In this series, I aim to talk you through some of the considerations that should be made when designing a training programme for expecting mothers.
Assuming no contraindications exist (see below), a comprehensive resistance training programme can be a fundamental component of a maternal exercise programme (ACOG, 2002).
As I am sure you will now appreciate, having read our previous two blog posts, there are so many benefits of taking part in vigorous resistance training during all three trimesters.
Hemodynamically significant heart disease
Restrictive lung disease
Multiple gestation at risk for premature labor
Persistent vaginal bleeding
Placenta previa after 26 weeks
Premature labor during the current pregnancy
Unevaluated maternal cardiac arrhythmia
Poorly controlled type 1 diabetes
Extreme underweight (body mass index ,12)
History of extreme sedentary lifestyle
Intrauterine growth restriction in current pregnancy
Poorly controlled hypertension
Poorly controlled seizure disorder
Poorly controlled hyperthyroidism
The primary consideration when designing a resistance training programme should be the health of both mother and fetus, of course. The general training goal should seek to maintain a reasonable level of fitness rather than optimise it (Stevenson, 1997; ACOG, 2002). A training programme with sufficient volume and intensity to improve fitness may be somewhat stressful and difficult to recover from, and therefore the maintenance of strength, muscular conditioning etc should be the primary focus.
Based on the current literature, vigorous maternal exercise has not been shown to produce any adverse effects in women who are well trained and can potentially help to sustain high levels of health and fitness as well as increase exercise adherence throughout pregnancy (Kardel and Kase, 1998; Kardel, 2005).
Research suggests that those with reasonable training experience should be allowed to continue exercising at or near their current level of activity without any negative effects.
When designing a routine, particular emphasis should be placed on training the trunk, glute, and hamstring musculature, which can help to counteract lumbar stress and alleviate symptoms associated with Lower Back Pain (Dewey and McCrory, 1994; Suputtitada, et al. 2002; Kinnunen, et al. 2007).
Static, endurance-based trunk exercises (such as plank variations, bird-dogs and side bridges are ideal for the pregnant woman because they have been shown to promote back health while minimising stress to the spine (McGill, 2002). Dynamic trunk exercises, such as crunches, also can help to improve core strength, although these movements tend to become difficult as term progresses and may be best tolerated during the first trimester only.
Although no definitive research has been performed to assess optimal maternal training frequency, my experience has it that a 3-day-a-week routine can be conducted with great success. Training should be performed on nonconsecutive days to allow for sufficient neuromuscular recovery (MacDougall, et al. 1995).
A greater frequency of resistance training is unnecessary at this time, given the previously mentioned goals of maternal exercise, and could possibly result in overtraining, given the physiological and psychological changes seen during pregnancy (Baechle, Earle and Wathen, 2008).
In my experience, a full-body routine may be preferable to a split routine because it helps to prevent blood from pooling in a particular areas of the body (Baechle, Earle and Wathen, 2008). When using this approach, a single exercise should be performed for each of the major muscle groups. The one exception here is the trunk musculature, which may benefit from the use of multiple movements.
Beginners should perform 1 difficult set per exercise, whereas intermediate and advanced trainees can experience greater benefits from 3 sets (Baechle, Earle and Wathen, 2008).
Recovery between sets should last approximately 2 minutes, allowing enough time for recovery of maternal heart rate. To develop multiple bio-motor abilities, a multiangled approach should be taken, meaning that exercises are varied in all 3 planes of movement. Bear in mind that maximal effort work needs to be performed in a sagittal plane bilaterally to allow for maximal force production, however exercises involving both the frontal and transverse plane may be used to help develop coordination, balance and mobility.
All modalities of resistance training can be employed, including free weights, machines, cables, bands, and body weight movements.
Given that joints are significantly more lax during pregnancy, a higher repetition range is recommended using an intensity of less than 70% 1RM (12 repetitions or more per set). This may decrease joint-related stress and hence reduce the risk of injury (Artal and O’Toole, 2003). Sets should be somewhat challenging but should not progress to the point of absolute muscular fatigue. Similarly, static exercises should be held until the muscles are challenged but not to the point where the pregnant woman can no longer maintain the support of her bodyweight or external load (barbell / dumbbell).
It is advised that the Valsalva manoeuvre be avoided at all costs because breath holding increases both heart rate and blood pressure and can decrease splanchnic blood flow and uterine perfusion (Wang and Apgar, 1998), which can potentially be dangerous to the fetus. Expectant mothers should be instructed to breathe out on the concentric portion of each dynamic movement and inhale on the eccentric action; during static exercises, breathing should be regimented and rhythmic throughout the duration of exercise (Wescott and Feigenbaum, 2004).
Repetition speed should be slow to moderate, taking approximately 2 seconds on the concentric action and 3 seconds on the eccentric action. Given that motionless standing tends to cause pooling of venous blood and can decrease cardiac output, it is best to stay active between sets (Wang and Apgar, 1998; Artal and O’Toole, 2003). This can be accomplished by walking around the room or performing light dynamic stretching movements.
Prenatal exercise should always begin with a light warm-up and end with a brief cool-down. Generally, 5–10 minutes of light cardiovascular activity is generally sufficient for both the components. It is best to exercise after meals to avoid hypoglycaemia. Most importantly, it is essential to be aware of the warning signs to stop exercise should adverse symptoms arise.
