Exercise prescription in the postpartum period – the need for clear guidelines

The postpartum period is the ideal time for health care professionals to recommend and educate women on evidence-based lifestyle interventions including exercise. The short-term benefits of postpartum exercise include improved mood, promotion of weight loss and maintenance cardiorespiratory fitness¹. The long-term benefits are well demonstrated for both women and their children including the reduction in postpartum depression and anxiety, weight management, reduction in chronic cardio-metabolic disease, reduction in breast cancer risk and modelling health behaviours for families^2,3,4. Incorporating evidence-based exercise prescription into the postpartum period is important for both supporting lifelong healthy lifestyles and public health benefit^2,4.

Many women never return to pre-pregnancy physical activity levels⁴. Data from the Australian Longitudinal Study on Womens Health shows a sharp decline in physical activity three years postpartum⁵. The most common barriers cited are lack of time, fatigue and depressive symptoms⁴. Other barriers include physical discomfort, parenting duties, lack of partner support, social isolation, financial concerns, neighbourhood safety, weather and lack of prioritizing health over competing responsibilities¹.

General practitioners are in the ideal position to educate and prescribe exercise in the postpartum period⁶. Most new mothers will attend a GP with their baby multiple times in the first year. Postpartum mothers should attend a dedicated appointment in the first six weeks postpartum. Unfortunately many women do not make separate medical appointments to discuss and prioritize their health. Studies demonstrate the majority of new mothers will access social media for their postpartum health advice⁷ (concerning as it is without evidence-based regulation). The common belief among new mothers is that women need to be cleared to exercise at six weeks postpartum, however it is more detailed and complicated than this².

It is difficult to locate clear postpartum exercise guidelines and often these recommendations are entwined with pregnancy guidelines¹. Depending on the mode of delivery and whether there were any complications, gentle exercise can often resume sooner than six weeks postpartum². This includes low intensity physical activity including walking, pelvic floor and abdominal muscle exercises^1,2. The most recent guidelines published by the American College of Obstetrics and Gynecology in 2020² suggests:

1)  Pelvic floor exercises can be initiated in the immediate post-partum period.

2)  Abdominal strengthening exercise can begin soon after birth – these must be specifically drawing in exercises (transversus abominus activation). This has been shown to decrease the incidence of diastasis recti abdominus and decrease the inter-rectus distance.

3)  Return to regular aerobic exercise improves cardiovascular fitness without affecting milk production, composition or infant growth.

If recovery post birth is progressing well, women are often encouraged to begin to progress from low intensity physical activity to more aerobic dynamic exercise at six weeks post vaginal birth and eight weeks post Caesarean section. At this stage post partum, women are recommended to following the Australian Guidelines for Exercise¹¹:

1)  Be active on most, preferably all, days every week.

2)  Accumulate 150 to 300 minutes (2 ½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1 ¼ to 2 ½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities each week.

3)  Do muscle strengthening activities on at least 2 days each week.

There is ongoing confusion surrounding resumption of more aerobic and dynamic exercise on the pelvic floor. A 2021 published review⁸ indicates there are many ongoing knowledge gaps that need to be filled to understand the full effects of strenuous and non-strenuous activities on pelvic floor health. Referring to our women’s specialist physiotherapists andexercise physiology colleagues can assist with this assessment and management.

It is well documented that general practitioners need to improve their knowledge surrounding exercise prescription in general^9,10. Our exercise prescriptions need to be specific formulations as if we were prescribing medications¹⁰. Many GPs feeling they lack the time and resources to provide this care in general, before considering specific patient populations such as postpartum women⁶. We need clear and accessible exercise guidelines, which will allow GPs to up skill and opportunistically target health interventions for this group^4,6. Exercise prescription needs to be an essential skill in primary care and with our interest in lifestyle medicine we need to be at the forefront of this change. We have to educate ourselves and our colleagues and link in with our community services to support healthy lifestyle changes in postpartum women.