Post-Partum: Evidence-based strategies and guidelines for return to sport/ life

This article will discuss evidence-based principles for post-partum women who are breastfeeding and want to resume or begin training for endurance sports and activities. Depending on any comorbidities or trauma from the birthing process, the starting timeline would vary. One reason to improve fitness before and during pregnancy is the ability or capacity to return to sport and activities much sooner. A study found that 38% of elite female athletes returning to running withing 6 weeks postpartum compared to only 4% in nonathletes (Bø et al., 2018). Examples of absolute contraindications would be restrictive lung disease, severe anemia, serious cardiovascular, respiratory or systemic disorder (Wise, Binkley & Binkley, 2020). If one has an uncomplicated delivery, guidelines are to begin a structured exercise regime within 4-6 weeks postpartum (Pruett & Caputo, 2011).

 Some research has even reported benefits of beginning low impact strengthening and flexibility routines like Pilates within 3 days post-partum (Ashrafinia et al., 2015). However, for the sake of preparing for cardiovascular endurance, beginning at 4-6 week postpartum is advised. One reason for implementation is that postpartum women usually have decreased VO2max compared to their pre-pregnancy fitness (Zourladani et al., 2015). The RCT by Zourladani et al. (2015) of 42 women investigated implementation of 50–60 minute training sessions done 3 days per week for 12 weeks which included aerobic, flexibility, and resistance training. Aerobic efforts were done at an intensity of no greater 60-70% of predicted maximal heart rate or 12 of 20 of the Borg fatigue scale. The control did not engage in formal exercise. Modes of aerobic included low-impact dance aerobics for 20-25 minutes.

Resulting outcomes of the intervention group was improved VO2max versus control with no negative side-effect or lactation issues.

A three-stage progression principle should be used as a framework to progress from postpartum to full engagement in an endurance event such as cycling or running. According to the NSCA’s coaching considerations for postpartum training, first is returning to some level of physical training below the intensity when they were pregnant. Second stage is to return to the specific sport, but a lower intensity and volumes. Third stage is to progress back to the baseline (or surpass) which was present in the pre-pregnancy period (Bø et al., 2018).

A recent study by Zhang et al. (2025) evaluated aerobic and resistance training for 10 weeks in 21 postpartum participants to improve issues of pelvic floor dysfunction. The exercise regimen began when participants were between 42 days to 3 months post-partum. Modes of aerobic training consisted of stationary cycling 3x/ week for 20 minutes not exceeding 60-70% of max heart rate. Additionally, brisk walking for 20 min 3x/ week. Progression began at week three increasing cycling to 25 minutes and intensity maintained at 70-80% max heart rate. Brisk walking also increased to 25 minutes. Weeks 7-10 involved 30 minutes of stationary cycling at 70-80% max heart rate and walking kept at 25 minutes.

Therefore, according to the previously mentioned RCT’s and guidelines, I would recommend beginning gradual exposure of aerobic training in uncomplicated postpartum population around 4 weeks after birth. In highly trained females, they could start sooner and at higher volumes and intensities, but still lower than their pregnancy fitness levels. General guidelines for average fitness levels I would suggest the Borg scale working no more than a 12 of 20 effort (60-70% max HR) with low impact aerobic activity (cycling, incline treadmill, elliptical, stepper) performed 3x/week for 20 minutes. Brisk walking/ pushing stroller for another 20-25 minutes done 3x/week. These activities could be progressed for 10-12 weeks via increase in duration, frequency, and intensity. By 12 weeks the gradual exposure to more impact aerobics should be considered if desired (i.e. jogging, pickleball/ tennis, mountain biking). Regarding networking/ referral, Usually the OB/GYN will give permission for formal exercise after 4-6 weeks postpartum if the birth was without complications (Pruett & Caputo, 2011). Other efficacious special considerations may need to be with a registered dietician (Bernier et al., 2024).

References:

Almquist, N. W., Sandbakk, Ø., & Solli, G. S. (2022). Performance-Related Physiological and Haematological Changes During Pregnancy and Postpartum in a Well-Trained Cyclist Performing Endurance Training. Frontiers in Physiology, 13, 762950. https://doi.org/10.3389/fphys.2022.762950

Ashrafinia, F., Mirmohammadali, M., Rajabi, H., Kazemnejad, A., Sadeghniiat Haghighi, K., & Amelvalizadeh, M. (2015). Effect of Pilates exercises on postpartum maternal fatigue. Singapore medical journal, 56(3), 169–173. https://doi.org/10.11622/smedj.2015042

Bernier, E., Simoneau, C., Desroches, S., Morisset, A. S., & Robitaille, J. (2024). Implementation of Postpartum Nutritional Interventions in Healthcare, Community and eHealth: A Systematic Review. Maternal and child health journal, 28(11), 1897–1910. https://doi.org/10.1007/s10995-024-03985-5

Bø, K., Artal, R., Barakat, R., Brown, W. J., Davies, G. A. L., Dooley, M., Evenson, K. R., Haakstad, L. A. H., Kayser, B., Kinnunen, T. I., Larsen, K., Mottola, M. F., Nygaard, I., van Poppel, M., Stuge, B., & Khan, K. M. (2018). Exercise and pregnancy in recreational and elite athletes: 2016/2017 evidence summary from the IOC expert group meeting, Lausanne. Part 5. Recommendations for health professionals and active women. British journal of sports medicine, 52(17), 1080–1085. https://doi.org/10.1136/bjsports-2018-099351

Pruett, Michele Dell PhD, ATC1; Caputo, Jennifer L PhD, CSCS2. Exercise Guidelines for Pregnant and Postpartum Women. Strength and Conditioning Journal 33(3):p 100-103, June 2011. | DOI: 10.1519/SSC.0b013e31821c3261 

Wise, Stephanie L. MS, ATC, CSCS1; Binkley, Jean L. MSN, MEd, RN2; Binkley, Helen M. PhD, ATC, CSCS, NSCA-CPT, FNSCA1. Pregnancy and Postpartum Training: Coaching Considerations. Strength and Conditioning Journal 42(4):p 93-104, August 2020. | DOI: 10.1519/SSC.0000000000000557

Zhang, L., He, J., Zhang, Q., & Wang, L. (2025). A Study on 10-Week Combined Aerobic and Resistance Training Exercise Prescription for Female Patients with Pelvic Floor Dysfunction. Healthcare (Basel), 13(6), 592. https://doi.org/10.3390/healthcare13060592

Zourladani, A., Zafrakas, M., Chatzigiannis, B., Papasozomenou, P., Vavilis, D., & Matziari, C. (2015). The effect of physical exercise on postpartum fitness, hormone and lipid levels: a randomized controlled trial in primiparous, lactating women. Archives of Gynecology and Obstetrics, 291(3), 525–530. https://doi.org/10.1007/s00404-014-3418-y

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