Childbirth, Pelvic Floor Injury & Prevention: An Engineering Perspective — with DR. MARIANA MASTELING

What if we could prevent major pelvic floor injuries before they even happen?
 
🤔 In this episode, I sit down with biomedical engineer Dr. Mariana Mastering, whose groundbreaking research on the pelvic floor began with one simple yet profound question: "Mariana, are you incontinent?" 

This curiosity led her from medical school to biomechanics, exploring the complexities of intra-abdominal pressure, incontinence, & childbirth-related pelvic floor injuries. 

Her PhD research @uofmichigan reveals how the birth canal stretches, offering invaluable insights that could change the way we approach pelvic health & injury prevention.

We talk about:  
🔹 Understanding the normal range of pelvic health  
🔹 Translating research into practical applications  
🔹 The variable causes of prolapse  
🔹 Why Kegels aren’t always the answer  
🔹 Capacity demand & pelvic floor health  
🔹 Reducing the risk of birth injuries  
🔹 How age affects birth-related injuries  
🔹 The biomechanics of childbirth  

Have you ever wondered how biomechanics could change the way we approach postpartum health? 

Time Stamps

1:00 Introduction

6:24 understanding the pelvic floor

11:14 pathology of prolapse

16:23 findings of their research

21:45 potential effects of evulsion 

27:02 explaining capacity demand

32:45 working towards preventative measures

38:57 pelvic floor injuries with c-sections

43:05 increased birth injuries with age

48:39 research looking at time of birth

51:33 racal differences in birth

55:36 connections between clinic and research

57:40 upcoming research

CONNECT WITH CARRIE

IG: https://www.instagram.com/carriepagliano/

Website: https://carriepagliano.com

CONNECT WITH MARIANA

LINKEDIN: https://www.linkedin.com/in/marianamasteling/

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Transcript

SPEAKER_02 0:06

And your associate guide for staying active with public health institutions financial metaphobic and beyond whether you're a fellow mom physical therapist or women's health professional. Join me where I'll share expert insights, real life stories, and the latest research to help the approach running CrossFit yoga philodendrist or whatever activity you love with confidence and evidence-informed guidance. Let's start the show. All right, we're going to have a really cool conversation today. Our next guest is Dr. Mariana Masteling. She is a researcher looking at a lot of aspects of the pelvic region and pelvic floor birth injuries in a very, very different way. And before I go any further, I'm going to let her introduce herself and then we'll dive right in. Welcome to the podcast.

SPEAKER_00 0:55

Thank you so much for having me today. Yeah, so I am a researcher at the University of Michigan, and I did my PhD in biomedical engineering. I did my bachelor and my master's also in the same field. I'm originally from Portugal. That's where I did my undergrad and my master's. And then I went to do my master's thesis at the University of Michigan with a Fulbright scholarship. And the reason why I went to Michigan is my undergrad professor in biomechanics asked in a class, oh, so if anyone wants to do biomechanics research, just let me know. And I always knew I wanted to do biomechanics. I actually first went to medical school because you can go to medical school right after uh high school in Portugal. And then one of the like Dean level professors told me, Mariana, you asked too many questions to be here. And I and I was like, maybe that's the compliment. Yeah, like this is not for me. And so I went to engineering school, which was on the other side of the street. So I always knew I wanted to study biomechanics because I knew my body worked in different ways. And if I I always did sports, and I knew if I changed my technique, I would swim faster, or I also played music, played uh euphonium. And so I also knew depending on how I hold my instrument, it would hurt some parts of my body or not. And I was like, I need to figure out why that is. And so in that biomechanics class, I was like, I want to study why my body hurts when I play my instrument. And uh my professor asked me, so what do you play? And I said, I play an euphonium, which is a small tuba. And he asked me, Okay, so basically, so what do you do? And I said, Well, if I blow harder, it has a higher pitch note. If I don't blow as hard, it has a different type of note. And he said, So you raise your intrabdomal pressure. And I was like, I don't know what that means, but I guess, yeah, like I put pressure in my lungs and my belly, so I guess yes, I raised my intrabdomal pressure. And then in a full room of undergrads, he asked me, So, Mariana, are you incontinent? And I was like, Oh my god, like I was like, What? What are you talking about? He's like, I know, and he was like, I think there is something to it because we knew that young gymnasts that do trampolines or lots of jumping, they leak during their activities, so probably musicians do too. They just don't talk about it, and I was like, Yeah, okay, I'll go read into it, and that's how I came to pelvic floor. So I started reading about the pelvic floor. I wrote this review about like how, in theory, young females that play wind instruments, and wind instruments are instruments that like you play with your mouth, put air into it, um, should also probably have some incontinence. So then I started reading about pelvic floor, and I realized that all the papers were either written by the group at Michigan, by Dr. Aston Miller and Dr. Delancey, or they cited their work. And you know, you are young and confident, and I was like, Well, the worst thing can happen is that they never answer my email. So I emailed Dr. Ashton Miller and I said, I really would like to work with you. How can we make this happen? And then he said, You definitely can come work with me if you find your own funding. And that email was like 2013, so it's more than 10 years ago. And I was like, okay, we'll find it. We found this grant. I was able to get to Michigan, do my master's thesis, and then from there I just stayed on, first as just a research assistant, meaning helping others with projects, and then I started my PhD, which I finished last year, and now I continue working with them as a research fellow, meaning I continue supporting some projects for my PhD and also support other project people's projects. Considering I'm an engineer and I do a lot of software as well, I help people make their projects easier to do. So trying to automate as much as we can, doing a lot of late analysis, and also trying to do a lot of work on just showing our work and making it more accessible, not just keeping it in the academic journals, but also things like participating in this podcast, posting on LinkedIn, trying to get a better presence and showing this work so that people can recognize it and um that we can actually help women that are suffering from the consequences of childbirth to have a happier and healthier life.

