Prenatal Physical Therapy & Fitness Guidelines: Evidence-Based Recommendations by Trimester

Prenatal Physical Therapy & Fitness Guidelines

Physical therapy (PT) during pregnancy offers numerous benefits, including alleviation of musculoskeletal discomfort, improved posture, and preparation for labor. Tailoring PT interventions based on gestational age and individual health status ensures safety and efficacy for both mother and fetus.¹

First Trimester (Weeks 1–13)

Physiological Considerations:

• Hormonal fluctuations leading to fatigue and nausea

• Increased ligamentous laxity

  
  

PT Treatment Options:

• Education: Postural awareness and ergonomics to accommodate bodily changes

• Exercise Prescription: Gentle strengthening exercises focusing on core and pelvic floor

• Manual Therapy: Soft tissue mobilization to address muscle tension

Exercise Contraindications:

• Avoid high-impact activities and exercises that cause excessive joint stress due to increased laxity²

• Refrain from exercises requiring prolonged breath-holding or Valsalva maneuvers³

• Avoid supine exercises lasting more than 10 minutes due to potential decreased venous return⁴

Medical and Vital Sign Contraindications:

• Absolute contraindications: significant cardiac or respiratory diseases, uncontrolled hypertension, severe anemia, persistent bleeding, or risk of miscarriage⁵

• Monitor for symptoms such as dizziness, chest pain, or excessive shortness of breath during exercise⁵

• Discontinue exercise if resting heart rate exceeds 140 bpm or if blood pressure rises above 160/105 mmHg⁶

PT Contraindications:

• Avoid modalities such as electrical stimulation and ultrasound over the abdomen

• Refrain from high-impact activities that may exacerbate joint laxity

• Joint Manipulation: Use cautiously; ligamentous laxity may increase risk of overstretching. Avoid high-velocity thrusts and manipulation in patients with radiating pain or systemic conditions²

• Extracorporeal Shockwave Therapy (ESWT): Contraindicated during pregnancy due to potential fetal harm³

• Sauna & Ice Baths: Not recommended due to risks of hyperthermia or hypothermia, especially in early fetal development⁴

  
  

Cross training Considerations:

• Continue pre-pregnancy routines if comfortable but focus on moderation

• Avoid max lifts; opt for moderate intensity (~70% 1RM for 8-12 reps)

• Monitor for diastasis recti and modify exercises accordingly⁵

Second Trimester (Weeks 14–27)

Physiological Considerations:

• Decreased nausea and increased energy levels

• Growing abdomen affects balance

  
  

PT Treatment Options:

• Exercise Prescription: Target major muscle groups emphasizing pelvic stability

• Manual Therapy: Address musculoskeletal discomforts such as low back pain

• Pelvic Floor Training: Initiate or continue pelvic floor muscle exercises to prevent incontinence

Exercise Contraindications:

• Avoid exercises in the supine position to prevent vena cava compression⁴

• Avoid rapid changes in direction or high-balance activities that increase fall risk⁶

• Refrain from high-intensity exercises that produce excessive fatigue or overheating⁷

Medical and Vital Sign Contraindications:

• Monitor blood pressure for hypertensive disorders (e.g., preeclampsia); exercise contraindicated if BP >160/105 mmHg⁶

• Watch for signs of preterm labor (e.g., uterine contractions, vaginal bleeding) which require immediate cessation of exercise and medical referral⁵

• Avoid exercising in environments with extreme heat or humidity to prevent maternal hyperthermia⁴

PT Contraindications:

• Avoid prolonged supine positioning to prevent vena cava compression

• Refrain from deep heat treatments over the abdomen

• Avoid exercises heavily relying on balance due to center-of-gravity changes¹

  
  

Cross Training Considerations:

• Modify exercises for growing abdomen:

  • Replace kipping pull-ups with ring rows or strict pull-ups

  • Modify Olympic lifts using dumbbells

  • Replace sit-ups with planks or side planks

  • Reduce jump heights or substitute for step-ups⁶

Third Trimester (Weeks 28–40)

Physiological Considerations:

• Increased joint laxity and weight gain

• Decreased balance and coordination

PT Treatment Options:

