In today’s episode we’re going to be talking about issues surrounding female health, particular pelvic floor dysfunction. If you usually listen to the podcast episode with little ones listening in, I just wanted to give a heads up that we will be discussing anatomy and having a frank conversation. So there’s your potential TMI warning.
Also, different than my normal interviews, I’m actually going to start off with a bit of a personal introduction. Maybe you’re wondering why in the world I’m having this conversation on this podcast. So let me tell a bit of my own story to get us started. I’ll just set the awkwardness stage so everyone else feels a bit more comfortable, shall I?
It’s a bit of a cultural joke that moms can’t jump or laugh without a little bladder leakage. But it’s actually no laughing matter. Not only that, but the symptoms associated with a weak pelvic floor can be a lot more painful and embarrassing than just peeing when you laugh.
But while I heard lots about diastasis recti as a young mom, I never heard anyone really talking about what I’ve since come to realize are common pelvic floor struggles. So when I began having increasing issues with rectal incontinence, pressure, and even pain, I attempted to just power through.
Once, while out on a run over a mile away from home, I lost complete control of my ability to hold in my bowel movement. The resulting traumatic experience of getting to a restaurant and having to use their bathroom to try to clean myself and somehow get to the point of being able to get home was one of the most humiliating moments of my life.
But even that wasn’t enough to convince me something was really wrong, and maybe I needed help. I kept doing my kegels and my other exercises, assuming things would just eventually fix themselves over time. It wasn’t until I was in my regular cycle class and literally thought my organs had started to fall out into my vagina that I called my OBGYN in tears, went in for an appointment, and received the recommendation to go to a specialized physical therapist.
After my experience, I became a bit passionate to talk more openly about this neglected topic. And when I started opening up about it, so many mamas started replying! “I’m not the only one?!” was a common reply. When I let folks know about this interview, I probably got more email replies and social media DMs with questions and comments than any other topic! That surprised me, but it probably shouldn’t have.
We may not be able to get to all those questions today, but I hope this conversation first of all just helps people know they aren’t alone. I had felt so embarrassed and ashamed like there was something wrong with my body alone, and it was a relief to realize how common (if hidden) these issues really are.
Second, I hope you can come away with some practical tips and solutions to begin your own process of healing. I also hope it encourages other moms to get help as needed. Our bodies are strong and powerful and have nurtured babies and (if you’re listening to this podcast) are now educating the next generation. It is worth it to take the time to protect our bodies, to help them heal, and to help them stay strong.
Finally, I hope having this conversation just right out in the open, in your earbuds, on the internet, starts to take just a little bit of the sting of the awkward out of this incredibly important conversation. The more we normalize these discussions, the easier it will be for moms to get the care we all need.
So. There’s my big long introduction and the WHY behind this episode. Now let’s meet today’s guest, Meghan O’Hara!
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Who is Dr. Meghan O’Hara
Dr. Meghan O’Hara has been specializing in pelvic health physical therapy since 2016. She graduated from Stanford University with her Bachelor of Art in Human Biology, and from Duke University with her Doctorate in Physical Therapy. She holds certifications in orthopedic manual therapy from the Institute of Advanced Musculoskeletal Treatments and in pelvic rehabilitation from the Herman and Wallace Pelvic Rehabilitation Institute, and is trained in trigger point dry needling. She is passionate about helping people of all ages and genders stay active, healthy, and happy through personalized physical therapy and wellness care. Outside of treating, Meghan assists in education at Duke University in the Doctor of Physical Therapy program, and with professional continuing education at Herman and Wallace Pelvic Rehabilitation Institute.
Watch my interview with Dr. Meghan O’Hara
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Meghan, thank you so much for coming and for sitting there patiently with that very long-winded introduction. Can you tell us a little bit about yourself and what you do?
Dr. Meghan O’Hara: Yes, absolutely. Thank you so much for having me. I’m so honored that you thought of me when you think of pelvic health issues because, honestly, everybody that I know says they can’t take me anywhere without me talking about pelvic health. It’s one of those topics that, like you’ve already said, people everywhere have these issues. People just are not talking about it enough.
Like your lovely introduction for me, my name is Meghan O’Hara. I am a physical therapist. Been specializing in pelvic health for over six years now. I got into pelvic health not really knowing anything about it because it isn’t something that people talk about a lot. I got to PT school and thought, “Yes, I’m going to go into sports. I’m going to work with a professional sports team. I’m going to be just an orthopedic leader,” right?
I had a couple of classes and was really fortunate enough to have some professors and mentors in PT school that were big women’s health advocates and pelvic health advocates. They were kind enough to let me shadow with them and it just got me really started and really excited. I was able to pursue some of those additional certifications and classes after graduation and a little bit while I was a student that had let me just hit the ground running, specializing in pelvic health.
A little bit about, “What on earth pelvic health physical therapy is?” You touched on it a little bit in that introduction, some of the things that we talk about, but it does seem like a thing that you think about physical therapy and you think like, “Well, maybe I had knee surgery or back pain, and I need to get a little bit of help with that,” right? People don’t really think about pelvic health as something that physical therapists do.
They think about OB/GYNs, midwives, that kind of thing, but it’s actually been a specialization in the pelvic health field for nearly 50 years, about 45 years. It’s come a long way. You’ve heard me say “women’s health,” and then you’ve also heard me say “pelvic health.” We started out as women’s health. Now, we’ve realized that there are so many more conditions that pelvic health therapists treat. We treat men, we treat kids, we treat transgender folks, we treat everybody.
It’s now called “pelvic health,” although you may still hear it called “women’s health” out and about. I’m going to try my best to call it “pelvic health” because I treat everybody. Basically, the little elevator speech here is that we treat bowel, bladder, and sexual dysfunction as pelvic health specialists. Basically, it’s just a pretty wide practice pattern. That’s why there’s so much extra education that we do and so much specialization to become these pelvic health experts.
What is pelvic floor dysfunction?
Amy: Well, can we start just with the big picture for someone maybe who’s not familiar. What exactly is pelvic floor dysfunction? How common is it? What are some of the symptoms associated with a weak pelvic floor? I’m assuming most of my audience is predominantly homeschool moms, who’ve probably given birth to a few children. They probably know a little bit, but I would love to hear your big-picture explanation.
