The Ultimate Guide to Early Stages of Recovery Post-partum

Q&A: Hi Jen… I just gave birth two days ago and I’m wondering which exercises I can already start doing for pelvic floor strengthening and DR rehab. I recall during our training session that you said there are some things that can be done right from the beginning. If you have any video resources even better!

Hey Ilana. Thanks for the question. First of all, Congrats! And secondly, well done for being so pro-active with recovery!!

I’m going to do my very best to answer your question as I think it’s really important and can benefit lots of others in this group, but please be warned! It’s not that simple and it might not be the answer that you’re hoping for… And it’s looooong!

It’s really important to point out that you only gave birth a week ago, so your body has a lot of healing to do. It’s really important to give it the rest that it needs, and you shouldn’t be starting any kind of exercise programme before getting the all clear from your doctor at your 6 week check-up.

WHAT DOES POST-PARTUM RECOVERY INVOLVE?

Before prescribing any exercises for recovery, any professional working with post-partum women would need to ask the following questions:

1. Did you have a vaginal delivery? Were there any tears/stitches? What grade? How are they healing? Episiology? Is the pelvic floor actually weak? (it might not be…)

2. Did you have a C-section? How is the scar healing?

3. Do you have an abdominal separation? How wide is it? How deep is it? How does it react to different exercises (does it bulge or “tent”?)

4. Can you do a pelvic floor contraction? Is it even? (Is one side weaker than the other?)

5. Do you have even a mild grade of prolapse?

6. How much are you sleeping?

I don’t expect you to answer these kinds of questions here of course! But just so you know that these are the kinds of questions that a trained professional has in mind (or should have in mind) that will dictate exercise selection.

There are only a few things that I can really suggest at this stage, ESPECIALLY at this stage after birth and without having the answers to the questions above (and without actually seeing you with my own eyes).

GENERAL GUIDELINES FOR THE FIRST 6 WEEKS POSTPARTUM

1. Breathing.

Diaphragmatic breathing (or the “Piston Breath”) into the belly and pelvic floor. This ensures that the tissues are moving through a small range of motion constantly and will assist with healing.

Most people breath up into their chest (aptly-named chest-breathing), and often the tummy actually comes IN on the inhale (paradoxical breathing). We want to flip this around.

You can practice this lying on your back: On the in-breath, your diaphragm should descend, essentially pushing all your abdominal organs downwards (towards your feet). This should cause your belly to rise and your pelvic floor to gently relax and descend. On the exhale, the opposite will happen: your pelvic floor and abdominal muscles will recoil to where they were, and your diaphragm will relax and go back up into your ribcage.

You do not have to pull your belly in or do a pelvic floor contraction with the breath.

This is the first way in which we can start to engage these muscles to help them heal. The breath is their first function (look at your baby!)

2. Posture / alignment.

It's important to understand that there's no such thing as "bad" posture, and study after study confirm that posture doesn't actually cause pain. However, it does seem that spending too much time in one position, not being able to adopt different positions, and getting "stuck" there can be unhelpful for a number of reasons.

Pregnancy tends to drag us into the position of this mannequin below - hips jutted forward and upper back rounded, translated backwards, and bum tucking under. Shoulders can start to internally rotate.

Then when the baby is born, we will tend to adopt this position while nursing, cradling our newborn and carrying him/her around. (I made this pic below rather naively when I was starting out - you DON'T have to carry your baby around like the pic on the right the whole time, but it does illustrate how we slouch and hang off our skeleton).

Getting stuck here does tend to make some muscles sore - tight hip flexors, hamstrings and lower back - and a lot of mamas do get a lot of aches and pains. The solution isn't walking around with perfect posture all the time, but it does help to notice our default and get out of it wherever we can, adopt different positions and MOVE. (See the point on mobility for more on how to mobilize these tight bits).

Finally, getting into better alignment does seem to have a positive effect on the muscles of the core. Julie Wiebe describes it as making the muscles (abdominal muscles, pelvic floor) more available, which means they can respond better to the breath and changes in position. It DOES NOT mean pulling your shoulders back, chest up and stomach in! It means ensuring that your ribcage is on top of your pelvis, that it is not slanting backwards, that the pelvis is "untucked", which means that it is in a neutral position, not in posterior OR anterior tilt. This ensures that your diaphragm and pelvic floor are parallel to one another, which means they are more available for recruitment to support and stabilize you.

3. "Blow Before You Go" Make sure you use the mantra “blow before you go” from Julie Wiebe. When you lift your baby, child, washing (try to avoid lifting if you can, but when you do need to lift something, make sure you aren’t holding your breath. Exhale on the effort, and don’t strain. This can put a lot of pressure down on the pelvic floor and abdominal muscles.

