Ep 237: The Importance of Pelvic Floor Physical Therapy with Dr. Marcy Crouch

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The American healthcare system doesn’t value preventative care, especially when it comes to reproductive health. One tool that could help in preventing injury and improving healing after birth is pelvic floor physical therapy. It’s not a standard part of maternity care so its benefits aren’t widely known by practitioners - even I didn't know that pelvic floor physical therapists could help with pregnancy and birth related issues until years into my practice. It may not even occur to providers to recommend it to you.

That’s where clinicians like Marcy Crouch come in. With over 180K followers on Instagram, Marcy, AKA The Down There Doc, is spreading the word of the benefits of pelvic floor PT. She believes in and practices pregnancy-related preparation and recovery through manual therapy and functional training just like you would with any other muscle. Someday I hope to see pelvic floor physical therapists as a routine part of birth including in-hospital care but until then, listen to this episode and ask your healthcare provider about pelvic PT.

In this Episode, You’ll Learn About:

  • What makes Marcy so passionate about her work
  • How and why Marcy began offering pelvic floor physical therapy online
  • What, exactly, a pelvic floor therapist is
  • What kind of training and certifications are required to do her work
  • What to expect if you go see a pelvic floor physical therapist
  • Whether PT is covered by insurance
  • What the most common types of pelvic pain are
  • Which tools are helpful in recovery and how to choose the right ones
  • What are vulvar varicosities and what can be done

Links Mentioned in the Episode

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I want this podcast to be more than a one sided conversation. Join me on Instagram where we can connect outside of the show! Through my posts, videos, and stories, you'll get even more helpful tips to ensure you have a beautiful pregnancy and birth. You can find me on Instagram @drnicolerankins. I'll see you there!

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Dr. Nicole (00:00): This is such a fun and informative conversation with pelvic floor physical therapist, Dr. Marcy Crouch. Welcome to the All About Pregnancy and birth podcast. I'm Dr. Nicole Callaway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now, let's get to it.

(00:52): Hello there. Welcome to another episode of the podcast. This is episode number 237, and whether this is your first time listening or you've been here before, you know I'm glad you're spending some time with me today. In today's episode, we have Marcy Crouch. She is also known as the down there doc on social media. She has over 180,000 followers on Instagram. She is a mama and a doctor of physical therapy dedicated to serving, empowering and equipping women in the birthing community from birth preparation through postpartum recovery by providing elevated care and setting a new standard for women. Marcy arms her clients with confidence, valuable tips and information that will maintain their physical health and wellness for a lifetime. She believes that by simply addressing and fixing pelvic floor trauma and dysfunction from pregnancy and birth, we can change the course of a woman and a mother's life to one of a quality, power, confidence, and arm her with a strong sense of self that opens doors that have been shut and helps her become the woman and mother she is destined to be.

(02:05): Yes, amen to that. So we have an incredibly informative and just fun conversation about what exactly is a pelvic floor physical therapist, when should you go see a pelvic floor pt? What kind of test and exam should you expect? How frequently the care is? We talk about different types of pelvic pain, maternity belts, maternity pillows, HER three Ps system for reducing vaginal tears and much, much more. You are going to absolutely love this conversation with Dr. Marcy Crouch. Now, before we get into the episode, one of the things we talk about in the episode is preparation, and that's why I created the birth preparation course. That is my online childbirth education class that gets you calm, confident, and empowered to have a beautiful birth with a particular focus and emphasis on how to get prepared for birth in the hospital. We know that having a baby, especially in the US, can be a challenge.

(03:07): It's a system that too often tries to take away power from women over what happens in their own bodies. It can be racist, and you really need to be prepared to advocate for yourself within that system. Over 2000 women have gone through the birth preparation course and and found it incredibly helpful, and I would love to have you inside of the course too. You can check it out@drnicolerankins.com slash enroll. But remember that I'm so passionate and childbirth education is so important. If you don't take the birth preparation course, please take something because childbirth education is an absolute must. All right, let's get into our conversation with Dr. Marcy Crouch. Thank you so much, Marcy, for agreeing to come onto the podcast. I am so excited to have you come on and talk about this topic.

Dr. Marcy Crouch (03:59): Oh, well, thank you. I'm so excited to talk about it. I mean, it's my favorite thing. Lets talk all about it.

Dr. Nicole (04:05): Right. So why don't you start off by telling us a bit about yourself and your work and your family, if

Dr. Marcy Crouch (04:11): You like. Yeah, yeah. So my name is Marcy Crouch. I'm a pelvic floor physical therapist. I have two boys, ages six and eight, so it's real loud at my house all the time. Holy moly. I have an older sister, so I'm not used to this boy situation, but I love it and love being a boy mom, and they're great, and it's just like wow, energy constantly. So my family and my work collide a little bit. My husband is a coach, volleyball coach at Auburn University here in Alabama. And so we move around a lot. And being a physical therapist in the past, I've had brick and mortar clinics, I've worked for other practices, I've worked in hospitals, that sort of thing. I've owned my own practice. Then when my kids were little, and we were living in LA about three years ago, in 2018 is when we moved there, we were kind of moving every three or four years, and it's hard to have a brick and mortar when you're not totally sure that you're going to be in one place for an extended period of time. And so I realized that with my family life and the ages of my boys and really the need of the type of work that I do as a pelvic floor pt, there had to perhaps be an additional answer to only in clinic work.