Dr. O’Hara: Yes, absolutely. Pelvic floor dysfunction is that bucket diagnosis of, “There’s something not working with a group of muscles,” right? That group of muscles is the pelvic floor. We can subdivide that dysfunction into what we say as hyper or hypotonic, which basically means your muscles are either working too hard or they’re not working enough. If they’re not working enough, that’s going to be our weak pelvic floor.
We see this probably most commonly after pregnancies and deliveries. I always think about it as you basically had this little baby jumping on the trampoline of your pelvic floor over and over and over again for nine months, getting bigger the whole time, right? Then you have to get that bowling ball through the trampoline, right? That big, heavy baby has to come through. Those muscles, until we think about them and we have an issue, we’re usually not strengthening them, right?
We’re not usually thinking about how the pelvic floor functions. You can think about how your arms work. If you’ve carried a heavy suitcase, you’re like, “Man, that was a lot for those muscles.” You don’t really think about your pelvic floor having to do that same kind of workout, right?
As far as how common is it, much more common than I think we’re even seeing in the research right now.
There is a lot of statistics out there that say for urinary incontinence, it’s up to 50% of women at some point will have urinary incontinence postpartum. When we say incontinence postpartum, we’re also talking about after that 6 to 12 weeks past delivery. Very, very common immediately postpartum. Once you get through that standard healing phase, we expect those symptoms to completely resolve. If they don’t, that’s that 50% that we’re seeing.
If we take another side of pelvic floor weakness, we talk about pelvic organ prolapse, which basically means that part of your pelvis and part of your pelvic organs are actually sitting lower than they should be. Our pelvic organs include the bladder, the uterus, and the colon, or the bowels there. Those can all move a little bit south for a lot of reasons. Pregnancy and delivery is one of them.
Extreme weight lifting can be one of them. Endurance exercise can be one of them. There are lots of reasons. Chronic coughing. Lots of reasons why we can develop pelvic organ prolapse. It’s not isolated just to pregnancy and it’s not isolated just to people who have been pregnant. You can get pelvic organ prolapse without ever being pregnant or delivering. That can be a prevalence of about 75%.
If you know three other women in your life, probably the majority of them have had some degree of pelvic organ prolapse. That might be that things are sitting just a tiny bit lower. It could be that you might feel a little bit of heaviness and pressure in the pelvis or it might be that you’ve known somebody who’s needed a bladder sling or they’ve had a hysterectomy because their uterus was sitting lower.
That feeling of you standing up out of the saddle, maybe riding a horse, but maybe riding a bike, and it feels like your organs are going to fall out, like something is falling out of the vagina? That’s a classic symptom of a weak pelvic floor that’s associated with pelvic organ prolapse. All that to say, it’s pretty common and it’s much, much, much more likely than not even if we’re not talking about pregnancy that you know someone with pelvic organ dysfunction.
Amy: I just think that’s so fascinating. Again, just how common it is and yet no one really talks about this is a common issue that women are dealing with.
Dr. O’Hara: Absolutely.
How are the pelvic floor and abdominal wall health related?
Amy: Well, how are issues with our pelvic floor related to or associated with other abdominal wall issues like abdominal wall separation and things like that?
Dr. O’Hara: That’s a fantastic question. I think it’s something that’s getting a lot of media presence right now. There’s a lot of these different diastasis recti or kind of that mom tummy rehab programs that are out there and lots of do’s and don’ts and lots of scary things out there.
Basically, the abdominal wall and the pelvic floor are best friends. When you get a good pelvic floor contraction, if you can do a Kegel or a pelvic floor squeeze, your abdominal wall, that deep, deep layer of abdominal wall, it’s called your transverse abdominis, that muscle will contract as well.
There’s really good evidence that says they have to work together as a team. When we have a separation in the abdominal wall or we have surgical scars along the abdominal wall, maybe that’s from a C-section, maybe that’s from other abdominal surgeries, gallbladder or hernia repair, something like that, your abdominal wall needs to be able to work to have your pelvic floor work and your pelvic floor needs to work to give your abdominal wall support.
When we have any of those types of dysfunctions in the abdominal wall, we really need to train those groups of muscles together and get them to be as functional as we can.
Amy: I know we’ll talk about this more later on probably, but so often we think, “Okay, I have an issue in this one little part of my body, so I’m just going to hyperfocus on that one piece of my body and try to fix it,” but we forget that everything is connected and they have to work together properly. You can’t just isolate the one piece of your body as if that’s all you have to think about.
Dr. O’Hara: Absolutely. Yes, for sure.
What forms of exercise are ok?
Amy: A mom’s listening to this and she’s like, “Oh, yes, I relate to this,” or maybe it’s a mom who is new to all this and is like, “Oh, I want to avoid these issues entirely.” A general question because I feel like there’s a lot of conflicting information about this or advice. Just in general, what forms of exercise are okay? Running, yoga, lifting weights? Are there any that we should definitely avoid?
Dr. O’Hara: Yes, also a great question. My least favorite word in the English language is “no.” I don’t like being told what not to do. I don’t like being told no. I hate saying that there’s a bad exercise or an exercise not to do. There might be exercises that are better for you at a certain time or better ways to do them for your body, but I’m not a big fan of limiting everything. I don’t like these programs that say, “You can never do a crunch again.”
If it hurts when you do a crunch or you’re seeing your belly dome out or you’re feeling a lot of pressure and pain or discomfort in the pelvic floor, crunches are probably not the greatest exercise to be working on for core strength. It doesn’t mean you can’t ever do them. It means that maybe we need to find a professional to work with like a PT, who can help you figure out how to do those exercises better.
For general advice on, “Hey, what do we do today? What can I go do today that’s going to be good for my body?”
I think walking is probably the most underrated form of exercise out there. It’s available. You could walk to your mailbox. You could walk around the neighborhood. You could go to a park. You can push a stroller and take your kids with you. There’s so many places that we can walk. I know here in the Raleigh area, I’m super lucky. There’s so many greenways and parks and great places to go that even when it’s miserably hot outside, there’s still some shade out there. There’s a nice breeze.
There’s so many good places to walk and it is something that you don’t have to commit hours and hours and hours to. It can be a 10-minute walk to just get a little bit of blood pumping and get your heart rate up. It’s fantastic. It’s good for overall body awareness. It’s good for blood flow. It strengthens. It’s good for cardiovascular system. Being outdoors helps your mental health. There’s so many good things about just walking.
