Promoting Postpartum Exercise

An Opportune Time for Change

Erika N. Ringdahl, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO.2 - FEBRUARY 2002

In Brief: The postpartum period is an ideal time for clinicians to promote the importance of physical fitness, help patients incorporate exercise into lifestyle changes, and encourage them to overcome barriers to exercise. New responsibilities, physical changes, and competing demands for time may make exercise seem impossible. By emphasizing weight control, stress reduction, and other benefits, clinicians can help new mothers establish healthy exercise goals for the rest of their lives.

Many lifestyle changes occur postpartum. Responsibility for a newborn alters eating and sleeping habits, work schedules, and time allocation. The demands of parenthood may reduce or prevent exercise in even the most committed athlete (1). These same demands may make initiating an exercise program appear impossible to the previously sedentary patient. By 6 weeks postpartum, many women may have established a routine that excludes regular exercise; however, the desire to return to prepregnancy size and shape, the need for increased energy, and the need for stress reduction can be effective motivators to start or resume exercise. (See "Olympian Outlines Postpartum Exercise Benefits," below.)

Postpartum exercise enhances a new mother's cardiovascular fitness and mental health (2) and prevents the postpartum weight retention (3) that can lead to obesity and other morbidities. More than one third of US women are overweight (4). While average postpartum weight retention is only 1 kg (2.2 lb) (5), the childbearing years are a time that many women gain weight (6). Women who are overweight before pregnancy and who gain more weight than recommended during pregnancy are the most likely to retain weight after giving birth and between pregnancies (7). Weight control should be addressed before, during, and after pregnancy, not just in the postpartum period.

Pregnancy motivates some women to make major lifestyle changes. The postpartum period is an opportunity for clinicians to promote the importance of physical fitness, facilitate incorporation of exercise into lifestyle changes, and decrease barriers to exercise (see "Baby Workout Buddies: Obstacle or Opportunity?").

Postpartum Weight Changes

Although the average permanent postpartum weight gain for US women is small, 70% of women are unhappy with their appearance at 6 months postpartum (6). Many women are told that because it took 9 months to acquire the weight, they should expect weight loss to take an equal amount of time. In fact, women lose the most weight in the first 3 months after delivery. Weight loss of 4.5 kg (10 lb) to 5.8 kg (13 lb) occurs with the delivery of the infant and placenta (8). After 1 week, an additional 3.18 kg (7 lb) to 5.0 kg (11 lb) is lost through perspiration, diuresis, lochia, and uterine involution (8). Weight loss between 3 and 6 months postpartum averages only 1 kg (2.2 lb) (8). Therefore, women who have not returned to their prepregnancy weight by 6 months are likely to retain the extra weight long-term.

Some women are at risk for postpartum weight retention. The most important predictors of postpartum weight loss are prepregnancy weight, gestational weight gain, parity, and antepartum exercise (9). For women younger than age 35, primiparas lose more weight than multigravidas at each postpartum interval studied (10). Primiparas over age 35 average 2.9 kg (6.4 lb) weight gain over their prepregnancy weight at 1 year postpartum (11). Women who return to work sooner tend to lose more weight than those who take a longer maternity leave (10). Race may also be a risk factor. White women who gain 25 to 30 lb during pregnancy retain an average of 1.6 lb; African-American women retain an average of 7.2 lb (12). Excessive gestational weight gain predisposes a woman to postpartum weight retention; antepartum physical activity diminishes postpartum weight retention (13).

Walker and Freeland-Graves (14) concluded that lifestyle factors were associated with the amount of weight gain in women who bottle-fed their babies. Mothers who bottle-fed and had higher postpartum weight gains exercised less and had higher fat intake than mothers who bottle-fed and had lower gains. For this population, lifestyle-focused programs for weight management can be especially beneficial.

Perceived Barriers to Exercise

Obstacles to postpartum exercise include physical changes, competing demands, lack of information about weight retention, fear of interference with breastfeeding, and stress incontinence. Clinicians can emphasize the benefits of exercise and how to overcome excuses to support adherence by new mothers (see "Exercising After You Have Your Baby").