(05:43): And I was finding that, you know, are in clinic too. It's like you can only see so many people per day, right? There's geographic location problems. There's time when my kids sick, I'm calling out of the clinic. And so I didn't really feel like I was helping as many women as we could. And so I decided actually before we moved here in 2020, that I wanted to kind of transition or add on to an online platform, online wellness space. And a lot of people are like, oh my gosh, how do you do that as physical therapy? And honestly, if you had asked me that before covid, I would've been like, there's no way. There's no way.

Dr. Nicole (06:25): But

Dr. Marcy Crouch (06:26): Covid really kind of forced us into a new way of thinking about what we can offer.

Dr. Nicole (06:31): Absolutely. Women

Dr. Marcy Crouch (06:31): And moms. And what I was seeing in the clinic too is that I was losing a lot of patients after maternity leave was over. Gotcha. This is just hard for moms to get in the clinic, and there's lots of barriers to that. So my work now, I still am in the clinic about two days a week here in Auburn, and then I also have an online platform. So I took what was working in the clinic and would transfer over into videos live q&a programs, all the things for birth prep from a pelvic floor standpoint, early recovery in that acute stage. So from a zero to six weeks and then longer six weeks on recovery. So I created a program for that to help moms reduce the risk of vaginal tearing and trauma during delivery, heal better and quicker in that acute stage because there's new resources for moms at all from zero to six weeks, but that's not the case for any other muscle injury, which I'm sure we'll talk about. And then this kind of longstanding support. So that's where we are now from a work and family standpoint. And the online programs have been going for about two years now, two and a half years, and we just put out our third version of them.

Dr. Nicole (07:50): Awesome. Love it. Love it. And a very big online community in the intro. I can record the intro after we record the interview, and I will have mentioned the size of your audience, which is quite large.

Dr. Marcy Crouch (08:00): Thank you. Thank you. Yes.

Dr. Nicole (08:01): Yeah. So let's hop into a couple of things. One, I want to talk about what is a pelvic floor physical therapist? And then what training have you gone through? The first question is because I don't necessarily know that people understand what pelvic floor physical therapists do. And then the second is because there's a whole lot of people out here online and doing all the things. And I think it's important for people to know the background, the education that people go through when they're talking about a topic.

Dr. Marcy Crouch (08:32): Yeah, I think that's such a good point. And to just kind of touch on that a little bit too. I'm sure you see it also being an expert in your field and social media and online stuff is great, and it really brings people together and it's a great network of wealth of information. But the caveat is you really do need to know who you're getting your information from, what their training is, are they qualified? And a lot of times on my side of things, it's people who have had kids and now all of a sudden they're like, oh, I'm this pelvic floor expert because I had kids. And I'm like, okay, that gives you a little bit of experience. But it's like I've had a pap smear. I'm not an OB GYN, so I'm always just careful. It can be so overwhelming. So yeah, my initial training, so I have a doctorate in physical therapy, and the school, we graduate as generalists.

(09:28): So we all have to take the same national board exam. We are considered physical therapists, and then you can decide to specialize in certain areas of physical therapy. There's orthopedics, neurology, pediatrics, all the things, women's health, pelvic floor, physical therapy is one of those avenues. And so after I graduated, I knew that's what I wanted to pursue. I applied for an additional year of training, which is we consider a residency. That residency was a year of only pelvic floor and women's health. It was pre and postpartum lymphedema, breast cancer, female athlete, pelvic pain, basically everything that encompasses the umbrella of women's health. And then after completion of that residency, that allowed me to sit for the board certification in women's health pt. So that identifies me as a women's clinical specialist. And then you recert every 10 years, which is what I just did. And that was like, oh my gosh.

(10:29): So stressful, as you know. And then I have been fortunate enough to work in practices after residency that have been only women's health and pelvic floor. So I've never really had to do half and half or 60 40, which some people do when they're getting into women's health. You might see orthopedics or neuro inpatient. And then a smattering of pelvic floor has always, my experience always has been pelvic floor. And I've had amazing mentors who kind of paved the way in women's health and pelvic floor PT throughout my career. So that's pretty much kind of my initial training. And then over the years we take more courses. I've developed courses for PTs, I've taught other PTs.

Dr. Nicole (11:12): So you're obviously very serious and committed and educated about this work. This

Dr. Marcy Crouch (11:16): Is my life. People are like, oh, you're a pt, my elbow. I'm like, no, no, nope. I was like, I haven't touched an elbow. I was like, tell me everything about your vagina

Dr. Nicole (11:26): And then I can help you. I got you.

