They're not exhaling, what often happens is they're holding their breath. And then that pressure, that tension doesn't have anywhere to go. So it goes towards the path of least resistance, which is the diastasis. If you have diastasis recti, or it goes towards prolapse, which is the bottom of the barrel parent pelvic floor, there's actually a really funny article. It's actually not funny at all. But it's a really interesting article about how many studies and it's in the 10s of 1000s have been done on Viagra and erectile dysfunction versus female pelvic pain and painful intercourse and women and it's like it's an under addressed under researched under funded issue. It's a really common experience, but there's so much help for it so that you don't have to just tolerate it I hear so often I can tolerate sex like sex should be enjoyable, not just tolerable.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, everyone, I'm Sarah Reardon, a pelvic floor physical therapist, wife and mom of two and also have an online presence on Instagram as the vagina whisperer. I am a pelvic floor physical therapist and have worked for over 15 years with individuals during pregnancy, postpartum menopause and all across a woman's lifespan, working on pelvic floor dysfunction which can span from urinary incontinence, painful intercourse, abdominal separation or diastasis recti prolapse and also just helping women prepare for birth and recover postpartum. I am so excited to be a guest here on the down to birth podcast and excited to dive into all things pelvic floor.

Well, we are very excited to have you Sarah, when we first started this podcast, you were one of the very first people that I targeted as we have to get her on the show. I think your your Instagram page is just your name is fabulous. I mean, who wouldn't want to know what the vagina whisperer knows? Why don't you start by telling us the most common issues that you see as far as post birth, what women are experiencing what they are suffering with and what can be done?

Absolutely. So I think just to even take a step back, and if someone isn't even familiar with what is the pelvic floor and what is a pelvic floor physical therapist, I think it's really helpful to just understand the part of the body that we're talking about. So when I talk about pelvic floor muscles, there's actually a basket of muscles that sit at the very base of your pelvis. And they swing from the pubic bone to the tailbone front to back and side to side. And they sit like a hammock and these organs help support I'm sorry, these muscles help support your pelvic organs like your bladder, your rectum and your uterus which holds a growing baby, or babies. These muscles also have sphincters that hold in urine and stool throughout the day. And then when we want to use the restroom, they relax for us to empty and these muscles also have the vaginal opening for vaginal birth for menstruation and for vaginal intercourse. So these are really important functions. And again, we don't talk about this part of our body often. But yet the role of this part of our muscles in our body is so important. When we talk about pelvic floor dysfunction, it's really when one of those systems may not be working well which can lead to urinary leakage or fecal leakage, which is the loss of stool or gas. It can lead to painful intercourse, which actually one in four women will experience at some point in their lifetime. It can lead to prolapse, which is when your pelvic organs are not as supported by that hammock as we would want and it gives us sensation of something falling out, or pressure, heaviness in your pelvis or urinary leakage or incomplete emptying during bowel movements. And then also which we don't think about often connect to the pelvic floor is your abdominal wall and your abdominal wall and your pelvic floor are actually part of your core. We talk about our core lot with respect to our abdominals, but your pelvic floor is the very base of that core. So another condition is called diastasis recti, which is an abdominal separation. That can often happen after pregnancy as well. And I always use this analogy of you know that pelvic floor is the hammock that helps support a growing fetus in the uterus and we get these emails throughout pregnancy that are saying your baby's the size of a blueberry then it's the size of an avocado then it's the size of a pumpkin. Well we think if we think about a hammock, think about a hammock holding a blueberry or or an avocado, it's probably not going to change that much. But if a hammock is holding a watermelon or a pumpkin, that's a significant change to that hammock where the muscles are stretched, the ligaments are, they're being required to do more. And so just pregnancy itself can change our pelvic floor. And I think often, even if a mother gives birth via cesarean section, we think, Oh, her pelvic floor is spared. However, it's just pregnancy itself that can actually change the pelvic floor function. And then in addition, because the abdominals and pelvic floor connected to Sarah and birth mom has also may have some pelvic floor changes as well.

Exactly.

I believe in an episode that we did way back in the very beginning with another pelvic floor specialist, Tara Gibson, we she talked about how it sometimes in C section birth, that can be worse, because you've actually cut through so many layers of muscle and tissue. And depending on how the healing process goes, it can really impact your lower pelvic, your pelvic floor, not just your abdomen.

Right, right, absolutely. And we think about a cesarean birth, I mean, that's major abdominal surgery, they cut through a lot of layers of skin and tissue and fascia, the muscles are separated. But after a surgery, we don't just pop back up and kind of start doing our day to day. And I think this kind of, you know, is a bigger issue in our health care system or just about postpartum care for mothers in general is that there's just not enough of it. But especially after a cesarean birth, there's just very little guidance or kind of acknowledgment about how do we help these moms really recover?

So we open to the episode by talking about you've mentioned four major things, prolapse incontinence, painful Sex and the diastasis recti. Can we just sort of run through the list beginning with prolapse, and you can talk about how a woman would know that she has that how common it is. And then we'll talk about ways that we can prevent all these things and what to do to treat them.

