Active Living

For years, it was believed that women should reduce their level of physical activity during pregnancy, and that pregnancy was a time to effectively ‘put one’s feet up’. Current research debunks such thinking.^1,2 It is now widely established that pregnant women who do not have any extenuating medical conditions should participate in regular, moderate-intensity physical activity after consultation with their health care provider in order to gain optimal health benefits for themselves and their developing offspring.^1,2,3,4,5,6

It is reported that many more women today want to maintain their current fitness level during pregnancy and that others want to initiate an exercise program during pregnancy due to its many benefits.² Despite this information, women in Ontario⁷and elsewhere^8,9 are still not meeting the recommended guidelines for physical activity during pregnancy.

The Canadian Community Health Survey (2005 – 2008) found that among 623 pregnant women aged 15 – 49 years in Ontario only 58 percent participated in regular physical activity (15 minutes or more on at least three days of the week), and only 23 percent met the Canadian guidelines for physical activity during pregnancy (30 minutes on four days per week). It was also found that women were less likely to meet the national guidelines for physical activity during pregnancy if they were single, divorced, separated, or widowed; a visible minority; or had a household income between $20,000 and $79,999.⁷

Many pregnant women want to engage in aerobic exercise during pregnancy, but still seem to be concerned about possible, adverse effects on their pregnancy outcome.^7,8,9,10 Promoting physical activity and its benefits during pregnancy, needs to become a stronger health education message.^7,11 Women need to be given information on the benefits of physical activity during pregnancy, and be given the opportunity to discuss their concerns about physical activity during pregnancy. They can be encouraged to develop a safe exercise routine, which they are comfortable engaging in throughout their pregnancy.^7,11

Women often feel that they need a social support system as well as economic resources to achieve their exercise goals during pregnancy. Women can be encouraged to incorporate physical activity into their daily life. This can include household chores, walking, dancing, or participating in sports. Many communities have walking groups and pregnancy fitness classes. This information may be especially beneficial for those who do not have a strong social support system. The social determinants of health cannot be forgotten when educating pregnant women on the importance of physical activity during pregnancy.^7,12

The benefits associated with physical activity are numerous. Some of the benefits associated with physical activity during pregnancy for women include:^{5,6,7,8,12,13,14,15,16,17,18}

• Increased cardiovascular function (improving maternal-placental blood flow).
• Decreased risk of excessive gestational weight gain.
• Decreased musculoskeletal pain (especially lower-back pain).
• Decreased muscle cramps.
• Decreased lower-limb edema.
• Decreased risk of developing varicose veins and deep vein thrombosis.
• Decreased risk of developing gestational diabetes.
• Decreased risk of developing hypertension and pre-eclampsia.
• Decreased symptoms of anxiety and depression.
• Decreased fatigue.
• Improved coping skills.
• Increased self-confidence.
• Decreased length of labour (in some cases).
• Decreased need for instrument-assisted birth.

Some of the benefits associated with physical activity during pregnancy for a developing fetus include:^3,13,18,19

• Decreased risk of preterm delivery.
• Increased heart rate variability of the fetus.
• Decreased risk of a low birth-weight infant.
• Decreased risk of childhood obesity.

Canadian recommendations for physical activity during pregnancy for women with no adverse risks include at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week. Being active every day is encouraged. Include a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga or gentle stretching may also be beneficial ⁷⁸.

Aerobic exercise of moderate-intensity requires a woman to increase her heart rate and breathing pattern and to lightly perspire. Its purpose is to effectively stimulate the cardiovascular and the cardiorespiratory systems of the body.²⁰

If women are already physically active and have no risks associated with physical activity during pregnancy, they will likely be able to continue a similar exercise regimen during pregnancy. Pregnant women are advised to consult with their health care provider to clarify risks and make modifications to any physical activities. The Physical Activity Readiness Medical Examination for Pregnancy ( PARmed-X for pregnancy) can be used as part of this process.^4,6

While women should be encouraged to be active during pregnancy and to participate in activities that they enjoy, pregnancy is not the time to try to reach optimum fitness goals or to train for strenuous fitness competitions.^2,4,18

Initiating an aerobic exercise program during pregnancy

It is recommended that sedentary women who want to begin to exercise during their pregnancy gradually increase the amount of exercise that they engage in.

