Returning to exercise and running after birth

Short answer: There is no single date for returning to exercise after birth that fits everyone, and any source that gives one is saying more than its evidence allows. The accepted principle is that exercise can be restarted gradually as soon as it is medically safe. When that point arrives depends on the type of birth, on whether there was a medical or surgical complication, and on the assessment of a physician. Walking, and exercises for the pelvic floor (the layer of muscle and connective tissue that closes the base of the pelvis from below), can begin very early where it is medically safe. For running and other high-impact activity, the calendar does not make the decision. The load the trunk can carry at that moment does.

Why no single date can be given

The answers to this question on the internet do not agree with one another. One page gives a number of weeks, a second writes a longer period for a caesarean, a third says to start when you feel ready. The disagreement comes from something simpler than a gap in knowledge: a date that fits everyone genuinely does not exist.

There is a concrete reason for this. Two women who give birth on the same day go home in two completely different states of recovery. In one, labour was short, bleeding stayed within the expected range and no stitches were needed. In the other there was a long labour, a wide episiotomy (a cut made between the vagina and the anus during birth) or a caesarean incision. To that add how many births she has had, what her sleep looks like now, how active she was before the pregnancy, and any continuing health problem. A calendar knows none of this.

Pregnancy and birth do not go the same way for every woman. After a loss, after a difficult birth or after an unexpected medical course, returning to movement stops being a question about tissue healing alone. The framework set out on this page is a general one, and how it applies to your own situation is settled by your physician.

The accepted principle: gradually, as soon as it is medically safe

The internationally accepted principle is that exercise routines can be resumed gradually after pregnancy as soon as this is medically safe, and that the timing depends on the type of birth and on whether a medical or surgical complication occurred. The same principle states that some women are able to return to physical activity within days of giving birth.

One detail here deserves attention. The week counts that circulate in Turkish and English sources come from secondary summaries, and they could not be verified as the wording of the primary document that sets out this principle. They are not repeated on this page, because repeating them would offer you a certainty that nobody actually holds.

The decision belongs to the physician. At the postpartum check the course of the bleeding, the healing of the stitches or the incision, blood pressure and any problems carried over from the pregnancy are reviewed. Physiotherapy comes in after that assessment and works inside the limits it draws.

The same source gives a target of at least 150 minutes of moderate-intensity aerobic activity a week, and treats that target as applying to the period after birth as much as to pregnancy. The figure is where you are heading, not a condition for starting. A woman whose first weeks consist of five-minute walks is already moving towards it. That source also notes that physical activity may have a part in preventing depressive disorders after birth.

What can begin very early: walking and the pelvic floor

Light activity such as walking, and exercises for the pelvic floor, can be started soon after birth where it is medically safe. This is the second half of the principle above, and it is the half that tends to get skipped. The waiting period in which nothing at all is done is a good deal shorter than most people assume.

Walking counts for more than it is usually given credit for. Short and frequent walks may contribute to circulation, and they lengthen the part of the day the trunk spends upright, which can lay some groundwork for the loads that come later. Five minutes to the end of the street and back is already a real start. For most women, spreading the walking time across the day is easier to keep up in the early weeks than lengthening a single walk.

Pelvic floor exercises need a note of their own. The strongest evidence for them sits in prevention. In pregnant women who do not yet leak urine, pelvic floor muscle training given during pregnancy has been shown, with high-quality evidence, to reduce the risk of urinary incontinence between the third and the sixth month after birth. In women who are already leaking, there is no evidence that training given during pregnancy brings that same benefit. That distinction changes the approach and the timing, and it does not make assessment of the pelvic floor after birth unnecessary. The evidence on each side of the line is set out on the urinary incontinence after birth page.

A pelvic floor contraction cannot be seen from the outside. At the moment a woman believes she is contracting it, the abdominal or the buttock muscles may be doing the work instead. Whether the right muscle has been found can only be established through an assessment, and having that settled once may help the work done at home reach the muscle it is meant for.

A caesarean is abdominal surgery

Standing alone on a page, that sentence can look cold. In practice it explains a great deal. The incision passes in turn through the skin, the fat beneath it, the sheath around the abdominal muscles, the straight abdominal muscles parted at the midline, the lining of the abdomen and the wall of the womb. A wound that has closed on the surface does not tell you that every one of those layers has healed at the same rate.

