Pet peeves about exercise in pregnancy…
Recently I had the honour of being asked by the Canadian Women’s Health division to answer some questions for their newsletter entitled “Exercise is Medicine”.
Here are my answers…
While acknowledging the benefits of exercising, what in your experience is the greatest risk around exercising during pregnancy?
I’m glad that you addressed the question in that way, as most of the international guiding bodies agree that for women with uncomplicated pregnancies the benefits associated with exercise in pregnancy far outweigh the potential risks. If we exclude women who are in high-risk pregnancies (ie have pre-existing significant medical conditions or obstetric conditions that may be adversely affected by exercise), then the risks associated with exercise in pregnancy are actually very small, especially when women are under regular obstetric care. I think we are very fortunate living in places like Canada and Australia, where we have access to such fantastic medical care and can easily send our clients to their GP or hospital if we have any concerns.
In my opinion I think that the biggest potential risks would be overheating (especially here in Perth in the height of summer), injuries from falls or contact sports, or pelvic floor dysfunction from doing heavy impact activities (if a woman pushes past her body’s ability to cope with the load).
I do not work with elite athletes who are pregnant, but there have been some recent guidelines published within the BJSM for those who do work with that population.
What is your view about running (continuing or starting) during pregnancy? Running with a stroller?
I would suggest that the appropriateness of running in pregnancy depends on a number of factors, such as:
- is she a regular runner? (if not, then I don’t think she should start in pregnancy)
- are there any obstetric reasons why she shouldn’t run (eg incompetent cervix)
- how does she feel when she runs? (ie any pain, heaviness etc?)
I am personally not a massive fan of running in pregnancy due to the high load on the pelvic floor (esp in the third trimester), but I do acknowledge that for some women the mental health benefits of higher intensity exercise may outweigh the potential risks. I do recommend that those clients who continue to run in pregnancy monitor their bodies and cease if they have any bleeding, pain, incontinence, heaviness or any other symptoms that they are concerned about. In my experience most women stop running during their pregnancy when they feel that it is no longer appropriate, but there will always be some women who push through these symptoms and they need to be aware of potential consequences.
With regards to the second question (I’m assuming that you are talking about the postnatal period now), I prefer running without a stroller, but I can see that for some women it may be the only way that they can get their running in and I know some ladies really love it. If a women really wants to run with a stroller, she needs to make sure the the baby is developmentally ready (usually 6-12 months, but check with the doctor) and that she finds a stroller that is designed specifically for running. She should swap arms regularly, keep the shoulders relaxed and try not to let her butt stick out as she runs.
Are there any specific exercises you would recommend to avoid during pregnancy, even if practiced before?
I tend to stick with the RCOG/ACOG guidelines when I make my recommendations to women about exercise in pregnancy. This includes avoiding the following : supine exercises after 16 weeks (edit: this has changed now), scuba diving, water skiing, contact sports, hot yoga/pilates, skydiving.
If people ask me about weight lifting, heavy abdominal work and impact exercise I will point out that these exercises may be harmful if your body is (a) not used to them or (b) if the exercises become too challenging for the body as pregnancy progresses. I will usually educate women about the pelvic floor and abdominal muscles and empower them to make the right decisions for their body and to monitor how their body is coping- of course it is easy for me in a group exercise setting when I can observe them in action!
When I run classes I don’t do high level rectus abdominis work (eg crunches and planks) or high impact exercises such as jumping and running. I think there are plenty of other exercise options that do not pose as many potential risks to the pelvic floor.
Are there specific types of physical activity that you believe are safe to be recommended to most pregnant women?
I think that once you exclude the above-mentioned contraindicated activities, then most activities can be recommended to women in pregnancy, depending of course on their previous level of activity, how they are faring in their pregnancy and what they actually enjoy.
The most common types of activity that I see women enjoy in pregnancy are: walking, gym, pregnancy yoga, pregnancy pilates and swimming/hydrotherapy.
In an ideal world recommendations would be made on an individual basis rather than blanket recommendations for all pregnant women.
For example, if a woman enjoys working out at the gym, then she can continue to do so through her pregnancy, with appropriate modifications (usually that will involve things like reducing the weights, cutting down impact exercise and removing supine exercises).
If a woman has never been a regular exerciser, then walking or supervised pregnancy exercise classes (eg yoga or pilates) might be a great start for her. If a woman is overweight / obese then she may find exercise in water (eg hydrotherapy) to be particularly enjoyable.
