Fitness in Pregnancy and the Pelvic Floor

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi, everyone. I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time. During this season we are focusing on topics related to pregnancy and obstetric concerns. On this episode, I'd like to welcome Dr. Rachel Barron and Katie Menard who will be talking with us about physical activity during pregnancy and the pelvic floor. Dr. Barron, Katie, thanks so much for joining me on the podcast.

Rachel Barron, MD:

Thank you so much for having me.

Kathryn Menard, DPT:

Thank you.

Erica Newlin, MD:

Can you each tell us a little about your role in the Cleveland Clinic and a little about your background? Katie, you can go first.

Kathryn Menard, DPT:

Yeah, sure. Like she said, my name is Kathryn Menard, DPT. I'm one of the pelvic floor physical therapists within Cleveland Clinic. I have been with the clinic for about eight years now and I am located at Lutheran Hospital, see females, males within the pelvic health space.

Rachel Barron, MD:

And I'm Dr. Barron. I am a, what's considered general obstetrician/ gynecologist. So I do a little bit of both sides of the practice. I deliver babies, take care of pregnancies that are both low risk and high risk, but I also do gynecologic care and everything from just abnormal uterine bleeding, menopause. I do surgeries. But definitely I have a special interest in healthy pregnancies and helping pregnancy stay healthy as far as exercise.

Erica Newlin, MD:

Let's start by talking about exercise and pregnancy. Can you exercise in pregnancy?

Rachel Barron, MD:

I try to kind of simplify it for patients. I want you to do most things, but I just don't want you to fall or get hit in the abdomen. So running, walking, ellipticals, swimming, yoga, different resistance exercises, there's all sorts of things that are good but, and, a good example I think of, for example, falls stationary bike is a really excellent low impact exercise, but I don't really want patients on a road bike because there is that chance of hard falls off your bike.

Similar to that like a lot of different sports are great, but a lot of them have that potential to get hit in the abdomen. So a lot of team sports and such that you might have been doing, great but it's time to pause for pregnancy. So there's so many things you can do but kind of just looking out for, again, things where you could fall and things where you could get hit in the abdomen. And like you could fall walking down the street.

But I'm kind of looking for, like I said, like that road bike where it's a very dangerous fall. The other thing I stress is kind of temperature. We know that it's okay to get warm, it's okay to get sweaty, but we want you to avoid where it's like incredibly hot outside and you can't cool down your body getting dehydrated. Or the other thing that can come up a lot, for example, hot yoga where the environment is artificially elevated to be more hot. Great sometimes in your life, but pregnancy is a time we don't want your body overheating.

Erica Newlin, MD:

Yeah. I've had a couple patients who were downhill skiers and they're like, "But I'm a good skier." It's like probably not the best.

Rachel Barron, MD:

Mine's horseback riding. I've had a few of those too.

Erica Newlin, MD:

Yeah.

Kathryn Menard, DPT:

Oh.

Erica Newlin, MD:

Yeah, yeah, yeah.

Rachel Barron, MD:

I'm like, great core engagement. But if you fall off that horse, even if you're excellent, it can be something that turns into a very dangerous situation when you're pregnant. So I think the most simple answer is just yes, yes, anybody, whether you're having a low risk and most high risk pregnancies, whether you're in shape, you're not in shape, pretty much anyone that's pregnant, there is some form of exercise we not only say you can do but actually should do.

Erica Newlin, MD:

Let's talk about cardio exercise. Is there a safe amount? What should people think about when it comes to pace? What considerations should people have?

Rachel Barron, MD:

ACOG, which is the American College of Ob/Gyn, they kind of give us a general target to aim for, which is 150 minutes a week. But that specifically is split up. Like we don't want you just exercising that in one big bulk workout once a week. They even say, preferably you're working out a little more than three days a week or on average three days a week and kind of splitting that up. But that's still a lot of minutes. That actually comes out to being about 30 minutes five times a week, which is asking a lot of most people.

Erica Newlin, MD:

And when it comes to intensity of cardio exercise, are there limits for people?

Rachel Barron, MD:

Cardio is probably the thing that's best studied in pregnancy. The overall statement they say is that they're looking for a what's called a moderate intensity or a moderate vigorousness. So there's not really like a number we look at as much as like how much does it feel like to you? Cause everyone's going to have a different level of fitness. So they talk about that you can get breathy, but you can still say a sentence. And that's just kind of a safe level that we can say for everybody. That's not the max that everyone can do.

