Physical activity is important for parents during pregnancy and in the postpartum period. That said, the body needs time to recover after pregnancy.

Those eyeing a return to more intensive endurance training may need to wait several weeks or months before they begin their comeback.  

“The plan for a return to exercise, especially more structured training with an eye towards competition after pregnancy, is highly customized,” says Meagan M. Wasfy, MD, MPH, a Mass General Brigham sports cardiologist. “This reflects how variable the pregnancy and postpartum journey is for new parents, including their levels of exercise during pregnancy and their birth experience.”

Working together with your prenatal care provider, primary care provider (PCP), and other specialists can help ensure a healthy recovery and return to training. Dr. Wasfy and Adam S. Tenforde, MD, a Mass General Brigham sports medicine doctor, share tips for postpartum endurance athletes eager to regain peak performance.  

Here’s what you can do:

1. Keep bones healthy.

Producing milk requires calcium. Experts believe milk production, or lactation, pulls calcium away from the skeleton. Without enough calcium, bones may lose bone mineral density (BMD), which keeps them healthy and strong.

Athletes exercising with low BMD may develop overuse injuries to bones, referred to as bone stress injuries. Load management — gradually increasing the length and intensity of workouts — can help prevent these injuries.

While foods high in calcium will not prevent bones from losing BMD during chestfeeding, postpartum athletes must meet the daily minimum requirement for calcium intake. Ask your PCP about calcium supplements, or consider:

• Drinks or foods fortified with calcium and vitamin D. This helps promote bone health.
  
  
• Salmon or sardines, preferably with bones
  
  
• Spinach, collard greens, bok choy, mushrooms, or taro root added into vegetable dishes
  

BMD often returns to normal when menstruation begins, or when children wean off chestmilk.

2. Care for your heart.

The heart works harder than usual during pregnancy. It pumps more blood and beats faster to deliver oxygen to a developing child. After birth, your heart doesn’t need to work as hard. It will, however, reap the benefits of an 8-to-9-month workout.

“The heart is getting stronger from having to pump more blood to the baby. But, as soon as the baby leaves the body, the heart remains strong and no longer has as heavy of a lift,” says Dr. Tenforde.

Some athletes or weekend warriors may return, or even exceed, previous performance levels in the years after pregnancy thanks to the preexisting cardio workload. Contact your doctor if you experience any new symptoms suggestive of a heart issue, such as excessive breathlessness, palpitations, or chest pain.

Blood loss

Blood loss during labor and birth can lead to a shortage of healthy red blood cells, or anemia. These blood cells carry oxygen throughout the body.

Anemia can make you feel:

• Tired 
  
  
• Cold
  
  
• Dizzy 
  
  
• Irritable
  
  
• Short of breath 

Iron allows red blood cells to carry oxygen along the bloodstream. You may need checkups for blood screenings every 3 to 6 months after birth to check your iron levels. Eating foods with iron or taking supplements can help the body produce healthy blood cells and avoid iron deficiency in female athletes.

3. Protect your abdominal core.

Pregnancy can stretch and damage the abdominal muscles, especially those across the belly. These muscles, called rectus abdominis, extend from the bottom of the breastbone to the belly button. A small ridge splits the muscles lengthwise. Together, the muscles support the back and protect vital organs, such as the stomach, liver, and other intestines.

When too much pressure builds against the rectus abdominis from a developing child, the ridge separating one side of the abdomen from the other stretches wider. If stretched far enough, a gap can form in the middle of the abdominal wall. This condition, called diastasis recti (DR), may persist long after giving birth.

Overstretched muscles can weaken the abdomen, compromising its ability to support surrounding organs. DR can also:

• Change posture 
  
  
• Worsen, or contribute to the development of, low-back pain
  
  
• Labor breathing
  
  
• Limit range of motion

For some people, postpartum DR can last for several years. To prevent injury and maximize performance, perform supervised abdominal and pelvic floor exercises to gradually rebuild core strength.

4. Control the pelvic floor.

The pelvic floor sits at the bottom of the abdomen, serving as a hammock-like group of muscles across the pelvis. These muscles hold together the uterus, bladder, bowel, and other pelvic organs.

Like the rectus abdominis, the pelvic floor strains against mounting pressure from a developing child. Those with a weakened pelvic floor may:

• Feel heaviness or fullness in the vagina
  
  
• Struggle to urinate or completely empty their bladder. Urinating may feel painful.
  
  
• Experience frequent urinary tract infections (UTIs)
  
  
• Leak urine after coughing, laughing, or exercising
  
  
• Leak stool or gas
  
  
• Feel an urgent or frequent need to urinate
  
  
• Feel constipated

Returning to exercise too quickly can further stretch this delicate group of muscles. You may accidentally lose control of your bowel or bladder during exercise, such as during a long run.

