Ep. 10 | Pelvic Wellness: Birth and Beyond with Molly Bachmann, PT, DPT, Birth Doula

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This episode features an in-depth conversation with Molly Bachmann, a Birth Doula and a Doctor of Physical Therapy specializing in Pelvic Health. This episode contains insightful discussions about the importance of pelvic health and how it contributes to holistic wellness. The conversation dwells on the complications associated with pelvic floor muscles and Dr. Molly suggests practical solutions gained from her vast experience. Removal of stigma around issues like urinary incontinence and sexual dysfunctions is a key focus. The episode also sheds light on strategies to minimize injury to the pelvic floor, importance of birth positioning, and implications of stress on pelvic health. The discussion underscores the key idea that everyone deserves respectful and thorough examination for pelvic health issues. Dr. Molly also presses on the need for more awareness in rural areas about pelvic health and the necessity of having holistic treatment plans.

What moved you toward Pelvic Floor Therapy as a profession?

Molly Bachmann, DPT: I got into pelvic health very quickly after graduate school. I had done a rotation in orthopedics and there was a pelvic floor PT where I was working. I had never really considered pelvic health, but I thought to myself, you know what, I should probably just go and observe and see what it's about so that I can refer my patients better. And I'll never forget that session that I sat in on. The patient was in her 30s. She was newly married. She was having such horrific pelvic pain during sex that she was unable to get pregnant and that really was her dream was to have this family and the root cause of her musculoskeletal dysfunction in the pelvis came from a history of abuse. And so to hear where she started and then where she was the day that I saw her was such a huge leap, that I left the session in tears because I felt so empowered. I mean, I felt horrible for her situation, But I was also so proud to be a part of a field that could provide somebody with so much progress towards their ultimate life goal. And I really thought to myself, wow, this is a form of justice work, right? Like really giving somebody their body back after somebody took advantage of it. And I knew right then and there that I needed to be a part of the pelvic health community. Like, oh my gosh, if we can do this, what else can we do? After college, I got a job as an orthopedic physical therapist, but told the person hiring me, I'll only let you hire me if you allow me to become a pelvic health physical therapist and pay for my education and training.  And so that's what happened. Eventually I moved on to Pelvic Health and Rehab Center and was working in San Francisco for several years. And we decided to open a clinic here in Ohio, which is actually where I'm from. So that's how I ended up. getting into it.  

What I see is a lot of physical therapists get into pelvic health because they develop issues themselves and in search of an answer, they're like, wait a minute, there's this whole specialty that I didn't even know about–but that was not my situation. The field of pelvic floor physical therapy is a specialty that's actually been around for about 30-40 years. It's not new. It's definitely new to the consciousness of American minds, but it's not actually as new as people think it is. It's been around for a while.

What is Pelvic Health and who can benefit from Pelvic Floor Therapy (PFT)?

Molly Bachmann, DPT: Pelvic health is a specialty that focuses on the pelvic floor muscles, which are three layers of muscle that sit at the base of the pelvis. They control urination, bowel, and sexual function, as well as support organs, so it's really involved in our core support and keeping our organs inside of us, which means that every single person on this planet has a pelvic floor, not just women. And in fact, at any given time, 50 percent or more of my caseload are men.

As a society, we haven't talked about pelvic health, let alone for, for women and for men. But you see a lot on social media conversations about pelvic floor for women, specifically with pregnancy and postpartum care. But actually there's an entire spectrum of people and conditions that really need our specialty. I mean, think about any sort of prostate surgery, abdominal surgery, even back surgery, all of those things have a direct impact on the pelvic floor. So if you're somebody who's gone through one of those procedures, or maybe you were walking and slipped on ice and fell on your tailbone,  those are the people who could benefit from pelvic floor physical therapy, you don't have to have gone through birth to benefit from our services. 