SPEAKER_02 5:26

Yeah, no, that's uh that's that's providence. That that's what that is, the fact that you took that very narrow path to get here. I think the thing that um got my attention about you, and I I forget maybe it was uh uh Jenny Lacrosse who's at Michigan as well. Um, somebody had posted something of yours and you had a it was a picture of a 3D reference of um a pelvic region that kind of included ligaments and fascia and all this stuff. And for somebody that, you know, I've been a clinician 25 years, I've had my own pelvic floor injuries. I think it's even it's even challenging as a health provider to visualize that part of the body um beyond some of the basic models that we were given, you know, and and even you know, the average person listening to this, you know, they're told, oh, the pelvic floor is a hammock, this, that, whatever. But it's actually much more intricate and involved. And like you can appreciate that on, you know, cadavers, but the average person doesn't want to look at a cadaver. I mean, if we start with just kind of, you know, what you've learned about and even how you measure and and kind of help us get an understanding of what the pelvis is and the contents and all of that, like what would be the simplest introduction to you know the average person to understand what that area even looks like?

SPEAKER_00 6:51

Okay, so my first thing is, and this is the if you need to remember one thing from this talk today, is the pelvic floor is not an hammock. Thank you. It's not a hammock, and it's not a hammock, it's more like imagine a bookshelf. So a hammock, it's like a lid that looks like a bowl, but now flip that bowl. That's how the pelvic floor is. We're actually using it to as a shelf to hold hold up all the pelvic structures. And so, why do we think it's a hammock? It's because when we do things with cadavers, they there is no more muscle tone, meaning someone has passed away, and so there is no blood, there is no more things moving around, so the muscles aren't in tension anymore. So imagine if you have a big uh like uh tablecloth and you are holding it really tight on both ends, it's gonna stay stiff and and and straight, but if you let go a little bit, it just starts gonna start to sag. That's kind of what why what we see in calibers. And so when someone is alive, we actually can see that the muscle, the pelvic floor is very tight, and not in a sense of tight, bad, but tight in the sense it holds everything together. And so when we started doing um imaging using MRI, which is magnetic resonance imaging, sometimes you might hear of MRI like, oh, someone has an injury to their knee, so they do an MRI as a form of medical imaging to see what happens. So uh the University of Michigan has a very large MRI database, and so uh a lot of my work is measuring things on MRIs to try to understand what is normal, what's the normal range? How can we say that someone has something that's abnormal if we don't understand what's normal?

SPEAKER_02 8:34

So, you know, I mean, when you're trying to translate, you know, what you're finding on MRI to does this mean anything, or kind of who does it mean something to? Like, how how do you kind of go about that thought thought process, understanding this from your perspective as an engineer? Because it's completely different than I think how a clinician would approach it.

SPEAKER_00 8:58

Yeah, so like MRIs are very expensive, so you do not do one to everyone that comes into your clinic goes, oh, I have some complaints, let's do an MRI. No, we do not do that. Uh, we might do an ultrasound that's getting much more uh like much more available, and especially because ultrasound is what already been used to analyze the baby. So like uh your prenatal care office that will do your postpartum visit are probably already has an ultrasound. So we are doing a lot of work trying to understand. We see this really clearly and really nicely on MRI. So, how do we see similar things on ultrasound? And so we are working on that. Um, I kind of forgot the line of questioning we were, uh, but um, I think so, from an engineering perspective, when you measure things, let's say you want to see what's the difference in the muscles between someone that's young and someone that's older. And let's say we measure what's called cross-sectional area, which is like how big your muscle is. So imagine um when if you have your arm and you want to know how big your biceps is, you measure cross-sectional area, which is an area of the muscle. So we do that as well for some pelvic floor muscles. And imagine we we know in science you we always say we need a group of 30 and 30, because if you can show a difference in a group of 30, let's 30 young and 30 old, then you probably that that difference is true. But in some of our studies, in just five subjects, meaning if we measure in five young first people and five older people, we already see differences. That makes it uh show to us that we don't even need, we would like to do much more, but MRIs are very expensive, so we can't do more. But if we see a difference in five, it means it's a true difference, and we should continue trying to understand why is a difference and if this difference is important, not from a clinical perspective, but also like, okay, what does this affect in the long term with aging, with childbirth, with uh activities of daily living?

SPEAKER_02 11:02

So we're starting with normals, trying to get a sense of that, and then those of us that are clinicians, we want to know the next piece is like, what's the difference now with those people that have some sort of pathology? And you you looked at um women, older and younger women with and without prolapse. Um, what kind of what did you what made you consider looking at prolapse specifically versus something else? And then what did you find?

SPEAKER_00 11:31

So science is you can do science because you get money from the government normally through grants. And science is really hard to do to quantify normals. Because, well, if they are normal, why do you need to measure them or study them? Because, oh, they are normal. Well, because if we don't know the normals, we don't know what's abnormal. So uh we actually started doing a lot of studies on people with had prolapse, they had incontinence, they had urge incontinence, stress incontinence, and then we finally also got okay, can we just do normals? Right? Like people that have never had childbirth, so we can actually know what's the difference. And an interesting word that has come out also from our research group is so we say that someone has prolapse, and we, oh, you have prolapse, you have prolapse, you have prolapse. But then if we go and look at your MRIs and try to understand, okay, so what is happening in your prolapse? Okay, you have a bulge coming from your vagina, but for some people, the the reason for all these prolapses is different. Some have an injury to their muscles, and so the muscle detached from the pubic bone, it's also called an abulgent, meaning that this muscle is not connected to the pubic bone anymore, and so it can't support the pelvic organs anymore, and you can have injury injury. But some for other people, it might be that the tissues that hold the top of the vagina in place aren't as strong anymore. So that's why there is a bulge coming through the vagina. So there is so many different reasons, so many different combinations that in all these prolapse subjects we got, no one has the same reason for having a prolapse. So, in the same way that someone has cancer and someone has cancer, but we all know those cancers are different. In our space, we are still calling everyone prolapse the same thing, while we are starting to, research is starting to show actually it's not the same thing, but we still don't really understand what's different. And there is no easy way to measure the difference, so it's hard to apply clinically.

