Hello everyone and welcome to the Barbell Mamas podcast.

My name is Christina Prevett.

I'm a public floor physical therapist, a 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 Barval Mamas podcast.

My name is Christina Previtt, and today I want to be talking all about Kegels in pregnancy.

Now, I feel like social media and really healthcare kind of in general has done this really big pendulum swing where we were saying, yes, do Kegels all the time for everyone.

Let's do it.

We should do it in pregnancy.

We absolutely should do it postpartum.

Rah, rah, rah Kegels.

And in the last couple of years, now we've seen this rise of this anti-Kegel movement where it's said the exact opposite that you shouldn't do Kegels, that for birth you are need to relax your pelvic floor.

So stop kegling in pregnancy.

And you know what happened?

We confused y'all.

And really the answer, as with almost everything that we do, is the answer is somewhere in the middle.

So I want to kind of do a deep dive in what we know about pelvic floor muscle training.

What are some of my pros, cons, some of my criticisms potentially about the research that we have so far in this, and where I think you should go.

So first and foremost, if somebody is telling you to do Kegels in pregnancy, it is based on very high level evidence.

So if we think about our levels of evidence, where the higher levels of evidence are considered the most rigorous and the highest quality, our Cochrane reviews are pretty much the creme de la creme, the chef's kiss, the highest, most rigorous amount of research, the highest and most difficult amount of methodology, like it is the top.

And when I say we have Cochrane level evidence that pelvic floor muscle training, specifically talking about this squeeze or contraction in the prevention of postpartum pelvic floor dysfunction, that we have cochrane level evidence there.

I am not lying.

It is absolutely true.

And so firstly, when somebody tells you as a blanket statement, do not do Kegels in your pregnancy, be very weary of this person because they are not going with the evidence.

It is legitimately misinformation.

And so we need to consider that we have very strong evidence, especially on the prevention space, that performing pelvic floor contractions in pregnancy can prevent postpartum urinary incontinence.

And our new exercise guideline, physical activity guideline, postpartum, also said initiation of pelvic floor muscle training, including the squeeze postpartum, can reduce incidence of pelvic floor dysfunction postpartum.

So if you are told to do pelvic floor contractions, you are absolutely going in line with the evidence.

However, what we are seeing is that of course, with everything, there is nuance and there are recommendations that are going to apply very strongly to somebody and recommendations that I wouldn't prioritize as heavily.

When I am looking at the research in pelvic floor muscle training, one of the things that does frustrate me more than anything else is that we have focused so much on the squeeze and the strengthening aspect.

And when we're looking at the pelvic floor as a system, what I wish pelvic floor muscle training as a term encompassed was the contraction, relaxation, and appropriate coordination of this system because the pelvic floor is a system.

We can isolate it from a muscle perspective, of course, but really we want to think about it as part of our force transfer system and part of how we move around in space.

And so when we are thinking about our really active individuals, where they may not have to prioritize pelvic floor muscle strengthening as much is when you already have a lot of reserve in the tank.

So if you are a person who has a lot of strength or a lot of strength in that system already going into pregnancy, then your need to prioritize pelvic floor muscle strengthening may not be as high, right?

And you can prioritize fitness very generally.

But if I have a person who maybe in their preconception, in their three to six months or longer before baby, was not doing as much exercise as they had wanted to, or they had stepped away from exercise, or just really don't like exercise in general, then that strengthening might be higher on my priority list in order for them to feel really good and really solid in pregnancy.

When we are looking at pregnancy physiology and the demand that comes on your body when you are pregnant, especially, you know, in that second half, as baby starts to grow and comes out of your pelvic cavity into your abdominal space and ab wall lengthens and baby's weight starts to increase, what we see is that your pelvic floor muscles and your hip muscles are doing more work.

And what that means is that your body needs to be able to respond to that increase in workload.

And it is also happening in combination with this lengthening of your abwall, which is a part of that force transfer system.

So we've kind of weak-linked a little bit, potentially, one side of your force transfer system, and we put extra demand on the bottom of that core canister.

What that means is our body needs to be able and ready to handle the demands that we are putting on it.

And so we want to have reserve in the tank.

And so what that can mean is if we're getting to a position where our pelvic floor is working at 100% moving around, and then say you have to cough or sneeze, right?

Then that can mean that maybe your pelvic floor isn't strong enough to close off your urethra, which allows P to come through and you can have some incontinence.