If that doesn’t float your boat, honestly, the best thing to do exercise-wise is something that you’re going to keep up with and something that feels good for your body. My favorite example is underwater basket weaving. If I told you underwater basket weaving was the greatest exercise known to man and you’re like, “Meghan, I don’t know how to weave. I don’t have a pool and I hate getting my hair wet. Why would I do that? I’m not going to. I don’t care how great that exercise might be,” you’re not going to do it, right?
If you love cycling but you’re having pelvic pain, maybe we need to work on some strengthening for the hips or we need to work on getting some padded shorts that help just cushion things a little bit. There are lots of ways that we can modify those exercises if there’s something that you really love to do that doesn’t feel quite right after having babies.
Amy: I think one of the things that I learned as I was going through my own PT was just to be more aware of muscles and the way they were working that I hadn’t actually probably even able to feel them, really notice some of those underlying muscle when I was even using them, right? Now, I’m just much more in tune.
There was a time when I took some time off from some of the things I really loved to do like cycle class. It wasn’t good as I was healing at that time. I’ve been able to go back to it, but I’m just much more aware now. I can tell when something isn’t helping my body, then I’d known enough now to make those adjustments so that I don’t get to the point where I’ve injured myself again, right? Just like you wouldn’t try to do too much weight on your arm muscles because you’re going to hurt yourself. It’s the same thing, right? Just listening to your body sometimes makes a big difference.
Dr. O’Hara: That first step is awareness. I think you just touched on that a little bit was recognizing, “Hey, I’m doing this cycle class and it doesn’t feel great,” right? How do you step back?
One of my other biggest pieces of advice, if you’re not into walking, you don’t want to listen to anything else I’ve said, is make sure that you can breathe. You’ll hear probably every pelvic PT talk about this forever and ever and ever, but a lot of the time when we run into trouble is we’re doing these exercises where we have to hold our breath.
We’re doing these crunches or we’re doing even weight lifting or picking up our kiddos and we’re holding our breath and we’re bracing. It’s creating a lot of basically downward force. We call it intra-abdominal pressure in the PT world.
If you’re holding your breath, you could imagine your diaphragm, that muscle that you breathe with that sits in basically the bottom of the rib cage, that muscle locks down.
It takes all of your abdominal contents and it pushes it down toward the bladder and toward the pelvic floor. If we’re bracing with that diaphragm, we’re bracing by holding our breath, we’re not effectively using the pelvic floor and using the core or the transverse abdominis muscle, that deep belly muscle for support.
If you are doing an exercise and it doesn’t feel great or you just want to think about where can I start, diaphragmatic breathing is a fancy way to say deep belly breathing.
That’s my favorite, favorite, favorite place to start, and then you start to use that in exercise. Make sure that you’re breathing out on the hard part of a movement. Even bending down to pick up your baby or pick up your kid, breathe out as you go to lift them, and that will help to take some of that pressure off the pelvic floor. If there’s nothing else you learn from this podcast, take that little piece away and that will help pelvic floor issues so, so much.
Amy: That is a great tip. It’s one that you can just start applying right away. You don’t have to do a fancy exercise. Just be aware of when and how you’re breathing. That’s awesome.
What exercises can help heal and strengthen the pelvic floor?
What about more specifically, if someone’s wanting to promote healing or strengthening of the pelvic floor, are there some exercises that can help with that? Then that’s after the fact, and then thinking about women who might be pregnant, are there exercises or ways that we can do some preventative care so that we’re not going to have some of these issues later on?
Dr. O’Hara: Yes, absolutely. Once we’ve mastered that diaphragmatic breathing that we’ve just talked about, we know how to breathe, we’re using our bellies to actually stretch and let go. Once we can do that, then we start to think a little bit more about that strengthening piece and promoting that healing of the pelvic floor.
It’s not all about Kegels or Kegels. You can really say it either way, but we tend to think like, “Okay, yes, if I’m going to strengthen a muscle, I’ve just got to squeeze, squeeze, squeeze all the time,” right?
It’s a small piece of the puzzle. It’s absolutely great to be able to contract and relax your pelvic floor. It is one of the metrics that we look for for strength and healing and recovery, but we know that the pelvic floor muscles are connected into so many other things.
Breathing again is that foundation. You can master your breath. You can start to help the pelvic floor move better.
Then we think about mastering that deep core. If we contract the belly again without bracing, without holding our breath, without crunching forward and squishing in, that deep layer of the belly is almost like if you imagine during pregnancy, you’re trying to, without moving, give your baby a hug. You’re almost like drawing that belly button up and then that’s how you activate that transverse abdominis muscle.
It’s just that low engagement, that pull-in. That’s one of the best things. Once we can breathe, once we can contract it and release the pelvic floor, we want to find that transverse abdominis muscle. We want to be able to engage that. That’s really building our deep foundation. It’s like pouring the foundation for a house, right? You can’t put the walls up until you have that nice solid structure.
Then it becomes even more about the functional things, right? What are your hips doing? How are your glutes functioning? We talk a lot about the glute amnesia or the sleepy butt muscles. Basically, you get the mom butt where it’s just tucked under and it’s not working well for you and you feel like, “Where did it go? Do I even have muscles there?” Strengthening those is a really, really great way to start to promote healing and strengthening in the pelvic floor.
That can look like a glute bridge if you’ve ever done yoga or bar, a super easy exercise to start waking up the glutes. Even squats, lunges, single-leg balance.
One of my favorite little tricks is standing on one foot while you’re brushing your teeth. Way harder than it sounds. You get a lot of that dynamic control because you’re having to balance at your ankle. You’re balancing at your knee. You’re balancing at your hip to stay on one foot.
Balance on the left leg while you brush the top teeth and then balance on your right leg while you’re brushing your bottom teeth. It’s a good challenge. If you’re brushing your teeth long enough, that’s a pretty good workout. Those can be just some little things. Some of that squats, bridges, single-leg balance, lunges, even step-ups, that sort of thing are all really, really good for creating that integration of pelvic floor strength with the hip strength and those other muscles that are going to give you really good balance.
Amy: Again, what just came up is, again, all that integration of all the different muscles and how they’re working together.
Strengthening pelvic floor muscles during pregnancy
Dr. O’Hara: Yes, for sure. Then what do we do during pregnancy? Because it’s a marathon, not a sprint, right? You want to really strengthen these muscles, prepare the body, and you got some time to do that during pregnancy. It’s not necessarily a time that we want to be starting something new. If you haven’t been a big exerciser, this is not the time to join some boot camp for hours and hours and hours a day, but it’s absolutely a time where, again, we can be walking. We can be doing even prenatal yoga.
