Postpartum back pain: the baby is born, the bump is gone, and the back keeps hurting as much as before, and sometimes more. When you look for an explanation you almost always find the same two: it is the hormones of pregnancy keeping the ligaments lax, and it is abdominal diastasis that has left the spine without support. It is worth saying this straight away, because it changes what makes sense to do: neither of the two, looked at in the studies, holds up the way it is told. What does hold up, with moderate-certainty evidence, is the least exciting and least viral thing: training the trunk muscles really does reduce pain.
This article brings the two things together: what the research says about postpartum back pain and what to do the morning after. The practical advice on how to lift the baby, how to breastfeed without staying bent for forty minutes and how to organise the changing table all remains valid: it simply has not been demonstrated by a randomised trial, it is common sense about load. I report it for what it is, and I clearly distinguish when I am citing evidence and when I am giving reasoned advice.
⚠ Important: read this before continuing
The exercises and advice in this article are general indications and may not be suitable for your situation. Every person has a unique clinical history: what works for others could be counterproductive for you.
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First of all: when you do not start with exercises
Low back pain after childbirth is almost always a musculoskeletal problem, but the period just after birth is also the only moment in life when a painful back can conceal infections, complications of anaesthesia or bone fragility. For this reason the alarm signs must be read before the exercises, not after.
Go to the emergency room, or call your doctor straight away, if you have:
- Fever together with back pain. An infectious problem must be ruled out, from infection of the uterus after childbirth to urinary tract infection travelling up to the kidneys.
- Weakness, numbness or persistent tingling in the legs, especially if they worsen within hours or days.
- Loss of bladder or bowel control, or loss of sensation in the area that rests on a bicycle saddle. It is a neurological emergency at any age and in any condition.
- Pain, redness or swelling at the point where the epidural or spinal was given, particularly if accompanied by fever or a severe headache when you stand up.
- Unbearable pain that does not change in any position, that regularly wakes you at night and responds neither to rest nor to light movement. Among the rare but described causes in this period is vertebral fracture linked to osteoporosis associated with pregnancy and breastfeeding. A systematic review that gathered all the published cases between 1990 and 2020 found 338 of them in 65 articles: it is therefore a rare condition, back pain is the symptom through which it presents, and in 91.5% of cases the pain appears between the last 3 months of pregnancy and the first 3 after childbirth, more often in a first pregnancy and in the transition zone between the thoracic and lumbar spine. Rare does not mean non-existent: this is why a sudden, very severe pain in the upper back or the upper lumbar area must not be handled alone.
- Burning or pain on urination, blood in the urine, flank pain.
To be discussed with a professional, without urgency but without postponing indefinitely: urinary or faecal incontinence that continues beyond the first few weeks, a sensation of heaviness or bulging in the vagina, and pain that, after a couple of months of constant exercise, has not moved a millimetre or is getting worse.
What is proven and what is not
What can really be done in the first weeks is set out in the first month after childbirth; and on returning to the office, as the days change, there is going back to work after childbirth.
Three claims circulate about postpartum back pain with the same tone of certainty, but with very different foundations.
That exercise reduces the pain: proven, and this is the good news. A systematic review with meta-analysis published in the British Journal of Sports Medicine gathered 37 studies conducted in 15 countries on 3,769 participants in the first year after childbirth. With moderate-certainty evidence, exercise-only interventions, including various strengthening exercises for the trunk muscles, reduced the severity of lumbopelvic pain more than not exercising: the mean difference is 2.21 points on a visual analogue scale from 0 to 10 (4 randomised trials, 210 participants), with a broad effect on pain-related disability as well (6 randomised trials, 296 participants). Translated: those who train are measurably better off than those who wait. It does not mean "zero pain", it means a real gain, large enough to be felt during the day.
That it is the fault of relaxin: not proven. A systematic review looked for the association between relaxin levels and pregnancy-related pelvic girdle pain: out of 731 references identified, 6 studies met the criteria, and among the 4 judged to be of high quality, as many as 3 found no association. The authors' conclusion is that the level of evidence for this link is low. An important clarification needs adding: those studies measured relaxin during pregnancy, not after childbirth. The most widespread version of the story, that the hormone stays in circulation for months after birth, and even more so if you breastfeed, keeping the ligaments lax, has not been refuted by this review simply because it has never been put to the test. To sum up: hormonal laxity is an elegant explanation that has circulated for decades, but it is an unproven hypothesis, not an established mechanism, and above all it is an explanation that gives you nothing to do, whereas the modifiable causes give you plenty.
That it is the fault of diastasis: not proven, or in any case much weaker than it is made out to be. A systematic review of 12 studies on 2,242 participants found no significant association between the presence of rectus diastasis and lumbopelvic pain, nor with incontinence. A prospective cohort of 300 women having their first child, followed up to one year after childbirth, points in the same direction: women with diastasis and women without it reported the same amount of lumbopelvic pain.
