Ep 156: How to Push - Interview with Pelvic Floor PT Dr. Amanda Shipley

In this episode of the Aligned Birth Podcast, Dr. Shannon and guest Dr. Amanda Shipley discuss the muscles of the pelvic floor and their role in pushing during labor and birth. They emphasize the importance of pelvic floor physical therapy and debunk misconceptions about tight and loose muscles. They also highlight the interconnectedness of the pelvic floor with other parts of the body, such as the diaphragm and deep hip rotators. The conversation covers:

• when to seek pelvic floor physical therapy
• the emotional aspect of pelvic floor health
• the differences between hyper and hypotonicity in the muscles. 

In this conversation, Dr. Amanda Shipley, PT and Dr. Shannon discuss the importance of pelvic floor health during pregnancy and postpartum. They address the misconception that prolapse is a normal part of aging and emphasize the need to pay attention to signs and symptoms of pelvic floor dysfunction. They also discuss the pushing stage of labor and the importance of being in tune with your body and following the urge to push. Dr. Shipley provides tips on how to push effectively and efficiently, including the use of gravity and different positions. She also emphasizes the importance of preparing both the mind and body for childbirth.

Resources mentioned:
Ep 145: Push It Real Good

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• 9:35 (Cont.) Ep 156: How to Push - Interview with Pelvic Floor PT Dr. Amanda Shipley

Transcript

Dr. Shannon (00:02.761)
Hello, hello, you're listening to the Aligned Birth Podcast. Our birth topic today is all about pushing, how to push. We've done an episode about pushing positions. We're gonna go into that a little bit today, but really looking at the muscles involved with pushing and the aspect of the pelvic floor and the role that it plays. So I'm Dr. Shannon, one of the hosts of the show here.

Dula Rachel is usually with us, but I have a guest on today. So we have Dr. Amanda Shipley, who is a pelvic floor physical therapist. And so she's the perfect guest to have on today to highlight the muscles of the pelvic floor, defining what that is, the type of clients that she works with, when to see pelvic floor PT. It's not just tight muscles. It can be loose muscles. Like I think sometimes there's some misconceptions in there.

looking at the muscles that are involved in pushing in labor and birth, and then ways to push, prepping for pushing, all of those good things. So again, we have Dr. Amanda Shipley on today. She's the founder of Renew Pelvic Health. She's been a pelvic physical therapist for 17 years now, passionate about preventing pelvic floor issues and supporting her patients through life transition. So we're looking at pregnancy, postpartum,

perimenopause, before and after surgeries, like all aspects of life support. Her goal is to change the standard of care so that pelvic physical therapy is part of a complete wellness strategy. Her and her team see patients in Atlanta here. She also has an online course in pelvic health through Progressive Pelvic Education, a company she co -founded with her identical twin sister. And then she is also the creator and host of the podcast, Kumbayaal, the Whole Woman's.

So I'm so excited to have you on the show today, Dr. Amanda.

Dr. Amanda Shipley, PT (01:51.532)
Thank you so much. I just have to say that I love your podcast and I've been following it and I love the information and the wonderful work that you're doing. You're putting out in the world and I am just so honored to be here. So thank you.

Dr. Shannon (02:05.897)
Yay, you're welcome. I love it. I know. Well, you actually met Rachel, the Dula co -host on the show in real life at a Spitting Babies conference, I believe. And so I know you guys had chatted and then it was in my email and then I came up, Rachel and I did an episode on like the pushing positions and I was like, man, I really want to have a pelvic floor PT on and talk about how to push. And then I saw your email in there and I was like, sweet, this is what we're doing.

Dr. Amanda Shipley, PT (02:16.204)
Yes.

Dr. Amanda Shipley, PT (02:31.18)
Yay. Yes. Perfect. And I love to talk about it too. So great.

Dr. Shannon (02:34.409)
Yes, I know right? Yeah, anytime you ask any of these birth workers I'm like, do you want to talk about this? I was like, yes, I would love to. So I want to jump right in and we've had I don't think we can have enough pelvic floor PT guests on the show. Like I don't think I can have enough mental health guests, chiropractic guests, doula guests, like all of the things. So but it doesn't hurt to hear information multiple times because sometimes it doesn't stick until you've heard something like 18 times. So I want to go through because I know we've defined the pelvic floor before.

but let's talk about the pieces parts of the pelvic floor.

Dr. Amanda Shipley, PT (03:11.02)
Okay. Yeah. It's a great place to start. So your pelvic floor is actually three layers, right? So that's getting really nerdy about it. But if you look here, if you're watching this on YouTube, we actually have a model. And so you can see that there are muscles that are kind of closer to the surface. And so we call those the superficial genital muscles. That's kind of like layer one. And they go right around the urethra, the vaginal opening, but they also go around the anal opening as well. So that's really important to know.

Just with treatment and stuff because we can work on things vaginally but we can also work on things rectally and if you're having problem with this superficial muscle group then that can be a really important place to work. So then layer two is just like this little hallway if you're watching this and can see the video there's actually like a little fascial plane like a little space in between layer one and layer three and we don't talk about it a lot but that's just to be really thorough.

So then you get to the levator anii and that is what I think most people think of as their pelvic floor is the deeper bowl that's at the bottom of your body. So all your pelvic floor muscles run from your pubic bone in the front to your tailbone in the back. And the tailbone is literally our vestigial tail, right? It's the bottom of our spine and all the muscles kind of attach into that. And then that comes into play, you know, we need to make sure that gets out of the way for birth and things like that. And so that comes into play with the...

with your birth position. But if you can see on the model here, these muscles are really closely associated with the pelvic floor. And so muscles on this model are in red. So you have pelvic floor muscles. They're basically between your body. So they are part of your body that would be covered by a bathing suit, right? So not on your leg, but at the very bottom of your body. And then kind of in your pelvis, you have these deep hip rotators. And so,

If you're seeing a pelvic physical therapist, if you're considering giving birth, you know, it's really good to have information about these guys because your pelvic floor attaches directly onto your obturator internus. So, and that is a deep hip rotator. So now just to orient, if we have your pelvic floor is the bottom of a box, we use this box analogy of your core, your trunk, your diaphragm is the top of that box.

