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Postpartum: Starting to Exercise Again

Starting a moderate exercise program during the postpartum months is beneficial in many ways. Regular exercise improves immune function and increases the production of antioxidant substances in the body. It helps you to sleep better at night and feel more energetic during the day. A brisk walk does wonders for depression or anxiety. A bout of exercise helps to suppress your appetite for sweets and junk food and increases your appetite for natural, nourishing foods. Flexibility and muscular strength stave off uneven strain on the skeleton that can lead to pain and injury over time. If your muscles are strong and your joints supple, you are less likely to throw your back out or injure yourself in some other way as you lift, bend, twist, and maneuver through your day. And if you start easing into exercise in a balanced and educated manner during the first postpartum year, the transition into more strenuous exercise later – should you choose to make that transition – is sure to be much smoother.

While some exercise is a very good thing for a new mom, doing too much too soon can be harmful. This is especially true for women who are low on the adrenal hormone cortisol. When you exercise, your adrenal glands pump out cortisol to increase your heart rate and breathing rate, and to increase blood flow to your muscles. As explained previously, there is a significant drop in cortisol levels postpartum. Going out for a run two weeks after giving birth will draw on the tapped resources of your adrenals before they are ready, and this will knock your recovering body out of balance. If laboratory tests show that your cortisol levels are low, you should postpone all but the most mild exercise until those levels return to normal.

You may have enjoyed an increased degree of flexibility during pregnancy. Your joints will still be loose for the first few weeks postpartum, and loose ligaments mean greater risk of injury. Exercising too hard in those first weeks can also delay the healing of episiotomy and cesarean incisions. If you hemorrhaged after giving birth, you may be anemic, and you will need to build up your iron levels for a while before you're ready to exercise.

Unrelenting or recurring muscle or joint pain in the hips, legs, or back can be related to the skeletal strain of late pregnancy and birth. If you have this problem, you may need to visit a skilled chiropractor or osteopath, who can assess any skeletal imbalances and correct them.

Starting to Exercise Again
An important point to remember about exercising postpartum is that you should not start too soon. But how soon is too soon? There are conflicting opinions on this. Some experts recommend waiting six weeks to do any exercise at all, while others tell new mothers that they can start as soon as the day after they give birth. In some rare instances, women are truly well enough to get up and walk a short distance the day after giving birth. This is more likely to be true of women who have given birth a few times before, and whose bodies are used to the transition into postpartum. On the other end of the continuum are women who have had a complicated birth and difficult recovery. Such women may need a full six weeks of rest before moving their bodies in any kind of vigorous way. Most women, however, fall somewhere between these two extremes. We recommend that new mothers do nothing but rest and recover for a full two weeks postpartum.

The First Two Weeks
For the first couple of days, if at all possible, stay in bed with your baby, nursing as often as possible and getting up only to use the bathroom and to do herbal sitz baths. One woman we know absolutely had to have a shower only three or so hours after giving birth to her first baby, and hobbled into the bathroom alone while her husband and baby dozed. She sustained a good smack on the head when she fainted in the stall. If, during those first few hours, you feel a sponge bath just doesn't get you clean enough, take a shower with your partner – sit on a stool and let him wash you and rinse you off (a hose attachment for your shower helps a great deal with this, and is a good thing to have for bathing your baby).

After the first two days, ease into regular activity gradually. Don't think that after a little bed rest you should scour the house and cook a three-course meal while your baby sleeps. Many expectant families enlist the help of friends and family, setting up a schedule that allows others to help out by bringing home-cooked meals and helping with chores and the care of older children.

One exception to this guideline: You can start doing Kegel exercises as soon as the day after giving birth. Hopefully, your doctor instructed you in how to do these, and advised you to do them regularly during pregnancy. If you haven't been doing Kegels, here's the basic exercise: Contract the muscles in your vagina as though you were holding back the flow of urine, and hold them that way for ten seconds at a time. Then relax. Do this whenever you think to do so, building up to five sets of ten repetitions three to four times a day. Kegels help to keep blood flowing to your genital and perineal areas, encouraging your body to heal from tearing, swelling, or bruising. They help to tone and firm the muscles in the vagina, counteracting that feeling some women have that their insides are going to slide out of them through their vaginas after giving birth. Kegels also help to control the leaking of urine that affects some women postpartum.

