Empowering Post-Surgery Recovery with Rebeca Segraves

In this engaging episode, we sit down with Rebeca Segraves, a leading physical therapist specializing in women's health, to explore the complexities of post-surgery rehabilitation. 

From her residency at Duke, where she honed her expertise in urogynecology, to her pioneering programs in early rehabilitation post-surgery, Rebeca shares her journey and insights into specialized care for women. Discover the critical role of early intervention after procedures like mastectomy, hysterectomy, and childbirth, and learn about the challenges and triumphs in implementing comprehensive care models. Tune in as Rebeca advocates for better postoperative recovery practices and addresses the pressing need for enhanced care for postpartum women.

You can find more information on Rebeca Segraves  at:

IG: @rebecasegraves_

X: @rebecasegraves

FB: @rebecasegraves

Linkedin: @rebecasegraves

00:28 Introduction to Rebeca Segraves and Her Mission

00:53 The Journey to Women's Health Physical Therapy

01:48 Collaboration and Early Intervention at Duke

03:20 Expanding Early Recovery Programs Beyond Duke

04:57 The Importance of Education in Post-Surgery Recovery

12:30 Challenging Traditional Post-Delivery Care Practices

23:17 Scaling Up Birth Recovery Services

29:17 Advocacy and Future Directions 

Transcript

Okay. Hi, I'm here today with Rebeca Segraves. She is a physical therapist and a women's health advocate who believes that every woman deserves easy access to early and successful recovery from birth, pelvic surgery, and mastectomy. And she has done a lot of work in this space and I'm so excited to talk to her today.

Welcome. Thank you so much for having me, Dr. Sarah. How did you, how did, how did this happen? How did you get interested in pelvic floor physical therapy? Yeah, I did a residency at Duke, which was the first women's health physical therapy residency in the country. And that was in 2015. Uh, before then I thought I was on a path to neuro, um, physical therapy.

My mother had a stroke about three months before I started PT school and I absolutely loved everything about neuro. And after that, I couldn't treat someone without seeing her. And so I said, I had to pivot. Uh, neuro is not my future. Um, what else is there? And so I discovered, uh, pelvic health and women's health and a rotation in PT school and decided to apply to the residency at Duke.

And that completely changed my world. So that's really how I, how I got started in women's health physical therapy. When you were at Duke, did you work just with the physical therapists or was it more multidisciplinary? Did you work with the, they have a really strong urogynecology department there. Oh, that's, that's actually where I started.

So, uh, yeah. And Hillsborough was actually, um, Dr. Allison Whitener. I started to observe a few of her surgeries and then she started to see, you know, that, uh, there's a benefit to, To physical therapy, treating her patients before surgery and immediately after. And so I started, you know, working with Dr Kawasaki and just, you know, Anthony Visco, Tony Visco and just.

That whole team and they were really kind of the, the team that introduced me to this early intervention after pelvic surgery or women's health surgery because the urologist were already ahead at Duke. I was seeing men within 2 weeks of prostatectomy. I mean, they were already ahead of the game, but after hysterectomy, we weren't seeing women like that.

And so the male urologists were ahead of the game, but the urogyne team. Really allowed me to be in the surgery to observe, to talk with them and then see their patients before they even had surgery. So they were really, I felt like the future and then I've been trying to get back to the future ever since. 

Um, they're a pretty amazing team. I mean, that's a group that I know pretty well. Um, and they're, you know, great clinicians. They really care about, um, their patients and I think they're always looking to do things better. Right. And to kind of move forward. So you were doing this clinical work and you observed that women weren't getting, um, physical therapy around the time of hysterectomy.

And so then were you guys able to start that? Yeah. So I moved on from that residency. I started practicing at Mission Health in Asheville, North Carolina. And so what I learned at Duke is that we were actually seeing women after mastectomy within The first couple of weeks as well. And so what Duke kind of laid the foundation for me was physical therapy or rehab in general is normal after surgery.

It's normal after orthopedic surgery. So why not women's health surgery? And so we started these early programs after mastectomy, after hysterectomy, obviously after prostatectomy, men were getting physical therapy pretty early after their pelvic surgery. And the uphill battle began when I left residency.