Again, it really does depend on the human and your body and your considerations, but that's kind of one mechanistic approach that could be relating to why we see an increase in urinary incontinence during uh pregnancy.

This is in combination with the fact that because we have so much um relaxing going through our bodies and we see that ligamentous laxity, when we see a change in our static supports, our dynamic supports have to carry more of the load.

Pun intended, I guess.

And so what that means is that our our muscles are working harder and they have to do more.

And so that combination of the weight of baby and some of the ligament changes means that we could be using up more of the reserve that we have in those buckets.

And if we hit this critical point where our reserve doesn't meet the demand of what we're asking of our body, we can have some incontinence going on, especially in pregnancy.

When we're looking at really active individuals, they can sometimes be in this unique camp where they already have a lot of reserve in the tank.

And as soon as they get pregnant, they worry a lot about their pelvic floor.

So they end up doing too much strengthening of their pelvic floor.

And then my recommendation in that situation is that you need to relax.

The best way to figure out which one is you is to try it out and do a trial and error, right?

If you're already doing a lot of pelvic floor muscle training, then maybe ease off and work on some relaxation positioning, like happy baby or child's pose, and really think about allowing your pelvic floor to relax and telling your body that your body is safe if you're feeling that load from pregnancy on your pelvis and see if that reduces any incontinence or pelvic issues that you are having.

That means that the recommendation isn't a universal need for highlighting or prioritizing pelvic floor muscle training.

That does not mean that nobody should be doing pelvic floor strengthening and that you are dooming yourself to a harder labor and delivery.

So let's kind of talk about where the pendulum has swung.

One of the other reasons outside of our really active individuals who may not need to prioritize pelvic floor muscle training, one of the other reasons why we've seen this shift away from Kegels in pregnancy is because of the need for the pelvic floor to relax during labor and delivery.

So when you are thinking about the act of pushing baby out, that's our second stage of labor, the smooth muscle of our uterus is contracting rhythmically, and that is allowing baby to descend further into the birth canal and eventually be delivered if we are delivering vaginally.

When that is happening, your pelvic floor muscles go through an intense amount of stretch.

And so those muscles have to relax.

And what we know is that if those muscles are having a hard time relaxing, so if we have levator ani coactivation during the pushing stage of labor, then the pushing phase can be longer.

I've had moms that I've seen, and I've seen them in a second or third delivery, and we start talking about pelvic floor relaxation, and they say to me, Oh, I was absolutely working against myself and I was having a really hard time relaxing my pelvic floor.

What the thought process sometimes is, is that if you're doing so much strengthening and resistance training, where when you are performing resistance training, you're doing it on a contracted pelvic floor, that that might be a perfect storm to make it hard for you to relax during labor and delivery.

If I'm being completely honest with you all, I absolutely reject that idea.

And here's why.

You all are so smart and in tuned with your bodies when given the proper education and given everything that you need to succeed.

And so if you are having the right education, people are putting things out online, hey, here's when you contract your pelvic floor, and here is where you relax your pelvic floor.

I have no doubt that you all are going to be successful in that endeavor.

And so I think it's unbelievably reductionist to say you should never do Kegels because your pelvic floor has to relax in the 30 minutes to two hours that you are spending pushing.

When I am thinking about strengthening in any other area of physiotherapy, I would never say I'm not going to strengthen your bicep muscle when you're having bicep issues because I don't think you're going to be able to straighten your elbow.

Right.

I'm being a little bit tongue-in-cheek here, but I think that it's really important that when we think about so much around exercise modification and pelvic floor and health in general, our education and that informed understanding of what is happening within your body, what is expected of your body, what treatment or intervention is going to look like is such a pivotal part to the success and how individuals feel when you are going through your pregnancy, when you are in the labor and delivery room, and when you are approaching return to movement and this big transition into motherhood postpartum.

And so when I am working with a human, I'm going to teach them how to contract their pelvic floor and relax their pelvic floor.

I'm going to tell them when their pelvic floor needs to contract, when it needs to relax, and I'm going to make sure that it's doing the right thing at the right time.

Right.

And so when we are thinking about that type of prescription, right, I don't want to make the assumption that because I am doing that strengthening that this person is going to be unable to relax their pelvic floor.

What that means is that when we are thinking about our recommendations, what you're going to hear me say, and if you've been listening to the podcast, you've heard me say this before, is I truly believe in frameworks over protocols, right?

