Pelvic Floor Physical Therapy

Early in my pregnancy with Twyla, I heard a Birth Kweens podcast about the Fourth Trimester period during a baby's first 3-months of life. As a first time parent, and someone who hadn't paid much attention to pregnancy and birth until I decided to go down this path myself, the period after delivery completely captivated me. From everything I read and heard, in this period mother and baby seem developmentally in tandem. Both in diapers. Both re-establishing communication with their elimination functions. If nursing (and perhaps if not?) both need to eat around the clock. Both enduring strange sleep cycles less tied to the sun while wrestling with exhaustion. Both finding their body in a different state, geographically, physically, with brand new sensations.

Some East Asian traditions feel that the postpartum period sets the tone for a woman's menopause and old age-- that by active care during this period you establish a stronger foundation for later in life. Intrigued, I began cultivating my own postpartum care.

I learned that in France it is standard care for all women to have at least 10 postpartum pelvic floor physical therapy sessions, no matter how they birth nor how the birth goes. In any birth, there is still a lot of pressure and stress (not unhealthy, but action) on the pelvic floor. The common advice given to prenatal women, at least in the United States, is to do a lot of kegels or actions to strengthen the pelvic floor. I think this is because, logically, when there is so much weight of a baby on your pelvic floor, there's a sense that you need to be strong enough to bear it.

However, most of us actually have really tight pelvic floors. That doesn't necessarily mean strong, but it does mean unyielding. For a woman to fully dilate and birth a baby, the pelvic floor has to be responsive and soften to the birth. I knew through my yoga practice that I fell in the tight camp. Years of active practice and aggressive mula bandha had tightened my pelvic floor. I also learned about a fascial connection between jaw and pelvic floor. As someone with periodic TMJ and teeth grinding, I knew that was also symptomatic of a tight and less yielding pelvic floor.

I didn't want to tear, so I began learning how to soften and open my pelvic floor in pilates, prenatal yoga, and also pelvic floor physical therapy.

This type of physical therapy retrains this important muscle group through external and internal work. In the United States, there are very strict rules about who is permitted to do internal physical work-- usually, just OBGYNs! While that makes sense in theory, it means that in so many ways, the types of touch and the relationships we have with our body are stymied. I didn't realize that until I engaged with the practice myself.

I've practiced yoga since I was 16. I felt like I was fairly integrated and embodied. Knowing that I wanted to do postpartum pelvic floor physical therapy, no matter how the birth went, as a preemptive action to restore my whole health, I found a pelvic floor physical therapist, Dr. Amanda Heritage. We had an initial phone call and saw that we were both very excited about the possibilities both of her modality and how pregnancy and birth can be used as periods to shore up overall health. Dr. Heritage recommended that I do a prenatal visit to ready my perineum to stretch, hopefully rather than tear, during birth.

In our first session, we first talked. I explained some of the "lightening crotch" sensation that I'd been feeling. That's a fun one! Dr. Heritage showed me models of the nerves in the pelvic bowl. I began to understand that I would feel sensation in my legs because my baby was triggering a nerve much higher inside my pelvis and the sensation was referred away. I was utterly fascinated, but also somewhat reassured throughout the rest of my pregnancy.

We then began the actual work. Physical therapy always involves patient action, movement, and integration. Pelvic floor physical therapy also includes bodywork. Dr. Heritage used myofascial work on my abdomen and hips before slowly moving towards perineal work. She taught me perineal massage. With every action, there was conversation and consent.

When the session was over, I felt that I'd had an experience that I didn't yet have the framework to process. That happens from time to time like if I'm in a foreign country where people are living in a way that's beyond my previous conception. It takes time for my brain to catch up to a reality that I'm witnessing. I don't have a file to place what I'm seeing.

I sat in my car and felt that I was in uncharted territory. My impulse is often to numb out by scrolling on my phone. As I've begun recognizing what's occurring in real-time, my current response is to just sit quietly. That's what I did. I sat in the pine shade and acknowledged that I was growing, something was shifting, and it would require time.

By giving myself that allowance, my brain actually does catch up more quickly. I realized that I was stretching into integrating my body in a completely new way. My arm has had a huge history of touch. I've felt my own arm and said, "arm," knowing it cognitively. My arm has been bruised and touched lovingly and touched clinically.

