The Three R’s of Postpartum Recovery: What Every New Mom Needs to Know Before Hitting the Gym

The Three R’s of Postpartum Recovery: What Every New Mom Needs to Know Before Hitting the Gym

You’ve recently given birth, and at your six-week follow up appointment, your obstetrician clears you for exercise. They don’t say much more on the topic, and you wonder:

Should I get a gym membership? My stomach looks and feels like mush -- should I get back to crunches right away? Can I do sit ups after a c-section? Can I run my first half marathon in five months? These are just a few of the questions that might cross your mind, with the biggest one being: where do I even start?

With 15+ years of answering these types of questions, I’ve boiled it all down to a simple framework. To maximize postpartum healing and return to physical activity with minimal risk of injury, you must respect the Three R’s.

#1. Reactivate
Definition: learn to contract weak and overstretched muscles again.

At 40 weeks of pregnancy, your four abdominal muscles are stretched maximally. Immediately after delivery, it’s important to learn how to reactivate the two down the middle, as they have been stretched the most: the transverse abdominus (TVA), followed by the rectus abdominus (RA, known commonly as the “six pack”). Because 100% of pregnancies result in diastasis rectus abdominus (also incorrectly called “split abs”), TVA’s are needed to create tone between the middle edges of the RA, and therefore allow your diastasis to recover. Learn to activate your TVA’s by gently sucking in your belly button without puffing up your chest or changing the shape of your spine.

A diastasis rectus abdominus that is not controlled will dome when the RA’s are contracted (left).

A diastasis rectus abdominus that is not controlled will dome when the RA’s are contracted (left).

Learning to reactivate your TVA’s will eliminate this doming (right).

Learning to reactivate your TVA’s will eliminate this doming (right).

It is also important to learn to reactivate your pelvic floor, regardless of whether you’ve had a vaginal birth or c-section. It is possible to experience urinary incontinence for weeks or months following childbirth, and/or painful sex. Despite anecdotal advice, this isn’t considered normal and should be addressed early on.

Finally, you will never spend more time sitting in your life than during the first few months postpartum. Along with deceased physical activity, the end result are sleepy gluteus maximus (buttocks) muscles. Because these muscles are incredibly important in posture, sports and preventing low back pain, I teach every new mom to properly contract their glutes and supporting musculature.

#2. Repattern
Definition: learn to move weak and overstretched muscles correctly.

Muscles don’t contract in isolation -- to accomplish a movement, your muscles contract in groups and in a particular sequence. However with pregnancy, your body changes the sequencing (or muscle patterning) to accommodate a growing fetus. In other words, your baby gets in the way of moving normally.

Pregnancy compensations occur with many movements including breathing, sitting up, and spinal alignment/posture. Since these incorrect movement patterns can remain long after childbirth, teaching the body to move correctly will greatly reduce the chance of injury when returning to physical activity/sports.

In my practice, I have seen women skip this Repatterning stage of healing and return to physical activity/sport. This is premature and will cause chronic pain and injuries of seemingly unknown origin -- it is only a matter of time. Common examples include low back pain, knee pain and rotator cuff strains. Don’t be a statistic: do your repatterning homework and do it well!

Breathing often needs to be repatterned after pregnancy since the lungs are pushed way up into our torsos. On all fours, can you draw in your belly while sending your breath into your ribs?  (photo: @pictonatphoto)

Breathing often needs to be repatterned after pregnancy since the lungs are pushed way up into our torsos. On all fours, can you draw in your belly while sending your breath into your ribs?
(photo: @pictonatphoto)

#3. Restrengthen
Definition: loading of movement patterns with correct form.

Only when the first and second R’s are completed does Restrengthening make sense. And nailing the correct form always matters.

I see this frequently: people at the gym squatting, deadlifting and bench pressing impressive weights...but they’re doing it wrong, resulting in chronic pain and, eventually, inevitable injury.

