The Barbell Mamas Podcast | Pregnancy, Postpartum, Pelvic Health
The times are changing and moms have athletic goals, want to exercise at high-intensity or lift heavy weights, and want to be able to continue with their exercise routines during pregnancy, after baby and with healthcare providers that support them along the way.
In this podcast, we are going to bring you up-to-date health and fitness information about all topics in women's health with a special lens of exercise. With standalone episodes and special guests, we hope to help you feel prepared and supported in your motherhood or pelvic health journey.
The Barbell Mamas Podcast | Pregnancy, Postpartum, Pelvic Health
Reframing Pelvic Floor Research
Groundbreaking research is reshaping what we know about pelvic health for active women. This episode dives into three significant developments that challenge conventional wisdom about incontinence, pregnancy exercise, and pelvic organ prolapse.
The first revelation? Athletes who experience leaking during exercise actually have stronger pelvic floors, not weaker ones as previously thought. Recent studies from both strength athletes and endurance runners confirm this surprising finding. The real culprits appear to be coordination deficits (the pelvic floor contracting too late during impact) and weak gluteal muscles that fail to properly support the pelvic floor system. This suggests we need to move beyond simple Kegels to address the entire core system.
Equally exciting is new research examining highly active pregnant women who exercise more than 300 minutes weekly in their third trimester. These women experience fewer delivery complications than less active counterparts, though they show slightly higher rates of diastasis recti postpartum. Rather than recommending exercise reduction, we should focus on strengthening these athletes' core muscles and considering external support options to help them safely maintain their preferred activity levels.
Perhaps most transformative is the medical community's reconsideration of pelvic organ prolapse definitions. With up to 50% of women having anatomical findings that would classify as prolapse but only 3-8% experiencing symptoms, we're questioning whether we're pathologizing normal anatomy. The vagina naturally moves and shifts throughout the day—it's not a rigid structure. Current assessment methods don't reflect real-world function, creating unnecessary fear for many women.
These research developments collectively signal a more sophisticated approach to pelvic health—one that considers coordination, functional movement patterns, and individual variability rather than simplistic strength-focused solutions. For active women navigating motherhood, this evolution promises more effective support with fewer unnecessary restrictions.
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Hello everyone and welcome to the Barbell Mamas podcast. My name is Christina Previtt. I'm a pelvic floor physical therapist, researcher in exercise and pregnancy, and a mom of two who has competed in CrossFit, powerlifting or weightlifting, pregnant, postpartum or both. In this podcast, we want to talk about the realities of being a mom who loves to exercise, whether you're a recreational exerciser or an athlete. We want to talk about all of the things that we go through as females, going into this motherhood journey. We're going to talk about fertility, pregnancy and postpartum topics that are relevant to the active individual. While I am a pelvic floor physical therapist, I am not your pelvic floor physical therapist and know that this podcast does not substitute medical advice. All right, come along for this journey with us while we navigate motherhood together, and I can't wait to get started. Hello everyone and welcome to the Barbell Mamas podcast. Christina Previtt here.
Speaker 1:I hope that you all are staying cool in the heat. It's funny. I taught a pelvic health course this weekend and I was in Montana and everybody at home in Ontario was talking about how stinking hot it was and we were in this big heat wave and I was like here for that because we had such a cold spring and then I go to Montana and it's like 35 degrees Fahrenheit, approaching zero in the degree Celsius in the nighttime and and I was like what just happened, why am I back in the cold? I feel like I brought my Canadian cold with me to Montana. But I hope you all are staying nice and cool and you are trying to get outside when it's not too too hot.
Speaker 1:Today's episode I thought that this is going to kind of be a little bit random in that I'm going to be talking about three different topics, because I wanted to talk about three big areas in research that I'm starting to see new evidence emerging that is starting to reframe even more or change the way I'm starting to think or give us evidence for what I've kind of been seeing in clinical practice around the pelvic floor. So the three things that I wanted to talk about was one about athletes that leak having stronger pelvic floors. The second topic we're going to touch on today is a new study that came out for women who are exercising more than 300 minutes per week around having lower delivery rate complications but higher rates of DRA. So like what the heck's going on? And then three is new commentary that's coming out of our MD researchers. That's talking about revising our definition of what pelvic organ prolapse is, and I am super on board with this.
