The Legacy of Pregnancy

Elite Athletes and Women in Arduous Occupations

Thea Jackson; Emma L. Bostock; Amal Hassan; Julie P. Greeves; Craig Sale; Kirsty J. Elliott-Sale


Exerc Sport Sci Rev. 2022;50(1):14-24. 

In This Article

Current and Proposed Management

There is a lack of evidence available to develop best-practice guidelines for the care of pregnant and postpartum elite athletes and women employed in arduous occupations. Consequently, beyond the standard care provided by the UK National Health Service (NHS), there are disparities in the guidance and care available. For uncomplicated pregnancies, standard NHS care provides a midwife and general practitioner-led model of care, and women are offered additional care provided by specialist teams, if problems are identified.[144] The management of pregnant and postpartum elite athletes is guided by the experiences of support staff and any medical professionals that form part of the wider support team (e.g., sports physiotherapists) rather than by scientific evidence or clinical guidelines. As such, there is no standardized approach to managing a pregnant/postpartum elite athlete, and organizational policies make little to no reference to the support of pregnant or nursing athletes at competitive events or even for day-to-day training. Women in arduous occupations are subject to unique organizational policies, for example, there are differences in the UK approach to returning women to physical training after childbirth between the Royal Air Force, Royal Navy, and the British Army. The British Army provides women with a graduated return to fitness program for 6–12 wk after their return to work, whereas the Royal Air Force and Royal Navy do not provide a specific phased return to physical activity, unless requested by the individual.

Herein, we propose an approach that could be implemented to address inconsistencies in the management of pregnant and postpartum elite athletes and women in arduous occupations using a multidisciplinary team (MDT). An MDT approach has been successfully adopted in many sporting contexts including both team and individual sports. For instance, Dijkstra et al.[145] describes an MDT and integrated approach to athlete health that underpinned the success of the UK track and field team at the London 2012 Olympic/Paralympic Games. An MDT approach (Figure 1) provides a range of skills and expertise for holistic athlete health management and, consequently, achievement of performance goals. It also ensures specialist care is provided and the unique implications of pregnancy and childbirth are addressed.[136] In this model, different members of an MDT are required at different stages throughout an athlete's journey, for instance, coaches, physiotherapists, and nutritionists are required to adapt physical training, performance, and dietary needs for a pregnant athlete (Figure 1), and the priority of care is adapted to an individual's needs and stages of pregnancy.

Figure 1.

Novel integrative concept to return elite female athletes and women in arduous occupations to high-level performance after pregnancy. CV, cardiovascular; HR, heart rate; RED-S, relative energy deficiency in sport; RER, respiratory exchange ratio; RPE, rating of perceived exertion.

Women in arduous occupations face similar physical and psychological demands as elite athletes, and on this basis also warrant an MDT approach to care. At present, UK servicewomen, policewomen, and firefighters access standard NHS care throughout pregnancy and after childbirth. Access to an MDT, such as specialist pelvic health physiotherapists, is not routine practice. Only in the presence of symptoms will they be able to access additional services. It is, therefore, vital that women, coaches, employers, and members of the wider MDT (Figure 1) develop a sound understanding of the adaptations that occur during each trimester of pregnancy and after childbirth and how these changes may impact upon exercise physiology. Women also should be encouraged to evaluate their own risk for exercise participation during pregnancy, using tools such as the Canadian Society of Exercise Physiology "Get Active Questionnaire for Pregnancy".[146] Using a questionnaire such as this in combination with better awareness of pregnancy adaptations (Table), women and MDT are better placed to make informed decisions regarding training, performance, or occupational duties through pregnancy to avoid injury and complications and to facilitate postpartum recovery (Figure 1).

Contrary to traditional approaches and beliefs, it is possible to prevent common complications associated with pregnancy, such as urinary incontinence[144] and lower back pain.[147] Often, women wait until after childbirth to address common complaints, meaning that they have become more established conditions and are harder to treat.[148] Evidence suggests that if the intervention is intensive and early enough, pelvic floor muscle training throughout pregnancy in healthy women (with no prior pelvic floor dysfunction) may reduce the incidence of urinary incontinence and pelvic floor dysfunction in late pregnancy and the postpartum period.[10,143,149] Adverse pregnancy outcomes, such as preterm birth, preeclampsia, and intrauterine growth restriction associated with physically demanding occupations, could be prevented through careful consideration of workplace guidance and strategies that reduce activities such as prolonged standing (>4 h), prolonged walking (>4 h), and heavy lifting (>100 kg·d−1).[134] The use of similar preventative approaches in elite athletes and women in arduous occupations may help limit pelvic floor dysfunction throughout pregnancy and after childbirth and reduce the risk of adverse pregnancy outcomes, although more research is needed to investigate preventative strategies within these cohorts.

After an uncomplicated pregnancy, labor, and birth, individualized rehabilitation can start as early as the first day after birth.[142] Using a phased approach, such as the one proposed by Bø et al.,[10] and updated by Deering et al.,[136] elite athletes and women in arduous occupations should progress through three distinct postpartum phases: active recovery, training, and performance, under the supervision of an MDT (Figure 1). The "active recovery" phase should support the transition into motherhood and address pregnancy-and birth-related concerns. To enhance continuity of care, a pelvic health physiotherapist should be employed throughout pregnancy to address the musculoskeletal complaints and pelvic floor dysfunctions identified in Table. The "training" phase should prioritize functional or sport-specific exercises in preparation for returning to competition. During the "performance" phase, the primary goal is to develop athletic performance that requires continuing communication between all members of the MDT involved. The transition between each phase is a dynamic process, whereby women can reenter phases dependent upon injury or after competition in an off-season. We suggest that a similar approach should be adopted by women in arduous occupations to ensure graded return to exercise including a progression from low- to high-impact exercise and an increase in training volume before intensity. The initial active recovery phase would not need to be altered; however, the training phase should place emphasis on occupation-specific exercise and functional tasks replicating occupational demands. The final phase should encourage occupational performance, enhancing maternal well-being and improving physical and psychological health on returning to work.

The unique adaptations of pregnancy and childbirth pose a significant challenge to elite athletes and women in arduous occupations, requiring person-centered, MDT-based management. It is important to raise awareness of the changes that occur during pregnancy and the possible implications on health and performance in elite athletes and women in arduous occupations and to educate the MDT. Furthermore, preventative approaches during pregnancy aimed at improving maternal health after childbirth require further investigation within the context of elite sport and arduous occupations. Women in arduous occupations urgently need improved provision and accessibility to services to reduce injury and illness concerns upon returning to work. Overall, it should be emphasized that recovery after childbirth is not necessarily linear and women should be prepared to transition back and forth between training and performance phases.