This fourth trimester (the first three months of your baby’s life) can be a profoundly difficult time for new mothers—you’ve just given birth to a new baby and are adjusting to all of the new changes all while trying to heal and get your body feeling “normal” again. It was truly a shock for me after my first realizing that I had just carried this human for 9 months and then just like that, she was in my arms and I was having to adjust to my new role as a mom all while relearning my new postpartum body.

While you are not pregnant anymore, your body is still adjusting to this new life and that is why I like the relatively new term for the 3 months postpartum— “fourth trimester” —aka the last stage of pregnancy. I think it is fitting because many of the physical issues we dealt with during pregnancy are still affecting us during this postpartum period. Things like a weakened pelvic floor, loose joints, and our compromised abdominals. This can be a hard because we are beginning to feel more “normal” again, but physically we should still be working out as if we are in our third trimester.

While we all handle this postpartum period differently, I always stress that our primary concern should be bonding and caring for our new littles and getting all of the necessary rest. We also need to make sure we are eating enough nutritious food, drinking lots of water, showering (when we can haha), and sleeping when the baby sleeps (ha).

With that being said, it is recommended that you return to exercise once you have gotten permission from your physician—normally at the six week post-labor check up. Prior to your 6 week checkup, if you are feeling up for it, you can start walking. This helped me so much to be able to get out and get fresh air. It is also so important to keep doing/start your core breathing your practiced in each trimester and that is something you can do right away and heal your pelvic floor. If you do this, you will prevent injury in the long run that could put you out for a long time.

I will discuss the differences in the recovery for vaginal vs. c-section more in detail below, but in general for the first six weeks you should only do limited exercise that make you feel better both physically and mentally.

Reasons to Workout During This Trimester (birth to 3 months pp)

• Studies have shown that a return to exercise is linked to a decrease in postpartum depression (Artal, 1992).

• Exercising with baby in the beginning provides additional benefits that solo exercise does not including:

• More likely to stick to routine

• Less guilt about leaving baby with someone

• Can stop and feed baby/take care of baby’s needs

• Gives you a chance to get out of the house and do something for yourself, while also allowing you to bond with your baby

• participating in exercise sets a positive example for your littles from a young age

Psychological Changes in the Fourth Trimester

The most common postpartum psychological issue is postpartum depression. Postpartum Depression can affect either parent after the baby is born. Some of the symptoms to look for are: mood swings, sadness, anxiety, inability to sleep, and general disinterest in the baby. I am sharing this because it is reality, and it is part of why exercise, sleep (not all in our control) and the return to routine is crucial if your body is ready!

Three Stages or Categories of Postpartum Depression

There are three stages or categories of postpartum depression. It is good to know these so you can get the help when you need sooner.

Baby Blues

• What it looks like: you may feel unnaturally weepy, overwhelmed, and/or irritable. It normally lasts a few days. At most 10 days.

  1. 80% of women will experience some kind of mood change or “baby blues” after pregnancy.

  2. How it is treated: There is no official treatment. Most people find that some extra sleep and a little time away from the baby helps. For me exercise, my friends and family and a good nap helped me get through this.

Postpartum Depression

• What it looks like: Sadness, anxiety, changes in appetite, insomnia, and/or guilt. These feelings usually persist for two or more weeks.

  1. Approximately 15% of women experience significant depression following childbirth.

  2. How it is treated: Counseling and/or medication

 Postpartum Psychosis

• What it looks like: Mania, Paranoia, severe depression, and/or violent thoughts or tendencies

  1. Less than 5% of women experience postpartum psychosis

  2. How it is treated: Inpatient Psychiatric treatment.

 Postpartum and antepartum depression are temporary and treatable with professional help.  You can read more at the Postpartum International website at www.postpartum.net or call (800) 994-4PPD.

The Physical After Effects of Labor

What to expect if you had a Vaginal Birth:

There can be many different experiences when having a vaginal birth—For some it was easy and others traumatic— Were there complications or not? Did you have an episiotomy or tear?..etc. all of these things can affect how your healing process will go. Never compare your journey with anyone else’s because they are all uniquely ours.

After a vaginal birth, you can expect to bleed for 4 to 6 weeks. If you had some level of tearing or an episiotomy that needed to be stitched up you will expect to have to take care of the stitches and watch for infection. I needed one suture with each baby and it healed within 10 days (most common), but the stitches took a few weeks to fully dissolve.

During labor, the Levator ani muscles relax so that the baby can descend down the birth canal and there will be some level of trauma to the pelvic floor and is why doing your kegels and pelvic floor exercises are so important! Then the uterus will take 4 to 6 weeks to get back to normal size, and swelling (edema) will decrease as water weight gain dissipates, in 1 to 2 weeks.

What to expect if you had a Cesarean Delivery

A Cesarean section aka a “c-section”. This type of birth is done via a surgical incision in the abdomen and uterus to allow a baby or babies to be born safely when a doctor determines a vaginal birth is not in the best interest of the mother or baby. The current cesarean rate in the US is over 30%.

In most C-sections, they do not cut through muscle. Instead, the doctor cuts the skin and moves the muscle away to open the uterus and deliver the baby. Most people are nervous to engage their ab muscles as they believe they have been cut during their c-section.

It will normally take longer for someone to heal after a c-section than women who have had a vaginal birth, which means a later return to regular exercise. You may be cleared by your doctor at 6 weeks postpartum, but remember that you should only do so if you feel ready— you know your body the best. 

If you had a C-section, you should also start doing Kegel exercises to rebuild pelvic floor strength immediately after birth just like those who had a vaginal birth.  Current ACOG guidelines say that kegels should “be initiated in the immediate postpartum period.” as you will heal faster if you practice Kegels regularly.