Residency was like this very. Fairy world, right? Like, like all these great and even I was told by my residency mentor is that where you go from here, you're not going to see the same level of care. And I knew that going in and so what we did within two years of my residency is we started a program where every woman was offered rehab within two weeks of her mastectomy and within three weeks of a hysterectomy.

And that was more with oncology. And so we wanted to treat women before they actually had more radiation and chemo and other cancer treatments. So we really started with the oncology population and expanded it to other populations as well after pelvic surgery. And what's the benefit? I mean, what, what were women lacking?

Um, when, you know, we just operate and we say, you know, go home and heal. Um, what aren't they getting? Well, great question. I think it was more of the education of how to function. Um, women were still, uh, under the impression that they could do light activity like unloading or loading their dishwasher and doing laundry.

They weren't realizing the incredible pain that would cause. So a lot of it was just confusion and unraveling kind of the myth of what recovery actually was. And so, It was a lot of education around the two to three week mark to say, you, you're doing exactly what you're supposed to do. Rest really, truly is physical rest from a lot of things that use your core.

And here are ways that you can even do simple activities that you wouldn't think would actually cause a lot of. Um, really a lot of, uh, of energy. Um, and that would be just getting out of bed. I mean, people actually after C section I found were being readmitted to the hospital because their incision was separating just from getting out of bed and not having that hospital bed or rails at home.

And so a lot of it was just education and, and just making them feel, um, a lot more confident in their movement. That's so interesting. That's actually the example that I was going to give because, you know, I think it's interesting after surgery, how little things become very difficult, right? Like getting out of bed and how, you know, rolling to your side and then pushing up is so much easier, but not intuitive, right?

Because you're just used to getting out of bed the way you get out of bed and people don't realize how much they use their core. I mean, our surgeries hurt your core, and I don't think you realize how much you use your core until you're in that, in that predicament. Did it matter what type of hysterectomy somebody had?

I mean, would you advocate education and, um, teaching and physical therapy for any type of hysterectomy, whether it's done vaginally or through a big incision or laparoscopically? Yeah. So also great question. It was. 2018 where a patient about eight weeks after her hysterectomy just point blank asked me why wasn't I referred to you sooner and she would have been someone that we've really would have missed.

She had a vaginal hysterectomy, wasn't open and you know, we just weren't really thinking that those minimally invasive. Surgeries were really, um, would really benefit from an extra component of, of, of our interventions and we were completely wrong. And so what we started to do is just really analyze.

Well, if we were seeing men after prostatectomy, and these were not open procedures, um, Typically, why not offer that same education to women after hysterectomy, right? Same, you know, kind of scenario where it was done minimally invasive, but yet there's a lot internally that's still keeping them from.

Functioning at their best from performing really well. And so we just decided, okay, let's just offer this service to everyone and see where the chips fall. And we, we haven't had anyone. I mean, that program is still running to this day. Um, that said, this was a waste of my time. No one said that. Um, I. You know, a vaginal hysterectomy, you don't see the incision, right?

Because it's all internal, but it takes a lot of work to get the uterus out. And, and so it, you know, those women can have a lot of discomfort afterwards too. And especially if they're, it's someone who went into surgery. Um, You know, with some pelvic floor hypertonicity, right? It can, it can be just for a really difficult recovery.

Um, and yeah, it's just so interesting what we tell people and what we don't tell people. And then, you know, kind of the paradigm, like, you know, why are we sending men after prostatectomies and not sending women, right? That doesn't make any sense that you wouldn't. Kind of do that across the board. I'm sure you have lots of feelings about that.

Well, sure. I mean, I think honestly for men, I really started to question, is this really necessary? But there was no happening. Urology was just like, no, we need physical therapy for our patients. But in their case, I met so many men who had support at home. Someone was going to be cooking their meals.

Someone was going to be doing their laundry. They knew that they weren't going to be lifting the 5 to 10 pounds. But for women They were used to those roles and I hate to be so gender specific, but that was just the reality we were treating in North Carolina and we were treating within a four hour radius of Duke and then in Western North Carolina, same Appalachia was very just, uh, role specific that women were just so used to doing these light roles.