Physical changes. Women who exercised regularly during pregnancy may not tolerate their usual workout postpartum. Weight gain and decreased activity associated with pregnancy contribute to deconditioning. Ligamentous laxity associated with increased levels of relaxin during pregnancy may increase a woman's risk of postpartum injury. Although relaxin levels return to normal within the first week after delivery, its effects may persist for 3 months after delivery (15).

Competing demands. It can be difficult for a mother to schedule time to exercise with an infant at home, even more so with several young children at home. The clinician can help mothers identify potential solutions. There may be gyms with childcare available in the community. Mothers may be interested in watching each other's children so each can have time to exercise. Jogging strollers allow women to exercise with their children. Finally, exercise videos and home exercise equipment allow women to work out while their children nap or play in the same room. Use of a playpen or safety gate helps protect young children from injuries around exercise equipment, especially treadmills and stationary bikes.

Uncertainty. Women who are eager to exercise may be unsure when it is safe for them to resume exercise. The American College of Obstetrics and Gynecology notes that the physiologic effects of pregnancy may persist for up to 6 weeks postpartum and, therefore, advises gradual resumption of activity as tolerated (16). Specific guidelines do not exist for resuming activity after normal pregnancy and delivery, much less after pregnancies complicated by preeclampsia, third-degree laceration, or cesarean section. Women who have had complicated pregnancies or deliveries may need to increase their exercise programs more gradually, based on their physical discomfort levels and exercise tolerance.

Exercise and breastfeeding. Some women may deny the need to exercise for weight loss while breastfeeding because increased calories are expended with lactation. Breastfeeding, however, has little impact on postpartum weight loss, presumably because of a compensatory increase in caloric intake and a decrease in activity (17).

Some women may be concerned that exercise will adversely affect breast milk production and, therefore, infant growth. Studies (17-19) found that regular aerobic exercise had no adverse effect on lactation. Lovelady et al (17) concluded that the growth of infants who were exclusively breastfed was not affected by maternal weight loss of 0.5 kg per week between weeks 4 and 14 postpartum (see "Do Moms' Diet and Exercise Affect Breastfeeding Babies?"). Exercise coupled with a small reduction in calorie intake is preferable to diet alone for weight loss in lactating women (20). Dieting reduces more maternal lean body mass; exercise plus diet burns more fat while conserving lean body mass. If a mother doesn't want to exercise because she is concerned that her infant isn't getting enough nutrition, she may only need reassurance from her physician. Supplementing with formula is not recommended because it will decrease demand for feeding and further reduce lactation.

After exercise, only 7% of mothers note such problems as increased infant fussiness or refusal to feed (18). Infants, though, may prefer preexercise milk compared with postexercise milk, which contains increased levels of lactic acid (21). After maximal exertion, lactic acid levels in breast milk remain elevated for up to 90 minutes, but no significant increase occurs after moderate exercise (22). Other factors may also affect the lactic acid content of breast milk. Women who exercise with full breasts have peak lactic acid levels sooner than women who exercise with empty breasts (10 minutes versus 30 minutes postexercise) (21).

Armed with this information, women can minimize difficulty nursing after exercise. Women should nurse or pump just before exercise. Awareness of when peak lactic acid levels occur should guide feeding times when exercising at maximal intensity. Women can avoid dehydration by drinking adequate amounts of fluid during and after activity; drinking before exercise may increase incontinence. Those who experience discomfort while exercising with enlarged or engorged breasts should wear supportive bras. Wearing two sports bras may be necessary to provide adequate compression and stabilization.

Stress incontinence. The more vaginal deliveries a woman has had, the more likely she is to have stress incontinence (23). Two studies (23,24) suggest that many women do not discuss incontinence with their physicians. In one study (23), 30% of women who exercised regularly reported stress incontinence, and 20% of them stopped exercising because of it. Stress incontinence can occur with almost any activity, particularly running (21). Women might consider alternate low-impact activities (such as walking, biking, swimming, or low-impact aerobics) postpartum so they can quickly resume physical activity while strengthening the pelvic floor.