SPEAKER_02 13:34

But I think even just acknowledgement of that fact and kind of confirmation of that with your imaging support is an incredibly important concept. I mean, um, I mean, I think probably surgeons that operate there understand the intricacies involved. I think it does get oversimplified when you're trying to explain it to a patient or even a newer therapist. Um, because I don't know of any other area of the body that we work on with such three-dimensionality and you know, null space and that sort of thing that you can't see with your own eyes. So we're we're kind of trying to understand this in our mind's eye, also understanding, and I I have a son with visual spatial deficits, and so understanding that there's some people that can't visualize that, period. So, but I do think for for PTs, it's one of the most challenging places for us to understand because we started with just such a simplified understanding, but again, to understand the three-dimensionality and the parts and pieces involved and the fact that it is so complex that we may have different reasons for someone to have a diagnosis of prolapse or those symptoms. But again, I think even like that black and white acknowledgement is such an important point. And I think someday we're gonna look back and be like, oh, yeah, of course. But right now, um, again, for those of us that have been in this for a long time, like we knew it was complex, but it's just so beautifully complex. Like, do you ever have moments when you're looking at this, you're like, wow, that's really cool.

SPEAKER_00 15:09

Yeah, yeah, totally. And it's also like when someone is knee pain, they can tell you, okay, it hurts on this part of my knee. My left knee hurts, my right knee doesn't hurt. Yeah, someone has an issue in their pelvic floor, it's like, okay, it hurts, and okay, what does it hurt? Like, oh, I I don't really know. And then someone goes to pelvic PT and there is palpation, it's like, does it hurt here? And it's like, yeah, maybe, but maybe it's not there, and it's just like it's really hard to quantify. Yeah, and also um, it's severely underreported, right? Because a lot of people still have a lot of stigma, even telling their providers that they have uh issues. Some people think it's normal to wear like diapers because that's the way they can get through life, and it's like that's not normal. But if we don't talk about it, people don't know there is other things they can do about it. So yeah. Yeah, it's complex.

SPEAKER_02 16:02

But again, like I feel like it has to be. Um, but someday we'll get to a point that it's complex but simple. So you you did this study um with a group looking at the measurement of the cross-sectional area um for older and younger women with and without prolapse back in 2019. Um, what did you guys find? Is there a difference?

SPEAKER_00 16:23

So I think the most interesting fact is that if I would show you two MRIs today and I would told you one is young and one is old, and I wouldn't tell you which one is which, you would be able to tell. Because when we look at young anatomy, we can see this really striking contrasts, everything is really aligned. These muscles are so in MRI, it's like a black scale, so it's like every it's either dark black and there is white. And the muscles in the type of sequences that we do, they appear as black, and so it's a nice black contrast. We know that fat and water is kind of white. So when we look at other individuals, their muscles, you can see the contours, but the inside start to have little white speckles into it, meaning there is fat into it, meaning that their muscles aren't going to be as strong as someone that's young, and that's that's expected, and we see that in other parts of the body. But what we are interested in knowing is like, okay, so now if someone has prolapse, is this change because of their prolapse, or is this change with age? And then the prolapse got worse because there is changes that are ready with age. So it's like, what's the normal thread trajectory without injury and then with injury? And then I think another important concept is that for some people, so when they are having a vaginal delivery, the baby goes through their birth canal, which is basically babies in the uterus, the cervix opens, meaning like dilates, that's like the dilation we talk about during childbirth, and then the baby needs to go move through the vagina out. And around the vagina, there is this muscle, which are called levated ani muscles. It's like a U shape, it goes behind the vagina and holds onto the pubic bone. And when the baby goes through it, they need to stretch about three times their length, meaning that if your arm would stretch three times, and then a couple weeks later it would go back to its original size. Yeah. So that's what happens to your pelvic floor. And we know for some people that either because their muscles don't stretch well or they're or they are already small to start with, and they have a large baby, so they need to stretch more than three times, and their muscles can like withstand that. So they kind of break. And when they break means that they detach from the pubic bone. So now people have less one muscle. And right away, some for some people they can feel right away that something is wrong and that they like that they're like something is missing, but for a lot of people, they don't really feel it, and they will only notice it later, 10 to 20 years later, when they develop prolapse. So when we say that everyone should do kegels, it's not gonna work for everyone. And that's and why? Because the kegels is you moving this muscle and you contracting this muscle. So if your muscle is not there anymore on either one side or on both sides, or let's say instead of having one full muscle, you only have 25% of a muscle. When you do kegels, your kegels are not gonna be enough because the muscle that is the kegel muscle isn't there. And so a lot of people are like, I do all my kegels and I do religiously do my kegels, but nothing happens. Well, maybe because unfortunately, you have a major injury to your muscle, and that isn't really anything we can do about it right now.

SPEAKER_02 19:44

Yeah, and I again, even just acknowledgement of that, I feel like is such an important thing for people to understand because when we talk about um tearing, for example, I think most people think of perineal tearing, and it's never discussed with them in any meaningful way the possibility in delivery of a muscle tearing away from a bone or tearing in any other aspect other than that parent, you know, that that opening. Um, I don't think it and I'll be honest, I mean, the evolution was even such a I guess because we didn't have a way to necessarily diagnose it, um, it wasn't a part of my initial training at all. And the hard part now is even if we diagnose it, what are we going to do about it? I know there's some doctors come trying to work with PRP and things like that and see if that helps at all. But again, just the acknowledgement that you can have a tear. And I think people understand that concept in other parts of the body, like if you have a rotator cuff care or something like that. I think conceptually people get it, but it's it's not, I think, normalized enough in in or even introduced as a possibility, which I think why it kind of adds a little bit to the trauma on the other side of women being like, well, no one told me that this was a possibility.

SPEAKER_00 21:11

Um it's like 16 to 30 percent. So it's like different studies have like different um uh like percentages, but a lot like 15% is like it's always like yeah.

