Guidelines and Practical Tips for Training the Prenatal Client

Abstract

PRENATAL AEROBIC AND RESISTANCE TRAINING CAN HAVE TREMENDOUS BENEFITS FOR MOTHER AND CHILD, IMPROVING DELIVERY AND POSTPARTUM RECOVERY. DAILY MOVEMENTS TO ENCOURAGE DEEP CORE STRENGTHENING, EMPHASIZING THE IMPORTANCE OF POSTURE, AND AVOIDING EXERCISES THAT CAUSE DISCOMFORT MAY MINIMIZE COMMON AILMENTS OF PREGNANCY MEANWHILE IMPROVING MOBILITY OF DAILY FUNCTION. A VIDEO ABSTRACT OF THIS ARTICLE CAN BE FOUND IN VIDEO, SUPPLEMENTAL DIGITAL CONTENT 1, HTTP://LINKS.LWW.COM/SCJ/A218.

Pregnancy can bring about a variety of changes that will require modification and adjustment of workouts as the pregnancy progresses but including both aerobic and resistance training can bring about tremendous benefits for both mother and child (^18–19). Appropriate modifications and emphasizing deep core strengthening, while avoiding certain movements, will better prepare your client for pregnancy, delivery, and the functional and physical demands of motherhood.

Before beginning any exercise sessions with a prenatal client, it is recommended the exercise professional (EP) has written permission from her physician, along with asking the following questions:

• How far along is her pregnancy (how many weeks)?
• How many pregnancies has she had in the past? If any, how old are her other birth children?
• Was she on bed rest or limited activity any time during the current or previous pregnancy?
• What types of exercise is she interested in and has she previously engaged in (weight training, pilates, yoga, high intensity, low intensity, spinning, running, crossfit, etc.)?
• Does she have a history of miscarriages, surgeries, chronic pain, scoliosis, etc.?
• Is she currently experiencing any discomfort?
• Does she have diastasis recti (see Diastasis Recti section)? Umbilical hernia? Pelvic organ prolapse? Incontinence daily or with force (coughing, sneezing, jumping)?

The more that is known about the prenatal client's current health and health history the better because a specific program can be created. Create a workout that is more than just a workout but also creates balance throughout the body. Provide take home tips that the client can perform throughout the day, such as “stand or sit tall”; such simple little tips can help carry out the techniques taught in the exercise sessions and apply them to daily life.

Start each session by asking how she is feeling; some days she may feel much better than others, and adjust the workout accordingly. Although it is important to work on increasing strength during the first trimester (described in the next section), it is also important to help the client feel her best. The client should leave feeling better than she was when she walked in. If she is more exhausted when she finishes a workout session that indicates intensity or duration or both may be too high. Each and every exercise must serve a purpose, and if it does not feel good for that day, or for a longer period even after the appropriate modifications, move on to other exercises.

PRENATAL EXERCISE GUIDELINES

During the first trimester, it is important to focus on strength, helping her find her deep core connection, creating good posture, and teaching “body awareness.” Include exercises she will (or may) not be able to do later on in the pregnancy such as back strengthening exercises in the prone position, full range of motion lunges and variations, planks and variations, and core exercises.

It is recommended that prenatal women exercise most days, if not every day of the week for approximately 30 minutes or (¹) even up to an hour, (⁵) at a moderate intensity; using the talk test to determine intensity, she should be able to carry on a light conversation; if she can hardly speak, she is working too hard and the intensity should be decreased (¹). Include resistance training, as research has shown resistance training and aerobic exercise to be more beneficial than just aerobic exercise on its own, specifically noting a significant decrease in gestational diabetes and hypertensive disorders (¹⁸). It is important to understand the absolute and relative contraindications to exercise for your prenatal clients (See Tables 2 and 3 in the complimentary Special Populations column “Training the Prenatal Client”). For specific exercise prescription recommendations using the frequency, intensity, time, type (FITT) principle, see Table 1 of this column.

Table 1: Using the FITT principle during pregnancy

ENCOURAGE GOOD POSTURE

Encourage good posture and proper lifting to prevent and minimize back pain, especially if she already has another young child.

