The Barbell Mamas Podcast | Pregnancy, Postpartum, Pelvic Health

Pregnancy Exercise: Do We Really Need Modifications?

• Christina Prevett

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Exercise during pregnancy has long been shrouded in caution and confusion. What if many of the modifications we've been taught are unnecessary? Drawing from both cutting-edge research and personal experience through multiple pregnancies, this episode challenges conventional wisdom about prenatal exercise.

The fitness landscape for pregnant women has dramatically evolved over the past decade. Where once pregnant women received advice limited to walking or gentle yoga, we now recognize the benefits of maintaining strength and conditioning throughout pregnancy. But questions remain: should every pregnant woman modify exercises in the same way? Does holding your breath while lifting actually increase your risk of pelvic floor issues? What's the difference between physiologically-based recommendations versus outcome-based evidence?

Two distinct approaches have emerged in pregnancy fitness guidance. One camp bases recommendations on physiological changes happening during pregnancy, suggesting universal modifications regardless of individual fitness levels. The other acknowledges the body's remarkable adaptability, suggesting women continue their pre-pregnancy routines until symptoms indicate a need for change. My journey as both a clinician and researcher has led me from firmly believing in the first approach to increasingly embracing the second.

Most compelling is emerging evidence showing that fitness level entering pregnancy serves as a protective factor against pain and dysfunction. Rather than focusing exclusively on which movements to avoid, we might better serve pregnant women by emphasizing the importance of strengthening their bodies before and during pregnancy. This represents a profound shift away from fear-based messaging that can unnecessarily limit movement during a critical life stage.

Ready to explore how your body's signals might guide your pregnancy fitness journey better than universal modifications? Listen now to discover why the most beneficial approach might be less restrictive than you've been led to believe.

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Speaker 1:

Hello everyone and welcome to the Barbell Mamas podcast.

Speaker 1:

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 everybody and welcome to the Barbell Mamas podcast, christina Freved. Here and today we are going to talk about are movement modifications or exercise modifications in pregnancy even necessary? Now, this is obviously a really big hot take. We're going to get into the nuance. That's why I love this podcast, because we get the chance to go into the nitty gritty of the details with this. But what prompted this is actually, brianna Battles and I had a conversation online because she was saying you know, just doing what you always do is a sign of like it's kind of leaning into lazy coaching, and I thought that was a really big hot take. And so her and I I actually really respect Brianna Battles. I think she's amazing, she's done incredible things for the exercise and pregnancy space and I hope that we're one day going to be able to meet in person. This is no way a slam on her, but it was more of this thought process that for me, has changed and how we can kind of come at different conclusions around exercise and pregnancy, depending on what your background is, what your thought process is and kind of how the research has evolved. So I think this is actually really cool to discuss and it just kind of prompted this thought experiment for me, which I think is neat.

Speaker 1:

Where this is coming from, and I think how we have to approach this conversation, is how far we really come when it comes to exercise and pregnancy. Now, even 10 years ago, we really had not a ton of information about exercising and pregnancy and what that would look like, and we absolutely did not have anything at all when it came to any type of high impact, high load, any strength training, anything like functional fitness, like nothing with CrossFit. And so there were so many pregnant women who were doing these types of exercise programs who became pregnant and then thought, frick, now what? And if you looked at the research, the research was very, very low intensity, basically talking about walking and maybe some yoga, maybe weights that were one to two pounds. A lot of it was treadmill walking, so that didn't really give us a lot of insight. And even the research that we did have wasn't looking at how we modify pregnancy or if we modify pregnancy and how that relates to the muscles and bones and the ligaments and how they change in pregnancy pregnancy physiology. It was very early preliminary research that was looking at if you exercise in pregnancy pregnancy physiology. It was very early preliminary research that was looking at if you exercise in pregnancy, what did that do from a health perspective? And over the last 10 years we've made a lot of progress in terms of really pushing the boundaries, of saying exercise in pregnancy is safe.

Speaker 1:

But what is still very much a black hole in our research base and I'm really excited. I cannot share my data with you right now, but I just did some data analysis. That is blowing my mind and I cannot wait to get those papers out. I feel like it's going to blow everybody's minds, but what we are seeing is that, because there is actually no research at all that's looking at types of exercise and if or how they may contribute to pelvic floor dysfunction or core issues postpartum, we really were and still are in many ways, left in the dark when it comes to what to do in pregnancy and, of course, the first thing that happens when you become pregnant is you ask what the heck do I do and how do I set myself up as a pregnant person for success postpartum, or I have goals postpartum, or I really want to keep exercising. So there really is a big black hole there and there's a huge gap in the research and, as I said, we are working on those questions, especially in the functional fitness and running spaces with my postdoc research, but we are still waiting, obviously, to get manuscripts out and things like that. But I do think that we will have a lot more certainty on this in the horizon, or at least the beginnings of answers to these questions, because we don't have anything right, I think universally, no matter what camp you are in, you can say I think exercise is safe.