So most people could be at a much more vigorous level, which is, you know, not really being able to say more than one or two words. Again we're, there's some heart rate things that we're looking at, but again, so many people's heart rates are different just due to being pregnant or just people have different levels that their body just lives at.

So I have more focus on what we call perceived exertion, like how hard does it feel. And if you're used to being somebody who does vigorous exercise, so running, you know, biking hard, getting yourself out of breath, sweaty really for the most part that is safe to maintain while you're pregnant.

Erica Newlin, MD:

So would suffice to say that there's not a specific heart rate limit as much as an exertional limit?

Rachel Barron, MD:

Yes. And sometimes I talk about not exceeding like the 90th percentile rates and such like that, but again, I find most people they aren't monitoring that throughout. It's more trying to stay aware of, like, we don't want you to be trying to beat your best ever time, to push yourself to either a speed or, or a level of exertion that you've never been to before. Pregnancy is not really the best time for that. But if you're maintaining what you have done, that is very safe.

The other thing though is for people who have never worked out and they're nervous to say like, "Well, I'm trying to make some good changes, trying to develop some new habits. Can I get myself to that place of being uncomfortable?” That's where we're kind of looking at that moderate intensity. That is a safe place to kind of push yourself to, even if that's not something that you've previously been comfortable with.

Erica Newlin, MD:

And you mentioned that exercise is still safe in high-risk pregnancies. So would it be fair to say that there are few situations where exercise would be what we say contraindicated?

Rachel Barron, MD:

So what was really interesting was to be ready for this, I tried to really look up those high-risk pregnancy situations because in general in obstetrics we always are a little extra cautious. And a lot of times it's, it's a hard thing to study. You're not volunteering your baby and yourself for a lot of these studies if you're already having something high-risk going on. But there's kind of a short list of things that we kind of say, If these are going on you should be more cautious or like really have a good discussion of your doctor, like, how concerned are we about these things and what's the right decision for me?

Cause in a lot of them, we don't actually have evidence that it, it harms your pregnancy but they're things that we do want to pay more attention to and, and that's where you should pause and talk with your doctor. So kind of what I have on my list is what we call cervical insufficiency where that means your cervix seems to have in a prior pregnancy or in the current pregnancy not be holding well.

Or if you've had a cerclage placed, definitely you should talk with your doctor about what you decide together as a safe amount of activity for you. If you've had a history of preterm labor or PPROM, which is a premature preterm rupture of membranes, in other words your water breaks early. We would also want you to kind of discuss because there is some signs that actually exercise decreases preterm birth.

But in the people who've had preterm birth, we actually... Nobody has really signed up for or done a good study on that. Vaginal bleeding or if your placenta is in an area what we call a previa, if you've had issues of high blood pressure, we'll... I think we're going to talk about that in a little bit. But, again, just something to maybe talk about. And the other big thing is anyone who has heart conditions, so more than a lot of people have what we call palpitations.

They might kind of feel like they're heart beating a little bit harder and that's not so much what I'm talking about. But if you have a known heart condition where you're already seeing like high-risk doctors to make sure your pregnancy goes well, definitely you should touch base with them on how much can you stress your heart and exercise.

Erica Newlin, MD:

And we were talking a little bit about bed rest before we started recording. We kind of historically a lot more people were placed on, on bed rest during pregnancy and now it's been determined that was doing more harm than good.

Rachel Barron, MD:

Yeah. We've actually shown risk to being less mobile. It decreases not only our strength but it can increase our risk of clots. And it really has not been shown to affect most of these kind of complications I just listed. Like holding still doesn't seem to help. It may actually hurt and moving may actually help them have a lower risk.

Erica Newlin, MD:

Let's pivot over to strength training and weight training. Is there a weight limit to lifting in pregnancy?

Rachel Barron, MD:

This is even less studied than aerobic exercise and kind of just looking through studies and also just we were kind of talking amongst ourselves. It's such a tricky thing because everyone has like a different, you know, baseline strength. What are you lifting? How are you lifting it? There's so many different ways to do strength training or resistance exercise is another thing we mentioned. So you can be working strength without actual weights. You can be doing various body weight things or resistance devices. So there's not like a top weight to answer your question that we tell people you can't use.

