I I

Fatures

J. A. Bullard
Exercise and Pregnancy
SUMMARY
Evidence is beginning to appear that
complications of pregnancy are fewer in the
athlete than the non-athlete. Studies show
that after childbirth, sports performance
improves in a majority of women. A few
activities could prove hazardous to the
woman and her fetus. In view of the
increased participation of women in sports
and recreation, it is imperative that the
benefits as well as the dangers are
considered and discussed as part of
prenatal care. (Can Fam Physician 1981;
27:977-982).
SOMMAIRE
Il devient de plus en plus evident que la femme
sportive subit moins de complications durant une
grossesse que la non-sportive. Les etudes
demontrent qu'apres un accouchement, la
performance sportive s'ameliore chez la majorite des
femmes. Le manque d'activites peut presenter des
dangers pour la femme et son b6b6. Etant donne que
les femmes participent plus activement aux sports
recreatifs, il est imperieux de considerer ces activites
comme partie integrante des soins prenataux et d'en
discuter les bienfaits aussi bien que les dangers.

Dr. Bullard, who has a special
interest in sports medicine, is in
family practice in Calgary, AB.
Reprint requests to: Calgary
Associate Clinic, 214 Sixth Ave.
S.W., Calgary, AB. T2P ORL.
"Pregnancy is a physiological state
during which most women are
healthy" . I
1/OMEN HAVE been encouraged
by family physicians and obste-
tricians to consider the blessed event
as a normnal physiological process.
Every little complaint from the preg-
nant woman during her prenatal period
is then easily explained away. The
term 'natural childbirth' is designed to
give the expectant mother a feeling
that t1ei-e is a right and a wrong way to
have a baby, and that this particular
method is the ideal one, yet we all
know that this isn't exactly true. A
percentage of women certainly enjoy
their pregnancy and claim that they
have never felt better. Others dread the
CAN. FAM. PHYSICIAN Vol. 27: JUNE 1981
thought of it happening again, because
they feel 'ill' throughout the nine
months. How much of this can be attri-
buted to psychological factors or
to physical changes is never really
determined.
In the first trimester nausea and
vomiting, tenderness of the breasts and
frequency of urination are common.
Although total blood volume reaches
its peak at 20-28 weeks, most of the
increase occurs in the first trimester,
depending on the size of the individual
and of the fetus.1 Plasma volume may
increase from 40% to 90%. Associated
with an increase in blood volume is an
increase in cardiac output, renal blood
flow and glomerular filtration rate.2
Ventilation rate increases from the
norm of approximately seven liters per
minute to almost ten liters per minute
at term.2
In the second trimester (13-28
weeks) there is considerable breast hy-
pertrophy and the nipples and the
areola enlarge. Oral contraceptives are
known to increase breast tissue by
more than 60 ccs, and during normal
menstrual cycles breasts can increase
more than 100 ccs. At term, up to
1.5 lbs of the total weight gain may be
attributed to the breasts.3
The uterus rises out of the pelvis,
above the pubis, and into the abdo-
men. Its bulk gradually accentuates
pelvic lordosis and kyphosis. The liga-
ments involved with the pubic bones
and the sacroiliac joints soften; in-
creased mobility about these joints
often leads to low back pain and stiff-
ness. Delay in gastric emptying and
hypomobility of the gastric intestinal
tract can lead to constipation, which in
turn can cause the appearance of hem-
orrhoids. At about the fourth month
the ureters begin to dilate and become
hypotonic. Many women complain of
dizziness and some experience syn-
cope. This is particularly noticeable in
the warmer weather and is thought to
be related to a decrease in the cardiac
output, resulting from a lowered ve-
nous return from the legs and dilata-
tion of peripheral vessels to help dissi-
pate body heat.'
