Ep 13: Pregnancy and exercise: Is it safe?

Voiceover (00:02):

Welcome to the Confident Body, where experienced health professionals discuss how to get the most out of your body for the lifestyle you choose. We believe everyone can exercise and get the most out of life, regardless of your injuries or health issues. Now here’s your host, senior physiotherapist, Michael Dermansky.

Michael Dermansky (00:22):

Hi everyone, and welcome to the show that helps you become more confident in your body so you can keep doing the things you love. I’m Michael Dermansky. I’m senior physiotherapist at MD Health, and today I’ve got a special guest today. Her name is Justine Gorman. She’s one of the physiotherapists at All Women’s Health. Justine, welcome to the show.

Justine Gorman (00:40):

Hi, thanks for having me.

Michael Dermansky (00:41):

Fantastic. We’ve got a special topic today, Pregnancy and Exercise. Is it safe? So let’s start firstly with a little bit about yourself. Tell listeners about who you are and what you do and a bit more of your qualifications as well?

Justine Gorman (00:55):

Yeah, so I’m a qualified physiotherapist. I’ve been working as a physio in both musculoskeletal settings and pelvic health settings for the last few years. Graduated eight years ago and in the last three years I’ve been doing a lot more women’s health stuff. And this year I’ve just finished studying my masters of Continence and Pelvic Health or Women’s, Men’s Pelvic Health Physiotherapy.

Michael Dermansky (01:22):

Fantastic, congratulations. Well, what does that mean, now you’ve finished your masters in women’s men’s health and pelvic floor continence?

Justine Gorman (01:31):

Yeah, so I’m currently 30 weeks pregnant, so this topic, exercise and pregnancy is very, very dear to my heart and I’ve got a few more weeks of work finishing up with some patients and then I’ll be on mat leave for the next few months.

Michael Dermansky (01:46):

Congratulations. Well done.

Justine Gorman (01:48):

Thank you.

Michael Dermansky (01:50):

Well let’s start with the topic as well. So the first one is, what are the direct benefits of exercise during pregnancy?

Justine Gorman (01:55):

Yeah, so there’s lots, I guess very similar to the benefits of exercise for the general population as well, but there’s some really specific things in pregnancy that exercise can help with or conditions that you may be at more risk of during pregnancy that exercise can really help reduce the risk of. So some of those are things like gestational diabetes, developing diabetes just during pregnancy and also reducing risk of developing high blood pressure and preeclampsia in pregnancy as well. So lots of great heart and respiratory benefits like the general population as well. There is also some evidence that exercise can reduce the risk of instrumental delivery during labor as well. So if you’re having a vaginal delivery, there is a small low quality amount of evidence that that may help with that as well.

Michael Dermansky (03:03):

So that one you said high blood pressure and preeclampsia as well. I mean preeclampsia is a very important one too. Not everyone might know what preeclampsia is. Do you want to explain what that means?

Justine Gorman (03:14):

Yeah, sure. So I guess you would start out with high blood pressure. And so when you go and see your care provider, they’re checking your blood pressure at every appointment and if it starts to climb higher, that’s obviously a concern for both you and the baby. But there is then a condition that comes after that if the blood pressure continues to climb and it’s not well controlled called preeclampsia. And so preeclampsia is basically that really high blood pressure that’s affecting you. It can have effects on the blood flow to the baby as well and then obviously can lead to more systemic issues too. So these women are often very sedentary, not able to do a lot of exercise and things until their blood pressure is controlled. Sometimes it can be well controlled with medications, otherwise it leads to quite significant risks for both mom and baby. Cardiovascular.

Michael Dermansky (04:15):

I mean my first child when he was born, their mom developed preeclampsia as well. So that was a really very serious one where one day they came in, and this is very late in the pregnancy, I mean this is 37 weeks, where coming into the obstetrician, the blood pressure skyrockets just absolutely through the roof.

Justine Gorman (04:36):

It’s very quick.

Michael Dermansky (04:37):

It’s very quick, very, very quick.

Justine Gorman (04:40):

Yeah.

Michael Dermansky (04:40):

So one day you’re okay and the next day this headache and then suddenly it’s super high and it’s emergency C-section that day.

