Returning to Exercise Post Childbirth – What should I know?

Editors note: If you are an athlete who is post-partum there is a section further down below that is important for you to read.

Over recent years we have seen an emerging social phenomenon with successful return to sport of many elite athletes. Guidelines and important points for athletes and non-athletes returning to exercise post childbirth are included in this blog.

Ideally seek medical guidance prior to returning to exercise post-partum. If you have had an uncomplicated pregnancy and birth your physiotherapist is one of the best suited professionals to seek advice from at this point.

The general guideline is that healthy women gradually return to physical exercise aiming to accumulate 150 to 300 minutes per week. Low impact endurance training should start gradually but can start early as desired as there is minimal impact on the pelvic floor. Return to high impact exercises and strength training may need to be delayed several months. Some exercises need to be more gradual especially exercises increasing intra-abdominal pressure. The initial focus should be on strengthening pelvic floor muscles.

Important points to be aware of for athletes and non-athletes:

  • The pelvic floor is weak and injured in most women postpartum and will require rehabilitation to return to its “normal” functions. Those who struggle to perform the above exercise guidelines and those that have not completed pelvic floor muscle training prior to the birth may need an individualised and supervised programme to regain appropriate strength and control.
  • Any physiological changes that occur during pregnancy and persist for four to six weeks post birth, such as elevated hormone levels, may mean your joints are more mobile than normal so take care with activities that require large amounts of movement, flexibility and dynamic exercises.
  • Certain birth types may lead to complications. For example, C sections are more likely to cause abdominal pain postpartum.  Pain management and wound healing are therefore important prior to any return to exercise.
  • Low back pain is common so must be considered prior to return to exercise. An assessment of this with a specific treatment and rehabilitation programme may be required.
  • Stretched, weakened or separated abdominal muscles (Diastasis recti abdominis) may also delay or impede exercise ability.
  • Increase energy and fluid intake if breastfeeding when returning to exercise.  Ensure particularly when breastfeeding that nutrition demands of both lactation and training are met. The caloric cost of breastfeeding is estimated to be around 600 kilocalories per day.
  • Adequate intake of calcium and vitamin D during breastfeeding is essential.
  • Ensure adequate hydration throughout the day.
  • Consider psychological readiness to return to exercise as this is important post childbirth. Fear of movement is common particularly post C section and has been associated with restricted postpartum physical activity.
  • Exercising after breastfeeding will likely be more comfortable to avoid engorged breasts.
  • Take care with those exercises that cause high gravitational load on the pelvic floor or high impact activities in early stages.
  • Complicated births such as a forceps delivery or levator ani avulsions are likely to slow down return to exercise post-partum and potentially lead to elevated complication rates of pelvic floor dysfunction and pelvic organ prolapse if time is not given to heal appropriately and rehab is not completed.
  • Ensure that return to exercise is gradually increased.
  • Consider the importance of individualized breast support – support rather than compression is important from a comfort perspective.
  • If an obvious Diastasis Rectus Abdominis (gap in between abdominal muscles) see a physiotherapist for an assessment to have a programme prescribed at the correct level and to ensure safe return to exercise without complications
  • Sexual dysfunction is common postpartum. Those suffering may benefit from pelvic floor rehabilitation to improve this.

Stress incontinence (involuntary emission of urine when pressure within the abdomen increases suddenly, as in coughing, running or jumping) is one common post-partum complication. Pelvic floor rehabilitation post childbirth can be used successfully in resolving this issue in a large percentage of the population. If you or anyone you know is suffering from any stress incontinence, please contact the clinic and book in for a pelvic health assessment as this is often an extremely limiting condition that can be resolved relatively easily.

  • Factors that may predispose you to post-partum stress incontinence are:
    • Giving birth,
    • Increasing age,
    • Vaginal delivery,
    • Pregnancy stress incontinence,
    • Running related pre pregnancy incontinence,
    • Partaking in high impact activities,
    • Women with multiple children, and/or
    • Return to high impact activities before the body has healed i.e., running.