Speaker 1:Let's kind of go through all of these different topic areas and do kind of just like this fireside chat about new things that we're seeing coming into the evidence. The first one is maybe it isn't about pelvic floor strength at all in our new and emerging evidence that athletes that are having incontinence have stronger pelvic floors. It is no surprise if you are an athlete yourself or you work with athletes as a coach, as a therapist, as a physician, whatever that. Our rates of incontinence in female athletes is outrageous Across almost all especially high load, high speed and high impact, fatigue, training or sports. Our rates of pelvic floor issues specifically usually leaking is what people are talking about is between 30 and 50%, and that is whether you have given birth or not. This is our college-aged adolescent women and females that are leaking with sport. Then we have mamas, get pregnant, postpartum, etc. And some of those risks go up because of the stretch injury that happens to the pelvic floor during a vaginal delivery and because of what we have talked about with pelvic floor muscle training being Kegels or strengthening. There's a general consensus or idea that athletes that are leaking have weaker pelvic floors and need to strengthen their pelvic floor in order to fix their pelvic floor problem.
Speaker 1:Over the last couple of years, there's a couple of things that we are starting to see in the research and there's a couple of reframes that I think needs to trickle down into how we are talking about things on social media. The first thing is our definition on what pelvic floor muscle training is. When I am thinking about training a muscle and I'm kind of going to filter this through the pelvic floor we want our muscles to be able to go through a full range of motion. We want to be able to strengthen that muscle, we want to be able to relax that muscle and we need that muscle to be firing at the right time, at the right intensity to meet the demand that we are asking of it. Right, if you have a shoulder injury, we're going to try and make sure you get your full range of motion back, that you can contract that muscle and that, if you're holding too much tension, you can relax that muscle.
Speaker 1:In our research on pelvic floor muscle training, the first thing that I think is really important for us to put our eyeballs on is the fact that we have talked almost exclusively about strength training, kegels, three by 10 prescriptions, et cetera, but our evidence actually isn't backing that up, especially in our active people. And so it's interesting because we have research now from 2018 in our strength training athletes, or strength athletes, that those athletes that have incontinence have a stronger squeeze pressure or a stronger contraction of their pelvic floor than our athletes that do not have incontinence. In the last year we are seeing the same thing in our endurance runners. So our endurance runners with incontinence also have stronger squeeze pressures or maximum voluntary contractions, depending on how you're reporting it, than our continent runners are. That kind of gives you like a head scratcher, right, like okay, well then, why is everybody telling us that we need to be contracting our pelvic floors and is that actually going to help?
Speaker 1:And again, in the last couple of months, kari Bowe and Christine Skog out of Norway just posted a very big randomized control trial that was looking at weightlifters, powerlifters and crossfitters who had incontinence and they got them doing a 16-week pelvic floor muscle training program and they saw that the group that was doing pelvic floor muscle training saw like a one point change on an outcome measure around incontinence compared to the control group, and what that means is that was not. It was statistically significant, but it wasn't clinically relevant. And what that means is is that, yes, on our statistics there was a difference between groups, but the amount of change on the outcome measure doesn't usually relate to athletes saying, yes, my incontinence is better. Now, I wouldn't have expected that to be different. Right, because it makes. Where we have gone wrong as researchers and then as clinicians, is that we have focused so much on the squeeze and not enough around the system that helps to facilitate it. So what do I mean by that?
Speaker 1:When we are thinking about pelvic floor and we are thinking about moving our bodies intentionally, especially with effort, we are oftentimes talking about this core canister right, the coordination of the pelvic floor, abdominal wall, chest wall and spine muscles, and how we need your core to contract together at the right intensity and at the right time in order for you to generate pressure in your belly that allows you to move your limbs, whether that is to run, to play, to lift something heavy. That is what we are trying to do. Where we need to go now is to kind of think a bit broader and zoom out, and so that is starting to happen, especially in our endurance research, and so some of Shefali Christopher's work and some of Nicole Ron's work is now looking okay. If it's not the pelvic floor, the strength of the pelvic floor, what is it? And what we are starting to see is a couple of things.