In some cultures, it is common practice for women to bind their bellies after giving birth. While belly binding is not medically necessary, and may not do anything to improve your shape, some of our patients tell us that it does feel quite good to gather everything in tightly. Belly binding may even help to speed the knitting together of separated abdominal muscles.

Some sporting goods stores sell snug midriff wraps that close with Velcro. Many women's clothing stores now sell camisoles, tank tops, or tube tops made from stretchy combinations of cotton and Lycra. Before your baby is born, look around and see if you can find anything like this to keep handy postpartum. If you have already had your baby, send a friend or relative out to search for something that feels snug and secure and allows you to nurse and rest comfortably.

After the First Two Weeks
Walking is a good first exercise for both you and your newborn. Put your baby in a stroller or carrier and start walking. Start with a trip around the block, and gradually increase the distance you stroll.

If you have a gym membership and you have someone who can care for your baby for a couple of hours, check into postpartum exercise classes or gentle yoga classes. At home, you can begin doing the strengthening and stretching exercises described in the following pages one to three times a day while your baby naps or spends time with Dad.

Once you start exercising, be alert for signs that you may be working too hard. Watch for increased lochia flow (bleeding) after exercise sessions, especially in the first month postpartum. This is your body telling you to cool it. Otherwise, just listen to your body's signals. If your vagina, perineum, or cesarean incision are not healing well, if your breasts are too full and sore for even your most supportive bra, if you need a nap more than you need exercise, or if you experience dizziness or extreme fatigue, stop and try again tomorrow or the next day. You do not have to do this quickly, and rushing it will not make much difference in the end.

During the first month postpartum, don't worry too much about stretching your lower body. Your ligaments are still stretchy from the effects of the hormone relaxin. Nursing and carrying a newborn can cause the muscles in your shoulders, neck, and back to tighten, however. Stretches can help to relieve that tightness.

Easy Push-Ups
Get down on your hands and knees. Lower your chest down to the floor and then bring it back up. Try doing one set of ten with your elbows pointing out (to work your chest muscles), and another set with your elbows coming into your waist (to work the muscles on the backs of your arms). Most of your body weight should be supported on your knees. After the first week, try doing two sets of each per session.

Shoulder Blade Squeeze
This exercise helps to prevent the tense shoulders and upper back that new mothers often experience. Stand with your feet hip-width apart or sit in a straight-backed chair. Squeeze your shoulder blades down and toward each other, then release. Do this ten to twenty times per session.

Head and Shoulder Lifts
Most women have a diastasis, or separation in their abdominal muscles, after giving birth that feels as though someone had unzipped their abs down the center from top to bottom. This separation can be closed up with the right abdominal strengthening exercises. Before you try any abdominal exercises, check to see how wide your separation is. You can do this during this exercise.

Lie on your back and cross your arms over your chest. Inhale and slowly lift your chin toward your chest and curl the tops of your shoulders up off of the floor. Imagine that you are pressing your abdominal muscles down toward your belly button. Inhale as you release back down. Start out with ten repetitions and work up to twenty per session.

To check your diastasis, reach down with one hand as you hold your chin and shoulders up. Hold your hand with the palm facing your face and find the gap just above your belly button. You may be able to fit three or four fingers into that gap. If you have a diastasis wider than three fingers, take special care to build up your abdominal strength slowly. Don't attempt to do "crunches" (in which you lift your entire upper back off of the floor) or other more strenuous ab work until the gap has closed to less than three fingers in width. Wrapping your arms around your waist and hugging the two edges of the gap together as you work your abs will help close the gap.

Pelvic Tilt
This is an excellent first postpartum abdominal strengthener. Lie on your back with your knees bent and feet flat on the floor or your lower legs resting on the seat of a chair. Feel the small gap between the curve in your lower spine and the floor. Inhale deeply, and as you exhale, use your abdominal muscles to gently press your lower spine down. Imagine that your tailbone is curling up and around toward your navel. Release as you inhale again. Start with ten repetitions and work up to twenty per session.

Against-the-Wall Stretch
Stand facing a wall, about an arm's length away from it. Clasp your hands and bend forward from your hips, placing your forearms against the wall. Keep your knees slightly bent and your elbows as close together as possible as you slide your forearms down the wall. You should end up bent at the hips at about a 90-degree angle. Allow your chest and head to sink toward the floor and breathe deeply.

