In the late 19th century, pregnant women were deemed frail, but strong
enough to perform light housework. (Lucky them.) In an extensive review of
studies on pregnancy and exercise since the 1950s, Kehler & Heinrich
(2015) reported that views on pregnancy progressed significantly with the
rise of feminism, the boom in health and fitness, and an increasing
willingness to question unsupported notions about maternal fitness. (Lucky
To earn 2 AFAA/0.2 NASM CEUs, purchase the CEU Corner quiz ($35) and successfully complete it online at www.afaa.com
Even as recently as 30 years ago, there were two schools of thought on
prenatal workouts. According to Exercising Through Your Pregnancy
(Addicus Books), written in 1998 by renowned obstetrics researcher James F.
Clapp, III, MD, and updated in 2012 with exercise physiologist Catherine
Cram, MS, the "conservative school" feared moms venturing beyond inactivity
and bed rest, while the "liberal school" included women who had exercised
safely throughout pregnancy and believed it to be "not only normal but
This drove a wedge between many pregnant women and their caregivers-and
sometimes friends, family and fitness professionals-that hasn't quite
disappeared today. Fortunately, it also sparked interest in
research on pregnancy and fitness, which also continues.
Pregnancy is not something women or their trainers need to take lying down.
In most cases, exercise is good for mom and baby alike-it just requires
some common sense and science-backed precautions.
Fitness Pros and Pregnant Clients
Some fitness pros hesitate to work with pregnant moms because they're not
sure how to do it safely. That's part of a conversation that needs to
change, says Tatum Rebelle,
NASM-CPT, a 16-year pre- and post-natal fitness and nutrition expert and
founder of Total Mommy Fitness™. (totalmommyfitness.com).
"Culturally, we need to change the way we talk about pregnancy. There's a
pervasive attitude that your job is to sit back and relax and have a baby,"
says Rebelle, who was in the third trimester of her first pregnancy when
American Fitness caught up with her. Rebelle says she has
struggled with "mommy guilt" and well-wishers who panicked when she'd pick
up a box or move a chair. Even when people's concerns come from a place of
love, notes Rebelle, "those misconceptions end up doing more harm than
Exercise has proven benefits for mothers and children (see sidebars).
Even so, pregnant women face substantial barriers to exercise-including
physical changes (nausea, fatigue, discomfort), negative perceptions of
maternal exercise, and their own uncertainties about how to modify workouts
for safety and success. And while fitness professionals are uniquely suited
to help women navigate this territory, Rebelle says many won't work with
them because of fear, uncertainty and a lack of knowledge about the
Actually, it can be good business forfitness trainers
and instructors to have a
basic understanding of exercise during pregnancy "so if they have a client
who gets pregnant, it's not a dead stop…or, God forbid, (trainers)
treat them the same as other clients and they become injured," says
Rebelle. In addition to expanding your marketability, you can become part
of the solution, dispelling pregnancy-exercise myths by sharing
evidenced-based research on the topic.
You may even develop a passion for working with this population, as was the
case with Rebelle and Cram, a leading expert in maternal fitness and
founder of Prenatal & Postpartum Fitness Consulting
"Working with pregnant women is absolutely the joy of my life," says Cram,
who has done so for 17 years. "I want to always uplift and educate and
empower. Pregnancy puts women who are very strong in a very vulnerable
place, and we need people in this field to help give them back that sense
of trust in their own body because they're the best person to determine
what's right for them."
Guidance from the Medical Community
"Women with uncomplicated pregnancies should be encouraged to engage in
aerobic and strength-conditioning exercises before, during, and after
pregnancy," the American College of Obstetricians and Gynecologists states
in a 2015 position paper. The key word is "uncomplicated," Cram says.
Pregnant women should always consult with their healthcare provider to
determine whether they have any complications that may make exercise
contraindicated. Once their doctor clears them for exercise, remember to
keep your lines of communication open and request updates at every workout
to help you adapt quickly if a client's circumstances change. In most
cases, ACOG "encourages ambulation," even if there are complications.