Other Physiological Changes To Consider

Pregnancy takes a toll on the body. The physical after-effects of pregnancy are generally related to one of three places:

1. Relaxin in the joints

2. Weakened (sometimes injured) pelvic floor

3. Compromised abdominals

Relaxin

Production of relaxin stops when the placenta is delivered. However, the changes in the joints will exist until new tissue is reformed without the presence of relaxin. This can take up to 5 months (or as long as you are breastfeeding so remember that your joints may still feel unstable!

Pelvic Floor

Your pelvic floor consists of muscles and fascia that attach to the pubic bone and coccyx to form a hammock that supports your bladder, uterus, and bowels. Your pelvic floor is put under serious stress during a normal pregnancy; just the weight of carrying the baby through the last trimester causes most to have a weak, overstretched pelvic floor. On top of that, during vaginal labor, the pelvic floor gets extremely stretched out to allow the baby to be born, which leaves the pelvic floor bruised and swollen.  

You may have experienced or have heard that its “normal” to pee yourself while laughing, jumping, working out etc. after having a baby, You may notice this in the beginning, but it is not normal for it to continue. This means that your pelvic floor has not healed

The recovery and healing of the pelvic floor is extremely important when it comes to postpartum exercise. If you have done kegels and other pelvic floor exercises and nothing seems to work, there are many PT’s that specialize in pelvic floor recovery, and in a few sessions you can get your pelvic floor back in working condition. This will make you feel so much more confident and more likely to workout.

Compromised Abdominals

The uterus stretches out and becomes 15 times heavier during pregnancy. By 4 to 6 weeks after birth, the uterus should be back to its pre-pregnancy size of 2.5 ounces. However, as a result of stretched and elongated core muscles, you may notice that you still look pregnant even after the uterus shrinks. The time frame for the return of elasticity of your abdominal muscles depends on your age, amount of weight you gained during pregnancy, time frame between pregnancies, awareness of the abdominal muscles before and after delivery, as well as proper recruitment of the abdominal muscles during daily activities and with exercise.

It is important to check to see if you have Diastasis Recti (the separation of the rectus abdominis) and to what degree. Making sure to still avoid crunches, oblique work or any exercises that put excessive stress on the abdominals until you have healed.

Breastfeeding Considerations

Getting accustomed to milk production and breastfeeding takes time. Many women experience engorgement regularly at first, and you may need to stop exercising to feed your baby for relief.

It is a myth that exercise decreases milk production—As long as you are meeting your caloric and hydration needs, your milk production will not suffer from exercise. Research has shown that moderate-to-high intensity exercise does not impair the quality or quantity of breast milk (Dewey, 1998). Be sure to clean off the sweat from your breasts after exercise, as your baby may dislike the salty sweaty taste and refuse to feed.

If you are breastfeeding, you will need to add an additional 300 to 600 calories a day to your diet and be sure to stay hydrated. Dehydration affects the volume of milk produced—so be sure to drink plenty of water before, during, and after exercise.

Lastly, be sure to wear a supportive nursing bra during exercise. Here are the ones I like to wear when exercising—Nursing sports bras.

Weight

You may not want to hear this but, don’t expect to return to your pre-pregnancy weight for a while.  You will lose a significant amount of weight immediately after delivery. (Most women lose approximately 12 pounds after birth (a 7-8 pound baby + 1 or 2 pounds of placenta + 2 pounds of blood and amniotic fluid). Then your edema will go down and you can expect to lose another 4 pounds of water weight in the first week.

Weight loss after the first week postpartum is based mainly on your diet and exercise. keep in mind that it took you 9 months to gain the weight, and it will take approximately 6 – 12 months for some to reach your pre-pregnancy weight. (again it all depends on the person!!)

In one study, Dr. James Clapp compared women who exercised through pregnancy and postpartum to non-exercising women. His findings were fascinating:

• One year after birth the average weight retention of the women in the non-active group was three times greater and fat retention was twice as much as the women who exercised.

  1. In the group of exercisers, six months after birth, 55% had returned to pre-pregnancy weight.

  2. One year after birth, 75% had returned to their pre-pregnancy weight.

     
     

When to NOT Exercise

Doctor Clapp's guidelines are:

No exercise if you have:

• Heavy Bleeding

• Pain

• Breast infection or abscess

 When to be careful/potentially avoid exercise if you have:

• Cesarean birth or traumatic vaginal birth (until cleared and you have none of the symptoms above)

• Breast discomfort

• Heavy urine leakage or pelvic pressure during exercise

Easing into Exercise

After your six week checkup, and you are given the go, you may want to jump right back in as if you took no time off—while I wanted to do the same, I do not recommend overdoing it, as you will be surprised by how weak and out of shape you feel. It is important to remember that you are still physically recovering from labor and will have symptoms from 3rd trimester and should give yourself a break :-). Start slow as if you are new to exercising and then you can begin to get moving like you used to.

Key Moves in the Fourth Trimester

1. Kegel Exercises— to avoid incontinence and build back pelvic floor

   • Pelvic floor exercises Sit and lean slightly forward with a straight back. Squeeze and lift the muscles around your vagina as if you are trying to stop your pee. Hold as you count to 8; relax for 8 seconds. If you can’t hold for 8, just hold as long as you can. Repeat about 8 to 12 times.

2. Hollowing out your core (Pulling belly button to spine) close the gap. avoid “traditional core” to avoid making diastasis worse.

3. Chest stretches - breastfeeding and motherhood in general causes a lot of a lot of back pain

4. Walking

When in doubt, listen to your body and feel free to ask any questions you need. I promise, it will get “easier” and you will eventually feel more like yourself! Give your body time to heal and enjoy the bonding time with your new precious baby. Keep doing your kegels, belly breathing, chest stretches and walking and then continue to add little by little.

xx Taylor