Dr. Shannon (05:22.633)
Mm -hmm.

Dr. Amanda Shipley, PT (05:33.132)
So your pelvic floor doesn't work in isolation for some of its functions. The pelvic floor is really miraculous and really detailed and it really is responsible for huge quality of life and for a lot of things that I think we take for granted, right? But one of the functions as a stabilizer, it doesn't function by itself. So it functions with your diaphragm is the top of that box. Your transversus abdominis is your deep abdominal muscles and those fibers run horizontally.

Dr. Shannon (05:51.305)
Mm -hmm.

Dr. Amanda Shipley, PT (06:01.548)
Kind of like a corset in the mainly the front of your body, but those deep abdominal muscles are the only ones that actually Via this like fascial connected tissue matrix connects to your stabilizers in your back and those are you called your multifidus or multifid I for plural so That's in a nutshell kind of like your core system pelvic floor, but we can't forget these deep hip rotators They are super super important as well

Dr. Shannon (06:05.673)
Mm -hmm.

Dr. Shannon (06:31.273)
I love how you said too that the the pelvic floor doesn't work in isolation and I think that's why I wanted to go through and really define because I guess yes people think of just that bowl that bowl shape of like in that pelvic girdle kind of thinking kind of what you're saying like okay it covers the bathing suit that's everything in the pelvic floor and when you say it doesn't work in isolation yet those muscles intrinsically don't work in isolation but then

the connection points as well to don't work in isolation. And I think the diaphragm is, to me, is the one that most people don't know is connected to it and how your breathing is so intimately connected to the pelvic floor. And because, you know, the hip rotators, you can, like, those are close. Like, so in my mind, I'm like, people can be like, yeah, that makes sense. But the diaphragm, that's huge. Yeah, does not work in isolation. I love that you said that.

Dr. Amanda Shipley, PT (07:24.428)
Mm -hmm.

Dr. Amanda Shipley, PT (07:28.812)
And really the diaphragm, because it's the top of the box, it's like, you know, your pelvic floor has to meet equal and opposite pressure to the diaphragm. So if you have fascial restrictions up near your bra line, then your pelvic floor isn't going to be able to function optimally, right? So if you can not coordinate your breathing well, if you're holding your breath or breathing, you know, weird, then that will also affect the whole canister, right? So.

Dr. Shannon (07:30.793)
Let's... -huh.

Dr. Amanda Shipley, PT (07:56.3)
And then there's also fascial planes where your diaphragm has horizontally arranged fascia, your pelvic floor has horizontally arranged fascia. So there's just so many ways that they interconnect and they work together. The interconnection with the deep hip rotators is really that if your deep hip rotators are weak, then your pelvic floor has to overwork to compensate. And it's kind of like walking on sand versus walking on concrete.

If you're walking on sand, you have to work so much harder because your ground is not stable beneath you. And that's why we need to make sure that our deep hip rotators are on point and supporting us optimally. Yeah, there's so many, there's the relationship of the pelvic floor to the voice. I mean, we can go, we can nerd out all day on anatomy, so, but.

Dr. Shannon (08:43.337)
I know, Rachel and I just recorded an episode too because I wanted to talk about how your jaw tension is related to your pelvic floor tension. And so we went through and it hasn't come out yet. I don't know when that episode is coming out, but it was, yeah, it's the whole, that is connected. So relaxing your jaw can help relax the pelvic floor because it really is. So yeah, we talked about, okay, this is the definition of the pelvic floor. But then I'm always like, well, everything's connected in the body. So it's like, sorry guys.

Dr. Amanda Shipley, PT (09:06.924)
Totally. Mm -mm.

Dr. Shannon (09:11.881)
Okay, so you mentioned, you talked about the walking on sand and walking on concrete, and that's a really good segue into the aspects of when to seek pelvic floor physical therapy, or maybe not even like, sometimes people are like, I know I need to go, and it's the typical, now we're learning more about, well, urinary leakage, if there's prolapse, like if there's big...

problems, I feel like people are really kind of in tune to it, but there could be other dysfunctions like you were saying where the pelvic floor has to be really tight because our hip rotators are very weak. So let's talk about like when to see like signs that you might need to see pelvic floor physical therapist. I guess in the birthing community aspect as well too. So that helps you hone it in a little bit.

Dr. Amanda Shipley, PT (10:01.484)
Mm -hmm.