Speaker 1:

Right about how. We have a consensus statement that just came out from the American Heart Association that basically said that sedentary behavior or sitting more during pregnancy can increase your risk of adverse outcomes. It can increase your risk of gestational hypertension, et cetera, which really mirrors what we're seeing in the non-pregnant research. Right? Ideally, we should be moving more and sitting less, and our culture is really bad at trying to encourage that, because a lot of us are sitting for jobs et cetera, but you know whatever. So I think all of us are in agreement that exercise is beneficial in pregnancy.

Speaker 1:

But where we diverge or where there are differences of opinion and that's totally fine is around how we approach that. And so what are these two camps? We have this first camp and I used to be in this camp and I have changed my mind over especially the last three years is you have certain changes that are happening to your physiology because you are pregnant, so because of pregnancy, change X, I want you to change Y, so this is physiological plausibility, right? So, based on what we know is changing within your body and based on the fact that we don't have any health outcomes data that is telling us. Either way, we are going to make these changes in every pregnant person who is exercising to try and respect your body and where it's at in pregnancy from a core wall and pelvic floor perspective. And that's where kind of Brianna sits with her thought process, which is totally fine, right. So she's kind of in that camp, the secondary camp, which is the camp that I've kind of shifted to.

Speaker 1:

I probably say that if you were talking to me in 2020, 2021, I was in the or I guess even 2019, I was definitely in that physiology camp and then I kind of merged to like half and half and now I feel like I'm a little bit more rooted in the second camp, which is your body is going to adapt to pregnancy and until it gives me a signal that it's not ready for the exercise you want to do, I'm going to let you do whatever you want. And there's a lot of people who are very critical of the idea that if you were doing it before you were pregnant, you can keep doing it during pregnancy, and I've talked on this podcast about how I think that's really great advice, because if you were not running and then you start a running routine and go from doing nothing to 10K. Whether you're pregnant or not, your body's not ready for that right. You've never strength trained in your life and the first day you go in the gym you're doing a one rep max deadlift. Like not a smart idea, whether you're pregnant or not. And so these adaptations in pregnancy actually happen pretty slowly.

Speaker 1:

And if you have a lot of reserve in the tank, your when I come in from a modification perspective, being in this second camp is saying, hey, if you were doing it before, you can keep doing it now. Here are the signals that your body may be giving you, that is, telling you that it's time to modify. This is number one, is kind of where the nuance in this camp goes. And so I say, hey, if you're feeling pain, heaviness, pelvic floor dysfunction, it's just not feeling good, those are all reasons for you to check in on your exercise program and say, hey, maybe for me that's time to do something different. And then the second way in that camp that I talk about exercise modification in pregnancy is auto-regulation. And so in pregnancy you're going to have some days where you feel really great. Some days you don't that. So in pregnancy you're going to have some days where you feel really great, some days you don't. That is similar to if you're pregnant versus not, and so using things like braiding up perceived exertion and trying to have a little bit of an ish in your paces or in your expectations for intensity and exercise is a really helpful mindset shift.

Speaker 1:

If you're kind of in the camp of I'm going to keep doing my exercise routine until my body tells me that I can't, and so what's kind of led me being from camp one to camp two and I truly think that probably we're going to land somewhere in the middle when it comes to these modifications. But what has kind of led me here is that number one I have so much variability in my own caseload and in my own experience and my own coaching of different moms as they're pregnant and then go into postpartum, of how they feel during pregnancy, when they start to feel different sensations in pregnancy and their fitness going into pregnancy, their goals and expectations of pregnancy and while the physiology of pregnancy is the same, your fitness going into pregnancy really does make a difference for stacking the deck in your favor of how you're going to handle the stress of pregnancy, favor of how you're going to handle the stress of pregnancy. For example, we had a systematic review that just came out that showed that the level of fitness you had going into pregnancy was positively predictive of the amount of pain you're going to have in pregnancy. What I mean by that is the vast majority of individuals have some amount of muscle ache and pain in pregnancy, whether that's low back pain or pelvic pain. Pubic symphysis pain are three big areas of discomfort Like some estimates are like 75 to 80% of pregnant women will have some amount of pain and discomfort, but we are now starting to have consistent data that says that your fitness going into pregnancy is protective, where those who have higher amounts of fitness have lower severity of pain and lower duration of pain while pregnant. And again, like if you had pain in pregnancy, this is not saying that your fitness was insufficient or that it wasn't enough, but when we're looking at statistics and relative risk, we see that there's a protective effect of fitness going into pregnancy, and so what that means is that as you are going through your pregnancy, if you have more reserve in the tank coming into a really stressful event, then your body is better able to handle this.