Recovery after a caesarean therefore runs on a different timetable from recovery after a vaginal birth. Movements that raise the pressure inside the abdomen quickly are harder on the tissue around the incision in the early period. "My scar is numb and it pulls" is one of the questions this guide was written around. Numbness, a pulling sensation or tenderness to touch around the scar can occur, and that change in sensation can last a long time. Where it does, it is worth mentioning at the postpartum check. Work on the scar and on the mobility of the tissue around it is one of the things that can be taken up.

A woman who has given birth vaginally has no incision on her abdomen, but there may be a tear or an episiotomy in the perineum (the area between the vagina and the anus). Difficulty sitting and tightness around the stitches come to the fore in this group. Pain during intercourse also comes up here, and it is dealt with in its own right instead of being folded into a general recovery plan. Because the two groups struggle in different places, the programme is built differently. Nor is the type of birth the only thing that sets the pace of the return.

What gradual actually means

The word gradual is used constantly and filled in rarely. The load an activity puts on the trunk has four components: how often it is done, how long it lasts, how hard it is, and how much impact it carries. Progressing gradually means raising one of those four at a time.

Put concretely, a woman who lengthens her walk does not also pick up the pace in the same week, and does not switch to a hilly route. A woman who starts a movement with a hop in it does not raise the weight she lifts that week. When two components rise together and a symptom appears, there is no way of telling which of them was too much, so the week teaches you nothing.

The next day tells you as much as the session itself. Feeling fine during the activity is not a sufficient measure on its own. The useful information turns up that evening and the following day, and if symptoms are clearer then, the load was too much for that day.

Returning to running, and where the twelve-week figure comes from

A widely adopted expert guideline recommends roughly twelve weeks, independent of the type of birth, together with a criterion-based assessment. Running is the part of this subject that comes up most often, and underneath the question there is usually more than running itself, because running stands in for the life someone had before the birth, and the real question is often whether that life is still available.

The standing of that guideline should be set out plainly. The document was not published in a peer-reviewed journal. It is a practice guideline that its authors published themselves with open access. It has been taken up widely, and on the ladder of evidence it stands at the level of expert opinion.

That has two consequences in practice. The first is that the sentence "research has shown you need to wait twelve weeks" is not true: a group of experienced clinicians came together and proposed this period along with a framework for assessing readiness. The second is that the twelve-week mark is not itself a starting signal. The guideline recommends that readiness for running be assessed around that point. Reaching the date does not on its own mean being ready, and not having reached it does not mean the same thing for every woman.

The four-phase framework and its limits

A clinical review that treats the rehabilitation of the postpartum runner in four phases is also used often here. It describes the intensity, the frequency and the type of exercise, sample exercises for the hip, the abdomen, the pelvic floor and the foot, how running itself is progressed, and which targets have to be met before moving from one phase to the next.

A clinical review of this kind carries less weight than a randomised trial. This one did not come out of a study in which one group of women was worked with under the framework and compared against another group. Its content is existing knowledge arranged by specialists. Its value is that it puts scattered recommendations in order and shows what is being looked at from one step to the next. That is also where its limit lies: putting existing advice in order is not the same as testing it.

What criterion-based assessment means

Criterion-based assessment replaces the question "how many weeks has it been" with the question "what can the trunk carry right now". It falls under four headings.

Pelvic floor and abdominal recovery. The assessment looks at whether the right muscle can be found, whether the contraction can be held, and whether control survives a sudden rise in pressure such as a cough or a sneeze. The midline of the abdomen is watched under load for doming (the midline pushing outwards as a dome when the abdomen is loaded) or for a ridge running lengthways. This is set out in more detail on the separation of the abdominal muscles page.

Load and strength tolerance. The movements used here vary with the person carrying out the assessment and with what the woman is aiming for. They have one thing in common: they test carrying weight on one leg, and the strength of the hip, without bringing symptoms on. Running is a load in which the weight of the body is met on one leg over and over again, which is why endurance on a single leg is taken as a precondition.