Exercise guidelines:

  • Research highlights that all post-natal mothers, regardless of delivery mode, should be offered pelvic health assessment from six weeks post-natal to comprehensively assess the abdominal wall and pelvic floor. In NZ this is uncommon and requires the mother to generally access private health providers for this. There is currently a movement for this to change so all mothers in NZ can access private pelvic health physiotherapy assessment and rehabilitation in the future which we believe is essential to the long term health and wellness of mothers in NZ.
  • High impact activities, such as running, are associated with a sudden rise in intra-abdominal pressure and load the pelvic floor as a result.  For this reason, it is advised that you return to low impact activities post-partum prior to a return to running.
  • Low impact exercise can be implemented within the first three months post-natal followed by a return to run between three to six months.

Key signs or symptoms of pelvic floor and or abdominal wall dysfunction:

  • Urinary and or faecal incompetence,
  • Urinary or faecal urgency that is difficult to defer,
  • Heaviness pressure bulge dragging in the pelvic area,
  • Pain with intercourse,
  • Obstructive defecation,
  • Pendular abdomen, separated abdominal muscles and or decreased abdominal strength and function, and/or
  • Musculoskeletal lumbar-pelvic (low back) or pelvic pain.

Risk factors for potential issues returning to running and sport:

  • Less than three months post-natal,
  • Pre-existing hypermobility conditions i.e., Ehlers-Danlos,
  • Breastfeeding,
  • Pre-existing pelvic floor dysfunction or lumbar-pelvic dysfunction,
  • Psychological issues that may predispose a post-natal mother to an inappropriate intensity or duration of running as a coping strategy,
  • Obesity,
  • C-section or perineal scarring, and/or
  • Relative energy deficiency in sport (RED S).

A referral to a pelvic health physiotherapist is further highlighted if any of the following signs and symptoms are experienced prior to or after attempting returning to run:

  • Heaviness or dragging in the pelvic area,
  • Leaking urine or inability to control bowel movements,
  • Pendular abdomen and or noticeable gap along the line of your abdominal middle,
  • Pelvic or lower back pain, and/or
  • Ongoing or increased blood loss beyond eight weeks post Natal that is not linked to your monthly cycle.

An inability to exercise may affect both your mental and physical wellbeing. It can be socially isolating not being able to complete exercises as you previously had. Please ensure that you reach out to us for an assessment if this sounds like you.

To book a pelvic floor assessment please call 07 576 1860 or email reception@buretaphysio.co.nz.

Exercise in Athletes Post Partum

Across the board, athletes return to sport sooner than non-athletes with a greater percentage within six weeks post-partum. Research also highlights that a large percentage of those athletes returning to elite sports post childbirth return to the same if not a higher level of performance. If you are intending on returning to competitive sports post pregnancy, ensure you include a multidisciplinary team in your planning.

Be aware that just as if you were returning to running or sport post injury, when you had a significant reduction in your training load, this is a period that exercise must be gradually resumed. Ideally, this would start with pelvic floor rehabilitation, alongside low impact activities, prior to a gradual reduction in high impact activities and those that result in significant increases in intra-abdominal and pelvic pressure such as lifting weights.

Moderate to vigorous physical activity in sport will not negatively affect breastmilk volume, alter the composition of breastmilk or affect infant growth if there is appropriate food and fluid intake.

Note that post-natal women with a history of RED-S (relative energy deficiency in sport) are at increased risk of stress fractures, pelvic dysfunction and fertility issues so must have appropriate multidisciplinary involvement regarding their return to training.

Things to take note of:

  • Regaining functional control of the abdominal wall to manage intra-abdominal pressure and load transfer should be achieved prior to return to run or sport, otherwise overload and compensatory strategies may occur.
  • Return to running with a diastasis if it is functional i.e. it is present but there are strategies to control intrabdominal pressure and transfer load across the abdominal wall that are adequate.
  • Shoe/boot size can alter permanently with pregnancy and footwear previously worn should not be presumed to be the correct fit.
  • Sleep deprivation in athletes is associated with increased injury risk. Sleep is key for recovery from both physical and psychological stress and is frequently restricted in the postpartum period. Utilise naps as able to optimise sleep quantity.
  • Utilise sleep hygiene guidelines to optimise sleep quality.
  • Similar to post injury situations, build training volume prior to increasing training intensity.
  • Minimise large and sudden increases in load.
  • Take note of key individual signs that need to be monitored during your return to run/sport i.e. heaviness, dragging, incontinence or moderate to severe pain may suggest excessive training distance or intensity.
  • Mild musculoskeletal pain 0-3/ 10 which settles quickly after a run with no pain lasting into the next day is often acceptable; as is used in the management of tendinopathy and other conditions.
  • If running with a buggy it must be a buggy that is specifically designed for running. Two handed technique where it is possible should be utilised and ideally your baby is greater than six months old as per buggy manufacturers guidelines. Note also that pushing a buggy has an increased energy cost when compared to running independently.

In summary:

Post-natal women will benefit from individualised assessment and guided pelvic floor rehabilitation for the prevention and management of pelvic organ prolapse, the management of urinary incontinence and for improved sexual function post childbirth.

Return to running is not advised prior to three months post-natal or beyond this if any symptoms of pelvic floor dysfunction are identified prior to or after attempting return to running.

Exercise During Pregnancy

In the general population, in the absence of contraindications, all pregnant women are encouraged to be physically active for at least a minimum of 150 minutes per week. This should consist of moderate intensity aerobic activity. Depending on your usual volume of exercise it is common for this total volume to be reduced in the first and third trimesters due to a number of pregnancy related issues such as fatigue.

The below guidelines are a great starting point for exercising during pregnancy. These guidelines relate to those women who have an uncomplicated pregnancy. If you have additional health or pregnancy related concerns, please ensure you speak to your health care provider prior to undertaking exercise when pregnant.

  • Exercise during pregnancy does not increase the risk of adverse pregnancy or birth outcomes

  • Research says that pregnant women who were inactive prior to pregnancy should be encouraged to be active during pregnancy commencing low intensity activities such as walking and swimming and progressing to the lower end of the range recommended and national guidelines of 150 minutes per week or 30 minutes per day of activity on most days. If you are unsure throughout, please seek advice from your health care practitioner.

  • There is strong evidence to support the benefits of physical activity for pregnant women including improvement or maintenance of:
    • muscle strength and endurance
    • cardiovascular function and physical fitness
    • decreased risk of pregnancy related complications such as hypertension
    • reduced back and pelvic pain
    • improved fatigue levels
    • improved mental health including reduced  stress, anxiety, and depression
    • reduction in excessive gestational weight gain and postpartum weight retention
    • fewer delivery complications
    • to aid in the prevention of urinary incontinence
  • Those who should be cautious with or complete low level exercise only with professional collaboration with medical personnel include those with a history of:
    • previous spontaneous abortion
    • history previous preterm birth
    • mild to moderate cardiovascular or respiratory disorder
    • anemia
    • malnutrition or eating disorder
    • twin pregnancy after 28th week
    • obesity  BMI >30
    • intrauterine growth restriction
    • other significant medical conditions such as poorly controlled type one diabetes or hypertension
  • There are contraindications to physical activity during pregnancy and these include those women who have below:
    • ruptured membranes
    • signs of preterm labor
    • hypertensive disorders of pregnancy
    • incompetent cervix
    • growth restricted fetus
    • high order multiple gestations eg  triplets
    • placenta previa after week 28
  • Woman who have experienced the following symptoms should seek advice from antenatal care provider before continuing exercise:
    • abdominal pain
    • amniotic fluid leakage
    • calf pain or swelling
    • chest pain tightness or palpitations
    • decreased fetal movement
    • dizziness or presyncope
    • dyspnea (shortness of breath) before exertion
    • excessive fatigue
    • excessive shortness of breath
    • muscle weakness
    • pelvic pain
    • preterm labor
    • severe headaches
    • uterine contractions
    • vagina bleeding
  • If any of the above complications relate to you please ensure you discuss any planned or proposed exercise regime with your lead health professional.

Our Pelvic Floor Physiotherapists can ensure you get an exercise plan that works for you and your pregnancy. To book please call 07 576 1860 or email reception@buretaphysio.co.nz.

Exercise During Pregnancy

If like me you are stuck at home and pregnant during this isolation period, you may be looking for pregnancy-appropriate exercise to keep you busy, fit and healthy. Exercise during pregnancy can help with:

  • Promoting muscle strength, tone and endurance.
  • Back pain, constipation, bloating and swelling.
  • Improving mood and energy levels.
  • Improving sleep.
  • Prevention of excess weight.
  • Reduction of gestational diabetes risk.
  • Shortened labor and reduced C-section risk.

As a rule, research suggests that if you are pregnant and have no contraindications to exercise, you should be aiming to meet the general physical activity guidelines for adults aged 18-64 years, which are:

  • 150-300 minutes of moderate intensity per week, OR
  • 75-100 minutes of vigorous intensity exercise per week, OR
  • A combination of the two above.

