Pregnancy & Postpartum Pelvic Floor Health: An Interview with Women's Health Physical Therapist Julie Brehm

Julie Brehm is a physical therapist specializing in pelvic dysfunctions, including pelvic pain, incontinence and pregnancy-related dysfunctions. She graduated from Mount St. Joseph in 2002 with her master’s in physical therapy.  Since graduation, she has completed her Certificate of Achievement in Pelvic Physical Therapy- Pelvic floor dysfunction and is writing her case reflection for submission for Certification of Achievement in Pelvic Physic Therapy-Obstetric. She is board certified in Biofeedback-Pelvic Muscle Dysfunction through bcia.org and is the state of Ohio representative to the Section on Women’s Health through the American Physical Therapy Association. She is currently finishing her submission to CAPPA (Childbirth and Postpartum Professional Association) for becoming a Certified Labor Doula. She also enjoys  reading, exercising, dancing, being outdoors and spending time with her family. 

I have known Julie for a little over a year, and we work together regularly as CAPPA trained back up doulas for each other's clients. Having seen firsthand the benefits and impact of Julie's work in the pregnancies and births of many of my clients, I wanted to share a little bit more about her on my blog today! Here we go!

What is women’s health physical therapy, and how does it apply to pregnant and postpartum women?

Women’s health physical therapy is focused on working with women across the age span, including women who are pregnant, to address pelvic floor dysfunction. I see teenagers up through eighty plus year old women for various issues, including back pain, pubic symphysis pain, tailbone pain, hip pain, pain with intercourse, incontinence, and urinary urgency.

Looking at pregnancy specifically, the most common diagnoses I treat include low back pain, pubic symphysis (pubic bone) dysfunction, tailbone pain, rectus diastases (separation of the abdominal muscles). Postpartum, the same diagnoses apply, and also include recovery from pregnancy and birth. This may include recovery from episiotomy or tearing, post c-section rehabilitation including scar tissue mobilization, abdominal pain post c-section, and rectus diastases treatment. Just because a woman has had her baby doesn’t mean that her back pain is magically cured. If you think about how many times you lift and bend while holding a baby, it’s not that dramatically different to being pregnant, so back pain can still persist. 

One of my favorite pieces of research talks about how women with back pain during pregnancy have a 50% chance of going on to experience further pelvic floor dysfunction including pelvic pain, incontinence, and constipation.  Addressing the issue during the pregnancy is tremendously helpful. Why are so many 40 and 50 year old women experiencing chronic back pain? Even before I worked primarily in women’s health patients would tell me, “Oh my back pain started when I was pregnant.” When I speak to the Physical Therapy students at the University of Cincinnati, I tell them, “Do not blow these women off! They are serious, and they are right.” They just didn’t get the right treatment during their pregnancy to address their back pain. And unfortunately, on they go with back pain, incontinence, dyspareunia (pain with intercourse), etc. They have really set themselves up for a much more chronic situation, that sometimes ends, unfortunately, in having to look at longer time frames for rehabilitation, more medical interventions, or surgical routes to fix their symptoms.

Could women benefit from seeing a women's health physical therapist prior to conception? 

There are many women with underlying musculoskeletal issues. They may have been gymnasts, dancers, athletes in high school or college with ACL tears, etc. Maybe they have a history of abdominal surgery or a prior history of pelvic pain. It is so much easier for me to mobilize scar tissue and free up those adhesions in a non-pregnant state. These women should definitely be flagged for potentially having issues during their pregnancy.

There’s really no harm in physical therapy, and there are no negative side-effects. It’s also great when people come to see me at the beginning of a pregnancy, and set up a solid foundation. It makes a big difference in their pregnancy and delivery.

How did you get into this line of work? 

I went to Mount Saint Joseph in Delhi, and graduated in 2002. My husband, Matt, and I moved to Knoxville, Tennessee, and I worked in a physical therapist owned clinic. One of the many subspecialties they had was women’s health physical therapy, so I had one of the great fortunes of training with Patti, who was one of the physical therapists who had been doing women’s health physical therapy for 20+ years. I trained with her for about 6 months, and then moved on to help them grow their women’s health program in several different locations around the Knoxville area.

Matt and I moved back to Cincinnati almost 10 years ago. I had found that when I was working with this population, there was so much gratitude from people for getting their life back. Women could go out with friends without having to stop at a bathroom; others felt tremendously better throughout their pregnancy. It was so amazing to see these life altering changes, and I didn’t want to stop treating this population just because I was back in Cincinnati. So I started the women’s health program at TriHealth, which is where I am at currently.

You have been there for some time, but it seems like a lot of people are just finding out about you! 

Word is out, and that’s an awesome thing; so many women have been helped by pelvic physical therapy! The community in Cincinnati is just amazing, and word-of-mouth has really taken off.

What is your favorite part of the job?

Getting women ready for labor and delivery is probably my favorite thing. But when an eighty year old woman tells me she no longer needs to use the bathroom multiple times at night, she's not leaking urine all day, and she has her life back? That is just as rewarding. It’s serving an underserved population, and that to me is really amazing.

Kegels are a hot topic in the birth world. What are Kegels and Should women be doing Kegels, or avoiding them? 

