Your running shoes have been sitting on top of the shoe cabinet since you were six months pregnant, the laces still double-knotted the way you left them the last time you took them off. Your baby is seven weeks old. This morning the baby went back to sleep after the five o’clock feed, so you took the shoes down and went out to the end of the lane for a test run. The horizontal cesarean scar low on your belly no longer hurts when you walk, so you thought a very slow run would be fine. After a few hundred meters your lower belly felt heavy, as if something were dragging down, and each time your foot hit the ground a little urine leaked out. You walked home, sat down on the front step and opened your running app. Your last run before pregnancy was still there: twelve kilometers.
That morning does not mean your running days are over. The American College of Obstetricians and Gynecologists (ACOG, 2020) states that women who already exercised regularly and vigorously can continue to be active both during pregnancy and after birth. But the way back passes through one milestone at a time, and the first milestones are the pelvic floor and the scar. Distance comes later.
Every step lands on the pelvic floor
The pelvic floor is a layer of muscle stretched like a hammock across the bottom of the pelvis. It is the only muscle group in the body that can support the bladder, uterus and rectum, along with the openings of the urethra, vagina and anus; that is how the pelvic floor physical therapy book edited by Kari Bø (2015) describes it.
When you walk, that job is easy. Running is different. Each time your foot lands, the road pushes back up with a force of about 3–4 times your body weight, a figure from Hay (1993) cited in the same book. The authors suggest the pelvic floor has to be much stronger to withstand it. They also note that stress urinary incontinence (leaking urine on exertion) is common in sports that involve jumping and running, even in young female athletes who have never given birth.
Women who had a cesarean birth often assume their pelvic floor is fine, because the baby did not pass through the vagina. In fact, the pelvic floor changes a great deal over the course of pregnancy, and some women push for a long time before needing to switch to a cesarean. That is why the physical therapy textbook by Hall and Brody (2005) advises starting pelvic floor contractions, or continuing them, right after the surgery.
Leaking urine while running is common, but with the right exercises it often improves. Bø’s book reports that 17 out of 23 women with stress urinary incontinence had less leakage when jumping and running after a course of exercises targeted at the pelvic floor muscles. No one can remember to squeeze with every step while running, so the goal Bø sets is for the pelvic floor muscles to contract on their own in time before each landing. To contract the right muscles, it is best to have someone guide and check you. In 1991, Bump and colleagues found that with verbal instructions alone, only about half of women contracted correctly, while a quarter bore down instead of lifting up.
Three weeks is the minimum, not an appointment date
Ask how long until you can run again, and the sources give three numbers, each answering a different question.
The earliest number is a few days. For healthy pregnant women who have a vaginal birth, ACOG’s patient information page (2022) says you can usually start exercising a few days after birth, or when you feel ready. If you had a cesarean or complications, ask your obstetrician first. If exercise hurts, stop. “Exercise” here means walking, breathing exercises, pelvic floor exercises and gentle exercises for the abdomen and back, not running yet.
The second number is 3 weeks. Christopher and colleagues (2024) gathered expert opinion using the Delphi method (asking the same experts again over several rounds until they agree) to produce an international consensus on returning to running after birth, which recommends a recovery period of at least 3 weeks, followed by an individual, gradual plan with careful questions about symptoms. The word worth holding on to is “at least”. Before three weeks there is no talk of running, and even after that it is not necessarily time to lace up your shoes.
The third number is 3–6 months. The postnatal return-to-running guideline by three British physiotherapists (Goom, Donnelly and Brockwell, 2019) recommends light exercise first and a return to running somewhere between the third and sixth month. The authors themselves note that no study has been done specifically in postpartum mothers, so this advice is at the level of expert opinion.
Put the three numbers together and you get a set of steps:
- The first days: breathing, walking and gentle pelvic floor contractions, since ACOG advises starting pelvic floor exercises early;
- When long walks feel easy: add strength exercises for the hips, abdomen and pelvic floor, which the consensus on postpartum return-to-running programs (Deering and colleagues, 2024) includes in the plan;
- Then walking mixed with running, starting with short running intervals;
- Only after that, gradually increase your running time.
Stay on each step until your body no longer gives any warning signs of discomfort, and only then move on. Ligaments and connective tissue remain under the influence of hormones for about 12 weeks, so the Hall and Brody textbook advises avoiding jerky movements, overstretching and heavy weights during that time if the joints are still lax. The book also advises correcting anemia before starting sessions of moderate or greater intensity. If you are unusually tired even at the walking step, have a blood test first.