Dr. Marcy Crouch (11:29): I got you. How was your poop this morning? Tell me all the things. Yeah,

Dr. Nicole (11:34): I love it. Love it, love it. So when someone goes to see a pelvic floor physical therapist, what should they expect? And I asked this question because literally someone DMed me the other day and they're like, I went to a pelvic PT and she didn't do an exam, and I thought they would do an exam. And I was like, to be honest with you, I don't know because I'm not a pelvic pt, so I dunno what to expect. So what should you expect when you go see a pelvic pt? Yeah,

Dr. Marcy Crouch (12:00): It's such a, oh man. I mean, I'll tell you how I do it. And I do think that this is important, and I do feel that an internal exam is warranted to get a really good idea of what is going on with the pelvic floor. But let me backtrack a little bit. Sure. So we as physical therapists are really skilled in injury prevention, rehabilitation, muscle physiology, movement, science recovery, that sort of thing. So just like you would go to a PT for your knee or back pain or post-op, whatever, we do the same thing as pelvic floor PTs. We're just working in a different area. So I kind of say my territory is breastbone down and knees up. So pelvic floor PTs really are the specialists in incontinence, pelvic organ prolapse, any sort of vaginal or anal or genital pain, difficulty with sex, difficulty with tampon use, gynecological exam, any sort of abdominal surgery, laparoscopic surgery, c-section, endometriosis, menstrual problems, basically anything in that kind of soup to nuts area that would be disrupting daily activity.

(13:18): And my specialty and where I've niched down over the last couple of years is this pregnancy, early recovery and birth injury prevention. Gotcha. So it kind of depends on what you're going to see your pelvic floor PT for regarding what the exam would look like. And of course, patient consent is always important. Absolutely. And there are some contraindications to internal exam and that sort of thing, but generally speaking, you would expect a pelvic floor PT to do an internal exam barring no other red flags or contraindications because you really do have to get an idea of what the muscles are doing to be able to prescribe movement or exercise. Just like we would assess a shoulder. I can't just look at somebody's shoulder with my eyeballs and be like, oh, it's this problem, this problem, this problem. I have to take it through tests and I have to go through differential diagnosis and all the things. So same thing for your pelvic floor. And then you can expect some manual therapy techniques. You can expect some exercise, some postural reeducation, pain management, basically anything that you would expect for a sprained ankle you can expect for your pelvic

Dr. Nicole (14:30): Floor. That makes sense. That actually makes a lot of sense and helps to make it relatable and understand what people should expect. So then obviously, again, I know this varies, but how frequently does someone go to a pelvic pt? How long do you need to do it? I know that's going to be dependent. Totally,

Dr. Marcy Crouch (14:49): Totally varies. And what I always say is my job is to get them out of the clinic, get my patients out. If I have to keep seeing them over and over again, I'm like, I'm not helping that much. You need to go back to the drug board. But using the framework of what we know about muscle physiology and exercise science and tissue healing, if we just use that framework, tissue healing takes six to eight weeks. So if there's an acute issue, you're right postpartum or you have an abdominal surgery or C-section, we can expect tissue remodeling and scars to be ready to go by six or eight weeks. Then for muscle hypertrophy, for strengthening, for actual change in the muscle itself, that's another six to eight weeks on top of doing a really good progressive resisted exercise program just like you would see in the gym. Right.

(15:50): And then if we're talking about persistent pain, chronic pain, people that have been having pelvic pain for years and years and years, then we also have to add in the pain centralization component and reworking the central nervous system and brain education and all those things. That might take a little bit longer too. But generally from a postpartum standpoint, I like to see my patients around the third trimester just start to do some birth prep stuff and maybe we just need a couple sessions depending. Then I like to see them right after for some help with getting out of bed and that first poop and how do you carry a baby? The car seat is real heavy and now you have a waterbed for an abdomen and your vagina is all over the place. So how do we help with just these daily activities? And then I like to see them six weeks once we're cleared for exercise to start the recovery process. And that could potentially be up to a year or so, but not weekly appointments. I like to kind of space it out and get them back to work and back to childcare and do all the things. And then at each kind of phase or new demand, then we come in, reassess, and then out the door. Okay.

Dr. Nicole (16:59): All right. Awesome. I love it. Very detailed, very helpful. I'm learning so much myself.

Dr. Marcy Crouch (17:03): I see. Yeah, I know.

Dr. Nicole (17:06): So before we get into some advice, we want to definitely give some people help through the conversation. Is pelvic VPT typically covered by insurance?

Dr. Marcy Crouch (17:16): That is a wonderful question. So it depends.

Dr. Nicole (17:21): I figured like anything else.

Dr. Marcy Crouch (17:23): Yeah. Yeah. Technically yes, because it's regular physical therapy, so it falls under your pt, OT speech. We have benefits, whatever those are. Gotcha. Now the caveat is this, if you are going to a private practice or a small practice like me where it's just maybe one or two clinicians, three clinicians, privately owned, chances are that we will be out of network. And we are what's considered a cash-based practice where we take payment for services rendered at the time. We hand you what's called a super bill, you submit that to your insurance and get reimbursed for your out-of-network coverage directly by insurance. And this is because two reasons. One, insurance reimbursement for physical therapy is abysmal. And because we're only seeing really one patient an hour in pelvic floor pt, that insurance reimbursement is like 50 bucks an hour and you can't even keep your lights on. You just can't even pay rent on your space. And then the second reason is that a lot of times, which is this is a huge problem, is that insurance doesn't recognize our diagnosis codes and our ICD 10 codes as medically necessary. Of course. And I know that this is a whole nother,

(18:41): This is a whole nother dissertation, and they don't pay for preventative care. So if I see a woman in the office for birth prep and we're going through manual therapy and we're doing functional training and we're doing it with a goal to reduce the risk of muscle injury and tearing, they won't pay for that because there's no diagnosis, no injury. You know what I mean?