Most of the physiological effects of
pregnancy have stabilized by the third
trimester (29-40 weeks). The major
change then taking place is an increase
in the size of the uterus. A continued
977
decrease of venous return, particularly have relatively stable cardiopulmonary the remaining six were moderate and
from the legs, and pressure of the diseases which have become disturbed they were marked in one. This one
uterus on the pelvic veins, leads to by extra physical stress. Similarly in- case produced profound and prolonged
edema of the lower limbs. Puffiness of formation related to the effects of exer- bradycardia followed by suptained
the face and hands is another manifes- cise on pregnancy is limited, leading tachycardia in the fetus considered as a
tation of retention of fluid. Fatigue be- to many unfounded comments as hypoxic fetal heart rate pattern. They
comes most noticeable, together with women brave the challenges of activi- felt such exercise in the pregnant
dyspnea and insomnia, which are ties previously frowned upon for their woman may decrease uterine blood
probably related to a combination of sex. They are exposed to dire warnings flow and hence put a temporary addi-
weight gain and pressure on the dia- of damage to the pelvic organs, abor- tional load on the transfer mechanism,
phragms. The pregnant woman be- tion and difficult labors. which under some circumstances
comes increasingly awkward in her might reflect with an abnormal fetal
movements, has a tendency to lose her Specific Research Studies heart rate pattern.
balance and to fall. Abdominal mus- In 94 Finnish women who had com-
The only really large study has been peted at national level in baseball and
cles are maximally stretched and by Gyula J. Erdelyi on Hungarian fe-
symptoms of myalgia may appear with swimming, and subsequently married
the use of unfamiliar muscles.
male athletes.4 His findings are inter- and gave birth,8 major disorders such
Any approach to an exercise pro- esting and encouraging to the elite fe- as toxemias were found to be the same
male athlete. The application to the for athletes as for non-athletes. The
gram related to pregnancy must ob-
casual or to the intending athlete may duration of labor was shorter by about
viously bear in mind these so-called require closer study. Such athletes
physiological changes which women 20% and perineal tears appeared to be
start in top physical condition before less. The incidence of cesarean sec-
experience in varying degrees during conceiving, and in most instances,
this reproductive time in their life. tion, outlet forceps, manual removal
their body systems have adapted to of the placenta and blood transfusions
In many underdeveloped countries, considerable change. Training is long
women are forced to continue their were far less than considered normal.
and many inconveniences such as fa- In 107 outstanding German women
daily labors until the last moment, and tigue and soreness of muscles are ac-
often give birth virtually unassisted. athletes, the total duration of labor was
cepted as normal. These women have considered shorter than the control
An interesting study has been made of the ability to blank out many things
the habits of Korean women who dive group, with the third phase of labor
considered by non-athletes as unac- lasting only half as long.8 It was found
for food even in the winter when tem- ceptable.
peratures can be a mere 50 degrees.27 that they attained their best perfor-
Erdelyi reviewed his data on 172 mances after the birth of their first
This occupation can last more than ten pregnant athletes and found that two
years of their lives, but apparently child.
thirds continued their usual sports ac- From the foreign literature comes
does not interefere with childbearing. tivity during the first three to four
They tend to dive almost up to the time one of the few adverse reports on preg-
months of their pregnancy.5 Most of nancy and exercise,9 suggesting that in
of delivery and to breast-feed between them stopped activity after the fourth
shifts. These divers, called ama, live fencing, weak abdominal press and a
month because of decreased efficiency strong pelvic base produced a ten-
and work along the sea coasts of Korea and performance.6 Complications of
and Japan where this form of work and dency to complications in the second
pregnancy, including toxemia, oc- phase of childbirth, leading to a high
activity has taken place for centuries. curred less often in these athletes and
Their menstrual cycles also appear to percentage of operational treatments.
abortion did not exceed the average. After the childbirth, the sports perfor-
be unaffected by their work. Similarly, labor and- delivery met the mances increased in 73% of the fenc-
In contrast, members of the North average expectation and the rate of ce- ers and 27% registered no change.
American society had gradually lapsed sarean sections was half that of the Using bicycle and treadmill exer-
into a life almost devoid of exercise. control group. The second stage of cise, Knuttgen and Emerson studied
The appalling morbidity and mortality labor lasted only half the time of the 13 women from the sixth month of
rates associated with cardiovascular non-athletes. pregnancy to six weeks postpartum.10
disease have aroused the populace to Hahn and Wohlgemuth of New Their findings suggested that preg-
think of doing something about it. Haven, Connecticut, reviewed the lit- nancy offered no greater physiological
Men, women and children have been erature produced from studies on stress to exercise other than that pro-
encouraged by the President's Council uterine blood flow.7 These, they vided by added weight gain and a pos-
in thie United States to improve their found, suggested that in certain situa- sible encumbrance of fetal tissue.