If, however, you were previously inactive or you are in the higher BMI weight range, you should be starting with 15-20-minutes of moderate exercise 3-4 times per week and building up to 30-minutes as able.

It was previously thought that if you are pregnant you should not be exceeding a heart rate of 140 beats per minute, however specific heart rate limitations are no longer recommended.

When it comes to the type of exercise, there are plenty of great options, including:

  • Walking, swimming, or stationary cycling.
  • Pregnancy-specific yoga and Pilates.
  • Strength-based gym classes or home-based strength workouts.

If you were a regular runner or participated in impact sports pre-pregnancy, you can also continue this as comfort allows. However, running is not something I would recommend starting during pregnancy.

Specifically, it is also super important to work on lower abdominal and pelvic floor strengthening during and post-pregnancy. Exercises such as kegels and transversus abdominis strengthening are a fantastic start, and as physiotherapists we can prescribe a home-based program for you specific to your fitness level and needs.

There are also certain exercises that should be avoided, particularly after the first trimester, which include sit-ups or other abdominal exercises that compress the abdomen or stress the rectus diastisis. Further, if you are experiencing aches and pains resultant from your pregnancy, exercise is a fantastic tool to help increase strength and stability and reduce pain.

For specific assessment and prescription of appropriate home based exercises, get in touch with one of our physiotherapists on 07 576 1860 or email reception@buretaphysio.co.nz.

 

Core Strength and Back Pain

What is Core Stability?

This is a term which describes the firmness and stability of your trunk muscles. These are the muscles which wrap around your trunk like a cylinder or brace. They lie between your ribs and your hip bones just like the corsets worn in Victorian times.

The core or trunk muscles are the foundations of the body. The back, arms and the legs work much better if the trunk muscles are stable. When the trunk muscles are working together they support your body when walking, bending, lifting and even sitting upright and give you more energy.

Once working correctly they will also help protect the back from injury.

Why is Core Stability useful in the treatment of back pain?

Pain has been shown to turn muscles off. Pain encourages sufferers to adopt pain relieving positions but ultimately they add to the problem. This leads to recurrent low back pain. Improving core stability will help stop this pain or reduce it a lot and encourage better posture which will prevent further pain. Improving posture may reduce pain immediately. Improving core stability will reduce pain over time.

How can we help you?

We need to teach your muscles how to work again. This training is done one on one with your physiotherapist. Once the muscles are working correctly we can then give you a programme of exercises to improve your strength even further. These need to be monitored and are progressed as the muscles slowly strengthen and work together correctly. We also offer pilates classes and strength classes which incorporate core strength. Call us now to book into our classes. New times and more classes coming 2015…………. New schedule up on website in Jan

Pregnancy Massage – Is it safe/ what are the benefits?

Debbie McNamee – Massage Therapist @ Bureta Physiotherapy explains the benefits of pregnancy massage

We all know that pregnancy is a beautiful but often trying time for expecting mothers. The changes to our bodies are not always pleasant. Luckily pregnancy massage is a proven safe and effective complementary therapy designed to help expecting mothers feel more comfortable while their bodies are going through all those pregnancy changes. It is generally performed from the second trimester onwards, right up until the birth for uncomplicated, low risk pregnancies. For women with higher risk pregnancies such as, cardiac, pulmonary or liver disorder; chronic hypertension and previous pregnancy problems, should consult with their doctor or mid-wife first.

Pregnancy massage uses long gentle effleuraging strokes to help relieve uncomfortable pregnancy side effects such as aches and pains, cramp, swollen hands and feet, stress and insomnia. Internally pregnancy massage helps to steady your pulse and blood pressure; help with regular blood flow to the uterus, placenta and foetus; reduce fear and anxiety and ease built up fluid in your lower limbs.

Muscular back aches and pain during pregnancy primarily occurs due to the weight gain on the front of the body. As the weight on your front grows, you naturally lean backwards to accommodate this new weight. This lean causes a change in your centre of gravity which places greater stress on your lower spine and can bring about achy lower backs.

Pregnancy massage can be performed sitting on a massage chair, side-lying on a massage table and in our case, lying on your stomach thanks the addition of our holo which accommodates and supports your stomach and lower back. Pregnant woman deserve to be massaged…so don’t be shy!

To book an appointment with Debbie call now

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