4. Toilet Habits

Likewise, pay attention to toilet habits. Don’t push or strain on the toilet, and don’t hold your breath. This also puts lots of pressure down on the pelvic floor and organs. Lean forward with a number one, rest your elbows on your knees, let your belly go (don’t pull it in) and focus on RELEASING and OPENING the pelvic floor. For a number two, the same guidelines apply, just use a stool or a squatty potty so that your knees are above your hips. Lot’s of women experience constipation after giving birth. Try not to strain on the toilet as this can do a lot of damage to your pelvic floor muscles and/or fascia that may be weak, swollen and damaged.

5. Mobility

It drives me crazy that no postpartum programmes talk about mobility. As we mentioned earlier, pregnancy can have quite an impact on our posture and alignment, and many women tend to get stiff and achy. Nursing adds insult to injury and we do tend to get stiff spending many hours in the same position.

Some gentle mobility exercises should be a priority early on. We want to mobilize the spine with cat-cows, stretch the backs of the legs with a forward bend, stretch the hip flexors, work on squat and hip mobility, twist the spine and put the shoulders into full flexion (overhead) like in a down dog.

6. Gentle Core Exercises

At some point you may be able to incorporate some gentle core exercises, like heel slides, [here's an example at 3:20]. However I’m not entirely sure that I can legally recommend even that, so I’m not, but keep in mind that there may be things that you can do before you’re 6 week check up.

7. Glutes, not Core!

When you are ready to start to incorporate some gentle exercise, try to prioritize gentle glute exercises like glute bridges, clam shells and hip thrusts. It's best to start with these supine or side-lying exercises as this reduces load on the pelvic floor which may still be healing. Try to leave the core alone at this stage unless you are sure that you are not doing anything too strenuous. Strong glutes will support the pelvic floor, back and core, and they are easy to do at home with no equipment. I did a series of glute not core exercises that you can find here.

You want to ensure that you exhale on the effort with each of these movements.

THAT’S IT! These are the only GENERAL guidelines I can give – anything beyond this depends a lot on the questions above and should be highly personalized. I know it might feel like I’m holding out on you, but it really wouldn’t be ethical to pretend that I know exactly which exercises will be right for you and your body without a full assessment (although there are a lot of fitness professionals that will try).

HEALING THE PELVIC FLOOR

It’s a really popular belief that you can just “do pelvic floor exercises” or “kegels” and that’s how you strengthen the pelvic floor, and that’s the ONLY way to strengthen the pelvic floor, AND that it’s a must, all the time, everyone must do this, no exceptions. (I wrote a blog post on this that you can find here)

Specifically in terms of pelvic floor exercises, beyond breathing and good toilet habits (which is mainly to protect the pelvic floor from damage), there is NOTHING that I can prescribe. It is impossible for me to know what your pelvic floor is doing, if it is weak, how it is weak and what would strengthen it if it is. I mean I can take a stab at it, working closely with pelvic floor physios I’m getting pretty good at guessing based on the symptoms you describe – but there are certain things that ONE CANNOT KNOW without an internal assessment (like mild prolapse, which you would want to do you very best to manage and avoid worsening). All women should be assessed by a pelvic floor physio, or Women’s Health Physio 6-8 weeks post-partum. This professional can then do an internal and external assessment of your pelvic floor function. Trust me you don’t want someone guessing when it comes to this stuff.

Just a note on ethics here: I am a “Pre- and Post-Natal Fitness Specialist” and it’s important for professionals like me to fully understand our scope of practice. We have a very in-depth understanding of the pelvic floor, but we are not trained to assess your pelvic floor function, nor is it our job to dish out kegels or any other pelvic floor strengthening exercises – ESPECIALLY over the internet. Anyone who tells you otherwise is unaware of the damage that they can potentially do (and is less trained than the ones who won’t tell you exactly what to do!)

My colleague, Liron Murphy, Women’s Health Physiotherapist, does recommend kegels as part of postpartum recovery. You can find her recommendations for postpartum recovery here.

HEALING DIASTASIS

In terms of healing the diastasis, it’s equally important to individualize such exercises to the woman, at whatever level she is at. It’s important for me to see how the muscles and connective tissues respond to different exercises. Again, it’s a really popular belief that you can just “do these 3 exercises to fix your diastasis!” and that certainly sells! But in truth exercises need to be carefully selected.

In a nutshell, you need to ensure that you are CHALLENGING the core, without OVERWHELMING it (so “tenting” would be an example of overwhelming the core, losing form, or holding the breath – these are all signs that the exercise is too hard and won’t be helping you heal). I have made a video library on youtube of “No-crunch core” which can give you some ideas for exercises that MAY suit you – you are absolutely welcome to try and do this yourself, that’s what I made the videos for! Just be sure to pay attention to what your tummy is doing in each exercise.