It is my opinion that the best kinds of physical activities for a woman to do in pregnancy are ones that are fun, convenient and make her feel good (ie relieve aches and pains, help her sleep better etc).
What do you think is (are) the biggest barrier(s) for practicing physical activity during pregnancy?
I think time is the biggest barrier to regular exercise in pregnancy. Many of the clients that I see work full time or have a family to look after, leaving them very little time and energy to devote to exercise. This is one of the reasons why I developed an online program that women can do at home!
Fatigue and nausea can be a limiting factor in the first trimester (and sometimes longer!) and tiredness/heaviness can stop women exercising in the final trimester. I find that pain can be a barrier for some women, but I do try and find ways to keep women exercising throughout their pregnancy wherever possible, by modifying the exercises to reduce/eliminate pain.
Do you have any advice or recommendations about when and how to return to exercise after delivery? (return to physical activity)
I personally believe that the first 6 weeks after you have a baby should be all about rest, recovery and caring for/ getting to know your baby. If a woman really wants to exercise, then short periods of walking are probably the best place to start. Gentle pelvic floor contractions can also be started early on and can actually help reduce pain and swelling in the perineum after a vaginal birth.
After the 6-week check most women can usually start doing some gentle exercise (I recommend that my clients have a check up with a women’s health physiotherapist first). The rate of recovery postnatally is HUGELY variable. I have some clients who are back running at 12 weeks without issues, but I find that most women take somewhere between 6-12 months to get back to a moderately intense level of exercise. I usually say to women that it takes 9 months to make a baby and around 9-12 months to recover, so that they change the timeframe in their mind and make a more gradual return to activity.
I do think that many women push themselves too hard and too soon postnatally and it may be one of the contributing factors to incontinence and prolapse. Where possible women should get guidance from a qualified health or fitness professional so that they can safely get back to doing the things that they enjoy.
What is your pet peeve around exercising during pregnancy?
I think people can get quite extreme in their views on pregnancy exercise – either that exercise is too dangerous or that it is never dangerous.
For example, If a super-fit pregnant lady continues doing what she has always done (eg run or do cross-fit), you’ll see people have really strong negative opinions about her and her ability to be a mother. These internet trolls say that she is doing damage to her baby and that she is ignorant/crazy to be doing higher-level exercise, which will “definitely” ruin her body and that the baby may be “strangled by the umbilical cord.” These groups of people feel that exercise in pregnancy should be minimal and very gentle.
At the other end of the spectrum you hear of groups of women being extremely competitive in their exercise (eg heavy weight lifting and impact exercise) pushing one another on and doing themselves damage in an effort to show that pregnancy hasn’t slowed them down at all.
We need to be somewhere in the middle! I believe that we need to encourage women to stay fit and active in pregnancy, but also acknowledge the fact that when we are pregnant we have physiological changes that need to be taken into account! Women should expect their bodies to change in pregnancy and for their exercise program to change along with it.
Do you believe the practice of physical activity during pregnancy differs between nations/countries, and if so why?
It is not something that I have done a lot of research into, to be honest. I’m sure in some less developed nations women are more physically active in pregnancy through necessity (eg carrying water over long distances or working in fields). Those of us in more westernised countries often have quite sedentary jobs and are less active throughout the day.
Are you concerned that recommendations for practicing physical activity during pregnancy do not address the issues of UI (Urinary Incontinence) and POP (Pelvic Organ Prolapse)?
Ooh…good question. I do believe that more should be mentioned about symptoms of UI or POP in the guidelines so that women know what to look out for. I teach pregnancy pilates and have an online education/exercise program, and in both I do educate women on what the pelvic floor is, how it is affected by pregnancy and birth and signs/symptoms of dysfunction.
We do need to acknowledge that obesity and inactivity are risk factors for pelvic floor dysfunction though, so we have to find the balance between getting people moving and not pushing them past their abilities. I personally don’t see a lot of women pushing hard in pregnancy and creating POP/UI… BUT I’m not a women’s health physiotherapist, so it may just be the women that I work with. Many of the clients who I’ve referred on for pelvic floor management during pregnancy have had longstanding issues prior to the pregnancy, rather than it being a new complaint.
I would add that I see more women having pelvic floor issues postnatally – related to the birth itself or from inappropriate exercise in the postnatal period. I find that many women are not getting sufficient information during pregnancy on how to potentially reduce the risks during birth and how to safely get back into exercise in the postnatal period.