My pelvic floor is a very different story!

I realized that prior to the first session of pelvic floor physical therapy, I had experienced only clinical and sexual touch. This experience felt like neither of what I had previously known. It was clinical touch but at a slower pace and more time for me to make the same cognitive connection of "Oh! That's my perineum." Pregnancy is new, relentless sensation and this was a process of naming and embodying each feeling. The mystery was both contracted and expanded. In a way, it felt more like the friendly touch you would get on a shoulder in a part of my body that had never been dealt with in that way. I realized I wasn't fully living in every part of my body as I had previously thought. I had no point of comparison until my range of feeling and touch was expanded.

In learning about the postpartum period, I learned about many rituals that various cultures offer to this rich time. These rituals often occur in cultures that mark many points in a woman's life like the onset of menstruation, partnership, and menopause.

I imagined if I had pelvic floor physical therapy when I first began menstruating. I wonder how I would have known my own body with that information? If pelvic floor physical therapy was in a way, a ritual we utilized not only in times of distress but in marking new evolutions in our body. What if we used this modality as mapping and a point of integration? Each time the body evolves into a new function and iteration, here is a way to know it and be in it.

I had two prenatal sessions and go for my first postpartum session in a few weeks. I'm living in a completely different body. My current body is no longer pregnant but also still bears some of the space and aftermath of pregnancy. My body is not and will not be what it was prior to pregnancy. It's taking a new form. I'm excited to know it more deeply.

Filling the Mind

It's not hard (for me) to rest in solitude. The new, demanding practice is resting without sleep and keeping attention trained on the needs of a tiny, vulnerable human. I've been on silent retreats where I feel utterly restored by the ability to give the fullness of my attention to myself, to let my imagination wander unrestrained, and feel saturated by that spaciousness.

This is very different.

Time is a bit shapeless. It gains contour at dawn, with a kind feeding and the knowledge that soon Kevin will be up. There will be someone who will speak to me in the English language and in full sentences.

I steal naps where I can, furtively blinking open my eyes to see the small baby chest rise and fall with breath.

I watch for cues-- the fist to mouth to signal hunger, the red face for poop, the "O" mouth for pee. I judge myself for missing or responding slowly.

I've begun dubbing her expressions, "the weather." Storm clouds pass over and she winces. A soft smile opens her brows. What she feels moves quickly. She is experience-- reality unfolding.

I sneak in my own maintenance when she first falls off my breast drunkenly. Wedge her somewhere that's hopefully safe. Go to the bathroom. Refill water. Grab a snack. Begin to brush hair. She wiggles and squeals. I abandon brushing teeth and swig mouth wash instead.

I try to put my feet on the ground but really my body wedges in whatever shape keeps her to my breast or afterward jiggles and moves her to help her tiny, not-yet-properly-functioning-digestion run as optimally as possible.

Kevin rests, cleans the house, prepares my food, and runs our errands. And I have the nerve to resent his freedom. And he meets my glare with compliments on how well I care for our daughter. I soften. He's an incredible father. And he does understand-- we have so few responsibilities and simultaneously so many. There is very little to do-- meet the needs of a tiny human. And that task demands everything.

I feel my attention stretching. I'm working to build endurance as I would a muscle. Each day, working to attune.

Not to be a martyr. Not to deny myself. But to meet the agreement that I made with her: I will care for you. I will do everything I can to help you feel a sense of safety in the world. Because you will only ask this of me for a season. I do my best to rise to the moment.

I knew parenting would be demanding. The cascade of labor, birth, and ceaselessly flowing into the sleepless, sore-nipple aftermath would be stunning if I had time to even process it.

I talked about the postpartum period to so many parents and they all got a far-away look on their faces. "We would talk about it more," one replied, "if we remembered it."

I know this period will blur into more defined seasons where she and I venture forth into the world. Our lives will again gain recognizable shape.

When I read accounts of pregnancy, birth, and new parenthood, the postpartum period was the gap. There was so much on pregnancy and birth and then crickets. I wrote about my plans for the postpartum period, acknowledging that I was working from limited accounts. I anticipated some challenges in lying low for a month and attending solely to my own and Twyla's care. What I didn't expect was the specific challenge-- directing my own attention from its previous freedom.

