Long And Short Term Potential Effects Of Early Return To Moderate- Vigorous Exercise Postpartum Part 1
There is no shortage of messages that pushes women to rush back to high level workouts ASAP postpartum. The question is, what are the risks and benefits of choosing to do so? It seems as if the story is different depending on with whom you speak and with what website you find. Finding answers about what to do and when can be exhausting. Let's talk about the Risks and Benefits of High Intensity Exercise during the early postpartum months. This blog will outline the Risks and Benefits. Part 2 will go over some tips and guidelines.
When I had my first child 10 years ago it was standard to wait 6 weeks whether you had a c section or uncomplicated vaginal delivery, and you would be magically cleared to return to your previous workouts. Recently, I have read some articles that say you can return to exercise within a few days of delivery and others that recommend the 6 week waiting period or more! It is impossible to not be confused. The Continence Foundation of Australia recommends a slow progression of activity and full resumption of prior level of activity at 16 weeks postpartum. The ACOG (American College of Obstetricians and Gynecologists) notes that there is a variance in what is an appropriate return to exercise based on the pregnancy and delivery, but does note that some can begin exercise within days of giving birth. It recommends exercises such as lifting weights, sit ups, push ups, yoga and pilates. It also recommends Kegels. The ACOG recommends women start with simple postpartum exercises (but doesn’t list a single one or any references) and suggests a progression to moderate and vigorous exercise. This makes it very difficult for women to make smart choices with regards to their postpartum return to exercise. The terminology- return to light exercise is vague and open to interpretation. How long should one take to progress to vigorous exercise? The timeline is variable based on several factors.
The Variables That Impact Return To Exercise Include:
The Short & Long Term Benefits of Exercise Postpartum
There are 6 guidelines worldwide that discuss the benefits of postpartum exercise. Some benefits include:
The Short Term Risks of Early Return to High Impact Exercise
The Long Term Risks of Early Return to High Impact Exercise
Take Home Message
There are short and long term consequences for everything and you cannot prepare for them all. We each need to take into account the long and short term benefits and risks of each choice. There is no dispute that in most cases return to light exercise (walking, proper breathing technique) is beneficial postpartum. But, when and how to progress to moderate-vigorous exercise is more complicated.
A c-section is major abdominal surgery. There are protocols of rehabilitation for many major surgeries. Most orthopedic surgeries require physical therapy afterwards. No one would have an ACL reconstruction and wing it after surgery. Why aren’t women encouraged to seek out physical therapy post baby?
A look at C-sections from the outside in
Scar tissue healing is a process and to heal optimally, it is imperative to address it properly. When scar tissue forms it lays down in a haphazard fashion that is mechanically inefficient in distributing forces. Massage helps to organize the tissue to heal stronger. Post ACL surgery, patients are taught how to massage the scar tissue to promote healing and prevent the scar tissue from binding down to the tissue below. Often knee and ankle surgeries get the most attention for scar tissue management as they can bind to the bone below easily. But, what about abdominal scar tissue healing or binding to lower musccular levels and/or organs? For optimal healing the scar not only needs to heal externally, but also needs to organize properly internally to help transmit forces placed on the abdomen properly. All women post c-sections should be educated on scar tissue massage.
The breach of the abdominal wall can impact breathing, and disrupt the muscle patterns of activation that support and stabilize the body during movement. If a person post ACL surgery is not out running at 6 weeks, why can a woman post c section be lead to believe she can/should run and do sit ups at 6 weeks without a conversation and evaluation by a specialist? The abdominal musculature of all pregnant women becomes stretched and mechanically inefficient during pregnancy. Adding a c-section surgery can further the dysfunction of the abdominal wall. The inner core musculature is pain regulated, meaning the muscles can shut down with pain. While our body's are very resilient, not all abdominal muscles return to a totally optimal state of activation post pregnancy and c-section.
Women who have had a c-section often are glad for the lack of trauma to their pelvic floor. However, if you had bowel or bladder leaking during pregnancy, pelvic pain during pregnancy or you pushed for an extensive time during labor prior to your c section it can be assumed you are at increased risk of pelvic floor dysfunction post baby.
What Should Moms Post C Section do?