Dr. Nicole (19:04): Even

Dr. Marcy Crouch (19:05): Though it would lessen the need for interventions down the road. So

Dr. Nicole (19:11): Again, that's a problem with our US healthcare system doesn't focus on a lot of prevention periods, so I'm not surprised. Okay. Well, that's helpful to know. That's helpful

Dr. Marcy Crouch (19:19): To know. But there are bigger practices that, and usually hospital-based outpatient will take insurance, and that's usually because they absorb the cost of pelvic floor PT because they have ortho and inpatient and all those other things. So I have worked for practices that take insurance and they're out there. And then when I've owned my own, it's always been cash-based. Gotcha.

Dr. Nicole (19:39): So let's get into some conditions and things that people can do to help. We're going to try and get through as many as we can. So let's start off with what are two or three of the most common types of pelvic pain that happen during pregnancy and what can folks be done to help, especially curious to hear your thoughts about maternity belts?

Dr. Marcy Crouch (19:58): Yeah. Yeah. So that goes right into one of the most common pain syndrome. So this is generally, it's kind of diagnosed under this umbrella of sciatica, which is that irritation of this huge nerve that comes out of your butt and goes all the way down to your foot. But oftentimes that's really not what it is. What we call it is posterior pelvic girdle pain in pregnancy. And this is, yeah, it's like a mouthful.

Dr. Nicole (20:25): Yes,

Dr. Marcy Crouch (20:26): Yes. And this is usually one-sided back pain that's a little bit lower kind of in your SI area, your area, and it can radiate down into your butt and go into the back part of your thigh, which is oftentimes why people are given. They give it the name of sciatica and it can be very sharp, it can be very painful and it can radiate to both sides. But oftentimes it's usually one. Okay,

(20:54): If there's a dysfunction in the SI joint, which oftentimes there is, you can also see it go around to the front. And we have what we call pubic synthesis dysfunction, which is another very common pain syndrome in pregnancy. And this is that joint that's right underneath your pubic hair. And a lot of times it's like when you go one leg into the car or you're trying to kick a box with your foot and you get that like, oh my gosh, pain in that joint, or you're stepping into the bathtub or any kind of asymmetrical. And that can radiate down into your adductors, which are the interior part of your thigh, your groin. Sometimes people have these, we call it lightning crotch. You get that leg zinger. And I would say those are the two most common that I see in breakings when people are like, oh my god, my back. It's so bad I can't lay down. I can't get up. And it's super sharp and gets just like that. So one treatment for that, or I would say adjunct is a belt. I tend to favor a belt that's designed specifically for the SI joint. It's a little bit thinner and it goes lower and it just compresses the joint versus lifting the belly up.

(22:15): There's nothing wrong with either kind, but people might not get as much relief if there's an essay problem with only the belts that kind of lift the belly up. And sometimes we would do both, just kind of depends on what they need and what their demands are.

Dr. Nicole (22:31): Gotcha. Gotcha. Okay, that makes sense. And then what about pillows? Do you think paternity pillows help?

Dr. Marcy Crouch (22:37): Yeah, I do. I love it. I call it the husband replacement or the partner replacement. I'm like, no room for all three of you in there. Somebody's got to get out. Yeah, I think they can be really helpful. Sometimes they're too fluffy though. They're too big. And somebody might be like, man, my knee was all the way open and oh my god. So thinner ones sometimes can be helpful. The thing that's great about them is that you can put them underneath your breast and side and belly, and it still is long enough to go down in between your knees and then also into your ankles. And I think a lot of people kind of miss that. They might just put a pillow in between their knees, but you really need it all the way down to keep the joint neutral versus Yeah, if you just have it on your knees, then your knees are separated and then your ankles are closed and the joint's like, but yeah, those pillows are great. I had one. And then you can coil it up and put your baby in it. You can use it to nerves. It's multiuse. Yes. Love

Dr. Nicole (23:37): It. Love it. So then let's talk about something that I think people don't realize happens, but as frequently as it does, but let's talk about vulvar. What are those and what can be done? I think people freak out when they see 'em.

Dr. Marcy Crouch (23:54): I know. I mean, they're scared. I mean, if you've never seen one before, it's like, oh my gosh. So this is where you have a vein in your vulva, which is your outer part of the vaginal opening. It's like your labia majora, and it's a vein that it's a varicose vein just like you would get in your legs, and it just happens to be in your labia. And it can be very painful and it can cause a lot of swelling. Oftentimes, it doesn't affect the ability to have a vaginal delivery. A lot of people think that it can, but it's more painful and uncomfortable while you're pregnant, especially as you get into your later stages of pregnancy because you have more weight, more blood volume, more fluid and tissues are just very engorged down there. From a physical therapy standpoint, there's not a ton that we can do for the vein itself, but there are some compression garments that we can recommend that you can wear underneath your clothes that do direct compression onto the varicosity to help reduce swelling and help reduce some of that pain. There's a couple different types of garments, and there's some that, there's one that's called the V two supporter. It kind of looks like a jock strap, like a female jocks strap, but you just put it on over your underwear and then kind of Velcro it, so it just lifts up and gives you a little bit of support, and usually that's helpful. And then after pregnancy, they go away. Sometimes the vein is still there, but it's not as engorged, but you probably will have it engorged again in future pregnancies.