Speaker 1:One, there is a coordination issue, and I'm seeing this in our strength training athletes, and I'm definitely starting to see this in our runners too, where we see in some athletes that the pelvic floor contracts too late, and the best comparison I can make is when you pee, when you sneeze, when you are about to sneeze so many times as you are sneezing, people trying to contract their pelvic floor, and the problem with that is that it's oftentimes too late. And so we will do an education around a technique called the NAC, which essentially is that you squeeze before you sneeze. The reason why is because the pelvic floor has to be closed before you sneeze and generate that pressure in your belly so that it can keep your holes closed when that pressure comes on when you sneeze. And so what? Our new research on incontinence with impact and jumping and running is showing that there's a delay. Now, that delay is not something that we're going to be able to voluntarily control like we could with a sneeze right, like I can't, every time my foot strikes the ground when I'm running, think about doing contractions or squeezes of my pelvic floor. But I can start working on some of my coordination with something like bracing, which is what we do with our strength training athletes, to make sure that I'm not putting too much pressure down on my pelvic floor so that I can allow my pelvic floor to contract and relax as it needs to across something that's really repetitive, like running or jumping or jump rope. The second thing that we're seeing. So there's this coordination component, which we clean up with making sure that you aren't pushing down into your pelvic floor as you are bracing. The second thing that we're starting to see is that the butt muscles of our incontinent runners is less than our runners that have continence, and we're seeing this in two areas of the research Our non-pregnant research and just seeing in general what are some of the differences.
Speaker 1:And so what you want to think about is our butt muscles are like the support beams of our pelvic floor. That's like the trampoline right. So when we are thinking about our inner abdominal pressure, we're generating pressure in our belly so that we can run, play, jump, sneeze, cough, vomit, et cetera. Our pelvic floor contracts and also accepts that pressure. So that's why you see that little bit of downward movement when pressure is higher in the belly. That's not bad, except if it's excessive. But it's going to accept that weight. And then our butt muscles are like the support beams of that trampoline. So we have our two support beams and then the pelvic floor is kind of nestled between them, and if the support beams are not strong enough or not taut enough in this analogy, it makes it difficult for that pelvic floor to accept that weight and resist against it, for a very like kind of simplified way of explaining it. And so what we're starting to see is that our butt muscles are weaker in our athletes that have incontinence.
Speaker 1:The second area where this is also being shown is in our pregnant runners. We see that pain towards the end of pregnancy with running is quite high. When we look at the biomechanics of our non-pregnant versus pregnant runners, some of the changes, like our increase in our back arch to make room for baby, what it does is it turns off our butt muscles, and so again we're seeing this connection between pain, pelvic floor issues and glute muscles being one of the big predominant factors, and glute muscles being one of the big predominant factors. And so what we need to think about now, and what my call to action is thinking about this from a clinical perspective, from an athlete perspective and from a research perspective is that we need to move beyond just the squeeze of the pelvic floor and start thinking in systems. We do not have any research that works on pelvic floor muscle training in combination with functional core strengthening in our pelvic floor dysfunction space, except with our men in radical prostatectomy, so men who have had their prostate removed. We show that pelvic floor muscle training works, but pelvic floor muscle training works, but pelvic floor muscle training plus functional training works more, which, like duh, I feel like it's like, of course we would, but we've just spent so much of our research focusing solely on the pelvic floor that I think we're missing a really big and really critical piece of the puzzle. And so some of this new research that's coming out is really exciting, because I feel like it sets up our justification to start really zooming away from the pelvic floor, using it as a piece in the puzzle but not, as, like, the only thing that we're looking at right. So that's kind of exciting to see and it definitely mirrors what a lot of pelvic floor PTs are telling me that they're seeing in clinical practice too. That's number one athletes that leak have stronger pelvic floor. So there's something else like what's that missing piece of the puzzle? It's probably a coordination and a butt strengthening issue.
Speaker 1:Number two is a new study that is coming out that is looking at athletes that do more than 300 minutes of endurance exercise per week in the third trimester. This is so exciting. This was a cross-sectional study that was published in Sports Medicine literally last week. It's ahead of print and it came from some of my lab group. Margie Davenport and Guyann Baines are two of the authors, and then Dr Melanie Heyman as well, and Sabrina I forget Sabrina's last name. I'm so sorry.