Justine Gorman (04:45):

Yeah.

Michael Dermansky (04:49):

Yeah, it’s a very, very serious condition. But I mean the obstetricians are looking for that too. They know it’s a very important one. They’re looking for it straight away in pregnancy.

Justine Gorman (04:56):

And so it can develop any time after 20 weeks generally, but your risk is a little bit higher as you go through pregnancy, obviously because pregnancy is progressing, you’re getting higher blood volumes pumping both through your system and baby’s system as well. And so that’s something that they check really regularly. There are some symptoms, some women don’t have any symptoms at all. So some symptoms like swelling in the limbs, feeling dizzy, really nauseous, things like that. Severe headaches like you were talking about. So there’re things to watch out for but regular appointments with your care provider there are always checking for blood pressure as well.

Michael Dermansky (05:37):

Strength training or cardiac training. What do you think is the most important one during pregnancy?

Justine Gorman (05:42):

Both. Yeah.

Michael Dermansky (05:47):

I’m I asking the correct question? But yes.

Justine Gorman (05:47):

Both are super important. So we’ve just had some changes to the Australian Government Department of Health exercise guidelines for pregnancy as well in the last couple of months, which has been really exciting. So I might go through a bit of those today because they do recommend both cardiovascular exercises and strength exercise.

Michael Dermansky (06:06):

Great. So what are the recommendations as well?

Justine Gorman (06:09):

Yeah, so one really great thing that I think a lot of women will really appreciate the changes in these guidelines is that vigorous intensity exercise has now been included in the guidelines as well. So prior to this we had only said, we don’t really know how safe those higher intensity exercises are for women in pregnancy. So there’s been a little bit more research done in this in the last few years and we can now say that moderate intensity of 2.5 to five hours per week or 30 to 60 minutes on most days is recommended or vigorous intensity of one and a quarter to two and a half hours per week, which is 15 to 30 minutes on most days is recommended for your cardiovascular exercise and endurance. In terms of moderate intensity, we talk about being able to hold a conversation so you might be able to have few word sentences and still not feel too puffed or out of breath.

(07:12):

Vigorous intensity obviously a little bit higher than that and we can’t really talk. We still don’t know what the upper limit of that vigorous intensity is. So it’s really important that women are talking to their care provider about what type of exercise they’re doing. We’re taking into consideration what exercise they’ve previously done as well. And so we are not recommending women that have not really exercised before, only doing some incidental walking to go straight to doing high intensity interval training type stuff.

(07:49):

But it’s really wonderful for those women that have been doing those things that they can now feel safe and comfortable, that that’s okay to be recommended provided the pregnancy is not complicated and going well. In terms of those guidelines as well, they talk about some strengthening exercises on two days a week too. So that can be body weight exercises but preferably something with light weights or resistance bands, things like that where we’re using that little bit of extra resistance to load our muscles. We know how important that is for bone health just for general strength. But in terms of pregnancy and postnatal, I think a lot of women forget that once Bob is born you’re then providing all this care for them as well. So holding and settling a lot and those demands on your body are changing all the time too. So the strengthening component is really important.

Michael Dermansky (08:51):

I mean I guess my bias was on definitely strength training because the two most common problems I oversee during pregnancy is number one is pelvic instability. So it can start very early in the pregnancy and so that loss of control around the hips and pelvis, it very, very commonly starts called this ache around the bottom and it gets progressively worse. And when women work on it’s a big, big difference. And the second biggest issue we see, as you said, postnatally after they’ve had the baby is when they’re looking after the child or breastfeeding, the mid-back problems are very, very common. And so making those areas stronger beforehand makes a massive difference.

Justine Gorman (09:30):

So we run a lot of classes at our clinic as well and they’re a really big focus. So not only do we have cardio component to those classes, we have strength component working on a lot of postural control. So a lot through our upper and middle back. And then particular emphasis like you said around that glute stability and pelvic stability as well because we know women can get a lot more discomfort around that area and they’re carrying a lot more load around that area as the pregnancy progresses as well.

Michael Dermansky (10:04):

I mean going on from that too, what are the most common issues that you find with women during pregnancy or after pregnancy as well that can be helpful with exercise?