They should begin with 15-minute sessions three days a week and gradually increase to at least 150 minutes of moderate-intensity exercise over a minimum of three days per week, at the appropriate target heart rate for them. It is important for women to listen to their bodies and reduce or increase activity when they feel ready.^{4,6, 78}

The following is a list of aerobic activities recommended during pregnancy:^4,21,22

• Brisk walking.
• Cycling indoors on a stationary bike.
• Dancing.
• Swimming.
• Water aerobics.
• Low-impact aerobics.
• Cross-country skiing (with care taken not to fall).
• Snowshoeing (with care taken not to fall).
• Exercising on a stair trainer, elliptical machine, or other cardio machines in a fitness centre or at home.

These activities are recommended during pregnancy as they pose a reduced risk for women to lose their balance or fall . They activities also cause minimal trauma to joints and ligaments.^21,22

Water aerobics

Exercising in aquatic environments is highly recommended during pregnancy.^1,23,24,25

It has been shown to decrease joint stress, lower-back pain, and edema in the lower extremities. It can also improve mobility, increase blood flow, and increase overall comfort levels for pregnant women as the buoyancy of the water helps support the enlarging uterus.^1,25

Water aerobics (or aqua-fit) can be especially beneficial in the third trimester of pregnancy when the size of a woman’s abdomen, perception of clumsiness, and lower-back pain tend to be the greatest.¹

Nurturing the mind and supporting positive mental health during pregnancy is as important as physical activity. During pregnancy, women can be exposed to a variety of psychological stressors. If women do not adequately address these stressors, biological responses can be triggered that can lead to detrimental health outcomes.¹⁸

Wellness activities include yoga, tai chi, meditation, visualization, and deep breathing. They involve a variety of benefits and are available for a low cost, if any, and can be performed daily.²⁶

Yoga

Yoga is an ancient Indian tradition that combines physical and spiritual practices. It is becoming increasingly popular as it confers many physical and physiological benefits.²⁷

Yoga involves three elements simultaneously:²⁷

• Asana (postures).
• Pranayama (breathing techniques).
• Dhyana (meditation).

The benefits of yoga during pregnancy include:^{26,28,29,30,31,32,33}

• Improved muscular strength.
• Improved cardiovascular fitness.
• Lower blood pressure.
• Improved immune functioning.
• Less aches and pain.
• Improved mood.
• Improved ability to sleep.
• Reduction in the risk of preterm labour.
• Shorter length of labour.

Prenatal yoga classes, specifically for pregnant women, are available in many major urban centres across Canada. Certain yoga poses are less appropriate during pregnancy, and variations can be provided.^29,33

Tai chi

Tai chi is a Chinese martial art that involves slow, steady movements. It can improve balance and decrease symptoms of anxiety, depression, and insomnia among pregnant women.^26,34

Meditation

Meditation, or mindfulness, is traditionally a Buddhist practice which involves forming an astute sense of mental awareness and openly accepting one’s current thoughts, sensations, bodily states, and environment. Its purpose is to promote self-reflection and to practice managing difficult emotions.^35,36,37

Meditation generally requires:³⁸

• A quiet place.
• A comfortable position (seated, standing, walking, side-lying).
• Focused attention on a mantra, an object, or the sensation of breathing.
• An open mind towards distracting thoughts that may arise.

Women who practice meditation during pregnancy can experience decreased levels of anxiety and stress.^37,39,40

Visualization

Visualization, or guided imagery, helps people cope with challenges they face in life by imagining positive outcomes.^41,42

Assisting a woman to look forward to her life with her baby, for example, can help her cope with some of the challenges in her pregnancy. If a woman is unable to visualize positive outcomes on her own, CDs with positive affirmations are available.⁴²

Deep breathing

Deep breathing exercises require a person be calm, focused, and engaged in a rhythmic pattern of breathing in and breathing out. Women who engage in such exercises during pregnancy can increase their level of relaxation, improve their oxygen saturation, and decrease their perception of pain through distraction. ⁴³

Deep breathing exercises combined with light aerobic exercises, like bouncing on a birthing ball, can provide increased distraction from pain.²²

Deep breathing can be useful during labour. It is best to practice deep breathing during pregnancy to optimize these benefits during labour.⁴³ See the Labour Support file for more information on breathing techniques.

