I met Amanda about a year ago. A CrossFit athlete who’d trained throughout her pregnancy, she believed she’d done everything right. She’d listened to her doctor, her coaches, and her body. Sure, she had the occasional leak here and there, but she brushed them off as a normal part of pregnancy.
Six weeks after giving birth, Amanda received clearance from her doctor to resume her workouts, as many women do. But this time things felt different.
She realized that her core was caving inward. She started leaking more frequently during her training sessions. And she noticed what felt like “marbles” rolling down her vagina.
She sought out a physical therapist specializing in the pelvic floor. The news wasn’t what Amanda wanted to hear.
She was diagnosed with a hypertonic (overactive) pelvic floor and organ prolapse. Her therapist couldn’t assess the degree of her prolapse because her pelvic floor muscles were far too tight.
The therapist suggested Amanda suspend her strength training. Naturally, this was a hard blow.
That’s when Amanda hired me. During her initial assessment, I could hear the sadness in her voice. She felt her body was broken and blamed herself. At one point when I was checking her core, she jumped up at my touch and had to use the washroom.
In our first session, I had Amanda do the usual pelvic floor exercises—glute bridges, clamshells. I could tell Amanda was less than enthusiastic about this gentler program. She is, after all, an athlete at heart.
So I made a decision that would change the direction of my career. I put a barbell in her hands and got her lifting.
Amanda’s body language changed instantly. For the first time in a while, she was hopeful. I scaled back the standard rehab moves and taught her strategies to manage and heal her pelvic floor.
Amanda is hardly alone. There are lots of women out there just like her. They crave higher-level training and are bored and discouraged by traditional pelvic floor rehab, which feels like a massive step backward.
That’s why I switched my focus from everyday moms to postpartum female athletes dealing with pelvic health issues.
I focus on my clients’ strengths, not their symptoms. Your client, not her condition, comes first. That’s what I learned from Amanda. If they enjoy lifting, I’ll work with them to include it in their program in a safe, restorative way, because women heal best when they feel empowered.
I’m not saying there’s a quick fix. There isn’t. Depending on the severity of your client’s symptoms, it can take a year or more for her to get back to her 1RM, much less achieve a new PR. But those goals are possible, and these strategies will keep her moving toward them.
But first, a quick anatomy lesson.
What Is Pelvic Floor Dysfunction?
It’s when your pelvic floor muscles aren’t working right. (Aren’t you glad we cleared that up?)
Your pelvic floor isn’t actually very floor-like. It’s more like a pelvic hammock, spanning from your tailbone to your pubic bone and supporting organs like the bladder, bowel, and abdomen.
When the hammock works like it should, it holds those organs in place and helps prevent leakage. But if it isn’t functioning properly, things can get pretty screwy (and more than a little damp).
Sometimes the urethral muscles are affected, causing leaks. Sometimes bowel control is compromised, causing … other leaks. And sometimes you get prolapse, when the organs inside the pelvis slip from their normal spot and bulge into the vagina.
Pregnancy and childbirth can trigger it, but in fact many things can bring the condition on: aging, chronic coughing, even heavy lifting. In fact, some one in three women have pelvic floor disorders. It affects more women than high blood pressure, diabetes, or breast cancer, but you don’t hear about it nearly as often. I mean, it’s not exactly cocktail party conversation.
But you will have to bring it up. Which brings us to the first item on our list of postpartum training do’s and don’ts.
Do: Ask your client’s consent to talk about it
Asking clients about their private areas can be uncomfortable. The only way to get past this is to ask for her consent. Ask for it early; ask for it often.
Here’s a script I’ll use:
“I see you’ve had a baby recently. Congratulations!
I’m going to ask you some questions that may seem personal. If you’re uncomfortable at any time, it’s 100 percent okay to tell me you don’t want to answer, and I’ll stop. Is that okay with you?”
Explain what the pelvic floor is and its anatomical purpose. Tell her that pelvic health symptoms can be common after birth and that there are things you can do to manage them and keep the pelvic floor safe during training.
Sarah Ellis Duvall, PT, DPT, CPT, recommends literally pulling out an anatomy book during this talk. Not only does this make it easier for the client to visualize what you’re explaining, it also makes the conversation feel less personal.
