The 4th Trimester: Redefining Postpartum Care

Last May, the American College of Obstetrics and Gynecologists (ACOG), came out with an article about redefining the postpartum visit in order to better serve women. In the article, the ACOG writes about how postpartum care should be an ongoing process and not just a single visit to the doctor’s office. This process can begin right after birth and can last for the duration of the first 12 weeks after birth, which is why these weeks are being dubbed the “4th trimester”:  three trimesters before birth and a trimester for the mother to recover and take necessary steps to heal. The ACOG state that the comprehensive postpartum visit should include a full assessment of physical, social and psychological well-being. The ACOG article has a list of components of postpartum care which includes but is not limited to the following:

  • Mood and emotional well being

  • Infant care and feeding                               

  • Sexuality, contraception, birth spacing                                  

  • Sleep & Fatigue

  • Physical Recovery from birth

  • Chronic disease management

  • Health maintenance

Just one important aspect of postpartum care should entail going to see a physical therapist who specializes in women’s health or pelvic floor dysfunction. Working with a physical therapist will incorporate diastasis assessment, pelvic floor assessment, body mechanics to help carry or lift your baby and modalities or manual therapy for pain relief. Pregnant and postpartum women are at risk for abdominal muscles separating, which must be assessed 6 weeks postpartum to determine if the abs are split or not. Exercises should be progressed safely  in order not to make the separation worse. Women may also experience bladder control issues, incontinence or pelvic pain, all of which can be addressed with a specialized physical therapist.

Although this article was written last May, it is important to spread the word and inform as many women as you know. In France, every woman who has a baby is covered by insurance to go to PT after giving birth just to make sure everything is working as it should be. America should be doing this as well! Pelvic floor physical therapy is just one part that should be incorporated in the 4th trimester. The ACOG took the first necessary steps to start redefining the normal care of pregnant and postpartum women, and now it’s time for us to spread the word.

ACOG Clinical Guideline.png

”Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists.” Obstet Gynecol 2018;131:e140–50. Accessed March 25, 2019.

-- Dr. Brooke David, DPT

10 Reasons to See a Pelvic Health Physical Therapist after C-Section

  1. You are experiencing lower back pain.

  2. You are leaking urine upon exertion or when your bladder is full and you have to urinate.

  3. You want to get back to your pre-pregnancy exercise routine.

  4. You have pubic symphysis pain.

  5. You have a separation of your abdominal muscles known as Diastasis Rectus Abdominus.

  6. You still “feel 3 months pregnant.”

  7. You have pain with transitional movements ie.  getting in and out of bed, sit to stand, lifting your baby.

  8. Your scar is tender, uneven or lumpy.

  9. You experience urinary urgency/frequency, pain with sex, or constipation.

  10.  You feel fine but want to make sure you are on the right path to recovery!!

mom and baby.jpg

Did you know that in France, a pelvic health physical therapy evaluation is standard at 6 weeks post-partum?  Why don’t we do that in the US? At Zion PT, we are trying to bring awareness about all of the symptoms that could present themselves after a vaginal or C-Section delivery that could impact a woman’s quality of life and that she may think is “normal” or “will go away eventually”.  Take charge and schedule an evaluation with one of our highly specialized pelvic health therapists today!

If you’d like to make an appointment, please call 212-353-8693!

5 Exercises to Re-establish Core Strength after Vaginal Delivery or C-Section!

So you just had a baby...congratulations!  It’s about 6 weeks post-partum and you’ve been cleared to exercise again by your OB or midwife.  Great. But where do you start? Good question!

During pregnancy, the body’s hormones allow the abdomen and pelvic girdle to stretch and shift to accommodate the little person growing inside of you.  This is all truly amazing and necessary however what happens after you give birth? Does it matter whether you’ve given birth vaginally or whether you’ve had a C-Section?  Does everything immediately go back to your pre-pregnancy state? Not necessarily.

After having a vaginal delivery, there may be trauma to the pelvic floor in addition to laxity in the abdomen from pregnancy.  After a C-Section, all of the abdominal muscles under the umbilicus are cut in order to access the uterus and then are repaired.  

