Six months after my sister gave birth to twin daughters via Caesarean section, she was ready to get back to an exercise routine.
I gave her an eight-week program she could do in her living room with just her body weight and some resistance bands.
One of the biggest challenges women face postpartum, especially after C-sections, is a weakened core. So it seemed like the right place to start.
I warmed her up with some basic activation drills to get her contracting her abs, and then got into glute and hamstring work, including glute bridges, bird dogs, and banded clamshells.
She felt pretty good, and wanted to try some tuck-ups and sit-ups.
As she attempted to pull her body off the ground, a look of panic overtook her face. She was stuck. She laid back down and tried again, this time with some momentum.
“What’s going on?” she cried, sounding surprised. “I can’t even do a sit-up. I used to be able to do 40 in one minute.”
My client Kyla has a similar story, following a vaginal delivery.
“I remember trying to do a hollow hold and completely failing” after she gave birth to her first child,” she told me. After her second baby, she couldn’t even use her abs to sit up in bed without assistance from her arms.
“My lower back got more and more sore from the lack of core strength, and my pelvic floor was weak and sore from being overstretched during birth,” she added.
For my sister and Kyla, it was their abdominal muscles that seemed to take the biggest hit from pregnancy. Meanwhile, for my client Audrey, her hips caused the most grief after giving birth to her son four years ago.
“I was more bendy, especially while I was still breastfeeding, so stability was hard,” she said. As a result, Audrey had to avoid movements like lunges for a number of months, as they felt unstable and weak.
For a new mom, core dysfunction is the new normal
If you’re a woman who’s getting back into fitness postpartum, you can probably relate to my sister or Kyla’s abdominal woes, or to Audrey’s unstable hips. Rest assured, you’re not alone.
Physiotherapist Kate Powell, a two-time Canadian Olympic gymnast who works primarily with postpartum clients, can attest to this. The abdominal weakness begins during pregnancy, when pressure from the growing baby stretches the linea alba, the strip of connective tissue connecting the two sides of the rectus abdominis. Virtually every new mom ends up with some degree of diastasis recti.
While every case is different, Powell says, every woman she’s worked with has experienced significant abdominal weakness by the end of their pregnancy.
“Sometimes it takes a while for the muscles to come back together again,” she says. She relies on a combination of Pilates and traditional physical therapy to help her clients learn to activate and strengthen their abdominals.
The pelvic floor is the second big concern for postpartum women.
“Some women have more pelvic floor problems, and some have more abdominal problems, and some have both,” Powell says. “But regardless, they’re always related, because if one isn’t working properly, neither is the other.”
Unstable hips are the third big concern. Unsurprisingly, it’s related to the other two through connections in the deep abdominal muscles and the pelvic floor.
“If you lose control of that deep layer of abdominal muscles, this has a huge impact on your ability to control your pelvis,” Powell says. “If you can’t control your pelvis, you can’t control your hips.”
Because their pelvis and abs “are holding on for dear life,” many postpartum women find their hip flexors and quads becoming more dominant. That means less work for the posterior chain, and a higher risk of back pain.
Powell recommends the following steps to get those muscles back on track.
Three steps to retrain the abs, pelvic floor, and hips
Step 1: Breathing
“We use breath to drive everything,” Powell says. Breath regulates intra-abdominal pressure, and has a big effect on your client’s ability to activate her abs and pelvic floor and stabilize her hips and lumbar spine.
So what is good breathing?
Think of your core as a cylinder, Powell explains. With each breath, you want to expand the cylinder in all directions, from your rib cage at the top to your pelvic floor at the bottom, from front to back, and on both sides.
And when you exhale, you should feel your abs activating.
The process requires your diaphragm, transverse abdominis, pelvic floor, and lower back to work together as a team to manage abdominal pressure.
Step 2: Activation
Working with a postpartum client is a lot like working with someone who’s recovering from an injury.
“If you tear a hamstring and you just leave it alone, it will eventually reattach and heal,” Powell says. But it won’t be as strong or functional as it was before the injury, leaving you vulnerable to a future hamstring tear, along with any number of injuries, imbalances, and dysfunctions.
The same is true of the pelvic floor and abdominals after pregnancy. At minimum, your client’s tissues have been stretched and strained. There’s probably been some amount of tearing, even if it didn’t require stitches. And if she had an episiotomy or C-section, those surgical sites need time to heal.
But simply healing isn’t enough. To become strong and functional again, your clients need to heal correctly.
That means imposing the “right amount of stress,” Powell says, which requires learning how to reactivate those muscles.
The potential consequences of not reactivating them could be incontinence or even pelvic organ prolapse.
Step one is learning to contract and release the individual muscle groups. “If you’re holding on for dear life in your pelvic floor because nothing else is turning on, it’ll be hard to get your abdominals to work properly,” she says.
Here’s the process for activating the abdominals:
- Have your client stand with a neutral spine. Tell her to contract her abs, as if she’s bracing to take a punch, and then relax. She can also try this lying on her back or positioned on all fours. In any position, don’t let the client turn it into a crunch. She’s activating the muscles, not using them to move her torso.
- The next step is to have the client activate her core muscles when doing squats or step-ups with just her body weight. “Doing everything unweighted and neutral is a good way to practice pressure management,” Powell says.
Step 3: Posture
The recovery steps we’ve discussed so far work best with a lengthened, upright posture, and the head, shoulders, back, and hips stacked on top of each other.
Poor posture can put your diaphragm or pelvic floor in a suboptimal position, compromising your breathing and your ability to activate your muscles. Powell says it’s like “beating yourself against a brick wall.”
She uses a dowel rod on the back to help create postural awareness. The goal, as shown in the first minute of this video from Girls Gone Strong, is to have the client create tactile feedback by keeping her head, upper back, and glutes in contact with the dowel throughout a hip hinge movement.
Final thoughts: Don’t forget postpartum self-care
So what does your postpartum client want you to know?
- She’s injured. Before pregnancy, her uterus was the size of a peach. Nine months later, it was the size of a watermelon, stretching and squeezing everything from the pelvis to the ribs. And then the baby tore anything that wouldn’t stretch to accommodate its exit.
- She’s a little freaked out. Things she used to do easily, like using her ab muscles to lift her torso when she gets up from the floor, are suddenly difficult, if not impossible.
- She doesn’t know what she doesn’t know. Especially if she’s a first-time mom, her post-pregnancy body is a mystery. It looks different, feels different, and certainly performs different.
As debilitating as the physical ailments most new moms face can be, the mental and emotional challenges can be equally daunting. Strangers no longer tell her how wonderful and healthy she looks. If they notice her at all, it’s with some combination of pity and concern.
That’s why my client Audrey urges coaches to help their postpartum clients find a support network.
“It’s a wild and scary ride,” she says. “The kid is your first concern, and the temptation is to let everything else fall by the wayside. Finding a way to schedule in some self-care was the hardest.”
And when she did, the guilt of “letting the kid sit in a poopy diaper while I finished my workout” would’ve been overwhelming if it hadn’t been for the support of the other moms in the gym.