Yoga has prepared me well. I'm used to working with my mind and my thoughts. I'm accustomed to witnessing my own inner tendencies and acknowledging that they're not fixed, that there are ways to shift my interior towards a new goal or alignment. I have tools.

Twyla is my new mantra. Twyla is my new drsti. Her singularity is both the most compelling and demanding practice yet.

I'm used to cheap escapes. I can still myself and focus for a beat and then fall out of the pose to no consequence. I can let my mind wander in meditation and no one knows but me.

Twyla knows.

And this too will change. As she takes more freedom, my focus on her could become a burden. I find a pattern emerging now that I imagine will continue-- as soon as I feel like I steady a bit, as soon as I gain ground and muscle and maybe even anticipate her needs-- she shifts. My knowledge becomes largely useless. An unrelenting teacher, she nods at my growth and pushes me to the next.

Twyla's Birth Story

Many thanks to Returning to Birth for publishing Twyla's birth story! Read on here:

https://www.returningtobirth.com/birth-stories/singing-my-baby-into-this-world?fbclid=IwAR3cFbpP5lIvtBQa0DRc0J6dvCaM7B6S3KttVh-fB6sMdqmdC2hN3HvfoHY

The heavy: weeks 38 and beyond of pregnancy

All in all, being pregnant with Twyla was pretty sweet. My body seemed to respond well to the hormones and shifts of pregnancy and-- most importantly-- I wanted her, I wanted to be pregnant, so mentally and emotionally, I adapted to the changes more willingly. While there were shifts, documented in other posts specific to various trimesters, it was pretty navigable.

And then week 38. It was kind of overnight. Everyone said at a certain point you won't want to be pregnant anymore and I thought, "Nah." And then I woke up and thought, "Oh." Walking through the world with a full grown baby in me elicited constant, "are you ready?" comments from friends and strangers. The truth was, "No." Every option was intense-- staying pregnant meant more nights awake on the couch, staying upright because anytime I laid down meant insane acid reflux, trying to find something new on Netflix while I resented Kevin snoring in our bedroom. Labor was its own mystery but obviously not a light-weight scenario. And then, a newborn. The most terrifying option of all!

The weeks of 38 and beyond (I went to 41 weeks) were full. Heavy. Laden. For both Kevin and me. I hit week 40 the day after his students graduated 8th grade and he was officially on summer break. For the first few days of that week, he was so happy to be able to shift his mental energy fully into baby. He made us a screened in porch. He got lots of groceries. There was plenty of readying and nesting.

And then we both got restless. We sat in the baby pool we'd purchased to cool off. He drank a beer. I ate cake.

I'd expend my energy by maybe running one errand per day. Being in the world was so bizarre. Being pregnant already makes you a walking target for unwanted and unexpected advice but being THAT pregnant meant I was eliciting constant birth stories. Lots of "you're lucky! I went early" to "let me tell you how crazy painful my labor was!" Cool. Cool.

Of course, I was grateful to have a full-term healthy baby. I also had no room for anything beyond the lives I was carrying.

Throughout pregnancy, I noticed how much unprocessed material is carried within so many people-- and how any pregnant person can unwittingly become target. I got better at deflecting and redirecting. And I resented having to learn this skill when so much of my energy needed to hold my own experience. I was breathing patience. I was softening into something I couldn't predict nor expect. I was on a constant precipice of radical change, and I needed to just live in that window.

It's strange to live right before you and your life changes unrecognizably. I think the truth is that we always live there, but certain periods make that more apparent and undeniable. Being so very pregnant is one of those seasons.

As much as being that pregnant was not the best, I did not want to rush her labor. I really wanted Twyla to arrive on her own timeline. Human gestation is organic, not mechanic. While there are trends of full-term babies arriving weeks 37-42, really, if allowed, babies arrive when they're ready. I knew there might be certain specific scenarios that would warrant a medical induction, like if the amniotic fluid levels varied or anything like that, but barring those circumstances it was important to me to guard Twyla's birth. I wanted her to initiate. I wanted her to be ready. My work was to surrender to patience and mystery.