SPEAKER_02 21:26

Well, and and again, I I think back to um kind of explanations that we have tried to provide. Um, I think we've been more acknowledging as physios of the possibility of um higher tone public floor muscles in postpartum. And I would be curious as to correlation between um as as like a management strategy if there's you know an incidence of avulsion and then the the the brains trying to find some way to to make up for that. Is that why we're seeing, you know. An increase in tone or something like that. I had a lovely conversation this past year with Linda McLean. And she's like, you know what? Sometimes you don't necessarily know the right reason, but your intervention works. That doesn't mean you have to throw everything out. And I was very appreciative of that because again, there's all these things, again, like evolsion. We, we, this is not something that we were taught. It's now on our radar screens and we're trying to figure out our narrative around it. What are the things that we're saying that we had explanations for that actually was related more to an avulsion? How can we get better at kind of diagnosing it clinically? Um, because we don't all have an MRI in our back pocket.

SPEAKER_00 22:47

We we have a study that showed that actual palpation correlates very well with um with our MRI findings, findings, but you need palpation to be taught by the right person, right? And there isn't that many people that know how to to thought how can they teach it. And so that's one of the issues. And then like asking someone to contract their pelvic floor is like asking, oh, can you raise your eyebrow right eyebrow three times? And it's just like, well, I can't do it for more the more I try. And like, and it's just like it, it's it's just so hard because it's not like okay, I can actually visualize when you ask me to okay, can you put your hand to your elbow, like to your shoulder? It's like, okay, I can understand, even I don't know what parts it is, I can look in you and do it. But the pelvic floor is just like you can't see it, so it's really hard to look roach in.

SPEAKER_02 23:38

Well, it it again, it also it makes me think back to some of the research that we do have. Um, I mean, one of the things that we were always given as guidance was that, you know, the certain percentage of people um they don't know how to do their pelvic floor muscle contractions correctly. And so that's one of our roles as physios is to instruct this. But, you know, it's one thing to kind of talk about that in norms, but it's another if you do have somebody that had some sort of pelvic floor injury, if we go back, you know, years ago when this research was done, was was that a consideration? Were people with avulsions diagnosed and you know not included in those studies? Like it just makes me kind of think that we're gonna have to rethink some of the things that we might have thought for a long time, but that I kind of understand clinically, like there are some people that really they cannot connect and I don't spend time on it and we just move on. But then there's other people um that again, maybe it's something else. Maybe it's so I again, I don't know. I I think the more we kind of understand about that area, I think a lot of our assumptions and how we looked at it really just need to change. Um, I don't know, what do you think?

SPEAKER_00 24:46

Yeah, totally. And I think like I think people now are like, okay, evolution does exist. And we're like, okay, we moved at step four because maybe five years ago, people were still questioning that the bulsion existed, but we are still seeing pushback on why evolution happens. So there is like some confounding theories. Some people say it's because the baby put pressure on the muscles that babies have, and then the muscles lose uh supply, uh like blood and um neural supply, and that's why they then uh degenerate. Uh well, we have enough evidence to show that it's for some people that does happen, but the main reason why overshin happened is because you stretched it out too much, and that's why it's it ruptured. And we when we look at MRIs from someone that actually lost one of their levator, one of the sides, because the elevator is a muscle that it crosses the body, so there is a right side and a left side, so there's actually two levators that connect behind your vagina into what's called a perennial body, which is that region between the vagina and and the anus, which is a really important component, because that's where everything kind of joins there. And very interestingly, we don't know how why, and we don't know how it's made of, and we don't know what works, and people give it a lot of importance, but we still don't have enough evidence of like, okay, what's actually part of it? And is there anything we can do to try to make it more stretchy? Is there anything we can do to try to help it stretch more during childbirth? So that's a very interesting point. Um, yeah, so there is still a lot of conflicts in the in the scientific community about why um elevator injuries happen. And so that's a lot of work we are doing and show we have enough evidence from all these MRIs and all these computer studies that show this is why it happens. And like, can we move on to a different issue?

SPEAKER_02 26:43

Yeah, no, it's I I I mean, just sitting here now, I'm trying to think of all the variables that might be involved, um, you know, any genetic predispositions, collagen makeup, those sorts of things, even before you get to, you know, muscle strategies, that how people have used those muscles. Um, then you get to pregnancy and, you know, is there any change as far as um impact to those muscles and structures because of other musculoskeletal issues? And then then you get to okay, the actual physical impact of that growing fetus. And um, I had a patient ask me the other day, and she's like, this is gonna be a silly question. She's like, so somebody told me that our baby or our bodies wouldn't make a baby that it couldn't deliver. And I just I was like, wow, okay, like I it doesn't work that way. Because basically, guess what? You'd die.

SPEAKER_00 27:44

Yeah. Yeah, totally. So, like we we we we we have this theory and that's called capacity demand. And um capacity meaning your pelves is just so big, right? It has a size, and what we call your hiatus, which is like the soft tissue. So, like you have uh we have two hiatus, but we can think about it like the distance from the if you look at someone's vulva from the top to like the bottom of the their vagina, and your baby needs to go through that. That's the smallest loop it needs to go through. So let's say it's normally it's measured about two centimeters in someone that's not not delivering. So in someone that's not that's pregnant, it's about to live a baby, it's about two to three centimeters, but then you have a baby's head that's about ten centimeters. So that piece of tissue that during pregnancy already stretches a little bit and a little bit, then in those hours between someone tells you, okay, you are fully dilated, so the actual baby comes through, it's about let's say one to two hours, that that the those tissues need to stretch so much so that this baby can go through. And so the the size of the mom's pelvis is the the capacity and then the demand is how big the baby's head is. So if you have someone that is always very uh already starts with a little bit larger um opening, even if your baby's a little bit larger, it's gonna fit easier than someone that's has a really tight opening and has a large baby. And so uh anecdotally, like some people we work with say, like, oh, we are we always like to know the size of the mom and the dad, because if you have a really big dad and a small mom, it's like it might probably gonna be difficult labor just because the baby genetically tends to have a bigger head. And so um it's it's both like what's your initial size, like how how what's your initial size to start, and then also like can your are your muscles stretchy or not stretchy? Because if you have someone that is a small pelvis but they can stretch really well, that's okay. But if you have someone that has a big pelvis but they don't stretch, that's still a problem. So it's very there is a lot of of confounding um issues here.

