Let’s set the stage. You’ve finally gotten to that ‘magic’ 6 week mark, and you’re excited to have your OB follow up. You know that you’re ready to keep moving on with your life (especially getting back to exercise), but you have some concerns in doing so. You definitely have questions about what to do, where to go, and how to do it. You hop up in the stirrups, your OB takes a look, pokes around, asks a few questions, and says “You look good! Go ahead and resume activity as tolerated, just start slow.” Well, you still have questions, but your OB gave you the green light….and they know what they’re doing right? So you go home, lace up your tennis shoes, and say to yourself “I’m going to start with an easy 15 minute jog. Just gonna start slow.”…..All to find out, your pelvis feels heavy, like it has a mind of its own, and urine was leaking for the whole 15 minutes. Your mind is flooded and you’re thinking “Oh my gosh, this can’t be my pelvis. I was just cleared to exercise by my OB. Jogging feels terrible. But how else am I going to lose this baby weight?! And here I am leaking! I thought I was good to go?! Running and exercise keeps me sane! If I can’t exercise, I’m going to go crazy!” Your #1 question at this point: What do I have to do to get back to exercising safely without pain and urinary incontinence?
Out of all of the questions a postpartum mom may have, this is the #1 question I get in the clinic. Totally fair, right? Women want their body back…and exercise, in the right amount, offers so many benefits. At that ‘magic’ 6 week OB check up, if everything looks/sounds “normal” for that stage of healing, then women are usually given the ‘thumbs up’ to resume activity (ie, exercise + intercourse) as tolerated. Problem being, 6 weeks postpartum is only the tip of the iceberg. The body has literally just transitioned in and out of some MAJOR changes. And good news/bad news: at 6 weeks, the changing ain’t over yet. Many times certain symptoms (ie, urinary incontinence, pelvic pain, low back pain, pelvic heaviness, etc) are present at 6 weeks and tend to linger. These symptoms are often deemed normal because after all, a baby was a just born. But while these symptoms may be common, they aren’t normal. So how do we get mom exercising safely again postnatally?
The short answer: It depends. Postpartum, there’s much to consider for a woman’s safe return to exercise. So – all you postpartum mums out there. Consider your unique and individual prenatal, delivery/OB, and postpartum story. What was your prior level of exercise pre-pregnancy and during pregnancy? How did your pregnancy go? Did low back, hip, or pelvic pain prevent you from exercising? Were you placed on bed rest? Or were you running half marathons until week 36? Consider your birth and delivery methods. Vaginal delivery? Any tearing? Long duration of stage 2 labor? C-section? How’s all that scar tissue healing? Also, how do you feel physically AND mentally postpartum? Super great? Cloud 9? Extreme fatigue? Depressed? Pelvic pain? Any urinary incontinence? Sheesh. Now you’re starting to see why there’s so much gray area in answering when it’s appropriate for a postpartum woman to return to exercise. Because there’s so much variability with your unique story, it’s best to have an individualized assessment from a pelvic floor PT to assess the pelvic floor muscles, pelvic fascial layers of support, abdominal control, postural concerns, strengths, weaknesses, etc. It is well documented that postpartum women can benefit from guided pelvic floor rehab for the prevention and management of urinary incontinence, pelvic organ prolapse (ie, when pelvic organs descend into the vagina due to lack of pelvic support), and for improved sexual function.
So, gals, if you start exercising because you’re revving to go and your OB says ‘go for it – have fun!’ and you begin experiencing these signs/symptoms:
• Urinary and/or fecal incontinence • Urinary and/or fecal urgency that is difficult to defer • Heaviness/pressure/bulge/dragging in the pelvic area • Pain with intercourse • Obstructive defecation • Doming in the abdomen or separated abdominal muscles • Decreased abdominal strength and function • Low back/hip/pelvic (girdle) pain
Push PAUSE! It doesn’t mean something is terribly wrong, but it means some things need investigated. If you’re already seeing a pelvic floor PT, certainly let your PT know what’s going on. If you haven’t already been evaluated by a pelvic floor PT, please do so at your earliest convenience (Note: most states have direct access, which means the patient can call up a pelvic PT and get right in without a doctor’s referral. However, this is state and insurance policy dependent. Also, in the event that a telehealth visit is needed, e-visits are still highly beneficial!).
Whether you’re seeing a pelvic PT or you have yet to do so, there are some risk factors you can consider for potential issues to occur when returning to running & exercise postpartum. So before you get too ambitious with your mileage and intensity, consider if you:
•Are less than 3 months postpartum • Have pre-existing hypermobility conditions (ie, you’re one of those super flexible types) • Are still breastfeeding • Have pre-existing pelvic floor dysfunction or low back/pelvic pain • Are struggling with psychological issues which may predispose you to inappropriate intensity and/or duration of running as a coping strategy • Are challenged by obesity • Have c-section or perineal (vaginal area) scarring • Have significant energy deficiencies (beyond the “normal” – more on this later!)
As medical providers, we almost need to consider postpartum moms as post-operative patients. After all, if you had a rotator cuff repair, we would never send you home without rehab + specific guidance in all of your phases of healing! So following c-section delivery, consideration should also be given to the healing and remodeling of the abdominal and uterine scar (we can’t forget the uterus – it literally just supported life for 9 months). Get this: through the use of abdominal ultrasound, it has been shown that uterine scar thickness at 6-weeks post c-section demonstrates early phases of scar remodeling, meaning that full uterine scar healing extends beyond the traditionally accepted 6-week period. This is further supported by the research showing that the abdominal wall has only regained ~50% of its original strength by 6-weeks post c-section and ~70-90% of its original strength at 6-7 months postpartum.
Given all of this information, it is recommended that a low impact exercise routine is followed within the first 3 months postpartum, followed by a return to running between 3-6 months postpartum at the earliest. Now don’t worry – there are things you can start even within a week of delivering (albeit simple things, but these simple things go a long way). In part 2 of this series, we’ll talk about what you can do in order to be proactive during your phases of healing using integrative approaches and gradual exercise building routines that prep your body and mind for getting YOU back to that exercise routine that keeps you sane, happy, pain-free, and leak-free.
“Patience, child, patience. Remember, life is a journey. If you got everything you wanted all at once there’d be no point to living.”– Jackson Kiddard, entrepreneur, philosopher, yogi
(Resource: Returning to running postnatal – guidelines for medical, health and fitness professionals managing this population, published March 2019, Tom Goom, Gráinne Donnelly and Emma Brockwell – I truly thank this group of researchers for their fabulous efforts in working to establish better care and guidance for postpartum women)