Postpartum Physical Therapy: Podcast Episode #127
Alyssa talks with Amanda and Katie, Women’s Health Physical Therapists at Hulst Jepsen Physical Therapy, about postpartum physical therapy and what pelvic floor physical therapy looks like after having a baby. We talk about incontinence, diastasis recti, symphysis pubic dysfunction, constipation, and so much more! You can listen to this complete podcast episode on iTunes or SoundCloud.
Welcome. You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting. Let’s chat!
Alyssa: Hello, Amanda and Katie! Good to see you. Today, we are going to talk about postpartum physical therapy. You are both women’s health physical therapists at Hulst Jepson, and we’ve had some beautiful conversations in the past. And I think we haven’t really covered what physical therapy looks like yet specifically in the postpartum period. So, yeah, let’s get started. What does that even look like?
Katie: Yeah, let’s dive right in. I think the first thing that women think about is probably their six-week follow up with their doctor. Usually it’s at the six-week mark that they talk to their OB-GYN. And we would love to see this visit be standard practice and standard practice for referral to pelvic floor physical therapy. That’s common in a lot of countries. I think France is the one that is often cited. But often there’s a really quick check of you and baby, and you’re told, okay, you’re good to go, without a lot of other details. So this can be a great time to talk to your doctor about a referral to see a pelvic floor therapist. That visit should be about the baby but also about you and how your body is doing, too. A couple things that might be red flags that you need to see a pelvic floor therapist would be any urinary leaking, any continued constipation, any pain with sexual activity, any pelvic heaviness, just to name a couple.
Alyssa: What is pelvic heaviness? What is that?
Katie: People that will describe that it feels like my organs are falling out; like, it feels like there’s a lot of pressure there, or it just feels like there’s a lot of tissue there, and I just don’t have a lot of sensation around it. Or things just feel loose. Like, my body doesn’t feel like it felt before I was pregnant, and it felt like everything was held together more. It feels just kind of fluffy.
Amanda: Yeah, I’ve heard that one a lot. Like it feels loose or feels like a golf ball is kind of hanging there. And that’s typically – definitely your OB-GYN will take a look, we hope, to diagnose or say, hey, there’s prolapse; you know, the scary word for postpartum. But it shouldn’t be, definitely not, because that’s something we can help with. But that pressure sensation can be because there is some prolapse there, and that will definitely kind of – when we dig into different diagnoses we see postpartum, we’ll dig into that one a bit more because there’s a whole series of things that people come in with that they already know they have or something that we find. And the diagnosis that we describe obviously can happen if it’s a vaginal birth or a C-section. Obviously, it’s a different experience for mothers, and in some ways, we treat that differently, but in some ways, some of the symptoms of it can be very similar. Obviously, a C-section, with the abdomen we pay a little more attention to that area and healing and scar massage and whatnot to kind of get the abdomen to activate, and then that vaginal delivery, it’s like, okay, questions regarding, like, kind of lochia, like that discharge and stuff. Where are you sitting with that? How active can we be? To kind of help you in every part of that journey. As Katie said, six weeks out is a great time. Obviously, if you’re having symptoms of incontinence or heaviness feeling, discomfort in that pubic bone in the front, or if you’re feeling pretty good but just really want to get back to running or that high-intensity interval training or just walking, if walking is uncomfortable. We love partnering with new moms or could be your fifth kid or second kid to say, hey, yeah, let’s get you back in shape for the life that you live.
Katie: And if you don’t feel ready at six weeks, that’s fine, too. A lot of women are overwhelmed. There’s a lot going on. They’re getting used to a new baby and a new lifestyle. So it doesn’t have to be six weeks. It can be months later. It can be years later. And we’re going to take into account what’s going on at home that you’re telling us, too, and try not to give you a million more things to do at home. We’re going to try to integrate things you can do into just what you’re doing anyway for you and for baby.
