This week The Pelvic Rehab Report sat down with faculty member Ken McGee, PT, DPT. Ken (they/he) is a queer transmasculine pelvic health physical therapist based in Seattle whose mission is to bring greater awareness to the pelvic health needs of the LGBTQIA2S community. Their practice, B3 Physical Therapy, centers on transgender and perinatal rehabilitation. Ken also provides peer bodyfeeding support and doula care, and can be found on Instagram at @b3ptcob3ptco.

You can join Ken in their remote course, Perinatal Mental Health: The Role of the Pelvic Rehab Therapist, scheduled for October 22, 2022.

Who are you? Describe your clinical practice.
Experiencing inadequate care for my own pelvic health conditions as a teenager motivated me to become a pelvic health physical therapist. Being a member of the queer community further drove me to offer trauma-informed care and develop better access to care through home visits. Currently, I split my time between providing gender-affirming physical therapy and serving as a birth doula.

What lesson have you learned (in a course, from an instructor, or from a colleague or mentor) that has stayed with you?
Very few clients will remember detailed biomechanical explanations or every exercise you teach them. However, each client will remember how you treated them and how you made them feel. Asking clients about their preferences for care and following up go a long way in establishing rapport.

What do you find is the most useful resource for your practice?
One of my favorite resources is Decolonizing Fitness. It is an educational platform by Ilya Parker, PTA, (he/they). It provides a catalog of exercises and trainings for people looking to improve their care of gender-diverse people and People of Global Majority.

What books or articles have impacted you as a clinician?
The healthcare field regularly puts people in boxes to determine care. For example, many providers might determine care based on whether someone is a transgender woman or man. However, gender is actually someone’s individual experience rather than a category. Kate Bornstein’s My New Gender Workbook is a good starting point for understanding gender as uniquely one’s own, rather than part of a treatment algorithm.

What made you want to create this course, Perinatal Mental Health?
I wanted to create this course because, as a parent and physical therapist, I see both the challenges that the perinatal period presents, as well as the ways that rehabilitation providers can support mental health. In developing the content, I drew upon my background as a volunteer for a perinatal mental health warm line.

What need does your course fill in the field of pelvic rehabilitation?
Pelvic rehabilitation providers regularly interact with people who have mental health challenges. However, there are very few courses that specifically address the needs of the pelvic health providers serving folks in the perinatal period. This course looks at perinatal mental health from the perspective of pelvic rehabilitation providers, while offering specific actions providers can take to support their clients.

Who, what demographic, would benefit from your course?
Rehabilitation providers of any experience level would benefit from taking this course. Providers who are new parents or considering becoming pregnant may also find the content personally enriching. While the research discussed in this course focused on the perinatal period, much of it can be extrapolated to other populations.

What is your message to course participants who are just starting their journey?
For people just starting in pelvic rehabilitation, I would recommend focusing on patient education. For me, I find that the greatest amount of client improvement comes through reviewing the basics. It’s okay to still be developing skills in manual therapy.

Perinatal Mental Health: The Role of the Pelvic Rehab Therapist

Price: $150

Contact Hours: 5.75

Course Date: October 22, 2022

Description: This one-day remote course covers mental health considerations in pregnancy and postpartum and is targeted to the pelvic rehab clinician treating patients in the peripartum period. Topics include common mental health concerns in the postpartum period including depression, anxiety, OCD, and PTSD, as well as the connectedness between mental health and physical dysfunction. The course will introduce useful screening tools and how to connect patients to resources and diagnosing professionals. Labs will include partnered breakout sessions to practice listening and dialogue skills. The course also includes a review of coping techniques to support mental health and physical symptoms.

Megan Kranenburg, PT, DPT, WCS created the course Doula Services and Pelvic Rehab Therapy to present the unique challenges of merging a rehab practice with Doula services. Megan is a physical therapist who has balanced her solo outpatient pelvic health practice and Doula work since 2016. She lives and works in the nexus of Doula training near Seattle, Washington - which has provided plenty of opportunities to observe and participate in birth conversations and process the experience through the Physical Therapist's mind and heart.

As a pelvic floor practitioner, you may know that nearly 24% of women in the United States have pelvic floor dysfunction (as reported by the National Institutes of Health) and that this frequency increases with age. Childbirth can contribute to pelvic floor dysfunction, and it can be beneficial for pelvic therapists to know the doula's toolkit

So what is a doula? Doulas are often the first and sometimes the only people with whom a birthing person will feel comfortable discussing pelvic floor-related issues. Dona International defines a doula as a trained professional who provides continuous physical, emotional, and informational support to a mother before, during, and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible.