level of fitness, and Canadians have tions which included maternal exer- A single case study of a 27-year old
followed suit. cise, there was decreased uterine blood woman followed over four years
Unfortunately, certain aspects of flow and that maternal exercise put a through two pregnancies is interesting
these programs have not been ade- temporary additional load on utero- but hardly scientific proof of either
quately researched or explained to the placental reserve. They studied 26 beneficial or harmful effects of strenu-
public. This has resulted in a new pregnant women, utilizing the three ous exercise.10 In view of the sparse
surge of medical problems particularly minute, two step exercise based on age literature on this topic, it is interesting
prevalent among joggers. Many peo- and weight. Their study showed that to note that she ran six to 18 miles a
ple are unsuited to this form of activ- maternal exercise had little or no effect day, and in spite of the high caloric
ity, due to potential skeletal problems on the fetal heart rate patterns in 20 of cost, developed no problems during
in their feet, knees and backs. Others the 26 patients. The changes in five of pregnancy other than nausea. Delivery
978 CAN. FAM. PHYSICIAN Vol. 27: JUNE 1981
was uneventful and she was able to
breast-feed throughout.
Morris, Osborne and Wright carried
out studies in London utilizing the
clearance rates of radio sodium from
uterine and thigh muscles in 21 normal
pregnant women and 19 pre-eclamptic
patients.1" In the discussion they point
out that a rise in both systolic and dia-
stolic blood pressure with exercise in
patients without cardiac abnormality is
an accepted physiological finding. On
moderate exertion the systolic pressure
may reach high levels, but the diastolic
pressure seldom rises more than
15 mm of mercury.
Their observation showed a similar
trend in pregnant women, with the
greatest rise (70 mm of mercury) in
the pre-eclamptic group, whereas in
the normotensive woman it was only
40 mm of mercury. When exercise
was stopped, the diastolic pressure in
both groups fell during the first few
minutes, to resting or even lower val-
ues. Coincident with these blood pres-
sure changes, the blood flows of both
leg and uterine muscles were ob-
served. An increase in leg muscle
flow, together with reduction in
uterine blood flow in normotensive
women, approached that recorded by
pre-eclamptic patients who already
had a diminished uterine blood flow.
On cessation of exercise, changes in
leg and uterine blood flow were re-
versed.
It was apparent to them that during
exercise there was a diversion of blood
flow from the splanchnic area to the
musculoskeletal tissues of the legs and
that this diversion is rapidly reversed
after exercise was stopped. This phe-
nomenon of restoring uterine blood
flow is often extremely dramatic, lead-
ing to a faster clearance rate than ini-
tially recorded, and they suggested the
term "flush-back" for it. This led
them to consider that the uterus pos-
sessed reserved powers to withstand
the effects of reduced blood flow dur-
ing exercise.
Certain diseases can further aggra-
vate these changes. One example can
be found in mitrostenosis resulting
from rheumatic heart disease in which
blood flow may be obstructed, leading
to increased pressure in the left
atrium.' In turn, this increases pres-
sure in the pulmonary veins and pul-
monary capillaries which is intensified
by increases in cardiac output, pulmo-
nary blood volume and tachycardia.
CAN. FAM. PHYSICIAN Vol. 27: JUNE 1981
Since pregnancy itself produces some
of these changes, the woman with mi-
trostenosis is closer to pulmonary
edema when she is pregnant. The com-
bined demands of pregnancy and phys-
ical activity could limit the heart's
ability to respond and thorough assess-
ment is necessary in such a case.
Congenital heart disease, cardiac ar-
rhythmias and hypertension may be
similarly aggravated by the addition of
pregnancy and exercise.
Prenatal Preparation
Introductory brochures and lectures
for prenatal classes emphasize the
need for physical and mental prepara-
tion and the possibility that this may
reduce the need for drugs and anesthe-
sia in labor. At the same time, the
reader is warned against strain and
sprain, avoidance of fatigue and the
need for frequent change of position to
avoid "circulatory congestion and
continued pressure on nerves and
veins". Considerable detail is given
on muscle stretching, posture,
shoulder circling and gentle calisthen-
ics, but virtually nothing to promote
cardiopulmonary fitness. The closest
statement in one brochure suggests
everyday work and play activities can
continue during pregnancy.12
Once a clear history of the patient's
normal exercise program has been
taken, explicit instruction should be
given. From zero, the woman should
engage in calisthenics and walking.
