• Dr. Kelly Sammis, PT, CLT

Pregnancy + Postpartum Exercise


The pregnancy and postpartum periods should not be related to periods of captivity or confinement. Pregnant and postpartum mamas should be encouraged to engage in safe exercise and physical activity to support a healthy and pain free experience. Unfortunately, there are currently no national/international guidelines that provide a framework to support when and how a new or experienced mama should exercise during pregnancy, nor return to exercise postpartum. While there are safe and effective ways for each mama to move at any stage of the pregnancy and postpartum journey, there are also a plethora of unsafe and ineffective exercises that can pose a risk for injury. Pregnancy and childbirth present unique changes in a woman’s anatomy and physiology, those of which are often associated with adverse pregnancy and postpartum conditions such as musculoskeletal pain, stress urinary incontinence (SUI) and abdominal separation, otherwise known as diastasis recti [1]. Oftentimes, exercise during pregnancy and the return to exercise in the postpartum period are accompanied by these symptoms that are all too common, but certainly not normal.


Exercise During Pregnancy


Internationally, exercise guidelines demonstrate a lack of focus and clarity for pregnant women. There is a vast amount of conflicting information available and it is often difficult to know what you should and should not be doing to stay healthy and strong as an expecting mama. However, there is one thing that we can all agree upon, and that is the importance of continuing safe exercise and activities throughout pregnancy. Exercise during pregnancy can promote healthy weight gain, reduce back and pelvic pain, ease constipation, decrease your risk of gestational diabetes, improve your overall general fitness, strengthen your cardiorespiratory system [2] and can prepare you for delivery and the birth marathon! Exercise prescription during pregnancy should be focused on the development and maintenance of fitness in the cardiorespiratory (aerobic exercise) and musculoskeletal (resistance, stability and flexibility exercise) systems [3].


The American College of Obstetrics and Gynecology (ACOG) and the Centers for Disease Control and Prevention (CDC) recommend that pregnant women get at least 150 minutes of moderate-intensity aerobic activity every week [2]. It is suggested to divide the 150 minutes into 30-minute workouts on 5 days of the week or into smaller 10-minute workouts throughout each day [2]. In addition to aerobic exercise, pregnant women should also consider resistance training, postural stability, pelvic floor and flexibility exercises as part of their weekly routine.


The National Institute for Health and Clinical Excellence guidelines on the management of urinary incontinence in women recommends that pelvic floor muscle training is offered to women in their first pregnancy as a preventative strategy [4]. Additionally, the 4th International Consultation on Incontinence showed that continent pregnant nulliparous women who participated in intensive supervised pelvic floor muscle training were less likely to experience urinary incontinence in late pregnancy and the postpartum period [5]. Pelvic floor muscle training should also be offered as first-line therapy to women with persistent urinary incontinence 3 months after delivery [6]. Pelvic floor exercises should ALWAYS focus on both the shortening and lengthening phase of contraction, it is not as simple as “just do your kegels” like we have all heard! The lengthening phase of pelvic floor muscle contractions is equally as important for both prevention of pelvic floor dysfunction and rehabilitation. If this is greek to you, you might be due for an assessment from your local pelvic health specialist!


ACOG recommends that women with the following conditions or pregnancy complications not exercise during pregnancy:

- certain types of heart and lung diseases (discuss with medical team)

- cervical insufficiency or cerclage

- pregnancy with multiples with risk factors for preterm labor

- placenta previa after 26 weeks pregnancy

- preterm labor or ruptured membranes during pregnancy

- preeclampsia or pregnancy-induced high blood pressure

- severe anemia


ACOG also explains warning signs that indicate exercise be immediately discontinued:

- bleeding from the vagina

- feeling dizzy or faint

- shortness of breath before starting exercise

- chest pain

- headache

- muscle weakness

- calf pain or swelling

- regular, painful contractions of the uterus/pre-term labor

- decreased fetal movement

- amniotic fluid leaking from the vagina


Contact your local pelvic health specialist for exercise recommendations and safe programs to follow throughout your pregnancy journey!


Postpartum Return To Exercise


Similar to pregnancy, the exercise guidelines continue to demonstrate a lack of focus, clarity and consistency for a safe return to exercise in the postpartum period. ACOG recommends the following as it relates to the frequently asked question (FAQ) When can I start exercising after pregnancy? If you had a healthy pregnancy and a normal vaginal delivery, you should be able to start exercising again soon after the baby is born. Usually, it is safe to begin exercising a few days after giving birth—or as soon as you feel ready. If you had a cesarean birth or other complications, ask your health care professional when it is safe to begin exercising again [7].


As you can imagine, this can be interpreted in many different ways and doesn’t offer any parameters on what qualifies a normal vaginal delivery and what type of exercise is safe to return to. For example, what if you had a normal delivery that required stitches following a perineal tear or episiotomy…are the guidelines the same?


Additionally, ACOG further provides the generalized guidelines of aim to stay active for 20-30 minutes a day. When you first start exercising after childbirth, try simple postpartum exercises that help strengthen major muscle groups, including abdominal and back muscles. Gradually add moderate-intensity exercise [7]. Overall, you can see that current guidelines demonstrate a significant lack of clarity and consistency, leading us to additional questions.


You might be wondering…

- What constitutes a gradual return to exercise?

- What exercises are considered simple postpartum exercises?

- What type of exercise is the safest for recovery and preventing additional dysfunction?

- What if I had a caesarean section versus a vaginal delivery?

- Should these exercises be the same for every postpartum mama?


It is important to identify the answers to each of these questions, especially since returning to exercises that are inappropriate for your stage of postpartum healing can contribute to pain, pelvic floor dysfunction and/or abdominal separation. While it may be safe to return to low intensity activation exercises to reconnect to your body immediately following pregnancy and delivery, parameters should be established so as not to over exert your healing body. After having a baby, the core system is often not functioning optimally and may require education, treatment and exercise instruction to recover effectively. This approach should be specific to each woman’s journey and should always be developed by a specialist who has the knowledge base of postpartum recovery. This could occur at any time postpartum, however a 2014 study identified that the 6-week postnatal check is too long to wait for postpartum women to resume or begin a low intensity physical activity program [8].


Postpartum women need adequate time to heal and regain strength following pregnancy and delivery, particularly in the abdominal and pelvic floor muscles. It is not uncommon to experience pelvic floor muscle injury following vaginal delivery. Oftentimes, the levator ani muscle becomes injured and research has shown that healing of the muscle and associated connective tissue and nerves is generally maximized by 4-6 months postpartum [9,10]. Following caesarean section delivery, consideration should also be given to the healing and remodeling of the uterine scar. Ultrasound investigations have shown that uterine scar thickness is still increased at 6-weeks postnatal, suggesting that the process of scar remodeling after caesarean section delivery extends beyond the traditionally accepted period [11]. This is further supported by the understanding that abdominal fascia has only regained less than 60% of its original tensile strength by 6-weeks post caesarean section and 73%-93% by 6-7 months postpartum [12]. It is of the utmost importance to allow your connective tissue to heal prior to over-exerting the abdominal wall. If you are noticing tenting or doming of the abdominals during performance of an exercise, that is a sign that the exercise is too stressful for your current stage of healing!

A gold standard for expecting and new mamas should be to consult with a pelvic health specialist pre-delivery and prior to the 6-week postnatal check. Pregnant and postpartum women can benefit from an individualized assessment and guided rehabilitative strategies for the prevention and management of pain, incontinence, sexual dysfunction, pelvic organ prolapse, bladder dysfunction and bowel dysfunction [13-17].


When do you consult with a specialist?

1) If you are unsure what exercises are safe for you to perform at any stage of your pregnancy or postpartum

2) If you are unsure if you have abdominal separation

3) If there is a presence of urinary incontinence

4) If there is a presence of fecal incontinence

5) If there is a presence of pelvic pressure/bulge/dragging in the vagina or pelvic area

6) If there is a presence of abdominal tenting/doming/gapping during exercise

7) If you are experiencing sexual dysfunction

8) If you are experiencing pain of any kind

9) If you have questions about changes in your bowel/bladder habits postpartum

10) if you plan to resume high impact exercise at any stage postpartum


A 2018 study revealed that high impact exercise was found to have a 4.59 fold increased risk of pelvic floor dysfunction compared to low impact exercise [18]. This is likely two-fold: 1) high impact activities are associated with a sudden rise in intra-abdominal pressure that your transverse abdominis cannot support and 2) increased ground reaction force is associated with higher demands on the pelvic floor musculature [19]. This helps to explain why weak and less coordinated abdominal and pelvic floor muscles in postpartum women may not achieve the level of function necessary to carry out their roles in pelvic organ support and continence [19]. It is important to note that this can occur at any stage postpartum. If you are still experiencing leakage with performing a double under 1 year postpartum, go see a specialist!


If you have additional questions, please leave a comment below or reach out to me at holisticpelvichealth@gmail.com!


Also, check out my handouts page for a recently published Return to Running Postnatal Guide for professionals and clients!


To health + wellness for your pelvis,

Kelly


References

1. Blyholder L, Chumanov E, Carr K, and Heidercheit B. Exercise Behaviors and Health Conditions of Runners After Childbirth. Sports Health. 2016; 9(1): 45-51.

2. American College of Obstetricians and Gynecologists. Frequently Asked Questions Pregnancy. FAQ119. July 2017. https://www.acog.org/Patients/FAQs/Exercise-During-Pregnancy?IsMobileSet=false.

3. Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for Exercise During Pregnancy and the Postpartum Period. British Journal of Sports Medicine. 2003; 37(1): 6-12.

4. National Institute for Health and Clinical Excellence. The Management of Urinary Incontinence in Women. NICE Clinical Guideline 40. 2006. www.nice.org.uk/nicemedia/pdf/CG40NICEguideline.pdf. 5. Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, Thom D. Epidemiology of Urinary (UI) and Faecal (FI) Incontinence and Pelvic Organ Prolapse (POP). In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence: 4th International Consulatation on Incontinence. 4th ed. Paris: Health Publication Ltd; 2009. p 35-112.

6. Burgio KL, Zyczynski H, Locher JL, Richter HE, Redden DT, Wright KC. Urinary Incontinence in the 12-month Postpartum Period. Obstet Gynecol. 2003;102: 1291-1298.

7. American College of Obstetricians and Gynecologists. Frequently Asked Questions Labor, Delivery and Postpartum Care. FAQ131. October 2018. https://www.acog.org/Patients/FAQs/Exercise-After-Pregnancy?IsMobileSet=false.

8. Evenson KR, Mottola MF, Owe KM, Rousham EK and Brown W. Summary of International Guidelines for Physical Activity Following Pregnancy. Obstet Gynecol Surv. 2014; 69(7): 407-414.

9. Shek KL, Pirpiris A, and Dietz HP. Does Levator Avulsion Increase Urethral Mobility? European Journal of Obstetrics and Gynecology and Reproductive Biology. 2010; 153(2): 215-219.

10. Staer-Jensen J, Siafarikas F, Hilde G, Benth JS, Bo K, and Engh ME. Postpartum Recovery of Levator Hiatus and Bladder Neck Mobility in Relation to Pregnancy. Obstet Gynecol. 2015; 125: 531-539.

11. Hamer BD et al. Ultrasound Evaluation of the Uterine Scar After Cesarean Delivery: A RTC of One- and Two-Layer Closure. Obstet Gynecol. 2007; 110: 808-813.

12. Ceydeli A, Rucinski J and Wise L. Finding the Best Abdominal Closure: An Evidence-Based Review of Literature. Curr Surg. 2005; 62: 220-225.

13. Bo K. Is There Still A Place for Physiotherapy in the Treatment of Female Incontinence? EAU Update Series. 2003; 1(3): 145-153.

14. Dumoulin C, Cacciari L , and Hay-Smith EC. Pelvic Floor Muscle Training Versus No Treatment, or Inactive Control Treatments, for Urinary Incontinence in Women. Cochrane Database of Systematic Reviews. 2018. https://doi.org/10.1002/14651858.CD005654.pub2.

15. Price N, Dawood R and Jackson SR. Pelvic Floor Exercise for Urinary Incontinence: A Systematic Literature Review. 2010; 67(4): 309-315.

16. Hagen S et al. Pelvic Floor Muscle Training for Secondary Prevention of Pelvic Organ Prolapse (PREVPROL): A Multicenter RTC. The Lancet. 2017; 389(10 067): 393-402.

17. Braekken IH, Majida M, Ellström EM, Holme IM, Bo K. Pelvic Floor Function is Independently Associated with Pelvic Organ Prolapse. BJOG. 2009; 116(13): 1706-1714.

18. De Mattos LT, Matsuoka P, Baracat C, and Haddad J. Urinary Incontinence in Female Athletes: A Systematic Review. International Urogynecology Journal. 2018; 29(12): 1757-1763.

19. Leitner M, Moser H, Eichelberger P, Kuhn A and Radlinger L. Evaluation of Pelvic Floor Muscle Activity During Running In Continence and Incontinence Women: An Exploratory Study. 2016. Neurourol Urodynam. 9999: 1-7.

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