Don’t: Do anything without professional guidance
Next ask if your client has a pelvic floor physical therapist (physiotherapist in Canada). If she does, great!
But there’s a good chance she doesn’t; plenty of women are unfamiliar with pelvic floor physical therapy. In fact, it’s entirely possible that no one, not even her doctor, has asked about her pelvic floor function, much less explained treatment options.
While pelvic floor problems are common, they’re not normal, as many pregnant and postpartum women assume. And for anyone experiencing these symptoms, they can and should seek treatment.
In my opinion, seeing a pelvic floor PT is the best way to start.
If you need help finding one, try the American Physical Therapy Association. (And if you plan on training women with pelvic floor issues, I suggest you make some friends in that field.)
Have your client book an appointment and be sure she receives assessments both while lying down and standing up. Many therapists don’t think to do a standing assessment, but you don’t do many lifts from a supine position.
The therapist can provide your client with training guidelines based on the assessment results. For example, the therapist may recommend avoiding a wide stance, or single-leg or lateral moves, all of which are problematic for women with prolapse.
When one of my clients complained of incontinence and pelvic pain following her workouts, I collaborated with her physical therapist to come up with a routine where I’d have her lie down during breaks and focus on relaxing her pelvic floor.
Don’t be afraid to reach out to the physical therapist directly. Introduce yourself. Ask to have a copy of the assessment emailed to you. Make it clear that you want to work together for your mutual client’s benefit. In my experience, physical therapists respond very well to that.
READ ALSO: “Top Five Things to Know About Post-Pregnancy Clients”
Do: Coach her to do Kegels
Most women have heard of a Kegel, but that doesn’t mean they know how to do one.
They may squeeze too hard or too much, possibly leading to an overactive pelvic floor. Or they may be pushing down instead of lifting up and in.
A proper Kegel contraction should feel like you’re lifting your vagina and anus up and into your body, like you’re trying to pick up a marble using those muscles.
You hold it isometrically, and then relax the muscles. Both phases, contraction and relaxation, are critical for strengthening the pelvic floor. As Duvall explains in this video, it’s no different from building the biceps with arm curls: If you can’t work the muscle through a full range of motion, shortening and lengthening it, you won’t get all the benefits of the exercise.
To make sure your client is doing her Kegels properly, you need to be comfortable asking about it. Encourage her to work on them with her physical therapist. (Good thing you’ve made sure she has one!)
I like to have my clients work on Kegels by incorporating a diaphragmatic breath (aka connection breath, piston breath, and/or core breath). I usually have the client lie on her back, but she can also do this seated, side lying, or standing.
- Have her lie on her back with knees bent and feet flat.
- Tell her to imagine pulling her hip bones into her belly button. (This cues her to activate her transverse abdominis, providing extra protection and stability.)
- Now have her inhale through her nose, drawing breath up into and expanding the ribcage.
- Next have her exhale through her mouth (as if she’s blowing through a straw) while performing a Kegel, gently contracting her pelvic floor (20 to 30 percent of max effort is all it takes).
Big caveat here:
If your client has a hypertonic (overactive, excessively tight) pelvic floor, she may not be ready for Kegels yet.
That’s okay. Simply scale back the load until her PT gives the go-ahead to start doing them. At that point, you can work on building strength and endurance and gradually add back load.
Until then, she should focus on “reverse Kegels” — relaxing her pelvic muscles.
Don’t: Have her do the Valsalva maneuver
You’re probably familiar with the Valsalva maneuver, in which you hold your breath to stabilize your spine during heavy lifts. It puts a lot of pressure on the pelvic floor, which is bad news for a woman who’s still healing that area.
One solution is to teach your client a modified version of the Valsalva. I like to use Julie Wiebe’s “blow before you go” cue, telling clients to exhale slightly just before a lift. This relieves a bit of the intra-abdominal pressure.
But if even that is too much for your client, you may need to scale back the intensity to avoid any kind of breath holding. Once your client is symptom-free, you can reintroduce the Valsalva into her lifts.
Do: Incorporate Kegels into lifts
Cuing her to exhale slightly and do a Kegel before her lifts can help provide support. I’ll use the barbell deadlift as an example.