The moderately active pregnant
woman should be encouraged to con-
tinue exercising as long as she feels
comfortable to do so. Certain sports
will naturally prove too great a chal-
lenge in the later stages of pregnancy,
but basic walking and calisthenics can
be continued into the third trimester.
For the elite athlete, sufficient evi-
dence is available to show that perfor-
mance drops off at about the beginning
of the second trimester. These women
may find it more desirable to partici-
pate rather than to compete or to
change to some less strenuous form of
exercise.
Conception
Among the many suggestions aimed
at discouraging women from partici-
pating in all forms of physical activity
was the unfounded statement that it
could interfere with conception. It is a
fact that participation in strenuous
physical activity can appreciably alter
the menstrual pattern. Anovulation
and oligoamenorrhea are the major
physiological variances.13 Both are
considered a reflection of physical
changes and subtle biochemical alter-
ations occurring in body fat content
and in pituitary and ovarian hormono-
genesis, presumably secondary to hy-
pothalamic function. The decrease in
body fat percentage is linked with
amenorrhea and the emotional make-
up of the individual. A study of female
long distance runners, who were more
than ten pounds in weight below the
average for their height and weight,
had less adipose tissue and lost over
5% of their total weight from the be-
ginning of their training.13 There was
a markedly increased incidence of
oligo- and amenorrhea in the study
group. In multiparous athletes, the in-
terference with menstruation is far less
noticeable, considered perhaps as a re-
flection of hypothalamic maturity. The
authors of this particular study believe
that cyclic menses, and fertility if de-
sired, can be expected to return after
the decrease of training, and an ade-
quate gain in weight. In certain cases
of delayed onset of menstruation,
drugs such as Provera may be indi-
cated.
Protection of the Fetus
Although the fetus is well protected
by the mother's anatomical structures,
it is unwise to challenge this fact. The
elements of suspension incorporated in
the uterine attachment to the pelvis,
the wall-like protection in front and
behind, and amniotic fluid in which to
float, provide excellent protective fea-
tures for the fetus. The "Guidelines on
Pregnancy and Work"' issued by the
United States Department of Health
Education and Welfare were formu-
lated by a team of obstetricians and
gynecologists: "Even a minor blow to
the abdomen can damage the uterus or
disturb the placental attachment. The
unaccustomed abdominal protrusion
and increased susceptibility to falls
make the pregnant worker particularly
vulnerable. Climbing ladders should
be avoided. Belts and safety harnesses
usually present no difficulty if they are
not constrictive". Such recommenda-
tions may have been made with litiga-
tion in mind.
For exercise purposes as opposed to
work, certain sports can prove hazard-
ous. Should a pregnant woman take a
979
typical dive while playing volley-ball,
violent contact with the floor could
take place. It is difficult to provide
specific stages of gestation to cease
physical activity, but a bulging, preg-
nant abdomen is obviously meant to be
protected. Dewly of Chicago, com-
menting on women falling during
pregnancy, suggested: "There are
documented cases where a woman will
lose a baby because of a fall, but this is
very rare. The primary danger is that
the woman is going to hurt herself.
The baby is well protected. Mother
Nature was no fool"'.14 The fate of a
fetus when mother falls down a whole
flight of stairs, compared with just the
last step, is well known. The fetus
often survives the major event.
Thus in all things the pregnant fe-
male must be reasonable, and each
must be considered on her individual
physical and physiological merits,
when physical activity and protection
of the fetus are considered jointly.
