Anne Nicholson Weber: 00:00 Welcome. This is episode six. I’m so glad you’re here. Today we’re talking about pelvic therapy for the postpartum period. Four Chicago- area PTs join me to explain common postpartum issues that you don’t have to just live with, and why every postpartum mother can benefit from a pelvic floor assessment after birth.
Anne Nicholson Weber: 00:28 This is the BirthGuide Podcast, conversations about building your circle of support in the childbearing year. We connect you with experts in our community who can help you conceive, stay healthy in pregnancy, have a safe and satisfying birth, and embrace the joys and challenges of becoming a new family. I’m your host, Anne Nicholson Weber, the founder of BirthGuideChicago.com, where every month thousands of Chicago-area families find relationship-centered care, from preconception through the postpartum period.
Anne Nicholson Weber: 01:06 Today I’m talking with four Chicago area physical therapists who have special expertise in treating pregnant and postpartum women. They are Suzanne Badillo with Link PT; Jessica Kerr with Allied Therapy Partners; Sapna Patel with Pelvic Therapy and Fitness; and Kate Utech with New Journey Physical Therapy. Thank you all for joining me. This is a really important topic and I think perhaps not as well understood as it could be, um, the importance of physical therapy and pelvic therapy around the perinatal period. So let’s start with this question. What are some of the most common postpartum complaints that PT can treat? And Sapna, maybe you could kick us off.
Sapna Patel: 01:48 Sure. I think there’s a wide range of diagnosis that you can see postpartum. I think it can range anywhere from pelvic pain, pain with intercourse. I think you can have some stress incontinence. I think most frequently we’re starting to see a lot of postpartum tailbone pain. People sitting, then nursing, kinda sitting on that tailbone; thoracic pain, low back pain, um, just from the change in the ribs. So I think that’s probably the most common. Prolapse is in there. But I would say that, um, that’s what we see most commonly over here.
Anne Nicholson Weber: 02:23 Suzanne, is there anything you would add to that list?
Suzanne Badillo: 02:25 That’s pretty comprehensive. I think maybe the way to look at it more functionally also is anything that might be limiting a person from their daily activities. So it could be a pain, it could be muscle soreness, it could be, as Sapna said, urinary issues or bowel issues. Um, you know, so if you think about it, birth has a really big impact on the body. And then all the activities of childcare that the parents have to do ongoing could be really stressful on the system too. So depending on when we see them, they may come in with different kinds of complaints, but it could be any of those that she listed.
Anne Nicholson Weber: 03:10 And that raises a question that I had going into this, which is I think many postpartum women think, well, of course my body’s bruised and battered and things don’t feel quite right. Um, and I presume it will get better. At what point, Kate, would you say that you start to say, oh, this isn’t resolving as quickly as it should, like what’s normal for recovery and at what point would you then say, I need some intervention?
Kate Uttech: 03:34 Yeah, so I mean, one thing that’s not as well known as I’d like it to be is that everyone kind of benefits from pelvic floor PT and postpartum physical therapy. So just the fact that you were pregnant and then had a baby, whether cesarean or vaginal delivery, means you would benefit. You could be pretty good and only really need a little bit of rehab. Or you could be in a state where it’s pretty obvious to you that you’re having a lot of pain and incontinence and it’s more obvious. But as the physical demands of life increase after having that baby, most people start to feel something at some point. And so I really like to get people in at like a six week postpartum visit for evaluation, sometimes even five weeks, and not doing that internal pelvic floor assessment yet, but being able to help people as they start to feel like they’re ready for more movement, to be able to help them go on that process at the beginning. Anything that hasn’t resolved by 12 weeks is probably not going to on its own.
Anne Nicholson Weber: 04:46 So I’m seeing a lot of nods. It looks like that timeframe seems sensible to everyone on the call. Jessica, is there anything you want to add to that first topic of when do you say I should go see somebody?
