Birth, pelvic health, Pregnancy, Prolapse

Pregnancy After Prolapse – Pelvic Floor Physiotherapy

If you’ve read anything else on this blog you’ll know I am a massive advocate for pelvic floor/pelvic health/women’s health physiotherapy (or physical therapy as it’s called in the US). I believe ANY woman who has given birth, or is going to give birth can benefit from it, even if it is just a one-time assessment.

So obviously, I am not the exception to this recommendation. I’ve talked about my previous experience with PFPT as a postpartum woman and when dealing with my prolapse, but this is the first time I have seen one as a pregnant woman. I wasn’t quite sure what to expect, or even sure if I needed to go! I had seen some posts on Instagram from women I follow about seeing PFPT in their pregnancies (Brianna Battles & Michelle Coels of One Tough Mama) and wondered what their trigger was to actually book an appointment to see them. Then I finally got my head out of my own ass, and realized I am legitimately having symptoms that I would be telling my clients to go to physio for. I was having some minor leaks and heaviness, which in and of itself is enough to warrant physio, so I just got down of high horse, and booked an appointment.

I was a bit nervous. Was she going to think I was wasting her time? Was she going to just tell me everything I am feeling is normal and look at me like I’m an idiot? I know, irrational, but those were my fears. Luckily, the physio I saw was one of the nicest women I have ever met, and let’s be honest, I’ve never met a physio I didn’t like! She heard and validated my concerns, assured me that what I was feeling was common, but definitely not normal, and then we jumped right into an assessment.

She was so thorough, it made my nerd heart happy! She had me stand and felt my abs and glutes, she had me squat, then single leg squat on each leg, and me do side bends each way, then had me lay down and contract my TA and then coordinate that with movement. She assessed my diastasis and we discussed how to monitor that moving forward. She examined my PF muscles, and had me do some contractions and assessed where I was feeling pain, how my prolapse was doing and gave me some exercises to work on.

We discussed strategies to deal with my symptoms. One of which was some leaking, or stress urinary incontinence, which I had never experienced before I got pregnant the this time around. Even when I was full term with Bruce, I never leaked, nor did I postpartum. She mentioned bladder irritants, which I had heard of and discussed with the physician at the Pelvic Floor Clinic when I was diagnosed with prolapse. I knew they could contribute to frequency, but what I didn’t know is that they can also contribute to incontinence! The way she put it is, if your bladder is already irritated by certain foods, then when you add a cough or sneeze on top of it, you’re more prone to leaking! This totally made sense to me, because otherwise I could not find any sort of pattern or correlation to my leaking. It was so infrequent, and didn’t seem to relate to my activity level or even the fullness of my bladder when I put any pressure on it, but I hadn’t taken my diet into consideration! And after chatting with a few friends, they all corroborated these thoughts anecdotally.

We also discussed the strength of my muscles. She rated my PF muscle strength a 3+ out of 5, whereas previously I’d been a 4 out of 5. So I mean, considering I am 23 weeks pregnant, those tissues are so swollen and loosened because of relaxin, I’m pretty happy with a 3+! I mean, obviously, I’d love to be 5/5, but I gotta take what I can get! She gave me a few things to work on, and we found while the front half of my muscles were weaker, the back half was actually quite tight.

The we discussed preparation for labor & birth. She had some suggestions on positioning, like don’t lay flat on your back, which I mean, is kind of common knowledge these days, I think? Isn’t it? Or maybe that’s just for birth & pelvic health junkies like me! She suggested I try to squat or be on all 4s as much as possible and also encouraged me to avoid pushing using a crunching motion, which a lot of women get sucked into. She suggested I focus on keeping my arms up, at least shoulder height if not overhead with something to hold on to. She said this stops the crunching motion and allows the TA to aide pushing better. We discussed things like perineal massage and EPI-NO, but not in depth. Overall we both agreed that I am in a much better place going into this labour because I actually know how to relax my PF muscles, and that was probably what made my pushing experience so drawn out the first time. I remember feeling SO vulnerable when I actually did relax those muscles, and not feeling encouraged or well coached by my midwife when I did.

This is the #1 reason I suggest all first time moms (or any pregnant woman who hasn’t delivered vaginally, but wants to) see a PFPT in pregnancy! They will help you learn how to connect with those muscles and how to know what it feels like when you both contract AND relax those muscles, because relaxing them is key when it comes time to allow baby to pass through them.