There are a lot of really good options for that, both in-person classes. There are a lot of online options. It’s one of those good things that have come out of the last two years. There’s a lot more content available online now than there used to be, whether that’s prerecorded classes or live classes you can follow along with online. Tons of great just like prenatal yoga, right? It’s just moving. It’s getting blood flow.
It’s getting you finding some of these muscles around the hips, around the core, around the pelvis that are really going to go through a lot during pregnancy.
I like to break it up almost into trimesters like you break up parts of the pregnancy are the phases that you should be doing exercise during pregnancy.
You might not feel super great in that first trimester, right? Maybe this is the time where we’re maintaining the type of exercise that we were trying to do before pregnancy, but with some modifications, right?
If you were a big runner and you’re just feeling awful, maybe you, again, walk a little bit more. You’re taking that same time you’d spend running, but you’re going for long walks. Maybe you’re thinking about just doing some gentle strengthening at home. This could be squats, bridges, lunges, little things that just feel good to move. That can be a bit of a challenge when you aren’t feeling your best, but I promise even setting a timer for five minutes and practicing some deep breathing, just a little bit of movement can actually help you feel a lot better.
In that second trimester, we tend to get that almost a spurt of energy. Sometimes you start to feel a little bit better, but that weight and pressure in your body maybe hasn’t quite caught up. Again, don’t start training for a marathon at this point, a literal marathon. We’re training for a figurative marathon here, but we can do a little bit more strengthening. Maybe those walks are longer. Maybe we’re continuing to do exercise pretty consistently throughout that time and we’re still focused on strength here.
Again, we talked about that trampoline of the pelvic floor that’s trying to support growing baby. We need that to be strong. We can be doing some Kegels here. We can be working on hip strengthening. We can be working on that deep core strengthening too, keeping those muscles strong because they’re going to have a lot of stress on them coming up.
Then as we move into that third trimester, we’re thinking a little bit more about mobility. You’ve built that foundation of strength in your muscles. Now, we need to make sure they have that movement and that capacity to be able to relax and lengthen. There’s a common misconception out there that the pelvic floor muscles push the baby out. The pelvic floor muscles absolutely do no pushing whatsoever. The uterus itself is what’s contracting and releasing to help move the baby down.
The pelvic floor muscles really have to open to let everything out and to let baby out, right? This is assuming a vaginal delivery, right? There are lots of different gentle C-sections and things like that where you can push for a C-section. That’s a whole different topic of conversation, but talking just strictly about a vaginal delivery here, your pelvic floor muscles have to be able to open. Your hip flexors have to be able to open to create enough space in the pelvis to get the baby out.
We want to be thinking about that lengthening and that releasing. Again, breathing can be great here. There are a lot of different hip openers and different stretches that we can work on. Then at the very tail end of pregnancy, usually, around that 34 to 36 weeks, there’s something called perineal stretching or perineal massage that some people might be familiar with.
That’s a great thing to talk to your OB and your birth team about because that’s something that you can start practicing at home. There’s, again, a whole other topic that we could dive into here on, “Okay, is it helpful to do that perineal massage? Is it not? Is it going to stop you from tearing?” There’s not a lot of great evidence that says doing a ton of perineal massage will stop you from tearing. There’s no good evidence for that, but is it going to make you more aware of your pelvic floor?
Is it going to help you coordinate those muscles? Is it going to help you prepare for delivery a little bit better? Is it going to give you tools and techniques that might help? Yes, it’s like if you’ve ever gone to a hot yoga class, you can touch your toes in a hot yoga class if you haven’t been able to touch your toes regularly. You’re going to feel terrible later after you’ve done that. [laughs]
If you could practice a little bit of stretching ahead of time, then when you have to touch your toes in that hot yoga class, it’s going to feel a whole lot better the next day because those muscles were more ready for it. It may not prevent tearing, but it’s absolutely still a technique and a tool that’s worth it. As far as prevention, one more quick topic. I might be rambling a little bit here, but one more quick–
Amy: Keep going.
Dr. O’Hara: One more thing that I love to touch on here is I get this question all the time about, “Should I have a C-section to save my pelvic floor?” Absolutely resoundingly, the answer is no, it is not a C-section or vaginal delivery to save your pelvic floor. It’s what is best for you and your birthing team and your baby. There is just as much incidence of things like urinary incontinence and pelvic organ prolapse whether you’ve pushed a baby out or not, or had a C-section.
It’s a very personal choice for sure and a very emotional choice a lot of times, but there isn’t one way to save your pelvic floor. All of these things that we’ve just talked about, all of this prevention and this activity, and staying strong and staying mobile, and honestly just becoming aware of what your pelvic floor muscles are able to do and how you can use them, how you can relax them best, those are the things that are going to help your pelvic floor. It’s not a matter of the method of delivery, so to speak.
Amy: I love that you brought up too, all the reminders about the importance of being able to relax those muscles and the opening of those muscles because, a lot of times, we think if we’re starting to have– sometimes I thought I was just like, “I need to work the muscles harder.” Some of the issues may actually be that they’re not able to relax properly, which you don’t think about. That’s a lot harder to wrap your head around or to become aware of even how to do that, right?
Dr. O’Hara: Absolutely.
Post-partum and the Pelvic Floor
Amy: Okay, so like I told you, I got so many questions. I’m going to lump together a few of the questions here that are related to postpartum care since we just talked a little bit about pregnancy there. Some of the questions I received were, how can you know if your perineal tearing is healing well? What to do if it’s not healing well? If breastfeeding affects pelvic floor recovery, how can pelvic floor issues affect sex? How do you know if your body is ready to resume intimacy?
Then a big one that actually came up several times was, if you know you plan to have more children, is there even a point of trying to heal your pelvic floor or resolve issues with abdominal wall situation between babies? There were several questions, so you can answer that however [chuckles] it works best for you.
Dr. O’Hara: I love it. I love it all. Let’s take it piece by piece here.
Starting with tearing, lots of different factors there, of course, but in general, I like to think about that a lot like any other cut or tear or laceration in the body, right? We’re talking about normal healing time and that can take around four to six weeks at a minimum. That’s a lot of where they get that, okay, six-week cut-off.