Absolutely. So going back to the function of the pelvic floor is a supportive structure like a hammock prolapse, again, is when the pelvic organs are not as well supported. So maybe that muscle gets stretched out. And it can lead to the bladder or the rectum or the uterus or service kind of pushing into the vaginal walls. People used to say like it's your bladder is falling out. And it's not your bladder is not falling out, it's pushing into the vaginal wall. And that vaginal tissue is kind of descending and is more visible or palpable. So sometimes people feel this if they're taking a shower, and they kind of start rinsing the volver area, and they feel like there's a bulge there, or they feel heaviness or pressure in their pelvic floor, it typically gets worse towards the end of the day, because gravity plays a role. All of that pressure just kind of adds up over the day, and they start to feel heavy and achy. And almost it's like you want to take your hand and like hold your vadra because it's just heavy. So again, it's a common experience. But what we can do for prolapse is there's several things is one, stop straining. So if you are straining bowel movements, make sure that you're targeting constipation and having easier bowel movements. If you follow me on Instagram, you know, I am an evangelist of the squatty potty, which is a little stool that you put under your feet, you can use a toddler stall, you can use yoga blocks, but it just helps put your hips in a position to better relax for bowel movements. So you don't have to strain. Also not power peeing, which is when we sit on the toilet and push really hard to empty your bladder. I know moms, including myself, were notorious for trying to rush through everything. But when you sit to pee, you really want to just relax your pelvic floor muscles and let your bladder do the work to empty and then also strengthening after birth. I think that, you know, again, we just go back to our day to day activities of taking care of our other children or going back to the gym. And so these muscles have been stretched and lengthened over the course of pregnancy. And then depending on if you push during birth, or you experienced a perineal tear or pz Atomy. We want to make sure that we strengthen rehab those muscles to better support your organs to minimize the risk of prolapse.

Would you say that it's safe to say that all women experienced some amount of uterine prolapse after childbirth, and that it's just to the degree of severity depending on your symptoms, post birth whether or not you need more aggressive intervention, or just over time, it sort of repairs itself.

So there's a couple of things I would say that it's not the data is really variable where it's somewhere between like 40 to 70 something percent of of moms, postpartum women experience some degree of prolapse. And it's not typically the uterus, it could be the bladder, it could be the rectum. However, what we're finding is what we call a grade one prolapse is kind of considered within normal range. So that's really where your organs is still supported. They're above the hymen or their vaginal opening. And you can kind of function without leakage or constipation. When we get to what's called a grade two, which is a little bit lower and kind of just to the vaginal opening, we start being concerned with like, Okay, we really, this could only get worse with time if you don't address it. it. So I wouldn't say it's normal. But I would say it's common. And I think we also have to look at how long did someone push at birth? How many kids have they had? Do they have a family history of prolapse? Do they have a history of constipation. So all of these are risk factors that I would say play a role into whether someone's more likely to experience prolapse in their lifetime.

It's pretty common for women to experience some amount of changes in their urinary function after birth, at least for a short time. So for the woman who is experiencing a little bit of leakage after birth, how do you speak to her about whether that is normal or not normal? Is it going to self resolved? Does this mean I have prolapse? What does this mean for me?

Right? So I typically say the general rule of thumb is if at three months postpartum, you are experiencing any symptoms, whether it's prolapse, heaviness or pressure, whether it's urinary leakage, hemorrhoids, or constipation, painful intercourse any symptom, it's at three months, the data really shows that you're more likely to still be experiencing those symptoms at 12 months postpartum. So I want as a pelvic floor PT, my life dream is that everyone gets a postpartum pelvic floor, check in around six weeks, just like we would with our physician or midwife or medical provider that everyone gets a pelvic floor check in. But also, just if you're not able to make that at 12 weeks, if you're still experiencing symptoms, I would proactively check in with a pelvic floor physical therapist, the reason that incontinence typically occurs is when those sphincters that are kind of openings in the pelvic floor muscles are just not closing as well. So that could be weakness of the sphincters. It could be also scar tissue at the perineal opening from a perineal tear on a PC Atomy where that tissues kind of stuck in scar tissue is an allowing kind of better contraction of that muscle. It could sometimes even be tension. A lot of you know people after birth experience pelvic floor tension, it's almost like a muscle spasm or tight muscle where their muscles are trying to squeeze and they're kind of stuck and not squeezing as effectively. So it's not so blanket, it's like everybody, just two key goals. But again, I think checking in to say like, what's the cause of this? And how do we address it because it typically will not resolve on its own if at three months, you're still experiencing it.

I couldn't agree more with your dream that everyone would go see a pelvic floor specialist because it there's so much silence around it. Women are so afraid that there's something wrong, they don't know who to speak to. It's been my dream, which I think fall short of yours. And it just occurred to me it falls short of yours. But my dream has always been that obstetricians and midwives would know more about the pelvic floor. I mean, they their bar is so low, to just say You're fine, you're in the clear, and these women are going home and there for months. They're they're having embarrassing situations. They're experiencing pain, they're having painful sex. I had a woman in my postpartum Group on Tuesday, who within five minutes of all of us convening, she just started to cry and said, I think I need to have vaginal surgery, everyone because of prolapse. And she talks about feeling ashamed and being embarrassed in front of her husband. And you know, it's just unbelievable that she too, just got the clearance like you're good to go. I guess my question is, if someone does start seeing a pelvic floor specialist, is there still a point they sometimes need surgery for this? Can you talk about that?