Allison: Yeah, I love that you pointed that out. I was not familiar with pelvic floor therapy until I had my second child. So I've got three–and with my second child, I had an unmedicated VBAC (vaginal birth after cesarean) with her and it was very traumatic, lasting 2 days essentially. I had hired a doula for that birth. So it was my first time doing a VBAC, having a doula and all that. And she recommended pelvic floor therapy afterward. I was very open to anything at that point, but it was something I'd never heard of. So I was like, okay, you know, but it was awesome. I mean, you've got to be open to different ideas, right? And it's not like just going into a doctor's office. It's a little bit more intimate than that but it helped me so much. And so with my third and last pregnancy, I went ahead and went to pelvic floor therapy through that pregnancy and after that. And I mean, it was just awesome. It helped me tremendously. But I can only speak from being pregnant and postpartum. 

What are some reasons someone may see a Pelvic Floor Therapist?

• Prepare for childbirth

• Recover from childbirth

• Genital pain

• Pain during sex (dyspareunia)

• Urinary urgency

• Urinary frequency

• Chronic constipation

• Small Intestinal Bacterial Overgrowth (SIBO)

• Interstitial Cystitis (IC)

• Endometriosis

• History of Prostate or Gynecological cancers

Molly Bachmann, DPT: Let me first talk about pregnancy and postpartum care. Throughout all pregnancy and birth–I find that the easiest example that I can compare it to is a soccer game or a football game, some sort of sporting event. I think most Americans can conceptualize that. It would be ridiculous for me to say, “Allison, I want you to show up to this soccer game. I know you've never played before, but I want you to show up to this soccer game and score ten goals”. It's ridiculous. When we think about pregnancy and birth, we essentially historically have asked women the same thing. I know you've never given birth before, I know you don't know what's going to happen in that OB office or in the midwife office or at your home. But I want you to go and just expect to know how to push and expect to know how to recover safely. That's what we've asked women to do, and I really fundamentally feel it's not fair because what the entire body goes through, let alone the pelvic floor, during labor and birth, whether it's cesarean or vaginal birth, is equivalent to running two marathons. I mean that's the amount of metabolic load, that's the amount of muscle strain, the amount of stretching and activity that's going on, and we just expect that women inherently know how to do it, inherently know how to recover. So I explain birth in the concept of an injury, not as a way to scare people, but just to inform and what you're going through is a really big change for your body.

And all of these changes are necessary to ensure the safety of you and the safety of your baby and that everybody arrives to one good place safely. But we need to do it from an informed perspective, and there's a way to prepare your body for this event and help recover afterwards. 

Additionally– especially in San Francisco– a lot of my clients were in their 20s and 30s who were experiencing genital pain. So, pain in their clitoris, pain in the vulva, pain in the vagina. This could be pain with sitting. It could have been pain with their exercise. It could have been pain during sex. So that’s definitely a big portion of the clients that I see have some sort of genital pain, most of which was not related to a procedure or surgery, but almost develops kind of like an overuse injury that you might experience in your Achilles tendon or in your rotator cuff, for example, or a low back pain–any other part of the body. Because there are muscles that function just like anywhere else. So, I saw a lot of people who had genital pain, a lot of penile pain, scrotal and testicular pain. Sometimes those kinds of pain syndromes develop after a hip labral tear injury. or maybe hip arthritis, or maybe they had a history of low back pain and their body chose to do their squats with a different pattern than they're used to, and then they overuse some muscles in their pelvic floor and that becomes pain. 

I also see a lot of people who have symptoms that they may not think are muscle related, such as urinary urgency and frequency. So any sensation where they're urinating more frequently than every three hours. I've had people who are coming in and saying, Oh my gosh, I'm getting the urge to pee every 15 minutes and I've been to the doctor and they keep telling me my cultures are coming back negative. I don't have a urinary tract infection. Well, come to find out those symptoms can also be symptoms of muscle dysfunction in the pelvic floor. So, I see a lot of urinary dysfunction in that regard. I also have a lot of patients who have chronic constipation. They've tried the fiber, they've gone to the GI specialist, they've been told they have IBS, which is just a huge spectrum of symptoms, right?  

Allison: It's just a big Band Aid diagnosis!