Breasts and Bras
Many women with large, pendulous
breasts experience problems with
physical activity, particularly sports
involving running. The changes al-
ready noted in the breasts during preg-
nancy will naturally be aggravated by
frequent movement. In a survey of 115
colleges and universities across the
United States, Haycock found that few
breast injuries were reported, but that
72% of female athletes experienced
sore or tender breasts after exercise,
particularly with running, basketball
and weightlifting.'5
Bayne, in another study, admitted
that serious breast injuries during sport
are rare but that painful blows to the
breast causing contusion and hemor-
rhages in the loose fatty tissue were
quite common.16 This kind of observa-
tion has led to the development of two
types of bra-one to be worn under the
regular bra to protect against breast in-
jury, the other a supportive type. The
latter appears to have great merit for
controlling the discomfort associated
with enlarging breasts and exercise
programs.'7 This type of bra, accord-
ing to one manufacturer, includes a
minimum of elastic and maximum
support to decrease motion and breast
fatigue and to hold the breast closer to
the body. 18 Many factors, including
exercise, have been implicated in de-
creasing milk production in the lactat-
ing mother.
980
This is not a constant feature: two
examples, the ama in Korea and Erde-
lyi's Hungarian studies, disagree. A
strong desire to breast-feed and free-
dom from anxiety, depression and
frustration will probably have greater
bearing on the success of breast-feed-
ing than exercise.
Postnatal Exercise
After delivery, women should be
encouraged to continue programs of
exercise developed during the preg-
nancy. Evalyn S. Gendel studied 100
patients aged 18-23 years complaining
of chronic low backache and fatigue
following pregnancy.'9 After exclu-
sion of orthopedic, pelvic, psychologi-
cal and other common causes of these
symptoms, 35 patients were left and
were found to have several factors in
common. A history of lack of regular
physical activity during childhood,
poorly developed abdominal muscles,
and longterm post-delivery complaints
resulted in poor functioning as wives
and mothers. A steady reduction of
these symptoms was achieved by in-
troducing gradual physical condition-
ing on an individually prescribed and
demonstrated basis over six to ten
months.
Specific Sports
The physician whose pregnant pa-
tient wants to continue many physical
activities needs to know the hazards
inherent in certain activities and the
extent to which the patient intends to
become involved. He should already
know her state of fitness. It is no
longer reasonable to assume that
women will enter sports and recreation
in a non-competitive manner. The de-
creasing ability of the pregnant woman
has already been outlined; however,
the serious athlete will feel that partici-
pation is necessary for a healthy preg-
nancy. The physician must know the
dangers to which the mother and fetus
might be subjected, in order to advise
his patient.
Water Sports
A 25-year old patient whose profes-
sion involved scuba diving insisted
that she would continue to do so until
at least her 20th week of pregnancy. A
question arose whether she might be
endangering herself as well as the fetus
by so doing was posed to the editor of
The Physician and Sportsmedicine.
Dr. Albert B. Craig, Jr.,20 of the Uni-
versity of Rochester and an editorial
adviser, replied: "It was generally felt
that diving during pregnancy should be
limited to combinations of depth and
time that did not require decompres-
sion, because nitrogen exchanges be-
tween the fetus and the mother are not
well understood. Except for this reser-
vation, the mother and fetus should not
experience difficulty". The editor, Dr.
Allan Ryan, added that the woman
should be advised not to dive deeper
than 33 feet at any time during and im-
mediately after the pregnancy. The
outcotne of this particular pregnancy
was a happy one and no problems were
detected in mother or fetus up to six
months following delivery.
More recent observations on women
and diving recommend that pregnant
women do not scuba dive nor work in
any compressed air environment.2'
This advice is extended to women ex-
pecting to become pregnant, and to the
period six weeks following delivery.
The authors add that in these two par-
ticular stages, if the woman insists on
continuing she should be advised not
to dive deeper than 33 feet, since both
the mother and the fetus may be at
risk. The mother could develop 'the
bends', because of edema, and the re-
sultant altered tissue profusion and dif-
fusion characteristics. The fetus could
form intravascular bubbles after expo-
sure to hyperbaric oxygen.
A most disturbing survey of certi-
fied scuba divers who dived while
pregnant quoted 5.5% of obstetric
complications and congenital anoma-
lies:2' 12.5% of women who dived to
depths of 100 feet or greater had in-
fants with birth defects. Extreme cau-
tion must therefore be given to the
woman who wants to continue diving.
Swim iing and Water Skiing
Most public indoor pools have a
steady, controlled temperature in both
the water and the surrounds. To pre-
vent chilling, it would be advisable for
the pregnant woman to avoid outdoor
pools, and certainly the unpredict-
ability of the temperature in the lakes
and the ocean. Water does not readily
enter the vagina, except perhaps in the
grand multipara with an open introitus
vaginae. Concerns about infection are
not normally substantiated.