Jessica Kerr: 05:01 Yeah, so I actually love this topic because I think people can come in sooner. I’ve had a lot of patients come in like a week after vaginal delivery because they’re having pain when they’re pooping or they’re peeing, they’re having trouble sitting on the toilet, they’re having pain and discomfort nursing their child. So I think there can be a benefit to even going in there a little bit earlier to assist with some of those positioning techniques, assist with pain management. There wouldn’t be any sort of internal assessment or anything done at that time, but certainly you can start working on some breathing techniques, some pain management, um, toileting techniques. And I think a lot of people are really thankful to have us in there that early, not only to help them with making these recommendations for positioning, but also to just have someone there screening them.
Anne Nicholson Weber: 05:58 Mm-hmm. <affirmative>. Right. Well now a couple of you, I think, have made the distinction between internal exams or internal work — and I’m honestly really ignorant about exactly what pelvic floor PT looks like and I imagine I’m not the only one. So maybe it would be helpful to go there. It sounds like there’s PT that’s more like typical PT with whole body exercises and then there’s PT that’s more targeted to the pelvic floor. Suzanne, maybe you could just explain what that looks like.
Suzanne Badillo: 06:31 Sure, that’s a great question. <laugh>. Um, you know, that’s probably what sets us apart with our specialty is that we are specially trained in the pelvic floor assessment and interventions. I tell my patients I’m a typical PT as well, that I can see you for your back and see you for your knee injuries and ankle and we incorporate all that, but what our specialty is is in the pelvis. So in addition to that, we don’t always think about it, but we have muscles and joints and bones in the pelvis too. We just don’t always think about how they work or that we have to go to the gym for it or anything like that. And so as PTs, we assess the muscle function and the overall function of that system. So when you ask about internal versus external work or assessment, it’s taking a look at the pelvis as a whole externally at some point. And then, when appropriate, also doing an internal exam; postpartum, oftentimes it is a vaginal exam, in some cases we may do a rectal exam. But it’s really to assess the muscles — more specifically, their function, their strength, endurance, timing, coordination, pain, you know, all the same things that we would do for any other body part if there was an injury or some sort of condition that’s affecting their function.
Anne Nicholson Weber: 08:01 All of us who have been pregnant know that carrying a baby around on that sling of muscles feels like a lot of work. And once the baby’s gone, that sling of muscles does not feel the same as it used to. <laugh>. Um, Sapna, maybe you could talk about what is a normal recovery like, if everything goes as it should. Does the pelvic floor ever return to the pre-birth state or is it okay if it doesn’t? Just talk about that a little.
Sapna Patel: 08:28 Sure. Just to circle back really quick, you had asked about, you know — one thing I think as pelvic PTs we’re all doing is educating doctors. And maybe this podcast will help that women, if they do want to come in, they can come in one to two weeks then. And I think just getting in for support. Like I go out there and I tell these doctors — they have no idea that we can even see them. And then they’re telling their patients, no, you know, don’t go until six to eight weeks. So just to circle back, I think that’s important for women to know that they can come. As far as how long, I think it’s really patient dependent. I think it really depends if you have someone with a grade one tear vaginally versus a grade three tear, you’re looking at a very different type of timeline healing.
Sapna Patel (cont’d): 09:11 What do their functional limitations look like? Are you talking about someone who has a mild diastasis, just a little separation that they want to kinda work on? You’re talking about maybe, you know, six weeks, eight weeks, depending. And if there’s someone who’s got more intensive, more difficult labor, they pushed for a long time, then you’re, you know, talking about maybe dealing with a lot more functional limitations that could give it a little bit more towards that six to 12 week mark. It’s really hard to, I would say, to put a number on it. It’s so patient-dependent. And a lot of times, I don’t know how the other ladies feel, but once they come, they don’t really want to leave. They’re like, “can I work on this? And can you work my back? And, you know, I don’t really want to leave you, can I come every three weeks?,” you know. And I think that’s great. I mean, I’m thrilled that I can help them through that journey and get them where they feel like they’re confident to go back to maybe taking a class or working out, like releasing — I want them to be happy.
Anne Nicholson Weber: 10:05 Kate, anything you want to add to that?
Kate Uttech: 10:07 Yeah, I would say most of my clients are on a similar timeline. Every once in a while I have someone where we’re just tweaking a few things and it might just be a couple of visits. And sometimes I have someone who might, you know, be with me for longer because they did have a more complex pregnancy, complex delivery or maybe they weren’t as active before they got pregnant or during their pregnancy. And so there’s more to work on before they really feel like they can become active again. You know, if they want to reach a little bit higher level than they were at before.
