Exercise in pregnancy: what is possible and when to stop

Short answer: Where there is no obstetric reason against it, meaning no problem arising from the pregnancy itself, and no other medical reason, physical activity in pregnancy is regarded as safe and desirable, and the recommendation most often cited is at least 150 minutes of moderate aerobic activity a week. There are conditions in which exercise is not appropriate, and there are warning signs that mean stopping and contacting a health professional; pain and swelling in the calf sit apart from the rest of that list. In pregnant women who are not yet leaking urine, pelvic floor muscle training has been reported with high-quality evidence to lower the risk of leaking after the birth. In women who are already leaking, the same training given during pregnancy has not been shown to produce that benefit, and the plan in that group is built differently. Movement in pregnancy is not aimed at a performance target and not aimed at weight control.

Is it safe to move during pregnancy

This question usually arrives with two fears attached to it. The first is the fear of harming the baby. The second is the fear of making an existing complaint worse with one wrong movement. At guideline level the answer is stated plainly: in the absence of obstetric or other medical complications and contraindications, physical activity in pregnancy is regarded as safe and desirable, and pregnant women are encouraged to continue safe activities or to begin them. That wording comes from the American College of Obstetricians and Gynecologists, in its committee opinion number 804 on physical activity and exercise during pregnancy and the period after birth.

The two words in that sentence carry separate meanings. Safe says that there is no finding that movement harms the pregnancy. Desirable says something further, because the guideline does not merely permit activity, it encourages it. Treating pregnancy as an illness and applying a restriction close to bed rest is not what current practice supports, unless the physician following the pregnancy has a particular reason for it.

A woman who did no regular exercise before she was pregnant is also covered by the recommendation. Where she starts and how quickly she progresses are set individually, and that is decided in the assessment, not on a page. The familiar thought of having left it too late is not what the guideline says. In practice a beginning often looks unremarkable: a short walk on level ground, with breathing that is allowed to quicken without becoming laboured, and some attention paid to how the rest of the day felt afterwards. The conditions in which exercise is not appropriate, and the warning signs that mean stopping, are set out separately further down this page. Whether movement suits your pregnancy is decided by the physician following it.

What at least 150 minutes a week means

The recommendation is at least 150 minutes of moderate aerobic activity a week, both during pregnancy and after the birth. Moderate is roughly the level at which your breathing has quickened but you can still hold a conversation. If you have to stop in the middle of a sentence to take a breath, the intensity has gone above moderate for you.

The time can be spread across the whole week. Short walks divided through the day tend to be more workable for most women than a single long session, and that is particularly so in the weeks when nausea is marked or tiredness has increased. The figure is meant as a target, and it is not a bar that has to be cleared. When the weekly total is not reached, the movement that was done does not stop counting.

Work that is not aerobic, such as strength and balance work, does not replace those minutes, though it can sit alongside them. What weight to use is set for the individual woman. How the breath is used is set the same way, by watching what she actually does while the movement is happening. In pregnancy the real issue in strength work is usually the breath being held during the lift. Holding the breath raises the pressure inside the abdomen, and that pressure presses down onto the pelvic floor below and out against the midline of the abdomen in front.

The benefits that have been observed, and their limits

Reductions in gestational diabetes, which is raised blood sugar appearing during pregnancy, and in caesarean birth have been observed in women who exercise while pregnant. Physical activity has also been described as a factor that may matter in preventing depressive disorders after birth.

How those findings are read matters as much as the findings themselves. They are differences observed across groups, and they make no promise to any one woman. A woman who moves regularly can still develop gestational diabetes and can still give birth by caesarean. Depression in the months after the birth is not ruled out for her either. Exercise cannot promise that any of these will be avoided; it is offered as one factor that may shift the odds. If you come across a page telling you that exercise will give you a vaginal birth, that page is saying more than its source does.

Next to the observed findings it is realistic to put the ordinary ones. Sleep, bowel function, the course of muscle and joint aches, the use of breathing capacity and the level of energy through the day are all things that can change with movement. These are changes women report themselves, and they are not presented on this page as research findings.

