Postpartum Exercise

Regular participation in a pre/postnatal exercise program has many benefits for a woman. Research has demonstrated that pregnant and postpartum women who exercise at a mild to moderate intensity at least three times per week experience increased cardiovascular fitness, improved well-being, reduced constipation, fewer leg cramps and a quicker return to prepregnancy weight compared with their nonexercising counterparts (ACOG 2002; Clapp 2002; Sampselle et al. 1999; Ohlin & Rossner 1996).

However, fitness professionals working with women in the postpartum period should be aware of the challenges new mothers face. A woman goes through more physical changes in the 9 months of pregnancy than a man is likely to face in his lifetime, and many of these changes may continue to affect her throughout the postpartum period. She is expected to deal with these changes (while getting less sleep!) and at the same time take on one of life’s biggest physical challenges—caring for a newborn.

The American College of Obstetricians and Gynecologists (ACOG) notes that the physiologic effects of pregnancy may persist for up to 6 weeks postpartum and therefore advises gradual resumption of activity as tolerated (ACOG 1994). Before working with this population, you should obtain clearance from your client’s physician and make sure you are familiar with the current ACOG exercise guidelines (ACOG 2002).

In addition to experiencing all of the physical changes brought on by pregnancy, the new mom is challenged by various movements that can cause serious distress to her body if not performed functionally. You can help clients lessen the risk of injury and even permanent degeneration by teaching proper movement patterns for the following typical activities.

Pushing a Stroller. Simply pushing a stroller can pose postural challenges, since the natural tendency is to hunch over, lock the elbows and extend the wrists while pushing. Teach clients to

• keep the head and chin up, with ears over shoulders;
• keep the shoulders depressed and retracted slightly, with chest leading;
• hold the arms in a softly bent position, not locked;
• keep the wrists in neutral (because of swelling caused by fluid retention during pregnancy, carpal tunnel is prevalent in the pre/postnatal population);
• engage the abdominals throughout the movement; and
• take full, comfortable strides.

In addition, make sure clients purchase a stroller that fits them, since some strollers are not appropriate for especially tall or short clients.

Carrying the Baby. The new mother spends many of her waking hours holding a baby and can frequently be seen in a slumped position with her spine “collapsed,” or with one hip jutting out to the side. (Most often she will hold her baby on one side to have an arm free.) Chances are that her wrist will be flexed to get a good grip on the baby, and her scapula will be in a stretched, protracted position.
Clients should be taught to

• keep the spine in neutral alignment, with shoulders pulled back;
• bring the baby to the body’s center whenever possible; and
• maintain a neutral wrist position, especially if experiencing carpal tunnel issues.

Feeding. A new baby is likely to eat every 2 hours. This can be a physical challenge for the new mom because she will often hunch to bring her breast to the baby, which can wreak havoc on the spine. Other concerns when feeding are holding the breast for the baby (compromising the wrist) and crossing the legs (causing pelvic and spinal imbalance). Ideally, the nursing woman should

• sit in neutral-spine position in an ergonomically correct chair and use a footrest;
• maintain a better feeding posture by using a support pillow to raise the baby; and
• set up a nursing station where everything is handy, to avoid reaching and twisting.

Carrying the Car Seat. The car seat that slips out of the car and snaps into a stroller may seem like a convenient invention, but it can be very troublesome physically. Seats are often heavy and hard to hold, placing torque on the carrier’s spine. Moms are regularly seen holding a heavy diaper bag over one shoulder and lugging a car seat outstretched on the other arm.
The best thing a mom can do is

• use the car seat carrier as little as possible, taking baby out of the seat and holding her close or putting her in a stroller. According to a study presented at the 2006 annual meeting of the American College of Sports Medicine, it is better to manually hold an infant and lift an object than to perform a lift while holding the baby in an infant carrier (ACSM 2006).

When the car seat is essential, moms should

• use correct posture to pick it up: When removing the seat from the stroller, first find neutral spine; stand in front of the car seat with the seat at the center of the body; bend the legs and bring the seat in toward the body, engaging the core muscles while standing up. When taking the seat out of the car (or putting it in), get into the car. Keep the car seat close to the body and engage the abs when lifting. Be careful of twisting motions and of carrying the seat away from the body.
• use the biceps to hold the seat, rather than letting it hang from the end of the arm. A best-case scenario is to hold it in the center of the body like a laundry basket.

Using a Front Pack Carrier. The front carrier is a great way to keep baby close to mom while leaving the hands free. However, the fact that the baby is weighted in the front contributes to a forward-slouching posture. To use a front pack carrier most effectively, moms need to

• remain cognizant of keeping the core engaged, spine in neutral and shoulders retracted;
• make sure the carrier fits properly; and
• keep the baby snugly against the body.

Changing and Lifting the Baby. Of course, every baby is different, but a new mom can expect to change six to 10 diapers a day. When using the traditional changing table, a woman is slouching, with her head jutting forward. Ideally, she should

• purchase a changing table that is tall enough to save her from bending over to use it;
• keep all the necessities nearby, to avoid twisting or bending to reach items while keeping one hand on the baby; and
• employ correct lifting posture whenever picking the baby up or putting him down.

Dynamic Warm-Up
A dynamic warm-up lasting 7–10 minutes (or longer in cold temperatures) and focusing on the major muscle groups of the body should be performed before each exercise session (Nordahl, Peterson & Jeffreys 2005). The warm-up should incorporate dynamic stretching exercises that prepare the muscles and joints in different planes of motion for the upcoming activity. Begin with a low-level cardiovascular activity, and then follow with exercises like leg swings (front and back, side to side) to improve joint balance and coordination of muscle relaxation and contraction.

