a moderator here. You know, for those who had relatively low levels of discrepancy, pelvic floor symptoms were not associated with mental health symptoms. In contrast for those who reported a high discrepancy, there was a really strong relationship between those pelvic floor mental health symptoms.

[00:24:32] Melissa: And, and, and I think just saying, like you said, pelvic floor, so pelvic floor physical therapists obviously deliver a lot of this information. We're not the only people. There's a lot of different people out there, healthcare providers that are helping to deliver this information. But one of the things you mentioned in the conclusion is just that the, the prenatal pelvic floor education is a key aspect in, you know, yes, reducing some of the symptoms, but also just [00:25:00] decreasing the distress. Like you said, spoiler alert earlier that, that, that education before, you know, did help with not only some of the outcomes, but the, the distress levels, right?

[00:25:12] Kimberly: Yeah, absolutely.

[00:25:14] Melissa: So can we talk a little bit about then, first of all, I can't thank you enough for not, not only sharing your story, but like taking that experience that you had and turning it into a huge positive Kimberly, like I. Awesome. Like that you're shedding light on this because I think a lot of, I know a lot of people listening to this, I get a lot of listeners reach out and say, thank you so much for shedding light on this, because I, I assumed I was the only person, so thank you for doing this work.

[00:25:45] Kimberly: Yeah. Thank you for that. I, it's been a really kind of positive part of my own meaning making experience and all this, and you know, while I will never say that, like you have to make meaning from a trauma in order for it to, you know, you to heal or, you know, I [00:26:00] definitely reject the, like, slap of silver lining on it. Positive, you know, toxic positivity kind of culture. I, for me, this taking something that happened that was really shattering, using it so that fewer people feel as shattered as I do, as I did, has been really redemptive, so thank you.

[00:26:19] Melissa: And I, so as I, you know, we talked through all this, we listened to some of these numbers, pull out some of your conclusions, and it, it's so easy to sit here and say, well, why don't we do a better job of this? And I think that you mentioned that one of the things that a lot of the healthcare providers say is, you know, I, I don't want to bring up all the negatives, or I don't want to worry them because I, I absolutely can see that as passionate as I am about sharing this information, I find whenever I ask people that, let's say they come into the clinic and they're experiencing pelvic pain. I, I'm, I, I, it hurts to run or it hurts to get out of bed. So we talk about pelvic [00:27:00] pain and they often say, "You know, should I come back?" And that's where I try to really start to tease out if they haven't brought up preparing for birth and understanding the pelvic floor as it relates to birth, I sometimes find that opening up that conversation. I don't wanna create more stress for them. I don't wanna put more on their to-do list. Because they've just come in telling me about all their stresses and their worries. So I do find that's a bit of a dance, trying to tease out, I have some information to share. Can I share this with you? And, and so, because I don't want them to all of a sudden think, oh my gosh, now there's all these other things that I need to think about and worry about because I'm already just getting past this next ultrasound scan to make sure the baby's okay or, you know?

[00:27:42] Kimberly: Right, right. Yeah. I mean, there's a lot of anxieties that can come up in pregnancy. You know, without fearing, without worrying about birth injuries and stuff. So I, I do get that. Yeah.

[00:27:54] Melissa: And some of the other, go ahead. Did I cut you off there?

[00:27:57] Kimberly: Yeah. Oh, I was just thinking like, the challenge is that [00:28:00] I do see it as providers responsibility to provide information that is had, right? Like if we know certain things about the prevalence of birth injury, if we know things that can reduce the risk, I do think that there's an ethical responsibility to share that. Just like so much else is shared, right? Like there is so much else, you know, risky during pregnancy that is shared where the prevalence is actually a lot lower. So the things that we are told, you know, as pregnant people, the things that we're told to do or not do to reduce certain risks that happen at a lower rate than birth injuries, like why are birth injuries left off the table?

