Training During Pregnancy: The Why’s, How’s, And What To Avoid
There are still a lot of myths about training during pregnancy due to how conservative early guidelines were. The American College of Obstetrics and Gynaecology (ACOG) released their first leisure time activity guidelines for pregnant women in 1985 and these were based on the limited research available at the time. This history may be the reason that there is a lot of misconception surrounding exercise in pregnancy. Speaking from experience, pregnant women (and the people around them) often have guilt and anxiety surrounding this topic so the goal of this article is to equip practitioners with the knowledge to put their client’s minds at ease and to guide them through a healthy, fit and safe pregnancy.
Many women’s quality of life is compromised during pregnancy. Changes in sleep and hormonal regulation may also lead to increased mood swings, depression and anxiety contributing to reduced psychological health (O’Connor et al., 2019). Physiological changes during pregnancy include an increase in blood volume, heart rate and stroke volume as oxygen uptake increases, resulting in breathlessness and contributing to increased fatigue. The increase of oestrogen and relaxin result in joint laxity which may cause lower back (LBP) and pelvic girdle pain (PGP) as well as an increased risk of joint injury. Balance may also be impaired due to postural changes that occur to
accommodate the weight of the growing baby. As a result, lumbar lordosis is common in pregnant women which may also contribute to the increased prevalence of LBP (Kader & Shuchana, 2014). In addition, around 60% of pregnant mothers remain sedentary throughout pregnancy (Schoenfeld, 2011) and only around 10% utilise RT (White et al., 2012). Unsurprisingly, the rate of overweight pregnant women is increasing which further increases risk for mother and baby (Kader & Shuchana, 2014) including a greater risk of caesarean section (Ellekjaer, Bergholt & Løkkegaard, 2017).
Exercise has been shown to help manage excess weight gain during pregnancy and therefore reduce the risk of gestational diabetes and preeclampsia whilst improving foetal development (Schoenfeld, 2011). In addition, RT leads to better psychological well-being, improved body image and better overall quality of life (O’Connor et al., 2019; Deol & Warburton, 2020; Schoenfeld, 2011) by helping to manage psychological symptoms that come with an expanding family. A pregnancy that includes RT may benefit from a reduced risk of joint injury, lower back pain (LBP) and pelvic girdle pain (PGP) as RT can strengthen connective tissue and help prevent joint laxity (Deol & Warburton; 2020). Arguably one of the more important benefits of RT during pregnancy is to help prepare the body for labour and demands of raising a young child. The muscular strength required during child birth is no joke as early labour can last days or weeks with active labour lasting up to eight hours. Exercising mothers can benefit from reduced risk of C-section, easier shorter active labour (Haakstad & Bo, 2020) and shorter hospital stays after birth without being linked to any negative outcomes (Deol & Warburton, 2020). Babies of active mothers tend to have healthier foetal birthweights which may reduce risk of preterm births (White et al., 2012). Considering these points, it may be safe to say that an active pregnancy may be less risk associated than a sedentary pregnancy, provided that some guidelines and common sense are followed.
First: it is important to: get medical clearance from your client’s physician that it is safe for them to exercise (Birsner & Gyamfi-Bannerman; 2015). Secondly, any exercise with a high risk of falling or getting a blow to the stomach risking foetal trauma should be avoided (Kader & Shuchana, 2014). Olympic lifts, barbell hip thrusts and extremely unbalanced exercises with no support as the belly grows are clear examples of things to eliminate.
Many women will need to adapt how they approach their training once they learn that they are pregnant. As fitness professionals it is our job to educate our clients on what expectations are realistic now their body is changing rapidly. Fatigue, poor sleep, LBP and PGP will likely make maintaining strength in most trained women a challenge, so adjusting the benchmarks of a good workout and addressing expectations are key to keeping the training safe and maintaining motivation.