Quantity, Duration and Intensity
ACOG recommends that pregnant women follow a workout regimen that aims for
at least 20-30 minutes of moderate-intensity exercise per day, most or all
days of the week, and adjusting "as medically indicated." It's no
coincidence that this is the same advice for all healthy adults issued by
the U.S. Department of Health and Human Services in 2008.
But what about more-intense exercise? Alas, research hasn't determined a
safe upper limit for exercise intensity during pregnancy. However, ACOG
notes that women with healthy pregnancies who were working out regularly
before conception should be able to continue high-intensity exercises such
as running, jogging and aerobics "with no adverse effects."
ACOG adds that hypoglycemia (low blood sugar) can become a concern for
pregnant women during high-intensity exercise or sessions lasting more than
45 minutes, so caloric intake beforehand is especially important, as is
The Obstetrician's Role
Currie et al. (2016) note that physical activity "is not a priority for
health professionals providing antenatal care, as there are many other
important health messages and information to be delivered during routine
visits." But the benefits to the health of both mom and baby mean that they
have a vested interest in patients exercising safely (see sidebars).
Sadly, adherence to exercise guidelines is dismal among pregnant moms,
whose participation rate is just 16%, which is 10 percentage points lower
than exercise adherence among nonpregnant women (Hinman et al. 2015).
While obstetricians typically aren't experts in exercise, their
support of prenatal workouts can make a very real difference. According to
ACOG (2015), "Patients are more likely to control weight, increase physical
activity and improve their diet if their physician recommends that they do
so" (ACOG 2015).
Health organizations recommend that pregnant women consult with a
healthcare professional on their exercise regimen. Further, the National
Academy of Sports Medicine Women's Fitness Specialization encourages
fitness pros to work closely with clients' obstetricians and follow their
recommendations (NASM 2012).
Cram notes that people would like to have a simple list of dos and don'ts,
but a cookie-cutter approach to exercise doesn't work for any
population-especially pregnant women. "A woman's doctor may say 'don't lift
anything heavier than 20 pounds.' For some women, that's way too heavy, and
for others it's nothing," she says.
What the obstetrician can do is closely monitor how the baby is
growing and alert the mom if there is a concern and explore appropriate
modifications. For instance, if a woman is training heavily and the fetus'
growth rate isn't on target, the mom may need to increase caloric intake,
decrease intensity or otherwise modify her program. Medical professionals
will also be watching for complications and absolute contraindications to
pregnancy exercise, such as an incompetent cervix, placenta previa,
preeclampsia or severe anemia (ACOG 2015; ACOG 2016).
Pregnancy Changes That Affect Exercise
These physical challenges include far more than navigating a belly bump and
supporting a larger bust. Besides serious issues like complications and
contraindications, pregnant women's workouts may collide with symptoms such
as nausea, fatigue, heartburn/reflux and sciatica. These are some of the
most common changes that appear during a normal, healthy pregnancy:
As the anterior abdomen expands to accommodate the fetus, women often
develop a deep low-back curve (progressive lordosis). This shifts the
body's center of gravity, affecting balance and often causing lower-back
pain. Low blood pressure can trigger dizziness, especially when
transitioning from sitting to standing.
As early as 2-5 weeks into pregnancy, resting heart rate increases and
stays elevated until late pregnancy. Blood volume, stroke volume, cardiac
output and resting VO2 also rise. Blood pressure declines as hormones cause
veins to relax and open wider to accommodate the increased blood volume.
Some of these changes can trigger symptoms such as fatigue, nausea and
During pregnancy, a condition called diastasis recti emerges when the
rectus abdominus separates vertically down the center of the abdomen, along
the linea alba, to allow the fetus room to grow (NASM 2015). Wearing a
belly support belt may help relieve back and hip pain, and performing
transverse "abdominal" exercises may help strengthen surrounding muscles to
prevent problems. This is one of the conditions for a healthcare
professional to monitor throughout pregnancy.
The body increases production of the hormone relaxin, which loosens
ligaments in the pelvis and pubic symphysis in preparation for childbirth.