Amanda: Yeah, I just had a mom. I asked her if she could do things at home for her low back. She says, oh, every time I go on the ground, my three kids run and jump on me. I’m like, well, that may not help your low back, so let’s try maybe before they wake up and after they go to sleep or during nap time. We’ll kind of navigate that with every individual that comes in our door.
Alyssa: That’s really good to note because, you know, life with kids is so busy, whether you have a newborn or a newborn and three other kids. Knowing that, okay, I’m not ready at six weeks yet, but I can come in a couple months and I’m not going to ruin myself. Or I can do these – maybe I need to get up – like, I even find personally I need to wake up at 6:30 in the morning before my daughter wakes up at 7:00 and leave the dog in the crate, because same thing, if I’m on the floor doing yoga, I have a kid and a dog on me, without fail. So as much as I love them, I need to do that alone to get an effective workout. So allowing moms to say, okay, this isn’t going to work for me, so here’s my lifestyle. What can you give me to fit into that? That’s great.
Katie: Exactly. I think another great example is with diastasis recti. So you’ve heard of “mummy tummy” or the splitting of the abdominals. A lot of people get really nervous about that. That’s something that we can easily assess. We can look at your core strength. We can show you how to close that gap in your abdomen, and that can be as easy as doing a little contraction that we teach you to do while you’re picking up your baby. Or, you know, while you’re putting your baby into the crib. So you’re getting a workout with stuff you would be doing anyway. You’re just slightly modifying it, like we instruct you to do, to get the most out of that routine in your day.
Amanda: That’s huge, and that one, with the diastasis recti, there’s always going to be some sort of separation. There has to be, because your baby has to grow. Your belly will grow. But what we kind of dig into is to say, okay, how is the tissue? How does it feel? We can diagnose it with finger widths. We take a look at that at the belly button, above and below. But then we take at look at, is it firm? Is it boggy? How is the integrity of that tissue? And based on that, okay, you’re ready for level A type of exercises, let’s say, or hey, you can – yeah, go jump on that bar and do some pullups. It’s fine. Your abdomen has good integrity. You’re not going to have any sort of herniation or anything like that. So it’s nice to work with the patient to help them get to the level they want to be and then also kind of meet them where they’re at and say, this is where we need to start, based on our findings.
Katie: Yeah, a lot of women will come in and say, oh, my doctor told me the diastasis would heal up just fine. Just do some planks. And that works for a lot of women, but not for every person. That tear in the abdomen sometimes isn’t straight. And so I’ve seen women where sometimes they can do, like, one half of a bicycle, like maybe the right arm and left leg, but if they do the left arm and right leg, then it will actually open the diastasis more. So that’s why seeing us, we can help you figure out what exact exercises are going to be the best for you so that you can get quicker into whatever workout you’re interested in doing. Plus, it has the nice side effect of flattening the stomach muscles of that abdominal canister. And if that wall isn’t as firm as it’s going to be, then we can see some more dysfunction in your pelvic floor, since that’s also part of that.
Alyssa: I think that’s an important note, that just because one exercise might work for most, you could actually be doing your body damage and making things worse if you don’t actually have a professional assess, hey, this is what your muscle is doing, and this is the exercise you need to do to fix it, not just this – you know, the blanket statement of, do some planks. Right? That’s like – everyone calls – I get calls all the time. I have a six-month old; how do I get them to sleep? Well, there’s no one answer just for you. If it was that easy, I would write the book and become a millionaire. But there’s not just one answer. So I think knowing, especially with our bodies and different exercises, that we can really do our body harm if we’re doing – trying to do the wrong things.