The same applies to new moms. In the postpartum phase of restrengthening, we must rethink what “getting strong” looks like. It doesn’t have to mean a sweaty, hour-long workout at the gym; loading can be accomplished in infinite ways. Sure, you can do it with dumbbells and barbells. But you can also increase load by doing one extra rep of an exercise, or exercising one extra day, or exercising one extra minute, or running just a bit faster than the last time. When load is progressively increased, you get stronger. It’s that simple.

Strengthening doesn’t have to happen in a gym exclusively. You can do your core strengthening using your couch while your baby plays next to you.

Strengthening doesn’t have to happen in a gym exclusively. You can do your core strengthening using your couch while your baby plays next to you.

Overall, my Three R’s apply to recovery from just about any injury, not just childbirth. And yes, childbirth is considered an injury -- despite being natural, the symptoms and path to recovery are similar -- the only difference is that this injury is totally worth it.

Guidelines for Exercise during Pregnancy

The focus of this article is to briefly overview the North American medical community’s existing prenatal fitness guidelines, and explore how they can help shape your beginner or advanced athletic workout.

Not all women are athletes, but pregnancy will make an athlete out of you. Train accordingly.

I tell this to my pregnant clients, friends and family all the time: there is no other time in your life that you'll gain 25 to 40 lbs. in nine months, experience full-body joint aches and pains, and, in the end, endure a workout lasting an average of 12 hours -- AKA "giving birth". Indeed, not all women are athletes, but pregnancy will make an athlete out of you. Train accordingly.

IMG_1366.JPG

My obstetrician (OB) agrees. When we first met, I asked him for his opinion on exercising while pregnant. His reply stuck with me: "Would you run a marathon without training for it?" I guess not. It seems crazy now, but only a generation or two ago, women were warned by members of the medical community to be cautious during pregnancy -- it was a seemingly delicate condition -- sometimes to the point of bed rest. But fast forward to today: expectant moms are encouraged to stay active through regular, gentle exercise. And the anxiety about a pregnant woman's fragility has begun to dissipate.
 

WHERE TO START

With 13% of Canadian women of childbearing age being overweight, exercise during pregnancy is more important than ever before. But it doesn't have to be daunting. It starts with talking to the healthcare provider who is monitoring your pregnancy: whether you are new to exercise or a seasoned athlete, it is always best to be cleared for physical activity by your OB or midwife, who will be able to identify factors that may increase the risk of fetal or maternal injury. I often recommend that my clients start informing themselves by reading the PARmed-X for Pregnancy (Physical Activity Readiness Medical Examination) and formulating useful questions to ask their healthcare provider. This document is a health assessment to clear you for safe exercise, and is also an excellent resource providing general guidelines to an exercise program for pregnancy.

Once you have your OB/midwife's green light, you can consult a prenatal fitness professional.

DSC_7413.jpg

EXERCISE PROGRAMMING CONSIDERATIONS

When working with pregnant women, I offer three solid rules of thumb to follow during aerobic activity and weight training:

1. FITT Principle:
FITT stands for Frequency, Intensity, Time and Type -- the four variables in a workout that can increase or decrease the challenge. Recommendations for a woman's workout are suggested depending on her athletic experience.

Frequency (i.e. # of exercise sessions per week):
- Beginner athlete: 3x/week
- Seasoned athlete: as per pre-pregnancy levels ("as previous"), up to 6x/week

Intensity (i.e. level of challenge, which can be measured many ways, including):

  • Talk Test: see below
     
  • Rate of Perceived Exertion: see below
    - Beginner athlete: 12-14 (somewhat hard)
    - Seasoned athlete: as previous
     
  • Heart Rate:
    - Beginner athlete: 100-144 bpm, depending on age
    - Seasoned athlete: 130-156 bpm, depending on age

Time (i.e. duration of workout):
- Beginner athlete: 15 min
- Seasoned athlete: as previous

Type: see below

2. Talk Test:
The Talk Test is used to subjectively grade the intensity of your workout. The aim is to exercise such that you're just too out of breath to carry a conversation comfortably. In other words, if you cannot carry a conversation, you need to slow down; if you can chat with ease, it's time to turn up. If you are new to exercise, the talk test will tell you when you're working into a caution zone -- usually around 70% of your maximum heart rate.