Speaker 1:

Here's a really fun case example of myself. So this is my fourth pregnancy, third kiddo, god willing, that I am experiencing and I have been active through all of my pregnancies. But it's interesting because my first pregnancy I was training for weightlifting. So I was not doing any aerobic activity outside of you know, walks and things like that, but I wasn't purposely training aerobic activity. I was 100% in the resistance training camp. For baby two, same thing. I wasn't in competition mode per se because we were in the pandemic, but I was still very, very heavily leveraging resistance training and then fast forward, very heavily leveraging resistance training and then fast forward. I am older baby three and I am very much hybrid. So one week I'll do three runs and two resistance training sessions and then the next week I'll do three resistance training sessions, two runs. So I'm very much in this 50-50 camp because I've kind of stepped away from competition et cetera. Whatever it is so fascinating In my first two pregnancies.

Speaker 1:

The thing that I noticed the most in the first trimester was my resting. Heart rate went up, so I was sitting in the low 50s and I jumped up to the mid 50s almost immediately and it gradually increased from there so that I was in like the low to mid 60s by the time I hit the end of my pregnancy. Something that has been freaking me out this pregnancy is that I'm not even experiencing those changes, right, I had a resting heart rate of like 45 to 46 and I am still. My garment is still showing me that my resting heart rate is sitting at 46 to 48, 49 and I'm approaching the end of the first trimester. I'm 10 and a half weeks pregnant with this third baby and it's just so interesting to think that my heart was stronger to handle some of the adaptations potentially right. And I was talking to Margie my supervisor, like you know, is there like something that could be with this around this conditioning effect of the heart being able to handle the stress of pregnancy, and she's like, yeah, there's absolutely potentially something there in this idea of having reserve to handle the stress of pregnancy and it just makes so much sense, right.

Speaker 1:

And so into the exercise modification piece. Right, when we are making these blanket statements, we aren't considering the person's level of fitness and their person's readiness for this type of activity going into pregnancy. And it can be translated into trimester specific modifications or you have to do this or you have to do that, and so the first thing is that seeing this variability in clinical practice, that didn't really make sense to me. Right, and honestly, bree agrees with that because she sees so much variability as well. She does not disagree with that, but she kind of says how we want to be proactive about pelvic and core health. So then, on that space, the secondary piece is that my own data has started to challenge my belief systems on the need for these recommendations, and so it's going to be interesting, with my retrospective and prospective data analysis, to see if this is a consistent trend that we see.

Speaker 1:

But I remember one of the kind of knee-jerk scales that everybody does is they talk about how, when you are lifting weights, you shouldn't hold your breath in pregnancy because it puts too much strain on your core and pelvic floor that are already under strain during pregnancy. So already we have an increase in interabdominal pressure because you're pregnant. I believe that too, and I used to say, hey, like when you're pregnant, just change your breath strategy and it will be potentially protective. Fast forward, and my own data that we published at the end of 2022 says, hey, like those that continue to hold their breath while lifting and those that decided to modify away, didn't have a change in pelvic floor dysfunction postpartum. I was like well, dang, and then Kari Bowe's work came out and they were looking at the intensity of abdominal exercise and the risk for DRA postpartum and they said there was no association between how often or how much core training you did in pregnancy and DRA postpartum. And then they actually showed that the weaker your core was, someone, nicole Beamish's work was showing that one of the modifiable risk factor was a lower strength in the rectus abdominis and the obliques.

Speaker 1:

And so then I really started to noodle and I, when we start making some of these recommendations right, and changes to pregnancy, there was a midwife that I commented on who basically said that you should never jump in pregnancy. It's not worth it, and she's like I have really strong feelings about that. I'm like I have really strong feelings in the opposite direction, like let's talk about it right, like let's have this conversation and what can happen and this is not on Bree at all, she's not like this at all. But what I see in other influencers and creators is that this gets interpreted as safe versus unsafe, or you should always do this and not do that, and so kind of bringing this full circle, like whatever camp you are in.

