By Debbi Goodman, MSPT
The postpartum time period is very exciting for most women, but it can be very stressful as well. Women are going through the process of healing their bodies after the birth, dealing with drastic hormonal changes, and adjusting to life with a newborn. Most women are physically exhausted and may have extreme emotional swings. Regaining their prepregnancy body is often a main concern.
In order to work with postpartum clients, Pilates instructors should have knowledge about the physical transformations of pregnancy and how they impact the musculoskeletal system.* It is common knowledge that the abdominal muscles stretch a great deal over the course of the pregnancy, and it is our challenge to help women restore the proper length, strength and tone of these extremely important muscles.
The Postpartum Body
During the course of pregnancy, the abdominal muscles will stretch over 50% of their original length. During the fifth month of pregnancy, the majority of women will begin to notice that their rectus abdominus is no longer united in the center and has moved laterally. This is called a diastasis recti. The diastsis recti is a normal occurrence and is actually a protective response. It’s able to occur due to the hormonal softening that occurs in the body’s soft tissue structures. The rectus abdominus is a narrow muscle with less surface area to stretch, so the separation and lateral movement helps prevent excessive stretching.
After the birth, with time, the abdominal muscles will shorten due to the demands of normal activities of daily living, but without specific exercises and focus, they often do not shorten to their pre-pregnancy state. The diastasis recti, likewise, may naturally close without too much attention, but in most women, specific focus on abdominal rehabilitation is necessary to close the diastasis.
Guidelines for Postpartum Rehab
After giving birth, obstetricians and midwives generally instruct women to abstain from exercise for six weeks. This is a very vague guideline, and although the obstetric community is very knowledgeable in most aspects of prenatal and postpartum care, typically they are not well trained when it comes to dealing with the musculoskeletal system, particularly when it comes to making exercise recommendations. The six-week guideline is based on the fact that it takes about six weeks for the uterus to heal from the birth. Resuming a high activity level too quickly following the birth can impede the healing process.
However, it is unlikely that a new mother is actually going to be resting. The demands of new motherhood are quite taxing. Babies need to be fed throughout the day and night, which means new repetitive movements, whether she is breastfeeding or bottle feeding, as well as lots of sitting. Several days after the birth, the baby will need to be seen by the pediatrician. This means loading the baby into the car seat, lifting the heavy car seat into the car and then transporting the baby into the doctor’s office. Newborns are often very fussy initially and may need prolonged periods of standing and rocking or swaying. This requires tired new mothers to stand up and hold the new baby for long periods. Clearly, new mothers are extremely active—especially if they have other small children at home—and they will be doing all of these new activities with extremely weak abdominals and major postural weaknesses.
The postural changes of pregnancy should really be viewed as a changing orthopedic state. Orthopedic physicians and physical therapists know that the sooner we address muscle weakness after a traumatic event, the sooner the body heals. Likewise, after the rigors of birth, the sooner women begin to do gentle supportive exercises, the faster they will regain their former muscle tone, strength and posture.
Furthermore, research has proven that people who strengthen their muscles before and especially immediately after a surgery have a better rehabilitative outcome. Therefore, this same logic should apply to women following a cesarean section surgery. Women who begin strengthening the abdominal muscles and addressing the scar tissue early on will have a better outcome. So, women should begin to exercise in the first six weeks, but the exercises need to be the right ones.
What to Do in the First Six Weeks Postpartum…
The most important exercises that women should focus on in the first six weeks after the birth are transversus abdominus and pelvic floor strengthening. The first six weeks are an exhausting time for women, and it is usually difficult for them to focus on carving out time to exercise. However, it is important for women to spend a couple of minutes a day practicing engaging these two muscle groups in an effort to begin shortening and strengthening them.
It is safe to begin TVA contractions and Kegels the day after the birth. Women can work on short duration holds (5-10 seconds) and gradually increase to longer durations holds (30 seconds). Other helpful exercises are ones that focus on breathing to help reeducate the diaphragm. Pectoral stretching is necessary to open the chest and counter all the hours spent sitting and feeding the newborn. This also helps prevent common postpartum upper extremity issues such as carpal tunnel syndrome. Gluteal, piriformis and hip flexor stretching may be necessary as many pregnant women continue to have pelvic and hip pain after the birth. Women who spend a little time working on supportive exercises often have an easier time handling the physical stresses of new motherhood.
