Exercise after pregnancy - RACGP
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Focus | Clinical
Exercise after
pregnancy
Philippa Inge, Jessica J Orchard, BENEFITS OF REGULAR PHYSICAL ACTIVITY return to physical activity after giving
Rosie Purdue, John W Orchard on physical and emotional health are birth. The most common specific barriers,
well documented and widely accepted.1 as detailed in this article, relate to
Short-term benefits include improved musculoskeletal structures (in general) and
Background
Exercise is a critical protective factor for mood, promotion of weight loss and specific pelvic trauma related to childbirth
most chronic medical conditions and is maintenance of cardiovascular fitness. (whether by Caesarean section or vaginal
strongly recommended during pregnancy Longer-term benefits for both mother delivery). A suggested list of referrals and
and the postpartum period. The and child include weight management, indications is included in Box 1.
preventive health effect of exercise status reduction in chronic cardiometabolic
(versus non-exercise) is similar to the
disease, management of mental health
effect of being a non-smoker (versus Challenges to return to
smoker). This makes lifelong exercise
and modelling healthy behaviours for
families. There is strong evidence that exercise faced by women
habits for the population critical for public
health. Childbirth is a traumatic process exercise is beneficial for the majority of in the postpartum period
(whether vaginal or by Caesarean section) Australia’s national health priorities.2 Musculoskeletal issues
that temporarily prevents usual exercise Exercise during pregnancy is strongly Lower back and pelvic girdle pain
postpartum. recommended3 and can be performed Up to 50% of women experience
Objective safely without risk to the mother or pregnancy-related pelvic girdle pain (PGP)
The aim of this article is to describe the fetus.4 Women who remain active or lower back pain during pregnancy and
return to normal exercise in the months during pregnancy are more easily able in the postpartum period. Although most
postpartum, including the additional to incorporate an exercise routine recover spontaneously soon after delivery,
challenge of commencing good exercise postpartum. up to 20% report pain persisting for
habits for those new mothers who were
Despite these benefits, many women years.6 Caesarean delivery increases the
not regular exercisers before childbirth.
do not return to pre-pregnancy physical risk of severe persistent PGP six months
Discussion activity levels, with a sharp decline in postpartum.7
Pelvic issues, regardless of mode physical activity levels reported three years Early intervention with exercises
of delivery, affect return to exercise
postpartum.5 Common barriers include focusing on dynamic control, ergonomic
postpartum. Development of
physical discomfort, social isolation, advice and development of strength and
musculoskeletal injuries is also a
significant risk, for example De Quervain’s financial constraints and difficulties endurance is recommended as first-line
tenosynovitis from new activities such as in prioritising health over competing management.8
changing, bathing and nursing. Hormonal responsibilities.
and postural changes, extra body weight General practitioners (GPs) have the Hand and wrist problems
and support networks all affect potential to contribute to far-reaching De Quervain’s tenosynovitis (inflammation
successful return to exercise.
societal implications by helping women of the tendon sheath of the first extensor
© The Royal Australian College of General Practitioners 2022 Reprinted from AJGP Vol. 51, No. 3, March 2022 117Focus | Clinical Exercise after pregnancy
compartment of the wrist) is commonly Diastasis recti abdominis and depression and are significant
seen in the postpartum period. This occurs The rectus abdominus is the most barriers for returning to exercise after
as a consequence of new and repetitive superficial of the four abdominal muscles giving birth.15
movements (ie lifting, holding and and consists of two separate muscle bellies In the postnatal period, women can
nursing a newborn).9 In other contexts, enclosed by a fascial layer, joining at the benefit from individualised assessment
it is managed by reducing wrist and hand midline to crease the linea alba. Diastasis and guided pelvic floor rehabilitation
loading, but this can be very difficult recti abdominis (DRA) occurs as a result for prevention and management of
for a new mother until a time when the of stretching of the linea alba during urinary incontinence and pelvic organ
child can walk independently. For this pregnancy, separating the muscle bellies of prolapse, and improved sexual function.16
reason, it is best managed using a thumb the rectus abdominus. This expansion is a Consequently, educating women in the
immobilising splint. A corticosteroid natural adaptation during the later stages postnatal period about optimal health
injection is an option for reducing of pregnancy and childbirth, although choices, including correct pelvic floor
symptoms in severe cases; however, this many women experience longer-lasting muscle training as part of safe return-to-
can affect breastmilk supply so requires dysfunction, with an incidence of 60% exercise guidance, is a priority for primary
careful consideration.10 Not enough at six weeks and 32.6% at 12 months care (Box 2).
