I don’t envy GPs tasked with giving the ‘six-week check’ to postnatal women.

As a pelvic health physiotherapist working in private practice, I have the privilege of time that many hard-working NHS colleagues do not. And so, I thought it may be useful to use a patient example of how I harness the typical enthusiasm of new mothers to get moving again while making sure they don’t do any lasting damage to their bodies in the process.

Not long ago, I treated a patient who in her spare time enjoys participating in triathlons. Six weeks after having her baby, she came to see me get the ‘green light to start running again. This was a woman in her early 30’s who was at the peak of her physical fitness before getting pregnant, had a low-risk pregnancy and had an uncomplicated birth.

Returning to exercise is so important for new mothers for many reasons including the desire to feel themselves again, to ‘reclaim’ their bodies, to improve their general health and to support their mental health.

‘Exercise’ to a new mother could mean taking their baby for walks in the park or getting into a warm pool for baby swimming. It could also mean joining their local ‘buggy fit’ class or, as in this instance, a combination of swimming, cycling and running.

Before advising women on when and how they might to return to exercise, I need to define what ‘exercise’ means for them. Why? Because all exercise is not created equal and certainly not when considering the pressure, it can put on the pelvic floor. 

For this reason, I always make it a priority to understand what my patient’s short and long-term goals are, and what exercise she specifically would like to return to.

I also take time to make sure my patient understands the function of the pelvic floor, the changes that her body has gone through, and most importantly why her body needs time to heal.

Clearly, for this patient, exercise is a big part of her identity and, after having a baby, one she was keen to revisit. I didn’t want to dampen her enthusiasm for an active lifestyle (and the mental health benefits it can bring), but I didn’t want her to set herself back with a pelvic floor presentation by prescribing high-impact exercises from the get-go.

I used the example of a sports injury; explaining that if an athlete breaks their ankle, they would give themselves time to recover and rehabilitate. Just as an elite runner might injure themselves, a new mother needs to bear in mind that carrying the weight of a baby for nine months has a significant impact on their pelvic floor and the associated muscles to hold and deliver the baby. And just as an injured elite runner might not attempt to sprint before they can walk again, a new mother – who naturally through late pregnancy and early motherhood will have had some time out of their usual training schedule – needs to slowly regain her strength and stamina from the inside out.

Education is all good and well, but my patient had her own expectations. She wanted timelines and a plan.

Before providing her as much, it was vital that I understood her obstetric and medical history and checked if she was experiencing any red flags for pelvic floor dysfunction such as heaviness or dragging (an indicator for prolapse), incontinence or an overactive bladder, bowel dysfunction (i.e. constipation or straining), pain with intercourse, vaginal dryness or pelvic pain.

As a pelvic health physiotherapist, I also assessed the patient both internally and externally. Upon internal examination her pelvic floor lift and drop was moderate, her strength was optimal, but she needed to work on her endurance. I also checked her fascial integrity and her genital hiatus to in order to give me an understanding of her baseline.

I assessed the tension and depth of connective tissue across the linea alba. This informed me as to how much-loaded core exercise she could tolerate, to optimize strengthening while managing intra-abdominal pressure. I noted that she had moderate tension across the linea alba with minimal depth (1cm) and width (< 1 and a half fingers). The patient was upset that she had a diastasis of rectus abdominus (DRA) but I assured her this happens to all women by 35 weeks of pregnancy and explained some women’s DRA (like hers) could be minimal post-partum due to a combination of genetics, a smaller baby, good pelvic health and appropriate exercise during pregnancy.

I also put her through some functional body-weight tests to assess her movement patterns and global conditioning. She moved well and carried out the movement with no symptoms such as leaking, vaginal heaviness or pain, however she lacked power and endurance when performing sit to stands and squat jumps. This highlighted to me and the patient that we needed to focus on power and movement.

NICE guidelines suggest that practitioners recommend pelvic floor muscle training for all post-partum women, with guided training programmes for those with added risk factors such as damage to the anal sphincter, a ‘back-to-back’ vaginal birth, a pushing stage of active birth lasting more than one hour or assisted vaginal birth with forceps or a vacuum.