You’re going to have a six-week postpartum check. We’ll see if you’re ready to go as they say. That’s basically to see, has everything healed the way that we would expect it to by that point? If you’ve ever had a scar or anything you know that how it looks at six weeks is not ultimately how it ends up healing, right? That six-week time frame is, “Hey, what is going on? Are we still having any bleeding there?”
You shouldn’t be having a lot of bleeding past that six-week mark. You shouldn’t be feeling any significant pain with sitting or want to hear a lot, “It’s like it feels like something’s pulling when I squat or pulling when I sit down or like a heaviness or a stinging sitting on the toilet maybe.” Those are all things that we would say, “Hey, maybe we should get this checked out again if it’s kind of that sharp stabbing really uncomfortable or stingy pain.”
Then as things heal, we think about it like a tight scar. Assuming that everything heals on the surface, looks good. No tearings that are still open. Then we want to say, “Hey, is there some sort of tightness in that scar, and do we need to mobilize that?” Just like you can massage scars anywhere else in the body ready for a knee replacement. You might massage that scar to help it feel better. Again, we talked about that, perineal massaging.
There are lots of different things out there that we can do to help massage some of that. I oftentimes will recommend using a vibrator on that area as well. Actually, it can help to just desensitize and break up that scar tissue. For anybody who’s super curious, we’re talking about like a small bullet-style vibrators, not giant ones. It’s all external that we’re working on that scar. Lots more detail that we could go into on that as well.
We want to make sure that that scar is moveable. It doesn’t feel super stiff or thick and it’s not stinging, burning, or tight. Those are all things that your OBs can assess, pelvic floor PTs can assess as well, and give you some tips and tricks if it doesn’t feel like it’s healing very well. There’s one other little caveat to that if you want to look at a scar as it’s healing. If there’s a lot of extra pink tissue, there’s something called granulation tissue that can happen with scars as well.
It basically is like you ever had an ear piercing or something that grew a little too thick. You can kind of get a keloid-type scar or that granulation tissue in the perineum as well. If something just doesn’t look right, doesn’t feel right, it feels like a little skin tag or a little flap or just one super sensitive area, I always recommend going back to your OB and just saying, “Hey, I think there might be some granulation tissue,” is sort of the keyword there.
It’s a super simple procedure oftentimes where they can actually paint that with a little bit of silver nitrate and it will just help it go away. It’s quick fix on that one, so there’s that. There’s your little tip on tearing. Look at it, honestly, is my biggest thing. It can be a little bit scary, but get out a hand mirror and just take a look. Be familiar if you haven’t had babies yet on what things look like before, know that it’s going to look a little different after, but knowing your body can really help you see if that tearing is healing well.
Breastfeeding and the pelvic floor
Then as far as what happens with breastfeeding and the pelvic floor, great question. Pelvic floor muscles are estrogen-sensitive and breastfeeding actually does kind of keep our estrogen levels just a little bit lower. Estrogen typically drops a little bit in the last phase of pregnancy and then it stays a little bit low, especially if you’re breastfeeding or you’re lactating, and then it slowly starts to come back up.
Your hormone levels don’t actually return to normal until at least six weeks after you stop breastfeeding. It can take a while. It can take even longer than that as well. Generally, we do have that decrease in estrogen with breastfeeding or lactating, so if you’re pumping as well. What that means is that the pelvic floor tissues, the vaginal tissues, might just be a little bit drier. Sometimes that dryness can affect healing.
It’s like having dry skin. It doesn’t heal quite as well as nice, soft, moisturized skin, but much like you can put lotion on your skin, there are moisturizers for your pelvic floor. Not the same necessarily as moisturizers you use in other parts of the body, but there are great things out there. If there aren’t any other hormone concerns, there are some topical estrogens that your healthcare providers, your OB/GYNs can provide and prescribe that actually can just help on that tissue itself.
They’re minimally absorbed into the bloodstream, so talking about that with your provider can be really helpful. Mixed evidence basically on whether it affects milk supply, but good conversation to have with your providers on that one.
Then if that’s not an option for you, you’re just not feeling like doing that topical estrogen, there are other vaginal moisturizers. There is something called Replens. There’s the vitamin E oil, coconut oil, aloe, lots of different potential things.
Again, that’s going to be kind of a personal decision based on what you’re feeling and then what your birth team can recommend as well. Each of them have their pros and cons. Using oil-based moisturizers or lubricants, not a good option if you’re using condoms as contraception postpartum because the oil actually can cause them to be more likely to tear. Lots of different things to think about with that.
Long story is you have a little bit of a drop in estrogen with breastfeeding and with lactating that can affect dryness in the pelvic floor. Not a reason to not breastfeed, but it’s just something to think about and to know that there absolutely are options and there are things that you could do to help with that dryness for sure.
Resuming intimacy post-partum
I think our next question there was, “How can pelvic floor issues affect sex and how to know when you’re ready to go back?”
Well, lots and lots and lots of personal decision there, for sure. There’s so many things surrounding pregnancy and delivery, if we’re talking about that as where the pelvic floor dysfunction comes from. If you feel ready, that’s a good start, right? It’s not something that needs to be forced, it’s not something that has a specific timeline, this can look different for everybody, and if you’re not feeling into it, at 6 weeks, or 10 weeks, or 12 weeks, that’s okay.
In general, we say, wait that amount of time because your uterus is still shrinking back down to its normal size, the pelvic floor muscles are still healing, the cervix is still closing. A lot of that wait at least six weeks, it’s kind of an infection risk side of things. That’s something that I always say, listen to the most, you can listen to that six-week timeframe as far as going back to sex or intimacy.
There are lots of things you can do that are not penetrative sex as well and those can be good ways to kind of build that intimacy, especially as a first-time parent, it can be really hard to find that with your partner, again, you just been through something amazing and crazy and traumatic on the body and sometimes, that can create maybe a little bit of stress on a relationship, or it can create a little bit of strain on you as a person too and even just sitting on the couch and holding hands with your partner or cuddling with your partner and your baby, like everybody together.
There’s a lot of that level of intimacy that can be really, really powerful, and really helpful for just creating that bond postpartum because you’re just trying to navigate this whole new family set up, this whole new sensation in your body. This whole new idea of who you are as a person and a parent, and that can be really, really challenging.
