PREGNANCY AND POSTPARTUM EXERCISE MYTHS AND FACTS
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8/13/18
What if
there was
a pill that
provided
all these
benefits…
PREGNANCY AND
POSTPARTUM
EXERCISE MYTHS
AND FACTS
Exercise during Pregnancy: A History
■ 1950’s: avoid “violent” activities; stick to “gentle” activities like
housework and easy walking
■ 1960’s: the standard begins to unravel
■ 1970’s: studies published showing benefits of exercise during
pregnancy
■ 1980’s: more science, more questions
■ 1990’s: evidence-based guidelines…with some holes
■ 2000’s: still some gaps and contraindications in the literature
■ 2010’s: continued support for exercise during pregnancy – and more
emphasis on risks of NOT exercising
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Current Pregnancy Exercise Guidelines:
■Vague
And
■General
Pregnancy Myth #1:
vI shouldn’t start a new exercise program
when I’m pregnant.
Women who BEGAN exercise programs
while pregnant:
§ Improved aerobic fitness and muscular strength, had
comparable size infants, significantly fewer cesarean
deliveries, and faster postpartum recovery. (Price et al,
2012)
§ Had no difference in birth weight or length of gestation
(Haakstad & Bo, 2011)
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Pregnancy Myth #2:
vI should keep my heart rate under 140 BPM.
Heart rate and pregnancy
■ There is an increase in resting heart rate by 10-15 beats per
minute in pregnant women. (Avery et al, 2001)
■ Response of sympathetic system to strenuous exercise can
be blunted. (Avery et al, 2001)
■ Relationship between heart rate and oxygen consumption
altered during pregnancy. (Pivarnik et al, 2002)
ACOG Guidelines
The 15-Grade Scale for Ratings of Perceived Exertion ^
■ 6
7 Very, very light 8
9 Very light
10
11 Fairly light
12
13 Somewhat hard 14
15 Hard
16
17 Very hard
18
19 Very, very hard 20
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Pregnancy Myth #3:
vLifting weights is dangerous while pregnant;
I should stick to walking and prenatal yoga.
ACOG Guidelines
Examples of Safe and Unsafe Physical Activities During Pregnancy*^
■ The following activities are safe to initiate or continue*:
■ Walking
■ Swimming
■ Stationary cycling
■ Low-impact aerobics
■ Yoga, modified †
■ Pilates, modified
■ Running or jogging ‡
■ Racquet sports ‡§
■ Strength training ‡
The following activities should be avoided:
– Contact sports (eg, ice hockey, boxing, soccer, and basketball)
– Activities with a high risk of falling (eg, downhill snow skiing, water skiing, surfing, off-road
cycling, gymnas-tics, and horseback riding)
– Scuba diving
– Sky diving
– “Hot yoga” or “hot Pilates”
Current Research?
■ Ravanelli N, Casasola W, English T, et al. Heat stress and fetal risk. Environmental
limits for exercise and passive heat stress during pregnancy: a systematic review
with best evidence synthesis. Br J Sports Med Published Online First: 01 March
2018. doi: 10.1136/bjsports-2017-097914
■ Pregnant women can safely do up to 35 minutes of high-intensity aerobic exercise
(at 80 to 90 percent of their maximum heart rate) at air temp of up to 77 degrees F
and a relative humidity of 45 percent.
■ Can safely do aquatic aerobics in water temps ranging from 83.8-92.1 degrees F for
up to 45 minutes.