Minimally, moms should be shown how to massage the scar tissue to optimally heal the tissue superficially and reduce the risk of internal adhesions (which can continue to develop well past the scar healing externally).
Women should see a women's health PT to assess their inner core pressure management strategy post baby to ensure proper abdominal activation.
Core exercises should be started with your spine in a neutral position and be progressed according to your individual ability to activate your core muscles during exercise once medically cleared.
Moms should be taught proper lifting strategies for baby right away.
There are many variables that impact whether or not a woman is ready to return to high impact exercise postpartum. I have written about this before and I am writing about it again because it is the number 1 question and frustration that moms ask me about during their sessions. I wanted to take the time to outline the abagueties that plague this topic.
Variables in definition
It is important to consider previous injuries that might impact your return to fitness post baby. Previous knee/back/hip injuries, pelvic pain and more might impact your ability to optimally return to exercise. If you were a “flexible” (loose ligament) gal prior to baby, chances are you're going to want to take more time for your body to recover postpartum before engaging in high load exercises that stress ligaments. If you nurse, keep in mind, your ligaments will stay loose a bit longer. If you had any issues prior to delivery (incontinence, back pain, S-I joint pain, or any complication during labor (long labor, extensive pushing, tearing, c section) it is possible that your body has developed a compensatory movement pattern that might put you at risk for injury/dysfunction even if the symptoms have subsided. Even if you have no overt symptoms, it is important for long term health to make sure your body is onboard with optimal muscle activation patterns to lessen the risk of a faulty compensation strategy and future injury/dysfunction.
Listen to your body. Do you feel pain, pressure or pulling? Remember it is NOT “No pain no gain.” Start slow. Take into account your previous injuries and general make up. If you are a loose ligament gal, go slow and make sure your mechanics are spot on. I truly do recommend a quick screen (by a physical therapist ) to assess your baseline breathing strategy and pressure management strategy with exercise. A pelvic floor assessment is ideal, but if that feels like too much, seeing a female health Specialist and getting a primary assessment is great. You want to receive strategies to optimize the potential of a successful return to high impact exercise. It is so much better to go into postpartum fitness educated about your own body and how to best harness it’s strengths and protect it for your future than go in blind and think you can run your way past pelvic pain or incontinence. If you are eager to return to your HIIT class please consider a session at a facility like Newburyport Wellness, LLC. You want to make sure that your pressure management system is working to keep your spine stable and dissipate forces appropriately. You also want to make sure that your hips are on board to optimally control high impact landing. Your long term health is worth the small investment in time now.
You were born breathing, but could your breathing strategy be working against you?
Task 1: When you are done reading this paragraph, close your eyes and sit or lay quietly. Imagine you are doing a squat. Can you imagine your hips and knees bending? Can you envision your glutes and quads turning on? Can you feel the drive from your feet up through your hips as you return to standing? Were you holding your breath or breathing throughout the motion? What was your torso doing?
Task 2: Can you imagine that you are doing a push up? Can you feel your chest and triceps working to control you downward and then power you up? Can you feel your core- your abdominals, back, and pelvic floor? What are those muscles doing? Were you breathing or holding your breath?
My guess is many of you could easily imagine the feeling in your legs with a squat and the feeling in your arms and chest with a push up. It is a bit more difficult to imagine how your breath and core contribute to the proper execution of basic functional and exercise movements. It is even more difficult for most people to key in to what your pelvic floor is doing.
The moral of the story:
Your core (abs, back muscles, pelvic floor muscles, fascial system (and more) are the epicenter of movement and yet we are often least connected with how it works to carry us successfully through day to day activity or how dysfunction in this system can effect the long term health of the remainder of your body. We often take breathing for granted and assume that breathing is a natural body function and that there is nothing to think about. However, it is easy for our body’s to activate a faulty breathing pattern to cover for weaknesses in other areas of our body. Breath dysfunction is NOT an issue isolated to adults. Children may have inefficient breathing and stability patterns too! Even though breath patterning is different when at rest versus sprinting, being aware of your breathing patterns and smaller muscle groups of the core is central to optimal physical health. Below I have listed just a few of the scenarios that may leave people at higher risk of breathing dysfunction. Remember that proper breathing patterns provide a dynamic yet stable platform for our body’s to work. And, inefficient breathing patterns may be impacting your function and long term health. Taking the time to re-establish a strong brain-body connection with your core and breath is invaluable!