This, even this, um, some hospitals say that you should be doing a hundred Kegels a couple of times a day for the first six weeks postpartum.

And some of my clients, like that would be way too much on their pelvic floor.

And for some people, maybe it is sufficient.

But what they were trying to do is create enough of a stimulus for everybody to see that improvement.

And so they kind of missed the mark, in my opinion, when it comes to that prescription.

And so when we think about this as a framework, then I have these filters and this kind of algorithm that you all can go through and say, okay, is this something that I need to prioritize?

So off the top of my head, this is not well thought out at all.

But if I was thinking about this as a framework, it would be going into pregnancy, did you have a strong pelvic floor?

Before pregnancy, were you experiencing any signs or symptoms of pelvic floor dysfunction, like leaking, heaviness, or having to go to the bathroom very suddenly and not being able to delay it?

Okay.

So if the answer was they did not have a strong pelvic floor or they were already struggling with pelvic floor dysfunction before pregnancy, then they would be a person that I would put into a moderate to strong recommendation to initiate pelvic floor muscle training once pregnant or before pregnancy, but in pregnancy.

If you are a person that had a high amount of strength in their pelvic floor muscles and had a high amount of fitness, was not experiencing any pelvic floor dysfunction, I would put them on a low priority list of putting pelvic flora dysfunction in their program.

And then give the buoy that if experiencing an increase in pelvic floor dysfunction or sudden onset of pelvic symptoms, consult with a provider that may be able to get you on the right plan for you of are we doing pelvic floor strengthening or relaxation?

So I have a stronger recommendation category and I have a lower priority group with respect to pelvic floor muscle training.

And so with that, then if I'm in the stronger group, then we can figure out what our dosage is for that individual.

As you said, I as I said have said in previous podcasts, I also don't really have a dose response curve for pelvic floor muscle training.

It doesn't really exist.

And I love that because some people might need three by 10.

I know a lot of humans, myself included, so this is definitely a bias for me.

Um I think sitting down and finding dedicated time for pelvic floor muscle training is boring.

And as a busy mom, soon to be mom of three, and I have a job and I have family and all that kind of stuff.

Like that's just not something that I prioritize.

Even in the presence of pelvic floor dysfunction, I'm gonna find ways to snack it throughout the day.

And if I'm experiencing pelvic symptoms, I'm gonna start working on those contractions and squeezes at different memory prompts in my day, like brushing my teeth or sitting at a red light or whatever that might be to try and work on that strengthening if that is something that I'm prioritizing.

And so when we shift this mindset, then it stops this team Kegel or team anti-Kegel, which is honestly the hardest part is that I feel like it just is so confusing for you all.

And I get really upset on the anti-Kegel group because we have so much evidence around pelvic floor muscle training.

Yeah, have we overly leveraged it for sure?

In pelvic, have that been a big part of our identity of who we are for a really long time?

Yeah, but we're not there anymore.

I don't think that I know a single provider who the only thing they ever recommend is pelvic floor strengthening now.

Like that was where we were 10 years ago because that was where the state of the evidence was, but that's not where we are now.

Um, and so I'm a pro-Kegel when necessary.

And I think that there is nobody who needs to be anti-Kegel.

That's just me.

And I would gladly go on one of those entertaining debate things to be the, but I'm only gonna be the pro-Kegel side.

I'm not gonna be the anti-Kegel side.

And so I hope I kind of did this as a snapchat episode, but I hope that that clears up any of the confusion that you might be having on, you know, is Kegel's right for me?

Especially during pregnancy and especially within the domain of exercise and fitness.

You have such strong intuition around what your body is ready for and what your body is doing.

I talked about how we've seen the shift between pregnancy-driven exercise recommendations and going to more symptom-driven recommendations.

I feel like this is another one that really kind of fits beautifully into that latter category where we have some understanding on the prevention side of who might be the best person to be in that prevention bucket.

Um, and if you are not, then you can kind of prioritize general or global fitness.

I hope you all found that helpful.

If you have any other questions, comments, or concerns that you want to bring up to me, please let me know.

I feel like this is gonna be another big area where we're gonna see a lot of shifts and a little bit more nuance come into the research as well.

Um, this is an area that I'm kind of looking at, not with respect to prevention postpartum, but just about exercise recommendations in general.

And I'm just really excited for where we're gonna be.

Have a wonderful week, everyone, and we will see you all next time.