Help pregnant clients train for each trimester and the physical rigors of parenting a new baby.
A woman’s body will change more in 9 months of pregnancy than a man’s will in his lifetime—and she needs an exercise program to match the transformation. So says maternal exercise expert Farel Hruska, national fitness director of FIT4MOM® (formerly Stroller Strides®) in San Diego. “The biomechanics of motherhood are unique and specific,” Hruska explains. “A mom-to-be will need to master strength, agility, balance, speed, acceleration, deceleration, directional change and rotation . . . all with load that increases every day.”
For these reasons, a “functional” fitness plan for an expectant client may look different from a nonpregnant person’s gym routine. This article describes how fitness professionals can help moms-to-be more comfortably perform the movements and tasks unique to a pregnant person, and how to prepare clients for their birth experience and new role in a functional way.
Training for Function
“Functional training” means exercise designed to increase an individual’s ability to carry out everyday tasks—that is, movement that mimics the real-life tasks someone must carry out in an average day (Price & Sharpe 2009), such as repeatedly picking a baby up out of a crib or performing beloved hobbies. These tasks are often described as activities of daily living (ADLs).
ADLs traditionally reference very basic activities, such as bathing, dressing, grooming, toileting and transferring (moving oneself about), says Andrea Talmadge, MS, owner of FIT FUNdamentals and creator of the PregnaFit!™ program in Albuquerque, New Mexico. However, a more comprehensive definition of “function” for an expectant mom might also include being able to work 8 hours a day, shop, cook, drive, and do housework, laundry and yard work, Talmadge adds.
Certainly, there are medical conditions that preclude physical activity during pregnancy. Fitness professionals should always obtain a medical opinion before training an expectant client; they should also seek ongoing input from a physician during training and should coach the client to listen to her body’s signals and slow down when needed. However, for women without medical complications, physical activity during pregnancy has been associated with important health benefits and should be encouraged (ACOG 2009).
Despite the advantages, like most of the U.S. population many pregnant American women do not meet current recommended exercise guidelines (Pearce et al. 2013). A recent study concluded that most pregnant women don’t receive much diet and exercise counseling from their obstetricians (Duthie, Drew & Flynn 2013). Therefore, as a fitness professional, you are likely on the frontlines of wellness education for your pregnant clients. Here are the need-to-know functional facts for moms-to-be.
The Biomechanics of Pregnancy
The natural adaptive changes triggered by pregnancy may affect a woman’s posture and biomechanics in the following ways:
Inceased joint laxity. During pregnancy, a woman’s body produces more of the hormone relaxin, which “relaxes” ligaments (increases joint laxity), especially in the pelvis, hips and low back (Clapp & Cram 2012). This allows the female body to accommodate the growing uterus and, critically, prepares a woman to give birth vaginally. Relaxin production increases tenfold throughout pregnancy, peaking between weeks 38 and 42 (Calguneri, Bird & Wright 1982). This typically makes pregnant women noticeably more flexible than normal. Caution is advised during stretches.
Increased body weight. A woman who begins her pregnancy at normal weight will gain, on average, around 0.29 kilogram (0.64 pound) of weight per week in her lower trunk area (Jensen, Doucet & Treitz 1996). She should gain 25–35 pounds of weight overall at a rate of roughly 1 pound per week in the second and third trimesters (ACOG 2013). This can make her less stable and more likely to lose her balance and fall, especially in later pregnancy, notes Holli Clepper, an education consultant for the C.H.E.K Institute and author of Prenatal Health and Happiness Through Exercise and Nutrition (Vervante 2013), who lives in San Diego.
Increased low-back and pelvic pain. The weight of an expectant woman’s growing fetus may pull her pelvis forward into an anterior pelvic tilt (lordosis), and her growing breasts may create a kyphotic posture (shoulders rounded forward), says Hruska. In one study, about one-half of moms-to-be reported pregnancy-related pelvic-girdle pain, one-third noted pregnancy-related low-back pain, and one-sixth had both (Wu et al. 2004).
Postural changes. To maintain good posture and be “functionally fit,” a person must be able to effectively recruit and use three important groups of muscular stabilizers: the deep abdominals (transversus abdominis and internal obliques), the hip abductors and rotators, and the scapular stabilizers (Boyle 2004). Yet pregnancy strongly impacts all these stabilizing muscles. As a woman’s belly grows, her abdominal muscles are gradually lengthened over her growing uterus, and the rectus abdominis muscles sometimes separate (a condition known as diastasis recti). In a mom-to-be, the abdominals lose tone, making them less able to effectively contribute to the maintenance of neutral posture (DSRC 1997).
The hip stabilizers are also subject to unusual stressors. The authors of a 2000 study observed gait kinematics in pregnant subjects. The researchers concluded that the physical adaptations of pregnancy were likely to place additional demand on hip abductors, hip extensors and ankle plantar flexors during walking (Foti, Davis & Bagley 2000).
