Core Training Exercise

Selection During
Pregnancy
Timothy J. Piper, MS, CSCS*D,1 Emily Jacobs, MS, NSCA-CPT, CHES,2 Mike Haiduke, BS,3
Mike Waller, PhD, CSCS*D,4 and Cathy McMillan, MS1
1
Department of Kinesiology, Western Illinois University, Macomb, Illinois; 2Health Fitness Corporation at Trustmark
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Companies, Lake Forest, Illinois; 3Haiduke Personal Training, Hoffman Estates, Illinois; and 4Human Performance and
Physical Education, Adams State College, Alamosa, Colorado

SUMMARY
ABDOMINAL AND CORE MUSCU-
LAR CONDITIONING IS SELDOM
RECOMMENDED FOR PREGNANT
POPULATIONS. A LITERATURE RE-
VIEW CLEARLY INDICATES SUP-
PORT FROM THE MEDICAL FIELD
FOR THE APPLICATION OF CORE
MUSCULAR TRAINING DURING
PREGNANCY TO HELP ALLEVIATE
MANY ISSUES ASSOCIATED WITH
PREGNANCY. SPECIFIC CORE EX-
ERCISES ARE DESCRIBED TO AID
IN THE IMPLEMENTATION OF SAFE
AND EFFECTIVE TRAINING DURING
PREGNANCY.
INTRODUCTION
regnancy causes significant cha-
for pregnant women should be carefully
constructed with the cooperation of the
individual and their physician. This article
offers a review of the literature related to
core exercise training and recommenda-
tions for specific core exercises that meet
the American College of Obstetricians
and Gynecologists (ACOG) guidelines
but have been previously overlooked or
unmentioned in the literature.
PHYSIOLOGICAL CHANGES
RELATED TO PREGNANCY
The 2002 ACOG guidelines support
regular exercise during and after preg-
nancy for both healthy and sedentary
women. The changes that occur to the
body during pregnancy are no longer
seen as a limitation; rather, women are
pregnancy, both anatomically and
physiologically. During pregnancy,
one of the most obvious transforma-
tions is weight gain. This may cause
many changes to a woman both at
rest and during exercise. Weight gain
may take a toll on the woman’s joints
resulting in discomfort. Pregnant
women typically become lordodic in
the lumbar spine, creating a shift in
their center of gravity. This shift in low
back pain can directly affect posture
and balance. Posture should be ac-
knowledged both during exercise and
at rest, and quick directional changes
should be avoided to decrease the risk
of injury (2,15).
Throughout pregnancy, a woman’s
blood volume increases by approxi-
mately 40–50%, stroke volume by 10%,

P nges within a woman’s body. Low

back pain has long been acknowl-
edged as a common ailment during
pregnancy, but only sparse and remedial
exercise recommendations have been
offered to sufferers. Stretching, relaxation,
and pelvic floor strengthening have been
indicated for treatment of pregnancy-
related low back pain. Additional con-
cerns of modern day mothers-to-be are
related to maintaining their abdominal
musculature and physique during and
after childbirth. All these issues revolve
around the training of the core muscu-
lature. Currently, little information is
available to personal trainers or pregnant
mothers regarding appropriate and safe
core training exercises. Program design
encouraged to practice healthy habits
during this period. Numerous authors
concur that there are few, if any, adverse
affects related to exercise during preg-
nancy for those not determined by their
physicians to be at risk of complications
(8–10,14,26,27). According to the
ACOG, pregnancy is a prime time to
make behavioral health changes in
a woman’s life to better the health of
herself and her baby. Pregnancy should
not be considered a ‘‘state of confine-
ment’’ (2). By implementing positive
and healthy changes, these habits can
influence and shape the future of both
the mother’s and the child’s health.
There are many physical changes that
take place in a woman’s body during
and heart rate by 20%. With these
increases, cardiac output may rise
almost 50% (15). Not only does this
increase cardiac output and blood flow
in the mother but it also enhances
blood flow and output to the fetus
through the placenta (15). As a result of
these increases, the woman’s mean
arterial pressure decreases by 5–10
mm Hg at the second trimester and
moderately increases to normal pre-
pregnancy blood pressure levels during
the rest of the pregnancy.
KEY WORDS:
pregnancy; abdominal training; core
training