Half Head Rolls
Sit or stand comfortably with your back against a wall. Drop your right ear toward your right shoulder, keeping both shoulders relaxed (don't bring the shoulder up to meet the ear). Then slowly allow your head to roll forward, chin to chest, to the left, and back to the center. Repeat this a few times to loosen your neck and upper back muscles.

Cat Back, Dog Back
On your hands and knees, make your back flat, like a tabletop. Inhale and arch your back up toward the ceiling, tucking your chin toward your chest and your tailbone between your legs (this is the "cat back" portion of the exercise). Exhale, returning to the flat, neutral spine. Inhale again as you arch your back the other way, looking up to the ceiling and pointing your tailbone up (the "dog back" portion). Return to flat back again as you exhale. Repeat this a few times. Your baby will probably enjoy lying face up beneath you as you do this stretch.

Upside-Down Chest Stretch
Stand with your feet wider apart than your hips but not so wide that it strains anything, toes pointing forward. Clasp your hands behind your back, elbows straight, and inhale slowly and deeply. As you exhale, slowly bend forward until your head is hanging down. Do this slowly to prevent dizziness. If this feels like too much stretching in your legs or low back, bend your knees. Let your arms sink toward the floor behind your head. Stay in that position for at least ten seconds and be sure to come out of it slowly. If you feel dizzy or lightheaded even if you do this stretch slowly, do it in a chair with your knees spread and your feet flat on the floor.

Hamstring Stretch
Tight hamstrings put extra pressure on the lower back muscles, so be sure to do this stretch often. Sit on the floor with one leg extended straight out. Bend the other knee, let it fall to the side, and tuck the foot of the bent leg into the thigh of the straightened one. Straighten your back as much as possible, then lean over the straightened leg, pointing your tailbone back behind you. Gaze out at the extended foot. The bend should be happening in the hip joint, not the lower back. Feel your lower back with your hand – it should feel straight and flat, not rounded. You may be able to lean forward only slightly. That's okay; the object is not to put your nose on your knee, but to stretch the muscles in the back of the thigh of the straightened leg. Reach for the leg and gently draw your torso down toward it. Hold this position for at least half a minute, then switch legs.

Supported Backbend
Stack two or three pillows on the floor or on your bed. Sit right up against the stack with your back facing it, with your legs outstretched, then gently lie back over the pillows so that your head is hanging over the edge. Allow your arms to relax into whatever position feels best – try letting them stay by your sides, cross them over your chest, spread them wide, or raise them over your head. Breathe deeply as you stay in this position for up to two minutes. To get out of the backbend, roll to one side and off the pillows.

Child's Pose
This yoga pose is excellent for releasing tension from the entire body during and after pregnancy. Sit with your legs folded beneath you, so that you are sitting on your heels with your knees parted. Fold your body forward so that your torso sinks toward the floor between your thighs. Gently rest your forehead on the floor. You can extend your arms overhead, out to the sides, or down toward your feet. If you like, you can relax forward onto a pillow. Remain there for as long as you like, breathing deeply to allow deep inhalations to expand your lower and upper back.

Older babies that are crawling and pulling themselves up on objects love it when their moms stretch on the floor. Their favorite food source, piece of furniture, comforter, and entertainment system suddenly takes on a new role – jungle gym!

Four to Six Weeks Postpartum and Beyond
After the first four to six weeks have passed, you will be feeling much stronger. Your uterus will have gone almost completely back to its prepregnancy dimensions, although it is not likely that you will fit into anything but your baggiest prepregnancy clothing. At this point, your body is almost certainly ready for more vigorous activity. Some women are raring to go by a month postpartum, and others need a full six weeks before they feel really ready to work up a sweat.

If you were highly fit before pregnancy and kept up with workouts during pregnancy, you probably will have no trouble getting back into that groove – and more power to you if that is your plan. Everyone has heard of some woman who did an hour of step aerobics days before she gave birth and who was back training for a marathon within a month postpartum. Feel free to say hooray for her, but don't feel compelled to live up to her example, especially if you were not super-fit before and during pregnancy. You will only end up sore and miserable and, perhaps, even injured. More is not better when it comes to exercise. The key to maintaining a successful exercise program is to find what works for your individual body. For one woman, climbing sheer rock walls is just the thing, while another woman may thrive on a daily slow swim in a warm pool, and yet another feels best when she practices yoga a few times a week.