Asthma: 26% of Americans have asthma. Even mild asthma can effect the way that people breathe from a young age. The importance of optimal breath patterning when at rest and with activity is critical for these individuals. Working to maintain optimal breath patterning participate at their highest level of activity with less overall strain. It will allow kids to better interact with peers and help to optimize core stability. 55% of women with asthma have been found to have urinary incontinence. This can effect quality of life and general happiness. The earlier young kids with respiratory dysfunction connect with their breathing and optimize pressure management the better.
Individuals with low tone: Muscle tone is not the same as muscle definition. Muscle tone is part of what helps us to hold our body in optimal posture. We all have muscle tone and there are low ends of normal and high ends of normal. Kids/adults with low tone might have slouched posture and really want to sit whenever they get the chance. Some signs of a low tone individual: you’ve had poor posture for as long as you can recall
Back pain: Some of the muscles of your deep core central breathing mechanism are pain inhibited. This means that if there is pain in that area, the muscle turns off. It doesn’t always turn back on efficiently when the pain dissipates. This can leave you at risk for additional injury. Proper breath is central to low back injury recovery and prevention.
Sports: This is the least recognized area of “breath centric” exercise importance in my opinion. Repeated ankle sprains can result in deactivation of the adductors (inner thigh muscles) and then core stability disruption can ensue due to the asymmetric pull of one adductor on the pubic bone or the disruption of specific patterns of muscle activation that act as key stabilizers of our body. This can leave athletes at risk of re-injury. Kids with mild asthma, low tone or generalized weakness status post growth spurt may develop sub-optimal breathing patterns that while developed to optimize a skill, is a poor substitution overall.
Incontinence: A little pee now. A lot of pee later or maybe even organ prolapse. Still so many women I meet, tell me they are just going to keep doing Kegels. We need to make this clear- Kegels are not the answer! The entire system of pressure management in the abdomen needs to work to avoid excessive pressure on your pelvic floor.
photos by John Hain
The 6 Week Return To Exercise Myth
For as long as I can recall the guidance has been women can return to exercise at 6 weeks postpartum wether you have had a c section or vaginal birth. Until I gave birth, I held issue only with post c section return to activity based on the fact that I could abdominal surgery whether c-section or anything else is never addressed from a rehabilitation perspective. Our core is our center of movement, breath and life force. How can it not need a proper reboot after surgery? Once I had my daughter, I realized that post partum recovery and return to sports is an individual process and NO blog, website or exercise guru give a guideline that is applicable to all.
The Guidelines Provided By the Return to Running Guideline
The Guideline suggests that running begin no earlier than 3 months postpartum when there are no symptoms of pelvic floor dysfunction (see Return to Running Part 1). It also recommends a pelvic floor assessment for all postpartum women to complete more formal testing of the abdominal wall and pelvic floor and functional movement. From a functional perspective it is recommended that women can walk a brisk 30 minutes without symptoms prior to running. It recommends grading the return to run with 1-2 minutes of running followed by walking for a few minutes prior to running again for 1-2 minutes, etc. This is slower than many moms want to go, but, I have to say, there is nothing better you can do for yourself than protect your recovery to prevent long term health issues. The guideline also takes into consideration breastfeeding. Evidence suggests that a woman's hormone profile leaves them more at risk of injury when still nursing. If you are a woman who considered yourself "hypermobile" prior to pregnancy, you may want to take it slowly and better yet, see a PT for evaluation prior to running.
The Bottom Line
Unfortunately, mommas, this manual does not give a global prescription to provide you with regards to a solid guideline for return to running or any high impact sport. This is the same answer I give at every talk or postpartum check up I perform. Everyone's body is different and their pregnancy and delivery is different. How your body responds to a return to exercise may be different than your best friend. The easy items to check off your list would be to make sure you are optimizing sleep, wearing supportive clothing including good sneakers, and good nutrition. The take home message is to take the pressure off of yourself to do it all the minute you are cleared to exercise and to seek out specialists to make sure you are covering all of your bases to protect your long term health!