But it's not discriminating; it also relaxes ligaments in other joints, so
pregnant women need to be careful with stretching/flexibility, joint
movement, balance and activities that require quick cutting and directional
Pregnancy hormones cause increased metabolism and affect how energy in the
form of blood sugar is delivered to mom and baby. Specifically, they cause
"a glucose-sparing effect, where glucose goes to the fetus and the mother's
cells experience an increase in fatty acid oxidation" (NASM 2012).
Resting respiration increases by 50% due to deeper breathing, although
pregnant women generally feel short of breath. Interestingly, though, the
lungs become more efficient at oxygen uptake during pregnancy.
Increased blood flow to the skin makes the mother's body better at
regulating temperature. However, caution is still necessary: Exposure of a
pregnant mother to excessive heat (as in a hot tub, sauna, hot yoga session
or extreme temperatures indoors or outdoors), particularly during the first
trimester, can result in neural tube defects in her baby.
For women who begin pregnancy at normal weight, the Institute of Medicine
and ACOG recommend a gain range of 25-35 pounds (ACOG-1 2016). This
includes the fetus, placenta and amniotic fluid, as well as increases in
maternal fat stores, uterine and breast tissue and blood volume. Breast
enlargement and compensations to body changes can lead to an excessive
roundness of the upper back (kyphotic curve).
Basic Workout Guidelines
Pregnancy presents opportunities to encourage women to take better care of
their health for the sake of their fetus. In fact, this may motivate a
mom-to-be to start an exercise program.
If you're working with experienced exercisers, urge them not to compare
today's performance to how they did before they were pregnant. Aim for
consistency and fitness-not gains.
These reminders can help keep your pregnant client safer and more
Choose a safe place.
Conduct sessions in a climate-controlled environment, avoiding high heat
and humidity. Encourage her to wear lightweight moisture-wicking clothing
to stay cool. She should not train at altitudes above 6,000 feet unless she
is already acclimatized (ACOG 2015). If she participates in group training
or does weight training in a room with others, be sure she is well away
from those who could bump, kick or otherwise connect with her.
Use RPE or the talk test.
Heart rate is all over the place during pregnancy, so it's not a reliable
gauge of workout intensity. Use the rate of perceived exertion (RPE) or the
talk test instead.
Modify one thing at a time.
Pregnant women should modify their workout routine for comfort and safety
as their pregnancy progresses. If you need to back off as a pregnancy
progresses, reduce intensity first, then duration. Try to maintain
frequency, even if it's at a much lower intensity. This can help keep her
in the habit so she will continue exercising after delivery.
Keep an eye on nutrition
. Make sure she consumes enough calories and hydrates properly. This is
particularly important for pregnant women training for longer durations or
at higher intensities, such as elite athletes and fitness pros.
Discuss activity choices
. ACOG says pregnant women should avoid high-risk activities including
scuba diving and sky diving. It also advises against playing contact sports
like soccer, basketball and boxing, as well as activities with a high risk
of falling, such as skiing (water and snow), gymnastics, off-road cycling
and horseback riding.
Cheer her on.
Be positive and supportive of her efforts-and encourage her partner to do
the same. "Women tend to be very hard on themselves, so the trainer's job
may be to give them permission to take care of themselves in a way that
they haven't before," says Rebelle.
Modifying Specific Moves
Cram is reluctant to place any type of exercise (save scuba diving, hot
yoga and hot Pilates) completely off-limits to pregnant women. "Most types
of exercise can be modified," she says. For instance, mountain bikers can
switch to flatter, straighter roads. When clients ask Cram if they can keep
doing something, she asks them, "Does this make sense?" and "Is it worth
"In most circumstances, the fall risk for the baby, I think, is
overstated," adds Cram. "The baby is very well-protected. With some
activities, I'm more fearful of the mother getting injured." Bringing home
baby is enough of a challenge on its own; doing so with a sprained ankle or
other injury is less than ideal.
"It's better to prevent being injured than to get injured and try to
recover," says Rebelle, who pulled a groin muscle early in pregnancy
(chasing her dog, not exercising) and still hasn't healed. "Now I know
firsthand why I tell women the things I do!"
