Birth Matters Podcast, Ep 78 - A Pelvic PT’s Curve Balls in Pushing

As a doctor of physical therapy with a pelvic specialty, Helene Darmanin started off pregnancy with unique and applicable skills that informed her decision to pursue an unmedicated delivery in a hospital. She shares about the various things that helped her have mostly the kind of labor and birth she had hoped for, including support from her husband and doula, breathwork, a peanut ball, hydrotherapy, and more. When it comes time for pushing, both the position and the technique she ends up using are not ones she ever would have guessed she’d do nor would she recommend to clients, but that felt necessary due to both exhaustion and a medical concern for the baby. Helene also shares about her early breastfeeding and healing challenges, and how going through this process personally inspired her to start a fully virtual pelvic PT and other perinatal care support service offering.

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Episode Topics:

  • Miscarriage in first pregnancy & emergency D&C

  • Uncomplicated 2nd pregnancy

  • Lots of self-care in last few weeks

  • Erica Shulse & Sam Hom - doulas from NYC Birth Village

  • ~10am Friday - Walking tons when she thinks she’s in early labor a few days shy of her due date

  • 9pm - getting more intense

  • Driving from Queens to Mt Sinai West, lots of painful potholes

  • Gets to hospital at 6cm around 2am, really tired

  • Doula Sam supporting her with peanut ball and other comfort measures

  • Shower, hands and knees

  • Breaking waters manually

  • In pushing stage, baby shows signs of distress

  • Cord wrapped around his shoulder they later realized was causing decels & drop in O2 saturation

  • Ended up pushing on back with directed pushing which she never thought she would do

  • Meconium in fluid so baby didn’t get to come straight to her chest

  • Feeling really exhausted at the time of baby’s birth

  • Internal tearing, really painful to sit for a while

  • Experiencing challenges with breastfeeding, takes precedence over her physical healing

  • Getting phone support from lactation consultant, Disa (who’s now part of Helene’s practice)

  • Identifying the need for pelvic PT -- doing 3 sessions with Liz at Thrive

  • Covid hits and she starts treating pregnant and postpartum folks virtually

  • Describing her private virtual practice - pelvic PT, lactation services, nutrition, childbirth education

  • Helene’s tips on preparing for a healthy birth and protecting the pelvic floor -- breathwork

Interview Transcript

Lisa: Welcome to the Birth Matters podcast. Today I have with me Helene Darmanin. Welcome!

Helene: Thank you.

Lisa: I'm so glad to have you today. Would you please just start us out by introducing yourself a little bit, Helene, and share maybe how long ago you gave birth and what you do for a living since it's especially relevant to the listeners? Anything else maybe where you live, if you want, whatever you'd like to share

Helene: Absolutely, absolutely. So I'm Dr. Helene Darmanin. I am a pelvic health and orthopedic physical therapist and I specialize in treating pregnant and postpartum folks. I was fortunate enough to have my son 18 months ago, which sometimes feels like forever and it sometimes feels like yesterday. We just relocated from New York City to Paramus, New Jersey. We are now the butt of our own jokes being New York natives, New York natives who live in New Jersey, but we're loving the, loving the space and especially the yard. I just planted some vegetables this morning, which is like,

Lisa: I love gardening!

Helene: Yeah, I'm pretty excited.

Lisa: Especially when you have a little one. As your little one grows, for them to see where their food comes from is so great and so important, I think. Yeah, we have gone to our CSA farm in past years when our kids were littler and got to walk out in the fields and show them like, here's how the carrots grow. And it was just such a great educational thing. And so to have that in your backyard, that's really cool!

Helene: Yeah. And I think also just caring for things. He comes out with me every morning and we water the plants, we water the flowers; the vegetables not as much yet because this morning he was trying to throw the dirt around, that had tiny seeds in it. It's like. Not now, not now! Usually I'm all about throwing dirt, but not this dirt.

Lisa: Right. Precious dirt with seeds to grow things. Nice. All right. So let's start off by, can you talk a little bit about your pregnancy? How did your pregnancy go? What were the different ways that you prepared for the transition into parenthood?