Kegels are exercises that were designed by Dr. Arnold Kegel back in the 1950s to tighten and strengthen the pelvic floor muscles, which are a grouping of muscles that help to support your organs, including your bladder, urethra, uterus, and rectum. They are a hot topic in the pregnancy world. Some may promote that one should do 300 Kegels a day during pregnancy! I treat a lot of pregnant women and have the great fortune to delve into pelvic floor dysfunctions during pregnancy. During pregnancy you have relaxin hormone, estrogen hormone, and progesterone hormone that help to soften the ligaments throughout the body, and specifically the spinal and pelvic ligaments, which can cause the pelvic girdle to become unstable. The body is smart, and it will try to maintain balance in whatever way it can, and the pelvic floor muscles can spasm in response to that. Pelvic floor muscles also have to work a lot harder because of weight gain. They are a really complex set of muscles, and strength is just as important as flexibility. They are a small group of muscles that you can’t see, and this makes it very challenging to know exactly how to contract and relax the pelvic floor. The pelvic floor muscles are a missing link for pregnant women and have such a major role in their pregnancy, labor, and postpartum.

So basically there is not a universal rule about Kegels?

Yes, some people need more strength in the pelvic floor, but some people need more flexibility and fewer Kegels. Having the kinesthetic awareness to appropriately work the pelvic floor muscles is a challenge. Some women may be very strong and work out or run, but find it very difficult to appropriately work their pelvic floor muscles.

What is your best piece of advice for women who are looking to have a healthy pregnancy and postpartum?

Come see me! There is so much to learn about, and it doesn’t require lots of physical therapy visits to see a difference. But if they can’t come see a physical therapist, my next best piece of advice is to stay active during their pregnancy, which is not always easy to do as your center of gravity becomes challenged and you gain weight. There may be things that you have to trouble-shoot to continue that active lifestyle; maybe you shift to working out in water, or instead of running you try walking. Do not neglect or overwork pelvic floor and abdominal muscles. 

There can also be some confusion about using your abdominal muscles during pregnancy. Yes, one should not be doing sit-ups during pregnancy, but there are deep stabilizing exercises using the abdominal muscles that are safe to use during pregnancy and can improve your posture, improve your pelvic stability, and reduce rectus diastases (the separation of the abdominal muscles).

Yes, I think that is a pretty common misconception. That yes, you shouldn’t be doing crunches, but that doesn’t mean you can’t do anything during pregnancy for your abdominal muscles.

Yes.

Any other advice?

I would also advise women to avoid sitting for long periods of time during pregnancy and to be aware of good posture while sitting, sleeping, and standing. Poor postural habits are very common culprits for back and pelvic girdle pain.

Do women who have had c-sections benefit from seeing you after having their baby?

Absolutely. Research says that women who have had a vaginal childbirth may be experiencing more incontinence immediately postpartum versus women who have had c-sections. But one year postpartum, both groups of women are equivalent. Just because you have had a c-section does not mean you won’t have urinary incontinence or prolapse. Post c-section requires more more rehab through the abdominal cavity when looking at scar tissue mobilization and hip flexor dysfunction that is very very common post c-section. The abdominal muscles may have been under even more of an attack during the actual c-section itself. Absolutely, there is lots to work on and learn about post c-section.

Do you have any success stories that really stand out in your mind?

Yes, I do have lots of great success stories! Here is one I am sharing with permission. This woman saw me with a third pregnancy. Her first pregnancy was rather uneventful with a long labor. Her second labor was a lot more challenging. Her water broke at work, and she went to the hospital shortly after that and found that her baby was posterior. She ended up with a coccyx (tailbone) fracture during the birth. She had issues with her tailbone postpartum, which were increased after a fall down the stairs during the postpartum period. 

When she was pregnant with her third, she developed pilonidal cysts. She and her OB discussed that this was likely to be a very challenging labor. So she came to see me. She had a lot of pelvic girdle dysfunction, a rectus diastases, and obviously tailbone dysfunction as well. We worked through all of her pain and dysfunction. 

I was also her doula for her labor. She went into labor and had an amazingly smooth labor. She got to the hospital and did not want to know where she was at with dilation because of how long her previous two labors had been, and it turned out, she was 9cm! She had a very short pushing phase; her birth was amazing and she was so excited. It went from, “Oh this is going to be a really hard delivery,” to “This was super easy!” I have many other stories like that. These women work really hard during their pregnancy and they feel so much better during their pregnancy. The wonderful labor is the added bonus.

You are a trained doula now, working on your certification, in addition to your physical therapy work. How do those two professions work together?


I always struggled with the lack of continuous care and having to leave my patients during the most critical time: during the labor and delivery. But one of the physical therapists that I took a class from a couple of years ago was also a doula. She made it reality for me. I thought, “If she can do physical therapy and be a doula, I can do that too.” Penny Simkin, the founder of Doulas of North America (DONA) is also a physical therapist and doula. I have found that my physical therapy work really informs and complements my doula work. I am not doing anything clinical during labor and delivery, but I absolutely do make suggestions about positions during labor based on what I observe during the mother’s labor. The two really do go hand-in-hand.

How can people get a hold of you, either for Physical Therapy or to see about having you as their doula?

You can contact me at Group Health (part of Trihealth) in the West Chester office at 8040 Princeton Glendale Road, West Chester, OH 45069.  Our phone is 513-246-5475 and our fax number is 513-246-5499.  You can also reach me via email at julie_brehm@trihealth.com.  You can reach me for doula services at betterbirthjulie@gmail.com.

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