Household activities that were really not conducive to healing. Yeah. And so it made more sense to expand these services to them. But yet that was a floodgate that we couldn't handle on the physical therapy side. And so a lot of my work has been to train upstream. And even to see them before surgery. So they had the tools beforehand and they weren't in those situations without a lifeboat. 

It, it is hard to, um, get people to change kind of their habits and their roles at home. I mean, I spend a lot of time talking to people about how really I don't want you to vacuum and I know you think you have to vacuum, but somebody else is going to have to vacuum, right? And it's so part of their identity and their role and how they take care of their house.

And, you know, even if their husband is. Willing to do it asking. And, um, you know, I mean, there are just so many kind of social barriers that happen there. It's really, it's interesting, right? When you kind of break that down and talk to people there, I have to say, it's funny that you say that because I was in the room of a woman I treated after C section, this was when I moved from outpatient pelvic health practice into treating women after surgery in the hospital.

And that very example that you just said, a nurse. Was giving a patient discharge instructions after a C section. And she said, you know, you could do, um, dishes, light vacuuming. And I just, you know, like stop what I was doing. I'm not sure what I was doing at that point, but you know, it was a great conversation because I pulled the nurse aside and she had not given birth herself.

Neither had I, but I think she just said, Rebecca, I just was going down the list. This is what we tell every everyone. Yeah. I couldn't blame her, but it's also the information that people are getting. Before they even leave the hospital. Yeah, it's fascinating. I mean, I have lots of conversations with people about.

So what's your vacuum cleaner like? Are you going up and down steps? Are you carrying that? How heavy is that? Is it, you know, just one of those wall vacuums that you can plug in? You know, you don't want people to do nothing, um, but it's so important to kind of identify how you're using your body. And it's not like anyone's coming into your home and assessing those things.

Right. We really let people just go home and, and, and do things on their, on their own. Well, let's switch gears a little bit and talk about delivery. So, you know, traditionally what we do in the U S is we. Let people deliver. Most women deliver vaginally. They spend one night in the hospital. They go home the next day.

They follow up with their obstetrician in six weeks. Um, what's, what's wrong with that? What are we missing? Yeah. I mean, that's, that's a system based on equality, right? And we just know that, um, equality is not equity. That's not an equitable system. And so to offer a one visit at six weeks postpartum to everyone is really negating the differences that we all have, the unique experiences that we have.

And every birth is as unique as our fingerprint. And so when I teach people about equity, I'm teaching them in a way that brings in what, uh, dr Catherine Sylvester, she's a founder of operation myths. And she, she did this at a talk that we did, uh, this past February in Boston, where she had everyone stand up in the room and whether they were in heels.

Tennis shoes, you know, their physical therapy conference. So we had an array. She had everyone run in place  and she said, if I were to have you run in place, but not tell you to change your footwear, how would that feel across the room? You'd have different feelings, especially if you're in high heels like I am, she said, or if you're wearing tennis shoes, which someone could probably last a lot longer.

And so that idea of offering. One visit at six weeks postpartum to everyone. Well, that's a system based on equality. We know that that doesn't work any longer because a lot of people have different experiences, especially around the time they're giving birth and immediately postpartum, they have different.

environments they're going home to. Someone may have two parents and their spouse helping to take care of children and another person might be a single mom of several children. And so that one visit, it doesn't work. Um, simply, uh, in most physicians, I feel like are, are seeing that with their patient populations.

Um, And the one who taught me about post, uh, delivery care was actually Dr. Karin Fox. And she was the first physician in the largest medical center in the world, the Texas medical center to automatically order acute care physical therapy for her patients after cesarean hysterectomy. And then that. Um, quickly within six months grew to every patient after C section and she wanted every person to have a physical therapist assess what their home environment was like, uh, if they had stairs, uh, to navigate, if they were a single mom, if they had multiple children so that they could really determine, nah, this person might need more than one visit at six weeks postpartum.

Um,  So that's fascinating to me because that is so different than the standard of care, right? And I would tell you that as a urogynecologist, I think a lot about women after difficult vaginal deliveries, right? So people that have big lacerations, you know, people that have forceps deliveries, vacuums, needing additional care, needing pelvic floor physical therapy.