Helene: Yeah, so I actually, my first pregnancy ended in a miscarriage about seven weeks pregnant. I actually went into my first prenatal visit with my OB. And she said, "Oh, you're here for your first prenatal visit!" and I was like, "Actually, I think I'm having a miscarriage right now." Because I had started bleeding and a lot of the discomfort that I was having was actually starting to disappear. So my breasts had been tender and then they stopped being tender and I started to have some abdominal cramping. So I was pretty sure and sure enough, she confirmed and then it was a bizarre time because then they couldn't quite confirm it with blood work yet and then it turned out I needed an emergency D&C because I had a blood clot blocking the shedding of my uterine lining. So it was sort of interesting to have that intense medical experience around and it didn't leave as much room for the emotional experience right off the bat. So that took a back seat for a little while. It took a little while to then process after that couple of weeks of, "Is everything okay?" My OB was having my husband watch to see if I needed to go to the hospital because of blood loss. She reached a point where she was concerned. So,

Lisa: And how many weeks were you when you, when...

Helene: About seven weeks. Yeah. I mean, I hear a lot of different things. People saying, "Oh, it's just an early loss. Oh, it's just a chemical pregnancy." And then I hear the pushback of, but it was a loss.

Lisa: That's what I was going to ask is, did you find that people minimized it because it was earlier on?

Helene: Some people did. I mean, I think I did. And my husband certainly did. He often forgets that I was pregnant another time, so I don't feel like everyone needs to look at the silver lining when you've had a miscarriage. It's sad and it's hard. I felt very fortunate that things turned out okay and we were able to get pregnant again really quickly after that. Which for me, that helped my healing process because I kind of thought the first pregnancy almost laid the groundwork for the successful second pregnancy. But it also made me a little bit desperate at the beginning of my second pregnancy to really make sure it took. So my OB had had two miscarriages herself, so she was really amazing about it.

I loved her approach, which was very much like, "Look, they tell us to tell you that it's a chromosomal abnormality at this point in time. That didn't help me at all when I was having a miscarriage, it's terrible!" And I just appreciated her frankness so much. And then during my second pregnancy, she prescribed some progesterone suppositories, vaginally. She was like, "Listen, the evidence is 50/50. It might help, it might not help, but you'll appreciate doing something. And I was like...

Lisa: Yeah, it gives you a sense of agency.

Helene: Hit the nail right on the head. That was exactly what I needed at the beginning of the second pregnancy to feel like I was doing something to try to hold on to it. And putting a little progesterone popsicle in my vagina every night, certainly felt like I was doing something because it was pretty uncomfortable. But yeah, so that was the beginning of my second pregnancy. I was really lucky to be able, like I said, to get pregnant again. The first month we tried after I got my period back and I did some wonderful acupuncture with my friend, Sara at Avalon Acupuncture, which helped to regulate my hormones again so that I did get my period back rather quickly after that D&C. Cause it can take two months and I got mine back in five weeks and then was able to get pregnant again right away, so that was very fortunate.

And then I feel like my pregnancy experience was pretty average. I didn't have morning sickness, which was very lucky. I had a little bit of nausea. And for some reason, a croissant was the one thing that would always calm my nausea, so the coffee cart guy got to know me very well! "That time of day again, I need a cinnamon coffee and a croissant."

Lisa: Sounds good.

Helene: It was delicious. And first trimester the most significant thing for me was exhaustion. And I was a personal trainer for 10 years before I became a physical therapist, so I love to exercise; I exercise so much. And that first trimester, it was all I could do to get on a stationary bike and put on an episode of Outlander and just keep my legs moving.

I was like, "If my legs are moving, this counts as exercise." Because I wanted to make sure that I was exercising for myself and for my kiddo. So that was the first trimester, just those tiny bits of exhaustion and lots of tiny bits of nausea and lots and lots and lots of exhaustion. Some breast tenderness, but nothing really remarkable.

