Returning to Exercise After Childbirth: A Clinical Guide for Physiotherapists

As physiotherapists, we play a central role in guiding safe, evidence-based return to physical activity after childbirth. This article outlines the key clinical principles underpinning postpartum exercise rehabilitation.

Why Exercise Matters in the First Year Postpartum

Research demonstrates substantial benefits of postpartum physical activity:

• 45% reduction in the odds of depression
• 37% reduction in urinary incontinence risk
• Improvements in BMI, lumbopelvic pain, sleep, mood, and energy levels

Importantly, initiating or returning to moderate-to-vigorous physical activity within the first 12 weeks postpartum appears particularly beneficial for mental health outcomes .

For physiotherapists, this reinforces the importance of early, appropriate, and individualised exercise guidance.

Who Should Exercise After Childbirth?

The short answer: most postpartum women and people without contraindications should be physically active.

However, certain clinical presentations require medical review prior to moderate-to-vigorous intensity activity, including:

• Unresolved heavy vaginal bleeding
• Severe abdominal pain
• Haemodynamic instability
• Postpartum cardiomyopathy
• DVT symptoms
• Chest pain or neurological symptoms

These are relative contraindications requiring medical guidance — not permanent exclusion from exercise.

Evidence-Based Exercise Prescription

The current evidence supports the following targets during the first postpartum year:

At least 120 minutes per week

Of moderate-to-vigorous intensity activity, spread across at least 4 days per week.

This should include:

• Aerobic training (e.g., brisk walking, cycling, swimming)
• Resistance training
• A combination approach rather than one modality alone

Daily Pelvic Floor Muscle Training (PFMT)

Daily PFMT reduces urinary incontinence risk by 37% and is one of the strongest recommendations in the guidelines.

Given that approximately one-third of women experience urinary incontinence in the first year postpartum , pelvic floor screening and technique correction should be routine components of physiotherapy assessment.

Early Mobilisation: Start Gently

Early mobilisation is encouraged, including after caesarean delivery. Research shows early ambulation reduces postoperative complications.

Initial focus:

• Gentle walking
• Light daily activities
• Pelvic floor exercises

Progression to moderate-to-vigorous intensity should occur when:

• Incisions or perineal tears are healed
• Vaginal bleeding does not increase with activity
• Pain is manageable

Clinically, bleeding response can be used as a practical marker of tolerance.

Progression Must Be Symptom-Based — Not Time-Based

A key principle in postpartum rehabilitation is individualised, gradual, symptom-led progression.

Rather than rigid “6-week rules,” consider readiness markers such as:

• Wound healing
• Pelvic floor symptom control
• Musculoskeletal pain management
• Energy availability
• Mental health stability
• Sleep adequacy

Avoid rapid return to high-impact training if:

• Heavy bleeding persists
• Pelvic floor dysfunction is present
• Pain or fatigue worsens

Pelvic Floor and Core Rehabilitation

Pelvic Floor

Daily PFMT is essential. Technique supervision improves outcomes.

Screening for dysfunction postpartum is highly recommended, with referral to pelvic health specialists where indicated.

Core Rehabilitation

Gentle abdominal retraining should begin early as tolerated. Avoid exercises that cause abdominal doming or bulging.

Progressively integrate pelvic floor and deep core function as a coordinated unit.

Breastfeeding and Energy Availability

Exercise does not negatively affect breastmilk quality, quantity, or infant growth .

However, lactation increases caloric requirements by 450–500 kcal/day .

Low energy availability can lead to:

• Amenorrhoea
• Impaired recovery
• Fatigue
• Bone health concerns
• Poor milk supply

For active, breastfeeding patients, physiotherapists should consider:

• Nutritional intake
• Hydration
• Fatigue levels
• Possible anaemia

Mental Health: The First 12 Weeks Matter

14–23% of postpartum women experience depression or anxiety .

Exercise in the first 12 weeks postpartum is associated with:

• Reduced depression severity
• Improved anxiety
• Improved sleep

Given that postpartum depression often peaks during this “fourth trimester,” physiotherapists are in a strong position to support early, safe activity as part of a multidisciplinary care approach.

Severe cases require referral — exercise is supportive but not a substitute for mental health treatment.

Sleep and Sedentary Behaviour

More than half of postpartum women report poor sleep quality. Guidance should include:

• Sleep hygiene education
• Avoiding prolonged sedentary behaviour (>8 hours/day)
• Breaking up long sitting periods

Small behavioural shifts can support recovery and mental health.

Managing Barriers to Return to Exercise

Common barriers include:

• Pelvic floor dysfunction
• Diastasis recti
• Musculoskeletal pain
• Fear of movement
• Fatigue
• Lack of support

Every postpartum journey is different. Tailoring recommendations to the individual’s physical, psychological, and social context is essential.

Clinical Takeaways for Physiotherapists

• Aim for ≥120 minutes/week of moderate-to-vigorous activity.
• Encourage daily PFMT.
• Promote early mobilisation.
• Progress based on symptoms and healing, not arbitrary timelines.
• Screen for pelvic floor dysfunction routinely.
• Consider mental health, sleep, energy availability, and breastfeeding demands.
• Address fear and psychosocial barriers.

Even partial adherence to recommendations confers meaningful health benefits. The postpartum period is not simply about “getting back” to pre-pregnancy fitness, but about building long-term physical and psychological resilience.

References

Davenport, M. H., Ruchat, S. M., Jaramillo Garcia, A., Ali, M. U., Forte, M., Beamish, N., Fleming, K., Adamo, K. B., Brunet-Pagé, É., Chari, R., Lane, K. N., Mottola, M. F., & Neil-Sztramko, S. E. (2025). 2025 Canadian guideline for physical activity, sedentary behaviour and sleep throughout the first year post partum. British journal of sports medicine, bjsports-2025-109785. Advance online publication. https://doi.org/10.1136/bjsports-2025-109785