Postpartum Exercise to Restore The Core
The focus of exercise in the postpartum period should be on pelvic girdle stabilization. The ligaments that hold the joints in place, known as form closure, are stretched out and become permanently deformed as a result of extra hormones in pregnancy. This requires extra help from the muscles, or force closure, that hold the pelvic girdle together.
Muscles required for stabilization include the gluteus maximus, the inner thighs and and the deep core. The deep core is a system that includes the diaphragm, pelvic floor, transverse abdominus and multifidus. When the core system is working as it should, dysfunction and pain does not occur. However, since pregnancy disrupts the core in women, the core needs to be retrained or other muscles can remain perpetually tight, leading to dysfunction. According to 20th century physician, Vladimir Janda, muscles that become abnormally tight in the lumbopelvic girdle include the piriformis (buttocks), hamstrings, hip flexors, obturator internus (hip rotators), paraspinals, pelvic floor, short adductors (groin) and rectus abdominus. Symptoms of abnormal tension in these muscles include back pain, hip pain, pelvic pain, urinary urgency or incontinence, painful penetration and more. In summary, the muscles that need to be retrained during and after pregnancy to properly stabilize the pelvis are the glutes/buttocks, quads/thighs, inner thighs and especially the core! All the other muscles need to be down trained or relaxed.
REDUCE THE JELLY BELLY
The abdominal wall should be assessed before beginning an exercise program in the postpartum period. Click here to read more about DIASTASIS RECTI, a vertical abdominal split between the rectus abdominus muscles. Risk factors of an abdominal split include low back pain, urinary incontinence (involuntary loss of urine) and pelvic organ prolapse.
Exercise should be aimed at retraining the tranverse abdominus, or deepest abdominal muscle. The function of this muscle is so vital to core health; it is the timing and sequencing of this muscle that is so important. Doing sit-ups or crunches not only doesn't target the correct muscle, it can increase back and neck pain and put abdominal stress on the pelvic floor, leading to organ prolapse, diastasis recti and/or urinary leaking. Click here to read our blog on why sit-ups and crunches are not the best core exercise.
To activate the transverse abdominus (TA), sit with good posture on the edge of a chair or a physioball. Place your hands on the lower abdomen for extra feedback. Exhale through the mouth while making a noise such as "sh" or "ss" and drawing in the lower abdomen as if closing a draw string bag. Waist size can be minimized in just one month if this exercise is repeated 10 times during 5 feedings a day. This is the foundation for all core exercises and must be mastered before starting a Pilates program or exercise progression. If you can't feel much happening, don't worry. You can encourage the lower abdominals to contract by squeezing a ball between the knees as you EXHALE. This will also activate the pelvic floor muscles, that are part of the deep core. You can also try activating the TA in a hands and knees position to work the muscle against gravity.
EXERCISE TO INCLUDE IN THE POSTPARTUM PERIOD
The deep core muscles can be further activated by adding the glutes and quads to maximize time and engage synergistic muscles.
BRIDGE WITH BALL SQUEEZE Simultaneously EXHALE and squeeze a ball, press hands into the floor and lift the buttocks off the floor. Pause and return to the start position. Repeat 10 times. (do not do if you notice a bulging of your abdominal wall or pain)
PILATES POSTURE OF POWER
Lie on your back with the heels together, spread toes, tighten thighs, squeeze buttocks and lower shoulder blades towards the back pockets. Hold for 1 minute while breathing deeply and slowly through the diaphragm.
Lie on your back with knees bent. Press the low back into the floor by rotating the pelvis backwards. EXHALE and slide one leg until it is straight and return to the start position, in one breath. Repeat with the other leg. Repeat 10-20 times. Stop if your back begins to arch.
EXERCISE TO AVOID IN THE POSTPARTUM PERIOD
Pelvic girdle instability can persist in the postpartum period due to hormones that contribute to joint laxity, as well as during the second half of the menstrual cycle (from ovulation to menstruation). Some of these hormones remain in high concentrations, especially if you are breastfeeding. Until your core is properly retrained, avoid sit-ups or crunches, the adductor machine at the gym for the inner thighs, lunges or scissoring activities, step aerobics, high impact such as running and stair stepping. Gluteus maximus and medius strengthening should be emphasized to support your low back and pelvis.
The six-week check-up is often when you will be given the green light to return to all activity, including exercise and sexual activity. If there is a delay in healing or an infection, the time frame will be longer. A good rule of thumb to follow for returning to full activity is generally after the lochia, or postpartum blood flow, subsides. The postpartum period is a great time to return to exercise. This is a time when motivation is high to regain your waistline and maintain the training effects of pregnancy (your body thinks you ran a marathon). If you begin retraining the core initially right after birth, it will be easier to return to all activities, such as running. If you haven't gained sufficient core strength, I recommend postponing running or impact activities until the core is able to transfer the load from your feet to your pelvis effectively. The following symptoms are a result of the core not working properly and need to be addressed, or they will worsen and lead to chronic problems.
WHEN TO SEEK HELP
Severe or debilitating back, pelvic or hip pain
Back, pelvic or hip pain during or after activity that persists beyond 6 weeks
Pain during or after intercourse, or lack of sensation
Fear of pain with intercourse
Pain with urination or bowel movements
Urinary leaking, urgency or frequency (>8 voids in a 24-hour period)
Urinary retention or inability to empty the bladder completely
Diastasis recti or doming of the abdominal wall with exercise or activities
Inability to perform a Kegel
If you attempt to return to exercise and continue to have problems, it is time to seek the help of a women’s health physical therapist who specializes in treating the pelvis and postpartum dysfunctions. With proper exercise and hands-on manual therapy, the muscles can be retrained to function properly, even after many years of dysfunction. To find a qualified physical therapist in your area, click here. You deserve to be the best version of yourself and to have a healthy core!
Lee L-J, Lee D. 2011. Chaper 7: Clinical Practice - The Reality For Clinicians. The Pelvic Girdle, 4th edition. Elsevier, Edinburgh.
Janda V, Va'Vrova'. 1996. Sensory motor stimulation. In Liebenson C (ed). Rehabilitation of the Spine. Wilkins & Wilkins: Baltimore. 319-328.