The second trimester was the sweet spot. That's where it was at. My energy levels were back up. I started to have the little baby bump, which was exciting. Everyone could tell I was pregnant and I was really excited to have made it to the second trimester and not have experienced the loss this time. And it was right over the summer. It was my birthday, it was a beautiful time. And then third trimester was when, similar to everyone I know and everyone I work with, I started to feel like a whale and that led to some back pain. Also, I had a ton of swelling in my hands and feet, which may have had a little bit to do with the fact that I kept craving Chinese food so bad.

Lisa: Sodium content?

Helene: Because of all that sodium, my hands and feet were like sausages and that gave me some carpal tunnel syndrome, which was a bummer and I did see someone for physical therapy during that third trimester, which helped me, because I worked in person as a PT until 38 and a half weeks pregnant.

So I was on my feet. I was commuting. I needed some support and I did use also a belly band and lots of compression socks, but I was grateful. I was grateful to be able to be working and I was still working out all the way up until 38 and a half weeks. And then I took a week and a half before my due date off, which was such a good idea.

I just watched movies and baked cookies and had time for myself. I got a pedicure, which was one of the best things I could've done because I couldn't reach my toes. And I didn't think about my toes for months after that. So that felt lovely. So I highly recommend.

Lisa: Everybody listen to Helene, like if you're able to stop work and do a lot of self-care, even if you can't stop work, just self-care, self-care, in that, in those last couple of weeks or few weeks, even if you can.

Helene: Yeah.

A

Lisa: great tip. I'm glad you were able to do that.

Helene: Yeah, it was, I suggest it to all my clients and all my friends, there's nothing like it. And then interestingly, the last few days when I was really eager and anxious to go into labor, doing puzzles was the thing for me. I don't like puzzles normally, but I needed something to keep me busy and keep my mind occupied so that I wasn't just, "Come! Come out of me!" all day long. So that was really fun. My husband and my sister and I worked on some really difficult puzzles, which was great, the harder, the better to keep my brain occupied and then...

Lisa: You were ahead of the curve. So many people, including our family, have gotten really big into puzzles in the pandemic, but you gave birth shortly...

Helene: Just before the pandemic.

Lisa: Just before?

Helene: Yeah, yeah. October before, so almost five months before. Yeah, it's true. I had one day of false labor about a week before; it was the Saturday before, and then that Friday I started to feel contractions and I was like, "This will not be false labor!" And I started walking around the block furiously and I lived in Ridgewood, Queens, so the blocks there are like all those long residential blocks. And I think I lapped that block like 10 times that day. My doulas were texting me, they were like, "No! Rest!" and I was like, "No! I'm going into labor now!" And I really wish I would've listened to them because I was so tired. Waddling around a block 10 times is a lot when you're that big.

Lisa: And in the work you do, you probably just already knew about doulas. Did you hire them early on?

Helene: Yeah, that's a great question. Yes, I have always planned on having doulas. I found New York Birth Village and they do pairs of doulas, which I had never heard of before. And I think it is just brilliant.

Lisa: I love them.

Helene: Yes, they're wonderful. Narchi and Karla are awesome, but I worked with Erica Shulse and Sam Hom, who's no longer in doula work, but she's in reproduction...

Lisa: I didn't realize that!

Helene: Yeah, she's doing some work in reproductive justice. So she's awesome. They are both awesome. And I loved having them. I hired them as early as I could, I think I was 12 weeks, so that I could have their support during the pregnancy, as well as during delivery and postpartum.

Yeah. They were invaluable. When I had anything going on, "Should I call the doctor or should I ...?" of course you should not rely on your doulas for medical support. You should talk to your doctor, but it's still helpful to know like,

Lisa: Just to sort of, another voice.

Helene: "Is this something normal?" because even though I've worked with pregnant folks, it's nothing like experiencing it yourself. There's nothing like it. So.

Lisa: And important to get out of your clinical head as much as you can, too.

Helene: Yes, yes! That's so true. That is so true.

Lisa: So you're talking about this early labor or pre labor. And how many weeks were you at this point?

Helene: I was just a couple days shy of my due date.

Lisa: Okay. That's what I thought, but I just wanted to be sure.

