Last week, in Part 3 and Part 4, we discussed how to modify the squat, bench press, deadlift, overhead press, and power clean, as well as programming adaptations you can make to training while pregnant. Here we are discussing the postpartum period and how it relates to training. “Uhh.. aren’t you missing something? What about labor and delivery? Can’t you tell us how heavy lifting will make our labor and delivery easier and we’ll stroll right into the hospital and deliver in 3 pushes without so much as popping an Advil?” Unfortunately we cannot. Each delivery is different and we’ve heard and experienced drastically different accounts from each mom we’ve worked with.
Some studies suggest that exercise during pregnancy may result in shorter labor, while others studies found no correlation. At this time we cannot conclusively state if or how exercise affects the length of labor and delivery. Similar findings have been reported regarding the mode of delivery as well as medical intervention, with some studies suggesting that regular exercise during pregnancy can reduce the risk of cesarean section and birth complications. Additionally, women who exercised during pregnancy have reported lower ratings of perceived exertion (RPE, ay?) during labor than sedentary women and therefore may accept less medical intervention. Regular exercise during pregnancy either does not affect or is beneficial for labor and delivery outcomes. However, there are many factors that play into a woman’s birthing experience that there is no way we can predict, with certainty, how your labor and delivery will go based on whether or not you barbell trained during pregnancy.
Some moms train consistently throughout pregnancy and end up having an emergency cesarean section after a 36-hour labor. Some moms train sporadically then have a 4-hour labor and delivery, in about 5 pushes, with no medications. I’m not even going to tell you which end of the spectrum I fell on because I don’t want you to think that I did anything special to contribute to this experience, nor that I am promising the same will or won’t happen to you if you take our advice. If you want to read about the known benefits of exercising while pregnant, you can find them here.
The postpartum experience is so multi-faceted that it’s impossible to touch on every single aspect. What I’ve done here is addressed the physical aspects of training as a new parent within my scope of practice. Perhaps I will write more about the mental and emotional aspects another time ;) Your journey will not be the same as the next person’s, but I hope that this article will help you navigate these unfamiliar waters with a little more certainty than if you were doing it alone.
Breastfeeding and Calories
Even though we’re all respectful adults with our own valid opinions I feel the need to say this right off the bat so that someone doesn’t accuse me of formula-shaming: how you choose to feed your baby is your decision and there is no right or wrong way so long as your baby gets what they need. Fed is best. Period. Moving on.
There are training and dietary considerations for a strength athlete who has decided to breastfeed so it needs to be addressed. The amount of calories that is needed to maintain both breastfeeding and training is substantial! Listening to your hunger cues is a good strategy from a milk supply standpoint, especially when babies are very young or going through growth spurts.
If you want to count calories or macronutrients, studies show that most women need at least 1800-2200 calories a day to maintain adequate milk supply, or a 300-500 calorie surplus above their pre-pregnancy maintenance calories. Dropping your calories below 1500-1800 is generally not recommended for a breastfeeding mom (or a strength athlete, for that matter!). If you want to keep breastfeeding when you return to training, make sure that both your protein and calorie consumption are sufficient to support your training goals and your milk supply.
So what if I really do want to diet and lose the baby weight? A lot of us want to, and are able to, but the key for a breastfeeding mother is: it’s a marathon, not a sprint. Lactation experts suggest waiting until the baby is at least 2 months old to attempt weight loss for a couple reasons:
Over the first several weeks you will naturally lose several pounds of pregnancy weight associated with excess fluids, excess blood supply, and the enlarged uterus without the need to diet
If you want to breastfeed your baby long term, the first few weeks are an important window for establishing your milk supply
Breastfeeding or pumping can often assist with maternal weight loss in itself! But what if several months go by and the body fat is unwilling to budge? Decrease the calories gradually and keep an eye on your milk supply as well as your training progress. If either are affected by the drop in calories, back off the pedal a little bit.
