A woman’s body goes through significant physiological and psychological changes during pregnancy, and labor and delivery. As a health and fitness professional, you have a duty to understand:
- How your client’s body changes during pregnancy
- Any potential birth trauma they may have experienced
- How to help them rehab and recover post-pregnancy
- How to help them return to exercise safely and effectively
While the goal is to help women be as strong and positive about birthing as possible, it is just as important to have a good understanding of potential traumas, and to treat postpartum clients much like any other client whose body needs time and care to heal and rehabilitate, without making them feel like an injured person.
Be thoughtful about the language you use to describe what you observe or think regarding their body and their experience. Do your best to keep their interactions with you positive, especially during any type of assessment. Your client may already feel judged, evaluated, damaged, or unhappy about their current state or their birth experience.
Do your best to ensure that you’re being welcoming, sensitive, compassionate, and constructive throughout your postnatal assessment process. At this time, it is important that you don’t point out all of the things that are “wrong” or “off” about your client, the way they move, how they’re recovering, or how they are coping.
Focus on using the assessment as an information-gathering session instead of an opportunity to point out all of the things your client may need to work on in the near future.
Before You Begin: Getting Medical Clearance
To start, it’s important to confirm that your postpartum client has received clearance from their healthcare practitioner — typically at the six-week check-up — to return to exercise. If a client is less than six weeks postpartum and is anxious to get back to their workouts, and you’re wondering if you can train them without clearance from their doctor, remember this: Your work as a coach at this early stage is to help set their expectations.
Whether your client had a vaginal birth or a C-section, they must understand that they are in recovery mode, and that returning to exercise immediately isn’t likely to be in their best interest. During the first few weeks postpartum, there is important foundational work they can do that includes breathing techniques and gentle bodyweight movements. This work will prepare them to move forward through the rehabilitation phase, with consistent and gentle testing by you to gauge improvement along the way. However, you should obtain approval from your client’s doctor before encouraging them to engage in any physical activity.
The Postnatal Physical Activity Readiness Questionnaire
Once your client is cleared to return to exercise, you will perform a screening process that includes a questionnaire and a movement screen, just as you would with any other client. However, your screening process should be specifically designed for postpartum women.
Note from GGS: the Coaching & Training Women Academy’s Pre- & Postnatal Coaching Certification provides students with a comprehensive Postnatal Physical Activity Readiness Questionnaire (P-PARQ), which will not only guide your exercise programming considerations, but it will also help you determine when to refer a client to another professional.
Along with general information, such as name, contact details, and emergency contact, you should obtain information about your client’s delivery date and type (vaginal or C-section), number of pregnancies, outcome of the six-week check-up, breastfeeding status, and any continued bleeding.
In some cases the P-PARQ may reveal minor issues that wouldn’t prevent you from coaching a client. While getting approval from — or consult with — a healthcare professional is technically not required, communicating with your client’s healthcare provider is recommended. You could share the conditions that were revealed in the questionnaire and request feedback on the exercise program you intend to give to this client.
If you or your client suspects that they may have issues with their pelvic health such as pelvic organ prolapse or incontinence, your client will need to be assessed by a doctor or specialist, like a pelvic health physiotherapist. While all pregnant and postpartum women should ideally be under the care of a pelvic health physiotherapist, concerns about these issues might be a good catalyst to encourage your client to make an appointment if they’ve been hesitant about it in the past.
Knowing when to make a referral is a critical part of working with a postnatal client. If the P-PARQ reveals a serious condition, something doesn’t seem “normal” or your client has any concerns, that is your cue to refer.
Examples of what’s not normal include, but are not limited to:
- Bleeding or passing clots past six weeks postpartum
- Pelvic or back pain
- Urinary or fecal incontinence
- Downward pressure or heaviness in the pelvis
- Protruding tissues around the vagina
These types of issues should always be referred. As a coach it is important that you trust your gut and if doesn’t seem right, then follow up.
Remember: when in doubt, refer out!
Visual and Physical Movement Screen
You may already have a system in place to analyze a client’s posture, strength, relative weakness, and mobility. As a coach, you should gather all of the skill sets you have acquired in practice and apply them to the postpartum population.
During pregnancy and the immediate postnatal period, the increase in weight through the anterior part of the body may result in postural changes. As the abdomen grows heavier and protrudes, the pelvis can tilt forward (anteriorly), increasing the lordotic curve in the lower back in some women. This may result in lengthening of the glutes and hamstrings and may reduce the ability of the pelvic floor muscles to function optimally. Anterior pelvic tilt may also contribute to stretching of the already lengthened abdominal muscles. In some women, you may find that this posture also results in shortened (or stiff) lower back muscles.
Conversely, you may notice that a client’s pelvis is tucked under (posterior pelvic tilt) producing a more flattened lumbar spine and reduced gluteal bulk. Your client may be over-engaging their superficial abdominal muscles (or not).