Pregnancy After Prolapse (4)

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pelvic health, Pregnancy, Prolapse, Self Care

Pregnancy After Prolapse – The First Trimester

~Read where you left off here~

So the line was pink. I was officially pregnant. Again.

It happened so much faster than we had anticipated. It was no longer a debate of being ready, because ready or not, it was happening. One week after learning we were expecting our second little one, my husbands parents were scheduled to come for a visit. We debated whether or not to share the news, it was SO early after all, but we decided if this pregnancy ended prematurely, their support would be so needed, so we told them.

That just reinforced how great it was. They were ecstatic! Of course they were, what grandparents aren’t excited to learn they will be welcoming more grandchildren? I looked to my mother in law for support, my husband and his older brother are only 13 months apart after all. She reiterated what we already knew, it would be hard in the beginning, but so worth it. And we had planned it after all, it will all work out in the end!

Overall the first few weeks I felt pretty good. I still had energy, continued my workouts, and kept up with life. Things were great!

Then I was struck with vertigo.

I had cared for patients with vertigo, and knew it was awful, but I always thought they were over dramatic. But let me tell you, from first hand experience, it is all consuming. When you feel like the world around you is spinning, and closing your eyes just makes it worse, and you haven’t figured out what triggers it so it hits you randomly, it is hard. So hard. Even harder when you have a toddler to care for, and pregnancy nausea has hit. The vertigo was the worst in the morning, which, lucky for me, coincided with when I was feeling the most nauseated. The two just fed off each other and I felt awful. Caring for Nugget was even harder, because bending down or doing anything that required me moving my head out of vertical, set it off. Add that to nausea and it was a sure fire recipe for a trip to visit the porcelain throne. But I was lucky, after couple of weeks, it self-resolved. I didn’t really do much besides give into my salt cravings and drink as much water as I wanted.

But all the vomiting did a number on my core. The force required for that really puts some pressure on the pelvic floor, I now understand why some women leak when they throw up! I started having a lot of heaviness and discomfort. I freaked out. I was so worried that I was causing my prolapse to return and went to a pretty dark place. The combination of vertigo, with pelvic floor symptoms and exhaustion all added up to my headspace being all out of whack. I had a lot of very negative thoughts. There were many moments where I freaked out that I was damaging my body beyond repair. I even had really low moments where I hoped I would just miscarry so I could not worry about it anymore. I laid in bed crying, feeling like a terrible person and mother for wishing this very much planned, very much wanted, pregnancy away. The emotional turmoil you go through after being diagnosed with prolapse can really mess with you, and I didn’t realize how deeply, until then. It was like I was back to the day I was diagnosed, spiraling down a dark hole of ‘what ifs’, fearing I would never get out again.

I talked to some other moms they offered so much great support. They validated my feelings and helped me see what was really important – that I wanted this baby and I knew exactly what to do to get him or her here as safely as possible.

My symptoms waxed and waned over the next few weeks, and came to a peak around 11 weeks. I finally asked my prolapse support group, and they all suggested I talk to my pelvic floor physio. I mean, I knew I should, but I was in a bit of denial. I let my ego get the best of me, and thought I knew everything I possibly could, and there was nothing she could tell me that would help. But I emailed her anyway, and I am so glad I did. She replied quickly, and said it was totally normal to feel like that at the end of the first trimester. The uterus gets heavy, but has not come up above the pubic bone yet, so the entire weight of it is supported by the PF muscles. She reminded me to take it easy and it should pass, but to call her if I had any questions.

And she was right! Within a week, all my symptoms were gone! I even went on an 8 km hike up a mountain, and felt totally fine at the end and still the next day!

Then I was just tired.

So. So. Tired.

I never really noticed the exhaustion with Nugget, because I didn’t already have a kid and could sleep or nap whenever I wanted. Not the case when you have a 15 month old who gets up at 6 or 7 every morning. No sleeping in when you’re a parent, and even less so when your husband is working 6 or 7 days a week. This did not work out well with working nights. I work nights the majority of the time, and it was catching up with me. I started getting reflux to the point where I avoided eating because it felt like nothing ever left my stomach, I basically felt like my digestion came to a screeching halt. I started losing weight, which is the opposite of what you want to happen in pregnancy. Not to mention I was basically a zombie whenever I was not working. My poor toddler had the worst mom.