Speaker 1:

We also need to acknowledge, at least now, that we do not have any data that says that the way you exercise in pregnancy is going to change your risk for pelvic floor dysfunction postpartum. Like we don't have any evidence that if you ran versus not, you lifted versus not, we do have data that says that if you are running and strength training, you are less likely to have postpartum pelvic floor dysfunction than if you are running and not doing the strength training piece. That was a cross-sectional study that had come out very recently, so some evidence is looking at a protective effect of exercise on pelvic floor dysfunction, and so what this means is that we cannot have absolute certainty about either camp just yet. Wink, wink, nudge, nudge and some of my data that hasn't been published yet is showing that when this advice around core and pelvic floor considerations come into active individuals and they're getting this advice, it actually makes them more afraid of exercise because they're worried that their exercise is going to lead to pelvic floor dysfunction and core dysfunction, and so that is a manuscript that is going to be submitted very soon, so keep that on the DL. But what we are seeing is that if we go too far on the pregnancy physiology camp, what we can inadvertently, unintentionally do is create fear and certainty of risk for dysfunction when that evidence doesn't exist. And so that has really like been this journey for me of like shifting away and, honestly, like my outcomes as a clinician and coaching women has not. I have not had an increase in risk of pelvic floor issues postpartum or individuals coming with more severe injuries, and so that's really interesting to me. Obviously, I can't use my own clinical judgment in isolation, right, and it's why I'm doing the research that I'm doing, but it is really interesting to see that that association or that relationship hasn't existed, and so we really want to be mindful of that online and just avoiding the absolute language and the unbelievable amount of confidence that people have that this is going to help when we really don't know, and so this is kind of leading to this big reframe that's happening. We saw this in the postpartum exercise guidelines, where what the recommendation ended up being from Margie and her colleagues was that return to exercise postpartum cannot be blanket prescriptive, that it is going to be individualized, personalized and should be symptom guided right, and what I hope is that this is eventually going to be mirrored in pregnancy, where we're going to be able to use a symptom-based modification, and so it's interesting that we're seeing this in the postpartum space and I hope it's going to be mirrored in pregnancy.

Speaker 1:

And the last thing about this around the symptom guidance and what a lot of people, especially who are in the very physiology-driven camps, will say is well, what about our long-term outcomes? What about this? What about that? What about this, what about that? And I understand where people are coming from, but I really disagree with the sentiment. And so when I think about, for example, me and my exercise routines now, I do think about my health in my 80s, right, I'm thinking about can I take my muscle mass and my aerobic fitness, keep them as high as possible within a reasonable capacity of how busy I am and hold onto them for dear life until I'm in my 80s? Right, like that is a longevity lens. But I don't want my thought process around how I'm exercising now for fear of an outcome down the road that we don't know if it's going to happen or not.

Speaker 1:

So some of the feedback that happened with some rehab providers with the symptom-based management, postpartum, so some people can go back early, some people will go back a little bit later based on their individual circumstances. They were saying, well, what about if they develop prolapse in 10 or 20 years? And my insensitive thing for that is well. So what, like? Why is that going to stop you from exercising early postpartum? And sure you can put that in your equation if you want to. But why, like, I'm not going to come up to a basketball player and say, hey, you shouldn't play basketball right now because if you do hurt your knee you could have arthritis in your 60s, right? How many athletes do you see who are in middle to later life and have an increase in ache or pain in the joint that they injured themselves in when they were playing recreational basketball? They weren't playing at a competitive level, they were playing single A hockey and busted their knee, right.

Speaker 1:

We can't control all those variables, but the advice in those scenarios is never to not exercise or don't do it, because 20 or 30 years down the road they could have an injury or they could have something that they have to manage. Right, they're looking at their health and their enjoyment, their mental health, their quality of life now and then aiming to mitigate some of their differences when they're in their 50s and 60s. Like my husband is 32, played university level, college level football. Never made it professional, was a pretty good player when he played and now at 32, his body hurts from some of his. He's had a host of concussions. People were trying to break his fingers when they were in the huddle. He's had shoulder reconstruction, all this kind of stuff, but the advice was never don't play football, right.

Speaker 1:

And so if we kind of take that into the postpartum space is, yeah, I want to teach proper bracing and I want to make sure that I'm respecting recovery, but I'm not going to stop a person from exercising and put fear on them that, hey, recovery. But I'm not going to stop a person from exercising and put fear on them that, hey, how you exercise is now may doom you to prolapse dysfunction in 60 years, because we don't even know if that's true or not. And honestly, for me, like this is going to be my most unfiltered truth to you all I started exercising with both my kids less than a week postpartum. I started exercising with both my kids less than a week postpartum, gradual, very core and pelvic floor intensive, not heavy, but just started moving and I've said this before on the podcast because I was terrified of postpartum depression. It impacted and rocked my family. It changed my childhood and I almost didn't have kids because of that risk and I'm obviously so glad I did. But I truly believe for me that exercise was something that kept me healthy and so if I have to have prolapse surgery in my 60s, but I was able to enjoy exercise now and enjoy my kiddos, and my mental health was good, like even if that was part of my cost benefit, which it's not, but if it was, I would accept that risk every single day.

