Exercising Thorugh Your Pregnancy

(Editor's note: This was listed by my local bookshop as out of print but I had no trouble obtaining it from Amazon)

James Clapp is Professor of Reproductive Biology at the Case Western Reserve University, and Research Professor of Obstetrics and Gynaecology at the University of Vermont College of Medicine. He has been studying the effects of maternal exercise on the course and outcome of pregnancy since the late 1970s/early 1980s. This book details his experiences of over 250 women who exercised before, during and after pregnancy and another group of 50 women who began structured exercise programmes during pregnancy.

The title “YOUR pregnancy” led me to believe that the book is aimed at pregnant women themselves, however my general impression is that much of the, quite detailed, information given would be of more interest, and make more sense, to the exercise professional than the lay reader..

The first part covers the myths that surround exercise in pregnancy and how they still persist, and the previous lack of research based knowledge on the effects of maternal exercise both on the mother and her baby. In 1970/80s women’s interest in regular exercise grew rapidly, and many pregnant women wanted to carry on exercising, however most health care providers had a conservative view because they simply didn’t know anything about the possible risks or benefits. Supposed risks were mainly theoretical and supported by the first set of ACOG guidelines issued in 1985.

There is a detailed review of the physical and physiological adaptations to pregnancy and to exercise in pregnancy, including research references prior to the studies on which this book is based. The heart and circulatory system explanation includes the reasons why standard heart rate calculations do not work well in pregnancy (in particular the 1985 ACOG guideline of 140 bpm maximum[1]) and why the Borg RPE scale is a better indicator of effort level. Lung function and oxygen transportation, body temperature, sweating, metabolic and hormonal responses, muscle, ligament and bone adaptations and postural changes are also covered. The findings relating to adaptations to exercise do not support previous concerns and show how both mother and baby gain positive benefits from increased protection against physical stress.

Part 2 covers James Clapp’s findings from his own, more recent studies. He first looks at the idea that exercise can cause fertility problems and that in early pregnancy it may cause miscarriage or birth defects. I was interested in this part because I frequently see mums whose midwives or doctors have told them to stop all exercise for the first 12 weeks. This sometimes causes an emotional conflict for the mothers because they do not want to stop an activity they enjoy, however are concerned because they have been introduced to the idea that they may be somehow harming their baby. I was reassured to read that Clapp’s findings are that previous concerns about exercise while trying to get pregnant or in early pregnancy are supported only by anecdotal information and scientific results taken out of context, and these unfounded concerns have then been perpetuated by health care providers. Clapp’s studies show no evidence that healthy women need to change their exercise habits at this time. He admits that there are no studies on women who begin to exercise when trying to conceive or in early pregnancy, however it appears that it should be safe providing intensity and duration are limited.

Clapp then looks at the idea that the physical stress induced by exercise in mid to late pregnancy may cause premature labour or problems with foetal and placental growth. This was all covered in fascinating detail and, again, his findings are all in favour of continuing to exercise at a moderately hard to hard level. The studies concluded definite benefits to the baby, by improving tolerance levels to the stresses of labour and delivery. Breastfeeding and infant growth are then covered. I was disappointed in this section because it is a review of previous studies rather than new work and contains a lot of “maybes”. I found myself wondering how much Clapp actually knows about breastfeeding and the individual interaction between mother and baby.

The chapter on maternal benefits of exercise starts with reduced weight gain and fat accumulation. The message comes across that overall weight gain is bad and I didn’t feel entirely comfortable with this. Clapp says that for exercise to be beneficial it needs to be “regular, weight bearing and sustained”, therefore the usual advice to swim in pregnancy, although well intentioned probably does not confer the same benefits. I was not surprised that Clapp’s results conclude that women who are already exercising regularly need less exercise to control their weight than women who start exercising in pregnancy. Strength training and flexibilty were not specifically studied. I was disappointed with the lack of detail on intensity levels (although this is obviously individual) and type of exercise undertaken.

