Dr. Nidhi Sharma, a board-certified women’s health specialist, creates a series of patient education modules. In this episode, we focused on 【Pelvic Organ …
– Hi, my name is Nidhi Sharma.
I'm a women's health physical therapist
here in New York
working at FuncPhysio Physical Therapy.
I am a clinical specialist in orthopedics
and women's health
and I've been treating for over 12 years.
I mostly treat women and men
with pelvic health problems
before pregnancy, after pregnancy
throughout their lifetime.
I treat pelvic pain, I
treat women after menopause
all urogynecological problems
and pelvic health problems
through the spectrum.
So, today we're talking
about pelvic organ prolapse
during pregnancy and postpartum.
We had mentioned this a couple of times.
This series of presentation
is meant for population,
general population patients
women who are pregnant, who
were pregnant in recent past.
It's not meant for
practitioners in detail.
If you're a practitioner,
we're happy for you to listen
but we do have more modules coming up
where we will actually
talk to practitioners
and teach practitioners
in helping these women
get back to function and avoid problems.
Okay, so feel free to type
any questions you have.
Okay, so pelvic organ prolapse.
What is pelvic organ prolapse?
Basically, inside the pelvis
so this is the pelvis, there's
a bone on the right side
bone on the left side.
There are three organs inside the pelvis.
So if you look at the pelvis as a bowl.
Bone on one side, bone on the other side
and there's pelvic floor at the bottom.
There are three organs inside this pelvis.
Bladder, where you collect your pee.
Rectum, where you collect your poop
and uterus where the baby is.
So basically, these three
organs live inside this cavity
or space called pelvic cavity.
The bottom of this cavity
is made by a muscle
and taped tissue called pelvic
floor muscles and fascia.
And you can see in this picture
basically looks like a
sling under the pelvis.
And the organs are inside.
So here they don't show all of the anatomy
the organs are not just sitting there.
They're not just resting there.
They're basically hanging
or suspended from the sides of the pelvis.
So, I'll just clarify
this here, where is this?
Yup, so from that picture to this picture
if you look at it,
there are organs, right?
The bladder, the rectum, the bowel
the bladder, bowel and the uterus.
They are inside the pelvis,
there are bones on both sides.
And then there are thick ropes
that attach these organs
to the side of the bones.
So you can see these ropes
are called ligaments.
And then there's pelvic
floor at the bottom.
So pelvic floor forms this muscle
kind of forms like the
water in under the boat.
The boat is the organ,
ligaments form the ropes
that are hanging the boat.
And then there are muscles
on top of the pelvis
the back muscles, hip
muscles, abdominal muscles
that keep this pelvis together.
So, what happens during pregnancy
if you have attended the previous seminars
I talked about this.
These bones become a little bit looser.
They start to move, they
start to expand a little.
The muscles of the back and the abdomen
they both become looser.
The abdominals have to stretch a lot
because there's a baby growing there.
The pelvic floor in the
bottom stretches out
and then there's a baby inside the organ
which means the organ becomes heavier.
So all together, the organ is heavy.
The pelvic floor is weak or stretched out.
The muscles of the sides are stretched out
and the bones of the
pelvis are moving more.
So together, what happens
is now the ligaments
get to stretch a lot more and
the organs tend to sit lower.
So, in normal scenario
when we look through the
vaginal opening opening
we should see nothing.
We should see an opening of the vagina
an opening of urethra and anal opening.
With prolapse, we sometimes
see a little tissue
or some part of organ protruding
through that opening, okay?
So as all these changes happen
or the prolapse is when
the organs start to descend
or move down from their original position.
And it's not just because
the organ is heavy
it's also because the pelvis is wider
because the ligaments are stretched
because the pelvic floor is weak.
All of those things together.
That's why I showed you that picture.
Three organs were there,
bladder, rectum and uterus.
Either one of them can move down.
Usually it is the bladder
because bladder is the most mobile organ
inside the pelvic cavity.
So, similar picture from
the last time you see
we're cutting from the
side and we look inside.
There is the bladder, uterus, rectum.
And this is what the
pelvis would look like
without a prolapse.
Bladder is up here.
You see this is the opening called urethra
where you pee from, this is the vagina.
This would be the anal
opening where you poop from.
And all these three
openings have their own line
and organs are in their place.