[00:28:38] Melissa: Absolutely. I feel like I've, I've just had to be really creative with how I deliver that and, and for example, yeah, like this podcast is full of uh, full of information helping you to prepare for birth. But I'll just say, Hey, do you listen to podcasts? I've put a lot of information on here. Why don't you just listen to episode one, which is just a very general, get to know your pelvic floor episode, and then I say, look at the [00:29:00] other episodes and see if they interest you, because I don't wanna shove information down their throat, but agree. Or if they say, you know, what would I come back for? That's where often I'll say, some women find it's very helpful to learn about their body and how their pelvic floor relates to birth. Would that be something you're interested in? So I, I just find, I've had to be a little bit more creative with, there is information out there that would be very helpful. Here's where you could consume it. This is where you can find evidence-based information and I think that this is one of the biggest reasons why I wanted to talk to you is because this episode will do, will be, I will share this so much with those women that are wondering, well, why would I learn about it before?

[00:29:41] Kimberly: Yeah. Yeah. And I will say like, in addition to sharing the information, I think it's important that providers don't share it in a, especially I think PTs I, I know especially can be prone to this of, you know, sending this message that if you do all these right things in all the right ways, you can have this birth experience that you want and [00:30:00] not have any birth injuries you know, follow this program and you won't have birth injuries. Follow, you know, these recommendations and your birth will be really smooth and if you use these birth positions, you know, you'll allow for physiologic labor to unfold, et cetera. And so I think that there's, like you said, there's a lot of important nuance that needs to be included in this conversation. Including the fact that you can do all the right things in all the right ways and still experience a birth injury. Because I think, you know, communication can fall apart in both directions, right? On one hand, the lack of communication is problematic, but on the other hand, sending a message that if you do all these things, you can prevent all birth injuries is also problematic because then for those who experience it, there's this reinforcement of like, I guess I'm really broken then, right?

[00:30:42] Melissa: Absolutely.

[00:30:42] Kimberly: I guess I missed something. I guess I didn't do something right. Was it, this was it, this was it, this, and that can really fuel these shame spirals and regret spirals. So, you know, my, obviously, like I haven't empirically studied this, but what I would have liked, I can just say personally, what I would've enjoyed hearing from providers is that, [00:31:00] you know, here is how the pelvic floor functions in the context of pregnancy and childbirth. Here are things we know that can reduce its risk or reduce the risk of complications during labor and postpartum. These complications being, you know, stalled, progress, different forms of birth injury. Here are the types of birth injury that can happen. And you know, at times we can't prevent everything. And so even if you do experience x, y, z here are some resources that can help. So that kind of conversation would have been really huge for me in this postpartum period looking back Yeah,

[00:31:35] Melissa: Well I actually, episode 42 is all about that. It's about a woman you just described. She went in doing everything eyes wide open and birth injury and really struggling to get back to running. And she talks about how she felt pretty well equipped though to deal with that after because, mm-hmm, she said I, no, I wasn't expecting it cuz I did all the things, but mm-hmm, it's here and I'm learning about [00:32:00] my body and I'm learning to navigate this in my own body with tools to empower myself. And so Right. Exactly what you just described. Yeah.

[00:32:09] Kimberly: Yeah. I mean, if I, if the first thing I had heard about managing a birth injury was from a provider who said, here are some things we can do to progressively build back towards these things that you love, versus is there anyone who can help you hold and lift your baby? The impact would've been so different, right? Mm-hmm. . Mm-hmm. . Because I would've, I would've from the outset approached it like an injury that I could rehab to some level versus, this fundamental broken part of myself that was gonna take everything I loved. And that's why I've, I've shifted to start. I've really talked about it as birth injury versus even like, I typically don't use the terms pelvic floor dysfunction or even prolapse. I mean, I'll specifically name what's going on, but I think birth injury is a term that helps tackle that stigma and helps people approach it like an injury that [00:33:00] it is, versus like you did all these wrong things and now your pelvic floor's messed up.

[00:33:04] Melissa: Well, I think that there's a lot of people that really dislike the term injury as it relates to birth, because while birth is so natural, I hate to term term it an injury, but I absolutely agree with you. And I say as a physio, our clinic is filled with people that have injuries, and I don't see that as catastrophic. People are in here all the time knowing that there's help for injuries. And so I think the problem with not calling it an injury, like you said, it, it, well then what is it? Because I know conceptually that I can recover from an injury I j I, yes. I need to put in some time. I need to reach out to someone maybe for some help, but that doesn't, injury doesn't equal broken, I think in, in most, in the rest of our body.

