Until recently, exercising during pregnancy was not very common. Research supporting exercise during pregnancy was vague, and studies or guidelines on how to return to exercise after childbirth were sparse. Even athletes that were training while pregnant often had to hide the fact from their sponsors and fans.

With more celebrities documenting their pregnancy and postpartum journeys through social media, and with pro athletes like Alysia Montaño and Kara Goucher talking about the lack of maternity leave in high-profile places like the New York Times, more attention is being brought to training and racing during and after pregnancy. Now, as more pro athletes return to the running, triathlon, and even basketball post-childbirth, our understanding of what is possible is changing—but research hasn’t necessarily kept up.

Return to training postpartum can be one of the most challenging things an athlete goes through. During pregnancy, the body adapts to the growing needs of the fetus, and the cardiovascular, musculoskeletal, and physiological systems are significantly affected. For example, resting heart rate and oxygen consumption increase, there may be a separation between the ab muscles, and several changes in posture and walking mechanics have been documented.

While the definition of postpartum is 6-12 weeks, this assumes that the body recovers at this time—but there is extremely limited research in athletic postpartum populations. Though the cardiovascular and physiologic changes of pregnancy are temporary, we can’t say for sure this is true of musculoskeletal changes (including changes to strength and flexibility). This is why it’s important to listen to your body as you return to postpartum training.

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The challenge of returning to training postpartum

Despite this renewed attention to the fourth trimester, the postpartum state, exercise prescription and advice still seems to be vague. One document that highlights the lack of recommendations is the recently published committee opinion on pregnancy and postpartum physical activity by the American College of Obstetricians and Gynecologists (ACOG) in 2020. Of the total words in the document (3840), 221 words (5.75% of all words)—less than one page of the article—had guidelines for the postpartum athlete. In the two paragraphs discussing postpartum exercise, ACOG stated that health care providers should “reinforce a healthy lifestyle” and assist new mothers as they resume or start new exercise. They recommended resuming old exercise routines and adding pelvic floor exercises once medically safe. ACOG advised lactating mothers to feed the child prior to engaging in exercise, because exercise with full breasts can be uncomfortable. While the section on exercising during pregnancy included specific details on duration and intensity, the section regarding postpartum return to sport was brief and lacked detail. Without more information and with only vague guidelines to follow, postpartum athletes may start or return to high-impact sports like running with pre-existing risk factors for injury, like pain, that could have long-term implications on their physical and mental health.

Even if better research and guidelines existed, a return to training can be challenging for a variety of reasons. Due to the anatomical and physiologic changes in pregnancy and from childbirth related-trauma, recovery should be considered similar to any major injury (like a bike crash or rupturing your ACL). A variety of factors can influence your return to training after a bike crash: How bad was the crash and what structures were affected? How many days did you have to take off from training to recover? Were there any complications in the healing process? For someone who scraped their knee, there may be no time lost and they may be back in the saddle; however, for someone who broke their clavicle this could be a very different situation.

Similarly, athletes’ pregnancies and labor experiences will be very different. Some cannot train through pregnancy and may even be put on bedrest; some may have a perfect pregnancy but a complicated delivery with significant birth-related trauma; and some may be able to continue running up to the due date and have no delivery-related complications. You may have a planned or unplanned cesarean section, which could require additional restrictions on lifting and weight-bearing for a few weeks. With a vaginal delivery, there may be minimal perineal tearing (knee scrape) or a lot of tearing (more rehabilitation and potential pelvic floor complications).

But one thing almost every new mother has in common is that they find they can’t just start up where they left off in their training plan. Childbirth is a big event for the body, and that requires recovery time. Everyone’s pregnancy and postpartum journey is individualized, and therefore there aren’t any return to training plans out there that are one-size-fits-all. But there are some general guidelines athletes can follow when returning to training after pregnancy and delivery.

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How to start returning to sport post-partum

The first step to exercising during pregnancy or returning to training postpartum is to talk to your medical provider (the one supervising the pregnancy) about exercise-related goals as soon as you can. If newly pregnant, the provider will check for any reasons you shouldn’t exercise over the next nine months—these can include premature labor, heart and lung complications, or issues with your cervix.

Physical activity during pregnancy, though, has been seen to have a lot of benefits for the mother and baby, and exercise is now encouraged. The mode of exercise should be safe—no risk of abdominal trauma or falling (so staying on easy, paved trails and bike paths with minimal fall risk)—and the environment should be safe (e.g., not too hot). Exercise should be stopped if there is any vaginal bleeding, dizziness, shortness of breath, contractions, amniotic fluid leakage etc. If able, athletes have been seen to exercise right up to their due date and each mother should do what is comfortable and best suits them, whether that is changing the mode (from running to run-walk intervals or just swimming) as the pregnancy progresses.

RELATED: Training in Pregnancy: How to Swim-Bike-Run Safely

Post-childbirth, the first step is screening for readiness to return to training. The birth provider can refer the athlete to a physical therapist with experience in postpartum return to exercise. The physical therapist will perform a thorough screening and evaluation of muscle strength, flexibility, motion, physiological variables (sleep, fatigue, depression, cardiovascular health), pain, infection, how the person responds to impact-related screening (such as hops and jumps), review medical history, and watch for any change in swim, bike, or run mechanics to decide where the person needs to start.