Impact tolerance. Movements with hopping and jumping in them are tried, and the hopping patterns closest to running itself are left until last. The point of the test is what happens while the movement is being done: whether leaking urine, a sensation of downward pressure or pain appears.

Following the symptoms. Symptoms are watched and written down at every step. Where a step brings none, the next one follows. Where one appears, the woman stays at that step or goes back to the one before it. This loop of testing, watching and adjusting is the part of the framework that does the actual work, and it is also the part most often left out when the framework is copied onto a website as a list of phases.

Which symptoms mean a step back

When one of the findings below appears, the load has been too much. Treat them as feedback. They are not a sign of failure.

• Leaking urine during or after the activity. A few drops count.
• A sensation of downward weight, of pressure, or of something bulging.
• Doming along the midline of the abdomen, or a ridge running lengthways.
• An increase in pain in the lower back, the groin, the tailbone or around the incision.
• Bleeding starting again, or increasing noticeably after it had settled.

None of these means that a movement is closed to you for good. It means that the movement is too much at this load, for this long, or this often. Reducing the load, going back to the previous step and trying again a few days later is the first move in most cases. Where the symptom continues at the reduced load, an assessment is needed. Bleeding that starts again is different from the rest of the list and calls for a physician directly.

Lifting, and carrying the baby and the pushchair

The question usually arrives in this form: "Is carrying the baby and the pushchair doing me harm?" There is something particular about it, because these are not loads anybody chooses. The baby is carried every day and gets a little heavier every week.

Avoiding that is not possible, and no programme is built on the idea of avoiding it. A programme is built on being able to meet these loads. Daily carrying is in a sense gradual loading in itself, since the baby's weight rises slowly and the trunk adapts as it goes.

There are a few points where technique helps. Breathing out as you lift, instead of holding the breath and straining, may help limit the sudden rise in pressure inside the abdomen. Getting a pushchair up a flight of steps, at a metro station or at the door of a building, may put less strain on the lower back when the load is kept close to the body and lifted while facing the direction of travel, not pulled up with the trunk twisted. If a sensation of downward pressure or leaking urine appears while carrying, that is the sign to have the technique and the carrying capacity looked at.

The question of sit-ups, planks and press-ups

These three movements are the ones women hesitate over most after birth. All three raise the pressure inside the abdomen quickly and load the midline and the pelvic floor at the same time. In a trunk that cannot meet that load in the early period, the result becomes visible as doming along the midline, as breath being held, or as leaking urine.

Even so, they are not presented here as a list of things forbidden. The measure is how the trunk responds to the movement. The same woman may hold a plank on her knees for short periods with no symptom at all while her midline sinks in a full plank. Where that happens, going back to the version of the plank the trunk can meet, and progressing from there, is appropriate. Detail about the midline of the abdomen is on the separation of the abdominal muscles page.

Breastfeeding, broken sleep and energy

Breastfeeding and broken sleep bear directly on how demanding a programme can be. Raising the load after a week without sleep does not produce what the same load produces in a rested body, and a programme that ignores this will not survive contact with the week ahead.

"Does exercising while breastfeeding affect my milk?" is asked often, and it deserves a straight answer. The sources this page rests on do not contain a detailed assessment of how breastfeeding and exercise interact, so nothing definite is claimed here, and where there is hesitation the decision is made together with a physician. Beyond that, what can be offered belongs to practice rather than to evidence. Putting the exercise after a feed may be more comfortable because of breast fullness, and a supportive bra may reduce discomfort during movement.

One thing is worth settling at the outset. A programme for movement after birth is not built around changing body measurements. The measures followed are the load the trunk can carry and the symptoms being experienced.

Findings that call for a physician

In the situations below, the right move is to stop exercising and see a physician. The list is not exhaustive. Where there is any doubt, ask a physician.

• Bleeding starting again, bleeding with clots, or bleeding heavier than expected.
• Fever, shivering, or feeling generally unwell.
• Redness, discharge, a bad smell or increasing pain at the stitches or the incision.
• Swelling, redness, warmth and pain in one calf.
• Breathlessness that comes on suddenly, chest pain, or palpitations.
• A severe headache that does not settle with rest, blurred vision, or newly raised blood pressure.
• Burning on passing urine, needing to pass urine very often, or being unable to empty the bladder.
• A noticeable lump in the vagina, or a sensation of something coming down.
• Low mood that persists, intense anxiety, or thoughts of harming yourself or the baby.