Suzanne Badillo: 10:41 Can I add to that?
Anne Nicholson Weber: 10:43 Yeah, Suzanne,
Suzanne Badillo: 10:43 You know, there’s a lot of evidence now to show that even in the most uncomplicated birth, the vast majority, if not all people have some sort of musculoskeletal injury. You know, it could range from muscle tearing to edema to fracture. And it’s often times compared to a major sports injury. I think what’s new is that now we’re actually having the tools and evidence and now experts to actually know what to do about it, you know, and to have some sort of support and guidance or even recognition that this is a thing and that we could actually do something about it.
Anne Nicholson Weber: 11:22 And maybe that’s — Oh yes, Sapna, go ahead.
Sapna Patel: 11:25 I just wanted to add to that really quick. I, you know — being a therapist for over 20 years, I would tell you that I think the pelvic floor is the most forgiving muscle that there is. But understanding even after your first birth how that pelvic floor works, I think sets you up very well to have that second birth. A lot of people are having multiple children and if you’re going to compare that to a regular orthopedic condition, not everybody’s having four ACL surgeries within a period of time. But if you are giving birth and doing that multiple times and you really understand that pelvic floor — which I think, like Suzanne said, we finally have these special therapies, specialized therapists who can help women understand how to optimize that pelvic floor — I feel like you’re setting yourself up for success down the line.
Anne Nicholson Weber: 12:09 Kate, what were you going to say?
Kate Uttech: 12:10 I was going to say, we also have research showing that some level of abdominal muscle separation is normal. We have studies saying that a hundred percent of people experienced some level of separation during pregnancy, so those muscles couldn’t really contract and your body wasn’t able to rely on them for the control of instability for your spine and your pelvis through pregnancy. Your pelvic floor muscles with a vaginal delivery are stretched. Most of the time people are experiencing some level of tear, and therefore those muscles were stretched as much as they could lengthen and then a little bit beyond that . . . or sometimes a lot. Hopefully, you know, some people do stay intact and that’s wonderful and we love that. But those muscles, if they’re torn, their function has been impacted and affected. So reeducating those muscles and making sure that people are in tune with those muscles and the muscles are responding to the brain and the brain is really sending the right signal down the nerves to engage the muscles at the right time — that’s complicated. And expecting all of that to happen without expert guidance, I think is sort of problematic. And this is going to come back to bite you for a lot of people <laugh>, if you don’t do it early. So why not do it now when that trauma is occurring and make sure that you really do recover so that you can set up yourself, set yourself up for lifelong activity.
Anne Nicholson Weber: 13:48 Did you want to say something Jessica?
Jessica Kerr: 13:50 I was just going to add to that, um, Kate, in terms of, um, I know we’ve been talking a lot about vaginal delivery, but also for c-section recovery with cesarean section. Um, you know, if you get it, have an ACL tarn, you have knee surgery or you have hip surgery, they’re always going to recommend PT before and after. And so it just baffles me too sometimes why physicians are not recommending PT for cesarean section recovery. So just something else that <laugh>, I just wanted to put out there.
Anne Nicholson Weber: 14:21 Again, a lot of nods. Well, and I think it’s a problem really in our culture that c-section has become so normalized. And of course we all know it’s a wonderful lifesaving option when it’s needed, but it does have a lot of consequences for mothers going forward. And you’re saying one of those is that their abdominal muscles are compromised and of course they need to work on rebuilding those as they would from any other surgery.
Jessica Kerr: 14:51 Right. And not even just that. Like our abdominal muscles connect with our pelvic floor and they all relate to our diaphragm function and there’s just a whole connection between that, um, the cesarean section and the pelvic floor and all the other wonderful things that the pelvic floor does.
Anne Nicholson Weber: 15:09 One thing that I think I hear all of you saying in one form or another is that you don’t need to accept impairment after pregnancy and birth. You don’t need to say, well yeah, of course I’ve had a couple babies and things don’t work and of course I pee a little bit when I laugh or whatever it is. Those don’t have to be accepted as just par for the course. Yeah, Kate.