This is the mild prolapse.
Mild prolapse is when the
bladder start to move down
from its position.
It's sort of drooping down
and now it's coming through
or pushing into the vaginal canal.
And we can see that here.
And then the grade two
would be coming out more
and coming to the level
of the vaginal opening.
Stage three would be when it's coming out
of the vaginal opening
and four would be coming out all the way.
Most common prolapses and
in during or after pregnancy
stage one or two.
Three sometimes happen.
Four almost never happens, it's very rare.
Happens usually after surgeries
or in older age for other reasons.
Similar thing can happen
to uterus and rectum.
Exact same thing different tissue
but coming through the vaginal opening.
Again, we focus a lot more on bladder
because bladder and
rectum are the two things
that prolapse most during pregnancy.
We're talking about pregnancy here.
Why does it happen?
So all of those things happen
so we can show why it would happen
but why this has happened in some women
and not in others, okay?
So what are the risk factors?
The first risk factor is genetic.
We don't exactly know
some women with some specific
size or shape of their pelvis
specific size or shape
of their vaginal opening.
The distance between their vaginal opening
to anal opening.
Different factors, anatomical factors
can predispose some women.
We don't discuss this an awful lot
because these are not modifiable.
We're not gonna change
the shape of your pelvis
or shape of your vagina.
So, some genetic factors are
there and basically just there.
Second is obesity.
So, remember, I said the
organs sort of move down.
Now when the organs are moving down
anything that pushes on them from the top
what can cause them to move down more.
That's one of the reasons
this happens during pregnancy
because there is the weight of the baby.
So, body prepares you to
take the weight of the baby
and we should do the exercises
to take weight of the baby
but if you were obese
or you have a high BMI
going into pregnancy,
then you have extra weight
even more weight than the weight
what baby is going to give you
and that tends to push down
or create constant or repetitive
pressure into the organs
which might predispose
women to having prolapse.
Habit of bearing down.
Again, any pressure that
gets you to move down
gets the organs to push down.
So habit of bearing down
usually is in constipation.
If you are somebody who
has had constipation
for a long time, you know
what I'm talking about.
You sit at the toilet and
every time you pass some stool
you have to push a lot.
So if you're creating bearing down
if you're going (groans loudly)
If that's what you're, trying
to get your bowel to move
you are creating that extra
pressure into the pelvic floor
and we'll talk about, we'll
look at a detailed picture
a little bit later.
Multiple pregnancies, parody
is one cause or risk factor.
So consecutive babies
second baby is a little
bit more than first.
Third baby a little bit more than second.
So if you have a mild prolapse after first
you should rehabilitate your pelvic floor
and get stronger before you
go into the second pregnancy
so that you prevent the
chances of it getting worse.
Vaginal delivery is also
sometimes considered more
than the cesarean delivery.
Vaginal delivery in itself seems
to not be such a big issue.
It is really the use of forceps.
I talked about this in my
Instagram stories today.
It's really the use of forceps
that'd be if you look at
the vaginal delivery closely
we find the women who had
instrument assisted deliveries
especially use a forceps
are the ones that tend to
develop the prolapse a lot more.
Large babies and pelvic floor
muscle injury during delivery.
So if you are feeling weak down there.
If you're feeling loose down
there, if there's a tear.
If they used forceps, if
you have had multiple babies
all these are causes
for you to go seek care.
50 to 60% of women will develop
prolapse grade one or two.
A huge majority of these women
are not symptomatic,
they don't feel anything.
And that's a good thing.
If you're not feeling anything.
Remember, I said the grade
one is when the bladder
is sort of moving down
but it's not coming to
your vaginal opening.
And because it's not coming
to your vaginal opening
you may not feel it
and that's a good stage
to take care of it.
So, after you have the baby
go to a physical therapist so we can look
where is your bladder?
Is it in place?
And if it's drooping
down just a little bit
that's an excellent time to get stronger
and reverse that prolapse.
Grade one and grade two can be reversed
and improved with the organs
going back to their place.
Prevention, get
constipation under control.
Again, I'll talk about
constipation a little bit more
but constipation means you're bearing down
constantly wearing down, okay?
So if diet is something
through which you can control
your constipation, I want you to do that.
Healthy weight gain, more
weight means more pressure.
You are going to gain weight
because you're pregnant.