The Three Functional Needs of Pregnancy
The functional needs of an expectant client are not static. They evolve along with the demands of nurturing her fetus and then her new baby. Consider the three impending “life events” for which she must train:
A new lifestyle. Functional fitness must be customized. Will your client work a physical or sedentary job during and/or after her pregnancy? Does she want to train for specific labor positions, such as a full squat? Does she have other small children whom she must carry around on one hip throughout her pregnancy? These are the kinds of real-world concerns that must be factored into her functional exercise program.
Labor and delivery. Functional training for labor and delivery is akin to a sport specific protocol, says James Goodlatte, Miami-based CEO of Fit For Birth Inc., a company that provides pre- and postnatal fitness continuing education courses to industry professionals. Goodlatte coaches clients to prepare for birth in a manner similar to the way an athlete trains physically and mentally for a major competition. After all, pregnant clients will likely experience intense pain and muscular contractions during labor, all while possibly remaining awake for more than 24 hours. They need to train accordingly, says Goodlatte.
New motherhood. The demands of early motherhood must also be factored into a pregnant client’s fitness plan, says Lisa Westlake, a physical therapist in Victoria, Australia, and author of Exercising for Two (Hachette 2011). Hruska agrees. “Spend some time thinking through [these demands], or watch a mom in your life as she moves through her world in a maternal role. You will start to see some much-needed movement patterns to incorporate in [your client’s] training that will help her feel strong and possibly avoid injury.”
Functional Training by Trimester
“In general, most functional exercises a woman can perform prior to getting pregnant can be performed during pregnancy,” says Clepper. Here’s how things break down by trimester.
First Trimester(Weeks 1-12) And Foundational Concepts
Goals for early pregnancy. “The key point during the first trimester is to help a woman ease into the tremendous shifts occurring in her body and prepare for the challenge the growing baby will put on her musculoskeletal system,” says Catherine Cram, MS, Verona, Wisconsin–based coauthor of Exercising Through Your Pregnancy (Addicus 2012) and owner of Comprehensive Fitness Consulting, a company that provides pre- and postnatal certificate trainings and distance learning courses for exercise professionals.
At the outset of the first trimester, Goodlatte assesses clients with a “primal movement” screen based on four key parameters, listed in order of functional importance: core loading, hip loading, scapular loading and pectoral loading. “For most pregnant women, the primary focus should remain on the hip loading and core/diaphragm/pelvic-floor activation,” says Goodlatte. Scapular loading is the third priority, followed by all other concerns. Here’s how you can help with each:
Core loading (abdominals, diaphragm, pelvic floor). The diaphragm is the foundational component behind nearly all muscle imbalances, asserts Goodlatte. He calls proper diaphragmatic breathing “the single most important exercise that will ever be instructed for the modern pregnant woman.” “Proper coaching of diaphragmatic breathing will look like this: Fill the belly, ribs and lower back first,” he says. “Only with a very deep breath does the chest/neck rise, and if it does, it should be only [during] the last one-third of the inhalation.”
Next, “every woman should start incorporating pelvic-floor (Kegel) exercises in her first trimester,” says Cram. (A woman can find her pelvic-floor muscles by stopping her urine mid-stream while going to the bathroom; these are the muscles that Kegel exercises strengthen.) The earlier this training begins, the better, agrees Westlake: “Gaining pelvic-floor awareness is easier prior to [introducing] the load of a growing baby. Gaining and maintaining pelvic-floor strength will help prevent back and pelvic pain, incontinence during pregnancy and, most importantly, long-term incontinence and possible [organ] prolapse.”
Finally, early pregnancy is also a great time to incorporate core-strengthening exercises, says Cram, who uses the supine Sahrmann rehabilitation series for expectant clients (modified by propping the client up to a semi-sitting position using pillows or a wedge after the first trimester).
Hip loading (glutes, low back). “A new mom is going to find herself bending at the changing table, at the car seat and just about everywhere else until her kid is old enough to no longer be carried everywhere,” says Goodlatte. He emphasizes the importance of educating clients in correct hip hinge technique (loading the glutes) versus just rounding the spine when lifting. Indeed, most pregnant women’s glutes are underactivated, says Goodlatte, and dead lifts can improve this. Westlake notes, however, that a pregnant woman’s back is significantly more at risk during unsupported forward flexion than when she is not pregnant; be cautious with your clients.
For women who consistently struggle with dead lift technique, try a squat instead, says Clepper. She recommends sumo squats, which support the sacroiliac joints as a woman’s relaxin levels increase and her pelvis becomes increasingly unstable. When sumo squats are done correctly, the feet are about 6–10 inches wider than the shoulders, with toes turned out about 15 degrees. Progress both dead lifts and squats by having clients hold a dumbbell at one shoulder in a manner that reflects how they will later be holding a newborn, Goodlatte adds.
Finally, encourage women to try the deep squat position (knees and hips fully flexed, as if squatting to go to the bathroom outdoors) as labor-and-delivery training. This position creates the shortest and widest opening for the birth canal. says Goodlatte.