SPECIFIC GUIDELINES FOR PREGNANCY
The first trimester is the most important period for foetal growth, including development of limbs and internal organs. During this time, major physiological changes take place without significant changes in maternal anthropometry / body measurements (Blackburn, 2007). While blood volume expands and the uterus enlarges, weight gain averages less than 4.5 kilograms. Thus, there generally is no need to modify exercises based on considerations.
Despite evidence that maternal exercise-induced hyperthermia is not a concern, it is nevertheless important to take precautionary measures and avoid large increases in body temperature while exercising during pregnancy (Wang and Apgar, 1998). This can be facilitated by wearing loose-fitting clothing and making sure the training environment is cool and well ventilated (typically less than 16ºC). Moreover, it is essential to keep well hydrated throughout exercise to increase heat dissipation. Consuming 300 ml of water before training and then an additional 300 ml for every 15 minutes of exercise is a good rule of thumb to maintain fluid balance. Any loss of weight after exercise is due to water loss and should be replaced with fluid in the post-exercise period at an amount equating to 1 litre of fluid per kg of weight lost (Artal and O’Toole, 2003).
Secretion of relaxin increases significantly during the first trimester, causing joints to become less stable (Artal and O’Toole, 2003). Hence, it is particularly important for the pregnant woman to use proper form during exercise. Ballistic or explosive movements should be avoided as they can heighten the possibility of strains and tears of muscles, tendons, and ligaments. For this reason, the main competitive lifts of Olympic Weightlifting exercises, such as cleans, snatches, hang variations etc are contraindicated. On the other hand, slower more controlled derivatives such as pulls and squats are completely fine.
The first trimester is often complicated by nausea, vomiting, and excessive fatigue. These sensations can have a profound effect on a woman’s ability to exercise, and exercise intensity therefore should be modified accordingly. When in doubt, it is best to err on the side of caution.
Significant changes take place throughout the second and third trimesters, with weight gain averaging 22–35 pounds. Making matters worse, weight gain is centred about the midsection / trunk, altering posture and centre of gravity (Perkins, Hammer and Loubert, 1998). This can make the execution of many exercises difficult or impossible to perform. Breathing can become more difficult due to the fetus pressing on the diaphragm (Artal and O’Toole, 2003). It therefore can be necessary to modify exercises to suit a woman’s comfort level. If necessary, towels and pillows can be used to facilitate performance.
Several exercise-related restrictions are warranted at the onset of the second trimester. First, the supine position (lying on back) should be avoided as it tends to obstruct venous return from the uterus compressing the vena cava. This can decrease cardiac output and result in orthostatic hypotension (Avery, et al. 1999) - lack of oxygen to the foetus.
Second, it is advised that exercises that require forward flexion at hips and/or waist performed with caution after the first trimester. The pregnant woman’s uneven weight distribution tends to make these moves awkward and places increased stress on the lumbar region (O ̈stgaard, et al. 1996). Provided exercises can be executed with good form and sufficient postural control, I am happy for my client to continue with exercises such as RDLs and Bent Over Rows, however I may avoid these with new trainees. They can result in dizziness.
A modified 'all-fours' position (hands and elbows on floor) can be employed to allow certain prone exercises to be performed without discomfort (Schoenfeld, 2000).
Overhead lifting exercises should be executed with caution after the first trimester too. Postural changes can place excessive stress on the lower back, and overhead movements tend to exacerbate lumbar stresses. Front raises, lateral raises, and reverse flies can be substituted for shoulder presses to work the deltoid and rotator cuff muscles (Schoenfeld, 2000). Again, provided that the client can perform overhead exercises with sufficient postural control, I am happy for them to continue lifting overhead.
Other modifications to exercise may be necessary. For example, if you normally perform Swiss ball leg curls for developing hamstring strength about knee flexion, changes will need to be made as the supine position cannot be held from the second trimester. In addition, prone hamstring exercises such as reverse hypers or band-resisted leg curls on a GHD cannot be performed as lying on top of a machine will be impossible. In the example illustrated within the image above, knee flexion can still be trained by attaching a resistance band to the ankle - you'll be amazed how hard and effective this variation is, particularly as the knee passes 90º flexion.
Example training session:
Back Squat 3 Sets: 15 @55%, 12 @60%, 10@65%
Assisted Pull Ups: 3x 10-12
Barbell Reverse Lunges: 3x 6-8/leg
DB Alternating Overhead Press 3x 10-12/arm
Barbell Stiff-Leg Deadlift / RDL: 3x 10-12
Plank-ups: 3x 10/arm
Side Bridge: 2-3x 60secs/side
Jackknife on Gym Ball: 3x 15-20
Maternal resistance training is essential to the health and wellness of expectant mothers.
Resistance training, in particular, can provide a plethora of physiological and psychological maternal benefits as well as helping to improve movement ability throughout the term. By following correct guidelines, a pregnant women can safely engage in a vigorous and detailed resistance training program.
Clearance should always be obtained from the GP or Midwife to rule out any contraindications before commencing a routine, of course.
To experience optimal benefits, exercises should be carried out in all 3 planes of movement with an emphasis on trunk / postural stability. 1 to 3 sets of 10–15 reps is suggested, taking approximately 2 minutes rest between sets.
In the absence of any complication or contraindication, there is no reason that in most cases training cannot continue until immediately before delivery.
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