Kate Uttech: 15:33 Something we often say in the pelvic floor world is, common does not mean normal. So incontinence is relatively common and it used to be more common when we as pelvic floor therapists weren’t there to help. But pain is not normal, incontinence is not normal and there is help out there to address these symptoms.
Anne Nicholson Weber: 15:59 So Jessica, maybe you could build on some of what’s been said before about what pelvic floor therapy actually looks like. We’ve talked about the fact that there’s external exercise and assessment and internal, but once you’ve done an internal exam and found, you know, whatever that the . . . well, tell me what you might find and then what you might do about it.
Jessica Kerr: 16:22 Yeah, so for pelvic pt it’s physical therapy and we basically use it to treat pelvic floor dysfunction. And all of our treatment is — there’s different strategies used to how people go about this. So there’s manual therapy, where we basically use our hands or tools to help decrease pain, to help work out muscle tightness, help with range of motion, help with scar tissue mobilization. That can be done, like we talked about, externally on the pelvic floor or also internally, either rectally or through the vaginal canal. And yeah, so that internal assessment basically gives us information as to any pain, any tightness in the pelvic floor muscles, what the endurance is like, what the coordination is like, what the timing is like, and what the strength is like. We can also assess where the internal pelvic organs are, and then we use that to give us information about how we’re going to help the patient.
Jessica Kerr (cont’d): 17:31 So that could include manual therapy using our hands or tools. It could include exercise prescription. It could use some biofeedback tools to help the individual understand what their body sensations are. Sometimes we will use just activities that focus on a patient’s functional tasks, like how they’re lifting their children, how they’re putting their children in the car seat, things that might be causing some of these symptoms. We’ll take a closer look at those. We do a lot of education about anatomy and physiology and then of course we refer out if there’s something that’s beyond our scope of practice or if we think that the patient should follow up with another medical professional.
Anne Nicholson Weber: 18:15 Anybody want to add anything to that description?
Sapna Patel: 18:18 I think she did a great job explaining everything. And then just kind of following up, being able to . . . if they have a specific activity or exercise they want to get back to, like running or CrossFit. I’m getting a big slew of, you know, heavy lifters who want to come back postpartum. So just kind of, you know, making an exercise program that’s specific to their needs and goals.
Suzanne Badillo: 18:43 Can I add to that too?
Anne Nicholson Weber: 18:44 Yeah, Suzanne,
Suzanne Badillo: 18:46 Um, you know, both of those points highlight the importance of the assessment. I think that it’s important to understand that initial evaluation with the pelvic floor physical therapists. We really spend time, you know, understanding the story, their history, their goals, as well as doing the physical assessment. And that will help us really prescribe the right program. And as Sapna was saying, it’s, you know, sometimes it’s very high level types of goals like going back into higher impact, high intensity types of activities. Sometimes, and probably most commonly, they’re basic functions such as being able to lift the baby without pain or, you know, things that have to do with urinary control or being able to walk a certain distance. So all of that becomes established and starts to progress as we go along through time. But that first assessment is really important because there’s so much variation on their status and what we could do.
Anne Nicholson Weber: 19:46 And it’s my understanding that in European countries, it’s typical that everyone gets a PT appointment shortly after birth. Again, lots of nods. And that brings us I think to sort of some practical things. One is insurance. Um, does insurance cover this kind of PT for most women? For some women? What could you say about that, Kate?
Kate Uttech: 20:13 So my practice is out of network, but some of my clients do seek reimbursement. Insurance covers physical therapy if there are impairments present. And so it depends on making sure that there’s a diagnosis to get reimbursement or if you’re using an in-network provider for your care. Um, but it’s covered typically like other physical therapies. We’re just regular physical therapists. We just have additional training in treating the pelvic floor as well.
Anne Nicholson Weber: 20:48 Great. Yes, Sapna.
Sapna Patel: 20:49 So Anne, I do take Blue Cross and Medicare and I’ll tell you, um, and I take AMITA’s HMO. For the most part they cover, but it is dependent on your insurance company. Like Cigna has codes that they refuse to cover. So that’s why a lot of pelvic PTs have to end up going cash-basis, because it is a frustrating experience to fight for payment. UnitedHealthcare is another one that can give people kind of some difficulty. So absolutely to Kate’s point, usually if you have the right diagnosis and the right coding, insurance will cover it. But it does depend on the insurance company. It really does.