Listen to your client! Some days, because of the rapid changes taking place in the body, movements will feel awkward or wrong. If something feels wrong, it usually is. Regress or avoid an exercises that causes pressure, dragging sensations or pain the pelvic floor or perineum, faecal or urinary incontinence or the sudden need to use the bathroom as this suggests the core and pelvic floor may not be managing the additional stress safely (Mitchell & Elsler, 2009). Ballistic movements should be avoided due to increased hormone levels increasing the laxity of connective tissue (Dumas & Reid, 1997). Supine exercises may be contraindicated if mother has symptoms such as light headedness, nausea or feeling generally unwell (Mottola et al, 2018). Furthermore, Valsalva manoeuvre is likely to put too much additional stress on the pelvic floor and should be avoided in pregnancy (Wolfe & Davies, 2003).
The core musculature is under more stress than ever and labour is likely to be its greatest challenge yet (Haakstad & Bo, 2020). Although core training shouldn’t be neglected (Schoenfeld, 2011), it is
important to consider Diastasis recti abdominis (DRA). DRA is the separation of the abdominals down the linea alba to make room for the growing baby. It is most likely not avoidable and may impact up to 100% of pregnant women (Mota et al., 2014). When training the core in pregnancy there is a need for conscious bracing of the TVA to avoid bulging tissue at the linea alba as this may not be conducive to DRA recovery in the post-partum period (Acharry & Kutty, 2015). Bulging may be a sign that the core musculature is not coping the additional stress and so the current available evidence suggests that movements that cause bulging should be regressed to a point where bulging cannot be observed. For example, elevating the elbows on a bench instead of leaving them on the floor for a plank may prevent bulging and therefor may be enough to make this exercise pregnancy safe. A key addition to core training should be the connection breath: In heathy individuals a connection between a submaximal contraction in the transversus abdominis (TVA) and the pelvic floor. During pregnancy this co-contraction can be lost and using breathing exercises where the inhale is associated with relaxation of both the TVA and PF and exhale is associated with submaximal co-contraction of both of these muscles. This strategy should be used from the very early stages of pregnancy well into the post-partum period (Werner & Dayan, 2019) to increase strength and coordination between these muscle actions as well as training the client to properly relax these muscles when necessary. Both of these may help reduce the chance of tearing during labour (Leon-Larios, et al., 2017).
Total body routines may be ideal to prevent blood pooling in the lower limb (Schoenfeld, 2011). Featuring plenty of movement variability in training may help keep a variety of positions available as the body grows. During labour, a variety of positions are needed and holding them for a long time is required. Exercises in sitting, kneeling, squatting, half kneeling and planking positions are just some options to consider. Additionally, it is important to include exercises that help prepare for the demands of early parenthood with unevenly loaded exercises, upper back strength, etc. Think about the life of a new parent. How on the demands of their body going to change? Well planned exercise can help prepare them for these changes.
Manage intensity: moderate to vigorous exercise is shown to be safe in pregnancy (White et al., 2012) but beware of using rate of perceived exertion scales as heart rates have not been shown to line up with perceived intensity in pregnant women (O’Neill et al., 1992). Instead, consider aiming for intensities where clients can talk but they couldn’t sing. However, even on days when training is tough, something is better than nothing. Even low to moderate intensities help to reduce feelings of fatigue (O’Connor et al., 2019). When strength training, monitoring how many repetitions are in reserve (RIR) at the end of the set to ensure the intensity isn’t maximal and therefore putting undue stress on the core and pelvic floor. Aiming for around 10 repetitions per set with around 3RIR may be a good guide (Schoenfeld, 2011). Checking for bulging on the stomach as well as checking the client doesn’t feel any uncomfortable sensations in the pelvic floor during the set is vital to checking how well the body is managing the load and intensity.
In conclusion, training during pregnancy is safe, effective and important in uncomplicated pregnancies for health, risk management and quality of life. As fitness practitioners we need to have an understanding of the rapid changes that happen during pregnancy carefully manage sessions to reflect them. Sessions and intensities should be adapted with careful attention paid to how the mother is feeling at any given time. It is our responsibility to above all listen to and educate clients to help them make informed decisions based on their own bodies at any given time.
References
Acharry, N., & Kutty, R. K. (2015). Abdominal exercise with bracing, a therapeutic efficacy in reducing diastasis-recti among postpartal females. Int J Physiother Res, 3(2), 999-1005.