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Core Training During Pregnancy
RISKS, PRECAUTIONS, AND
GUIDELINES
Exercise during pregnancy has been
a concern due to its effects on the
developing fetus, and it is recommended
that pregnant women should consult
with their physician before undertaking
any exercise program (11). Recent re-
search shows that if the mother is
healthy and experiences no complica-
tions, fetal injuries during exercise are
not likely. However, exercising during
high-risk pregnancies may cause com-
plications, such as increased fetal heart
rate, intrauterine growth restriction, or
fetal bradycardia, which can be caused
by vagal reflex, cord compression, or
fetal head malposition (2).
According to the American College of
Sports Medicine (ACSM), both repro-
duction and physical activity are
a healthy part of life and combining
the 2 make for a positive pregnancy (1).
These recommendations are intended
for women who have been fully eval-
uated and cleared for exercise by their
physician. However, these recommen-
dations come with some restrictions. A
commonly mentioned restriction in-
volves supine exercise concerns. Lying
supine should be avoided after the first
trimester of pregnancy due to cardio-
vascular changes in the body
(2,11,21,23). With the redistribution of
blood during exercise, the transporta-
tion of oxygen, carbon dioxide, and
nutrients are a concern for the de-
veloping fetus. During exercise, the
mother’s body may experience a lack
of oxygen while the body tries to keep
up with oxygen demands. This could
potentially cause fetal tachycardia and
increased fetal blood pressure as the
baby protects itself. Lying supine and
motionless standing can create
a decrease in cardiac output because
of the blockage of venous return.
It is recommended to avoid any exercise
or activity that may place the mother at
risk of abdominal trauma (15,21,23). To
reduce the risk of balance issues that
could lead to falls and subsequent fetal
injury, activities that involve abrupt or
jarring movements should be avoided
(22). Other cited exercises that may
56 VOLUME 34 | NUMBER 1 | FEBRUARY 2012
increase risks of falls include lunges,
squats, and stiff-legged deadlifts (17).
Also, graded exercise testing should be
avoided if it requires a maximal effort
unless under the direction of a physician.
It is also recommended that submaxi-
mal testing should be stopped at 75%
heart rate reserve rather than 85% heart
rate reserve (24).
BENEFITS OF EXERCISE DURING
PREGNANCY
Much of the research to date regarding
exercise during pregnancy is related to
direct risk to the fetus, such as
abdominal trauma, or alterations in
blood supply. Although these concerns
must be taken into account, cardiovas-
cular fitness should be encouraged
within the ACOG guidelines. Contrary
to concerns related to high-risk preg-
nancies, reports of small fetal heart rate
changes are not associated with fetal
risk but rather heightened fetal wake-
fulness during exercise (3). Babies born
to mothers who maintained physical
activity during pregnancy are shown to
be less agitated and more alert (9), are
self-quieting, and are better able to
handle the stress of labor (15).
Besides the cardiovascular adaptations
and benefits previously mentioned,
muscular strengthening exercises have
long been recommended for the im-
provement of pregnancy and labor.
Before the 19th century, it was believed
that enhanced muscular work would
benefit the mother in various ways (5).
In 1967, Blankfield (5) reported that the
primary exercise recommendations of
the early 19th century encouraged only
light activity during pregnancy, such as
croquet. Most authors now agree that
unless the mother and fetus are at risk of
complications, exercise should be con-
sidered an acceptable and regular part
of pregnancy (3,5,19). The most com-
monly reported benefits include easier
labor, shorter labor times, and enhanced
recovery after birth (5,7,8,11). Brown (7)
also cited bone mineral density benefits
that may offset lactation-induced bone
mineral loss for nursing mothers.
Although early recommendations for
more efficient labor and birth included
exercises, such as lunges and squats (5),
which are now considered contra-
indications due to risks of falls (17),
little beyond pelvic titling exercise were
indicated for low back pain sufferers
(5). Low back pain relief often involves
posture correction training by means of
pelvic tilt training, muscular endurance
training, and postural stabilization
training (5,11–13,18,20).
Other literature encourages abdominal
strengthening exercise for the preven-
tion of low back pain but still fails to
offer specific exercise choices for the
reader (19). Although this recommen-
dation may be correct, the ambiguity of
this advice leaves the reader with little
useful information. Some authors who
have consistently recommended ab-
dominal training limit the choice of
exercises to pelvic tilts, Kegel exercises,
and various forms of isometrics for the
core musculature (5,6,11,12,13,18,20).
Talmadge et al. (23) further recom-
mend transverse abdominus (TVA)
exercises in the form of an abdominal
squeezing action. Performing these
TVA exercises may also combine with
concomitant pelvic floor muscle con-
tractions similar to Kegel exercises.
For women who have trained hard to
develop aesthetically pleasing abdomi-
nals, the changes that naturally occur as
their child develops in the womb can
lead to frustration. As the fetus grows, it
causes a natural expansion of the
abdominal wall and subsequent abdom-
inal musculature separation via expan-
sion of the linea alba. Depken and
Zelasko (11) have found that the degree
of separation of the abdominal muscu-
lature is decreased if muscular strength
training is maintained, without any
stress or concerns to the mother or
fetus. It is inevitable that the abdominal
and core musculature may weaken
during pregnancy, (18) especially during
the third trimester (13).
GENERAL EXERCISE
RECOMMENDATIONS
When assisting any pregnant woman
with exercise selection, a complete
health history and exercise history
should be performed and any possible
complications should be taken into
consideration. Only a physician may

