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Counseling Postpartum Patients About Diet and Exercise

(Updated July 2008)

The First Postpartum Visit

Typically, the first postpartum visit is scheduled for four to six weeks after childbirth for women who have had an uncomplicated pregnancy and a vaginal delivery. Women who have had a cesarean delivery or complicated births may be seen earlier. This is a time to review and discuss postpartum diet, nutrition and exercise.

Dietary Recommendations

The Dietary Guidelines for Americans form the basis for nutrition counseling for postpartum women.1 A moderately active, non-pregnant, non-lactating woman can be advised to consume 1,800–2,000 Kcal/day. An additional 500 Kcal/day is recommended for women who breastfeed (e.g., 2,300–2,500 Kcal/day).1 Even higher intake may be recommended for lactating women who are underweight, women who exercise vigorously, or women who are breastfeeding more than one infant.2

Many women consume less than the recommended amounts of calcium, magnesium, zinc, vitamin B6, and folate (see table).2 If you suspect a nutritional deficit, you may want to suggest that the woman restart or continue taking prenatal vitamin and mineral supplements.

Nutrient Recommended Amounts
Food Sources
Supplements
Calcium

1,000 mg/day for pregnant, non-pregnant, and lactating women ages 19–50;

1,300 mg/day for adolescents1

Low- or no-fat dairy products; fish such as sardines, salmon, ocean perch, clams; greens; tofu. Refer to Fish Consumption subhead for specific counseling guidelines. Prenatal supplements generally do not include a significant amount of calcium. Because a nursing mother transfers 250–350 mg of calcium daily to the baby through breast milk, she may experience transient bone loss.3 Calcium carbonate is readily absorbed by most people and is the least costly form of calcium supplement.4,5 To improve absorption, calcium supplements can be divided into two or three doses and taken with meals. Vitamin D facilitates absorption of calcium. Recommend a supplement that contains 400–800 IU of this vitamin.
Fluids About 91 oz (11.5 cups) of fluid a day for women.6 Advise women to drink water to satisfy their thirst and to prevent constipation. Refer to Alcohol and Caffeine subhead for counseling guidelines. Water, fruit juices, low-sodium soups, decaffeinated coffee and tea, water-rich fruits (watermelon, berries, grapes, and peaches) and vegetables (tomatoes, lettuce, summer squash)  
Iron 15 mg/day1 Fortified cereals, oysters, beef liver, lean beef, tofu, potatoes with skin, watermelon, figs, spinach, chard, dried fruits Postpartum iron supplementation may be recommended when blood loss is higher than usual during vaginal delivery or the interval between pregnancies is <2 years. When hemoglobin or hematocrit is low and other causes of anemia (e.g., thalassemia) have been ruled out, 60–120 mg/day of oral iron supplements can be recommended.

Fish Consumption

The health benefits of fish and seafood have been well documented, but industrial pollutants—mercury and polychlorinated biphenyls (PCBs)—in these foods can be harmful to children. Therefore, breastfeeding mothers should continue to limit consumption to no more than 12 oz per week (two servings) of fish with low levels of mercury and fat (e.g., cod, haddock, pollock, shrimp, tilapia, chunk light tuna). Breastfeeding mothers should also continue to limit consumption to no more than 6—12 oz per month (1—2 servings) of fish with high levels of PCBs, high in fat and low levels of mercury (e.g., farm-raised salmon, herring, and sardines). Breastfeeding mothers should not consume fish with high levels of mercury (e.g., swordfish, shark, king mackerel, and tilefish).7

Alcohol and Caffeine

According to the guidelines of the Institute of Medicine (IOM), breastfeeding mothers can drink occasional small amounts of alcohol and moderate amounts of caffeine-containing products (e.g., a morning cup of coffee), but timing is relevant.8 If nursing, women should drink alcohol after breastfeeding rather than before.9 Women also can be advised to delay breastfeeding until alcohol is cleared from their milk—e.g., to express milk and store it before they drink alcohol.9

Guidelines for Postpartum Weight Loss and Exercise

Most postpartum women want to return to their pre-pregnancy weight. The goal should be gradual weight loss. With a healthy diet and exercise, much of the weight gained during pregnancy will be shed naturally during the first year after delivery. For all but women who had high or very high pre-pregnancy weights, the recommended weight loss after the first month postpartum is a maximum of 4.5 lbs/month.10 The minimum caloric intake is 1,800 Kcal/day, and this figure may need to be increased for considerations such as breastfeeding, nutritional status, and level of activity.1,11 When women don’t consume enough calories, they may experience more postpartum fatigue and a negative impact on mood, especially if they are breastfeeding. Post-pregnancy dieting may lead to a significant decrease in bone mineral density.3 Often, instructing lactating women to focus on nutritional foods and exercise, and to eat to satisfy their hunger, will result in the desired slow pattern of weight loss.

