Preparing to ease back into exercise after having a baby is rarely straightforward. Many women yearn to feel like their old selves again, but are dealing with common and unpleasant postpartum symptoms like incontinence from a weakened pelvic floor. It can be tricky to know how much to ask of your postnatal body, and when you might risk making those symptoms worse.
Baz Moffat, formerly a member of the British rowing team and now a coach at The Well HQ, is an expert at coaching postnatal women, specifically around their pelvic health. She’s passionate about helping women to get their pelvic floor working and breaking the taboos surrounding the topic. The Well HQ is a platform for education and change, a community that helps women – and those who support and train them – to understand the female body at all stages of life.
Moffat explained how to work with rather than against your postnatal body, how to tune in to your body’s needs, when to give yourself a break and when to dial it up a notch. We spoke about everything from the importance of the pelvic floor to dealing with abdominal muscle problems, what to do if you have prolapse symptoms and why women shouldn’t put up with wetting themselves.
What’s the best way to look after your body after having a baby?
There really isn’t one way. I feel that, generally speaking, women fall into one of two brackets. The first group are petrified of getting it wrong, of doing the wrong kind of exercises and increasing their diastasis recti or tummy gap, or of damaging their C-section scar, or of making prolapse symptoms worse. They’re almost petrified into inactivity.
This group responds well to good-quality coaching. The coach needs to meet the woman where she is at, mentally and physically, and provide her with hope and progression at a pace that she is comfortable with.
The other group are often really committed to exercising, and probably before they had the baby they had a clear idea of where they would be at what point, such as training X times a week within six weeks, or they’ve entered a half marathon or a 10K. These people have a really fixed mindset, and they kind of ignore what’s happening with their body and what’s happened to them.
With the second group, it’s really about helping them to understand and acknowledge what has happened to them through childbirth and the impact it may have on them. Some of them probably can return to exercise without any consequences, but in the long term, unless you’ve taken the time to build up your fitness and your core strength, and allowed your body to heal and recover before building strength, then five, 10, 15 years down the line you will start getting issues. It’s a tricky conversation to have with many active women who are desperate to feel like they did before they had the baby.
Why is it so important for postnatal women to strengthen the pelvic floor?
It’s essential to strengthen the pelvic floor, regardless of how you had your baby. Many women who had caesarean sections feel that doesn’t apply to them, but they probably put on a lot of weight – at least 10kg. Also with the change in hormones during pregnancy all the ligaments have been stretched, and your posture will have changed, so without a doubt the pelvic floor will have been affected. It’s certainly more affected if you have a vaginal delivery, but it is still relevant with a C-section.
The pelvic floor just needs a little care and attention: it has done a lot, and needs to gain strength back so that we can be continent. Ideally you’ll have started doing exercises during pregnancy, but if you haven’t, it doesn’t matter – you can start whenever. You don’t have to wait for your six-week check before doing your pelvic floor exercises, you can start from day one if you feel up to it. If you’re lying in bed or sitting in a chair you can just very gently start by connecting with your pelvic floor, then learning how to relax and let go of it. In the early days it’s all about building that brain-pelvic floor connection so that your brain can feel where it is. If it doesn’t feel right, leave it.
What kind of exercises can strengthen the pelvic floor after childbirth?
The NHS has an app called Squeezy, which costs £2.99 and is really useful. It walks you through the exercises, tells you how long to hold for, how long to relax for, and gives you a countdown.
Doing that two or three times a day is a really good habit to get into. I used to do it as I was breastfeeding my baby. I think many women find that useful, whether you’re breastfeeding or bottle feeding – you’ve always got your phone, you’re sitting down… it’s ideal.
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What kind of fitness classes are best for postnatal women?
I would recommend going to people who define themselves as being a pre- and postnatal trainer. They should have done a CIMSPA-approved course on pre- and postnatal training, but if they did it 10 years ago it’s good to check what they have done since: you want someone who’s really up to date with the latest approaches, who is reading and learning and going to conferences. That’s applicable to one-to-one training but it’s the same for classes.
Even when it’s a postnatal class, the instructor will have a fitness qualification but they might not be qualified to teach a postnatal class. You need to ask. A good clue is that they should be asking you lots of questions, there should be a really detailed pre-screening before you work out with them. They’ll want to know how your birth was, they’ll want to do a diastasis check. They need to be able to adapt the exercises to the state your body is in so they should be able to accurately assess where you’re at.
You also want to go to the classes that are all about function, getting you to move well, not about getting you to “bounce back” or to “lose the baby weight”. You don’t want that kind of language. You want people who can help you as a postnatal woman get the most out of your body.
Some postnatal women experience a gap between their abdominal muscles, known as diastasis recti. How can you repair this through exercise?
One hundred percent of postpartum women will have diastasis recti to some extent, where the linea alba splits. That connective tissue in the middle needs to come back together and it takes time. For some women it won’t ever completely come back together. Some forms of exercise will exacerbate the problem, whereas others can help draw it back together – that’s why it’s really important that you have a personal trainer who understands that.
So many women are really desperate to get their tummy back into shape, but if that’s what’s important to you, you need someone who can help support you to do exercises where you’re focusing on drawing the abs closer together, with the breath, with the pelvic floor, not just telling you to smash it out, because that’s not going to help the gap. Even if you’re super slim and you’ve lost all the baby weight, you can still have a gap, and it might not bother you now but it probably will as you age.
It’s not something to be scared of or super-concerned about, you don’t have to spend loads of money trying to sort it out. But if you are particularly concerned about this, I would recommend you go and see a women’s health physiotherapist. They are available on the NHS, but you may have to go private to see one – it’s a bit of a postcode lottery. Having a postnatal check with a women’s health physio will help you see where you are at and you can feed that back to your trainer.
