**4. Postpartum recovery and common postpartum conditions**

Before discussing postpartum exercise, it is important to have a solid understanding of the postpartum recovery process and common postpartum conditions that impact a woman's return to exercise. No two postpartum experiences are alike and there are a plethora of different conditions that may or may not occur after every delivery. All of the following conditions should be carefully considered by the clinician, coach, or trainer and discussed thoroughly with the postpartum woman and her medical provider if necessary, before designing a postpartum exercise program.

Although commonly thought of as the space between the vagina and the anus, the female perineum is a diamond shaped structure spanning from the pubic symphysis and the coccyx. The perineum is essential for supporting the pelvic floor and when tearing occurs in childbirth, damage can be done to muscle, fascia, veins, arteries, and nerves housed in the perineum. Tears range in severity from a 1st degree tear (first layer of skin around the vagina) to 4th degree tear (extends from the vagina to the anus). A 2nd degree tear is most common and 85% of women experience some degree of tearing in a vaginal delivery [35]. Tearing can impact the perineum's ability to support the pelvic floor and unresolved trauma can lead to urinary and fecal incontinence and prolapse [36]. This type of birth injury can have a direct impact on postpartum physical activity and should be a consideration for program design.

C-sections are performed when vaginal delivery is too risky for the pregnant woman or the fetus, when labor has become complicated or fails to progress, or can be elected through consultation with the patient and obstetrician. This surgery involves cutting through skin, fat, fascia, and the uterus. Abdominal muscles are separated, not cut.Incisions are generally 12–17 cm, or 4.5–6.5 inches and the resulting scar tissue can make the surrounding skin and fascia tight and restricted [37]. The scar can also be painful, tender, sensitive, or lacking in sensation. This will have an impact on the recovery and return to physical activity timeline. As a general rule, no physical activity should occur before the incision has closed and clearance from a healthcare provider has been obtained.

Arguably, the condition most commonly exacerbated by premature return to postpartum physical activity is prolapse. At six weeks postpartum, 83% of women have some degree of prolapse and at 7–11 weeks postpartum, 52% of women develop a new prolapse, or a prolapse that was not present at the 6 week checkup [38]. Resistance training and running can generate intra abdominal pressure that pushes directly down on the pelvic floor that creates or exacerbates prolapse [2]. Prolapse can be avoided by gradually progressing the training program and scaling back when symptoms dictate. Prolapse and its impact on physical activity is related to perineum tearing and resulting scar tissue, pelvic floor resting tone (how tight or loose the pelvic floor muscles are), and whether or not the woman experienced prolapse or pelvic floor dysfunction during pregnancy. All of these factors should be considered before returning to physical activity.

Postpartum women commonly experience urinary (and sometimes fecal) incontinence with physical activity [2, 39]. It is referred to as stress urinary incontinence and is the leaking of urine without an urge and is brought on by a stressor such as running or jumping. When the muscles of the pelvic floor are not strong enough to support the bladder and/or contract the muscles that tighten the opening of the urethra, urine may leak when a stressor is introduced. It is important to recognize that while urinary incontinence is common in postpartum women, it is not normal. It is a sign of pelvic

floor dysfunction and needs to be rehabilitated as any other injury before physical activity begins or continues. Urinary leakage needs to be acknowledged as a symptom of dysfunction and a potential precursor to prolapse and a sign that running and resistance training may not be appropriate until proper pelvic floor rehabilitation has taken place [2]. Pelvic floor therapy is not recommended to pregnant or postpartum women as a standard of care in the United States, leaving women to self advocate for such treatment [2]. Informed clinicians, coaches, and trainers could be instrumental in recognizing these signs of pelvic floor dysfunction and recommending or referring a client or patient for pelvic floor therapy.

Diastasis recti, while a normal adaptation of pregnancy, needs to be rehabilitated and permitted to heal before strenuous physical activity occurs. Some natural healing of the linea alba and surrounding fascia does occur spontaneously in the early postpartum weeks [17]. An estimated 60% of postpartum women have a diastasis at 6 weeks postpartum which decreases to 32% of women at 12 weeks postpartum [16]. There are several factors that impact the severity of diastasis recti including genetic factors related to collagen and elastin, advanced maternal age, ethnicity, number of pregnancies carried to term, pregnancies with multiple fetuses, high birth weight, and maternal weight gain [8, 16, 19]. All of these factors can impact the amount of spontaneous healing that is possible in addition to postpartum hormonal changes that regulate tissue healing.