Speaker 1:I want to give credit to the authors where they're due, but what they did was they differentiated our for our endurance runners or endurance athletes, rather all types of exercise, those that were running more than 300 minutes versus those that are going less. So many of these individuals were hitting the exercise guidelines, which is trying to accumulate 150 minutes of moderate intensity exercise. These athletes were blowing that out of the water and we had 20 athletes who were more than doubling it, so they were at 300 plus minutes and they subgrouped these individuals and took a look at what did their labor and delivery look like, was there any complications? And what did their postpartum return or postpartum fitness, pelvic floor et cetera, look like. And the really good news is that, one, there were absolutely no heightened risks in these groups and, secondly, our really active group actually had a lower risk of delivery complication compared to our control, which is super exciting.
Speaker 1:And so the upper limit from a fitness perspective or from a pregnancy perspective does not seem to be met, or I don't want to say the limit does not exist, because I'm sure there's a point where the limit does exist, but it's much higher probably than previously believed, right? So if you're doing more than 300 minutes like I know that when I'm running, especially because my heart rate is like all over the place, I would definitely be hitting over 150 minutes, probably a vigorous intensity exercise each week, and then I'm two plus days a week of strength training. So I'm definitely in that 300 plus of combination of moderate and vigorous physical activity, and I feel like a lot of people are who are kind of in that elite athlete camp or in even that recreational to national level exercise camp, and so that's fantastic news. Now the part that I felt really called to talk about was that the high exercise group had a higher rate of postpartum diastasis recti, and now it was only five out of 20. So it was a smaller portion but it was statistically higher than our control group that was exercising less than 300 minutes.
Speaker 1:And if you kind of think classically about the way findings like this have been interpreted, is that very commonly it would be okay. Well, just don't do this, right, if we don't know, the answer is no, and if we're worried at all, we're going to tell people to restrict or modify or scale back. And when I was talking to Margie about this finding, that was what I was telling her was my biggest concern. And you know she said, you know, this is great news. Like all these complications, like they're okay and DRA, we don't even have any. You know, downstream functional issues, except for, you know, a lot of it. Cosmetically people are really stressed about it, but it hasn't been shown in the research anymore to link to pelvic floor dysfunction, low back pain, all those other things that had made us put a big spotlight on DRA in the first place haven't really panned out. So she said you know, this is a great finding. And I said it is a great finding. I totally agree with you.
Speaker 1:But I can absolutely see the interpretation being don't exercise as much, exercise less than 300 minutes because your risk of DRA is higher. And so I kind of want to pull a reframe and I posted a reel about this earlier in the week where the reframe that I want to have at if you are an athlete who is in that bucket or you are a provider working with athletes in that bucket is if we know that that may be something that is a consideration for these athletes, what are we going to do about it? Right, it's so important for us to get this quote, unquote, negative finding or these considerations, because that's how we problem solve, brainstorm and help serve these athletes who are in higher levels of fitness, who are doing more than the recommended guideline, our general exercise guideline. So what does that mean? So, if they have higher rates of DRA, the first thing that I'm going to consider is that I am going to strengthen the bajibas out of these athletes, course. And so if we think about what DRA is and what we think in pregnancy right when we think about our core or our ab wall.
Speaker 1:During late stages of pregnancy, our six pack muscles are going to move further apart, and our linea alba, our six-pack line, is going to lengthen and stretch. It's supposed to do that, and it will do that in 100% of pregnancies, because it's this beautiful mechanism that our body has developed in order to allow baby to grow and for us to accommodate baby size in our bodies during pregnancy. What that can do, though, is it can make those core muscles weaker Not weak, but weaker and it can also, with a lot of endurance, which can be impact and moving up and down, it can put a lot of stress on those passive tissues. Up and down, it can put a lot of stress on those passive tissues, and so, in order to support those passive tissues, maybe, we want to think about bringing up our core strengthening and so really prioritizing all amounts of core training not just dead bugs and stuff in neutral, but also maybe doing sit-ups and other things that are going to get those six-pack muscles, that rectus muscle, to be as strong as possible. So we're going to use our internal supports, meaning our muscles to support our under-stressed passive tissue. So that's number one is I'm really going to try and prioritize some of that muscular strengthening and definitely something that we've been advocating at the Barbell Mamas and prioritize some of that muscular strengthening and definitely something that we've been advocating at the Barbell Mamas and in some of my coursework to clinicians for the last several years. That's kind of number one.
