Though the topics are gaining more traction in the fitness and CrossFit communities, there is still a lot of misinformation out there regarding safe training during and after pregnancy. For this piece I have paired up with my friend and colleague Dr. Rachel Kilgore of Flow Rehab to address these issues.
We have collaborated to write this series for women who are feeling overwhelmed by conflicting information. The goal was to use our different backgrounds to best serve this patient population.
In short, we went to PT school together, graduating in 2007 from the University of Washington with our doctorates in Physical Therapy. We both now work in cash-practices which have specialized focuses. Flow Rehab is a clinic which emphasizes treatment of both orthopedic conditions as well as women’s health. At Arrow Physical Therapy, we focus mostly on rehab for the CrossFit and weightlifting patients as well as the hip impingement population.
In this 3-part series on exercise during and after pregnancy we will address 3 main topics for fitness athletes:
Physical changes during and after pregnancy: PART ONE (BELOW)
Ways to modify exercise during pregnancy & why this is important: PART TWO
Safely returning to strengthening after baby: PART THREE
Physical Changes During and After Pregnancy: Part 1
How do I know which exercises are safe after I have a baby??
The answer is simple… “it depends!” If only there was a cookie cutter set of appropriate exercises to give patients after they had a baby that would achieve great strength, the coveted flat tummy, and no urinary leakage in a few minutes a day! The hurdle to this dream set of exercises lies in the fact that we are all different. We have different levels of strength to begin with, our connective tissues are genetically different (some people have more rigid tissue and some more stretchy), and no pregnancy or delivery journey is the same. Therefore, we may all need different exercises to achieve our individual goals.
Why does it matter? Why is it an issue?
Following pregnancy, your body has been through many physiological changes that increase your likelihood of suffering from low back or pelvic pain, urinary leakage, pelvic organ prolapses, and Diastasis Recti Abdominis. Therefore, completing exercise and strength training incorrectly can lead to several health problems involving your abdominal muscles, back and pelvic floor muscles.
What physical changes can occur DURING MY PREGNANCY?
Low Back Pain:
Following pregnancy, you might suffer from low back pain or pelvic girdle pain (pain in the front of your pelvic bones or in the back of your pelvis at your SI joints). Pain here is common during pregnancy with research stating that 45% of women experience this during pregnancy, 25% experience it after pregnancy and 5-8% have pain in this area which is persistent. (1)
During pregnancy the abdominal and pelvic muscles are lengthened, which can weaken them. Also, the center of mass changes when the belly is growing and this makes us move differently and use our muscles differently (either too much, “overactive” or not enough, “weak”) with our daily postures and movements and also with exercise. Low back pain can make it difficult to complete daily tasks around the home or at work. It can be painful and hard to lift and hold your new baby, and can be a barrier to exercising and strengthening after having a baby.
Urinary incontinence occurs when the pelvic floor muscles are too weak or overworked to hold back urine. Leaking will also happen if the pressure exerted through the abdomen is too great for the pelvic muscles to hold the urine, as when people hold their breath with lifting (known as a Valsalva maneuver).
Urinary incontinence can lead to skin irritation or infections around the perineum, it can be a barrier for some people to getting out in the community due to embarrassment, depression, reduced quality of life, or can prevent people from running or completing exercise or strengthening that they enjoy. During the last trimester about 45% of women who have only had one child reported urinary leakage and 85% of women who had had more than one child had urinary incontinence during the last trimester of pregnancy. (2) Of those women, 44% continued to having urinary leakage 5 years later. (3) 92% of women who have urinary leakage at 12 weeks after giving birth will continue to have leakage 5 years later if they do not seek help for the issue. (4)
Pelvic Organ Prolapse:
Pelvic organ prolapse is when a pelvic organ such as your bladder, rectum, uterus, or intestines is pushed down into the vagina.
Up to 50% of women have pelvic organ prolapse after giving birth. (5) This can happen when muscles and supportive connective tissue in the pelvic region are weakened or overly stretched due to childbirth, poor lifting habits (holding your breath, more on that later) or surgery. People who have this condition usually feel discomfort, heaviness, pressure or pain in the pelvic region. Prolapse can make daily activities, exercise and sex difficult or uncomfortable.
Diastasis Recti Abdominis
“Diastasis” means separation, and “Recti” refers to the outermost abdominal muscles: the Recti Abdominis. You have one rectus muscle on the right and one on the left; they are held together with connective tissue (this is your “six pack”).
The connective tissue holding these two muscles together is called the “linea alba,” meaning, white line. When you are pregnant that same connective tissue is called the “linea nigra,” meaning, black line. The color change is due to hormonal changes occurring with pregnancy. This tissue becomes very stretched during pregnancy as your abdomen grows.
Mota et al reports 100% of women at 35 weeks into their pregnancy have Diastasis Recti and that separation persists at 6 months after giving birth. (6)
Diastasis Recti can continue longer than 6 months and can lead to pelvic pain and pelvic floor muscle dysfunctions such as pain with sex, urinary or fecal incontinence, constipation, back pain, and poor posture. “Poor posture” can make one still “look pregnant” and can lead to other limitations such as neck and midback pain. Most importantly, this lack of stability in the abdomen can impact trunk and core strength and mobility. In extreme cases it can lead to herniation of the intestines or other organs resulting in surgery. (7)
In addition to Rachel and myself, there are some fabulous resources out there putting out blog posts, social media posts and lots of encouragement. See the list at the end of PART THREE of this blog. In particular, I want to highlight the risk of Diastisis Recti with my CrossFit athletes and point them toward these resources. This is so common in our population because of the kipping, overhead work, breathing patterns, abdominal strengthening exercises we do and tight muscles we see in the athletes pre-pregnancy.
Again, as stated, after pregnancy, your body has been through many physiological changes.
As physical therapists we would liken pregnancy to any other injury that you might need to rehabilitate from. Of course you get an amazing prize for this one!!
In our next two posts we will discuss how to limit your chances of these pregnancy-related limitations through:
Modifying exercise when pregnant
Safely returning to exercise after baby
1) Wu, W. H., Meijer, O. G., Uegaki, K., Mens, J. M. A., Van Dieen, J. H., Wuisman, P. I. J. M., & Östgaard, H. C. (2004). Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal, 13(7), 575-589.
2) Mørkved, S., Bø, K., Schei, B., & Salvesen, K. Å. (2003). Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial. Obstetrics & Gynecology, 101(2), 313-319.
3) Wilson, P. D., Herbison, P., Glazener, C., McGee, M., & MacArthur, C. (2002). Obstetric practice and urinary incontinence 5-7 years after delivery. Neurourology and Urodynamics, 21(4), 5-5.
4) Viktrup, L., & Lose, G. (2001). The risk of stress incontinence 5 years after first delivery. American Journal of Obstetrics & Gynecology, 185(1), 82-87.
5) Hagen, S., & Stark, D. (2011). Conservative prevention and management of pelvic organ prolapse in women. The Cochrane Library.
6) Mota, P. G. F. D. (2014). Morphological and functional adaptations of the abdominal wall during pregnancy and in the postpartum period.
7) Lee, D. (2017). Diastasis Rectus Abdominis. Surrey: Diane Lee.