But I, I think Thinking about it after a cesarean is really advanced thinking, right? That that is really unique and and not something that is practiced in most places. But I think most people, most women could benefit from it, right? I mean, the ergonomics of having a baby and carrying the baby and the car seat and, you know, all of those things.

It's plus. Um, a major incision, you know, that, that can heal just fine on its own, but we could definitely make that a lot easier for women. Absolutely. I, not just an abdominal incision, but, uh, remember treating a climber and she was a professional climber. Her husband was in the room and her OBGYN had just walked out and said, you know, you had a large, Third degree laceration is just going to take a long time to heal. 

And we found out later she hadn't repaired her at the time of delivery. And so that was going to take. You know, subsequent, um, intervention from that point. And so this patient is in distress. And at that time we weren't really treating women after vaginal delivery, even after large degree perennial tears, we were really focused on the cesarean population and within that visit, we were able to get her to move and get into different positions because all she was doing was lying inside, lying in her fetal position, breastfeeding that way.

She, she wasn't actually told. It's better to be in a stretched out position. It's better to actually lie on your back or stretch or even gently put your, your feet or legs in a butterfly position that would actually allow that tissue to heal in a lengthened way. And so we even used, um, the example, I balled up my fist and I had her do the same.

And I said, this fetal position is the equivalent of how your pelvic floor is healing. One that gave her so much more confidence to it reduced her pain and three gave her more hope for the activities that she wanted to return to months down the road because she was a professional climber. And so even education to me, I.

I, I, I can't imagine waiting to tell her that at six weeks or even later, you know, to be honest with you, she would have seen her, her physician, her OBGYN first, and then they would have referred her to the health core PT. I couldn't imagine waiting that long to just give her that information right then and there in the hospital, because I'm thinking also about mental health.

Not just physical recovery. So I agree with you. And that's actually what I was thinking, too, right? People that are professional athletes, actually, so many people use exercise to control their mental health and to treat their mental health. And so when we remove those things, it, um, it is so difficult for them.

And, and I think a lot of times after. A vaginal delivery, you just know your body is working differently and not the way that you are used to it working and, and perhaps working poorly. So you know, you're doing a lot of education, you're guiding people through their delivery. I think it's nice for people to have touch points before they deliver, right?

So that they have an understanding of how everything works and, and are known to you. But are you also finding that people functionally do better? Yes, I do. It's a great is this is a great conversation because, um, we use the example of the bed and my personal example was actually having a family member that we didn't realize that after her C section, she was actually going home to a couch.

And my nephew calls me at four o'clock in the morning, frantic, because he Was able to get up and keep the baby's crib from falling over because she was using that to try to get up  and I realized  had she had been given a physical therapy eval, which we were advocating for, but the physicians were adamant.

We don't offer that here. Has she been given a physical therapy evaluation after her C section? I don't think that that would have happened. I don't think that she would have gone to try to use the baby's crib to get up. She would have been taught other ways to get out of bed and they would have worked with my nephew to help her, you know, especially if it's in the middle of the night, she has to go to the bathroom.

So in terms of functional like performance, I really do. I see birth, especially surgical birth, where there was a large perineal laceration. There was a tear that needed. Surgery interventions to, um, to, uh, heal, I think about those things in terms of just function. I have to look at it through a movement science lens is that when we allow someone education and practice and, um, you know, just intentional, um, Training on their performance.

They do better after any injury, after any trauma, after any event. And so what we're looking at birth, I think, um, we're looking at as like this natural event that everyone experiences. We're not actually looking at at it as surgery. You know, or injury or wound, um, healing that needs to occur. And I think that's kind of the, the change in the shift in thinking that I want to bring to the public is that this, this was a medical event and your function matters after that medical event.

Yeah, I think you're completely right. Right. We assume birth is natural and people go home and everything just magically heals. And. And the healing in that time is truly amazing. I mean, it is amazing what the female body can do and how much everything can stretch. And nobody really likes it when I say this, but birth is a huge trauma.

I mean, a huge trauma, no matter how that baby gets out, no matter how big that baby is. I mean, sometimes it's a bigger trauma than others, but it's always a huge trauma. And there is a lot of healing there. And it's also a part of the body that, um, Most people don't understand well, don't understand those muscles, don't understand how it's put together and it's, it's hard to assess, right?

