Postpartum Surgery Decisions

You’re cleared for pelvic surgery and then someone hands you a rule that says you can’t lift more than 10 pounds. Meanwhile, your toddler weighs three times that and your life doesn’t come with a pause button. We’re talking about the gap between real postpartum life and the way recovery advice is often delivered, and what the research actually says about returning to activity.

We walk through common postpartum surgeries and why the “right” option depends on symptoms, goals, and context: midurethral sling procedures for urinary incontinence, prolapse repairs like sacrocolpopexy, and abdominal surgery such as abdominoplasty for diastasis recti. I share how I think about conservative management first, why I’m not anti-surgery, and how pelvic floor physical therapy and prehab can support you before and after an operation. We also dig into what rehab can genuinely improve (strength, coordination, function) and what it cannot promise (a specific look at rest), especially when genetics and connective tissue play a role.

Then we get into the spicy part: post-op lifting restrictions. We unpack why “strain” is relative, why blanket limits are rarely evidence-based, and how studies comparing strict vs liberal return-to-activity protocols show that gradual progression can be safe and can reduce symptom burden faster. If you’re considering postpartum surgery or recovering now, this will help you ask better questions, advocate for individualized guidance, and protect your quality of life.

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Transcript

Welcome And Podcast Purpose

SPEAKER_00 0:07

Hello everyone and welcome to the Farbell Mamas Podcast. My name is Christina Farman. I'm a public form physical therapist, researcher, and exercise in pregnancy, and a mom of two who have competed in constant, powerlifting, or weightlifting, pregnant, post-partum, or both. In this podcast, we want to talk about the realities of being a mom who loves to exercise. Whether you're a recreational exerciser or an athlete, we want to talk about all of the things that we go through as females going into this motherhood journey. We're gonna talk about fertility, pregnancy, and postpartum topics that are relevant to the active individual. While I am a public floor physical therapist, I am not your pelvic floor physical therapist, and know that this podcast does not substitute medical advice. All right, come along for this journey with us while we navigate motherhood

Surgery Options After Birth

SPEAKER_00 1:04

together, and I can't wait to get excited. Hello everyone, and welcome back to the Barball Mamas podcast. Christina Previtt here, and today we are going to be talking about surgery. In the postpartum space, with the incidence of pelvic floor dysfunction and diastasis recti being higher postpartum than pre-conception, there are considerations in situations where individuals may be considering surgery. There are surgeries for incontinence, such as a midurethral sling. There are surgeries for pelvic organ prolapse, like say, crocal pexes or other type of prolapse mesh repairs or biological conduit repairs. And there are surgeries for the abdominal wall, such as an abdominal plasty. Each of these surgeries has its unique characteristics, has its own symptom profile that it is trying to ameliorate or resolve, and is a very nuanced conversation when it comes to is surgery right for you? That question. Where I stand, I'm gonna kind of do my disclaimers at the front of this podcast. I am obviously not a surgeon. So the ins and outs of the surgical procedure, all of that type of nuanced conversation, that is definitely a conversation reserved for the person who is in the operating room. As a pelvic floor physical therapist, I come alongside moms in prehab to post op to help with recovery. And we are often a referral source around surgery. Where I stand is I am not firmly rooted in any camp. And sometimes I feel like that actually makes me really unique in the conservative management allied health space where I am not anti-surgery at all. And maybe this is because so much of my practice is in geriatrics, where yeah, I am not anti-surgery, but I am pro-conservative management first or forward, meaning that I have had clients who see resolution of their diastasis, symptoms of prolapse and incontinence conservatively. And I have also been one of the providers advocating for the surgical consult for individuals with more severe symptoms. Because of that, I want to go through some of the conversations that I would have with you if you were my client, what to talk about, what to expect with some of these considerations.