Dr. Amanda Shipley, PT (10:05.484)
Right. Yeah. So if we're, if we're thinking about pregnancy and postpartum, I think a lot of things get dismissed, a lot of pain, a lot of complaints with women specifically when we're talking about healthcare. So you just realize that your provider may dismiss or may tell you that, it hurts your hips or you have pain in sleeping when you're lying on your side. That's normal. It'll get better when the baby comes or, you have round ligament pain, honey. It's your first birth. It's just going to happen. It's got to stretch.

you know, deal with it, right? And so I'm gonna empower you to know that that's just bad advice. Like nothing, you don't need to deal with anything. Pain and incontinence, any sign that you're having difficulty doing something that you used to do or pain or leaking, frankly, pee, poop or gas, that all should be addressed. Nothing, everything is common, yes. Everyone has, you know, heard of someone having hip pain or...

back pain or pain with sex or around ligament pain, lightning crotch, you name it, and leaking a little bit when they're pregnant or postpartum, but that is not normal. Just because people have experienced it and it may be common does not mean it's normal. There are many people that go through their entire multiple pregnancies, don't leak, they don't have pain, right? So that doesn't mean that you have to suffer with it. So I would say if any of those things are showing up,

definitely get in to see a pelvic physical therapist. But I would also say that, you know, really just going to a pelvic physical therapist is important because we know that your pelvic floor gets affected greatly at these different stages of our life, right? So when we start menstruation, when we end menstruation, hello, perimenopause is like the 10 years before you officially stop menstruating. Then we've got pregnancy.

no matter how you give birth, but then after you give birth, right? Your postpartum journey. And then if you're having abdominal or pelvic surgery, that's planned for, you have an awareness. I really think it's good to see someone before and after that. So that could be a C -section, right? And so what I find is that most, many women don't have this awareness of their pelvic floor. And so they're going through life, they don't use the correct terminology. We have this...

Dr. Shannon (12:13.577)
Mm -hmm.

Dr. Amanda Shipley, PT (12:24.364)
shame and taboo around the pelvic floor in our society. So that creates tension and fear and lackless lack of awareness around that part of our body. So it just causes the stress in our body. And so the more that you can learn about your body, especially if you're pregnant, it's going to help your birth. It's going to help you have an easier birth. So I really think that everyone should see a pelvic physical therapist at least once in their life, right? But if you're pregnant at least once or twice, I think,

Dr. Shannon (12:44.873)
Mm -hmm.

Dr. Amanda Shipley, PT (12:54.156)
you can get a lot of benefit out of just even two sessions because you can have your pelvic floor muscles assessed. You can get that awareness about your body. We can pick up on any opportunities there are for improvement in your muscle strength, in your flexibility, in your facial mobility, how you're functioning, how you're breathing, how you're coordinating things. And then we can also teach you.

things that you can be doing to prepare for your birth, right? And to set you up for smoother, easier healing postpartum. And one of my biggest recommendations is don't wait until the final six weeks of your birth or of your pregnancy to prepare for your birth, right? It's, we can put it like this. You sign up for a hip hop dance class and you know that recital is coming. And yet you wait to practice for your recital until the last.

Dr. Shannon (13:37.577)
Mm -hmm. Mm -hmm.

Dr. Amanda Shipley, PT (13:47.34)
couple days, you know, I mean, why would you not spend all that time that you have knowing that you can possibly prepare for that recital and not just wait to the last minute, right? You wouldn't do that. You would absolutely prepare the move, you know, work on your moves and on your dance routine. But yet we tell women repeatedly to wait to the final six weeks and then they go into labor three weeks early. So they've had three weeks to really prepare their body, prepare their mind for a hugely transformative event.

Dr. Shannon (13:59.593)
Mm -hmm.

Dr. Amanda Shipley, PT (14:16.812)
And this is where I think, you know, not only do we dismiss women's pain and what we're feeling in healthcare, I think that we are minimizing this hugely transformative time in your life. That we know the pelvic floor is going to be affected by birth and your pelvic floor is going to affect your birth. So this is a huge opportunity to be preventative, to be proactive, and to try to set yourself up for success and the easiest healing and the...

Dr. Shannon (14:33.961)
Mm -hmm.

Dr. Amanda Shipley, PT (14:45.58)
best quality of life for the rest of your life. All right.

So I'm quite passionate about this as I see it all the time, six weeks before your due date, do perineal massage. But right, if you go into your birth, right, and all you're doing is perineal, yeah. So again, we can nerd out on the anatomy a little bit, but why that's so dangerous is because your pelvic floor muscles,

Dr. Shannon (14:51.401)
Yes, mic drop for Dr. Amanda here.

Dr. Shannon (15:01.801)
Yes, yes, no.

Mm -hmm. I, yeah, you said do it too. Mm -hmm.

Dr. Amanda Shipley, PT (15:18.028)
are stabilizing muscles. And what we know is that stabilizing muscles are anticipatory muscles. So they respond to your thoughts and our body is perpetually in the present, right? It doesn't know past or future. It doesn't know good or bad. And especially for a first birth, even for a second birth, you have so much to do. It's so easy to stay distracted and feel like you're fine and you're not fine, you know?

you're not processing and even that busy work again, even if it's not a negative stressful state that you're aware of, you're just happily preparing for all the things that have to come before you have your baby. It's still staying busy and you're not in your body and you're not calming yourself. And what that equates to is busyness and stress and worry in your mind equates to tension in your pelvic floor muscles and what your pelvic floor muscles need to do kind of jumping in here, but like they need just to relax and lengthen and open.

Dr. Shannon (15:44.745)
Mm -hmm.

Dr. Amanda Shipley, PT (16:12.716)
for your baby to pass through. They are not what actually does the pushing, right? They just need to get out of the way. And so when your mind is stressed, it doesn't matter if you've been doing perineal massage for three weeks or six weeks, if you go into your birth and your pelvic floor muscles are subconsciously being held tight because of unprocessed emotions around birth, you're gonna be fighting an uphill battle.

Dr. Shannon (16:18.505)
Mm -hmm.

Dr. Amanda Shipley, PT (16:37.388)
So there's so much time that we could be preparing women and you can be doing things during your pregnancy that will absolutely allow you to have a smoother birth.

Dr. Shannon (16:43.209)
Mm -hmm.