I think don’t underestimate some of the non-pelvic floor-related levels of intimacy there, but as far as the pelvic floor, knowing that your muscles feel okay, right. If we’re not having pain with sitting, we’re not having pain with urination or bowel movements. Those are really good kind of checkboxes to say, hey, am I ready for this.
And then don’t forget that lube is definitely your friend postpartum. Again, we talked about that dryness, you might need a little more than you did before baby, maybe you might need a different kind entirely and there are many options out there to kind of find that right fit and you might have to try a couple of them before you find the best one for you, but that’s definitely one of my top things, make sure you’ve got a lubricant with you when you do feel ready and don’t want anybody rush you.
Amy: Just to be willing to have those maybe awkward conversations with your spouse, I think is valuable, because they can’t read our minds. If you get upset at your spouse, because they didn’t read your mind, maybe use words to communicate, it might make it a little bit easier.
Dr. O’Hara: Communication is huge and it’s silly that it’s something we can be embarrassed about, especially when it comes to intimacy and sex when you might have been married for years, right? You could have been with this person forever and ever and ever and it can still feel awkward for some of us to talk about especially postpartum because things that were good or worked well or felt good before, might not feel the same postpartum and that’s perfectly normal, perfectly okay but again, your partner can’t read your mind. They do not know that and they’re going to be like, what on earth? I thought this was great. Why do you not like this anymore? You gotta tell them.
Should you work on pelvic health between pregnancies?
Amy: Right, exactly. What about this issue of if you’re going to have more children or you’re thinking about planning for that in the future? Is there a point to doing anything now?
Dr. O’Hara: Absolutely, yes. That is a resounding yes. There’s definitely a point to doing something between babies. Again, I think the easiest way to think about this is really to get to other parts of the body. If you ran a marathon and it didn’t go really well, but for some bizarre reason, you had decided I’m going to sign up for two marathons. Let’s say that they’re are a year and a half apart, and you’ve already signed up for them. You’re going to do these two marathons. You do the first one, and you’re like, oof, that training maybe wasn’t great. Maybe I pulled my quad running this race or, got ankle pain, and I don’t know, it doesn’t feel good. Would you do the exact same training before the next race?
No, absolutely not, you would try and heal and recover, you would treat that quad strain, you would treat your nagging ankle, you’d buy some new shoes and get yourself some new running clothes and you would try it again a little differently, right?
When we do have some of these things that arise postpartum, your body’s been through a marathon, right? It grew this baby, it got this baby out and into the world and it is beautiful and amazing and we want to honor that and we want to let those muscles recover because it’s going to make things feel much better the next time. Again, rehabbing the core, if we’re talking about diastasis, if we think about the abdominal wall is again, kind of giving the baby a hug, right?
We expect to have a separation of those muscles at the point of delivery, anybody who makes it full term will have some degree of separation in the abdominal wall. Absolutely normal. It absolutely can heal on its own. Sometimes, it needs a little bit of help and the stronger we are going into pregnancy and delivery, the easier that recovery is. If you have a diastasis after the first pregnancy, you can heal that, rehab it, get it strong and it will make that next delivery much easier, it will make your recoveries here.
I think what I see time and again, in this field is a lot of people say hey, I didn’t think there was a point in doing something for first baby, or I felt really great after the first pregnancy and then waited five or six years and for the next one, I wasn’t prepared.
Learning where these muscles are, learning how to strengthen, can really just help set you up for success and make that recovery just so much easier and I always like to remind people, after the first pregnancy and delivery, more often than not, you are kind of recovering as your baby gets more mobile, right? Baby’s not going anywhere the first couple of months right after you deliver, right?
When you have a second one, the first one is mobile. The first one may or may not be old enough to help out but they’re definitely going to be more mobile and moving around so you’re going to have to chase after them and you’re not going to have that same kind of slow introduction into mobility and so when you’re stronger going into that, right, it can just make that whole transition from, one to two, two to three, whatever number we’re at, baby wise, it can just make that much easier. Yes, heal and recover between for sure.
Amy: I love that word picture of you wouldn’t do one marathon and then just be like, wow, I pulled a muscle. I guess I just won’t do anything to prepare for the next marathon. Yes, I was like, that’s where I’m like, oh, guys, please learn from my mistakes. Don’t wait like five children in before you try to deal with problems. Not a good plan.
Pelvic Floor, Urinary and Rectal Incontinence, and other Bathroom Issues
Another really common question that came up repeatedly was all sorts of related to bathroom issues.
Of course, there’s common issues of urinary incontinence or frequent urination, or difficulty emptying the bladder fully. One listener mentioned that she has an urge to pee whenever she lifts or carries her toddler. A lot of people ask questions related to bowel function, and sometimes, it’s difficulty evacuating the bowels or feeling like there’s a bulge or pressure or then the opposite end with rectal incontinence. Are there any practical strategies we can implement to deal with all of these elimination issues because this can just really affect your ordinary life and they can be embarrassing.
Dr. O’Hara: Absolutely. The easiest number one thing you could probably do today without having to go anywhere is get yourself a Squatty Potty. I wish they paid me to sell squatty potties, but they do not. If you’re not familiar, look it up. They were on Shark Tank, I think a number of years back. Basically, they just got this awesome market on creating a step stool for your toilet. Most of us here in the US have what they like to call Comfort Height Toilets, which mean you don’t have to squat down as low to sit on the toilet but it also puts your pelvic floor and actually a really not great position.
When you sit on the toilet and your knees are lower than your hips, your pelvic floor doesn’t relax all the way because you’re almost still standing a little bit. You’re still in kind of this upright sort of position. For your pelvic floor muscles to be able to relax, you really want your knees up a little bit higher than your hips and you want to be fully supported.
This does not mean that you’re perching on the side of the toilet or you’re holding your knees up in the air with your hands. I’ve seen all sorts of creative things. It doesn’t mean pointing your toes so that your heels are lifting up.
It means prop your feet up on a little step stool. It could be your kid’s little potty maybe if that’s by the toilet, it could be a trash can, if you could turn it on its side and prop your feet up on that. I’ve seen people use two rolls of toilet paper to put their feet up on to get their knees up a little higher. Whatever works, but Squatty Potty brand is out there. Their basic one will cost you 20 bucks on Amazon, I think, or bed bath and beyond.
They’ve got fancy bamboo ones that will match your decor. They got the market on everything. They got a SpongeBob-themed one out there, everything. That Squatty Potty is great and it’s marketed to help with bowel movements, but I do find that it can be helpful for emptying the bladder as well.