Amanda: Yeah, and I think after pregnancy, that’s a change on your body, and then labor, that’s a huge change. I mean, your body is kind of relearning how to walk again in some ways. So picture those muscles as just kind of a baby itself, trying to relearn, and that’s where you want to make sure it gets that neuromuscular control in the proper way. And that takes – it definitely takes help from a professional to help you through that. Not everyone’s the same, and just to get that repetition of the correct way, the correct cueing, the correct postural form for it. And as Katie mentioned, the correct pressures, too, because obviously, with delivery, whether it’s C‑section or a vaginal, the pelvic floor is probably going to change a little bit. We know that it stretches over 100% during delivery, and then baby, when you are pregnant, it has to hold up baby during that time. And that’s where we kind of mention, hey, that pressure sensation, that that’s not – the pressure right in the canister, it can lead to pressure pushing down into the pelvic floor, and that’s where we come in and say, hey, did your – you know, with your medical exam, did they say anything about any prolapse, I guess you could say? And if they did, awesome. Let’s check it. Let’s see how you’re doing. So that’s where we can come in and check that. We don’t necessarily medically diagnose. Physicians don’t love it when we do the diagnosis, but we can definitely check the integrity of the pelvic floor, if it’s kind of a boggy sensation. And we can do postpartum via internal assessment or we can definitely kind of externally get a sense where, if you try a pelvic floor activation, do we feel pressure into our hand, or do we feel lift, and that’s really nice to do externally. If you had a kid six weeks ago, maybe internal isn’t what you really want to go through at that point. And then help you with breathing patterns, core activation, to help kind of get those pressures proper again. And typically if you don’t have pain, we can help you kind of reactivate that pelvic floor to make, basically, the base of that trampoline strong again and bouncy again to get that pressure sensation off. And that’s fun to work with females on whether they say, hey, as I walk with my stroller, ten minutes in, I get that pressure. All right. We’re going to train you. I want you walking for ten minutes not feeling that pressure, and then take it from there.
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Katie: Yeah. Going back to that prolapse, that’s when your bladder or your rectum or your uterus are collapsing into the vaginal canal, and because they’re kind of falling lower than they should sit, that can cause some pressure. But just because you feel pressure doesn’t mean that is what’s going on. And your doctor is the best one to assess that, but we can easily see it, too. Like Amanda said, it doesn’t mean that we’re going to necessarily diagnose it, but we could send you back to the doctor to see if you needed some more support than what we can give you. So we can help support, like with what Amanda said, teaching you how to do exercises that will help push those organs back up where they should be. But some women, the exercises are going to help, but they also might need a little bit more support from something like a pessary, which is going to be like a plastic platform pushing things up in place, too. So that’s once again where we work closely with your gynecologist to help you figure out the best solution, and not everyone has that.
Alyssa: Because there’s obviously different severity levels? Prolapse is, like, a horrifying word.
Amanda: As I said it, I was like, do I dare say it? I don’t want to scare people.
Alyssa: No, we do have to say it because it’s a real thing, right? It’s a real possibility, and there are different severities. I don’t know; just knowing that it could happen, what to look for, and that physical therapy might easily help what you have. And if not, you can work with a medical team to figure out, like, okay. They’re going to do this, but we can also continue to work on exercises to continue to build strength.
Amanda: Oh, 100%. Yeah. Definitely don’t get discouraged if they’re like, oh, we think you’d benefit from a pessary, because we work with women with pessaries to get the pelvic floor stronger to say, hey, can we live without that pessary now? So definitely, definitely ways to make things stronger, for sure.
Katie: Yeah. If you hear the word prolapse, it doesn’t mean that you can’t return to HIIT workouts or can’t return to running.
Alyssa: I think we all think of the worst; like, literally something falling, like an organ falling out of the vagina. That’s instantly where our brain goes, and it’s like, oh my God.
Amanda: That’s not the case! No, no. And then other things that we see come through our doors is obviously leakage. That’s one that we’ll get postpartum, and I know we talked about that in a previous podcast. We dug more into that, about helping females through that process, too. And then constipation. I know, Katie, you’ve had a little bit more on that.