Dr. Nicole (25:27): Yeah, yeah. Gotcha. So let's get into vaginal tearing because I know folks are going to want to hear about this. So what are your top two or three tips maybe things people should do to help reduce the risk of vaginal tearing?

Dr. Marcy Crouch (25:43): This is my favorite. This is my thing. So there are three. I have a system that I call the three PTs, and this stands for peroneal massage, push prep,

Dr. Nicole (25:58): And

Dr. Marcy Crouch (25:59): Practice like you play. So this is where it all comes together. So if you look at the literature for peroneal massage, it's kind of all over the place, but some studies say like, yes, totally reduces the risk. Others studies say like, Nope, doesn't do a thing. But most of the studies that say it doesn't do anything, looked at it being performed for the first time while the baby was crowning by a nurse or somebody that's not like a muscle person.

Dr. Nicole (26:32): Sure.

Dr. Marcy Crouch (26:33): The studies that show it is beneficial are what we base our treatment off of, and this is where we do it earlier in pregnancy, just like you would stretch your hamstring for whatever you need to do, whatever your legs need do. Right, exactly. So we apply the same idea to the pelvic floor muscles because they're skeletal muscle, they're made up of the same stuff as your bicep, as your quad, as your hamstringing. So those muscles can be trained both from a strengthening side of things and also a lengthening side of things. And for vaginal delivery, they have to lengthen and open. So peroneal massage is a technique that I like to start around 30 weeks, 32 weeks, and we just start to work on the tissue stretching, increasing blood flow, softening. If there's a prior tear that has some scar tissue there, we want to work on that scar tissue to make it more mobile.

(27:29): It's all about creating space and mobility. We're not ever going to stretch the pelvic floor to the size of a baby's head, but we can start to get it moving better. Awesome. So that's great. So that's the first one, parallel massage. The second one is push prep. So this is where I teach women how to actually mechanically bear down and push effectively. So the pelvic floor gets out of the way. A lot of times people think that you do key goals to push a baby out, but your pelvic floor does not do anything to help you with delivery except get out of the way. Pushing comes from bearing down uterine contractions, fetal ejection reflex. It's not your vaginal muscles. Those muscles have to open, they don't contract. Listen, you are just making all kinds of sense here. I mean, it was go crazy. It just might work, doc.

(28:26): Right? It's so crazy. So we need to make sure that you have that range of motion, just like we would need range of motion in your shoulder if you were throwing the baseball, right? Yes. So same idea. Yes. So I teach women how to do that. And then the third P practice like you play is where we put it all together. And this is on the principles of what we know with muscle physiology, movement science, motor control, functional training. I want you to practice perineal massage and push practice in different positions just like you would be doing in the delivery room. So you're going to do that on your side. You're going to do that squatting, you're going to do that reclined, you're going to do it on all fours. So your brain and your body can be like, oh yeah, I've done this before.

(29:13): I know that inside lying with my partner holding my leg here and me breathing with my mouth open, I get a really good push and it doesn't hurt my back. And I feel great about it as opposed to being like, oh my God, I have no idea what I'm doing. Some person is just wrenching my feet into stirrups and what the hell is going on? None of that. Just like we would do sports specific training for a soccer player or baseball pitcher, same thing applies for birth. And that's really where I focus on and what is missing. We don't think about birth that way

Dr. Nicole (29:50): At all or

Dr. Marcy Crouch (29:51): At all. We think about it as, I don't even know what the right word would, but not in a way that's like functional movement, training, prep, recovery. It's just like diagnosis, baby flies out and

Dr. Nicole (30:07): You

Dr. Marcy Crouch (30:07): Deal with the consequences.

Dr. Nicole (30:08): Yeah. Yeah. And your ob, we don't know. I mean, let's just be honest. We are not taught anything about No, nor should.

Dr. Marcy Crouch (30:19): Yeah, nor should you. I mean, it's the same, right? I don't prescribe medication or perform hysterectomies. That's not my training. But we're here to compliment that. And oftentimes it makes it easier for the obese one

Dr. Nicole (30:34): Midwife percent. I think from my perspective, it makes me sad that I didn't even know that pelvic physical therapist could help with pregnancy and birth related things until years into my practice. I know. So when I say we don't know, I mean, sometimes it may not even occur to us to recommend it to you either during pregnancy or the postpartum period. For instance, in France, I think everybody gets referred to a pelvic PT after they have a baby. We don't do that here and we don't see you for six weeks. We're trying to change that, but we're not going to see you for six weeks. So I'm just saying all that to say, take in this information. Don't expect that your OB is going to necessarily tell you about this. You have to take it upon yourself to look for it.

Dr. Marcy Crouch (31:21): Yep. It's true. And I do see it changing a little bit now on the other side of things, like we do grand rounds and we'll talk about how we can compliment your practice and what patients we can help with and that sort of thing. And there is a little bit of a mind shift change where it's like, oh yes, let's bring everybody to the table work. But I mean, when I was first starting out 13 years ago,

Dr. Nicole (31:46): It was like, what? Yeah.

