Whether you're a recreational active or an athlete, we want to talk about all of the things that we go through as females going into this motherhood journey.

We're going to talk about fertility, pregnancy, and postpartum topics that are relevant to the active individual.

While I am a pelvic floor physical therapist, I am not your pelvic floor physical therapist and know that this podcast does not substitute medical advice.

All right, come along for this journey with us while we navigate motherhood together and I can't wait to go to Hello everyone and welcome back to the Bar of All Mamas podcast.

Christina Bro here.

And today we're going to be taking questions about postpartum return to exercise.

We are down the Reddit rabbit hole.

I am loving this series.

It is giving tons of real-world examples of questions and comments that you all are having or looking for answers for.

And to be honest, as a researcher, it is freaking great that I am able to see some of these questions and answer some of these things on this podcast.

So I have four uh four uh more like longer uh comments and questions that I think really cover a wide range of topics.

So super excited to be um to be to be talking about this.

So can't no question number one Can postpartum or diastasis recti postpartum really be healed through exercise?

I now have a four-finger diastasis recti with two knuckles deep, which is severe.

My belly protrudes a lot, starting above the belly button to big pooch in the lower part.

Not sure what I have done to cause this.

I was very mindful of 360 breeding even during pregnancy and while lifting weights.

So I love this question.

I'm gonna answer the can this be healed through exercise part, but before I do that, I just want to take a bit of a lens on the blame game and the verbiage.

When we are talking about diastasis recti, right, right now the gold standard is that anything over two fingers where you there's a the gap between the two rectus muscles on a headlift is greater than two fingers, you are considered to have a diastasis recti, right?

And four fingers is more um distance.

And I don't know how far postpartum this human is.

So if you are early postpartum, your body adapted to your pregnancy in order to make room for baby.

And so we expect to have some distance between those two rectus muscles because your body has to kind of recalibrate and transition into the postpartum period, and that takes time.

The word healed is really interesting because one, about 50% of our population, when we look at a non-postpartum population, has a two-finger gap or more.

Like our newborn babies have diastasis recti.

My I see a lot of gentlemen in their 50s and 60s with central adiposity that have a um two knuckle deep or more, three, four-finger gap uh diastasis recti, and they don't really worry about it.

Um and so it's just kind of interesting this shame, blame, and upset that happens um around diastasis recti that um just doesn't happen in other areas where that distance between the two rectus muscles is very prevalent.

The second part of this was she is blaming herself and she's saying, Well, I must have done something wrong in order for this to have happened to me.

And that part of this question was what made me so sad.

Because this is where I think that as exercise professionals and as pelvic physiotherapists, we need to take a little bit of the blame here because we talk about exercise or using exercise or modifying exercise in a way that is gonna protect your core wall against postpartum diastasis recti.

And I need to be so clear here, we have zero evidence to support those claims, right?

We just had a paper that came out that said 50 to 60% of the information online about diastasis recti and pregnancy and postpartum is wrong.

And what that does is it shifts blame.

And people say to me, Christina, like people are trying the best they can.

They are.

I totally agree that there is good intent.

Some of it is marketing intent, let's be real.

But what happens is they say, I did those right things.

This influencer told me I was not gonna have postpartum issues with diastasis recti because I did everything right.

Now I have it, and I'm thinking literally WTF.

In the true reality, is that yes, strength, maintaining strength during pregnancy and having core strength postpartum is a modifiable factor for diastasis recti.

And there are certain genetic predispositions and body shape size situation or positions or anthropometrics that also are big matters or big factors in your risk postpartum.

So if you are a person whose static supports tend to have more movement in them.

So you're a person who's kind of double-jointed, you have a diagnosis of something like Ealer-Danlow syndromes or lichen sclerosis, you are more likely to have postpartum DRA.

If you are a person with a short torso and a big baby, your body needed to accommodate more by moving belly out in front of you because baby didn't have space to grow into your ribs, because ribs are really close to your pelvis.

And so you're more likely to have more distance between those two recti muscles in pregnancy and therefore more to recover from postpartum.

360 breathing is not going to fix diastasis recti.

It is not going to protect anything, right?

How you are breathing does not change your risk factor for diastasis recti postpartum.

I love that you're doing 360 breathing.

It's not that 360 breathing is bad, but I am so sad that somebody told this person that 360 breathing while lifting, instead of holding their breath, is going to protect them against diastasis recti because now they're going to the internet with all this shame and blame.