Tips:

• Ask how she spends her days, (sitting, standing, or slouched over) and encourage her to change positions often, get up from sitting, and do a short set of squats or walk around.
• Remind her to lightly activate her deep core throughout the day, by standing tall and lifting through the top of her head and avoid locking her knees.
• Properly pick things up and avoid lifting with her back. Lunges and squats are good exercises for teaching proper techniques for picking up.

DIASTASIS RECTI

Diastasis recti is the separation of the rectus abdominals, specifically widening of the connective tissue, the linea alba (⁹). Pregnancy creates tremendous stretch on both the skin and fascia of the abdomen, and women older than 45 years appear more likely to experience more severe diastasis recti (⁹). There is a lot of minimizing of diastasis recti that can be done for the prenatal client.

These suggestions could help in preventing and minimizing separation:

• Avoid supine forward flexion (¹¹) once in the second trimester or sooner if there is coning of the belly. This holds true for any exercise that creates any coning effect of the belly. The pregnant belly should be smooth and round in the center; coning is when you see a slight bulging in the midline of the belly, this could indicate that there is some separation or at least widening and thinning of the linea alba.
• Focus on strengthening the deep core muscles (see section on Deep Core–Focused Strengthening), along with good lengthened posture for each exercise.
• If her belly feels really tight (most common with first pregnancies), have her practice relaxing her belly (Figure 1) to allow the abdominal muscles and skin to stretch.
• To transition to lying on her back, teach her to start on her side, then roll to her back. This can greatly decrease the intra-abdominal pressure. To transition from a supine position to an upright position, teach her to roll to either side to get up from her back or out of bed. It is good to practice getting up from both sides to minimize creating imbalances. If she is feeling the need to rest, or is feeling lightheaded, recommend to lie down on her left side to avoid compression of the inferior vena cava and decreased blood flow to the heart.

Figure 1.: Relaxed belly position and deep breathing. Include this relaxed belly position and deep breathing to help relieve low back pain, improve oxygenation and breathing, and allowing for relaxation of the deep core muscles. This is particularly important in the third trimester.

It is important to understand that strengthening the deep core by stimulating fascia in the abdominal wall plays a big role in helping to minimize diastasis recti during pregnancy and promotes easier healing postpartum (⁹). Even if she has previously experienced diastasis recti or already has diastasis recti, further separation can be minimized by strengthening the deep core effectively (see Deep Core–Focused Strengthening section).

DEEP CORE–FOCUSED STRENGTHENING

A structured exercise program, including exercises focused on strengthening deep core muscles with the pelvis in a neutral position, is optimal (¹²). This combination can help minimize current symptoms of incontinence or prevent future occurrences, low back pain, hip pain, neck pain, poor posture, pelvic organ prolapse symptoms, and diastasis recti. It is important to avoid exercises that put stress on the pelvic floor or cause incontinence, as that indicates the deep core is not strong enough for such movements or exercise (⁹).

The deep core includes the following:

• The pelvic floor muscles and obturator internus muscles (⁸).
• Transversus abdominis and internal obliques (^8,12).
• Multifidus, intercostals, and thoracolumbar vertebral column (⁸).
• Diaphragm and psoas muscle because of the fascia that blends with the pelvic floor (⁸).
• The fascia that intertwines within the core, including the layers of fascia in the abdominal wall (^8,9).

All the deep core muscles play a critical role in functioning together (⁸). Pelvic floor strengthening has been shown to increase the likelihood the active phase of labor will last under 60 minutes (¹⁶). The importance of relaxation also plays a major role as discussed in the third trimester in preparing the body for labor.

Strengthening deep core muscles through movement and exercise plays a key role in improving overall strength and energy, decreasing aches and pain, improving confidence, minimizing diastasis recti, and setting up for a potentially easier and quicker labor and recovery, while decreasing the chances of an emergency cesarean delivery (^1,4,16,18,20).