attention is given to prevention, which postpartum.11
would be to regularly use the wrist for Specialist referral and exercise Weight management and relative
similar tasks pre-birth so that the upgrade prescription by a qualified women’s energy deficiency in sport
in load from lifting is not as sudden. health physiotherapist is recommended Weight gain
with a graduated return to abdominal On average, weight retention one year
strength, function and control. Patients postpartum ranges from 0.5 kg to 4 kg.17
Box 1. Suggested referrals and with DRA need a cautious and gradual Excessive weight retention postpartum
indications approach to reloading and often have is associated with increased long-term
challenges with abdominal-dominant risk of obesity, type 2 diabetes and
• Sport and Exercise Physician – Exercise
exercise programs in the early cardiovascular disease.18
prescription and return to activity/
management of RED-S/diagnosis of
postpartum period. There has been some
musculoskeletal injuries controversy surrounding surgical repair
• Pelvic health physiotherapist – of DRA after pregnancy. In 2016 it was Box 2. Pelvic floor functions and
Assessment, diagnosis, education, removed from the Medicare Benefits symptoms that may warrant referral
equipment prescription and exercise Schedule (MBS) because of concerns
programs, including pelvic floor muscle that funding was being used for cosmetic Five functions of the pelvic floor
training purposes; however, it is expected to • Maintain urinary and faecal continence
• Musculoskeletal physiotherapist – return to the MBS in 2022. Surgery is • Support pelvic organs (bladder, bowel
Management of musculoskeletal injuries not the first line of treatment for DRA and uterus)
• Podiatrist – Management of foot pain postpartum12 but may be considered in • Provide support during pregnancy and
postpartum, footwear advice cases where DRA limits function and aid vaginal childbirth
• Dietitian – Management of nutritional decreases quality of life. • Assist in sexual function
needs/assistance with weight loss/
• Work as part of the ‘core’ muscle group
management of RED-S
Pelvic floor and related issues to maintain stability and generate intra-
• Psychologist – Behaviour change in the Physiological changes to a woman’s body abdominal pressure.
management of weight gain/RED-S/
during pregnancy and the consequential Pelvic floor signs and symptoms that may
management of postnatal depression
strain on her pelvic floor begins long warrant a referral
• Continence nurse – Assistance with
before the onset of labour. Risk factors • Accidental leakage of urine with a cough,
the management of faecal and bladder
incontinence
for pelvic floor injury include multiparity sneeze, laugh, lifting, exercise
and vaginal delivery; however, pregnancy • Inability to hold onto urine on the way to
• Lactation consultant – Assistance and
education if breastfeeding difficulties arise alone is a risk factor for pelvic floor the toilet
dysfunction.13 • Sudden urgency to urinate or defecate
• Exercise physiologist – Individualised
exercise prescription and safe return to After childbirth, approximately one • Inability to hold onto wind
the gym in three women experiences urinary
• Painful intercourse
• Urogynaecologist – Management of a incontinence, and up to one in 10 has
• Needing to strain on the toilet, with or
grade 3–4 pelvic organ prolapse faecal incontinence. Up to half of all without pain
• Colorectal surgeon – Management in the women who have had a baby will have
• Feeling of heaviness or dragging in the
event of a third- or fourth-degree tear some degree of pelvic organ prolapse.14 vagina
Incontinence and prolapse can decrease
RED-S, relative energy deficiency in sport • Not recognising the urge to urinate
quality of life, are risk factors for anxiety
118 Reprinted from AJGP Vol. 51, No. 3, March 2022 © The Royal Australian College of General Practitioners 2022Exercise after pregnancy Focus | Clinical
Increased energy intake and nutritional 4–6 months postpartum, well beyond the longer recovery timeframes, compared
choices, together with a decrease in traditional six-week postpartum review. with those with uncomplicated vaginal
exercise levels (energy expenditure), is Caution needs to be taken to ensure deliveries.24 Consequently, this will
the main contributing factor to weight an individualised and gradual return- affect their return-to-exercise plan, and
gain. A perceived lack of time for meal to-exercise program (Figure 1) with a healthcare professional should be
preparation and exercise needs to be consideration given to medical history, consulted before returning to any form
addressed holistically. exercise history and complications during of exercise before six weeks postpartum.
