The female body undergoes amazing changes during pregnancy and birthing. The abdominals in particular undergo significant changes in length and strength due to the growing foetus, connective tissue softening associated with pregnancy hormones and changes in physical activity during pregnancy. As a result, many women post-partum have deficits in their core strength and abdominal function, which can predispose them to other musculoskeletal problems such as low back and pelvic girdle pain.
Safely re-building core strength in the post-partum period can take many forms. There is not ‘one’ right way to do it or ‘one’ right exercise to do. There are however some principles that should be followed, and some special conditions that should be considered.
The abdominals are a group of four muscles, all of which are important for core stability and function.
Good core rehabilitation should include exercises that target all of these muscles, working together to support the spine and control movement. In the early post-partum period, these exercises should start gently, and typically focus on the deepest layer, the transverse abdominis. It is important to regain good control and activation of the transversus abdominis early as this is one of the primary low back stabilisers, and serves as a foundation for higher levels of core control. In the early phase of recovery it is also worth including exercises that work the gluteals and back muscles (such as bridging) as these muscles work with the abdominals to achieve core stability.
As transversus abdominis control and activation improves, more challenging abdominal exercises can be included, such as modified planks, push-up’s, crunches and oblique exercises. Again these need to be started at an appropriate level, and progressed as core control improves. The aim of the early phase of rehabilitation is to regain good technique and coordinated activation of the abdominals, low back muscles and pelvic stabilisers.
An example of a basic program of core exercises could include:
- Transversus abdominis activation (+ pelvic floor activation) with knee lifts or leg extensions
- 4 point kneeling with alternating arm or leg lifts
- Split stance bicep curls against a light resistance band (with transversus and pelvic floor activation)
- Transversus exercises
- Bridging progressions
- Plank progressions
- Tricep push-up progressions
Diastasis of the Rectus Abdominis Muscle (DRAM)
In the presence of an ongoing DRAM, core exercises will need to be modified to ensure that the DRAM improves rather than worsens. The key things to monitor are the size of the ‘gap’ during abdominal exercises (not widening), and avoid any abdominal bulging/doming/herniation through the DRAM.
Above is an example of bulging at the DRAM (to be avoided during exercises)
If you do have a significant DRAM, then you should consult a Physiotherapist who is trained in Women’s Health. They will assess your DRAM and the impact of different core exercises on the DRAM. Due to significant individual variation, there is not one correct or ‘safe’ exercise for DRAM. Some people’s diastasis improves most with activation of transversus, whilst others do best with crunches or modified oblique exercises. Your Women’s Health Physio will assess you doing a variety of exercises and prescribe the one that is most effective for you.
Pelvic Organ Prolapse/Weak Pelvic Floor
If you have pelvic organ prolapse, then it will be important to ensure that your prolapse is not negatively affected by the abdominal exercises you do. Crunches are often implicated as an exercise to be avoided by women with weak pelvic floors or pelvic organ prolapse. Research suggests that when done properly, the pressure on the pelvic organs and pelvic floor is less during crunching than when simply standing still. As such, doing crunches with correct technique may be safe even if you have a weak pelvic floor or pelvic organ prolapse. Similarly, plank and push-up style exercises can increase the pressure on the pelvic organs and pelvic floor, but if done well with good technique (including correct pelvic floor engagement), may be safe. It is important to get your Women’s Health Physio to check your technique and pelvic organ position during these exercises to ensure they are safe for you.
Exercises such as basic transversus activation and bridging are typically safe for women with weak pelvic floors or pelvic organ prolapse as they do not exert significant pressure on the pelvic organs or pelvic floor.
Post Caesarean Section
If you have had a caesarean section, it is important to minimise lifting, carrying and abdominal load during the first six weeks. This is essential to allow the abdominal and uterine incisions to heal well. After the first six weeks (if the wounds are healing well), gentle core rehabilitation should be started gradually, and may include gentle, progressive activation of the transversus abdominis, bridging style exercises and light resistance exercises in functional positions. These exercises can be gradually progressed until you are 12 weeks post Caesar, at which point more challenging core exercises can be added (as per the general principles section above) provided you have developed good base level control and activation.
Overall, it is important to rebuild your abdominals and core control after pregnancy and birth to regain function and reduce the risk of other injuries. If you are unsure of how to proceed, or feel any symptoms whilst doing core exercises (pain, incontinence, vaginal pressure/heaviness/bulging) then you should consult a Women’s Health Physio for an assessment and provision of a tailored exercise program.
Happy exercising Mum’s!