Prenatal Care for Twin Moms: The Tupler Technique

Labor is just like any other athletic event in that women must prepare both their minds and bodies. However, women are frequently told: “Don’t start an exercise program if you haven’t been exercising.” The misconception here lies in the definition of exercise. Muscle strength, flexibility, relaxation and proper nutrition are the other components of fitness and are vital before, during and after a woman’s twin pregnancy.

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Featured Expert

  • Julie Tupler

    New York Magazine calls her the guru for pregnant women. She has been featured on many national television programs such as the Today Show, Regis & Kelly as well as in many fitness, medical, and women’s health magazines.

    The Tupler Technique® is the only research based program to treat a diastasis recti (see Columbia Study). More research is now being conducted in the UK on the Tupler Technique® and diastasis recti.

    Read Bio >

Episode Transcript

Christine Stewart-Fitzgerald 0:05
So whether you are planning a vaginal or surgical delivery for your twins, did you know that there are things you can do for your body to have a better birth and faster recovery? For many expecting twin moms prenatal visits with their medical provider typically focuses on the development of the twin babies and the birth plans. But very little time is spent on the women as a whole and what she needs to do to prepare for such a strenuous event as birthing twins. Today we're here with Expert Julie Tupler. To dig into the secrets most doctors aren't talking about how to prepare your body for a better twin birth. This is twin talks. The ultrasound shows your babies to be healthy. What did you say babies? You're huge. Are you having twins? Are they natural? Which one do you like? Better? Winds ha my neighbor's cousins, brothers uncles a twin. So can they read each other's minds? How do you tell them apart? Twins, you got a two for one twins run in your family double trouble. You're not having any more. You just you're not Octomom. If you're pregnant with twins, or you're an experienced twin parent, odds are you've heard it all before. Now it's time to hear from the experts. This is twin talks, parenting times two. Welcome to twin Talks. My name is Christine Stuart Fitzgerald. And I'm your host, I'm a mom, two identical twin girls, where now they're 14 years old, and a singleton girl who is 11. And she thinks she's 15. And I'm passionate about being healthy in all aspects of life, especially through pregnancy. So during my twin pregnancy, I felt like I was just flooded with tons of data and information. And a lot of it was scary to be quite honest. So I had to figure out what was truly important and what would make the biggest impact on my twin pregnancy and birth. And so for me, that meant that I needed to learn how to strengthen my body nutritionally and functionally to carry the two babies and to deliver them in the way that I hope to. So I'll share more about my story in just a bit after we introduce our guest speaker for today's discussion. So now, if you haven't already, be sure to visit our website at New mommy And subscribe to our weekly newsletter, which keeps you updated on all the episodes we release each week. And another way to stay updated is to hit that subscribe button on your podcast app. And if you're looking for a way to get even more involved with our show, check out our membership club, and it's called Mighty moms. And this is where we chat more about the topics that we discussed here at the show. And it's also an easy way to learn about our recordings so you can join us live. So for today, I want to point out that for this episode, we are trying something new. So we're featuring video of our discussion. So this is a little bit of a new exercise for all of it. All of us. We haven't done it before. But when I first talked with our expert, I realized that there are so many really great important things that can't be shared with just words. And so video is really important. So so you'll get to see us all chatting and all those weird expressions that I might make, and you can laugh and I promise I won't be offended. So let's let's meet our guests today. We're introducing Julie toddler. She is a nurse, an author, birth educator, and has been focused on helping women for over 30 years with all the research and evidence based called the toddler technique. So she trains medical and birth professionals all over the world. And her program has been translated into seven languages. So Julie, I am so thrilled to have you on the show today. And I have to say I remember during my own twin pregnancy, I'd heard a little bit about your program from my physical therapist. And I'd heard about pelvic health. But because I just getting some physical therapy. But even during my physical therapy, there really wasn't much discussion about pelvic floor and abdominal walls and how they work together. And I had only learned about your program after I delivered my twins. So I'm really curious about your story, how you became an expert in your field and how did it start? So, Julie, please tell us how it all began.