Katie: Yeah. So constipation is pretty common during pregnancy, after pregnancy. I think that’s maybe something women talk to each more about, preparing themselves for that experience. But I mean, I’ll have people coming in with constipation who are like, I’m taking MiraLAX. I’m taking a lot of other things, and I’m still having issues, and I don’t want to be on these medications, and I’m feeling a lot of pressure. What can I do? And it’s amazing. After one visit of talking about posture on the toilet, things improve so much. So from a mechanical perspective, there’s a lot you can do to help relieve constipation and that pressure. So we talk to people about how they’re sitting on the toilet. Can your feet touch flat when you’re sitting on the toilet? If you’re short like me, they cannot, and so you might need to use a stool, or I know the squatty potty, that’s been more popular mainstream. But getting those feet to sit flat and relax is really important. If we have our toes curled, that can tighten our pelvic floor, and if our pelvic floor is tight, it is hard to get the stool out. So relaxing our feet and then, for some women, a slight lean forward can help. And then we can talk about breathing to help also with getting the stool out. So Amanda’s talked a lot about breathing and expanding the pelvic floor with inhaling, with exhaling. You can do that on the toilet, as well. So you can breathe out like you’re blowing on a pinwheel, and you can try to expand your belly out and downward. And all of that can help open up the pelvic floor, open up your rectum, and make it so much easier and less painful to poop. So even talking about that for a session makes a huge difference.
Amanda: Yeah. I hope some of you are running to the bathroom right now to just try that.
Alyssa: Do you like the squatty potty overall for anyone as a general rule, even tall people, just to get your – I guess it would be your intestines or your bowel in the right position?
Amanda: Yeah. I think – I know for me, I’m taller, and I think just having the knees above the hips, the pelvic position, it does create a little bit more relaxed position just to allow – we tell that not only for bowel movements but for when you urinate as well, to just say, yeah, no rocket peeing. Relax on the toilet. Let the pelvic floor fully open.
Katie: I would say it just depends on the person. Sometimes, if you’re very tall, or just depending on the positioning of things in your pelvis, because every pelvis is a little bit different. If you have your knees up way too high, it may actually cause things to compress a little bit more. So I wouldn’t say that it’s necessary for everyone. I think a lot of it is based on height, and then oftentimes, I’ll have people try putting their feet up maybe on a pile of books or something they have at home first, and then if they like it, then the squatty potty is a good way to go. But it doesn’t work for everyone. Often, the breathing is the key thing.
Amanda: Just even a laundry basket, I’ve told people to use, too, so they don’t have to buy something new.
Alyssa: If you have older kids, too, like my daughter has a step-stool just to get to the sink. I’ve tried that before, too.
Amanda: Yeah. And like she said, it doesn’t work for everyone, but it’s nice to give it a shot, for sure. Yeah, and kind of moving past that constipation piece, another thing we see is that symphysis pubic dysfunction, to pain right in the center of the pubic bone, kind of the center of your pelvis. And that, we look at a lot of rotation of the hips, what’s going on there. So once again, this is external, because obviously, those rotations can pull on that pelvic floor. We talk about, hey, how are you holding baby; what are some postures you’re putting yourself in? Do you have some unilateral weakness? And those, when you’re getting back into higher level activity, is there kind of a brace or something that, just for now, could you wear to do some of those higher-level activities? Not forever, but just during this time when it’s painful and you’re trying to get your muscles back working well.
Katie: Yeah, that old SI belt you may have used during your pregnancy can actually be really helpful afterward to give a little bit more support to that abdomen, especially if you’ve got some of that diastasis recti or the pubic symphysis pain. So we can help you adjust that to work for you, too.
Amanda: Yeah. Very common, for sure. And again, the next one is the scarring piece, whether it’s an episiotomy or Cesarean section scar. Teaching people, hey, it’s good to kind of massage that. We can help with that, but mostly, hey, start working on that at home so you know where the restriction lies there. It can affect the muscles’ activation, just resting position, and obviously, pain levels, as well. So we both do that, too.