Helene: Yeah. I think I was three days shy of my due date, so yeah, that Friday. So then the contractions were increasing, which was, I was like, "Yes! Yes! It's happening! This time it's happening. And then finally at nine something, we were like, let's go to bed and get what rest we can. I had started trying to use a contraction timer app, but it was kind of in and out of it.

And then I woke up at 12:30 and I was like, "Nope! This is it." I'm like, I can't stay quiet during the contractions anymore. I am just like, I can't sleep in between them anymore. I know this is time. And I remember my husband calling the hospital and being like, "Okay, we have to come in!" And of course my OB was on call Thursday and Friday until midnight and then off Saturday and back on Sunday and Monday and I went into, I needed to go to the hospital just after midnight, on Friday night into Saturday morning. And so he talked to the doctor who was on call and she was like, "Oh, how's your wife doing?" And then she heard me in the background, and she was like, "Yeah, it's time, you better bring her in." And I will never forget, he was like, "Okay, I'm going to take a shower now." And I was like, "You're gonna do what!?" He's like, "Yeah, we'll probably be at the hospital all weekend and I'm not going to shower there. So I'm going to take a shower. You just chill on the couch, okay?" And I was like, "I'm gonna kill you!"

Lisa: That sounds more like a doula trick than a partner trick.

Helene: I was like, "Are you, are you crazy?" So he took his shower while I. I was on the floor, leaned over the couch moaning because Sam was going to meet us at the hospital. And then we drove about a half hour. Oh, and it was bumpy, those New York potholes. Because we were at Mount Sinai West, and so we drove from Queens over the 59th Street bridge.

Lisa: That was my first labor commute as well.

Helene: Yeah? It's not a bad one, but those midtown potholes were not my friend.

Lisa: Totally, yeah. I always say like, maybe it's helping progress because it's ramming the baby down on the cervix and the pelvic floor, but it's not pleasant.

Helene: It's not pleasant. It is not pleasant. And my husband still says, "Oh, you were shouting at me every time I hit a pothole! Look, I tried my best." I was just sitting in the back like, "What are you doing!?" We got to the hospital, maybe 2:00 AM. And I was in active labor, which they had an intern do my initial cervical exam, which was not pleasant, but necessary. So I was about six centimeters and pretty effaced. So they admitted me, went to labor and delivery. My sister and my mother came, my in-laws came. Everyone popped in to say hi. And Sam was there with me. She attended my birth or was my support at my birth, which was amazing.

Of course, as a pelvic floor PT, I was like, "I'm going to want to be doing squats and walking around and getting in the bath tub and hands and knees." And I was so tired by this point because I had slept for maybe three hours interrupted by contractions after my marathon of walking the day before, or just a few hours before. I was so tired. Every time she was changed positions, I was like, "No! Leave me alone! I'm just laying here. That's it!"

Lisa: That's one of those tricky things in labor, is finding that balance between rest and activity, because you don't know how long you're going to have to do this. So it's really hard to know how much to pace yourself.

Helene: Yeah. Totally agree.

Lisa: And can you just clarify, how many hours was this by the time you got to your birth place from whenever you would call it the start of labor?

Helene: I think I started having contractions at 10 or 11:00 AM on Friday, but really mild, really spaced out contractions every 15 minutes and I could, I'd have them while I was walking and I'd be just fine. And then about 9:00 PM when went to bed, they had started getting a little bit closer together, a little bit more intense. And then when I woke up at 12:00 AM or 12:30 AM, they were just a couple of minutes apart and very intense. So by the time we're in the hospital, 2 or 3:00 AM might have been since 11:00 AM the day before, math, 13...

Lisa: It's okay, the times are fine.

Helene: 12, 13, 14 hours.

Lisa: Long time.

Helene: Yeah. Yeah. But it was for the most, the majority of that time, it was like, oh, there's a little, little cramping action. Like, oh, there's a little that kind of like wave like cramping. I was able to still, I think I baked more cookies too and watched movies and did puzzles. So...

Lisa: Nice. All those early labor activities.

