Returning to Running after Baby

Running is cheap, easy, and gets you outside in fresh air. For many, it's an important stress reliever and cornerstone of their exercise program.

Many of our new moms are tempted to throw on their running shoes right after their six week follow up, but based on research and our experience, we recommend some caution before heading out the door. Not all exercise is the same, so being cleared for all activities at your postpartum checkup often overly simplifies the risks and benefits of how you return to activity.

Running is an activity that requires stability, flexibility, and good coordination of the deep core muscles: diaphragm, abdominals, lumbar multifidi and pelvic floor. A recent EMG study showed that the pelvic floor increases its activity in anticipation of and as a reaction to the heel strike of a stride during running (Leitner 2016). So, doesn't that mean that running will help strengthen the pelvic floor postpartum? Maybe, but what are the associated risks?

Running is also an impact activity which increases intra-abdominal pressure. The peak pressure increase during running is slightly less than what occurs when coughing, but it is cumulatively more total pressure because running is such a repetitive activity and a cough generally occurs only a few times in a row (Shaw 2014). 

The pelvic organs (bladder, uterus and rectum) are both suspended in the pelvis by connective tissue structures and supported from the bottom by a hammock of pelvic floor muscles. These passive and active support mechanisms are the only tools the body has to counteract the effects of IAP on the pelvic organs, so they must be in good working order to withstand the demands of running. 

In general, we ask the following questions before making our recommendation about returning to running:

1. Are you currently experiencing urinary leaking with coughing, sneezing, laughing, lifting, jumping or running? Urinary incontinence indicates deficits in pelvic floor muscle strength, coordination, or both that cannot withstand these increases in pressure. Pregnancy, regardless of birth mode, can weaken the pelvic floor so it produces less force with less endurance postpartum.

2. Are you currently experiencing a feeling of heaviness, "falling out," or bulging in your vagina? These symptoms indicate the likely presence of some degree of pelvic organ prolapse. This occurs in up to 50% of women, and the largest risk factor for prolapse is pregnancy with a vaginal delivery. Prolapse indicates a lack of passive connective tissue support for the pelvic organs that cannot fully withstand the effects of normal daily activities and increases in this pressure.

3. Are you producing milk (breastfeeding or pumping)? The presence of prolactin, which stimulates lactation, suppresses levels of estrogen. Estrogen is essential in the production and remodeling of pelvic connective tissue in the female body, meaning it is an important player in maintaining mechanical strength in these tissues (Zhou 2016). Therefore, lowered estrogen levels while lactating generally correspond with decreased mechanical strength in the connective tissue that supports the pelvic organs (regardless of the activity).

When a postpartum client asks us about returning to running, we have to look at risks and benefits, the patient's current symptoms, and their ultimate goals. In general, we recommend against returning to running until your body has the sufficient strength and support.

It's also important to ease back into running (both in distance and speed) when it is appropriate. Running on soft surfaces is gentler than hard surfaces, and smaller strides create less pressure than longer strides. 

If someone with symptoms of prolapse feels strongly about returning to running, we often strongly suggest the use of a bladder support such as a pessary to increase passive support to the pelvic organs and decrease risk of worsening organ pressure. 

Cardiovascular exercise for conditioning and weight loss can be achieved without as much impact, such as with brisk hill or stair walking, swimming, or stationary cycling. Even doing bodyweight strengthening exercises such as squats, lunges, wall sits, wall push ups, tricep dips, and bridges in a high intensity interval format raises the heart rate and promotes improved metabolism through increasing muscle mass and cardiovascular challenge.

If you aren't sure abut when or how to return to running, it's important to consult a physical therapist or exercise professional specializing in the postpartum body. Feel free to book a phone consultation or in-person evaluation with us for more information!

 


Leitner M, Moser H, Eichelberger P et al. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurourol Urodyn. 2016 Oct 29. doi: 10.1002/nau.23151.

Shaw J et al. Intra-abdominal pressures during activity in women using an intra-vaginal pressure transducer. J Sports Sci. 2014 Jun; 32(12): 1176–1185.

Zhou L et al. Estrogen and Pelvic Organ Prolapse. J Mol Genet Med 2016. 10:221. doi:10.4172/1747-0862.1000221

The Wide World of Lubricants

Do you have a favorite lubricant? Or is your strategy to grab whatever happens to be at Walgreens that day? Having a good lubricant can increase pleasure for anyone, and at certain times it's even more essential for comfort. 