Doulas can offer position ideas for comfort and labor progression, while their skilled hands can assist a mispositioned baby find its way through the pelvis. They can also support the birthing parent in learning how to push safely, effectively and protect the pelvic floor for birth. Doulas may hear several different symptoms of pelvic floor conditions from their clients through the perinatal experience. Two examples of natural birth/ pushing that a doula and pelvic therapist can spot or assist with include:

• Long hours of pushing can contribute to long-term muscle weakness and damage as well as lead to incontinence and pelvic organ prolapse.
• Uncoordinated pushing can result in weaker pelvic floor muscles that can last for several months postpartum. This weakness can also contribute to incontinence.

Similarly, Sara Reardon shared in a blog for Doula Trainings International a few symptoms of pelvic floor conditions that doulas may hear from their clients and can be looking out for throughout the birthing experience (1):

• Pain above the vagina that is sharp or achy and is exacerbated when rolling over in bed, or standing on while leg while getting dressed. This can be pubic symphysis dysfunction due to ligament relaxation.
• Pain in the back or lower back on one side that is sharp and is felt with a deep lunge, or when standing for a long time. This can be sacroiliac joint dysfunction due to ligament relaxation.
• Heaviness or pressure in the vagina that is worse at the end of the day, after exercise, or when standing. This can be a prolapse of pelvic laxity/varicose veins/swelling.
• Leakage of urine or poop, constipation, hemorrhoids and straining with bowel movements, incomplete bladder emptying, urinary urgency.

During vaginal birth, the baby passes through the ‘levator hiatus’ in the pelvic floor. This process can damage the fascia, muscles, connective tissues, and nerves. The levator muscles are stretched by 1.5 to more than 3 times their normal length as the baby passes through, depending on the size of both baby and pelvic floor muscle opening. (2) After this fascia is stretched, or torn, it doesn't heal like before. This fascia is attached to the bone and supports the urethra, vagina, and rectum.

Pelvic therapists and doulas can both make a big difference in the health of their clients. The following simple list is a very basic list that can be shared with clients that can make a difference in their healing.

• Breath - Inhale for the count of 2. Exhale for the count of 4. Repeat. Allow the exhale to be longer than your inhale.
• Nutrition - Choose nourishing whole foods. Collagen and mineral-rich foods, good quality protein, zinc, vitamin C are critical for tissue integrity and supporting new connective tissue repair.
• Hydrate - Easy & often. Don't wait until the end of the day to hydrate. Manage fluids throughout the day.
• Movement - Start with a good walk and build up from there. Spend time sitting on the floor with your baby and practice getting up from there.
• Sleep when the baby sleeps. Regular sleep and deep restorative rest are important for healing, recovery, and supporting mental energy.
• Each birth story is important and valid.

Doula Services and Pelvic Rehab Therapy is scheduled for April 3rd, August 6th, and December 10th this year. This is a four-hour, beginner-level course. Practitioner's who register are recommended to have completed Pelvic Floor Level 1, and the following reading:

• Preparing for A Gentle Birth, Calais-Germaine
• Reviving your Sex Life After Childbirth, Wallace
• The Birth Partner, Penny Simkin

1. 5 Pelvic Health Lessons For Doulas From The Vagina Whisperer. The DTI Team. Doula Trainings International. Nov 5, 2018. https://doulatrainingsinternational.com/5-pelvic-health-lessons-for-doulas-from-the-vagina-whisperer/
2. Pelvic Floor Muscle Damage. Australasian Birth Trauma Association. https://www.birthtrauma.org.au/physical-birth-trauma/pelvic-floor-muscle-damage/#:~:text=The%20levator%20muscles%20are%20stretched,and%20pelvic%20floor%20muscle%20opening.&text=In%20many%20women%2C%20these%20muscles,sometimes%20torn%20off%20the%20bone.

Katie McGee, PT, DPT, (they/them) is a pelvic health physical therapist based in Seattle. Katie received their Doctor of Physical Therapy from the University of Washington in 2014 and their board certification as a Women’s Health Clinic Specialist (WCS) in 2018. Their practice, B3 Physical Therapy, centers on transgender care and perinatal rehabilitation. Join H&W and Katie to learn about perinatal mental health in Perinatal Mental Health: The Role of Pelvic Rehab Therapist - Remote Course scheduled for February 5, 2022. 