Instruct how to connect her deep core:

• First relax the deep core muscles on the inhale (including pelvic floor)
• Exhale to initiate light contraction of the pelvic floor muscles (from pubic bone to tail bone and sit bone to sit bone)—then move if doing an exercise
• Cue to “lightly zip up” or “lift a wet towel” from the pelvic floor up through the top of the head.
• Avoid sucking the belly to spine as this restricts deep core activation and proper breathing (⁹).
• Lengthen tall through the torso and top of the head to positively affect posture and deep core strength.
• Encourage diaphragmatic breathing (inhaling out to the sides and back of the ribcage); exhale feeling the lengthening as stated above while also adding a light wrapping “down and around” of the lower ribcage. Avoid exercises that cause her to hold her breath as this could put unnecessary force on the pelvic floor (⁹).

Teaching her to lightly connect and avoid gripping the pelvic floor muscles and glutes is key; an EP can partially identify that by the client's breathing and position of the pelvis. If holding of the breath or tucking of the pelvis is noticed while trying to keep the deep core connected, she is likely overactivating. For many, this feels foreign initially, but with practice and time, it will improve. Squats and other full-body exercises can be good for strengthening deep core muscles, whereas lengthening through movement plays a critical role in helping her find and keep muscle and fascial activation.

MINIMIZING BACK PAIN

More than 60% of pregnant women experience some form of low back pain during their pregnancy (¹); however, pain can be minimized and prevented from getting worse as the pregnancy progresses. Teaching deep core strengthening plays a major role, including exercises that encourage articulation of the spine which can help minimize range of motion from decreasing too drastically. Including stability ball exercises may reduce low back pain during pregnancy and make daily life function easier (²⁰). Encourage daily movement and provide 1 or 2 simple exercises such as forward rolls, cat cows, and arch and round, which all focus on articulation of the spine with deep core activation (Figures 2, 3, 4). Full body exercises such as squats with rotations (Figure 5) along with foam rolling release exercises (Figure 6) and encouraging good posture throughout the day, can help minimize back pain during pregnancy.

Figure 2.: Cat cows. Include cat cow exercises to help relieve hip, low back, and pelvic pain. Inhale to lengthen and exhale to round for cat cow. This is a good movement for strengthening the deep core muscles throughout pregnancy and relieving tightness around the hips, abdomen, and low back.

Figure 3.: Arch and round. Include this arch and round exercise to help relieve hip, low back, and pelvic pain. It is a good movement for teaching your prenatal client how to find and strengthen the deep core muscles throughout pregnancy while relieving tightness around the hips and abdomen.

Figure 4.: Forward rolls. Forward rolls can help to relieve back pain and neck pain, improve deep core strengthening, and elongate the spine. It is important to focus on articulating the spine through the movement and keeping the hips over or behind the knees to avoid increasing intra-abdominal pressure.

Figure 5.: Squats with rotations. Squats with rotations are an important full-body exercise to improve overall body strength and fascial stimulation, while improving posture, deep core strength, and relieve aches and pains.

Figure 6.: Foam rolling release. These foam rolling releases can help to relieve aches and pains of the low back, hips, and sciatic area.

REMAIN STRESS-FREE

Anxiety during pregnancy has been related to outcomes such as fetal development (¹⁷), fetal distress, premature labor, low birth weight (⁶), and possible childhood problems (¹³). Keeping the pregnant client's workouts stress-free is extremely important. You want her to leave feeling more energized and empowered then when she walked in. This will vary depending on your client, as some need a more intense workout to relieve their stress but many, especially as they near the end of their pregnancy, will find it more of a stress release if exercises are chosen in order to feel better, while executing each repetition in a slow breath-focused manner.

EDUCATING ABOUT THE BENEFITS OF EXERCISING

Proper awareness and education are popular roadblocks for many prenatal moms. Physical activity declines during pregnancy for many, with more than half of prenatal women thinking activity will actually decrease their energy (¹⁰). Many are unaware that staying active during pregnancy could decrease their risk of gestational diabetes and do not realize that if they are overweight they are more likely to have a child who is overweight (¹⁰).

