There is so much intricate and important work happening in the bodies of pregnant, laboring, and postpartum people! Today we’re bringing you some expert information about perinatal pelvic floor health from our community partner Dr. Melissa Hines, a licensed physical therapist, the founder of Wellest Integrative Health, and an all-around awesome holistic health professional. Here’s a glimpse into her journey to this work, her sense of the importance of pelvic floor health, her thoughts on barre workouts, and her tips for labor.
But first, some humor:
Our interview with Dr. Melissa Hines
How did you come to this work?
MH: I decided I wanted to be a physical therapist in high school when my mom was going through breast cancer treatment. When I went to physical therapy school, I knew I wanted to treat an underserved population. I actually just happened to come across pelvic floor physical therapy when looking for more holistic physical therapy internships. At a young age, I had a lot of health issues which have lead me on the path to where I am today. Through my personal experience working through chronic autoimmune disease, I have done a lot of work on myself and developed an intuitive as well as compassionate approach to my treatments. I have always been a kinesthetic learner with a fascination with the body.
I remember during my first 16 week clinical rotation, my mentor specialized in pelvic health. I remember the first client I ever worked with was a young woman who had vulvodynia or pelvic pain. She was unable to sit without intense vaginal pain and unable to have intercourse or insert a tampon. She had been to over 10 doctors with no answers and that completely shocked me. Through pelvic floor physical therapy she was able to improve 100%. I knew then that this was my calling. I hate to see people stumble from doctor to doctor with no diagnosis.
Recently, more and more people are coming to me around the perinatal period, which is great! When I first started this work I rarely saw people for preventative care during pregnancy and postpartum rehab. There recently was a great article posted in the New York Times about the importance of postpartum care. It’s great that there is more awareness around this issue. I mean it seems crazy that one 6 week follow up appointment is given after the baby is born. “Okay you are cleared to have sex!” This is just outrageous. You just went through one of the most traumatic things in your life and no follow up care is given. My goal is to provide my clients with the care that they need and deserve after giving birth.
For goodness sake, in Europe, the postpartum population is given six pelvic floor physical therapy treatments that they MUST use or they could lose their health insurance. This is how important pelvic health is.
How would you locate and describe the pelvic floor for someone who is unfamiliar with this area of the body?
MH: Your pelvic floor is located within your pelvic girdle. All the muscles create a bowl or hammock for the internal organs. It is a major stabilizer of the body. You have many muscles that all have various jobs to perform. Some muscles support the rectum and others support your urethra to prevent any urinary or bowel dysfunction. They all come together at the perineum or the space between your rectal and vaginal opening (this is generally the source of tearing with vaginal deliveries). Essentially, your pelvic floor is between your pubic bone and between your sitting bones.
You can see in this photo, all the red is muscle. Like any other muscle, it should be able to contract and relax.
How do pregnancy and birth impact the pelvic floor?
MH: Your pelvic floor is one of the main points of stability in the body. Your pelvis should widen and expand during pregnancy in order to accommodate the baby. With this, the pelvic floor muscles generally become tight and weak. They are working in complete overtime to provide stability to the various joints in the pelvis that become hypermobile or extra mobile during pregnancy due to hormone changes.
I think one misconception is that when my clients have urinary incontinence during their pregnancy, they think kegels are the answer. That is generally not the case — in fact, sometimes doing endless kegels during pregnancy can cause issues when it is time to deliver. I would say 90% of my pregnant clients do not know how to properly release their pelvic floor. In fact, they actually contract or perform a kegel when I ask for a pelvic floor relaxation. You can see how this would be a challenge during a vaginal delivery when you are trying to release the pelvic floor muscles to get the baby out!
During the postpartum period, the biggest complaint is dyspareunia or painful intercourse. This can be from perineal scar tissue which can be worked on through physical therapy but can also result from the lack of estrogen in the pelvic floor tissue. Breastfeeding dramatically decreases the estrogen flow to your pelvic floor muscles and that results in poorer circulation and nerve irritation that irritates any scar tissue and muscle imbalance in the pelvic floor. I generally recommend a salve called “Vital V” to be applied daily to your vulva to help manage vaginal dryness in the postpartum period. The wild yam acts as a natural estrogen.
Do certain situations or characteristics put people at risk for a weakened pelvic floor?
MH: The most common things I see that cause even more pelvic floor weakness than the actual pregnancy itself are intense exercise (barre, crossfit, spin class, etc.), morning sickness, constipation, and postural imbalances. I see a lot of women nowadays doing a lot of barre thinking they are helping their pelvic floor muscle weakness but really it is making it worse. Because you tend to overuse the bigger stabilizers in these classes, the pelvic floor cannot keep up and becomes tight and weak causing weakness. These exercise classes also contribute to diastasis recti during pregnancy. Severe morning sickness or vomiting during pregnancy generally causes people to have weakened pelvic floor muscles due to the increased intra abdominal pressure with vomiting. Constipation can also cause pelvic floor weakness from straining to get stool out. History of back/hip pain generally coincides with pelvic floor imbalances.
What can birthing people do during labor to care for their pelvic floor muscles?
From a pelvic floor stand point, it is best to deliver in a gravity dependent position.