Diastasis And Abdominoplasty Reality Check

SPEAKER_00 3:56

And then to speak a little bit to the post-operative side of things when it comes to recovery and some of the things that I noodle on as a researcher and a pelvic health clinician. When it comes to the abdominal wall, when it comes to diastasis recti, an abdominal plasty is considered often a cosmetic and non-emergency type of surgery. Many pelvic uh surgeries are not considered emergencies or life-threatening in any way, but especially on the abdominal plasty side, um, it is very much considered a cosmetic surgery. Because of that, um, in many cases, I can't speak to all over the US, but oftentimes it is because it's considered elective, it is not covered by insurance unless there is some sort of symptom that is trying to be results resolved that is not the appearance of the abdominal wall. When it comes to abdominal plasties and it comes to diastasis recti, one thing that I think is really important as a pelvic health provider is that all of our assessments around diastasis recti are on the functional capacity of the ab wall, right? Our gold standard for testing for diastasis recti, which is a lengthening of the linea elba, usually uh decided as above or more than an inch of length between the two rectus muscles on a headlift maneuver, we are looking at that headlift, which is going to cause your two six-pack muscles to come closer together. That is the action of that muscle. All of our testing and all of our strengthening for diastasis recti is meant to improve function of the ab wall when it is working. While we do see recovery for many in the resting position of the ab wall, for a lot of my moms, it is that standing feeling of mom pooch or distension of the belly and easy to bloat of the belly that is often a chief complaint. When I have somebody coming to me specifically for diastasis recti, the promises I can make versus can't make is a really important part of the informed consent process. I can make your abwall stronger. I can teach you the proper coordination of your core wall. I can help with motor reprogramming and strengthening and resiliency, but I cannot promise that it is going to change the look of your belly at rest. Have I seen uh cases where that has changed at rest? Absolutely. But I cannot make that promise because all of our assessment is done in functional movements and not in resting positions. For many that are getting or considering abdominal plasty, what we see is that the non-modifiable factors around your core wall, specifically what your fascia and connective tissue are made of, that is largely dictated by your genetics, is often a very strong predictive factor of persistent lengthening of that linea elba postpartum. Many of my clients with more significant length of their linea elba postpartum are those that kind of have this joint hypermobility, kind of have this hypermobility syndrome, Eler Danlow spectrum type of conditions that they were aware of before they got pregnant. And because of the nature of their genetics, they are more likely to have that persistent length of that tissue. While their abwall can get stronger and function-wise are going to see just as good of improvements, we sometimes do not see the resting tone changes. And online, many individuals on social media, these are individuals who have that very protruded abdomen look, even several years postpartum. And it is those individuals that are that may be a little bit more likely to opt into that abdominal plasty. I think it is really important if you are considering an abdominal plasty to recognize how significant and serious of a surgery this is. There is a very big incision that happens from hip bone to hip bone across. So it is about twice the length of a C-section scar. The recovery is not just a couple of weeks when you have drain it, drainage and you need to have those drains in. There is a lot of undulation and fluctuation of bloating and fluid across the abdominal wall, upwards of a year into surgery or post-op recovery. And you still need to understand the functional training of the core wall in order to see the strongest recovery we can have from the resting position. The abdominal plasty will absolutely uh tackle that. But then from the functional recovery piece, too, we want to make sure that we we create this strong abdominal wall that is coordinated with our pelvic floor and low back in order to feel the strongest we can postpartum or postoperatively. So there's a lot of considerations in the abdominal plasty space. When it comes to pelvic floor surgeries, this is where there's a lot of nuance, there's a lot of different surgical approaches. You're gonna be in consult with your physician to

Who Pelvic Surgery Is Really For

SPEAKER_00 9:55

figure out what approach is best for you based on your symptoms, your considerations, etc. Um, when it comes to opting into a surgical intervention, most of our surgical guidelines that are leading the decision-making frameworks for our surgeons describe surgery as an intervention for more moderate to severe symptoms. This is true with incontinence. This is also true with prolapse. And some of our new guidelines for prolapse are talking about prolapse surgery being reserved for individuals with stage three to stage four prolapse, where the vaginal wall on a bear-down is approaching the opening of the vagina or coming past the opening of the vagina, where now outside or inside tissue is being exposed to outside environments. Even in that, I just had a client, she's in her late 60s with stage four prolapse, and her physician, her surgery surgeon, when she went for her consult, actually said, you know, I don't think you should get surgery right now because of what your sexual activity is like in risk for post-operative pain with sexual activity. And so, you know, she said, you're not having infections, you're not limited physically, your symptom burden is actually quite low. I would hold off on the surgery, even for those with stage four. I tell this story because it's nuanced and it was very interesting for me to be coming alongside this client who, you know, I would consider higher up on the surgical candidacy uh criterion. And the surgeon was like, actually, no. And I and I love that. I love having those conversations with the team, the healthcare team with my client in the center. So when it comes to pelvic floor surgeries, we're thinking more moderate to severe symptoms. Ideally, we are having individuals trial conservative management first. There's a couple of reasons why I believe that. Obviously, surgery is intense. Um, every time you go in for surgery, surgery leaves scars. Um, it is an intense uh recovery process. And we want to make sure as well that our tissues are healthy and we try trial the non-invasive option first. That's number one. We want to trial that non-invasive option. A lot of times, symptoms can be resolved in non-surgical routes for incontinence. That's pelvic floor muscle training and kind of global strengthening for prolapse. We also have the option of a pestry, which is like a bra for the vagina, as our conservative management. And with failed conservative management, we can then transition over to potentially

