After the birth of a baby, at some point, many mothers think about how and when to return to some form of exercise. There are many reasons why women should be encouraged to return to exercise. There is high-level evidence demonstrating that exercise is beneficial for mothers’ physical and mental health. Regular exercise reduces postpartum weight gain and promotes faster return to pre-pregnancy weight. It improves overall physical conditioning and emotional wellbeing and is believed to reduce the risk of anxiety and postpartum depression. For some high-level athletes, having a baby may be carefully planned to occur between important competitions. If the pregnancy and birth are uncomplicated, there is evidence that an elite athlete can return to the same level of performance or better than before pregnancy.

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However, when discussing a return to exercise and sport, there are considerations specific to this time in a woman’s life. The decision is multifactorial and can be complex. A woman’s primary health provider during pregnancy (obstetrician/midwife) plays an important role in providing this advice in the postpartum period. However other professionals including physiotherapists, sports and exercise physicians and coaches are also able to support and offer guidance to women on this topic.

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There is no consensus on the definition of ‘postpartum’, but the term often refers to the first 6 weeks after birth, with others extending the definition to 1 year after birth. Many of the physiological changes that occur during pregnancy persist for 4-6 weeks after birth. One example is the hormone relaxin which remains elevated during this early period. This can reduce joint stability and increase risk of injury. The general recommendation is that healthy women gradually return to physical activity, aiming to accumulate 150-300 minutes per week of moderate to vigorous aerobic exercise.

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Low impact endurance training should increase gradually but can start early since there is minimal pressure on the pelvic floor. Return to high impact exercises and strength training may need to be delayed several months and needs to be even more gradual, especially exercises that increase intra-abdominal pressure such as leg press, bench press and abdominal exercises. The focus should initially be on strengthening the pelvic floor muscles.

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The advice to mothers may also vary depending on how the baby was delivered, whether there were complications at birth and the woman’s medical history. For example, women who have undergone caesarean birth are more likely to have abdominal pain postpartum than those who have had a vaginal birth. The timing of return to exercise will therefore also depend on multiple factors including pain management and wound healing.

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Low back pain is a common problem during pregnancy and often continues after birth. Usually, this improves after 6 weeks. Stretched and weakened or even separated abdominal muscles (diastasis recti abdominis) may also delay or impair exercise ability. Many women experience symptoms relating to weakened pelvis floor muscles after birth. There is strong evidence to support the use of regular pelvic floor exercises during pregnancy and after birth to prevent and treat postpartum urinary incontinence.

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Exercise for women who are breastfeeding is safe, but these women should be advised to increase their energy and fluid intake if they are exercising. If this intake is adequate, there is no reduction of volume or quality of breastmilk, even if the exercise is vigorous. If, however, the infant appears unsettled when feeding after their mother has exercised, the recommendation is that she could try feeding her baby before the exercise, wait an hour before feeding, or use expressed milk. A sports bra that offers support rather than compression should be worn.

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Clearly, the return to exercise and participation in sport and competition for women after the birth of a baby is not a one size fits all prescription and must be flexible and individualized.

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References:
Sports Medicine Australia Position Statement. Exercise in Pregnancy and the Postpartum Period. www.sma.org.au
Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3 – exercise in the postpartum period. Br J Sports Med 2017;51:1516-1525.

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