Speaker 1:The second one and things that I have been thinking about is providing external support, and what I mean by that is some sort of compression, which, as we're in a heat wave, that probably sounds miserable for our pregnant women who are trying to get outside and run, which is probably something that we need to brainstorm. However, it kind of brings up this conversation around would something like a compression garment give a little bit of like a brace to those passive tissues that are under more strain because of your level of activity? Because we know this, we can problem solve things to do, but I do not want that interpretation to be just stop doing it, right? That is our knee jerk reaction a lot of times in healthcare and that is not helpful, right, and so we really want to be noodling on. Okay, if we know that maybe this is a concern for very high levels of activity. How can we keep these athletes continuing to exercise and then set them up for success in the postpartum period? Now, if we would have shown you know, that there was some sort of complication or consideration in that respect, then heck yeah, like we'll scale back. I'm not saying that my I would never went in line with new evidence, scale back, modify or regress in any way. That is absolutely not the case. But when it comes to something like DRA, I think before our response is to bring that intensity below 300 minutes, there are other things that we can consider and conceptualize in order to better support these athletes and their continued engagement in that type of exercise. So that was Miles in maternity. That was this new paper that came out.
Speaker 1:Number three is around changing some of our definitions for pelvic organ prolapse and oh my gosh, this is so long coming, but I'm so excited when we are thinking about prolapse if you are not in this space. What prolapse is is an increase in the range of motion of one or more of the vaginal walls, in combination with complaints or sensations of bulging or heaviness around the vaginal opening, and that's kind of a simplified definition of what it is, but there's a lot of I don't want to say controversy, but there's a lot of conversation in the prolapse space, because changes in range of motion of the vaginal wall is something that we experience with age, something that we experience with every vaginal delivery, and it also depends on what your tissues are like. What I mean by that is like individuals who tend to be more double jointed and more flexible in their joints are also likely going to see more range of motion at their vaginal walls. That's kind of just the way that their body is made up likely going to see more range of motion at their vaginal walls. That's kind of just the way that their body is made up. And what we're seeing is that there is a lot of people who would be considered, to quote unquote have a prolapse, but they have no symptoms, they have no sensations that are abnormal around their pelvic floor, and it's created a lot of debate. Where we are now seeing our guidelines say is that you need both. You need that range of motion, change and symptoms.
Speaker 1:And then what has been coming up over the last several months in some of the research and we are super here for it is that we probably shouldn't even be diagnosing prolapse unless they are at a grade three or higher, and so unless your vaginal walls, their range of motion, is approaching the opening of the vagina or going beyond it. Now this is a very big change, right? Because so many people come up to me and they say, christina, I was diagnosed with a grade one or grade two prolapse, and they do have symptoms. So what do you mean? That this doesn't count as a prolapse?
Speaker 1:There's a couple of things that we need to deconstruct with this that I think is going to be really important for us going forward in this space. Number one is that our vaginal walls are supposed to move right. Our vagina is not a hollow tube made of cartilage that is rigid and stuck in place. So where your vagina is sitting in the morning after a good night's rest, versus if you've been on your feet all day or doing a whole bunch of trampolining, like those vaginal tissues are going to look different and that's expected, like that is not something that is abnormal, that is not something that is wrong with you and that's okay, like that is a normal response to a day of movement if you have a vagina. That's number one. Number two is that with 50% or more of our population having a grade two prolapse, but only between three and five to three and 8% of people with that prolapse having symptoms, with that prolapse having symptoms, the question then becomes are we creating a problem by telling women and people that that feeling of that movement or that movement in general is bad? And so then the third thing is have we as healthcare providers actually made you feel very sensitive around your pelvis and created this hyper awareness of your pelvic floor because we have told you to expect that that range of motion is that something is wrong with you and you are living now with this chronic condition called prolapse. And I think that that's all really interesting, right, because I posted. It's funny because this is so bias confirming.
