I’ve never seen a Pelvic Floor Physiotherapist (PFPT). I drove to the appointment not knowing what to expect. I have carried three babies to term, had 3 vaginal deliveries, tears to my perineum, experienced urinary incontinence, diastasis recti (DR) and have an umbilical hernia. I was the prime candidate for assessment. After my second child I experienced symptoms of pelvic organ prolapse such as trouble holding in urine (of course 5 years ago I didn’t realize these were prolapse symptoms as I was often told a little leakage postpartum is normal). I speak to women all the time who have accepted their prolapse symptoms as normal. When they see me for core issues and I mention symptoms such as pain during sex, struggling to insert a tampon, and a feeling of heaviness they are shocked to realize the secret issues they have been secretly struggling with are all interrelated.
Nobody talks about the postpartum body. We see images of the snap back, celebrities sell you their weight-loss shakes and laxatives teas and flaunt their flat postpartum bellies. Meanwhile behind the scenes women are accepting chronic pain and leakage as normal.
I never heard the words diastasis recti until I had it. People laughed about moms peeing themselves but nobody talked about its significance. I recently watched a reality TV show where a group of women discussed incontinence over lunch yet no mention of exercise was made. They spoke of lasers and surgery to address the issue yet both of these strategies have a much lower success rate than corrective exercise. Nobody tells you constipation could be a core issue. They don’t tell you what to do if your hips hurt or if it feels heavy in your pelvis. Nobody talks about prolapse. Until a couple of years ago I had never heard of the term. A pelvic organ prolapse is when your pelvic organs shift from their natural position due to compromised Pelvic Floor Muscles (PFM). This means the bladder, uterus or rectum move and drop from position affecting their ability to function properly. This is why it can cause you to leak urine under pressure (coughing, laughing, sneezing, jumping), to be unable to have a successful bowel movement (constipation) and to feel the weight of your pelvic organs on your pelvic floor (the heaviness). In some cases a pelvic organ even can fall into and even out of the vagina! Many women don’t know this can even happen until faced with it.
Seeing a Pelvic Floor PT should be a standard service for all postpartum women. Yet when I tried to make my appointment I discovered my local hospital did not provide this service nor was it covered by insurance. I had to pay $125 out of pocket to be accessed. The irony is that if I needed surgery to address pelvic floor issues it would be covered by the health authority, a process that would cost much more than seeing a PT and is often much less effective.
You are physiologically different after having a baby. Over 9 months of pregnancy a growing fetus and uterus means that other organs are pushed out of place. The PFM go from carrying little load to supporting the weight of a growing fetus, enlarged uterus, placenta and amniotic sac. The diaphragm muscles, which allows the lungs to expand and contract during breathing, becomes restricted so breathing becomes more difficult (which is why heavily pregnant women often feel out of breath). The inability for the diaphragm to fully contract and lower during the third trimester of pregnancy means this muscle weakens, making it less effective postpartum. Oxygen is needed to release energy so when the diaphragm is compromised many women experience low energy. Over 9 months your body changes, then labour happens, and over several hours your body dramatically changes again. The baby is delivered but all your organs are still displaced. Your PFM are weaker than they were, your diaphragm is weaker, your abs are more relaxed and your fascia is stretched. It is important to know this because many women don’t understand how much they have changed physiologically.
Did you know a woman goes through more physiological changes in nine months of a pregnancy than a man will experience his entire life?
Pregnancy affects the position of your organs, the laxity of your muscles, the amount of pressure within your body and the load on your muscles. Huge amounts of internal pressure are generated during labour and if not well managed this pressure can be extremely damaging to the body causing micro tears in the fascia that connects the abdominal wall and damage to the pelvic floor. Postpartum is recovery. Pregnancy affects the body like an injury . So much is written about bouncing back but you don’t bounce back from a major injury. You recover from an injury. Can you imagine any other instance of a major injury where physiotherapy is not recommended?
If you have surgery on your knee you would not expect to run a marathon 6 weeks later. After surgery surgery your first course of action would not be to go to a gym and start doing high intensity training. That would be a sure fire way to ensure you never ran again again. You would see a physiotherapist and rehab the knee. Then after several months you would start gently training it with low impact movements. Over time you would increase the intensity based on how the recovery was going.
Women come from having babies and their bodies are in recovery mode. But instead of seeing a PFPT they are jumping into high intensity training and bootcamps, suffering through and not understanding why their symptoms are worsening. Women are being given clearance by their doctors to return to normal exercise at their 6 week appointments, sometimes with no internal exam, no assessment of the function of their abs or pelvic floor and no general guidance as to how to begin.
“Every woman needs a vagina coach”- Kim Vopni (@vaginacoach).
Yesterday I had my first appointment with a PFPT. The appointment began with a chat. I was asked questions that I knew were to indicate if I had any symptoms of prolapse:
Did I ever leak pee when I laughed, coughed or jumped?