I just don't want you to gain more weight
than what's appropriate for your age
and your height and your weight.
So make sure that you talk to your doctor
if you gain too much weight.
If there are ways you can eat healthier.
Pelvic floor muscle strengthening.
That was the muscle that
was underneath the pelvis
that can help the pelvis
go up, organs go up.
So strengthening of pelvic
floor is one of the primary ways
we try to prevent and manage
pelvic organ prolapse.
Proper bowel movement strategies.
If you are going to bowel movement
if you're pooping by
constantly bearing down
that's something that's
going to create pressure.
So we want you to change that
and I'm gonna talk about
that a little bit later.
Healthy labor movements.
This is not always possible for all women.
If you are constantly pushing
a lot throughout the labor
you're creating downward pressure, okay?
So, the ideal scenario
is when the stage of (mumbles) of labor
is a little bit shorter
and you don't need to push down as much.
Again, not something that
you can always control
especially if you've had epidural.
Regular exercise, exercise
is going to strengthen
all the muscles we talked about
and hopefully give you a better chance
of not gaining too much weight.
So here we are, constipation and prolapse.
So we're looking at ultrasound picture.
So we're looking straight
up through the vagina.
I put the ultrasound head
on her vaginal opening
and we're looking straight
up into the pelvis.
So the reason I'm showing you this is,
I wanna show you in real time
what happens when you bear down.
When you're constipated and
you're constantly bearing down
to have a bowel movement.
What does it do to your organs?
So this big bag, black bag is bladder.
This is kind of the same side
view that we had earlier.
This is the bladder, this
is vagina, this is rectum
and in rectum is where the stool would be
so there would be stool
and it will come down here.
So, the picture, what she
did was, I asked the patient
to bear down.
Like she would have tried
to have a bowel movement
and this is what happened.
So she's gonna bear down and
create the pressure down.
And you can see that the
pressure came through here
and stool will move down, right?
So, you are basically
pushing the rectum down
so the stool moves down but
look what else you push down.
You push down on the bladder.
So there is no way that when you push down
you push down only on one organ.
You're gonna push down
on all three organs.
So if you push down on
uterus, while having a baby
you're also pushing down on bladder.
If you push down on rectum
while trying to poop
you're also going to push down on bladder.
So, anything you do any of those organs
you push down or bear down a lot
and it's going to travel
to all three organs
and all three openings.
So, constant or chronic constipation.
So everyone pushes once
or twice to get started
when you have a bowel movement.
But you should not be pushing
for 20 minutes or 30 minutes.
You should not be pushing every time
to get the bowel to move.
So one more time.
Push down and you can see how
far into the vaginal opening
that bladder moves down.
Right, there it is.
Okay, so what should you do?
During pregnancy
constipation is very common
because we're taking the iron supplement
which makes the stool move slower
and increases the density of stool.
So more water, more vegetables
all the diet changes
that you can do, okay?
More fiber but apart from
that, there is a technique
to bowel movement
which we all basically
do wrong these days.
So I'm gonna talk about
that technique a little bit.
So, the way that rectum
works is this is the rectum
where your poop is and
this is the anal opening.
So usually there it's
a little bit of a kink
like this, okay?
And there's a muscle
that pulls on this kink
and that's how you hold your poop.
So this is a pelvic floor
muscle that pulls up.
So when you're standing up,
your rectum looks like this.
There's a kink in it and
that's why you can control it
and the poop is not going to leak out.
When you sit down in
that 90 degree position
the first position in the picture
what happens is, it
comes down a little bit.
So the kink is not quite strong
it's a little bit less, okay?
So you can move the stool
a little bit easier now
because there is less of a kink.
But there still is a kink, okay?
It's not straight.
What will make this whole
kink a lot more efficient
is if you were to get into position
where you were almost squatting
where your knees were close to your chest
and that basically takes
this rectum from here
and brings it here and pretty
much straightens this tube.
And now obviously, the tube is
straight, your stool is soft
you should not have to push a lot, okay?
You should push once or twice
and then the stool should just move.
So, there are these little
stools that are in the market.
The most common brand
is called Squatty Potty.
It's affordable stool, you
put it under your toilet
in front of your toilet,
you put your legs up on it.
We want your hips to be above your knees.
And if you're pregnant,
your belly is in the way.