Anne Nicholson Weber: 21:33 So you can’t count on it. And that makes me want to put in a little plug here for BeHerVillage, which I think is an amazing business that allows women to include on their baby registry requests for their friends and families to fund services like postpartum PT. A I think that for many, many families having a pot of money to spend on services would be more valuable than having all of the amazing baby gear that we tend to get at those baby showers. What would you recommend that a woman be looking for if she’s looking for postpartum PT specifically? Suzanne, maybe you could answer that.
Suzanne Badillo: 22:16 Sure. Um, you know, there are various PT locators out there. You know, the ones that I can think of at the top of my head are the professional organization, the American Physical Therapy Association. They have a PT locator, so you can go on their website and look for one that has the specialty. Our specialty section is called the Academy of Pelvic Health within the A P T A. The things to look for are someone who has the advanced training that we have. You know, there’s various certifications, there’s various coursework, but there should be some postgraduate training in pelvic floor physical therapy.
Anne Nicholson Weber: 22:59 So it’s very much of a specialty and you don’t just want any PT, you want someone who has invested in training to understand the specific conditions of postpartum and how to treat them. Anything anyone wants to add to that question?
Kate Uttech: 23:13 I think a lot of times you can read those profiles and see too that someone is mentioning someone might have pelvic floor training and not have pregnancy and postpartum training, or they might have pregnancy and postpartum training but not pelvic floor. So from my standpoint, knowing that I have both of those advanced training in both areas, I do prefer if I’m referring someone that it’s someone who does have training in both and does keep up on continuing education and postgraduate work in both of those two areas. Because there are things that are affected that are obviously within the pelvic floor, but then some other areas that I think are helpful to make sure that you have sort of an eye on looking at those things as well postpartum.
Anne Nicholson Weber: 24:05 It’s all one system. Yes, Sapna.
Sapna Patel: 24:07 Yeah, so you know, around me there’s a lot of hospitals and so they have a couple just, you know, hospital-based pelvic PTs. And they have that first level, so the hospitals will just hire them as that pelvic 1. But then when you have — to Kate’s point — you have these postpartum women, you really need that ability to understand what happens postpartum. And typically I’ll get a phone call six sessions later and they’ll be like, nothing’s changing with my prolapse symptoms or I’m still running and I’m still leaking, you know. And when I ask, it’s very minimal internal assessments, sometimes none at all, maybe one. So you really do need to kind of look at . . . Or even make the call. I have people who call and I spend 20 minutes talking, so I’m letting them know what this is going to look like. The free consultations, when you have a website where someone says, “Hey, we’re going to offer you this free chat free consultation so you know what you’re getting into.” I think that’s great because that means they really have something to really offer you.
Anne Nicholson Weber: 25:01 Yeah, that’s great advice.
Jessica Kerr: 25:03 Can I just add to that as well? Um, that’s a very good point that you made just now, because a lot of people will have like their first level pelvic health training, but I can tell you from experience that training does not really prepare you for working with a patient that’s postpartum, working with someone who is deadlifting and wants to get back to deadlifting like the female athlete. It doesn’t really prepare you for that. It teaches you how to do a very basic internal examination and just very basic conditions. But for anyone who has a little bit more going on, it might be helpful for them to actually seek out those professionals that specialize in whatever it is that’s going on with their body.
Anne Nicholson Weber: 25:48 Oh yeah. Kate
Kate Uttech: I also wanted to add the other sort of sort search tool that I really like is the pelvicguru.com. Again, you’re going to find people who have the specialty, both on the one that Suzanne mentioned, on the Academy of Pelvic Health, and on the pelvic guru. You have to pay to be a part of that organization or the academy in order to be listed there. So you’re finding people who are passionate about what they’re doing and this is what they’re committed to. Rather than just someone who’s taken their first course and is getting a feel for pelvic floor and whether this is something they want to really be a big part of their career.
Anne Nicholson Weber: 26:28 Right. One, just one other little option that I think people should be aware of. And Jessica, you could talk to this I know and I think Kate as well. Um, and that’s the option of in-home therapy.