Justine Gorman (10:12):

Yes. So I guess quite few things. There’s lots of changes posturally happening throughout pregnancy. So I guess the main one that we would see is pelvic girdle pain. And so that’s either pain through the front of the pelvis around the pubic bone or around the back more towards your tailbone lower back type area as well. So that’s probably the main pain I suppose, musculoskeletally that we see. And then even during pregnancy, I know you mentioned postnatally with breastfeeding and holding, we get a lot of mid back pain, but I find particularly women that do a lot of seated work do get quite sore and stiff through their middle back as well as pregnancy progresses. But starts to grow and push up a little bit. We get a little bit less rotation through our trunk and things as well, which means that that can cause some stiffness and discomfort.

(11:14):

So exercise, even just some gentle stretching and some general strengthening through that area at home can really help. So it’s really about working with each woman and what exercise they enjoy and what they can fit into their day based on how we progress and manage their symptoms.

(11:40):

So we get a lot of women just coming in saying this is the exercise that I really enjoy doing. I don’t know whether this is safe or not. And so we’re providing, that’s probably apart from musculoskeletal pain is the other main reason why women would come to see us during pregnancy to talk about exercise because whether it’s that their care provider said, oh I’m not sure, or I think you should be able to do this, but go and consult a pelvic floor physio or a women’s health physio about that before you start or continue. And then obviously the other big one is for us, any pelvic floor concerns as well. So we know that pelvic floor muscle training is really important in pregnancy and it can reduce your risk of urinary incontinence and other pelvic floor symptoms as well. So that’s often quite a common thing that we see in pregnancy or a common concern for women that might come in going, I’d like an assessment and I’d like to do some exercise for this because I would like to prevent that ongoing.

Michael Dermansky (12:51):

So how much can you do during pregnancy? I mean, we’ll talk about two things. Firstly, the pelvic floor control and then in terms of exercise, as you said, the guidelines have changed a little bit and I know that the biggest thing we get to hear is that okay, is it safe to exercise? Well it depends on what you’ve done beforehand. So if you’re 20 weeks pregnant and you want to start a new program, it’s not a good idea where if you’ve done this for the last five years and it’s your normal and you just happen to be pregnant right now, then absolutely it’s something you can do going forward as well.

Justine Gorman (13:22):

Yeah. There’s some really interesting research coming out in that space as well, which I’m super excited about around weight lifting and lifting heavier weights and higher intensity exercise and pregnancy as well. So hopefully in the next couple of years we’re just going to see that evidence grow and grow and grow and women are feeling more confident and more comfortable to either start lower strength training programs during pregnancy and feel safe or continue those really heavier more intense weights and cardio training and feel safe in that respect.

Michael Dermansky (13:59):

So where does pelvic floor control come into it too? So when should they start, what’s the right time to question it and what is a good thing to do during pregnancy?

Justine Gorman (14:08):

Yeah, so it’s recommended that all women should be doing pelvic floor exercises during pregnancy. I mean ideally in a perfect world we’d all be doing them before we fall pregnant as well. But it’s not something that we always think about, particularly if we’re not having any symptoms. So yeah, basically starting as soon as you can is really important. So the earlier you start the better, again providing there’s no complications. So always checking with your care provider first to make sure that they’re happy for you to start that. But we do know there are a significant proportion of women that actually aren’t activating their pelvic floor correctly as well. So we talk about a lift and squeeze of the pelvic floor, like you’re trying to hold on to stop the flow of urine on the toilet or squeeze around the back passage, those types of cues. But we know when we cue women to do that, sometimes they’re getting the opposite effect and they’re actually pushing down or they’re holding their breath or not quite doing it correctly.

(15:13):

So we really advocate for women coming in and seeing a pelvic floor physio during their pregnancy just to make sure that they’re doing it correctly. And then like any strengthening program, we can then tailor that program specifically to them. So in terms of how many seconds we’re holding for and how many reps and sets and things like that to do. Now generally we say if you’re not having any symptoms, so we’re not getting any incontinence or anything that we’re worried about, you can often leave that till into the second trimester. So after 12 weeks, often about 18 to 20 week mark is good, but you can do it as soon as possible, particularly if you’re having concerns. And so we would do an exam to check your technique and then write up a specific pelvic floor program for that person. And that may be all that they need in the pregnancy is just to, yeah, I’m doing it correctly, I know what I’m doing. And then off they go.

