Tag Archives: postnatal exercise

How you can help your pelvic floor

I was asked by someone this week about rehabbing the pelvic floor post birth, in preparation for getting back to running.  I was so pleased that she was aware of the importance of taking her time – things keep popping up in my timeline about postnatal classes where people are running with buggies, skipping and even doing jumping jacks! All of this can have a deleterious effect on the pelvic floor and continuing to overstress a weakened pelvic floor can lead to prolapse.

However taking your time, making a few lifestyle changes and building up core strength can mean that even if you’re currently experiencing pelvic floor dysfunction (any leaking, back pain, heaviness in the pelvis) you may be able to get back to your previous exercise routine.

I prolapsed after my first child and was given very little advice about it other than being told I would probably need a hysterectomy when I go through menopause.  Because of this experience I have spent my time learning more and applying it to my own life as well as in my work with others.

First thing I implemented was no impact.

As someone who wasn’t a runner, this wasn’t a big change.  But I did have to stop jumping around in my aerobics classes and also give my trampette a wide berth…!  I can now run for the bus without worrying and I played rounders in the summer where I was sprinting for quite a while with no effect.  So I could probably run now if I wanted to but I’m still choosing to stay low impact most of the time.

Second thing was no crunches

The downward pressure created by crunches/sit-ups will push on the pelvic floor.  Full planks and press-ups and exercises with both legs lifted also creates a lot of pressure and so I avoided them.  However there are alternatives – for example in press-ups performing them on an incline, plus incorporating crunchless core exercises – so there is no reason to stop exercising, just make a few changes.  Bear in mind that sitting straight up in bed is also a crunch (and how many times do you do that a night?) – I roll over to get out of bed instead.

It’s not all about what you shouldn’t do though. There are things that I needed to start doing:

  • alignment/posture

particularly the with respect to the pelvis.  Try tucking your tailbone under and bringing your hips towards your ribs.  Lift the pelvic floor now.  Then take your hips away from your ribs, allowing your lower back to arch more, then lift the pelvic floor.  Then bring yourself to a neutral pelvis where your level through the front and the back of the pelvis (think of it like a bowl) – the pelvic floor lift should feel easier in this position.  Pelvic floor works best when we are in alignment, with the head, shoulders, rib cage, pelvis and heels all stacked up in line

  • breathing

both looking at how you breathe during exercise and from day to day.  During exercises you need to breathe out on the effort and lift pelvic floor at the same time.  This also applies when you are lifting a weight – baby, shopping etc. – and also when you go from seated to standing (The knack – as you go from sit to stand but vice versa too).  The other aspect of breathing is to stop breath holding and sucking your stomach in.  When you breathe in your stomach should actually swell not suck in.  I see so many people who’s stomachs stay still when breathing and instead their shoulders lift.  Try lying on your back with your knees bent, feet flat on the floor.  Put one hand on your chest and one hand on your stomach.  As you breathe in you should feel your chest move first then your stomach.  Your stomach lowers as you breathe out and then your chest.

All these changes I’ve made have meant that my prolapse has improved and I’m hoping to avoid that hysterectomy!  I know that there’s still work to do and I’m currently learning more about another part of the puzzle:

  • relaxation

stress can affect the pelvic floor, there’s also some evidence that lower limb injuries and back injuries will impact the pelvic floor too, even years after healing or the pain has stopped. There may also be scar tissue from episiotomies or tears.  I’ve just learnt some trigger point release for that – sitting on one of the spiky balls!  It’s uncomfortable but definitely has an effect – I will let you know how that goes!  And it’s also helped to introduce deep breathing, mindfulness and relaxation practices into my daily life.

 

So when looking at rehabbing the pelvic floor, it’s not just about a list of exercises to do – we need to think of the body as a whole and the pelvis at the centre of that, and looking at improving in all these areas

Is postnatal exercise just for YOU?