What I more describe to patients is there's something called the Valsalva maneuver. I think of it as like that pushing into your pelvis, like if you're trying to have a bowel movement, kind of that sensation you feel in your pelvis, specifically what we tell you to find to push your babies out. We don't want you to be pulling or pushing something where you're really having to engage your core like deep into your pelvis and push.

We've actually not shown that that is harmful, but it's kind of again, us taking the cautious approach that if we're using that to push other things out, you know, is it safe to be putting that much pressure on the uterus, on the pelvic floor while pregnant? The other thing is the Valsalva can sometimes change both our, like our blood pressure, our blood flow, depending on how long and how intensely you're doing it. So there's a question of does it like temporarily interrupt blood flow to the uterus and therefore the baby?

Again not well proven but just kind of always taking that cautious approach. That's kind of the line I tell people to work towards. But that being said, there's a lot of things we can do to engage our muscles, strengthen our muscles, including... And we'll talk about this a lot more, like we do want to strengthen our core, our pelvic floor, our lower body. Like that is not something we're trying to avoid either.

Erica Newlin, MD:

What accommodations should someone consider if they already have a strength training regimen?

Rachel Barron, MD:

Couple of things. One, your center of gravity is going to be different. And then also there's a natural joint laxity that comes with pregnancy, pregnancy hormones. So we don't want you to be supine for too long, which means laying on your back. Again, short bursts probably fine. It's kind of one of those cautions that's been in OB care forever. But probably short bits of it is okay. If you're doing something where you were going to be on your back for an extended amount of time, I'm talking 20, 30 minutes, we would say like let's alter that. Let's kind of change maybe how long you're there, the positions you might be doing.

The whole reason for that is that there's a very important vein that runs right down the middle of our back and our uterus is going to put pressure on it the bigger it gets and we don't want to slow that return of our blood flow for too long. But again, it's never actually been shown to be harmful but just us kind of taking the whole picture into consideration, being a little cautious. We want to just be mindful of how long we're in that position.

Another thing I bring up to people is kind of making sure you do have good form. We don't want to kind of exacerbate any injuries with that joint laxity with having, you know, kind of poor form. If somebody is really new to exercise, it's good to be under some instruction to just make sure you're kind of doing things appropriately. And then the other thing is kind of really rapid movements, again that joint laxity. You can be quicker to hurt yourself because you don't maybe have the strength and support that your body had non-pregnant.

Erica Newlin, MD:

Are there any regimens or exercises that have been shown to improve pregnancy outcomes?

Rachel Barron, MD:

Kind of looking at everything as a whole. There's definitely some benefit that's been shown for aerobic exercise and strength training. But a lot more of the data is looking at aerobic exercise. Walking, spinning, ellipticals, running, swimming, like basically things where you're moving your body, getting your heart rate up.

Most of our most common complications of pregnancy there has actually been shown to be benefits towards, so one of the most important things I think we should mention is that fetal growth. We look at small size of babies for a reason to worry about like that we've stressed the pregnancy or the placenta doing something to the pregnancy that's not allowing the baby to grow as much. So that's kind of been one of the targets we've looked at with exercise is do we see that like vigorous exercise, intense exercise, does it lead to a smaller sized baby like a concerningly small baby where we're worried that like things are not growing as well as they should and there's actually a lot of data that says, no. Exercise, even vigorous exercise does not cause what we call fetal growth restriction.

I think that's one of like the things that we say like not only is it good but we have shown that even intense exercise does not seem to cause harm. As far as the things we don't want to be happening, gestational diabetes, gestational hypertension. So these are things that the pregnancy is causing those conditions to happen. Preterm birth, large for gestational age. So when babies are getting too big, a lot of the data it is all trending towards, it helps all of these conditions either happen less or happen less intensely.

Actually, again, kind of really diving into some of the studies, there can be a huge decrease in the rate of gestational diabetes kind of depending on where your risk starts. So everyone, even a normal weight woman will have less of a rate of gestational diabetes if they're able to stay active throughout pregnancy.

But definitely if you have a higher rates like the rates of gestational diabetes was going down even faster with continued movement exercise throughout pregnancy and really into the third trimester. So this is when it's becoming hard. It's becoming uncomfortable. It's hard to breathe. They showed better rates of control of the gestational diabetes by continuing to remain active.