EPs see firsthand that working out can actually increase energy, which is why it is recommended to keep the line of communication open and adjust the workouts accordingly. EPs may know their client is capable of working out harder but at this stage of pregnancy she may not feel comfortable doing so. Thus, it is important to follow her lead but continue to encourage her to keep staying physically active and moving often.

TRIMESTER-SPECIFIC MODIFICATIONS

A summary of modifications and suggestions for exercise prescription within each trimester of pregnancy is available in Table 2. More details are provided regarding each modification within the sections here forward.

Table 2: Overview of trimester-specific modifications

FIRST TRIMESTER EMPHASIS AND MODIFICATIONS (GESTATIONAL WEEKS 1–12)

• Avoid supine forward flexion:
• after the pregnant belly becomes noticeably present, or
• if abdominal coning is present and she can no longer maintain deep core connection in a neutral spine position, or she reaches week 12 of pregnancy.
• Avoid overstretching because of the hormone relaxin (²); encourage stretching to a point that feels good but never painful. Limit movements that could overstretch the pubic symphysis and surrounding pelvic areas. It is more likely she may notice discomfort in and around her pelvis as her pregnancy progresses. Stretching through exercises that encourage length and strength will best benefit as pregnancy progresses (Figures 2, 3, 4, 5).
• Avoid positions that increase the likelihood of falling. Changes in hormones causing vasodilation and an increase in blood volume can cause her to feel lightheaded or dizzy easily (⁴).
• Modifications to the total volume of exercise may not be necessary. Dr. James Clapp II demonstrated conditioned pregnant athletes can safely exercise 5 + times/week at 65–90% of their regular intensity providing they do not feel overly exhausted afterward (⁴).
• Use the talk test to determine moderate intensity. She should be able to carry on a light conversation; if she is extremely winded, the intensity should be decreased (¹). It is always better to stay on the lighter side than overdo the pregnant client.
• Avoid jarring exercises, movements that change direction quickly, and exercises such as downhill skiing, contact sports, and scuba diving (²) (See Table 4 of the complimentary Special Populations column in this issue entitled “Training the Pregnant Client”).
• Running may be a good option for some pregnant women if they have previously been regularly running before pregnancy, but if running does not feel good or is causing pain, running volume can be decreased or replaced with other cardiovascular exercises such as walking, swimming, and elliptical and stationary biking (²).
• Staying hydrated is important when working out especially if working out in a warmer temperature. However, the concern about body temperature getting too high is actually low because of pregnancy improving the ability to get rid of heat through the skin and lungs (⁴). That said, it is still best to play it safe and avoid extremely warm temperatures. Encourage dressing for warmer weather with layers and encourage her to drink plenty of water.
• It is important to work the major muscle groups using a variety of body weight, free weight (¹⁵), and exercise band exercises such as squats, lunges, seated or standing rowing, lat pull-downs, tricep pull-downs or kickbacks, and bicep curls and modify as pregnancy progresses by:
• decreasing the weight
• decreasing range of motion
• changing the direction of the pull (such as seated lat pull-downs may need to be adjusted to kneeling lat pull-downs to decrease intra-abdominal pressure, typically occurring midway through pregnancy).

SECOND TRIMESTER EMPHASIS (GESTATIONAL WEEKS 13–26)

Many pregnant women may not feel like exercising during their first trimester because of increased fatigue or nausea or may have had reasoning from their physician to avoid or limit first trimester activity. Once in the second trimester of pregnancy and a physician has given permission to begin or resume physical activity, it is then safe and encouraged to get started on a regular prenatal workout routine. The EP should gradually progress and modify exercises as appropriate for the current level of fitness.

Create workouts that include both resistance and aerobic exercises. There is a positive correlation between exercise and improved fetal oxygenation, even when a prenatal woman begins exercising during the second trimester (¹⁴). Improvements in fetal oxygenation may reduce risk of gestational disorders associated with impaired endothelial function (¹⁴).