Breastfeeding and Exercise
Just as exercise is highly beneficial for the mother-to-be, it is equally beneficial for a new mother. Some benefits of exercise for mom include:
Improved cardiovascular fitness
Favorable lipid profile and improve insulin response
Feelings of well-being and reduced stress levels
Increased energy levels
Possible assistance in alleviation of depressive symptoms
Exercise itself does not compromise milk supply nor does it adversely affect the breast milk itself. If you feel your milk supply is suffering once you return to training, consult a lactation specialist to narrow down potential causes. One interesting thing watch out for that many people may not mention is clogged ducts from wearing tight athletic clothing (ouch!).
“Core Weakness” and Diastasis Recti
For most women, the abdominals will be very weak and possibly separated following pregnancy. Many women who bring this complaint to their doctor are prescribed physical therapy for “core stability training” to treat abdominal separation, back pain, and weakness. This therapy may involve a lot of laying down or quadruped abdominal isolation exercises. The problem is, our abdominal muscles do not work in isolation. If you went to push something heavy, you would just brace and push. You wouldn’t try to single out certain muscles and not others unless someone told you to do so. So why would you try to train them in isolation? After pregnancy, all of your “core” is weak, and all of it needs to be trained.
The other problem with this approach is that such exercises cannot be incrementally loaded and progressed to get you stronger (they are submaximal). The strength of contraction you can produce in various paper thin muscles in “the core” while lying flat equates to activities such as picking up your purse or unloading the dishwasher. On the other hand, let’s take a moment to appreciate the dynamic forces that must be controlled by “the core” when squatting, pressing a barbell overhead, or lifting something heavy off the floor. The main barbell lifts performed in an incrementally loaded, linear fashion are sufficient to re-strengthen not only your entire core, but your entire body as well. Sure it takes time and persistence, but get back under the bar and you will get strong again, core and all. If the 45lb barbell poses too much of a load when you return to training after giving birth, start with something lighter, or even just body weight, on day 1 and progress from there. It’s possible. You can do it.
Diastasis recti is a separation of the outermost abdominal muscles during pregnancy due to stretching of the linea alba. Training did not cause it and training will not make it worse. Some think that heavy lifting worsens abdominal separation but this is not supported by evidence. The separation can decrease with time but may never go away completely. Additionally, there are no long term health consequences. Diastasis recti is not a contraindication to barbell training. There is no good reason to abandon the barbell lifts for direct ab work like crunches, leg raises, dead bugs, etc., as these will not improve the condition. You can, and should, wear your belt when indicated for heavier sets to support the diastasis recti and your spine.
Incontinence
About 1 in 3 women will experience urinary incontinence in the postpartum period (no shame) and this resolves with time for many women*. There are several types of urinary incontinence, but for the purposes of this series, we will focus on stress urinary incontinence (SUI) which is the involuntary loss of urine with effort or physical exertion (e.g. lifting heavy barbells), or cough or sneeze. The development of pelvic floor dysfunction (PFD) and SUI is multifactorial: there are numerous identifiable risk factors and some that researchers have not even identified nor fully understand.
Pregnancy itself may be an important risk factor in the development of PFD and SUI (our cross to bear, mamas) but the details of this are beyond the scope of this article. Age, ethnicity, having multiple children, mode of delivery, history of pelvic surgery, birth weight, obesity, family history, and genetics are among other common identifiable risk factors for pelvic floor dysfunction and urinary incontinence. The point is, don’t ever say to yourself or someone else “you’re having this problem because _____”. It’s probably not true, and it’s also not your place. In fact, Dr. Rori is currently conducting an Institutional Review Board study through Adelphi University on many of these risk factors in the female powerlifting population. Stay tuned for more on that!
It’s common for women who are experiencing PFD or SUI in the postpartum period to question whether it could be due to their method of delivery or the fact that they had an episiotomy. Vaginal delivery is just one potential risk factor. The presence of SUI in those who deliver via cesarean section has been shown to be significantly less than those who deliver vaginally immediately postpartum, but there is no long term significant difference and therefore c-section should not be recommended as a means to prevent PFD or SUI in the absence of other risk factors. The role of episiotomy on pelvic floor dysfunction is still unclear but current evidence does not support that episiotomy protects against postpartum UI nor that it is highly correlated with its development.