And it makes me so sad and a little bit upset because this is the challenge.

Like it's so confusing.

So I really need people to be mindful of like who they are consuming information from online, even with the best of intentions.

And then the second part is can diastasis recti really be healed through exercise?

The answer is that I cannot promise you anything.

Especially if your main concern is resting tone.

When we are assessing for diastasis recti, it is important to know that we are doing an active headlift.

We are feeling those two six-pack muscles come close together because that is what the rectus muscle or the six-pack muscle does on a headlift.

So when you go into flexion, which is that headlift, there's an approximation or a coming together of those two six-pack muscles.

When you are doing exercise with proper progressive overload, you are going to see an increase in the strength and sometimes that hypertrophy or like the thickness of that muscle.

And that can create more tension.

So instead of like the two knuckles deep with more tension, it won't have the same depth quality to it.

And you're likely to see some improvement in how much distance is between those two rectus muscles on a headlift.

Especially if you are in those camps of having, you know, some ligamentous laxity or somebody who whose static tissues, like your fascial tissues, tend to be more flexible and more able to stretch.

And so I think it's really important that we have these very real conversations of these are things we know, these are things we don't know.

These are things that I can promise you, these are things that I can't.

With exercise, you will absolutely feel stronger and more recovered functionally from your pregnancy.

A lot of people tell me, oh my gosh, I was super active in pregnancy.

And then I felt like I lost all my strength in that early postpartum period.

And it's because your body adapts to that growing baby because it happens pretty slow, but postpartum happens really fast.

And so your body has to adjust and it feels really vulnerable and it feels uncertain and it feels like a body you don't know because you don't know it yet.

And therefore, those are promises I can make.

Like functionally, you will feel better.

It'll feel easier to do your tasks at home.

It will feel better with lifting weights and exercise.

That I can promise.

I cannot promise that your uh resting tone is going to look different with exercise.

And please, you did absolutely nothing wrong.

You did nothing wrong.

It was not your fault.

It was likely something around like baby size, anthropometrics, genetics, things that are completely outside of your control.

And I really hope that you do not hold that blame because you don't need to hold on to it.

You can let that go.

Okay.

The second one is y'all, I got my period three and a half months postpartum.

Can I get pregnant by accident?

I want to also say that I am concerned about my hormones, even though my thyroid, I did a thyroid panel and it about a month ago and it came back good.

But I didn't have estrogen, prolactin, testosterone, et cetera, tested.

I'm three weeks three and a half months postpartum, and for a few weeks now, my feet hurt every time I stand up and start moving, and I have a frozen shoulder, both of which I heard can go along with menopause or perimenopause.

But I would think that menopause or perimenopause would stop my periods, not increase them.

I have heard that estrogen is required for prolactin, which is the hormone necessary to sustain breastfeeding and stops the period.

So now I'm wondering: is this an estrogen thing?

So the reason why I picked this question is number one, we have so much that we need to make sure that moms have the education on related to their postpartum bodies.

Number one, when your period comes back, is super individual.

I have had some clients who get their period back literally six weeks postpartum, and they're exclusively breastfeeding.

And I have some moms who it's eight or nine months before they're getting their period back and they started supplementing with formula.

So it does seem to be highly individualized.

You can get your pregnant by accident, even if you are exclusively nursing, even if you do not have your period.

We do know that there's a decreased likelihood.

Sometimes they talk about it suppressing ovulation when you're exclusively nursing, but that is not a guarantee.

Like, like, do not use I'm exclusively nursing as a birth control method.

It is not, it's not gonna work out well for you.

Or maybe it will, but you're you're taking a risk there.

When you are in the postpartum period, especially if exclusively nursing and especially early postpartum, your hormone profile mimics that of menopause.

So in this way, this um this poster is correct, right?

Some of the things that she is feeling may be related to her hormones, and in particular, the fact that she's still kind of in this lower estrogen state, specifically frozen shoulder.

So um adhesive capsulitis or frozen shoulder, one of the biggest risk factors is being female between 45 and 55.

And the fact that, like, that those are known risk factors for a really long time, and it's just been recently that people are like, huh, I wonder if it's that menopause thing that might be uh causing that risk factor is just legit mind-boggling to me to think about.

But, anyways, um when we are thinking about and how we are educating moms postpartum, I think it's important for you to know that about your estrogen profile, right?