The exception to this is in water ski-
ing, in which it has been reported that
female skiers travelling more than 30
miles an hour can experience a vaginal
CAN. FAM. PHYSICIAN Vol. 27: JUNE 1981
douche and rectal enema should the
derriere touch the water.22 Cases of
hydrosalpinx have been reported. Spe-
cial protective pads are available for
this situation. Some of the spills taken
by water skiers can be very serious and
therefore women in the later stages of
pregnancy should not be encouraged to
pursue this sport. Water and atmo-
spheric temperatures should again be
noted before skiing. Rubber suits worn
by some skiers could prove hazardous
to the pregnant woman and control of
her body temperature.
Winter Activi'ties
The length and severity of our
winters inevitably force some pregnant
women to participate in outdoor activi-
ties to maintain a level of fitness. Nor-
mal precautions to protect against
chilling and frostbite should be recog-
nized. In the cold, less exercise will
produce greater demands on the car-
diopulmonary system and symptoms
of dyspnea and fatigue will appear
much earlier. The simple procedure of
tying a woollen scarf over the mouth
and nose can reduce the stressful effect
of breathing cold air. Downhill skiing
will probably have to be given up
much earlier than cross-country ski-
ing, but both will prove increasingly
difficult as a loss of balance becomes
more apparent. The softness of the
snow and heavier clothing can give the
woman a certain amount of leeway,
but this does not apply to skating, in
which little protection can be afforded
against falls on the hard surface of the
ice. Again, the stability of the individ-
ual will determine how long she con-
tinues her activity.
Although not included in the cate-
gory of physical activity, snowmobil-
ing has become a popular sport. This
vehicle is now used for racing, both
cross-country and on tracks. A jour-
nalistic eye-catcher appeared in the
local news23 praising the entry of a fe-
male racer in the local snowmobile
cross-country short circuit meet: "Not
only did she bump and hack her way
into third place against the men . . .
but she was two months pregnant". "I
suppose I must be mad", said Eve
after the race, "but I asked my doctor
first before I continued racing. He said
that it would not do any harm as long
as I was fit ... but to watch the
bumps". Further comments on what
the physician might have said are
really not necessary, but we should all
CAN. FAM. PHYSICIAN Vol. 27: JUNE 1981
be aware of the extremes that some of J. Ryan feels that most people want to
our pregnant patients will go to chal- be reasonable about what they do in
lenge what you think is reasonable. the way of exercise.25 The major con-
cern at present about women running
Racquet Sports during pregnancy is the possible tera-
Pregnant women can play racquet togenic effects of increased fetal body
sports, including tennis, badminton, temperature in the first eight weeks. In
squash and racquet ball, with little pregnancy, the mother is able to dissi-
problem. Limiting factors will of pate fetal heat, which usually runs
course include size of the abdomen about one degree above her own.'
and her equilibrium. In the earliest However, in the presence of abnor-
stage of pregnancy, some women may mally high temperature and humidity,
develop a high core temperature as this may prove difficult. In certain cir-
they become very competitive in cumstances, particularly with this
squash and racquet ball. In addition, form of strenuous exercise, the woman
both sports are played in a confined may be unable to cope with increased
space where the air often becomes circulatory demands, resulting in diz-
quite stale. ziness, impairment of mental function,
syncope, heat stress and heat exhaus-
Running tion. The fetus could be severely af-
Many women have now found jog- fected by these drastic responses.
The
ging to their liking and tend to con- a few weeks first trimester naturally contains
tinue this pursuit well into their preg- during which the woman
may be totally
nancy providing that they have not pregnant. With these unaware that she is
developed problems of the lower limbs observations in
mind, it seems reasonable
such as ankle edema, varicose veins or patient involved in strenuous to advise the
joint problems. In contrast, marathon for example marathon running,activity,
running probably emphasizes the dif- her pregnancy if at all possible toandplan to
ference between the casual athlete and
reduce her
the elite athlete. It also shows the dra- first six to level of participation in the
matic rise in the number of women, eight weeks of pregnancy.