Did I ever find it difficult to pee?
Did I ever had a sudden uncontrollable urge to pee?
Was I ever constipated?
Did I find sex painful?
Was I able to insert a tampon with ease?
Did I have a feeling of heaviness in my pelvis?
These are questions that you’d think you should be asked by a doctor at your 6-week check-up but this is the first time any health professional had ever asked me these questions. She tested the strength and mobility of my back and hips. She checked the DR and tested its depth and how well tension transferred through my linea alba. Then she began the pelvic floor exam. The first part of the exam was external. I was directed to do a pelvic floor contraction and she watched how my muscles and organs reacted. She checked whether I knew how to lift my pelvic floor. She checked the position of my pelvic organs during the exercise, and said that many women when told to kegel bear down instead. The second part of the assessment internal. At my 6-week postnatal check-up my doctor had not given me an internal exam, so this was the first time since delivering I’d been checked. She asked me to perform a pelvic floor contraction and felt how the different parts of my pelvic floor and pelvic organs reacted. She checked if any organs has descended or shifted position. She tested the strength of my perineum and checked for restrictions and scar tissue (I’ve had stitches there 3 times). She asked me to cough and tested how well my pelvic floor was able to handle the pressure generated.
After the appointment we sat down to talk about the results. The PFPT was able to tell me that my pelvic floor functioned well under pressure, it responded to changes in internal pressure and was able to contract when needed and relax without issue. It demonstrated good strength and endurance. She said my pelvic organs were in their correct positions and did not appear to have shifted or dropped from their natural position. I have not had any pelvic floor issues during my recovery from this third pregnancy so it was a review I expected. She said she would expect a woman’s pelvic floor to return to to the state that mine is in by 2 years postpartum so at 8 months postpartum I was well ahead of the curve. I’m glad I made the appointment and was pleased with the results but I know had I had this appointment 5 years ago the results would’ve been quite different. I’ve said more than once the DR was a blessing in disguise because it put a focus on my core health and made me have to learn how to re-train it for strength and function rather than aesthetics. It is the same techniques that healed my DR that healed my pelvic floor. DR meant I had to stop just looking at my body from the outside and start considering what was happening on the inside.
I remember after having my second child and learning of my own diastasis recti. I made an appointment with the doctor to confirm the self-diagnosis. When I was examined the doctor confirmed that my abs were significantly separated, my linea alba did not demonstrate much tension and confirmed the existence of a hernia. She recommended surgery as a course of action (never making any mention of exercise) and requested an appointment with the General Surgeon. I was told there was a long waiting list and it may be several months, so I went home to wait. Beyond the distended belly I experienced other symptoms: a constant aching lower back pain, inability to hold in urine so began using panty liners to control the leakage. I felt constantly tired and like I was living in a body much older than my years. While waiting on an appointment with the General Surgeon I decided to see what my other options were. Through research I discovered instances of people improving and even healing their DR by corrective exercise. I decided to learn as much as I could about how exercise could help heal a DR. I bought every book I could find, read every free program, and purchased a couple of paid programs. Later I would go on to get certifications in personal training, postnatal fitness, fitness nutrition and diastasis recti. Over several months my DR and overall physique began to improve. It was 7 months before I was able to see the General Surgeon. By the time of my appointment I had significantly healed. My stomach was no longer distended, I understood how to prevent the doming and trenching in certain movements and I had a better understanding of how my core strength affected the appearance of my abdomen. My back pain was nonexistent, I no longer experience leakage or had to wear panty liners. After being examined I was told that my linea alba demonstrated good tension and my abdominal muscles were strong. The same team that several months earlier told me I needed surgery was now telling me I did not.
The human body has an amazing capacity to heal but women are often not given the tools to heal it. Diastasis recti presents itself as aesthetic and it is the doming belly that often gets your attention. I am thankful for it because without the doming belly I probably would’ve never addressed my pelvic floor issues, would have never discovered a passion for exercise, would have continued training incorrectly and I would have continued, like many women, accepting incontinence and pain as normal. Many women are wearing pads daily to control the leakage. They are being sent for surgery rather than therapy. Women are being sold waist training as a means to reduce their waistline and toxic teas as a way to flatten their stomach. If you want to recover properly postpartum start with the place it all began. Go get your vagina assessed. You need to see a Pelvic Floor Physiotherapist.
If you need help healing your diastasis recti, check out my 12-week core retraining program, Abs After Baby. It is a step by step progressive full body exercise program with a focus on the recruitment of the deep core muscles needed to heal a diastasis recti. The program comes with a digital full colour guide along with video links to the exercises with demonstrations and movement breakdown. Included is access to a private Facebook group where videos can be posted for remote personal training (review of form and technique). There’s help every step of the way to get your abs, core and pelvic floor strength back after babies.
Photo credits: Samantha Stuart Photography, Adrien Barrieau Through the Glass Photography, Samantha Adrianne Photography