I talked to my midwife, and we agreed it would be best if I stopped working nights. I felt so guilty coming to that decision. I actually quite enjoy night shift! Plus, as a nurse, working nights is a bit of a badge of honor. I felt like I was being a baby by giving them up so early in my pregnancy, but I knew I had to do what was best for me and this baby.

It was like the clouds parted. I was finally sleeping at the same time every night, and sleeping through the night again. Before, with such a wonky sleep schedule, I was waking every couple hours because my body couldn’t figure out it’s rhythm. My reflux resolved, I had energy to exercise and play with Nugget again, and surprisingly my skin almost completely cleared up!

Moving into the second trimester, I finally started feeling like myself again.

Pregnancy After Prolapse (2)

Pregnancy, Prolapse

Pregnancy After Prolapse Series – Am I Ready?

This series of blog posts will follow my journey after healing my prolapse from my first birth, into my second pregnancy and beyond!

After I was diagnosed with my prolapse at 8 months postpartum with Nugget, I was devastated (you can read about that here). I thought my life was over and I wasn’t sure if I’d ever be prepared, physically, for another pregnancy and birth. I was terrified of picking up my baby out of the crib, never mind growing a second one!

Then I went to pelvic floor physiotherapy, and subsequently healed my prolapse. Then came rewiring my brain to actually accepting the thought that, maybe, I can have another baby. I mean, ever since I decided that kids were in the cards, I knew I wanted a lot of them! Like, 3 or even 4!

Before I was discharged from physio, I made sure to ask her thoughts on pregnancy, birth and postpartum. She had zero concerns with me getting pregnant again, gave me some great advice for labour and suggested I come back in for a check up at 6 weeks postpartum.

So, I had the go ahead from the professionals I trusted, but was I ready? Emotionally, I was SO ready. When I was pregnant with Nugget, my plan was to have him, then start trying for number 2 at 8 months postpartum, so they could be super close in age. Well, obviously, that didn’t happen. My husband wasn’t quite as antsy as I was to have babies right on top of each other, and I was still nervous about my body. I had felt betrayed and needed to learn to trust it again before taking on the challenge of pregnancy.

So I focused on getting strong. I started a new workout program, committed to working out every 2-3 days and for probably 2-3 months I stuck to it. I loved it. I was so happy with how my body felt, how my clothes fit, and how I felt in general. My body finally felt strong again. All of my muscles had blossomed, my core felt so supportive, and I was finally feeling like myself again.

I was ready. My body felt ready. My husband was ready.

It was time.

It took 9 months to conceive Nugget, so even though I was ready to start trying, I had absolutely no expectations for it to happen anytime soon. I was okay with that, prepared for a long road ahead.

Still, I did all the things. I peed on sticks. I took prenatal vitamins. I tracked my basal body temperature. I even tracked my mucous.

But even then, with perfect timing, most couples only have a chance of conception of 20% for any given cycle. Like I said, prepared for a long road.

We didn’t want to put our life on hold to have another baby, so we kept living it. We used the hot tub, we drank our fair share of wine, beer and coffee, we didn’t change our diet or exercise regimes. We just lived our lives.

I was so prepared for it take months to happen. After all, it had the first time, and nothing had changed in that department, as far as we knew, besides being a couple years older.

And then, two months in, it happened.

The line turned pink. The stick flashed ‘pregnant’.

Next thing we knew, we were preparing to be the parents of two under two.

{continued here}

Pregnancy After Prolapse

 

fitness, pelvic health, postpartum, Pregnancy

Pregnancy is Temporary, but Your Choices Last Forever

Being avidly interested in perinatal fitness & a new mom myself, I come across a lot of advertising and social media posts about exercise in pregnancy and postpartum. I often find myself scrolling through the comments to see what the general consensus is on the latest (usually controversial) video or message is.

One comment that almost always crops up is:

“I did crossfit/ran marathons/did crunches/did what I always did when I was pregnant and my baby turned out perfectly fine”

And all I can think is you just don’t get it!

While there are definitely recommendations for exercise in pregnancy circled around maintaining baby’s health, Mom’s health is just as important!

(I know, groundbreaking stuff, right?)

