This time last year I got together with an amazing group of women to have a very exciting meeting, with Baroness Cumberlege who is the Independent Chair of the Better Births Maternity Review, working to ensure women receive the treatment that they deserve when having their babies. We wanted her advice about how we could take forward our campaign for better postnatal care, the Pelvic Floor Patrol.
So today I thought I’d share some advice about how to approach your postnatal recovery. It’s not about jumping straight into running (especially if you’ve never run more than for the bus before) to ‘lose the baby weight’, but to approach your body has having been through a huge physical transition, one that invites deep care and attention for full and proper rehabilitation. At the end of 2018 it was announced that physiotherapy is at the heart of the government’s 10-year plan for the NHS. This is great news, of course, but will take a bit of time to implement so we must keep the momentum going for bringing physio and adequate attention to postnatal physical recovery to the forefront of the conversation about birth.
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How can you keep yourself safe when returning to an exercise programme post baby?
1. Even though you’ve been signed off at your 6-week check, your body is still healing.
The six-week postnatal check typically marks the formal end of maternity care in England. But at six weeks your body is far from “back to normal” – you’re not yet fully healed, and you are still postnatal. You are always postnatal from now on. Six weeks leaves just enough time for the first stage of soft tissue to heal. It can take several months for the abdominal and pelvic muscles to recover fully, for your connective tissue to completely firm up and organs to have reassembled themselves into the space your baby has left. This process will take longer if you’re breastfeeding, because of the ongoing hormonal fluctuation in your body. Your postnatal body is still extremely vulnerable to injury during this time, so vigorous exercise comes with risks. The GP check has never been intended as a ‘sign off for exercise’ but for some reason that’s what we’ve accepted it as being.
2. You need to strengthen your core first and foremost.
Pregnancy hinders the ability of your core to work effectively, as – well, there is a living baby affecting (and sabotaging) a lot of the connections you normally require to be strong and functional. Your core is your body’s stability system: the diaphragm at the top, the pelvic floor at the bottom, the transverse abdominis (TVA) at the front, and the multifidus at the back. The core doesn’t automatically return to a functional way of working immediately after birth or, magically, when you reach six weeks postpartum. We need to re-educate your postnatal core to work together as a team, whether you gave birth vaginally or via C-section. Let’s take the TVA muscle as an example. This is the deepest of your four abdominal muscles and has attachments to your pelvic floor. As your bump grows, your TVA stretches. It’s placed in this lengthened position for months and, as a result, becomes weakened. After birth, before taking on high intensity activity, you need to restore its full strength because, without it, the core will have one team member which isn’t pulling its weight, exposing you to a risk of injury or dysfunction in the pelvic floor or within your abdominals.
3. Your bum needs a bit of work too.
After pregnancy, it’s very common to have ‘flat mum bum’. Hormones and changes in your posture can cause weakening and lengthening of the glutes (your bum). Strong gluteal muscles are very important when it comes to stabilising your pelvis, particularly while running and for other high impact exercises. If they’re not firing on all cylinders you’re more likely to experience low back pain or have issues with your hips, knees and ankles. So, as well as addressing your core muscle strength, your bum needs to be sufficiently rehabilitated before returning to high impact workouts, to make sure your foundation is ready to be challenged.
4. The 6-week postnatal check only skims the surface.
You may be surprised by how cursory your 6-week check is – often mums report now that it’s about the baby, with possibly a question about contraception, which, let’s face it, may feel like the least relevant issue right now. GPs have a lot to cover on the health of mum and baby in a very short appointment, and you may feel that your needs are squeezed out. Be ready to mention anything which doesn’t seem quite right, and don’t assume that not being asked about something means it’s a normal after-effect of childbirth. I taught a pelvic floor workshop yesterday and a mum of a 5 month old (vaginal birth with episiotomy) said to me she was suffering with aches and pains in her vagina, couldn’t have sex and generally felt like things were really not ok down there…but she hadn’t had the courage to ask her GP and had never had an internal check, because she felt that it must just be normal as she hadn’t heard that it wasn’t. Make sure you tell your GP if you’re struggling with incontinence or flatulence, you have the sensation of something heavy in your vagina as this can be a symptom of prolapse; or having sex is painful. Any of these things can indicate the need for further follow-up or onward referral. In a nutshell, and what Pelvic Floor Patrol is campaigning for: all women should really see a physio post birth. But currently that’s not in the standard pathway of care, so you may need to proactively seek it as a treatment option for you.