Strategies that may reduce stress incontinence include voiding immediately before exercise, avoiding caffeine for several hours before working out, and wearing a tampon during exercise to increase urethral support (25). Isometric exercises that strengthen the pelvic floor muscles are an effective incontinence treatment in over 50% of women who have the condition (26). Many contraction regimens for pelvic floor muscles exist, but most women simply do not do the exercises with enough frequency or regularity. Because these exercises can be done inconspicuously, women can be advised to form the habit of doing ten 5-second contractions whenever they are at a stoplight, talking on the phone, or watching television commercials.

Kegel exercises are more effective than electrical vaginal stimulation or vaginal cones in the treatment of stress incontinence (26); however, vaginal cones may be most appropriate for women who have difficulty isolating the appropriate muscles to contract. Vaginal cone use is limited by the need to use them for approximately 20 minutes at a time in a private setting. Finally, various barrier devices can be used to block the external urethral opening (27). They are held in place by suction or adhesives and must be removed to void. Results of a more recent study (see "Treatment of Exercise Incontinence With a Urethral Insert: A Pilot Study in Women") for a new type of device are also promising.

Promoting Change

Postpartum counseling should give women realistic expectations for weight loss and present individualized exercise guidelines. Rather than giving the blanket admonition to resume or start exercise at 6 weeks postpartum, physicians should tailor their recommendations to the patient's previous level of fitness and any complications she may have experienced during pregnancy and delivery.

Common obstacles to postpartum exercise, such as concern about nursing or urinary incontinence, may be overcome with patient education; these issues should be addressed during the third trimester and immediately after the birth of the baby. Lifestyle changes that occur postpartum may affect a woman's health for decades.

References

1. Godin G, Vezina L, Leclerc O: Factors influencing intentions of pregnant women to exercise after giving birth. Public Health Rep 1989;104(2):188-195
2. Sampselle CM, Seng J, Yeo S, et al: Physical activity and postpartum well-being. J Obstet Gynecol Neonatal Nurs 1999;28(1):41-49
3. Ohlin A, Rossner S: Factors related to body weight changes during and after pregnancy: the Stockholm Pregnancy and Weight Development Study. Obes Res 1996;4(3):271-276
4. Kuczmarski RJ, Flegal KM, Campbell SM, et al: Increasing prevalence of overweight among US adults: the National Health and Nutrition Examination Surveys, 1960 to 1991. JAMA 1994;272(3):205-211
5. Subcommittee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine: Nutrition During Pregnancy, Part 1: Weight Gain. National Academy Press, 1990, p 468
6. Walker LO: Weight-related distress in the early months after childbirth. West J Nurse Res 1998;20(1):30-44
7. Williamson DF, Kahn HS, Remington PL, et al: The 10-year incidence of overweight and major weight gain in US adults. Arch Intern Med 1990;150(3):665-672
8. Crowell DT: Weight change in the postpartum period: a review of the literature. J Nurse Midwifery 1995;40(5):418-423
9. Boardley DJ, Sargent RG, Coker AL, et al: The relationship between diet, activity, and other factors, and postpartum weight change by race. Obstet Gynecol 1995;86(5):834-838
10. Lederman SA: The effect of pregnancy weight gain on later obesity. Obstet Gynecol 1993;82(1):148-155
11. Schauberger CW, Rooney BL, Brimer LM: Factors that influence weight loss in the puerperium. Obstet Gynecol 1992;79(3):424-429
12. Keppel KG, Taffel SM: Pregnancy-related weight gain and retention: implications of the 1990 Institute of Medicine guidelines. Am J Public Health 1993;83(8):1100-1103
13. Ohlin A, Rossner S: Trends in eating patterns, physical activity and socio-demographic factors in relation to postpartum body weight development. Br J Nutr 1994;71(4):457-470
14. Walker LO, Freeland-Graves J: Lifestyle factors related to postpartum weight gain and body image in bottle- and breastfeeding women. J Obstet Gynecol Neonatal Nurs 1998;27(2):151-160
15. Mittelmark RA, Wiswell RA, Drinkwater BL: Exercise guidelines for pregnancy, in Exercise in Pregnancy, ed 2. Baltimore, Williams & Wilkins, 1991, pp 299-312
16. American College of Obstetrics and Gynecology: Exercise During Pregnancy and the Postpartum Period, ACOG Technical Bulletin number 189. Washington, DC, American College of Obstetrics and Gynecology, February 1994, pp 1-5
17. Lovelady CA, Garner KE, Moreno KL, et al: The effect of weight loss in overweight, lactating women on the growth of their infants. N Engl J Med 2000;342(7):449-453
18. Dewey KG, Lovelady CA, Nommsen-Rivers LA, et al: A randomized study of the effects of aerobic exercise by lactating women on breast-milk volume and composition. N Engl J Med 1994;330(7):449-453
19. Dewey KG, McCrory MA: Effects of dieting and physical activity on pregnancy and lactation. Am J Clin Nutr 1994;59(2 suppl):446S-453S
20. McCrory MA, Nommsen-Rivers LA, Molé PA, et al: Randomized trial of the short-term effects of dieting compared with dieting plus aerobic exercise on lactation performance. Am J Clin Nutr 1999;69(5):959-967
21. Wallace JP, Inbar G, Ernsthausen K: Lactate concentrations in breast milk following maximal exercise and a typical workout. J Women's Health 1994;3(2):91-96
22. Carey GB, Quinn TJ, Goodwin SE: Breast milk composition after exercise of different intensities. J Hum Lact 1997;13(2):115-120
23. Nygaard I, DeLancey JO, Arnsdorf L, et al: Exercise and incontinence. Obstet Gynecol 1990;75(5):848-851
24. 24. Nygaard IE, Thompson FL, Svengalis SL, et al: Urinary incontinence in elite nulliparous athletes. Obstet Gynecol 1994;84(2):183-187 [erratum in Obstet Gynecol 1994;84(3):342]
25. Elia G: Stress urinary incontinence in women: removing the barriers to exercise. Phys Sportsmed 1999;27(1):39-52
26. Bo K, Talseth T, Holme I: Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;318(7182):487-493
27. Nygaard I: Prevention of exercise incontinence with mechanical devices. J Reprod Med 1995;40(2):89-94

