written by Kristie Norquay, Pelvic Health Physiotherapist
The intention of this post is to give all women a basic understanding of their pelvic floor and core system, as well as other important considerations for exercise and activity in pregnancy and postpartum.
Unfortunately, there seems to be a lack of basic information, or misinformation out there about exercise during pregnancy and postpartum recovery.
References for this post include some of the latest research, including the “2019 Canadian Guideline for Physical Activity Throughout Pregnancy” and “Return to Running Post-Pregnancy Guide” (for medical, health, and fitness professionals) published in 2019. I have included other passionate physiotherapists and wellness professionals that I have learned from, at the end of this post – they all offer valuable resources for the pregnant and postpartum population and work specifically with female pelvic health.
Disclaimer: This is simply a guide; every woman is unique, and because of that, the best thing to do is have an assessment with a pelvic health physiotherapist to learn more about your individual body and help you reach your personal goals.
Here we go!
Anatomy and Structure Basics
The deep core, also known as your inner core stability system, includes your diaphragm, transverse abdominus (abdominal muscles), multifidus (back muscles), and pelvic floor. Ideally, these all work together. Think of a canister, with the diaphragm on the top, pelvic floor on the bottom, and abs wrapping around the middle. Within this is a pressure system – we want to optimize intra-abdominal pressure during our daily activities, to improve core and pelvic floor function. If one part of the system is compromised, it often affects the others. For example, shallow, chest breathing or breath holding affects the efficiency of the core and pelvic floor muscles, not just the diaphragm. A c-section scar or separation of the abdominals may also affect breathing and pelvic floor function. Pelvic floor tension, weakness, or injury can affect your core stability and breathing mechanics. Certain habitual postures can affect this system as well. Consider some of the unusual or asymmetrical postures you might take while holding your baby. Think of how a scrunched up/slouched position while breastfeeding your baby potentially alters your breathing mechanics, changing pressure in the abdomen, and impacting the pelvic floor and pelvic organs. Normal postural changes occur during pregnancy as your baby grows and your center of gravity changes. Sometimes these postural adjustments stick around postpartum, impacting our core and pelvic floor, until we consciously work to correct them.
Everything is connected, so we can (and should) also look beyond these basic structures when considering pelvic health, but for the purpose and simplicity of this post, we will leave it at that.
Pelvic Health Physiotherapy
A pelvic floor physiotherapist (PFPT) can assess your core and pelvic floor muscles at any point pre and post-natal. A visit while pregnant can help prepare your pelvic floor muscles for birth and encourage a faster recovery postpartum. Once you have been cleared by your midwife or doctor (usually after 6 weeks) you can be reassessed and given guidance for recovery along with an appropriate exercise plan tailored to your specific needs. A PFPT will also look at other common complications of pregnancy, labour and delivery such as a separation in the abdominals (DRA), vaginal tears, or c-section scars. These all impact your body’s healing and therefore also impact how and when you should return to exercise.
Activity in Pregnancy
Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. Women with uncomplicated pregnancies are encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.
All women without contraindications (any concerns that would be discussed with your doctor) can begin or continue physical activity during pregnancy. The benefits of physical activity during exercise for both the baby and the mother’s health are now recognized to the point that women are encouraged to exercise during their pregnancy, even if they were not physically active before. Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications. Physical activity should be accumulated over a minimum of three days per week; however, being active every day is recommended. Pregnant women should include a variety of aerobic and resistance training activities to achieve the greatest benefits. Incorporating yoga, especially prenatal specific yoga, can be beneficial to improve strength, flexibility, body awareness and can be used as a tool for stress management.
Pregnancy changes the body, therefore putting new and different strain on many structures. With that in mind, it’s encouraged to continue being active and doing what you love. Most health care providers recommend staying active in pregnancy, at a moderate intensity – this means you should be able to talk while exercising.
Variables and considerations for activity in pregnancy include joint laxity from the hormone relaxin, an increase in blood volume, heart rate, breathing, and energy expenditure.