Women need to be mindful of the intensity level while engaging in aerobic exercise during pregnancy. Exercise that is too intense may compromise fetal well-being by restricting utero-placental blood flow.^44,45 The intensity of aerobic exercise can be evaluated using the talk test and target heart rate zones.^4,6

The talk test

The talk test is a simple way to evaluate the intensity of physical activity. During moderate-intensity aerobic exercise, a pregnant woman should feel slightly out of breath but should still be able to carry on a conversation. If she cannot, she should reduce the intensity of her workout.^4,6

Target heart rate zones

A more objective way to monitor the intensity level of exercise during pregnancy is through heart rate monitoring.^4,6,46
During pregnancy, a woman’s resting heart rate increases by approximately 10 – 15 beats per minute. This increase in resting heart rate compensates for the increased demands of the growing fetus. As a result, the maximum target heart rate during pregnancy decreases.^4,47

An age-corrected heart rate target zone for pregnant women has been developed, which also takes into account a woman’s current activity level and BMI (Table 1).⁶ It is important that women who are starting a new exercise program or who are at the end of their pregnancy stay in the lower end of their heart rate target zone.⁴

Pregnancy raises body temperature. This results in an increase in perspiration. If water loss from sweating is greater than fluid intake, dehydration can occur. It is important that women stay well hydrated during pregnancy. Pregnant women should not wait until they are thirsty to drink. It is recommended that pregnant women drink before, during, and after physical activity to avoid dehydration.^48,49

The signs of dehydration (from light to moderate effects) are:⁵⁰

• Poor skin turgor.
• Feeling thirsty.
• Inability to spit.
• Dry mucous membranes.
• Sunken eyes.

A pregnant woman’s increased body temperature increases her risk of heat stroke and hyperthermia.⁴⁹ Hyperthermia in pregnancy increases the risk of neural tube defects.^53,54

During pregnancy, women should avoid practicing Bikram (hot) yoga, sitting in a hot tub, and exercising in very hot weather or humid environments.^53,54,55

When exercising indoors, pregnant women should be encouraged to use a cooling fan to prevent overheating.⁵⁶

While physical activity is highly encouraged, there are some activities that pregnant women should avoid.^4,6,56

Dangerous activities

Activities such as horseback riding, downhill skiing, ice hockey, gymnastics, and mountain biking on difficult trails should be avoided during pregnancy. These activities can cause a loss of balance and trauma which can, consequently, put a fetus at risk of harm.^4,56 Exercise guidelines for pregnant women do not recommend activities involving risks of falls, trauma, or collisions.⁵⁷

Activities involving extreme or reduced air pressures

Activities that involve changes in pressure such as scuba diving or hiking or climbing above 1,600 meters should be avoided during pregnancy as a fetus is not protected from the effects of decompression sickness.^4,58 If pregnant women do engage in these activities, they should decrease the intensity of the activity they are engaging in.⁴

Heavy lifting

Heavy lifting can trigger the Valsalva manoeuvre (i.e., holding one’s breath while working against a resistance). This can cause a change in blood pressure, which should be minimized during pregnancy. Heavy lifting can also increase women’s susceptibility to joint injury due to the accumulation of a hormone called relaxin during pregnancy.^6,59,60

Women should be advised that if they do heavy lifting or a lot of bending and stooping at their place of employment, they may need to modify their work during pregnancy.⁶⁰

If strength training is done during pregnancy, women should focus on correct form and use lighter weights.^6,59,60 Women should also ensure that they breathe through the activity, exhaling on exertion and inhaling on relaxation.⁶

Supine position

It is recommended that pregnant women avoid prolonged exercise flat on their back during pregnancy, especially after 16-weeks’ gestation. The enlarged uterus can put pressure on the inferior vena cava (the vein that returns blood from the lower extremities to the heart) and the abdominal aorta (the main blood supply to the uterus).

This pressure can cause dizziness, shortness of breath, and reduced utero-placental circulation, which can affect fetal well-being. To avoid this effect, activities can be modified to be done in side-lying, sitting, or standing position.^6,61,62

If a pregnant woman experiences any of the following symptoms (which rarely occur), it is strongly recommended that the activity be stopped and a health care provider be consulted:^4,6,56,57

• Dizziness or fainting.
• Blurred vision.
• Excessive shortness of breath.
• Chest pain.
• Abnormally high heart rate that does not drop when the activity is stopped.
• Pain or edema in the calves.
• Sudden swelling of hands, face, or feet.
• Sudden change in body temperature.
• Strong, sharp pain in the pubis, back, abdomen, or chest.
• Painful uterine contractions.
• Vaginal bleeding.
• Any gush of fluid from the vagina.

The pelvic floor is comprised of a group of muscles and ligaments, which support the bladder, the uterus, and the bowel. The pelvic floor muscles attach to the pubic bone at the front and the tail bone at the back and run along the base of the pelvis. Due to their location inside the pelvis, the pelvic floor muscles are the only group of muscles in the body which provide structural support for the urethra, the vagina, and the rectum (the organs with openings that pass through the pelvic floor).⁶³

Under normal conditions, a conscious, voluntary contraction of the pelvic floor muscles results in a squeeze and an inward lift causing the urethra to close, stabilize, and resist downward movement.^64,65

When the pelvic floor muscles are strong, they support the pelvic organs to prevent problems such as:^63,66

• Incontinence (the involuntary loss of urine or faeces).
• Prolapse (or disposition) of the bladder, uterus, and bowel.