Julie Tupler 4:29
Well, when I moved to New York, I was besides being a nurse, I was a fitness instructor. So I started teaching exercise at this health club. And they said, You're a nurse, you should teach the prenatal class. Now, at that point in time, nobody was doing prenatal the American College of Obstetricians and Gynecologists had pretty much just written the guidelines for working out. So it was a whole new territory, there was a physical therapist that I, I took her course she was the only one. And I didn't really agree with what she was teaching. So I thought, Well, I'm gonna have to do this on my own. And when the women in the class found out that I was a nurse, they started picking my brain about labor. So I thought, well, let me become a childbirth educator, and let me see what they're teaching. And what I discovered after becoming a childbirth educator, is that they were only preparing the mind. There was no body preparation. Now, you wouldn't run in a race. All right. Without preparing your mind and your body, well, it's the same thing with labor. You have to prepare the mind and the body. It's sort of like I called it the Marathon of labor, because it's hard work. Absolutely. So. So that was how it got started. So then I realized there was this whole all these people that were interested in prenatal, so I started my business in 1990, called maternal fitness, and it was preparing women for the marathon of labor and motherhood. And basically, the whole point of the program was preparing the mind and the body. Now when I talk about the body, I'm basically talking about the partnership between the abdominal muscles and the pelvic floor muscles because they are connected. So what happens during pregnancy to the abdominal muscles is that the relaxin that comes in a pregnant woman's body affects the joints, the cartilage in the blood vessels, but it also affects the connective tissue. You know, that connective tissue in between the outermost muscles, alright, so. So what happens is when the baby starts growing, and there's this forward force, the abdominal muscles have a tendency to separate. Now, you can control that separation, okay? Because so this separation of the abdominal muscles is called a diastasis. And that word diastole. This means separation, and rec die, which is the outermost abdominal muscles. So this separation is not a good thing. All right, it's not a good thing, because the whole point of these abdominal muscles is to support your back and support your organs. So when the abdominal muscles separate, the connective tissue between them stretches sideways. So it becomes like a piece of saran wrap over your abdominal muscles, so it's not supporting your organs and it's not supporting your back, okay? Now, when the muscles are separated like this, and you look at them under ultrasound, and you go to engage them, they move side to side, okay? Now, this movement is not the movement that they're supposed to be going in, that's not the direction. And what you need to do is bring them closer together, so that they move in a front to back direction, this front to back direction is what strengthens the muscles, this is the direction that they need to move in, pushing in labor. So the whole point, right, is to keep that separation as small as possible during the pregnancy. The other thing that happens for pushing in labor, and the other thing is that when the muscles separate, this is what happens to the uterus. So here's my uterus, and on the bottom of the uterus is the cervix. Now, the cervix needs to be lined up with the vaginal canal. So it's a straight shot for the baby to go out the body. Okay, so when the muscles separate, the top of the uterus has no support. It tilts forward and the cervix is now pointing sideways instead of downwards, and if that cervix is pointing sideways, you cannot have a vaginal birth. So Keeping the diaster sets as small as possible, is important to keep the uterus lined up and for pushing in labor. Now, when I was doing maternal fitness classes, we would check the diathesis in week one, and week six. And what we were discovering is that in six weeks, the dialysis was actually getting smaller even as the belly was getting bigger. And basically, my aha moment was because I was doing transverse abdominal work. One of the women who happened to be a physical therapist said, Julie, honestly, I don't feel my muscles working. And that was because they were doing this. Okay, they were moving side to side. So I took a scarf. And I manually brought the muscles closer together. And I said, Okay, let's do the exercise now. And she goes, Oh, my God, I can feel my muscles working. So that was the beginning of me, repositioning the abdominal muscles and the connective tissue that stretched out connective tissue.

Speaker 1 11:18
So Wow. So Julie, I gotta say, that's really interesting that you just you just dove in where there was a need and jumped in. And it sounds like your your career really took off from women not getting the information that they really needed. So we're going to take a break. And when we come back, we're going to continue our discussion.