How do we get these muscles working again?  Sit-ups? Planks? Running?


FIRST, we have to isolate, re-engage and create proper coordination of the deeper core muscles in order to re-establish a solid base to support our spine and extremities during activities of daily living and return to sport.

This video offers a 4 step exercise progression for getting back in touch with your deepest core muscle, the transverse abdominus.

The fifth exercise adds a final layer which is a bridge, shown in this video.

It is important to work with a trained pelvic health physical therapist to ensure you are performing these exercises correctly without compensation.  Every woman post-partum starts out at level after delivery unique to their body and a full evaluation of the abdomen and lumbar spine/pelvis and hips should be completed to make sure the exercises being done are appropriate for you.  An individualized exercise progression can then be prescribed as well to help you meet your goals!

 If you have questions or would like to schedule an appointment to have one of our pelvic health specialists evaluate you, please call 212-353-8693!  It’s never too soon or too late to get the proper help to get your back to doing what you love best!

-Dr. Staci Levine, PRPC

MomStrong Workout: Baby Edition

Let’s be realistic. It’s awesome to have childcare available to get to your favorite fitness class, but it’s not always feasible. And we know flexibility and convenience are cornerstones of keeping up with your fitness goals. Here, I share some of my personal explorations of “making it work” with a baby at home. These exercises are what made sense for me, after two months of focused foundational exercises for the core and hips.

Feel free to try them, knowing that some moves are more advanced than others.  Don’t jump into it if you are having back pain, pelvic pressure, or a diastasis that has not been checked out.  Or, we can work on exercises together to build an at-home workout that makes sense for you, as part of our MomStrong program.

Suggested Duration: 6-18 minutes (or until baby is over it)
1 min/exercise, 1-3 times through  

Baby Bird-Dog

Find your neutral spine and then don’t let it move. Extend your opposite arm and leg away from each other, keeping the core engaged and the body stable. Come back to all fours and then alternate sides.

Find your neutral spine and then don’t let it move. Extend your opposite arm and leg away from each other, keeping the core engaged and the body stable. Come back to all fours and then alternate sides.

Side Plank with Rotation Tickle

Start in a side plank. Twist the torso to the floor and return to side plank in one smooth motion.  30 seconds each side.

Start in a side plank. Twist the torso to the floor and return to side plank in one smooth motion.  30 seconds each side.

Airplane Abs

Start with the legs at 90 degrees in a tabletop position, slowly extend the legs a couple of inches away while keeping to back pressed against the floor and return to baseline.

Start with the legs at 90 degrees in a tabletop position, slowly extend the legs a couple of inches away while keeping to back pressed against the floor and return to baseline.

Baby Sumo Squats

Start with the legs wider than the hips, toes pointing out, and the core engaged, bend into a squat pressing the knees out so they stay in line with your toes. Squeeze your glutes on the way up to stand.

Start with the legs wider than the hips, toes pointing out, and the core engaged, bend into a squat pressing the knees out so they stay in line with your toes. Squeeze your glutes on the way up to stand.

Straight Leg Baby Lifts

Bend at the hips keeping the back flat and core engaged. Go just to the point of feeling the hamstrings stretch, then thrust your hips forward and squeeze your glutes to return to standing.

Bend at the hips keeping the back flat and core engaged. Go just to the point of feeling the hamstrings stretch, then thrust your hips forward and squeeze your glutes to return to standing.

Twisting Baby Lunge

Start with legs wider than hips. Twist to the right and bend the back leg so that you are making two 90-degree angles and the torso remains fully upright. Return to standing before turning to the left to lunge.

Start with legs wider than hips. Twist to the right and bend the back leg so that you are making two 90-degree angles and the torso remains fully upright. Return to standing before turning to the left to lunge.

Running Strong through the Trimesters: A Therapist’s Perspective

I run to feel good, both physically and mentally; therefore, I needed running even more during pregnancy. But running while my body was (and still is) constantly changing presents some new challenges. Here’s a guide of some helpful tips to avoid running into any problems.