Sure. So let's take a step back and touch a little bit more on prolapse. And I think that there's two things with prolapse, it feels kind of scary, like, oh my gosh, my organs are falling out. And again, it's not uncommon. But I always say that our bodies give us information, right. And so if you're experiencing prolapse, it's information that your pelvic floor muscles may not be supporting you as well as we would want, that the tasks that we're asking them to do is maybe too high for where they are. So that may mean heavy weightlifting or high intensity exercise, like running or even lifting heavy, you know, kiddos when our pelvic floor has not been rehabbed to be able to sustain that. So I think we want to look at how is the muscle functioning, but will also are we asking it to do too much when it's not quite ready for that? What we do when we see pelvic when we see patients in the clinic for pelvic floor physical therapy, is we you know, we go through a battery of questions of, you know, let's ask about your urinary function and bladder health, your bowel function, your exercise habits, what do you do for work? Who else is in the home? Do you have help with the other kids? What are your goals, you know, someone being maybe experiencing leakages and they're like, actually, I'm more concerned about painful intercourse and the leakage. So we want to make sure that these plans are really individualized. And we also want to stress that there are things that you can do, you can work on pelvic floor strengthening, which part of that includes key goals, but if you just sit at the stoplight in your car and do key goals all day, that's not going to be what helps you we need these muscles to function during the tasks you're asking them to do. So lifting your kids doing jumping jacks, you know, lifting that box Costco groceries, running. So all of these things, we really need to train our muscles to a much higher level as we would any other sport that we do in life, but also looking at how can we modify the things that you're doing? Is constipation an issue? Are you power paying, you know, things like that, that we're trying to really dig into? What can you start doing now to help. And then, you know, typically we see patients in our clinic, it could be three to four sessions over the course of a month, it could be, you know, six to 12 sessions over the course to three to six months, I would say I see most patients between three to six months, they come in either once a week or once every other week. And we really try to work on what they're doing at home that can help. So exercise is part of that minimizing straining, and too much pressure is also part of that. And then also, we may not get a patient to where they need to be I mean, we can't guarantee everyone is dry and continent. So if they are still experiencing symptoms do or do they feel like they're ready for surgery is surgery, something they want to consider down the line, we do recommend waiting one year post birth or post breastfeeding, for someone to consider pelvic floor reconstruction, and that they're not planning on having any other children after that.

Can I just ask a question that goes back a little bit to the what you said about asking, Are we asking the pelvic floor to do too much too soon? How does a woman know that she's asking too much too soon, you had mentioned vaginal heaviness of feeling like you want to sort of like put your hands in there. And you know, give yourself some support. Also urinary incontinence and leakage. But is there anything else? Is there anything else that women could sense about their body that would tell them hold on take a step back? This is too much too soon?

Right? I mean, I think unfortunately, our system, our society is set up that most postpartum women are doing too much too soon. I mean, the research shows that almost 25% of women go back to work within two weeks after giving birth. I mean, you're still bleeding. And so it's just the reality of our system, our society that this is, unfortunately, where we are, really, that's very first week, try to rest as much as you can, I know that there's a lot of pressure to be social or attend things. But really just giving your body that really early time to recover as much as possible, let some of those tissues kind of draw back in, hydrate yourself, have your first bowel movement, you know, increase your fluid so that you can, you know, help your milk come in or recover from the blood loss, but you're really recovering. And, you know, I have friends that are going out days later to events and they it's good for their mental health, but for their physical health could be impaired. So try to rest as much as you can, at least that first week, if not the second, and then start to tune as you get more active, start going for walks, you know, check in with a pelvic floor PT around four to six weeks, start doing some exercises to just reconnect with your pelvic floor and your core. And then it's really recommended to not go back to any high intensity exercise like jumping, running until 12 weeks postpartum, if you've strengthened. So some of it is symptom based, but also some of it is being proactive and saying, Can we just rest as much as possible, and do some early healing to prevent longer term issues?

So Cynthia, and I actually teach a fourth trimester workshop. And one of the things that we tell the women in that workshop is that they really should be staying in bed near the bed or on the bed for a full two weeks. Yeah, and that that little extra investment in rest makes an incredible difference in their long term healing.

It does.

I think another thing we forget that or we don't even think about, honestly, is that our pelvic floor matters our entire lives. It is not only the part of our body that is for having babies, I mean, long after we have babies, we still need a very healthy pelvic floor. So that makes recovery all the more important. Sometimes I think women lower the bar a little bit. Or I think sometimes when women realize they've had their last baby, they think they're in a livable, acceptable situation. So they just tolerate some weakness or inconveniences that they just figure they have to live with. But we really want to strengthen it now. Because it'll matter when we're old women still, right?

