When you’re recovering after having a baby, even if you had your babies a long time ago, a Pelvic Health Physical Therapist is definitely the professional you need in your recovery team!

These medical professionals specialize in pelvic and women’s health, from diastasis recti through to pelvic pain, dysfunction, and incontinence. If you’re dealing with any postpartum symptoms that don’t feel right, these are the professionals you need to seek out.

We’re so excited that our very own MUTU Pro, Angie Peters, who is a Pelvic Health Physical Therapist based in Hawaii, has agreed to answer some of your questions relating to postpartum recovery. From surgery considerations to a hypertonic pelvic floor, read on to get the pelvic floor 101 from a Pelvic Health PT.

Angie Peters

Angie Peters Pelvic Health Physical Therapist - MUTU System - MUTU ProFrom the Aloha state of Hawaii! Allow for me to make a brief introduction of myself. My name is Angie Peters. I am a pelvic health physical therapist, MUTU Pro, and a mother of a 9 year old girl. I began my career in pelvic health in 2004 (graduating with my Masters in 2002) and have been blessed to gain the respect of my community to support a successful and solo practice of PT on Maui. It is my pleasure to take this time to answer some FAQs from the MUTU community! So, let us begin…

A question from Barb

“They say that weak bladder/urine leakage is normal in perimenopause/menopause due to hormone changes/dropping levels. Is this true even if you are ‘in shape’? Using supplemental hormones is not desirable due to cancer risks. Thanks.”

Barb, mahalo for your question! It is one I come across often and am happy to address to the best of my knowledge. Reduced levels of estrogen starting around menopause can cause thinning of the lining of the urethra, the short tube that passes from the bladder to out of the body. As a result, women at midlife and beyond are at increased risk for urinary incontinence or involuntary leakage of urine. I see all ages, all body types, all levels of physically fit or unfit women in my practice. It is my opinion that your hormone levels are a factor in a “weak bladder”, but not the only factor at play. Others would include how many children one has had and how strenuous labor was (remember that one carries child for 10 months and the pelvic floor has to work with this additional load), any history of heavy lifting, chronic constipation, allergies or asthma. Also, being overweight and simply not having a pelvic floor regimen of exercise.

A Question from Laura

“I had issues with a ‘too tight/hypertonic’ pelvic floor after the birth of my baby due to trauma/tearing/generally not a great birth. I spent the best part of a year learning to “let go” and for the pain down there to ease. MUTU helped tremendously and seeing a pelvic PT. What can I do to avoid this from happening again if I have another baby?

Laura, your question is posed for a greater population of women that commonly experience what you are saying. Thank you for speaking up and voicing your experience. Let’s dive in…

There are a multitude of reasons that you may have experienced what you did. Some of these would include but not limited to:

1- scar/adhesions from childbirth

2- poor postural habits in postpartum

3- lack of breath awareness

4- a decrease of estrogen with breastfeeding

5- fear/avoidance of vaginal penetration

Scar from tearing, episiotomy, or cesarean section may all influence our pelvic floor tone. Caring and addressing the scar tissue through the guidance of a pelvic PT is important. Fascial restrictions from scar can refer pain, hence mobilizing any restrictions in a safe manner is indicated.

Caring for a little one in postpartum continues to alter our posture. We tend to be with more forward head and shoulders, an increased curve in our mid back (kyphosis), and a loss of our normal low back curve or lordosis as we often “sacral sit”. Our daily habits with child include breastfeeding, cuddling, caring for, holding/wearing/carrying, changing, and co-sleeping in this postpartum period. Our posture can often take a “back seat” with these monstrous responsibilities. Alignment of spine is key and having an awareness of balance with these challenged muscles is needed. For example, if I sit in a couch with lackadaisical posture and I am not with a tall spine or sitting on my sit bones with back support, I am likely putting my muscles in my pelvic region in a “passively shortened position”. My tailbone is closer to my pubic bone and my sit bones are closer to one another. In turn, my pelvic floor muscles think that this is “their new normal” for tone because of their bony attachments to our pelvic rim. Posture paired with internal awareness of what is a “resting and relaxing baseline tone” in our pelvic floor is key. This is also influenced by our breath.

Lack of breath awareness may lead to undue pelvic floor muscle tension. It is not uncommon for new mommies to want to hold their belly muscles in and chest-breath. There may be a time and place for this if you are trying to fit back in the sleek cocktail dress or jeans that used to fit, but it is ultimately not healthy in your healing phases and overall habit. Apical breathing or chest breathing does not allow for your breathing diaphragm to lengthen and expand. Your pelvic floor muscles naturally follow what your breathing diaphragm does. So imagine that if you are a shallow chest breather and hold in your tummy, your pelvic floor is lifted and tense. A hard but necessary habit to break.