During the postpartum period, the breasts often grow in size significantly which, in conjunction with the common postures observed in new mothers (e.g. while breastfeeding, carrying the baby on one side or the other), can mean that the muscles of the chest become shortened and the muscles in the upper back lengthened. In this case, you may notice that the client’s hands come forward from the anatomical position with their palms facing backward. These postural adaptations can be compounded by lack of sleep, a change in routine, and low mood.
It is important to keep mind that there is probably no such thing as a “perfect posture.” Many studies have shown that there doesn’t seem to be an actual link between certain postures and pain, so we need to be careful about dictating the idea that things always have to be done a certain way [1-2]. For example, we cannot confidently say that a client will not experience pain by adopting a neutral spine.
Having said that, you may find that changing a client’s alignment helps their healing process or reduces pain by allowing better activation of some deeper muscle groups and by reducing load on sensitive structures. Some postures may influence breathing patterns and the pressures on the pelvic floor and through the healing linea alba. If your client habitually stands in a sway posture and has back pain when rocking their baby for six hours per day, you may find that simply teaching them to shift their pelvis backward helps reduce that pain.
Keep an open mind when it comes to assessing posture and alignment. Is that posture actually helping your client achieve what they need to do functionally, or are they adopting a posture that is actually contributing to their pain or is detrimental to their performance? Do they have a variety of postures that they use throughout the day or do they tend to stay in sustained postures? Our bodies crave variety in movement, so encourage your client to adopt lots of different postures throughout the day where possible.
In the left hand drawing, the pelvis and knees are forward. In the right hand image, the ribs are thrusting the top half of the body out in front of the lower body
Performing a movement screen will help you identify potential issues at the outset so that you can program some remedial work to correct any imbalances that might be relevant. Your screening process should be based on your scope of practice and your expertise. For example, if you have been trained in FMS, you can incorporate this training into your postnatal practice. The following are important to assess in the postpartum population:
- Standing Posture
- Breathing Patterns
- Diastasis Recti
When looking at standing posture, try not to draw any initial conclusions from what you see — just observe and document. Remember that everyone will have asymmetries, leg length discrepancies, or little postural quirks, many of which are not causing them pain or dysfunction.
Ask your client to stand facing you, so that you can observe them from the front. You may notice some asymmetries such as unequal shoulder heights, reduced bulk of the quadriceps in one leg, obvious foot pronation, or everted feet.
Next, look at your client from the side and assess their alignment. Start at the feet and work your way up to check alignment of the ankles, knees, hips, shoulders and ears. You are looking for:
- Anterior or posterior pelvic tilt
- A flat derrière
- Palms facing back
- Abdominal profile
- Flared ribs
- Shoulders rounded forward
- Neck jutting forward (chin-poke position)
Observation from behind can also show muscle asymmetries (e.g. around the shoulder blades and spine) and other potential postural concerns.
Remember that some of the anomalies you may see might not be problematic at all for your client, while others may benefit from postural cues in order to reduce pain or to better perform an exercise. For example, if your client tends to rotate their ribcage upwards in a standing position and complains of pain in this posture, you could cue them to relax their ribcage down. If their pain lessens, then changing this posture may be of benefit. Likewise, if you notice that your client adducts and internally rotates one knee while squatting, you could cue them to direct their knee over the middle of their foot. If they notice that their knee feels better, or if they feel more work in their glutes, this may be a useful cue for them.
Assessing breathing patterns can be important for all clients, and particularly for postpartum clients, who often adopt poor strategies when recovering from pregnancy. Without prompting your client, observe how they are breathing throughout the screening process. What is their breathing like when they are sitting upright? Check again in supine, where gravity changes the pressures in the abdomen. Ask your client to place one hand on their abdomen and one on their lower rib cage and ask them to tell you what they feel moves on the inhale and the exhale.
In quiet breathing, you should observe the abdomen and rib cage expand when your client inhales and relax down when they exhale. There should be minimal movement in the upper chest in quiet breathing. Interestingly, it is estimated that around 10 percent of the population has a breathing pattern disorder, but it is more common in women (14 percent) . A breathing pattern disorder will often present as an upper chest breathing pattern and hyperventilation, and may be accompanied by symptoms like mood changes, anxiety, increased pain sensitivity, and neck/shoulder pain.
You may notice that your client barely moves their abdomen at all as they breathe. This may be habitual or as a consequence of “sucking their tummy in” in an attempt to reduce the size of their tummy. You should encourage your client to relax their abdominal muscles and see if they can allow the rise and fall of their abdomen with each breath.
Clinically, some of us have also seen situations where clients don’t move their rib cages at all and just pump the abdomen up and down. This could be considered dysfunctional as well.
In this article, you learned how as the abdomen expands in pregnancy and the linea alba stretches, the inter-recti distance between the abdominal muscles increases. This is considered to be a normal response to accommodate the developing baby.
Diastasis recti abdominis has become a hot topic for many new mothers, with many articles and programs all over the internet helping women “close the gap”. When working with pregnant and postpartum clients, it is beneficial to know how to assess the extent of the inter-recti gap, when to refer to a healthcare practitioner, and how to monitor the abdominal wall during exercise.