Jessica Kerr: 26:40 Yeah. So that was actually something else I was going to mention is also like what fits into your schedule, right? So like if you’re looking for a pelvic health physical therapist, do you prefer to go to a clinic? Do you prefer to have someone come to you in the home? There has been an increase in providers that are able to go in the home now, and sometimes with the home you get a little bit more flexibility. Like it doesn’t matter if your child is there, you don’t have to travel to get somewhere. So that is a benefit that my practice offers is that we are able to go to the home. And I know that there’s a lot more practitioners that are starting to do that as well.
Anne Nicholson Weber: 27:14 And to me, for the postpartum period that just seems so valuable. I mean, we don’t give women enough time just, you know, stopping <laugh> and this is one way that I think, at least for some families — and I imagine there’s some for whom that doesn’t seem like a good idea at all and others for whom that sounds really appealing. So it’s, I think it’s just important to note that that option exists. Kate, were you going to add something?
Kate Uttech: 27:37 I was going to say, yeah, we do that, you know, on a limited capacity. Usually those people who are really early, like we were talking about earlier where Jessica was saying, you know, before that five week mark. Those are the people where I’m going, I don’t want you to be packing everything up and carrying your baby in the car seat into my office and you’re going to do as much harm as good at that point. I’d rather come to someone at their home and then when they’re further out, they can transition to coming into my office — which for a lot of people, once they’re a few more weeks out, they actually appreciate sometimes, that reason to leave the house, reason to have some time to themselves. Or bring the baby with them is fine, but they can have something to go do, that can actually feel good at that point.
Anne Nicholson Weber: 28:24 Getting a breath of fresh air. Yeah, Suzanne?
Suzanne Badillo: 28:27 Um, absolutely the practical nature of the appointments is really, really important, you know. And that’s oftentimes one of the biggest barriers is how to even get there. But one quick note, you know: early on in the pandemic when we had to really kind of shut down and people weren’t coming out of their house, we opened up telehealth. And you know, one silver lining was we were able to see these women virtually, in their house through telehealth. And we’ve kept that. And especially in that early, early postpartum period, clearly we’re not going to do a hands-on exam, but we can see how they’re nursing or they’re getting in and out of bed or how they’re changing their diaper on the actual diapering diaper changing table and see how their back is. And it’s really been very enlightening, as well as empowering, you know, for women to really be able to do their exercises and get some relief within their home without much disruption in their day.
Anne Nicholson Weber: 29:32 That’s such a great point. I’m really glad you raised that. So there are really three options, and one is in office, one is virtual and one is in home, and each of those might be appropriate for different women at different points. Yeah, Jessica.
Jessica Kerr: 29:45 And then just another thing that I thought about with in-home too is that — just going on what Suzanne said — you get to see how they live. And so a lot of times you can’t really recreate that in the clinic. Sometimes it’ll be like, “I have trouble every time I turn to the right”, and then I go and see them in their house and I see the exact place that they’re telling me they have pain or incontinence when they’re turning to the right. And so that helps me just get a little bit more information about what it is that they need and what we can adjust in their own home environment to help with their symptoms as well.
Anne Nicholson Weber: 30:18 Yeah. That makes so much sense. Well, let me ask you all now, what didn’t I ask that I should have? What is important to get out there that I didn’t give you a chance to say?
Sapna Patel: 30:28 I would just say, don’t suffer in silence, you know. To any woman out there, we’re here for you. Like there’s so many pelvic PTs now in the Chicagoland area. And you know, get help. Just even if it’s one session. Understand your pelvic floor. See what you can do and let us educate you. Like Suzanne said, that first session is so important, it can make all the difference in the world.
Jessica Kerr: 30:51 And then the other thing too is, don’t wait until after you’ve had the baby. Like when I was pregnant, I was having diastasis symptoms while I was pregnant and I went to a pelvic health pt. So there’s a lot of things that we can also help you with while you’re pregnant.
Anne Nicholson Weber: 31:07 And that is a whole other podcast episode <laugh>. Great. Yes, thank you so much. I really appreciate your, uh, participation and I’ve learned a great deal and I imagine some of our listeners will as well. Thank you. Thank you.