First Trimester Pregnancy Guidelines

As personal trainers, when it comes to taking on prenatal clients it may seem a bit of a mystery. Much of the research that’s out there proves that “exercise during pregnancy is good and beneficial,” but what about the details?  What should you focus on with your prenatal clients when getting started?

Learning Objectives:

1. Learn what questions you should be asking your prenatal client.
2. Understand the training focus for a prenatal client in her first trimester.
3. Discover recommended exercises and exercise modifications to be included in a prenatal client’s exercise program during her first trimester.

1st Trimester: Week 1 through Week 12

2nd Trimester: Week 13 through Week 26

3rd Trimester: Week 27 through Week 40

Questions to Ask Your Prenatal Clients

Be sure she has talked with her physician and received approval to exercise prior to beginning an exercise program. You should familiarize yourself with absolute and relative contraindications to pregnancy as stated on ACOG.org such as: vaginal bleeding, thyroid disease; cardiovascular, respiratory or systemic disorders, previous miscarriage(s), previous preterm birth, anemia, malnourished or other significant medical condition. It may be a good idea to have written permission from each prenatal client’s physician prior to beginning any sessions.

If she is a first time client you must ask her about previous exercise experience along with any health or potential health issues. It’s important to know the answers to these following questions: 

• How far along is her pregnancy (how many weeks)?
• How many pregnancies has she had in the past, if any?
• How old are her other birth children?
• Was she on bed rest or limited activity any time during current or previous pregnancy?
• What types of exercise is she interested in (e.g., weight training, Pilates, yoga, high intensity, low intensity, spinning, running, CrossFit, etc.)?
• Does she have a history of miscarriages, surgeries, chronic pain, scoliosis, etc.?
• Is she currently experiencing any discomfort?
• Does she have diastasis recti? Umbilical hernia?

The more you know about your prenatal client’s history the better you can create a specific program for her. Rather than just providing her with a workout, create a program that is also creating balance throughout her body. Give her extra “take-home” tips that she can do throughout her day, such as “stand or sit tall” - simple tips like that can help her carry the techniques you are working hard to teach her and apply them to her everyday life.

Start each session by asking her how she is feeling and then adjust her workout accordingly. Some days she may feel much better than others. While it’s important to work on increasing her strength during her first trimester, it’s also important to help her feel her best. You want her to leave the workout session feeling better than when she walked in.

You are there to encourage her along the way and help her feel confident with her workouts, so be sure to understand and communicate why you are selecting the exercises for her. Each and every exercise must serve a purpose and if an exercise or program doesn’t feel good for her body that day, even after you made the appropriate modifications, move on to exercises that do.

1st Trimester Focus Points

Yes, she can exercise even if she didn’t prior to pregnancy.

Now is not the time for your prenatal client to venture out and start a new sport, but that doesn’t mean she shouldn’t exercise if she didn’t prior to becoming pregnant. Research shows how important resistance training is for expecting women. So, start slow and gradually increase her sets and weights if she is new to resistance training. You may find performing just one set of resistance exercises in a first workout is best. Then, progress from there. It’s important to focus on her form and muscle connection to ensure that she feels the exercises correctly, rather than focusing on the amount of weight she is lifting.

Focus on increasing strength.

During her first trimester it’s important to focus on her strength, help her find her deep core connection, create good posture and teach her “body awareness.” Include exercises in her first trimester that she will not (or may  not) be able to do later on in her pregnancy due to modifications, such as: back extensions, full lunges and lunge variations, planks and plank variations, core exercises and other appropriate exercises. (We will review recommended exercises later in this article.)

Teach deep core activation.

Teach your pregnant client how to connect her deep core muscles:

1. Exhale to lightly activate pelvic floor (kegel), cue with: “lifting a wet towel up through the center of your body.” This lifting up through the belly helps to activate transverse abdominals and multifidus (avoid the sucking belly button to spine approach), and continuing to lengthen through the torso helps to create good posture.
2. Inhale to allow a deep diaphragmatic breath into the sides and back of the ribcage, while maintaining a light deep core connection.

Teaching her to “lightly” connect and avoid “gripping” her pelvic floor and transverse abdominal muscles is key; you can partially identify that by her breathing. If you catch her holding her breath while trying to keep her deep core connected she is likely “over-activating.” For many this may just take time to learn. It’s also a good idea to teach her how to recruit her pelvic floor muscles by performing squats. (See “Squats” below for more on teaching pelvic floor recruitment).

Recommend a minimum of 30 minutes of exercise (most days).

It’s recommended that expecting women exercise most days of the week for about 30 minutes (and some research shows an hour a day). Including resistance training is beneficial as current research results by E. White show that resistance training and aerobic exercise is more beneficial than just aerobic exercise on its own; specifically noting a significant decrease in gestational diabetes and hypertension disorders.

Minimize barriers to exercise.