Take it Slow

Let’s start with the usual disclaimer: make sure you are cleared by your doctor (obstetrician/midwife/gynecologist) before beginning an exercise program. There are a number of medical and obstetric conditions that may make exercise unsafe during pregnancy.

With that out of the way, the current guideline for exercise during pregnancy calls for about 30 minutes of moderate intensity exercise, most days of the week (as per the American College of Obstetricians and Gynecologists). Fortunately, running is an activity that allows you to moderate the effort you put forth. You may be a seasoned runner, aware of how hard you feel you’re working and able to regulate on your own. Or, your doctor might want you to wear a heart rate monitor and stay within a certain range. As for me and my slightly competitive nature, I needed additional external factors to slow me down. I ran with my dog so that his incessant need to stop and smell the roses would force me to take rest breaks, or I chose a running partner who was slower than my current pace (shown below at 34 weeks gestation, with my 60 year old dad).  

Staying out of the red zone is important because your blood volume is increasing tremendously (from 30-50% as early as 16 weeks gestation), causing your heart rate to be higher than normal even at rest. And if you’re like me, your iron stores haven’t necessarily caught up with the increased red blood cells, so your risk of anemia is increased. Add to that your difficulty breathing now that your rib cage has expanded and your diaphragm is less efficient (it’s stretched out and contracting against more resistance), and you’re likely to find yourself short of breath way earlier than usual. So, go for your run, but be prepared to slow down and incorporate intervals of walking.

Don’t Overheat

If you’re in warmer climates or it’s summertime in the city, be especially cautious to not overheat, which could be harmful for your developing baby. I usually like to get a tan while I run, but soon I found more comfort in taking routes that were shady instead of sunny. The thought of carrying a water bottle with the weight I had already gained seemed preposterous, so I memorized all the water fountains along the route as well. If you have retained fluid during your pregnancy, and have found that your hands or feet are swollen on the regular, keep this in mind. Dehydration will come on sooner (especially if you skipped your normal glass of water pre-run so that you could last a little longer without a bathroom break.) By my third trimester, during the heat of the summer, I kept all my runs close to home, sometimes just circling the park next to my apartment, just in case.


Do Your Kegels

It was early on in the second trimester that pressure built on the pelvic floor and the pelvis started to stretch and change, which meant leakage, first with sneezing and then with running. I had to up my kegel game immediately. I ran with a liner at first, but I caution you that you must change out of your running clothes pretty immediately after your workout, as UTI risk is higher during pregnancy. I recommend a pretty solid kegel routine as soon as you become pregnant (some apps even let you track your sets and reps), but make sure that you’re holding the kegel for 5-10 seconds at a time for improved endurance. I would try to focus on my pelvic floor contraction during the first half mile for good strengthening practice under running conditions and was able to get rid of my leakage in about one month. If you need more help on this front or aren’t sure you’re doing them correctly, check in with us.

Strengthening Rules Still Apply

Logically, it’s fair to say that your joints now think that you’re going out for your usual jog while wearing a weighted vest. This is not something most people do voluntarily to enhance their training, and for good reason. An increase in one pound of body weight multiples by 3-4 times that amount when you are running, and it will take its toll on your joints. So strengthening is even more important now than it was even before. Keep up your squats and lunges throughout the pregnancy to ensure support for the knees and hips as you gain weight. I chose to stick with my usual HIIT classes (high intensity interval training) with the support of some solid teachers (check out the great team below) and a number of modifications to make it a MIIT class (moderate intensity interval training). 

Recover Well, Stretch With Caution

Recovery is more important for the same reason, mostly by means of rest and refueling. If you were an avid stretcher or just love to feel flexible, this is where you might need to hold back. With your ligaments being looser than ever, stretch with caution as it’s easier now to “over-stretch.” Keep it gentle with a minimal intensity stretch instead of moderate. I had to change my usual runner’s lunge stretch for my hip flexors to more conservative quad stretches, since it started to make me feel a little unstable (more on that later).


