Therapeutic Forum: Essential advice on postnatal exercise

Appropriate information about exercising after childbirth can bring significant health benefits.

NICE recommends that postnatal care for new mothers should include advice on diet and exercise.1 The health benefits of physiological adaptations to regular aerobic and weight-bearing activity are well documented. Benefits in the postnatal period may include improved social and emotional well-being, antidepressant effects2 and weight management, preventing future adverse pregnancy outcomes.3

Specific re-education following the physical challenges of pregnancy and the demands of motherhood should include advice on pelvic floor and abdominal muscles, pelvis and knee stability, and posture, to avoid and manage back and shoulder problems. Perceived limitations may be lack of time, fatigue4 and the unproven assumption that exercise can affect breast milk.5

In uncomplicated cases, women can begin some exercise, such as gentle walking and pelvic floor work, immediately, according to the Royal College of Obstetricians and Gynaecologists.5

The current consensus is that most women can start to be more active after the six-week postnatal check, on the assumption that their health will have returned to normal, but there is little evidence to support this.6

The Association of Chartered Physiotherapists in Women's Health (ACPWH) recommends commencing with pelvic floor exercises and gentle abdominal hollowing as soon as possible.7

One author suggests an individual approach, where women are guided by how they feel, with absolute contraindications in the first six weeks being heavy bleeding, pain and breast problems.8 Adjustment to the reality of motherhood means that many women will take much longer.

Contraindications to exercise

Contraindications to vigorous, high impact, or resistance exercise include caesarean section, wound or breast infection, bleeding, hypertensive or thrombotic conditions, pelvic floor weakness, joint or back pain, previous pelvic conditions (for example, symphysis pubis dysfunction) and diastasis of the rectus abdominis (RA) muscle. All of these require individual assessment and specialist treatment. The loosening effects of raised relaxin levels in pregnancy may affect joint stability for up to five months after the birth and it is thought that breastfeeding hormones may accentuate or prolong this effect.9

Activity placing undue strain on vulnerable areas of the body, or excessive stretching, may not be wise before joints have regained strength and stability in good alignment. ACPWH recommendations are that more vigorous exercise should only be started three to six months after the birth because of potential problems with joint laxity.7

The RA should be checked for diastasis,10 because this may have important implications for future back problems or hernia.

The key postnatal exercises

Essential exercises for all postnatal women are listed in box 1. Pelvic floor muscle training should involve slow and fast maximal squeezes, performed regularly throughout the day. Feeding and nappy changing can be used as reminders.

Recruitment of slow and fast twitch muscle fibres strengthens the support structure, to prevent prolapse and improve sphincter control, in turn preventing leakage on sudden, excessive demand, such as a sneeze or cough.

NICE suggests that exercises should be performed three times a day for three months.11 If little or no improvement is seen, referral to a continence nurse or physiotherapist in women's health should be considered.

Recruitment of the transversus abdominis (TA) muscle can help to stabilise the spine and pelvis. Women should be encouraged to draw in the lower abdomen, especially before bending or lifting. Any form of sit-up or curl-up should be avoided until the TA and the pelvic floor can be successfully recruited and the RA has drawn together; if the lower abdomen domes or bulges out, the TA is not effectively engaged.

Once effective TA recruitment is achieved, the challenge can be increased by adding single leg sliding, pelvic tilting and the all-fours position after six weeks.7 It is possible that this type of stabilisation training may also help with low back pain and stress urinary incontinence.12

Posture awareness, with a long spine, open chest, low shoulders and shoulder blades drawn down towards the waist, can counteract stooping, and neck and shoulder tension. Women should also be made aware of the correct, functional postural technique when lying down, sitting and standing up.

A specialist modified postnatal Pilates or exercise class will focus on pelvic floor and TA recruitment, posture, joint alignment and stability, as well as providing social opportunities. The Guild of Pregnancy and Postnatal Exercise Instructors (www.postnatalexercise.co.uk) provides a list of specialist instructors across the country and many classes offer women the opportunity to bring their baby along as well.

Women will typically join an exercise class when it is right for them and continue until they are strong and stable enough for a greater physical challenge.

Unless there are major pelvic floor or joint problems, pram or buggy pushing should be practised to ensure good posture and recruitment of the TA and, ideally, pelvic floor muscles. The pram handle should be at waist height and if possible, the baby should face the mother.13

This is a free, convenient and effective way to exercise, involving the baby and offering social opportunities. The aim should be to start with a few minutes a day, gradually increasing the time and varying the route.

Making progress

Progression to more challenging exercise, including more intense cardiovascular work, weight-bearing exercise and resistance training, can begin as soon as re-education about posture, stability, TA and pelvic floor structures has been completed.

Mothers frequently report reductions in memory, balance and co-ordination during the childbearing period and this can be a good opportunity to retrain proprioceptive and motor skills by attending a postnatal or beginners' exercise class. The appropriate time to start will depend on each woman's individual situation, circumstances and physical ability.

Any activity should be developed gradually, increasing time and intensity as strength and stamina return; this will add the health benefits of cardiovascular challenge and muscle and bone strength. However, onset of knee or back pain, or recurrence of pelvic floor weakness, may be a warning sign that the increased challenge is too great, in which case, the activity should be reduced or postponed and specialist help sought.

Moira Clark is a postnatal exercise tutor in Kent and a member of the Guild of Pregnancy and Postnatal Exercise Instructors

REFERENCES

1. NICE. Routine postnatal care of women and their babies. Clinical Guideline 37. NICE, London, 2006.

2. Daley AJ, Macarthur C, Winter H. The role of exercise in treating postpartum depression: a review of the literature.

J Midwifery Womens Health 2007;52:56-62.

3. Bainbridge J. Lingering pregnancy fat puts women in danger. Br J Midwifery 2006;14:644.

4. Symons Downs D, Hausenblas HA. Women's exercise beliefs and behaviors during their pregnancy and postpartum. J Midwifery Womens Health 2004;49:138-44.

5. Royal College of Obstetricians and Gynaecologists. Exercise in pregnancy. RCOG statement 4;2006.

6. MIDIRS. Health and care after childbirth. MIDIRS Informed Choice Leaflet for professionals, 2005.

7. Association of Chartered Physiotherapists in Women's Health. Fit for motherhood: advice and exercise for new mothers following vaginal or caesarian delivery, 2006.

8. Clapp JF. Exercising through your pregnancy. Addicus Books, Nebraska, 2002.

9. DiFiore J. The complete guide to postnatal fitness. A & C Black, London, 2003.

10. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988;68:1082-6.

11. NICE. Managing urinary incontinence in women. Clinical Guideline 40. NICE, London, 2006.

12. Savage AM. Is lumbopelvic stability training (using the Pilates model) an effective treatment strategy for women with stress urinary incontinence? J Assoc Chartered Physiotherapists Womens Health 2005;97:33-48.

13. Child Literacy Trust. Buggies - which way should they face? 2007. www.literacytrust.org.uk/talktoyourbaby/pushchairs.html

BOX 1: KEY EXERCISES FOR THE POSTNATAL PERIOD
Pelvic floor muscle training
To prevent stress incontinence and prolapse
Recruitment of the transversus abdominis muscle
To compress the abdomen, draw edges of rectus abdominis together and
stabilise spine and pelvis
Posture awareness
To counteract stooping from pregnancy posture and feeding position, and
reduce neck and shoulder tension
Pram or buggy pushing
To benefit posture, recruit transversus abdominis and, ideally, work
pelvic floor muscles

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