When I (and many other well-educated fitness professionals) say maybe it isn’t the best idea to do crunches, or run long distances, or lift super heavy, I’m not saying this because I think you are putting your baby’s health at risk. I am saying these things because you are putting yourself, your body and your future function at risk!

Yes, you can powerlift (or sprint, or do jumping jacks, or whatever) when pregnant, and baby will probably be fine, and it might feel okay for you at the time, but should you? Probably not.

Something one of my idols in the fitness industry, Brianna Battles says regularly about exercise in pregnancy is:

Just because you CAN, doesn’t mean you SHOULD.
~Brianna Battles, Everyday Battles

It all circles back around to training with intention. When pregnant, a lot of women fear losing themselves when the baby comes (I know I did. I so did!) so they try to keep doing what they’ve always done and enjoyed through their pregnancy, as if to prove to themselves that they are the same! But, as much as you are the same, you are so not the same during (and after) pregnancy. You are growing a human! That is a big-freakin-deal! You need to respect that. You need to surrender yourself to the fact that as important your personal goals are, the priority should be keeping your body healthy and strong in this (so very short) chapter of your life.

There are so many more factors at play in the perinatal period when it comes to exercise and fitness. Hormones influence your connective tissues. A growing uterus influences center of gravity, balance and movement patterns. Diastasis recti influences core function and strength. The weight of baby on the pelvic floor influences it’s ability to respond appropriately (hello, pee sneeze – not normal!). So we need to take all of these things (and more) into account when training in pregnancy.

Yes, we can program exercise along the same lines you are used to and enjoy, they just might look a little different. The how of exercise is often more important than the exercise itself. It’s about strategy rather than just do’s and don’ts. If you follow Brianna (mentioned above) Jennifer Cambpell of Mama Lion Strong & Healthy Habits Happy Moms, or Jessie Mundell, or Julie Wiebe or Katy Bowman, they all preach ‘ribs over hips’ and keeping your ribs, spine and pelvis neutral.

[Side note: I would be literally nowhere if it wasn’t for all I have learned from following these amazing women and for their trail blazing in this field]

So, can you complete a heavy overhead press while 30 weeks pregnant? Yes. Okay, but can you do it while maintaining your ribs over hips, without your diastasis bulging, and without holding your breath? No. Then that exercise isn’t the best choice for you in this chapter of your life. If you say you are just going to do it because it feels fine to you, my next question is why? What is the value of continuing to do an exercise that maybe isn’t the best for your body at this point? Is it because you think you should be able to do it? Is it because you’ve seen other pregnant women do it and you want to look ‘badass’ like they did? Is it because you’re afraid of looking like a weakling or a failure who didn’t have the guts to go for it? Take a look inside yourself, and analyze why you feel you need to do a specific exercise or program. Is it worth the risk? Spoiler alert: putting your glory ahead of your future function is not badass and doesn’t take guts. You know what takes guts? Putting yourself first. Saying no when someone challenges you. Looking within yourself and standing up for your own values. That’s badass. That takes guts. Going with the flow because everyone is doing it, that’s cowardly. Having the courage to stand out on your own is the pinnacle of strength.

Now I’m not saying you can never do your favourite not-so-ideal-in-pregnancy exercise again. That is definitely something you can return to. However, it’s something you need to work up to, and be mindful of how your body is functioning, and be ready to maybe take two steps forward and one (or two or three) steps back along the way. It’s about checking the ego, and respecting where your body is at during this very important period and allowing yourself to surrender to it. This chapter in your life is temporary. Eventually it will end, but the choices you make within it can have lasting consequences if you aren’t smart about it. In closing, I’d like to bring it back around to another quote from Brianna;

Pregnancy is temporary, Postpartum is forever.
~Brianna Battles, Everyday Battles

Try not to forget that, because your body won’t.

having-the-courage-to-stand-out-on-your-own-is-the-pinnacle-of-strength

Birth, pelvic health, postpartum, Prolapse

How I Healed my Prolapse (Part 3)

Continued from Part 1 & Part 2

After seeing Kristen, I felt so much better. I wasn’t worried about picking up and carrying Nugget around, I wasn’t worried about carrying laundry up from the basement or hauling in groceries. I was able to actually live my life.

