Advancing your fitness level postpartum has been a gray area for a long period of time in regards to available research and information for moms. If you’ve already read the Postpartum Exercise: The First Six Weeks article, you know to start very gently (and what to start with)! But it has only been in recent years that more research is being done on the various aspects of exercise after pregnancy, and there are still many unknowns. This article intends to address how to return to exercise in the postpartum period in regards to your pelvic floor. And it is intended for anyone postpartum, no matter how long ago your baby was born (the information on pelvic floor protection is also applicable to women who have not or do no plan on being pregnant)!

So how do you safely move on from that initial low level of activity in the immediate postpartum period? The answer varies from person to person, but your six week check that usually clears a postpartum woman for exercise is by no means actually related to your level of readiness. In my and my patients’ experiences, providers tend to say something along the lines of starting gradually. But what does that even mean? In all fairness, your obstetrician or birth professional is likely not skilled in addressing exercise and fitness, or anything that goes along with it. They are primarily concerned with you having a healthy pregnancy and delivery, and a healthy baby-or babies-at the end of all that. But even with that being said, how many of you have been checked for or discussed diastasis recti (a widening of the tissue between your ‘6 pack’ abs), incontinence (leakage of either urine or stool), or prolapse (descent of the pelvic organs) at that postpartum visit? These are all factors that are important considerations prior to advancing activity, and are definitely something your birth provider should be addressing with you in case you need a referral to an appropriate resource. Pain is also a way for pelvic dysfunction to manifest and you should also be screened for this prior to starting an exercise regimen, but it is outside the scope of this particular post.

Before we get in to how to advance your fitness, let’s review some of the major changes that happen physically during pregnancy. They are so easy to forget (thank goodness), but very amazing in regards to how quickly the body adapts to both pregnancy and return to a non-pregnant state. For the sake of time we will just focus on changes to your core, which consists of your diaphragm on the top, abdominal wall in front, spinal extensors and rotators in the back, and the pelvic floor on the bottom. As the uterus expands, the abdomen extends and muscles lose contractility due to stretching. The ribs move outward and up to accommodate both internal organs and a growing baby, and the diaphragm rests 5 cm higher by the end of pregnancy due to rib changes and limited abdominal space. The spinal extensors increase in activity to counter the increasing weight in front of the body. In regards to the pelvic floor, animal models suggest an increase in muscle stiffness and muscle fiber elongation occur to protect this muscle group for pregnancy and delivery (something to the tune of a 300% stretch). And there are so many other physical and physiological changes in the body and core area not even listed here.

Now that we have reviewed some of the physical changes and addressed how your postpartum visit is not really a determining factor for readiness to exercise, one of the important take aways from this post is to allow yourself time for healing (breastfeeding also plays a role in recovery and can delay it due to hormone effects on the body). Another takeaway is to avoid falling into the trap of having ‘springing back’ to your previous size, shape, etc. be a short term goal. Each of the changes listed is variable between individuals and even between pregnancies, as is the body’s return to ‘normal.’ We also know that every woman’s fitness and health journey is highly individualized, with a variety of different goals. Have patience with your body in achieving these, and review some of those physical changes that so quickly appeared if you are feeling frustrated. And with all that in mind, what is the safest way to progress after that six week check?

First and foremost, it is important that you listen to your own body and know when it is telling you that you have done too much. Unless you have guidance from an experienced physical therapist or personal trainer (I highly recommend getting assessed by a physical therapist and then continuing with a personal trainer if needed because it can be difficult to really know how you are doing), you need to pay attention to what your weakest link is in your recovery and specifically train there prior to advancing your activity intensity. If we go back to the components of our core, let’s imagine it as a juice box. It is a beautifully maintained pressure system: if you squeeze one side another side gives a bit to accommodate that pressure change but the box still remains intact. If you add the straw, you now have an area of weakness that will leak if you squeeze too hard. The pressure system still functions if you don’t add too much of a squeeze, but don’t stand too close in case you accidentally squish that box!

In our core after pregnancy, there are likely multiple areas of weakness (as in the straw hole) that heal gradually. But some of us maintain an area of weakness for various reasons (and some don’t!). For example, 33% of women have some urine leakage weekly at one year postpartum. That would indicate that your pelvic floor is likely weak (although there can be other causes), and likely your weakest link to advancing exercise. You may also note heaviness or fatigue in your pelvic floor, which can be a symptom of prolapse (pelvic organ descent). If your abs are your weakest link, you may note some bulging or even a dip into the abdomen along your midline and up from the naval with ab exercises. You may note back pain from continued overactivity in your spinal muscles. And in some women the ribs have difficulty returning to their original lower position, which can be uncomfortable and decrease the efficiency of the diaphragm. Any area of specific weakness or dysfunction will need specific focus prior to advancing your exercise.