Michael Dermansky (16:25):

Fantastic. I mean one of the big pieces of advice you hear sometimes and I know it’s not correct, is that, oh, I’ve been told to do my pelvic floor muscle exercise all the time. So every time I’m at a traffic light to contract my pelvic floor muscles. And it’s like any muscle, you don’t want to work your biceps every time you get to a traffic light. I don’t think it’s great advice. What are your thoughts?

Justine Gorman (16:49):

Yeah, so again, not only a proportion of women that don’t quite do it correctly, but there are a proportion of women as well that have what we call maybe an overactive or a non relaxing pelvic floor too, which is also a problem. Like you talked about, if I’m holding my bicep better, really my arm at a really bent position all the time, if I then go to cough or sneeze or pick something up, then I might not have that full power to lift up and support against that load as well. So that’s where women can be having some issues with some incontinence as well. Not if they’re not necessarily if they’re weak, but if they’re non relaxing too. But a lot of these women often get pelvic floor pain as well, so that’s another indication of why we should need to do them.

(17:47):

But having a pelvic floor assessment will obviously tell us is it not relaxing or is it a little bit weak? And then we’re either doing some more down training exercises, so trying to get that pelvic floor to calm down and to let go, or we might be doing some strengthening. So it’s really hard to know. It really needs to be individualized and that’s why there’s a lot of advocacy for women coming to see pelvic floor physio during pregnancy to get something that’s tailored specifically to them. But if you are in Melbourne like yourself Michael, and you hit 30 sets of traffic lights on your drive to work, you’re probably doing a bit too much.

Michael Dermansky (18:31):

And the muscles are fatigued, and your muscle group, they get tired. And so you’re no longer actually doing what you think you’re doing, you’re just contracting everything around it instead and you’re not supporting the right motor pattern.

Justine Gorman (18:44):

Yeah. Yeah, for sure. I think though, also it is quite important to do because we do have some good evidence that if you are doing it correctly, you can actually reduce the length of your second stage or pushing stage of labor a little bit with good pelvic floor muscle control. So that’s not just strength, but that’s good relaxation as well. And there’s also a small emerging amount of evidence that it might reduce the risk of severe perineal tears or tearing during labor too, which is a really large concern or a big concern for a lot of women that we see as those obstetric factors as well. So not only does it help reduce incontinence rates in pregnancy in early postpartum, but those effects on labor as well.

Michael Dermansky (19:38):

I mean those tears are quite significant too. They make a big difference in your recovery afterwards too.

Justine Gorman (19:45):

And subsequent quality of life as well. So anything that we can be doing to reduce the risk of any pelvic floor muscle injury or any pelvic floor dysfunction, I think is only beneficial.

Michael Dermansky (20:00):

And so in terms of going back to exercise during pregnancy, when should women start? When should they stop? And when should they restart after having the baby?

Justine Gorman (20:09):

Yeah, great question. So basically general exercise, start as soon as you can. So hopefully most women are doing some exercise before they’ve fallen pregnant anyhow. That first trimester, I mean, speaking from experience as well can be really tricky if you’re not feeling too great. So a lot of women we find will back off a little bit in terms of the intensity or the amount of exercise that they had been doing just because they’re feeling so poorly. But then gradually building it up again as they start to feel well. As I said before, pregnancy is probably not the time to start high intensity training or really heavy weights if that’s not something you’re accustomed to.

(20:59):

But if you’re not sure what you should or shouldn’t be doing, going to see a physio that has some experience in pregnancy exercise or seeing a pelvic floor women’s health physio can be really helpful. But those Australian Government Department of Health guidelines give you a really good starting point. So I can link you to those.

Michael Dermansky (21:22):

That would be great. We can put that in the show notes. Absolutely.