For honesty, the rest of that review also needs stating, since it is not all in favour of this reading: a small association between the presence of diastasis and pelvic organ prolapse was found, and the width of the separation, not its mere presence, could be linked to the severity of lumbar pain, as well as to lower abdominal strength and poorer quality of life. The authors describe all this evidence as weak, and the methods used to measure diastasis varied widely from study to study. So the correct reading is not "diastasis does not matter at all", but: its presence does not explain your back pain, whereas a very wide separation is an element to be assessed together with everything else.
How is this information used anyway? In two very concrete ways. First: if you have diastasis, it is not automatically the explanation for your postpartum back pain, and spending months "closing it" in the hope that the pain will go away as a result is a gamble. Second: since what works is progressive trunk training, the time is invested there - in strength and control, not in chasing millimetres of separation.
Why the back hurts after childbirth
With the two explanations that do not hold up set aside, what remains are the factors that make mechanical sense and on which one can act.
The load has changed suddenly, the strength has not. During pregnancy the abdominal muscles progressively stretch and lose their capacity to generate tension, and general conditioning almost always falls. After childbirth the weight of the bump disappears in a day, but a new and repeated load arrives: lifting, holding the baby, breastfeeding, bending over the changing table, carrying the car seat. A high demand imposed on a temporarily less trained system is the simplest and most useful explanation for postpartum back pain.
Very long static postures. Breastfeeding does not hurt because of the position itself, but because of its duration: staying for twenty, thirty, forty minutes in the same flexed position, several times a day, without anything moving, is exactly the condition in which tissues start to protest.
Pain that was already there during pregnancy. This is the most concrete prognostic factor. A prospective study of 288 women having their first child by vaginal birth described the trajectories of trunk pain: among those who had pain in all three sites during pregnancy (thoracic, lumbar and pelvic girdle), 34% still had pain in all three at 6-10 weeks after birth, and only 13% were pain-free. Those who arrive at childbirth with more painful sites are less likely to see everything resolve on its own, and have more reasons to start a pathway early instead of waiting.
Broken sleep. This is not a consoling joke. In a cross-sectional study of 120 women who had had lumbopelvic pain during pregnancy, at 4 months after birth the pain persisted in 45 of them (37.5%), and sleep disturbance was associated with the persistence of pain even after adjustment for age, body mass index, parity and history of pain before pregnancy (odds ratio 2.98; 95% confidence interval 1.31-6.75). It is an association, not a demonstrated causal relationship, and at this stage sleep is not entirely within your control. But it explains why the same load hurts much more in a bad week, and why "sleep when the baby sleeps" is clinical advice and not just a saying.
The pelvic floor. It works in synergy with the abdominals and the diaphragm in controlling the trunk, and pregnancy and childbirth put it to the test. Be careful, though, about what is proven: as we will see, its training has solid evidence for incontinence, not for back pain.
An important tip: before trying these exercises, make sure you have received a correct diagnosis. People often think they have one problem, but the real cause of the pain is another. Performing the wrong exercises can make the situation worse instead of better.
How long it lasts
On how long postpartum back pain lasts, the honest figures are less reassuring than the slogans, and more useful. In the prospective study of the 288 first-time mothers, 94% reported trunk pain during pregnancy and 75% still reported it at 6-10 weeks after birth; in detail, at that check lumbar pain affected 52% of the women and pelvic girdle pain 41%. These are high percentages: the fact that you still hurt two months later is not an anomaly and not the fault of something you did wrong.
In the same cohort, however, the movement in the opposite direction is also visible: among the women who had both lumbar and pelvic girdle pain during pregnancy (32% of the total), at 6-10 weeks 20% no longer had any pain and 18% still had both. The picture changes, for the better, for many. What no study allows you to say is an expiry date: anyone who promises you "six weeks and it passes" is making it up. The variable you can act on is not the calendar, it is what you do in the meantime.
Trunk control and strengthening exercises
This is the chapter with the best evidence. The repetition guidelines below are reasonable starting points, not a validated protocol: the real criterion is that the exercise does not increase pain and that progression is gradual.
Activation of the transversus abdominis. Lying on your back with your knees bent, gently draw the navel towards the spine, as if you wanted to button a pair of slightly tight jeans, without completely flattening the lumbar area against the floor. Hold the activation for about ten seconds while breathing normally, then release completely. It is the basic exercise for regaining deep control. Roughly 10-15 repetitions, even several times a day.
Coordinated diaphragmatic breathing. Still lying down, breathe in letting the belly and the lateral ribs expand, then breathe out slowly while activating the transversus. Coordinating breath and deep activation is the foundation on which everything else rests, and it is the easiest thing to fit into a chaotic day. About ten breaths at a time.