It is important to educate your client that management of diastasis recti is not all about the “mummy tummy.” It is about improving the function of the core. Clinical experience tells us that many women who have a wide, deep diastasis will often find it more challenging to do higher level strength activities, as their linea alba does not transfer load as well.
Having said that, the research also tells us that the presence of diastasis recti abdominis is not always a good indicator of the potential for back pain or pelvic floor dysfunction . In fact, some women and men who have not been pregnant have an inter-recti gap and are fully functional. A study performed in 2009 on 150 women who had never been pregnant concluded that a separation of 22 millimeters at a point 3 centimeters above the umbilicus was considered normal . Additionally, for many women, this gap closes naturally without any need for further intervention.
While many physical therapists will use real-time ultrasound machines in the clinical and research setting to measure the diastasis recti abdominis, this is usually not possible for those of us in gym settings. Manual palpation can also be very effective for monitoring a client’s diastasis recti abdominis over time, when the assessments are performed by the same person .
You need to pay special attention to a diastasis recti if the gap is more than two fingers apart or is very soft. If the gap is two fingers or less and has good tension that the client can easily create (e.g. through cueing certain muscle groups such as the pelvic floor or transversus abdominis), then you usually won’t have to program specifically for diastasis recti. A general postnatal program focusing on correct breathing and alignment, along with appropriate core and glute work, will often suffice.
Continue to monitor whenever the intensity of the abdominal exercises increases, such as when progressing from modified to full planks, or when commencing exercises such as deadbugs. Monitoring can be done through observation and palpation — don’t be afraid to get down on the floor and palpate abdomens (with your client’s permission, of course!)
Remember that women who gave birth 10 years ago can still address this issue, so don’t write them off just because they are some years postpartum.
If your client has a diastasis greater than two fingers in width, or lacks any tension in the linea alba, a referral to a physical therapist who is trained in diastasis recti abdominis is essential. A diastasis is not a contraindication to general exercise, but you can work closely with a physical therapist to keep your client moving well.
Other Useful Assessments
Other assessments that can be helpful with this population include, but are not limited to: gait, core function, and functional movement.
If you’re interested in learning even more about assessing postnatal clients and designing programs to help them rehab and retrain their core and pelvic floor, and return to exercise after pregnancy, check out the Coaching & Training Women Academy, which offers the world’s first evidence-based, body-positive, interdisciplinary Pre- & Postnatal Coaching Certification.
It was created by 16 world-class women’s health experts including:
- 6 physiotherapists
- 4 pre- and postnatal fitness experts
- 3 PhDs in psychology, exercise science, and molecular biology
- 1 OB/GYN
- 1 doula
- 1 nurse practitioner who is also a midwife
These experts come from five countries and have over 200+ years of experience (and two dozen children!) between them.
This self-paced, fully online certification comes with a ~500 page textbook, 100+ page workbook, and a mobile-friendly online portal that houses instructional videos, workout templates, downloadable PDFs, and much more.
Your assessment of a postnatal client is an essential starting point for postnatal rehab.
It will give you the confidence to know whether your client is physically ready for exercise by flagging any contraindications or precautions for exercise. It will also serve as a way to set goals with your client.
Assessing your client and discussing goals from the outset will ensure that you are both on same page when it comes expectations, exercise program design, and tracking progress over time.
- Barret E, O’Keeffe M, O’Sullivan K, Lewis J, McCreesh K, Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review, Manual Therapy, Volume 26, December 2016, Pages 38-46. https://www.sciencedirect.com/science/article/pii/S1356689X16306877
- Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM, Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents, Phys Ther. 2016 Oct;96(10):1576-1587. Epub 2016 May 12. https://www.ncbi.nlm.nih.gov/pubmed/27174256
- Thomas M, McKinley RK, Freeman E, Foy C, Price D, The prevalence of dysfunctional breathing in adults in the community with and without asthma, Primary Care Respiratory Journal, 2005 Apr;14(2):78-82. https://www.ncbi.nlm.nih.gov/pubmed/16701702
- Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K, Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain, British Journal of Sports Medicine, 2016 Sep;50(17):1092-6. doi: 10.1136/bjsports-2016-096065. Epub 2016 Jun 20. https://www.ncbi.nlm.nih.gov/pubmed/27324871
- Beer GM, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber SA, The normal width of the linea alba in nulliparous women, Clinical Anatomy, 2009 Sep;22(6):706-11. doi: 10.1002/ca.20836. https://www.ncbi.nlm.nih.gov/pubmed/19637295
- Mota P, Pascoal AG, Sancho F, Carita AI, Bø K, Reliability of the inter-rectus distance measured by palpation. Comparison of palpation and ultrasound measurements, Manual Therapy, 2013 Aug;18(4):294-8. doi: 10.1016/j.math.2012.10.013. Epub 2013 Jan 5. https://www.ncbi.nlm.nih.gov/pubmed/23298825