Speaker 1:I posted on social a little while ago that I think that the way that we do a prolapse assessment, which is a max bear down on a relaxed pelvic floor on your back, isn't really that helpful, because we get this grade but one. You never actually push that hard, except when you're giving birth vaginally, and so many of my clients' complaints aren't in that position doing that motion. It's after standing for a long time or their resting position of their vaginal wall, especially when I'm working with individuals after menopause, and because of that, I don't like doing assessments that aren't really functional or telling me anything that's going to give my clients insight into how they can help themselves and the way that they're feeling around their pelvis. And so I kind of put that out there and I had a lot of people like push back on me, saying that by me not disclosing that finding of that max bear down that I'm removing informed consent and I'm not trying to remove informed consent. And I'm not trying to remove informed consent, I'm trying to change the way that the assessment is done in general and then give the findings of this new and more relevant type of assessment. If you hear Quinn a little bit screaming in the background, I'm sorry. He's playing right outside where I'm filming this podcast, so that is just mom life right there.
Speaker 1:What that means is that what we're pushing for and now what seems to be mirrored in some of our urologists is that we need more of a functional evaluation of pelvic floor dysfunction. That means maybe doing some of our tests in supine but then seeing how, or sorry, on our backs, but then thinking about how do those assessments on our back translate into assessments that we do in standing, how do those assessments link to how a person is feeling with movement and exercise? And then what are things that are going to predict if people are going to have worsening of symptoms with exercise versus not? And we just aren't there yet. And so to see the medical community kind of say you know, this assessment that we use to grade prolapse probably isn't that functional and isn't that helpful. I just love to see that because there's a lot of people who are afraid because of prolapse.
Speaker 1:I've had a lot of people in my DM say that they don't want to have any more kids because they're afraid that what they're already paying so much attention to in their pelvic floor or around their vagina, they don't want to make that worse by going through another pregnancy which is changing the way that you want your family to be structured, and that's really devastating and that symptom stress is really high. And so can we do something that's going to give a little bit more clarity and is also not going to potentially scare people when what we're starting to see is actually a normal finding after giving birth? Because where I have done podcast episodes and I'm going to kind of finish with this is we do a great job of setting up expectations around pregnancy, but we don't do a really great job of setting up expectations around what you're going to feel postpartum. And if I'm seeing you during pregnancy and I've done podcast episodes on this we are going to be talking about hey, this is how your vagina is going to feel in the first couple of weeks to a couple of months postpartum. I expect that you're going to feel some heaviness around the opening of your vagina as you push exercise in the early postpartum period. Consider that DOMS, you're going to have more up and down movement.
Speaker 1:I'm not going to diagnose you with any type of prolapse for at least the first three months, so please don't even ask. You know why? Because stuff is still swollen, right, your body is still recovering. You just pushed a baby out. Of course, things look a little bit different and a little bit closer to the surface of your opening of your vagina, because they are, because you just pushed a baby out of there and it's going to take your body a little bit of time to find its new normal and it probably is going to look different than it did before you had a baby, and that's also okay. That's what we expect with vaginal delivery or a trial of vaginal delivery, and then a cesarean, and then even a little bit with a cesarean section.
Speaker 1:And so by having these conversations in the research and then me being able to have these conversations with you all in this podcast, I think that's how the narrative starts to change and how we highlight and identify things that we need to, like potentially this DRA with high levels of exercise and pregnancy.
Speaker 1:But we also acknowledge where sometimes we are too hyper-focused on an assessment like this prolapse assessment that doesn't seem to change functional outcomes that much or in some ways actually scares people when we don't need to be afraid.
Speaker 1:So I love that we're seeing in both directions, that we're starting to question some narratives in a lot of ways to the strength of the athlete's pelvic floor and thinking about glute strengthening. That's all trying to push this narrative forward, and what that means is that we need to change a little bit the way that we're starting to talk about these things in light of new research, which just makes my heart so excited. It means we're learning, it means that we're changing our minds and refining our messages, and that's so exciting. It's so exciting and I hope you all find it as exciting as I do to see and advocate for, you know, our currently pregnant and soon to be postpartum or pregnant again athletes and exercisers, and it's just an exciting time to be in this space and I feel very fortunate to be part of the research community. That's maybe, maybe in a very small way, driving some of these narratives forward. All right, if you have any questions about those three things that we talked about this week, please let me know. No-transcript.
