Pelvic Floor Exercises for Women Over 40 and Menopause

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Kim: It's well established in the research that Kegels are an effective way to overcome pelvic floor dysfunction like pelvic organ prolapse, like incontinence. But never have we been given proper education on what a Kegel is. So most people, and this is even established in the research as well, do them incorrectly. And then they think they don't work. So then they don't do them. If Kegels are going to work, you need to first do them correctly, and then you need to be doing them consistently.

Nikkiey: What is going on, everybody? Welcome back to The WarriorBabe Show. Today I'm very, very excited and honored to have Kim, the Vagina Coach, on the show. Kim is a leading expert in women's pelvic health, a passionate educator, and the founder of the Vagina Coach. With her practical approach and the wealth of knowledge she's going to share with us today, she's changing the conversation around pelvic health and empowering women worldwide. What I'm so excited about is we get to talk about the vagina on our podcast today. So I'm super stoked. Kim, welcome to the show.

Kim: Thank you for having me. It's always a good day when we get to talk about vaginas.

Nikkiey: Let's go. So Kim, just open it up. Share a little bit about you, your background, and why you're so passionate about what you are sharing.

Kim: Thank you. Yeah, thanks for having me and for sharing knowledge. That's how the world will move forward in this realm, when we're all talking about it. I grew up with a bit of fear about childbirth. I saw a childbirth video as part of my sex ed. When I went back home and talked to my mom about it, my mom was an OR nurse. She was very open about bodies and anatomy with my brother and me.

She told me about her birth and she told me she'd had episiotomies. And then as I continued to grow up, I saw her experience incontinence when she was running. She had chronic back pain. She had a tummy that wouldn't flatten no matter what she did. And she would often say, oh, it's because of your brother and you. The picture was painted that pregnancy and childbirth aren't necessarily friendly to the female body. So I grew up saying I'm never going to have kids. And that was my story until I met my husband and decided I did want to start a family.

Then it was about educating myself on how I could have a different story than my mom. So I thought, well, maybe if I have a cesarean and don't have a vaginal birth, I'll be fine. I learned more about that, and that's not the answer. Anyway, I became pregnant. I used a product called the EPI-NO, which is a biofeedback device for the pelvic floor manufactured in Germany. It came from a doctor who saw women in Africa using gourds of increasing size to prepare their perineum and pelvic floor for birth. And he thought that's a great idea, but that's not going to fly in the rest of the world.

So he designed a medical device. EPI-NO stands for no episiotomy. It's a device that allows you to connect with a part of the body you can't see, which is the pelvic floor muscles. You have the device inserted. It's like a little balloon. When you contract and relax, it reads on a little gauge, so you can see the contraction and relaxation. In the last few weeks of pregnancy, you would leave it inserted and gradually inflate it to a bigger diameter to stretch the tissues. Not so much pre-stretching, but introducing these concepts of stretch and pressure and discomfort, which is what you're going to experience during childbirth. The intention is basically the principle of specificity from fitness, applied to the pelvic floor specific to birth.

So I used this and had a great experience. I did prevent tearing. With my knowledge at the time, I thought if I don't tear like my mom did, or if I don't have an episiotomy like my mom, then I won't have incontinence. That was my very basic knowledge at the time. It is not correct, but that's what I thought was accurate. Then I used it with my second son and developed incontinence.

And I thought, well, wait a minute. Why do I have this? I didn't tear. I thought I did all the right things. Around that time, I was thinking I was going to turn this into a business. I started to learn about pelvic floor physical therapy. I started to educate and work with as many people as I could to learn, and I wanted to bridge this gap, because it was all very medical, and we're talking about muscles. So why were we not applying the same principles we use for other types of training in the body to the pelvic floor?

So that's kind of where it started. It was an e-commerce store initially, and I had the EPI-NO plus many other products. I then formed a second business called Bellies Inc. I was working with a pelvic floor physical therapist and another trainer like myself. We wanted to optimize postpartum recoveries, because we know pregnancy and childbirth are risk factors for pelvic floor dysfunction. So if we could impart knowledge ahead of time, have people birthing differently than they are, and have them optimize and even honor that recovery process, could we help?

So we designed a postpartum wrap and coupled it with restorative exercise. I juggled the two businesses for a while, and then started to move things online. We created a certification course for fitness professionals who wanted to help women with incontinence and organ prolapse and so on. And that's where I am now, almost 19 years later. Bellies Inc. has been sold, and the majority of what I do now is help support women preventing and overcoming common pelvic floor challenges.

Nikkiey: That's awesome. Thank you for sharing that whole story, A to Z. It started out with your own personal experience, well, really your mom's, and then you were holding that story for yourself. You're like, nah, I want to rewrite the script. Then you learned through your own experience, and you're like, oh man, I want to be able to help people. I love those stories, because it evolves from your own personal pain or experience, and then you learn, and then you're able to spread the word. So that's super cool.

Kim: Yeah. And you see the voids and you think, well, I can't be the only one that wants to know this or that. And seeing my mom struggle and then starting to understand how common it is, and how currently people think that it's normal. We have pad companies telling us it's just part of being a woman. So there's this acceptance that we should be wearing pads for the rest of our life. And I wasn't okay with that. I'm not okay with that.