Helene: Yeah. So it was still totally fine. I don't know when I, when people talk about how long they're in labor, I'm never quite sure if they're referring to since the very first time they felt a contraction or...

Lisa: Yep. And that's what I always point out in class, is a difference between someone saying they had a six hour labor versus a 24 hour labor might be the six hour person slept through early labor or just didn't count it because it wasn't intense and started counting it when it got really intense, versus some of us want all the credit for all those hours work that our bodies have done. And I say, you deserve the credit. So you get to count as much as you want.

Helene: Yes. Yeah. So there we are in the hospital. I don't want to change positions. I just wanted to lay on my side and Sam was awesome. She was putting the peanut ball between my legs and helping me. I have my hips in internal rotation, external rotation to help the baby progress through the pelvis. As I just like put a fan on me.

My water actually did not break. Unlike all the television shows, there was no dramatic moment of flooding fluids. So Sam was encouraging me to try to change positions and I did at one point, get into the shower. I tried hands and knees and both in the shower and on the bed and it still wouldn't break them. I was like, "I am just too tired. I cannot keep changing positions." So I let them break my water manually, which did help progress labor. Not that it was ever stalled. It was progressing pretty steadily and then came the big excitement, which was that as we were getting very close, they discovered that every time I pushed his heart rate was dropping and he was desatting, so his oxygen levels were also dropping, which is very normal for pushing, but it didn't feel normal at the time because when you're in that hospital setting, you hear the beeps slow down, you see them, you see the doctor and the nurses start to be concerned. So he was initially, he was stuck on my pubic bone and then once they were able to get him past there, that was still happening. It turned out he had a cord wrapped around his shoulder. So every time I would push, the cord would get pulled taut, his heart rate would drop and his saturation would drop. So I ended up doing exactly what I had hoped not to do, which was in the lithotomy position, on my back, knees bent, held back, not even a pillow under me, which if I had been in my like PT mindset, I would've put a pillow under my sacrum to allow it to have a little more room to move --and doing directed pushing, so that inhale and then hold your breath and push for 10 seconds, which the combination of that position and the directed pushing is a recipe for perineal tearing, which is exactly what happened.

But at the time it seemed like an emergency. In retrospect, I'm not a hundred percent sure it was. But it happened. So we didn't get to do what we had hoped to do, which was delayed cord clamping and immediate skin-to-skin contact because by the time they cut the cord while he was, when he was not fully out yet, because they needed that to, for him to be able to come out so that it wasn't continuing to pull him back in by his shoulder.

And then they had to take him to make sure that he didn't need suctioning because there had been meconium present in the fluid. So that was not quite what we expected, but what birth ever really is. But all the medical panic was really, in retrospect, I wish that that had not been the case. I think they did a good job of not ever saying like, this is not possible any longer to have an unmedicated vaginal delivery, because they knew that that was really, really important to me.

So they never pushed any other alternatives. And they did ask like even before breaking my water, they talked to me about it. I'm not sure that I answered in any way coherently, but I said yes, but, so I feel like they respected my autonomy, but there was a little bit more of that medical "everything's afire" kind of feel to it than I would have liked, but he was fine. He did not need to be suctioned, which I was very grateful for. And then we got to hold him immediately after, which was great.

Lisa: Nice. So you're saying they took him over to the bassinet briefly to just check and be sure the meconium hadn't caused any need for suctioning and then, yeah, okay.

Helene: Yeah. And he was, I mean, he had a great Apgar score, so we were very relieved at that point. Yeah.

Lisa: Nice. And any reflections, just emotionally, on those moments of meeting your child, your baby?

Helene: I was so tired. It was so hard to be fully present and aware. And part of me later felt a little bit guilty about that, but like, I'd like to share that in case anyone else has a similar experience because it took me a little while to be like, "Oh, he's like mine. He's my kid!" Obviously, as I was holding him, I had that love and the joy of seeing his little face, but it took a day or two for it to really fully sink in of me, just, he roomed in with us then in the recovery, and I was just staring at him for a while - "Oh." It wasn't an immediate, it wasn't exactly what I expected because I expected that immediate, "Oh my God, it's my kid!" overwhelming, which is not to say that I didn't love him right away, but you know, it just, it was more of a process than I expected.

