I was very excited to see that Cross Fit HQ came out with an article earlier this month that provided some strategies for coaching pregnant women. The article gave much attention to diastasis recti, an issue that I believe more coaches should be educated on. It even provided helpful guide for scaling as a free download. Please take some time to read the article and the free guide, especially if you’re unfamiliar with scaling methods and you have pregnant and postpartum CrossFitters in your care.
Pregnancy: A practical guide for scaling
There are a number of issues that concern me, however, about the coaching and care of pregnant and postpartum women that still need to be addressed. First is the categorization of pregnancy with typical injuries. In the article, Nicole Christensen writes,
“Over the years, countless women have contacted me to inquire how they should train while pregnant. They often explain that their coaches can’t guide them because they’ve never been pregnant and don’t know how to scale for pregnancy. I’ve never broken a foot, had shoulder surgery, recovered from cancer, lost a lung in an accident, had a vasectomy, herniated a disc or cracked a rib, but I’ve coached people who have. You don’t have to experience pregnancy to scale for it; you just have to apply sound CrossFit principles: Work within pain-free range of motion to preserve the intended stimulus and movement patterns whenever you can.”
I do believe with the correct education and support, any coach who has not been pregnant can safely coach pregnant and postpartum women. However, there is a lack of knowledge on the part of coaches about how to consider pregnancy and how to coach clients through it. Pregnancy is different than an injury. It is a whole body change that adjusts hormones, circulation, digestion, weight, heart-rate, center of gravity, balance, connective tissue quality, shape of the musculoskeletal system, and much more. I can’t think of a common injury that affects that many body systems. And furthermore, the sound Cross Fit principal of working “within pain-free range of motion to preserve the intended stimulus and movement patterns whenever you can” isn’t actually all that helpful. For example, when I was pregnant, there were many safe and non-harmful things I needed to do to survive (like pooping, standing, getting up, walking, etc.) that now felt weird and painful. And there were many very unsafe things that I did that have contributed to lasting physical harm (like kipping and double-unders) that were not painful at all during my pregnancy.
Second, there is an assumption on the part of coaches that pregnant women are receiving quality practical education from the medical community on what they should and should not be doing while pregnant or postpartum. From my experience and from the experience of many moms I know, this is not the case. The general information given to many women including myself is the following: 1. Anything you were doing consistently before pregnancy is ok to do while pregnant. 2. If it hurts, stop it. 3. Listen to your body. Postpartum, I heard similar things plus: 4. If it makes you pee or bulge, stop it. While there is a purpose for standard advice, it doesn’t really help practically or restore folks to their lifestyle or sport. Seriously, if I hear one more person say “listen to your body,” I might lose my shit. What does that mean exactly? Are there going to be bodily alarms that go off every time I do something that’s bad for me? There were many things that I continued to do throughout most of my pregnancy (like pull ups and double-unders) that likely contributed to my DR and pelvic issues, but it never felt wrong to me while pregnant. As I mentioned before, there were other normal daily activities that felt so very wrong because in the third trimester, everything feels awful. Moms need visible or tactile, measurable, individualized indicators to have the safest and fittest pregnancy and postpartum experience. Please no more of this “listen to your body” crap.
Third, many modifications that were suggested in my experience were to protect the baby and not me. I was told over and over by well-meaning folks including PA friends and some coaches that if I did X, it would hurt the baby. I don’t remember any suggested modifications for my own sake. My kid came out strong and kicking like a mini warrior ninja princess and I was the one who was trying to stuff my guts back into my broken body. There aren’t many folks out there coming up with lists of postpartum scaling guidelines either, because once the baby is out, who cares? Far less craps are given about mom than baby. I’m not suggesting that coaches, doctors, and physical therapist should not address concerns for baby; however, baby’s thriving is dependent on the mothership’s wellbeing inside and outside the womb. If you take care of mama, you’re taking care of baby.
Fourth, postpartum care–in general–is crap. I was in labor for over 33 hours with nurses yelling at me for sneaking in food (did you study nutrition in nursing school?), pushed for over 3 hours, tore terribly, and nearly passed out multiple times before my baby was delivered with the help of forceps (think salad tongs in the vagina to pull baby’s head). I received no special instructions or descriptions of what I should expect my recovery to be like. They just sent me home bleeding, incontinent, still looking pregnant and repeatedly told me that everything I’d experienced during labor and postpartum was normal. I had to bother the crap out of my doctors just to get someone to both acknowledge and provide care for my abdomen and pelvic floor. I am not the only one with this experience. Most women go to a doctor or midwife after about a month and a half and are “cleared” for working out. And that’s it. Doctors don’t assess pelvic strength, analyze alignment, check hip stability, or even conduct observations of patients doing the typical movements they want to return to. They simply aren’t trained to do that. So why are doctors clearing mom’s for fitness?