Really if somebody is like starts out pregnancy really strong in their first trimester and then as they get uncomfortable they kind of weed down, we actually see some of that benefit disappear. So it's really like that continued movement. And I do stress to my patients as I'm saying this, I never want somebody to feel like they're doing a bad job if they're like, "I'm so uncomfortable. I'm so tired." I mostly want to mention these things as showing that we have shown benefit and that's not something to be scared of.

But I know I'm also asking a lot when I tell people there is benefit, keep moving, get out there 30 minutes a day. That is a hard ask, but so many people also do shy away from it because they've been told by people that you're doing the wrong thing. You're, you're putting your baby at risk. And actually it's the opposite. You're helping things. Just to mention birth modes too. So we see a trend. It's not crazy towards what we call more normal birth sizes or avoiding large for gestational age.

So large for gestational age is those babies that are getting so large that we worry about fit problems with birth. So we see less of that in women who are active and that seems to correlate towards a lower C-section rate, higher vaginal birth rate. So of course both of those things can still happen with both giant babies and, and normal sized babies. But we definitely see that all of those three seem to correlate together. And also independent of baby size, you do see also movement again correlating with less C-sections, higher vaginal birth rates.

Erica Newlin, MD:

So it sounds like you tell your patients a very similar thing that I tell mine is give yourself grace and you may not be able to be as active as you were pre-pregnancy but do what you can and also don't let anyone make you feel guilty for continuing to-

Rachel Barron, MD:

Yes.

Erica Newlin, MD:

... to exercise.

Rachel Barron, MD:

Kind of both.

Erica Newlin, MD:

Yeah.

Rachel Barron, MD:

I want, I want women to feel very supported that they can, but I also want you to know if you're telling me, "I know that this is going to help and I just can't do it.” We totally understand. It is a really hard ask what I've just said, but just trying to kind of dispel some of the fear around it too.

Erica Newlin, MD:

Katie, can you tell us what do we mean when we refer to the pelvic floor?

Kathryn Menard, DPT:

Right. So it's, yeah, it's a very hot topic nowadays. The pelvic floor is a group of muscles and connective tissue that sit inside the pelvis. They're kind of like a hammock or a sling, the bottom there. And they provide support for your pelvic organs. So in female anatomy, uterus, bladder, rectum. And then they also provide stability through the trunk in the core as well as control. So they're there to help with continence of urine and feces and very, very important throughout pregnancy and then also in the postpartum period, of course.

Erica Newlin, MD:

What kind of natural or physiologic changes happen to the pelvic floor during pregnancy?

Kathryn Menard, DPT:

Right. So there are a lot of changes that we can see including, you know, pressure in our increased weight going down onto the pelvic floor can cause us to have to rely more on other structures in the body. We have hormonal changes happening. We have relaxin and progesterone going through our body which can cause some ligamentous laxity. Our postural changes as Dr. Barron said, our center of gravity is changing and that can cause some changes down onto the pelvic floor as well.

We have, like I said, that increased growth is putting some pressure also on our bladder so we're going to see some changes in probably our urinary frequency, urinary urgency which can also cause some issues with urinary incontinence throughout pregnancy. And then also we're seeing blood flow changes to the area. So with that increase in blood flow sometimes people can feel some heaviness or some swelling during pregnancy as well.

Erica Newlin, MD:

For sure. And I think one of the most common complaints or concerns I see in the office is lower back pain or pelvic pain in pregnancy, which can be very scary for people because they worry about is this labor? Is something wrong? Can you touch on what normal expectations of discomfort might be during pregnancy?

Kathryn Menard, DPT:

Right, yeah. So unfortunately about 80% of women are going to experience some level of discomfort in pregnancy whether, you know that's location and time of pain is different for everyone, but it's very common for women to experience, like you said, low back pain, side joint pain, which are those kind of little notches above the buttock area on both sides. And that can be one-sided or both-sided.

Pubic symphysis pain so you may feel some discomfort in the front. Sometimes that can be a kind of a sharp stabbing pain as well. And then another complaint we see is round ligament pain. So just because that ligament is attaching to the uterus, we're getting a lot of stretching. So if people can have some discomfort, especially with you know, transitional movements. So I think, you know, just recognizing that those could be symptoms that you experience throughout pregnancy. You don't want pain that is going to be causing bleeding to happen. You don't want to be feeling regular pain that's like a contraction, you know, that's something to be concerned about. But just know those kind of general aches and pains that you're feeling may be common in pregnancy.