Nikkiey: Let's go, changing the script. I love it. Breaking the norms, baby. Cool. All right. So for the listeners listening, can you just share what the pelvic floor is?

Kim: Yeah. As I've been saying, it's a group of muscles that closes off the base of our pelvis. We can't go to the mirror and flex our pubococcygeus muscle. We can't necessarily see them, so it makes it a little bit more challenging to access. But think about the landmarks. Wherever you are right now, you can put your fingers on your pubic joint. People say pubic bone, but it is actually a joint at the front. And if you're sitting on a hard surface chair, or even if you're standing, pull the flesh of your butt cheek away and you should feel a bit of a bony point in your bum. Those are your sit bones, your ischial tuberosities. Those are also attachment points for the pelvic floor. Then on the backside, we have a triangular bone, the sacrum, and at the base of that we have our tailbone, or coccyx. That's also an attachment point. So pubic joint, coccyx, and the ischial tuberosities make a sort of diamond shape. That's where the pelvic floor muscles attach. And it's muscles, plural. It's not just one muscle.

It's three different layers. The first layer is primarily responsible for sexual response. The second layer is primarily responsible for continence. If we think about our urethra, our vagina and our anus, the three openings, the muscles help manage those openings so that they stay closed when we don't want things to come out, and they open when we do want something to come out, or in the case of insertive sex, something to go in. The third layer is primarily responsible for supporting our organs. We have the bladder, uterus and rectum, and we want them to stay in their proper anatomical position. The pelvic floor plays a role in helping them stay there.

The muscles attach, as I said, to the base of our spine and to our pelvis, so they play a role in our core stability. In fitness, we've heard about core exercise and core fitness for decades now, and nobody has talked about the pelvic floor as being part of that core. It's the foundation of our core. It also works in synergy with our diaphragm, our breathing muscles. So every time we're breathing in and out, the pelvic floor is moving in concert with that.

And that in and of itself is a way to strengthen the pelvic floor and also learn to relax it: just coupling it with the breath. So those are the main functions of the pelvic floor, where it is and what it does. When things are working well, we don't even think about it. It's just there. And again, we don't see it in the mirror, so we don't necessarily even know that we have a pelvic floor. But when things are not working well, we may have painful sex. We may not be able to orgasm. We may not be able to have anything inserted.

We may leak urine. We may have very strong urges to go to the bathroom and not make it in time. That could be both urinary and anal. We may feel pressure or heaviness, or feel like something's in our vagina when there's nothing there, so we might be starting to experience prolapse. We might have chronic back pain. We might have joint pain in our pubic joint or tailbone. These are just a few. There are many different challenges people can have with the pelvic floor, the most common being incontinence, organ prolapse and pelvic pain.

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Nikkiey: Wow. Okay. My brain just went to three different buckets there, and I want to circle back to each one of them. My brain went to, okay, we have pregnancy issues, right? There's incontinence with that. There are exercises and things you want to pay attention to, and also ensuring that the pelvic floor is stable for pregnancy and for afterwards. Then my brain went to the core, which I love that you brought up, because I definitely want to circle back to that. And incontinence is floating above all three of these. Then the diaphragm and breathing. And I've never thought about it this way, but how you said it: it's a muscle that we don't see. So how do we know it's even working? How do we know those things?

Kim: Yeah, it's hard to know. A lot of what I do is help people feel or understand that relationship, the position of the pelvic floor, its movement, that it does move and that it's okay for it to move, with visualization, imagery, posture and different positioning. Because just saying to somebody, relax your pelvic floor or activate your pelvic floor, especially if you don't even know what a pelvic floor is or where it is, is not something you can just do willy-nilly. We might've heard in classes, engage your core, or brace, or different cueing, maybe pull your belly button to your spine.

Those are all well-intended. But again, when we don't have knowledge of what the true core actually is, everybody will interpret those cues differently. So it's about finding the best cue for a person and the best position for them, showing them imagery, and showing them models, like the pelvis model that I have, so they can see what we're talking about and understand what it looks like within their body.

Nikkiey: So let's bring that cool thing out. Guys, if you're watching through video, actually, I would highly recommend you watch this entire podcast on video, but I know some of you only have Apple or Spotify. Can you demo?

Kim: Yeah.

Nikkiey: Can you demo what this is and what the pelvic floor is?

Kim: And just as a sidebar, whether you have male or female anatomy, you have a pelvis and you have a pelvic floor. Being a vagina coach, I work with people with vaginas. I work with women. But a lot of the principles that we're talking about will apply: posture, breath, different visualization and cues. The male pelvis is not so wide. It's a little bit narrower. They don't have a vaginal opening. They don't have a vagina. They don't have a uterus. They don't go through menstrual cycles. They don't go through hormonal changes. They don't go through pregnancy and birth. They don't go through menopause.

Nikkiey: They're not superhumans like us women.

Kim: Yeah. Thank you very much. I just wanted to put that there as a disclaimer, because I'm asked all the time, will these exercises work for men? Short answer: yes.