A long time ago I wrote a blog about my return to running post baby #1. I learned some pretty significant lessons about the reality of postpartum return to exercise 10 years ago. I ran and did strength training to the last minutes of pregnancy (not high mileage or fast, so maybe a jog?) I learned that despite being in great shape prior to pregnancy I won no free passes in the healing process post baby. I learned that the path to recovery is NOT an event, but a process. (I say that about many things, but, it
There Isn't One Answer That Fits Every Postpartum Momma
Many of my clients are so eager to hit the road and return to pre-baby exercise and body ASAP after baby is born. I was there too. I get it. But, not everyone has the same pregnancy, delivery or postpartum experience. In an age where googling an answer to everything is possible, it isn’t fair to yourself to do that with postpartum recovery. It is really hard to hear that there isn’t a one answer fits all response to postpartum return to exercise. To be honest, I have felt a bit over-conservative at times. But, now there is a publication that lends support to the clinical reasoning I have shared with my clients over the years.
What Research Has Found About The Effects of Delivery on a Momma's Body
There is a group of rock star clinician’s who have dedicated endless hours into reviewing research and reaching out to other clinical experts to create a template for returning to running or high impact activity post baby! I am so grateful to these clinicians for organizing the hard work many of us clinicians have tried to do over the years on our own and taking it a step further to create a template for decision making. I am going to take a few weeks to go through some of the highlights with readers to help them better understand the importance of a postnatal wellness check, overall pelvic health and individualized return to high impact exercise. Read further moms that have big baby’s now. This info will help you understand your body too!
What happens to your body during labor & delivery (PS- this is not an exhaustive list. I could go on for pages about the potential short and long term effects of pregnancy and delivery on a woman’s body.)
This just highlights some facts to support my earlier blog about return to exercise post baby. Many of us need it for our mental sanity. But, we definitely need to ratchet back our expectations according to the signs our body is giving us. There is NOT a one size fits all return to exercise plan for all new moms. There isn’t even one for Veteran Moms who may finally be finding the time to exercise 3,5, or 10 years out. The faulty mechanics that can arise from birthing or injuries years ago might impact a women’s plan to return to exercise.
Signs That Your Body Isn’t Ready To Run (from Return to Running Postnatal Guidelines..):
Ceydeli, A., Rucinski, J. and Wise, L. (2005) Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 62, 220–5.
Goom, Donelly, Brockwell, Return To Running Postnatal Guidelines for Medical, Health and Fitness Professionals, 2019
Hamar, B.D., Saber, S.B., Cackovic, M., Magloire, L.K., Pettker, C.M., Abdel-Razeq, S.S., Rosenberg, V.A., Buhimschi, I.A. and Buhimschi, C.S. (2007) Ultrasound evaluation of the uterine scar after cesarean delivery: a randomized controlled trial of one- and two- layer closure. Obstet Gynecol 110, 808–13.
Stær-Jensen, J., Siafarikas, F., Hilde, G., Benth, J.Š., Bø, K. and Engh, M.E. (2015) Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy. Obstet Gynecol 125, 531–539.
Mom's Want Answers. Here's 3 Things to Keep in Mind With Regards to DRA
I am a science minded practitioner, I could spend the better part of a day going down a rabbit hole of investigating new science related to a myriad of topics I love. DRA (diastasis recti abdominus) is one of those topics. DRA is a thinning of the central abdominal tissue that can occur with pregnancy. Mom’s often worry because they feel that they look pregnant after baby is born. Some moms experience back pain, urinary incontinence or feelings of vaginal heaviness as well. It is something many moms are concerned with these days. There are a ton of programs to prevent and eliminate DRA. Let’s be real for a second. There is not enough science to have exact answers or guidelines for every type of client that walks into my office. There isn't a hidden answer that fits all moms. I just completed a Women’s Health 8 day 2 hour/day Webinar series and I would love to share with my community of amazing moms some current thoughts about the topic of DRA.
As of right now there are a limited number of studies that examine DRA recovery and even it’s clinical significance with regards to long term function. Some studies look at DRA and apply treatment principles but fail to examine how the severity of the DRA impacts treatment outcomes. So, for example how does a large DRA respond to exercise vs a small DRA. How about the make up of the woman’s collagen? Some of us get wrinkles earlier in life and some older. Some got stretch marks during pregnancy that went away and some still have them. Our collagen make up dictates much about our post natal recovery with respect to DRA. In addition, bowel dysfunction can add pressure to the abdominal system that impedes the ability of proper breath to be strong enough to overcome the outward pressure of gas and bowels. DRA does not happen overnight. It takes a long period of sustained abdominal pressure for a DRA to form. Men and even kids can have it too! Bottom Line: There is not one program or one exercise that will help all people with DRA or prevent DRA with 100% assurance.