Because when you are early postpartum, moms can experience night sweats.

Like those are vasomotor symptoms, similar to hot flashes that happen in a peri- and post-menopause.

They can experience vaginal dryness again, which is that sign or symptom of being uh low estrogen in menopause and postpartum.

It can cause pain with sexual function.

So dysperenia, um, that chafing and that dryness, that lack of lubrication from being in that low estrogen state can make sexual activity very painful in some scenarios, not all, obviously.

Um, and the increase in joint arthroplasty or um arthralgia rather, or like the pain in those joints uh can be increased without a mechanism for why that increase has happened.

And so that is um, we're starting to talk about the muscle skeletal syndromes of menopause, and they are likely mimicked in the postpartum period.

Though, of course, our evidence just isn't there yet.

Just clinically, we tend to see this.

And so what we need to be doing is having this education on the front end, right?

So now this mother, she's concerned about her hormones, but really her hormones are just kind of doing what we would expect them to do in the early postpartum period.

Again, as her body heals and recovers from pregnancy, sustains the act of lactating, of developing or um keeping going with breast milk production.

And then what that breast milk production is doing from a sex hormone perspective.

And then as she stops nursing, as baby starts eating, as she gets further postpartum, that estrogen rebound will start to occur.

Again, it we don't know about the poster, about what her age is.

What can happen if you are in your early 40s and in the postpartum period, you can transition directly into menopause from the postpartum period in some cases.

And so, in in that case, those joint symptoms may continue or persist longer, and it may be a sign of that transition.

And and that's a new, you know, as mothers are becoming a little bit older based on a lot of um things in Western culture right now.

Um, it we see a lot of moms who are starting having babies mid to or early to mid-30s, finishing having babies early to mid-40s.

And what that can do is have that transition happen pretty um, pretty uh close together from being postpartum to being perimenopausal.

And so the the answer is like, now I'm wondering if this is an estrogen issue.

The answer is it is an estrogen issue, but it's not an estrogen issue that is not what I would expect for where you are at in your postpartum journey.

All right, my number three question is hi, mamas.

Wanted to get any insight from moms who've experienced this as I am a first-time mom.

I am currently 34 weeks pregnant, babies expected at the beginning of August.

I know the suggested recovery time is six weeks before doing any sort of physical activity, but I've also heard that this is relative to each mom and how birth goes.

I'm curious if there's any moms in here that have competed in a powerlifting meet shortly-ish after giving birth.

I did.

Um, I have high hopes of doing a competition in December.

Um, if all goes to plan, I'll be about four months, 60 weeks postpartum.

So far, I've had a lowest pregnancy with zero complications, and I've been able to maintain my training with some minor modification.

So I love this question.

Personally, I did a powerlifting meet 12 weeks postpartum.

I was three months postpartum, and then a um a weightlifting meet at five months postpartum.

So um love this because I'm in the club of this, and um, this was with my first kiddo because I was a national level lifter before I got pregnant.

I was trying to get back to that.

COVID put a little bit of a dent in that, and then I got pregnant again, but um was able to come back to a pretty high level.

And so let's kind of break this down.

So I have had lots of podcast episodes where we're talking about trying to get rid of or abolish that six-week do nothing rule, where depending on your circumstances and situations around your birth, you can absolutely start coming back to exercise earlier if you so wish.

If it is your goal to return to a sporting event, whether we're talking about powerlifting in this situation, but it could be uh, I want to sign up for a high rocks.

What about this marathon that I really want to do, et cetera?

Um depending on your labor and delivery, your obstetrical uh like history, like what happens during labor and delivery, is gonna be your biggest predictor, likely, of you being able to participate in that sport.

Baby sleep is another one that can be a big shifter in how you feel and how you feel training's gonna go in that postpartum period.

But definitely obstetrical outcome is gonna be um a big one.

If you were a person who was like, I want to do this in December, the first thing that I would do is wait to sign up until after baby is born.

So baby is expected beginning of August.

Wait until August before and just kind of see how your labor and delivery went in order to like kind of see what you're feeling like.

The second thing that I would say is from a weight class perspective, in a powerlifting meet, you are a weight class.

Um try to not hold yourself to a standard of I need to get back to the weight class I was before pregnancy.

I was a 63, 64 kilo lifter in weightlifting.

I competed in the 69 kilo class, um, 12 weeks postpartum.