Dr. Marcy Crouch (31:50): I mean, it's still an uphill battle, but I mean, yeah, it was. It's

Dr. Nicole (31:54): Getting better. But you're right, it

Dr. Marcy Crouch (31:56): Is getting better.

Dr. Nicole (31:57): Yeah, for sure. So let's talk about postpartum and maybe we can do a couple things short-term, couple things. As I mentioned, the way our system is set up, we don't see you for six weeks postpartum. Typically for some practices, we might try to do it sooner, and there's actually a push within our specialty to at least touch bases with people sooner. But it's not going to be a lot of help necessarily about how to heal. So what thoughts do you have

Dr. Marcy Crouch (32:25): About that? Yeah, so again, same idea as what we're doing for musculoskeletal injury. So ideally, and if I was ruler of all things pelvic floor, I would want pelvic floor PTs in the hospital. So

Dr. Nicole (32:42): Okay. Alright.

Dr. Marcy Crouch (32:46): I know that those first couple of days in postpartum and anti are crazy. I know that

Dr. Nicole (32:52): I've been lactation consultant and pelvic physical therapists. Right on. Right on in there, girl.

Dr. Marcy Crouch (32:58): Because all we need 20 minutes, and this is what we'll show you how to do. It'll give you a little handout. We'll show you how to get out of bed. Yes. Especially if you've had a C-section.

Dr. Nicole (33:09): Yes.

Dr. Marcy Crouch (33:10): Okay. We'll show you how to poop to protect your perineum. Why don't

Dr. Nicole (33:16): Show we do this? I mean I'm, because these are the most common things that people are like, I can't get out of bed. I can't

Dr. Marcy Crouch (33:23): Get out of bed. I'm worried about poop. Poop. I

Dr. Nicole (33:24): Can't poop. Girl, you are okay know. I

Dr. Marcy Crouch (33:28): Know. And here's the thing. That's so wild. Okay, here's the thing that's so

Dr. Nicole (33:32): Wild.

Dr. Marcy Crouch (33:34): If you had laparoscopic surgery in your abdomen, if you had a gallbladder removed, if you had arthroscopic surgery in your knee, three little tiny holes and they clean up a little cartilage, what do you get?

Dr. Nicole (33:47): Inpatient

Dr. Marcy Crouch (33:49): Physical therapy, outpatient physical therapy, all that. They all of it. And then a mom, but it's a

Dr. Nicole (33:55): Vagina.

Dr. Marcy Crouch (33:58): They're like, oh, here's your squalling baby. You have a waterbed from an admin and your vagina's falling out like bye.

Dr. Nicole (34:06): It's just like, wow.

Dr. Marcy Crouch (34:07): We don't do any of that. So again, if I was ruler of all things pelvic floor, I'd want somebody in the hospital to just do basic body mechanics and early recovery. And that's what we do with our online stuff. So I say it's like from when baby flies out until six weeks. So that first couple, that's so important for tissue healing and long-term recovery. So pain management, swelling management, body mechanics, postural reeducation, getting you in supportive garments, medical grade compression, red flags, signs and symptoms to look for that warrant, a call back to the doctor, how much bleeding is normal, what can you expect with your hemorrhoids? All

Dr. Nicole (34:49): Those things.

Dr. Marcy Crouch (34:50): How to lift up that baby carrier, what positions you should be nursing in, what to look for from scar healing, all those things. Then I would love to see someone two to three weeks postpartum. And this can be a virtual appointment. And I actually think that telehealth really has a big place here, because we can do a lot. We can see your house and be like, okay, that's how you're lifting your baby into that crib or whatever. Or it's like, okay, I see that's what your couch looks like. So let's do this and let's do that and make it more comfortable, help you move better, posture, all the things. And then if they need any sort of manual therapy that's not internal, then we can see them in the clinic for SI and low back and how much do we have neck pain from holding a baby and looking down? Or if you have mastitis and now you have upper back problems and kind of all of those things, sleeping, posture, all those things, mechanics, mechanics.

(35:52): Then we can do some really basic exercise. I'm hesitant to say that word because I know we're not cleared for exercise until six weeks, but I'm talking functional movement. You're already lifting a baby, so let's make it better. We can do some very basic stuff in that acute phase. And then at the six week mark, after you clear them for sex and exercise, then we start rehab. We don't go to the gym at six weeks because now we're cleared or we don't just start running that day. Nothing magic happens at six weeks compared to five weeks and six days where all of a sudden we could run and now we can't or vice versa. So it's like we need to rehab. And that's strengthening, that's motor control, that's connecting your brain back to muscles in your core that have not been working properly for nine months because they've been accommodating a baby.

(36:47): What if you have a tear? What if you have a c-section? All these things that we need to manage from a rehab standpoint, just like we would manage a knee or a shoulder, it's the same idea. And then we put together a rehab plan or protocol based on what the patient needs or what their goals are. And then the huge part of that also is return to sex, because so many women, nine out of 10 have pain with sex the first time they have sex after having a baby. And a quarter of those women will still have pain at 18 months postpartum. So that needs to be incorporated into your postpartum rehab as well. And it's not just for vaginal penetration, but it's tampons, spike and limb exam, kind of all the things. So that's kind of what I would love for everyone and what we're trying to do with our online stuff to provide that, because there's not a lot of us pelvic floor PTs, there's insurance problems, there's all those things that we talked about in the beginning. And I just feel very strongly that those should not be barriers to this type of basic care. I mean, it's not that complicated.