Invest in a New Sports Bra

First trimester feels a bit like all the other runs you’ve done while at peak-PMS. Mostly your boobs hurt and you feel bloated. Over the course of the pregnancy, you may need to invest in a new sports bra, the same as you will with your other bras to accommodate the change in size. Mostly, my bras made it feel hard to breathe because they were too tight against my expanding rib cage (which can widen up to 3-4 inches over the pregnancy). I ended up doubling up on some older, looser sports bras to stay supported and comfortable at the same time.

Consider an SI Belt

If you have a history of sacroiliac (SI) joint pain or low back pain, are feeling excessive movement in your pelvis while running, or are dealing with some SI joint, or sciatica symptoms now that you’re pregnant, consider wearing an SI belt (with extender strap) while running to decrease shear forces on your pelvis. I love the Serola belt and keep one in my office in case you want to do a trial run before you purchase. Just make sure to read the instructions to make sure you’re wearing it at just the right level.

Check Your Shoes

My old posterior tibialis tendonitis (an inflammation of the tendon that runs along the inside of the ankle) said hello during second trimester. Since the ligaments of your feet are also stretching, your lower leg muscles will be working overtime to stabilize your ankle as your foot hits the ground. If you notice your feet are expanding or you start to feel pain in the arches of your feet, considering switching out your neutral or minimal shoe to a stability shoe for some more extrinsic support. I threw my old orthotics into my running sneakers and it remedied the situation immediately. Couple that with a shortened stride to reduce joint loading and you should be on your way to safely running in trimester three.

Suffice it to say that being a good body-listener becomes more important than ever, especially since you’re listening for two. If you’ve been cleared to exercise but just want a little more guidance, if you are struggling with feelings of heaviness or incontinence, or if you are having any pain, don’t hesitate to reach out. Zion’s physical therapists specialize in treating both prenatal clients AND orthopedic cases, so rest assured that we can put the pieces together in a way that works for you and helps you keep exercising safely throughout your pregnancy.

REZIST class with Gino Caccavale

REZIST class with Gino Caccavale

walnut beach 5k with dad

walnut beach 5k with dad

ironstrength class with dr. Jordan Metzl (and guest Edem tsakpoe)

ironstrength class with dr. Jordan Metzl (and guest Edem tsakpoe)

Training: The Importance of Rest


Contributed by Guest Blogger, Coach Mikael Hanson

I wanted to begin with a discussion on the importance of rest – an area that I see over-looked all too much and which is increasingly important especially as we get older. 

In my twenties recovery came easy and rest days, well those were few and far between and in my opinion for the weak minded. I used to become overcome with guilt for skipping a training day. Even when I was sick, I lived by the mantra that somewhere, someone is training and when you meet them in competition, they will beat you. They say, with age comes wisdom. I no longer feel guilty for missing an occasional workout, and realize that some of my best performances have come after a period of forced rest. It may have taken two decades of lessons, but I now look forward to my recovery days and it is not uncommon for me to string together back-to-back rest days. The forty-something me is also much more in tune with my body.  I take my resting heart rate and check my body weight every morning, looking for those early warning signs of not being properly recovered (perhaps bordering on obsessive-compulsive behavior).


As someone who has battled with the debilitating affects of insomnia I know all to well what a lack of sleep can do to not only one’s performance but also to their state of mind. Former professional triathlete and now endurance coach, Wes Hobson, believes one should not train unless they got a minimum of 6 hours of continuous sleep the night before - if that were the case, I would have had to skip the last half decade of training!

Living in New York City, one complaint I constantly hear from many of my athletes is their inability to get enough sleep. Work commitments, quality family time, training, recovery, all take their toll on us amateur athletes. A close look at the training regimen for any professional endurance athlete will invariably include at least 8 hours of sleep each night PLUS a nap. Now if we could all do that, I think most of us would be able to elevate our performances!

I have battled sleep troubles for years and knew I really needed to focus on my own sleep routine if I wished to stay competitive on the racing scene as well as just plain healthy as a person with a family. This is one of the reasons I have my athletes keep track of their own sleep patterns and resting heart rates as part of their training log - to help them identify when they have not gotten enough rest and need to take it easy!

