Pelvic Floor Under Pressure! - How to get back to running after a baby.

Your baby is here, you feel amazing, and you're itching to get back to running as soon as possible. And that’s great! But before you reach for the trail shoes, it is important to pause and evaluate whether your body is truly ready. Running is high-impact. Even if you feel fine, your pelvic floor, amongst other things, may not have regained the strength to handle it. Furthermore, postnatal healing is affected by things like breastfeeding, how you delivered, hormones, personal health status, and so much more. So, whilst some women will be good to go 12 weeks after delivering, others might have a much longer wait.
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​As a pelvic health physiotherapist, I frequently meet women seeking help for injuries caused by running too soon postpartum or escalating their training too quickly. They always tell me that they wish they had known the risks beforehand, as they might have avoided their present discomfort. I do not seek to deter you from your sport; on the contrary, my aim in writing this article is to introduce you to some of the things you need to consider so that you can set yourself up for a safer return to running. Careful monitoring of your recovery and well-planned preparation for impact training is essential. 

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What could go wrong if you start too soon?
​Even if you are an experienced runner, it's important to remember that your body has been impacted by pregnancy and the birthing process. It deserves fair recovery time, and certain muscles will need rehabilitation. Tempting as it may be to skip that process, the hard truth is that if you jump back into training too soon, your risk of injury increases almost fivefold. This is due in part to the sudden rise of intra-abdominal pressure when you run. Your pelvic floor and abdominal muscles need to be strong enough to cope with that pressure. If they are weak, the stress can cause bladder leaking, pain, and even problems like pelvic organ prolapse or abdominal diastasis. Don't rush to start before your body is ready. The potential consequences are not worth it. 
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Inner core, pelvic floor, pressure—what does all this mean? 
​The inner core comprises the diaphragm, the pelvic floor, the Transverse Abdominis (TA) and the Multifidus. Together, these muscles form the intra-abdominal pressure cylinder. The diaphragm is the roof, the Multifidus is at the back, the TA forms the walls, and the pelvic floor is the base. In this cylinder, the pelvic floor and diaphragm behave as a piston. The diaphragm pushes pressure down as you inhale, and the pelvic floor recoils it back with each exhale. The TA walls keep that pressure contained. Working as a team, these muscles generate and maintain pressure within your abdominal cavity. 

​Abdominal pressure gets a bad rep, but it is super important! In a well-balanced core, the pressure is good. It splints your spine and shields you by increasing pressure when larger external forces are acting on your body. In practical terms, it stops you from collapsing in the middle of your body when you jump up and down and protects your organs if you're jabbed in the stomach. Yay pressure!

However, if the inner core is impaired, this pressure can cause big problems. It is common for at least one of these muscles to be affected postnatally. When this happens, you will either have difficulty generating pressure or you won't control it effectively. In either case, the result is a lack of central stability. Your body has to compensate for that to ensure you can still carry on moving and functioning. But this ‘compensation’ strategy often recruits muscles that are not designed for the job, and they squeeze the ‘pressure canister’ in all the wrong places. The outcome: pressure ends up pushing too strongly into the abdomen and the pelvic floor.

What can you do to fix all this and get back to running? 
Ultimately, it comes down to time, retraining the core muscles to work together, and ensuring that all those muscles are strong, flexible and able to do their jobs properly. Please note that the following tips and advice do not replace the importance of a check-up with a women's health physio. If you have a prolapse, incontinence, pain, diastasis, hyper-mobility, or any existing health condition, then you must get professional advice before commencing your run training, and even individuals without any complications really should do the same. With that in mind, let's get started!
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Be patient! 
The first three months after birthing are a time of healing and remodelling in the body. You should not attempt to start impact sport until you are at least 12 weeks postnatal. Even then, it should only be undertaken if you have absolutely no other issues. It's good to remember that soft tissues continue to improve for up to two years postnatally, so if you are not ready now, don't fret; things will get better. The key is to be patient, eat and hydrate well, keep fit with low-impact exercise, and let nature do its thing.

​Correct your alignment. 
During pregnancy, the ribcage has to accommodate your growing baby bump, so it widens and literally tilts back to get out of the way. With your ribs pointing skyward, your brain rewires some information so you don’t feel like you are tipping backwards. Postpartum, your midline perception may still be off-centre, so it’s easy to keep walking around with your upper body hanging behind your hips and not even notice. This posture is problematic because now the ribs (where the diaphragm lives) are no longer in line with the pelvis (where the pelvic floor lives) and this means they lose their synergistic piston relationship. This alignment also makes it hard for your TA walls to engage and keep pressure under control, too. Simply put, the inner core cannot function effectively when you are orientated this way. 