So what’s a mom to do?
Number 1: Whether you have DRA or not, I cannot recommend enough getting a postnatal breathing and movement assessment. Proper breathing mobilizes your spine and organs! It also allows for optimal pressure management of your core for stability and organ health. When you learn about your specific breath pattern you can then best incorporate new strategies to optimize restful breathing so it works for you.
Number 2: Learning how to exercise properly for your body is critical! If you have signs of doming (popping out of your belly) during exercise classes, post exercise back pain or vaginal heaviness, maybe you need a modification or two to participate in class best. Maybe that means you need to revisit how you lift, breath and function during basic daily activities because let’s face it- just being a mom is a workout! To activate a system that creates good tension throughout the front of your belly and around the thorax is critical for lifelong abdominal health.
Number 3: Remember- there is not one magical cure. We need to relax and understand that as much as we would like, there isn’t a one answer fits all block that can help you in the same way it helped your best friend. We need to recall that DRA doesn’t occur overnight so it won’t go a way overnight. Proper assessment and understanding how your body is currently functioning and how to best promote proper function is key! Recovering from birth is not an event that occurs at 6 weeks, it is a process.
Since May is Mother's Day I am offering 15% off of first visits! call today! 9783933736
Everyone’s body comes to this planet with different strengths and weaknesses. To use a phrase from my PT professor, “It behooves” us to understand our individual body’s strengths and weaknesses in order to manifest our best long term health!
Spring is the time for a body tune up; a chance to reconnect with your body and tune in to what it might be telling you it needs. Falls on ice, illness, overuse injuries, carrying kids and groceries or that intermittent back pain that seems to eventually go away, can leave us at risk for injuries or costly compensatory techniques. Those old ankle sprains from college might actually have long lasting effects you haven’t even noticed! Those subtle changes in our body can leave you at risk of injury and maladaptive compensatory movements. So many people tell me they "fell apart" at 40 or 45. They didn't fall apart. In truth their body finally could not keep up with all of the compensatory strategies to cover for a lifetime of injuries.
With the onset of spring, many are renewing the vow to exercise more. As runners and bikers increase their mileage or gym lovers increase their workout intensity, many go without thinking about the changing needs of their body. Our needs change with age and diversity in our fitness plan is essential to long term health. You would benefit from a tune up if you have agree with any of these statements:
Because I want every person to understand how their individual body works best, I am offering $20 off of your Spring Tune Up at Newburyport Wellness. Understand your body like never before! You will leave with an understanding of your body that will leave you feeling empowered.
Do you ever feel like the medical care and family response to your health goals are lacking? For certain, there are situations where women get better care than men and there are times when men get better medical care than women. By and large however, studies are based on men and some dysfunctions that only females face are sparsely or no where to be found in research literature. How are we to make sound decisions about our body without adequate information? How can we expect our healthcare practitioners to adequately guide us without this information? We need to be our own best advocates. We need to teach our daughters to do the same.
It is all too often that female issues are negated by medical professionals. I think back to my own childhood and recall being told by an MD to “act more like a girl, get a Barbie Doll and give up on sports.” In college the ligamentous laxity (looseness) resulted in a greater workload on my postural muscles to hold me together. I had severe back and hip pain and was told it was in my head because my range of motion was totally fine. I had to learn on my own that staying strong meant less pain and eventually no pain. I sprained my ankles over and over due to the same condition. NO one pointed out that this lead to dysfunction all the way up to my core and left me at a higher risk for new sprains and other injuries. NO one guided me in a PROPER return to exercise post partum. If this is my life, I can’t imagine how many others have suffered the same or worse.