It's not like hurting your arm, right? Where you can look at your arm and say, Oh yes, I hurt here. I see what's going on, right? I have a big cut. It, it  is really hard to know what's going on. So the, the big thing that I'm thinking about in, in what your, saying is how do you scale it? Giving this education and this home assessment to women before and after delivery.

I mean, I can see where that would be so important for so many people, but there's, there can't be enough physical therapists in the United States to do that. Definitely not even pelvic health, physical therapists, right? Right. So what we did with mastectomy, because that was a huge surgery, but nowhere near as much as cesarean section, right?

There's 1. 2 million cesarean sections performed. It's the most common surgery in the United States. And so what we did with mastectomy, we use the model of there's not enough lymphedema or oncology cancer trained therapist. We have to train our ortho therapists, our shoulder therapists, those guys that are used to seeing individuals after rotator cuff repair to treat this population.

And so what we did to scale birth recovery was to train acute care therapists who are already treating people after gallbladder surgery, after major intestinal surgery, after stomach cancer surgery, after liver surgery. And we said, here's a person. After C section, they had a major abdominal open surgery.

They're going to have to care for their newborn with which is an occupation. And they're going to be expending energy. A lot of them are not going to be offered a shower chair, like your patients to just sit while they're showering, they're going to actually have to stand and expend more energy. And we have the maternal health population that's not doing so well in the United States.

Yeah. So can we combine your training? With this population, and that's how we've been able to scale getting patients in the hospital seen after birth by a physical and occupational therapist. People really forget what that field does. And they're focused directly on self care, showering, uh, taking care of baby, um, meal prep, laundry, doing all those things that really are hard to do after a major surgery.

And that's really what we've been able to do is recognize there's not enough pelvic health physical therapists. So who else can we use on the team? And then can you talk to me about your enhanced recovery? And delivery course, what that is all about. Enhanced recovery after delivery was solely an extension.

It was meant to be an extension of enhanced recovery after surgery. And honestly, it was probably, um, I have to give her credit cause I'm speaking with her later on today, but Dr. Karn Fox, the maternal fetal medicine, a physician who automatically ordered a cesarean hysterectomy. She inspired me with her use of enhanced recovery after surgery protocols to reduce post op illness in her patients.

And so she was an early adopter of ERAS and I thought, well, that's phenomenal. She's prioritizing function and mobility after these major surgeries. Well, we could do that by adding physical therapy to the maternal care team as well. And so enhanced recovery after delivery was really an extension of the ERAS protocol of prioritizing mobility function early on and these postoperative patients.

So we really primarily focus on introducing rehab to the maternal care team after any delivery type and after any, um, definitely after any pelvic surgery at the time of birth. So cesarean hysterectomy as well. How much resistance do you get when you talk about this with a new team? I think a lot of it is more questions.

I don't even see it as resistance anymore. Um, because, you know, take for example, the heart of the health system nurses at first is very much like, well, you'll be doing my job. I do that already. And when they finally, like when they, when we sit down, we have a conversation and they realize, Oh, I don't practice stairs with my patients.

Well, I'm not necessarily teaching them the log roll. I'm sometimes too busy to teach them how to put on the abdominal binder. They are realizing, Oh my gosh, you're taking so much off my plate. You're helping my patients. My patients are actually happier and in less pain when you've. Treated them. And so what we're using occupational physical therapy as in the hospital system is as a tool to help other disciplines.

And so I think that's really the beauty of our service is it's not taking anything away. It's actually adding more time to the disciplines who are already there. Yeah, we're so used to how we do things in medicine, right? I think anytime there's a paradigm shift, it takes people a little bit of time to adapt to that.

I agree with you. I think nurses are the heart of the system and they always want what's best for the patient. And so once you kind of demonstrate that, you know, I think it is, um, You know, it becomes an easy win. I mean, you're making it sound like it's so easy. There have to be so many barriers to introducing that to the hospital.

And I mean, even just finding time to meet with the patient, right? Because there are so many other things that they're doing, you know, while they're in the hospital. Absolutely. The barriers that we're probably encountering the most are on our team, occupational and physical therapists. We are stretched thin as a, as a profession.