[00:33:46] Yeah, some of the other things that you pointed out in your paper as far as barriers to some of this information making it to our clients. So, you know, we already talked about how we don't wanna increase stress and anxiety. I think that's one of the reasons why women [00:34:00] aren't told about this information. But some of the other ones you brought up were that the, the expert doesn't have the knowledge themselves, and I think that's, that is another huge barrier, is that, yeah, the most of the physicians and midwives that I talk to say I, we don't learn about this in our training, so I don't know how to deliver that. And I think there's also, you know, there's a lack of awareness as to what some other healthcare providers, I think, most doctors and midwives sometimes don't even know what we can provide as pelvic health PTs. And so I think that is another huge, you know, barrier to, to women receiving information.

[00:34:37] Kimberly: Yeah, I think, you know, I, I do feel strongly that that needs to change, right? That providers need to be informed about birth injuries. But I agree that in my experience, it is more of a true gap in knowledge and a true blind spot, you know, which isn't an excuse for that, but it's, it's more of that than an intentional hiding of information because [00:35:00] I, you know, I know a lot of people feel really lied to and, you know, it doesn't feel a lot better to say like, well they actually didn't even know themselves, cuz they should cuz the information's out there, right? Like there is the research supporting that kind of information. But I, I think it, it, it's at least nice to know that I don't think most providers are intentionally hiding these catastrophic injuries from patients.

[00:35:23] Melissa: No, absolutely not. No, absolutely not. But yes, I, I do see that. I, I think that there, there needs to be, you know, unfortunately there, the, another barrier, you know, someone like a pelvic health PT, I mean, if you don't have extended medical benefits, it costs money to get that information. Yes. Right?

[00:35:43] Kimberly: Yeah. Yeah. Which, you know, is actually a cool side effect of the pandemic in a way that there are all these new online courses Yes. That are more affordable and definitely better than nothing for pregnant and postpartum people who couldn't otherwise afford. [00:36:00] You know, weekly pelvic floor PT. So I do see that as another option to have

[00:36:04] Melissa: Another barrier to that I see, cuz I have a program very similar to that, it, it is that it walks you through the very first module during pregnancy is all about learn about your core and pelvic floor, like you mentioned. I, what does it look like? How does it behave? How does it work for me in my day-to-day life? Cuz we don't generally have an awareness of these muscles. So. In order to feel connected to them or feel that you can influence them first, you need to understand them. And so, you know, I walk you through that, walking through, understanding how your body's changing during your pregnancy, how to prepare from a mental point of view and a physical point of view at how do these relate to birth. I guess what I'm trying to say is that, this program exists, but I think there's barriers to people signing up for that. I think sometimes, yeah, there's a lot of information out there, so people have a hard time knowing what should I even, what should I even consume? And I think, right. Make sure that [00:37:00] whatever you're purchasing, like, what's the evidence behind that program they've created? Because that's where, like I can say for myself, everything in there is based on like current evidence and best practice, but that's not the case for a lot of programs out there. And it's, right. Yeah. Like look into that because you want to know that you're consuming information that's, that's trustworthy, right?

[00:37:22] Kimberly: Yeah, absolutely.

[00:37:24] Melissa: And I also think that there's barrier to us taking care of ourselves. There's, as mothers, it's, everything's about baby . I mean, I think we spend a lot of our time, energy, and money on a nursery, on clothes, on things, and so it, we only have so much money, so sometimes it's hard to justify, like, these programs still cost money. Right. And so Yeah, that's right. There's that, there's that barrier. During pregnancy, I find that, uh, a lot of women will say, I don't have the time and the financial resources. Yeah. So I think that, but I don't [00:38:00] prioritize that. It's just not a priority.

[00:38:02] Kimberly: Yeah. Mm-hmm. And there are, like you said, there are very real structural barriers, like not truly not being able to afford these things. And then there are these other kind of societally shaped barriers. Like, I need to p put my baby first, always. Mm-hmm. . The irony of that being that by putting yourself in the backseat always, you actually compromise your baby's wellbeing. Right? Absolutely. Because we know that there, you know, there is a lot of research showing, you know, the health and developmental benefits to baby of having parents that are, you know, in a great place mentally, right.

[00:38:40] Melissa: Absolutely.

[00:38:40] Kimberly: Feeling taken care of and feeling supportive. And you know, it's not, and, and I don't want that to be confounded as like, you can't have mental health challenges and be a good parent. Like absolutely. But there are benefits of prioritizing your own mental health, your own wellbeing, physical health. All the things you can do for yourself will also have positive fallout on [00:39:00] the baby.

