A recent article in the Guardian explored postnatal return to sport in view of Serena Williams’ decision not to compete in the Australian Open. Pinpointing a time-frame for postnatal return to sport, the article stated: “While recovering from birth can be relatively speedy, most experts recommend waiting until you have had your postnatal check-up (usually around six weeks) before embarking on vigorous exercise. A caesarean birth might require more time.” This way of thinking seems to be quite commonplace. You have a baby. You may take it relatively easy for the first 6 weeks, following the midwives’ advice to lift nothing heavier than your baby, and doing the odd clench of your pelvic floor when you remember/can be bothered. At your 6-week postnatal check (if you’re offered one – some women are not) you’re given the all clear, and off you go. Business as usual. I vividly remember exercising for the first time after my first child was born. I went for a run. It appealed to me because it was something that required no equipment, it cost nothing and it could fit fairly easily into my suddenly-chaotic day. I gave no thought, before heading out on my first postnatal run, to how suitable this activity was for my sensational post-baby body, two months after giving birth and still breastfeeding. Five years later and now a postnatal Personal Trainer, I shudder a little when I think about it.
In this blog, Emma Brockwell, specialist Women’s Health Physiotherapist, and I give some gentle guidance to 2013 Elizabeth on why going straight into vigorous activities like running (or boot-camp style classes or tennis or anything else high impact) postpartum may not be the wisest decision. We give her some pointers on what to do to keep herself safe and some exercise suggestions to help her to feel good and prepare her body for the more vigorous activities she loves.
1. Even though you’ve been signed off at your 6-week check, your body is still healing.
Though the six-week postnatal check typically marks the formal end of maternity care in England, at six weeks your body is not yet healed. In fact, six weeks leaves just enough time for the first stage of soft tissue to heal. It can take several months or more for the abdominal and pelvic muscles to recover fully, and for the connective tissue to completely firm up. This process will take longer if you are lactating, because of the continued presence of pregnancy hormones in your body. The postnatal body is still extremely vulnerable to injury during this time, so know that vigorous exercise comes with risks.
2. You need to strengthen your core first and foremost.
Pregnancy hinders the ability of your core to work effectively. The core is your body’s stability system. It is made up of the diaphragm at the top, the pelvic floor at the bottom, the transverse abdominis (TVA) at the front and the multifidus at the back. The core doesn’t automatically return to a functional way of working immediately after birth or, magically, when you reach six weeks postpartum. Often, we need to reteach the postnatal core to work as a team. This is the case whether you gave birth vaginally or via C-section. Let’s take the TVA muscle as an example. This is the deepest of your four abdominal muscles and has attachments to your pelvic floor. As your bump grows, your TVA stretches. It is placed in this lengthened position for some time and, as a result, becomes weakened through pregnancy. Once you’ve given birth, before embarking on vigorous activity, you need to take steps to reclaim its full strength because, without it, the core will have one team member which isn’t pulling its weight, exposing you to a risk of injury or dysfunction.
3. Your bum probably needs a bit of work too.
After pregnancy, it is very common to have a ‘flat mum bum’. Hormones and changes in alignment cause weakening and lengthening of the gluteals, i.e. the bum muscles. Strong gluteal muscles are very, very important when it comes to running and other high impact exercises. If they are not firing on all cylinders you are more likely to experience low back pain or have issues with your hips, knees and ankles. So, as well as addressing your core muscle strength it is imperative that the gluteal muscles are sufficiently rehabilitated before returning to your more vigorous workouts.
4. The 6-week postnatal check only skims the surface.
You may be surprised by the brevity of your 6-week check. Resource squeezes mean that GPs have a lot to cover to check on the health of mum and baby in a very short appointment. Be ready to mention anything which doesn’t seem quite right and don’t just assume that not being asked about something means it’s a normal after-effect of childbirth. In particular, be sure to tell your GP if: you are having trouble holding urine, wind or faeces; you have the sensation of something in your vagina; or having sex is painful (and, for the avoidance of doubt, 2013 Elizabeth had not even contemplated having sex at 6 weeks postpartum, but 2018 Elizabeth and Emma are trying to be thorough). Any of these things can indicate the need for further follow-up or onward referral.
The best way to know how your pelvic floor has been affected by pregnancy and childbirth (whether via C-section or vaginal) is to see a women’s health physiotherapist for a full musculoskeletal and internal examination. A women’s health physiotherapist will look at your alignment, breathing, joint movement, and global muscle strength, as well as assessing your tummy for diastasis recti and checking your scar tissue, if you have any. The internal pelvic floor assessment is pain-free and does not require the use of a speculum. It allows the clinician to assess the condition of your vaginal tissues, identify any pelvic organ prolapse, assess if the pelvic floor is contracting and relaxing and measure just how strong it is. From the assessment, a bespoke treatment plan is made to ensure that you return to optimal health and the activities you enjoy as soon as possible.
Emma did my postnatal Mummy MOT, and she and I are united in our belief that every woman should be seen by a women's health physiotherapist after having a baby, regardless of symptoms and delivery. You can request a referral from your GP or, if you are happy and able to pay, you can self-refer.
5. There are safe activities you can be doing to help you to build a solid foundation.
First and foremost, start your pelvic floor exercises as soon as possible, regardless of how your baby was delivered. The sooner the better (so long as any catheter has been removed). If you had a perineal tear, whatever grade, you should still begin these exercises, as they will promote healing and help you to regain the strength of the pelvic floor. To do your pelvic floor exercises correctly, imagine you are trying to stop the flow of urine while simultaneously stopping passing wind, then squeeze and lift. Try not to breath hold while exercising your pelvic floor; focus on timing the squeeze-and-lift manoeuvre with an exhale, and then allow the entire pelvic floor to relax on the inhale. Do a few repetitions, slowly and intentionally, three times every day. So what about other activities? Walking is a fabulous exercise that you can do as soon as you have the energy. Hill walking or walking on an incline on a treadmill will activate your gluteal muscles, so it’s a great way to begin to combat the flat mum bum discussed above. At 6 weeks, so long as you have stopped bleeding, you can start swimming. If you haven’t been checked for diastasis recti, remove the arm strokes and instead hold a float while kicking the legs. Gentle cycling is also generally suitable, but hold off launching back into spin-type classes, if those are your thing, because they are typically quite vigorous and require good core stability.
If you hire a personal trainer check that they are qualified in postnatal exercise prescription, regardless of the fact that you’ve had the sign-off at your postnatal check. Postnatal ladies quite rightly count as a special population, meaning trainers and instructors need to undertake additional training before working with this client group.
With any return to postnatal exercise, the key is to go steady and to take time to build a solid foundation before adding impact or load. Doing something which is too challenging for your current condition will most probably set you back. Serena Williams is a sporting legend. Ultimately, although (in her own words) she felt “super close” to being ready to compete, she recognised that she was not quite where she wanted to be. This kind of patient and compassionate approach to her postnatal body’s physical capabilities and limitations is something we could all learn from.
If you would like to book a Mummy MOT with Emma Brockwell, contact the Halo’s Clinic, Oxted.