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ACOG Guidelines
Absolute Contraindications to Aerobic Exercise During Pregnancy^
■ Hemodynamically significant heart disease
■ Restrictive lung disease
■ Incompetent cervix or cerclage
■ Multiple gestation at risk of premature labor
■ Persistent second- or third-trimester bleeding
■ Placenta previa after 26 weeks of gestation
■ Premature labor during the current pregnancy
■ Ruptured membranes
■ Preeclampsia or pregnancy-induced hypertension
■ Severe anemia
ACOG Guidelines
Relative Contraindications to Aerobic Exercise During Pregnancy^
■ Anemia
■ Unevaluated maternal cardiac arrhythmia
■ Chronic bronchitis
■ Poorly controlled type 1 diabetes
■ Extreme morbid obesity
■ Extreme underweight (BMI less than 12)
■ History of extremely sedentary lifestyle
■ Intrauterine growth restriction in current pregnancy
■ Poorly controlled hypertension
■ Orthopedic limitations
■ Poorly controlled seizure disorder
■ Poorly controlled hyperthyroidism
■ Heavy smoker
ACOG Guidelines
Warning Signs to Discontinue Exercise While Pregnant^
■ Vaginal bleeding
■ Regular painful contractions
■ Amniotic fluid leakage
■ Dyspnea before exertion
■ Dizziness
■ Headache
■ Chest pain
■ Muscle weakness affecting balance
■ Calf pain or swelling
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Pregnancy Myth #4: Exercising will make my
pregnancy symptoms worse.
■ Exercise during pregnancy can reduce low back pain.
(Garshasbi & Faghih Zadeh, 2005; Shiri et al, 2018)
■ Exercise is associated with reduced risk of pelvic girdle pain
(Andersen et al, 2015)
■ Exercise may help reduce presence of diastasis rectus
abdominus (abdominal separation) (Chiarello et al, 2005;
Benjamin et al, 2014)
Pregnancy Myth #5:
■ If I run throughout
my pregnancy, I will
“bounce back”
more quickly.
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rcog.org.uk
Patients > Patient
information leaflets >
Physical activity and
pregnancy
Postpartum Exercise Myths and Facts
Postpartum Myth #1:
■ I can safely resume all exercise after my 6
week check up.
OR
■ I can run immediately postpartum because I’m
a runner.
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What does the research say about
postpartum return to exercise?
Postpartum physiological changes –
abdominal wall
■ Diastasis rectus abdominus (DRA) present in 100% of women in
late stages of pregnancy (measured via diagnostic ultrasound)
(da Mota et al, 2015)
■ DRA present in 60% of women at 6 weeks postpartum, 45% at 6
months, and 33% at 12 months (Sperstad et al, 2015)
■ The rectus abdominus starts to thicken and the inter-rectus
distance decreases after 2 months, but does not return to
control values at 12 months postpartum (Coldron et al, 2008)
Postpartum physiological changes –
pelvic floor
■ Rectal branch of the pudendal nerve stretches up to 35% (Lien
et al, 2005)
■ Increased latency in pudendal nerve in women with vaginal
delivery or those who had a c-section after laboring – 12 of 22
women at 6 weeks postpartum and 4 of 22 at 6 months
postpartum (Sultan et al, 1994)
■ Less than half (33-40%) of women achieve a normal, atraumatic
vaginal delivery (Caldwell-Hall et al, 2018)
■ 64% of women have at least 1 “bothersome” symptom of pelvic
floor dysfunction 1 year after their first delivery (Lipschetz et al,
2015)
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Postpartum physiological changes –
muscle activation
■ Decrease in trunk flexor strength and endurance at 8 weeks and
26 weeks postpartum (Deering et al, 2018)
■ 57% of women in immediate post-partum setting perform pelvic
floor contractions (Kegels) incorrectly (Neels et al, 2018)
■ Women with DRA have significant decrease in trunk rotation
strength and more difficulty performing a sit up (Hills et al,
2018)
Postpartum Myth #2:
■ I shouldn’t do ANY exercise until after my 6
week check up.
Current postpartum exercise guidelines:
§ Postpartum exercise linked to improved
mood/decreased anxiety and depression,
improved cardiorespiratory fitness, and weight
control/loss. (Evenson et al, 2014)
§ “Greater clarity in guidelines would be more useful
to both practitioners and the women they serve.”
