Current Guidelines and Recommendations for Postnatal Exercise

Original Editor - Wanda van Niekerk based on the course by Fiona Healy

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction[edit | edit source]

Physical activity and exercise during pregnancy and postpartum have been proven to have beneficial maternal, foetal and neonatal health outcomes. These include reduced risk of excessive weight gain, gestational diabetes mellitus, preeclampsia, preterm birth, delivery and newborn complications, and postpartum depression.[1]

Mothers who engage in regular physical activity/exercise as a healthy lifestyle choice tend to have families who engage in regular physical activity.[2] Rehabilitation professionals play a key role in supporting women to return to exercise and/or engage in physical activity, which can have a positive impact on society and healthcare systems.

Physical Activity Recommendations[edit | edit source]

UK Chief Medical Officers' Physical Activity Guidelines, 2019

All pregnant and postpartum women without contraindications should aim to[3]:

  • Undertake regular physical activity through pregnancy and the postpartum period.
  • Accumulate at least 150 minutes of moderate-intensity physical activity throughout the week.
    • For substantial health benefits, it is best to incorporate a variety of aerobic activities (e.g brisk walking, swimming, stationary biking, low-impact aerobics, jogging, modified yoga and modified Pilates) and resistance training activities (e.g. bodyweight exercises such as squats, lunges, push-ups).
    • Adding gentle stretching may also be beneficial.
  • In addition:
    • Women who before pregnancy habitually engaged in vigorous-intensity aerobic activity or who were physically active can continue these activities during pregnancy and the postpartum period.
    • If pregnant and postpartum women are not currently meeting these recommended guidelines, doing some physical activity will bring health benefits. They should start with small amounts of physical activity and gradually increase frequency, intensity and duration over time.
    • Pelvic floor muscle training (Kegel’s exercise) may be performed on a daily basis to reduce the risk of urinary incontinence.
    • Pregnant and postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits.

The American College of Obstetricians and Gynaecologists published a Committee Opinion on Physical activity and exercise during pregnancy and the postpartum period. Their recommendation is[5]:

  • Moderate-intensity exercise of 20 to 30 minutes per day on most or all days of the week.

The Royal College of Obstetricians and Gynaecologists recommend:

  • After an uncomplicated birth, some women may be able to resume gentle or low-impact physical activity within days of delivery.
  • If the delivery was complicated (e.g. long second stage, caesarean section, occiput posterior (OP) presentation or instrumental delivery), a medical caregiver should be consulted before resuming pre-pregnancy physical activity levels. There is a link between forceps delivery and denervation of the pelvic floor nerves, therefore a longer recovery time should be expected.[6]
  • See this helpful infographic: Physical Activity for Pregnant Women

Postnatal Return to Running Guidelines[edit | edit source]

These guidelines recommend that all women, regardless of delivery, be offered a pelvic health assessment with a specialist pelvic health physiotherapist.[7] Strength, function and coordination of the abdominal wall and pelvic floor muscles should be comprehensively assessed. A vaginal and a possible anorectal examination if indicated should be conducted. Postnatal women can benefit from an individualised assessment and pelvic floor rehabilitation programme. This may[7]:

Read these guidelines here: Returning to running postnatal–guidelines for medical, health and fitness professionals managing this population[7]

Objective Measures to Assess before Graded Return to Running[edit | edit source]