And I say we only get one, you only get one pelvic floor. So one I think it goes to you know, when you know, young women are hitting puberty or having their first menstrual cycle or having intercourse for the first time really educating them on pelvic health and kind of what's normal, what's not what can we do to prevent issues, but also I think that you know, when we encourage moms to stay in bed or I, I second that, but I also want to, I think that that does two things is one it gives people permission. It says it's okay for me to rest. I don't have to go back to my workout class within two weeks. It's gives them permission to take it easy and not feel guilty that we're not back 100% Two days later, unfortunately, we have other kiddos we have to take care of we may not have partner support available all the time. And then we have some people who have children in the NICU and they don't have the luxury of that. So, but what can we even do to just help with healing of, you know, giving them advice on how to ice their scar or ice or their, you know, vaginal flora afterwards, how to get out of bed, how to have their first bowel movement without training just those day to day things of still helping them minimize the risk of issues, but knowing that they may not have the luxury of bed for two weeks.

So let's let's talk a little bit about some of the practical things they can do like one, are there certain things that you tell women post birth? Absolutely do not do these things? And then talk to us about like, how to have a soft first bowel movement. What does that look like how to pee your first couple of times after giving birth?

Yes, I talk a lot about poop and I love it.

My volume, I said no one ever. No one ever and my two young boys love

that we talk about poop openly in our home? Like I'm sure they do. Right, exactly. So so but you know, when I talk about pooping, it's because if you have had a terrible first bowel movement after birth, that can be more memorable than birth sometimes. So some of the things I encourage folks is to get on stool softeners. Day one, whether you've had pain medication, whether you've had an epidural, whether you've had an unmedicated birth, take stool softeners day one and take them for two weeks is that a medicine? What exactly isn't that a stool softener is like something like cold lace, or it's an over the counter medication that just helps soften your stool, they will give it to you if you ask at the hospital, and then you can also get it over the counter at home. But what it does is, you know, you have a lot of blood loss after giving birth and you also are a lot of the fluid in your body is going towards making breast milk. So you tend to get dehydrated, which is a risk for constipation. And if you've also had surgery or pain medication that also slows your your bowels down. So we just want to get that stool softener and hydrate as much as possible. The other thing, which we already mentioned, is getting a squatty potty or using a stool under your feet to help put your pelvic floor in a more relaxed position. The optimal position for pelvic floor relaxation is squatting. So if we think about you're in, you know, East, Asia, or you're camping or wherever, people used to squat to have bowel movements, because it's the physiological optimal position for pooping. So putting a stool under your feet so that your knees are a little bit elevated. It's how we do it. It's how we do it in the woods, right? It's really your potty. That's what you do. That's what you do. But honestly, Sarah, should all women be doing that all the time should all the time, I actually have a stool in my downstairs bathroom, from the time that my kids were little it was there to help them get up on the potty, but it's still there. And should everyone always be putting their feet up when they have a bowel movement, I recommend that all of my patients put their feet up when they have a bowel movement. And I do I really think that we should just proactively do it. And there are exceptions, if you are experiencing prolapse, and it's too much pressure on the pelvic floor. However, I would say it's an optimal position to get your pelvic floor to relax and constipation is the most common gastrointestinal complaint in the United States. So with our diets and our sedentary lifestyles, or whatever the case may be wearing masks and we're not hydrating, I think it's really optimal to just go ahead and put a stool under your feet. And then the last thing I was wanting to mention is not is to breathe out and tell people to blow out like they're blowing up birthday candles or like they're blowing through a straw. Because if you hold your breath in strain, that tends to cause more pressure towards your pelvic floor versus relaxation, and straining like that with your mouth closed can lead to prolapse over time, just like we see that a lot with there's a little bit of controversy about how you should push with birth Exactly.

There shouldn't be a controversy around it really, we need to breathe, we need to breathe, it's just that the controversy is perceived because we're still advising women incorrectly in hospitals to say hold your breath and push as if it's a function of effort. But you can't keep the baby in at that point. So how do I facilitate this relaxation in this process is to exhale and breathe.

I am with you 1,000%. And I educate a lot of nurses on this practice. And I mean, and I'll bring up the research and I'll say like the data clearly shows respiration and breathing leads to better outcomes. And so for the mom and for the baby, so um, you know, we're trying to unwind a system that has just been in place for a long time. And so we're working on that hard every day.

How about as it relates to ping, some do's and don'ts?

Absolutely. So, you there's two things that typically happen after birth is one you have extreme urinary incontinence that you kind of stand up from bed and you're like, I feel like my water just broke but it was my bladder. And so Oh, that's really where the muscles may not be strong enough, right, then the bladder may be really full, everything's just super exhausted. So give that a few weeks to see if that does get better. And if you are still experiencing again, leakage with coughing or sneezing, check in with a pelvic PT. But I would say that you want to stay hydrated. People often think that if they over drink water, or fluids, it's going to lead to more leakage. But it actually can lead to urinary tract infections because their urine gets too concentrated. So make sure that you're staying hydrated, sit on the toilet don't hover. So instead of squatting over that hospital toilet or you know birthing center toilet, you really want to sit and then take some big deep breaths, breathing is actually part of the system that helps relax your pelvic floor. So you know kind of straining or pushing actually only causes your muscles to tense up more restricting the flow of urine. So sit, breathe, turn on the running water if you need to do it in the shower if you need to, but just really try to have those first couple of urination in a very soft, relaxed manner without pushing.