SPEAKER_02 29:53

Yeah, I feel like we need to have like a sample group of women that had no birth injuries. I my my neighbor across the street had three kids, they're all teenagers now, and she doesn't know why I have a job because she just had a really easy time delivering her kids and just cannot relate at all. I'm like, we need to study you, we need to understand what isn't about you.

SPEAKER_00 30:16

So easy is also like, oh, I leaked a little bit of B all my life, so like, oh, I now I look right at being it's like it's it's normal. And yep, so there's a lot of that as well, which is it's it's very interesting. I think it's like first it's a very taboo issue because women have it, right? Then they have it when they are uh like like perimenopause, menopause, when they like they already most like boom, like the time they wouldn't be in the workforce anymore, so it wouldn't be really an issue. And so like now millennials are coming, it's like, well, I had a baby, now I need to wear diapers, it is not normal. Can some why does not no one know do anything about it? And we're starting to see all this funding to women's health, we're starting to see a lot of these new companies pop up. But I think an important aspect as well is like we're starting to see so much awareness now that so many people are coming up with ideas and saying, Oh, my probiotics are gonna solve your pelvic floor, or my device does this and it's gonna solve your pelvic floor. Mine, and it's just like we still need a lot of it's like we have been trying to do that for 20 years in a lab, we haven't been able to do it. How like maybe we should uh understand better how things work. And I see that that some like a research lab, okay. We have we follow scientific method, we have slow progress, but it's also like we try to make sure that the foundational knowledge is here, so then when new innovations come, they are actually based on anatomy and biomechanics, and we know that they're supposed to work and how, so then we can actually help uh improve people's quality of life.

SPEAKER_02 31:56

Yeah. No, I mean you you mentioned kind of hormones and perimenopause and that sort of thing. And obviously, we're getting a lot more information out now and and and much more open to conversations about hormones. I mean, that piece alone, the impact on you know, estrogen on tissues, I think for so long, my uh, you know, physios, we we we have, you know, created the problem of relaxing, quite honestly, when actually, you know, okay, relaxing a little bit, but you know, estrogen really does impact um tissues far more than people realize. And again, with that one, even just wrapping our heads around the fact that estrogen is so much more than a sex hormone, you know, it's in so many tissues in our body, it's in our brain, it's in our gut, you know, tendons, all those sorts of things. Um, again, I think it's just we're we're kind of ready to walk away from that oversimplification and really get a much better understanding. But with that, um definitely I think our field is working towards preventative measures and like, are there things that we can understand um to reduce risk of birth injuries and things like that? And you you did a little bit of work on that kind of um understanding prevention of uh pelvic floor injuries at birth in a paper this year. Can you tell us a little bit about that?

SPEAKER_00 33:15

Yeah, so my like my PhD work was on injury prevention. So, what does that mean? So we know that um the mom has a certain size pelvis and you have a certain size baby, and that's a very important combination. But then also knowing how much someone can stretch their pelvic floor tissues is important. So um I used data from a clinical trial that has has been published this year, and um they stretch the pelvic floor before during labor, right before the baby was coming, with the goals that like if we pre-stretch the tissues, then it's like you go to the gym, you exercise, and then like you probably when you go and like you're not gonna do your PR weightlift right away, right? You start with five pounds, ten pounds, twenty pounds, and so so if we stretch your tissue pelvic floor tissues, then when your baby comes through, it's probably easier because they already know how to stretch. And from a mechanical perspective, when we know how much something stretched and how much force was needed for this to stretch, we can actually use equations, so we can use math to try to quantify that. And what we found is that, like, in just a little bit, a really small amount of time, we could actually see, and okay, this person stretches a lot, and this person doesn't stretch. And so meaning that if we can do that in a small test, then it's like much easier for us to uh also use it in clinical practice, like, okay, could we actually do this? And someone would know, okay, it's easy for you to stretch your pelvic floor, so that's great, or if for other people, it's like, oh, actually, it's really hard for you to stretch your pelvic floor, so we should do other things.

SPEAKER_02 34:51

Yeah, and I I think that's incredibly important, um, not only for us as physios, kind of helping uh patients kind of understand what to do next and how to prepare, but I think it's it's also important for moms to know, because especially first-time moms, they want to do the you know the right thing. And this may be one of the situations where they have the capacity or they may not have the capacity. And so when you have only a certain amount of time and resources to spend towards prevention, um, can we be better about triaging who's going to best benefit from that versus somebody that might do it and they're not actually going to benefit from it much at all?

SPEAKER_00 35:29

Um, totally. Because for some people, you are born with muscles that don't stretch, and there is like absolutely nothing we can do about it. At this point, maybe in 10 to 20 years, there is drugs that we can do and help stretch muscles, the same way we already stretch um the cervix, like someone that their labor needs to be induced, they are given drugs and their cervix expands so to allow the baby. So, but we don't know yet. We the thing is, since we don't know what's normal, we can't quantify it. People don't think it's important, so there is nothing we can do about it. So the first step is find a way to quantify it. Because when you give a number to something in medicine, it becomes relevant.

SPEAKER_02 36:05

Yeah.

SPEAKER_00 36:06

But we are at a point like we are still in a step behind, like, okay, we know that this will be important, but we can't measure it. So how can we measure it?