So here's the pelvis. I'll turn it this way. This is the pelvic floor. If this is a person lying on their back, here's the anal opening. Here's the vulva. Here's the vagina. Here's the urethra. This is a layer, here's a layer, and you can't see the other one on the inside. So there are multiple layers of muscles, and there are the attachment points: the pubic joint, the two sit bones, and, you can't see it here, the tailbone at the back. So this is the pelvis, and this would be our spine at the back.

If I turn it around, here is our sacrum and there's that tailbone. We have our two hip bones and our sacrum. And this here at the front is actually a joint. People refer to it as a pubic bone, but it's actually a joint. Inside we have the bladder, the uterus and the rectum. And up above would be our diaphragm. At rest, the diaphragm is kind of like an arc. When we inhale, the diaphragm flattens and spreads, so our ribs ideally are expanding to allow that to happen. What ideally should be happening down below, and I'm just going to turn this to the side, is the belly expands and the pelvic floor lengthens as well. Again, we don't necessarily see that, but with imagery and different positions we can feel almost like there's a fullness in our pelvic floor and perineum. Then when we exhale, the pelvic floor contracts and lifts.

The belly moves inwards. So there's that pull-your-belly-button-to-your-spine cue. That's kind of what we're asking it to do, in a sense. And then the diaphragm comes back up. So there's this dance happening with the pelvic floor and the diaphragm as we breathe. If we have disordered breathing, or if we're holding ourselves in ways that the pelvic floor isn't able to move through that range, this dance might not be happening very well. We might have more shallow breathing and not get as much oxygen. We might feel tired all the time. We might start to have pain in the pelvic floor, or we might start to become symptomatic, because if the pelvic floor is being held in a shorter, tighter state, it's not getting good blood flow, it's not getting circulation, and it's not moving through its range of motion as we breathe. If that makes sense.

Nikkiey: Yeah, that totally makes sense. So you've highlighted some of the struggles there. What are common struggles people face? You've pinpointed them a couple of times. I guess what I'm searching for is, how do we know? I mean, we would experience the pain, we would feel the things. How can we make that better?

Kim: Yeah. So take back pain: 95% of women with low back pain have some form of pelvic floor dysfunction. And yet we go to massage therapy, acupuncture, chiropractic, we stretch, we do yoga. All of those things can absolutely be beneficial, but so often the missing link is the pelvis.

So pelvic floor physical therapy is always my number one thing. And I argue it's something we should be doing every year, even if we have no symptoms, just like we go to the dentist for a checkup and a cleaning. Why don't we do that kind of care for other parts of our body, especially the pelvic floor? We've been conditioned from a young age: brush, floss, go to your dentist once or twice a year. And when we get a clean bill of health from the dentist, it doesn't mean we then stop brushing and flossing.

It means we continue doing what we're doing and go back again for another checkup, and they screen for things before they become big issues. If we had that same practice with the pelvic floor, then maybe a little bit of niggly back pain could be understood. Maybe early signs of pelvic organ prolapse could be caught before they're a big issue. Maybe changes to the tissue, like low estrogen states or the beginnings of autoimmune conditions like lichen sclerosus, could be caught earlier before they become major issues.

So back pain is very common. It's also very common with prolapse. Leaking urine: obviously you're going to be aware if you're leaking urine. When you're not sitting on a toilet and urine is coming out of you, that is incontinence. You do not have to be an older person in a nursing home to experience incontinence. You can be a young, fit teen. It can happen to anybody at any time. If urine is coming out of your body when you don't want it to, that is incontinence. And it's very treatable. There's stress urinary incontinence, where you leak a little bit of urine when you laugh, cough, sneeze, jump, lift or push.

There's urgency, where you're fine, but then you see a bathroom, or you're putting your key in your front door when you get home, or you hear running water. There are lots of triggers that all of a sudden set off an alarm, and your bladder gets very excited and starts to send you major sensations that you have to get to a bathroom right away. You might leak a little bit or you might have a full release of your bladder. There's frequency.

I feel like I have to go to the bathroom all the time. I'm in there every half an hour. That's not normal. Every two and a half to four hours would be considered normal. Then constipation. Like you said, you talk about poop. Poop is like a vital sign. If we're not pooping well every single day, that constipation is going to contribute to bearing down and straining to get a poop out, and that's damaging to the pelvic floor. Also, stool that doesn't get eliminated creates urgency and can increase stress urinary incontinence as well.

So if you have constipation, it can be damaging to the pelvic floor, but your pelvic floor muscles could also be contributing to why you have constipation, if you have tightness.

Nikkiey: Okay. So thoughts here, because I hear this all the time from women who are postpartum. They're like, I can't do anything with a pop, like pop squats or pop lunges, because I'm going to have incontinence. Exercises. Kegels, right? Would Kegels help? Do Kegels work?

Kim: Yes.

Nikkiey: Okay.