(Evenson et al, 2014)
98/13/18
Postpartum
Exercise Truth:
Women will be
ready to return to
exercise within a
variable time frame
at a variable
intensity
Postpartum Myth #3:
■ I had a C-section so my pelvic floor is totally
fine.
v Pregnancy is associated with bladder neck lowering,
increased bladder neck mobility, pelvic organ descent,
decreased levator ani strength, and decreased urethral
resistance (Van Geelen et al, 2018)
Postpartum Myth #4:
I just had a baby – I can expect certain
symptoms.
It’s normal to:
■ leak urine when I exercise/cough/sneeze.
■ Have painful sex
■ Continue to have back pain
108/13/18
Practical advice to new moms:
1. Start where you left off
2. Increase gradually over time – 10% increase per week in intensity OR
duration
3. The best exercise is what you enjoy
4. No exercise is a BAD exercise, IF it can be done without pain or
symptoms
5. Consider symptoms a CALL TO ACTION
6. Request pelvic floor physical therapy – especially if you have lingering
symptoms of back or pelvic pain, incontinence, pelvic
heaviness/prolapse, or pain with intercourse
Pelvic Floor PT locators:
■ http://pt.womenshealthapta.org
■ https://pelvicrehab.com
■ https://pelvicguru.com/2016/02/13/find-a-
pelvic-health-professional/
118/13/18
Angie Robertson, PT, DPT, OCS
abr.dpt@gmail.com
www.inbalance-pt.com
Andersen, L. K., Backhausen, M., Hegaard, H. K., & Juhl, M. (2015). Physical exercise and pelvic
girdle pain in pregnancy: A nested case–control study within the Danish National Birth
Cohort. Sexual & Reproductive Healthcare, 6(4), 198-203.
Avery, N. D., Wolfe, L. A., Amara, C. E., Davies, G. A. L., & McGrath, M. J. (2001). Effects of human
pregnancy on cardiac autonomic function above and below the ventilatory threshold. Journal of
Applied Physiology, 90(1), 321-328.
Bahls, M., Sheldon, R. D., Taheripour, P., Clifford, K. A., Foust, K. B., Breslin, E. D., ... & Newcomer, S.
C. (2014). Mother's exercise during pregnancy programmes vasomotor function in adult
offspring. Experimental physiology, 99(1), 205-219.
Benjamin, D. R., Van de Water, A. T. M., & Peiris, C. L. (2014). Effects of exercise on diastasis of the
rectus abdominis muscle in the antenatal and postnatal periods: a systematic
review. Physiotherapy, 100(1), 1-8.
Caudwell-Hall, J., Atan, I. K., Rojas, R. G., Langer, S., Shek, K. L., & Dietz, H. P. (2018). Atraumatic
Normal Vaginal Delivery: How many women get what they want?. American journal of obstetrics and
gynecology.
Chiarello, C. M., Falzone, L. A., McCaslin, K. E., Patel, M. N., & Ulery, K. R. (2005). The effects of an
exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health
Physical Therapy, 29(1), 11-16.
Coldron, Y., Stokes, M. J., Newham, D. J., & Cook, K. (2008). Postpartum characteristics of rectus
abdominis on ultrasound imaging. Manual therapy, 13(2), 112-121.
da Mota, P. G. F., Pascoal, A. G. B. A., Carita, A. I. A. D., & Bø, K. (2015). Prevalence and risk factors
of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with
lumbo-pelvic pain. Manual therapy, 20(1), 200-205.
Deering, R. E., Cruz, M., Senefeld, J. W., Pashibin, T., Eickmeyer, S., & Hunter, S. K. (2018). Impaired
Trunk Flexor Strength, Fatigability, and Steadiness in Postpartum Women. Medicine and science in
sports and exercise.
Ekholm, E. M., & Erkkola, R. U. (1996). Autonomic cardiovascular control in pregnancy. European
Journal of Obstetrics and Gynecology and Reproductive Biology, 64(1), 29-36.