Speaker 1 11:48
So today, we're talking with expert, Julie topler, to learn what twin moms can do to prepare for a better birth. So let's dive in. So first of all, let's talk anatomy. I mean, you had mentioned a few terms in your introduction about, you know, the the pelvic floor and the abdominals. And I've just want to make sure everyone listening understands, you know what that really means? You know, so So what muscles are you talking about? I mean, I know, I think we're not trying to get a six pack, right, when we're when we're pregnant. But sometimes we might hear the names of the abdominal muscles, and how do they work together? Can you elaborate on that?

Speaker 2 12:31
Absolutely. So you have three layers of abdominal muscles, you have the outermost muscles, which are the rectus abdominus, you have the middle layer, which are the oblique said come on a diagonal. And then you have the innermost muscle, the transverse and my favorite muscle that wraps around the whole body and connects to the outermost abdominal muscles. Okay, so, during pregnancy, what happens is those outermost abdominal muscles, which are connected to the innermost abdominal muscles, separate that connective tissue between them gets stretched out, and, and it stretches out sideways. So this is called a dyad. Stasis and the word diastole. This means separation, wreck die, which is the outermost abdominal muscles. So that's what a diastasis recti is, is a separation of these outermost abdominal muscles with the pelvic floor, which are connected to the abdominals, the pelvic floor, figure eights around where the urethra, that's where you pee, around the vagina and around the rectum on a manacles around the penis in the rectum. Okay, so that's like your support system. Sort of like I explained it, like if you have a bag of groceries, okay. The bottom of the bag is like your pelvic floor, and your organs are like the groceries. So when the the pelvic floor gets weak, or the or the bottom of the grocery bag gets swept the groceries fall out, and that's what happens to your organs to the prolapse. Wow. So yeah, okay,

Speaker 1 14:14
now I heard prolapse, but I, you know, and I've never honestly never heard of this idea of it, because I think so often we think of the abdominal wall as being here and then the pelvic Oh, that's just, you know, they're not even connected with like, I don't even I didn't hear about that even in physical therapy quite so much. It's just It was sort of like your these two things that were

Speaker 2 14:37
separate muscles, but there is a co contraction between them. So if somebody has pelvic floor issues, they really need to handle the abdominals as well. Because, because, think about it. If the muscles are separated, they move side to side. All right, if they're separated four fingers apart or more. Okay, So if they, if you can't work the abdominals, it's going to be hard to work the pelvic floor. Okay? So it's very important for the abdominal muscles to be strong in order to work the pelvic floor better.

Speaker 1 15:15
Well, so now, you know, when it comes to during like a, you know, in in as an expectant mom, so if you're in pregnancy so what are some things that the twin moms should you know, watch out for? So how would they know if it's functioning properly during the pregnancy or you know, if there's something that they should be concerned about?

Speaker 2 15:43
Well, the whole point, during pregnancy, with or without twins, with twins, even more so and I have trained a lot of twins, I was even in the twins book. So that separation in a twins mom gets bigger. Okay. So it's very important for twins mom, to think about keeping that diathesis as small as possible. By doing by doing the by doing my program, which, you know, can make it smaller, even during the pregnancy.

Speaker 1 16:25
So it's so the real goal is to throughout the pregnancy is to try to keep that diathesis as small as possible. And do

Speaker 2 16:38
and we do that by strengthening that weakened and stretched out connective tissue between the separated muscles, and strengthen it by repositioning the muscles and the connective tissue, preventing that connective tissue from getting stretched, and then doing the exercises to strengthen both the connective tissue and the muscles.

Speaker 1 17:00
Okay. And so how does this translate into the birth? So I know, you know, a lot of our moms are thinking, Okay, I really I want to do a vaginal birth. And they're really, you know, hoping to have a successful delivery. vaginally, then there's there also might be some moms that are saying, hey, you know what I'm just planning on cesarean. So So what, like, how does working on this help in those different kinds of birth plans?

Speaker 2 17:31
And that's, this is my favorite question. Now, whether you're having a vaginal birth, or a C section, it doesn't matter. It's really really, really important to to strengthen the abdominal now for pushing. All right, there's a pushing technique that you need to learn. And this pushing technique can get the baby out faster and prevent all the issues that are unnecessary of the pelvic floor like the prolapse or the falling down of the organs, the hemorrhoids the urinary incontinence, all this can be avoided if you push correctly. And if you're having an if you know you're having a C section, it's really important to know how to do this program in the recovery process. Because what happens when they do the C section, they cut that connective tissue so knowing how to use your abdominal muscles in the recovery process is very important for a woman that's had the C section as well.