If a mom is lucky, she’ll get to work with a physical therapist, someone who can actually help address muscle weakness, lack of coordination, breathing, and alignment. The problem is, if a mom is lucky enough to have a women’s health physical therapist in her area, it doesn’t mean that the therapist has an extensive sports background. So, she might do some exercises like the heel slide and clams for months and then be released back into CrossFit, running, etc. OR she might be given a standard list of things she should never do again. I’d like to suggest an alternative physical therapy progression for every single mom, especially athletic ones
1. Restorative exercises (clams, heel slides, pelvic tilts, bent knee marching on back)
2. Restorative exercises + drills focused on desired functional movements (breathing and alignment focused training to transition into desired movements)
3. Functional movements with modifications such as restricted ROM, no weight, slow speed (going through movements with focus on correct breathing, alignment, and muscular engagement)
4. Cautious reintegration back into sport pursuing gradual building back up to new postpartum capacity
If moms with extensive postpartum issues are only helped with the first step and not taken through 2-4, she will most definitely experience symptoms when heading back to CrossFit, Zumba, triathlon training, etc. In most cases, there will not be anyone with enough knowledge to help her. For example, let’s say a postpartum mom starts leaking while doing box jumps. She either stops doing them or a coach tells her to stop and switch to step ups. In most cases, that’ll be the end of it. She may have the physical capacity to do a box jump without leaking, but there isn’t someone to figure out what exactly isn’t working for her. Is her transversus abdominus engaged? Does she just need to work on pelvic strength for a few months? Is she coordinating her pelvic floor and diaphragm? Is she holding her breath? Or should she stop impact altogether because her bladder is about to fall out? Telling moms “just don’t do that anymore” is sometimes great advice if the cause of the leakage can’t be fixed by training. But what if she’s leaking because of a coordination issue? That can be safely trained. She might not have to give up something she loves if she just receives some specific coaching. The goal should be to return her safely to all possible movements acknowledging it might not be possible in all cases.
I was given the standard list of things not to do after bladder prolapse. I figured it meant that I shouldn’t do those things until I healed further. I vividly remember the day when after months of physical therapy, I asked my therapist, “When will we start a jumping or running progression?” She gave me a puzzled look and reminded me about the list of restrictions. It took me a second to process that I wasn’t ever supposed to do those movements again. No running, no jumping, no impact, ever. I’m not sure if I thought it or said it outloud, “Then what hell have I been doing here?”
Here’s the problem with postpartum care. Between doctors, physical therapists, and coaches, there are either assumptions that someone else is teaching mamas about that stuff or there are standardized restrictions imposed in order to err on the side of safety because many providers don’t know how to help a postpartum mama back into CrossFit safely. So this puts a mom in a scary world of figuring out for themselves what their doctor, PT, and coach could not figure out OR she’ll say “screw it!” and not comply to the restrictions very possibly injuring herself further. I’m not sure who is responsible for better care. I don’t think it’s quite fair to expect doctors to have physical therapy training, or women’s health physical therapists to have specific sport training, or coaches to know how to help with every postpartum medical issue. However, a good OBGYN better damn well know when to refer patients to PT, and PTs would help clients better if they knew some quality area coaches, and coaches should be able to recognize symptoms indicating clients should go see a physical therapist or doctor.
With all the women flooding into Cross Fit over the past decade, it’s an issue that all Cross Fit gyms need to be aware of and be prepared to address more fully than providing a scaling chart. One possible solution? Mama on-ramp courses. I’ve seen these work. Just to be abundantly clear–I’m not referring to those classes where the “hot mom” by virtue of her 6pack abs leads all the other lazy dopes through tough-ass workouts to whip them “back into shape”, as if the only thing keeping postpartum moms from fitness is their lack of work ethic. Instead, one women’s health conscious coach has a close working relationship with a women’s health physical therapist in the area. Together they design programs to help reintegrate moms safely back into CrossFit classes. Mama on-ramp classes would include general strategies that most moms will find helpful (i.e. how to breathe when lifting weights postpartum) as well as individualized strategies for specific struggles (i.e. “What visible or tactile indicators show me that a movement isn’t safe for me right now?”). If a client presents an issue beyond the coach’s training, clients are referred to the physical therapist. If a gym is rather small, this program could be shared between a few local gyms. Coaches and physical therapists could host classes and seminars at various boxes in an area…I could ramble on and on. I think this is do-able.
These problems won’t go away. CrossFitters will continue to have babies and will want to go back to CrossFit. Keep up CrossFit, PTs, and Docs! Mamas need your help!