Why Try Conservative Care First

SPEAKER_00 12:52

a surgical option. The other reason why I strongly believe in at least prehab management with an allied health provider is that there is a risk, particularly particularly with prolapse surgery, there is a high uh risk of post-operative other pelvic floor symptoms. So prolapse repair turns into having incontinence post-op or dyspreneur or pain where the mesh is. And then there's also a higher rate of revision for our prolapse surgeries. One of the reasons why I believe that to be true, and this is where I blend clinical experience with my research, is that the reason why there is an increase in range of motion isn't appropriately addressed with surgery. We're fixing the range of motion issue with the vagal walls with surgery, but we aren't getting to why that tissue was being strained in the first place. Very often, when I see individuals with persistent prolapse, they have risk factors like size of baby's head, number of deliveries, their obstetrical status, their menopause status, estrogen status, et cetera, their connective tissue issues, chronic constipation, chronic cough, BMI, like these are all kind of in the modifiable to non-modifiable bucket of risk factors. When I evaluate people, many times the coordination of their core when doing effortful tasks is off, meaning that when they should be contracting their pelvic floor and having a good co-contraction across their core canister, abdominal wall, chest wall, low back muscles, pelvic floor, when they should be kind of contracting together, they end up bearing down or straining down into their pelvis. Now you can imagine if you do that as somebody who is constipated and constantly straining against their pelvic floor, if they're having cough, they're someone who coughs frequently, some somebody who um is every time they lift their kid, that is a very effortful movement. There are a lot of instances of high strain on that pelvic floor across a given 24-hour period. As individuals get older, we see that we lose strength in our body and we lose strength in our pelvic floor. And our butt muscles are support beams for our pelvic floor. So if you are already putting extra strain on your pelvic floor and now you're losing some of the strength of your butt muscles, then we kind of have this perfect storm where we can see this need for revision repair because we haven't taught the coordination, we haven't kept the strength up. And so having that education on how we unintentionally put extra strain on our pelvic floor and can have that change in vaginal wall range of motion over time is a really important consideration for pre-operative management and then post-operative care so that we have no need for revision. How this has been translated, though, sometimes in that need to not put excess strain on the pelvic floor, has been instead of promoting resiliency and making sure individuals stay strong but lift appropriately and are taught well how to brace with their whole body, not just putting strain on their pelvic floor, is that post-operatively there are oftentimes lifting restrictions that are placed on individuals for a variety of lengths and amounts. And