Pregnancy is a great opportunity to listen to your body. As your baby grows a little bigger every day and things are changing in your body, activities that may have been easy pre-pregnancy can feel different, and potentially much more challenging now! Understanding the physiological and hormonal changes in pregnancy can help you have more kindness and compassion towards yourself, especially if you are used to being highly active and pushing your limits.
Preventively, you can follow your regular training guidelines – not increasing by more than 10% each week, taking into consideration if you took a long break from activity because of fatigue or sickness in early pregnancy, keeping your heart rate and breathing at a moderate intensity, and seeking help if you start experiencing pain, leaking, pressure or heaviness in the vagina, or any other concerns. There are lots of ways to be proactive and manage your pregnancy symptoms, so hopefully – you can keep up with your regular activities!
Symptoms such as incontinence, urgency, or frequency of bladder & bowel are not normal. Also, feeling heaviness, pressure, or bulging in the vagina is a reason to slow down. Any type of pain (low back, hips, SI joint, pubic symphysis, etc) can be assessed and treated. If you have symptoms while active, it’s recommended to check in with a pelvic floor therapist to have an assessment and receive treatment for your concerns.
Ideally, every pregnant woman (with or without symptoms) would have a pelvic health physiotherapy assessment to receive personal guidance on how to prevent or manage anything that comes up in pregnancy, and prepare for postpartum.
Pelvic floor muscle training (e.g., Kegel exercises) may be performed to reduce the risk of urinary incontinence and symptoms of pelvic organ prolapse. Instruction in proper technique is recommended to obtain optimal benefits. When doing a Kegel, we want to feel a “squeeze and lift” sensation, and ideally in a nice balanced way between front and back, right and left. Just like everywhere else in our bodies, we can have muscle imbalances in our pelvic floor. This is the perfect reason to get an assessment by a qualified therapist – make sure you’re doing your Kegels effectively!
Please see a pelvic health physiotherapist to determine whether pelvic floor strengthening is an appropriate recommendation for you or not. Sometimes, women should focus on letting go of tension in their pelvic floor muscles, before starting a strengthening program.
Core exercises: It is important to stay connected to your core throughout pregnancy, however you may notice this gets more challenging as pregnancy progresses and the muscles continue to stretch. Foundational core exercises such as TA engagement in laying or on hands and knees is great, adding in (or taking away) more challenging exercises like planks or side planks as appropriate. Sit ups are never really recommended, and they are not helpful for core stability anyways. A pelvic health physiotherapist can recommend a core stability program for your specific needs, if you’re not sure where to start.
Becoming aware of your breathing is part of a healthy core and pelvic floor. There are many helpful breathing exercises, but diaphragmatic breathing is one of the most common. This type of breathing is done by bringing the breath lower into the abdomen on the inhale, with awareness of the ribcage expanding, followed by a nice long, full exhale. The diaphragm moves with the breath creating a rising and falling of the abdomen. Inhale – expand, Exhale – relax. There are many resources available for learning this type of breathing and understanding the role breath plays in pelvic health. Having someone assess your breathing is ideal, so you can get hands-on personalized help with this.
Is it ok to lay on my back? Pregnant women who experience lightheadedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid laying on their back. If you feel good laying on your back, it’s ok to do so.
6 weeks postpartum has been the longstanding general guideline for returning to exercise, but this is vague, and depending how it is interpreted, can be too soon or too late. Return to sport and exercise depends on many factors, and is best discussed with your doctor, midwife or physiotherapist to determine when and what is appropriate for you.
In pregnancy and again postpartum, it’s important to find your core muscles! Pregnancy, c-section or vaginal delivery all impact the core and pelvic floor muscles. Learning to properly use and train these muscles before and after pregnancy is very important in your recovery.
As a general guideline for immediate postpartum care, breath, gentle core, and pelvic floor exercises are safe to start right away. Getting re-connected with the diaphragm, deep core muscles, and pelvic floor is a good start while you rest and recover. Just doing these exercises once a day, or whenever you think of it, is great. Try to reduce any heavy lifting and keep your activity gentle in the early days and weeks. After your 6-week checkup with your doctor or midwife, you should consider making an appointment with a pelvic floor physiotherapist to evaluate your readiness for return to activity. A doctor or midwife doesn’t (usually) evaluate pelvic floor and abdominal muscle function, so a visit with a PFPT is required to get an accurate return to exercise evaluation.
There are a lot of factors to consider when discussing return to exercise postpartum: how the labour and delivery went, vaginal or cesarean birth, any associated injuries, how well you’re sleeping, whether or not you have a support system, how stressed you are…etc.
What you should be doing and how often you should be doing it depends on your body and if you have any specific concerns. Sometimes pelvic floor, hip and abdominal muscles hold too much tension and the treatment is primarily focused on relaxation of the muscles. Sometimes they are weak, or we aren’t well connected with them, so the treatment is focused on “waking up”, reconnecting to muscles and strengthening. You would progress your exercises based on how you’re doing and if you’re achieving your goals.
Diastasis Rectus Abdominus
After you have your baby, get checked for a diastasis rectus abdominus (also known as diastasis recti). DRA is a separation of the abdominals in the midline. This separation in the abdominals is very common in pregnancy, and if it persists postpartum, can usually be corrected with hands on treatment, exercise and proper movement guidelines. The sooner it is addressed, the better.
Some studies show 100% of women have a diastasis by 30-35 weeks of pregnancy, while others have found around 60-70%. Either way, all studies demonstrate that a high number of women will experience a diastasis during pregnancy and that it’s not necessarily something to be alarmed about. Ideally, the separation heals well postpartum, but some women need intervention to assist with a full recovery. Get checked out by a PFPT for personal guidance in your rehab. Abdominals continue to heal, and abdominal strength continues to increase for 6 months postpartum, so take advantage of this early healing time by doing helpful exercises.
Things to watch for during core exercise and in daily life (signs that may indicate a DRA): doming or “popping out” of the abdomen in midline, especially when sitting up from laying down or while doing exercises like crunches or plank. Softness, sagging, or wrinkling of the skin at the midline, or being able to feel a gap with your fingers (this usually isn’t noticeable until postpartum but may be felt in pregnancy).
We are learning now that it’s less important to close the gap and more important to be able to create tension across the midline, for better load transfer during activities. Ideally when you feel your abdominals, that softness or gap feels less when corrected. A PFPT can help you with this, as the correction usually requires a combination of exercises, hands on treatment, and looking further up or down the body if the tension generated by abdominal muscles is not sufficient to feel improvement. Surgical repair is an option, but rarely required unless conservative treatment (physio interventions, exercise, manual therapy) isn’t successful.
Specific Interest – Running!
Summarized from the Return to Running Guidelines by Tom Goom, Grainne Donnelly & Emma Brockwell.
These wonderful people put together guidelines and released them earlier in 2019. The link to the full document is listed below, in the reference section.
The general guideline for return to running (or high impact exercise) postpartum is between 3-6 months, longer if symptoms are present. Postpartum exercise for the first 3 months emphasizes low impact activity such as walking, as well as abdominal and pelvic floor muscle exercises prior to gradually introducing strength and balance, followed by high impact exercise. Seek out a pelvic health physiotherapist for an assessment to check strength, function, and coordination of the deep abdominals and pelvic floor prior to return to activity.
Reasons to go see a pelvic health physio, and hold off on running (or any other high impact sport):
- Incontinence (leaking)
- Heaviness, bulge or pressure in vagina (prolapse symptoms)
- Diastasis recti (separated abs) – potentially impacting the pelvic floor and load transfer while running
- Pelvic pain including pain around the SI joints, pubic symphysis, or low back pain
The decision to return to running can be based on timeline (3-6 months postpartum), symptoms, and assessment of pelvic floor/abdominal function (ensuring a base level of pelvic floor strength, appropriate fast contractions, adequate endurance, as well as an assessment for prolapse and diastasis).