Signs to step back down
Goom and colleagues recommend a pelvic floor physical therapy assessment if you have any of the signs below, whether before or after returning to high-impact exercise; the two signs about bleeding come from the physical therapy textbook mentioned above:
- Leaking urine, or difficulty holding in wind or stool;
- A feeling of heaviness, pressure or dragging down in the pelvis;
- Pain in the pelvis or lower back;
- A lax abdominal wall, or a clearly visible gap along the midline of the belly;
- Bleeding that increases, or bright red blood, after a session;
- Bleeding that continues beyond 8 weeks and is not a period.
A gap between the two rectus abdominis muscles does not stop you from running again if the abdominal wall is working well, Goom and colleagues write. If the midline of your belly bulges out or sinks in when you exert yourself, your exercises need adjusting, but that is not a reason to give up running.
The horizontal scar low on the belly
No trial has yet established how long after a cesarean you can do abdominal exercises, let alone run. If you had a cesarean, ACOG advises asking your obstetrician before exercising. Hall and Brody allow breathing exercises, leg movements and pelvic floor contractions to start within the first 24 hours, but progress more slowly than after a vaginal birth.
The hard part is the scar. Ciechanowicz and colleagues (2025) pooled studies on pain after cesarean delivery and found that about 16.7 % of mothers (roughly 1 in 6) still had pain in the scar or abdomen at 3–6 months, and 11.4 % (roughly 1 in 9) at 6–12 months; the certainty of these figures was rated very low. And 3–6 months is also when the guidelines suggest returning to running. For women who had a cesarean, whether the scar is ready is as weighty a question as the pelvic floor.
No number of weeks applies to every scar, so the clinic judges by signs. The scar has closed fully, is dry, not red and not oozing. Coughing, sneezing, lifting your baby, climbing stairs and walking fast no longer cause a sharp pain in the scar. The clinic set these markers itself to be cautious; there is no shared standard like this yet. A different kind of pain needs its own examination. Burning or electric, shooting pain spreading to the groin, with numbness around the scar and one very tender point at the end of the incision, may be a trapped nerve branch (Loos and colleagues, 2008). With this kind of pain, do not try to run through it.
Hips and scars after birth
Garten (2016, p. 494) notes that the piriformis and obturator internus (two small muscles lying deep around the hip joint) are functionally connected with the pelvic floor, so when the pelvic floor is weak, the hip becomes less stable too. That is why, when a mother wants to return to running after birth, muscle testing in Applied Kinesiology (AK) goes through the hip region first. The gracilis on the inner thigh may be working below threshold, meaning weaker than its true strength, because the obturator canal, the path of a nerve, was compressed during pregnancy (Garten, Muscle Test Handbook, p. 108). Walther (Synopsis, p. 515) counts overwork with too little sleep among the stresses that overload the adrenal glands (small glands sitting on top of the kidneys that help the body cope with stress). The sartorius and gracilis are related to these glands, and, again according to Garten on the page above, when they are weak the pelvic bone tends to rotate backward, and the inner knee hurts and feels unstable. At the clinic, mothers who have spent months getting up at night to breastfeed often show exactly this pattern.
A scar that has closed on the surface may still have unfinished business underneath. Sensory receptors and pain receptors in the scar may still send faulty signals, and the nervous system compensates by letting some muscles around the abdomen and pelvis work below their strength. Garten (2016, p. 428) lists the cesarean scar as one of the places to think of when the pelvic floor contracts weakly on one side.
The doctor tests in turn the gracilis, sartorius, gluteus medius and abdominal muscles, then retests a strong muscle while you place your own hand on the scar. In the AK reading, if that muscle weakens, it usually suggests the scar is contributing to the way the body handles load. Once the stitches are out, the doctor may use the Injury Recall Technique (IRT) or P-DTR (Proprioceptive Deep Tendon Reflex, a technique for correcting faulty signals from sensory receptors) to re-stimulate the signals from the scar area. If the gracilis and sartorius are weak in the pattern linked to adrenal overload, the doctor asks in detail about your sleep and then mobilizes the pelvis in the direction shown by challenge, that is, the direction that changes the muscle’s strength on retesting. And when the gracilis only becomes strong again with B vitamins, the nutrient Garten lists for this muscle (p. 109), the doctor also looks at blood tests and your breastfeeding before prescribing.
The feed first, the shoes second
Many women hesitate to run for fear of losing their milk. ACOG (2020) states that aerobic exercise (endurance exercise such as brisk walking, running or cycling) does not affect milk supply if you breastfeed or express milk before the session and drink enough water. Hall and Brody add two things: wear a firmly supportive bra, and feed first so your breasts feel less full and uncomfortable while running.
As for the cup of coffee or caffeinated gel before a long run, the level usually cited for breastfeeding is no more than 200 mg of caffeine a day from all sources, according to the European Food Safety Authority (EFSA, 2015). We have only read this figure in a news summary, not in the original document.
A hundred days of confinement
In the past, a new mother was kept in her room by her grandmother and mother during the postpartum “confinement” period (ở cữ), and told not to carry things or do heavy work, and to wait until “a full hundred days” had passed. Hai Thuong Lan Ong, in Hai Thuong’s Medical Compendium, advises that after birth one should not rush into exertion and should keep the confinement rules for up to 100 days; those with weak qi and blood should keep them longer, regardless of the date, and only go back to work when qi and blood are normal again. The gynecology handbook by Xia Guicheng divides recovery into milestones of 1 week, 1 month and 100 days, and records the folk saying that after birth “the hundred joints are empty” (百节空虚 / 百節空虛, bǎi jié kōng xū).
A hundred days falls around the third month, right at the start of the 3–6 months set out in the running guideline. The advice of earlier generations and today’s guidelines travel separate roads, then arrive at the same idea: do not rush to put heavy load on a body that has just given birth. Hai Thuong’s phrase “regardless of the date” comes even closer to the individual plan recommended by the 2024 consensus. The only caveat is that confinement should not be taken to mean lying still in one place for a hundred days, because walking, breathing and pelvic floor contractions are still advised from early on.
Modern traditional medicine books sum up the postpartum state in three features: “much deficiency, much stasis, much cold” (多虚、多瘀、多寒 / 多虛、多瘀、多寒, duō xū, duō yū, duō hán; Xia Guicheng), meaning the body is easily depleted, blood easily stagnates, and the body easily gets cold. The deficiency, according to the book, comes from the effort of pushing and the blood lost during birth, so when you want to return to running, your body often still carries some of that deficiency. Some women lean toward qi and blood deficiency, some still have stasis, and some tend toward deficiency with cold. After the examination, the doctor prescribes a decoction in ready-to-drink 50 ml pouches matched to that pattern, individually for each person; this use has not been tested in postpartum mothers returning to running. If you are breastfeeding, the formula leaves out Gan cao (Glycyrrhiza uralensis root, licorice); if you are trying for another baby, the doctor leaves out herbs such as Niu xi (Achyranthes bidentata root) and Hong hua (Carthamus tinctorius flower). The herbs only support qi and blood; they do not replace pelvic floor exercises or the time needed for the cesarean scar to heal.
If you are pregnant
In a pregnancy without complications, ACOG (2020) considers physical activity safe and encourages it, and women who already ran regularly can keep running, aiming for at least 150 minutes a week at moderate intensity; ACOG sets no figure in kilometers and gives no specific advice for long distances. For long trail races (running on trails and mountain paths) or high-altitude areas, the clinic advises saving them for after the birth, and that is our own view; for everyday training, avoid hot and humid hours, drink enough, and eat enough before runs longer than 45 minutes. You can still have an AK examination while pregnant, but once the pregnancy is well advanced the doctor does not test the pelvic muscles, and the clinic does not perform acupuncture on pregnant women.
When to come in for an examination
Come in for an examination if you leak urine or feel heaviness in the pelvis every time you run, if the scar still hurts after three months or has a burning, electric, shooting pain, if you have unusual bleeding after a session, or if you have already set your sights on a race in the first year after birth. Leaking urine or a dragging heaviness within the first few hundred meters are two signs to step back down, and also reason enough to be examined before running further.
Dr. Pham Tran Dan Tam (MD, Specialist Level I in Traditional Medicine) looks at the postpartum side: the pelvic floor, the scar, bleeding and breastfeeding, and makes clear which parts need an obstetrician or a pelvic floor physical therapist so you go to the right place. Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) looks at the running side: which step you are on, how the muscles around your hips and pelvis work in motion, and a gradual plan for the months ahead.
Leave the shoes on top of the cabinet for a few more weeks. Tomorrow morning, after the five o’clock feed, you can walk once around the lane and do a few rounds of pelvic floor contractions first. Book a consultation.