Dr. Nicole (37:55): It's not.

Dr. Marcy Crouch (37:56): It's really not. It's

Dr. Nicole (37:57): Not. And it should be routine

Dr. Marcy Crouch (37:59): A hundred percent.

Dr. Nicole (37:59): We have a problem valuing women in general in our country. So that's just, or family, women and families, we don't necessarily do. So that's just a whole nother conversation. So just three questions as we wrap up. How did becoming a parent, a mother affect your work?

Dr. Marcy Crouch (38:16): Oh, yeah, that's such a good one. So I went through IVF for my kids. It took us five years to get my first one. Lots of miscarriages, lots of complications, lots of surgeries and bad news after bad news, after bad news. And so I think before we started that I had been doing this work, and I think being on the other side of the table, so to speak, feeling that sense of overwhelm, that isolation, that betrayal of my body feeling, the stress, the financial burden of all of that, I think it really just gave me another view into what women go through. And it really helped me, I think, kind of rethink about how I talk to my patients and how I prescribe things and how I treat them and what I need to be doing differently to really respect that side of what women have to go through.

(39:24): And then I had my kids and I was like, oh, okay. I totally get it now. And so that, I think from a postpartum standpoint, it completely changed the way that I prescribe things and treat patients. And I'm very like, okay. I mean, I get it. I have kids. I have a job. My husband's job is bananas. And so I'm like, okay, if you tell me if you have two minutes a day to do something that I tell you, what's your time? And somebody's like, okay, I literally have five minutes. Okay, then that's what we're going to do. I'm not going to just work with, we have to work. We have to meet our patients. I can't just expect someone to and be like, oh my gosh, this patient is noncompliant. It's like, no, that's not, we're doing it. They're just

Dr. Nicole (40:09): Living. Yes.

Dr. Marcy Crouch (40:12): Right. And I'm like, you can bring a screaming baby into my office. I care zero. I'm like, I will put that baby in the ergo carrier a screaming baby. And no childcare are not reasons why you cannot get what you need. So my office is full of baby toys and diapers, and my ergo from eight years ago, that's like coffee all over it and burritos, I'll put that baby in there and you do what you need to do. So I think that really kind of changed the way that, and it really opened my eyes to how screwed up it is for us out there. So yeah,

Dr. Nicole (40:51): All of that. All of that. So then what's the most frustrating part of your work?

Dr. Marcy Crouch (41:02): I think just not being able to help as many people

Dr. Nicole (41:06): As I want. That's what I thought you might say. Just that it's not accessible for everybody. It should

Dr. Marcy Crouch (41:10): Be. And that I still feel like it's an uphill battle with other members of the medical community. And I don't want it to be so stigmatized and I don't want it to be such a burden. I mean, what I say all the time is what I do should be just as common and just as important as what stroller you're out for everyone. I mean, we should be right in the office with you. We should be alongside doing prenatal and postpartum. And I think it's the financial component for a lot of women and just the availability of pelvic floor pt. And that's really what we're trying to solve with the online stuff is the accessibility and the affordability piece. It can't just be inpatient or nothing, or in clinic, I should say nothing. There has to be a better answer for that.

Dr. Nicole (42:06): Absolutely. Yeah, absolutely. And then one on the flip side, what's the most rewarding part of your work?

Dr. Marcy Crouch (42:10): I mean, working with the women I get to work with. And I mean, I am an open book and I try to create a community and a culture that is non-judgmental and supportive. And I want women to feel finally that somebody's listening to them. And I mean, I will get dms or private messages in the community and people will be like, oh my god, Marcy, this was amazing. I just had this, and I'll get baby pictures. I mean, just like you. And then we get to be a part of their lives maybe more than once, and we get to be through this transformative period. I had somebody come up to me this weekend and she's like, you don't know me, but I follow you on Instagram. She's older, her daughters are in college, and she's like, thank you. Just thank you. Nobody talked about this when I was having my kids, and this is so important. I'm just like, oh my gosh, yay. You never know. And she's like, God, I just wish my daughter's had this. And that to me is so, so rewarding. And I'm like, okay, this is made a difference for her. That's important.

Dr. Nicole (43:19): Yeah, definitely. Definitely. So then what's your favorite piece of advice that you would give to and expect it, mom?

Dr. Marcy Crouch (43:25): Yeah. I would say don't take no for an answer. And I would say if you are feeling, I tell my clients all the time, you're the expert in your body, right?

Dr. Nicole (43:38): 1000%

Dr. Marcy Crouch (43:39): Feels good to you. What is normal for you? What is not normal? That's the say, I'm not in your skin. I don't,

Dr. Nicole (43:45): Yeah, I'm an expert in ob, but I'm not an expert in you. Right,

Dr. Marcy Crouch (43:48): Exactly. So if you are concerned about something and it's not jiving, then let's try to figure it out. And I think a lot of times what happens is that people in pregnancy, they're like, okay, I want to do this, I want to do that. And then sometimes they're like, no, that doesn't work, doesn't do anything, blah, blah, blah. And then they feel like, oh, okay, maybe I am just overthinking it or being too sensitive. But it's like, no, no, you are important. Your body is important, your body the best, and we're here to help support that, whatever that is. So keep asking and keep doing it. Take matters into your own hands.