Speaker 1 18:38
Wow, okay, so it's so I mean, that's good to know that everyone can benefit from from really working on the strengthening and having better coordination from abdominal the abdominal muscles and pelvic floor.

Speaker 2 18:51
So would you like me to talk more about the pushing?

Speaker 1 18:55
Yeah, let's you know what, let's talk about the pushing but um, I think we need to take a break. And I think when we come back we will talk about some of the specifics of what women can do

Speaker 1 19:16
well, welcome back to Twin talks. Before the break, we were talking with Julie topler of the toddler technique and learning why the pelvic floor and the abdominal wall are so important to working together for a better birth. So now we are going to look at some of the things you can actually do to strengthen those muscles and make them work together even better. So alright, so Julie, so tell me can you maybe you can show us or you know, talk about what are the some of the practical things that the woman can do.

Speaker 2 19:49
Okay, so I I'd like to go over the big picture what you're doing with pushing. Okay, because this is not taught By childbirth educators. And this is really important, because it needs to be practiced during the pregnancy so that it becomes second nature, when you get to labor, you practice it, you cannot do a new skill when you're in pain. All right, it takes at least 21 days to learn a new skill. So if you practice this, this pushing technique during the pregnancy, then as I said, it will become second nature. So the goal of pushing, if this is my uterus, okay, the goal of pushing is to push with the abdominals and relax the pelvic floor that's been strengthened and stretched. During the pregnancy, we don't want you to tighten this and tighten that. Okay. So during pregnancy, in the exercise, when I'm doing the abdominal work, I always start with saying, relax your pelvic floor. When I'm working the pelvic floor, I always say relax the abdominals, so that they know how to tighten up above, relax down below. Alright, this is important that they know. So every time they go to the bathroom and have a bowel movement, which is very similar to having a baby, all right, they put their hands on their belly, and they use their abdominals and think of the pelvic floor opening up down below the image, when you first start to urinate, you have to like release that release, or I would say at the end of a Kegel exercise, open up like a little flower. So that image of opening like a flower or releasing is what is important to be able to do now it's important that the pelvic floor be toned that you strengthen it, a lot of times people say, you know, don't, don't strengthen the pelvic floor, it's going to get too tight down there. The strength of the muscle has nothing to do with the ability to relax it. And a tone pelvic floor is going to go back behind the baby's head instead of a weak pelvic floor that's going to go with the baby's head. So it's important to strengthen it. So it's toned, but learning how to relax it. That's crucial. So when they get to the birth, they tighten with their strengthen abdominals that they've strengthened. So they can push for as long as they need to push and relax the pelvic floor. So they have to practice that. So then they know how to do it. So I would say to my clients all the time, so that to make them laugh. And remember, I would ask them, so who are you thinking about? In the morning when you're having a bowel movement? I hope you're thinking about me. I get a lot of job satisfaction when that you're thinking about me at this precious moment in time. So they laugh. And then they remembered to do it. So that's really important to practices because they're going to the bathroom. Now, the other thing is during pregnancy, you know they get a little constipated. So I asked them to put their feet up on a little footstool about seven inches. And what that does that supports and aligns the bow. All right, because the toilet was invented by a plumber Thomas Crapper who did not recommend it did not recognize the mechanical advantage that squatting offers the body. So, so for pregnancy, that's important to put your feet up on a little footstool when you're doing this pushing technique.

Speaker 1 23:40
Wow. Okay, so, so what I am getting out of it is that we need to learn the relaxation as much as we need to think about the strengthening and it's interesting, you had mentioned that in the cables. I mean, I think you know, a lot of us, you know, we hear about cables all the time from medical providers, and it's okay, this tightening up and it's holding, but not so much about the relaxing and the releasing. So I think that's kind of a new

Speaker 2 24:09
if they because because that ruins the whole thing with the pushing. Because if they tighten here and tighten here, it's like keeping the cap on the toothpaste. Okay. You know, you can't you can't, you know, push the toothpaste out if the cap is on. So you have to let that go

Speaker 1 24:37
wow, okay, I'm sure we could do a whole episode just on you know, cables and re relearning right, what cable would good cables. Oh my gosh. So let me ask you on some of these because you're talking about like some of the pushing exercises and then also show the pelvic floor right.

