When and how to return to running after birth

When and how should you get back into running after birth…?

Women’s Health and Continence Physio and owner of FitRight, Taryn Watson answers that very question.

In March a set of guidelines were released by three UK-based physiotherapists to help health professionals (such as our team of FitRight Physios) determine what to look at for each of our individual clients.

Why were guidelines for returning to running after birth created?

Prior to these guidelines being released, our main international guidelines were documents that referred to ‘Exercise During And After Pregnancy.’ However, about 90% of the information was about pregnancy modifications and precautions, with a token paragraph at the end about returning to exercise after birth.

These relatively small sections of the documents contained statements such as:

·  “Wait until your medical clearance to return to exercise”

·  “Start exercising after 6 weeks and listen to your body with regards to intensity”

·  “Take care with high impact exercise”

I would read these documents and shake my head. While I understand that it’s important to “listen to your body,” there was rarely, if ever, mention of the fact that vaginal prolapse is often asymptomatic until it progresses to a point that the organ/s are near the vaginal opening.

So while you could “listen to your body,” if you didn’t have pain or incontinence, you may return to the type of load and impact exercise (such as running) that is inadvertently worsening a prolapse, without realising.

The new guidelines about returning to running after birth are a breath of fresh air – not only do they explain why medical clearance is inadequate for returning to running, they heavily promote getting a vaginal exam done by a specialist physiotherapist, as well as a whole-body assessment of your strength, balance, fitness and endurance.

They look at the whole picture.

Why are postnatal women more prone to pelvic floor issues?

Pelvic floor muscle injury and/or weakening is relatively common in the postnatal period.

This is due to factors such as the extra pressure and weight that was on the area in late pregnancy, the hormonal changes in pregnancy that made everything more flexible and moveable in preparation for birth, and then the physical stretching (and possible injury) that occurs during a vaginal birth, where the baby passes between two sides of the pelvic floor.

One of the biggest factors in a vaginal prolapse is the size of the space between the two sides of the vaginal wall, which is called the ‘Levator Hiatus.’

This gap widens significantly during pregnancy and then even more significantly during vaginal birth and has been shown to take between 4-12 months to return to it’s ‘normal’ (which is likely to remain wider than previously).

This period of time where the levator hiatus is more ‘open’ is a high-risk time for the organs (bladder, uterus, bowel) to drop down in the middle and for prolapse to occur.

Why is running considered a high-risk activity with regards to pelvic floor muscle issues?

There has been a lot of research that has shown that high impact exercise (running, jumping, skipping etc) is linked to causing and worsening pelvic floor muscle dysfunction (incontinence and prolapse) in women, even in those who haven’t had a baby.

This is due to the sudden rises in pressure in the abdomen with impact, with ground reaction forces of up to 1.6 to 2.5 times normal body weight occurring when running at 11km per hour.

Women who participate in high impact exercise have a 4.59 fold increased risk of pelvic floor issues compared to those doing low impact exercise.

This was the topic of my Masters research back in 2013. We looked at the rate of stress urinary incontinence (leaking with exertion, like coughing or running) in almost 400 women attending gyms and found that nearly 50% of them said yes, they did experience stress incontinence.

This is why I created FitRight – I wanted to show women that there were low impact options for exercise and that it could be used to increase cardiovascular fitness, pelvic floor function and general strength with the aim of returning to high impact exercise.

I’ve never wanted women to be turned off activities like running, as there are so many other aspects of overall health that can be benefited by high impact and higher load exercise, like bone health and heart health.

What other ‘non-vagina’ issues should we be considering in returning to running after birth?

If you’ve had a caesarean, you need to consider the healing of all of the layers that have been repaired in your abdomen. By 6 weeks postnatal, this area has usually only regained 55% of its tensile strength and this could be further impacted if you had any infections or wound break down in the early weeks. Studies have shown that 80% of the tensile strength is usually regained by 6-7 months postnatal.

What about your joints? Your body very cleverly prepared for childbirth by producing hormones through the pregnancy that softened the joints in the pelvis to allow a baby to fit through. These hormones also would have affected other joints and connective tissue in your body too, such as your knees and ankles.

The body stops producing relaxin when the baby is born, but research is unclear regarding how long after childbirth the effects take to subside, or whether breastfeeding has any impact on your joints remaining more flexible.

In my experience, I seem to see more ankle sprains and knee pain occurring in women who return to high impact exercise like running in the early postnatal period.

How strong are your muscles in your legs and trunk? Some women are returning from a period of relative inactivity – perhaps being put on bed rest in late pregnancy, or being housebound for the early weeks after baby was born.

Muscle wasting can happen very quickly and I see women develop issues like shin splints and tendon issues because they return to running before the muscles in their calves, upper thighs and glutes are strong enough.

