Getting fit after pregnancy can be complicated

When Amanda Clark returned to her Cross Fit gym two months after an unplanned Caesarean section, she knew she would have an uphill climb to get back to her pre-pregnancy fitness level. What the 36-year-old Maryland mom of two didn't know, however, was that her challenges would include pelvic floor dysfunction and a severe separation of the abdominal muscles, or diastasis recti, during the pregnancy that failed to heal on its own.

Clark's coaches at the gym, she says, “were a couple of young guys with no experience helping postpartum women.” The regimen left Clark feeling frustrated. She also received no guidance from her physician when it came to postpartum fitness.

Her story is not unusual. In an ongoing, small study of postpartum physical and mental health, Jaime DeLuca, associate professor and chairman of the department of kinesiology at Towson University, found that 90 percent of the participants in her study reported receiving no guidance from their physicians beyond “take it slow.” The internet, they responded, serves as their main source of information in this regard. The study, which has enrolled 33 participants so far, began in October 2017.

Increasing numbers of women are active throughout pregnancy, but it's not always clear what's the best and safest way to get fit once the baby is born.

The American College of Obstetricians and Gynecologists has provided some loose guidelines for pregnant and postpartum women.

And while the federal government's recommendations on physical activity in the postpartum period say exercise is important - “Studies show that moderate-intensity physical activity during the period following the birth of a child increases a woman's cardiorespiratory fitness and improves her mood.” - they don't provide much detail: “Women who habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period.”

“We're still far away from good evidence-based data for postpartum exercise,” says Jaclyn Bonder, medical director for Women's Health Rehabilitation at NewYork-Presbyterian-Weill Cornell Medicine Center. “OBs generally see women at six weeks postpartum and clear them for exercise because there is little evidence to support or negate that advice.”

With little to go on, women don't know what's normal or abnormal in their journey.

Being pregnant and delivering a baby is hard on a woman's body. Many face conditions such as Clark's diastasis recti, which one study suggested is experienced by 60 percent of women postpartum, or uterine prolapse, incontinence or generalized pain in the pelvic girdle.

“Women accept these conditions as normal and if they don't get the help they need, they won't get better,” Bonder says.

Like Clark, Nicole Paterson experienced frustration with her postpartum return to fitness. “With my first pregnancy, I dealt with early contractions and was put on bed rest for my final six weeks to avoid preterm labor,” the 34-year-old says. “I still went into labor early and at five days postpartum, I tore an abdominal muscle.”

As a result, Paterson's road back to fitness was long. For the first eight months, she did little other than the occasional yoga class. When she became pregnant for a second time, she was determined to stay strong and active for as long as possible. She turned to a coach/physical therapist who also specializes in postpartum fitness. The difference was noticeable.

“I wanted to avoid the feeling of disempowerment I felt with my first pregnancy,” she says. “I still went into labor early, but this pregnancy and recovery was a cake walk compared to my first.”

At four weeks postpartum, she was back in the gym with her coach/physical therapist Ryan Smith, who has trained with physical therapists who focus on women's health issues.

“The typical postpartum advice is to rest or do what you feel up to doing, neither of which is ideal,” he says. “Complete rest doesn't address the tasks that come with being a new mom, like feeding, carrying the baby and other physical demands in her life. The flip side - going by feel - is difficult because there is misinformation everywhere” on the internet and elsewhere.

In addition to a lack of guidance, Smith says that women face many obstacles in a return to health and fitness. “New moms have the demands of a baby, work and sleep deprivation, among other issues,” he says. “They forget to care for themselves.”

When they do make the effort to return to a fitness routine, many, like Amanda Clark, often are dealing with not-uncommon complications. Couple this with a medical and athletic world ill-equipped to handle the situation and you get an entire population of discouraged women.

Smith says he believes more physical therapists and gyms are recognizing the need for programs geared toward postpartum women. “Women in general are strength training more and realizing that they don't need to feel awful after giving birth,” he says.

Bonder recommends that struggling postpartum women turn to physiatrists with a specialty in diagnosing pelvic health dysfunction. “Get an accurate diagnosis of your issues and then a referral to a [physical therapist] who can help treat you,” she says.

In a case such as Clark's, for instance, in which the diastasis recti isn't healing, a trained PT can prescribe the proper set of exercises and measurements to turn things around. “With DR, the practitioner should be looking for the width and depth of the separation to get smaller,” Bonder says.

In general, says DeLuca, the six-month mark should be the point where women can start looking for light at the end of the tunnel. “This is where most women are getting more sleep and have lost most of their pregnancy weight,” she says.

But a 2016 pilot study by DeLuca found that this is often the point where women actually feel worse and may throw in the towel with exercise.

“We can only hypothesize at this point, but there are many contributing factors at play here,” she says. “A return to work, an inability to return to pre-pregnancy weight and less time for leisure activities may have set in by this point.”

If, however, postpartum women have enough free time to exercise and can find and afford a knowledgeable trainer or PT, their outcomes can be much better, DeLuca says.

A research review by Raul Artal, chairman emeritus at the Department of Obstetrics, Gynecology and Women's Health at St. Louis University, shows that a postpartum exercise routine helps mentally and physically.

And a review of international guidelines on postpartum fitness came to similar conclusions. “Ideally we are headed in a direction that will offer more guidelines for postpartum fitness,” says Kelly Evenson, lead author of that review and research professor at the University of North Carolina's Gillings School of Global Public Health. “Right now, there just aren't many medical touch points for women after six weeks - and not much guidance for physicians, either.”

Clark and Paterson are now well on their way to restored health and fitness.

“After going through a physical assessment, I met with Ryan twice a week for six weeks,” Clark says. “I had to take a step back at first [and reduce exercise levels], which was tough. It felt like slow progress but we've gradually reintroduced exercises and I've improved.”

“As a culture, we need change on multiple levels,” Evenson says. “In the meantime, ask and look for support. Being active postpartum is essential to overall health and happiness.”

Tips for getting back on track exercise-wise

Even after their doctor has cleared them to exercise, many postpartum women are confused about how to safely return to fitness.

For his clients, CrossFit coach and physical therapist Ryan Smith first evaluates their fitness levels and goals before, during and after giving birth. “There's a wide range of what women want, from simply feeling fit and healthy to running marathons,” he says. “We set up milestones for measurement from there.”

For instance, when can the patient run and jump without incontinence? Is her diastasis recti responding to treatment by getting smaller and shallower, or staying the same? “In an evaluation, I have women break down the movements they need to complete the exercises they want to do, whether aerobic activity or strength training,” he says. “It's all about giving women the tools they need to improve and not normalize the conditions they experience postpartum.”

Jaclyn Bonder, medical director for Women's Health Rehabilitaion at NewYork-Presbyterian/Weill Cornell Medicine Center, said women should be monitored by a health care provider as they restart an exercise regimen.

Her recommendations:

• A woman should make sure all post-delivery bleeding has stopped and any tearing healed before even thinking about resuming exercise. This can range from 10 days to six weeks in some cases.

• For a Caesarean section, look for incision healing and minimal abdominal pain, generally requiring six to eight weeks.

• A good starting point for rebuilding stretched and weakened muscles is to focus on core strengthening exercises. They should emphasize deep-core muscles — those in the abdomen and back — and pelvic floor muscles, such as pelvic tilts, hip bridges and toe taps.

• For aerobic activity, begin with low-impact exercises such as walking, which in nice weather can easily be done with a newborn, elliptical training or swimming.

— Amanda Loudin