Exercise Recommendations

Research confirms the importance of regular exercise in the postpartum period to promote healing and support emotional well-being, although it may not have a significant effect on weight loss without specific calorie restriction.12 Women can be reassured that exercise will not hinder their ability to breastfeed. Even strenuous exercise causes only a minimal increase in lactic acid in breast milk and has no effect on the infant’s acceptance of breast milk one hour after exercise.13,14

The first postpartum visit should include an evaluation of the integrity and function of the pelvic floor and the diastisis recti. Kegel exercises can help reduce the incidence of stress incontinence,15 but proper technique is important. Patients should be instructed to contract their pelvic muscles for 10 seconds and then relax them for 10 seconds for 15 minutes, four times per day. Women may need help from a qualified provider to locate the right muscles before partum.

Providers can offer information on postpartum exercise programs available at the YMCA, fitness centers, or hospitals in the community, as well as postpartum DVDs and videos. The appropriate exercise level will depend on each woman’s medical history, obstetrical course, level of fitness, and postpartum recovery. Some women may be able to start exercising within days of delivery; others may need to wait four to six weeks.16 Like weight loss, a gradual approach is recommended for resumption of exercise. This will allow the woman to gauge effects and identify a suitable level of intensity.

Exercise Recommendations Cesarean Delivery

Recommendations for exercise after cesarean delivery depend upon obstetric and medical history and rate of physical recovery. In most cases, exercises to restore abdominal muscle tone can start as soon as abdominal soreness diminishes.17 Some experts suggest that straight and diagonal curl-ups can be done safely within the first few days after cesarean birth and can help bring the rectus muscles back together.18

References

  1. US Department of Agriculture Dietary Guidelines. Available from: http://www.health.gov/DietaryGuidelines. [Accessed May 15, 2008].
  2. Institute of Medicine. Nutrition Services in Perinatal Care. 2nd ed. Washington, DC. 1992.
  3. Oliveri B, Parisi MS, Zeni S, Mautalen C. Mineral and bone mass changes during pregnancy and lactation. Nutrition 2004;20(2):235-40.
  4. Heaney RP, Recker RR, Weaver CM. Absorbability of calcium sources: the limited role of solubility. Calcif Tissue Int 1990;46(5):300-4.
  5. Heaney RP, Dowell MS, Bierman J, Hale CA, Bendich A. Absorbability and cost effectiveness in calcium supplementation. J Am Coll Nutr 2001;20(3):239-46.
  6. Institute of Medicine. Dietary reference intakes: water, potassium, sodium, chloride, and sulfate. Press release, February 11, 2004. Available from:
    http://www.iom.edu/CMS/3788/3969/18495.aspx.
  7. Steuerwald U, Weihe P, Jorgensen PF, Bjerve K, Brock J, Heinzow B, et al. Maternal seafood diet, methylmercury exposure, and neonatal neurologic function. J Pediatr 2000:136(5);599-605.
  8. Institute of Medicine. Nutrition During Lactation. Washington, DC. 1991.
  9. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. St. Louis:C.V. Mosby; 2000.
  10. Institute of Medicine. Nutrition During Pregnancy and Lactation. Washington, DC. 1992.
  11. Jensen LB, Kollerup G, Quaade F, Sorensen OH. Bone minerals changes in obese women during a moderate weight loss with and without calcium supplementation. J Bone Miner Res 2001;16(1):141-7.
  12. Larson-Meyer DE. Effect of postpartum exercise on mothers and their offspring: a review of the literature. Obes Res 2002;10(8):841-53.
  13. Wright KS, Quinn TJ, Carey GB. Infant acceptance of breast milk after maternal exercise. Pediatrics 2002;109(4):585-9.
  14. Bopp M, Lovelady C, Hunter C, Kinsella T. Maternal diet and exercise: effects on long-chain polyunsaturated fatty acid concentrations in breast milk. J Am Diet Assoc 2005;105(7):1098-103.
  15. Elia G, Bergman A. Pelvic muscle exercises: when do they work? Obstet Gynecol 1993;81(2):283-6.
  16. ACOG Committee on Obstetric Practice. ACOG Committee Opinion Number 267: Exercise During Pregnancy and the Postpartum Period, Washington, DC: American College of Obstetricians and Gynecologists; January 2002.
  17. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. Williams Obstetrics. 22nd ed. Dallas, TX: McGraw-Hill; 2004.
  18. Noble E. Essential Exercises for the Childbearing Year. Waltham, MA: New Life Images; 2003.

Funded by an unrestricted educational grant from GlaxoSmithKline Consumer Healthcare