Molly Bachmann, DPT: Exactly. But one of the reasons why somebody might have chronic constipation is actually because the pelvic floor muscles are dysfunctional, and they're not able to lengthen and relax appropriately in a way that the stool would evacuate. I also have a group of people who come in with a specific diagnosis like endometriosis, interstitial cystitis, SIBO, maybe they've had a history of gynecologic cancer or prostate cancer and the treatments associated with those conditions have had an impact on their pelvic floor in some capacity. So it's a really big spectrum of people that we work with. 

What are some ways to reduce injury to the pelvic floor? 

• Don’t strain while having a bowel movement

• Move your body

• Manage stress 

• Increase hip mobility

What are some things you see that cause pelvic floor muscle injury?

Molly Bachmann, DPT: 

Chronic Straining. So, for example, maybe they're constipated, but maybe they're not. They were just taught that every time you go to sit on the toilet for a bowel movement, you should push to get your poop out. That's actually not a normal voiding pattern. A normal and healthy situation is you feel the urge, you go sit on the toilet, your poop comes out within two minutes or less without any effort at all. So people who are chronically straining (meaning holding their breath, bearing down and constricting their air) actually puts a lot of adverse pressure on the pelvic floor muscles, which sit around the anus and rectum. And so every time you push, those muscles get overstretched. If you think of your bicep muscle, if I were to overstretch my arm day in and day out, sometimes for years on end, eventually this muscle is going to falter, which means it's either going to tear, so sometimes people have chronic fissures, for example or it's going to become effectively more weak because it's been overstretched. Or, sometimes the body will actually have the opposite reaction and it will tighten as a way to prevent that downward force from above. So really working on your pooping mechanics is actually one of the best things that you can do for your pelvic floor. For some people that means sitting with better posture on the toilet, other people it means breathing better. For some people it means changing up their diet so that their stool consistency is better. But we really just want to reduce the amount of times that that pelvic floor is negatively stressed in that way. 

Sedentary Behavior. Here’s an example–in the pandemic, everybody got a Peloton, right? And everybody was sitting a lot more because we were confined to our homes. So they may be working from home and probably don’t have a standing desk. So they're sitting for 9-10 hours a day for work. And then their activity of choice is sitting on a bike. Even though it's exercise, it's still in that similar position. So if you were to take (again) my arm, for example– If I were to apply moderate pressure for 10 hours on my muscle, eventually that muscle maybe isn't going to get enough blood flow or oxygen or nutrients. And then when I go to get up and do this big workout, it's very hard for those muscles to function optimally. We've got a lot of very superficial pelvic nerves down there that can be sensitive to the amount of oxygen and blood flow that we're either getting or not getting. And so I saw a lot of nerve injuries during the pandemic. Improve the amount of time that you spend sitting down.

Stress. So we have an evolutionary reflex when we're in fight or flight to engage our muscles to get ready to run away from the bear, which is great. We need that reflex. The problem is when we live in a world with a lot of metaphorical bears, work stress, relationship stress, you know, fear of COVID or whatever it is, that those pelvic floor muscles tend to live in a state where they're chronically ready without letting go. And so again, if we use the example of my bicep, if I'm holding it contracted like this all day long, eventually, it's gonna fatigue, it's gonna hurt, it's gonna be strained. The same can happen to the pelvic floor. So really knowing,I can't necessarily avoid all stressors–but what can I do when these stressors come up to better manage them so that they have less of an effect on my body?

Allison: I think that that plays into so many different things though: Trying to manage your stress better and your breath work better and blood pressure and all of these things, but also your pelvic floor.

Molly Bachmann, DPT: 

Lack of Hip Mobility. You think of going to the gym, maybe you're picking up some weights, you're doing your squats, your lunges, your deadlifts. All of those are wonderful. I want to really encourage people to do that– AND I want you to also think about “how is my body moving through that full range of motion?” So if I'm only doing a squat, maybe I'm just going 25% of the way down every single time, eventually my body's going to say, hey, I need something different. And it's going to let you know that it needs something different by maybe giving you pain or maybe some sort of pelvic information. Whereas if I'm going to the gym three days a week– maybe on Mondays and I go 25% of the way down, Wednesdays I go 50% of the way down and Fridays I go 75% of the way down–now I'm working my body throughout the full range of motion that my hips have to offer. And so really considering how you're training, not just how often and how long you spend doing it, but what does your program really look like? And am I giving my body, particularly my pelvis, enough variety of movement? 