Kim: Yes. It's well established in the research that Kegels are an effective way to overcome pelvic floor dysfunction, like pelvic organ prolapse, like incontinence. But never have we been given proper education on what a Kegel is. So most people, and this is even established in the research as well, do them incorrectly. And then they think they don't work, so then they don't do them. If Kegels are going to work, you need to first do them correctly, and then you need to be doing them consistently.

And my bias is also about Kegels and the more dynamic, explosive movements you talked about, like pop squats. If we had somebody do Kegels sitting in a chair, or while brushing their teeth, or sitting at a red light, which is where we often hear you can do your Kegel exercises, it may help a little bit, but it is not going to translate long term into the explosive movements. We need to retrain the reaction time of the pelvic floor and build up its resilience and capacity to respond to explosive movements, rather than doing a static exercise and hoping that it will translate.

Nikkiey: So women should be doing exercises. Like you're saying, it's like going to the dentist. People need to really focus on the health of the pelvic floor every single year. So would you say postpartum is almost too late to be trying to make it better? Like this should be...

Kim: It's never too late. I have a 92-year-old woman in my community who has made changes. She never had any education at all through her whole life and was experiencing incontinence and prolapse. So change is always possible. But yeah, if we can step in ahead of time... We can't always 100% prevent, but if we can reduce our risk, it would change the world.

Honestly, it would change the world. And the other piece I'll add is that my bias has been that we need to train the pelvic floor dynamically. Yes, we have established evidence with Kegels and voluntary contraction and relaxation of the pelvic floor. Now, thankfully, we have some evidence showing that Kegels done prior to resistance training, or done as part of resistance training, which is what I do, are more effective, and people get results quicker.

Some people say, well, if I'm doing exercise, CrossFit, boot camps, yoga, Pilates, it doesn't matter what type, if I'm doing whole-body exercise, is the pelvic floor not being trained? It is. But we can see from research that it's better when we target it. Doing a whole-body routine will have some effect on most muscles in my body. But if I really want to get stronger in a certain part, I need to do targeted exercises for my back or my biceps or my legs. And the pelvic floor is no different.

It's a group of muscles with type two and type one muscle fibers, and we need to take it through a variety of movement. We need to emphasize relaxation and suppleness as well as contraction, endurance holds, and quick contract-releases, the more explosive movement. As we age, we lose more type two muscle fibers, and we have a lot of type two muscle fibers in the pelvic floor. Those are for explosive movement. So we need more of that type of training as we age to offset the fact that we're losing more type two muscle fibers.

Nikkiey: So what are some effective exercises listeners can incorporate to help pelvic floor health?

Kim: Yeah. I take an ABC approach. A: ideally, the pelvic floor is in a good position in the body, good alignment, so that relationship with the breath can happen. Then we take that and use what I call the core breath. So B for breath.

We reestablish that connection. We go through it in child's pose, or seated, or lying down. It doesn't matter. You can try it in all of those positions so you can feel that movement with the pelvic floor and get connected with it. Then C, coordination. So alignment, breathing, coordination. We coordinate that core breath into movement. And then we apply the principles of progressive overload and specificity. We start to do more sets, more reps.

We add more speed. You work with all the other variables. And with things like squats, lunges and bridges, the pelvic floor is very active. So if we take those and add the core breath, we're killing two birds with one stone. We already know the pelvic floor is active, almost like plyometrics.

So let's add voluntary activation to harness that engagement within the movement. There's no magic exercise per se. It's about the principles of the ABCs, and then progressively overloading the pelvic floor with a diverse range of movement.

Nikkiey: I love it. I feel like I need to add a pelvic floor specific exercise into my weekly routine. That's important. I didn't realize how important this was until you shared all these insights and this knowledge. So thank you.

Kim: Yeah, you're welcome. And I think the other piece that hopefully will help: sometimes people say, I'm fine. I don't leak. I don't have back pain. I'm good. My pelvic floor is good. I've never given birth. All the reasons. And that's great. We all want to be symptom-free. However, we want to come in and ensure we aren't trying to overcome a problem. Let's try to prevent that problem from happening in the first place, because in the perimenopause and menopause transition we have an additional layer. We have age-related muscle loss, age-related strength loss, bone loss, all the things. And then as we get to menopause, we have a steep decline in estrogen. Guess what's all around the pelvis and the vulva and the vagina and the bladder? Estrogen receptors.

So when we have a loss of estrogen, we might've been symptom-free, or we might've just had, oh, I only leak if I really jump hard on a trampoline. Any of those things we could kind of excuse away, all of a sudden either you get symptoms for the first time or they become much stronger: urgency, frequency, bladder irritation, painful sex, and also an increased risk of UTIs.

So low estrogen states are going to exacerbate or bring on these symptoms. Over 80% of women will experience genitourinary syndrome of menopause. GSM is the umbrella for all of the signs and symptoms we've been talking about that happen around the menopause transition. And they do not get better with time.

Nikkiey: So can you demonstrate an exercise? I know it's hard to do on a podcast, but how would you do a squat while engaging the pelvic floor effectively?