Postpartum hormones are responsible for maternal recovery but also prepare the woman's body to produce breast milk. The four key postpartum hormones are estrogen, progesterone, oxytocin, and prolactin [40]. Relaxin is also a hormone produced in pregnancy that remains present in the postpartum body. For the purposes of this chapter, we will primarily focus on postpartum estrogen and relaxin levels as they have the greatest impact on physical activity.

Estrogen level dramatically drops to 10% of the prenatal value and reaches its lowest value by 7 days postpartum [40]. If the postpartum woman breastfeeds the newborn, estrogen levels will remain low until ceasing breastfeeding. The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months and urges greater support for mothers to nurse until at least 1 year of age [41], so this could be a significant period of low estrogen. This has a profound effect on postpartum tissue healing as estrogen is directly linked to tissue healing [42]. Low levels of estrogen may delay perineal tearing and c-section incisions. Additionally, long term suppressed estrogen due to breastfeeding may delay the soft tissue healing of the linea alba in regards to diastasis recti healing.

Relaxin, the hormone responsible for relaxing the ligaments in the pelvis in preparation for delivery, remains present for 12 months after delivery and longer if breastfeeding [43]. This means that women who do choose to breastfeed will have the effect of relaxin; ligament relaxation and laxity, possible SIJ pain, and pelvic pain. There is also some evidence to suggest that increased levels of relaxin in postpartum women can delay healing of diastasis recti because relaxin is designed to increase soft tissue laxity [17, 43]. The linea alba serves as the anchor for the rectus abdominis and transverse abdominis and if its tissue integrity is compromised by relaxin, abdominal strengthening and healing of the diastasis recti may be delayed [17].

After delivery, the hormone prolactin will prompt milk production. If a woman chooses to breastfeed, levels of prolactin will rise and fall in proportion to nipple stimulation [40]. When a postpartum woman's milk comes in, they can experience engorgement of the breasts which can range from uncomfortable to painful. Direct nursing or using a breast pump will relieve the engorgement. Breastfeeding continues

#### *Guidelines for Prenatal and Postpartum Resistance Training DOI: http://dx.doi.org/10.5772/intechopen.109230*

on a supply and demand basis, meaning that the more the baby nurses (or the more milk that is pumped) the more the breasts will produce and if the baby nurses less (or less is pumped) then the supply will go down [41]. This process will fluctuate over the course of breastfeeding until weaning is initiated and eventually prolactin levels drop and milk ceases to be produced. For women who choose not to breastfeed or cannot breastfeed, prolactin levels usually return to normal around 7 days postpartum [40].

It is to be expected that new mothers will experience significant sleep loss and fatigue following the birth of their baby. Postpartum women experience disrupted sleep patterns that can lead to sleep disturbances and sleep deprivation. Common postpartum sleep patterns include lack of nocturnal sleep that is replaced by daytime sleep. Many women report that sleep disturbances continued well past the 3 month postpartum mark [44, 45]. Sleep disturbances and sleep deprivation are closely intertwined with depressive symptoms and postpartum depression. Postpartum depression is most common 3 weeks after delivery up until the 6 month mark but can present later as well [46, 47]. Women who experience miscarriage or stillbirth are at a higher risk of developing postpartum depression and those experiencing preterm delivery are at an increased risk for posttraumatic stress disorders [47].

#### **4.1 The postpartum checkup**

At six weeks postpartum, women are seen by their healthcare provider, usually the obstetrician's office that oversaw the pregnancy, labor and delivery. At this postpartum checkup the provider will check the incision if a c-section was performed and the perineum will be checked if tearing occurred or stitches were used. The uterus will also be externally evaluated and the breasts will be examined. The provider will also do a general medical assessment in taking blood pressure, height, weight, and heart rate. The postpartum patient will also complete a survey to assess for postpartum depression.

Barring any major red flags, the postpartum woman is medically cleared to resume physical activity, usually with very little guidance as to where to begin or how to progress safely. Many women incorrectly assume they are ready to return to running and resistance training at this point. There are several reasons why returning to physical activity after giving birth needs to be done as a gradual progression including; perineum tears, c-section incisions, healing prolapse, urinary and fecal incontinence, healing diastasis recti, hormonal changes, breastfeeding and changes to the breasts, fatigue, and mental health considerations.