Estrogen, as mentioned in an earlier question posed, does influence the vitality of our vaginal mucosa and surrounding muscles. We are typically low in this hormone in postpartum period, especially during breastfeeding. Consider a discussion with your doctor about a low-dose estrogen vaginal cream and if it is appropriate for you.

Lastly, and not least, is the return to intimacy with spouse and vaginal penetration. It is important to be prepped for this event. Good position, well lubricated with a water-based and glycerin free lubrication, tissues with proper blood flow and relaxed from diaphragmatic breath practice, and a partner that is willing to listen to your needs. Make sure that there are no other issues in the relationship besides “just pain with penetration”. If there are trust issues, pressure to perform issues, previous vaginal trauma from sexual abuse or assault, you may need to seek care with a sex therapist or counselor.

A question from Aleatha

“I don’t know how to decide whether surgery is the right solution for me. In the medical community, I’ve been told it’s the only option that makes sense, but when I read about diastasis I have the impression that there are other options.”

Thank you for speaking up for all of the mommas out there! By the third trimester, all expectant mothers have diastasis recti separation. It is a necessary part of expansion, growth, and accommodation of the growing fetus.

There are typically two issues with diastasis in our “fourth trimester”. First, medical concerns. The abdominal separation lends itself to a compromised “transfer of forces” if you will. Our daily tasks and movement patterns as a mother are filled with what would cause pressure. For example, lifting, pushing, pulling, carrying, transitional movements such as getting in and out of bed, coughing, sneezing, etc… The abdominal wall paired with the pelvic floor and your breathing diaphragm come together to form a pressure valve, similar to that of a piston in a car engine. What we do in our day affects the ability to counteract the forces of pressure. If the pressure exceeds what we can handle, the pressure may manifest in the form of hernia. Hernias are not always surgical, but if painful and larger in nature, they may require surgery. There are several areas that a hernia may appear, and with this said, do not confuse a hernia for the midline bulge seen with diastasis. A hernia is an actual hole within the abdominal wall that the abdominal contents come through. It is often visible to the naked eye and can occasionally be “pushed back in” or reduced with finger.Secondly, aesthetic concerns. Your belly may not look like it once did. It may be stretched, soft, and entirely not what you would have expected. So, your options are also of two. First, you may conservatively work toward strengthening your abdominal wall in a safe manner. This will also create a leaner and stronger appearance, but of the greatest benefit is feeling strong with what you do. The latest research states that postpartum efforts to reduce diastasis are not as much about “closing the width gap”, but rather creating a protective tension on the depth control of the gap or firming of the “midline seam” of the belly muscles (also known as a ‘functional diastasis’). MUTU system is astoundingly incredible with this process. It takes time and effort, but take a moment to observe some of the before and after photos from MUTU mommas. More importantly, their comments on self-perception and confidence with the end result of MUTU System.

In summary, surgery should not be your first outlet unless there are medical justifications. Surgery will entail an abdominoplasty (tummy tuck), a hernia surgery, or a combination of both. In the end, it is still tremendously beneficial to learn how to use the deep abdominal muscles for your daily function. Surgery does not “repair” its function, but your efforts to strengthen and learn through MUTU and/or pelvic PT will.

A question from Paula

“I’d like to hear more about the mind and muscle connection and how to be better at that”.

What a great question to end with, Paula. Yes, we often hear about what this entails, and it is different for everyone! You can imagine that after childbirth, some tend to disassociate with their bodies – so much trauma, so much change. Some just hope that their bodies rebound to where they were once before with no effort and just time. Others are quite the opposite and perhaps overly mindful of the process and expect rapid results with too much efforts. Either way, internalizing what is happening and the process of healing does need to be both mental and physical. They say that 40% of those that kegel do it improperly! Tightening of the buttock muscles or holding your breath up and in with an effort or exertion. One must consider the isolation of muscles, breathwork, awareness of position and effort, understanding what task or load is simply “too much”, and more. Meditations for processing your internal systems is one way – there are apps for phones that are free and easily accessed. This could be a guided experience or simply just “checking in” occasionally. Self-talk is helpful. Knowing when you have reached fatigue is important. And lastly, seek professional assistance for making the connection of your mind to your body, if you cannot make this connection independently. MUTU system incorporates this fluidly into their program. Other practitioners also dive into the mind and body connection such as yoga instructors, pilates instructors, somatics, feldenkrais, and of course, a good pelvic PT!

It has been a pleasure to answer some of your MUTU questions. I am hopeful that others may comment on their personal experiences, to build on my discussion. As a pelvic health PT, I often work with women after a problem has occurred. When I have the opportunity to educate for preventive measures, I feel even more blessed with the path I have chosen in helping others. We are in this process of healing and recovery together! Mahalo nui loa for this opportunity. A hui hou!


Angie Peters MPT

Do you have questions about your own postpartum recovery? Comment below.

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