Couple other really, really big tips that I think you can start doing right away is quit speed peeing. If there is somebody at the door knocking, tell them to wait, your kids will be okay for the next five seconds that you spend sitting on the toilet and breathing and releasing everything. If you are trying to force urine out super fast, you actually can create some tension in the pelvic floor so you’re stopping yourself from emptying all the way.
Sit, relax as best you can. I know it’s easy to say relax, and it’s not a very relaxing thing, but making sure that you can breathe, letting everything go, don’t try to force it out. Those are some super helpful things.
As far as not being able to empty the bladder all the way, sometimes it’s again about that positioning of the bladder.
We talked a little bit about prolapse and this could be bladder emptying or bowel emptying. If your organs are sitting a little bit lower, there might not be quite as direct an exit for the things inside. We may have to do some little rocks side to side. You’re doing a pelvic tilt if you’re familiar with that, or twerking a little bit, but in slow motion.
A little like rock forward and back or side to side, even just leaning side to side. Those little movements can help shift things around a little bit better as well.
As far as bowel movements, there are some different techniques that you can use to help just give a little bit of support, even using a little bit of pressure, just gently against the perineum can help with rectal prolapse or any bowel prolapse.
Just giving a little bit of support externally to the pelvic floor can actually be helpful for emptying the bowels, but lots of different strategies. If none of those are working for you, then do give your local pelvic PT a call because we would love to talk in more detail with you about it for sure.
One more thing I wanted to touch on there with the urge to pee whenever you lift the toddler or the baby.
That always comes back to breath for me. Whoever you are out there who has this question, try breathing out when you lift your toddler. A lot of times, it’s just that pressure of lifting the baby up, holding your breath, that’s pushing down onto the pelvic floor.
Then it’s the physical pressure of baby sitting on your belly or your bladder or toddler sitting on your belly or your bladder. Try just giving a little bit more support, don’t rest your toddler on your hip or on your belly, and then make sure that you’re breathing the whole time. That should be really helpful for that as well.
Amy: Really good tips. I’ll say too, I was at Aldi and saw it must have been an off brand. I doubt Squatty Potty was at Aldi, but they’ve even come to Aldi so you can find anything you need there. Such an easily accessible thing that can make a huge difference.
How can we choose the best online pelvic floor or diastasis recti program?
Well, one mom asked, she said I’ve been looking into online or do at home programs for pelvic floor and diastasis recti healing because right now, she doesn’t have access to a PT and she’s seen some similarities among the programs and some differences. She was wondering what she should be looking for and if there are any red flags, if she sees it as she’s reading or researching a program or any methods she should avoid, or I guess on the flip side, be looking into.
Dr. O’Hara: Yes, one of the things that I really look at with all of those online programs is be wary of things that promise you everything. When you have a program saying, so we can help you with all of these different things. We’re going to help you have a super-strong pelvic floor and heal this and heal that.
If it sounds too good to be true, it probably is.
We want to make sure that we have qualified people that are creating these programs and providing the content. What I see a lot is people who have gone through pregnancy and done their own exercise journey and they’re trying to market this saying that, “hey we have the best core exercises. We’re going to help you with everything.”
Certifications aren’t everything, but personal experience also isn’t everything. Knowing that who is designed the program is qualified to do so. Are they a personal trainer with actual credentials in pregnancy and postpartum rehabilitation and conditioning, there are certifications for that.
Are they pelvic health, physical therapist? There are programs out there that are designed by PTs and do they offer you resources for if this doesn’t work? A lot of times, these programs will say, this is what you should be doing. You’ve got to do all of this and it feels too good to be true. They put the blame on you. Well, if this doesn’t work, it’s not our fault. It’s you that didn’t make it work in this program.
That’s not the case, not all programs work for everybody. They are not one size fits all, but they are fantastic resources. Don’t listen to every single thing that’s out there and take that as the one thing you’ve gotta do, be inquisitive, be questioning for some of these different programs, and look at the credentials for who developed them. Do they give you resources for your local community or places to find that?
As far as access to PT, I know there’s lots of different types of access out there, but again, one of the nice things that’s come out of the last couple of years is that there are a lot more online resources. While it’s not our first go to most of the time for pelvic floor conditions, for diastasis, there are PTs myself included who offer telehealth services and that can be really great.
For some practices, some providers, it can be covered by insurance or reimbursed by insurance, which is great too. There are options.
If you find a program that doesn’t seem like it’s working out for you and you want a little bit of extra, there are other options out there that could be more of a personalized, but still virtual, helping with that access side of things too.
Amy: I’m so thankful that I was able to come and get help from you a few, several years ago. It was not covered, but I just sort of, my husband and I talked about it and we viewed it as a worthwhile investment because if I continued down the same path, I was going to end up needing surgery or some crazy intervention later on that was probably going to be a lot more expensive in both time and money than doing a little bit of prevention on this end.
Is a Specialized Pelvic Physical Therapist Necessary?
For the mom who is able to go to in-person physical therapy, what are the first steps she should take? Is it necessary to go to a pelvic specialist if you’re dealing with these issues? Are internal exams necessary? I know one of my listeners emailed and mentioned she had gone to her doctor and to a PT that neither did an internal exam to evaluate her prolapse, which seemed a little odd to me, but maybe that’s typical. How do we go about just choosing a PT who will actually help us? Because we’re busy. If we have to take the time to do this, it needs to be worthwhile.
Dr. O’Hara: Yes, absolutely. Again, there’s so much out there these days. I think in the world of social media, there’s a lot more people who are hearing about pelvic health, providers included, and who want to market that.
It’s not necessary all the time to do an internal assessment. I have lots of patients who come in and they maybe just don’t want to. They’re just not comfortable with that internal assessment.
For anybody who doesn’t know in the PT world, an internal pelvic floor assessment is basically how we do muscle testing and we see the tone of the pelvic floor muscles and we figure out what your strength is and how well the right sides work and the left side work and all that jazz. It’s a little bit seeing a gynecologist, although we just use a gloved finger inserted vaginally or rectally, depending on what we’re assessing.
We don’t use stirrups or speculums. It tends to be much more comfortable than a lot of those speculum exams, but it does help us assess for strength and prolapse and really get that good idea of what is going on with your muscular system.