What exercise in pregnancy is not

The distance, the pace or the weight you managed before the pregnancy is not kept as a measure. As the pregnancy goes on, the same walk may be done more slowly and the number of repetitions may fall, and some movements are set aside altogether. None of that counts as going backwards, because there is no performance target here in the first place.

Exercise in this period is not planned around a weight goal. Watching and interpreting weight gain in pregnancy belongs to the physician following the pregnancy. What is discussed on the physiotherapy side is how the body can carry the load it is carrying more comfortably, which movement is making which complaint worse, and how the tasks of an ordinary day can be made less demanding. Those tasks are concrete: getting shopping up a flight of stairs, lifting a toddler out of a car seat, standing through a two-hour seminar.

Exercise cannot be presented as a preparation programme that determines how the birth will turn out either. The course of labour is set by a great many factors, and most of them lie outside anything a woman does in a session. The reasonable frame for movement in pregnancy is an arrangement that makes the pregnancy easier to carry and keeps daily function, and that may contribute to entering the period after birth better prepared.

Conditions in which exercise is not appropriate

Some pregnancies rule exercise out for a period, and the reasons for that are specific. The items below are among those listed in committee opinion number 804 of the American College of Obstetricians and Gynecologists:

• Rupture of the membranes, meaning that the waters have broken.
• Cervical insufficiency, meaning that the neck of the womb does not stay closed enough to carry the pregnancy.
• Persistent bleeding continuing in the second or third trimester, the trimesters being the three roughly three-month stages a pregnancy is divided into.
• Placenta praevia persisting later in the pregnancy, meaning that the placenta lies in a position covering the neck of the womb.
• Preterm labour.
• Pre-eclampsia, meaning raised blood pressure in pregnancy together with the findings that accompany it.
• Heart conditions that affect the way the heart pumps blood.
• Lung conditions that restrict the expansion of the lungs.
• Severe anaemia, meaning a marked shortage of red blood cells.

This list cannot be offered as a complete one. Situations other than those named here can also call for exercise to be postponed or restricted, and the decision is taken pregnancy by pregnancy. If you recognise your own situation on the list, or if you are unsure, you need to speak to the physician following your pregnancy before you start exercising. The same applies the other way round: if something is troubling you that does not appear on this list, the physician is still the person to ask.

Where exercise is considered unsuitable in a pregnancy, that does not always mean the woman has to stay still. Which activity is restricted, and for how long, is decided by the physician. Physiotherapy works inside that frame and makes use of whatever the physician has left open.

Warning signs that mean stopping

The same document sets out what should happen if certain findings appear while a woman is exercising. The activity is stopped at that moment and a health professional is contacted. Those findings include the following:

• Vaginal bleeding, or a leak of amniotic fluid.
• Shortness of breath appearing before exercise has begun.
• Dizziness.
• A feeling of being about to faint.
• Headache that does not settle with rest.
• Chest pain.
• Muscle weakness.
• Pain in the calf, or swelling of the calf.
• A decrease in the baby's movements.
• Signs of preterm labour.

These are the findings named most often, and it is possible to meet another one that also means stopping. A single sign rarely carries only one meaning. What to do when one of them appears is the same in every case, though: stop the activity and be assessed. Waiting it out in the hope that a short rest will settle it is not the right response here.

Pain and swelling in the calf need a paragraph of their own, because the risk of deep vein thrombosis, which is a clot forming in a vein of the leg, is increased in pregnancy. Pain or swelling in the calf is therefore not brushed aside as a cramp, and pain or swelling affecting one leg more than the other is the pattern that most often prompts urgent assessment. Working out what the finding means belongs to a physician, and if shortness of breath or chest pain comes with it, care is needed without delay.

Where pelvic floor muscle training fits in pregnancy

The evidence on pelvic floor muscle training was brought together in a Cochrane review published in 2020, which drew on 46 studies and 10,832 women from 21 countries. Its strongest result sits under prevention.