ACOG guidelines for exercise prescription
Absolute contraindications to
aerobic exercise during pregnancy
Hemodynamically significant heart
disease
Restrictive lung disease
Incompetent cervix/cerclage
Multiple gestation at risk for
premature labor
Persistent second or third trimester
bleeding
Placenta praevia after 26-wk
gestation
Premature labor during current
pregnancy
Ruptured membranes
Preeclampsia or pregnancy-induced
hypertension
ACOG = American College of Obstetricians and Gynecologists.
determine the presence or absence of
any potential complicating factors.
Personal trainers should ensure that
all pregnant clients have physician
clearance for exercise before recom-
mending exercises.
Just as an exercise program would be
designed for a nonpregnant individual,
the frequency, intensity, time, and type
of exercise should be considered. Both
aerobic and strength training exercises
can be performed during pregnancy.
The aerobic exercises can include any
aerobic activity that uses large muscle
groups in a continuous motion, such as
jogging, swimming, and cycling. Both
strength training and flexibility exercises
should be individualized for the preg-
nant woman based on exercise history
and safety (1,2). Both weight-bearing
and non–weight-bearing exercises are
Table 1
Relative contraindications to
aerobic exercise during pregnancy
Severe anemia
Unevaluated maternal cardiac
arrhythmia
Chronic bronchitis
Poorly controlled type 1 diabetes
Extreme morbid obesity
Extremely underweight (body mass
index , 12)
History of extremely sedentary
lifestyle
Intrauterine growth restriction in
current pregnancy
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled seizure disorder
Poorly controlled thyroid disease
Heavy smoker
recommended, as long as they are safely
modified to meet the mother’s individ-
ual needs.
ACSM (24) recommends that pregnant
women can workout between 50 and
80% of their maximum heart rate range,
depending on prepregnancy exercise
status. In place of heart rate monitoring,
the rate of perceived exertion is a useful
tool when monitoring how a woman
feels. On a scale of 6–20, a pregnant
woman can exert up to 12–14 (some-
what hard) during moderate exercise.
Women who are experiencing a healthy
pregnancy can follow the same recom-
mendations of approximately 30 minutes
of exercise most days of the week (2).
Although the ACSM recommends that
pregnant women can follow the same
general guidelines to exercise as non-
pregnant women, all exercises should be
Strength and Conditioning Journal | www.nsca-lift.org
Warning signs to terminate exercise
while pregnant
Vaginal bleeding
Dyspnea before exertion
Dizziness
Headache
Chest pain
Muscle weakness
Calf pain or swelling (need to rule
out thrombophlebitis)
Preterm labor
Decreased fetal movement
Amniotic fluid leakage
modified for the safety of the fetus and
mother. The goals of the exercise pro-
gram may differ from the goals for
a pregnant woman. For example, weight
loss is usually a main goal for an exercise
program but would not be a main goal
during pregnancy. The goals of
the exercise program should reflect
the highest level of physical fitness
possible while still maximizing safety
for both the mother and the fetus.
Also, a pregnant woman should be
encouraged to drink enough fluids
before, during, and after a workout
and to avoid working out in hot humid
conditions. Temperature regulation dur-
ing pregnancy is important because the
mother’s core temperature rises 1.5°C
during the first 30 minutes of exercise
(2). The baby’s core temperature is
1°C higher than the mother’s core
57
58