Kegel exercises can help strengthen the pelvic floor. People can practice these exercises anywhere: sitting down or standing up.

How to do Kegel exercises

When practicing Kegels, relax and tighten the muscles responsible for controlling urine flow. It may feel like you’re pretending to urinate and then holding the urine in. Keep your thighs, buttocks, and abdomen muscles relaxed. This leaves all the work to your pelvic floor muscles.

Practice Kegels 3 times a day. Always remember to empty your bladder and bowels before beginning. Then:

• Tighten your pelvic floor muscles.
  
  
• Hold the muscles tight and count to 3 or 5 seconds.
  
  
• Relax the muscles and count to 3 or 5 seconds.
  
  
• Repeat 10 times.

5. Prioritize your mental health and tell your health care providers if you need support.

Pregnancy not only affects the body. It affects the mind. 

The body must transform to support a growing baby. A flood of hormones triggers the necessary physical changes, not to mention changes in mood. According to the American College of Obstetricians and Gynecologists, hormone levels can decrease sharply hours after childbirth, affecting mood further.

New parents may experience postpartum depression (PPD) or develop eating disorders after giving birth. Consider seeing a mental health care provider together with a return to any sport. They can provide therapy, prescribe medication, or suggest lifestyle changes that can help you manage these and other mental health conditions. 

Postpartum depression

One in 5 people experiences PPD within 12 months of giving birth. The condition also increases the risk of depression later in life. PPD shares many of the same symptoms as depression. If you have any signs or symptoms of PPD, talk to your health care providers. There are effective treatments for PPD.

Signs and symptoms of PPD include:

• Fatigue
  
  
• Feeling sad, hopeless, or overwhelmed
  
  
• Trouble sleeping or eating
  
  
• Losing interest in things you once enjoyed
  
  
• Withdrawal from loved ones
  
  
• No interest in your child
  
  
• Thoughts of harming yourself or your child
  
  
• Feelings of worthlessness or feelings of doubt about not being a good parent; doubting your ability to take care of your child

Symptoms usually last for more than 2 weeks and can range from mild to severe. Several factors increase the risk of PPD:

• Family health history of perinatal emotional complications, or a previous personal history of depression
  
  
• Low social support and stressful life events
  
  
• History of mood symptoms associated with your menstrual cycle
  
  
• Pregnancy and birth complications
  
  
• Alcohol or drug use
  
  
• Trouble getting pregnant
  
  
• Giving birth to more than one child at a time
  
  
• Having a premature baby (before 37 weeks of pregnancy)
   

Eating disorders

Weight gain occurs in every pregnancy. Supporting your own health and that of a developing child requires more food than usual. According to the Centers for Disease Control and Prevention (CDC), people typically need about 340 more calories per day during the second trimester, and 450 more calories per day during the third.

Eating disorders can occur during and after pregnancy. Common examples include binge eating disorder, anorexia, and bulimia. They are associated with:

• Pregnancy complications, including premature birth
  
  
• Increased risk of PPD
  
  
• Low energy during exercise or ordinary activities

6. Adjust your diet to get the right nutrients. 

Athletes who chestfeed and engage in regular exercise need to monitor the foods they eat and drink. Exercising and chestfeeding require a lot of extra energy. Those who hydrate and increase food intake prior to exercise can minimize the risk of dehydration and burnout. 

Six months after giving birth, remember to:

• Eat 25 more grams of protein per day
  
  
• Drink 900 more mL of water per day
  
  
• Incorporate appropriate amounts of calcium into your diet, and consider a vitamin D supplement

Chestfeeding also increases the need for several key vitamins, including B vitamins. These vitamins help the body process food into energy. Replenish lost vitamins with:

• Fruits
  
  
• Vegetables
  
  
• Whole grains
  
  
• Nuts
  
  
• Legumes (beans)
  
  
• Dairy products (milk, yogurt)
  
  
• High-quality protein (fish, chicken, pork, lean cuts of red meat)
  
  
• Oils

Avoid fasting or diets cutting food intake, unless otherwise instructed by a doctor.

“Just as you needed fuel before pregnancy, you’re going to need fuel to support recovery from exercise and to achieve peak performance,” says Dr. Tenforde. “Skipping meals is going to lead to lower energy intake, resulting in slower recovery and reduced performance during exercise.”

Self compassion drives success

The arrival of a new child can come with lots of excitement, not to mention plenty of uncertainty. Amid the rush of emotions, anyone returning to competitive exercise can benefit from a self-compassionate approach to their physical and mental health.  

Athletes and weekend warriors on the journey back to peak performance can feel discouraged by what may feel like a lack of progress. Patience and persistence can help athletes and weekend warriors author their comeback stories without jeopardizing injury or developing other serious health conditions.