both pregnant and non-pregnant, who Contact Sports
engage in strenuous exercise. An arti- Activities such as basketball,
cle appeared in one of the Calgary powder-puff football and hockey are
papers spotlighting a 24-year old pri- sports with serious hazards involved.
mipara and her intent to run a mara- Volleyball, gymnastics and equestrian
thon (42.2 kilometers) while six pursuits follow close by. The increas-
months pregnant.24 Accustomed to ing weight gain, loss of equilibrium,
running eight kilometers a day, sup- dyspnea and discomfort should be de-
plemented by a 26-32 kilometer run on termining factors, not necessarily the
weekends, training for the big event implications of blows to the abdomen.
was not out of the ordinary. She had However, every one of these sports
previously competed in four marathon carries with it a risk of injury, most of
races. An added motivating factor was them involving the unpredictability of
her husband, also an outstanding mar- an opponent's action or equipment
athon runner. unreliability.
Comments on this pregnant
woman's plans by the president of the Suggested Approach
Alberta Society of Obstetricians and 1. The woman should be en-
Gynecologists suggested "that preg- couraged to begin a conditioning pro-
nant athletes should not take up a new gram before conception.
sport or increase fitness activities. In 2. The physician should discuss ex-
general, they should maintain what- ercise programs with his pregnant pa-
ever exercise they are accustomed to". tient in the same serious manner as nu-
The interviewer and the doctor both trition, drugs, prenatal care and
appear to have avoided the issue of the delivery.
six-month pregnant woman's plans to 3. During the first trimester the pa-
attempt to complete 42.2 kilometers. tient can usually participate in what-
On this occasion the young woman ever sport and recreation to which she
completed 26 kilometers and wisely is accustomed. Certain reservations
stopped. This supports Erdelyi's find- may have to be made about very stren-
ings that performance definitely falls uous exercise, as well as certain activi-
off as pregnancy proceeds. Dr. Allan ties such as scuba diving.
981
 4. Continued participation -can be
encouraged during the second trimes-
ter to a level which gives mental and
physical satisfaction, being aware that
there is a gradual decrease in effi-
-ciency and performance.
5. The final three months must be
approached very much on an individ-
ual basis. Most women will find that
frequent stretching exercises and short
walks will be quite adequate, certainly
in the last three to four weeks of the
pregnancy.
6. Exercise programs can gradually
be resumed after pregnancy with par-
ticular attention to the abdominal mus-
cles. Serious training, including com-
peting, can be started at five to six
weeks postpartum.6 Breast-feeding
may or may not be affected by exer-
cise.
Condusion
For many women pregnancy is an
enjoyable experience deserving of the
description "a normal physiological
process". For them exercise within
reason may be continued almost
throughout the term of the pregnancy.
For others, it is a true confinement and
the changes noted in each trimester be-
come a terrible burden to both mind
and body. Although physical activity
is beneficial to the good health of both
mother and child, these less fortunate
women are unlikely to want to partici-
pate. Similarly, should the pregnant
woman suffer from certain conditions,
particularly of the cardiovascular sys-
tem, a critical review must be under-
taken before encouraging rigorous
physical activity.2
In complete contrast, the more for-
tunate pregnant athlete may maintain
the element of motivation and contin-
ued participation at a high level in the
first trimester. Certain precautions
should be given and the woman should
be advised that competitive perfor-
mance will drop in the second trimes-
ter. Opinions are mixed as to the ef-
fects on labor. Muscle development
can be both an advantage and a disad-
vantage in promoting the downward
descent of the fetus through the birth
canal. Erdelyi found fewer complica-
982
tins n his elite athletes than, in the
general public, and more importantly,
that athletic performance tended to im-
prove after giving birth.26
From the few good controlled
studies covering this most important
development in our society, exercise
appears to be beneficial to the -pregnant
woman, and within reason, can be pur-
sued as long as she feels able. She
should be advised to plan an exercise
program before conception, thus enter-
ing the reproductive phase of her life
in top physical condition. Modifica-
tion of such a pr,gram would then be
made according to guidelines pro-
vided. After the rigors of extraordinary
muscle stretching, ligamentous and
joint laxity, venous overloading, in-
creased fat deposition, among many
factors, recovery can then be acceler-
ated by continuing physical activity.