As for how much sleep one needs - that is a very individual thing. Here are some tips to help you sleep or at least find a relaxed state:

  • Caffeine - Yes, the lifeblood of endurance athletes - but try to go decaf after 3pm!
  • Sugar - Ever see how your kid acts after a post-dinner cupcake? Well - we are the same and some extra sugar in the blood stream will keep you up!
  • Alcohol - No, a glass of wine or beer before bed DOES NOT help you sleep!
  • Dinner - Avoid eating late and spicy meals and you will find falling asleep a tad easier!
  • Environment - Make sure where you sleep is dark and try to avoid reading or watching TV in bed as you want the bed to represent a place to sleep in your mind.
  • Relaxation - Can't seem to leave work at the office? Try writing down the exact things weighing on your mind on a pad of paper before bed and get into a routine of relaxation before you sleep - a few minutes of stretching and deep breathing from the diaphragm will help!
  • Natural sleep aids - Valerian root and melatonin are both natural sleep aids that do help some (myself not included and be warned that Valerian root has a very distinctive smell!). Also magnesium is said to help open up the capillaries and can help you relax at night. Avoid taking your vitamins at night (better taken in the AM). One of my favorites - a nice hot bath before bed works wonders!


Over-training is a word endurance athletes hear a great deal and is something no longer isolated to the ranks of Pro athletes. Even us amateurs can fall victim to over-training, especially when trying to balance training and racing with a family and full time job. Over-training should not be confused with another term thrown out by the endurance world, over-reaching. Signs associated with over-training syndrome include:

  • Extended decreased performance
  • Elevated resting heart rate
  • Significant change in body weight (either up or down can be a sign)
  • Difficulty sleeping (perhaps a source of recent insomnia?)
  • Prolonged muscle soreness
  • Frequent illness or onset of colds
  • Low energy level and motivation (especially toward training)
  • Mood swings
  • Decreased appetite
  • Several poor workouts in a row

Besides training, several other non-exercise related factors can contribute to the onset of over-training; poor eating and hydration habits (before, during and after exercise), recent illness or injury (and resuming training without being fully recovered), poor sleep habits, travel and jet lag, are among the most common non-exercise contributors to over-training. Add to this list psychological stresses like death of a loved one, new addition to the family, stress at work or financial problems and you can see just how quickly over-training syndrome can sneak up on an athlete.

Over-reaching can be a normal aspect of one’s training regimen. To over-reach is when one ‘overloads’ their training volume over a brief period in hopes of seeing significant results in a shorter period of time. Pushing one’s body to this higher limit of activity (but not going into the over-trained zone), allows for the body to enter a super-compensation mode, where upon recovery your overall fitness level is much higher than before. The key factor for over-reaching to work is pairing it with proper recovery (without, you risk over-training).

While over-reaching may take several days to a week or more to fully feel like your old self again depending on the training load, over-training can take months to fully recover from. What is the remedy for over-training? Try simple, old-fashioned rest. Put the cycling or running shoes in the closet, skip some races and just chill. Let your body recover, so you can come back fresh and strong!

Top 10 Ways to Prepare for the Corporate Challenge

You signed up for the Corporate Challenge…. Now what!?

Top 10 Things to Do

10. Invest in a new pair of running shoes - running shoes typically last about 6 months

9. Write down a goal for the race - for example, finish time, don’t walk, have fun, high five spectators

8. Foam roll - most gyms have foam rollers, if not it’s $10 on Amazon..happy muscles = better running

7. Sleep more - our bodies recover from hard work while we sleep

6. Hydrate - drink water alone or with electrolytes often throughout day especially if you are drinking coffee and/or alcohol

5. Go for a run in the evening - the race is a 7pm or later start, acclimate to evening conditions

4. Practice fueling before a run so you know what to eat pre race - usually bland items, simple carbs

3. Look at a course map so you know where to expect ascents, descents, and flat terrain

2. Find a buddy to train with

1. Enjoy the process - exercise is fun! And even more satisfying when you achieve a goal!

- Amanda Scheer, DPT