The best positions that allow the pelvic floor to widen are squatting, on hands and knees, or side-lying with knees into chest. Proper pushing is key. When I assess this in treatment, I find that most birthing people actually do a kegel and contract when they are told to push. Pushing is a contraction of the pelvic floor but in the opposite position. You can practice this on a more gentle scale by diaphragmatic or deep breathing. It is helpful to have your legs supported on the wall in a squat so your pelvic floor is on a stretch. You inhale all the way into your vaginal opening and feel like you are passing gas or having an easy bowel movement on the inhale. This is what the sensation should feel like when you push. Obviously it is not as intense, but you want to feel like you are gently releasing your vaginal opening or creating space. Proper motor control of the pelvic floor can also help with minimizing tearing.
Let's talk a bit more about your practice. What sorts of therapies would someone expect to receive upon visiting your practice? What is a typical session like?
MH: A typical session is one hour in length and consists of assessing pelvic alignment and working into dysfunctional patterns through myofascial release, visceral manipulation, and craniosacral therapy. All these techniques are similar to a massage but very targeted to what is specifically needed. In an hour session, about 40 minutes is done with external release work around the pelvis and 20 minutes is designated for internal pelvic floor release. Obviously, the amount of time for internal/external depends on the condition. With the internal pelvic floor release, my clients are fully draped and I insert one gloved finger with lubricant either vaginally or rectally. (This is the only way to assess the pelvic floor muscles.) I can check for trigger points, scar tissue, and muscle strength. Like any other muscles in the body, your pelvic floor can become weak or tight but you do not notice it until you have urinary, bowel, or sexual dysfunction. This is all important to work on preventatively during pregnancy so that postpartum rehab is much quicker with fewer complications.
What are the benefits of seeking physical therapy for pelvic floor health?
MH: Seeking pelvic floor PT during pregnancy is extremely important in order to prepare your body for delivery by focusing on things like proper pelvic alignment, stabilization around the pelvis, pelvic floor strength and flexibility, perineal massage, and proper pushing during labor. By prepping the pelvis throughout pregnancy, it is a much easier recovery postpartum. The most ideal time to start pelvic floor PT in the postpartum period is after your 6 week follow up with your OB or midwife. I do see clients prior to the 6 week period but do not do internal work until cleared.
This is a great way to learn more about your body and what needs to be worked on. Having some concrete exercises is empowering after have a baby because it makes you feel like you are working to rehab your body while caring for your little one.
Why do you think so few people know about or seek out pelvic floor therapy during pregnancy or the postpartum period?
MH: When I first started specializing in pelvic floor about eight years ago, I rarely saw people during their pregnancy. I would often see people during the postpartum period who had traumatic deliveries and complications. Now, I am seeing A LOT of people for preventative care during pregnancy, which is just amazing! I do feel like there has been a major shift in women taking control of their health and speaking up about their issues. However, we still have a long way to go in integrating pelvic floor physical therapy into the standard of care for postpartum. In Europe, patients get 6 postpartum physical therapy visits in order to prevent issues down the road like prolapse during the menopausal period.
can you share a success story or impactful moment from your work?
MH: Oh, there are so many wonderful stories and that is what I love about my job! One that comes to mind is a woman who was about one year postpartum and could not have sex. She had been to many specialist in seek of help with not much success. She was referred to me by a 4th specialist she had seen at Lahey Clinic who recommended pelvic floor physical therapy. Her pain with sex was really specific to the areas where she had grade 2 perineal tears. She was extremely stressed about this issue because it was putting a tremendous amount of stress on her relationship and she also wanted to have another baby at some point. Her pain was so horrible she could not even tolerate any sort of penetration. After 4 months of physical therapy, she was able to return to sex with absolutely no pain! In the meantime, all of her doctors wanted to put her on antidepressants, valium suppositories, you name it. If she had gotten the proper care postpartum and been referred to a pelvic floor specialist, she would never have had to deal with this issue for a year. Now, she is currently pregnant and due in six months!
What is your favorite part of your job?
I love being able to build relationships with my clients during their pregnancy and postpartum. I love providing a safe place for my clients to feel empowered to take control of their bodies and not have to feel like they need to live with issues during and after pregnancy.
A huge thank you to Dr. Melissa Hines of Wellest Integrative Health for sharing her knowledge about perinatal pelvic floor health! Visit her office in Copley square or connect with her online to learn more!
Dr. Melissa Hines, PT, DPT is the founder of Wellest Integrative Health and a licensed physical therapist (PT) in MA. Since graduating from Simmons College magna cum laude with her doctorate in physical therapy, she has practiced in a wide variety of holistic settings specializing in GYROTONIC® rehabilitation, pelvic floor rehabilitation, and myofascial release.
Melissa specializes in Pelvic Floor PT (for women and men) through the prestigious Herman and Wallace Pelvic Rehabilitation Institute. Melissa's training in myofascial release, visceral manipulation, craniosacral therapy and GYROTONIC® has proven pivotal in the treatment of orthopedic conditions. She has taken continuing education courses through advanced Herman and Wallace, advanced myofascial release, certified GYROTONIC® instructor training. Melissa has a strong interest in teaching and currently mentors physical therapists and students in the field to help empower therapists to think holistically.
She treats widespread chronic musculoskeletal pain, postural issues, pelvic floor conditions for men and women, pre/postpartum health issues, concussions and sports related injuries. Melissa utilizes an intuitive touch and enlightened approach in each of her treatments.
Melissa lives in Boston’s South End with her husband and cat! She enjoys exploring the city, trying out new restaurants, sailing, and the ocean.