  • Modified Oxford Manual Muscle Testing (MOMMT)
    • If a score lower than grade 3 is recorded with the Modified Oxford Manual Muscle Testing (MOMMT) during digital vaginal or anorectal examination, running is not advised yet.[7]
  • Reduced pelvic floor muscle endurance
    • The recommended baseline in standing is[7]:
      • 10 fast repetitions
      • 8 to 12 reps of maximum voluntary contraction with a duration of 6 to 8 seconds
      • Submaximal 30 to 50 % contraction for 60 seconds
  • Evaluation of the risk of developing pelvic organ prolapse (POP) should be done with the GH+PB component of the Pelvic Organ Prolapse Quantification (POP-Q) System Assessment.
    • A number of more than 7 cm indicates that a woman is at higher risk of pelvic organ prolapse[7]
  • Pelvic Floor Distress Inventory (PFDI-20)
    • The use of the screening questionnaire, the Pelvic Floor Distress Inventory (PFDI-20), is cited as a way way to identify symptomatic women and refer them for a women’s health assessment. (Note: The full name of the PFDI-20 varies in the literature from Pelvic Floor Disability/Distress Index/Inventory). However, it is just as important to identify asymptomatic women who might be at risk if they overload their system too soon with higher-impact exercise.[2] Physiotherapists are often well-placed among healthcare professionals to assess a women’s fitness levels and abilities and provide support to them during their postpartum return to exercise. The combined skill sets of musculoskeletal or sports physiotherapists and pelvic health physiotherapists can provide invaluable support to postnatal women.[7]

Signs to Slow Down or Stop[edit | edit source]

The return to running guidelines by Goom et al.[7] recommend low-impact exercises within the first three months of the postnatal period. Return to running can, at the earliest, commence between three and six months postnatal. These guidelines are based on the available evidence and clinical experience of the authors and encourage clinical reasoning, but they are not currently validated.[7] There is research indicating that some women return to running within a shorter period,[8] but this is seen predominantly in athletes or women who were physically active before and during pregnancy.

Women who want to return to running or high-impact exercise postpartum should be aware of the following signs and symptoms that can be experienced before or after attempting to return to running. If they experience any of these it is a sign to slow down or stop, and seeking a referral to a pelvic health physiotherapist is important.[7]

  • Heaviness or dragging in the pelvic area (this can be associated with a prolapse)
  • Leaking urine or an inability to control bowel movements
  • Pendular abdomen or noticeable gap along the midline of the abdominal wall (this may indicate Diastasis Recti Abdominis (DRA))
  • Pelvic or lower back pain triggered by exercise
  • Ongoing or increased blood loss beyond eight weeks postnatal that is not linked to the monthly cycle

Exercise Progression Timeline[edit | edit source]

Week zero to two[edit | edit source]

  • Rest and recovery are priorities as the body is recovering from a significant event
  • Walking for cardiovascular exercise – as soon as a woman feels able
  • Gentle core activation exercises – pelvic tilt and gentle abdominal exercises
  • Pelvic floor muscle exercises
    • Short squeezes to help with blood flow and healing[2]
    • Gradual progression to 10 squeezes of 10 seconds duration and 10 fast squeezes as able[9]
    • After having a baby, the pelvic floor muscles are weak and injured in most women. Instruction and supervision on how to perform a correct pelvic floor muscle contraction are necessary, especially in women who did not train these muscles before pregnancy and birth.[10]
    • It is vital during the postnatal assessment of a woman to find out how the baby was delivered. The NICE guidelines recommend 12 weeks (3 months) of supervised pelvic floor muscle training of postpartum women who have had:
      • Obstetric anal sphincter injury
      • Assisted vaginal birth (forceps or vacuum)
      • Vaginal birth when the baby is lying face down (occiput – posterior (OP))
    • Read the NICE GUIDELINES here: Pelvic floor dysfunction: prevention and non-surgical management

Week two to four[edit | edit source]

  • Progression of walking
  • Progression of pelvic floor muscle strengthening and core rehabilitation
  • Introduction of squats, lunges and bridging  - in line with activities of daily living

Week four to six[edit | edit source]

  • Low-impact exercise eg. static cycling or cross-trainer
  • Continue with pelvic floor exercises and gradual abdominal strengthening

Week six to eight[edit | edit source]