The Truth About Lifting Restrictions

SPEAKER_00 16:41

it is from as simple as six weeks of no lifting more than 10 to 15 pounds to there is a Eurogyne surgical group in Australia that said you should never lift more than 30 pounds ever in your life. And do not let those fitness providers try and convince you otherwise because they are wrong and you paid a lot of money for this surgery. Like that was their language. Like, do not ever do planks again, do not ever go on a rower again. All of these things do not do. And it was very restrictive. When it comes to post-operative management, that kind of universal truth is nothing in the vagina for six weeks if that if um you were having a pelvic surgery. Where there has been a lot of controversy and where I feel very strongly is in this lifting restriction being bullshit. And so often they are told not to lift more than 10 pounds, 15 pounds, 20 pounds, 25 pounds, et cetera. When you ask Eurogynes and urological surgeons if these restrictions are evidence informed, first of all, only 24% of them believe that there is evidence to support these restrictions. There isn't. There is no evidence to support these restrictions. Number two is as early as 2013, we have started having RCTs comparing liberal restrictions to absolute lifting precautions. Meaning universal truth of nothing in the vagina for six weeks is held. Absolute is do not lift more than 10 to 15 pounds for six weeks or 10 weeks or 12 weeks or however long in the RCT. And then liberal restrictions is gradually return to activity. If you are experiencing symptoms of heaviness or aching around the pelvis or opening of the vagina, that is your body's sign that you are pushing it a little bit too much. It's time for you to rest. And you can kind of go within your tolerance. Now, you're probably not going to be surprised because I feel very strongly about this. Every single study from 2013, and we now have a new meta-analysis that got published in 2025, has shown universally that liberal restrictions do not cause an increase in complications, do not cause an increase in vaginal wall range of motion in early phases, and liberal restrictions actually reduce symptom burden post-operatively faster. So these absolute lifting restrictions not only unnecessarily restrict, but they actually lead to worse outcomes than our liberal restriction group. And when we ask patients about having to respond or keep up with these protocols, they say, I will do it because that's what my doctor said, but they are so disruptive to my quality of life and all the things that I need to do in my life upon discharge. So they are not evidence informed, and that's acknowledged by our surgical team. They are not consistently not shown to actually improve outcomes, reduce risk of complications. They actually make symptom profiles worse than liberal restrictions, prolapse symptoms and stress urinary incontinence symptoms are improved faster and to a bigger degree in our liberal restriction group. And our patients respond much better. There's a higher rate of satisfaction. And so now we have 10 years of data, including syntheses of data, that is telling us that these absolute lifting restrictions are not necessary. So if you are going for surgery, please advocate for yourself. The last piece to this, and the thing that I think is really important, and it kind of gets to the concept of these post-operative restrictions, is that strain is a relative construct. And in medicine, we keep trying to slap an absolute label on it. What I mean by that is that we are trying to reduce strain. But what is going to be strenuous for my 90-year-old with a mid-urrethral sling versus my 30-year-old lifter with a mid-urrethral sling is so different, but they are given the same precautions. It doesn't make any sense. We have to be starting to have a little bit more nuance to these conversations.

Self-Advocacy And Smarter Recovery

SPEAKER_00 21:01

And oftentimes people think it's just not worth it to have those nuanced conversations, like just don't do anything for six weeks. But after some of these surgeries for my clients who are younger that are postpartum, that have little kiddos that want them to be picked up by their mom. And I am seeing clients in their 30s and 40s who are getting these surgeries. It is so important about to recognize how disruptive that is. And when we asked the Euroguins, they said that their lifting restrictions were a little bit undulating in time and duration based on what the goal of post-surgery is. And I think that's wonderful. We should have that variation where we give individuals the tools of knowing where what the buoys are of doing too much too soon. You need to know what to look out for. And then that person is going to have that their own self regulation to understand what is too much and what isn't. My clients going into surgery are so desperate for an improvement in their quality of life. They are not trying. To mess up their repair, right? They care very deeply about their repair. What we see after mid-areth roll slang, for especially for individuals getting this surgery between 30 and 40, they actually go on to have more physical activity because those with moderate to severe pelvic floor symptoms, it is a huge barrier for them participating in exercise. And so we really want to kind of set up these conversations to, you know, acknowledge that nuance and be able to kind of lock shields together, physicians, client, rehab staff, and try and really hug in on our clients that they get the best outcome possible. So I hope you found this helpful. I I obviously took very broad strokes and I talked about this very broadly. And it is because it is such a nuanced conversation. Um, but just know that, for example, if you are my client and you were having these conversations, I really are in your mind, I really hope that you would open up to me as a provider or to say, hey, I've been thinking about this surgery, or I've been thinking about urethra bulking or talking about PRP or I heard about this thing. And I'm not gonna be an expert in everything, just like whoever your pelvic floor provider isn't gonna be an expert in everything. But being able to bounce ideas off of someone and give them, give you ideas of questions to ask, ways to advocate for yourself, those types of things can be unbelievably helpful. All right, everyone, have a wonderful rest of your week. And we will talk to you all next time.