They aren’t necessary, but they’re a huge part of the puzzle and they can be really, really helpful in, one, accurately figuring out what’s going on. There are a lot of symptoms that can sound like prolapse that are actually tight muscle in the pelvic floor. A knot in the pelvic floor can sound and feel from a symptom perspective, a lot like prolapse.
We want to make sure that we’re appropriately figuring out which one that is, so not necessary, but probably useful, especially when you’re diagnosing prolapse.
I would say if you’re having a lot of these pelvic floor issues, you’re feeling stress incontinence or fecal incontinence, so we’re losing urine or bowel movements when we don’t want to, you want to make sure that you’re going to a specialist.
Same thing’s true, even of diastasis recti. We touched briefly on the fact that the pelvic floor and the abdominal wall are best friends. If you can’t get that good assessment of the pelvic floor, or you’re not familiar enough with those tissues, you’re going to be missing something as a provider, treating somebody who has diastasis, if you’re not also able to address the pelvic floor. Long story short, yes, I do think that it’s pretty necessary to see a pelvic specialist.
The nice thing is there are a lot more orthopedic PTs out there that know when to send people to a pelvic specialist. If you’ve gone or you don’t have access to a pelvic PT, and you’ve gone to a regular physical therapist, most of the time, they know somebody who’s a pelvic floor expert and they can say, “Hey, I’m going to send you to this person or do you mind if I consult with this person and ask them a couple of questions about your case,” and so we’re pretty good at networking with each other in the PT world to make sure that our patients are getting the best care.
If you can’t get to a specialist, I don’t think it’s the end of the world but I do think that first choice gold standard would be, go see a pelvic specialist for these things.
Again choosing a PT can be so personal as well and there are so many options out there, much like the online programs, be wary of somebody who says they can do absolutely everything because we’re not miracle workers. We want you to be able to be successful.
Look for somebody who has the time to listen to you, and is going to goal set with you and not tell you, well, you can never run again because you’ve had a prolapse. That’s absolutely not true. You want somebody that says, “Hey, maybe if you have a prolapse and you want to run, maybe we’re going to modify that so you feel comfortable on these runs. Maybe we’re going to get you some support. We’re going to try these different things to make that run more comfortable or to let you be able to go to that cycle class and be more comfortable. We’re going to take it back before we build that up, but we’re going to get there.”
You want somebody that’s working with you setting those goals. Then, ultimately, who do you feel comfortable with because we’re going to ask you a lot of personal questions. If that wasn’t clear by the things that we’ve talked about so far today, we’re going to ask you all the questions and you don’t always have to tell us the answers right away, but you’ve gotta feel comfortable enough with your provider to figure that out and see if it is a good fit and are you comfortable asking those questions, answering those questions.
Most of us are more than happy to do what we call a consultation call. If you do find a PT and you’re curious, ask them if they do a free 15-minute phone consultation, or if you can email them and ask some questions.
To me, that’s one of the best ways, because I’m comfortable asking these questions, but I want you to be comfortable giving me the answers back so I am more than happy to talk to anybody on the phone first and see if it would be a good fit. Those are all good ways to see and there’s always the insurance question as well.
Some providers take insurance, some don’t, you already touched on some insurances cover therapy and some don’t. I think that insurance should cover everything, but it’s not always the case so if you are using insurance and you want to make sure that that’s covered on the front end, that’s a question to ask.
A lot of providers are also going to more of an out of network model where we’ll provide you with a super bill, will provide you with a itemization of what we do that you can submit to your insurance and get reimbursed later. It cuts out the middleman a little bit for the providers and it lets us be a little more focused on you versus focused on the insurance companies, which is a good option as well for those people who can go that route.
How do you know if you need to go back to pelvic PT?
Amy: Those are really good tips. I guess another question that came up is if someone goes to physical therapy, how common is it for the symptoms to be reaggravated or how do you know if you need to go back?
Dr. O’Hara: Yes. I always like to leave people with a toolbox so I want you to leave PT and not necessarily have exercises you have to do for the rest of your life, but I want you to have these tools, and we don’t all expect to feel a hundred percent all the time. Sometimes, we sleep weird and our shoulders hurt, or our neck hurts, or we stub our toes and we don’t feel great, but we know we can stretch our necks. We can sleep a little better, get a new pillow, stop running into the coffee table and we’ll feel better.
I want you to have those tools after you come to physical therapy and so you have these list of things that say, “Hey, if I go back to cycling and I start feeling some of that heaviness and pressure, again, I’m going to pull out this sheet or I’m going to pull up that email and I’m going to go through a couple of these stretches and exercises, and I’m going to do them for a little bit. If they don’t take care of that issue, that’s when I’m going to go back or if it feels different than it did the first time.”
It’s common to have things flare up and come and go, but it shouldn’t be to the same extent and a lot of the cases are we stopped doing our exercises. We got a little lazy, that’s alright. Life happens. That is totally fine, but you’ve got these tools where you can start them again. You can do them for a week or two. If it feels like things aren’t getting better in that week or two, call your PT, call your provider, and see if you need to go in again.
Amy: Yes. Again, it’s like just being aware of your body. I’m just so much more aware of things now so that I can make those micro-adjustments on my own so that I don’t end up back where I was. This has been such a great conversation. Thank you so much for taking the time to share with us. I know this is going to be an encouragement and a help to so many moms who are listening.
What Meghan is reading lately
I’m just really excited, but here at the end, I do want to ask you a question I ask all my guests just what are you personally reading lately?
Dr. O’Hara: Yes, I am a huge nerd. I will be perfectly honest. I read a lot of research articles on physical therapy because I love it and I think it’s fantastic. When I’m not reading research articles, I am a big fan of like murder mysteries and cheesy beach reads. I like things that are a little light and fluffy. Sitting on my nightstand right now is The Seven Deaths of Evelyn Hardcastle. I’ve heard good things about it. I think it’s a murder mystery of some sort, but I am not far enough in to tell you if it’s any good yet.
Amy: Okay. I will have to check that out. I’m a big fan of murder mysteries as well. There’s something very soothing for some odd reason, some murder mystery. Everything just gets tied up in a nice bow at the end. Justice is done. It’s lovely.
Dr. O’Hara: It really is.
Amy: Meghan. Where can people find you all around the internet?
Amy: Great. I will have those things linked up in the show notes for this episode over humilityanddoxology.com. Thanks so much, Meghan.
Dr. O’Hara: Thank you.