The barriers to exercise are abundant. Once becoming pregnant your prenatal clients will turn to you for advice and lots of questions regarding what she can and cannot do. According to new research by Fieril Petrov, “pregnant women strived to exercise if the exercise facilitators outweighed the barrier,” proof that it’s important for expecting women to feel a positive impact from exercise. This is when modifications to exercise should come into play as her pregnancy progresses.

“Listen” to her body.

One additional piece of advice is to remind her to always “listen” to her body. If an exercise doesn’t feel right for her body, skip it and move on. It may just be that day or couple of weeks, as things shift due to changes during pregnancy, the baby is growing, and the client is adjusting to weight gain; not to mention, hormones. Hormones are partly to blame for some of those pregnancy aches and pains.

1st Trimester Specific Modifications

Avoid supine forward flexion.

I recommend avoiding forward flexion in a supine position after your prenatal client’s belly starts to show, when you can identify a “coning” look to her abdomen and she can no longer maintain her deep core connection in a neutral spine position, or at the time she reaches week 12 of pregnancy. This includes avoiding traditional crunches in any position; she may be able to do supine forward flexion as long as she can maintain her deep core connection in a neutral spine position but only in her first trimester.

Avoid quick changes in her position.

The hormone Relaxin now present in her body causing vasodilation, combined with an increase in blood volume can cause her to feel lightheaded or dizzy easily, especially when changing positions quickly. So, encourage her to take her time during each exercise movement and be there to spot her when needed. 

Avoid overstretching.

Additionally, due to the effects of the hormone Relaxin, encourage her to avoid overstretching and only stretch to a point that feels good and never painful. Movements that could overstretch her pubic symphysis and surrounding pelvic areas should be limited.

Maintain an appropriate workout intensity.

The level of your prenatal client’s energy exertion is always a concern. According to Dr. James Clapp II, conditioned pregnant athletes can safely exercise 5+ times/week at 65%-90% of their regular intensity for 55-60 minutes. For those just starting an exercise program, 2 to 5 times/week at 55% of their maximum capacity for 20 to 40 minutes.

Since you won’t be doing any VO2 max testing with your prenatal clients instead use the “talk test” to determine how hard she is working out. She should be able to carry on a light conversation. If she is extremely winded, you should decrease the intensity of the workout. It’s always better to stay on the lighter side of intensity, rather than overdue, but don’t be afraid challenge her, too. I tend to challenge my prenatal clients when it comes to resistance training versus cardiovascular exercise. You want her to feel better and more energized after her workouts and not exhausted. Research by E. White has shown slightly more benefits of resistance training along with aerobic exercise during pregnancy than no exercise or just aerobic exercise. From my personal experiences I see tremendous benefits to including resistance training during pregnancy, such as less aches and pains overall, more energy, quicker pushing phase of delivery, decreased need for emergency c-sections and easier and quicker recoveries.

Prone exercises may need to be skipped.

Prone exercises, specifically back extensions, can be a safe exercise during the first trimester (only) for some expecting clients. It’s best to perform prone exercises during her first pregnancy as her uterus (and belly) remains smaller during this time and then will expand as the pregnancy progresses (and continue to expand with additional pregnancies). You may need to avoid any and all prone exercises if she does not feel comfortable on her belly.

Avoid high impact exercises.

Avoid high impact exercises and those that create quick changes in direction, especially if she has had previous miscarriages or pregnancies. American College of Obstetrics and Gynecology recommends avoiding other exercises such as downhill skiing, contact sports, and scuba diving.

Is running safe?

Running may be a good option for some pregnant women, but encourage your expecting client to back off if it feels “off” to her in any way. Recommend other cardio options such as walking, swimming, elliptical and even cycling.

Hydration.

Staying hydrated is important when working out - especially if she is working out in a warmer temperature. Remain cautious, but there’s actually little concern of the expecting client’s body temperature getting too high. According to Dr. James Clapp II “Pregnancy reduces the risk of a mother’s temperature rising high enough to bother baby by improving her ability to get rid of heat through her skin and lungs.”  Just be sure she is dressed for warmer weather and encourage her to drink plenty of water.

1st Trimester Specific Recommended Exercises

Watch the following video for a demonstration of the exercises detailed below:

Hip Rolls into Bridging

Incorporate supine exercises during the first trimester as they will become limited as her pregnancy progresses.

1. Lay supine with spine in a neutral position  knees bent and feet together. (Neutral spine is when the pelvis is balanced between the exaggerated posterior and anterior positions, the PSIS and ASIS points)
2. Exhale when lifting pelvis upward, while pressing legs together and maintaining neutral spine.
3. Start slow pulses (10 reps) to engage hamstrings and glutes. Avoid the ribs “popping.”
4. Elevate one leg and reach in a flexed foot position towards the sky. Continue 10-20 pulses, then switch legs.
5. Replace both feet together on the final inhale.
6. Exhale to slowly articulate rolling the spine back down one vertebrae at a time.