Um, and not many people realize what we do. And so I think that training these professionals to just say, listen, you have. A lot of range. Here is where you can save time and add a lot of benefit, um, to the team. That's been probably the most challenging, um, aspect because we're not taught about this population in PT and OT school.

Yeah. Like it's completely outside of our curriculums. Like we will go through stroke and musculoskeletal injuries and cardiovascular injuries and birth is just not there. You might have a day if you're lucky in some programs. Yeah. And so this population, the newness of it, the, um, mystery of it, I think really shakes them up a bit, but over time, I think we're going to change, um, the tides and really make maternal care as part of general practice for everyone to just be.

Able and willing and ready to provide services that really benefit someone who just gave birth. Yeah, I think it's such important work, right? And I think that, you know, when you see a young woman who just delivered, it's hard to think that they need additional care, right? You just see a young, healthy person, which is very different from someone who just had a stroke and the needs are clear, but it doesn't change that there is a need and that this is a really difficult transition in life.

So, So what's next for you? I mean, you started doing clinical care. Now you're creating these programs. You're advocating for women to, you know, facilitate their life journey. What's next on your plate? Yeah, I think the advocacy piece I haven't actually done, um, enough and my conferences, I realized they're actually changing to include those names that we're not saying publicly enough. 

And so when I spoke at the last conference, I did mention, um, in Boston at the, um, uh, combined sections meeting of the American physical therapy association. I, I said, and I spoke the name of Dr. Shanice Wallace, and she was an Indianapolis physician who died two days after her cesarean section. And I'm starting to speak these names because I realize.

It's a disservice to communities that are young women who were not, um, medically challenged at all before birth, uh, didn't have a lot of comorbidities. We're, we're rarely healthy dying before we even get to the six week mark. And so I think that it's just really important for me now to recognize that there are individuals who are not going to fit into the category of the individual who is going to be okay.

Just needs one visit at six weeks. They're not making it to their six weeks. And so my future, I think, is really an advocacy. And I think I'm going to be more intentional about that in the work that I do. I, I think those stories are always shocking, right? Because it's always, um, amazing young women, woman, right?

With a, just a horrible story. And it's, it's hard to put the pieces together about how the medical system failed that person. Absolutely. I'm hoping to change it to more of a positive that this is something we can do now before they even walk into the hospital. Yeah, I think it is more touches, right? And just being suspicious.

Sometimes young pregnant women or pregnant women, I guess I should just say we assume everything is going to be okay, right? And, and it, it is not always okay. And so I think there has to be, you have to be a little, um, suspicious at all points in time. There might be something else going on. So yeah, so that nothing is missed.

I think it's always better to double check everything a million times, right? And double check people who are actually fine so that you don't miss those people who really need additional care. I completely agree. We had a mom who was readmitted back to the hospital within three days of a spontaneous vaginal delivery.

She even said herself, I had no complications and she was diagnosed with acute Heart failure and postpartum preeclampsia, she had her mom and her mother in law and her husband there to watch all three Children. She had complete, you know, um, free range to rest and she still was readmitted. So we hear these stories of women who were, you know, sick or, you know, whatever the case, you know, had a lot of risk factors.

And then we see the Yeah. The opposite of that. And then we see women who are just doing fine who are athletes and who want to get back to their their their sport or their life or just want to be, you know, fully present and bonding with their Children. And I feel like at any point we can help any individual.

It really is up to them. It's not up to the medical system. And I think with enhanced recovery after delivery, we're advocating for people to just receive the education that they want and the options that they need. Um, in the end can choose for themselves. Well, and I think it is all about choice and patient need.

And, and sometimes it is so hard for patients to figure out where to plug in and where to get the care that they think they need, right. When something isn't quite right. So, yeah. Well, I applaud everything that you're doing. I love your work. I think, you know, the medical system is so much better when we all work together.

Because it's just amazing to me when I talk to someone who's in a different discipline, how you think about things a little bit differently and, and how much better we can make the system together. Completely agree. It's been a pleasure really talking with you today. Thank you for having me on. Yeah.

Thanks so much.