Speaker 1:

Right, my husband looking at his injuries and how he's feeling now. I've asked him before like, would you now, looking back, not have done or played football? And he's like absolutely freaking. Not, I loved playing, it was everything to me, it was my friends, it was my network. How many moms feel like that, going into a CrossFit gym, like they love doing CrossFit? There's the community, there's space, and there is another big provider who said gym owners shouldn't even let women come. So we always need to take a step back and we need to make sure, hey, the decision is ultimately up to the human right and we can give these recommendations, but we don't need to cast judgment and we want to make sure that we're helping them right now, setting them up for long-term pelvic health, for sure, but not scaring them in how they're moving because of fear of an event that may or may not happen in the future, and so I think that we're going to see this kind of mirrored in our pregnancy kind of space.

Speaker 1:

The last thing I want to add is very relevant here, but it's playing out in the sex differences in exercise space. So Stacey Sims is someone who's really popular for the saying that women are not small men, and she is well known for talking about differences in physiology between females and males and how that translates into changes in how females should train and specific programs for individuals who are female. She was just on a debate with Lauren Colenzo Semple, who is a researcher that also is working in sex differences in exercise, and what that podcast really showed to me was this difference between physiology dictated decisions versus looking at health outcomes. Right, we saw this in cycle syncing. We saw this in fasted training all these types of things where Stacey Sims uses physiology to dictate her decisions. Like, hey, we see that there is this difference between males and females. That means we should change this. And Lauren came in and said, hey, but when we look at this from a health outcome, the health outcomes that matter, like is there differences in adaptation? Is there differences in BMI, these health outputs, what we actually aren't seeing is differences. So, yes, there's differences in physiology, but it doesn't tend to be clinically relevant for the health outcomes of interest that we are looking at.

Speaker 1:

And that podcast I'll put it in the show notes the Docs who Lift podcast was fascinating because it showed one how these two camps that we're seeing in pregnancy can diverge and how we have to show caution when we're kind of hooking ourselves in one camp, because as new data comes out, it means we have to change our mind. Right, if you're in the physiology camp, I think that's amazing, but what you have to acknowledge is that as the health outcomes space comes out and more of our research comes out including research I'm actively generating right now you have to be okay with changing your mind. And that's the journey that I've been on, where I started in the physiology camp and now this data is coming out and I'm like, ooh, maybe we shift gears on this a little bit or we ease off the reins on it give a little bit more freedom and that allows us to go from here to here. And that's a scientific method, right, and I think it's so cool, right, because that's how we start.

Speaker 1:

We have to have a hypothesis and it makes good plausible sense that there are X Y Z changes during pregnancy. That's going to lead to us making X Y Z modifications in pregnancy. And then we test that hypothesis and say, hey, does this make a difference? And once we have the health outcomes, it's going to be like, okay, this was really good advice, we're going to stick this here, or this actually didn't make a difference and we can let that go. And then it's going to be really important for, well, I'm going to put emphasis on this from an education perspective. Is that I am talking about this from a yes or no perspective, right? And so one of the things that I showed was that Valsalva didn't seem to matter, so I eased the reins off that from my own recommendations.

Speaker 1:

What we did see was that the diastasis in the 300 plus minute group of runners was slightly higher.

Speaker 1:

So, hey, we're really going to focus on core strengthening and adding resistance training in for our endurance athletes, right?

Speaker 1:

So we are going to hold on to that recommendation in pregnancy and kind of in endurance athletics in general. And so this is really cool that we're at this space. And if you are a person who's in the pregnancy postpartum space, if you are a person who is in the pregnancy postpartum space, if you are a person who is in this spot of your life right now, what it's going to mean is that we just kind of have to keep an eyeball on the research coming out, because we are in just this innovative space where this area of research is still so new, right, it is still so new, right, it is still so new, and that means that the information and how we are thinking is going to change pretty quickly. But, as I said before, I think that's really freaking exciting. All right, that's all I got for you today. I hope you found that helpful how we kind of went across this journey. If you have any questions, please let me know. Otherwise I will see you all next week.

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Christina Prevett

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