Olympian Outlines Postpartum Exercise Benefits Returning to activity after pregnancy can seem daunting, even for some Olympic athletes. Alexandra Powe Allred, who earned a spot on the US Olympic women's bobsled team in 1994 when she was 4 1/2 months pregnant with her second child, found that she had the drive to quickly regain her former fitness level, but information was scarce. When other Olympic moms heard about Allred's athletic achievements during pregnancy, they turned to her for advice. The problems and solutions they had about exercise, pregnancy, and juggling motherhood and sports are detailed in a book that Allred, who lives in Midlothian, Texas, wrote for athletes and nonathletes alike: Entering the Mother Zone: Balancing Self, Health and Family (Terre Haute, Indiana, Wish Publishing, 2000). Allred knows how it feels to exercise—and not exercise—postpartum. She says she rarely exercised during and soon after her first child. However, achieving her bobsledding goals meant being active during and after her next two pregnancies. "Exercise was a major stress release," Allred says. "I was so much happier and I was so much better at handling the hectic times." Sports medicine analogies are useful for any patient who seeks a speedy return to former fitness level, says Allred, who also teaches martial arts. "It took about 10 months to have the baby, and it often takes about 10 months to get back in shape," she says of competitive athletes. "People who exercise understand injuries, and they look at the postpartum time as one big injury—they take it in stride." Breastfeeding during training included doing the heavier feedings before exercise. She notes that her babies did not reject their postworkout feedings. "I made sure to always find a quiet, isolated place to feed afterward where I could be alone with the baby," she says. Being active after pregnancy offers rewards for children, as well, Allred says. "By my being so active, my kids think it's perfectly natural to do what I do," says Allred, who recently tried out for a professional women's football team. "I know that Kerri, Katie, and Tommy are going to be very active people." Lisa Schnirring Minneapolis

Dr Ringdahl is a family practice physician in the department of Family and Community Medicine at the University of Missouri School of Medicine in Columbia, Missouri. Address correspondence to Erika N. Ringdahl, MD, School of Medicine, University of Missouri-Columbia, Dept of Family and Community Medicine, MA303 Medical Sciences Bldg, One Hospital Dr, Columbia, MO 65212; e-mail to ringdahl@health.missouri.edu.