Squats

Squats are a great exercise to teach your prenatal clients how to recruit pelvic floor muscles. For many, squats are better than doing kegels alone. Teach her right away how to properly perform squats, keeping neutral alignment (this will help with pelvic floor recruitment). Have her perform squats in narrow, wide, or medial rotated positions. For more support, have her hang on to a bar. You will learn a lot about her body just by watching her do squats. Perform 10-30 squats in a set.

1. Stand with feet hip-width to shoulder-width apart or medially rotated (turn her knees and feet inward)
2. Inhale and lower into a squat position, while maintaining a neutral spine. If she is having difficulty performing squats correctly, perform pulses or small range of motion squats. 
3. Exhale when returning to a standing position, and lightly activate pelvic floor and transverse abdominals.

If she is having difficulty recruiting her pelvic floor, have her practice releasing her pelvic floor as she lowers into a squat (instruct her to relax the muscles between her sits bones and front of her pelvis), while maintaining neutral alignment. Then instruct her to lightly recruit her pelvic floor as she stands by gently lifting that wet towel feeling that connects to her sits bones and front of her pelvis. 

Plank Slides

In order for your pregnant clients to continue to perform planks properly, she must be able to connect her deep core muscles and avoid her belly from “coning.” Be sure to modify the plank, if needed, according to each pregnant client’s individual level. Appropriate core exercises help to train your expecting clients how to engage the deep core versus the rectus abdominals, in hopes of preventing and/or minimizing diastasis recti. This is why avoiding “crunches” early in pregnancy is important. However, many women can connect the deep core in a planking position later in her pregnancy; especially if she has you next to her teaching her to connect properly. Once she can no longer perform a full plank properly, modify the exercise to the knees. If that isn’t working for her you can regress by using a bench or wall to perform a plank, or move on to side planking exercises. Perform 10 to 30 reps in each set.

1. Begin in a full plank position on forearms and toes. Press legs together to help engage the pelvic floor and transverse abdominals. Lift the pelvis upward while “zipping” up the belly and lifting through the top of the head.
2. Exhale while moving the body forward and maintaining a plank position.
3. Inhale while moving the body back. (Focus on stretching the calves in the backward movement).
4. Modify: Hold a modified plank on forearms and knees. Avoid planking exercises if it’s not a good fit for the client and move on to side planking exercises.

Modified Side Planks

Modified side planks are a safe core exercise for most expecting women. Be sure to emphasize engaging her deep core connection over her rectus abdominals and obliques. You can either have her hold for 30 to 60 seconds or add a small lift and lower for 10 to 15 reps.

1. Place elbow under shoulder and bend the bottom knee to line up under the hip.
2. Exhale while focusing on lengthening and lifting through the body while keeping the ribcage connected.
3. Inhale and breathe deeply into the ribcage or add a small amount of movement up and down. 

Back Extensions

Very early during pregnancy, expecting women can safely perform prone back extensions flat on the ground, as long as the movement feels good for her and her belly is not showing. She should avoid these movements once she is 12 weeks pregnant or when her belly starts to show (which may be much sooner). Perform 10 to 15 reps with each set.

1. Lying prone on the ground (avoid any extensions on exercise balls as that puts more pressure towards her abdomen), place hands by the hips and inhale to prepare.
2. Exhale while lifting back and lightly engaging the deep core and hamstrings.
3. Inhale while slowly lowering and turn the head towards one side (left or right) to release. Alternate the direction of the head turn with each repetition.
4. On completion of the set, release back into child’s pose.

Conclusion

Encourage your expecting clients to engage in daily exercise, even if it’s just walking, and assign some resistance exercises she can do safely at home on her own. One last important benefit to exercising during pregnancy is the impact it can have on reducing prenatal and postpartum depression and stress. Keep that in mind when creating her workouts. The program you create should help her feel stronger; more in control of her changing body, energized, and leave her feeling better than when she walked in.

Now that you understand what questions you need to be asking your prenatal clients, focus points for her first trimester, modifications and recommended exercises you can feel confident in creating safe and effective workouts for your prenatal clients.

References

American College of Obstetrics and Gynecology. (2015). ACOG.org

Clapp II, Dr. James (2002). Exercising Through Your Pregnancy. Addicus Books. 17-87

Smith MD, Coppierters MW, Hodges PW. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn. 2007;26(3):377-85

Perales M1, Refoyo l1, Coteron J1, Bacchi M2, Barakat R3. Exercise during pregnancy attenuates prenatal depression: a randomized controlled trial. 2015;38(1):59-72

Petrov Fieril K1, Fagevik Olsen M2, Glantz A3, Larsson M4. Experiences of exercise during pregnancy among women who perform regular resistance training: a qualitative study. Physical Therapy Journal. 2014;94(8):1135-43

White, E. Pivarnik, J. Pfeiffer, K. Resistance training during pregnancy and perinatal outcomes. Journal of Physical Activity and Health. 2014;11(6):1141-8