I saw an advert for a postnatal exercise class the other day that had a line about how mums were deciding to be selfish and take time for themselves.  Now I’m all for me-time as an essential part of a mums postnatal recovery and don’t see that as being selfish at all – in fact, if anything, mums aren’t selfish enough and always seem to put themselves at the bottom of the to do list.

But in addition to mums deserving to do something that benefits them, I also see so much benefit to the babies coming along to exercise classes too.

The NHS states that babies should be encouraged to be active throughout the day and avoid being sedentary for long periods of time – in car seats, pushchairs, bouncers etc.  This is why in my buggy class we tend to exercise in one area so that the babies can be let out on to the floor whenever possible!  And in Pilates, unless they’re sleeping, babies can get over an hour of play on the mat – giving them loads of room to roll, rock or for tummy time.

Babies getting the chance to be active along with their mums is good for two reasons:  first, they’ll see exercise as a normal and fun thing to do and secondly, they learn by copying.  Being active also helps the brain to develop.

There is some degree of sensory play in class as well – the balls, bands, mats and dumbbells are all a source of fascination.  One baby’s first crawl was because she wanted to get to the dumbbells!!  Outdoors the leaves and grass give vital feedback about their surroundings – and help their immune system too.  The fresh air is good for them and as an added bonus may help them sleep better!

The social aspect of the classes is also key – I know my daughter first started walking because she clocked an older child doing so.  I watched her watching him and as soon as she got home she grabbed hold of the high chair and off she went!!  There is also a lot of enjoyment in just watching their mums – I’ve a few video clips of babies laughing at the exercise!  And in Pilates there is often a very chilled feeling to the start of the class as the babies watch the flowing movement – they sometimes seem mesmerised!!

There have been lots of developmental firsts in my classes, from first rolling and crawling to first standing unaided and first steps.  Given time and space and a great example from mum gives the babies lots of opportunity to develop – so turns out class is as good for them as it is for you!!

Click here for a great pdf on physical activity guidelines for under 5s from the NHS

When can I run again?

If you search the internet for the answer to starting running again after baby you may well be confused by the information out there.  There are some people who are back to their normal regime way before 6 weeks postpartum, others who advocate avoiding all sorts of exercise.  So what’s right for you?

First up you shouldn’t return to formal exercise until 6 weeks postnatal (8-10 if you’ve had a caesarean) and you should be getting the all clear from your doctor, although I know some doctors wait to combine your check-up with babies 8 week check.  And some doctors don’t do them at all now.

However once you’ve had your check that doesn’t mean you can just start up where you left off.  At 6 weeks only the initial healing of your body has been completed – full healing could take a year or more!

Returning to impact exercise too early can reduce pelvic floor strength and lead to incontinence or prolapse so it is worth taking things slowly and building up gradually.

So once you’ve had your check, and assuming you have no pelvic floor issues or diastasis, it is fine to introduce low impact exercise and specific postnatal classes.  Body conditioning classes are also fine but need to be lower weights and avoid direct work on your stomach muscles (i.e. no sit-ups or crunches or planks).  Over the next few weeks you can gradually increase the intensity and the weights.

And then what, what’s the magic number of when you can start running/crunching/go to hardcore classes?

Unfortunately there is no definitive answer.  Some say 4 months, others 6, still others a year.  I thought I’d been conservative waiting 5 months after a C-section before then teaching a high impact aerobics class.  I wasn’t and I prolapsed because of it, despite having no warning signs so I do tend to err on the side of caution with mums who come along to classes.

So the only real answer to “when?” has to be – listen to your body.  If you have any pelvis or lower back pain after exercise, a feeling of heaviness in the vagina, any bulging or straining or doming of the stomach or the pelvic floor or any leaking these are all a sign that that exercise is too much for you at this particular time.  As is shaking during an exercise or breath holding.  Doesn’t mean this will be for always – just at the moment your body isn’t ready and you need to modify the exercise until you are stronger.

This should apply whenever you’re exercising not just in the early postnatal period.  Your form is the most important thing to be mindful of when exercising and how your body is feeling.  There is always a way to make an exercise easier or to bring the intensity down.