I'll see CrossFit athletes, for example, who are wonderfully strong, right? They can do all these amazing athletic feats, but they can't do a simple hip mobility exercise that I give to them. It may not necessarily be an issue of flexibility but their capacity to move that joint through the full range of motion is limited. So really working with somebody who specializes in looking at the full package of your exercise program, I think is really important.

How would I know if my pelvic floor is weak?

Molly Bachhman, DPT: You may not necessarily know on your own because it's not like it's not like a hamstring, for example, where you can say, Oh, I can stretch it. I can tell that is tight, right? The pelvic floor is different in that way because it's shaped like a bowl, right? There is not necessarily a beginning and end point where you take one piece and you manipulate it and you stretch it. It's a bowl. So it works a bit more like a trampoline. The way that a pelvic floor physical therapist might examine your pelvic floor certainly doesn't need to happen for every case. But it's usually through an internal exam, so either via the vagina or the rectum. The reason why we have to do that is because, again, there are three layers of pelvic floor muscles. The deepest layer is deep inside. And it is very challenging to evaluate that layer externally. So when they do that exam, they're able to say, Oh, this amount of muscle tone that you have is abnormal, or you're doing a great Kegel or pelvic floor contraction, but I'm noticing that you tend to squeeze your pelvic floor more towards the back rather than the front, for example. Let's see if we can problem solve or maybe you have great strength, but you have terrible pelvic floor muscle endurance. So yes, you need pelvic floor contractions, but we need to do them way differently. We need to get away from sets and reps and more from the perspective of endurance holds. So I do really encourage people to at least get an evaluation from a qualified pelvic floor PT so that you can get some very clear objective information on what your specific body needs. Generally, it's safe to say that if you're having genital pain or pelvic pain, the likelihood that you also have tight pelvic floor muscles is pretty high. And generally those people are going to benefit more from stretching, mobilizing, and improving the muscle elasticity. 

We're really getting away from saying, oh, you have leakage–it's definitely because your pelvic floor is weak, do some Kegels. Because that is not true, actually, for a lot of people! I really think of it like this again, those pelvic floor muscles are muscles that function just like any other muscle in your body. If you had knee pain, the doctor is not going to recommend surgery immediately. What's the standard of care? You go to physical therapy first and you do it for a period of time. The reason why you do that is because the research says that you're going to get better with physical therapy a lot faster than with surgery. And then in some rare cases where anatomical deficiency that needs a surgical repair–totally appropriate to go get surgery. We're trying to change that kind of mentality for pelvic floor as well. Historically, because we haven't had as much information about specifically women's pelvic health (and there's a lot of historical reasons for that). The standard of care has been surgical interventions. 

What we're slowly finding now as we get more access to research and more researchers are studying these pelvic floor muscle dysfunctions, that the same is true for knees, backs, necks, and shoulders as is for the pelvic floor, meaning when you have these symptoms and you get an appropriate physical therapy treatment plan first, you're likely to get better in a reasonable amount of time without ever having to need a surgery or procedure. And don't get me wrong, there totally is a place for some of those things, but on the whole, it probably shouldn't be our first go to medical response. 

What are some different ways to reduce injury to the pelvic floor during birth?

• Reduce changes of needing forceps delivery, vacuum delivery, and episiotomy- these will always increase your risk of perineal tearing

• Having a doula, midwife, or birth supporter

• Position of birthing

• Pushing mechanics

• Perineal massage

Molly Bachmann, DPT: Officially, per the research, of which there is so little, we don't know.  But what we do know about exercise physiology and movement are some really key things. So, in terms of reducing injury to the pelvic floor, one of the best things that we can do is reduce the chances of needing a forceps delivery, a vacuum delivery, or an episiotomy. Those three medical interventions will always increase your risk of perineal tearing, for example, because they're, they're very invasive, and an episiotomy is a direct cut to the perineum, where they're cutting the muscle so that the baby can come out, so working with a doula and or a midwife, some sort of continuous labor support is super important for reducing that kind of cliche evolution of labor is stalled, we're going to bring out the forceps and the episiotomy. So having that continuous labor support is going to reduce the chances of needing those medical interventions which do set you up for pelvic floor muscle injury. So that's definitely key. 