After the First Six Weeks…
After the first six weeks, many women, although still exhausted, tend to have an increased motivation to begin exercising. At this point, the focus should be on advancing the core stability program but with an emphasis on closure of the diastasis recti (rectus abdominus separation).
Closing the Diastasis
On average it takes most women (even extremely fit women) approximately six months to one year to regain full integrity of the abdominals. So, this is a slow process and one that should not be rushed. Advancing abdominal strengthening too quickly can jeopardize the joining of the recti and leave women with a central weakness. This is not always something that women can feel, but it is most evident if they later go on to have a subsequent pregnancy. They will begin the next pregnancy with a diastasis, which may put them at risk for separation of the deeper layers.
While a woman still has a diastasis, it is necessary to refrain from exercises that require a strong recruitment from the rectus abdominus, including exercises in the supine position that involve lifting the head and shoulders off the ground or lifting double legs off the ground (even table top). These more aggressive exercises should not be initiated until she is able to do these movements without her rectus opening, and this can be palpated by a skilled instructor.
Once the diastasis is closed and she has regained full proprioception of her abdomen, she can begin doing more advanced abdominal work. It is preferred that the woman has gained enough of an awareness to be able to feel that she is “drawing in” and uniting the rectus as she does more advanced movements.
Another important focus postpartum is restoration of the position of the ribcage. During pregnancy, the ribs flare considerably. The ribcage actually changes in diameter by 2 cm. Postpartum, it is necessary to restore the ribcage position as it affects the length of all the muscles attaching into the thoracic cage, including the abdominals, the pectorals, the erector spinae and the diaphragm. Following the physics principle of the length-tension relationship, as long as the ribs are flared, the body will not be able to reach its maximum strength potential. Furthermore, flared ribs put more stress on the diastasis recti and make it more difficult for the obliques to engage and the abdominal muscles to unite centrally.
A final important focus in postpartum rehab is posture. Pregnancy causes major postural changes to occur. All of the spinal curves become more exaggerated, and these excessive spinal curves often continue into postpartum. Most women have to pay attention to restoring their posture. They need to tune into their bodies and notice when they are slumping, and initially, the act of sitting up straight will be an exercise. Becoming aware of postural habits is the first step towards correcting them.
Pregnancy and postpartum is an incredible and exciting time but not without its physical challenges. New mothers need to be strong to handle all of the stresses that are placed on their bodies. Babies get heavy rapidly, and mothers need to be able to carry their babies into their toddler years. Women need to take care of their bodies so that they can enjoy wonder of watching their babies grow!
About the Author
Debbi Goodman, MSPT is a licensed manual physical therapist with specialties in women’s health, dance medicine and sports medicine. She has been a physical therapist for Westside Dance Physical Therapy, New York City Ballet, School of American Ballet and the Kane School of Core Integration. Debbi has had a private women’s health/orthopedic practice in New York City, and since moving to the Albany area in 2004, she has developed a private practice in the Capital District. Debbi is one of the few physical therapists trained in internal evaluation and treatment of the pelvic floor muscles. In addition, she is specifically skilled in treatment of pregnancy problems including: sciatica, back/neck pain, pelvic pain and rib pain, and postpartum problems including: cesarean section recovery, urinary incontinence, pelvic/vaginal pain and post-delivery scars. Debbi teaches continuing education workshops for physical therapists, trainers and Pilates instructors focusing on exercise during pregnancy, and she is an instructor for prenatal and postpartum group fitness classes.
*Before working with a postpartum client, make sure she has discussed an exercise program with her doctor.
Pilates and Pregnancy: Safe Ab Exercises
The Pilates Bookshelf: Top Pregnancy Resources
Restoring the Floor While Integrating the Core: 6 Essential Moves for Postpartum Health
Studio Profile: Centered
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