These recommendations are a good place to start:
• Avoid assessments that require her to be on her back after the
first trimester. In this position, the uterus presses on a large vein that
returns blood to the heart (ACOG 2016). Never ask a pregnant client to
perform a maximal exercise test. Some of the more-valuable results may be
found from push, pull, overhead squat, single-leg squat or balance
assessments, but also know that some movement assessments may be skewed by
• After the first trimester, modify prone or supine exercises by
propping up the back or hips or using a stability ball. Exercises can also
be done against a wall (such as wall pushups) or while turned on the side.
Avoid moves that twist the torso.
- Maintain balance training, but conduct it on a stable surface and
have a chair, wall or other source of support nearby.
- Add corrective training to counteract the effects of pregnancy,
such as an arched lower back or rounded upper back.
- Include exercises that strengthen the pelvic floor muscles.
- Provide clear and concise cuing to ensure client safety,
particularly when modifying exercises or demonstrating new ones.
- Emphasize the importance of proper breathing; ensure your client
does not hold her breath.
- Modify self-myofascial release to avoid prone or supine positions.
Avoid SMR on painful varicose veins or swollen extremities.
- Discuss modifications for other activities. For instance, some
martial arts drills can be performed without contact and with ample
distance from other participants.
- Use NASM's guidelines for Stage I (Zone 1) cardiorespiratory
training (below). Seek her doctor's okay before entering Stage II (below)
In the NASM Optimum Permformance Training model, training in Phases
1 and 2 during the first trimester is recommended, (visit the NASM website for more details on OPT:
even if the client is new to exercise. The NASM Women's Fitness Specialist manual adds that women who have been
training previously may also train in Phase 5, but they may need to modify
the intensity downward. After the second trimester begins, only Phase 1 is
recommended (NASM 2012).
In most cases, aim for maintenance of fitness rather than gains,
keeping safety front of mind. However, women who begin exercising
during pregnancy can start with 5-15 minutes of physical activity and
gradually increase over time.
Consider adding functional exercises that will help the mother when
the baby arrives, such as teaching her how to properly lift and carry her
Listen to your client. Watch her closely, and pay attention to her
energy level and form. Regress the exercise or modify it if form is
failing. Stop if she feels like she should stop.
Rebelle and Cram both stress the importance of telling your client to
listen to her body. Pregnancy, they say, can be a powerful motivator to
self-awareness and mindfulness.
Pregnancy in Fitness Pros and Elite Athletes
Hinman et al. (2015) mentions that two small studies-one with five
vigorously active women and another with six Olympic-level endurance
athletes-reported decreases in fetal heart rate and blood flow to the
uterus when the maternal heart rate exceeded 90% HRmax. But FHR returned to
normal soon after exercise was stopped, and neonatal outcomes didn't appear
to be significantly affected. As there is "only anecdotal evidence that
even strenuous activity causes preterm labor or delivery," ACOG's only
warnings seem to be avoiding excessive heat (hyperthermia) and ensuring
adequate intake of fluids and calories to maintain fetal growth. ACOG
recognizes that competitive athletes may need more fitness and medical
supervision during and after pregnancy due to their more-intense training.
Fitness pros may find that continuing high-intensity training throughout
pregnancy may produce fitness gains, even when following a maintenance
program (Hinman et al. 2015). In a recent clinical review, Hinman et al.
noted that doing so "significantly increased the VO2max from week 17
gestation to 12 weeks postpartum." Additional study summaries by Kehler
& Heinrich (2015) noted that a professional athlete training under
rigorous conditions and others exercising at high intensities had
uncomplicated labors, delivered healthy babies, maintained fitness and
returned to sport quickly. Those training at high intensity also had a
significantly shorter labor.
Rebelle adds that the mindset adjustment is one of the most difficult
aspects of pregnancy for elite athletes and fitness professionals. "They
don't want to lose everything they've gained, but this is not the time to
increase their 1-repetition maximum or shave time off their mile," says
Rebelle. It's also not the time to try to lose weight. Even for women with
overweight or obesity, the recommendation is usually to maintain
weight during pregnancy, not make losses or gains.