Figure 1 shows the difference between normal pelvic floor muscles and weakened pelvic floor muscles and their effect on internal organ positioning.

Figure 1: Pelvic floor muscles

It is very common for pregnancy and childbirth to cause the pelvic floor muscles to weaken.^67,68 It is estimated that about 50 percent of women lose some of the supporting function of the pelvic floor during pregnancy and childbirth.⁶⁸ The greatest damage to the pelvic floor usually occurs during women’s first vaginal delivery, especially if assisted birth (vacuum or episiotomy) is utilized.^67,69

If women have a caesarean birth, the effects of pregnancy can still cause their pelvic floor muscles to weaken.^70,71

Weakening of the pelvic floor muscles can cause:^63,66,67

• Urinary incontinence.
• Fecal incontinence.
• Pelvic organ prolapse.
• Sensory and emptying abnormalities.
• Sexual dysfunction.
• Chronic pain.

The most common effect is urinary incontinence.^70,71 It is estimated that approximately one-third of women suffer from urinary incontinence after birth.⁷¹ For women who experience incontinence for more than three months following birth, there is an increased risk that it will persist for more than five years.⁶⁹

Urinary incontinence can cause reduced quality of life for women. Involuntary urinary leakage can occur during activities such as coughing, laughing, sneezing, or engaging in physical activity.^67,71

The pelvic floor muscles are like any other muscles in the body requiring exercise to keep them strong and healthy. Pelvic floor exercises, or pelvic muscle-clenching exercises, strengthen and prevent muscle damage and improve urinary continence. It is critically important to encourage women to engage in pelvic floor exercises during and after pregnancy.^{63,64,67,69,70,71,72,73,74,75}

Kegel exercise

One of the simplest types of pelvic floor exercises is commonly referred to as the Kegel exercise named after Dr. Arnold Kegel who first developed it. A Kegel exercise involves consciously contracting the muscles of the perineum to increase their tone and strength.⁷²

One of the obstacles that decrease women’s motivation to do pelvic floor exercises is insufficient knowledge on how to perform them properly. Teaching women how to properly contract this muscle group encourages women to do the exercises.⁷⁴ A physiotherapist who specializes in pelvic floor rehabilitation can help with this.

The following is a description on how to do Kegel exercises:⁷²

1. Stand, sit, or lie down with your knees slightly apart (lie down if just beginning).
2. Relax.
3. Imagine that you are trying to hold back urine or a bowel movement. Squeeze the muscles you would use to do that. DO NOT tighten your stomach or buttocks.
4. Tighten the muscles for 5 to 10 seconds. Make sure you keep breathing normally.
5. Now relax the muscles for about 10 seconds.
6. Repeat 12 to 20 times, three to five times a day.

It is important for women to continue to do this exercise throughout their lives. Like any other muscle in the body, pelvic floor muscles only remain strong if they are exercised regularly.⁷²

If women have difficulty focusing on the muscles to contract, they can insert a finger into their vagina to feel the muscle contraction. When contracting, they should feel pressure around their finger and not feel pressure expelling the finger out.⁷¹

Women can promote better recovery of their pelvic floor muscles after birth by: ^76,77

• Maintaining adequate hydration and a healthy diet. This can prevent constipation, which can cause pelvic floor muscles to weaken further.
• Resuming low-impact exercises such as walking and swimming once given clearance by their health care provider to do so.
• Refraining from participating in high-impact sports such as running and jumping rope, which can increase pressure on the pelvic floor muscles.
• Refraining from strenuous efforts such as lifting the baby in its car seat until sufficient muscle strength has returned.

For exercise suggestions, see the Physical Activity Resource Centre (PARC) Active Pregnancy resource in the Resources and Links section.

The pelvic floor muscles have regained sufficient strength if the following conditions are present:⁶⁶

• Good control of gas, faeces, and urine.
• The ability to stop urine mid-stream.

Women and/or her support people may need to be referred for additional support if they:

• Are overly anxious about exercising during pregnancy.
• Are considering engaging in exercise above the recommended guidelines.
• Need more information about how to maintain or start exercising during pregnancy.
• Need support in doing pelvic floor exercises.

Women and/or her support people who need more information about exercise and active living during pregnancy may be referred to

• Their health care provider (obstetrician, family physician, nurse practitioner, or midwife).
• A physiotherapist who offers specialized pelvic health services.
• An exercise physiologist, or sports medicine specialist.