Seeing a women’s health physiotherapist for a full musculoskeletal and internal examination will help you to discover how your pelvic floor and whole body has been affected by your pregnancy and birth experience. A women’s health physiotherapist will look at your alignment, breathing, joint movement, and muscle strength, as well as assessing your tummy for diastasis recti (abdominal separation) and checking if you have scar tissue. The internal pelvic floor assessment is pain-free and doesn’t require the use of a speculum. It allows the clinician to assess the condition of your vaginal tissues, identify any pelvic organ prolapse, assess if your pelvic floor is contracting and relaxing and measure just how strong it is. From this assessment, a treatment plan is created for you, to ensure that you return to normal function (no more leaking), and the activities you enjoy as soon as possible. One of my mums in class yesterday loved sailing, she said it was something she did with her husband and she simply couldn’t do it right now at 6 months postnatal as her core wasn’t strong enough. Another was keen to get back to ballroom dancing but post caesarean she was feeling nervous about her strength – so this is truly important for your life, your relationships, your joy.
Every woman should be seen by a women’s health physiotherapist after having a baby. You can request a referral from your GP or, if you’re happy and able to pay, you can self-refer or go privately.
5. There are safe activities you can be doing to help you to build a solid foundation.
Start your pelvic floor exercises as soon as possible, however your baby was delivered. Download the Squeezy app and follow its reminders. The sooner the better (so long as any catheter has been removed). If you had a perineal tear, whatever grade, you should still begin these pelvic floor awareness exercises, as they will promote healing and help you to regain the strength of the pelvic floor. To do your pelvic floor exercises correctly, draw up your back passage as if trying to stop breaking wind, then travel that engagement forward and up. Try not to hold your breath while finding your pelvic floor; focus on timing the squeeze-and-lift manoeuvre with an out-breath, and then allow the entire pelvic floor to relax on the inhale. Do a few repetitions, slowly and intentionally, three times every day. So what about other activities? Walking is a wonderful and gentle way of moving your body, that you can do as soon as you have the energy. Hill walking or walking on an incline on a treadmill will activate your bum and begin to help build your muscular foundations again, in a low impact way. From around 6 weeks, so long as you have stopped bleeding, swimming is a great option, although avoid breaststroke if you still have any pelvic girdle pain issues.
If you hire a personal trainer or go to a Pilates class, check that they’re qualified in postnatal exercise prescription, regardless of the fact that you’ve had the ‘sign-off’ at your postnatal check.
With any return to postnatal exercise, the key is to go steady and to take time to build a solid foundation before adding impact or load. Test the waters and never fear movement or exercise as it is crucial for your mental health: but always respond to how your body reacts accordingly. If you run and you leak, it’s not time to run yet. Or, shorten the run and see when symptoms appear, etc…don’t ever ignore symptoms, always respond to what they are asking you to notice. Doing something which is too challenging for your current condition will most probably set you back with injury or pelvic floor dysfunction – I injured my knee when I trained to do a triathlon when my second baby was 6 months old…I simply wasn’t strong enough yet for the load I was placing on my body, and as a result made my recovery much longer than it needed to be, as I had to rehab a knee injury on top of finding my core strength. Serena Williams is a sporting legend. When she lost her Wimbledon final last year she spoke for mums around the world when she said that she tried, and the juggle is HARD. Getting back to ‘where you were’ is hard: takes time, patience and self-compassion.
How has your postnatal recovery journey been? Are you pregnant, and looking to how you can re-energise post baby? I’d love to hear from you.