Bring your knees apart and
bring your knees up, okay?
Put two trash cans or
something, whatever you want.
Get yourself in a squatting position.
And once you are in squatting position
you're going to breathe
deep into your belly.
So you're gonna go (inhales deeply)
and then you're gonna
keep your belly big, okay?
So don't breathe out, hold that
breath, keep your belly big
and then you're going to push down
or bear down with an open mouth,
so you go (exhales deeply)
And that should take
once or twice of pushing.
The reason I don't want you
to push with a closed mouth
is when you push with a closed mouth
you tend to close the pelvic floor.
If you're closing the pelvic floor
you're basically using that muscle, right?
It's going to create a kink.
That's what its function was.
So what I want you to do is,
you're gonna push a little bit
to get the movement started.
I want you to push with an open mouth.
Open mouth pushing, it makes
the pelvic floor relax.
And if you have taken any
childbirth education classes
they tell you that during labor too.
Pushing with an open mouth
will relax your pelvic floor
and the relaxing of pelvic
floor will open these openings
so that the stuff from
inside can come out.
Whether it's pee or poop or baby
because they're all coming
out from different openings
in the same structure.
Okay, so breathe in, hold the breath.
So breathe into your
belly, make your belly big
hold that breath and
then push down a grunt
with an open mouth, open
mouth is the important part.
Already did that, okay, relief.
So if you have pelvic organ prolapse
most often, in grade one,
sometimes in grade two
women don't know that
they have a prolapse.
So, if you are six
weeks after giving birth
four weeks after giving birth,
you don't feel any prolapse
that's a good time to go get checked out
by a pelvic floor physical therapist
so we can see if you have prolapse.
If you are starting to feel
prolapse during pregnancy
or after giving birth,
this is what you can do.
This is usually for after giving
birth, not during pregnancy
because you cannot get in these positions.
So, the organs are coming
down to the pelvis, right?
Usual symptom is,
you feel like there's
something in your vagina
like your vaginal opening is full.
Like you have a tampon there
or there is a fold of tissue
inside or there's a skin tag.
Sometimes women will say,
"I feel like there's so
much discharge there."
And when we look, there is no discharge
but there is some tissue there.
So good first advice
I'll give you is look, okay?
So if you're pregnant
and you have not looked
at your vaginal opening
look what it looks like.
So that when the things change
and you actually have
a skin tag or something
you can tell that that's a
skin tag and not a tissue.
Typically, if there's a prolapse
it's like a little tissue
here that you can push back.
Like it's movable.
If you push it back in inside,
it will go right back in.
So, we can tell typically,
that if your tissue
can be pushed back in
that it's not a skin tag
it's an actual prolapse.
Because gravity was the problem, right?
Descending to the vaginal opening.
If we take away gravity,
sometimes it helps the symptoms.
This is not a long-term solution.
This is not any solution at all, okay?
This is just so you can get some relief
from these symptoms in the meantime.
Get yourself lying down.
Put a big pillow, maybe
two or three pillows
under your pelvis, lift up your pelvis.
So at that first position.
When you lift up the pelvis,
the bladder, the rectum
all the organs basically
fall back down with gravity
so they go away from your vaginal opening
and you feel prolapse much less.
Usually, this position 10 minutes
women will say that
prolapse is a lot better.
Again, if you get up and
walk around and pick up stuff
it will come back.
But it's a good way to get relief
especially in those first two, three weeks
after giving birth
when your prolapse is not quite prolapse
it's just that the organs
haven't gone back to their place.
This is the other
position that you can try.
Both positions are for
all kinds of prolapse.
So you're gonna try both to
see which one feels better.
The second one is you take two pillows
and you basically hug
and you get the backside of the pelvis up.
So the front side of pelvis
is up in the first picture.
The backside is up in the second picture.
You can try both and see
which one feels better.
You basically will feel that that tissue
that was there is not there anymore.
That extra tissue
that bulged that fullness
in your vaginal opening
is gone or is less.
Okay, so you should do kegels, okay?
We already showed you how kegels
pelvic floor was that muscle
underneath all those organs.
When the pelvic floor contracts
it can help lift these organs.
Very often, I discussed a lot about kegels
in my couple of presentations ago
when we were talking about
incontinence or leaking.