Even without symptoms, restoring the strength of the pelvic floor is vital to all postpartum women, and framing it as ‘training’ is useful for our ‘injured athlete’ analogy.

For this patient in particular, I explained the importance of her pelvic floor endurance – as running is a high-impact sport which comes with an increased prevalence of urinary incontinence and prolapse in postnatal women (Blyholder et al. 2016).

My first port of call is to prescribe pelvic floor exercises. I prescribe three sets daily of the following:

1. x 10 back (anal passage to front wall), holding the squeeze for 5 seconds and relaxing down
2. x 10 back to front squeeze and relax
3. x 2 20-second holds at sub-maximal contraction (for endurance)

I tend to suggest women start pelvic floor exercises from a gravity assisted position such as supine, emphasizing how this can be a convenient opportunity for some postnatal self-care; and a moment for her to prioritise her health and recovery. 

But pelvic floor exercises alone are not enough for my eager triathlete, I appreciate she needs more to get on with and we need to work on the conditioning of her global muscles.

Our understanding of postnatal return to exercise is changing and we now know that exercises such as core exercises and seated movements with or without weights can be a good place to start.

For this patient, I provide her with a simple exercise program of low-impact squats and seated movements alongside two posterior chain exercises to focus on her glutes, which she needs to strengthen to condition her for running.

I also provide her with some general lifestyle recommendations to reduce load and stress on the pelvic floor i.e. drinking enough fluids, reducing constipation and minimizing babywearing. If she is breastfeeding, I advise about optimizing breast support and timing of feeds to support return to exercise.

In time I will expand on the exercises prescribed, but for now that is enough. I explain that, providing she commits to the pelvic floor exercises I provide her over the coming 12 weeks, she should be able to return to running by the spring. She also understands that her return to running will be impacted by breastfeeding and I will not recommend she runs while she is doing so.

With an hour for the postnatal assessment, we cover a lot of ground. For this reason I provide my patients with a report after their initial consultation. I restate the patient’s goals at the beginning and provide a broken-down plan and a timeline. This is to set expectations but also to motivate her and offer some structure in the face of the huge lifestyle change that comes with having a baby.

It can be encouraging to remind her that there may be no reason why she can’t return to full fitness, or even becoming a better runner than she was before, just because she’s had a baby. Even in cases of severe birth injury or trauma, with the right rehabilitation, we can see great progress in postnatal women. Another patient, who was told after birth that she would be able to walk again but not much more, is now lifting weights in the gym which she never would have dreamt of in her former life. This is one extremely committed patient, who took her time to rebuild strength with mat work, physiotherapy and incremental weight training, and that patience has paid off.

It also helps to remind women that it’s not a race; it’s about healing and listening to their body, even when certain voices in the fitness industry are shouting louder with their ‘snap back into shape’ messages.

And finally, I emphasize that a safe return to exercise requires a commitment from her to do her homework and prioritize her health. I reiterate that optimizing her pelvic health now will reduce her risk of pelvic floor dysfunction later in life and that the reality is, no one else can do this for you!

Was my triathlete disappointed not to get a simple green light?

Of course, it wasn’t the news she wanted to hear. But this is her first baby, she’s breastfeeding and up every three hours, she’s sleep-deprived and her immune system isn’t up to full strength. She understands that she needs to build up her conditioning to prevent injury and long-term pelvic floor dysfunction and get her performance back on track. She’s empowered with knowledge and ideas and she knows this will reduce the risk of injury going forward.

In her language, she knows postnatal recovery is a marathon not a sprint, and she has a plan to get there.

Useful Resources

• NICE Pelvic floor dysfunction: prevention and non-surgical management

NICE guideline [NG210] Published: 09 December 2021

• Returning To Running Guidelines
• Reframing Return to Sport: The 6 R’s Framework – Donnelly, G et al. 2021