Not too long ago, fitness guidelines dictated that you needed thirty to sixty minutes' worth of aerobic exercise – the kind that gets your heart pumping faster than 100 beats per minute – three times a week or more to be truly fit. On top of that, the guidelines recommended strength training two to three times a week to strengthen bones and muscles. Who has time for all of that? Certainly not a new mother. Those guidelines caused a lot of people to throw up their hands and give up on working out altogether.

Researchers then began to show that even mild physical activity, such as housework, walking around town to run errands, or gardening could offer the same long-term health benefits as more intense exercise. The notion that physical activity had to be continuous to be effective went the way of the dinosaurs when studies found that a few five- to ten-minute spells of activity throughout the day are just as health-supporting. This is true for women in the postpartum months as well as for anyone else.

Expand your notion of what exercise is. Taking your baby for a walk in a carrier or stroller is a great way to stimulate or soothe the child and improve your own fitness. Try walking to run errands whenever possible, and don't worry about getting your heart rate up to any particular level – that will happen on its own. Carrying your baby will strengthen your muscles and joints, and as your baby grows, so will your strength.

You should incorporate aerobic activity into every day in some way. One day you might do housework on and off throughout the day, walking and lifting and bending for ten minutes at a time. (Backpack baby carriers are great for toting baby while doing housework or cooking.) Another day you might go to the pool for a thirty-minute swim. Walking around in the mall with your baby and a friend or chasing older children around in the park also qualifies as exercise. Even the most irascible baby can be soothed by being gently bounced and rocked to music. Put your favorite music on the stereo, cuddle your baby in your arms, sling, or front pack – and dance!

Of course, if you like to go to the gym and lift weights and hit the treadmill, there is no reason not to do so once those first four to six weeks have passed. Moderate aerobic exercise increases the body's core temperature and makes it easier to burn fat and keep your energy levels high. Aerobic exercise also helps to burn off stress hormones. Overdoing it by allowing your heart rate to stay too high for too long (anaerobic exercise) actually triggers your body to produce more stress hormones, so balance is the key. Take the number 180 and subtract your age. The resulting number is your maximum safe heart rate. I recommend not allowing your heart rate to go above that rate for at least three months postpartum. For example, if you are thirty-five, you would subtract 35 from 180 to get 145, and you should not allow your heart rate to exceed 145 beats per minute. If you are feeling fatigued, it would be better to subtract 10 from that number and, in the case of this example, stay within a range of 125 to 135 beats per minute for the three-month period after you give birth. Work back into your prepregnancy routine gradually, and do not expect your body to be transformed rapidly back to its former state. It really does take about nine months, no matter how hard you work at it – so why deplete your body and stress yourself out needlessly?

In the following sections, we describe some more strenuous exercises you can do to help strengthen your muscles and stabilize your joints, even as you continue doing the stretching exercises described earlier. You can use these strengthening exercises in preparation for more vigorous activities, or simply stick with them over the long term to maintain strength and stability. Try to do them at least three times a week. For the last two exercises discussed, the Seated Rear Dumbbell Fly and the Seated Lat Row, you will need some light, handheld weights. Almost everyone has some of these collecting dust in some corner of the house. Start with three- to five-pounders and work up to heavier ones. These exercises will help to balance the strain of carrying your baby all day. They work the muscles across your upper back and the latissimus dorsi muscles, which run from your lower spine up to your shoulders.

Kegels with Wall Sit
Starting at four to six weeks after the baby is born, if you like, you can try substituting this more difficult version of Kegel exercise for the gentler type described earlier.

Stand with your back against a wall, then step both feet away from the wall about eighteen inches. Slide your tailbone down the wall into a partial squat. This will feel quite intense in your thigh muscles; you may be able to go down only a few inches at first. Hold the partial squat and do fast Kegels, contracting and releasing one to two times per second for fifteen to thirty seconds. Then slide back up the wall, straightening your legs.

Turned-Out Squats with Baby
If you have ever studied ballet, you might remember this as second-position pliés. It is a terrific exercise for strengthening the pelvic floor muscles, inner thighs, and lower back.

