How do you cater for the range of postnatal women coming to your programmes? Dianne Edmonds, Director of The Pregnancy Centre, shares considerations for programming following birth.
How do you cater for the range of postnatal women who come to you as clients, from the early postnatal mum coming back in the first few months to the mum progressing her training and wanting to build up and do more? How do you know if she is ready? What do you need to take into consideration?
Some of the factors to consider when working with your mums include:
Postural correction and awareness
- Adjusting from pregnancy postural changes
- Stretches and strengthening to counteract the forward-focused positions of caring for a baby
Shortening and retraining of the abdominal wall
- From lengthening that occurs during pregnancy, the abdominal wall needs to shorten and strengthen
- Retraining includes working through progressions to build response to load and forces
- Consideration of any abdominal muscle separation (diastasis)
Pelvic floor protection and restoration
- Retraining of the pelvic floor following pregnancy and birth requires a specific focus
- Protection from excess load as you build resistance and gradually return to higher intensity and impact exercises
There are many dimensions for each of these areas, so this article will focus on some key points that can be applied to each one.
Postural correction and awareness
During pregnancy, there is a change to each of the curves in the spine as the weight of the uterus increases, the abdominal muscles lengthen and the pelvis tilts anteriorly. The curve the lower back, called the lumbar lordosis, increases.
Postnatal exercises that work to restore the lumbar lordosis can include pelvic tilting exercises in lying, while sitting on a ball, in standing and in four-point kneeling positions. These will also use the rectus abdominis as it shortens during this movement and can provide a stretch to the back extensors for some clients, depending on the range they find it comfortable to move into.
As a postnatal exercise, breathing through the movement and during the feeling of stretch is advised.
In the thoracic spine, the curve (kyphosis) increases during pregnancy as breast weight and size increases. When postnatal, a mum is sitting often to hold and feed her baby and, if she is tired, curling forwards and rounding of the shoulders can accentuate. Focusing on exercises to promote pulling the shoulders back, opening the chest and moving into a comfortable degree of thoracic extension can help to restore posture and counteract the forces of baby-caring activities.
Postural changes in the cervical spine can result from pregnancy, and the head and neck position may compensate. Baby-caring roles can reinforce a forward head position; postural awareness plus neck stretches to counteract this can also be included in your programming.
Shortening and retraining of the abdominal wall
Initially, shortening of the lengthened abdominal wall is easiest for postnatal mums when their abdominal wall is in a lengthened position before they draw in the muscles, as they commence postnatal abdominal bracing. Positions such as side lying, standing, four-point kneeling and being seated work better in the early postnatal months when the abdominal wall is lengthened, as compared to supine, until the muscles shorten. It will depend on your client and the tone, length and activation patterns of their abdominal wall.
Baseline retraining includes activation of the lower half of the abdominal wall, where the muscles have been carrying the weight of the uterus during the later stages of pregnancy.
Load can be added as clients progress, with initial training instructions including:
- draw in the lower abdominal muscles below the belly button
- hold this for a moment and relax
- check that you are not sucking in the muscles under your ribcage
- you should feel no pressure downwards on your pelvic floor.
Lifting the pelvic floor first for some clients can be a helpful cue, as the pelvic floor is ‘wired together’ with the lower fibres of transverse abdominis.
Your client can build up the hold time and number of repetitions of this exercise, working in different positions and adding progressive load as they can control the movement.
Sam Kirker, a personal trainer, describes her early progressions this way to her clients:
“With a lot of the postnatal core work, I like to start with movements like ‘dead bugs’, but fully regressing it. So, lying on the ground, with knees bent, making sure we can gently pull our abdominal wall in. So, we’re bracing our tummy muscles and taking care that the lower back does not arch off the ground. Then, gently lifting one foot up and lowering it, before alternating with the other leg – a little like a slow motion, horizontal march. Throughout, ensure that the clients are able to breathe, and to maintain that contraction and good form. From there, we can progress to gently lifting the leg, sliding it out along the ground and then bringing it back in.
“After this, we can progress to ‘bird dog’ exercises. In four-point kneeling, brace the tummy muscles and lift the pelvic floor, keeping the hips nice and stable. Imagine you have a bucket of water on your hips and then, very gently, lift one arm up and then lower it. If you can do this, then you could progress the exercise by raising one leg. The next progression is to lift the opposite arm and leg at the same time and then bring them back in again, making sure the pelvis stays nice and stable, before alternating the legs and arms.
“Side planks are also good, performed with the knees (rather than the feet) as a point of contact with the ground: this enables the hips to be gently lifted and then lowered. Imagine you have strings on your side, lifting you up towards the ceiling and then gently lowering you. As you get stronger, you can progress from the knees to having the feet as the point of contact.”
No abdominal muscle exercise should cause bulging of the abdominal wall.
Bulging from increased intra-abdominal pressure can push out on the abdominal wall, which if not yet shortened and strengthened cannot counteract the forces involved. This involves risk if the pressure generated pushes down on the recovering pelvic floor and the pelvic floor is not yet able to counteract the forces created.
Doming of the linea alba with any exercise means the pressure generated is not being controlled and checking the degree of abdominal separation needs to be assessed and training reviewed.
Arching of the lower back (lumbar spine) with leg loading, for example, in the supine position also means that the abdominal wall isn’t able to maintain control and reducing the degree of load is recommended.
Pelvic floor protection and restoration
Pelvic floor retraining postnatally is best achieved through individual assessment of the pelvic floor muscles and exercise prescription, through a women’s and pelvic health physiotherapist. When this is available for your postnatal mum, she will be able to work at the individual level that is targeted at her level of pelvic floor fitness and function.
When training postnatal mums, pelvic floor awareness can be promoted during your programming, aiming to protect from the risk of increasing or causing any pelvic floor issues such as leakage of urine or pelvic organ prolapse. Mums should experience no pelvic floor heaviness, pressure, pain or leakage of urine during training and, if they do reveal to you that they are experiencing any of these symptoms, then it is advised that you refer them for assessment and treatment.
Encourage your clients to gain an awareness of how their pelvic floor feels during lifting, holding and relaxing the muscles when you do include pelvic floor exercises in your programme. A variety of positions can be used, including sitting, lying, standing, hands and knees, and clients can feel which positions work best for them at the stage of postnatal recovery they are at.
Look out for accessory muscle use, which is when they use muscles other than their pelvic floor to feel a stronger sensation, such as contracting the gluts, using the adductors or excessively tightening their abdominals. Gentle activation of the lower abdominal wall, which is co-contraction with transverse abdominis, is allowed without breath holding.
This guide updated in 2022 gives more information on introductory pelvic floor instruction and education: Pelvic Floor Health for Expectant and New Mums | Continence Foundation of Australia
To protect the pelvic floor during training focus on:
- avoiding breath holds with resistance exercises – use breathing out as a focus
- building return to load gradually in the return to postnatal training
- helping your client to become aware of the amount of effort needed for an exercise and monitoring their form with increased repetitions and sets so that, with fatigue, they don’t begin to breath hold or move in a way that puts pressure on their recovering pelvic floor
- for abdominal training, is their pelvic floor able to match the load generated inside their abdominal cavity?
For more information on this, see the Pelvic Floor First website:
The pelvic floor and core exercises · Pelvic floor friendly exercises · Pelvic Floor First
Pelvic Floor Safe Exercises · Pelvic Floor First
Want to learn more from Dianne Edmonds? Check out her 3 online courses… Third Trimester Training for Labour, Ante Natal Core Training and Early Post Natal Programming.