My google history was endless, "does this mean labor?" while my text exchanges were fending off about the same from those curious about Twyla's arrival. I felt Twyla's wholeness in every movement. Bending over was a thing of the past. I got good at squats. Trying to get up from being reclined (because laying down was not an option, given the relaxin-induced acid reflux) was an event in body awareness and movement. I became really grateful for all my years of yoga, running, swimming, and other movement practices because they meant that I had more ideas and dexterity to haul myself around.

There were so many suggestions to induce labor naturally. I looked into all of them and did some. From what I can tell, there's only evidence corroborating dates readying the perineum. Beyond that, all the pineapple, sex, spicy meals, eggplant dishes, and the rest are just anecdotal and accidental. I still tried plenty of them. Castor oil may be real, but also induces some of the worst experiences of people's lives. I left that alone.

Twyla continued to prepare me. She adapted me more or less to her sleep schedule on the outside. She made it mandatory that I kept snacks around, though my appetite and ability to eat a full meal had radically decreased (my stomach was somewhere hovering near my throat). She took up all the room in Kevin and my life even as we lived out our last few days without her on the outside. They're the days that leave an imprint because you know you're getting ready to live out the events you'll never forget: the first contraction, laboring with her, how she would be birthed, and beyond.

She created a full space, infused with her presence. We waited for her to arrive, to fill it.

The Ballad of Twyla

My baby,

You are made of mountains

When I was sorting out how to extend an invitation to you

I drove south

And west and out of the cities

And into the earth. The red clay, the pine trees, the land that held

You and me. For you were in my Mom, your potential, your life, as I was in my grandmother. I contain your daughters. You contain my great-granddaughters.

I drove into the thread back, winding through blasted shale, 

Mountains opened to their vein, left bare,

Sunlight blinking through their wounds.

I downshifted iron from them,

I heated my cabin with their energy.

The landscape down there gently swells and I feel

That, I feel you, now.

I swallowed the cosmos. Your Dad sent a spark and now

You’re nesting inside me.

I feel how you’re preparing me. I feel your drawing in

And down and I didn’t know I could love a word not yet whispered.

It shows me that truly, I am so loved, I was so loved,

How could I not have been given what I feel for you now?

I love carrying you. I love holding you

In my body. I’m starting to feel who you are, little twinkle,

Little twilight. I’m starting to sense you out.

We heard your name in a song.

I was feverish and wan, struggling through undiagnosed Lyme disease. We drove

Out on a spring Wednesday night to hear a favorite band, Calexico.

The lead singer said he had twin daughters who wrote a song. One of 

Their names was "Twyla" and that night lit upon me. I heard it with Kevin’s great-

Grandmother, the Irish Catholic, "Eulalia."

Eulalia, whose mother read the Imitation of Christ each night in Richmond. Eulalia, whose round vowels were too big for her grandbabies’ mouths so she became “Wa Wa.” 

I heard Twyla Eulalia. I heard you. 

I hear your name as a song.

I heard your name as a spell you could cast when you need to remember who you are.

The mountains who made you.

The parents who prayed for you.

Your mother, who heard you.

We listened to those Calexico songs, the driving beats of the US southwest and thought of you coming towards us.

We drove south and west back to Tennessee, where my grandmother was exiled after losing her mother.

I kept feeling my great-grandmother, Maggie, feeling her tugging at my sleeve. We saw her house. We learned of her losses-- her mother Susie Griffith who passed just two years before Maggie took her own life. That exile shot my grandmother and all her siblings out of Tennessee. They lost that land, those mountains, being known in that way.

We were in the south on Maggie’s birthday. And that’s when you took root inside of me.

I’m gathering your songs. So many women conspired to pull you here-- Maggie, my grandmother Sue, Eulalia, my Mom, and so many more.

We want you here. We’re making a place.

These are your mountains.

You come from this. 

From these heroines and devils. From the sweetness and the absolute worst. 

I’m still trying to figure out what to do with that material myself. But I think it’s a reminder that we contain it all. We’ll control our monsters and let our better angels win.

And when we forget, we listen to our song to draw us back in.