Part 3 covers the principles of exercise prescription using the information from the first two parts of the book. Clapp stresses that the individual differences between women and their individual goals should be the main concern when deciding frequency, intensity and duration, and that most women should not need to change their current programme unless a problem develops or they wish to increase the exercise load. Any woman wishing to take up exercise for the first time during pregnancy should be monitored and given specific advice. Clapp covers the differences between the traditional (swimming/cycling) approaches and the more liberal approach, with appropriate safety precautions, which offers greater variety. There are “dos and don’ts” and contra-indications to exercise. This is all covered in great detail and would be useful to the exercise professional, however it’s possible that the average, lay exerciser would find this part quite confusing. I was concerned that a pregnant woman might receive the overall message that it is OK to carry on with her usual exercise programme regardless of type of activity, level of exertion, individual capabilities and technique. In particular there are 2 photos showing heavily pregnant women exercising on a step, one in a ballistic move. An enthusiastic mother might be encouraged to ignore her own changing capabilities and limitations, and possibly not be aware of early warning signs in her own body signalling a need for a change in her training. The importance of being monitored when exercising is stressed, but this is not an option for most people.

The last part covers returning to exercise after the birth. The majority of women studied by Clapp resumed exercise at 2 to 6 weeks post birth (where did they find the energy?) and were followed up at 6 weeks, 3 and 6 months and 1 year post birth. They reported a more rapid physical and emotional recovery with a lower incidence of PND. Clapp puts this down to mothers having had some time for themselves without their baby, which I felt was a rather sweeping generalisation. There are suggestions for mothers in the first 6 weeks after the birth, including “start early and increase slowly”, however I found my hackles rising a little at the emphasis on how necessary it is for mothers to get away from their baby! He seems to assume that mothers should WANT to leave their babies. In my experience this is usually the last thing a new mother wants to do! My heart goes out to those poor, implied “abnormal” mums who feel distress at leaving their baby to exercise. I also felt slightly “boggled” at the suggestion that mums should exercise at least 3 times a week in the first 6 weeks – most of the new mums I know have trouble getting to 1 class a week on time! Clapp also suggests that exercising mums buy a baby scale (!) to check that their baby is not losing weight; an idea which I’m pretty certain would not receive support from a BFC, although he does give LLLs alternative suggestions for checking the growth of a baby.

Contra-indications to exercise are given for these early days, however Clapp is positive that returning to exercise even 2 weeks after a Caesarean is OK, unless there is pain or bleeding. His studies have not shown any problems in returning to exercise so soon. I was astonished that he has managed to find mothers to study who WANTED to do this, especially after a C-section! After 6 weeks, according to Clapp “most women who exercise are beginning to have everything under control”. My jaw did drop when I read this. Obviously American mums have something that mums in Kent don’t, possibly a full-time nanny…?

Postnatal joint laxity was noted as persisting however was not reported to cause problems. Clapp doesn’t seem to think that impact activity is a problem for joints, even from quite soon after the birth, in fact he advocates jogging. However, I couldn’t find any specific advice on the importance of technique and joint alignment. Clapp also finds that exercising women have fewer discomforts and a lower injury level, however the participant level of experience, technique and coaching is not detailed.

I find myself wondering why I see so many pregnant and PN women who report general knee pain/aching, SPD and sciatic type pain and problems from “going over” on an ankle, whether or not they are active or exercising regularly with a formal programme.

Abdominal crunches were resumed without problems and pelvic floor problems were fewer in Clapp’s exercising group compared to the control, however there are no details of how his studies were conducted or monitored. I wondered how much self-reporting by mothers was used to gather information. A mother who is keen to return to exercise as soon as she possibly can is hardly likely to report problems that may stop her doing what she wants. Also levels of perception of what is normal may vary and what is an acceptable problem to one mother may not be acceptable to another.

There is a broad range of information in this book including training the competitive athlete, training at altitude and the importance of adequate support for both the stomach and the breasts. The overall conclusions are that exercise in pregnancy has very positive benefits, and I found much here to encourage me to motivate normal, healthy women to challenge themselves in pregnancy within their own limits and capabilities. However, the book is SO positive that I am concerned that a lay pregnant woman looking for reasons to carry on exercising might miss, or choose to ignore the significance of some specific recommendations, guidelines and contra-indications given.

[1] A Daily Telegraph article 18/6/03 quotes the author of the 140bpm rule, Dr Raul Artal, as saying that he invented this number off the top of his head. The ACOG guidelines, revised 1994 and 2002 no longer include this recommendation.