What kind of exercises might exacerbate a tummy gap?
I really dislike saying these are the bad exercises and these are the good exercises, because people think that if they have a list and avoid certain things they’ll be fine. There’s good form and bad form. You can do a sit-up in a way which will pull the tummy apart, and you can do a sit-up in a way which will pull the tummy together. You need to understand in this postnatal phase how to use your breath and your core in a way that draws that connective tissue back in together.
Many women experience incontinence after childbirth. This can make exercising a problem. What can be done to overcome these issues?
Without a doubt you have to get on top of pelvic floor exercises, but the most important thing is to exercise: from a health perspective – physically, mentally, emotionally, socially – every single aspect of exercise ticks a box. If you leak while you are doing a HIIT session, or running, you need to adapt, you need to find a level where you don’t leak.
Let’s say you’re doing a couch to 5K and you notice that if you’re running downhill then you start leaking, then you need to walk down hills. Or if after 10 minutes of running you start leaking, then come down to nine minutes. You need to get to the place where you aren’t leaking, and then you progress from there, slowly. But that’s not going to happen unless you’re doing your pelvic floor exercises.
And you need a really good strength and conditioning programme, not smashing out the weights but really working on your glute strength, your back strength, your balance – you need your whole body to be really well conditioned so that the pelvic floor can do its job.
With stress incontinence especially, you can’t ignore it and think it will go away. The more you ask of your body, the more work you need to do on your pelvic floor. I coach a lot of women who have been working their bodies hard, and then they do, say, 10 pelvic floor exercises per day, while they’re in bed before they go to sleep, and they wonder why that’s not working. If the rest of you is a fine-tuned machine, and you’re just dabbling in the pelvic floor exercises, that’s not going to work.
If you’re postnatal and want to get back to double-unders in CrossFit, or get back to netball, you have to start with gentle pelvic floor exercises – but you need to progress those exercises just like with the rest of your body. If all you want to do is to be able to walk your dog, then you can probably get away with just doing your basic pelvic floor exercises, because walking is very low-impact. The more you ask of your body, the more training you need to do on your pelvic floor.
Some women experience prolapse, where pelvic organs slip downwards, after childbirth. How can exercise help with this?
That’s devastating for many, many women: 50% of postnatal women are likely to experience some form of prolapse symptoms. It’s weird: you might have symptoms and actually when you’re examined, the physiotherapist says it’s not that bad, or you might not have any symptoms, but you have an examination and it’s in quite a bad place. As with all things women’s health there’s not nearly enough research. But if you are symptomatic, for example you have a dragging feeling in your vagina, which is very common, it essentially means that your vaginal wall is not strong enough to hold the weight of your bladder, bowel and uterus above it.
For people who love exercise – that group of women we talked about who are desperate to get back into the gym postnatally – having prolapse symptoms can be devastating. If you are in that category you need to see a women’s health physiotherapist. If you can see one through the NHS then brilliant, if not, it’s worth working out a way to go private. They can hook you up with a personal trainer who understands where your body is at, and they can help you integrate your exercises around that.
Also, you need to not be constipated. Which sounds weird, but being constipated is a really common symptom for postnatal women and it exacerbates prolapse symptoms. So make sure you’re drinking enough water, especially if you’re breastfeeding, and eating loads of vegetables. I’ve coached so many women around constipation and it has such a big impact on prolapse symptoms.
Why isn’t the pelvic floor talked about more? How can we overcome the taboos around it?
Some athletes are now starting to, if they’ve had a baby, like Sophie Power, the ultrarunner who was pictured breastfeeding her child while doing the Ultra Trail du Mont Blanc. She’s very open about her pelvic floor issues.
I think it’s just one of those things that we feel we should be able to do: we shouldn’t be having irresistible urges to go to the toilet, we shouldn’t wet ourselves when we’re on the trampoline.
The incontinence pad brands normalise wetting ourselves and they make it quite infantile with their imagery. It’s sold to us as something that’s normal, that we should accept. But the reality is that we can do something about it – the exercises really work!
It’s tricky though because women often don’t know how to do the exercises. Also, the exercises are boring and you can’t really tell if it’s making a difference – you don’t get sweaty, or have sore muscles afterwards.
What about the next generation? How can we help them overcome these taboos?
Interestingly the NICE guidelines now say that all 12- to 17-year olds need to be taught this in school. I did a schools conference where there were 50 teachers and 200 girls: some from state schools, some from private, all of them were sports scholars, some of them were on Olympic pathways. I taught them how to do their pelvic floor exercises in a big lecture theatre. It was incredible, the number of girls who came up to me afterwards and said “I wet myself after every race, I just thought I had a weak bladder”, or “I wet myself all the time during netball, and I didn’t realise I could do anything about it”. It’s so important for them to be taught this, but even the teachers don’t know how to do it – no one has taught them.
At the Well HQ, we are on a mission to get more girls and women to be active and enjoy playing sport. Our way of doing that is through educating, supporting and empowering girls and women and those who support them, around their anatomy and physiology.
The pelvic floor is critical for all women, but especially for pre- and postnatal women. It’s not something that we need to be scared of. I want to get the pelvic floor on the gym floor so it’s not something where you have to hide away or go and see an expert. All fitness instructors, all PE teachers, all coaches should be able to have a conversation about this, and should incorporate pelvic floor work into their normal strength and conditioning and core programmes. It should just be normalised, as part of women’s training and conditioning. We’re a way off that at the moment but that’s my goal.
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