If a client is newly postpartum, we recommend using lubricant at least with the first couple of attempts at intercourse. The vagina is usually more sensitive during this time, and using a lubricant can improve comfort and decrease anxiety in the moment. Even if you've never needed it before, we think it's good to have one on hand!

If someone is producing milk (either breastfeeding, pumping, or both) estrogen levels in the body are lower than usual. This can produce a state of vaginal dryness and sensitivity that lasts while lactation is occurring. This low estrogen state also occurs (and lasts) after menopause. For some, this dryness is barely noticeable, and for others it is extremely uncomfortable and limits their ability to tolerate intercourse or exams.

If there is noticeable dryness, a personal moisturizer that is used outside of intercourse may be helpful. We often recommend applying coconut oil at the vaginal opening daily as a moisture barrier to help soothe the tissue (read more below under "plant oil based). A topical estrogen prescribed by a doctor can also directly improve tissue hydration during this time. During intercourse, it is also important to have a long-lasting lubricant. 

If you are experiencing discomfort or pain during intercourse and using lubricant resolves it, then continue using it regularly. If the pain does not resolve, it may be at least partly due to muscular tension. If this is the case, please contact a qualified pelvic physical therapist for evaluation.

 

All lubricants are not created equal! Here's a quick primer:

WATER BASED: Most common and affordable, compatible with all birth control/safe sex barrier methods. Most likely to contain preservatives and other irritants.

PLANT OIL BASED: Lasts longer, has a hydrating effect on tissues over time, can be 100% organic. Not compatible with condoms or other barriers made from latex or polyisoprene.

SILICONE: Lasts longest, works in the shower or bath, compatible with all safe sex barrier methods. Not compatible with silicone toys.

Other major characteristics of lubricants to consider:

pH: Vaginal pH changes throughout the menstrual cycle and becomes less acidic with decreased estrogen levels. Therefore if you are lactating or in menopause and use a more acidic lubricant, it can cause burning/stinging. 

OSMOLALITY: Basically, the concentration of water vs. other ingredients. A lubricant with high osmolality can cause dehydration and irritation of sensitive vaginal tissues by drawing out moisture. 

GLYCERIN: Avoid products with glycerin, as it can cause yeast overgrowth and has a high osmolality (potential for irritation).

Our favorites:

Coconut oil (yes, the stuff you cook with!)

Slippery Stuff (water based, paraben and glycerin-free)

Good Clean Love Almost Naked (water based, vegan and organic)

Sliquid (silicone)

 

Want even more detail? Here's a great guide to lubricants from Smitten Kitten

 

 

 

Epidurals and Perineal Tearing?

In recent weeks, it seems we’ve been asked this question more and more frequently by our pregnant clients. It’s overwhelming to try to take in all of the information about the risks and benefits of medical interventions during labor and delivery, and even more challenging when there is only a small number of high quality academic studies available to guide our choices.

An individual’s risk of perineal tearing during vaginal delivery is based on a myriad of factors, some under our control (such as birthing position and the use of hands-on perineal support techniques) and others not (such as the size of the baby and speed of delivery).  The choice to have epidural anesthesia is also dependent on a patient’s medical history, personal values and prior experiences, and often the duration and intensity of labor. However, more and more of our clients are basing this choice, at least partially, on whether an epidural will change their risk of perineal tearing with delivery.

Many studies attempt to separate the effect of variables such as the use of an epidural on risk of perineal tearing. The most recent analysis (Pergialiotis 2014) combined the data from 22 studies with a total of 651,934 subjects. Its conclusion was that those with epidural anesthesia had a 1.95 times greater risk of perineal tearing than those who did not. However, another large single study of 61,308 women showed that in its subjects, the increased risk of tearing with an epidural was not present when the analysis controlled for the fact that more first time mothers choose an epidural, and a first vaginal delivery is also more highly associated with perineal tearing. 

Take away: One study shows that epidurals increase the risk of tearing. Another says that the reason more tearing occurs with epidurals is that more first time moms choose epidurals and first vaginal deliveries are already associated with a higher risk of tearing. 

That’s a lot of statistical analysis to digest, but the short story is that, as with many things in medicine, it is almost impossible to draw definitive conclusions. However, we can definitively say that there has not yet been a study that shows that epidurals decrease the risk of perineal trauma with birth - only that it may increase it or not affect the outcome at all. Our advice to clients is to make choices regarding anesthesia based on other important risks or benefits, but to avoid using risk of tearing as the single deciding factor.  

