When Rachel Selman got pregnant with her first child in 2017, she sought advice from multiple sources on safe forms of exercise. The 31-year-old physical therapist spoke to her doctor, and she reached out to friends who are personal trainers and physical therapists. To her frustration, everyone shared a different opinion.

In the end, the former college soccer player listened to her doctor, who advised her to keep her heart rate below 140 beats per minute, lift no more than 25 pounds and avoid core workouts so as not to aggravate any abdominal separation that can occur during pregnancy. That meant Selman, who prior to pregnancy went to the gym 4-5 times each week, couldn’t even lift a barbell or run because her heart rate would surpass the recommended limit. Instead, she did occasional light lifting.

“I lost so much endurance and [musculoskeletal and cardiovascular strength] that I had been working really hard for as someone who had been active,” Selman told Women’s Running, while explaining that body changes during pregnancy also proved difficult on her mental health.

Three weeks after giving birth, Selman started to feel recovered and eager for some physical activity. Again she asked her healthcare provider how to proceed. They advised her to listen to her body and avoid running through any pain, she said. So, for the first time in months, Selman set out for an easy 10-minute run around her neighborhood. “I felt fabulous during the run because my brain was lighting up,” she said. “Then I came back and I felt horrific, like my organs were falling out of my body.”

In a panic, the Charlotte, North Carolina mom of two started googling her symptoms and worried she had uterine prolapse, a condition that occurs when pelvic floor muscles and ligaments stretch and weaken until they no longer provide enough support for the uterus. Seeking some guidance, Selman reached out to a friend from physical therapy school who specializes in pelvic health. She put Selman’s fears at ease and advised her to scale back the activity level and instead focus on healing, which included a set of pelvic floor exercises. Over time and with consistent physical therapy, Selman started to feel better. The experience also prompted a big aha moment for the new mom.

“If you sprained your ankle, I wouldn’t put you in a boot and bedrest for six weeks and then tell you you can go do sprints. There’d be a workup,” Selman said. “It’s crazy that we do that with pregnancy postpartum because it’s a super long event. Your muscles go through a ton. There should be some kind of step-wise rehab protocol, the same way we have for other conditions.”

Inspired by her own difficult experience and with the help of clinical professionals and fellow moms, she created a protocol that covers the first trimester through 13 plus weeks postpartum. In October 2022, the researchers’ findings on maximizing recovery in the postpartum period were published in the International Journal of Sports & Physical Therapy. The first of its kind study shares a rehabilitation model that assesses the full spectrum of pregnancy to postpartum with safe exercise progressions aimed to reduce postpartum symptoms and optimize performance during moms’ return to exercise.

Related: Runner’s Guide to Pelvic Floor Pain

Normalizing Pelvic Floor Health

The conversation surrounding maternal health and wellbeing among athletes has been gaining significant traction in recent years. A handful of elite runners, including seven-time Olympic champion Allyson Felix and 800-meter Olympian Alysia Montaño, have created nonprofits that support athlete mothers and pushed for the addition of maternity protections in professional athlete contracts as more women seek to extend their careers postpartum.

RELATED: Two Years In &Mother Keeps Removing Barriers

Amid the progress and increased awareness, there’s also been a dire need for more research in areas of pelvic health. Selman hopes their study can be a stepping stone for healthcare providers and encourage patients to utilize physical therapists that specialize in pelvic health, a concept that isn’t considered standard practice today.

To help fellow moms avoid making similar mistakes based on little guidance and conflicting information, Selman shifted her career focus from sports medicine and orthopedics to pelvic health in 2018. She started treating pregnant and postpartum runners by helping them stay active, return to activity, and remain healthy throughout the child-bearing process. “It was mental rehab for me to help other people go through the same thing, but with better advice,” she said.

In doing this work, Selman was continuously reminded of how little information exists on safe activity and rehabilitation for pregnant and postpartum runners. The lack of clinical research on pregnant women in general has been referred to as an “overarching problem” that public health experts trace back to a precedent set by a pregnancy drug crisis in the 1950s, which ultimately led to tightened drug testing regulations that blocked pregnant women from most U.S. clinical research trials for decades, according to NPR.

While beginning her research, the only resource Selman could find was a set of postnatal running guidelines and recommendations published by three healthcare providers in 2019. As Selman pointed out, the guidelines share important insights, but the article isn’t peer-reviewed and doesn’t provide a week-by-week program for runners to follow.