I started doing the ab work Kristen suggested, and I was absolutely astounded at how effective they were! Who knew such tiny movements like lifting your foot off the ground could have such a dramatic effect. The first day I did the exercise for a total of 6 reps. I know, barely anything, but I wasn’t able to maintain proper technique after 6 so I stopped. The next day I was blown away by how sore I was. We went grocery shopping and I was waddling around like I was 9 months pregnant because my TA was so sore! It was a total lightbulb moment for me. It made me realize just how much your TA functions in supporting your pelvis and trunk through every day movements, like walking! It made me understand further how diastasis recti can influence your movement and why it is so important to keep it in check if you have one.

I did the PF progressions she suggested. I was surprised to hear she suggested going PF contractions with a full bladder, but if you think about it, that’s like an internal load on your PF, and it’s like adding plates to the barbell! I was able to get even more in tune with my body, and really feel how and when my PF was contracting and monitor the forces at work.

I went back to see Kristen a month after our initial appointment feeling great. I informed her that a lot of my symptoms had subsided and other were explainable by reasons besides prolapse. She laughed “well you can go home now!” she said, jokingly, but I probably could have. She reassesed my abs, alignment and PF. After she was all done she said “Well you’re boring! There isn’t much going on here! Your PF is strong and contracting reactively and is well coordinated with your TA. Your anterior wall is ‘stretchy’ but I wouldn’t say you have a prolapse!”

I wanted to cry, again. But this time tears of joy.

But I hesitated. I was worried. Nugget was my first baby and I definitely had plans of having more, and hopefully sooner rather than later. So I asked Kristen what to do. I was nervous another labour and birth would do even more damage. Should I come see her in pregnancy? How does she recommend labouring and pushing from the perspective of a PT? Can I prevent prolapse with future babies?

So many questions.

We had a lengthy discussion about labour, pushing and delivery. It was so nice to talk to someone openly about birth who was about the function and physiology of the female body, and she gave me tools to go into my next pregnancy & birth feeling strong and confident.

And that’s how I want you to feel. Strong & Confident

Not broken, or fragile, or sad or depressed.

Strong.

We are all strong, we just need to see it within ourselves.

Now if you have read this series of blogs, hoping for a how-to list of things to do to heal your prolapse, I am sorry that I didn’t deliver.

However, I will give you this one To Do.

Find a pelvic floor physiotherapist. A good one. One that supports your goals and lifestyle. Not all physios are as open and supportive as Kristen, and you don’t have to accept that. If your physio refuses to give you progressions, or only tells you your options are to swim and walk, never lift anything over 5lbs (that’s realistic) and never spread your feet wider than hip width, find a new physio. There are good ones out there. If you don’t leave your appointment feeling confident you know how to live your life without fear and anxiety, you need a new physio. They should support your goals, not crush them.

 

how-i-1

Birth, pelvic health, Pregnancy

Hold Your Breath, Count to 10, Push Your Baby out, and Your Uterus too

Have you ever heard the term ‘Purple Pushing’?

I hadn’t either, until after I was diagnosed with a grade 2 cystocele (bladder prolapse) and a grade 1 uterine prolapse.

You read that right ladies, all that preaching I’ve been doing about being safe to prevent prolapse, well it didn’t save me.

And I’m about 99% sure I know exactly why.

Two and a half plus hours of ‘purple pushing’. Now the details of the pushing phase are a little foggy in my memory, probably due to the extreme fatigue I was hitting by that point. But I do remember on more than one occasion, grunting through a push and my midwife telling me to stop ‘pushing into my throat’… READ: shut up and bear down. Well when you bear down like that, you’re not only pushing your baby out, you’re pushing everything out. It’s really a matter of what gives first.

And you’re thinking ‘So what? Isn’t that what we’re supposed to do? That’s how it is in the movies, and on TV and in every birthing video ever

Nope. The research says otherwise. Actually, current UK & Canadian recommendations advise against directed pushing. Directed pushing is when the midwife or OB tells the woman when and how to push, usually at the beginning, middle and end of a contraction (that’s right, 3 full body, everything you’ve got pushes per 1 minute contraction) while they count to ten and you turn purple in the face (hence purple pushing).

