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:
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):
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.
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:
The hip flexor muscles include the Iliopsoas group (Psoas Major, Psoas Minor, and Iliacus), Rectus Femoris, Pectineus, Gracillis, Tensor Fascia Latae, and Sartorius. When the hip flexors are tight it can cause tension on the pelvic floor. This can pull on the lower back and pelvis as well as change the orientation of the hip socket, lead to knee pain, foot pain, bladder leakage, prolapse, and so much more. The ramifications of iliacus and iliopsoas dysfunctions are discussed in Ramona Horton's visceral course series:
A common issue with the iliacus and hip flexors is that they can shorten over time due to a lack of stretching or a sedentary lifestyle. When this happens, the muscle adapts by becoming short, dense, and inflexible and can have trouble returning to its previous resting length. A muscle that resides in this chronic contraction can become ischemic, develop trigger points, and distort movement in the body.
If you are treating patients with pain in their lower abdomen, sacroiliac joint, or that wraps around the lower back and buttocks, it could be because the hip flexors are tight. Traditional testing performed by medical practitioners tends to come back negative as many tests do not evaluate soft tissue issues. The best way to diagnose these concerns is through assessment with skilled palpation and structural evaluation.
One assessment test used for the iliopsoas is discussed in the Athletes & Pelvic Rehabilitation course. This is the Thomas Test which measures the flexibility of the hip flexors. In this test, the patient is supine while flexing the unaffected, contralateral leg at the hip until lumbar lordosis disappears. The length of the iliopsoas is determined by the angle of hip flexion displayed by the patient. The test is positive when the patient is unable to keep their lower back and sacrum against the table, the hip has a posterior tilt (or hip extension) greater than 15°, or the knee is unable to meet more than 80° flexion. A positive test indicates a decrease in flexibility iliopsoas muscles.
Treatment plans for the iliacus and hip flexors include stretching. An example includes the hip extension stretch or other active isolated stretches. Manual therapy, including trigger point release, can be used in conjunction with stretching to help muscle adhesion and release muscle tension. As with all treatment, the practitioner should discuss the risks, benefits, and treatment options, and obtain consent with patients. Prior to proceeding with manual therapy treatment make sure to establish a pain scale, assess the patient's range of motion and strength, and (if needed) perform the appropriate neurologic testing.
To learn more about manual therapy options for the visceral fascia, join Ramon Horton in her Mobilization of the Visceral Fascia Satellite Lab Course Series (multiple satellite locations available):
To learn more about treatment philosophies for the pelvis and pelvic floor and global considerations of how these structures contribute to human movement you can join Steve Dischiavi: