EBB 256 – Top 3 Recommendations for Preventing Pelvic Floor Dysfunction after Birth with Dr. Sarah Duvall, Founder of Core Exercise Solutions

Learn more about Sarah’s work and visit her website here

Take Dr. Duvall’s free courses about the Pelvic Floor here

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Rebecca Dekker:

Hi, everyone. On today’s podcast, we’re going to talk with Sarah Duvall, a physical therapist with Core Exercise Solutions, about the top three recommendations for preventing pelvic floor dysfunction after birth.

Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. My name is Rebecca Dekker, pronouns she/her and I’ll be your host for today’s episode. Today, I’m so excited to talk with Sarah Duvall of Core Exercise Solutions. Before I interview Sarah, I want to let you know we will be talking about Cesarean births and recovery after Cesarean. If there are any other detailed content or trigger warnings, we’ll post them in the description or show notes that go along with this episode.

And now, I’d like to introduce our honored guest. We are thrilled to welcome Sarah Duvall, pronouns she/her, Sarah is a physical therapist specializing in women’s health and fitness. As founder of Core Exercise Solutions, a center for continuing education and online programs, Sarah is passionate about empowering individuals to learn and grow in their own journey of healing. When she’s not hanging off the side of a mountain, Sarah is also a wife, mom, and adventure sports athlete who enjoys writing and presenting at coreexercisesolutions.com and figuring out how her clients can continue to pursue their dreams and lead strong adventurous lives. We’re so excited that Sarah is here. Welcome, Sarah to the Evidence Based Birth® podcast.

Dr. Sarah Duvall:

Oh, thanks for having me, Rebecca. I’m excited to be here.

Rebecca Dekker:

I was wondering if you could start off by telling our listeners what inspired you to focus on the pelvic floor and women’s health in your journey as a physical therapist.

Dr. Sarah Duvall:

This is a great question because I was a very die-hard orthopedic sports PT, and so switching to women’s health was not something that even was on my radar for, I don’t know, over a decade of practice. I think a lot of the people in many professions that end up helping women, we do so because we weren’t able to find the resources that we needed when things went wrong for us. I experienced some difficulty after my first child, pelvic floor issues, and was unable to get help in the area that I was living in and was unable to find help online because this was quite a number of years ago. So that led me down this field of I’m very passionate about being athletic and going after things. Now over the age of 40, I’m 41 now, I still want to be an athlete. I still want to push hard, and so I’ve just always had that passion for helping other women not have to give things up.

I feel like it’s one of those things where you have a baby and then you have issues and then you’re told, “Well, just become a walker now. That time has passed.” I really felt a lot of passion in that area, which is why I switched over and started helping women because it’s nice to be able to do the things that you love.

Rebecca Dekker:

Again, when you say people have issues after giving birth, what kind of issues were you referring to?

Dr. Sarah Duvall:

Absolutely. So things like incontinence. Yeah, incontinence, leaking when you cough, sneeze, jump, laugh, or public speaking even. I actually end up treating a lot of professors because projection is very hard on the pelvic floor because of intra-abdominal pressure. So prolapse, pelvic floor tightness. I’m just going to lump everything in when I say pelvic floor dysfunction, just all of the mini facets that go into that.

Rebecca Dekker:

People have problems with incontinence even with just public speaking, is what you’re saying?

Dr. Sarah Duvall:

Oh, yeah. Yes. So yelling at your kids or projecting when you don’t have a good microphone, like if you’re teaching in an auditorium and they don’t provide you with good equipment for speaking, yeah. You think about it, when you cough or sneeze, you generate pressure down. Well, if you’ve ever been hunching over doing something and had to yell at your kid to stop really quick, that might have… Somebody listening, this is probably like, “Oh, yeah, that’s a big problem for me. I have a lot of trouble yelling at my children when they’re across the yard.” So it can be a big issue that we don’t think about.

Rebecca Dekker:

And this is one of those issues that a lot of times you hear people just shrug off and say, it just comes with having kids.

Dr. Sarah Duvall:

Well, absolutely. You look at all of the commercials out now, which the normalization is great. We want to make women feel comfortable. All the CrossFit, the push to it’s normal to pee when you do double-unders or you’re not trying hard if you’re not peeing. There’s all the whole CrossFit push to normalize it. And the Poise pad commercials and even friends to other friends. I think it was one of the popular blogs like Scary Mom. One of my friends sent me a post. She said about how it’s just completely normal now as a mom to leak and it’s just something I’m going to have to experience. So I feel like when you haven’t been exposed to what’s possible for help, and granted there’s no two cases are the same, so I’m never going to say we can always fix it every time because I think that is unrealistic, but I do think that a lot of help can be found and I think there’s good and bad with normalizing things.

Rebecca Dekker:

So Sarah, when you’re talking about leaking urine, is it safe to say that’s part of pelvic floor dysfunction, so it’s not a normal part of our function? It’s a dysfunction?

Dr. Sarah Duvall:

Yes, I would definitely qualify that under the umbrella of incontinence being pelvic floor dysfunction.

Rebecca Dekker:

Okay. How many people are affected by pelvic floor dysfunction after pregnancy or giving birth?

Dr. Sarah Duvall:

There’s a lot of studies on this and it depends on which study you read for it, but there’re studies looking at let’s say like an athletic population, even including women that have not had children, just doing high-impact sports. It could be anywhere between 28% to 80% of women experience leaking during athletics, which is crazy high. Cheerleading is a high level. Gymnastics sports where you’re using high intra-abdominal pressure. Then on one study back from 2013 show that up to 50% of women had some level of prolapse with a physical exam. We were talking about leaking, but I just want to throw in the normal. It’s like we should start normalizing prolapse if we’re going to normalize incontinence as well.

Rebecca Dekker:

And, what is prolapse for our listeners who aren’t familiar with that?

Dr. Sarah Duvall:

Yeah. Pelvic organ prolapse, often shortened to just prolapse, is where the pelvic organs can bulge into the vaginal canal and then descend down and even out of the vaginal canal.

Rebecca Dekker:

Is that something you would feel or know that’s happening or what would this be like?

Dr. Sarah Duvall:

Maybe. This is a great question because I just went on this nice long rant about this. When you have a very low grade prolapse, it’s almost undetectable unless you know what you’re looking for or you’re real familiar with what’s happening in your vaginal canal before and after. You may experience it and you don’t have to have a baby to have prolapse. I’ve heard stories of 16-year-old girls that were in band that we’re bearing down to play their instrument and ended up with pelvic organ prolapse. Many women will have it before going through pregnancy. I don’t think it’s something that we need to say this is only an issue for this subgroup. I think that it can be experienced across the board. Chronic coughing is a risk factor for prolapse as well, so anything where we ramp up that intra-abdominal pressure.

Rebecca Dekker:

Can you talk about what are some basic things people can do to help prevent pelvic floor dysfunction either when they do become pregnant or when they’re postpartum? What are some of the top three things you recommend?

Dr. Sarah Duvall:

I really think a prevention is what is my ultimate dream for when I started online. I wanted to help women prevent issues because I just saw so much potential and I wanted to prevent all issues. I was like, let me have this giant orthopedic program where we’re just going to prevent neck pain and back pain and hip pain, but nobody wants to buy prevention. That’s one of the things that I learned very quickly. We wait until something goes wrong. I love it that in pregnancy, I feel like we get this sweet spot of window of women are like, “Okay, what do I need to do in pregnancy?” which is a time in their life where they usually aren’t asking… A 20-year-old isn’t saying, “What do I need to do to prevent neck pain?” We don’t normalize prevention quite as much as we do during that time period. So I think it’s such an amazing time period if the providers seeing the pregnant women are educated on things that they can do for prevention.

I think that’s where it opens that door of like, okay, let’s check these things. Let’s look at this. Let me just plant the seed or listen to this podcast about this or go to this website for more information. I think that prevention starts with education. But back to your question, I think the number one thing that women can do is to understand pressure management. What does pressure management mean? What does it feel like to bear down on your pelvic floor? What does it feel like to put too much pressure down? Being able to recognize that pressure and that is a very difficult thing, I feel like, for a lot of women to grasp and wrap their mind around until they spend time connecting with their pelvic floor. So I would say that is probably number one.

Rebecca Dekker:

Well, number one you said was being educated and connecting with your pelvic floor. What do you mean by connecting with your pelvic floor? Like noticing your pelvic floor or being mindful of it? What do you mean by that?

Dr. Sarah Duvall:

We have what we call kinesthetic awareness with our body, knowing where your body is in space when you’re not looking in a mirror. So you can take your hand, open your hand. You can tell you opened your fingers without looking at your fingers. If you close your fist, you can tell your fingers moved into a closed position. But a lot of women cannot tell, “Hey, I just beared down on my pelvic floor” or “I opened my pelvic floor. I blossomed my pelvic floor. I relaxed my pelvic floor muscles and I contracted or lifted my pelvic floor muscles.” You can tell when you’re contracting your hand, but you can’t tell when you’re contracting your pelvic floor. So that’s what I mean by developing awareness because the potential is there. Being very aware of this area of your body, you can feel what it’s doing during the day even while you’re multitasking just like you could tell what your hand is doing to some degree.

You might recognize like, oh no, I’m death gripping my steering wheel and I didn’t realize it, but it’s all about bringing that intention and awareness there. I feel like then you can control and redirect your actions to an area.

Rebecca Dekker:

This makes sense. Like, I’m thinking back to as a musician, when I was taking flute lessons, for example, as a young tween and teen, we would practice abdominal breathing and we were really focused on using the abdomen, but I don’t ever talking about pelvic floor with my teachers. It wasn’t until maybe five or 10 years ago that I realized when I’m playing a musical instrument that I can change how my pelvic floor is doing while I am breathing. Does that make sense?

Dr. Sarah Duvall:

Yes, not bearing down and also not overly clenching. So you’ve got a couple tracks here. You’ve got people who put a lot of pressure down. I was one of those people, relearning how to move, how habits of breathing and pressure management. So you’ve got that where you put a lot of pressure down, but also, we’ve got a lot of over gripping and tension being held. So awareness like I was talking about over gripping the steering wheel. You’ve got habitual areas where you can have a tendency to over grip or over hold like clench your jaw. You might pull your shoulders up by your ears. We all have our tendencies. You might grip your upper abs down. We all have areas where we tend to hold tension in our body and we can bring awareness to that no matter what it is and release that tension. So the same thing for recurring pelvic floor tension or tone. You can bring awareness to that area and start to release the tension, so then, the treatment will hold because you’re not continuing to reinforce it.

Rebecca Dekker:

Some people might have a looser pelvic floor and others might have too tight of a pelvic floor. Is that what your saying?

Dr. Sarah Duvall:

Yes. I would say it probably sits more depending on where the line is. If I say anything more than just optimal pelvic floor muscle tone, which would be just normal tone, so anything even a slight tightness, I would say probably maybe from what I’ve seen, and this is not a study, just from what I’ve seen, I would say probably 60% to 70% of women’s sit in the higher tone side just because high tone and weakness often go hand in hand. Because it’s just your instinct. If you put too much pressure down, your pelvic floor’s going to want to stop that pressure.

Rebecca Dekker:

Alright, the first recommendation from you was education and being more connected with your pelvic floor. What’s the second recommendation you have to prevent dysfunction?

Dr. Sarah Duvall:

After pressure management, which I feel like is number one because you can’t out strengthen, you can’t out hold too much pressure… It’s like there’s a floodgate that’s trying to hold in too much water. It’s just never going to work. All right. So the second would be strengthening not only the pelvic floor, but the entire kinetic chain. From my orthopedic side, I’ve really done a lot of intertwining of orthopedics with the pelvic floor and spending a lot of time helping women who were in internal pelvic floor PT to where they like, “Okay, I’ve done what I could, but I’m still not improving. What can I try now?” That’s where we get to take a step back and look at the kinetic chain. That’s when it gets really fun for me because I’m like, okay, this is a great problem to solve. We’re going to figure out what’s influencing your pelvic floor.

So I think there’s not enough emphasis on the rest of the body for the health of the pelvic floor. The pelvic floor is just in the middle and it controls so much, so having great hip, active hip range of motion and strength is extremely important. Things like responsive arches, if your arch is rigid and you can’t get your arch to pronate or you can’t bring up your arch and it stays pronated can influence the pelvic floor, which is it’s great to have the options, I feel like, to what your thoracic spine is doing, how much your mid-back can move, what your posture’s like where you hold your tongue and your mouth. Let’s do an experiment really quick.

I want you to take your tongue and I want you to press it forward into your bottom teeth I just want you to feel what’s happening to your pelvic floor while you do that. Now I want you to take your tongue and I want you to suction it to the roof of your mouth like you’re going to cluck like a chicken. Remember how to cluck. Suction it to the roof of your mouth and then slide it back a little bit. To create a nice suction, slide it back. What do you feel happened to your lower abdominals pelvic floor area? Go back and try the other tongue positioning and then try the suction again. Can you feel the subtle shift in your entire body and how you’re maybe a little bit more perked up when your tongue was suctioned to the roof of your mouth? How maybe your head was a little bit taller, how maybe you didn’t feel quite as heavy down on your pelvic floor versus when your tongue is pressed down to the bottom of your mouth.

Or maybe you’re a mouth breather. If you open your mouth and just mouth breathe for me for a minute or two and then just feel what happens to your body as it follows your mouth down. Looking at how we influence our pelvic floor with all those little things throughout our entire day, I feel like can go more into pelvic floor treatment sometimes than here do this one little thing, this one little exercise for one minute.

Rebecca Dekker:

It’s more about looking at the whole body rather than doing Kegels.

Dr. Sarah Duvall:

Yeah. That would be the number two for me is once we address our connection with the pelvic floor, looking past the pelvic floor and not discounting the influence of everything else, because-

Rebecca Dekker:

Of your hips and tension there.

Dr. Sarah Duvall:

Yeah. Somebody can do Kegels and they can do Kegels and they can do Kegels and they can improve a little bit and then they just plateau and you’re like, well, if I fix this in your hip, then we just got you to five out of five strengths without you doing a single Kegel and you’re just like, whoa, mind-blowing.

Rebecca Dekker:

Mm-hmm.

Dr. Sarah Duvall:

But we look at those primary pelvic floor muscles like your levator ani and they attach into your obturator internus fascia. I know I got a little anatomy on you there, but when we look at all the connections of the muscles in the fascia, then it’s like well, of course, it influences it.

Rebecca Dekker:

Yeah. It reminds me of two things. One, that silly children’s song, the hip bone’s connected to the leg bone’s connected to the shin bone. Yeah, I remember talking with a massage therapist one time about how you might have pain in the back but it’s related to the tightness in the chest and how it’s all connected and we just don’t think about it as a whole unit. We’re more focused on zeroing in on one area that hurts.

Dr. Sarah Duvall:

Exactly. That can be both a blessing and a curse. Because if I’m sitting in front of somebody and I’m like, “Oh, we have these 75 things that I like to look at on somebody,” I don’t know what the number is, but it’s a lot, because I can troubleshoot layers and layers and layers and layers until we figure out what the heck is going on, but that is incredibly overwhelming. You’re just like, give me the five exercises. Stop making me think so much. Stop making me work so hard. So on one hand, I consider it a blessing because I help so many women with prolapse, which can feel just devastating. It has taken your life from you. And I’m like, okay, we have a lot we can do to help this.

So on one hand, I feel like, “Okay it’s great that for me, it’s not so simple as do these five exercises. Oh, they didn’t help. Okay, sorry, this is just your pelvic floor. You have to live with this for the rest of your life,” but it’s also like, “Ooh, you’re going to have to try real hard and it might not be an overnight process. It might take years.” So I think that, blessing and a curse.

Rebecca Dekker:

The other thing that exercise reminded me of when you were doing the tongue and the jaw activity is how many doulas and midwives and childbirth educators tell their clients to relax their jaw in childbirth.

Dr. Sarah Duvall:

Yes. During birth, you’re like, let go because the tension you’re holding in your jaw. If we think about our glottis and our throat and closing off our throat and we think about our respiratory diaphragm or big diaphragm that sits in the middle, take a big inhale, that’s your respiratory diaphragm, and then we think about our pelvic floor on the bottom, think about these as the three structures that divide the body and control pressure and tension. So if you’re holding tension in your jaw, you’re going to most likely be holding tension in your pelvic floor and I find that to be a feedback loop. Women who hold tension in their pelvic floor will sometimes not be able to shake the jaw tension when their pelvic floor is tight and also vice versa. Sometimes they tend to hold jaw tension and then that creates pelvic floor tension. It’s kind of chicken and egg.

Rebecca Dekker:

Wow. Super fascinating. Okay, so number one was educating yourself, correct?

Dr. Sarah Duvall:

Number one was understanding pressure management. And wrapped up in understanding pressure management is you’ve got to become in touch with your body.

Rebecca Dekker:

Okay. And number two was?

Dr. Sarah Duvall:

Kinetic chain, understanding that the pelvic floor is more than just the pelvic floor for what influences how happy it is.

Rebecca Dekker:

What would you say is the third thing for improving your pelvic floor function?

Dr. Sarah Duvall:

Recognizing if you do have some pelvic floor tightness and getting that treated.

Rebecca Dekker:

Okay. How would you know if you have pelvic floor tightness? Because I hear people talking about having a tight pelvic floor but how do they even know their pelvic floor is tight?

Dr. Sarah Duvall:

Absolutely. How do you know if you have upper trap tightness? Take your hand right now. Pinch your upper traps. Find that levator. Oh, that thing is tight, right?

Rebecca Dekker:

You pinch your shoulder, yeah, my shoulders are tight.

Dr. Sarah Duvall:

Exactly. Okay. How did you know that your shoulders were tight? You could take your ear and take it to your shoulder and you’re like, okay, my neck feels tight here. Or you could touch it and you could say, oh, that muscle feels tight. When we think about the pelvic floor, we can one, ask the muscles to move, but if we don’t have that visual of the head moving and those subsequent feeling because our pelvic floor is supporting organs and helping with continence, it’s not-

It’s not moving. Yeah, exactly. I like to demystify the pelvic floor for like, okay, let’s think about it just like other muscles in the body and then all of a sudden, it’s like, okay, if you touch the muscles on the pelvic floor and they are tender, that is a sign that you have pelvic floor tension. Another thing that I’d like to do that is a little less invasive, I guess I should say, or personal for women, because not everybody feels comfortable. As comfortable as we do with the inside of the pelvic floor, that’s our jam, but one of the things I like to do is work on breathing. Just sit comfortably, relax back. I want you to give me the biggest breath you can, trying to send your breath all the way down into your pelvic floor.

Rebecca Dekker:

Like breathing in, you mean?

Dr. Sarah Duvall:

Yes. Nice big inhale. Try to send it all the way down into your pelvic floor. So your air and your subsequent pressure from bringing in a big breath of air will follow the path of least resistance. If you have pelvic floor tension, generally, what I will get from women is if they have a lot of pelvic floor tension, at least a degree where I’m like, okay, we need to work on getting this treated, then their air and their pressure feels like it stops at their belly button.

Rebecca Dekker:

Okay.

Dr. Sarah Duvall:

So it’s like, oh I just feel like I hit a brick wall. I can’t reach my pelvic floor no matter what position I’m in, even curled in a ball.

Rebecca Dekker:

You should be able to reach when you’re sitting in a chair at the seat of the chair with your breathe.

Dr. Sarah Duvall:

Yeah, if you don’t have pelvic floor tension. If you have a little bit of pelvic floor tension, then it might feel like it stops at your pubic bone. It doesn’t travel all the way down your pelvic floor. I like to think about it as a balloon animal. In the circus, they blow up those long balloons, but think about that as being your vaginal canal. I want you to think about putting pressure, air pressure down the length, that vaginal canal, but do it gently. You’re not forcing the air in there. You’re just guiding your breath a little bit. That’s where if you feel like you have to force it, then you probably have some pelvic floor tension because you’re having to force it through the tension.

Rebecca Dekker:

And if your pelvic floor is weak and overstretched, do you feel that too?

Dr. Sarah Duvall:

Oh, yes, and that makes women feel very uncomfortable. If they’re like, “Oh, wow. No, I just feel like everything blossoms out and my pelvic floor is going to fall out and it just feels like the breath just comes straight.” I’m like, okay, we’re not inhaling into your pelvic floor now because you have a lot of laxity and pelvic floor distension. We need to improve your pelvic floor tone and pelvic floor strength. That can be a great just a simple breath test to get a feel on where their pelvic floor is at the moment because things can change day to day even, especially for pelvic floor tension.

Rebecca Dekker:

Okay. Why would tension be a bad thing for birth and postpartum? Because I would think that would mean you’d be less likely to have incontinence after the birth because you have very highly toned muscles. Can you help me understand?

Dr. Sarah Duvall:

There’s some confusion with the word toned versus tension.

Rebecca Dekker:

Okay.

Dr. Sarah Duvall:

Think about tension in any other muscle in the body. As an orthopedic PT, if somebody’s holding a lot of tension in their neck muscles, is it going to make their neck feel great or is it going to make their neck hurt?

Rebecca Dekker:

It hurts.

Dr. Sarah Duvall:

Right? A highly toned, strong muscle is great, but a strong muscle can also turn off and relax. A muscle that is holding tension is not necessarily a strong muscle. If I had asked you to do one of the strong man coms where I’m like, “Pick up that 500-pound barbell with the shrug for your upper traps and carry it to this line,” and you’d be like, “I can’t do that.” I’ll be like, “Well, your upper traps are weak.” We can’t confuse strong with high tone or tension. Does that make sense?

Rebecca Dekker:

Yeah.

Dr. Sarah Duvall:

If a muscle is holding high tension, it’s not going to be very distendable like you can’t take your ear to your shoulder because your neck is tight. So if we are going to birth and the pelvic floor muscles are tight, then that might make them less able to stretch, less able to expand. When you ask somebody to do a really good contraction of their pelvic floor, if we think about the way muscles work, they work under what’s called a length-tension relationship. Basically, if I’m going to throw a ball really hard, I’m going to take my shoulder back as far as I can to throw it. I’m going to stretch and extend to then be able to throw and flex. Our muscles really like to go to full range to ramp up to get a really good contraction. So if you’re holding tension in your pelvic floor, let’s say it’s the levels…

I like to explain it as the levels of a house. So you’ve got first floor where everybody normally lives in a house. Then you’ve got your basement. Then you’ve got all the way, let’s say up to level five, which I feel like is lifting all the way the elevator all the way up to my belly button when you do a contraction. So you’ve got to be able to close the elevator door and if you give me a nice big inhale down, you’re going to inhale into the basement and then come back up to that resting tone on ground level. If you bear down, you’re going to go out the basement window and that’s what we don’t want. We don’t want all that pressure going out the basement window. So that’s when you’re thinking about creating that prolapse.

When we think about being able to contract the pelvic floor, if we live on the ground level or even if we can get a nice inhale stretch down and then a really good contraction, we’re going to be able to go all the way up to the floor number five. But if we can’t get that good gathering, then we might just be able to get to floor three or floor four, so it’s going to be a very weak, poor contraction, which is then going to lead to leaking and incontinence. So generally, the tighter somebody is, the more they may experience prolapse symptoms or incontinence symptoms. That brings me back to your prolapse question from the beginning that I think I didn’t finish fully answering. A lot of women confuse low-level prolapse symptoms with symptoms of tightness. What they’re feeling when they say my prolapse is painful is they’re often just feeling pelvic floor tightness. Yeah. Anyway, sorry, just to circle back on that.

Rebecca Dekker:

So number three is…

Dr. Sarah Duvall:

Treating tension if you have tension, because we can’t get a great contraction. From an orthopedic side, I may have to loosen somebody’s upper traps and their neck to really get their serratus on board, get their shoulder muscles firing well, get their scapula moving where that shoulder blade, getting it moving through so then their neck can say, “Ah, I’ve released tension now and everybody can move properly and be really strong.”

Rebecca Dekker:

One of the things I know you talk a lot about on your social media channel, Sarah, is Cesarean surgery and how that affects the pelvic floor. I was wondering if you could talk a little bit about that because I feel like a lot of people think that incontinence and pelvic floor dysfunction with having a vaginal birth, but it’s my understanding rom learning from you, that you can also have major pelvic floor issues after a cesarean. Can you talk about that?

Dr. Sarah Duvall:

Absolutely. Research does show that there is a difference with the type of delivery. Women who do have a vaginal birth have a higher chance of having pelvic floor issues, but that does not mean that having a C-section completely protects you from having pelvic floor issues. It also doesn’t mean that vice versa, so those who have a C-section have a higher rate of having a diastasis recti later postpartum than women who had a vaginal delivery. So when we think about it as just disrupting part of our system with a C-section, because all the tissue is cut through and then sewed back, if that area is not addressed, the scar tissue in that area is not addressed, it can lead to tightness that filters down to the kinetic chain. Our pelvic floor works with our lower abs. Go ahead and take your hand and place it right above your pubic bone for me and push in a little bit. Okay. Do your lower ab feel soft and squishy right now?

Rebecca Dekker:

Yeah.

Dr. Sarah Duvall:

Okay, great. So relax, relax your body, keep your lower ab soft and squishy. I want you to contract your pelvic floor for me. Just focus on a nice pure pelvic floor contraction. Did you notice how after about 10% to 20% of that contraction, your lower abs started to gather with your pelvic floor? If you were going to give me a big pelvic floor contraction, really contracting hard lifting all the way up, you’d have a lot of lower abs gathering in.

Rebecca Dekker:

Okay.

Dr. Sarah Duvall:

Now imagine we put scar tissue across those lower abs. The lower abs go hand in hand with the pelvic floor when it comes to pelvic floor function. So if we have scar tissue in one area, that’s going to affect the other area and how well it fires. Working through that scar tissue can be really, really important for the health of the pelvic floor because it can contribute to things like pelvic floor tightness, which we already know where that leads or can lead.

Dr. Sarah Duvall:

So scar tissue massage… I think is very important, making sure the scar is desensitized, mobile, and-

Rebecca Dekker:

When does this start or when should you start this?

Dr. Sarah Duvall:

Once the initial healing is done, so generally, six weeks is a very often safe measure, just once your scabs cleared, but you can start moving around the outside of the scar. You don’t have to directly touch the scar. Then once that is comfortable, then you can move into directly touching the scar. If you’re in for something else for physical therapy and you’ve never had your C-section scar looked at, just say, “Hey, PT or OT or anybody who works with scar tissue, come here. Check this out. Let me know if my C-section scar is moving like it should. Anybody who’s trained, even a massage therapist can help determine if that scar tissue is moving well. If it’s moving well, then the muscles will be a little happier around it.

Rebecca Dekker:

Are you trying to prevent adhesions, the scar tissue all sticking and creating tight spots that don’t move?

Dr. Sarah Duvall:

Yeah, exactly. You want the body mobile. If one part doesn’t move well, it’s going to affect everything else. Have you ever had a spot in your middle of your back bother you and then you end up with a headache from it? When things get little hang-ups around the body, it influences the vastness of the kinetic pain.

Rebecca Dekker:

Yeah. Do you feel like most people who have Cesareans know to do that, feel comfortable touching beneath their scar and self-massaging it?

Dr. Sarah Duvall:

They didn’t know. That answer is no. This comes in with that whole preventative as part of their birth provider, giving them education on it, letting them know that’s something that needs to happen. Right? Don’t you agree me?

Rebecca Dekker:

I have never hear of anybody receiving that in their postpartum education from their OB.

Dr. Sarah Duvall:

Yeah, right? We need to change. These are just really simple thing that you can do to help.

Rebecca Dekker:

Yeah. So what would you say? What would be instructions you would give to someone? Maybe they’re eight weeks post cesarean. How would you describe how you monitor and massage that area?

Dr. Sarah Duvall:

Well, I would show them.

Rebecca Dekker:

Okay.

Dr. Sarah Duvall:

Yeah. I would show them usually on me and then on the back of their hand, I’m putting this much tension. I am rubbing this hard. I am moving the skin this much, and so it’s really hard into accurately-

Yeah.

Rebecca Dekker:

Where can someone go to self-educate on these kinds of topics if their doctor is not covering it?

Dr. Sarah Duvall:

Just search YouTube. I know I have an Instagram video on the start of scar massage. That’s on Instagram, but you can basically YouTube it and there’s a ton of information and videos.

Rebecca Dekker:

Okay, so search for Cesarean scar massage. This is, in your opinion, just like basic education.

Dr. Sarah Duvall:

I’m going to massage anybody’s scar. I don’t care what the surgery was. Even if it’s an appendectomy, I’m going to make sure that scar moves. It’s just basic PT in my opinion.

Rebecca Dekker:

That’s so weird. As a nurse, I feel like this was something never something that we were educated on in nursing school. I helped so many people recover from different abdominal surgeries as a medical surgical nurse and it was never on their education or paperwork, like how to self-massage the scar after it healed.

Dr. Sarah Duvall:

Yeah. I actually recently treated someone for back pain and I was like, what is going on here? She didn’t have any kids and she didn’t tell me about any past surgeries. I was like, “Can I just look at your abdomen?” and she was like, “Oh, I had this surgery when I was a kid” and she had this big scar across our belly. I’m like, “Oh. If you had told me about this at the beginning, it would’ve saved us a number of sessions” because it was severely restricting her movement in her spine. I was like,” We’ve got to work this out,” and it improved things dramatically just by working out the scar tissue. But I find we tend to block things out. I’m a big proponent in not ostracizing any birth decisions. I feel like we hide the risk of pelvic organ prolapse with pregnant women in a lot of cases.

I guess the advice I gave a close family member to me the other day who they’re thinking, “I might need a C-section. What advice do you have for me?” I’m like, “Great. If you were in that position where it’s what you need, you should feel good about that.” Then I went on to tell her about all the things that can happen if the pelvic floor isn’t responding well to delivery. She’s just like, “Why doesn’t anybody mention this to me?” I’m like, well, there’s a lot of support groups who are after, but I feel like it’s something that we keep a little bit hidden and then women feel like they failed when they have a C-section. They feel horrible about this. I’m like, no, don’t. Think about the good that might have come out of you having that and how much heartache it might have saved you because there was a reason why you needed it.

I feel like if there was a little bit more education around pelvic floor dysfunction that when that decision needs to be made, there would be less disconnect from the C-section area. Because if you feel like you failed and you feel like I just can’t connect with that area, I don’t want to look at it, I don’t want to touch it, I hate it, and so I spent a lot of time-

Rebecca Dekker:

It’s a very visible reminder of how you can take care of yourself and in thinking about the word disconnect, when I mentioned earlier, that you know, part of my nursing school education, we did not talk about adhesions after abdominal surgery and we didn’t learn how to education patients on how to educate patients on how to massage scar tissues, but…

Dr. Sarah Duvall:

Yeah. If we had a little bit more education on that was a really good decision for you, you should feel proud of yourself for going through with that decision, and then I feel like there would just be less disconnect with our body after.

Rebecca Dekker:

there’s a disconnect I think too for clinicians because they tend to only see people immediately after the surgery, immediately after delivery when you’re very tender and obviously, you’re not going to be like, pushing on it and massaging it. It seems like there’s just this disconnect where people have their baby and then they go off. Then their OB might see them one time at six or eight weeks and the nurse would never see them again, so you don’t really have a chance to connect with the long term.

Dr. Sarah Duvall:

Which is why our postpartum care as a whole needs to change and involve more providers in that process.

Rebecca Dekker:

If somebody’s listening to this and they’re thinking, “Oh, my gosh, I have a lot of scar adhesions, I can tell” or “I think I might have pelvic organ prolapse,” who are the people you recommend they go to in their community? What should they look for? Do you go straight to an OB-GYN? Do you find a bodyworker? What do you do?

Dr. Sarah Duvall:

A lot of states have direct access for pelvic health professionals, so you don’t have to go to your OB in a lot of states. What you do, I would ask around friends if you feel comfortable. I would say, “Hey, do you know anybody who’s seen an internal pelvic health specialist? Because both PTs and OTs can become pelvic health specialists for that particular rehab. We’re thinking rehab umbrella. I would start by asking around if you feel comfortable. We have a database of continuing education providers that have taken my course, the pregnancy and postpartum course. Anybody can email in and we can help them locate somebody. We also have a list of like, “Hey, this person was recommended by somebody,” and so we add them to the list. Because that can be really nice to have that recommendation.

Then I recommend learning as much as you can. I have a ton of information on my website, YouTube, Instagram, just all these educational videos. Then you learn as much as you can, which stinks, but at the end of the day, you’re in charge of your own care. I just feel like we should all learn as much as we can. These are our bodies. Then you take that knowledge and you go in. Even if you’ve got to go see a random person, go in and see that random person. You ask them questions. You get an eval. You see what they know, you see what they recommend, and then you see if it works. If you’re not feeling at least some progress within a few sessions, or like, “Okay, I’m really wrapping my mind around this. I feel really good about the treatment they’re giving me,” then I would find somebody else.

Because just like you wouldn’t let any contractor build your house, I don’t understand why people will go to one provider for something and have a bad experience and then never try anybody else. Like, oh, a contractor messed up my roof. I’m never having a contractor ever again. They’re all terrible. I feel like that’s what happens with the pelvic health world and just PT in general too. An OB might refer out to a bad PT. Patient comes back with a bad experience and the OB would be never refer to PT again. I just feel like there’s the same thing that can happen within any profession.

Rebecca Dekker:

Yeah. So look for pelvic floor specialist and physical therapists and occupational therapists can get that specialization. Other countries outside the USA might call the pelvic physiotherapist. Which is a lot more common, I know, in countries in Europe to see pelvic floor therapy after the birth for most people. And, in contrast, we don’t do that in the US typically and we have so many here people struggling with their pelvic floor after giving birth. It has become so normalized that everyone has pelvic floor dysfunction.

Dr. Sarah Duvall:

Yes, it is. I know. It’s amazing. It’s just part of the birthing process, which here, it does not, unfortunately.

Rebecca Dekker:

Yeah. What kind of programs do you have at Core Exercise Solutions? Can you tell our listeners a little bit about the resources you have there?

Dr. Sarah Duvall:

Sure. I started out way back with an online program for women because that was when I was like, okay, I’m going to help women because I felt so let down by the system and just to help educate. We still have that, but we’ve primarily switched to continuing education. I just have such a passion for helping to educate providers because I learned so much the hard way. I feel like I read, I don’t know, hundreds and hundreds of research studies and pieced it together and experimented on patients, thank you patients for letting me experiment on you, and just pieced it together somewhat the hard way over the last decade. I like to shortcut education. I’m like, “Hey, let me tell you these five tricks I learned,” so I feel like continuing education is such a blessing for us.

Rebecca Dekker:

What kind of providers are taking your continuing education?

Dr. Sarah Duvall:

A little bit of everything, honestly, so PTs, OTs, chiropractors, personal trainers, even. We’ve got a lot of great fitness professionals that work with women because there’s a lot of areas where they’re not internal specialists or they have to drive an hour and a half to go to an internal specialist and they’re like, it’s just not worth it. I only leak a little when I deadlift. So then you’ve got this fitness professional who’s like, “Okay. Well, great. Now I’m in charge of this person’s pelvic floor because they’re not going to get help and I have to know a lot.” So I really like helping that education population as well because I feel like a lot of responsibility often ends up on their shoulders. And in towns where we’re lucky enough to have awesome relationships with providers, that’s amazing, but there’s a lot of places where that is not available. So being able to have knowledge to help women through exercise, prevention, and helping with improvement, I think is really important.

Rebecca Dekker:

And sometimes I have been struck by how physical therapy can be really inaccessible for some people who don’t have insurance or don’t have insurance that really covers it very well, or they have really high co-pays. I found though in our own family that we were able to see a physical therapist, but it was so inaccessible to us, we just got a regimen, like an exercise regimen from them and then go to somebody else who just helped us stay accountable. That was way more affordable than seeing a physical therapist than going, driving, and seeing a physical therapist once a week, which was inaccessible.

Dr. Sarah Duvall:

We have an online program, but sometimes, we’re like, you need to go see somebody in person. They’re like, well, it was 250 for one visit, which was great. That person’s highly educated and worth every penny, but the person who went to see them didn’t necessarily need a lot of ongoing internal work. So that’s where an online program is really helpful because then they can have six months of help for 250 and they can continue their education. But online programs don’t really give you accountability as well as showing up in person does, so it takes, I think, a special person to be able to do well online versus in person.

Rebecca Dekker:

Yeah. It also sounds like midwives and doulas would benefit from this program as well.

Dr. Sarah Duvall:

Oh, my gosh, yes. I’ve had a bunch of midwives. Sorry, I didn’t mention that. I’ve had a bunch of midwives and doulas take the course as well.

Rebecca Dekker:

Yeah, especially postpartum doulas because I’m sure they’re the ones who are seeing a lot of the after birth effects.

Dr. Sarah Duvall:

Yeah, but just the education on prevention. I go through how to prevent pelvic floor issues. I just feel like that prevention component has gotten so missed.

Rebecca Dekker:

Yeah, that’s something that prenatal doulas could include prenatally before they go to the birth with their client.

Dr. Sarah Duvall:

Yeah. Absolutely.

Rebecca Dekker:

Yeah. How can our listeners follow you and your work?

Dr. Sarah Duvall:

My website, Core Exercise Solutions. I’m on Instagram and YouTube. I send out a newsletter maybe twice a month where it sums up all new videos and articles and things like that. So hopping on that newsletter list can be really helpful for getting all the new things coming out, but I’ve got a lot of free courses on my website that are just very in-depth for the amount of material that is completely free. I would just highly recommend starting there. I’ve got a little tab at the top and you can sign up for one of those freebies and you’re just going to learn so much and it’s completely free.

Rebecca Dekker:

Yeah. Well, thank you, Sarah, so much for your work and all you do to help educate us about our bodies. I feel like I learned a lot today. Hopefully, our listeners were participating and breathing along and doing exercises and learning as well. This was incredibly valuable wisdom. Thank you, Sarah, for your teaching and your wisdom.

Dr. Sarah Duvall:

Oh, thanks so much for having me.

Rebecca Dekker:

Thanks, everyone for joining us and learning from Sarah about the pelvic floor. We’ll see you next week. Bye.

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