pregnancy and birth. During the first week following a Caesarean
Relative energy deficiency in sport Almost one-third of Australian mothers section, activities in the home (or hospital
Relative energy deficiency in sport give birth via Caesarean section.23 stay) should be limited to personal care
(RED-S) refers to a situation in which a Mothers who have birthed their babies via and care for the baby only. By the third
person does not take in enough energy Caesarean section or operative vaginal week, home activities may be resumed, and
to fuel the demands of exercise and delivery (episiotomy, use of forceps, specific care of the incision site should be
daily living. It can affect many aspects potentially vacuum) will have slightly taken, including limiting stretching, until
of physiological function including
menstrual function, bone health and
psychological health.19 The lifestyle of a
new mother is often coupled with sleep Stage Recommended exercise Tips
deprivation, change in nutritional habits,
lack of routine and increased nutritional • Continue exercising to ensure a • Adjust activity and intensity as
demands of breastfeeding (estimated to be good ‘base’ of exercise for both required
approximately 600 kcal/day), predisposing upper limb and lower limb • ‘Moderate’ means you are a little
• Recommended amount: 150 min bit puffed but can easily hold a
to RED-S and the sequelae. It is important of ‘moderate’ exercise per week, conversation
to ask about these on history and consider including two strength sessions
Pregnancy
bone stress injuries in the new mother who
presents with musculoskeletal pain on
returning to exercise.
• Begin pelvic floor and deep • Use a step counter to track
abdominal exercise from 1–2 days gradual increase in steps
Mental health: Postnatal depression • Gentle walking when pain allows • Drink plenty of water
Postnatal depression (PND), defined as (within first week) • Consider postpartum
depression occurring within 12 months • Gradually increase walking compression shorts/leggings
distance and speed (10% • Seek help if it does not ‘feel right’
after giving birth, is experienced by per week) • Consider what equipment/
approximately 20% of women.20 However, resources you need
0–6 weeks
up to 50% of women experience high
levels of depressive symptoms without
a formal diagnosis of PND. Exercise is a
• Continue to progressively • Breastfeed before exercise for
well-recognised treatment modality for
increase intensity comfort
depressive symptoms; in certain instances, • Pelvic floor assessment • If you cannot exercise with your
it is as effective as pharmacological recommended before return to baby, seek support of partner/
treatments.21 It has been shown to high‑impact exercise family/friend to watch baby
• Postnatal exercise groups; during exercise
improve emotional wellbeing and reduce
Pilates may be beneficial
symptoms of anxiety and depression in the 6–12 weeks
postpartum period.3
• Return to running/high-impact • New footwear may be required
Exercise prescription postpartum exercise possible because of change in foot
mechanics
A return-to-exercise program postpartum • Sports bra and professional fit
needs the same level of consideration, recommended
graduation and rehabilitation that is • Running stroller recommended
once baby has adequate trunk
required after ligament, tendon, muscle
and neck control
or bone injury. GPs are increasingly >12 weeks
prescribing exercise, although the skills
to do so have not traditionally been
part of medical school teaching and Figure 1. Return to exercise post pregnancy
training.22 Tissue recovery can take
© The Royal Australian College of General Practitioners 2022 Reprinted from AJGP Vol. 51, No. 3, March 2022 119Focus | Clinical Exercise after pregnancy
the wound is healed, which is expected at she needed to start exercising after Weight loss (in a steady amount
six weeks postpartum.25 Gentle exercise, giving birth by Caesarean section. The over months) is an additional challenge
such as deep breathing and walking, can patient was, in her own words, ‘not a postpartum, as are the issues of support
actually be effective in reducing pain great exerciser prior to pregnancy’. networks, which can assist with or hinder
following Caesarean section.26 Her pre-pregnancy weight was 68 kg. adequate return to exercise.