[00:39:00] Melissa: Absolutely.

[00:39:01] Kimberly: More so than the right nursery blanket.

[00:39:03] Melissa: Well, absolutely. And I wonder if then, kind of as we start to kind of close this up a bit, where do you want, where do you see, obviously we need to make some changes. We need to make some forward progress when once we start to have data like this, we need to put it into practice. What are, yeah, what, what have you already seen actually, Kimberly? Like since, since you, you've released this information, what changes have you already seen? If any.

[00:39:31] Kimberly: Yeah, so I was just really blown away in a, in a great way, how excited people were and receptive people were to this information. And. You know, honestly, it's kind of an ac academic's dream to publish something and then have it be immediately used to change clinical practice in a, in a really real way. So I, I've gotten a lot of messages from both you know, people who've experienced birth injuries and providers. You know, people who experienced birth injuries have told me, you know, I shared this article with my [00:40:00] OB and now she's including pelvic health resources for her new patients. And so that was just like so cool to hear because it means that the lived experience of all the people who contributed to this research is having an impact and not an impact in 10 years. An impact now. And so again, like that doesn't undo what we've gone through, but it means that it's being used for something beyond ourselves which can be real, can feel really healing. And then I've also heard from providers saying, you know, thank you for this information. I'm gonna be using this to try to help change, you know, the way I work with clients. I've also really appreciated the PTs who've said, you know, I'm gonna start shifting my language in terms of how I talk about prevention. Because that, like I said earlier, that can be really harmful when there are these kind of black and white all or none approaches to birth injuries. And I think we really need to find a way collectively to hold the two things in tension. That there are modifiable risk factors that we can intentionally that, that we can modify, right? To reduce the risk. And just like any risk factor, [00:41:00] eliminating that risk factor doesn't mean that the thing will never, ever, ever happen.

[00:41:04] Melissa: Absolutely. So I think that, you know, if, so for clients listening, you know, women that are preparing for birth or recovering after, I think if I was to summarize: spend some time educating yourself. And I think some, some of that onus is on us as clients. So I think sometimes our healthcare system is set up that we are always going to the healthcare provider wanting the answers and give it to me type of attitude. So I think that this is where the onus falls on us as client to, you know, fill in your gaps, right? And, and spend time figuring out what are your questions, because, you know, always kind of being in the driver's seat will never be a disservice. Right? And so I think yeah, making sure that you educate yourself and, and take some of that onus on. Yeah.

[00:41:53] Kimberly: I think one challenge there though is that we don't know what we don't know, right? Yes, yes. And so when you say like, what are your [00:42:00] questions? Like I don't know that I would've asked all these questions because I had no idea this was a thing, right? Yes. Right? Absolutely. I think oftentimes those of us who are in this world now in the pelvic health field, start to take for granted the fact that this is important information to have. And we forget what it's like to be a client with having no experience with this. Which is why I think dissemination of this information is so important because someone might see it and be like, wait a minute, what's this like, I'd never heard of this. Let me read a little bit more. And so I think that's a value of both social media and the role of providers too, to help fill in gaps that people wouldn't actually know to research on their own.

[00:42:35] Melissa: Absolutely. And I think that, I'm trying to break down the financial barrier a bit in that respect with this podcast. So I can do episodes Yeah. On, on all like, so let's talk about perineal massage. Let's talk about the evidence behind birth positions. Like let's just talk about it so that you can listen. And so that you can formulate your question because I, because you know, that doesn't cost anything. And so I find sometimes that's myself saying, here's where a [00:43:00] bunch of the information lives now listen and find out your questions.

[00:43:03] Kimberly: Yeah, yeah.

[00:43:04] Melissa: Right. So that you can fill in the gaps in care that you have. So I think I, I mean, that's one of the big takeaways I have for clients is, is spend some time just understanding what it all means and don't ever feel difficult asking questions.

[00:43:17] Kimberly: Right.

[00:43:18] Melissa: Ask them. Yeah. So I think, and then like you said, for clinicians listening, you know, this is what, this is what the evidence shows and how can we provide this information to our clients, like you said, in a very, you know, in a way that they can digest mm-hmm and that, you know, they go in feeling prepared and have a bit of a plan for who to reach out to postpartum.