3. Rate of Perceived Exertion (RPE):
This is a subjective score on a scale from 6 to 20; 6 is considered to be "very very light" and 20 is considered "very very hard". The PARmed-X recommends a range of about 12 to 14 ("somewhat hard") as appropriate for most pregnant women. Seasoned athletes are usually able to push themselves much further -- and a good prenatal fitness expert will be able to help you determine how hard to push.
 

TYPES OF EXERCISE

Whether a beginner or an experienced athlete, there are four types of exercise that I recommend to pregnant moms:

1. Aerobic activity is defined as what gets the heart pumping -- cardio, as we sometimes call it. By the end of your pregnancy, you will have approximately 50% more blood volume circulating in your body, in order to circulate oxygen and waste to/from your baby (source: "Pregnancy Day by Day", Herer and Blott). This means your heart works harder, even at rest. If your heart isn't trained to handle this additional stress, you might wind up feeling lethargic and struggling with everyday activities (e.g. climbing stairs). Thus, doing aerobic exercise strengthens the heart, allowing it to more readily meet the evolving demands of pregnancy. The Canadian Society for Exercise Physiology (CSEP) recommends 3-4 sessions per week, each session lasting 15-30 minutes long.

IMG_3599.JPG

2. Strength Training -- squat, squat, squat. And when you're done? Squat some more! Virtually all pregnancies will result in some degree of a hyperlordosis (an extra arched lower back), but back pain is greatly decreased with strong glute, back and core muscles. Furthermore, 100% of pregnancies will result in diastasis rectus abdominus, requiring you to strengthen your rectus abdominus and transverse abdominus with proper modifications. As such, squats and core exercises are critical before, during and after pregnancy, modifying at each stage of the journey; make sure you have a prenatal fitness professional to help guide this evolution.

3. Sports and Instructional Classes: the body was designed to move. And while pregnancy might not be the easiest time to start a new sport, an expecting beginner can safely participate in athletic activities (like prenatal yoga and pilates) if gently and properly introduced. Similarly, an athlete who has played a sport prior to pregnancy may be able to safely continue participating -- possibly for a part of the pregnancy or throughout the entire pregnancy -- given the proper instruction and tools.

Most of my pregnant runners stop running if they begin to experience too much pressure in their pelvic area, which occurs at a different time for each woman. However, some women feel well enough to run through their entire pregnancies. And while most women will cease high risk activities (e.g. contact sports, or those with a high risk of falling), others may be approved by healthcare professionals to continue. For example, I recently worked with a client who is an equestrian, and her OB cleared her to continue riding horses well into her third trimester, along with a list of "red flags" to look out for. As it turned out, the OB was also a seasoned horse rider, who was able to understand her athletic needs and provide guidance accordingly.

pregnant-2568395_1920.jpg

4. Stretching. During pregnancy, you will feel tightness in your body's muscles, and due to hormonal changes your joints will increase in laxity as you grow. If not modified for your specific stage of pregnancy, traditional static stretches may cause a problem. A safer way to stretch is by focusing on dynamic stretching or to use equipment like foam rollers or The Stick to lengthen the muscle tissue, or a lacrosse ball to address knots in your muscles ("trigger points").


OTHER TIPS FOR EXERCISING WHILE PREGNANT

  • Minimize your risk of falling. The risk of falling isn't so much for the mother's safety as it is for the baby's. A sudden fall can cause injury to the placenta, which is your baby's lifeline, providing all the blood and oxygen necessary for survival. With this in mind, you might want to reconsider participating in high-risk sports (i.e. full contact sports such as rugby and soccer). However, other sports might become less of a risk if just slightly modified, such as running on a treadmill indoors instead of running outdoors during the winter.
IMG_1321.JPG
  • Stay hydrated! Your body requires much more water just by being pregnant. For example, I mentioned earlier that by the end of 40 weeks, your body will carry up to 50% more blood volume -- this blood includes water, of course. You will also sweat more while pregnant. Now, add exercise and an increasing body weight into the mix: you will sweat a lot. Be mindful about drinking water, and check in with yourself throughout the day; if you feel thirsty, you're already dehydrated. One way to measure if you're well hydrated is by examining your urine colour: it should be a very light yellow colour. The darker your pee, the more dehydrated you are.
     
  • Wear appropriate clothing. Your pre-pregnancy workout gear may at some point become too restrictive to allow for comfortable movement. The band in your pants/shorts might start to feel tight at approximately 20 weeks (or earlier if it's not your first pregnancy). Similarly, bras will start to feel tight around the ribs as the rib cage expands (about 1-2 inches in diameter), and may cause heartburn or difficulty breathing. Select a bra that properly supports your growing breasts -- this allows for comfort during high impact activity. The bonus is that you will likely use this bra again after giving birth, if you exercise while nursing!
     

KNOWING WHEN TO STOP

An absolute contraindication is a "situation which makes a particular treatment absolutely inadvisable," whereas a relative contraindication is a situation that requires caution. Your health practitioner will be able to tell you if you have any contraindications, including common absolute contraindications such as an intrauterine growth restriction (IUGR), placenta previa, or an incompetent cervix. In each of these three situations, exercise of any kind is generally not advised until after the situation has passed or is under control.

And sometimes, even with a healthy pregnancy, some situations may arise while exercising where you should stop immediately and tell your healthcare provider ASAP. Examples include, but are not limited to:

  • vaginal bleeding
  • abdominal pain
  • unexplained faintness, dizziness, fatigue
  • sudden swelling of ankles, hands or face
  • deep ache in leg(s)
     

EXERCISE ALONE IS NOT ENOUGH

A final thought: much like physical activity while not pregnant, prenatal exercise is but one of three equally important factors to achieving good health. The other two are proper nutrition and rest/recovery, and they are extremely important in ensuring that you can maximize the effects of your workouts. Do not forget about these!

pexels-photo-545016.jpeg

Additional sources:

  1. PARmed-X for Pregnancy (Canadian Society for Exercise Physiology (CSEP))
  2. "Active living during pregnancy: physical activity guidelines for mother and baby" (endorsed by CSEP)
  3. Health Canada Prenatal Nutrition
  4. Exercise and Pregnancy (Society of Obstetricians and Gynaecologists of Canada)
  5. American Congress of Obstetricians and Gynecologists

Pain Prevention during Pregnancy: Stretching your Quads

As your pregnancy progresses, or if you spend a lot of time sitting (e.g. desk job), a very common body part that gets tight is the front of your hips: your hip flexors. A few muscles contribute to this, one of which is the quadriceps (quads), which are the muscles running along the front of your thighs. And so one way to relieve tightness in the hip flexors is to stretch the quad muscles:

  • Stand, and hold onto a stable object for balance  

  • Place one foot on a chair or table behind you, as demonstrated in the photo

  • Your standing leg should be at, or slight in front of, your bent leg

  • This is the most important part: SQUEEZE YOUR BUTT -- this tucks your tailbone under

  • You should now feel the stretch in the front of the thigh (quads) of the bent leg. Hold for 30 to 60 seconds, then release; don’t hold this static stretch for longer than 1 minute.

  • Switch legs and repeat.

If you feel the stretch in your bent knee, try adjusting/lowering the height of your chair or table. And contrary to popular belief, your heel does NOT need to touch your gluteus in order for this stretch to be effective. It’s a great little stretch at the end of your workout, and/or throughout your work day -- add it to your daily regimen!

Walking: the Best Pregnancy and Postpartum Exercise

Even the most physically active women wonder how to exercise “properly” once they become pregnant, and new moms are always asking me what the best exercise is after childbirth.

IMG_9691 copy.jpg

My answer might surprise you: it's walking.