The lack of research was the biggest hurdle Selman had to clear. To include a wide range of clinical knowledge and expertise, she partnered with specialists in obstetrics, gynecology, urology, and strength and conditioning, who contributed their insights to the study, which includes several focuses (cardiovascular, neuromuscular, strength training, and pelvic floor, for example) and recommendations for each stage of pregnancy and postpartum. Once the protocol was created, they conducted a case series that included six women who completed it. Throughout the process, Selman worked with the research participants to determine how they responded as they navigated the protocol. In the end, every mom experienced significant improvement in their strength, endurance, control, pain levels, function, and urinary symptoms. “They all saw pretty much full resolution by 12 to 16 weeks postpartum,” Selman said.

RELATED: Why Runners Need Pelvic Floor Therapy

The Power of Daily Goals and Progressions

The study begins by outlining the benefits of physical activity during pregnancy, which include a decreased risk of developing gestational diabetes, pre-eclampsia, hypertension, depression, and both prenatal and postpartum incontinence, among other conditions. It suggests cardiovascular activity, including running, is no longer limited to 140 beats per minute. Instead, it’s recommended that clinicians use a rate of perceived exertion scale (from levels 0-10) to assess moms’ activity during the first to third trimester, when they should aim for a light to moderate (1-4) cardiovascular effort.

Notably, the study also makes a case for safe exercises starting within the first two weeks of giving birth. The six-week postpartum check-in with the doctor is usually when moms receive medical clearance to return to physical activity, but often with little to no guidance on ways to navigate a safe return to exercise. The study suggests appropriate musculoskeletal interventions, including pelvic tilting and breathing exercises, clam shells, bridges, and a gradual walking buildup, among other exercises, can begin right after giving birth to help minimize postpartum symptoms.

When Joanna Wishart started seeing Selman for physical therapy at 28 weeks pregnant with her third child, she was suffering from severe pelvic pain. She also experienced urinary incontinence while sneezing and on her runs after her first two pregnancies. Prior to taking part in the study, Wishart considered dialing down her running goals, believing her postpartum symptoms were her new normal. But after completing the protocol, all of her symptoms went away and she felt better prepared in her return to exercise, she said. At 12 weeks postpartum, Wishart was able to do squats and lunges without peeing herself.

“I feel better now than I did after my second pregnancy,” Wishart told Women’s Running, explaining that she experienced debilitating lower back pain while carrying her second child. “I never thought I would say that. I thought my body was where it was and that’s what I got. I didn’t know there were professionals that can help you feel better and heal your body.”

Now the family nurse practitioner refers patients to Selman’s program and other physical therapists that specialize in pelvic health.

Providing Mental Health Benefits

Kelsey (requested her last name not be included because of her husband’s security role in the military) received a pelvic floor evaluation from Selman when she was 20 weeks pregnant with her second child. After having her son, Jack, she immediately started working on the return to running protocol.  Kelsey, who describes herself as smaller framed, had two 9-pound babies, which resulted in prolapse issues. “It was devastating because I didn’t know what was going on, what I was feeling, if I was ever going to feel normal again,” she told Women’s Running.

Selman’s own experience and expertise became crucial in Kelsey’s rehabilitation, which she navigated carefully given her challenging postpartum symptoms. Kelsey said they worked on breath work and biofeedback techniques, among other exercises, to help heal her pelvic floor muscles. Around four to five months postpartum, she was symptom free. She even completed Run Across Georgia, a 277.2-mile relay run across the state, when Jack was 6 months old.

Compared to her first pregnancy, which resulted in SI joint pain, Kelsey’s second pregnancy experience was “like night and day” thanks to the protocol, she said. It provided an outline to help ease her symptoms while making her feel safe and empowered in listening to her body’s cues. The protocol’s planning process and progression also provided key benefits to her mental health during a time that can feel isolating for many moms. “I was like Humpty Dumpty, and they put me back together again because all of that is tied into your worth,” she said.

At 13 weeks pregnant with her third baby, Kelsey said she’s looking forward to continuing the protocol and hopes more moms benefit from it. “Women cannot be dismissed for things that are not normal,” she said. “It’s not okay to pee yourself when you sneeze. It doesn’t have to be that way.”

Making the Program Accessible

Now Selman hopes the study acts as a springboard for more extensive research that includes bigger groups of participants who’ve had c-sections versus vaginal births, for example.

“Everything you publish is not going to work for a hundred percent of people a hundred percent of the time, but when we get this information out there, that’s the way we start improving the landscape,” she said.

The next step in Selman’s goal of standardizing the protocol is an app she and partners created called Stirrups to Sit-ups, which launched on the Fitr platform on January 25. The app provides daily exercises, movements, and tips throughout the pregnancy and postpartum journey in an effort to make the research more accessible, so more moms can move forward in a healthy way.

“There’s so many women who just never get back to that level of activity that they really enjoyed and were benefiting from,” Selman said. “Hopefully this bridges the gap for them.”