SPEAKER_02 36:14

Yeah. Well, and and I feel like the pendulum almost has to swing both ways before it can settle in the middle because um you need to have people trying to stretch to see, okay, who's it going to make a change in and who isn't? Um, but I also at the same time, I think there needs to be a little bit of a disclaimer. It's like, hey, we don't know this because a lot of women, again, oh, I stretched, I did all the things, I did all the right things, but I still had this birth injury. And then there's a lot of self-blame and guilt and things like that. When if you go back and look kind of genetically, they might never have responded to that. So again, I feel like it's it's we've got to put that information out to to at least get a good sample of what's going on and see the effects, but also with that disclaimer of we're we're still learning about this. I cannot promise you that if you do X, Y, and Z will occur. And I think that's really hard again for people that they they want to check the box and do the thing and get the ultimate result, which I always I joke half-heartedly that like that's kind of parenting though. Like you're gonna put your best foot forward and do the best you can, but you can't really promise what's gonna come out. At least not yet.

SPEAKER_00 37:25

Yeah, totally. And it's also like I think we also think as pelvic floor is like the same thing we think as a bicep. Okay, so if I go to the gym and I lift weights every day, yeah, over time you will be able, yeah. Everyone is gonna be able to increase their PR, right? But for some people, they can increase their PR like from the start day they start till three months later, they might increase 10%. For some people, they might increase 150% how much they can lift. And it's the same with the pelvic floor, but you need to add the thing that you don't really know how what you're doing because it's really hard to actually know how to stretch your muscles or and also like contract them. And then it's just like it's it's the same as when you go to the gym. Some people can do a lot of progress, some don't. And knowing that like showing up and like knowing that your your your your pelvic floor has these things and that what's feels good and what doesn't feel good is already a very big step forward. Because then if something does happen during childbirth that there is some injury, you will be much uh more prone to actually seek uh PT and other interventions if needed, so then you can have a better quality of life. But unfortunately, at this point, there isn't really anything besides surgery that can be done, but then surgery has all these other complications, so yeah, also fails in a lot of people because we are trying to fix different diseases with all the same approach, so of course it's gonna fail.

SPEAKER_02 38:53

Yeah, and yeah, yeah, so it's kind of definitely too. Right, we've got a lot to fix. Well, and I'm also thinking of too those um the C-section moms that you know somehow grasp their head around the idea that a C-section is preventative of pelvic floor issues. And um, that's not necessarily true. You may have, you know, still carrying that baby and having that pressure in that area, even if you, you know, don't have a vaginal delivery or get to to push or things like that. Um, there's still an impact on those tissues. And we we haven't even begun to try and to to quantify that. We're still trying to wrap our heads around, you know, uh vaginal birth injuries and whatnot. So it's no, go ahead.

SPEAKER_00 39:36

No, I got it. You're good. Oh, I was gonna say that for people that have C-sections, but they did need to go through active labor and push for a little bit, they have the worst of both worlds because they might still have a pelvic floor injury and then they have the recovery of a main surgery. And so it's just like it's very complicated. So you really try to avoid those to happen in the first place. And like one of the reasons, there is many reasons why c-sections need to happen during labor. And one of the reasons is also like if your muscles can just cannot stretch, there is no way your baby is gonna go through, and everything works fine, and your baby starts to descend, but they hit uh not a wall, but kind of a wall, like they don't go down. Yeah, that might just be because your muscles would not stretch, and so then you need to have a c-section. But if you knew from beforehand that your muscles wouldn't stretch, you could avoid going through that difficult labor and just go, like, this is not never gonna happen. Let's just go to a c-section. But yeah, I'm not advocating for c-sections, I'm just saying for very specific purposes that there is some individuals where you could make it in a safer C-section.

SPEAKER_02 40:43

No, and and I'm I'm nodding and smiling because that was very much my my oldest son. Um three-day induction did get to push. Um, I think I pushed for like two and a half hours, and then he just wasn't going anywhere. And then um he wasn't recovering because you know, we've been doing that for a couple of days and ended up with a C-section there. With um my daughter a couple of years later, very much had the conversation with my provider. I said, look, you know, we can try a V back, but I don't want to go through that whole thing again because you're doing the better part of two deliveries. And that's where I mean, that's where, you know, a lot of my stress incontinence came from, prolapse symptoms, things like that. And um, I don't wish that on anybody because it's really hard. Number one. But yeah, I would have loved to like had a little risk analysis ahead of time to say, hey, um, because again, if if you have a little bit more of that objective data, and I'm not saying we have the capacity to have those conversations yet, but but where are, you know, the where those conversations are going is, you know, I might have a client with a history of um certain things, like a history of hemorrhoids or a history of leakage or high tone pelvic flora, things like that. You know, we don't have the data yet to be able to say, hey, if you have these things, you might be more likely because I've had just as many patients go either way, you know, they they came in for painful sex and high tone, they were able to conceive and actually had a great delivery. And then I've had others that just haven't. Um, you know, can we take some of that subjective information in that presentation? Can we translate that to math that you're talking about? And can we pull together some sort of predictive um algorithm to say, hey, this is maybe when we could give you a better odds of this is going to be this way or this isn't? I think also the part that has to come. I have so many patients that they're told that their baby's big and then they have the baby and the baby's perfectly average. We need to be better about measuring that too. But I would hope someday I would hope for my daughter to be able to have a little bit more understanding of the capacity that her body has in a realistic sense and not just this over-generalization that everybody can do it. We've been doing it for thousands of years. And then when it doesn't work out the way that you planned, then you look at your body as a failure. And that's where, you know, I'm so appreciative of I told you before we started, I think women and STEM are going to save us. Like there has to be a math aspect to it. There has to be this very black and white understanding of capacity that is aside from this assumption or this societal expectation that we're we're women, this is what we were built and born to do. When in some cases, maybe not. And that's okay too. Um, so yes, women and STEM are gonna save us.