Kim: Okay. I'm currently sitting in a chair. If you are sitting somewhere, or if you want to do an air squat, that's fine too. Here's what happens with the pelvic floor through the range of a squat. I won't stand up right now, or you'll lose my face. But if we're standing, as we lower down into the squat, our pelvic floor is lengthening. We're breathing in, we're lengthening, we're getting ready. Just before we stand back up, the pelvic floor starts to engage. Then as we're standing, it's contracting and lifting. So I'm going to go through that range of motion. I'm standing here and I'm going to inhale.

There's different cueing. You can think of blossoming your vulva. You can think of these four points expanding away from one another as you take a breath in. So I inhale, and I'm lowering down into my squat. Sorry, my camera went blurry. Just before I stand back up, I'm exhaling and engaging. I'm going to think of picking up a blueberry with my vagina and my anus, or I could think about sipping a smoothie through a straw with my vagina. Guys could think about pulling the turtle into the shell.

And then I come back up. So I inhale down, exhale and activate first, then I stand back up. Inhale down. The reason initially you exhale and engage just before you come up out of your squat is because we need the pelvic floor to be strong, have endurance and be supple, but we also need it to react at the right time.

Sometimes leaking urine happens because our pelvic floor is tired, overworked, held in a shortened state, and doesn't have a lot of power left. So it's kind of like, oh, I almost could control that, but I couldn't this time, sorry. So we need to release tension, and we need to remind it that it should be pre-contracting just before we exert our movement, or whatever it is we're doing. As we progress, eventually we would exhale as we stand up from the squat.

Maybe then we add some resistance. The intention is that we shouldn't always have to think about picking up a blueberry or sipping a smoothie through a straw when we're exercising. We want to get back to the point where the pelvic floor works automatically. But that doesn't mean we no longer need to do pelvic floor exercise. I'm always adding pelvic floor work at some point in my routine, because I understand the importance of it and I want to do everything I possibly can as I age to maintain that group of muscles and that function.

So think about exhaling on exertion. That's a common strategy in a lot of fitness. Doing a bicep curl: exhale, pick up my blueberries, then curl. Inhale, let my blueberries go as I lower back down. Push-ups, pull-ups, we can apply it any time we're exerting. Initially we retrain by exhaling first, then doing the movement. Then we exhale as we do it.

Nikkiey: Thank you for the visuals. I love the visuals. My brain works and operates with visuals and analogies, like when you pinpoint straws and blueberries and all that kind of stuff. So that's awesome. I want to circle back to the pregnancy side of things before we dive into the core. What are some key considerations for exercising safely during pregnancy?

Kim: That's changed a lot over the years. It's gone from being very restrictive to now there's more freedom, and there's even more research coming out. It was always, yes, you can still move, but it needs to be very gentle movement. You could only walk, you could only swim, and you couldn't lift over X number of pounds. One bit of current research looked at heavy lifting loads in pregnancy. There was still incontinence, but there are a lot of other reasons incontinence happens. We can't just say, oh, it's because they lifted heavy.

So I say exercising safely means that, however you're exercising, you want to consider certain movements and certain positions, so you're not, for example, hitting your belly, those types of things. And I do still look at it this way during pregnancy. I forget the name of the woman. Is it Tia, the one who just did the CrossFit competition? So there are some people who are training for something very shortly after, but I view birth as the event we are training for when we're pregnant.

We look at what the most optimal birth positions are and the ways we can move during labor, and we move and train for those. Principle of specificity. A plank hold, to me, isn't something we necessarily need to do. In a prone position, I know my belly is stretching and the connective tissue is stretching. Why do that if it's not necessarily going to make me stronger for birth? I'm not going to labor in that position. I'm not going to birth in that position. So I would do lots of squats and lots of lunges, some four-point kneeling, and deadlifts, taking the body through a range of motion rather than a static held position like that.

Personally, lift comfortably, as long as you aren't starting to feel and become aware of symptoms like pressure or heaviness, because we are at an increased risk just by being pregnant. We have an additional load on the pelvic floor. We have hormonal changes happening. We have stretch to the abdominal wall and the connective tissue that is part of our core control mechanisms as well. So let's pay attention to our alignment.

Let's pay attention to our core breath. Let's coordinate it into movement that trains me for my event, which is birth. And when we train for an event, there is always a recovery period built into our training protocols. Birth is the same. Ideally, we aren't going back to the gym at two weeks. We want to harness that recovery period and give the tissue time to heal. That doesn't mean we're not doing anything. We can start the core breath.

We can start gentle pelvic floor activations. We can start things like the bridge and work on creating more control in our hips, based on the biomechanical and hormonal changes that have happened during nine months of pregnancy, and retrain the system. At six weeks, to me, it's not time to be told, yeah, you're fine, everything's great, go back to what you were doing. That's my green light to go to pelvic floor physical therapy and get your internal evaluation. See what the position of your organs is.

We know that a vast majority of people at six weeks postpartum, vaginal birth or cesarean birth, have some degree of pelvic organ prolapse. So let the body adjust. Let the body heal. Retrain. And then progressively load back to what you were doing. Don't just wait six weeks and then all of a sudden go back to where you were before.

Nikkiey: Right, right. So in that window of time, the recovery process you mentioned, what are some exercises women can do following birth, leading up until they can get back into the progressive overload of strength training?