Begin with about 50 percent of her former 1RM. (If she doesn’t know her 1RM, aim for a weight she can use for 10 to 12 reps without straining.)
- Have her stand with her shins against the bar, as she normally would, with her ribs stacked over her hips. (Depending on her symptoms, she may want to use a narrower stance.)
- Have her hinge forward, maintaining a neutral alignment.
- Have her grab the bar and inhale.
- A split second before the lift, she should exhale slightly (“blow before you go”), perform a Kegel, and then complete the lift.
It may take her a few tries. But once she has the hang of it, she can use the technique when lifting anything—a barbell, a baby, a grocery bag. I encourage my clients to use it in their everyday lives for practice.
But once again, if she’s not ready for Kegels yet, do not have her do them during lifts. She may need to work with a lighter load until her therapist gives her clearance.
Don’t: Assume what works for one will work for all
Every woman is different. Each will progress at her own rate. I’ve had women who can add weight within minutes of learning this technique. Others may need several weeks before progressing. The goal is to find each client’s symptom-free zone.
Let her symptoms guide you. If she experiences symptoms during a lift, reduce the load by 10 percent and try again. (You can add reps with the reduced load.)
With my clients, I like to increase the weight every four weeks. But it’s always a judgment call. If she’s adapting well and up for the challenge, she may be able to add weight sooner. If she experiences symptoms, go back to the original weight and try again in a few weeks.
Do: Encourage her to take the long view
It’s natural for female athletes to want to pick up right where they left off, and it’s hard to accept when their bodies won’t let them. They may compare themselves to other postpartum moms who appear to have bounced back faster.
If a client makes a negative comment about her body or progress, I validate her by saying “I hear you.” Then I encourage her to talk. Most of the time, she just needs to process her feelings. It also helps to know she isn’t the only one who’s frustrated about her recovery process.
At the end of an intense or frustrating training session, I like having her lie on her back with her feet flat on the floor and do some diaphragmatic breathing for a few minutes. As she does this, I tell her to think about “opening up” her pelvic floor muscles.
It’s a positive, rejuvenating way to finish a workout.
Don’t: Think you’re an expert now
Don’t get me wrong: I’m really glad you’re reading this blog post. I hope it’s helpful. But please don’t assume you now know enough to train postpartum athletes. When it comes to a client’s health and safety, more education is always better.
There are some great resources out there. If possible, I recommend collaborating with a postnatal specialist, or at least a colleague who’s experienced in this area, until you’re ready to go solo.
I’ve taken and highly recommend the following courses:
- Female Athlete: Ready for Impact and High Intensity (Julie Wiebe, PT)
- Pregnancy and Postpartum Athleticism (Brianna Battles)
- The Female Athlete: Bulletproof Your Core and Pelvic Floor (Antony Lo)
- Snatch: A Female-Inclusive Approach to Kettlebell Training (Haley Shevener)
Remember, the more you know, the more confident you’ll be. And the more confident you are, the more comfortable your client will be.
Back to Amanda
After four months of training with me, Amanda saw her symptoms disappear. Her therapist was happy. Most important, Amanda was feeling like herself again.
We kept in touch, and about three months ago, I caught her performing a 265-pound deadlift for three reps. She was happy to report no leaking.
Amanda is now pregnant again, and we’re working together once more. She’s still lifting, but with a better understanding of pelvic floor health, she’s doing it in a safer way, scaling back to guard against any post-pregnancy pelvic floor dysfunction.
Don’t get me wrong: I’m not saying you should push your client to go all-out. But I’m not saying you should treat her with kid gloves either.
What I am saying is that you’re not restricted to corrective moves on a yoga mat or stability ball. Those exercises can have a place in your client’s program. But lifting has its place too.
Teaching a postpartum client proper movement mechanics for lifting will help strengthen not just her pelvic floor but her confidence as well. And as we all know, it’s useful for everyday life.
I thought about this recently when I helped my husband lift a heavy piece of furniture. If I hadn’t worked toward regaining my 1RM after giving birth to my own children, I might be the one looking for a postpartum training specialist.
So I know from personal as well as professional experience that women with pelvic health symptoms don’t want to be coached as if they’re permanently damaged. And they don’t need to be. They’re resilient, not broken.