Um I did not cut any weight.

I was not trying to cut weight, I was just kind of seeing where I stood on the scale, the two-hour weigh-in, and where I lay, I lay.

Um, and that was helpful because I was still nursing.

I wasn't trying to be in a big calorie deficit.

And we do not want to be in a big calorie deficit or put that added stress on you when you're thinking about that return.

My next piece of advice.

So first piece of advice, do not um, do not sign up until after delivery.

Number two is don't try and be held on to a weight class.

Number three is do not skip out on the basics because you're worried about getting to this meet, right?

Do your core rehab, do your pelvic floor rehab, be very gradual with your loading schema, right?

Being four months, you can put a lot of weight on that bar and it will come, but don't skip on the foundations because then you're gonna hit hiccups later on, right?

So you wanna be very gradual, very progressive with your loading and do that in combination with your core and pelvic floor rehab program.

Um, ideally, if you can have somebody who knows powerlifting that is a pelvic PT come alongside you, that's like bonus points chef's kiss about this.

Um, we have a postpartum powerlifting program on the Barbell Mamas.

If you wanted to start there, we do a uh uh big kind of hypertrophy, more building phase um at the very beginning that you might have to shift away from um because it's higher reps as you get into that last four or six week block going into your meat prep.

But that would give you a lot of like the foundations um that could be helpful.

And we have kind of those filters of if you're feeling this, shift here, if you're feeling this, shift here.

Um, and so that that could be helpful.

So um good luck.

I hope that you get to enjoy.

Um and this was August when they posted, so maybe they're about to do their meet.

I think that's so great.

All right.

The last one is surgery decisions.

Okay, so I have two kids.

I'm 34.

I posted previously in this group a picture because I wasn't sure what I was seeing.

I just had my Eurogyne appointment and it confirmed my suspicions.

She basically said I have every prolapse.

Definitely vaginal cysto and recto.

Since I don't have any issues urinating besides having stress urinary incontinence and no issues with bowel movements, I don't need a pessary.

I kind of disagree with that.

Anyways, nothing to push up myself, however.

She said everything is low and gave me three surgical options.

She gave me options on a posterior vaginal prolapse repair with perennial body repair or a bigger surgery to fix it all, a sacrococopexia done laparoscopically.

And she was looking for advice.

So I am not a surgeon, so I am not gonna talk on the surgery piece, but I do want to talk about prolapse postpartum and some of like our clinical practice guidelines around um managing pelvic organ prolapse.

So, firstly, she said, I have two kiddos.

My guess is that she delivered vaginally.

And she, if she's taking a picture and she's seeing tissue, my guess is that she has a higher grade of prolapse.

What we know is after a vaginal delivery, there's going to be an increase of range of motion of one or more of the vaginal walls.

That is an expected change.

Um, and a change to the resting position of some of the tissues around the pelvis.

We need moms to know that early, right?

Those things are gonna shift.

I and I always make the comment, you know, your boobs change with pregnancy, your belly change with pregnancy, but we expect our vagina to go back to factory settings.

And that just isn't true.

Our body is permanently changed by carrying a baby to term and delivering term, uh, whether it's surgically or vaginally.

When we are looking at prolapse, we are talking about grades of prolapse, grade one, two, three, and four.

Grade three is to the level of the vaginal opening on a bare down.

So they ask you to push and they visualize the opening of your vagina and they look for how much movement down those tissues have.

And then a four is when those vaginal wall tissues herniate to the outside of the body, and then you can you can see them if you have a mirror down there.

When we are thinking about surgery, based on our American Eurogrynacology Society clinical practice guidelines, we are looking for a stage or grade three or more.

We are also looking at other conservative um options, management options before recommending surgery.

And it is in combination with subjective complaints.

The most common direct um symptom of pelvic organ prolapse is this feeling of bulging or a feeling of a uh tennis ball around the vaginal opening.

Like when you're going from a reclined position to sitting, that you feel like you're going over a ball.

And then there's some indirect signs and symptoms of prolapse that can be things like having trouble defecating, needing to place a finger into your vaginal wall and pushing back towards the rectum in order to help with defecation.

Um, some issues with incontinence can be exacerbated or made worse by the um where your resting tissues are, et cetera.

And so when you are thinking about prolaps, it was interesting that she said, since I don't have issues urinating, I don't need a pessary.

I would disagree if you're, especially if you're an active human.

Like I have had clients with prolafs who are experiencing stress, urinary, incontinence.

And that pessary just kind of tacks up those walls just a little bit.

And therefore, a pessary has been a wonderful conservative management tool to help.

And that is what our AGS guidelines also say.

Trial epessary and lifestyle management, which is clearing up constipation, looking at um chronic cough issues and uh weight loss, uh, because abdominal tissue can put more pressure down on those vaginal walls as ways to combat before kind of considering surgery.

Now, I am not an anti-surgery girly at all, but I am pro conservative management first.

And I am pro, if we can have a consult with a pelvic PT at least once before surgery, because what we do see is that there is a high fail rate or a need for revision of prolapse repairs.

And this person is young, right?

She's 34.

And the reason why I think that's happening, and I would love to do research on this, is that if we are not teaching how strain down on the pelvic floor should be managed, then if we decondition with age, life, or with surgical recommendations, don't even get me started on lifting restrictions after pelvic surgeries, because we have systematic reviews that say that lifting restrictions should not happen.

But when we get surgery and we don't know how our force systems and our force generation systems work and how the pelvic floor is so important in those force generation systems, what I mean is that when we are lifting, moving, running, we need to have a co-contraction of our core canister on a contracted pelvic floor.

And oftentimes prolapse can be exacerbated when that system is not functioning optimally and people are pressing down into their pelvic floor instead of utilizing their pelvic floor to help with force transfer.

And so this is kind of like a rant around this, but I just think it's so important to look at.

But yes, surgery can be an option.

And I have had so many clients who have seen such big changes to their quality of life at 34.

The odds of needing a revision again at some point in their life is definitely something to be spoken about and understood.

And then understanding, you know, the surgical options.

I can't kind of speak on the posterior vaginal uh repair, perennial body repair, or the bigger surgery, this uh sacrocopexes.

But um we do know that um us at least in the radical prostatectomy research that and midurethral slings, which is a stress urinary incontinence surgery, that those who have stronger pelvic flores going into surgery tend to have less persistent symptoms postpartum.

Um, and also know that you may uh fix the anatomy, but there are a lot of humans that still have symptoms, lower symptoms, but still have some symptoms in that post-operative period.

So um one of the things that I would love to see is that there is more referrals from urogynes to pelvic to help with like kind of system control, prehab understanding of the pelvic floor and the need for pelvic floor muscle training and the fact that your fitness going into that surgery really matters, right?

Because we use these lifting restrictions in order to reduce strain on the pelvic floor, but strain is a direct measure to fitness, right?

If you have somebody who has low fitness, you are more likely to experience strain on that pelvic floor because you're working at a high percentage of effort doing activities of daily living, like getting up from a chair.

If I have a person who has more resiliency because they have more muscle skeletal reserve, that getting up from a chair is not gonna be putting pressure on those new stitches.

And so I'm I'm not gonna go down that rabbit hole.

I feel very passionate about passionately about pelvic surgery stuff.

But um, again, I am not anti-surgery, but um our guidelines say we need to be leveraging conservative management first.

And um, so I would love to unpack more about this case.

It seems really interesting.

And um yeah, just uh thinking about all of those options.

Um, and I don't know that your guy could have gone through all of these, um, or she was coming in specifically because she had already made the decision that surgery was where she was going.

But I think it's just really important that we lay out all of these options um and what the downstream consequences of those things can be.

We do know though, after mid-ethral slang, um, that there is uh a good chunk of people that go back to higher amounts of physical activity.

So we do know that palvic flora dysfunction is a barrier to physical activity.

Uh so 50% of people with palvic flora dysfunction express that it is a barrier to the type of exercise they want to do, or it causes stopping of exercise altogether.

Um so maybe that this is gonna be that bridge to being able to be more active with her kiddos if that's something that she enjoys or wants to do.

All right.

Also, where's that postpartum?

I again, I'm not gonna go down this rabbit hole again, but just like there's just so many things, so many factors that I'm just guessing on when I'm reading these cases, but it's so fun for me to be like, and there's this, and there could be that, and there could be this.

All right, that is it for me for today.

We have a couple more.

I have one, two, three, four, five, and a response six that uh we are gonna be tackling next episode.

I hope you all find these helpful.

I love that I can kind of go in like all these random directions when it comes to our uh episodes.

Um, and otherwise, I will see you all next week.