Birsner, M., & Gyamfi-Bannerman, C. (2015). American College of Obstetrics and Gynaeocology. Number 804 (Replaces Committee Opinion Number 650)
Bø, K., Hilde, G., Tennfjord, M., Sperstad, J., & Ellstrøm Engh, M. (2015). Diastasis recti abdominis and pelvic floor muscle function. A cross sectional study of primiparous women during pregnancy and postpartum. Physiotherapy, 101, 161-162.
Deol, J., & Warburton, D. E. (2020). Resistance Training and Pregnancy. The Health & Fitness Journal of Canada, 13(1), 99–104.
Dumas, G. A., & Reid, J. G. (1997). Laxity of knee cruciate ligaments during pregnancy. Journal of Orthopaedic & Sports Physical Therapy, 26(1), 2-6.
Ellekjaer, K. L., Bergholt, T. & Løkkegaard, E. (2017). Maternal obesity and its effect on labour duration in nulliparous women: a retrospective observational cohort study. BMC Pregnancy Childbirth 17, 222.
Haakstad, L. A., & Bø, K. (2020). The marathon of labour—Does regular exercise training influence course of labour and mode of delivery?: Secondary analysis from a randomized controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 251, 8-13.
Kader, M., & Naim-Shuchana, S. (2014). Physical activity and exercise during pregnancy. European Journal of Physiotherapy, 16, 2-9.
Leon-Larios, F., Corrales-Gutierrez, I., Casado-Mejía, R., & Suarez-Serrano, C. (2017). Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery, 50, 72-77.
Mitchell, D. A., & Esler, D. M. (2009). Pelvic instability: painful pelvic girdle in pregnancy. Australian family physician, 38(6), 409-410.
Mota, P., Pascoal, A. G., Carita, A., Bø, K. (2014). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Therapy.
Mottola, M. F., Davenport, M. H., Ruchat, S., Davies, G. A., Poitras, V. J., Gray, C. E., Jaramillo Garcia, A., Barrowman, N., Adamo, K. B., Duggan, M., Barakat, R., Chilibeck, P., Fleming, K., Forte, M., Korolnek, J., Nagpal, T., Slater, L. G., Stirling, D., & Zehr, L. (2018). 2019 Canadian guideline for physical activity throughout pregnancy.British Journal of Sports Medicine, 52(21), 1339-1346.
OʼConnor, P. J., Poudevigne, M. S., Johnson, K. E., Brito de Araujo, J., & Ward-Ritacco, C. L. (2018). Effects of Resistance Training on Fatigue-Related Domains of Quality of Life and Mood During Pregnancy: A Randomized Trial in Pregnant Women With Increased Risk of Back Pain. Psychosomatic medicine, 80(3), 327–332.
O'Neill M. E., Cooper K. A., Mills C. M., et al. (1992). Accuracy of Borg's ratings of perceived exertion in the prediction of heart rates during pregnancy. British Journal of Sports Medicine; 26, 121-124.
Schoenfeld, B. (2011). Resistance training during pregnancy: safe and effective program design. Strength & Conditioning Journal, 33(5), 67-75.
Werner, L. A., & Dayan, M. (2019). Diastasis recti abdominis-diagnosis, risk factors, effect on musculoskeletal function, framework for treatment and implications for the pelvic floor. Current Women's Health Reviews, 15(2), 86-101.
White, E., Pivarnik, J., & Pfeiffer, K. (2014). Resistance training during pregnancy and perinatal outcomes. Journal of Physical Activity and Health, 11(6), 1141-1148.
Wolfe, L. A., & Davies, G. A. (2003). Canadian guidelines for exercise in pregnancy. Clinical obstetrics and gynecology, 46(2), 488-495.
Yaping, X., Huifen, Z., Chunhong, L., Fengfeng, H., Huibin, H., & Meijing, Z. (2020). A meta-analysis of the effects of resistance training on blood sugar and pregnancy outcomes. Midwifery, 102839.