Nikkiey: Hey, I just want to drop a huge appreciation to you guys listening to the show. It means a lot. I hope you're enjoying it, and there's so much more to come. If you are enjoying it, hit the subscribe button. I'd appreciate that tons, and it would help this podcast reach others who need to hear these messages too. Thanks so much, guys. Let's get back to the show.

Kim: Yeah. I always start within the first week with the core breath. Just get reconnected. There may have been some tearing. There is loads of pressure on the nerves, so there may be some disruption in messaging. So we need to let that healing time happen. But when we can start adding in gentle contraction and relaxation, we get blood flow, we get circulation, and it stimulates nerve growth factors. So that's important. Then we say, all right, let's do some bridges. It's almost like a gentle inversion. It's like we're guiding the organs back to where we want them to be, and working on our glute strength, gently.

Then we can start clams or bent-knee lifts, working on the lateral hips. Then we get more upright as we can accommodate more pressure on the perineum. Especially with a vaginal birth, there will be swelling. The vulva and pelvic floor will be quite tender, so sitting upright may not be comfortable right away. But we do want to get upright against gravity. We want to start doing some squats, because what do new moms do a lot of? They pick up their baby.

They put it down. They pick up a car seat. They put it down. They pick up laundry. They put it down. So we want to train those movements. Ideally, we've been training them throughout pregnancy. Now we're training them again with a little bit lighter load, but still some loading. At six weeks, go to your pelvic floor physio. Then we continue with the same principles. And it's more like four to six months before we're back to heavy lifting and more explosive movement.

There was a great protocol shared by Gráinne Donnelly and her team. She's a physical therapist in Ireland, and Absolute Physio is her handle. She put together a postpartum return-to-run protocol. It was logical: allow tissue healing, here are some early restorative exercises, see a pelvic floor physical therapist, and here are your prerequisite exercises that show you've regained the capacity to manage the loads of running before you just go and start running again.

Lots of movement practices are like that. You need to be able to do this move before you can do that one. It's so logical, and yet with everything about pregnancy and birth, we've just sort of said, oh, you're fine. You get sent home from the hospital and you're good. Just wait six weeks and now you're fine. And so many people don't even have an internal evaluation at six weeks anymore, which I think is crazy. So we want to harness and honor the need to recover. A lot of change has happened to the body.

And then there's the birth itself, vaginal or cesarean, which is essentially a surgical birth. We need time for those tissues to heal, we need to reconnect, and then we need to progressively overload them.

Nikkiey: Look, I've never had a baby and I've never been pregnant, but I feel like from this conversation with you, I could go into postpartum with the tools, resources, education and insight I'm learning from you right now. And a lot of our listeners are 45, 65, 75. They've been through the process. So you're probably resonating very hard with them and sharing valuable insights they maybe didn't know about. Maybe they could tell the younger people in their lives.

Kim: Yeah.

Nikkiey: Yes, exactly. You put in a little plug there about lifting heavy. I've been seeing some pregnant moms I follow on Instagram who just crush it. Everyone's totally individual, as you're saying, and it's about being aware of how your body is responding to things. But when you are pregnant, or even in general, is lifting heavy a bad thing?

Kim: We can't make a blanket statement that heavy lifting is bad, because with a lot of these people, we don't know. Maybe they have been training and that's very comfortable. That might even be a lighter load than what they used to do before they were pregnant. We don't know. We see it and it looks very heavy, but it might be lighter for them.

It might be heavy for me but light for them. We can't just use that term heavy. It really comes down to the person's execution of an exercise and how they manage their intra-abdominal pressure. If we are chronically bearing down with a lift, regardless of the weight, or chronically bearing down with a certain movement pattern, constipation, chronic coughing, that is the problem.

So we need to look at that person's strategy for managing pressure: change their breath, change the position, change the load, change the frequency. See what variables we can change to give them a better strategy that would help mitigate some of the potential risks of that chronic bearing down. Does that make sense?

Nikkiey: Yeah, totally makes sense. You've mentioned breath a couple of times throughout, and you shared a little demonstration of exhaling and inhaling during a squat. But when you're recovering postpartum in those weeks, what are some breath work exercises one could do?

Kim: Same. Core breath.

Nikkiey: Yep. Core breath.

Kim: Yep. In that first week, it might feel very tender, especially if you've had a cesarean and have an incision. It may not feel great to activate the muscles. But ideally, you would have been doing them throughout your pregnancy, so you understand that relationship.

So now you just inhale and exhale, visualizing what's happening in the pelvic floor. You're not adding the voluntary part, like picking up the blueberries or the jellyfish or the milkshake. You're visualizing what's happening. And then every once in a while, just try a gentle contraction. If it feels accessible, do a couple more. It's just building capacity. That's what's going to stimulate muscle memory and blood flow and circulation and all that. But it doesn't have to happen right then and there. It's the same thing. Core breath.

Nikkiey: And is that in alignment with what you mentioned earlier, that for a long time we've been taught to do Kegels wrong? Is the core breath, thinking about the blueberries and the straws, the way to do Kegels the right way?