Are Planks Safe?

The internet is a fantastic resource for many of life's questions. However, when it comes to how to strengthen your abdominals when you have diastasis recti (DRA), there seem to be more questions than answers. One of the most common questions our patients ask is whether it is safe to plank with a DRA. 

Like many questions about health and fitness, the answer is "it depends." We should instead be asking ourselves what we're trying to accomplish with a plank, or any other abdominal strengthening exercise.

If a patient comes to us with a DRA, our goal is to improve the ability of the deep abdominal muscles to hold the two sides of the separation together when she moves through her day. Over time, we hope that consistent, appropriate exercise will improve the tension and thickness of the ligament that runs down the middle of the abdomen (the linea alba) to keep the gap closed in the long term. 

With any strengthening exercise, we have to provide a challenge to the muscle we are targeting to cause it to change in strength. As strength improves, the difficulty of the exercise must also increase to provide a new and appropriate challenge. Exercises that are too easy will not cause any increase in strength, and exercises that are too challenging will cause compensations in the surrounding muscles and bypass the weaker muscle we are trying to target. In the case of a DRA, an exercise that is too challenging will cause the person to compensate by holding their breath, bulging their abdominals, and actually widening the separation in the moment. 

A plank is safe for you if you can do it while using your deep abdominals to generate good tension in the linea alba, while breathing and with good form throughout your body. 

So, when a patient comes to us for guidance in a strengthening program to treat DRA, we need to determine whether any exercise (plank or not) is the appropriate challenge. For many, we need to start simply by practicing recruiting the deep abdominals in positions such as hands and knees, sitting, and standing. For others, we start with a plank or even planks with moving arms or legs. The key is determining what their abdominals look like when they are performing the exercise; all of these patients may be equally challenged by their respective exercises but start at vastly different points. 

Most people need an outside opinion on how their abdominals are performing during an exercise, and even using a mirror may help you determine objectively what your body is doing. If you are unsure of which exercises are right for you, we strongly recommend consulting with a qualified postpartum physical therapist or exercise instructor. 

Postpartum Abdominal Binding

Our postpartum clients often ask us about abdominal binders, and whether they are a safe and effective way to regain abdominal function after birth. Many cultures have a long history of abdominal wrapping in the immediate postpartum period; modern products and programs have popularized the practice and advertise it as a way to correct abdominal separation (diastasis recti) that often occurs postpartum. We acknowledge the wisdom and importance of long-standing traditions, but also recognize that some practices are not right for the majority of postpartum moms. 

With a small number of exceptions, we do not recommend this practice for our clients, as it can adversely affect the pelvic floor (and the core in general) and does not show long term efficacy in correcting diastasis. For women following cesarian birth, gentle compression with a Baby Belly Band, snug camisole or high-waisted underwear can be beneficial to reduce soreness and speed healing. However, this compression should be discontinued within the first two months postpartum.

Explaining why this occurs requires an understanding of the “core.” The core is composed of the diaphragm, lumbar muscles, abdominals and pelvic floor, functioning together in one closed system. A good image is one of a soda can – the system is closed, meaning that pressure generated in one location affects other sides of the “can.” If a woman wears an abdominal binder wrapped tightly in the center of the core, it increases pressure upward and downward. The diaphragm is no longer able to expand as far to allow filling of the lungs with air, and pressure is increased downward onto the pelvic floor (the bottom of the can). In most postpartum moms, the pelvic floor is weakened after pregnancy and birth, and many experience urinary incontinence and pelvic organ prolapse. Women with diastasis recti are even more likely to have these symptoms of pelvic floor muscle weakness. If excess downward pressure is generated downward on the pelvic organs (bladder, uterus and rectum), the pelvic floor cannot adequately oppose it. For a woman who is already experiencing urinary leaking, pelvic or vaginal heaviness, or other symptoms of pelvic organ prolapse, wearing a binder will only worsen those symptoms. For women who are not experiencing those symptoms, they may notice them upon wearing a binder.

Simply put, wearing an abdominal binder may change the shape of the abdomen and size of an abdominal separation while someone is wearing it, but it does not actively train the abdominals and pelvic floor in relationship to the core as a whole. For long-term recovery and function, exercise and re-education of the core muscles is the most effective treatment. We recommend working with a physical therapists or exercise professional who specialize in postpartum recovery.