So if you haven't watched that one
I think you should watch that one
because we go a lot more
detail of pelvic floor in that.
Now I'm gonna briefly explain here.
So pelvic floor is here.
And what it does, is it
squeezes, it closes the openings.
But more than that, it
lifts up the organs.
It lifts up the bladder, the
bowel, the rectum, the uterus.
So what we want to think
about when you're doing kegels
is not just squeeze the vaginal opening
or squeeze or close the urethral opening
what we wanna think about
is lifting up, okay?
So there are a bunch of cues
I discussed in the other presentation.
The three cues
that I like the most are,
imagine there is a tampon
inside your vagina and
you're trying to pull it in.
Like the tampon is loose or
too small and it's falling out
and you wanna keep it in.
So think about pulling the tampon
inside the vaginal opening, okay?
You can also think about holding your gas
and then holding your pee at the same time
and then pulling both of those
openings towards each other.
So hold your gas, hold your pee
and then pull both of
them towards each other
or inside your body.
You can also imagine that
the inside of your pelvis
is like an elevator.
So we saw that picture earlier
it literally looks like a floor.
And I want you to think about
lifting that floor up, okay?
So these are the three kegels
cues that help the most.
Doing kegels during pregnancy
can help you prevent pelvic
organ prolapse and leak, okay?
So there is some evidence for that.
We definitely want you to keep
kegels during your workouts
during your day to prevent
these pelvic organ prolapse
and leaking problems from happening.
So in this picture earlier,
we said why what muscles
can help keep the organs in place, right?
We said these are the organs
they're suspended from the side.
All the orange shade here in
this picture are the muscles.
So the pelvic floor muscles can help
because they can help lift the organs.
The back muscles can help
because they can help keep
the pelvis more stable.
Abdominal muscles and I
identified hip muscles.
Abdominal muscles and hip muscles can help
because they can all keep
the bones more stable.
So bones will move, organs will move
pelvic floor will move.
We can't keep bones from
moving, bones are bones
but we can help the
muscles around those bones
so they are stronger
and they don't let the
bones move too much.
That's why hip muscles, abdominal
muscles and back muscles
strengthening all three of these muscles
can help the prolapse, okay?
So I'm gonna talk about
the hip muscles first
because they are the easiest to use
along with the other exercises, okay?
So your buttock muscles,
your inner thigh muscles
your outer thigh muscles
and your deep abdominals
not your six-pack of muscles
but your deep abdominals.
So we're gonna talk about
engaging the deep abdominals.
So we're going into the
part of the presentation
where these are the exercises that you do
to prevent prolapse.
And in the beginning four,
six weeks after giving birth
to basically help some of that prolapse
if you already have it.
Okay, again, this video I have shown
in pretty much all the presentations
but basically engaging the
deeper part of the abdominals
and pelvic floor together, okay?
So here it is.
So I'm gonna breathe into
belly and expand my belly.
As I breathe out, I'm gonna
blow out from my mouth.
I'm gonna go (exhales
deeply) and as I blow out
I'm gonna think about
making the side of my trunk
or sides of my pelvis, think
about bringing it together.
And then at the same time
think about pulling your tampon in.
This activity engages the
deepest part of your core muscles
or your abdominal muscles
that help you engage that part
and also the pelvic floor
in a supportive way, okay?
So breathe into my belly,
breathe out from the mouth.
Think about pulling the sides together
and then think about pulling
the tampon in at the same time.
I am not gripping my abs, I'm
not sucking in my stomach.
I'm gently breathing out
and thinking about moving
those bones together.
Those bones are not actually moving.
My hands are just showing the direction
and that I'm thinking about
pulling my tampon in, okay?
If these are too many cues,
you can just breathe out
and think about pulling your tampon in
at the same time, that's okay.
So breathing out or blowing
out (exhales deeply)
and pulling the tampon in
usually will get you to
do a good kegel, okay?
But if you add the side of the abdominals
that might help you get
even stronger contraction
of your abdominals that
will help your pelvic floor.
But do not suck in your
stomach, do not grip your belly.
Okay, using the buttock muscles can help.
So, similar thing breathing in.
As I breathe out, I'm gonna blow out.
Pull the sides together
and then I'm gonna lift
my bottom off the table.
The big muscles of your buttock can help
really stabilize that pelvic bone.