I have a question. So I mentioned that client in my postpartum group who started talking about prolapse. And then, of course, several women started sharing slash confessing from their perspective, their own issues. And one woman was talking about the degree of her incontinence, her son is, I believe, now nine or 10 months old. And she said she was playing with him and like blue raspberry, she liked it, that little thing with her tongue when she was playing with him. And she said she started urinating, and she couldn't stop it. It just released. And she couldn't hold it back. And I was I've been wondering all week, like what is happening in the Body Talk about everything being connected, right? What's happening in the body to trigger that? How is that happening?

It's a great question. So when you're blowing out like that, it's just causing more pressure down in your abdomen, intra abdominal pressure, and that probably just put a lot of pressure on the bladder that was really full. So it's a bladder being really full with his kind of added pressure, and then also her pelvic floor muscles not contracting in response to that instead, they relax. So some of the things that we work on are teaching woman, again, it's using that muscle when you need it. So Do a kegel before you cough, or Do a kegel, before you sneeze. And then if in this case, I would have her to practice a contraction before she blows out. But you know, you want to do it as a practice. And then when she goes to blow the little raspberry and her kiddos tummy, then she's, you know, her muscles have automatically been trained to turn on in that instant, but that reflexes kind of dampen and last over pregnancy because everything gets so weak. So again, this just goes back into kind of retraining our muscles to kind of turn on when we need them to so and she likely had a very full bladder, if that was the case. So you know, just paying attention to I need to go to the bathroom, when I feel the urge to go instead of delaying the the urge. AND, OR, AND or learning to strengthen the muscles so that they can turn on in those instances when we need them.

Can we touch on key goals for a second? Just I think there's a lot of confusion for women around when they should be cabling, and when they should not be cabling and how much to do, and whether to do them prenatally or just postnatally, when to start and how to do them. And that, you know, candles are so mystical, and they were really developed by a gentleman, which is ironic that they have to do with a woman's body. But so the the key goal is a pelvic floor contraction. So when we think about a contraction, think about your bicep, but when you bend your elbow, your bicep flexes, right? That's a contraction. So for the pelvic floor muscles, when you draw your pelvic floor up, and in the way often cue people to do it. It's almost like you're sipping a smoothie with your vagina.

I think what most people do is like they clench and clench and clench and I said to my clients, it's not a matter of fatiguing the muscle like work at work at work it it's about controlling the muscle, it is and it's teaching the muscle to be coordinated. So there's, you know, if you know that you have weakness, which it doesn't just go by based on symptoms, because there are people who have incontinence or prolapse who have tension. And so if that's the case, you don't do Kegel is if you know that you have pelvic floor tension. So things we often see with a tense pelvic floor are like incomplete bladder emptying a hard time starting your urine stream, constipation, painful intercourse, tailbone pain, those are typically associated with tension. And that's when you'd want to do more relaxation, work on breathing and stretching and maybe some intro vaginal trigger point release to the muscle to help it relax, and then you strengthen if it's just a pure weakness issue. So the muscles fatigue gets tired and you just need to work on contractions, which a pelvic floor specialist would be able to advise you on a pelvic floor PT, then you can work on Kegel exercises and that's that kind of drawing up an in maneuver with your pelvic floor. So the tricky part about this is that you want to start working that muscle and a lie Come down position where there's no gravity. So start just lying on your back in your bed on a yoga mat, taking some deep breaths and kind of contracting on the exhale and really getting coordinated withdrawing your pelvic floor in your lower abdominal muscles will turn on and getting used to that coordination. And then, you know, bringing other exercises like a bridge exercise, or, you know, a leg March or something like that using the Kegel contraction, then I transition people to doing the Kegel exercises in a sitting position, so then they have gravity and the weight of the organs on the muscle. So working against a little bit of resistance, and then but they still have support underneath them. So think of it of going from like a three pound weight for a bicep curl to a five pound weight. Once they can do those exercises really seamlessly. And well, then we move to a standing position where there's no support underneath the bottom. And then we go to movement, squats, lunges, overhead, leg lifts, overhead arm presses, leg lifts. So things to really, you know, we want this muscle to work when we are running after our kids when we're leaning back in our car to get, you know, to hand our toddler something when we're lifting a box. So really functionally kind of progressing, how we're strengthening the muscle, and then also bring it into our day to day lives.

So do you recommend that women start Kegel shortly after birth, when they're laying in bed and recovering or how long to wait.

So what I what I actually recommend is in those first two weeks, I actually haven't worked on their breathing. So just taking big deep diaphragmatic breaths and then doing a little Kegel contraction on the exhale. And it's less about strengthening, but it's more about kind of waking those muscles up kind of connecting mind and body. And then also just using a kegel contraction to pump some of the swelling and fluid out of the vulvar area, then when they start to kind of move and around four to six weeks is when I really start encouraging them to you know, they there, they may be healed, if they've had a tear, if they've had a cesarean birth and their scars somewhat healed, kind of get past that two week period, start doing some gentle walking, and then around four to six week, week, start doing some pelvic floor strengthening. If they're having a change in their symptoms, like pain is worse or you know, more leakage or constipation, I would say they may have tension and that's when I would check in with the PTE to say, Okay, I need to kind of relax these muscles first and then move on to strengthening.