Other things to bear in mind when exercising:

  • tiredness – fatigue can lead to injury as you push yourself through
  • sore breasts – if you can feed before exercise that can help.  A decent sports bra is important too.  There is such a thing as a feeding sports bra although they can be quite expensive.
  • loose joints – the effects of pregnancy hormones on your joints can last around 3 months post birth.  If you’re breastfeeding the effects are thought to last until 3 months after you finish feeding.

So bear these in mind when you want to start a particular exercise regime.  You can practice exhaling on exertion and lifting the pelvic floor before the 6 weeks (once any perineal damage is healed) – this way the core is protected and you will be rebuilding the body from inside out!

Pelvic floor first is a great website that’s worth visiting.  Their Returning to sport pdf gives a timeline of what’s recommended at various stages.

And remember, all my classes are pelvic floor and tummy safe!

What’s with the six week rule?

There’s been a few people in my classes recovering from injuries and minor operations recently.  Then of course there’s the mums who are recovering from childbirth – considered a trauma whatever experience they have had!  But despite the range of severity and site of injuries, there seems to be a six week rule – no returning to exercise until after six weeks .  What’s so special about six weeks?

Stages of Wound Healing

The answer lies in the four stages of wound healing.  Tissue is the same no matter who you are or what has happened and it will go through the same process every time.

  1. Haemostasis – this is all about stopping the bleeding and forming a clot.  It happens immediately
  2. Inflammation – this is the stage of fighting infection and keeping the wound clean.  There is increased blood flow to the wound – resulting in redness and heat.  There is likely to be pain, swelling and possibly pus.  This lasts for 4-6 days.
  3. Proliferation – new skin is formed over the surface, whilst tissue is rebuilding underneath. This pulls the wound closer. This starts after 3-5 days and can last for 2-3 weeks
  4. Remodelling – changes to the tissue strength and number of blood vessels serving it.  This is when a scar starts to go paler and flatter.  The process starts 2-3 weeks after injury, once the wound has closed, and can last up to 2 years!

These stages are not distinct but  instead overlap, so there is some variation in healing times.  6 weeks means that all the early stages have completed and the remodelling phase is well under way.

However, it will take up to a year and possibly longer to return to full strength and function.  And scar tissue is only 80% as strong as the original tissue.  This is worth bearing in  mind when you are returning to exercise after an injury and after childbirth.  At 6 weeks healing is not completed, so you need to begin gradually and listen to your body – don’t try to get back to your previous level straight away!

Pelvic Organ Prolapse

Pelvic Organ Prolapse (POP) is a secretive, not often talked about thing.  And yet last week every single day I ended up speaking with people about their prolapse so it just seemed destined that that is what I would write about today!

Prolapse is the descent of one or more internal organs that then push into the vaginal wall.  There are different stages – mild, moderate to extending outside the body.  There are many symptoms, many of which could be attributed to other ailments.

  • Urinary incontinence or urine retention – feeling of never fully emptying bladder
  • Constipation or faecal incontinence
  • Feeling of dragging, like your insides are falling out or heaviness/ache in rectum/vagina
  • Lump or bulge in vagina
  • Inability to hold a tampon in
  • Lower back or pelvis pain
  • Vaginal/rectal pain
  • Painful intercourse/lack of sensation
  • Leakage of urine/stool during sex

The earlier prolapse is discovered the better as there are preventative measures – surgery can be avoided or its severity lessened.  They will also help post-surgery.  Typically one prolapse can lead to another unless steps are taken to prevent this.  Understanding more about how it occurs can also help prevent it.