#### **4.2 Postpartum exercise readiness guidelines**

The first step in returning to postpartum exercise is gaining clearance from the obstetrician or healthcare provider. Even after a postpartum woman is cleared by her physician, it is highly recommended that clinicians, coaches, and trainers utilize a physical activity readiness questionnaire (PAR-Q ) to identify contraindications for postpartum exercise. These questionnaires are completed by the patient before any physical activity begins. If contraindications for exercise are identified, the patient should be referred back to her physician to address any health concerns [2]. If no contraindications are identified, the postpartum conditions outlined in the previous section should be carefully considered while creating an exercise routine (**Table 2**).

Contraindications and signs that exercise should stop for postnatal exercise include; postpartum bleeding (lochia) changes color, heavier flow, or starts again

	- Pubic symphysis dysfunction, sacroiliac joint dysfunction, or pelvic pain
	- Tearing/episiotomy or problem with stitches
	- Urinary or fecal incontinence
	- C-section wound discomfort
	- Diastasis recti (abdominal muscle separation)
	- Prolapse
	- Bleeding during or after exercise
	- Gestational diabetes

#### **Table 2.**

*Sample postpartum physical activity readiness questions [2].*

after stopping, feelings of heaviness or bulging in the vagina, leaking urine during or after exercise, pelvic pain, bulging or doming of the abdomen during exercise or discomfort afterwards [48], increased fatigue, dizziness or lightheadedness, difficulty breathing, chest pain, and pain or discomfort around the c-section scar or perineum stitches if applicable.

#### **5. Foundational postpartum physical activity timeline**

While prenatal exercise is largely scaling back as the pregnancy progresses, postpartum exercise is the reverse process; exercise needs to be gradually and progressively implemented over time. Every postpartum woman recovers differently and recovery is dependent upon several factors including her labor and delivery experience, health before and after delivery, mental health concerns, postpartum support, and the health and wellbeing of her new baby and other children and family members. Therefore, it is difficult to assign specific physical activity milestones to all postpartum women. However there are safety precautions and logical sequencing of rehabilitation and return to physical activity that can be utilized to ensure safe postpartum exercise.

For the purpose of this textbook, a focus on resistance training will take persistence over details about all types of physical activity including cardiovascular exercise. Historically, it has been advised that postpartum women do absolutely no exercise or mobility work in the first 6 weeks after delivery with many healthcare professionals still insisting on this outdated practice. Then they would be cleared for all activity at the 6 week postpartum check-up leaving a very wide gap in physical activity readiness leading to pain or injury of postpartum women returning to exercise. Updated protocols for postpartum physical activity do include foundational movements that can be performed in the early postpartum weeks to encourage healing and better prepare women for a return to physical activity [2].

In the very early postpartum weeks, weeks 0–2, if a woman wants to engage in movements, mobilization and postural movements need to be the primary focus.

#### *Guidelines for Prenatal and Postpartum Resistance Training DOI: http://dx.doi.org/10.5772/intechopen.109230*

Some examples can be encouraging anterior and posterior pelvic tilts for postural alignment and light standing open kinetic chain movements. In weeks 3–4 postpartum, women can initiate short duration (less than 15 min) walks as well movements such as transverse abdominis engagement and glute bridges. In weeks 5–6 postpartum, an increase in walking duration (less than 30 min) can be implemented as well as muscular activities such as standing and quadruped hip abduction and extension, double leg calf raises, as well as sit to stand movements [2]. The intensity of all movements during the first 6 weeks postpartum should be kept at an RPE of 0–2 [2].

Upon clearance at the 6 week postpartum checkup, postpartum women can progress to muscular strength tasks either with body weight or with additional weights if appropriate. These muscular strength tasks can include squats, single leg sit to stand, and single leg calf raises. It should be noted that most recent evidence suggests that impact exercises such as running and jumping should be postponed until weeks 8–10 postpartum. Before doing so, gradual dynamic movements should be progressed in the exercise routine and can include single leg calf raises, single leg hop down from a step, single leg hopping, and jumping in place [2]. It is recommended that RPE during tasks should be maintained under a 6 [2].

It is also highly recommended that every postpartum woman see a pelvic floor therapist at least once after delivery. After clearance from the healthcare provider at the 6 week checkup is an ideal time to seek pelvic floor therapy as they will be able to perform an internal examination. The pelvic floor therapist can determine if there are any contraindications to advancing further into exercise such as pelvic floor dysfunction or prolapse that could be made worse by more stressful physical activity [2].