Dr. Nicole (44:26): 1000%. All right. So where can people find you and find all of the fantastic you have?

Dr. Marcy Crouch (44:31): Yeah, so we hang out on Instagram most of the time. I can only manage one platform and

Dr. Nicole (44:38): Plus TikTok is a whole nother, I'm too

Dr. Marcy Crouch (44:40): Old. That's what

Dr. Nicole (44:42): I'm saying.

Dr. Marcy Crouch (44:45): I can't, no,

(44:48): I need a college intern to just do it because I'm like, I'm an old, I'm in my forties, I can't do that. So we hang out mostly on Instagram. The handle is the down there doc, same as my website, www.thedowntheredoc.com. That's where you can find all of our resources, online courses, webinars, all the information you need is there. And we're on Instagram all the time. Awesome. Yeah, just shoot us a

Dr. Nicole (45:14): Message. Alright, love it. Thank you so much. This was such a fantastic conversation. I really enjoyed it. Oh, thanks.

Dr. Marcy Crouch (45:20): Yeah, thank you for having me.

Dr. Nicole (45:28): Wasn't that a great conversation? You can tell that she is so passionate about her work and it really shines through in our discussion. Now, after every episode when I have a guest on, I do something called Dr. Nicole's notes, which I'm my top takeaways from the conversation. Here are my Dr. Nicole's notes from my conversation with Dr. Marcy crouch. Number one, I love the concept of treating your pelvis and vagina like you would treat a knee or a shoulder or any other body part. This is just another part of our body that we're helping get in shape after it's gone through some things. It's like you say the word vagina and all of a sudden it's like, oh my God, oh my God. And it really does not need to be that way. It's really great. And I believe just helps to stress the normalcy of it, right? That this is just another part of our body. We're helping to get in shape after it's gone through. Something that can, for some folks, can be traumatic. Doesn't have to be, but it can be. So I love that concept of how she approaches pelvic physical therapy.

(46:37): Next up is your OB probably is not going to bring up pelvic physical therapy. And if they do, it's almost always going to be in the context of if you had a more severe vaginal tear, they may bring it up even though it really should be standard for really everybody. So if this is something that you aren't interested in, especially if it's something that you want to do during pregnancy, because I know we don't think of it in that way. I personally didn't realize that that was an option or something that could be helpful until I started doing this online and social media work in this last year with the podcast and things like that. So if this is something that you are interested in and I think it's beneficial for everybody, then definitely bring it up with your ob. You may need a referral for your insurance.

(47:21): That's why I say bring it up. But if you don't need a referral from your insurance, then just go for it. Seek it out on your own, speak up advocate for yourself. Go check it out because it's something that can be quite helpful to help you get yourself and your body back to feeling good after having a baby. And speaking of feeling good after having a baby and getting your body back after having a baby, let's just go ahead and f the snap back Again, I've said this before and I'll continue to say it. It takes time to get your body back after birth to get used to the new normal of your body after birth. It is unrealistic. It's not healthy to think that you're suddenly going to get back to being a certain size or all of the weight is going to drop off or you're going to be able to do necessarily all of the things that you were able to do before.

(48:11): And that's not saying for some people. Some people do have a quick recovery and some people get back to feeling like themselves fairly quickly, but you don't have to. And there's nothing wrong if it takes you some time to rehab your body, that is okay. So give yourself some grace, be patient. It can take time. And then the last thing I'll say is that coverage for women's health issues can be so abysmal in our country in so many ways. Whether that is care in between pregnancies to help you go into your pregnancy in a healthy state, whether that is a lack of coverage for preventative care, whether that is a lack of coverage for things like pelvic physical therapy, it can just be abysmal. We don't value women and women's health and actually people's health in the United States like we should. When I hear in places like France, like referral to a pelvic physical therapist is standard for everyone.

(49:07): That just shows that the possibilities are there and we have a long way to go in the United States. And I say all that to say is that the way that things like this change is through advocacy and policy. Some examples of that, like breast pumps being covered by insurance is a result of the Affordable Care Act. Minimum guaranteed hospital stays after birth is federal legislation. Employers having to provide a space for breast pumping up until a year after the child's birth. That comes from the Fair Labor Standards Act. So in order for us to have these things in policies that help improve our health, it requires a policy on a higher level, and that is where voting comes in. So that is my plug to make sure you pay attention to legislation that's happening in your local, your state, your federal level, and please get out there and vote because it makes a difference.

(50:07): All right. So there you have it. Do me a solid share this podcast with a friend. I'm on a mission to reach and serve as many pregnant folks as I can, millions and millions, and your help in doing that would be so appreciated. Also, subscribe to the podcast in Apple podcast or wherever you're listening to me right now, and leave me an honest review, a five star review in Apple podcast. If you really enjoy the show, it helps other women to find the show, helps the show to grow. Also, check out the birth preparation course, my online childbirth education class that gets you calm, confident, and empowered to have a beautiful birth. Check that out at drnicolerankins.com/enroll. And also connect with me outside of the show on the gram. I'm on Instagram at @DrNicoleRankins. You can get helpful bite-sized nuggets of information to help you through your pregnancy and birth there as well. So that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.