Chapter 11 - Physical Activity & Pregnancy

Pregnancy and the postnatal period 

Pregnant women may be concerned that physical activity is not safe, however, there is no evidence suggesting adverse maternal or infant outcomes for healthy women resulting from moderate intensity physical activity. Instead, pregnancy offers an ideal opportunity to adopt a healthy lifestyle, with the increased motivation to self-care coupled with frequent access to maternity services. 

Physical activity can be safely recommended during and after pregnancy. UK Chief Medical Officers recommend that pregnant women aim for at least 150 minutes of moderate physical activity per week and muscle strengthening twice per week. It is important to highlight to women that ‘every activity counts’ and that they should always ‘listen to your body and adapt’ what they do accordingly.

 

PregnancyIndeed, there are clear benefits for both mother and baby. 1 - 3

Key Benefits of Physical Activity During Pregnancy 1- 3

  • Reduction in hypertensive disorders
  • Improved cardiorespiratory fitness
  • Lower gestational weight gain
  • Reduction in risk of developing gestational diabetes

 

Further low – moderate quality evidence exists for the women with reduced:4, 5, 6

  • Pelvic and low back pain
  • Pre-natal depression

 

 

 

  

 

 

 

Pre-Exercise Evaluation

There are very few absolute contraindications to physical activity during pregnancy and these are mostly related to the pregnancy itself e.g. risk of premature labour or presence of pre-eclampsia. However, there are a number of medical conditions where women need to be cautious and specialist input may be required 2. See table below. 

Absolute Contraindications

 

Risk Management

Risk ManagementOutside the conditions listed, there is no evidence that there is an increased risk of complications for the mother or the baby if a woman is active during her pregnancy; however, there are a few activities not recommended (See opposite table).2

Hyperthermia (>39.2°C): During the first trimester in particular, hyperthermia can increase the risk of developmental problems (e.g. spina bifida). There is no evidence that becoming slightly warm during activity can cause this, however, the woman should be advised not to become uncomfortably hot. Keeping hydrated will help.2

Modifications and Considerations:2

Due to the production of relaxin, ligaments around the spine, hips and pelvis will soften in preparation for delivery which may slightly increase the risk of injury. Stability exercises (e.g. Pilates – as long as it is modified for pregnancy by an experienced instructor) will help to manage this. Also, this softening will effectively increase a woman’s flexibility so in order to protect their joints, they should not stretch beyond their normal range.

Avoid exercising lying flat on your back or standing still for long periods after 16/40 weeks, due to venous compression and hypotension 2.

The combination of increasing lumbar lordosis and weight puts more strain on the joints, especially in the back and pelvis. In addition, as the pregnancy progresses, stress incontinence will become more likely (prevalence 32-64% 8). Stability and pelvic floor exercises will help to protect against this. Back and pelvic pain is not an inevitability during pregnancy (prevalence 45% 9). As the woman progresses through the second and third trimesters they should reduce the amount of any weights they are lifting.

When to stop and seek advice: 2

Advise to stop if there is

  • Vaginal bleeding
  • Regular painful contractions
  • Amniotic fluid leakage
  • Dyspnoea before exertion
  • Dizziness
  • Headache
  • Chest pain
  • Muscle weakness affecting balance
  • Calf pain or swelling

‘F.I.T.T.’ For Pregnancy

As with any physical activity advice, consider the woman’s activity history and preferences. During the first trimester morning sickness and fatigue may limit exercise ability, but most women will naturally reduce the intensity as it becomes more challenging.

FREQUENCY – most days of the week for aerobic work and twice weekly for performing 8 -12 repetitions of strengthening activities of all major muscle groups

INTENSITY – moderate: that is an activity that makes you feel warmer and breathe faster but still be able to hold a conversation.

TIME – aim to accumulate at least 150 minutes of moderate intensity physical activity every week, in bouts of any length of time.