Due to the COVID-19 pandemic, rates of perinatal mental health conditions—such as anxiety and posttraumatic stress disorder—have risen sharply1. Around 70% of pregnant people are now reporting psychological distress1. With many families under increased stress and financial worry, the odds of developing postpartum depression have jumped from one in seven to one in five(1)!

Fortunately, pelvic rehabilitation therapists can make a difference in the mental health of their perinatal clients. In fact, many pelvic rehab therapists are reducing the risk of perinatal mental health issues without even knowing it! Simply supporting clients in keeping up with physical activity and reducing bodily pain are proven strategies for lowering the risk of perinatal mental health issues (2,3). Pelvic rehab providers can go even further in supporting their perinatal clients’ mental health with some simple actions:

1. Ask – Many birthing people feel shame around negative feelings and thoughts related to pregnancy and postpartum. Asking perinatal clients about their emotional challenges can help break through that shame. A good ice breaker for talking about perinatal mental health is letting your clients know that a mood disorder is the number one complication of pregnancy. Be sure to listen attentively and avoid interruption whenever someone discloses their mental health challenges.

2.Screen – Screening for mental health conditions can guide pelvic rehab therapists to know when it’s time to refer clients to specialized care, such as medication and/or therapy. Pelvic rehab therapists are qualified to use several screening tools in the perinatal period, including the Edinburgh Postnatal Depression Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7. Best of all, these tests are free to use and easy to administer.

3. Gather resources – When a client discloses that they have thoughts of self-harm or are experiencing violence in their home, you want to be prepared with the next steps to help. Collecting resources ahead of time can go a long way in turning what would have been a fumbling offer to help into a confident action plan. Looking to grow your resource list? Check out these three links:

• Perinatal Mental Health Resources: https://www.postpartum.net/
• Intimate Partner Violence Resources: https://www.rainn.org/
• Substance Use Resources: https://www.samhsa.gov/

4. Connect – Racism leads to People of the Global Majority birthing in the United States to experience increased rates of preterm birth and low infant birth weights (4). Both these outcomes have been tied to worse postpartum mental health (5). Research shows that when People of the Global Majority are connected to culturally congruent birth doulas, rates of preterm birth and low infant birth weights fall (6). Other research similarly supports the concept that when people are paired with culturally congruent providers, health outcomes improve (7). Whenever possible, think about how you can offer your clients resources/referrals that match their identity and background to support their mental wellbeing.

5. Learn – Join Katie McGee, PT, DPT (they/them) for the Herman & Wallace course, Perinatal Mental Health: The Role of Pelvic Rehab Therapist - Remote Course scheduled for February 5, 2022. By participating in this remote learning class, you will:

• Develop a basic understanding of perinatal mood and anxiety disorders
• Bolster your listening skills for working with perinatal clients
• Gain additional tips for screening for perinatal mental health issues
• Learn how to help clients create perinatal wellness plans
• Expand your toolbox of coping skills to teach clients

Don’t miss this opportunity to truly change the lives of your perinatal clients!

References

1. Yan H, Ding Y, Guo W. Mental Health of Pregnant and Postpartum Women During the Coronavirus Disease 2019 Pandemic: A Systematic Review and Meta-Analysis. Front Psychol. 2020;11:617001.
2. Mathur VA, Nyman T, Nanavaty N, George N, Brooker RJ. Trajectories of pain during pregnancy predict symptoms of postpartum depression. Pain Rep. 2021;6(2):e933.
3. Marconcin P, Peralta M, Gouveia ÉR, et al. Effects of Exercise during Pregnancy on Postpartum Depression: A Systematic Review of Meta-Analyses. Biology (Basel). 2021;10(12):1331.
4. Andrasfay T, Goldman N. Intergenerational Change in Birthweight: Effects of Foreign-born Status and Race/Ethnicity. Epidemiology. 2020;31(5):649-58.
5. Anderson C, Cacola P. Implications of Preterm Birth for Maternal Mental Health and Infant Development. MCN Am J Matern Child Nurs. 2017;42(2):108-14.
6. Thomas MP, Ammann G, Brazier E, Noyes P, Maybank A. Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Matern Child Health J. 2017;21(Suppl 1):59-64.
7. Towning EJ, Purohit A. Black babies cared for by black doctors less likely to die in the US: revolutionize medical education to tackle the problem in the UK. BMJ. 2020;370:m3783.