What about reverse cables.

So reverse key goals are when you're kind of pushing and bearing down, or the opposite of a contraction would be kind of a bulge and reverse key equals or what I trained folks to do when we're preparing for birth, or if they have constipation, I'm training them to poop properly. Those are two instances where we want the sphincter to kind of open up with our breath. However, I don't have people work on reverse key goals as an exercise, I feel like it's, you know, more often people have weakness in the area than we really want to, I don't want them pushing their pelvic floor down all day, we need to have some strength to that muscle just to help us walk around and support our organs and keep us continent. But I do work on reverse. Kegel is teaching them to to bear down to exhale with that bearing down so they don't hold their breath to prepare for birth. And if they have pooping issues, and then I have them practice that, you know, for doing it for birth, I have them practice it lying on their back, I haven't practiced it and hands and knees position lying on their side to really again, functionally train that muscle to work in the position. We need it to work. But I don't want people walking around pushing their pelvic floor out all day. So in the case of the reverse kegel, you're saying you're showing them how to control the muscles, so they're not just like these lacks muscles inside the body. We're not really consciously aware of right, controlling coordination. I mean, you coordinate it with your breath, right? So don't hold your breath and try to push out really, we talked about how breathing is really the natural way to kind of relax these muscles, so about coordinating these muscles with our day to day.

So in pregnancy and late pregnancy in particular, are you recommending doing regular key goals or no need to key goal during pregnancy? I love to work on strengthening the first and second trimesters. And again, not just key goals, but hip strengthening, core strengthening, you know, all of these things again, teaching people how to squat and lunge and bring the pelvic floor into that their body is changing the pelvic floor is relaxing the abdominals are stretching. How can we keep them strong functional pain free during that process. third trimester I work much more on relaxation. I feel that we want to train women how to relax their pelvic floor, we do much more yoga type stretches perineal massage teaching them how to reverse kegel or exhale and bear down really working more on relaxing that muscle in preparation for birth.

The opposite of what many women think they should be doing, which is killing the heck out of things in the last couple of weeks. So they can have this really strong pelvic floor pushing back.

And that's the thing our pelvic floor muscles don't push our babies out, right? Our uterus does our uterus is a muscle that is contracting. That's what contractions are. And we're just trying to get the pelvic floor muscles out of the way to get maybe it's the opposite of most people think, right and so it's really we want to work more on relaxation, let's go into dialysis for a minute, because that is a big fear for people. And I think there's a lot of misunderstanding we've touched about it. We've touched on it a little bit in other episodes, but I think we can reiterate that, you know, what is normal for dialysis? And what should we expect? Post birth?

Right. So diastasis recti. And it everybody says it differently? I'm sure being from New Orleans, I say it different than y'all in Connecticut.

Is that is that proper diastasis recti, we would like to say properly, or diastasis recti or diathesis, wreck die. So it's Kegel Kegel, you know, okay, so but, so to take a step back about what is diastasis recti, is it's a stretching or thinning of the tissues at the midline of the abdomen. So you have these kind of six pack muscles, which we call the rectus abdominus. And there's a little line down the middle called the linea, Alba. And that tissue gets stretched throughout pregnancy, which makes sense, it's trying to support a growing baby. What happens when that tissue gets stretched, and it's not supporting your abdomen the way we'd like it to it leads to diastasis recti, which is when you if you did a little crunch maneuver during pregnancy, you almost see like a little dome or a coning, coming up with a midline. So that's kind of how we can tell somebody's hat has it during pregnancy. And they also may exhibit it postpartum as well. Or if you feel like your fingers are kind of sinking into the midline above the belly button or below the belly button. What it does, again, is it just gives us information, it's telling us that those tissues at the midline of the abdomen are not supporting us as well as we'd like. What we're asking them to do is a little bit more than they can handle right now. And we need to modify our activity. And we need to start strengthening the way that you rehab or re strengthen that diastasis is actually the same way that you strengthen your pelvic floor. When you do a kegel contraction, there's a deep abdominal muscle, cultural transverse abdominals that also turn on, they kind of work together. And that transverse abdominal contraction is what stiffens the tissue or kind of strengthens the tissue at the diastasis. So, pelvic floor and transverse abdominal contractions, we kind of do them together. But that's what helps kind of bring back in that, that diastasis and fix it. The things you can do for prevention is I teach people early on in first trimester how to get in and out of bed, instead of just kind of crunching up or like leaning back, they need to roll to their side and push up to get in and out of bed when they're getting out of a chair to use their arms to help them pull up instead of just using their abs. And then also what's called I tell them to do what's called exhale with exertion. So if they are lifting weights, if they're lifting their toddler, if they're lifting a car seat or a stroller to exhale as they lift, if they're not exhaling, what often happens is they're holding their breath. And then that pressure, that tension doesn't have anywhere to go. So it goes towards the path of least resistance, which is the diastasis if you have diastasis recti, or it goes towards prolapse, which is the bottom of the barrel parent pelvic floor, so I always teach exhale with exertion, and then modifying their activities during pregnancy.

