Exercise during pregnancy

Dr. Karen Nordahl (biography, no disclosures)

What I did before

I do a lot of prenatal care and deliveries. At the majority of appointments, especially in the third trimester, the women often complain about sciatica, back pain or incontinence, in particular stress incontinence. 30% of women report stress incontinence in their pregnancy when questioned. (1)

My response was usually the same: “It’s all part of the pregnancy, there is not much we can do about it…” and the best one “it will get better when the baby is born”!

I then began to take an interest in exercise and pregnancy, wrote two books on the topic in 2000 and 2004 (Fit to Deliver), and began to understand that these are not the ‘aches and pains of pregnancy’ and that there are actually a few things women can do about the discomfort.

What changed my practice

In 2003, the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Canadian Society of Exercise Physiology (CSEP) released joint Clinical Practice Guidelines that threw the old ‘rule’ about not allowing your heart rate to get above 140 bpm out the window and introduced the “talk test”. The guideline states that the exercise intensity is appropriate if the patient can maintain a conversation while exercising (2). Further, it was recommended all pregnant patients exercise during pregnancy, even if they had not before (2). This was a dramatic change, as we used to believe if a woman had not exercised before her pregnancy, she should not start when she became pregnant. As family doctors, we should be having discussions about the amount of exercise the patient is participating in at the first prenatal visit.

So what does this all have to do with the pregnant woman and back pain? It has been shown that 55% of pregnant patients reported some form of back pain during their pregnancy when questioned (3). Studies have demonstrated that if we get pregnant women moving, specifically working their pelvic floor with Kegel exercises and their ‘core’ (the cylinder of muscles that includes the pelvic floor, and the transversus abdominus, ab muscles front and back) they may have better pregnancy outcomes (i.e. lower rate of prolonged second stage labour [4], prevention of postpartum urinary incontinence [5], and reduced low-back pain [6, 7]). By encouraging pregnant patients to exercise, we may not only get them more comfortable during pregnancy, they may come out of it stronger than before pregnancy!

What I do now

Now, instead of telling the patient to ‘suck it up’ it is just part of pregnancy, I suggest a few simple things in the office:

Take a few minutes and show your patient how to do Kegel exercises, they have been demonstrated to reduce incontinence and perhaps aid lower back pain.

I tell my patients to start doing Kegel exercises. There are lots of websites that can teach them (baby centre http://www.babycenter.com/kegel-exercises, American Baby), but you can also guide them, explaining how it should feel like they are holding their urine, and then letting the muscles relax. The relaxation phase is very important, because if all they do is the Kegel contraction, and not the relaxation, the perineum can be quite tight, which may make birth a bit tougher.

It is also important to remember it is the quality of the Kegels, and not the quantity that is important; have them do the Kegels at the stoplight, when they are watching TV, or whenever they can remember.

If the discomfort or incontinence is quite severe, I send the patient to a physio who has experience in dealing with pregnant women, often just two or three visits make a significant difference in how the woman feels.

References

1. Ringdahl E. Promoting postpartum exercise – An opportune time for change. Physician Sportsmed. 2002;30: 31-31. (Request with CPSBC or view UBC)
2. Davies, G., Wolfe, L., Mottola, M. & MacKinnon, C. Joint SOGC/CSEP Clinical Practice Guideline: Exercise in Pregnancy and the Postpartum Period. Canadian Journal of Applied Physiology 2003; 28: 329-341. (Request with CPSBC or view UBC) http://www.csep.ca/cmfiles/publications/scholarly/Joint_SOGC_CSEP_Guidelines.pdf
3. Ovrieto, R., Achrion, A., Ben-Rafael, Z. & Achrion, R. Low-back pain of pregnancy. Acta Obstet Gynecol Scand 1994; 73: 209-214. (Request with CPSBC or view UBC)
4. Salvesen KA1, Mørkved S. Randomised controlled trial of pelvic floor muscle training during pregnancy. BMJ 2004 Aug 14;329(7462):378-80. Epub 2004 Jul 14. doi: 10.1136/bmj.38163.724306.3A. (View with  CPSBC or UBC) http://www.ncbi.nlm.nih.gov/pubmed/15253920
5. Harvey, M. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can 2003; 25: 487-498. Request from CPSBC
6. Garshasbi, A. & Faghih Zadeh S. The effect of exercise on the intensity of low back pain in pregnant women. Int J Gynaecol Obstet 2005; 88; 271-275. (View with CPSBC or UBC)
7. Sabino, J. & Grauer, J. Pregancy and low back pain. Curr Rev Musculoskeletal Med 2008; 1:137-141. (View)

Resources

1. Meher S, Duley L. Exercise or other physical activity for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2006:CD005942. (View with CPSBC or UBC)
2. Mottola M, Wolfe L, MacKinnon K, Davies G. Exercise in pregnancy and the postpartum period. Ottawa, ON: The Society of Obstetricians and Gynaecologists of Canada; 2003. (Free text available)
3. Da Costa D. et al, Self Reported Leisure Time Physical Activity During Pregnancy and relationship to Psychological Well Being, Journal Psychosom Obstet Gynecol 2003:24, 111-11 (Request with CPSBC or view UBC)
4. Clapp, James F., Influence of Exercise Endurance and Diet on Human Placental Development and Growth, Placenta (2006), 27, 527-534 (View with CPSBC or UBC)
5. The Cochrane Database of Systematic Reviews, Exercise or other Physical Activity for preventing pre-eclampsia and its complications, Volume (2) 2006 (View with CPSBC or UBC)
6. ACOG Committee. Opinion no. 267: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002; 99:171–3. (View) http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Exercise-During-Pregnancy-and-the-Postpartum-Period Accessed March 23, 2015
7. Clapp, James F. III, ‘Exercising Through Your Pregnancy’ Addicus Books 2002 (View)

Patient handouts:

1. Kegel exercises http://www.babycenter.com/kegel-exercises
2. Exercise During Pregnancy, The American college of Obstetricians and Gynecologists http://www.acog.org/Patients/FAQs/Exercise-During-Pregnancy: PDF for patients: http://www.acog.org/-/media/For-Patients/faq119.pdf?dmc=1&ts=20150601T1756594306

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Exercise during pregnancy

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