Erica Newlin, MD:

Sure. Are there any measures that people can take for pain relief outside of Tylenol?

Kathryn Menard, DPT:

Yes. Of course there... Yeah, there are several things. Exercise of course is amazing. I know we've talked a lot about how great exercise can be for pregnancy but it can also be really helpful with pain. Something that I like to tell my patients is that, you know, being pregnant is really hard but being pregnant and deconditioned is even harder. So exercise, whether that's strength training, cardio, exercise, yoga, whatever you really like I think is also helpful because that's something that you'll probably stick with. I'm a big proponent for strength training because we do have that ligamentous laxity. We kind of have to depend more on our dynamic structures of the pelvis.

Kathryn Menard, DPT:

And so strengthening those muscles around the pelvis and within the pelvic floor can be really helpful for pain. Another thing would just be some different support devices. So support belts that you can wear and I can kind of touch on those so you have some that you can wear around the waist, around the SI joint area or around the pubic symphysis area just to provide some extra static stability to the area.

But there are lots of different brands out there or there's also actual compression garments that you can wear over your abdomen and that can just provide some nice support for your low back or for the growing belly as it puts pressure down onto the pelvis. Obviously, you can do things like prenatal massage if you're really uncomfortable. There's chiropractors that specialize in pregnancy and then of course you can come see your favorite pelvic floor PTs and we can help with exercise, manual techniques and a lot of patient education just about, you know, ways to stay comfortable in pregnancy as well.

Rachel Barron, MD:

Sure. I do bring up to patients like if I ruled the world- I would have pelvic floor physical therapists involved in everybody's pregnancy and their postpartum care because I, I kind of say, you know, it's not going to be a quick fix. Your back pain is not going to be gone next week. But really like learning to support those muscles and how to strengthen them. Like I think a lot of us don't know how to properly strengthen like our core, we think of crunches and like kind of some other simple ab exercises but it's really like strengthening the whole way around the front, your back muscles around your hips.

And if somebody can really help you with that it, it can take weeks but I've seen people's back pain go from like just absolutely debilitating to mild. Like it may not be gone but it can make pregnancy a whole lot less painful if we can help you strengthen those things in the right way.

Erica Newlin, MD:

For sure. I think I love pelvic floor physical therapists. I tell every patient- I have a very low threshold to send any of my patients over to you guys. And-

Rachel Barron, MD:

If anyone asks I'm like already writing it in the computer. I'm like, "Yep, love that." Or I'm already bringing it up, one of the two.

Erica Newlin, MD:

For sure. You mentioned support belts or garments and there are a ton of different ones out there with tons of different straps and bells and whistles. Are there any you wouldn't recommend or say to avoid? Or what should people look for with-

Kathryn Menard, DPT:

Yeah, I think-

Erica Newlin, MD:

... what works for them?

Kathryn Menard, DPT:

... definitely depends on where their pain and discomfort is. I think if they're just looking for general support, nice compression can feel really good. So sometimes even nice compressive maternity leggings can do the trick if you are having more of that, SI joint pain or pubic symphysis pain. I like belts that wrap around not only once but they kind of have extra side supports to pull it a little bit tighter. They can be a little bit more cumbersome as far as what you're wearing outfit-wise. You know, you may not be able to wear it underneath all of your clothing but I think if you're in enough discomfort you probably don't care too much about what it looks like.

Erica Newlin, MD:

The belts are a harder sell sometimes in July, but-

Kathryn Menard, DPT:

Yeah, summertime it can be a little tougher too.

Erica Newlin, MD:

Yeah. Can you say what might someone expect if they go to a pelvic floor physical therapy visit during pregnancy?

Kathryn Menard, DPT:

Right. Yeah. So every, every visit may look a little different depending on what you are coming for. But we're trying educate patients on how the pelvic floor is working in relation to the rest of your body. So your abdominal muscles, your core, your hips, your spine, your diaphragm. So when someone comes in for a visit, we obviously get a little bit of background intake from them and then we're doing an assessment of them. I'll start typically with a more orthopedic-based assessment, checking out spinal movement, hip movement, single leg stability, look at their abdominal muscles and then if they're comfortable, we can also do both external pelvic floor muscle exams and internal pelvic floor muscle exams and that could be vaginal or rectal depending on their pain or their complaints that they're coming in for.