Dr. Shannon (16:51.113)
You, yes, I'm so glad you went into that, the emotional aspect too, because a lot of times I'm looking at that with care, like I want to impact nervous system function and how our body is processing those stressors too, to help regulate our stress response as well. Because when those muscles are holding that tension, you may not even realize it. And pregnancy has a very, is a perfect storm to,

for your body to remember past traumas or for past issues to come up and for you to hold that tension. And when we can come in a little bit earlier in pregnancy with information to help make those informed decisions, which is what you're going through, you know, as far as like education, then that can help you release that tension. So not only is it...

you coming in as a pelvic floor physical therapist and literally touching the muscles and noticing tension and noticing stress and helping release it. But then you are imparting that knowledge piece on that helps with that mental component of like, I am safe. I do know what's going on. I am autonomous in this birth and I am empowered in this birth. And I do have people on my birth support team. And yes, it is more of, can we do that early on? I know. Again, you're probably the same way.

I'll take you if you're 39 weeks. Yes, I will. Just there's limitations to matter. There's only, you know, we have a limited amount of time. I'm gonna do everything that I can. We got a lot to unpack there. And so that's where I do love like, just coming a little bit earlier. I'm glad you mentioned that. But yeah, I love the emotions. Mm -hmm.

Dr. Amanda Shipley, PT (18:29.9)
Well, that's it. Yeah. And I usually say, yeah, I mean, I absolutely, I absolutely recommend everyone sees a chiropractor in my online program. We recommend that strongly in my in -person clients. I recommend they all see a chiropractor throughout pregnancy. And like I said, two visits can be really impactful and could be powerful, but ideally I really love to see people once a month, you know, from like second and third trimester on, right? So first trimester,

Dr. Shannon (18:56.745)
Mm -hmm.

Dr. Amanda Shipley, PT (18:58.508)
Keep doing what you're doing. If you're feeling good, if you're not feeling good, then rest. And usually people start feeling better on second trimester. And that's when it's really good to start working on that mindset. And then every month we can just, as your body's changing, we can keep working on things and you can keep practicing. And truly a lot of the things that you can practice, it's creating that muscle memory. So no matter what happens or what life throws at you when you go into labor, your body is doing what you need it to do. And you've practiced that and you've...

you know, helped yourself prepare.

Dr. Shannon (19:29.961)
You've practiced it. Rachel and I talk about that. Like, you've got to practice your breathing techniques and you've got to practice your birth affirmations. It's not just like using it. And you mentioned to the hip hop dance, you know, I'm a runner. It's not like I'm just going to like go out and run a marathon without the training, without the practicing. But I think, you know, sometimes I get it. Pregnancy can be that it can be overwhelming and there's a short amount of time to fit all the things in, but it's also little bits at a time.

and you mentioned that muscle memory, you know, that's a lot of stuff in the office too, as far as like, I'm trying to break up some of that negative muscle memory to like, no, this is the functional pattern that we need. Can you speak to, like, I have found that a lot of times women will just talk about doing kegels or that the issue is a lot of just tension, that extra tension, but there can also be,

low tone that can be a dysfunctional pattern that can lead to issues as well. So can you speak on like the differences there as far as the hyper and hypotonicity in the muscles?

Dr. Amanda Shipley, PT (20:42.316)
Excellent, yes, that's a great question. And it really goes back to every body is different. So yes, your muscles can be tight, your muscles can be weak. Some people have just more laxity or looseness in their tissues. So they are gonna present very differently than someone who has just, you know, they're type A or they just, for whatever reason, they have a lot of tension and tone in their muscles. I think a lot of times, online, I know that...

Dr. Shannon (20:49.961)
Mm -hmm.

Dr. Amanda Shipley, PT (21:11.18)
Everyone hears about kegel, kegel, kegel. And I think now that that's starting to be changed. People are starting to understand that tight muscles are actually weak muscles. If your muscles are so tight, they cannot function optimally. And yeah, so we don't want that. Tight muscles can cause leaking, can cause constipation, painful sex, can cause urinary urgency and frequency. Just having to run to the bathroom, even if you don't actually leak, that is because of tight muscles, right? Or can be. So...

So that is something to address, but we have to unpack why are those muscles tight because we can't just go in there with dilators and do all the massages and all the stretches. If your deep hip rotators are weak, it's the analogy there is I'm holding something very valuable over a balcony, right? And I'm like, my bicep hurts. And yet someone comes up and says, let's massage it. Let's dry needle it. Let's help the bicep relax. Well, really it's not.

My bicep will relax when I get the valuable object off of, you know, over the balcony. Like if you can help me get my hand back so that thing isn't going to fall, then my bicep will. So the point is the tightness isn't maybe the driver. It's just a responder to something else. So that's where chiropractic comes in. Where in the body is there something not functioning optimally that we can optimize, right? For what we work with, we don't just work with the pelvic floor.

Dr. Shannon (22:11.721)
Mm -hmm.

Dr. Shannon (22:22.377)
Mm -hmm.

Dr. Amanda Shipley, PT (22:31.18)
We're not just like digging in. We look at the whole body. So you've got to say, okay, is there some thoracic or mid back joint restriction, fascial restriction, again, all around the level of the diaphragm, because if you're cinched up here and you're used to sucking in your abs, you have poor coordination with your diaphragm, your pelvic floor has got to meet equal and opposite pressure. You're going to be fighting a losing battle trying to just massage your way out of that. You've got to learn how to breathe.

Dr. Shannon (22:33.033)
Mm -hmm.

Dr. Amanda Shipley, PT (22:56.812)
get more mobility in your spine, up the chain so that your pelvic floor can be optimal down the chain, right? So, and then looseness, yes. I think most people are worrying about prolapse and everything, prolapse is when your insides fall outside of your body, typically through your vagina, but it could be through your rectum, right? Not as often, but people worry about that and feel that. And really, truly, I don't see that clinically until you're,

Dr. Shannon (22:57.961)
Mm -hmm.