Athlete clients need to understand that much of their pregnancy weight will
be accounted for by baby, blood volume, fluid and placenta, but gaining a
little fat is essential, too. Breastfeeding and training during recovery
will help them lose excess weight quickly postpartum.
Take Your Education to the Next Level
Pregnancy is incredibly complicated. It affects a woman's whole body-and
the body of her growing baby. The more you know as a fitness professional,
the better you can modify and individualize programming, keeping it safe
for clients who are pregnant or plan to be.
"I think education and support are incredibly important," says Rebelle.
"The information is out there to help trainers work with pregnant clients
and to help pregnant women feel comfortable in the gym." Rebelle began her
foray into the subject when a client purchased a 20-session package, got
pregnant and stopped returning her calls. "I thought, 'it shouldn't be this
way,' so I decided to become more knowledgeable about prenatal exercise."
Cram offers a Prenatal and Postpartum Exercise Design Course (4th ed.
2016), created with Gwen Hyatt, that includes a comprehensive and
informative workbook, an impressive exercise library, and guidelines for
strength training, water exercise and competitive sports (7 AFAA/0.7 NASM
CEUs). Rebelle's Total Mommy Fitness Pre and Postnatal Certification
provides a quick review of the research in a jam-packed manual, plus
medical illustrations and exercise videos and demos (10 AFAA/1.0 NASM
NASM Women's Fitness Specialization
(13 AFAA/1.3 NASM CEUs) delves into the unique psychological and
physiological considerations associated with adolescence,
pre/post-pregnancy, pre/post-menopause-and everything in between. It
includes insights into nutrition, barriers to exercise, special concerns
(like the female athlete triad) and exercise recommendations (core, cardio,
balance, flexibility, strength and more) with full-color photos. Explore
more with theAFAA Perinatal Fitness
course as well (7 AFAA CEUs). And this article can earn you 2 AFAA/0.2 NASM
Whatever further instruction you pursue, be sure the course is backed with
research and real-world experience, and it's not full of fear-mongering.
"Women need to be comforted and not scared," says Cram. "Pregnancy should
be a fun time. Your body is doing great stuff. Let's take the fear out of
CEU CORNER QUIZ: Fitness for Two
Learning Objectives: After reading the article, you should be able to:
- Identify current guidelines for and benefits of exercising during pregnancy.
- Explain physical changes of pregnancy and their effects on physical activity.
- List warning signs that an exercise should be modified or stopped.
- Create general exercise modifications for pregnant clients.
1. According to the American College of Obstetricians and Gynecologists:
- women who did not exercise before conception should not begin during pregnancy
- “ambulation” is encouraged for most pregnant women
- pregnant women with complications should never exercise
- pregnant women should engage only in aerobic exercise, not strength training
2. ACOG exercise guidelines on duration and intensity for healthy pregnant women recommend:
- about 15 minutes of exercise (or less) at a time and no more than 60 minutes per week
- about 75 minutes of low-intensity exercise per week
- about 150 minutes of moderate-to-vigorous exercise per week
- light housework but no strength training
3. ACOG’s 2015 position paper states which of the following?
- Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during and after pregnancy.
- Women with uncomplicated pregnancies should be encouraged to engage only in aerobic exercise before, during and after pregnancy.
- Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before and after pregnancy, but not during.
- Women with uncomplicated pregnancies should not be encouraged to engage in aerobic and strength-conditioning exercises before, during and after pregnancy.
4. The safe upper limit of exercise intensity for pregnant women:
- has not been officially established by research
- depends upon their preconception exercise routine and fitness level
- is the same for all pregnant women: low-to-moderate intensity only
- both a. and b.