Lisa: It feels, for many, the more birth stories I hear, I feel like more often than not there is that simultaneous exhilaration, but also really exhaustion and kind of, almost a feeling of shock of this labor often has taken many hours when it's a first time in particular. But that moment of the very end often feels very sudden, and this baby's thrust on you and you're like, "Wait, what's happening?" It's a lot. Yeah. So more often than not, this is what I hear is that people aren't immediately in love and just like, oh, love fest kind of thing. Sometimes that's the case, but I feel like more often than not it's just complicated. I love that you're pointing this out because too many people feel guilty about if they don't instantly feel connected or bonded to this baby in a deep way. And that is normal. That can totally take days or weeks or months to grow into that. So thanks for sharing that.

Helene: Yeah. There's just so many different terrifying experiences happening at the same time. Because there's birth, which is like your body having this massive, massive effort and sometimes trauma. And then there's now all of a sudden a newborn who you have to take care of. And that's just all of a sudden, every minute of the day, there's this kid to take care of and like you knew it, you knew that I would happen, but again, it's just, so...

Lisa: There's no way for us to understand experientially what that will feel like. Right? Yeah.

Helene: Yeah. And I remember too that I think I needed to intellectualize it for a minute, just to kind of process what was happening. And I remember talking to this poor labor and delivery nurse who was so lovely and so kind, and I think I gave her a whole monologue about this is why abortion should be legal because no one should be forced to go through that who didn't really, really, really want it.

Because I was just like, holy crap, you can't force people to do this. You need to be committed to do this. She was very, she really humorous and she was very kind. I was like loopy, completely sleep deprived, post-birth like so relieved that everything had turned out okay.

Lisa: That's great. All right. So then what? So you were saying that the pushing stage was not what you envisioned and that as a pelvic PT, you never recommend pushing on your back in the lithotomy position or directed pushing. So can you talk about then what happened and how did you get into this specialty and...

Helene: Yeah, absolutely.

Lisa: And are passionate about it?

Helene: Yeah. Yeah. So I had a grade two perineal tear, and stitching it felt like it took forever and ever because a lot of the tearing was actually internal. So it was a lot of the pelvic floor muscles themselves, and rather than just skin. And so I was in pain sitting down for a week, week and a half, really couldn't, was sitting off on one butt cheek in the car, trying not to put pressure on that area. And I also had some difficulty with breastfeeding, so that was kind of happening at the same time.

So that took priority over myself because we needed to make sure he got to a point where he was dehydrated and a little lethargic. And then he was having even more difficulty latching because he was dehydrated. So I got some amazing support actually via telephone from Disa who now is the lactation practitioner at Mama Bear PT, which is my virtual pregnancy and postpartum support practice.

And in addition to that, then I had this really a lot of discomfort in my perineum. So after about a week and a half, I was able to sit, but not particularly comfortably. And I went to my six week check up where my OB, I love her, but she did a typical OB thing where she was like, "Your stitches have healed. They're not actively bleeding or open anymore. You're good to go. You can have sex, you can be active." And I was like, "Are you crazy? I can't have sex right now. That sounds horrible!"

Lisa: Right?

Helene: That sounds terrifying.

Lisa: And that's how a lot of us feel at the six week visit. Yeah.

Helene: Yeah, so I was like, "I know I need some pelvic floor PT." And I asked her, I was like, "Please give me a prescription for PT." Which you don't always need a prescription for PT, but I knew that my insurance was more likely to cover it if I had a prescription. And then I was like, how do I get to PT? I have a newborn. Do I take him with me? Do I leave him home? Do I bring him somewhere to have someone babysit him? Do I want to bring him on the subway to go somewhere? I didn't know how to get to PT, even though I knew I needed it. I wanted some help. I didn't want sex to be terrifying because I would like to have sex and I would like to eventually have a second kid. And so eventually I figured it out and I did three sessions with a good friend of mine who's absolutely delightful, Liz at Thrive Physical Therapy.