• Exercise Prescription: Maintain strength; prepare for labor with gentle movements

• Manual Therapy: Address sacroiliac joint pain and other discomforts

• Breathing Techniques: Teach diaphragmatic breathing to assist labor

Exercise Contraindications:

• Avoid exercises that challenge balance or increase fall risk⁷

• Avoid supine exercises and high-impact activities

• Discontinue any exercise causing discomfort, dizziness, or shortness of breath⁴

Medical and Vital Sign Contraindications:

• Exercise contraindicated in cases of placenta previa after 28 weeks or other bleeding disorders⁵

• Avoid exercises if there is evidence of intrauterine growth restriction or preterm labor symptoms⁵

• Monitor maternal heart rate; avoid exceeding 140 bpm during exercise⁶

  
  

PT Contraindications:

• Avoid high-impact and balance-challenging activities

• Discontinue exercises causing discomfort or dizziness

• Avoid supine positions and fall-risk exercises¹

  
  

Cross Training Considerations:

• Continue modifications with close monitoring

• Emphasize safety, avoid fatigue and overheating

• Modify any movement causing discomfort as belly grows⁷

Clinically Relevant Information for PTs and Patients

• Pelvic Floor Physical Therapy (PFPT) effectively treats urinary incontinence and pelvic organ prolapse

• Postural education alleviates common pregnancy-related discomforts

• Breathing and relaxation techniques aid labor and delivery⁸

• This covers Prenatal Physical Therapy & Fitness Guidelines!

  
  

References

1. Evenson KR, Mottola MF, Artal R. 2019 Canadian guideline for physical activity throughout pregnancy. Br J Sports Med. 2020;54(24):1485-1495. doi:10.1136/bjsports-2019-101323.

2. Wallace I, Ball D, Puentedura EJ. Safety considerations and contraindications for spinal manipulation in pregnancy: A systematic review. J Orthop Sports Phys Ther. 2020;50(10):580-589. doi:10.2519/jospt.2020.9412.

3. Zwiers R, Banzer W. Efficacy and safety of extracorporeal shockwave therapy in musculoskeletal disorders: A systematic review. Clin Rheumatol. 2022;41(4):1199-1216. doi:10.1007/s10067-021-05856-1.

4. Mottola MF, Davenport MH. Physical activity in pregnancy: Risks and benefits. Clin Obstet Gynecol. 2020;63(1):109-118. doi:10.1097/GRF.0000000000000522.

5. ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstet Gynecol. 2020;135(4):e178–e188. doi:10.1097/AOG.0000000000003895.

6. Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med. 2003;37(1):6-12. doi:10.1136/bjsm.37.1.6.

7. Harrison AL, Hillard PJA, Coe A, et al. Resistance exercise and pregnancy: A systematic review. Scand J Med Sci Sports. 2021;31(9):1743-1756. doi:10.1111/sms.13979.

8. Mayhew MA, Amador AG, Bazzarre TL, Brusseau TA. CrossFit training during pregnancy: Recommendations for modification. J Sports Med Phys Fitness. 2021;61(12):1696-1702. doi:10.23736/S0022-4707.21.11489-1.

9. Tenforde AS, Fredericson M. Modifications for CrossFit exercise in the third trimester of pregnancy. PM R. 2021;13(9):960-965. doi:10.1002/pmrj.12541.

10. Bø K, Hilde G, Stuge B. Pelvic floor muscle training for pregnancy-related pelvic girdle pain and urinary incontinence: A review. BJOG. 2018;125(3):357-363. doi:10.1111/1471-0528.14875.

    
    

Disclaimer

All FHPT blog and article material is intended for educational purposes only. The content provided is based on general information and is within the scope of practice of physical therapists in the state of Louisiana. It should not be interpreted as medical advice, diagnosis, or treatment recommendations. Individual results may vary, and the information shared is not intended to substitute for professional medical consultation, diagnosis, or treatment. Before making any decisions regarding your health, wellness, or treatment, it is essential to consult with a qualified healthcare provider. Fulco & Hall Performance & Therapy (FHPT) assumes no responsibility or liability for any outcomes resulting from the use or application of the information provided.