Worth keeping
- In the first few weeks after birth, walk, do breathing exercises and gentle pelvic floor contractions every day, but do not run yet;
- Take at least 3 weeks off running after birth, and treat that as the minimum, not an appointment date;
- Move up one step at a time: strength exercises, then walking mixed with running, and only then gradually more running time;
- If you leak urine, feel heaviness in the pelvis, or your belly bulges along the midline when you run, step back down and get examined;
- After a cesarean, ask your obstetrician before exercising, and wait until coughing, lifting your baby and climbing stairs no longer cause a sharp pain in the scar;
- Breastfeed or express milk before a run, wear a firmly supportive bra, and drink enough water;
- If bleeding increases or there is bright red blood after a run, step back down and get examined.
References
Sources in Vietnamese
- Hạ Quế Thành. Sổ tay chẩn đoán điều trị phụ khoa (bản dịch tiếng Việt). Tr. 305.
- Hải Thượng Lãn Ông. Hải Thượng y tông tâm lĩnh. Hà Nội: NXB Y học. Tập 1, tr. PDF 874.
Sources in English
- American College of Obstetricians and Gynecologists (ACOG). 2020. Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstet Gynecol. 135(4):e178-e188. doi:10.1097/AOG.0000000000003772. PMID: 32217980.
- American College of Obstetricians and Gynecologists (ACOG). 2022. Exercise After Pregnancy (FAQ131) [Internet; last updated 2022 Sep]. Available from: https://www.acog.org/womens-health/faqs/exercise-after-pregnancy.
- Bump RC, Hurt WG, Fantl JA, Wyman JF. 1991. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 165(2):322-7; discussion 327-9. doi:10.1016/0002-9378(91)90085-6. PMID: 1872333.
- Bø K, Berghmans B, Mørkved S, Van Kampen M, editors. 2015. Evidence-Based Physical Therapy for the Pelvic Floor. 2nd ed. Edinburgh: Elsevier. p. 397, 401–404.
- Christopher SM, Donnelly G, Brockwell E, Bo K, Davenport MH, De Vivo M, et al. 2024. Clinical and exercise professional opinion of return-to-running readiness after childbirth: an international Delphi study and consensus statement. Br J Sports Med. 58(6):299-312. doi:10.1136/bjsports-2023-107489. PMID: 38148108.
- Ciechanowicz S, Joy RR, Kasmirski J, Blake L, Carvalho B, Sultan P. 2025. Incidence, Severity, and Interference of Chronic Postsurgical Pain After Cesarean Delivery: A Systematic Review and Meta-analysis. J Clin Anesth. 104:111832. doi:10.1016/j.jclinane.2025.111832. PMID: 40279839.
- Deering RE, Donnelly GM, Brockwell E, Bo K, Davenport MH, De Vivo M, et al. 2024. Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement. Br J Sports Med. 58(4):183-195. doi:10.1136/bjsports-2023-107490. PMID: 38191239.
- EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA). 2015. Scientific Opinion on the safety of caffeine. EFSA Journal. 13(5):4102.
- European Medicines Agency, Committee on Herbal Medicinal Products (EMA/HMPC). 2026. EU herbal monograph on Glycyrrhiza (Rev. 1).
- Garten H. 2013. The Muscle Test Handbook: Functional Assessment, Myofascial Trigger Points and Meridian Relationships. Edinburgh: Churchill Livingstone Elsevier. p. 108–109.
- Goom T, Donnelly G, Brockwell E. 2019. Returning to running postnatal – guideline for medical, health and fitness professionals managing this population. p. 12, 17, 19.
- Hall CM, Brody LT. 2005. Therapeutic Exercise: Moving Toward Function. 2nd ed. Philadelphia (PA): Lippincott Williams & Wilkins. p. 275–276.
- Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. 2008. The Pfannenstiel incision as a source of chronic pain. Obstet Gynecol. 111(4):839-46. doi:10.1097/AOG.0b013e31816a4efa. PMID: 18378742.
- Walther DS. 2000. Applied Kinesiology: Synopsis. 2nd ed. Pueblo (CO): Systems DC. p. 515.
Sources in German
- Garten H. 2016. Applied Kinesiology: Funktionelle Myodiagnostik in Osteopathie und Chirotherapie. 1. Aufl. München: Elsevier. S. 21, 428, 494.