There are multiple proposed mechanisms for the development of SUI after childbirth and many different avenues of treatment. Women’s health physical therapy and pelvic floor muscle exercises are among these, but much to the dismay of many women we have spoken to, this can often leave moms who lift even more confused about why they are peeing during their training sessions and what they can do about it. Future PRS content will focus more specifically on management of SUI, but for now, I want to put your mind at ease about what may or may not be true regarding lifting and your lady parts.
If you are seeing a women’s health physical therapist, you may be told that performing the Valsalva maneuver is the cause of your symptoms, so women then wonder if the Valsalva maneuver is the reason they are peeing. The truth is that the Valsalva maneuver does increase intra-abdominal pressure which can lead to urine leakage. But does this mean you should stop?
NO!
Quick and dirty oversimplified anatomy lesson: you tell yourself to pee, the external sphincter muscle relaxes, and urine is released from the bladder. In stress urinary incontinence, increased intra-abdominal pressure forces urine out through an overwhelmed external sphincter muscle involuntarily. During a pelvic floor muscle contraction, the external sphincter muscle is contracted and the bladder neck “lifted” or supported, holding in urine. In the majority of women, the Valsalva maneuver will be accompanied by a pelvic floor contraction, resulting in better bladder neck support. The Valsalva maneuver should not be confused with straining (such as in bearing down or having a bowel movement), wherein the pelvic floor relaxes. Valsalva-ing and straining are two different tasks with two different pelvic floor activation patterns. The Valsalva maneuver functions to help strengthen your pelvic floor and should therefore NOT be stopped. Barbell training, the Valsalva maneuver, and progressive overload of the pelvic floor is a topic for another day and another article. We will be back!
Nevertheless, for some women the pelvic floor is still unable to withstand the pressure caused by the Valsalva maneuver and urine will leak. This does not mean that the Valsalva maneuver is the cause of the issue, only that it is making it apparent. Women who experience SUI should not discontinue use of the Valsalva maneuver as it is essential in protecting your spine when lifting heavy weights. The implication here is for women who train to correctly learn how to perform a Valsalva maneuver (not just strain or “bear down”), be taught strategies to better maintain a pelvic floor contraction against the increased intra-abdominal pressure, and progress training in an incremental fashion from a starting point where the symptoms are not present with training.
It’s common for women to be told by their doctors that they are going to “blow out their uterus” by lifting heavy. I cannot even *eyeroll*. Pelvic organ prolapse is beyond the scope of this article but I did some digging nonetheless. A few recent studies suggest that pelvic floor muscle contraction may have a positive effect on pelvic organ prolapse after childbirth. There is no evidence to support that heavy lifting will increase the chances or severity of pelvic organ prolapse. For your doctor to tell you that lifting heavy will “blow out your uterus” is imprudent and irresponsible, at best. Do you know anyone whose uterus has fallen out of their vagina while deadlifting? I don’t.
The bottom line is that there is a lot that we don’t know about risk factors and treatments for SUI in postpartum woman as well as in strength athletes, and further research is needed in these areas. If you, or someone you know, is experiencing these symptoms then our best advice is a) it is common, b) the cause is not always simple and obvious, c) do not stop training or using the Valsalva maneuver, and d) find a practitioner who works with lifters that experience SUI for management strategies that are specific to you and what you do.
Pain
About 75% of women report back or pelvic girdle pain at some point in their pregnancy, but studies report an extremely wide range for the prevalence of postpartum low back and pelvic pain (.3-67%) with the average being about 25%**. In over 90% of cases, the pain spontaneously resolves, but a little less than 7% are left with severe chronic pain. There is no doubt that the relationship between pregnancy hormones, muscle weakness, postural and spinal changes that accompany a growing belly, pregnancy factors, method of delivery, activity level, weight gain, and psychosocial factors is highly complex when it comes to postpartum pain. At this time we cannot provide a single biomechanical explanation for postpartum low back or pelvic pain, but we do know that pain does not always have solely a biomechanical origin and is also influenced by psychological and social factors related to the individual. Sounds touchy-feely, but bear with me.