Most recent evidence suggests that 13 weeks postpartum is a safe point to return to running and sport activity given that the postpartum woman has progressed throughout other stages of postpartum recovery and exercise without complication [2]. Resistance training can begin to safely progress into more sets, repetitions, or weight depending on the lifting experience of the postpartum woman and her recovery process thus far.

#### **6. Guidelines for postpartum resistance training**

Upon successful progression through foundational physical activity milestones, postpartum women are capable of returning to resistance training. It is recommended that clinicians, coaches, and trainers discuss specific goals and exercise expectations with their postpartum patients or clients so they design exercise plans that progress realistically in conjunction with their patient or clients needs and desires.

Recall that beginning in the second trimester, front loading exercises including crunches, planks, pull-ups, push-ups, and leg lifts, were removed from exercise routines. Progressive reintroduction of these movements can be accomplished safely if the postpartum woman is monitored and educated on abdominal doming or bulging, diastasis recti and intra abdominal pressure management.

Diastasis recti can be assessed very simply through self-examination by lying on the floor with knees bent and feet on the ground. Then, while performing a small crunch with head and shoulders off the ground, palpate the linea alba from distal sternum to the pubic bone noting tissue tension (or lack thereof) and also noting the distance between the two rectus abdominis muscles. When the distance between the two rectus abdominis muscles exceeds 2 finger widths there is considered to be a diastasis [19, 43]. Tissue tension is an important factor for determining severity of a

diastasis as tissue integrity needs to be insured for proper biomechanical function. If a diastasis recti exists, front loading exercises in particular will need to be carefully prescribed and pressure management education will need to be administered. The clinician, coach, or trainer will need to watch for abdominal doming or bulging of the lower abdomen as it is an indicator that pressure is not being properly managed.

A common cause of abdominal doming or bulging in postpartum women is a lack of connection or firing of the transverse abdominis. These muscles are responsible for maintaining abdominal wall tension in order to stabilize the spine and the pelvis before movement of the limbs occurs [49]. Because the transverse abdominis muscles co-contract with the muscles of the pelvic floor [49, 50] and have altered firing patterns after pregnancy [49], it may take significant retraining to properly engage these muscles to restore a functioning core. Abdominal doming and bulging are an indicator that the transverse abdominis muscles may not be contracting or may not be contracting the proper sequence in relation to the rectus abdominis and oblique muscles [49]. Retraining the transverse abdominis is the first step in reintroducing front loading abdominal exercises to the postpartum woman.

Equipment selection and the amount of weight lifted are very important factors to consider when designing postpartum exercise plans. Equipment selection should follow a logical progression with a recommendation for starting with bodyweight exercises, followed by resistance band use, followed by hand weight or dumbbell incorporation, and working up to barbell introduction. The timeline for equipment progression will be dependent upon the postpartum woman's lifting experience, comfort level in using each type of equipment, and overall recovery process. If she is breastfeeding, relaxin levels will remain elevated and can cause ligament laxity and possibly pelvic or SIJ pain even if she is an experienced weight lifter [51].

Equipment selection and weight lifted will have a significant impact on prolapse. Women who return to strenuous lifting too soon postpartum can be at an increased risk for developing prolapse [2]. Women with prolapse can still lift lighter loads if they are able to properly manage intra abdominal pressure and are not bearing down into the pelvic floor while lifting. Bearing down into the pelvic floor while lifting is an inappropriate but common strategy for attempting to stabilize the pelvis when there is a lack of strength or function in the core. Addressing diastasis recti if present will also encourage proper intra abdominal pressure management and provide strength and function to the core and pelvis and limit the need for other compensatory movements and strategies that can lead to prolapse.

Jumping and plyometrics are some of the last impact exercises that are introduced in postpartum exercise plans. High impact exercises such as jumping and plyometrics can reveal pelvic dysfunction in the form of urinary incontinence. Because these exercises place a high level of stress on the pelvic floor, postpartum women who had not experienced urinary incontinence before may experience it for the first time while attempting jumping or plyometrics [2]. Urinary incontinence should be recognized as a symptom of pelvic floor dysfunction and a referral to a pelvic floor therapist should be recommended. It is also a sign that the pelvic floor is not ready for such high impact and scaling back may be necessary.

To date, there is no evidence to support a definitive intensity maximum after the 13 week postpartum period without any RPE or heart rate restrictions outside of normal, age-appropriate ranges. The ACSM does suggest that training volume should progress gradually at 2–10% per week in direct relation to postpartum recovery progress and goals of the postpartum woman [2].