Kim: Yeah. I would say probably 95% of the people in my program, when they're first learning the core breath and the alignment and all of it, say, I've been doing this all wrong. You're alive, you're breathing. I don't want to say you haven't been breathing properly.

Kind of, but it's just a bit of a mind shift, because usually they've thought of a Kegel as, oh, I need to suck something up. So they will inhale and suck up and then let go. But when we think about what physiologically happens in the body, the inhale is when the pelvic floor is lengthening. So if we try to take a breath in while contracting the pelvic floor at the same time, we're never going to get a great breath, and the pelvic floor is never going to go through its range of motion.

Nikkiey: So I'm literally sitting here doing the breathing at the same time, trying to think about engaging the core, the pelvic floor.

Kim: Yeah. When I'm working with people one-on-one via Zoom, since I don't really do in-person work anymore, one way I can see, within my scope, whether somebody has the capacity to activate and relax their pelvic floor is to ask them, sitting or wherever they are, to contract and hold their pelvic floor. I don't give them any cues. I just ask them to do a Kegel, or to contract and hold their pelvic floor.

Then I'll say, keep holding, now take a breath in. If they have a decent strategy for contracting and holding their pelvic floor, and then I ask them to take a breath in, I'll ask: was it harder, easier or the same to take your breath in? If they say harder, then I'm thinking, okay, they probably had a decent activation of their pelvic floor. They could hold it, and that made it harder to take a deep breath. If they said easier, then I'd say they probably didn't really activate their pelvic floor.

And so that didn't interfere with the diaphragm's ability to come into its nice flat state, because the pelvic floor lengthened. Are you with me on that?

Nikkiey: Yeah, I'm following. I'm trying to do it at the same time.

Kim: Yeah. And probably a lot of people listening are trying to do it at the same time.

Nikkiey: So you're saying if I'm engaging my pelvic floor, not my core, my pelvic floor, and taking in a deep breath, it should be hard?

Kim: You should not really be able to take in a deep breath. So here's the pelvic floor, here's the diaphragm.

When I take a breath in, the diaphragm flattens and the pelvic floor lengthens. On the exhale, the pelvic floor contracts and lifts. So if I contract and lift the pelvic floor and then try to take a breath in, the diaphragm usually wants the pelvic floor to relax. But if I'm holding it up here, the diaphragm is going to be hindered in its ability to let air fully come in. Ideally when we breathe in, we have a lateral expansion in our rib cage.

So if we look at somebody and there's no movement in the ribs, and we see a little bit more of this happening instead, that's another indication that they're probably not connected well yet to their pelvic floor.

Nikkiey: How would one get connected to their pelvic floor? Keep doing this?

Kim: Alignment, breathing, coordination, practice. Yep. ABCs.

Nikkiey: ABCs. Okay. Awesome. Thank you for all of this so far. This is so good. Let's transition over to the core. You talked about it a little earlier, but bringing it back here: why is core stability important for the pelvic floor and pelvic health? And what are some exercises we can do to strengthen the core while protecting the pelvic floor?

Kim: Well, the pelvic floor is what's helping us with that core control. When people think of the core, they think of it as maybe more aesthetic. I want to strengthen my core so I have flat abs, or so I don't have back pain. I hear that all the time.

Nikkiey: Right. That's why we do it. We're like, yeah, if that's going to flatten my midsection, I will do all the core exercise in the world.

Kim: And with Kegels, if we're doing the core breath and coordinating it into movement, you will get a flatter midsection. Here's the pelvic floor, here's the diaphragm, but we also have the transversus abdominis, the deep abdominals. When we take a breath in, the pelvic floor lengthens and the belly expands, or at least it should. On the exhale, the pelvic floor contracts and lifts, and the belly button moves inwards towards the spine.

We don't have to think about pulling the belly button to the spine. It naturally co-contracts with the pelvic floor. And this is an engaged core. When we exhale and engage, the transversus and the pelvic floor create that cylinder, like the canister is held. That being said, rigidity is not necessarily control or strength.

We need it to be fluid and dynamic, but the pelvic floor is what creates the core control. And we need that core control to transfer load through our body, to lift heavy things, to have freedom of movement, to maintain balance, and to keep our bones strong. So the core, our center, is what gives us more capacity in all the other things we want to do that help with our overall health and well-being.

If we're hindered in our core, if we have a weak core, it may be tightness in the pelvic floor. It may be laxity in the pelvic floor. It may be that the timing is off. It may be that it's not working in synergy with the diaphragm. Sometimes we can have bony shifts, maybe from an accident or a fall, that influence how the muscles work, and maybe they're not working in a balanced way.

So there are lots of different reasons we may not have great core control. Then we come back to the principles of the ABCs. Get back into our alignment. What do we need to lengthen? What do we need to strengthen? Work on the coordination and the breath, and then progressively load. And you talked about postpartum. There was one piece of research we used in that company I started, Bellies Inc., which was meant to optimize postpartum recovery with abdominal wrapping, which is used in many cultures around the world, and restorative exercise.