Speaker 2 24:57
So I'd like to mention that that when you're pushing, I initially taught, exhale pushing. But then, but then I found out that the women were told to hold their breath and bear down. So I had to change the way I taught pushing. And what I would say is whether you hold your breath and bear down, or whether you do exhale, pushing, you need to engage the transverse. So I always have them do the little exercise where they put their hand on their belly, and put their hand on their pelvic floor. And then I would tell them to hold their breath and bear down, and they would feel it in their face, because it's called the valsalva maneuver, and their abdominals would go forward, making the diagnosis bigger, and then you would feel a downward movement in the pelvic floor. And that downward movement is pulling on the uterus. And that's, that's not a good thing, then I would tell them to engage their innermost abdominal muscle, the transverse by bringing the belly button to the spine, holding it there, but their hand on the pelvic floor, again, hold their breath and bear down, engage in the abdominals. And this time, it would be a lightbulb moment for them, because they wouldn't feel it in their face, the abdominals didn't go forward, and there was no downward movement of the pelvic floor was a totally different sensation. Now, if me, you know, so, and people will ask me, if a woman has a prolapse, will my program help it? So once you have a prolapse, it's sort of like, you know, it's not like a rubber band, the ligaments of the uterus are like a piece of silly potty, once they're stretched out, they're stretched out. Okay. So, What my program does, though, is prevents them from getting any more stretched out than they are. Okay. So that's what it

Speaker 1 26:58
does. Wow. Okay. And I haven't heard that. So when

Speaker 2 27:02
people so when people push, using their abdominals, it saves the pelvic floor, okay. So they're not going to get the hemorrhoids, they're not going to get the prolapse of the organs, they're not going to get the urinary incontinence, it totally saves the pelvic floor. So having a strong transverse and then knowing how to use that strong transverse while relaxing the pelvic floor is crucial, crucial for saving the pelvic floor. Well,

Speaker 1 27:33
I wish I mean, like, seriously what you're talking about? I mean, it just seemed it makes sense. And I wish that more people were hearing this.

Unknown Speaker 27:42
I wish. That's why I'm here talking about Yeah, absolutely.

Speaker 1 27:48
So So let me ask you in doing this kind of, sort of program. So as a twin mom, I mean, you know, like, I just remember having, like, my to do list would just get so long, and there's like, oh, there's all this stuff I have to do in preparing for the twins. And I was like, you know, online internet research and learning, you know, so much stuff. And then I felt like there really wasn't enough time or that I'm spending talking about like, my own body. So So you know, for this kind of thing. Like, when should twin moms like start engaging and thinking about doing these kinds of exercises and you know, getting a program or, like, Does that happen right away or closer to birth? No, no,

Speaker 2 28:33
no, it's first trimester, right after the first trimester, second start of the trimester. Second, you know, for the second trimester, when the nausea has gone away, and they're feeling better. Okay? When they're feeling better, all the major organs are pretty much made, you know. So, the beginning of the second trimester is really the best time to start. I've had people start in the beginning of the third trimester, and have had results. The best time isn't starting in the second but, you know, hey, you know, two weeks before you deliver

Unknown Speaker 29:09
not a whole lot of benefit, right? Yeah, is

Speaker 2 29:12
is is is not as beneficial. But there are some benefits to know a little bit about this

Speaker 1 29:27
so sounds like it you probably we need to give yourself maybe for at least four months or something like that, you know, four or five months to really benefit the most from you know, doing these different types of exercise both from your body getting strengthening and learning how to relax and I think you mentioned earlier, even just the mental aspect of learning something new and and maybe even incorporating that into the birth plan because I know like when we go to To the different birth education classes, which could take, you know, maybe a couple months.

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