And with that, we're trying to assess their pelvic floor muscle tone, their coordination of their muscles, so how well can they contract those muscles, relax those muscles and lengthen them? We want to see if there's any areas of tightness or pain within the pelvic floor. And then once we get a good look at all of that, we kind of create a program with the patient to give them either, you know, some exercises or some manual techniques to help with their symptoms. And then like I said, a lot of patient education about how to kind of continue on through pregnancy and sometimes we'll see people throughout the full pregnancy as well.

Erica Newlin, MD:

Great. How might pelvic floor PT help with achieving a vaginal delivery?

Kathryn Menard, DPT:

Yeah. So we love to do labor prep with our patients. So what that might include would be education about, especially in the third trimester, getting a little bit more of that pelvic floor relaxation and lengthening down because, you know, those pelvic floor muscles have to move out of the way for a vaginal birth. We're not trying to Kegel when we're pushing a baby out, which sometimes I think people probably end up doing a lot of hip mobility and openers especially towards the end of pregnancy just to allow that to help them with the, the baby descending down.

And we also do some education about, you know, fetal stations with the baby and what part of the pelvis kind of needs to be opening up depending on where the baby is during labor. So doing some education about the stages of labor and different movements or exercises they can be doing while they're in labor. And we also do some education on pushing prep, so teaching them different techniques for pushing open glottis, closed glottis, ways, depending on, you know, what is needed in the delivery.

And then we teach them about things like perineal massage because there are, you know, different types of tears that can happen. With a vaginal delivery, we can have them do some perineal massage towards the end of pregnancy to hopefully help reduce the likelihood of those bigger tears that can happen. So it's really just a lot about education of things that they can do in the later weeks leading up to the labor and then things that they can do during labor to help reduce the likelihood that they would have to have a C-section.

Erica Newlin, MD:

For sure. And I think it's changed even in the past five years being in practice.

Because I feel like there's a lot more comfort now with... and a lot more things on... I have mixed feelings about social media but a lot more on-

Kathryn Menard, DPT:

Oh, yes, yes. Me too.

Erica Newlin, MD:

... social media about pelvic floor physical therapy. So I've found that more people have heard of it.

Kathryn Menard, DPT:

Mm-hmm, yeah. We have people come in all the time telling us, "I heard about this on the internet. I had no idea this was a thing." But a lot of the OB providers at the clinic are really good about referring over as well.

Erica Newlin, MD:

And the department has grown substantially too.

Kathryn Menard, DPT:

Yeah, yeah.

Erica Newlin, MD:

Which is awesome.

Kathryn Menard, DPT:

Yeah, yeah. I mean when I started eight years ago there weren't many of us on the west side and it has definitely, definitely grown a lot.

Rachel Barron, MD:

And I'm always amazed patients are kind of surprised that they'll come back from some of those like labor coaching visits and they're like, "I don't think I understood exactly which muscles were involved in this." Like, you think it's kind of intuitive but it's not necessarily. And sometimes just learning to identify them and how to engage them. I've had a lot of patients either first or second plus babies be like, "I feel like I'm ready to do this more."

And you know, I think it's great to kind of go into labor with that, just awareness of which muscles are you going to be using? Cause we're of course great at coaching people through labor. We do literally thousands and thousands of births at our hospital every year. But if there's either a need due to pain or, or we can get you that access, I think they have a lot to offer. And just learning which part of your body you're about to use.

Erica Newlin, MD:

What changes to the pelvic floor might someone experience after delivery?

Kathryn Menard, DPT:

Right. So, and this can be vaginal or C-section that you can see changes but a, a lot of times we can see weakness or just stretching of those pelvic floor muscles from delivery, which sometimes can lead to incontinence. But in other patients we may actually see tension and tightness develop. Sometimes their body reacts in a different way and so they may come in and have a lot of tension in their pelvic floor postpartum.

We may see changes if there was tearing that happened. So there may be some scarring down there which can lead to some discomfort postpartum. And sometimes we also see pelvic organ prolapse. So sometimes that pushing can really do a number on your pelvic floor and your pelvic organs and there's just so much intra-abdominal pressure that's kind of pushing down that we can see some prolapse of the structures down towards the pelvic floor.