That research looked at the abdominal wall at eight weeks postpartum. There's something called diastasis recti, where the connective tissue that holds the six-pack muscles in position at the midline stretches and thins, and often the rectus moves away from the midline and creates a gap larger than what would be considered normal. This research found that if nothing is done, the position of the abdominal muscles at eight weeks postpartum is what it's going to stay unless there's some sort of intervention.

So we said, well, let's harness that first eight weeks and provide things that will encourage realignment of the rectus and tension and activation in the connective tissue. We put together an eight-week protocol with things like bridges, clams, bent-knee lifts, standing on one leg and transferring load to build up balance in the lateral hips, squats, lunges. Functional movements we knew moms would be doing, but that would also stimulate the pelvic floor along with the deep abdominals and the thoracolumbar fascia to create tension in that connective tissue.

That way we're managing the loads we'll be dealing with when we rotate in the car to put a soother in our baby's mouth, and all of that. We call them the movements of motherhood. If you want to see a lot of variety of movement, follow a mom around for a day.

Nikkiey: Totally. This has all been really good information. So circling back to Kegels and resistance training: one or the other, or both?

Kim: Both. Both. With resistance training alone, whole body, there will be some overlap. It will help with the pelvic floor, but not enough, in my opinion. There has been research comparing Kegels to resistance training to both, and resistance training, exercise alone, was not enough to overcome the challenges.

So I believe in both. And I'm not just saying that because I believe it. We have evidence that when we couple it with resistance training, we get more activation. There was also a urogynecologist, Dr. Bruce Crawford, who I worked with for a number of years. He was the first person I found who was talking about the pelvic floor with a fitness perspective in mind. He's a urogynecologist.

He performed surgeries, and he said, I'm a good surgeon. I've performed a surgery, and this person is back X number of years later for the same surgery. I did a good job, so what's happening? There need to be other explanations here. So he took wireless surface EMG of the pelvic floor, the inner thighs, the glutes and the transversus abdominis. Critics are going to say surface EMG is not perfect.

I totally get that, but it did give us some information about activation of the core and the pelvic floor, and in which movements. He looked at 150 different Pilates, yoga and strength training movements. Where is the pelvic floor most engaged? And what if we add voluntary pelvic floor activation? When did Twitter come on the scene? I remember I got onto Twitter and started searching hashtag pelvic floor, and I found him.

So this was probably 2012, 2013, 2014, I forget. I reached out to him immediately and said, oh my gosh, you are the first person who's not talking about isolating the pelvic floor where nothing else can move. It is part of a system and part of a team, and we need to train it dynamically with movement. And that's what his research was showing as well: here's where the pelvic floor is most engaged, so let's add voluntary activation to get more pelvic floor engagement.

So we can do pelvic floor work with our resistance training. I always do a little bit in the mornings. I do another practice called hypopressive breathing, which is also great for the pelvic floor. And I do a few reps just lying on my back, connecting with the core breath and that movement. Then at some point in my day, when I'm doing my resistance training, I do my loaded, dynamic pelvic floor muscle training.

Nikkiey: Nice. Okay. Solid. I'm going to start incorporating this and thinking about it. I'm like, how can I integrate this, slowly, as something new? Bringing more awareness to it. Okay, there's mind-to-muscle connection, but now it's mind to pelvic floor.

Kim: Mind to muff.

Nikkiey: Mind to muff. I like it. Perfect. This has all been great stuff. One last thing before we wrap up. What do you use for the vagina demonstration behind you? What do you typically share?

Kim: The vulva.

Nikkiey: Yeah. What do you typically share about that?

Kim: So this is the vulva puppet.

Nikkiey: It's bigger than I thought. I wasn't ready for it. It's large.

Kim: Yep. It's large. I use this for anatomy, teaching people the different parts. I use it when I'm talking about vaginal estrogen and the application of vaginal moisturizers and estrogen creams. I sometimes use it when we talk about the core breath. A lot of the time, during the inhale, I'll have people think of blossoming their vulva. And then picking up. Even though this isn't really what's happening, it gives people an idea of something being drawn inwards and upwards. So that's typically what I use it for.

Nikkiey: Awesome. It's literally a puppet. That's great. Awesome, Kim. I'm going to have all your links below in the description so everyone can find you. But where do you hang out the most, where people can come and connect with you?

Kim: Instagram is where I hang out the most. All of my social media channels are at Vagina Coach, and Instagram is currently where I like hanging out the most.

Nikkiey: Awesome. Well, thank you so much for sharing your insights and your knowledge on this podcast. I love what you're doing. Keep going with it. Keep changing the conversation and the narrative, and bring more awareness to the pelvic floor. It's very important after hearing all your information today.

Kim: I really appreciate you having me. Thank you.

Nikkiey: Of course. Hey guys, real quick. If you're interested in taking your body to the next level, losing body fat, building more muscle and feeling more confident, do it alongside one of our 30-plus professional coaches. Work one-on-one with her to eliminate all of the guesswork you may have. All you need to do is the work she tells you to do to get to those goals of yours. To learn more, click the link below this podcast and apply to our VIP program right now.