  • Power walking – increase walking speed, increase hill walking
  • Increased duration/intensity of low-impact exercise
  • Deadlift techniques, starting with light weights (no more than the weight of a baby in a car seat (15kg))
  • Resistance work during core and lower limb rehabilitation exercises


Weeks eight to twelve[edit | edit source]

  • Progress strength and core training as tolerated
  • Swimming (if lochia has stopped and no issues with wound healing)
  • Spinning (if comfortable sitting on a spinning saddle)

Weeks twelve and beyond[edit | edit source]

  • Agree on short- and long-term goals
  • Graded return to running and impact exercise
  • Working with a running coach may be advisable if a woman is looking to increase distances in a shorter time frame
  • Consider risk factors for injury
  • Build training volume (distance and time) before intensity
  • Monitor signs and symptoms and modify the running programme appropriately or refer to the appropriate healthcare professional to address postnatal issues

Issues with Returning to Running Too Soon Postpartum[edit | edit source]

Between 35%[12] and 84% of women who returned to running postnatally complained of musculoskeletal pain in at least one body area.[13] This raises the question: are women well enough prepared to return to sport and high-impact exercise in the postnatal period?[2]

In a recent biomechanical study comparing postpartum runners and nulliparous controls, the following was found[14]:

  • Postpartum runners had a 24.3% greater braking load rate for anteroposterior ground reaction forces
  • Postpartum runners had 14% less hamstring flexibility
  • Postpartum runners had 25.9% less hip abduction strength
  • Postpartum runners had 51.6% less hip adduction strength

Although this is a small and exploratory study, there may be key differences in postpartum runners with braking forces during weight acceptance and hip strength. All of these factors have been associated with running-related injuries.[15][16] The rehabilitation of gluteus medius is key as it is a stabiliser of the pelvis and prevents hip adduction and femoral internal rotation during single limb stance.[17] Furthermore, weakness of gluteus medius has been linked to low back pain in pregnancy.[18] In individuals with urinary incontinence it was reported that strengthening of the pelvic floor muscles together with the hip synergic muscles resulted in less daily urine loss.[19]

Strength Tests for Postnatal Women before Return to Running[edit | edit source]

Based on expert clinical consensus, these tests should be done before returning to running in the postpartum population. Each movement should be performed with the number of repetitions counted to fatigue. The aim is to achieve 20 repetitions of each test.[7]

  • Single-leg calf raise
  • Single-leg bridge
  • Single leg sit to stand
  • Side lying abduction


Load and Impact Management Assessment before Return to Running[edit | edit source]

These tests assess a woman’s ability to tolerate the load of more demanding exercises such as running and high-impact exercises.[7]

  • Walking for 30 minutes
  • Single leg balance for 10 seconds
  • Single leg squat - 10 repetitions on each side
  • Jog on the spot for 1 minute
  • Forward bounds - 10 repetitions
  • Hop in place - 10 repetitions on each leg
  • Single leg “running man”: opposite arm and hip flexion/extension (bent knee) - 10 repetitions on each side

A gradual return to higher impact exercise such as running is advised. Ways to achieve this include having a walk-run strategy and having strategies in place to gradually increase the load on the pelvic floor and body.[7]

Other Considerations in Postpartum Return to Physical Activity and Exercise[edit | edit source]

  • Breastfeeding
    • Moderate physical activity will not compromise infant breast milk acceptance or infant growth.[5]
    • Conflicting reports exist regarding the overall influence of hormones on connective tissue, joint laxity and muscles and it seems to be inconsistent amongst individuals. Therefore, this may increase a woman's risk of developing an injury.[7]
    • Give consideration to the energy demands of breastfeeding and exercise.
  • Sleep
    • Sleep is essential for recovery from physical and psychological stress and is often compromised in the post-partum period.
    • Sleep deprivation increases injury risk.
    • Seven to nine hours of sleep are recommended.
  • Psychological well-being
    • Screen for Postnatal Depression (PND) – Edinburgh Depression Scale.
    • Many women use exercise such as running as a coping strategy, to manage body image or for escapism and healthcare professionals need to be able to signpost women who need specialised support services.[2]
  • Fitness
    • Focus on safe and appropriate postnatal exercise.
    • Individualised assessment and rehabilitation is needed based on the birth experience and specific issues of the individual.
  • Supportive clothing
    • A personally fitted sports bra may provide increased breast support and comfort.
    • Supportive footwear and the correct fit are important.
    • A new field of research into sportswear and clothing that supports the pelvic floor during exercise is developing. Okayama et al.[27] reported that "wearing supportive underwear (shaper) was almost as effective as pelvic floor muscle training at home in reducing urinary incontinence symptoms."