In pregnant women who are not yet leaking urine, pelvic floor muscle training has been reported with high-quality evidence to lower the risk of leaking between the third and the sixth month after the birth by about one third. Moderate-quality evidence showed that the risk also fell markedly in late pregnancy. That is the strongest reason for starting this work while pregnant.

The second thing the same review showed usually gets left out. In women who were already leaking urine, no evidence was found that training given during pregnancy reduced leaking in late pregnancy or after the birth. Concealing that distinction would not be honest. The limit of the finding needs writing down as well: the question has been studied, the quality of the available evidence is low, and no benefit was demonstrated in this group. It does not follow that nothing can be done for a woman who is already leaking. In that situation the direction of the programme is set by the type of leaking and the moments when it appears, together with the capacity of the muscle to contract and to release and the physician's assessment. On faecal incontinence the evidence is uncertain, and no firm claim of benefit can be written here.

On the safety side, the question that comes up most often is whether working the pelvic floor in pregnancy makes the birth harder. In the data from the antenatal studies included in the review, meaning the studies carried out during pregnancy rather than after it, no difference was found in labour or birth outcomes between the women who did pelvic floor muscle training and those who did not. What a correct contraction feels like, and why releasing is practised as a skill of its own, belong to the what the pelvic floor is page.

What changes as the pregnancy goes on

A programme in pregnancy is not written once and kept unchanged to the end, because the load the body carries and the way that load is distributed both change. What follows is tracked through a woman's own findings, not through the calendar.

• Balance: as the abdomen grows forwards, the centre of gravity shifts forwards and upwards. Movements performed on one leg, narrow surfaces, slippery floors and activities carrying a risk of falling are reviewed for that reason. A wet tiled changing room and a rain-soaked pavement belong in the same review.
• Joint load: with the gain in weight and the change in connective tissue, the joints around the pelvis, the knees and the ankle can come under more strain. Pain appearing in the groin or the tailbone means the movement should change. It does not mean the movement should stop.
• Heat and fluid: in a warm environment, or during a long session, body temperature and fluid loss become a problem sooner. Choosing a cooler hour, drinking through the session and the length of the session itself are therefore discussed separately. In an İzmir summer this is not a small point.
• Lying on your back: spending a long time on your back becomes a question as the pregnancy advances. If dizziness, nausea or a feeling of discomfort appears, the position is changed, and there is usually a version of the same movement that can be done on your side, sitting, or in a supported half-lying position.
• Breathing: the growing uterus narrows the space the diaphragm has to move in. A sense of breathlessness is common in this period, but shortness of breath that appears before exercise has begun is one of the warning signs and needs to be assessed.

The timing of these changes differs so much between women that week numbers on a page would mislead more than they helped. An adjustment that becomes necessary early for one woman may never be needed by another. The measure is what appears during the movement and afterwards. The calendar comes second.

Abdominal work and the midline

During pregnancy the linea alba, the strip of connective tissue running down the midline of the abdomen, widens, and the two bellies of the straight abdominal muscle, the rectus abdominis, move apart from one another. This is an expected adaptation that makes room for the growing uterus. What is looked at is whether the midline can hold its tension under load. How many centimetres the distance measures says little on its own.

If the midline of the abdomen domes forwards during a movement, or dips in along a line, that movement was too much for that day. Reducing the load or shortening the range of the movement is usually enough for the same movement to be carried on with, and changing the breathing sometimes does it on its own. Sit-ups and the full plank load the front of the abdomen from end to end, and in pregnancy they are frequently modified for that reason.

Whether the gap closes after the birth is not something that can be promised. Structured programmes have been shown in studies to narrow the distance between the muscles measurably. The same studies also reported that this anatomical narrowing did not turn into an improvement in a woman's day-to-day function. The aim is therefore to raise load-bearing capacity and reduce symptoms rather than to close the gap. The separation of the abdominal muscles page explains how the measurement is taken and why the threshold rests on consensus.