And stabilizing that pelvic bone
can help you keep those organs
from getting pushed down all the time.
Apart from the side
just going up will help
you with the gravity
for the organs to be pulled down, okay?
Hip muscles, the inner thigh muscles
and outer thigh muscles.
They both are good friends of
pelvic floor muscles, okay?
So, I said this in last presentation too.
I don't want you to engage these muscles
in place of kegels or
pelvic floor muscles.
I want you to engage these muscles
along with pelvic floor muscles.
So make sure that you're engaging
your pelvic floor muscles
with all those cues
on the last presentation we talked about.
And along with those kegels
or after you do kegels
you can add these hip movements
because they will help your kegels
and they will help your pelvis
stay a little bit more stable.
So I've taken a stretchy
band around my knees
and I'm just pulling it out
and that's gonna engage
the outer thigh muscles
which can help (mumbles)
Okay and then in this
one, I'm breathing in
and I'm squeezing a yoga block or a ball
whatever you can have
to engage the inner thigh muscles, okay?
Whenever I pull the band
or I squeeze the ball
I lift my pelvis.
All the exercise I did
every time I'm thinking
about breathing out
and pulling my tampon in.
Breathing out and pulling my tampon in.
Constant talk in my brain
is to bring the kegel or pelvic floor
into all of these exercises, okay?
These are a little bit higher level.
This is a chair pause.
So if you're pregnant
and you don't wanna lie down
your back, this is a good one.
If you starting to feel some prolapse
some organ coming down or leaking
take a yoga block between
your knees, squeeze it, okay?
And then go ahead, get into a chair pose.
And as you come up,
you're gonna breathe out
and you're gonna think about
pulling your tampon in.
Breathe out and tampon in, okay?
So and obviously, I'm squeezing
the block the whole time.
Okay, the other one, think
this one is pretty similar.
Squeezing the yoga block.
You breathe out, pull the tampon in
and lift up the pelvis, okay?
All of these exercises are pretty basic.
They are excellent exercises
to do to prevent prolapse from happening
to engage to basically
add these to your workouts
if you're already doing something.
And to do them in the first
four weeks after giving birth
when you're too weak and things
are a little bit too loose
to do anything else.
These are excellent
exercises to start then.
Pessary, is a device.
It's a little ring, sometimes
a plug, different shapes.
Basically device that can be
put inside the vaginal opening
to hold the organs up
in their place, okay?
It's not a long-term
solution for most women.
It's a short-term solution
while you try to get your
pelvic floor stronger.
So you're not constantly
creating a downward pressure
while you're walking
or lifting or carrying.
So pessary is a good idea to
do when you are trying to hold
the pelvic organs in place for short-term.
Usually is prescribed
and fitted by a O-B-G-Y-N
so you can talk to your doctor about it.
But usually, pessary is
not a helpful solution
if you're not doing something with it.
If you're not training the muscles
to do the job themselves basically.
So it's a good adjunct to
physical therapy and exercise
if you're doing both of them.
So pessary will usually
be fitted by the doctor
and you should discuss
that with your doctor
if you're feeling prolapse
and it can be a nice, short-term
adjunct to your treatment.
Okay, so again, what if you feel prolapse
with the exercises?
This is for when you're pregnant
and right after you're pregnant
but also for later, after giving birth
six months after giving birth
eight months after giving birth, right?
So now you find that most
things but some things you do
you feel a prolapse, right?
So let's say if you do a
sit-up, you feel a prolapse.
If you do squats, you feel a prolapse.
If you pick up your toddler
you feel some bulge or pushing down
but you don't feel it all the time, okay?
Prolapse is movable, first of all, okay?
If you lie down, the organs
go back in their place.
If you stand up for a long
time, they tend to come down.
If you push down with constipation
or picking up something
that you create a pressure
it will come down more.
So it can vary throughout
the day, it usually (mumbles)
So if you're feeling prolapse
with certain exercises
or certain activities
you should definitely go
see a physical therapist.
But in the meantime
or for practitioners who
are listening to this,
what are the things you
can try in the meantime?
Breathe out as you exert.
The simple way to think about
it is blow before you go.
Because breathing out, tends
to engage the pelvic floor.
So if you are not always
thinking about kegel
breathing out is usually
an easier way to think.