Erica Newlin, MD:

Sure. Is it normal to leak urine after delivery?

Kathryn Menard, DPT:

We definitely don't want our patients, you know, leaking urine. I would say it's very common that we see people leaking postpartum just because of all of the changes that can happen. But it's also very possible to not leak postpartum with the correct exercise, the correct guidance. And obviously, you know, healing can take some time but depending on how your labor and delivery went, you may have some leaking postpartum if you had, you know, a significant tear. Sometimes we'll see that especially those, you know, grade three or grade four tears that are starting to go into the sphincter muscles. But the goal is obviously we don't want to have any incontinence postpartum.

Erica Newlin, MD:

Yeah. A lot of patients ask me, "Is this normal?"

Kathryn Menard, DPT:

Mm-hmm.

Erica Newlin, MD:

And I was like, "Well-

Kathryn Menard, DPT:

Very common.

Erica Newlin, MD:

... common and normal don't mean the same thing, but…

Kathryn Menard, DPT:

Right.

Erica Newlin, MD:

... we can help with it.

Kathryn Menard, DPT:

Right. Yes.

Erica Newlin, MD:

What about sex? What changes in the pelvic floor or how might kind of those postpartum pelvic floor changes affect sex during pregnancy or postpartum?

Kathryn Menard, DPT:

Yeah, so during pregnancy I think also people just are, have increased sensitivity in the pelvis. So that can cause some discomfort along with just changes in our anatomical body. So sometimes just pressure in different areas can feel really uncomfortable. Obviously, the stretching that's happening during pregnancy can also be uncomfortable and painful. And I think also postpartum we see, you know, hormonal changes particularly in breastfeeding population with lack of estrogen. There can be some dryness and discomfort down there along with, like I said, if you have some sort of scar or you had stitching, you can have scar tissue and discomfort and that can be pretty painful postpartum as well.

So a lot of the things that we see postpartum for pain, we're typically teaching at patients how to do some manual techniques, stretching, relaxation of their pelvic floor to reduce that pain cause we don't want people to think that this is a normal part of their postpartum routine and it has to be something that they're going to live with for the rest of their life.

Erica Newlin, MD:

That mirrors a lot of what I tell patients that postpartum visits and like things might feel different but they shouldn't hurt. If things hurt come to us cause we can, we can help with that.

Kathryn Menard, DPT:

Right, yeah. There's things that can be done, yeah, both in physical therapy. I know some patients have also had if appropriate success if they're breastfeeding with estrogen cream and things like that now that can be provided to them.

Erica Newlin, MD:

And too, I think it's important to let patients know they shouldn't push through pain since that can lead to changes in the pelvic floor as well.

Kathryn Menard, DPT:

Right, right. Exactly. Yeah, we don't want them having sharp stabbing pain. We don't want them doing anything more to the pelvic floor postpartum. They've already gone through so much. We're trying to heal that area.

Erica Newlin, MD:

Moving up a little bit to the abdominal muscles, what is diastasis?

Kathryn Menard, DPT:

Yeah. So that's a separation of your rectus abdominis muscles. So it's occurring at your linea alba, which is that connective tissue that kind of holds those two sides together. This is also a very popular thing that people probably see online or read online and there's a lot out there that's probably not so true about it. So it's something that we have to definitely do a lot of patient education with.

So when you're pregnant your abdomen is obviously growing with the baby and so for the most part, most people will have some level of separation during pregnancy and I think that's important for people to know that there probably is going to be some level of separation. But to what extent, I think that's something that, you know, depending on modifiable and non-modifiable risk factors, we can have some sort of change with.

Erica Newlin, MD:

Does doing core exercises during pregnancy cause diastasis?

Kathryn Menard, DPT:

No, it's actually very helpful to be continuing to do core work in pregnancy. So deconditioned women and those who aren't exercising, especially in the core actually probably have more likely chance of having diastasis recti postpartum. Like I said, there's some things we can't necessarily control, so twin pregnancies and things like that may have a greater likelihood as well as women who are a little bit more lax or have connective tissue issues may be more likely to have diastasis.

But in general we want to see you doing core strengthening exercises during pregnancy and we can kind of educate patients on safe ways to do that throughout all the trimesters.