Common symptoms in pregnancy that go unmentioned

The symptoms below are common in pregnancy and in the period after birth. Being common does not mean they should be treated as normal and accepted.

• Leaking urine when coughing, sneezing, laughing or jumping.
• An urge so sudden and strong that you cannot reach the toilet in time.
• Leaking wind, and less often leaking stool.
• A sensation of downward pressure, heaviness or bulging.
• Pain in the groin, at the joint at the front of the pelvis, or in the tailbone.
• Pain during intercourse.

Urinary incontinence after birth affects roughly one woman in three, and it should not be expected to clear up completely on its own. If you have been told that everyone who gives birth has this, that is not a reason to leave the symptom unassessed. In the appointment these symptoms are named plainly, you are asked at what time of day each one appears, and the answer is written down.

None of these symptoms arises because a woman neglected something. Pregnancy and birth load the pelvic floor, and what that load produces differs from one woman to the next. There is no need to wait for a symptom to get worse before asking for an assessment.

How the assessment and the sessions run in pregnancy

The appointment opens with talking. The course of the pregnancy, what the physician has told you, previous pregnancies and births, current complaints, which movement makes which part of the day harder and what you want out of the work are all discussed. After that, posture, breathing and the movement of the trunk and the area around the pelvis are examined, and functional tasks such as sitting, standing up, stairs, standing on one leg and lifting are assessed. Wear clothes you can move in, because a good deal of this part is done on your feet.

A pelvic floor assessment does not have to begin with an internal examination. How that part would run is explained beforehand, verbal consent is asked for, and it is not done if the woman does not want it. Assessment is also possible through external observation and functional testing, and that usually gives enough information to build the first programme. The door of the room stays closed and a cover is available. Separate time is given for dressing and undressing. You may have someone with you in the room, and the assessment can be stopped at any stage. Whether an internal assessment is appropriate during pregnancy also depends on the physician's opinion.

Sessions are one to one, last 60 minutes and are held by appointment. For those who want to talk through how the process works first, there is a free fifteen-minute introductory call. Consultations can be held in English. Sessions take place at Erzene Mahallesi 113 Sokak No: 1/3. Evka 3 metro station stands in the same neighbourhood and is the eastern end of the M1 line, so a train heading that way finishes there and there is no stop to miss. The station immediately before it is Ege Üniversitesi, which serves the university campus.

Who makes the decision

Making a diagnosis, requesting imaging, prescribing medication and managing the course of the pregnancy are the physician's work. Physiotherapy comes in after that assessment and works within the frame the physician has drawn. Where a restriction has been placed on a pregnancy, the programme is written to fit the restriction.

If you have recently moved to Turkey, it is worth knowing what "the physician following your pregnancy" means here in practice. A pregnancy is usually followed by an obstetrician, either at a state hospital outpatient clinic or in private practice. Many women also register with a family physician (aile hekimi) at their local family health centre, and that physician can refer them onwards. Waiting times differ between the state route and the private one, and which suits you depends on your insurance and your circumstances. Whichever route you use, the person who answers the questions on this page about your own pregnancy is the physician following it.

What is written here is general information and does not replace an examination. If one of the conditions on the list above applies to you, if one of the warning signs has appeared, or if you have any doubt about your pregnancy, the physician following your pregnancy is where to turn. Seeing a physician before starting physiotherapy is what keeps the work safe and what allows the programme to be built on the right assessment.

Where to go next in this guide

There is no single date after the birth that suits everyone. The returning to exercise after birth page sets out how the staging is decided instead. The types of urinary incontinence, and which approach comes up in which situation, are covered on the urinary incontinence after birth page.

What the pelvic floor does through the day and how the assessment runs are on the what the pelvic floor is page, and the gap along the midline of the abdomen and its measurement are on the separation of the abdominal muscles page. The spinal load carried in pregnancy by a woman with scoliosis is a separate subject and is dealt with on the scoliosis in adults page. Appointment times and directions are on the contact page.