To progress to and maintain a healthy core, there are four basic areas of focus that will help take you from early postpartum through whatever level of fitness you would like to achieve. They are detailed below:

1. Posture. If we go back to your ‘core is a juice box’ analogy, you know that any deformation to the system creates pressure in another area, even in a completely healthy system. So the effect of slouching, essentially dropping the front ribs into the abdominal cavity, increases pressure on the pelvic floor and reduces the efficiency of the diaphragm for breathing. In the immediate postpartum period pelvic floor protection with good posture is essential (hard to remember during nursing but important to try). And posture especially comes in to play with higher intensity tasks like jumping or running because the pelvic floor provides some support to the internal organs, so increase in momentary downward pressure is normal. But the pelvic floor’s threshold of ability may be overpowered if combating both the downward impact of organs on landing and the added pressure that ribs with poor posture add. Stand upright, sit upright, breastfeed upright with proper support pillows.

2. Voiding habits. Bearing down, or pushing, to have a bowel movement should not be a regular occurrence. People with regular constipation tend to have pelvic floor weakness and can progress to prolapse due to repetitive strain. You may also note the presence of hemorrhoids or a flare with them. This is a sign of an over-pressured core system. Some women also report the need to strain to fully empty the bladder, which usually comes up after pregnancy if it’s going to happen. Again, repetitive strain is damaging long-term and this issue should be assessed by a pelvic health professional. See this article to help address any difficulties here.

3. Breathe properly. Many women under-utilize their diaphragms and overly tense their abdominal wall. Obviously, a tensed abdominal wall creates an aesthetic of a flatter tummy, but it also creates difficulty in using the diaphragm which is our primary breathing muscle. And if the diaphragm is forced into a tensed abdomen (it drops down on inhale), the core has to respond to that pressure increase by stretching somewhere else. Preferentially, the area of stretch is typically the pelvic floor (the spinal muscles don’t typically give way to pressure).

4. Exhale with exertion. Hopefully you realize this far in to the article that pressure is a balance within the core. So it stands to reason that any time you increase that pressure with exertion (this is completely natural and healthy), you will want to offset that pressure increase as you are able by exhaling on the most challenging part of the motion (unless you are doing a PR for weight lifting, in which case my understanding is that valsalva breath holding is the standard-but not appropriate for pelvic floor dysfunction and definitely not for early postpartum). This can be as simple as exhaling through a return to stand from squatting to picking up your toddler, and progress to exhaling while landing a jumping jack or box jump (starting the exhale slightly before landing). You may notice that if you have some residual difficulty with small amounts of urine leakage on high impact activities that this trick is all you need to eliminate leakage.

While these four areas of focus seem simple, they are starting points as well as great areas to come back to should you need a ‘reset’ at any point. This article is somewhat vague in its guidelines because each woman and each situation is different, however you now have the tools to start protecting your pelvic floor and core for your own benefit and fitness goals. Knowledge is power, this article is designed to both help you protect yourself on your fitness journey and to determine if you need some professional guidance to safely optimize your function on that journey.

It would be remiss to assume that all postpartum pelvic floor dysfunction is solely related to the musculoskeletal system. Nutrition plays a role in pelvic floor function as well, and if you find that the above information does not fully address your symptoms you may need to consider other factors. Lower vitamin D levels correlate to reduced pelvic floor muscle strength per this study done on postpartum women, and generally higher vitamin D levels are correlated to lower risk of pelvic floor disorders as noted here. And according to a slightly older text (but the most recent information I could find), lactating women who meet the RDA (recommended dietary allowance) for energy are likely to meet the RDA for all nutrients except calcium and zinc if the nutrient density of their diets is close to the average for young U.S. women. Calcium is essential for muscle contraction, including in the pelvic floor, and deficiencies would be a consideration in any weakness or dysfunction.

Hopefully this article has provided some insight into your pelvic health and overall longevity. Please leave a comment if you have any questions and I will respond! As I stated above, I highly recommend a pelvic health assessment postpartum because every woman is unique. Use this link to find a provider near you.