Benefits of Postnatal Exercise[edit | edit source]

  • Restores physical health
    • Improves blood circulation[29]
    • Strengthens abdominal and spinal muscles[29]
    • Accelerates constriction of the uterus[29]
  • Improves sleep quality
    • A significant improvement in physical symptoms associated with sleep inefficiency was seen in postpartum women who took part in a walking exercise programme[30]
  • Relieves stress
  • Prevention of depressive disorders such as postnatal depression
    • Regular physical activity during pregnancy and postpartum reduces the risk of depression as compared to inactivity[31] [32]
  • Increased energy[33]
  • Improved sense of well-being[33]
  • Reduced body weight[33]
  • Stimulates lactation[29]
  • Improves stamina levels
    • Enhanced ability and capacity to implement physical activity consistently
  • Alleviates postnatal issues such as diastasis recti, urinary incontinence, pelvic organ prolapse and pelvic girdle pain[34] [35] [36]
  • Social activity – exercising with other mothers may provide support and boost morale

Barriers to Exercise in Postpartum Women[edit | edit source]

Before prescribing exercise to postpartum women, it is necessary that physiotherapists have a good understanding of the barriers to exercise and physical activity.[37] Some of the barriers and suggestions on how physiotherapists can help women overcome these barriers are shown in Table 1.

Table 1. Barriers to Exercise in Postpartum Women[37]
Categories Barriers Suggestions to Overcome Barriers
Intrapersonal Tiredness and/or lack of sleep Educate women on sleep health strategies and the importance of sleep

Help women develop strategies to exercise to improve energy levels

Provide women with energy conservation techniques

Low motivation Inform women of local fitness classes or walking groups - social support often helps with low motivation
Physical or health limitations Assist women with musculoskeletal changes and modify exercises as needed
Interpersonal Time and/or unpredictable routine/schedule and busy with domestic chores/care/responsibilities Provide education and strategies for women who feel they cannot prioritise exercise

Create awareness that small, shorter workouts (10 to 15 minutes) all contribute to overall health

Sociocultural and Demographic Influence Lack of support from family, friends and other mothers Advocate for ways to share the load of caregiving

Recommend classes and gyms in the local community where women can bring their babies along

Physical Environment Weather and access to appropriate facilities and childcare Create awareness of facilities in the local area

Help women create exercise plans that can be done indoors

Make use of online resources

Health Care Environment Breastfeeding

Lack of information/advice/encouragement

Educate women about exercise and breastfeeding - it is safe to exercise while breastfeeding and the mother and child's health will not be harmed

Provide and disseminate accurate information on physical activity

Enablers of Postnatal Exercise[edit | edit source]

  • Partner support
  • Social support and networks
    • For example, postnatal exercise classes
  • Positive perception of the importance of exercise
    • Liva et al.[38] reported that women who had a positive perception of the importance of exercise and physical activity for their own health and well-being, made time for exercise and physical activity, despite all the other barriers such as lack of time or limited childcare.

Resources[edit | edit source]

References[edit | edit source]

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  2. 2.0 2.1 2.2 2.3 2.4 Healy, F. Current Guidelines and Recommendations for Postnatal Exercise Course. Plus. 2022
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