Justine Gorman (21:28):

Yeah. And so that gives you some ideas on some exercise that you can get started that are a bit more moderate intensity. And then if you’re looking for something more or you’re not quite sure, best to go and see somebody that specializes in that area. You should stop doing any pregnancy exercise if you develop any pregnancy complications or any medical conditions. So obviously it’s really important that you should speak with your care provider at that first session and keep checking in. This is what I’m doing for exercise. Is it okay? Most women will know if they’re having some sort of complicated pregnancy or some conditions that would stop them from being able to exercise. Most care providers would tell you what you can and can’t do. But yeah, there’s otherwise, in terms of stopping, we have plenty of women coming to our exercise classes that are still doing some modified activity all the way up until the week they deliver. So I think it’s really important to continue as long as you still feel comfortable.

Michael Dermansky (22:39):

I think the longest we’ve had is 42, 43 weeks, where they felt fine all the way to the end and wanted one more session in before the baby was born and they’re fine. But we have some women stopping at 36 weeks or 34 weeks and saying, “You know what? I feel really tired and whacked out. I go, I do my exercise program and I feel like I need to rest for half a day afterwards too.” That’s your body telling you stop, it’s time to stop. And it’s a pretty good indication that your body says enough and let the rest of the pregnancy happen.

Justine Gorman (23:12):

And I think the other thing that we forget sometimes too is it is called labor and it is quite intense and it can be quite long, particularly in first pregnancies as well. So we do need to conserve some type of energy for that as well. So really I think your comment on listening to your body and doing what feels best and comfortable for you is really important.

Michael Dermansky (23:36):

So when to start afterwards, I mean we tend to tell women it’s either with a natural, it can be three weeks onwards, ideally six weeks wait six weeks, but it’s three weeks onwards with official clearance and then there’s a C-section absolutely six weeks. Any different advice on that?

Justine Gorman (23:56):

And here’s where some of the research is changing a little bit as well because we used to say for most exercise, wait and wait until six weeks after a week, after a couple of weeks you can probably start doing some gentle walking as you feel comfortable regardless of delivery mode. But that’s starting 10 minutes a day, no heels type thing. But some really great evidence in the last couple of years or year even come out that has said starting low impact exercise is actually beneficial within those first couple of weeks providing you’ve got clearance from your care provider and you’re feeling well just to start some gentle general exercise. So there’s no right or wrong type exercise there, but starting some gentle walking and things like that are really important and actually have been shown to have a more favorable recovery in those first three to six months as well.

Michael Dermansky (25:02):

Oh, fantastic.

Justine Gorman (25:03):

Yeah, really important to listen to your body and do what feels right. Obviously you’re learning all these new things about your baby and probably very sleep deprived, so it’s really important to try and balance that. But there’s definitely, definitely some benefits in getting going gently and early. It’s in terms of strengthening, again, it really depends on what you’ve been doing pre-pregnancy and during pregnancy. There are quite a number of women who’ve been quite active throughout their pregnancy that we start seeing four, five weeks. You can start some gentle weights. If you think about what you’re doing day to day with this new baby, you might have a three and a half, four kilo baby, maybe five that you are bending, squatting, lifting all day. I don’t think it’s unreasonable to expect then that you can start to do some gentle body weight exercises and some really light light weights to start that gentle strengthening program as well.

Michael Dermansky (26:15):

Fantastic. And just finally, I mean, who shouldn’t exercise during pregnancy?

Justine Gorman (26:21):

Yeah, so there are a few conditions where it’s recommended sort of absolutely do not exercise in pregnancy. That will obviously vary depending on the extent or the severity of those conditions. And that decision is always made in discussion with the care provider of that woman. But preeclampsia, as we spoke about earlier, is one of them. Most of them won’t be able to exercise depending on how high that blood pressure is, but that’s generally a fairly absolute contraindication to exercise in pregnancy.

Another one is placenta previa, which is where the placenta is quite low and grows implanted over the top of the cervix. So those women are at higher risk of pregnancy bleeding and things like that. And exercise can obviously potentially cause some issues there with increased bleeding and things. So again, the care provider often says to us, it’s slightly risky, only low impact, or they might give us some guidance on those things. But that discussion was always had there as well. And obviously if you’re going, you’ve had what we call premature rupture of membranes or that early labor earlier in the pregnancy, then that’s 37 weeks, that’s a bit of a no as well. Otherwise, we say just check with your care provider, see what they say in terms of what’s going on for you medically. And we’re always back and forth having those discussions with the pregnant woman and their care team.