That is so interesting, I just want to slow down and let that hit home right now, I never understood that before. You explained why we need to exhale.

Exactly, it's about managing the pressure in this little in this cavity. So it's all about exhaling because if there's a path of least resistance, which is a weakness in the abs, or weakness in the pelvic floor, it's gonna go there. And that's the opposite of where we want it to go. So if you exhale, that pressure goes out.

It's such a shame that breathing has become so cliche, when everyone says, breathe, like you're under stress, breathe, when you're doing this, take a deep breath. And, you know, it's so nice to hear you just explain. And right there, you hear that one time, and you're always gonna want to breathe out when you pick something up now just do explaining that.

And it's interesting. I mean, it takes us slowing down a little bit because we move so quickly in our day to day mom life. But you know, when I pick my kids to get in and out of the car, or I'm pulling them in and out of the bathtub, I exhale. And so it's just automatic now and so if we think about how people get hernias, you know, it's an it's too much pressure, and the pressure has to go somewhere. So it pops a little hole in their abdominal walls, the same thing. So we just, again, I really feel like these are things we should all know. And it's just such a joy to be able to share them because it's just part of living that we should be educated on early on.

It's kind of like how the world realized 15 years ago, you know, the school system should be teaching kids about financial planning, because what's the point in getting an education making money if you don't understand financial planning? This is another thing. It's like we talk about health all the time. This is a major part of our health, that there's absolutely no education. How important is this area of the body in men? Is it equivalent or is it less complicated for them? It's equally important.

It's equally important that the difference is is that their bodies don't go through the same transformation because they don't experience pregnant See your birth? So, you know often I get asked, you know, a lot of questions about pregnancy birth, which is wonderful, but I always say you can experience pelvic floor issues all across the lifespan. The reason I really focus a lot on pregnancy and birth is because our bodies transform so much and there's such little education on how do we prevent issues? How do we know if we have issues and how do we get help? So but for male pelvic floors, we often see often it's more of a tension issue difficulty with bowel movements, weak urinary streams, pelvic pain, is there a prolapse possibility for them? There's not a prolapse possibility they there's in some cases, where like heavy weight lifters will have a diastasis as well you'll even see it on TV you can see their abdominal wall separating and heavy heavy weight lifters and they experienced you can see it on TV when they're lifting weights. Oh yeah, when they're not.

So and I'm like shaking my head no.

Tell the camera man just like reposition the camera or something that sounds like a really uncomfortable thing to watch. It just does not sound healthy or safe.

Can pelvic floor weakness impact their their erectile function.

So a pelvic floor weakness can affect erectile function. So either in a spasm or tension sense. Or if there's a weakness, we often see more of a weakness with urinary leakage or erectile function with males after a surgery. So if they have a prostate surgery procedure, that's more when they're more likely to experience symptoms. So I used to work a ton with male patients who had had a prostatectomy for prostate cancer, and they would often experience urinary leakage, or erectile dysfunction.

I just can't help but wonder. I mean, it's I more than wonder I, I am developing a theory that one of the reasons this area of our bodies has been so ignored is that it is specifically more complicated with women. I mean, you're nodding, right? I mean, it still affects men. But it seems like the painful sex doesn't affect them. It seems like the prolapse doesn't affect them. We're doing things that provoke the issues like giving birth. And therefore, I don't mean to sound cynical, but we see this a lot. I mean, this entire field is unaddressed it's just starting to become an awakening. Right, just starting to become things that pregnant women hear about when I got it. That's why as that's why I actually asked the question about erectile dysfunction, because if it were a very common thing for men, you know, there would be a lot more.

At the top of the list, Congress will be creating new bills.

So there's two things and I mean, this kind of goes on my whole, you know, rampage about, you know, women's health. But one, historically, research is done by male physicians. I mean, that is changing now that we have more female physicians in the field. But that has been where the research dollars have not been spent is on women's health, because we're not doing it. And that's changing now, like endometriosis and fibroids, two other completely unaddressed issues.

Exactly. And then the other thing is, you know, if there's actually a really funny article, it's actually not funny at all. But it's a really interesting article about how many studies and it's in the 10s of 1000s have been done on Viagra. And erectile dysfunction versus female pelvic pain and painful intercourse and women. And it's like a couple of 1000 on female pelvic pain. So it's an under addressed under researched, underfunded issue. And, you know, I think a lot of this is there's, when physicians, medical providers don't ask about pelvic floor issues, patients are not likely to share them proactively. So it really comes in all you know all angles that needs to change that. Medical providers start proactively asking about them, and then knowing where to refer them. I don't expect OBGYN or midwives to become pelvic floor experts just like I'm not, you know, going to be birthing babies, or performing surgery. But I think we all need to work in collaboration to say how can we offer the best experience possible for this patient to give them the best chance of out of positive outcomes. So it's a really team effort. And in my community here in New Orleans, we work with a ton of physicians, doulas and midwives. Because we're, we really want this to be a collective and personal experience for the patients. So one, practitioners need to ask about it and know where to refer them and not just give them a brochure to do key goals. To You know, I think that patients need to speak up about it and share their stories just like they did in your postpartum group because it it's one it's relieving to be able to talk about it and then more people start opening up about their experiences so you realize how common it is. You feel less alone and you can start getting resources.