During the postpartum period it is also imperative to screen for pelvic floor-related continence and prolapse issues, no matter the delivery method. If any symptoms of urine leakage, bulging or a sense of something falling out of the vaginal area, accidental fecal leakage, pain with bowels or intercourse/tampon use, or pain/ bulging in abdomen exist, a referral to a pelvic floor physical therapist is highly recommended.

A pelvic floor screening usually entails an external or internal exam, depending on the provider. If the internal exam is needed, it is usually performed 3-6 weeks after delivery, where the therapist will palpate the muscles with one finger and measure how the pelvic floor is contracting (speed, coordination, relaxation of the contraction). It is far less intrusive than a standard gynecological exam, as a speculum is not used.

If the athlete passes the screening, and has been cleared by the medical provider to begin return to sport, a gradual return is recommended. In the early stages the focus should be on the strength and endurance of the main muscle groups that drive the training movements and may have been most affected by pregnancy and childbirth. These muscle groups include the hips, core, pelvic floor, and foot.

RELATED: Pelvic Floor Pain: What It Is, Exercises to Do, And When to See a Therapist

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When can I safely begin training after having a baby?

Swimming

Clearance for exercise postpartum is extremely important, as some women have preeclampsia (high blood pressure) postpartum and may need to be hospitalized. A medical provider should also confirm all incisions have healed fully before returning to exercise.

For swimming, due to the lack of impact and support needed by the pelvic floor muscles, if all incisions have healed, strength and endurance of the core, upper body, and lower body muscles can be initiated in tandem with some swim yardage (depending on what an athlete was doing during pregnancy and how much time off they have had).

RELATED: Training Plan: Returning to Swimming After a Break

Running

Because of the individualized nature of the pregnancy journey and the process of childbirth, there is no set timeline or guideline on how to return to running. However, a recent article provides more guidance and ability to return to running. As always, medical clearance is recommended.

This return should begin with focusing on strength and the muscles most affected. Experts have recommended hips, core, pelvic floor, and foot strengthening. This can be done in conjunction with starting some walking intervals (starting at 10 minutes and building up to 30 minutes over a couple of weeks) to prepare for the impact of running. Currently, the recommended approach is to build the ability to walk 30 mins over 3-4 weeks before progressing to running.

Plyometrics are usually introduced during the last stage of return-to-running rehabilitation, to ensure the athlete is ready for the impact related demands of the sport. Although the exact “how” to progress is debated in the scientific literature, for the postpartum athlete a conservative approach of no more than a 10% mileage increase each week is usually used. For example, if after progressing from walking and run/walk intervals the athlete is running one mile every other day (48 hours of rest is recommended between workouts for adequate rest and recovery), their total weekly mileage for the week would be 3 miles and with the general 10% rule the next week the total mileage would be 3.3 miles, with each run only increasing to 1.1 miles.

Cycling

For cycling, athletes with a vaginal delivery or perineal trauma may choose to initiate this mode of exercise last, after significant healing has taken place. Over the course of 3-6 months, the athlete can prepare for a return to cycling by doing strength exercises, starting with those performing lying down (such as bridges and core work) and progressing to standing. From there, the athlete should progress from double-leg to single-leg exercises (such as squats), to increase strength and endurance and to match the demands of the sport.

Athletes may want to consider riding indoors on a spin bike or trainer setup at first. This will allow them to ease into riding again by building up technique and endurance; indoor riding also allows a ride to be paused quickly if discomfort is a factor. As the athlete builds up strength and endurance once more, outdoor riding can be resumed.

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Overall signs and symptoms as you return to training

During the return to sport rehabilitation, the athlete should be monitored for change in symptoms, including pain and pelvic floor symptoms as mentioned above. An athlete with certain symptoms (mild incontinence) may be able to continue the return to sport progression with medical management or as long as symptoms are not getting worse. Current injury prevention recommendations are recommending building up strength and endurance with a slow progression, as too much too soon may lead to injury, and the same principles should be applied postpartum. Building the body’s capacity is going to help with injury prevention in the future.

Breastfeeding (any changes to milk production), nutrition, sleep, and fatigue should also be assessed during this time and the workout plan should be altered based on how the athlete is feeling that day. If there have been several nights of poor sleep (<6hrs) and general fatigue, the training plan should be altered to more recovery-type workouts vs. harder or longer runs/rides.

It is possible to return to training and racing after pregnancy and childbirth—and even improve. Accessible research and advice is still lacking to provide more detailed guidance, however from what does exist, an individualized progression is highly recommended. Exercise is beneficial during pregnancy and postpartum, and each person should be encouraged to continue and return to exercise, if possible, once cleared by the medical provider supervising their pregnancy.

Dr. Shefali Christopher is a board-certified clinical specialist in sports physical therapy and assistant professor at Elon University. She completed a Ph.D. in 2021, which focused on risk factors for running-related pain after childbirth, and has given numerous talks on treating endurance athletes, especially the female athlete and the pregnant and postpartum runner. Shefali is also a contract physical therapist with USAT paratriathlon, including supporting the team at Tokyo 2020.