Katie: And it’s never too late to work on scar tissue. So if you have an episiotomy scar from several years ago and you’re feeling kind of just some numbness or lack of sensation there or you’ve still been having some soreness in the area, that’s something we can still work on years later is just trying to break through some of that scar tissue and get your normal muscle tone back.
Alyssa: That’s one of the things I learned at your office, actually, is that a scar – I mean, I knew that a scar left scar tissue, but that you can break it up, and I learned that a lot of the pain I was having was from scar tissue that had just – I mean, it didn’t even – like, it wasn’t even a thought. So I learned how to feel that and break it up, because when she did it, I was like, oh my gosh. That’s such an intense pain. Keep doing it because I can feel that it’s actually working. And then it continued to be less and less painful. But yeah, I had no idea that it could cause that much pain so much later.
Amanda: Yeah. They can be a little sticky. It’s like the tip of an iceberg sometimes where the tissue underneath just has to get worked on, which it can, which is great, by yourself or with help.
Katie: Yeah, that’s true for the C-section scar, too, because you’ll see that the scar, usually in the US, is more horizontal. But even though the scar is horizontal, you’re actually also stitched vertically underneath, too, with the way that you were opened. So we teach women not only to do the massage horizontally but to look above and below the scar, as well. There’s probably some tightness in the tissue there, too, deeper.
Amanda: So obviously a ton of things that we can help with. We can answer questions; we can explore with someone who’s a new mom, especially where it’s all very foreign. Or if the postpartum was just different this second or third time around. Yeah, we can encourage, definitely, hey, exercises at home, exercises here. We have a great setup in our gym for those returning to exercise, returning to running. We can take you through a program with that. Strength training is so important, especially with baby care, or if you have a toddler, as well, that you’re lifting. We always seem to be in that flexed position, so we really encourage extension, that opening. Breastfeeding; we can help with posture with that if there’s pain involved, how to set that up; or hey, what exercises should I do before or after breastfeeding to get rid of some of this pain, to avoid the pain altogether. There’s just a lot of things, which is so fun. It’s great to partner with females after birth to get them through and back to the body that they’re used to having, function-wise. And we just have fun with it.
Katie: Yeah. And it’s exciting to look at the whole body. A lot of times, we’ll have someone come in, and they’re really just focused on the leaking, maybe, that they’re having, or some urinary leaking. Or maybe they’re just focused on some heaviness or some scar tissue. But it’s really fun to take a look at the whole body and be like, hey, how can we help your neck and shoulders and your midback feel better with breastfeeding? How can we make your whole body feel more like it’s yours again?
Alyssa: That’s a really good point with breastfeeding because a new mom who’s doing that every two hours, 24/7, that takes a toll on your body. And like you said, that position, you just constantly feel – gosh, it seems endless, and the pain in your shoulders from that or your arms. Yeah, that’s a really good point.
Amanda: Yeah. I mean, I hold my seven-pound dog for 15 minutes, and I’m like, I’m exhausted. I got to step up my game! But yeah, strength training is huge.
Alyssa: Well, this is awesome. I know we’re running out of time. Do you want to just tell people where they can find you locally?
Katie: Yeah. Amanda and I are located at Hulst Jepson Physical Therapy. We’re at the East Grand Rapids location, although it’s not actually in East Grand Rapids. It’s just outside of East Grand Rapids. We are located on Burton between Breton and Plymouth. So we work well here as a team, and you’re welcome to call and talk to our receptionist, Lexi, and she can definitely set you up with a visit or with a free 15-minute consult. There’s other locations that Hulst Jepson has that may be more convenient to your home, as well. I think we have five different locations with pelvic floor physical therapy. And so looking online at their website to find the best location for you.
Amanda: Yeah. We’d love to see you and help.
Alyssa: Awesome. Thanks again. This was another really interesting conversation that we just need to keep talking about. Let these moms know that you’re here to help!
Amanda: Awesome. Thank you!
Katie: Thanks for chatting with us!
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