SECOND TRIMESTER MODIFICATIONS (IN ADDITION TO FIRST TRIMESTER MODIFICATIONS)

• Avoid supine forward flexion movements once in the second trimester.
• Avoid exercises that create coning of the belly, as this indicates she is not properly activating the deep core and that the intra-abdominal pressure is too great.
• Minimize lying in the supine position for more than a couple of minutes. Avoid it completely if she does not feel well lying supine or has been instructed by her doctor to avoid it completely. Signs to avoid lying on the back:
• lightheadedness
• nausea
• contractions
• she simply “does not feel good”
• Encourage her to deep belly breathe (relaxing her belly and body while breathing deeply into the sides and back of her ribcage and abdomen while also relaxing her pelvic floor) a little each day to encourage relaxation of her deep core muscles along with stretching of the abdominal muscles, fascia, and skin to help minimize severity of diastasis recti (Figures 1, 2, 3, 4).
• Challenge her with exercises that encourage the deep core to engage, such as squats with rotations (Figure 5), lunges with full range of motion and light weights, or for the advanced client with previous balance and BOSU training, squats on a BOSU. Squats on a BOSU should be supervised, and the EP should remain close by to prevent a fall, if the client was to lose balance. Body weight only is encouraged on the BOSU, so it is easier to focus on balance and catch herself in the event she starts to lose balance.
• The point at which lunges may need to be modified to more supportive stationary movements will need to be individualized. This is largely because of the rate of gestational weight gain and abdominal growth that will result in a shift of the women's center of gravity. When the exercise needs modified, a variety of squats can be included such as wall squats and sits, wall squats with a medicine ball between the legs, squats with rotations (Figure 5) or use of a cable pulley, or on a BOSU.
• Minimize movements that may contribute to round ligament pain such as lunges, running, and walking. The pain is usually a sharp or jabbing pain in the lower belly or groin area. As the baby grows, the round ligament which attaches from the uterus to the groin stretches and can cause pain for some during part or all of the pregnancy. Include exercises such as pelvic tilts and hip rolls (Figure 7) keeping the feet wider than hip-width apart (³).
• Minimize movements that may exacerbate symphysis pubic dysfunction (movement or spreading between the pubic bones causing pain) such as deep wide squats and lunges, running, and possibly even walking (⁹). Choose exercises that help stabilize the pelvis but encourage strength such as side lying leg exercises, small range of motion squats, quadruped-positioned exercises, pelvic tilts, hip rolls (Figures 2, 3, 7), and seated or standing upper-body exercises.
• Swimming is a good physical activity option as pregnancy progresses and could help with managing and decreasing pelvic or low back pain or both (⁷).

Figure 7.: Pelvic tilts and hip rolls. Include pelvic tilts and hip rolls to relieve low back and hip pain, specifically for those experiencing round ligament pain and to encourage deep core strengthening. Can be taught through pregnancy as long as she feels well on her back or her doctor has not instructed her to completely avoid lying supine.

THIRD TRIMESTER EMPHASIS AND MODIFICATIONS (GESTATIONAL WEEKS 27–40+)

The third trimester allows continuation of training the prenatal client according to what she was doing in the second trimester with the possible need to decrease intensity. The EP should be aware of the potential for the client to fatigue more easily; be aware that some exercises are likely to not work now and eliminate those movements. Include movements and exercises that help the client feel better and encourage her to continue to strengthen her deep core.

As the end of her pregnancy nears, encourage and include some relaxation exercises (Figure 1). Teach her to relax, specifically the pelvic floor muscles. Many strong women may tend to grip their pelvic floor muscles, especially when in pain, so it is important now to encourage her to think about relaxing as she prepares for labor. She can continue resistance and aerobic activity up until she delivers. Sticking with the exercises that feel best is encouraged, even if the EP finds himself or herself feeling as though the same exercises are taught during those last sessions of the pregnancy.

SUMMARY

Creating a well-balanced, deep core–focused, regular (preferably daily) workout regimen including both aerobic and resistance training will likely help the prenatal client to feel better both physically and emotionally, while increasing the chances of an easier and quicker delivery, improving maternal and fetal outcomes, and facilitating an easier recovery postpartum and life beyond pregnancy.