How Big Will My Baby Be?

Are you pregnant and concerned about your ability to birth a "big baby?"

In late pregnancy, ultrasound and other methods are used to try to estimate a baby's size at birth. We hear a lot of our pregnant clients worrying about their ability to birth their baby vaginally, especially those who have been told that their baby may be on the larger end of the spectrum. 

But how accurate are these estimates, and how does the information affect choices surrounding birth?

The medical community generally defines a large baby as over 8lb 13oz. Statistically speaking, fewer than 8% of babies born in the US meet this definition. 

A new study surveying 1,960 new moms found that four out of five of the mothers who were warned that they might have a big baby did not, in fact, give birth to a large infant. However, those mothers were almost twice as likely to have medical interventions such as labor induction, and almost twice as likely to have a planned cesarian birth.

A 2012 study showed that simply being told the estimated birth weight of a baby caused a significant increase in the percentage of cesarian births when all other variables were controlled. 

The American College of Obstetricians and Gynecologists (ACOG) has published guidelines stating that suspecting a large baby is only "rarely" an indication for a planned cesarian birth. These guidelines say that doctors should only offer a cesarian to women with a baby predicted to weigh over 11 lbs at birth.

As we learn more about the role of womens' past experience, fears, and preconceptions on the processes of labor and birth, it's important to recognize the effect of the large volume of information that women receive during pregnancy. While technological advances and the ability to collect more data can be helpful, anxiety regarding a baby's size may influence how an expecting mother approaches vaginal birth or considers elective cesarian birth. 

Psychotherapy for Irritable Bowel Syndrome

A recently published systematic review and meta-analysis showed that cognitive therapy, hypnotherapy, mindfulness, behavioral therapy and dynamic psychotherapy all showed benefits against the symptoms of Irritable Bowel Syndrome (IBS). This high-quality study showed that these therapies were significantly effective when added to standard care, with the benefits remaining at 6 and 12 months. See the full text article here. 

This study is an important reminder to physical therapists, doctors and patients that the management of abdominal and pelvic dysfunction is often most effective with more than one provider. If you are suffering from IBS, talk to a provider you trust about a multidisciplinary approach to manage the aspects of your symptoms beyond the gastrointestinal and musculoskeletal systems!

 

Pregnancy and Pelvic Floor Exercise

In our daily work with expecting mamas, we are constantly reminded that pregnancy is a time of information overload. Advice comes from all directions - family, friends, doctors, midwives, doulas, class instructors, books, magazines and the internet - and many women and their partners simply don't know how to make sense of it all.

As pelvic floor physical therapists, we frequently discuss concerns brought to us by our pregnant patients about the safety and efficacy of pelvic floor muscle exercise during pregnancy. With the volume and diversity of information available on this topic, it's easy to see why a lot of women are paralyzed by fear of doing the "wrong" thing.

So what's a mama to do? Our answer, ultimately, is the same that we would provide to any woman who comes to us with signs of pelvic floor dysfunction. It depends. 

Generalizing exercise prescription for any population of people, pregnant or not, will never completely address the needs of any one of those individuals, and may prevent many from getting relief from their symptoms. The state of pregnancy creates common features among many women, but each enters her pregnancy with a unique physical, gynecological and psychosocial history that must be determined by a thorough history and physical examination before any conclusions about the most appropriate type of pelvic floor exercise can be made. 

The most important "rule" about pelvic floor muscle exercise is that it should work to cultivate a strong, flexible and coordinated muscle group. Our best physical function occurs when our pelvic floor muscles can achieve a full range of motion during voluntary contractions and relaxations, respond appropriately to postural demands as a component of the deep core, provide stability and force closure to the pelvic girdle and lumbar spine, and adequately support pelvic organs against intra-abdominal pressure.

During pregnancy, it is very important to practice relaxing into the sensation of pressure and stretch felt at the perineum (see our home page video about perineal massage!). But it's also important that pelvic floor muscles can contract strongly and with good endurance to provide needed stability for the pelvic bones and give support to a growing uterus and pelvic organs (including the bladder). As with all things in life, moderation of all of these factors is the key.

The path to to get to this ideal state depends entirely on where our muscles begin - some individuals will need to work primarily on motor control and coordination, some will need to practice voluntary contractions, and others will need to focus on voluntary relaxation. The reason that our jobs stay so interesting is that every body is unique - so let's treat them that way!