Walking is the “best” exercise because it provides the greatest gains for a woman while being accessible to everybody. Unlike running, everybody can walk: how fast or far might be variable, but walking doesn’t require special training or instruction. It’s a high impact activity (which strengthens muscles, joints and bones), and increases your heart rate enough to give you cardiovascular gains. Walking is also a low risk activity even through to your 40th week of pregnancy. Postpartum, walking is the best and easiest way to restrengthen your core and to allow your body to fall back into proper movement patterns. All this being said, if you were a runner prior to pregnancy, then my prescribed exercise for you would most likely be running.

To keep you as safe as possible, here are some considerations for the pregnant and postpartum walker/runner:

  • Listen to your body. If you’re tired or have pain anywhere, decrease your intensity or frequency of activity. Conversely, if you feel good, go for it -- just be careful not to push yourself harder than pre-pregnancy efforts.

  • Stay hydrated. Your body is busy “working out” even at rest, pumping more blood and using building blocks to make a human. You will lose more water than you think.

  • Reconsider supplements. Many herbals in your workout supplements (pills, powders, etc.) may not be safe to consume during pregnancy. Check with your physician, naturopathic doctor or nutritionist/dietician.

  • Be mindful of your walking/running environment. Reconsider being active in rain, snow, mud, trails -- or any situation that might increase your risk of falling.

  • As you grow, take it slow. You will gain weight as your pregnancy progresses. Your joints will become increasingly lax. Some running muscles might become tighter or ache. Your centre of gravity will shift, sometimes so quickly that you will feel off balance. With these changes, the best thing to do is run a bit slower -- or walk -- and consider decreasing frequency and duration.

  • Invest in comfortable footwear. During pregnancy, your feet will likely change due to swelling, fluid retention, lax foot joints, and/or stress from carrying extra body weight. As such, you may find yourself needing orthotics or insoles to support falling arches, and/or different pairs of shoes as your pregnancy progresses.  

In the end, whether it’s walking or running or some other exercise, what matters is that pregnant and postpartum moms stay active, comfortable and safe. Think of me as your pregnancy and postpartum rehab coach*: at every stage of your unique journey, I will address the impact that creating life will have on your body.

 

*Talk to your obstetrician/midwife prior to beginning any exercise program during and after pregnancy.

"The Lies We Tell Pregnant Women" (TED Talk)

In this important TED Talk, Professor Jawad-Wessel discusses the dichotomy presented in the classic, socially-prescribed roles of Woman: as either the “virgin” or “slut.” She explores society’s habit of labeling the vocally-sexual woman as a slut (and therefore to be consumed and discarded), as well as idealizing the modest, virginal woman.

This discourse is further magnified for the pregnant woman, who seemingly loses her rights and decision-making power as others ask invasive questions and touch her belly -- a reality every pregnant woman has experienced. She also apparently loses her desires for sex: revered and virginal (innocent, fragile), she is deemed unsexual. It is not uncommon that a man will, upon learning that his wife is pregnant, immediately assume a nine month dry spell; in turn, his wife may feel dissatisfied or undesirable. This can cause huge feelings of frustration for everyone involved.

Jawad-Wessel exposes the truth: that while her body may appear different on the outside, the pregnant woman’s needs (for privacy, sex, etc.) may be exactly the same as before pregnancy.

“A [pregnant] woman who prioritizes her sexual needs prioritizes herself. And others find that threatening.” -- I couldn’t agree more with this statement. It’s scary for society to think that a pregnant woman could possibly have desires.

But scary as it may seem, it’s time to dispel the myth of the unsexual, weak and pregnant woman. Let’s invite partners to consider (gasp!) talking to their pregnant women, instead of assuming that sex and other needs are off limits.

Let's listen to the body that makes the baby.

I'm pregnant. What is a Diastasis?

Congratulations, you're having a baby! You're elated, you've got all the hope in the world... and you've also got an endless list of questions and concerns. What changes are your body about to go through? What common issues might you experience? And what are these "split abs" that people keep talking about?