And you're gonna think about breathing out
like blowing the candle,
so not (exhales deeply)
Remember I said, "Open
mouth, breathing out
"is going to relax the pelvic floor."
So (exhales deeply) this is relaxed
(exhales deeply) this is contact.
So you're gonna blow like
you're blowing a candle
as you exert.
And let's say have to pick up the baby
and put her in the car.
So when you bend over and
you're about to pick her up
you're gonna of (exhales deeply)
and think about your pelvic floor up
keep it and then lift
her up and then relax.
Again, not a long-term solution
but you can do those activities
blowing and trying to
engage that pelvic floor.
Do not grip your abdominals.
This is a picture here of a balloon.
This is what your trunk looks like.
When you squeeze your abdominals too much
so if you're gripping your abs
if you're sucking in your belly
if your pants are too tight
if you're putting a
very tight waist trainer
all of those things,
create this extra pressure
in your trunk basically
and pushes down in your pelvic floor.
So all that extra pressure
that you created here
is going to go somewhere
that typically is down
and it makes your pelvic
floor push down more.
You may not feel it right away
but that constant gripping of the abs
is going to keep you from
engaging your pelvic floor.
A lot of times women
who are engaging their pelvic floor
who gripping their abs
trying to look flatter after giving birth
are basically making their
pelvic through weaker
or keeping it from getting stronger
by always sucking in their abs.
There is nothing wrong
with working out abs.
There's something wrong
with thinking only about abs
and not about pelvic floor.
You have to engage the abs
and pelvic floor at the same time.
Those things work together.
And if you engage that deeper
core we talked about earlier
and then slowly progressed from there,
your abdominal exercises
cannot go stronger
than what your pelvic floor can handle.
Every time you engage the abdominals
you push down on your pelvic floor
which doesn't mean that it's wrong
it just means that you have
to strengthen them together.
This one is stronger, this is not yet.
So give it time, make sure
the pelvic floor gets stronger
then make the abs a little bit stronger.
So make sure they're going together.
So, do not grip your abdominals
do not suck in your stomach.
Do not wear very tight belly bands.
Do not round your upper back.
There's actually research that shows
that rounding of your upper back
tends to create more pressure, okay?
Tends to create more
pressure in the pelvic floor.
And it's a long discussion
but in short, if every
time every activity you do
is by rounding your back
and you keep feeling it
then that's something to correct.
Be a little bit straighter.
And we've talked about posture
in earlier presentations
so you can go over those.
You can try decreasing
the range of exercise.
So if it's a squat,
don't go as deep, right?
If it's a sit-up, don't come up as high
along with breathing out and
then you can decrease the load.
I really don't want you to
stop doing the exercise.
I want you to modify
it as much as possible
rather than stopping it.
The only we sometimes want you to stop it
is using doing isolated
abdominal exercises
like a sit-up or a crunch
tends to challenge the pelvic floor
a lot more than any other exercise, okay?
So that's not to say that they're bad
but it just means that your hip muscles
are not doing anything, your back muscles
are not doing much.
All you're doing is you're engaging
that six-pack muscle from the top
and it's creating a lot of pressure
that's going to push down
into the pelvic floor.
Ideally, what should happen
is that pelvic floor contracts back
and they basically balance each other out.
That's the ideal situation.
Now, the ideal situation
is not there because you have a prolapse.
So, this is one of those
situations that is challenging.
If you're feeling prolapse
in sit-ups and crunches
maybe it's better to do
more comprehensive movements
like squats and lunges,
even planks, hands and knees
(mumbles) kind of workout,
ball kind of work out.
There are so many things you can do
where you strengthen your abs
or you can do obliques
and sit-up kind of motions
more inclined, not lying down all the way
that can strengthen your abs
without challenge the
pelvic floor as much.
Okay, again, I'm not saying they're bad.
I'm just saying they are
very hard on pelvic floor
so make sure your pelvic
floor is strong enough
to take that pressure before you give it.
And that's sit-up and crunches
or any motion that kind of go like that.
Different exercises usually in (mumbles)
Are certain exercises bad for prolapse?
So, again, I brought this question up
on my Instagram yesterday.
Is lifting bad for prolapse?
Are sit-up bad for prolapse?
I'll show you a ultrasound
video here of my patients.
What I did was she had prolapse.