I remember my midwife telling me 2 pushes per contraction wasn’t good enough. I remember thinking there was absolutely no way I had it in me to put that much effort in, 3 times, every couple of minutes. No wonder I was passing out between contractions by the time we transferred to the hospital. It just didn’t feel right. It felt forced, and painful, and wrong. Birth shouldn’t feel like you’re working against your body. It should feel like your body is doing this amazing thing and you’re kind of just along for the ride and helping out a little, which is what it had felt like for me up until that point!

The fact is that pushing like this not only is exhausting, it is not effective, it is damaging your body and sometimes can increase the risk for your baby to go into distress before they are out.

Boy can I speak to how exhausting it can be to push like that. It is essentially flexing every muscle in your body, while holding your breath, for 10 or so seconds, 2-3 times in a row, every 2-5 minutes. For those of you who’ve been through it, you feel me. For those of you who haven’t, imagine doing a 1 rep max squat, 3 times in a row. Not fun. This has also been found in the research, the effectiveness of the maternal muscles in contracting effectively to push out the baby is related to how frequently they are asked to contract. So if you contract 3 times per minute, rather than once, the muscle contraction gets progressively less effective, decreasing the efficiency of the push.

If a woman is allowed to push spontaneously when birthing (i.e. when she feels she needs to), it has been found that she instinctively pushes with the peak of the contract, once per contraction, thereby maximizing the efficiency of the push and making the most of the effort she is putting in voluntarily (if you can call it that). If you triple that effort, without any marked increase in effectiveness, it is possible the woman may become physically exhausted, before the baby is born, increasing the likelihood of an instrumental delivery.

This is exactly what happened to me. I was SO tired, and we intended on going to the hospital to use a vacuum to assist. So we took a break from ‘coached’ pushing, I was basically left to push voluntarily for about 10-15 minutes during the transfer, and I believe that, coupled with the moving around required to get to the hospital, helped Nugget get to the point where we didn’t need a vacuum after all.

I also believe that pushing like this is what has caused my prolapse. You see any time you bear down (think actively pushing out a poop, sorry if that’s too vivid for some, but I think we’re way past that if you’ve read this far!) you are putting pressure on your pelvic floor. The act of bearing down creates tension in the diaphragm, core muscles and directs all of the pressure created in your abdomen downwards, onto, you guessed it, your pelvic floor and all of those lovely organs sitting on top of it. So if you think, 3 pushes per contraction instead of one, thats 3x the amount of pressure placed on all of those muscles and organs. No wonder 50% of women who have given birth vaginally are estimated to have some degree of prolapse!

This act of holding your breath and pushing also increases the risk of harm to the baby. Let’s think about this logically: when you hold your breath, you are not taking in oxygen. Now, sitting on the couch doing nothing and holding your breath for 10 seconds probably isn’t a big deal. But when you’re literally flexing every muscle in your body and also you are the only source of oxygen for another human currently contained within your body, you are consuming oxygen at a much higher rate. And if there is less oxygen circulating in the mother, there is less oxygen getting delivered to the baby. There is even evidence that bearing down for more than 5 seconds can cause late-decelerations in the baby’s heart beat, often a precursor to an emergency c-section.

So why are we still holding on to the era of ‘we must actively push the baby out’? There are a lot of reasons. The medicalization of childbirth, where it is made to be the most convenient for the doctor, woman on her back, with an epidural working against gravity. Another is our bodies are no longer the bodies of ‘natural’ humans. We no longer hunt & gather, walk miles and miles each day, squat to forage and toilet. Our musculature is different than that of our ancestors due to the vastly different environment we live in. More often than not, we hold a lot of tension in our pelvic floor muscles, and those interfere with childbirth, especially when we are tense and scared of the event at hand. But if we were to take care of all of those variables, the fact is we wouldn’t have to actively push at all to give birth. Do you see elephants and lions and any other mammal that has a uterus holding their breath and grunting on those nature shows? No. 99% of the time the baby animals literally just fall out of the mother, after the uterus does all the work!

This is why we have to take care of ourselves in pregnancy, be educated about our rights and options, and choose healthcare providers that align with our goals and intentions. We have to be our own advocates and stand up (both literally and figuratively in this case) for what we know is right! We have to listen to our bodies, and I mean really listen. We have to get to know them in great detail, know every sensation, what is normal and what isn’t. That way when big events like this come along, we are prepared to work with our bodies instead of against them.

And above all, Squat!

Just keep squatting everyone.

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