Glute bridge. Lying on your back, knees bent and feet hip-width apart, activate the transversus and then lift the pelvis by contracting the glutes. In the first weeks there is no need to go high: even a few centimetres is a load. It is one of the most useful exercises because it trains the glutes and the trunk extensors together, which are the muscles that pay most during this period. About 10-15 repetitions.
Heel slides. Lying on your back with knees bent, activate the transversus and slowly slide one heel along the floor, extending the leg, keeping the lumbar area still without it arching. Bring the leg back and switch sides. It is the first exercise in which the trunk has to resist a movement of the limbs, which means doing its job. About 10 repetitions per leg.
Progressive bird dog. On all fours with the back in a neutral position, activate the trunk and extend only one leg at a time, keeping the pelvis still, without rotation. When this becomes easy and stable, add the opposite arm. About 8-10 repetitions per side.
Slow cat-cow. On all fours, alternate rounding the back upwards and a gentle arching downwards, following the breath. It does not strengthen, but it relieves stiffness and gives relief, and it is a good way to start or finish the session. 10-15 very slow repetitions.
A note on progression, because it is the part that is usually missing. The studies that showed the reduction in pain used strengthening programmes, not just light activations repeated for months. Activations are the beginning: when you manage them without effort, the next step is to add load and complexity: single-leg bridge, standing exercises, movements that resemble lifting a child off the floor. Staying forever at level one is the most common reason a programme stops giving results.
Pelvic floor: what is proven and what is not
Here the distinction matters, because the two things are sold together around. The systematic review with meta-analysis on exercise in the first year after childbirth, which included 65 studies on 21,334 participants, shows with moderate certainty that pelvic floor muscle training reduces the odds of urinary incontinence by 37% (7 randomised trials, 1,930 participants) and of pelvic organ prolapse by 56%, the latter however based on a single randomised trial of 123 participants. These are important results and an excellent reason to do it. It is also worth knowing the limit: on the severity of symptoms, and not on the risk of having them, the same review judges the evidence still limited.
What those findings do not say is that working on the pelvic floor makes postpartum back pain go away. It is a reasonable hypothesis on the level of trunk control, not a finding. So: train the pelvic floor for continence and function, and train the trunk for pain. That in practice you do both together is perfectly fine - you just need to know what to expect from what.
How to do it. Contract the pelvic floor muscles, as if you wanted to hold back wind or interrupt the flow of urine - but without getting into the habit of actually trying this while you urinate - hold the contraction for a few seconds, then release completely. The release counts as much as the contraction. After a vaginal birth you can usually start early, with the go-ahead from whoever is following you. If you notice you feel nothing, or if the contraction hurts, it is worth having it assessed rather than insisting blindly.
Abdominal diastasis: what really changes
Let us start with the frequency, because it helps to put things in proportion. In the prospective cohort of 300 women having their first child, diastasis was present in 33.1% at 21 weeks of pregnancy, in 60.0% at 6 weeks after childbirth, in 45.4% at 6 months and in 32.6% at 12 months. It is a common condition, and in a significant share of women it reduces over time. In the same cohort, as mentioned, women with diastasis did not report more lumbopelvic pain than women without it.
How to check it. Lying on your back with your knees bent, lift your head and shoulders slightly and feel with your fingertips the space between the two rectus muscles above and below the navel. A separation of two fingers or more is the criterion commonly used to speak of diastasis. It is useful information to have, not a verdict.
On crunches, the most repeated and least proven rule. A randomised trial of 70 women between 6 and 12 months after childbirth with diagnosed diastasis compared 12 weeks of a home programme with head lifts and crunches, 5 days a week, against no intervention. The result: the programme neither improved nor worsened the distance between the rectus muscles, it increased the thickness of the rectus abdominis and abdominal strength, and its effects on the other outcomes - including lumbar, pelvic girdle and abdominal pain - were negligible or unclear. So the "forbidden crunch" has no evidence behind it; the "crunch that fixes it" does not either.
The practical criterion that remains valid is not a list of forbidden exercises, but the observation: if during an effort the belly bulges to a point along the midline or a clear dome forms, at that moment the load is higher than your abdominal wall can contain, and it is better to go back to an easier version. On reducing the distance between the rectus muscles, the meta-analysis already cited finds that abdominal training reduces it compared with not training, but with low-certainty evidence: expecting guaranteed closure is not realistic. If you want to explore only this aspect, I have written about it in full in Abdominal Diastasis Exercises: What Really Works.
Breastfeeding: position matters because it lasts
This chapter and the next are reasoned ergonomics, not results of randomised trials. I keep them because in clinical practice they are what new mothers most often report as immediate relief, and because they reduce the number of hours spent in loaded static positions - which is the mechanism we are working on.