Causes of prolapse are many and varied

  • Childbirth – 50% of all women who have given birth will prolapse
  • Menopause and age related drop in oestrogen levels
  • Chronic constipation
  • Chronic coughing
  • Obesity
  • Genetics
  • Neuromuscular conditions
  • Heavy lifting
  • Diastasis recti
  • High impact aerobic activities – running, jogging, high impact aerobics

It’s worth noting though that POP doesn’t happen overnight – typically many factors over a number of years will build up to cause it.  What’s crucial is intra-abdominal pressure – the build up of this results in bearing down on the pelvic floor. It’s a necessary bodily phenomenon – without it we couldn’t poo – but if there’s a constant downward pressure it can be more than the pelvic floor can cope with.

And this is where the knack comes in.  By mindfully contracting the pelvic floor before we stand, lift, cough, sneeze etc. we prepare for the force to come.  Practicing the connection with your outbreath and your pelvic floor contraction can retrain the body and help it to do it’s job.

Other things to bear in mind

  • Weight control – particularly the amount of abdominal fat you’re carrying
  • Lifting technique – never hold your breath.  Always exhale on exertion and lift pelvic floor
  • Toilet technique – no straining.  Try to have feet on a stool (2 toilet rolls will do) to raise knees above hips.   Vocalising can also help!
  • Exercise – pelvic floor safe exercises for those with a weak pelvic floor, prolapse or have had gynaecological surgery. Gentle Pilates. Core strength and pelvic floor activation. Exercises to avoid – crunches, double leg lifts, full plank position, high impact sports. Ultimately you need to decide what to stop and what to continue with – you can get support for exercise, from supportive shorts to sea sponges and pessaries.

For more information and support see the APOPS website at www.pelvicorganprolapse.support.org.  They also have a private Facebook group – pelvic organ prolapse.  Also Pelvic Floor First at www.pelvicfloorfirst.org.au

Good books – Sherrie Palm, The Silent Epidemic and Sue Coult, Pelvic Floor Essentials.  I have copies if anyone would like to borrow them

Get a kegel app for your phone – lots of free ones but the one most recommended by women’s health physiotherapists is the NHS Squeezy app

And as they say on Channel 4 – “if you have been affected by this” please feel free to get in touch.  I would be glad to give any help and advice.

The Knack – pelvic floor health

Do you sneeze wee? You need the Knack!

Do you sneeze wee? You need the Knack!

I was listening to an interview with acclaimed women’s health physiotherapist Michelle Lyons last week and was surprised to learn that going from seated to standing puts more pressure through the pelvic floor than lifting a 20lb weight! Bearing down on the pelvic floor that many times throughout a day could lead to, or worsen, pelvic floor disorders – such as incontinence and prolapse.

I have been working on correct standing technique with my pregnancy class for a while now but changed the emphasis last week and gave ‘the Knack’ to them as homework.  Now it’s your turn to practice daily! This is not just for pre and postnatal women – 40-70% of ALL WOMEN have incontinence and 50% of women who have given birth will develop prolapses.  These are stats worth avoiding!!  The Knack is a preventative measure to be used throughout our lifetime.

How to do it

1.  Sit at the edge of your chair, up on your sit bones, heels in line with your knees.

2.  Breathe in.  As you breathe out allow your pelvic floor to relax.

3.  Breathe in.  As you breathe out think of drawing your pelvic floor in and up.

4.  Continue breathing out and lifting the pelvic floor as you stand up.

5.  Once standing, allow the pelvic floor to relax.

You can see a video of me showing the knack here

At first try to practise this standing up after every visit to the loo.  Once you get used to it start to introduce the Knack every time you stand up from a chair.  Keep practising until it becomes second nature.  I’m still practising!

when can I return to exercise after having a baby?

With the rise of the yummy mummy and celebrities pinging back into their size 0 figures with seemingly little effort, there is immense pressure on the modern mum to follow suit.  Some will take drastic measures with their diet and some will try to fit straight back into their exercise routine.  That may have been suitable pre-pregnancy but is it now?  When is it ok to return to exercise after having a baby and what type of exercise is most appropriate?