She's basically at the Broadway-Lafayette station. She's phenomenal. And I figured out doing three sessions with her where I took my little guy in a carrier on the subway from Queens to the Upper East Side, dropped him off with my in-laws and got back on the subway, went down to Broadway-Lafayette, went to PT, which was, I felt like I was playing hooky because then I like got lunch afterwards. I was like, "Ohh, I'm going to eat lunch by myself!"

Lisa: It's like self-care for moms.

Helene: There was like that little guilty voice in the back that was like, "You've been away from him for two hours. You better get back! You better get back!" No! I'm going to eat a burrito and then I'm going to go back.

Lisa: That even shouldn't even be called self care, right, because you need to eat, and yet you feel guilty about it.

Helene: I say that all the time. I have moms tell me, "Oh, what self-care did you do? I took a shower." And I'm like, that's just basic hygiene. And not to say you shouldn't; you should take a shower, but then in addition to that, you should try to do something else for yourself.

Lisa: It feels like really pampering.

Helene: So maybe if you said I took an hour long bubble bath with a glass of wine and a good book, then I would be like, yes, that counts. The 10 minute mom shower, no, that doesn't count. So, yeah. Then I kind of got to thinking like, how can women get PT or birthing folks? How can they get PT after when they have this newborn? But I knew, like I knew what time my son would nap every day. I was really lucky early on; 9:00 AM, 1 PM, that kid went down, no variation at all. And I thought, God, if I could just do something while I was at home and then COVID hit and I started treating folks virtually out of necessity via video chat, and I started treating pregnant and postpartum folks virtually, and I realized I could have my son taking a nap in the other room. They could have their kid taking a nap in the other room and we could still give them tools to help them heal their pregnancy aches and pains, prepare for birth, and then return to whatever new normal they wanted to find postpartum. And that's different for everyone.

Some people are like, "Hey, I want to go back to doing the crazy boxing, weightlifting, HIIT stuff I was doing before pregnancy." And some people are like, "I just need my back to not hurt anymore as I pick my kid up and down or wash the dishes." And whatever it is, that's what you deserve. So, and I, one of the things I love about virtual care is that I give people tools and then they take them and run with them.

And I'm here to support and facilitate, as opposed to sometimes when you go to in-person care, then you feel like you're reliant on this machine, this person. And I never want that to be the case. I want my folks to do a few weeks of PT with me, and then I only want to hear from them with baby pictures and funny stories after that, just email me every couple of months. I want to see baby pictures.

But I want you to graduate. I want you to have the tools that you need to move forward on your own. So that's my big priority. And then I also, since I had such an incredible experience with Erica as my doula, I was telling her about my idea and she loved it. So she is now the pregnancy and postpartum coach from Mama Bear, so she helps folks figure out pregnancy, the emotional stuff, the practicalities, and how to prepare for that postpartum period, and then helps folks throughout the postpartum period, which could be as simple as figuring out how to change a diaper. It could be as much as helping figure out family dynamics and also how to eat and how to get the laundry done.

Lisa: Because she's a nutritionist, right?

Helene: Yeah. So she's also a nutritionist and she offers nutrition services as well. And she's a certified childbirth educator, so she does that as well for Mama Bear, all virtually. And then Disa, who is my lactation practitioner, also offers virtual support via Mama Bear. In addition to the physical therapy that I offer, I also do birth preparation sessions, more for the physical preparation for birth. So all that is virtual so that folks can, when you're pregnant and exhausted, and you don't want to get on a train or get in the car, it can be accessed virtually.

Lisa: That's so fantastic. I love that. Yeah. And in terms of lactation support, one thing I've heard is similar to what you were saying in terms of the virtual support, the benefits of that, of just hearing a number of my lactation consultant friends saying, "Yeah, it's like getting them to be autonomous from the get go." They're doing it, which is, that's the goal, exactly like you were saying. So it has been surprising and encouraging to see some of the benefits of virtual support and the convenience of it, especially for new parents who are overwhelmed and it feels hard to get out of the house to go anywhere.