Scapular loading (midback and chest). It’s very important to start strengthening the upper back and stretching the anterior chest muscles in order to combat the effects of gravity on a new mom, says Westlake. After all, she will soon spend hours rounding her shoulders forward to change, bathe, play with and feed her new arrival. Work on strengthening the muscles of scapular retraction, and include chest stretches. “I like to have women do a doorway stretch (hands on each side of an open door, elbows back, body leans forward) several times a day,” says Cram.
Also consider push-ups. “The soon-to-be-mom is going to find herself on the floor a lot, lying and playing with her newborn and emerging toddler,” Goodlatte explains. “She is going to be performing one-sided and other strange varieties of ‘pushing up’ off the floor. She must learn this pattern to be a functional mom.”
Second Trimester (Weeks 13–28)
Goals for mid pregnancy. The second trimester is when a pregnant woman finds that her energy level is returning and her “baby bump” is starting to show. A second-trimester client should begin building her strength and endurance in preparation for baby weight gain, says Cram.
At this stage, advise women to pay close attention to how an exercise feels on the spine, abdomen and groin, adds Talmadge. “When a client feels pulling or tightness, or it just doesn’t feel comfortable anymore, she should discontinue that particular exercise.”
Areas of importance include the core, the upper back and the arms:
Core stability. “Concentrate on core strength in various planes of motion,” says Hruska. For example, “the standing wood chop is a highly functional movement for moms.” Women should avoid lying flat on their backs at this point in their pregnancies, because the weight of the growing baby could cause a relative obstruction of venous return (it could impede the return of blood from the lower body to the heart). This may lower cardiac output and cause orthostatic hypotension (dizziness due to an acute drop in blood pressure) (ACOG 2009). Cram recommends doing modified supine (semi-sitting) or, possibly, standing abdominal exercises instead.
Upper back and arms. The second trimester is the perfect time to focus on the upper body, as the postpartum period will encompass a lot of lifting, says Cram. “Start thinking through the load imbalance of motherhood as well,” says Hruska. A new mom will hardly ever be equally loaded on both sides of her body, since she will often be carrying a baby in one arm for months to come. To compensate, use exercises that throw the body off just a little, such as low rows with one arm instead of two, Hruska suggests.
Also include upper-body movements that involve rotation and lever extensions. For example, “when a mom puts her baby in a crib, her arms are extended; she then rotates and flexes at the spine,” says Hruska. “Mimic some of that movement pattern in a biceps curl plus a forward extension of the arms, with weights or tubing.”
Third Trimester (Weeks 29–40)
Goals for late pregnancy. “The third trimester is all about keeping a pregnant woman exercising comfortably while maintaining fitness,” says Cram. This can take some skillful modification techniques, she adds. A client will have high levels of relaxin in her system by now. For this reason, avoid quick changes of direction, especially laterally (e.g., side lunges, wood chops), because the risk of ligamentous sprain increases, Talmadge notes.
Late-trimester functional fitness should also address the upcoming birth event and anticipated postpartum ADLs:
Training for labor and delivery. To promote the muscular endurance needed during birth, Talmadge encourages clients to practice holding a pelvic-floor contraction, a squat or an upright abdominal compression (pulling the bellybutton into the spine) for up to 90 seconds at a time. “Learning to hold muscle contractions for 90 seconds at a time will help tremendously during labor,” she says.
Clients should also learn to consciously relax the pelvic floor after every Kegel contraction, says Westlake, as this will develop mind-body awareness and an ability to relax the pelvic floor during the pain of a labor contraction. She also encourages clients to think of birth-positive mental imagery or phrases during third-trimester exercises.
Training for parenthood. Late pregnancy is a great time to educate a client about proper biomechanics for early motherhood. “When reaching in and out of the car for groceries, or getting a child out of the crib or car seat, your client should always find ways to perform the movements using her glutes, drawing her bellybutton in and protecting her back,” says Clepper.
A new mom will spend many hours seated in a forward-rounded position while breast- or bottle-feeding. This practice is wonderful for bonding, notes Clepper, but hard on the mother’s back. To mitigate this concern, teach quick mid-back strengthening exercises and thoracic mobilization moves that a new mom can do at home.
Focus on Function
Training for “functional fitness” during pregnancy means addressing both the postural and biomechanical shifts a woman experiences, as well as the impending events of birth and early motherhood. But the most important thing you can do is to teach a pregnant client to pay attention to her body’s signals and slow down when needed.
Exercise during pregnancy is to maintain the health of the mother and baby, and to prepare the body for birth, not to lose weight or get superfit, Clepper emphasizes. Pregnant clients should talk to their doctor or midwife and be smart about their exercise goals, she adds.
“There is never a more important time than pregnancy to listen to your body,” summarizes Westlake. “Expectant women should find a healthy balance between rest and exercise and remember it is a short time in the big picture.” That is the fundamental truth of functional fitness during pregnancy.