We can't end the episode without touching on painful sex because our sex lives matter to damage it Yeah, exactly. So if we needed more barrier is if we needed more barriers to having sex after having kids, right? So there's so many reasons and if there's pain on there, it's like absolutely no go. Nine out of 10 people, after giving birth will experience pain with sex the first time they have intercourse after giving birth. And, again, it's one of those things that if that is persisting, if at three months, it is still painful, you need to go check in with a medical provider or pelvic floor physical therapist. Commonly the reasons that someone experiences painful intercourse after birth are scar tissue. So a perineal tear and a Pz Atomy could be causing some restriction, some tightness tension at the vaginal opening and doing some soft tissue massage or perineal massage to the area may help if you've had a cesarean birth, people who have had a cesarean birth are actually more likely to experience painful intercourse because the fascia from the abdomen wraps down to the pelvic floor that fascia gets really tight and tense. And so working on some cesarean scar massage and then releasing internally can also help vaginal dryness, if you are lactating. If you have not had your menstrual cycle return, if you're on hormonal birth control or hormonal contraception, that tends to cause low estrogen in the body. And it can cause vaginal dryness, rawness irritation, and then tight muscles. Again, some people have muscle tension and muscle tension can make intercourse feel like either one their partner's hitting a wall or two with deeper insertion. It feels bluesy, it feels tender, and that's a sign of some tension that needs to be addressed. So, again, lots of reasons all in the pelvic floor region, using lubricant may help but it's not going to necessarily solve all of the issues. And if you do experience this, I mean, I've had people who I've seen two to three sessions, and the pain that they've experienced for 11 or 12 months goes away within a month, just working on some of the tissues, you know, and getting them soft and relaxed and teaching them to release. So it's, I think it's a it's a really common experience, but there is so much help for it so that you don't have to just tolerate it I hear so often I can tolerate sex, like sex should be enjoyable, not just tolerable. And so even within myself, I've experienced this postpartum. And I'm like, so thankful I have the knowledge of Let me try these things and see if they help and I can kind of target it. And I think of so many people who just don't have that awareness and could really use the support.

I'm glad you mentioned that the first time people have sex, postpartum nine out of 10 times they are feeling pain, because it isn't always that there's going to be chronic pain, post sex, but most 90% of people are going to feel it at least that first time and then that's just sort of your way of your body saying we need to go slow and reintroduce this give it a little more time maybe. And just be very conscientious and careful and gentle the first time.

Absolutely execs.

So Sarah, I think everyone can hear this and understand the importance of their pelvic floor health, how it's affecting other things in their lives. But in my own experience in working with women all the time and encouraging them to go to a pelvic floor specialist, I can tell you the obstacles that I always hear from them when they're delaying, or they're putting it off, when they're putting it off or they're reluctant to go is they're concerned about the effort involved. The fact that they have a baby to take care of the energy that will be required in doing their exercises at home, like any physical therapy, and then the cost because it's often not covered by insurance. I mean, I can't wait till we get to that point where it finally is like acupuncture and other things that should be naturopath, it. But can you respond to that? You know, what, what's your response to that? Because those are real obstacles, and we want to help women get past them.

Absolutely. So you know, they're a pelvic floor physical therapist all over the country of the United States, all over the world. And oftentimes, it's just asking your medical provider doing a Google search, there's a couple of websites, pelvic rehab.com, where you can actually find a pelvic floor PT in your area, some may take insurance and some do not. And so I would work with them to see if you can find one that does take insurance. And then with regard to effort, it does take effort. I mean, just like taking care of our body, I mean everything from taking a shower and brushing your teeth when you have a newborn to you know, fitting in exercise and fitting in a pelvic floor physical therapy session. So we allow babies to come to our clinic, you know, we have an area where a mom can pump or breastfeed or whatever the case may be to really try to facilitate the ease of that experience for her. You know, I develop this program over the past year with online strengthening online childbirth preparation, because I've found that it is really hard. I'm a mom myself to carve out the time to commit, you know, 10 minutes, three times a week. So just really kind of, I'm really trying to create a platform where it's just easy and accessible and affordable for people To be able to get these resources, pelvic floor physical therapy is really such an amazing tool to be able to help moms returned to function feel strong and not feel like they just have to suffer with this new body that they have that they can really still thrive and motherhood and do the things that they want to do

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Y'all I mean I think boy, this is like we all have a shared passion for this I get fired up because it's I mean, I just really feel so passionately about like what we're doing here and so And y'all are the same way so it was just really easy to play off of that.

You know what this makes me think of? You know what this makes me think of? Someone respond to me say yes we were just waiting for them.