Dr. Shannon (23:18.097)
Mm -hmm.

Dr. Amanda Shipley, PT (23:26.604)
Yes, I see signs of prolapse, but what happens is that your body is used to ... If your pelvic floor is supposed to be hanging out at the ground floor, and then when you push, it pushes to the basement. Then when you do a pelvic floor contraction, you're contracting up to the fourth floor of the building, right, of your body. Well, I find a lot of people, their pelvic floor hangs out on the seventh floor.

Dr. Shannon (23:43.049)
Mm -hmm.

Dr. Amanda Shipley, PT (23:51.596)
So they are higher and they have more tone than even a normal contraction should have. Right? Like I literally cannot put my finger inside their vaginal canal until we work on things and they learn this about themselves and they realize we're just all disconnected from that part of our body. It's our society. Right? So when they have a baby, then they come to me and they're like, my God, my insides are falling out. I looked with a mirror, I saw something and they'll take pictures and I say, okay, cool. I see that something is there. Right? Your tissues just had a lot of, you know, work.

Dr. Shannon (24:01.513)
Mm -hmm.

Dr. Shannon (24:09.481)
Mm -hmm.

Dr. Amanda Shipley, PT (24:20.78)
done because you just pushed a baby out. But they're, you know, and really, truly it's sometimes, I mean, I still can't fit my finger inside. Like they feel that pressure and you know, so their brain is freaking out because their body just went from the seventh floor, their pelvic floor was at the seventh floor. Now it's on the second floor. It's still not even at ground level, right? But they notice that change. So I just say that because a lot of people get worried about prolapse.

Dr. Shannon (24:36.553)
Mm -hmm.

Dr. Amanda Shipley, PT (24:47.436)
And as long as you're doing things to not make it worse, your body will heal. You need to kind of readjust that things maybe aren't as tight as they used to be. But I promise you, if you don't work with a pelvic PT, I see things just go back. Like if you have pelvic floor muscle tightness before birth and you don't work on it, it will come back after birth. Your body is just going to reset to its set point. And that may not serve you later on in life, right? But...

Dr. Shannon (24:57.097)
Mm -hmm.

Dr. Shannon (25:10.377)
Mm -hmm. Mm -hmm.

Dr. Amanda Shipley, PT (25:12.78)
Caveat if you're working with older people or you are someone who's older and you're done having your kids You're 65 and up now. We really have to worry about you know if you're sensing prolapse or You know weakness then it could actually be coming down We don't want things to come outside of your body if they're supposed to be in your body obviously, right? So I just want people to know that everyone freaks out about prolapse and there's a definite difference I see based on age

Dr. Shannon (25:33.897)
Mm -hmm.

Dr. Amanda Shipley, PT (25:37.676)
And if you're in your having your kids stage, or if you're in the perimenopause menopause transition and beyond, it's a totally different conversation. So we'll just stick with the pregnancy and postpartum and realize that prolapse is real. You should absolutely care about it. Do not, you know, ignore signs or symptoms from your body that things are vulnerable down there. That could be a vaginal like opening or gaping kind of sensation. It could actually be a...

pressure or heaviness or progress to like a discomfort or pain or like something does feel like it's falling out. All of those on that spectrum give you an alert to say, hey, I have an opportunity here to tune into my body and to cut back on something, modify something, not stop it forever, but to pay attention and listen and give my body what it needs.

Dr. Shannon (26:24.457)
Yes, pay attention to that. I love the analogies that you give. These are the best analogies ever because I love that you said to like your pelvic floor is hanging out up here. It's now kind of where it needs to be, maybe a little bit still a little bit tight and it's going to be a different sensation to you. So yeah, not to discredit that, but like seek out the pelvic floor PT like help.

and the experts in that area to get that covered. Like those sensations are different. Lean into it and be like, okay, what is going on? That awareness precedes any sort of change. So I do love the, I love the analogies and the visuals. I'm like, I can really visualize that. So, okay, so I wanna segue into now, so in, we've gone through pregnancy.

Dr. Amanda Shipley, PT (27:02.924)
Yeah.

Dr. Shannon (27:14.057)
We are at our final stages for labor and birth. And I want to talk about the aspects of like, not really like how to push, but it's almost like if you've got an allergy or some sort of visualization for of what is involved in the pushing stages and how the uterus and the contractions work with the body and with the sympathetic and parasympathetic nerves. I mean, I have to get that but like,

how what muscles are involved. And then we can even go into like when you change positions, it's gonna allow the muscles to engage differently, more effectively, more efficiently. So how do we push?

Dr. Amanda Shipley, PT (27:57.1)
Yeah. How do you push? Okay. So the biggest thing I would say, just even thinking about it, because you just kind of walked us through, like now you're at the end of your pregnancy. No, you're in your second trimester. You just passed that 12 week mark. You're telling people you're excited. Now let's get this awareness about your body. Now let's say, okay, am I pooping? Right? How should I be pooping? Right? And so, and there's a lot of similarities between...

Dr. Shannon (28:17.865)
Mm -hmm.

Dr. Amanda Shipley, PT (28:23.596)
being and having your baby. And so it's both the same movement, right? Where your pelvic floor muscles are not pushing your baby out, your uterus is pushing your baby out. Your pelvic floor muscles need to be able to relax and expand and lengthen and just get out of the way.

