New Canadian Guideline for Postpartum Physical Activity

During the first year after giving birth, mothers should work up to 120 min/wk of moderate to vigorous physical activity, such as brisk walking and muscle-strengthening exercises, according to a new Canadian guideline. The document focuses on postpartum physical activity, sedentary behavior, and sleep.

Produced by the Canadian Society for Exercise Physiology, the guideline also encourages light-intensity physical activity soon after childbirth to improve health outcomes. It suggests daily pelvic floor muscle training to reduce the risk for urinary incontinence.

Most of all, postpartum patients and physicians should develop individual, gradual plans based on symptoms, necessary healing time, and readiness to engage in postpartum physical activity, the authors wrote.

“Over the last few years, there has been increasing recognition that the postpartum period is far more complex than simply transitioning from pregnancy to not being pregnant,” lead author Margie Davenport, PhD, director of the Program for Pregnancy and Postpartum Health, Christenson Professor in Active Healthy Living, and professor of kinesiology, sport, and recreation at the University of Alberta in Edmonton, told Medscape Medical News.

“There are unique considerations, whether it’s recovering from a Cesarean section, experiencing baby blues, or having fragmented sleep to care and feed their infant,” she said. “This guideline is meant to address the 1-year transition period between the recommendations for pregnancy and the recommendations for adults.”

The guideline was published online on March 25 in the British Journal of Sports Medicine (BJSM).

Updating Postpartum Guidance

Previous guidance for the postpartum period in Canada, which was last updated in 2003, recommended pelvic floor exercises to reduce urinary incontinence and noted that exercise and breastfeeding could be safely combined, Davenport said. There was little guidance on physical activity after birth, however.

To develop this guideline, Davenport and colleagues analyzed 574 studies focused on the postpartum period, regardless of participants’ breastfeeding status, gender, cultural background, disability, and socioeconomic status. During the process, the authors consulted with postpartum mothers to ensure that their priorities were addressed. These priorities included 21 maternal and infant health outcomes such as injury, reduced breast milk quality or quantity, depression, anxiety, urinary incontinence, fear of movement, fatigue, and poor infant growth and development.

Based on recent research, the team concluded that engaging in at least 120 minutes of moderate to vigorous physical activity over 4 or more days per week was associated with a 45% reduction in the odds of developing depression, 37% reduction in the odds of developing urinary incontinence, and 28% reduction in the odds of developing type 2 diabetes — all without adversely affecting breast milk or infant growth — Davenport said.

The authors recommended leveling up to 120 minutes of activity in the first 12 weeks after giving birth for those with no health conditions or symptoms that would prevent them from being physically active. Patients with underlying conditions or symptoms, however, should seek medical advice before returning to moderate physical activity, they wrote.

The guideline also strongly recommended engaging in daily pelvic floor muscle training; developing a healthy sleep routine by avoiding screen time before bed and creating a dark, quiet environment for sleep; and limiting sedentary time to 8 hours or less, including no more than 3 hours of recreational screen time.

“Historically, advice has been given to obtain medical clearance at 6 weeks post partum before engaging in postpartum exercise,” Davenport said. “While this recommendation is intended to ensure adequate healing and recovery, some women are ready to be physically active well before 6 weeks, and others are ready well after 6 weeks post partum. This new guideline emphasizes that one size does not fit all.”

Advising Postpartum Patients

Several systematic reviews and meta-analyses cited in the guideline were also published alongside the guideline in a March 31 online issue of the BJSM. The papers supported numerous types of aerobic and muscle-strengthening exercises during the postpartum period, as well as interventions to reduce sedentary behavior and improve sleep.

“The important intersecting topics of physical activity, sedentary behavior, and sleep all need to be approached from a systems biology perspective, as they are in this guideline,” Sinéad Dufour, PhD, associate clinical professor of rehabilitation science at the Michael G. DeGroote School of Medicine at McMaster University in Hamilton, Ontario, told Medscape Medical News.

Dufour, who wasn’t involved with the guideline, co-authored some of the additional research published in the BJSM. She and colleagues recommended various muscle-strengthening exercises that target the trunk, which can decrease symptoms and lumbopelvic pain during the postpartum period.

“Several recommendations capture the need to understand the early postpartum period as a time of recovery that requires support and is unique for each mother,” she said. “All care providers need to consider the care they provide for new mothers through this lens.”

The guideline was endorsed by the Canadian Association of Midwives, the Canadian Physiotherapy Association, the Chartered Association of Sport and Exercise Sciences, and other groups. Feedback from the postpartum participants indicated that following the recommendations would be “feasible, acceptable, and equitable” and likely to incur minimal costs for patients, the authors wrote.

“My overall impression is that it is long overdue to have this trustworthy guidance,” Dufour said. “Healthcare providers and trainers alike understand that these are key issues to consider but generally don’t broach them head-on as they should, due to lack of guidance.”

The guideline was supported by the Christenson Professorship in Active Healthy Living Research Stipend. Davenport and Dufour reported no other relevant financial disclosures.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.