Erica Newlin, MD:

Are there certain core exercises to avoid that might cause it?

Kathryn Menard, DPT:

I think the big thing is everyone may look a little bit different with this. Some people are going to be able to tolerate higher level core work than others. So I think it's all about pressure management. So, you know, are you able to do an exercise without noticing significant coning or doming while you're doing it? Again, that's a tricky thing because we don't necessarily know if the coning or doming is a bad thing. We're going to lead to worse diastasis, but I think it's important to manage that intra-abdominal pressure.

I think the biggest thing is just loading your core in lots of different positions. So I often teach patients exercises that are on your hands and knees that are standing, that are rotational. I want you working, you know, the rotational movements, which that used to be something that people kind of avoided in pregnancy was rotational movements. Some things on your back for short periods of time. But we just want to be able to load the core in, in lots of different positions.

Erica Newlin, MD:

And then if someone has diastasis postpartum, what kind of exercises can help with that?

Kathryn Menard, DPT:

Yeah. So like I said, everyone is a little bit different on kind of where you'll start and what exercises are going to be helpful. But I think the biggest thing is working the core. So a lot of people are afraid or may have heard like I can never do a sit up again or I can never do a crunch again or I should never have both my legs up doing leg lowers. But those things are kind of, you know, outdated practices now. Like I said, the big thing now is we want exercises in lots of different positions. So working core exercises on your back, on your sides, you know, thinking things like side planks, standing.

I like something called a Paloff Press doing a chopping type motion, regular planks, but you kind of again are monitoring, "How well am I managing my core?" So when I'm watching someone do an exercise, if I'm seeing a lot of that coning or doming, I might re-coach, have them kind of engage their deep core, which is kind of running all around their body front back sides. And if they can do that exercise without the, the coning or doming, I'm going to give it the green light.

So again, I think it's different for everyone. I don't have, you know, a set list of exercises that I'm giving a patient because everyone is such a different fitness level. But I think the most important thing is getting active and doing exercise and loading those core muscles as best you can.

Erica Newlin, MD:

Great. And when you say that coning or doming, you mean when someone slightly does a crunch, they can see that separate, that outpouching?

Kathryn Menard, DPT:

Yes. You'll see kind of a bulging through the center of the abdomen. So sometimes that just can give us a little key that maybe you're not managing your intra-abdominal pressure well enough to do that exercise yet. It doesn't mean you can't ever do it down the line, but we just want to be able to manage that pressure as well as possible cause sometimes that can, you know, lead to issues down in the pelvic floor incontinence and things like that. So we want to manage that pressure really well and strengthen the core as, as safely as we can.

Erica Newlin, MD:

What I'm hearing too is it can be very complicated, very individualized. So if it's something that someone is worried about, definitely worthwhile seeing pelvic floor physical therapy or talking with their doctor.

Kathryn Menard, DPT:

Yeah, absolutely. Yeah, talk with your doctor and feel free. Get that referral to pelvic floor therapy. I think, you know, some people will tell me my friend did this or I did this last time, it's not working. What is something that I need to change? So I think just getting that assessment and that exam can be really helpful to create that individualized care for the patient.

Rachel Barron, MD:

And another thing I stress to some of my patients is a lot of this can take a lot of time. You know, we spent 40 weeks doing this to our body. I was so lucky. I have a physical therapist for a sister-in-law who guided me because the other thing that's not only individual but also as your body gets stronger sometimes you need different exercises. It took me about nine months to close my personal like separation of my core. And I was somebody who was very active in pregnancy. So I've had a lot of patients go, they go to like two visits and say, "You know, I don't know if my back is feeling better. I don't know if I'm feeling stronger."

And so much of this, it's not that much home commitment like they really do such a good job of figuring out the right exercises for you and then you do have to go home and do your homework.

Rachel Barron, MD:

And kind of keep up with it. But I mean it's five, 10 minutes maybe a couple times a week, like three to four. And then really sticking with it for the long term. And the payoff is so worth it. So much less back pain as you're in that first year postpartum. And I actually even think future pregnancies, like when you really take that time to recover your core, I see people have less pain in their future pregnancies. And just feel a little bit, you know, stronger and just better as they are healing. But I stress to people it can take some time.

Erica Newlin, MD:

Well, awesome. Well, thank you both so much for joining us. Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.