5. Adherence to ACOG exercise guidelines among pregnant women is:
- about 5%
- about 16%
- about 26%
- about 30%
6. The obstetrician’s role in exercise programming is to:
- assist with details due to an extensive background in fitness
- question patients’ desire to exercise and express concerns
- explain anatomy and physiology of pregnancy to fitness professionals
- monitor the health of mother and fetus, watch for problems and provide recommendations regarding exercise safety
7. The growth of the anterior abdomen in pregnancy can cause:
- an extremely arched low back
- a center of gravity shift
- lower-back pain and discomfort
- all of the above
8. A pregnant woman’s cardiovascular system goes through extensive changes, including:
- increases in resting heart rate, blood volume, stroke volume, cardiac output and resting VO2, and a decrease in blood pressure
- decreases in resting heart rate, blood volume, stroke volume, cardiac output and resting VO2, and an increase in blood pressure
- a decrease in blood volume and increase in blood pressure
- decreases in blood volume and blood pressure
9. Other ways in which a pregnant woman’s physical changes can affect exercise include:
- tightness in ligaments, difficulty regulating body temperature and weight gain
- slower metabolism, fatigue and weight gain
- balance problems, joint laxity, shortness of breath and weight gain
- tightness in ligaments, fatigue, balance problems, slowed metabolism and weight gain
10. A pregnant women should NOT train in which of the following environments:
- a traditional gym environment, weight room or group exercise class
- altitudes over 6,000 feet, and/or extreme heat and humidity
- an outdoor fitness venue such as a biking route or pool
- all of the above
11. What is the best way to gauge a pregnant woman’s exercise intensity?
- Use the talk test or rate of perceived exertion (RPE) but not heart rate.
- Use the talk test, RPE and heart rate.
- Wear a heart rate monitor.
- Keep training at her preconception levels.
12. For the safety of her fetus, a pregnant woman should avoid:
- scuba diving, sky diving and hot yoga
- scuba diving, sky diving, hot yoga and swimming
- scuba diving, sky diving, hot yoga and weight training
- scuba diving, sky diving, hot yoga and indoor cycling
13. When assessing a pregnant client:
- avoid assessing her until after she has delivered the baby
- use only assessments that require her to lie flat on her back
- use modified assessments to gauge overall fitness, and do a mini-assessment before every exercise session
- rely on her obstetrician to perform fitness assessments
14. What have studies of elite and Olympic-level athletes shown?
- They often can keep exercising at rigorous levels and high intensities throughout pregnancy and deliver healthy babies.
- Their labor and delivery is often more difficult than it is for nonexercisers.
- They require less supervision because they understand not to put themselves at risk.
- They cannot increase their VO2max during pregnancy.
15. A pregnant woman should stop exercising immediately if:
- she experiences warning signs like dizziness, headache and chest pain
- her friends and family warn her that exercise is dangerous
- she reads a blog on the internet about something she is doing
- she has a physician who does not think any pregnant women should exercise
To earn 2 AFAA/0.2 NASM CEUs, purchase the CEU Corner quiz ($35) and successfully complete it online at www.afaa.com.
ACOG (The American College of Obstetricians and Gynecologists). 2015.
Committee opinion: Physical activity and exercise during pregnancy and the
postpartum period. Accessed July 16, 2017:
ACOG. 2016. FAQ: Exercise during pregnancy. Accessed July 16, 2017:
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Blyholder, L., et al. 2017. Exercise behaviors and health conditions of
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Bø, K., et al. 2016. Exercise and pregnancy in recreational and elite
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Institute. Accessed July 20, 2017:
NASM. 2015. Precautions for pregnancy. The Training Edge, May/June
2015. Accessed July 16, 2017:
NASM. 2018. Exercise and pregnancy. In NASM Essentials of Personal Fitness Training (6th ed., pp.
450-53). Burlington, MA: Jones and Bartlett Learning.
Poston, L., et al. 2015. Effect of a behavioural intervention in obese
pregnant women (the UPBEAT study): A multicentre, randomised controlled
trial. The Lancet: Diabetes & Endocrinology, 3 (10), 767-77.
Rebelle, T. 2017. Total Mommy Fitness pre and post natal certification.
Accessed July 17, 2017: www.totalmommyfitnessonline.com/certification.