The principle is just one: bring the baby to the breast, not the breast to the baby. Everything else follows from this.
Use cushions to raise the baby, not your shoulders. One or more cushions on your knees, or a U-shaped nursing pillow, bring the little one to the right height without your having to bend. It is the single adjustment that changes the most.
Back supported, shoulders low, feet resting. Sit with good lumbar support, add a cushion behind you if the armchair is too deep, keep your shoulders away from your ears and your feet on the floor or on a footrest.
Change position and side. Alternate the cradle hold, the underarm hold and breastfeeding lying on your side. Varying distributes the load instead of always concentrating it in the same tissues.
Lying on your side, especially at night, takes the load off the spine and is often what gives the most relief when the back is already irritated.
The positions one by one, and how to change them after a caesarean or with twins, are in breastfeeding positions.
Everyday activities with a newborn
The changing table at the right height. It should be roughly at the level of your navel. Changing the nappy on the bed or on the sofa means bending dozens of times a day with a curved back and no support: it is the classic sum of small loads that becomes a big problem.
Lifting the baby. Get closer first, bring the baby close to your body, bend your knees and use your legs. Not because bending the back is forbidden in absolute terms - the spine is made to move - but because with a load repeated dozens of times a day it is better to spread the work over the hips and legs instead of always dumping it on the same spot.
The cot and the crib. Lower the side if possible and get as close as you can before lifting. A very deep cot, or one placed alongside the bed, changes the geometry of the movement more than any exercise.
Carrying. A structured baby carrier that spreads the weight across the shoulders and the pelvis is preferable to carrying the baby always on the same hip. If you use your hip, at least alternate it.
The car seat. Lifting the baby seat with the baby inside means lifting a heavy, unbalanced load held away from the body: the worst possible combination. Leave the base in the car and transfer the baby separately when you can.
Rest. Lying down when the baby sleeps is not laziness and is, given the links between disturbed sleep and persistent pain, part of the pathway as much as the exercises are.
Lifting, pushing the pram and carrying a bag each have their own technique: pushing the pram and carrying the bag without hurting yourself.
When to start, depending on the type of birth
Uncomplicated vaginal birth. Very light activations - coordinated breathing, transversus activation, pelvic floor - are usually started early, if they do not cause pain and if whoever is following you has not given different instructions. For the more demanding exercises the reference point is the postnatal check and the go-ahead from whoever followed you.
Vaginal birth with tears or episiotomy. Follow the instructions received for tissue healing; the exercises are resumed when local pain allows.
Caesarean birth. It is abdominal surgery in every sense: you always wait for the gynaecologist's authorisation and restart very gradually. The scar can remain sensitive and influence the way you recruit the abdominal wall, and it is worth having it assessed if you notice that the discomfort or tension does not change over time.
In all cases the criterion is the same: the exercises must not increase the pain, and progression is built on real tolerance, not on the calendar.
How a physiotherapist works on this
An assessment of postpartum back pain serves to answer questions that you cannot solve on your own: where exactly the pain originates, whether it is lumbar or pelvic girdle (the management changes), how much load the abdominal wall tolerates, how the pelvic floor is working, which everyday movements are feeding the problem. From there a progressive programme is built - which is the part that matters, because it is progressive trunk strengthening that has the best evidence - and it is updated as you improve.
Telerehabilitation suits this period well for a practical reason: most of the work is guided exercise and correction of everyday movements, and it can be done from home without organising trips with a newborn. If the pain does not move after a consistent pathway, or if one of the signs listed at the start appears, the next step is an assessment, not one more exercise.
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If you think the epidural is to blame, the studies say something different: Back pain after the epidural.
Sources
- Impact of exercise on musculoskeletal pain and disability in the postpartum period: a systematic review and meta-analysis, British Journal of Sports Medicine, 2025
- Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis, British Journal of Sports Medicine, 2025
- Pregnancy-related pelvic girdle pain and its relationship with relaxin levels during pregnancy: a systematic review, European Spine Journal, 2012
- Relationship between diastasis of the rectus abdominis muscle (DRAM) and musculoskeletal dysfunctions, pain and quality of life: a systematic review, Physiotherapy, 2019
- Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain, British Journal of Sports Medicine, 2016
- Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial, Journal of Physiotherapy, 2023
- Trajectories of lower back, upper back, and pelvic girdle pain during pregnancy and early postpartum in primiparous women, Women's Health (London), 2019
- Association between sleep disturbance and low back and pelvic pain in 4-month postpartum women: a cross-sectional study, European Spine Journal, 2021
- Pregnancy- and lactation-associated osteoporosis with vertebral fractures: a systematic review, BMC Musculoskeletal Disorders, 2021
Last source check: August 2026.
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