It makes sense: in order to accommodate your fully pregnant uterus (which will become 500 times its original capacity) and a full term baby (about 7.5 lbs), your abs will need to stretch. The abdominals are made up of four muscle groups, and the rectus abdominus (your "six pack") will experience something called a diastasis rectus abdominus ("DRA"): this is when the tendon that runs down the center of your abs will stretch wider, for an average of two finger widths. And by the way, your abs don't actually "split," they just stretch. This means the change doesn't have to be permangent, and can be corrected/improved.

100% of pregnant women will develop a DRA during their pregnancies. If the DRA distance is over 4.5 cm wide, manual treatment is strongly advised. However, research now shows that a DRA is considered "clinically significant" if the patient is unable to create tension between the edges of the rectus abdominus, and less so in the distance between the edges. Thus, even a small DRA is significant if you cannot use your abdominal muscles properly. There are no known determinants for the severity of DRA that will develop, and no link between lifting and DRA severity (as is often believed).

A DRA doesn't usually hurt as it develops, because it occurs slowly over the course of your pregnancy. But occasionally, a DRA happens suddenly, is associated with a muscle strain (and can be early in the pregnancy when you aren't "showing") and can be painful.

"How can I tell if I have a DRA that needs to be treated?"

You can have a clinical DRA while you're pregnant, or after giving birth. Here's how to test yourself:

  1. Lie flat on your back, exposing your belly.
  2. Lift your head.
  3. If doming occurs vertically down the center of your abs (see image on the right), you have a clinical DRA that needs to be treated.

“What are the implications of having a DRA?”

A DRA can affect every woman differently. Here are some possible issues:

  • Pelvic floor dysfunction, which may include urinary incontinence (peeing by accident), urinary urgency (suddenly needing to pee), pain during intercourse, constipation, pain/straining during bowel movements, and more
  • Pain in the lower back, pelvic region, genital area, or rectum
  • Increased risk of injury during exercise/physical activity, especially to the lower back, abs, hips and groin
  • Umbilical hernia
  • Cosmetic issues, such as a "tummy pouch" that doesn't go away with exercise or nutrition.

“What does ‘getting treatment’ mean?”

When you see me for DRA treatment, you will receive three things:

  1. Manual work -- this is hands-on therapy, just like what you might expect from a physiotherapist, athletic therapist or massage therapist. During this part of the session I will use various therapy techniques to stretch and manipulate muscles, tissues and joints. I might also use some tools and lotions as well. For those of you who like the therapy jargon: techniques used can include fascial work (cupping, osteopathic techniques, Fascial Distortion Model), trigger point release, and massage.
  2. Exercise -- whether I prescribe one exercise or an entire workout program for you, strengthening is very important to ensure that the effects of the manual work performed will last as long as possible. These personalized exercises also decrease the number of treatments needed.
  3. Education -- in addition to treatment, I believe it's crucial for a new mom to learn how to treat herself and manage her own aches and pains. This way, she becomes less dependent on me (when she's ready), and understands her body's needs. I will help lay out expectations for your pregnancy and postpartum journey from a therapy and exercise point of view, and suggest inexpensive tools like lacrosse balls, foam rollers, golf balls and resistance bands to complement your self-care routine.

“How do I prevent a clinical DRA?”

Prevention is simple: start doing the right strengthening exercises before you get pregnant, and while you're pregnant! This includes choosing the right exercises to treat your transverse abdominus (TVA) muscle and your pelvic floor muscles (Kegels), and learning to breathe properly. The stronger and smarter these muscle groups are, the faster postpartum recovery will be. Also, studies show that a proper general strength training routine unloads the rectus abdominus group, preventing clinical DRA. So add that into your routine as well. This is how 40% of DRA's will resolve spontaneously by six weeks postpartum, and 70% will have resolved by a year postpartum.

The second prevention tip is up for discussion in the therapy world. That is: if you keep your superficial abdominal muscles and fascia "loose" or with good "resting tone," a clinical DRA may not develop. This is where receiving regular manual therapy and a safe exercise program throughout your pregnancy is helpful.

“I think I have a clinical DRA. What do I do now?”

Whether or not you have a clinical DRA, proper care begins with working one-on-one with a professional. Contact me for more information -- let's inform, prepare and protect the body that makes the baby.