Core Training During Pregnancy

Table 2
Exercises that meet all ACOG and ACSM guidelines for training during pregnancy
VOLUME 34 | NUMBER 1 | FEBRUARY 2012

Exercise Trimester Description Target muscles

Kneeling rope ab 1st to 2nd Upper arms perpendicular to the floor Rectus abdominus
crunch
Crunch down until elbows are close to knees
Bring back to starting position and repeat
Planks 1st to 2nd Lie face down resting on forearms palms flat on floor Entire core musculature
Push off the floor, raising up onto toes and resting on elbows
Keep back flat, tilt pelvis, and contract abs
Hold for 10–20 s
Seated ab crunch 1st to 2nd Same as kneeling ab crunch but seated on bench Rectus abdominus
Standing crunch 1st to 2nd Same as kneeling ab crunch but standing Rectus abdominus
Kegals 1st to 3rd Squeeze the pubococcygeus muscle for 5 s Pubococcygeus muscles of the pelvic floor
Relax and repeat
Opposite arm/leg raise 1st to 3rd Begin on all fours Erector spinae, entire core musculature
Pull your belly button toward your spine
Raise your right arm and left leg until they are in line with your
body
Hold for 5 s and return to starting position
Alternate sides
Can-Can 1st to 3rd Sit upward on mat with your knees held in toward chest Obliques, rectus abdominus, erector spinae
Keeping waist lifted, twist legs to right
Bring legs back to neutral then twist to left
Standing MB rotations 1st to 3rd Hold MB with feet hip-width apart Rectus abdominus, transverse abdominus, obliques
Position hands at midline of your body
Contract abs
Slowly rotate torso in one direction and repeat in opposite
direction
 Table 2
(continued )
Seated MB rotations 1st to 3rd Sit on mat with knees bent, feet together Rectus abdominus, transverse abdominus, obliques
Sit upright with chest raised and back erect
Rotate torso and MB to one side
Pause briefly and rotate completely to other side
Modified V-sit on bench 1st to 3rd Sit on floor with legs extended in front Abdominals, obliques, illiopsoas, rectus femoris
or floor
Hands down on mat on both sides for support
Knees together and pull knees toward chest
Return to neutral position
Stability ball seated 1st to 3rd Sit on stability ball with knees bent, feet spread for stability
twists on crossover
Sit facing the machine, upright, with core muscles engaged
While holding x-over handle, rotate torso to one side
Pause briefly and rotate completely to other side
Seated bicycle 1st to 3rd Seated in a chair, raise knees to 45° Rectus abdominus, illiopsoas, rectus femoris
Hold spine in neutral position
Bring one knee at a time to your chest
Strength and Conditioning Journal | www.nsca-lift.org

Alternate knees and repeat

Standing twist on 1st to 3rd Stand facing machine with knees bent, feet spread for stability Rectus abdominus, transverse abdominus, obliques,
crossover erector spinae
While holding x-over handle, rotate torso to one side
Pause briefly and rotate completely to other side
Seated side bends 1st to 3rd Seated in a chair Obliques, quadratus lumborum
Spine in neutral position
Lean to right side and return to neutral
DB side bends (arms 1st to 3rd Hold onto dyna band with both hands about 3 feet apart Obliques, quadratus lumborum
overhead or at side)
Slowly lower and bend body to side without bending arms and
moving hips
Come back up to neutral position tightening abdominals
Repeat on opposite side
59