TYPE – mixture of aerobic, strength and stability, for example:

  • Swimming / aqua aerobics (water temp not >32deg)
  • Walking
  • Jogging / running
  • Antenatal Yoga / Pilates – beware not lying flat on your back after 16/40 / pelvic floor exercises
  • Gym classes (inform the instructor)
  • Dance

Advice to a pregnant woman who is new to physical activity: women who have been sedentary are advised to start a gradual progression of activity – ‘not active – start gradually’ and build up to 30 minutes on most days at a moderate intensity. Vigorous activity is not recommended for previous inactive women. Strengthening exercises twice a week are also recommended.

Walking is a good way to start. Once they are used to doing some walking on a regular basis they can add in other types of activity. Women should also be advised to avoid prolonged sitting and breaking up sedentary time. It is also important to highlight that every activity counts and women should ‘listen to their body and adapt’ what they do accordingly.

Advice to a woman who is already active: these women should be encouraged to maintain their physical activity levels. However, they may need to change the type of activity undertaken and adapt their activity throughout their pregnancy, for example, replacing contact sports with non-contact sport or an appropriate exercise class (see box 2)

 NICE guideline PH27 Weight management before, during and after pregnancy: 10

Includes numerous recommendations relating to physical activity, including advise from first visit, during pregnancy and after child birth. These are incorporated into the recommendations in this chapter.

 

Physical activity after pregnancy

Hormone levels remain high for at least 4 to 6 weeks after delivery meaning ligaments will still be relatively soft, potentially increasing the risk of injury. These effects will last longer if the woman is breastfeeding. Coupled with recovery from the birth and fatigue from caring for a newborn, regular training may be resumed gradually after pregnancy as soon as medically safe, depending on mode of delivery and the presence or absence of medical or surgical complications. 2

The UK Chief Medical Officers, have made the following recommendations and infographic. 11,12

Women after childbirth imageThe benefits of physical activity after pregnancy

 

It helps recovery and improves physical and mental health. Evidence is demonstrating that physical activity:

  • Reduces depression
  • Improves emotional well-being
  • Improved physical conditioning
  • Reduces postpartum weight gain and a faster return to pre-pregnancy weight

 

 

Is it safe to be active after pregnancy? 12 

  • Whilst the guidelines do not differ to those for the general population, women who have been sedentary and/or during pregnancy are recommended to follow a gradual progression of physical activity post pregnancy. Hence the infographic message, ‘not active before – start gradually now’.
  • Being active wont impact on breastfeeding.

 

 

Take home messages: Physical activity is an important part of any management for a patient who is pregnant, leading to:

  • Reduction in hypertensive disorders
  • Improved cardiorespiratory fitness
  • Lower gestational weight gain
  • Reduction in risk of developing gestational diabetes
  • There is no evidence of harm when healthy pregnant or postnatal women participate in moderate intensity physical activity
  • Keeping active in pregnancy could improve health outcomes for both mother and baby
  • Pregnancy offers an ideal opportunity to adopt a healthy lifestyle, with the increased motivation to self-care coupled with frequent access to maternity services

Consider: The importance of a healthy lifestyle should be reinforced throughout pregnancy.  This should be discussed in some detail at the first booking appointment (typically with a midwife).

Benefits for Midwives, Health Visitors and GPs:  Reduced complications, cost benefits and improved future population health.

Use the CMO infographics to discuss the benefits of physical activity with all women during pregnancy and in the postnatal period. Download pregnancy  here and postnatal here

 

Acknowledgments: We would like to thank the following authors for contributing their help in making this chapter summary entitled; Physical Activity - Pregnancy and the post-natal period: Eleanor Tillet of The Institute of Sport, Exercise and Health, London, Marlize De Vivo and Hayley Mills of the School of Human and Life Sciences, Canterbury Christ Church University and Brian Johnson, Honorary Medical Advisor to Public Health Wales.

Now part of the RCGP clinical programme on physical activity and lifestyle    

References: Can be found in Chapter 18 

 

 RCGP2 v2  BAsem  RCN


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