Other considerations before returning to high impact activity:
- Fitness levels
- Breathing – start at a pace that you can maintain a conversation (this helps optimize breathing strategies and coordination of diaphragm, abs and pelvic floor)
- C-section and perineal scars – ensure no pain/restriction
- Breastfeeding – hormones are still altered – lower estrogen, higher relaxin
- Sleep – sleep deprivation in athletes can lead to increased injury risk, lower general health and increased stress. Studies have shown reduced muscle protein synthesis and impaired maximal muscle strength
- Psychological concerns – using running as a coping mechanism may increase risks by not allowing adequate healing time for the body, try to find alternate coping strategies
Starting back to activity postpartum is always a balance of risk and reward. The same guidelines apply to any injury rehab program. For example: Start small, run/walk, build distance/time before intensity, increase no more than 10% per week, and ensure no increase or onset of symptoms. Musculoskeletal pain rated 0-3/10 that settles quickly and doesn’t last into the next day is considered ok. Running with a stroller leads to minor changes in kinematics and has an increased energy cost, and baby’s neck strength should be adequate before stroller running begins.
A note on recovery:
In my practice, I have noticed that there is an interesting disconnect about postpartum recovery.
Labour and delivery is a big event. There are varying levels of “injury” – at minimum being a stretch/stress/strain on vaginal tissue and at most being a major abdominal surgery or serious tissue damage to skin, muscles, bones or ligaments of the pelvis and pelvic floor. These things need time to heal! If you had a skin laceration requiring stitches, or a muscle tear anywhere else in your body, you would likely allow time for rest and healing before attempting to return to your regular sport or activity. Generally, an orthopedic injury requires 4-6 weeks minimum recovery time, followed by a gradual return to activity. This is comparable to an uncomplicated vaginal birth. More severe orthopedic injuries require 6-12 months recovery time with a gradual re-introduction to sports & activities. The same healing time and rehabilitation approach should be considered after a baby is born, taking into account the pregnancy, labour, delivery method, and any injuries or complications. Your unique recovery will depend on many factors; support and guidance along the way is highly recommended.
Culturally, a sprained ankle may be approached differently than a birth injury. Many people understand that after an ankle sprain, they need to rest and allow the tissues adequate time to heal. But in our culture, there is pressure for new moms to “bounce back” or “get your body back” or “lose the baby weight”. Sometimes, it’s just mama wanting to feel normal again. I get it. I hear you. I understand the pressure. And, I would love to invite you to offer yourself some extra love, compassion, kindness, and time for whatever it is your body needs to fully heal and recover.
A note on pain:
Pain is a really complex thing – sometimes resolving it is as simple as exercises or hands-on therapy, but more often than not it’s a biopsychosocial phenomenon – affected by our bodies, minds, and social connections. We are learning more and more that structural and tissue issues don’t correlate with pain. It seems pain is more about the brain and spinal cord than about the structure that is usually blamed. Whether our nervous system feels safe or in danger is ultimately what creates pain sensation or not. Pregnancy and new motherhood are times of big changes; sometimes stress, fears, stories you’ve heard from others, etc. can affect the sensations you feel in your body. I would recommend finding a physiotherapist that considers all aspects of your wellbeing to help you with your pain.
In conclusion, our bodies are unique, as are our birth stories, and our healing patterns. There isn’t a one size fits all program to reduce pelvic floor dysfunction, pain or strain, nor is there a one size fits all program for returning to exercise. Having an assessment by a qualified professional is the safest way to ensure your body is ready – they will take a thorough history, assess your pelvis, surrounding muscles, watch you move, and help you to reduce strain on your body.
Personally, I’d love to see women and health care shift towards being more holistic – recognizing that there are many factors at play in prenatal and postpartum recovery.
Thank you for being proactive in your pregnancy and beyond, for taking the time to read this, and to understand more about your wonderful body.
Return to Running Post-Pregnancy Guide (for medical, health, and fitness professionals)
Julie Wiebe PT – fitness, diaphragm/pelvic floor piston
Antony Lo – female athletes
Kim Vopni – vagina coach
Diane Lee – diastasis research & support
Tracy Sher – pelvic guru
Sara Reardon – vagina whisperer