[00:43:43] Kimberly: Absolutely. And you know, the more topics like this are collectively discussed, the more we will collectively build comfort discussing them, right? And the less they will feel taboo, the less they will feel, you know, so sensitive and difficult to discuss. It's just like anything that we do over and over and over again, like we [00:44:00] build comfort, right? We get better at it, get more comfortable with it. Mm-hmm. So I'm hoping that both providers building comfort with these conversations and also, you know, individuals, you know, postpartum pregnant people talking about pelvic health, like someday that will become standard and not at all weird.

[00:44:15] Melissa: Yep. Absolutely. And I think that, you know, I can see the, you know, stress might come if I was talking to a pregnant woman and saying, okay, and then incontinence is this, this and this, and prolapse is this, this and this, and diastasis is this, this and this. Whereas just being able to sometimes just use the terms, even just describe, sometimes you might afterwards start to have fears around prolapse or leaking or what have you. This is who you would reach out to. Like they don't have to have all of the information right away, but just, just so you know, these things would be normal. If you're having fears about these or having symptoms related to these, you don't have to wait six weeks to reach out about this or reach out. This is who you would reach out to. At least just give them a plan, right?

[00:44:59] Kimberly: Yeah, [00:45:00] absolutely. And you know, obviously I'm not a PT but in my experience and with the knowledge I've gained, you know, a lot of the risk factors for prolapse are also the risk factors for significant perineal and, you know, sphincter injuries and a lot of different types of postpartum complications. And so, you know, you can give similar prevention strategies that will cover a lot of things. Like you said, you don't need to like separate them all into these specific birth injury categories necessarily to provide good information.

[00:45:27] Melissa: Mm-hmm. And then I think if we were kind of giving a message to those that are kind of the perinatal care providers, you know, the ones that are overseeing the person as a whole, the midwife, the doctor, sometimes it can feel overwhelming to have to change your practice or to make big changes to your practice. But I think even just picking one thing, like you said, a one resource that you can send people home from, or you know, one, one link to something on your website, but just start small. And I think really quickly, you can make changes to your [00:46:00] practice, but knowing that this evidence is out there is helpful to be able to lean on, right? Like, lean on that. We know this about our postpartum clients and, and gaps in care. So one small change. Yeah. What, what other advice do you have?

[00:46:15] Kimberly: I would also say that in my experience, providers don't actually have a great concept of how distressing this is for people. I don't know if it's because they've seen it for so long and so many times that it just kind of, they become desensitized to it. But I think that if, I, I would strongly encourage providers to hold some space emotionally for the distress that is brought up by these experiences and injuries. And I know a lot of people, part of the, the distress is, like I said, not just the physical injury, but the way that others and, and the way that providers approach this. So I would encourage providers to take time to listen and ask what this is like in order to provide, you know, truly patient-centered recommendations for rehab. Make referrals to therapists and physical therapists, you know, like [00:47:00] mental health therapists and physical therapists, you know. Imagine being a marathon runner and told you can never run again. Imagine being a backpacker and told you can never lift anything more than 10 pounds. Like these aren't just minor inconveniences that postpartum people are living with. This feels really derailing for a lot of us, so that is another thing I would say to providers.

[00:47:22] Melissa: Mm-hmm. That's great. And, uh, and again, I think just finding out what's in your, what's in your community, what resources are in your community to, to be able to recommend. Yeah, absolutely. Yeah. Anything else, Kimberly, in closing, again, I can't thank you enough for not only the time today, but all the work that you've done. This is, this is, we need to make baby steps from here, but this is, this is big and I look forward to some of the Yeah, thank you, other work you're that you have coming.

[00:47:51] Kimberly: Yeah, me too. It's research is a slow process often, right? Like people, I think people don't realize how much time it takes to publish a single paper. But I [00:48:00] have, you know, others in the works right now and I'm excited to just continue this research trajectory and continue to slowly chip away at some of these things I hope to change. So, yeah, I don't think there's anything that I wanted or needed to say that I haven't. But I appreciate the opportunity to chat with you and hopefully this will be beneficial for both pregnant and postpartum people and providers.

[00:48:21] Melissa: And that's a wrap.


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