There are a number of issues to consider when deciding which exercise routine is right for you and when:

  • Relaxin.  The hormone that enables your muscles, ligaments and joints to relax and soften allowing room for your baby to grow and be born.  The effects of this hormone can continue for up to 6 months postnatally, affecting all your joints, leaving them unstable and more susceptible to injury.
  • Our amazing pelvic floors that did all the carrying and then pushing are severely weakened.  This is true even if you had a caesarean.  They need to repair and strengthen so they can continue to support the internal organs.  Exercising too hard or too soon can increase the likelihood of prolapse and incontinence.  According to the National Institute for Health and Clinical Excellence, 25-45% of women suffer from urinary incontinence.  The NHS says that up to half of all postnatal women are affected by some degree of pelvic floor prolapse.  If you had multiple births, ventouse or forceps, spent over 1 hour in the second stage of labour, severe perineal tearing or had a baby over 4kg you may be more at risk of pelvic floor problems.
  • The stomach muscles have stretched massively to allow for the growth of your baby. For up to 60% of us, our stomach muscles will have split.  These will need to come back together so that our backs are supported and additional pressure is not put on the pelvic floor.  One study reported that 66% of women with diastasis rectus (split in the stomach) had support-related pelvic floor dysfunction as well i.e. incontinence and pelvic floor prolapse (Spitznagle et al, 2007).  Any traditional abdominal work and twisting moves done whilst the stomach muscles are separated can cause these muscles to stay apart and can lead to doming of the abdominal muscles, making the mum still look pregnant.
  • Any pregnancy-related conditions you experienced can continue postnatally – pelvic girdle pain, carpal tunnel and sciatica.  These may also affect your exercise choice.

So given these considerations, when can you get back to exercise?  Most health professionals will require you to have had your doctor’s check before you can resume an exercise program – 6-8 week check for vaginal birth, 10-12 weeks for a caesarean.  This time is given to allow the uterus to shrink, stomach muscles to heal, ensure bleeding has stopped and the perineum is healing. Stitches may need to be removed and cases of anaemia dealt with.  Once you’ve had your check-up, this does not necessarily mean you are ready to start where you left off.  Given that every woman’s pregnancy and birth are different, there can be no hard and fast rules, merely guidelines.  You need to listen to your own body – it has gone through a lot physically and emotionally.  Determine which of the factors listed are still applicable and therefore what is appropriate for your postnatal body – it can be 6-12 months before you’re ready to resume your previous exercise intensity.

You need to avoid the following exercises before your check-up and only gradually add them to your exercise repertoire once your pelvic floor is strengthened and any diastasis is healed:

  1. Running and impact exercises
  2. Sit-ups/crunches
  3. Oblique twists
  4. Plank

In the meantime, there are some exercises that you can do soon after having your baby which will help to repair the pelvic floor and abdominal muscles.  These can (and should) all be done in a variety of positions – standing, sitting, side-lying and lying on your back.  Try to avoid kneeling on all fours to do the exercises in the first 6 weeks:

  1. PELVIC FLOOR FIRST – working the pelvic floor will also help to flatten the abs.  It brings blood supply to the perineum so is good for healing even if you’re still feeling sore.

Pelvic floor lifts – quick pulses and long holds.  Working from your back passage to the front, lift and release.  Try and maintain a good posture, no tucking the bum under or squeezing it; don’t hold your breath.

  1. Pelvic tilt – from a neutral position, tuck your bum under, drawing the hip bones towards the ribcage.  You should feel your lower back flatten and your stomach muscles start to engage.  Try not to squeeze the bum and concentrate on the pelvis only moving.
  2. Abdominal bracing – keeping your body in a good posture, think of drawing your hip bones towards each other.  Don’t tilt the pelvis, don’t suck in or hold your breath.  It is a small movement where you should feel your stomach muscles start to tighten, but no change in your back muscles.

You can also target the pelvic floor in the last 2 exercises by breathing out and drawing up the pelvic floor just before you start the movement.

By starting slowly and targeting key muscles first, you should be well on the way back to your regular exercise routine.