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Exercise After Childbirth: How, What, Why and When?
By Dr Brea Kunstler (Physiotherapist and Run Coach)
Can you imagine growing a human for 9 months, having it squish all your internal organs and making your pelvic floor feel like it’s holding up a basketball, then birthing that basketball via surgery or vaginally and then thinking: “When can I go back to running/sport?” Well, believe it or not, many women ask this question soon after childbirth and rarely get the answers they need. Let’s look at the evidence for return to sport (RTS) postnatally.
After birthing a child, a mother experiences a wide range of psychological and physical challenges. I couldn’t possibly cover all of them here, but the ones I think are most relevant to RTS are musculoskeletal injury (e.g. perineal tears after vaginal delivery, pelvic floor dysfunction regardless of delivery mode potentially leading to urinary and/or faecal incontinence, and surgical incisions post-caesarean section), sleep deprivation (poor sleep is an injury risk factor), breastfeeding (increased energy requirements of breastfeeding can leave little energy for exercise and recovery), mental health challenges (e.g. body image concerns, and “baby blues” or the more serious postnatal depression and psychosis), financial challenges that come with having another human to provide for, and lack of time due to 24/7 caregiving. Wow!
These potential barriers are in addition to the typical barriers everyone experiences to exercise, such as poor weather. Becoming a mother to one or subsequent children is an enormous psychological and physical challenge, so adding additional challenges in the way of exercise must be handled professionally and sensitively. Clinicians need evidence-based guidelines to help them do this.
Should Mothers Return to Sport After Having a Baby?
A recent scoping review aimed to identify/scope all the guidelines on postnatal RTS that exist globally. Overall, there were a lot of guidelines (33!) publishing inconsistent advice, with few providing the sufficient detail and guidance that women and their clinicians need. Most studies focused on return to running, neglecting other sports. Overall, there is a strong recommendation for women to RTS due to the numerous psychological and physical benefits of exercise, but special considerations are needed.
When Should Mothers Return to Sport
One consistent feature across the guidelines was the recommended timing for RTS. Many guidelines suggested “when medically safe” or after being reviewed by their obstetrics clinician, which was often considered to occur 6–8 weeks after childbirth. However, what “when medically safe” means is poorly defined and not every mother heals at the same rate.
For example, a woman who has had an uncomplicated vaginal birth with a perineal tear graded one or below is expected to recover significantly better and faster than a woman who had a grade three tear or who underwent a caesarean section delivery (which is considered a major surgery and should be treated as such). Therefore clinicians such as physiotherapists must work closely with the woman and her obstetrics team to determine when a woman is medically safe to RTS based on her birthing and postnatal experience.
They should use a biopsychosocial approach to RTS, where both physical and psychological concerns are addressed and managed professionally.
How Can Clinicians Support a Mother to Return to Sport?
A comprehensive screening stage is necessary before advising a mother when she can RTS. Only 12% of the guidelines identified in the review reported screening recommendations, and these focused on musculoskeletal function, pelvic health, mental health, sleep, nutrition and breastfeeding.
How to effectively screen many of these items relies on the use of valid screening instruments, such as:
- RED-S Clinical Assessment Tool
- Edinburgh Postnatal Depression Scale (for postpartum depression)
- Tampa Scale for Kinesiophobia
- Pelvic Floor Disability Inventory Short Form
All mothers should receive medical clearance from their obstetrician or GP prior to RTS, which can occur at the 6–8 week postnatal appointment.
Even if a mother is considered medically safe to RTS, she might have unique barriers preventing her return. She may not know when the right time is, she might fear hurting herself or already have a birth-related injury she doesn’t want to aggravate (e.g. perineal tear, tailbone bruising), or she might experience incontinence and/or vaginal heaviness/prolapse.
She also might not understand the potential for energy imbalance, whereby the increased energy demands of breastfeeding combined with inadequate diet and increased exercise can lead to Relative Energy Deficiency in Sport (RED-S) and, subsequently, injury.
These complexities mean the clinician must take a comprehensive medical history to truly understand the client’s full problem list and address each one individually.
General Guidelines for Returning to Exercise
Many guidelines recommend mothers return to physical activity soon after birth and when medically ready. They are encouraged to perform pelvic floor exercises in the immediate postnatal period, but specific guidance around frequency, intensity, type and timing is lacking.
Some guidelines also recommend meeting the recommendations for:
- Cardiovascular exercise: 150 minutes per week
- Strength activities: twice weekly
Further details regarding prescription are lacking except to suggest that gentle progression with cardiovascular (e.g. slowly increasing intensity and duration of activities like walking, swimming and cycling) and strength activities (e.g. body weight to weighted) is needed.
Returning to Specific Sports
Regarding returning to specific sports, only one third of guidelines mentioned this and almost half were specific to running.
- A gradual return to running was recommended 12 weeks after childbirth.
- Start with “jeffing” (walk–run approach).
- Commence after the mother has maintained a strength and pelvic floor training program to ensure strength for running.
Practically speaking, runners, and mothers doing similarly intense activities, might do well to:
- Breastfeed or express prior to exercise
- Wear a tailored exercise bra (nursing or regular) to minimise breast discomfort
- Avoid “pram running” with babies that lack a safety harness and sufficient head/neck control (typically develops at 6–9 months)
- Discuss nutrition to ensure adequate energy intake to support high-intensity exercise, recovery and breastfeeding
Many women don’t experience low milk supply in response to exercise and, therefore, may think they are sufficiently fuelling when they aren’t. Energy imbalance in this context can be a precursor to RED-S.
The guidelines identified by the scoping review that has informed this blog post are vague and, in a sense, unhelpful. Every mother is different and has had different birth and exercise experiences that will impact when she is ready to RTS and how she will do this, rendering any guidance to be supportive as opposed to prescriptive.
Therefore, a clinician experienced in postnatal RTS might see themselves relying on their own clinical and/or personal experiences when advising mothers on RTS.
Overall, following the advice provided by evidence-based guidelines is important, but what is most important is understanding the mother, her situation, her goals and her medical history to ensure a gradual and safe RTS.
Need Some Help Achieving Your Running Goals?
Book a telehealth appointment with Performance Medicine’s exercise and run coach, Dr Brea Kunstler, to see how she can help you achieve your goals. She can provide a referral to a trusted shoe provider who will give you 10% off the RRP of your new shoes.
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