Michael Dermansky (28:07):

So it sounds like, and we do this as well, if women do come to see us during pregnancy and they want to exercise. We get a clear obstetrician to understand what they have, what they don’t have and what it’s safe for us to do during their program as well. It sounds like that’s a very similar guidelines of what you do with your clients too.

Justine Gorman (28:21):

Yeah, so we always do a screening before we start any classes with any of our patients. And if we do have any concerns, we liaise with their midwife or their obstetrician regarding that. Those exercise guidelines that I’ll send you through for the show notes, actually have some of those things written down on them so you can go to those guidelines and check through and say, no, I don’t have any of those, or yes I do, maybe I need to check before I start exercise too. So that’s a really good starting point.

Michael Dermansky (28:58):

Fantastic. And finally, have you found a difference with women who do exercise during pregnancy and those that don’t during pregnancy in terms of how they feel, what they’re like afterwards as well?

Justine Gorman (29:11):

Yeah, I guess it’s really anecdotal. We don’t have a lot of evidence, but I tend to find women that are exercising throughout their pregnancy, they feel a lot more comfortable starting back exercise postpartum. They feel obviously exercise gives us all those endorphins and all those wonderful things as well. And so even just coming together in a social class and chatting with other women about how things are going during their pregnancy and that real mental health benefit is really important as well. I think even though the research doesn’t support it too much, women that are exercising tend to have maybe a little bit less low back pain or pelvic girdle pain. There is a small amount of evidence to show that it may reduce the severity of low back pain in pregnancy, but not actually your risk of developing low back pain. So there are some benefits there that we definitely see women feel a little bit better.

Michael Dermansky (30:19):

I mean it’s interesting, I mean interesting that no research evidence to show, but we’ve seen a big difference between women who do exercise and don’t particularly around that pelvic girdle pain. And so that strength around that area is really important. I mean, we can’t always control how much hormones are released, how relaxed it’s going to be, but the control of how different it makes them feel. We’ve seen many women, they’ve had a very, very tough pregnancy the first time around because they didn’t exercise and they were very, very, had a lot of pelvic pain. And the second time around where they exercised beforehand or during or early stages. They had a very, very different pregnancy the second time around because they’ve had that strength in their area and a lot more control meant they’ve had a lot more functional, easier life during pregnancy and their recovery had been a lot better afterwards too. So I haven’t kept an absolute record of who has what, but it’s really, really clear the difference. It’s a massive difference of how much their lives are affected before and afterwards too.

Justine Gorman (31:21):

And the difficulty with research, and particularly research in pregnancy is that there’s so many confounding factors as well. There’s so many different things that contribute to changes going on in a woman’s body that we can’t for sure. Like it makes a lot of sense that exercise would help those things, but there’s so many other things going on in that woman’s life and changes in that woman’s body that we just can’t necessarily put it down to that one thing. So I think that’s where our clinical experience really, really comes into play.

Michael Dermansky (31:53):

Fantastic. So Justine is there anything else you want to cover in today’s interview before we finish up?

Justine Gorman (32:00):

No, I think that’s probably about it. Just to say if you haven’t been an exerciser but you would really like to start during pregnancy, please go and talk to your care provider and then find somebody in your local area that has some experience and knowledge in this area because we do know the benefits of a really significant and important and hopefully will help improve your quality of life. So yeah, we just want to get the message out, but it is in most cases, really safe to exercise in pregnancy and actually really beneficial.

Michael Dermansky (32:37):

Fantastic. I couldn’t agree with you more. Thank you very much for your time today, Justine, and I hope everyone’s got a really great amount of information from today’s podcast as well. And we’ll see you next time. Thanks very much.

Justine Gorman (32:49):

Thank you

Voiceover (32:50):

Thank you for listening to The Confident Body. For practical articles to help you build a confident body, go to mdhealth.com.au/articles.