Special guest post today for you, reader!
Ashley Kochanek Weisman, MD reached out to me a couple months ago with a heartening message about how my pregnant athlete material had resonated with her and had been useful through her three trimesters of skiing, climbing, and running. When she was in town for a visit a few weeks later we connected over coffee and it must have been something to overhear. We bantered about evidence on performance and pregnancy, she nursed her fresh babe, and she recounted some amazing pregnant ski trips as well as her fast return to training postpartum.
Ashley holds a BS from Yale and received her MD from Harvard. She now practices medicine as an emergency room doc in Western Washington. This brainiac also has a penchant for alpine climbing, backcountry skiing, and ultra running - as well as a brand new baby. She and I both approached our decisions about pregnant athleticism, birth, and postpartum using peer-reviewed science and our deep levels of self-knowledge. And guess what: as similar as our experiences as pregnant athletes might have been our choices about where and how to birth were quite different!
When I asked Ashley to write a guest post for this here blog I had no idea how funny it would be. Please enjoy her tales of the birth send and how she navigated her glorious ten months of blood doping through the lens of her scientific mind below. Ashley's deep trust in herself as an athlete and the evidence around pregnant athleticism are notable.
"I think this is the SEND!" shouted my dudela/climbing partner/husband Dan, “I can see his head!”
I started laughing, took a deep breath, and pushed out our son. Pushing was hard and counterintuitive: It involved relaxing the glutes, hamstrings, quads and abdominal muscles that I had trained throughout my rock, snow, and trail-filled pregnancy. The delivery wasn’t graceful but felt damn good; if labor was an undulating 50k mountain run, pushing was a 5.10d offwidth finish. Little guy nailed the birth canal couloir descent into the hands of a family medicine resident, coached by an attending obstetrician, with a senior nurse and nursing resident in the active audience. Now everyone was laughing.
On my chest was a healthy baby born in the most natural way my pregnant-doctor-patient-athlete could imagine—in a quaternary care hospital with a level 4 NICU amongst a throng of doctors, nurses, and medical trainees learning by doing, with lots of references to skiing and climbing epics, without anesthesia or analgesia or a doula. This is certainly not everyone's picture of natural, but it was mine. Like the rest of my patient-doctor-athlete pregnancy, the birth was an amalgam of evidence-based medicine, medicine with no evidence, and instinct-guided winging it, all taken with a beginner’s mind and openness to change.
I started pregnancy as an emergency physician, ultrarunner, climber, and skier, 100% confident in the medicine I had learned from my physician parents, medical school, residency, and years of clinical practice. I was ready to abide by science and obstetric and pediatric society guidelines to the letter of the law. After my first positive home pregnancy test I dove into the medical literature to construct a list of dos and don'ts. Some recommendations were solid––don’t smoke or binge drink, minimize exposure to radiation or teratogenic diseases, get a flu shot, don’t gain too much or too little weight. Yet there was woefully little guidance on my definition of exercise--hours spent running, climbing and skiing––during pregnancy.
What do we know about pregnancy and exercise? By my best literature review, we know that healthy maternal lifestyles are good for moms and children. We also know that running does not lead to differences in birth weight percentile or gestational age. We know that pelvic floor muscle training in antenatal and postnatal periods can reduce incontinence. There is, however, no conclusive evidence showing significant reduction in gestational diabetes, preeclampsia, or perinatal depression from maternal exercise.
I concluded that there was no convincing evidence to stop my rigorous schedule of emergency medicine night shifts, distance running, climbing, and skiing. I also appreciated the counterpoint: there was no evidence that this was better than taking it easier. Of course, absence of evidence is not evidence of absence. In the case of pregnant athletes, there is much we have not studied and many topics we have studied inadequately—tiny sample sizes, retrospective methods, and leading hypotheses. For example, Kuhrt et al’s 2018 study of running in pregnancy is titled “Is recreational running associated with earlier delivery and lower birth weight?”. They could have asked: what is the effect of pregnancy on birth weight and delivery or is running during pregnancy associated with any number of untested, more positive outcomes like fewer epidurals or C sections or shorter recovery times, or less incontinence due to stronger pelvic floor muscles? But they didn’t.
So, I signed up for a fall trail race to celebrate thirteen weeks and booked backcountry ski trips to Japan for week twenty-two, Crested Butte for week twenty-six, and New Hampshire for some third trimester nordic. I found an awesome obstetrician who thought this plan sounded reasonable and FUN (bonus: she came to our first appointment in a dress covered in little skiers). We agreed that we were in a largely data-free zone but also acknowledged the benefits and risks of my plan.
Benefit: I was starting pregnancy with a high level of fitness and a demanding job and continuing this level of activity would make me happy and keep me fit for postpartum adventures.
Risk: Trail running, climbing, and skiing can injure moms and fetuses. We can take measures to mitigate this risk but these pursuits are incontrovertible riskier than a brisk walk. I agreed. I CHOOSE regular doses of prenatal athletic euphoria (with added risk of injury) over the statistically safest plan (fall and exhilaration free walking). Nothing like pregnancy and parenting to make you eat your words. I was hardly “following guidelines to the letter of the law”.
As I continued to see pregnant patients and field questions (and criticism) about my pregnancy decisions and others, I realized that patient and doctors rarely lead lives of pure science or non-science. We choose practices from evidence-based medicine, experience, anecdote, faith, and instinct. Sometimes our decisions follow science but our next decision may disobey evidence and feel just as right. In my own delivery, I chose a very medicalized setting out of anecdote and comfort (I love hanging out in hospitals as a provider or patient) as much as evidence (delivering in a hospital is a safe, evidence-based choice). I chose NOT to have a doula against evidence and trusted my adventure partnership with my husband and years of experience with and faith in medical trainees. I chose no pain control based on my love of physical challenges and very modest evidence.
Back to full schedule of ER shifts and athletic objectives three months postpartum, my lived experience as a postpartum patient-doctor-athlete has shifted my thinking. When I meet a pregnant women or a parent in the emergency room or on the trail somewhere between science, experience, faith, and the summit, I think:
HIGH FIVE! Pregnancy, breastfeeding, and parenting are freaking hard and very fun. RESPECT, for anyone trying their best for their family.
Check your biases at the door and listen. Medical choices in pregnancy and parenting are complicated and influenced by many factors (scientific evidence, absence of scientific evidence, anecdote, experience, the internet, mother-in-laws, and just about anything else). Despite beginning this journey as one of the most medicalized people out there, I made several choices based on faith in the exhilaration of mountain athletics and other choices based on science and was happier for it. My job is NOT to judge but to understand and help you be a kick ass pregnant athlete and backcountry parent.
My name is Ashley, I am a runner, climber, backcountry skier, and emergency physician. This post represents my personal experience and opinion. This is NOT medical advice. Please consult with your truest self and your obstetrician or midwife before making your own decision regarding pregnancy and postpartum athletics.