Fast forward to marriage and kids…. I distinctly recall several times when I REALLY needed a break and didn't get one. I felt bad for my husband to have to do more than he already was doing. I felt like I wasn’t doing my part if I took a break and felt like it was my duty to "suck it up". I felt like I was failing, not that my body was right and needed a break. Some of what we need to do to ensure adequate healthcare is to start by valuing ourselves enough to take a break before bad gets worse. Set boundaries. It is OK to do so! If we marginalize our own symptoms, how will someone else take them seriously?
How do you fight this marginalization of symptoms and concerns?
1-value your intuition
2- Use a new strategy to convey your concerns (writing them down isn’t always enough.
3- encourage your daughters to listen to their body from a young age
4- Categorize your concerns
5- Seek out medical professionals that will listen
6- set boundaries and stick with it
Do you want a handout to help strategize your conversations with medical professionals? Do you want to know a bit about how many medical professionals process the information you provide and how/why they ask certain questions? Come to Women’s Wellness Night, March 29th at 7pm at the Tannery where you will receive specific strategies and tools to help to ensure you get the care you deserve. RSVP today! www.facebook.com/events/521778148344830/
If you deny ever having something get in the way of your planned workout, stop reading. You aren’t human! As a mom, I can count more times that my workout has not unfolded as I planned than times that it has. When my kids were little, they could hear the click of the treadmill (why do kids need to have super power hearing?). As toddlers they would wake up early from nap, be sick or climb all over me. It was a never ending barrage of interruptions. Now, work, kids, school events and keeping up with my house can be deterrents to a great workout. So what is a mom to do?
First of all, unless we have a great family support system or send our kids to daycare without running off to work, it takes a brain shift to make working out meaningful and positive when we are juggling life as moms, wives and workers. Waiting for the day that you have a full hour or more to commit to exercise may never come.
When Work or Life Overtakes Your Workouts as a Woman Without Kids
So you have no kids, but, you miss a day at the gym and that can easily turn into 3 or 4 or 1 month! Don't let yourself skip. Even if you have had the worst day at work, make yourself do 5 minutes of something so you can pick up where you left off the next day. You are less likely to experience full on abandonment of your exercise program if you make yourself do a little bit on even the craziest of days.
When You Have Babies-Toddlers
I can remember the frustration…. Sneaking downstairs to workout, getting dressed and starting my routine to hear the cry of a little one. Don’t throw in the towel. Make them happy, get them cozy and exercise in front of them or take a walk pushing/holding them. I would walk besides the stroller doing lunges- forward, back, sideways. Push ups to standing up and kissing them. Take the program you had in mind and talk to your baby as you go. Hold them in front of you and do squats if you can support that added weight with good form. I would even do squats while pumping! Maybe you don’t get in an hour, but you can get in a lot!
When You Have Bigger Toddlers
This was my favorite stage of child development. Language emerging and new physical skills popping up every day. I would do the same routine as above when my daughter was willing to sit in a stroller. If not, she went into the baby swing and I would do squats or lunges between pushes, sprint across my backyard or park between pushes and encourage them to try some basic moves with me. Chase is always a great way to get your heart rate up! Because I was faster than my toddler (yes, that may be the only time in my life I have been faster than anyone!) I would stop and do push ups on my way to get her or monster walk to work my hips. My daughters also loved when I made them an obstacle course that kept them busy for me to squeeze in reps of my own exercises.
When You Have School Aged Kids
Now I have a 6 and 9 year old. “Fishy fishy Cross My Ocean” never gets old! (Hello Pelvic Floor Control!) Plank challenges and dance parties are fun for all! The other night we had a Hoola Hoop Contest and Dance off that was hysterical and a great work out. My daughters love to play “Superman” where I press them up to the sky with my feet while I hold onto their hands. This can be a good leg workout.
The more you include your kids in exercise, the more they see it as a part of life and the more time you can spend together doing something fun. If your plan to make it to the gym was thwarted by life, don’t give up. Even if today is a wash, tomorrow doesn’t have to be.
If you are struggling to balance work and home life, don’t let yourself get crossed off the priority list. Maybe you get in 10 squats and a couple of sprints up the stairs or a set of push ups before you read to your kids before bed. Your body will appreciate the small gestures of acknowledgement and self care.
BOTTOM LINE- DON’T WORRY ABOUT LOOKING SILLY! GET THE JOB DONE!
Ayla and I post hike.
Is a mom of two, life long exercise enthusiast and women's health coach & physical therapist.