Helene: Without COVID you're supposed to be a little bit careful about what germs you're exposing your little one to. So...

Lisa: Yeah, I'm really excited.

Helene: And that does count as self-care.

Lisa: Yes!

Helene: At least the PT part. Maybe not the lactation part.

Lisa: Well, so in the last few minutes that we have together, I'm just wondering if you have any basic tips for someone expecting a baby in how they can best prepare to protect their pelvic floor health and their physical health going through this journey of giving birth and beyond.

Helene: Yeah. So...

Lisa: I know there are many, many, many, but your best ones, just your highlights. A little teaser.

Helene: My number one, and this is for pregnancy and postpartum and it sounds so overly simple, but it's literally start a breathing practice. We know that it has tremendous benefits mentally and emotionally, but also your pelvic floor and your diaphragm work together, they mirror each other. So as your diaphragm descends, as you take an inhale, your pelvic floor also descends. And then as you exhale, your diaphragm comes back into that dome shape and your pelvic floor also ascends back into the body. So if you take a real full, deep breath, which will look like your whole rib cage, expanding circumferentially, so not just front to back, but also side to side.

And the back piece is often the hardest. So getting that back to also expand as you take that full deep breath, if you take a full deep breath like that, where you're expanding your whole rib cage and filling your whole belly and lower back with air. Then you're really moving that pelvic floor through a full range of motion.

And that is so beneficial for keeping it supple and flexible enough that helps prepare for birth. And then also in the postpartum period, when it's undergone this huge, huge thing. It had to hold the weight of the fetus up for 40 weeks and all the placenta, the increased abdominal fat, all that. And then it had, if you have a vaginal birth, this massive stretch in order to fit a child through there, or a Cesarean birth, where you had some trauma to the tissues around it, whatever the case may be, it means the first thing you need is to be able to move it fully again. So taking those deep breaths actually engages the abdominal muscles too, and the pelvic floor to help them work together and be able to move fully, which is the most important piece. I know a lot of folks want to start out doing kegels, but if you start doing kegels while your pelvic floor is still tight and not able to move through a full range of motion, it's like doing a bicep curl with your hand already at your shoulder. You're just going to vibrate your arm back and forth a little bit, and that's not particularly effective. And the same thing is true with your pelvic floor. We need that full range of motion before we add any strength component.

And a lot of times engaging the pelvic floor like that through a full range of motion. I find folks don't end up even needing kegels. Sometimes they do. It's like blasphemy for a pelvic floor PT to say, no one needs kegels, but...

Lisa: But there's an overemphasis on that for pregnant people, right? So many OBs are like, "Do your kegels, do your kegels." and that actually can backfire and make it harder, like you're saying, to have that full range of the ability to lengthen and bulge and relax to let the baby come through.

Helene: Yeah. I mean, kegels are not terrible during pregnancy and any strong supple muscle, if you can move through a full range of motion, it's not a bad idea to add some kegels in there, but it's not my go-to. My go-to is that deep breathing.

Lisa: Love that. Yeah, that breath work is so great for this purpose, for everything. Yeah, that's what I was about to say, for so many things.

Helene: Yeah.

Lisa: Just taught birth class last night and we were going into different breathing strategies for labor specifically. Yeah, wonderful. Well, is there anything that you haven't gotten to share that you wanted to share before we wrap things up?

Helene: No, I don't think so. I'll just share that you can find Mama Bear at mamabearpt.com or on Instagram @mamabear_pt or on Facebook, we're all over the place. If you find our website, you'll find us.

Lisa: Great. mamabearpt.com. I will include that in the show notes for this episode.

Helene: Yeah.

Lisa: Well, thank you so much, Helene. It's been lovely speaking with you. Thanks for sharing all these details and thanks for the work that you're doing. I hope that people can reach out for support if they feel like they could benefit. It's a really wonderful well-rounded offering that your practice has started doing so best of luck with that. And I hope to see you again soon.

Helene: Thanks, Lisa!