Changing The Narrative Around High-Intensity Exercise In Pregnancy & Postpartum

Emily McElrath, PT, DPT, MTC, CIDN  is instructing her upcoming course Pregnancy & Postpartum Considerations For High Intensity Athletics scheduled on March 9, 2024. Emily is highly trained in Sports and Orthopedics and has a passion for helping women achieve optimal sports performance and is certified in manual therapy and dry needling, which allows her to provide a wide range of treatment skills including joint and soft tissue mobilization. She is an avid runner and CrossFitter and has personal experience modifying these activities during pregnancy and postpartum.

It’s no secret that high intensity exercise during pregnancy and early postpartum has been debated for years. For many decades, pregnant female athletes have been told things like “you shouldn’t be doing that,” or “that’s not safe.” Are these claims rooted in truth or misunderstanding? I personally think more of the latter, and as it turns out the research supports that as well. In fact, the entire narrative around high intensity exercise in pregnancy seems to be shifting.

In truth, I believe some of the disconnect comes from a lack of understanding of high intensity exercise by clinicians. While many clinicians themselves participate in high intensity exercise, many others do not and also do not understand high intensity exercises like powerlifting, orange theory, crossfit, triathlon training, etc. The other part of the disconnect comes from a general lack of research on the subject. Thankfully, this is also changing and more research is being done on the impact of high intensity exercise on fetal and maternal health, as well as the pelvic floor and core. But up until recent years, we had mostly anecdotal evidence. Finally, we are seeing more and more clinicians being athletes themselves, which has led to a personalized understanding of high intensity exercise during pregnancy and postpartum. Interestingly enough, many of these athlete clinicians are on the frontlines of the current research.

Some of the most recent research that we should highlight includes:

“Clinical and exercise professional opinion of return-to-running readiness after childbirth: an international Delphi study and consensus statement.” This international Delphi survey was published in the British Journal of Medicine and surveyed over 100 clinicians and exercise professionals on readiness to return to running postpartum. They asked these professionals to define “runner” and “postpartum,” what biopsychosocial milestones they felt runners needed to meet, various methods of screening they recommended, supportive items they may recommend, a timeline for when and how to return to running, factors that may contribute to them advising a patient against running, and other educational points they felt were important. At least 75 % of the participants or more felt that, following a minimum 3-week period of rest and recovery, and as long as the patient has met all screening criteria, an individualized return to running progression can be considered.

“Impact of Pelvic Rest Recommendations on Follow-Up and Resolution of Placenta Previa and Low-Lying Placenta.” This retrospective study was published in the Journal of Ultrasound in Medicine in March of 2023 and reviewed 410 pregnancies of women who had placenta previa (144) or low-lying placenta (266). 45% of placenta previa patients and 12% of low-lying placenta patients were placed on pelvic rest. All of the study participants were given an ultrasound at 28 weeks gestation. Resolution occurred in 51% of the placenta previa patients and 75% of the patients with low-lying placenta regardless of whether they were placed on pelvic rest or not. This is exciting because it may indicate that women with placenta previa and/or low-lying placenta previa may not need to be placed on pelvic rest and/or limited from activity.

Another study done by Eichelberger, et al. in the American Journal of Perinatology in 2011 found that 84% of complete placenta previas and 98% of marginal placenta previas resolved naturally by roughly 28 weeks. This study is promising because it shows that while some pregnant athletes may be temporarily limited from exercise, they may be able to return after resolution of the previa.

A study published in 2020 by Chen et al looked at the role of exercise in treating low back pain in pregnancy and found that the transverse abdominis, multifidus, pelvic floor, and diagonal trunk musculature play a significant role in load transfer in the lumbopelvic region. This is important to consider when working with pregnant athletes as we can use these concepts via accessory work to support their tissues for more strenuous activity.

While many of these studies were small, and survey only in nature, it is promising to see more research being done. In the meantime, we have lots of anecdotal evidence that women who were high intensity athletes prior to pregnancy can in fact continue their desired level of exercise confidently and safely. Additionally, when we as clinicians have a thorough understanding of the musculoskeletal system, and how those tissues handle various loads, we can help patients modify as needed to continue loading those structures appropriately and without risk of injury. The goal of my course Pregnancy and Postpartum Considerations For high intensity Athletics is to help give clinicians the confidence they need to work with this patient population. I blend research, clinical experience, and personal experience as a pregnant athlete to help clinicians understand how to meet these athletes where they are to help them continue doing what they love. My mission is to empower women to feel strong, capable, and healthy (mentally, emotionally, and physically) throughout their pregnancy and as they recover postpartum and to change the narrative surrounding high intensity exercise during pregnancy from one of fear and misunderstanding to one of empowerment and encouragement.