SPEAKER_00 43:48

No, I I totally agree. And I think an important concept as well, like, is like people are having children much, much later in life. And just because we are giving babies later doesn't mean that that's that's the reason. Why now we need to suffer from pelvic floor dysfunction? Yeah. Um, we know from our MRI studies that at about 33 your risk for injury is much higher. And we also know from this data from like how stretchy our pelvic floor is, is that the pelvic floor of people below age 30 is much stretchier than those above age 30. So those those odds don't work well when the average age for first child is like 30, right? So yeah, that's not great. But so what can we do about that, right? And so I think it's very dependent on someone specific. So let's say you are having your first baby, but you would like to have more than one. So maybe a like c-section is really hard and bad when you want to have more than one children, child, because there is gonna be issues associated with having a previous C-section, right? So that's you should probably always try to get your vaginal delivery. But let's say you are 45 and you're gonna have you are like, I'm gonna have this one child, and probably never gonna have another child, your risk of pelvic floor injury is really high. It's like what do you want personally? Is having a vaginal delivery very important for you? And as your construct of birth, or do you think that being able to trying to avoid pelvic floor injury is sufficient reason for you to have a C-section? And I think those are individual conversations that need to be had between providers and patients, but because these conversations are not yet based on data, right? It's so subjective that it's it, yeah, we need to bring information to the table. But to do that, we need two ways to measure it. And that's where science and research comes into place. Okay, can we have a way to measure this?

SPEAKER_02 45:43

Well, and and I'm thinking specifically, my population here in in the DC metro area. My average first-time mom is 38 to 42. Um, we're we're a little driven down here, everybody, you know, very career oriented. Um, and again, that that's kind of a setup too, because they've been able to control everything in their lives up to that point. Um, I would I would love to be able to have knowledge and data because I think they'd be very receptive towards it. Um, because we have those moms that have been told that they are less than if they are having a C-section, they are less than if they are using an epidural, they are less than if they have tearing, um, and they've never been less than in their entire lives. So could I provide them with some sort of logical mathematical data to say, you know, if you don't want to have issues or if we want to reduce that risk, here are some of the things that we understand about you specifically in front of us right now. I would love that because I think they would be incredibly open to it.

SPEAKER_00 46:45

Um I think currently the only evidence and so we will look at this a lot from public floor perspective. Um, so take this within a great nose salt and understand my biases. So there was this really big trial called Arrive, where they did elective inductions at 39 weeks, and they found out that the level, the number of C-sections and the mortality and morbidity was all the same. There was no difference. And so this one group went, okay, so looking at these individuals from our hospital that did went through this trial, that let's look at their rate of pelvic floor dysfunction, levator evolution, complaints. And those that had a baby in the induced 39 weeks at much lower rate of pelvic floor dysfunction because their babies were slightly smaller, and so there is less strain on their pelvic floor. So when I delivered my 99%ile head baby, I was like, this needs to be born at 39 weeks, and I knew I I did that, and because like I was like, there is no way I'm gonna subject myself to having a full-term 99%ile head baby, right? And so it's like, but I did that because I had enough information and because I knew this, but like this is not publicly like it's publicly available, but it's not publicly accessible. And it's if we don't bring, give people this information that is based on science and has been measured and has been replicated, we we cannot like we we need to give people data so that they can make their own decisions, yeah. And I think that's it back to what you were saying is like if people don't have access to this data and information, then they can't make what's the best decision for themselves.

SPEAKER_02 48:29

Yeah, no, I mean it's and it's all fear-driven um because we don't want to do the wrong thing, and it's a very vulnerable position to be in. Um, you had a another paper I thought was really um an interesting uh title. It was uh differences in time of birth between spontaneous and operative vaginal births that you um was out with a group this year. Tell us a little bit about that.

SPEAKER_00 48:51

Okay, so this is very interesting. So this is a very big database of all the birds in the United States. And when you do your birth certificate, you tell what time the day your baby was born. And that is some where it also tells you, like, okay, there were instruments used, like meaning vacuum, which is they put a little suction cup on the baby's head to help pull it, or forceps, uh, which uh is like a little like kitchen tongues that you put around the baby's head and use to uh put pull the baby. Uh forceps are really bad for your pelvic floor. People that have had cervix uh that have had used forceps have probably like eight times more um probability of having uh pelvic floor injury. First, forceps were already used uh like in the 60s, 70s, 80s, so that's why we see so many older individuals now having pelvic floor dysfunction because they had forceps. People are trying stopping, trying to stop using them. Vacuum does about the same thing without so many injuries to the pelvic floor. Um but of course there are some situations where forceps still need to be used, and when you need to put the baby's life at risk for mommy's pelvic floor, baby's whips, right? So um, yeah, uh so that was a little segue. Um, so we looked at, okay, so if your baby is being born during the day, uh what time of the day, uh how many, how many normal vaginal deliveries there were, meaning no instruments, and how many deliveries with instruments occur during the day. And we saw that right before shift change, there was a very big increase in the number of instruments used to deliver the babies. Meaning that someone wants to go home at some point and they are like, okay, well, I waited all day for you to be born, you're gonna come out now, or they don't want to wait, like leave it, they don't want to get late, but they also don't want to leave that delivery for the next shift change. And so that means that there is a lot of education that can be done and resource allocation, and we need to look at this broadly. It's like, so why are people doing this a lot before shift change? And what can we do to avoid that? Because in the US, babies are born between seven and five, and in Europe, babies are mostly born through the night, and so it's like, why are babies in the US born nine to five? Like, probably like there is a lot of um resource allocation, and like, okay, baby needs to be born from this time to this time, and so yeah.

SPEAKER_02 51:23

That's gotta be a really interesting perspective that you have being from Portugal and then kind of working a bit in the states. Um, are there any other differences in that you've kind of noticed in not only maternal care, but even you know, access to postpartum resources like physio that are different?

SPEAKER_00 51:48

Um, I'm not really the best person to answer that question because like I went to the US when I was like 24. Uh like I'm almost 33, so I'm still in the US. So like a lot of this education about like, okay, I'm gonna have a baby, I'm studying and all that is a lot US-based, and also I don't really have uh like a really good understanding about how it works in other countries. I know the babies are born in in Europe during the night because there was a study. Ah, got it. Um, yeah, so it's it's just very interesting. And then, like, we in that paper we didn't even touch on racial differences and like differences on like uh zip codes and all of that. So that's also a big yeah.