Hold your baby firmly against you or put him in a front pack or sling. Stand tall and place your feet as far apart apart as you can comfortably, letting your toes turn out slightly. Bend your knees in the same direction your toes are pointing, actively rotating your thighs out and away from each other. You should feel some effort in the muscles along the back of your hips. Keep your torso straight up and down as you lower your pelvis toward the floor. Go as far as you can comfortably, then come back up, maintaining the outward rotation in your legs. If you can, hold a Kegel gently throughout the exercise. Repeat this five to ten times. If your balance is challenged during this exercise, hold on to a chair back with both hands.

Baby Overhead Press
You probably already do this countless times a day. Hold your baby at chest level and raise her above your head, straightening your arms, then lower her back down. Repeat this ten to twenty times. An optional addition to this exercise is cooing, making funny faces, and giggling with your "airborne" baby!

Leg Slide
This is an excellent abdominal strengthener. Lie on your back with your knees bent and your feet flat on the floor. Press your lower back onto the floor, drawing your belly button down toward your tailbone. Slide your feet away from your body, straightening your knees until you can no longer keep your lower back on the floor, then return your feet to the starting position. You can do this one with your baby sitting on your hips. Do ten to fifteen repetitions per session.

Double Crunch with Baby
Lie on your back on the floor with your baby lying face down on the shins of your bent legs. Hold on to baby and lift your entire upper back off the floor, bringing your knees toward your forehead as you lift your head and shoulders. This is a good chance to start counting for your baby! Go for fifteen to twenty repetitions. When you feel strong enough, add a second set.

Push-ups with Baby
You are probably strong enough now to do "girl push-ups," in which you straighten your body but rest on your knees rather than on your feet. Put your baby down between your hands and give him a kiss with each of your ten to twenty repetitions.

Seated Rear Dumbbell Fly
Hold a weight in each hand and sit in a chair. Plant both feet firmly on the floor and lean your torso forward, so that it rests on your thighs. Hold the weights with your palms facing each other. Keeping your elbows slightly bent, lift the weights up and out to the side, as though you were flapping your wings. Keep the motion smooth, slow, and regular. Repeat ten to fifteen times, and then rest, letting the weights pull your arms down in a stretch. Add a second set when you feel strong enough.

Seated Lat Row
Hold a weight in each hand and sit in a chair. Plant both feet firmly on the floor and lean your torso forward, so that it rests on your thighs. Pull your elbows back along your sides, letting the weights hang down toward the floor. Try to touch your elbows together behind your back. You won't be able to, but if you work in this way, you will be working the right muscles. Repeat ten to fifteen times, then rest. Add a second set when it feels easy.

Breastfeeding and Exercise
If you are nursing, you may have a new challenge on your hands when it comes time to do more vigorous exercise: breasts that are bigger and more sensitive to jarring and bouncing than they have ever been before. If you plan to do fast walking, jogging, or anything else that causes your breasts to bounce, it is a good idea to invest in a few supportive sports bras that minimize motion by pressing your breasts flat. Wear these bras for exercise only. The pressure they exert can lead to plugged ducts or mastitis if you wear them over longer periods. Also, nurse your baby before you work out. If you time it right, your hungry baby can empty your breasts and be ready for a nice long nap while you exercise.

Some women report that their babies do not like the taste of their milk right after a hard bout of exercise. Lactic acid that builds up during hard exertion can make breast milk bitter, but moderate exercise should not pose this problem. If it does, hand-express or pump off some milk before the postworkout feeding.

A Final Word about Exercise: Do What You Can
If you cannot stick to an exercise program after your baby is born, don't beat yourself up about it. Do what you can and add more when you feel able to. Every little bit you do helps your body move toward a fitter state. If, however, you are not exercising and find that you are feeling excessively tired or depressed, your body hurts, you are constantly getting sick, or you are gaining weight postpartum, keep in mind that exercise has healing effects on all of these symptoms. Remember that this isn't an all-or-nothing proposition, and let it be a natural part of your daily life.

From A Natural Guide to Pregnancy and Postpartum Health by Dean Raffelock, Robert Rountree, and Virginia Hopkins with Melissa Block. Copyright 2002 by Dr. Dean Raffelock. Used by arrangement with Avery, a member of Penguin Group (USA) Inc.

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