Exercise prescription during pregnancy She weighed 94 kg after giving birth,
is strongly recommended and requires and she developed gestational diabetes
consultation with the patient’s GP or during the pregnancy. She was advised Key points
obstetrician to ensure safety for the that regular light-to-moderate exercise • An early return to exercise is safe and
mother and fetus. Women who remain was vital for general health and that should be encouraged in the postpartum
active during pregnancy are more easily postpartum was as good a time as any period.
able to incorporate an exercise routine to make this lifestyle modification. • Pelvic floor exercise can be initiated in
postpartum. However, without a pre-existing base the immediate postpartum period.
of regular exercise and when weighing • Consider nutritional screening and
more than normal, the advice was to energy availability with breastfeeding.
Case studies progress very slowly. Most importantly, • The body goes through many physical
each month she needed to be slightly and hormonal changes during exercise;
CASE 1 more active than the last. Initially just it is important to be patient, as it will
A female patient aged 29 years presented planning a regular walking regimen take time to return to pre-pregnancy
to her GP asking for advice about a return while using the stroller was considered exercise levels.
to running after an uncomplicated vaginal sufficient, aiming for 3000–4000 steps
delivery from her first pregnancy. Prior per day, starting from a fortnight after
to her pregnancy, she was competing in returning home. After two months, Resources
5 km parkrun events and training towards this had increased to 6000 steps, and • ePARmed-X+ (a screening tool for
a marathon. She was able to keep running the patient added a ‘mums and bubs’ returning to exercise postpartum),
until the start of the third trimester. Her Pilates class twice per week, which she https://eparmedx.com
pre-pregnancy weight was 56 kg, and enjoyed. Her weight dropped to 79 kg, • Australian Pelvic Floor Questionnaire
her weight was 74 kg immediately after and she was encouraged to keep working (a screening tool for various pelvic
birth. Her main question was when it was on regular exercise to try to get back concerns including incontinence and
‘safe’ to start running. Her GP advised to pre-pregnancy weight, if possible, prolapse), www.ics.org/Abstracts/
that guidelines suggest three months, 6–8 months after birth. Publish/326/000292.pdf
although it depends on pelvic floor
status. Amateur athletes tend to return to
exercise less quickly than those at the elite Authors
level.27 The key is to start gentle walking Conclusion Philippa Inge MBBS, FACSEP, Sport and Exercise
Physician, Victorian Institute of Sport, Melbourne, Vic
a few days after hospital discharge and Pelvic issues are a key consideration for
Jessica J Orchard PhD, MPH, BEc/LLB(Hons), FESC,
to gradually increase the amount and women returning to exercise postpartum. Heart Foundation Postdoctoral Research Fellow,
intensity of walking. She was advised This is particularly the case after Caesarean Agnes Ginges Centre for Molecular Cardiology,
Centenary Institute, University of Sydney; Charles
that trying to ‘bridge’ from walking to delivery or assisted vaginal delivery Perkins Centre, University of Sydney, Sydney, NSW
running is safest (ie progressing from (eg forceps) where there is significant Rosie Purdue BPhysiotherapy, GradCert Sports
challenging walking, including hills and abdominal and/or pelvic trauma. Medicine, GradCert Pelvic Floor & Continence,
MAPA, Director, Hatched House, Melbourne, Vic
at a brisk pace, to very easy running), Development of musculoskeletal
John W Orchard MBBS, MD, PhD, FACSEP, Adjunct
which she managed to do at week 10 after injuries is a significant risk in both lower Professor and Sport and Exercise Physician, Faculty
giving birth. She was advised not to be and upper limbs. In the upper limb, wrist of Medicine and Health, University of Sydney, Sydney,
NSW
competitive in her running for at least injuries are the most common, such as
Competing interests: None.
4–5 months. At six months postpartum, De Quervain’s tenosynovitis associated Funding: JJO is supported by a Postdoctoral
the patient was able to finish a 5 km with extra loading due to changing, Fellowship (Award Reference No. 104809) from the
National Heart Foundation of Australia.
parkrun event in 24 minutes. Her weight bathing and nursing. Ideally this would
Provenance and peer review: Commissioned,
was 59 kg, and she was thrilled to be able be prevented with some light but regular externally peer reviewed.
to enter an event. wrist strengthening and range-of-motion Correspondence to:
exercises in the antenatal period. Lower john.orchard@sydney.edu.au
limb injuries, such as plantar heel pain,
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