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Evenson, K. R., Mottola, M. F., Owe, K. M., Rousham, E. K., & Brown, W. J. (2014). Summary of
international guidelines for physical activity following pregnancy. Obstetrical & gynecological
survey, 69(7), 407.
Garshasbi, A., & Faghih Zadeh, S. (2005). The effect of exercise on the intensity of low back pain in
pregnant women. International Journal of Gynecology & Obstetrics, 88(3), 271-275.
Haakstad, L. A., & Bø, K. (2011). Exercise in pregnant women and birth weight: a randomized controlled
trial. BMC pregnancy and childbirth, 11(1), 66.
Hills, N. F., Graham, R. B., & McLean, L. (2018). Comparison of Trunk Muscle Function Between Women
With and Without Diastasis Recti Abdominis at 1 Year Postpartum. Physical therapy.
Kuhrt, K., Harmon, M., Hezelgrave, N. L., Seed, P. T., & Shennan, A. H. (2018). Is recreational running
associated with earlier delivery and lower birth weight in women who continue to run during pregnancy?
An international retrospective cohort study of running habits of 1293 female runners during
pregnancy. BMJ open sport & exercise medicine, 4(1), e000296.
Labonte-Lemoyne, E., Curnier, D., & Ellemberg, D. (2017). Exercise during pregnancy enhances cerebral
maturation in the newborn: A randomized controlled trial. Journal of clinical and experimental
neuropsychology, 39(4), 347-354.
Lien, K. C., Morgan, D. M., Delancey, J. O., & Ashton-Miller, J. A. (2005). Pudendal nerve stretch
during vaginal birth: a 3D computer simulation. American journal of obstetrics and
gynecology, 192(5), 1669-1676.
Lipschuetz, M., Cohen, S. M., Liebergall-Wischnitzer, M., Zbedat, K., Hochner-Celnikier, D., Lavy, Y.,
& Yagel, S. (2015). Degree of bother from pelvic floor dysfunction in women one year after first
delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology, 191, 90-94.
Neels, H., De Wachter, S., Wyndaele, J. J., Van Aggelpoel, T., & Vermandel, A. (2018). Common
errors made in attempt to contract the pelvic floor muscles in women early after delivery: A
prospective observational study. European Journal of Obstetrics & Gynecology and Reproductive
Biology, 220, 113-117.
Pennick, V., & Liddle, S. D. (2013). Interventions for preventing and treating pelvic and back pain in
pregnancy. Cochrane Database of Systematic Reviews, (CD0011), 1-100.
Pivarnik, J. M., Stein, A. D., & Rivera, J. M. (2002). Effect of pregnancy on heart rate/oxygen
consumption calibration curves. Medicine and science in sports and exercise, 34(5), 750-755.
Price, B. B., Amini, S. B., & Kappeler, K. (2012). Exercise in pregnancy: effect on fitness and obstetric
outcomes—a randomized trial. Medicine & Science in Sports & Exercise, 44(12), 2263-2269.
Shiri, R., Coggon, D., & Falah-Hassani, K. (2018). Exercise for the prevention of low back and pelvic girdle
pain in pregnancy: A meta-analysis of randomized controlled trials. European Journal of Pain, 22(1), 19-
27.
Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis
during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic
pain. Br J Sports Med, bjsports-2016.
Sultan, A. H., Kamm, M. A. and Hudson, C. N. (1994), Pudendal nerve damage during labour: prospective
study before and after childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 101: 22-
28. doi:10.1111/j.1471-0528.1994.tb13005.x
Ravanelli, N., Casasola, W., English, T., Edwards, K. M., & Jay, O. (2018). Heat stress and fetal risk.
Environmental limits for exercise and passive heat stress during pregnancy: a systematic review with
best evidence synthesis. Br J Sports Med, bjsports-2017.
Van Geelen, H., Ostergard, D., & Sand, P. (2018). A review of the impact of pregnancy and childbirth on
pelvic floor function as assessed by objective measurement techniques. International urogynecology
journal, 1-12.
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