SPEAKER_02 52:34

Well, and that was another one. Um, you you had quite a year with the papers that you pumped out this year. There was the other one that was a comparison of vaginal and labial dimensions of ethnic Chinese and Western Nolipera. Um, I found that interesting too.

SPEAKER_00 52:47

So it's like um, like we are in Michigan, right? Michigan is uh we are, even though we are an urban center, that's like college town, our population is still very white, especially for individuals with prolapse because the older individuals around are all white. Um, and so um we were like, okay, so we know the stature is very different between an average white young individual and an average age, like in this case, Chinese individual. And so we did them a rise and we actually found that the vagral dimensions on in the Chinese population were about 20% smaller than those um that uh of white origin. And and uh and and and that's important because like if you want to do some pelvic like intervention, you need to like be aware that something is going to be way smaller than this other population. And now the question is okay, how does it also apply to various other uh racial groups and also like so trying to to to one again understand the normal because if we say the normal is white, it's a very colonialist approach, but and so we are trying to change that and making it much more broad and so that you can have a better understanding of what normal means.

SPEAKER_02 54:06

Yeah, no, I I I think you know that that's almost sometimes the reverse of how how we're taught sometimes we're we're taught to handle all the the issues and the stuff after the fact. And and again, I think understanding norms is going to help us um reframe how we do preventative care and um and you know risk management and mitigation and and all that kind of stuff. Um, but yeah, I mean it they I I feel like there's again the fact that we we just talk about what like four papers or three or four papers that you had this year. I mean, that that just wasn't normal even five or 10 years ago. I appreciate that there's so many more women like yourself in research trying to ask these questions, trying to establish a baseline. Um, but it does, it needs to come from outside fields like mine and and leverage fields like yours where you're actually quantifying and trying to understand the literal black and white in numbers. Um, and then we can try and figure out kind of what this means collectively as we pull that information together. So it it it it's it's such a unique, I think, multifactorial, multifaceted area of the body. There's so much stigma around it. There's so many, like even just talking about the times of day that people are delivering. Now we're bringing in, you know, um public health and you know, social norms, and it's it's there's so many parts and pieces to it that you know, how can we chip away at this issue and and make things better for the women who are are having babies? Um, it's cool. I feel like there's always gonna be questions.

SPEAKER_00 55:42

There's always we need to say that it's like we we have plenty of questions, but we're also always very happy to help answer questions from the community. And it's like you have your clinical practice, you start to see patterns, even though you might not quantify and you are like, this person, I I feel they had this and this, and then this is the outcome, this other person and this other outcome. And like we we are always interested in helping providers that actually are in clinical practice, be like, okay, I would like to know why this happens this way, and then we can try to see, okay, we actually have these MRIs that can help answer your questions. We have this ultrasound that answer these questions, we have this other thought process that might help answer your questions because research cannot just be silent at the university in a research center, it needs to be applied to clinicians and it needs to be applied to the population. Because if we aren't making an impact in someone's life directly, then like we need to keep doing that and be grounded on that.

SPEAKER_02 56:36

Yeah, and it and it and it's a it's a very reciprocal relationship, I think, which which I think like conversations and being able to share conversations like this with so many people. We need clinicians to drive questions and we need them to apply research. And um, you guys need to provide us some guidance and and you know, all sorts of stuff. But again, I I think the more that um the average woman can understand um that this is complex and there's people kind of working on this stuff and we're we're trying to solve these issues. It's it's not that we know everything, we're not even remotely close, um, but at least do the best you can to surround yourself with a team that's as evidence-informed as possible, but very much taking that evidence and applying to you as an individual, which I guess that's the art of all this, um, is is we take what we know in our our black and white and our numbers and and our clinical experience, and we do the best we can um to kind of predict and and help pave that path forward. So so what's what's next for you? What are you what are you working on now? What's coming up?

SPEAKER_00 57:43

Yeah, so uh we always have lots of research questions. So I'm working on different research projects to try to continue understanding more about like these mechanical properties, like how can someone, why does someone stretch a lot and why do some other people not stretch? And so trying to keep working on that, supporting a lot of different projects in the lab, very interesting work with trying to understand when are babies born and and and how is that implication on injuries during childbirth. So yeah, very different projects and always looking for answering more questions. So if you have any questions, please let me know. I like that.

SPEAKER_02 58:18

There was one thing, I I think it was another group that was looking at um being able to 3D print um individual pessaries. That to me sounds so cool too. But again, it's also understanding and appreciating that three-dimensionality and where you know there may be evolutions and and you know, things that we've got to navigate and whatnot. Again, I I that that picture that I initially saw on your LinkedIn, and I'll pop your LinkedIn up here. Um, you had me hook line and sinker there. I was like, this is so beautiful. Like I the the fact that I I can't wait for us to conceptually move forward from this oversimplistic view and really just appreciate how amazingly complex um this area is, um, and then be able to support it in the best way possible. I think the more that that more people understand that, um, then we're gonna demand for um, you know, just better interventions and and better risk kind of understanding and and so on and so forth. So the more you know, I guess.

SPEAKER_00 59:28

Yeah, the more you know, and more questions you have, and then we get back at questions and questions. So exactly.

SPEAKER_02 59:34

That's why research is already trying to help address those questions. And and we appreciate you guys for sure. So if you guys want to learn more about Marianna's work, you can find her over on LinkedIn because she posts a lot over there, which I really appreciate. It's not my jam, but that's where she's she's putting her stuff, which I love. Um, and Marianna Masteling. Mariana, thank you so much for sharing a little window inside what you do and some of your research. And we can't wait to see what's coming up next. Thank you so much for having me. It was a pleasure. Thanks. If you're navigating pregnancy postpartum or perimenopause, whether personally or professionally, check out all our free resources and upcoming courses at carypagliano.com. This podcast reflects the opinions of Dr. Carrie Pagliano and her guests, and it is for entertainment purposes only and should not be considered medical advice. Always consult your healthcare provider with any medical questions. If you enjoyed the episode, please take a moment to leave us a five-star review on your favorite podcast platform. And thanks for listening to you.