If you have not used the health system in Turkey before, the route is worth spelling out, because it is not the one you may be used to. The usual first stop is the family physician at the family health centre where you are registered, or the obstetrics and gynaecology clinic that followed you through the pregnancy. That physician decides whether any imaging or test is needed and whether a referral onwards is appropriate. Findings that are urgent, such as heavy bleeding, sudden breathlessness or chest pain, go to a hospital emergency department instead of waiting for an appointment. There is a state route and there is a private one. Which of them is open to you depends on your health insurance cover, and registration with a family health centre follows from that cover. Where both are available, the practical difference between them is mostly waiting time.

Diagnosis belongs to the physician. Physiotherapy follows that assessment and is carried out within the limits it sets.

Is there such a thing as leaving it too late

"It has been two or three years since the birth, so have I left it too late?" comes up often, and underneath it there is usually a feeling of having let oneself slide. The short answer is no.

There are data suggesting an advantage in starting early. A recent meta-analysis bringing together studies on the midline of the abdomen found that the narrowing measured in the distance between the abdominal muscles was greater where the programme had begun within the first three months after birth than where it began later. The same meta-analysis reported that this anatomical narrowing did not show up on a scale of functional disability, where no difference between the groups was found. Starting early therefore looks advantageous in terms of the distance measured, while the aim being followed is the load-bearing capacity of the trunk and the symptoms a woman actually lives with, not the closing of a gap. The finding does not make starting later pointless. Trunk capacity can be worked on years afterwards, and a woman needs no justification for coming in today.

For women planning a second pregnancy the question takes a slightly different shape. A new pregnancy will load the trunk again, and there is no avoiding that. It is not a reason to put the pregnancy off. Having worked on capacity beforehand may make things easier through the pregnancy and after it, and the decision rests with the woman and her physician. How movement is organised during pregnancy is set out on the exercise in pregnancy page.

How the assessment is carried out

The assessment opens with taking a history. The questions cover how the pregnancy and the birth went, whether this was a first birth, which symptoms appear in which movements, which activity the woman wants to return to, and how active she was before the pregnancy. A woman who wants to run and a woman who wants to carry her baby up the stairs without discomfort are aiming at different things, and the programme takes account of that difference.

An examination of the trunk follows. Posture and the position of the ribcage are observed, and the way the breath moves the trunk is watched. The behaviour of the midline of the abdomen under load is followed. Functional tests are used to assess endurance on one leg and the strength of the hip, and where it is appropriate, tolerance to impact is tested as well.

In the assessment of the pelvic floor, an internal examination is not an automatic step. If one is going to be carried out, what is being looked at is explained beforehand, verbal consent is asked for, and it is not done if the woman does not want it. Assessment through external observation and functional testing is also possible, and those steps usually give enough information to build a first programme. The assessment can be stopped at any point. Anyone who wants a companion in the room is welcome to bring one. Whether the baby can come along to the session is discussed when the appointment is booked.

Sessions are one to one and last sixty minutes, and attendance is by appointment. A free fifteen-minute introductory call can be held first, to talk through what would be involved and to ask practical questions. Consultations can be held in English. The practice is in Evka 3 in Bornova, at Erzene Mahallesi 113 Sokak No: 1/3. Evka 3 metro station is in the same neighbourhood and is the eastern terminus of the M1 line, so anyone travelling from the western side of the city simply stays on to the end.

Where to go next in this guide

If leaking urine is part of the picture as movement resumes, the urinary incontinence after birth page sets out in detail what the evidence says about prevention and about treatment. The gap along the midline of the abdomen, and how it is measured, are on the separation of the abdominal muscles page.

For anyone wanting to know what the pelvic floor does and how its assessment runs, the what the pelvic floor is page is a reasonable place to begin. How movement is organised during a new pregnancy is on the exercise in pregnancy page. Appointment and travel details are on the contact page.