What do you mean by continuous labor support?

Molly Bachmann, DPT: So when you look at the American College of Obstetrics and Gynecology (ACOG), which is the governing board for all obstetric care in the United States, their research shows us that when you have continuous labor support, meaning from a birth doula and/or a very well informed birth partner, could be your husband, could be your mother, but somebody who is really up to date on the evidence really reduces your chances of injury and improves your health outcomes really across the board for birth. So even if you're not interested in injury prevention, everybody really should have a doula. Obviously I'm biased because I am a doula, but actually the research really does reflect that. So what I will argue too, is that for people who maybe just want their husbands there or their mothers there, I totally respect that. And you, that may be the person that you trust most in the world. I have been in so many  birthing rooms where the husband is so wonderful and so nice, but doesn't know what to do, and that's okay, it's not their fault, they weren't trained in how to do this either, or they know what to do, but in the moment, there's a lot of anxiety. There's a lot of pressure. They may even have some what I would call performance anxiety where they freeze up and they're just kind of in shock and awe of what's going on. It's hard to rely on somebody who's having a response like that. And again, not their fault, but hiring somebody who is trained for these situations so that you've developed a good therapeutic relationship can be a really great resource for people. Do not underestimate the power of having an informed person by your side and the reduction of injury risk during labor.

The position that you give birth in, that is something that has been researched as far as the effect on the perineum. So the dorsal lithotomy position, which is what you see in all the movies and TV shows on your back, somebody's hiking your legs way back up actually has the highest risk for perineal tear of any position, and there's probably a couple of reasons why that is a if you think about the orientation of the vagina when you're on your back, you would actually be pushing the baby uphill,  literally trying to defy physics, which is hard for anybody to do. So that's probably a big piece of it for sure. One of the main reasons why people give birth on their back is because it's, it is very convenient for doctors and midwives to see what's going on. And we obviously want them to be able to assess and see what's going on. Another reason why people give birth on their back is, for a high dose epidural. You're temporarily paralyzed from the waist down. Even if you had that degree of an epidural, you actually still can give birth on your side those hospital beds are so malleable. You can get into what I would call a pseudo squat where you're not actually squatting, holding up your own body weight, but the bed is manipulated into a way that you're in a supported squat.  Birth position does really matter.  

The third thing that I often talk about is pushing mechanics. So how we're pushing out, (and this is a really great use of pelvic floor physical therapy) is actually figuring out what mechanics might work best for your body. So I'll have somebody come in, they don't have any symptoms, they just want to prepare for birth. We're doing a pelvic exam. And I will ask them, you know, if you were to try to push a baby out right now, how might you do it? Give me 50% of your effort (maybe not 100% effort– I'm not looking to deliver any babies in my room!) and we see what happens. Does the pelvic floor elongate? 

Do I feel enough pressure coming up from above? 

Do your abs contract?  

If we think of the abdomen and the pelvic floor like a balloon if I were to bear down and hold my breath, like what you see in the movies and in television, most people, not all people, but most people will actually tighten their pelvic floor instead of relax. What we want during birth is for the pelvic floor muscles to elongate and open like gates rather than shorten and contract because pushing a baby through contracted muscle is impossible. So it's my job as a pelvic floor PT to say, okay, what happens if we push with this breathing technique versus that breathing technique, how does that change your mechanics? Oh, that works really great. Awesome. Let's write that in your birth plan and get it put in your medical chart so that when the nurse comes in, she knows to cue you to push or breathe in XYZ way first as a good strategy for you. So that's something that really import is important when it comes to injury prevention during birth. 