The baby has a job to do in labor, right? So the baby has to rotate and turn and kind of descend and that, the baby doing its work is what's going to help your cervix style. And so that cervix, which is the opening to your uterus, that gets out of the way. Your pelvic floor muscles are relaxed. And now when you get to push, you're going to be putting force behind all those things naturally spreading and relaxing. So it's really about managing your intra -abdominal pressure.

in such a way that pelvic floor relaxes and you are adept at putting some force behind helping your uterus do its job. I have had patients, one patient I remember, she wasn't local here, she had given birth in another state and she said, I think they overdosed me. It was her first baby and she had the sheet on her, her husband was playing on his phone, no one else was in the room and all of a sudden she heard gurgling and her baby was outside of her body.

She's like, you never saw people run so fast to come in the room. Her uterus did its job. She was relaxed. First baby, I had never heard that before. So I do share that with some people though to say, hey, back in the day, they would knock women out and your uterus just did all the work. So we're just helping nature along. It's not that your pelvic floor is pushing your baby out. So really,

Dr. Shannon (29:51.369)
Wow.

Dr. Shannon (29:59.369)
Mm -hmm. Mm.

Mm -hmm.

Dr. Amanda Shipley, PT (30:08.364)
Now I'm going off. Okay, so I can, what did you say? There was another question there. You're like, you don't want me to teach how to push, but that's where I feel like I want to go. What did you want to know more?

Dr. Shannon (30:17.321)
But no, but like, yeah, how to push. It's like that, the different positions, how the muscles work effectively and efficiently in different positions, using like gravity to help you changing positions as well, maybe not being on your back, like does that help you push or not? Like all of those type of things.

Dr. Amanda Shipley, PT (30:27.66)
Right.

Dr. Amanda Shipley, PT (30:33.804)
Yeah.

Yeah. Yeah. So this may be an unpopular opinion, but I really teach people not to worry about position. Like if I were to say something about that, it's the research has shown, do not be on your back. So that's the only thing I ask my patients to remember is don't be on your back if you can at all help it, right? That locks down your sacrum. You don't have room for these bones to move and to open up and to increase that space.

Dr. Shannon (30:58.857)
Mm -hmm. Mm -hmm.

Dr. Amanda Shipley, PT (31:04.332)
and lying on your back. Now we're talking really pretty much on your back, reclined, kind of your partner behind you supported and your legs are just kind of up to the side. That's not the same. But if you're pretty flat down and you've got a nurse on one side, so you have two different people putting different forces through your legs, that can be not ideal. So if you can avoid just being flat on your back, that would be ideal. Turn a little bit, anything where you can get some room for that sacrum to move and use gravity, right?

Dr. Shannon (31:17.289)
Mm -hmm.

Dr. Amanda Shipley, PT (31:34.156)
That is my one recommendation. What I find is that when I work with people is that when we teach so much about which position do that, then they get all worried about that and then they stay in their head. So what I really encourage women to do is to get into your body, practice getting into your body because a lot of times during pregnancy, yes, you said, there's so many things to focus on. It's really ways to distract ourselves because we're nervous about birth, right? So the more that you can say,

Dr. Shannon (31:46.889)
Mm -hmm.

Dr. Shannon (32:03.081)
Mm -hmm.

Dr. Amanda Shipley, PT (32:03.852)
I really do need to pick a name and prepare for my baby shower and my, all the things, right? Prepare the nursery, but all those are really, it's just busy work to kind of distract you. As long as you're taking time every day to mentally prepare and carve out time and space for this new being coming in, I think that will help your mindset. That will help you calm down as you head into your pregnancy. It's going to help you when you get to pushing, I promise.

But one thing that also I think keeps people distracted is they learn all these different positions. And if you're not already a doula or someone who knows what's left sideline, what's this, a peanut ball, and they have never worked with a peanut ball before, then they stay in their head to try to decide what should I be doing next. So my recommendation is to hire a doula, to have a team with you that can give you all those, because those are really real. Like changing position matters. You absolutely should change position.

Dr. Shannon (32:56.105)
Mm -hmm.

Dr. Shannon (33:02.153)
Mm -hmm.

Dr. Amanda Shipley, PT (33:02.284)
But what I want them, you as the mom is to get in your body and try to practice just being in your body so that your team can say, let's try this. And just, they pass you a peanut ball. Let's try this. And you can be the input to say, yeah, that feels a little better or, heck no, I can't do that right now. Right? So that, so the position conversation, that's really where I, I, I kind of lean toward is just try to be in your body. If you're in labor.

Dr. Shannon (33:19.081)
Mm -hmm.

Dr. Amanda Shipley, PT (33:30.284)
Let your team support you about what to try. And then you say, yay or nay. I don't want you in your head thinking about, let's try left sideline. Let's try right sideline. Let me, you know, I just want you to feel into it and try all the different positions. Yes. Yes. Yes. It was.

Dr. Shannon (33:41.385)
You got to get out of that thinking brain. And I'm glad you mentioned that because that's the big thing with the doula as well too is to be like, hey, okay, we've talked about this. Let's try this. So what you can do what you are supposed to do, which is get you got to surrender and you can't surrender when you're like actively thinking.

Dr. Amanda Shipley, PT (33:58.956)
But I love -

Dr. Amanda Shipley, PT (34:02.828)
Well, and that's why I love, love, love your episode on the pushing. If you guys have not listened to it, go back. It was from early March. They had a great episode all about pushing. And I think that's so amazing because people do need to hear, okay, you don't have to be on your back. Like they don't even know that they can ask for anything else. So, you know, unfortunately not everyone can hire a doula. So if you can't hire a doula, at least listen to...

Dr. Shannon (34:20.578)
Yeah. Mm -hmm.

Dr. Amanda Shipley, PT (34:28.524)
their episode earlier, I think it was like March 6th or 2nd or something, yeah, about how, like different pushing positions because just to know, to try to advocate for yourself to do something different, to just change. If you're not feeling that position, just try to keep changing. And I think that's really, really important and really beneficial for a decrease in trauma, you know, to your perineum and to your pelvic floor during birth. So, yeah, so using gravity, all that matters, but that's about the extent of what I described. So,

Dr. Shannon (34:33.897)
Mm -hmm.