As a general rule, if you have DR, planks, crunches, sit ups and anything with leg raises is usually not appropriate – which means that it is too challenging and intra-abdominal pressure will leak out through the linea alba, or the front of the abdomen will bulge – but this also depends greatly on the “size” of the diastasis.

Healing diastasis is a whole other topic in and of itself. I made a video on fixing diastasis a little while ago, which may shed some more light on the topic. You can follow the link or watch the video below.

I made another video on "Which Exercises Will Fix DR" since I get asked constantly if I "can just give a few exercises to heal my DR". It's far more complicated than that. Each DR looks totally different and responds differently to different exercises. There are other factors, like alignment and faulty breathing mechanics that can contribute. All this means that the "treatment" I select will be highly individualized. There is no one-size-fits all.

HOWEVER – it’s really important to note that this kind of work isn’t really appropriate right now. Regardless of the type of labour and birth that you had, the “6 week postpartum period” is there as a safety net – your body has a lot of healing to do! A lot of tissues (muscles, organs, ligaments) have been stretched and pulled and pushed and maybe even torn! Breathe, rest and roll to your side to get up, blow before you go, sleep and if you’re feeling good start to move a little more every day. Listen to your body and let the tissues do their thang for a while! When you are ready to get back into training, it takes a bit of individualization, and isn’t a one-size-fits-all. There are a lot of factors that influence the training decisions that a coach will make.

A FEW MORE THINGS

Walking

You may want to try increasing the amount you are walking, although you should pay attention to any feeling of heaviness in the vagina at this stage. Try not to suddenly spend too long on your feel, especially if you are carrying the baby. Start with short walks and increase slowly. Don't suddenly go for your first walk 2 weeks postpartum, for 2 hours with your baby in a carrier. Start with 10 minutes and increase by a few minutes each day or every few days.

Baby Carriers

It's really popular to have your baby strapped to you 24/7, and so to some, this paragraph might seem like blasphemy. It does worry me that some women have their babies strapped to them on really long walks, or while getting up and down - they wouldn't do squats yet with no weight and now they are doing it with a few kilos on their chest. The weight and position of the baby will increase intra-abdominal pressure and the added weight may be too much for the pelvic floor if it is still healing. (6 weeks may not be enough - we know that it takes much longer for soft-tissue to heal). In particular when we add to this breath holding, poor posture and long periods on our feet.

(Baby-wearing exercise classes make me nervous for all the same reasons).

I'm not saying don't carry your baby - just be mindful of your breath, alignment and how long you are spending like this. Be aware of any discomfort or heaviness in your pelvic floor and see a specialist if you suspect anything is wrong.

Roll over

Try to roll over to get out of bed and off the floor (if you are doing supine exercises) and avoid doing big sit-up type movements. Exhale through the entire movement. This avoids putting too much strain on the abdominal muscles (and pelvic floor) while they are still healing.

TAKING IT FURTHER

I will make a some of videos on this topic, because there are a few avenues to go down here!

1. How to choose exercises for healing diastasis

2. Healing after a C-Section

3. What happens in a C-section

4. Healing after a vaginal birth

5. When to start working out again

6. Is there anything I can do in the first 6 weeks postpartum to assist recovery?

7. Should trainers prescribe kegels or pelvic floor strengthening exercises?

8. Should I go to see a pelvic floor physio?

9. How to breathe

IN CONCLUSION

I could go on and on, but I hope this helped. Here is a quick summary of the major takeaways…

1. Go to see a pelvic floor physio 6-8 weeks after birth to assess pelvic floor function, bring your awareness to any issues and give you personalized treatment/exercises to remedy any issues

2. Don’t start doing any formal exercise until at least your 6-week check-up with a gyno

3. Over the next six weeks, prioritize rest, sleep, good nutrition, diaphragmatic breathing, don’t do any sit-ups, blow before you go. Start to incorporate gentle movement like walking and maybe some gentle exercises WHEN YOU FEEL READY. Focus on the glutes and leave the “core” alone for now.

4. Enjoy the time with your baby! It’s a wonderful and challenging time. Let yourself off the hook and don’t put pressure on yourself.

FUTURE WORKSHOPS

Keep an eye out as I will be running a 2-3 hour workshop shortly on “How to heal diastasis recti”. It’ll be in a small-medium sized group setting, and will be highly practical - lots of tools and tips and assessment techniques to take away and build your own programme. Let me know if you would be interested in a workshop like this and share with any other women you know who may benefit from this.

I am also looking to run workshops with a pelvic floor physio on how to workout with pelvic floor dysfunction, like prolapse, leaking or hypertensive pelvic floor muscles. Watch this space for updates and be in touch if anything in particular interests you!

If this article helped you gain some clarity on what your focus should be in the 6 weeks immediately after birth, please share it with a friend who might benefit. If you agree or disagree with anything here, please let me know - discussion is super important, that's how we all learn!