(continued)
Core Training During Pregnancy

temperature. An increase of any more

than 1.5°C in the mother’s temperature
could potentially cause congenital mal-
formations. Avoiding high heat environ-
ments and avoiding elevation of core
temperature during exercise will allow
the body to dissipate heat by sweating,
Abdominals, transverse abdominals

Abdominals, transverse abdominals

and when working out in cool environ-
ments, the heat production will not
exceed heat dissipation, which makes
for a safer work environment.

ab = abdominal; ACOG = American College of Obstetricians and Gynecologists; ACSM = American College of Sports Medicine; MB = medicine ball.
Women with uncomplicated pregnan-
cies are encouraged to exercise during
pregnancy. Women who do not follow
a regular exercise program before
pregnancy should ease into an exercise
regime building up to 30 min/d. Re-
gardless of whether the pregnancy is
termed uncomplicated, the ACOG
guidelines presented in Table 1 should
With core muscles engaged slowly, tilt the pelvis forward as far as

be considered before and during the

Sit on stability ball with knees bent, feet spread for stability

creation of a workout program during

Pause briefly and tilt the pelvis backward as far as feels

pregnancy (2).
Muscle function is similar between
Rotate pelvis so that lower back touches the wall

pregnant and nonpregnant exercisers

(continued )

(13). Safe repetitions for muscular work

Table 2

of 12 or more reps while avoiding

the Valsalva maneuver have been
recommended by numerous authors
(4,15,17,24). One special concern that
Stand with back against a wall

may impact training is change in the

Contract abdominal muscles

mother’s center of gravity as the fetus

Feet shoulder width apart
Heels 14 inches from wall

grows. Modifications in exercises

should be focused on balance and
feels comfortable

Knees slightly bent

coordination. To maintain balance

during training, core strength and
comfortable

Hold for 10 s

stability are crucial.

Two recent articles that offer specific
exercise recommendations indicate the
importance of emphasizing strength-
ening for the adductors, hamstrings,
gluteals, upper back, posterior deltoid,
1st to 3rd

1st to 3rd

and TVA and Kegels (7,15). Exercise

recommendations from Pujol et al. (17)
further recommend specific core mus-
cular training to indicate the efficacy of
the standing leg lifts, quadruplex,
Standing pelvic tilts
Seated stability ball

abdominal isometrics, abdominal curl

ups until the 2nd trimester, seated
abdominal machine, side bridge, pelvic
pelvic tilts

tilts, and upper and lower back exer-

cises. A list of exercises that meet all
ACOG and ACSM guidelines for
training during pregnancy is provided

60 VOLUME 34 | NUMBER 1 | FEBRUARY 2012

in Table 2. This article is one of the few
that offers specific core exercise
choices to women and personal train-
ers. Although these exercise recom-
mendations are helpful, other exercises
could be included in an asymptomatic
and risk-free women’s program.
Fitness does decrease postpartum
because demands are placed on the
mother that may interfere with her
normal exercise routine and also with
recovery due to lack of adequate rest
and recovery with improvements in
fitness postpartum being realized
2 weeks postpartum (25). When
dealing with new mothers, indivi-
dualization of training programs
must consider the particular factors
that may influence fitness levels.
The same exercise list can be used
for new mothers once they have been
cleared for exercise by their physician
for exercises involving abdominal
exercise.
PRACTICAL APPLICATIONS
Pregnant women meeting the recom-
mended exercise guidelines are typi-
cally younger, white, non-Hispanic,
more educated, not married, non-
smokers, and have higher incomes
than their counterparts who do not
meet the recommendations (16). As
personal trainers, physical therapists,
and athletic trainers work with preg-
nant populations, extra encourage-
ment may be needed to ensure that
all women exercise the proper amount
of time, thus gaining the benefits of
fitness for both themselves and their
child.
Those who have experience working
with pregnant populations can attest
to words of Pujol et al. (17), who state
‘‘the exercise professional will need to
be creative in altering exercises to
meet the woman’s needs and the
safety requirements of the fetus.’’ If
this simple yet critical concept is at the
forefront of all training, women with
uncomplicated pregnancies should be
encouraged to take part in fitness
programs, which include the core
musculature exercises depicted in this
article.
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