Even without periods of inactivity, it’s amazing how our bodies had to adapt to a changing posture in late pregnancy and how this may have affected the strength in areas like our glutes and our deep abdominal muscles.

Here’s a recommended checklist that your health professional (ideally a physiotherapist with post-graduate training in pelvic floor health) should take into account before giving you the all-clear to run:

• No symptoms of pelvic floor muscle dysfunction – leaking from bladder or bowel, vaginal pressure or heaviness, no vaginal pain before or during return to running
• No musculoskeletal pain during return to running
• Optimal pelvic floor resting tone, pelvic organ support, pelvic floor strength and endurance tested on vaginal examination
• Optimal load management, including the ability to do things such as balance on one leg for more than 10 seconds, jog on the spot for a minute and do 10 hops on each leg without symptoms.
• Optimal strength in relevant muscles such as calves, glutes and quads.

What other factors should be considered with regards to being given ‘the all clear’?

• Weight – a higher BMI, especially over 30, is a big risk factor for pelvic floor and joint dysfunction and it’s recommended to start with lower impact exercise than running until your weight is decreased.
• Pre-pregnancy, pregnancy and postnatal fitness levels
• Your breathing pattern and how that might affect the pressure in the abdomen
• Psychological well being, taking into consideration that running can be a coping mechanism for some women with regards to mental health
• Diastasis Recti (abdominal muscle separation) and how well you can transfer load through the midline
• Caesarean and perineal scar management and whether tightness or pain needs to be addressed
• Breastfeeding and whether the timing of your run or the support that you have from clothing needs to be considered. Research has shown that running and other high-intensity exercise does not negatively affect breast milk.
• Foot support with appropriate shoes and perhaps inserts (which may need to change since pre-baby)
• Sleep (or lack of it) – lots of research shows that injury is more likely to occur in a sleep-deprived state and this should be considered with exercise choice on those days/weeks/months that this is a particular issue.
• RED-S – this is a condition where the amount of energy that you expend (with activities like high-intensity exercise) outweighs the amount of energy that is being taken in by the body (such as nutrition and sleep). This can be serious and can lead to issues with bone density, future fertility etc and does occur in some postnatal women.

How do the guidelines suggest to structure your return to running…?

1.    Start with 1-2 minutes of running during a walk and while monitoring symptoms. I think it makes sense to progress this over the first few weeks (or months) at a sensible rate until you are able to run comfortably for 5-10 minutes at a time.

2.    Once you get to this level with no pain, leakage or vaginal heaviness, the recommendation is to write out a training program that would allow you to increase your ‘training volume’ (distance or time) by no more than 10% per week.

3.    Consider setting short term goals and consider following a structured program.

4.    Concurrently work on maintaining pelvic floor, core and global body strength and well as regular stretching.

Lastly, how do you know if your baby is ready to go running in the pram with you?

It is recommended, for the mother’s benefit, to go running initially without the extra load and altered biomechanics of pushing a pram (if possible!).

It is also noted that, while the mother might get the all-clear to go running at 3 months postnatally, you need to check the pram manufacturer’s guidelines, which usually stipulate that a baby should be 6-9 months old to go in a running pram.

This seems to be decided with regards to the age when a baby has good enough head and trunk control to be independently left in a sitting position and is based around the safety for their spine and brain with the potential extra impact.

The safety checklist for prams that are suitable for running is as follows:

• 5 point harness
• Fixed front wheel
• Hand-operated brakes
• Rear-wheel suspension
• Pneumatic tyres
• 3 wheels
• Wrist strap

In summary, the new returning to running after birth guidelines advise:

1. Returning to running is not advisable in the first 3 months postnatally or beyond this if any symptoms of pelvic floor dysfunction are identified prior to, or after, attempting a return to running.

2. Start modified exercise early (prepare for your running return with a mix of core training, lower leg strengthening, low impact cardio and stretching), but keep it low impact for the first 3 months.

3. Every woman should be offered the opportunity to have a pelvic floor assessment with a specialist physiotherapist from 6 weeks postnatal and should be screened for signs and risk factors for pelvic floor dysfunction.

4. A graduated return to a running regime should be implemented between 3-6 months postnatal.

Want to know more about how FitRight can help you on your journey to running and other forms of exercise…?

From Joondalup to Armadale, Cottesloe to Mandurah – if you live in Perth and surrounds there are likely to be physio-led FitRight exercise classes in your neighbourhood.

These allow you to be supervised by a FitRight Physio in a small group setting while you focus on strength, core, cardio fitness and stretching.

Classes are available for pregnancy, early postnatal, mums with toddlers and women in middle age. The postnatal classes include community volunteers to care for your children in the same room while you exercise.

Private health rebates apply.

For more info head to the FitRight website.

This post is sponsored by FitRight.