She was feeling bulge in her vagina.
I had her do a sit-up.
She did a sit-up, she felt a bulge.
Then I gave her cues
basically engaging the deep
core that we talked about.
I said, "Blow strongly
and go (exhales deeply)
"before you lift up your head
"and gently pull the pelvic floor up
"or pull your tampon in."
And this What happened.
So, this is the first time
she is doing a sit-up.
Sorry, she is doing a sit-up
and you can see her bladder is moving down
into the vaginal opening,
it's pushing down.
The second time, I asked her
to engage the pelvic walls.
Sorry, second time, I asked
her to engage her pelvic floor
and blow out.
And now she's doing a sit-up
and the bladder didn't move, okay?
So this is an example of
you can change things.
It's not about what you're doing.
It's about how you're doing it.
This is not to say it will
work for everyone, it won't.
But just because lifting
is giving you symptoms
doesn't mean lifting is the problem.
It could be how you're lifting.
It could be how much you're lifting.
It could also be while
you're lifting, right?
If you're not paying attention
if you're lifting for
work, eight hours a day
that's different than you
lifting to get stronger.
I don't want you to stop
lifting or stop doing sit-ups
or stop working out
thinking that it's increasing the pressure
let's just not do anything.
If you don't do anything,
that might make it worse.
We wanna strengthen the muscles,
especially the hip muscles
and the back muscles and
your pelvic floor muscles.
And with a good variation
we also wanna strengthen your abdominals.
All of this strengthening is
going to help your prolapse
we just have to do it smartly.
So try not to follow a
restriction, don't do this ever.
That usually is not helpful.
Note about immediate postpartum period.
Most women get freaked out
after they watch this information.
When they come out of delivery,
a week out, five days out
and they feel a bulge
or they see something.
That's not prolapse or it is prolapse
but it's not permanent.
That's just your uterus
has just not shrunken
back to its size just yet.
So it's still pushing
on the bladder, right?
So give it four to six weeks
the vaginal opening is going to shrink.
All of the organs are going to shrink.
Things are going to go back.
So don't panic just yet.
It is an excellent time,
to go into that position
where the organs were going down, right?
So if you're feeding and you're resting
spend 10, 15 minutes, twice
a day, 10 minutes twice a day
in that position where the organs go back
and practice doing kegels.
Practice engaging your deep
core, practice breathing out.
Manage your constipation
definitely manage your constipation
especially right after giving birth
because it's a huge problem.
Take medication if you need to.
Don't put a very tight belly band.
A snug one is okay but
not a very tight one.
Do not strain to go to bathroom
and do not rush to sit-ups.
Don't think that I'm gonna
go do sit-ups right away
because now I can.
I don't have a baby, let
me just get flat abs.
Let me just start running.
Those things are going
to increase the pressure
into that pelvic floor
which hasn't returned back
to its position yet, okay?
So this time, use to strengthen your hips
use to do all the exercises
we talked about in this presentation
which are safe for all
the pelvic floor issues.
In physical therapy, we
get a lot more specific.
All both of those ultrasounds
were from my patients in the clinic.
I was showing them listen,
this is what happens
when you're doing a sit-up
and you don't breathe.
This happens when you do breathe.
This happens when you're lifting
and you hold your breath.
This happens when you keep your toes out.
So we're basically looking at
the pelvic floor internally
through our X-ray vision on the ultrasound
and we can change things.
So it's a lot more efficient.
Again, if you have a prolapse
you should go to physical therapy.
If you have a grade
one, we can reverse it.
If you have a grade two we can decrease it
and often the reverse it
even grade three we can
bring down a little bit.
So, make sure you do that
before you decide on surgery
or any other invasive measures.
If you do decide on surgery
know that there is a 50%
failure rate of surgery
for women who do not strengthen
their pelvic floor, okay?
So even if they pull the organs back
and put them in their place
if you're still pushing
down because of constipation
if you're still pushing down
because of the abdominals
if your pelvic floor is still weak
those organs are slowly going
to come down again, okay?
So even if you decide to do surgery
make sure you absolutely
do physical therapy
to rehabilitate and give
yourself best chances.
But this presentation
is excellent to prevent
and to use in those first
few weeks after giving birth.
All right, those are
references from earlier
and thank you.
All right, thank you, everyone and bye.

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