Dr. Amanda Shipley, PT (34:57.805)
When we get now to pushing, it really is, I think most people conceptually understand how to push, but having that confirmation of knowing that they're feeling it and how it should feel in their body is where there's some opportunity for improvement. So that's where you can see a pelvic PT. And what we can do is put one glove finger inside your vaginal canal and we can feel, are you doing it correctly?

Dr. Shannon (35:15.529)
Mm -hmm.

Dr. Amanda Shipley, PT (35:24.556)
and effectively. So what we first work is that you're not contracting when you should be pushing, right? Where you want the pelvic floor to relax and expand, not tighten. That's what we mean when we say contract. But then if you can actually coordinate everything and do it well, is it really a good strong push? And so I have some patients that will work through that and say, okay, you're doing it correctly, but it's really pretty weak still. So we've got time, we've got months for us to keep practicing, have you working on that.

Dr. Shannon (35:28.073)
Mm -hmm.

Dr. Shannon (35:44.425)
you

Dr. Amanda Shipley, PT (35:52.556)
And I really recommend everyone practice in bed at night before they go to sleep and on the toilet. So if you sit down and your poop just comes out like, cool, then you may not have an opportunity on the toilet to practice there. But if you have any awareness that like, Ooh, I have to put a little work into getting this poop out, then just, and I really say when you're practicing, again, this is second, third trimester, most of your pregnancy, if you can do it, is that you want to mentally get into the state that you're about to meet your baby.

Dr. Shannon (35:52.905)
Mm -hmm.

Dr. Shannon (36:01.321)
Mm -hmm.

Dr. Amanda Shipley, PT (36:22.38)
Right? I want you to, whether you're practicing on the toilet or in your bed at night, you want to first mentally think, my gosh, I'm about to be able to hold my baby in my arms. I'm about to meet him or her. And so kind of mentally and emotionally get there. That will help your body with that practice, with that mental imagery. And then what I tell people, we really start at the top. We start at your mouth. Your orifices are connected. They're just opposite ends of the same.

Dr. Shannon (36:25.289)
Mm -hmm.

Dr. Shannon (36:42.601)
Mm -hmm.

Dr. Shannon (36:49.001)
Mm -hmm. Same tube, exactly.

Dr. Amanda Shipley, PT (36:50.38)
You know, two basically. So, and then, exactly. And then this really helps because if you end up having an epidural during your labor and you can't feel the bottom half, you at least can feel the top half and your body has the muscle memory that you know that you're doing what you need to do. So you always want to start with a relaxed jaw, even the low tones, the humming, that's going to help if you're vocalizing, right? And then I turn to your lats. So your lats.

muscles are behind your shoulder blades, they're kind of under your arm, but more into your back. And so when you're sitting on the toilet, you have your knees higher than your hips, right? To have a bowel movement. You can really, you know, depress your shoulders and that's going to engage your lats. If you're in a birth pool, you can push down on the sides of the birth pool and that's going to engage your lats. So that's going to get a little more oomph behind your push. So it's jaw, lats.

Third is your belly. So this is what I don't see enough people talking about is, remember we were talking about the pelvic floor doesn't work in isolation, right? Well, the pelvic floor electrically works with your transversus abdominis. You can't separate them. So when you squeeze your pelvic floor muscles, you're also pulling in your lower abdominals or your deep abdominals. And the same thing happens in reverse. So when you push to have a bowel movement or...

push to have a baby, if you're relaxing your pelvic floor, your belly will relax and vice versa. So if you squeeze your abs in, you're going to get a contraction with your pelvic floor and you're fighting yourself. So what it should look like is you're relaxing your jaw, lower tones, you're pushing your shoulders down, you're pushing your belly out. We call it make it belly big, belly hard. This is how we teach people to poop too. So you push your belly out as you're pushing down on your pelvic floor.

And it's interesting to me when I practice with people and I say, okay, now push down on your pelvic floor. It doesn't connect. I changed my cue and they say, okay, now push your belly out and push like you're pooping. And then it connects. So if you see online, people say it's not like pooping. It totally is like pooping with both my children. I'm like, this baby is coming out of the wrong hole. It feels like you're pooping your baby out. But truly the way the mechanism works is you're starting at the top. And so,

Dr. Shannon (38:57.641)
Yeah

Dr. Shannon (39:01.641)
Hahaha!

Dr. Amanda Shipley, PT (39:10.156)
Let's back up. The breathing that we teach throughout, I mean, I really teach it to everyone is to do an open kind of like a big diaphragmatic breath. You're trying to relax your pelvic floor with the inhale. So I tell people the breath that you're practicing, this diaphragmatic breathing with pelvic floor muscle relaxation paired with inhalation, that is the same that you, that's what you do 90 % of labor, 70%, I don't know. Most of labor, you're just trying to get out of the way. You're just breathing and thinking about,

imagery as you breathe in your pelvic floor is an O that opens and widens as you relax. It's just kind of like a passive deflating. So that's most of labor. You just inhaling, feeling your pelvic floor, relax, moving, trying to get comfortable, trying to just keep things moving. When you get that downward pressure and you feel like you have to push, that's when you say, okay, now I'm not going to, it's just mental imagery, right? You're not going to exhale through your mouth. Now you're going to still do the same expansive.

Dr. Shannon (39:49.961)
Mm -hmm.