Strengthening the Upper and Lower Core
The muscles of the abdominals and pelvic floor are stretched and weakened by the stresses of pregnancy and delivery. Strengthening the core gives the new mother a stable base from which to move. If the foundation is weak, certain parts of the body must absorb extra stress to compensate. The problems caused by this extra stress can continue long after childbirth. In addition, strengthening the entire muscle system alleviates pain and makes simple tasks—such as carrying the baby, getting in and out of the car, and lifting and reaching—much easier.

Hip Bridges With Baby (2–3 sets of 10–15 reps)

• Lie supine on mat with feet flat on floor; knees bent to 90 degrees, about hip width apart and aligned directly over toes; head relaxed; baby resting on hips and lower abdominals.
• Switch on core muscles (like turning up the dimmer switch on a light).
• Push hips up until spine is in neutral. Hold 4 seconds.
• Return to start.

Squats With Baby (2–3 sets of 10–15 reps)

• Stand with feet hip width apart, knees slightly bent, baby in front carrier. (Alternatively, hold weights.)
• Keeping back straight and head up, look straight ahead.
• Switch on core muscles.
• Inhale and squat until thighs are about parallel to floor.
• While squeezing gluteals and pushing with quadriceps, exhale and return to start.

Side Planks (2–3 sets of 5 reps each side)

• Lie on side, knees bent and legs back, upper body raised, supporting weight on one forearm.
• Switch on core muscles.
• Raise hips until spine is in neutral, placing hand of nonsupporting arm on hip; hold 5–10 seconds.
• Return to start.

Note: Avoid this exercise if shoulder is sore.

Opposite-Arm-and-Leg Lifts (2–3 sets of 10–15 reps each side)

• Start on hands and knees.
• Inhale and switch on core muscles, keeping back in neutral position.
• Exhale while raising opposite arm and leg.
• Hold position 4 seconds.
• Return to start.

Rear Flyes With Resistance Band (2–3 sets of 10–15 reps)

• Stand with knees slightly bent and feet shoulder width apart. Hold resistance band in two hands, arms at shoulder height and about shoulder width apart.
• Switch on core muscles.
• Stretch band by pulling arms apart.
• Return to start.

Standing Rows With Resistance Band (2–3 sets of 10–15 reps)

• Stand with one foot forward, knees slightly bent and shoulders square, holding resistance band anchored under one foot.
• Inhale and switch on core muscles.
• Keeping shoulders down, exhale while bringing elbows back until wrists meet hips, and hold briefly.
• Return to start.

Reverse Crunches With Baby (2–3 sets of 10–15 reps)

• Lie supine, holding baby face down on shins.
• With knees bent and feet off floor, engage abdominal muscles by pulling belly button in toward spine. Keep a space between chin and chest (looking diagonally toward ceiling).
• Lift legs from hips, pulling knees to chest while focusing on abs.
• Slowly lower hips and legs back to start.

The cool-down period should include stretches for the hip flexors, hamstrings, quadriceps, gluteals and pectorals.

One thing to stress when working with postnatal clients is the importance of correct posture. Pregnancy and the postpartum period can affect posture in a number of ways:

• The increased weight of the breasts may cause a woman to pull her shoulders forward, leading to forward-head posture and an increased kyphotic curve in the thoracic spine.
• Weakened and stretched abdominal muscles (and the weight of the growing uterus during pregnancy) can increase the lordotic curve in the lumbar region.
• The tendency of the pregnant woman to shift weight to the back of the legs and feet can contribute to hyperextension of the legs.
• The hormone relaxin, which increases during pregnancy and remains in the body during the early postpartum period, promotes increased joint laxity. This can contribute to malalignment of the low back and pelvis and lead to low-back pain or problems with the weight-bearing joints. Joint laxity can also cause a flare-up of old injuries as the pregnant woman finds herself walking with a wider base of support—the typical pregnant “waddle”—to compensate for the increased weight and redistribution of body mass. These problems can continue throughout the postpartum period, and everyday activities may become difficult.

For these reasons, functional movement is an extremely important factor in the new mom’s exercise program.

Lisa Druxman, MA, is the founder of Stroller Strides® LLC, the country’s largest fitness program for new moms. She is an IDEA presenter and a writer for IDEA Fitness Journal and other industry publications. Her new book, Lean Mommy, is scheduled for release in early 2007.

Carl Petersen, PT, is a physical therapist and co-author of Fit to Deliver (Hartley & Marks 2005). He has lectured nationally and internationally at numerous conferences on many aspects of physical therapy, physical training, sports training and pre/postnatal exercise.

References
American College of Obstetricians and Gynecologists (ACOG). 1994. Exercise during pregnancy and the postpartum period. Technical Bulletin No. 189. International Journal of Gynecology & Obstetrics, 45, 65–70.
American College of Obstetricians and Gynecologists (ACOG). 2002. Exercise during pregnancy and the postpartum period. Committee Opinion No. 267. Obstetrics and Gynecology, 99, 171–73.
American College of Sports Medicine (ACSM). 2006. Lifting while holding infant in carrier may result in lower back pain. Press release from 53rd annual meeting. www.acsm.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=
5366; retrieved Aug. 25, 2006.
Clapp, J.F. III. 2002. Exercising Through Your Pregnancy. Omaha, NE: Addicus Books.
Nordahl, K., Petersen, C., & Jeffreys, R. 2005. Fit to Deliver: An Innovative Prenatal and Postpartum Fitness Program. Vancouver, BC: Hartley & Marks.
Ohlin, A., & Rossner, S. 1996. Factors related to body weight changes during and after pregnancy: The Stockholm Pregnancy and Weight Development Study. Obesity Research, 4 (3), 271–76.
Sampselle, C.M., et al. 1999. Physical activity and postpartum well-being. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 28 (1), 41–49.