There is no evidence to suggest that heavy lifting will cause pelvic or low back pain, pelvic floor pain and dysfunction, or pelvic instability postpartum, and barring any medical complications, it is perfectly safe to return to training after you’ve been cleared by your doctor to return to normal physical activity. Nonetheless, you may deal with postpartum low back or pelvic pain at some point in your lifting or coaching career, so here’s what you should know:
Manage stress, depression, and anxiety:
Parent: Remember self-care and seek help if you need it.
Coach: If you recognize signs & symptoms, softly recommend your client seek out the appropriate professional.
Pain doesn’t always mean damage: The spine and the pelvis are inherently strong and the hormones related to pregnancy, breastfeeding, and ovulation can play a role in symptoms. This is why it’s important to ensure you are working with proper lifting mechanics and progressing slowly but steadily. If training does not make your symptoms worse, it’s not causing any damage. If symptoms get worse with barbell training, you should stop the exercise, and consult with someone to help you modify your technique and program to help you continue to get strong despite your symptoms.
Know that 90% of people who experience back pain will get better! Postpartum pain is normal and should resolve over time, as your body returns to normal, and you get stronger.
Inactivity is your worst enemy! Find ways to manage your symptoms daily and keep moving! Use a progressive training program to move gradually into previously weak and painful ranges of motion. Resume your normal activities even when experiencing symptoms.
Train! Using gradual, incrementally loaded barbell movements vs. targeted “core strengthening” exercises. There is strong evidence to support the use of strengthening exercises in the management of low back pain regardless of the specificity of the exercise. We can provide you with many real-life clients who have resolved their low back and pelvic symptoms while using the main barbell lifts. We can get you in touch with them :) Get back under the bar as soon as possible!
You’re a Parent Now
Whoa, that sounds weird, I know. I still feel like I need my mom every time I put a chicken in the oven, yet here I am raising a human being. Being a mom is so special, but it also means saying a bittersweet goodbye to parts of your childless self. When I returned to training I often looked back at my old logbook to see how my new linear progression compared to previous ones. While it’s fun to look back and see how far you’ve come, I caution you: you’re a parent now! You have a different body and a different lifestyle. Recovery and progress may now be affected by the following:
You may be sleeping less
You may be more stressed
You may have pain
You have a different hormone profile
You may not be as intentional with tracking your macros
Your body has been through a physiologically demanding event
You have had a layoff from training and you will run a new linear progression (LP) which is the program that we talked about for novice trainees in Part 4 of this series. So how do you know where to start? Well, start it like any untrained person would. Begin session 1 by working up to a set of 5 where bar speed starts to slow but form is not compromised. You can even start with 1 set of 5 and work your way up to 3 sets over the next two sessions before adding weight so you don’t experience debilitating muscle soreness. There are no special modifications that need to be made to the linear progression nor the lifts for someone who has given birth. But when compared to your previous LP:
You may have to make programming modifications to rep scheme and between-session increments at a different point.
You may end your LP at different weights (either higher or lower).
Your mindset has to change about your physical self. Your body is not the same; you have a new body after giving birth and (holy crap), a new itty bitty person to take care of aside from just yourself.
And that’s it! Seems simple, right? Well, it may not always be as simple as you hoped. You will encounter many challenges and obstacles along the way but always remember one thing: your journey is your own. Some days you’ll feel like you can conquer the world and some days it may be all you can do to change out of your pajamas. Enjoy your precious baby and try to enjoy your training also! Take it one day, or even one lift, at a time!
Whether you’ve just popped out baby number five or children are only a distant thought, we hope that we have answered some of your questions about training before, during, and after pregnancy so that when the time comes you can proceed with confidence knowing that you are doing what’s best for you and your little peanut.
Citations:
* Thom D.H., Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand. 2010 Dec;89(12):1511-22.
** To WW1, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand. 2003 Dec;82(12):1086-91.
Dr. Elizabeth Zeutschel is a PRS Strength Coach, licensed physical therapist and certified Starting Strength Coach who resides with her husband and daughter in Meridian, Mississippi. You can contact her at liz@progressiverehabandstrength.com and on Instagram at @liz_nicole25