Dr. Amanda Shipley, PT (40:08.3)
open, inhale, relax the pelvic floor and the inhale, but now you're going to pretend that you're exhaling down through your body. And that's where you relax your jaw, depress your lats or push your shoulders down, push your belly out and push out a poop. And there you have pushing out your baby. And really, truly, the other important thing is to follow the urge to push.

Dr. Shannon (40:16.969)
Mm -hmm.

Dr. Shannon (40:26.857)
I, again, the imagery is so good with that. -huh, yes, that urge to just feeling it. But when you practice that, then you know. And so then it's easier once you are in that birthing space to then remember, okay, and then you can get out of your brain. You can get out of the thinking brain and been like, I have trained this that I go to my jaw, I go to my lats, I push the belly out. Like,

Dr. Amanda Shipley, PT (40:30.956)
Mm -hmm. Mm -hmm.

Dr. Amanda Shipley, PT (40:44.588)
This is good.

Dr. Shannon (40:55.145)
that gives you a flow to just, and you visualize the expansion. It was all beautiful. I love, I love, love, love, love, love that because that does help you get out of the thinking brain. It's not like, okay, let me try this position and blah, blah, blah, blah, blah. It's, yeah, it's that visualization, that imagery. But again, I think that's key with practicing it. As you go in for pelvic floor physical therapy and you work on those muscles and you know what it feels like to do that.

Yeah, I love it. And so you kind of went through ways to prep. Mm -hmm.

Dr. Amanda Shipley, PT (41:26.892)
I think it's so freeing too.

Yeah, it's just freeing too because I think there's so much nerves heading into labor and birth and to have to not be comfortable with your body and to not know all these things. And then you'll have to remember the position and do this. And then truly everything goes out the window anyway. So it's like, let's just have your body dialed in. So it's on autopilot. You know, you've got the muscle memory that what you're doing. And then.

Dr. Shannon (41:32.361)
You think what?

Dr. Shannon (41:39.945)
Mm -hmm.

Dr. Shannon (41:48.841)
Yeah.

Dr. Amanda Shipley, PT (41:53.868)
and then you just worry about, not worry, but you just plan on being in your body. That is your only goal is to be in your body. Follow the urges that you're following, trust your team, and you got the pushing, right?

Dr. Shannon (41:59.945)
Yeah, that's it.

Dr. Shannon (42:06.761)
You've got the pushing. Yay, this was so perfect. This is everything I wanted and more in this episode. I want you to speak a bit about where people can connect with you or if there's any other little tidbits that you wanted to go over that we didn't or yeah, like all of the good pieces there because you've got the online program and who you work with so people can kind of connect with you.

Dr. Amanda Shipley, PT (42:16.076)
Aww.

Dr. Amanda Shipley, PT (42:33.804)
Yes, thank you so much for having me again, honestly. If you are local to Atlanta, I do have a brick and mortar. I have a private practice indicator called Renew Pelvic Health. And Ariel and myself see patients there now. Yes, and we love to help people in person with all the ways that we talked about. And I do have an online program, Progressive Pregnancy. So I love helping people who either

want a little extra with that program or they aren't geographically close enough to see me in person. And the last tidbit I really want to focus on is really why I made that online program because I have an identical twin sister and she had an amazing first birth. She has one child and her birth was seven hours and it was amazing and I thought...

I've got this in the bag, right? I am a pelvic PT. I know what to do. And if you can't see me, I'm doing air quotes right now. And so I prepared like, yeah, I know everything, right? So, you know, you head into your birth thinking like everyone teaches you, you need to prepare for a marathon. You need to be strong. And so you're not wrecked afterward and strong to get through the pushing and it's just all wrong. And so I did that though. I prepared my body. I prepared my pelvic floor.

Dr. Shannon (43:37.385)
Everything, -huh.

Dr. Amanda Shipley, PT (43:56.044)
that I did not prepare my mind. It was not even on my radar. And if you had asked me for that birth, I would have said, my gosh, I'm so excited for this birth. Like, I can't wait to experience what my patients are experiencing. And then I got told, and I literally have a genetically identical twin who just rocked her birth. Like, I've got this in the bag. yeah, no. I had a 30 hour active labor. It was long and arduous. I still got my home birth, but it was, I bled for two.

two months afterward. I mean, I had so much, it just was such a long process. My body took so long to heal from that. And I realized, we're not preparing women the way that matters, right? You know, we cannot deny the mental peace. So I just want to put that out there that, you know, preparing your mind, body, and pelvic floor for childbirth is the best way to get the birth that you desire, wherever that is. And,

I find that when you're looking at mindset, there are five main fears that come up for people. And so I have a free training around one of those fears, which is, can I handle it? Can I handle the pain or the intense sensations of labor? So if you're interested in looking into that, it's at progressivepelviceducation .com forward slash birth mindset mastery. And it is a great training on how you can be preparing your

body in your mind for the intense sensations of labor, even if you're not pregnant yet. I mean, you can start working on this move really even before you conceive, but definitely all throughout your pregnancy and will absolutely help you. So I like to put that out there.

Dr. Shannon (45:36.105)
We're gonna, I'm gonna get all the links from you and we'll put all the links in the show notes. So that way it's a little bit easier for folks to find things and connect with you. And then I know you're on social media as well too. So we'll put those links in there. So this was so good. This was everything and more than that I'd wanted in this episode. And I learned a ton. That's why I like to do these things is cause I'm like, well, I just get to sit here and have a front row seat and learn and ask the questions I want to ask and things. So.

Dr. Amanda Shipley, PT (46:01.228)
Bye guys.

Dr. Shannon (46:05.545)
Again, thank you so, so much for being on the show. It was such a pleasure. And then, yeah, we have new episodes that come out every Wednesday, so stay tuned.

Dr. Amanda Shipley, PT (46:17.996)
Thank you.