Those of us who have practiced
medicine for more than 25 years can
still remember when labor was fol-
lowed by 14 days confinement in hos-
pital, most of this time being spent in
bed. The incidence of deep vein
thrombosis or 'white leg' was allowed
to continue unchecked. Finally, the
bold step of encouraging the mother to
get up at the earliest possible moment
and to keep moving was followed by a
reduction in the hospital stay to a mere
three or four days. Venous thrombosis
of the legs related to pregnancy has
now fortunately become uncommon.
Active participation in sport and recre-
ation could bring further benefits to
both the woman and her fetus. ()
References
1. American College of Obstetricians and
Gynecologists: Guidelines on Pregnancy
and Work. U.S. Department of Health Ed-
ucation and Welfare, Contract No. 210-76-
0159, 1977.
2. Page EW, Villee CA, Villee DB:
Human Reproduction, ed 2. Toronto,
W. B. Saunders, 1976.
3. Danforth DN: Textbook of Obstetrics
and Gynecology. New York, Hoeber Medi-
cal Division, 1966, p. 238.
4. Erdelyi GJ: Gynecology survey of fe-
male athletes. J Sports Med Phys Fitness
1962;2:1 74-1 79.
3. Ryan AJ: Sports during pregnancy:
O(her questions explored, discussion. Phy-
sician and Sportsmedicine 1976;4:82-85.
6. Ryan AJ (ed): Pregnancy and Sports,
Round Table Symposium. Physician and
Sportsmedicine 1974.:2:3541.
7. Hahn E, Wohlgemuth R: The electronic
evaluation offetal heart rate. Am J Obstet
Gynecol 1961;81:361-371.
8. Jokl E: Some clinical data on women's
athletics. J Assoc Physical and Mental Re-
habilitation 1956;10.48.
9. Zhanel K: Fencing in relation to men-
strual cycle and to gestation. Teorie a
Praxe tel vychovy 1970;18:103-106.
10. McArdle W, Katch Fl, Katch VL: Ex-
ercise Physiology. Philadelphia, Lea and
Febiger, 1981, p. 110.
11. Morris N, Osborn SB, Wright HP: Ef-
fective uterine blood-flow. Lancet
1956;2.481484.
12. Staff of Maternity Center Association
and Dietz JH: Preparation for Childbear-
ing. New York, Maternity Center Associa-
tion, 1977, p. 5.
13. Dale E, et al: Physical fitness profiles
and reproductive physiology of the female
distance runner. Physician and Sports-
medicine 1971;7:83-95.
14. Lefton D: Expectant mothers and un-
expected mishaps. Family Safety
1980/81;39:16.
15. Haycock CE, Gillett J: Susceptibility
of women athletes to injury. JAMA
1976;236:163-164.
16. Bayne JC: Pro + tec protective bra. J
Sportsmed 1968;8.:34-35.
17. Gehlsen G, Albohm M: Evaluation of
sports bras. Physician and Sportsmedicine
1980;8:89-97.
18. Schuster K: Equipment update: Jog-
ging bras hit the streets. Physician and
Sportsmedicine 1971;7:125-128.
19. Exercise during pregnancy. Physician
Research Digest 1978;8:18-20.
20. Craig A: A need to know. Physician
and Sportsmedicine 1978;6:118.
21. Kizer KW: Women and diving. Physi-
cian and Sportsmedicine 1981;9:84-92.
22. Noelle G: Water skiing hazards, na-
ture and prevention. J Sportsmed
1974;11:212-216.
23. Stewart R (ed): Mother-to-be racer
told: Watch for bumps. Amateur Sport Re-
port 1980;2:20.
24. Butlin C: Modern mother-to-be will
take gruelling marathon race in stride. The
Calgary Herald 1980, May 23.
25. Allan R: Personal letter. Editor, Phy-
sician and Sportsmedicine.
26. Erdelyi GJ: Physical Activity-Gen-
eral: Pregnancy, in The American College
of Sportsmedicine: Encyclopedia of Sports
Sciences and Medicine. New York, Mac-
Millan Co., 1971, p. 68.
27. Strauss RH (ed.): Sports Medicine and
Physiology. Toronto, W.B. Saunders,
1979, p. 310.
CAN. FAM. PHYSICIAN Vol. 27: JUNE 1981