To assess your alignment, place your index fingers on the bony bits at the front of your pelvis, and your thumbs on the rib cage directly above. If your alignment is good, the ribs will be stacked directly over the pelvis, meaning the thumbs and fingers line up perfectly. If they don't, then you can correct this. Exhale and draw the ribcage subtly down until those fingers and thumbs line up. Remember, your perceived centre of gravity might have changed, so don't be alarmed if it feels like you are falling forward; you won't. Keep checking and correcting through the day, and with practice, you will be posture-perfect before you know it! ​

​Optimise your breathing 
You know how to breathe, but do you really? Postpartum breath patterns can be quite muddled up. During pregnancy, the diaphragm gets trapped in a small range of motion for many months. This is because the baby bump blocks its descent path. Once baby has arrived, you might find your ability to manage intra-abdominal pressure is compromised, and you are subconsciously ‘breath-holding' to keep the pressure ‘in.’ This is bad news, as it is forcing that pressure down onto the pelvic floor when tasks get challenging. Sooner or later, the pelvic floor will get exhausted or injured, and result in bladder leaking and unpleasant symptoms in your lady bits.

To check your own breathing, try inhaling slowly, and feel where the breath goes. Did the ribcage and torso expand back, front and sides, did the pelvic floor descend? If so, great! If not, perhaps just your belly rose up and down, or maybe your shoulders moved and nothing else? Now, try exhaling slowly. Did the pelvic floor contract? Did the abdominals draw in? Did the ribs come down? If not, there may be a problem. There are too many dysfunctional patterns to talk about here, but you usually fix them in the same way, and if it proves tricky, please get help from a physio. 

To correct dysfunction and optimise your breathing, I recommend diaphragmatic breathing in a 90/90 position. This posture stacks your ribcage correctly over your pelvis, making it a great way to work on your breathing whilst keeping a good alignment. Once you feel good in this position, then you can progress to more upright postures.

​Train your pelvic floor 
The pelvic floor is a sling of muscles that act as a hammock for the bladder, bowel and womb. As we now know, when you run, abdominal pressure rises and your pelvic floor has to work hard to keep the pelvic organs supported against that. It also absorbs ground forces up to 2.5 times your body weight with every step and simultaneously performs its essential roles of pelvic stabilisation, maintaining continence, and core control, too. Phew! 

Doing Kegels now and again will not cut it if impact sport is your goal. Your pelvic floor needs to squeeze, lift, and move through a full range of motion with ease. It also requires endurance and coordination and must work synergistically with the other core muscles. To be frank, your pelvic floor needs to be in top condition to handle the forces involved with running. 

Get practising at least once a day until you can, in a standing position, easily perform: ten 8-second strong-holds, 60-second sub-max holds and ten fast Kegels with good coordination. At that point, your pelvic floor is probably run-ready, provided no other issues are occurring down there.  

Get to know Transverse Abdominis 
The Transverse Abdominis (TA) is a corset-like muscle that originates from your lower back and wraps around the side of your body. The two sides are connected at the front with a broad connective tissue sheet known as an 'aponeurosis.' The TA is crucial in managing intra-abdominal pressure. It provides tension in the abdominal wall by pulling the aponeurosis tight when it contracts, which keeps the pressure contained. It also attaches to the pelvis and has an important role in stabilising your hips, which is essential for those single-leg landings. All in all, training the TA is an integral component of your preparation to run safely.

To strengthen this muscle, first practice activating the lower, middle, and upper portions, then all three together. The sequence should look like this: Exhale, engage the pelvic floor, draw in the TA, then inhale and release. Start in side-lying if it’s difficult at first, and progress to sitting and then standing. When the whole muscle engages correctly, the abdominal wall will draw toward your spine with no kinks. Practice with a mirror so you can see if it stays flat as you contract it. Remember, the TA is part of a team with the pelvic floor and diaphragm, so coordinate it with your breathing.

​Make sure your legs are super strong!
Let's not forget your lower limbs! Your legs need power to drive you forward, endurance to keep a good form, and landing control to reduce the stress on your body from ground forces. To be strong enough for running, you should perform the following challenges with ease. If you can’t do these tasks, and don’t know how to fix that, then you guessed it: see a physio or fitness professional!

​Start your training and progress gradually
The key here is to take it slowly so that your body can progressively increase its tolerance. If you were running marathons before, you will need to be very patient. It takes time to work up to that level safely.

A good place to start is with the NHS's Couch to 5K programme. This interval training method begins with short-run phases, which gets you up to 30 minutes non-stop running over the 12-week period. You should keep a rest day after each run to allow recovery and adaptation. If you like to keep active on your off-days, you can do low-impact sports like swimming, cycling, and walking. It is also advisable to plan your route to have a mix of soft and hard ground and avoid running downhill where possible.

With that first 12-week phase achieved, you can continue to increase your distance up to 10% per week until you reach your goal. Don’t forget that the further and faster you run, the more pressure there is, so if symptoms suddenly arise at any point in your journey back to running, don’t ignore them. Reach out to a professional for help.

The bottom line
Taking the time to evaluate where you are in your recovery and doing the work to prepare your body for the high-impact sport is essential. If you have diastasis, prolapse, or another health condition, it does not necessarily mean that running is off the cards forever. Still, it may take longer, and you must seek advice from a specialist physio. The tips above will help you know what to work on to reduce your risk of injury, and you can make gradual progressions until you reach your goal. Running is a great sport; if you love it, you absolutely should plan to get back to it after having a baby. Just do it safely!