The fourth big thing is perineal massage. There's a lot of buzz around it, I'll say. There is some research that it's effective. However, the most recent Cochrane review came out with a glowing review of perineal massage. However, when you look deep into the research, a lot of the research is not of the highest evidence meaning that it's not double-blinded. It's very hard to say that it's the perineal massage that prevented the injury, if that makes sense. All that to say, do it or don't do it, may not actually matter, but if that's the only thing you're doing to prepare for birth is perineal massage, you may not actually get the result that you want. Likely, it's the perineal massage in addition to a lot of these other things that we're talking about in conjunction. The reason why I say that is when I see most people do the perineal massage, they do it with one finger or thumb. When a baby comes out, they're not just coming out on one side of the vagina right? The head is circumferential. It's stretching all aspects of the vagina and the perineum at the same time. So in order to do perineal massage correctly or more effectively, it needs to be done with at least two fingers. With a certain degree of pressure. So like the lighter pressure, if we're talking about birth prep, not actually during birth, the lighter pressure may not actually be effective. But the piece where I do think perineal massage is helpful for preparation is training your brain. To recognize what it feels to have a stretch in your perineum and not associate that stress with injury or fear or harm. Because many people that I see, they feel that stretch (or that ring of fire) or that pressure that's starting to come down as the baby's head is exiting the canal, and it's panic because that pain is (or can be, not always) kind of shocking. And so the body's reaction is to tense up and squeeze everything. But if we can practice that massage and we can use mantras or positive thinking and say, wait a minute, this is actually not pain–this is actually just a stretch. Okay. A stretch intellectually feels very different from pain, right? So that's where I think that it can actually be really helpful is training that mind-body connection, that when you're in birth and you're feeling that sensation, you can say, okay, I know that this sensation is not pain–this is a stretch and that's a good thing. That means my baby's on its way. My body's reacting the way that it should and we can reduce some of that fear. 

What else do you think is important for women to know?

Molly Bachmann, DPT: One of the biggest things that I see in pelvic floor physical therapy is a lot of emotional distress and psychological distress and grief about their symptoms. And a lot of that is because of social isolation, a lot of these topics are so taboo and it makes people feel so alone. What I want to provide as a counter offer to that feeling is, you very much are NOT alone. Remember that literally everyone in this world has a pelvic floor. You cannot survive without it. The majority of people, whether they realize it or not, will experience some sort of pelvic floor muscle dysfunction in their lifetime. Just like they'll experience some kind of back pain or an ankle sprain or something like that or a headache in their lifetime. These things are so common and you, just as a human, It is your right to receive compassionate, respectful, full evaluation and treatment. And so, if you aren't getting the answers that you need and the results that you need to live your life, keep going. It's so exhausting. But get second opinions, get third opinions. At Pelvic Health and Rehab Center, we offer virtual consultations. So if you're not in one of our areas, we're super happy to talk with you. We may not be able to give you a full treatment plan or provide you with treatment, but help brainstorm with you about how to get the treatment that you need.

Also, I think a lot of women have been made to believe this, but peeing your pants is not normal. It is not normal. I have to tell people that all the time. It is common, but it is not normal. It has been normalized. It is not inherent to being a woman. It is not inherent to giving birth. Don't let anybody tell you otherwise. AND pain during sex is not normal. It is something that has been normalized. It is not normal. And you deserve to be evaluated and treated for that if you wish to be. Don't let anybody tell you just drink a glass of wine and relax. Don't let anybody tell you you just need more lube. No. You deserve a full complete examination and treatment plan for that condition. It can be resolved. You’ve just got to find the right people. So, don't give up. I hope this empowers you to get care. 

Additional Resources:

• Squatty Potty (for better pooping posture😉)

• Effects of Perineal Massage During Childbirth

• ACOG’s Approaches to Limit Intervention During Labor and Birth

Connect with Molly:

• Instagram: @pelvichealth and pelvichealth_ohio

• Check out Pelvic Health and Rehab Center and schedule a virtual consultation

Connect with Allison:

• Instagram: @allison_and_wellness

• Facebook: allisonandwellness

• Website: www.allisonandwellness.com

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