Advancing Care for Pregnant and Postpartum Athletes: A Call to Action for Athletic Trainers

Key Points

• Pregnant and postpartum athletes require individualized, evidence-informed care, because current sports medicine guidelines are limited, particularly for competitive and elite populations. Athletic trainers must adapt training and rehabilitation strategies to account for unique physiological and biomechanical changes.

• Athletic trainers play a pivotal role on interprofessional care teams by monitoring athlete and fetal health, recognizing complications, modifying activity, and guiding safe return-to-play progressions. Their close patient relationships uniquely position them to advocate for patient-centered care.

• The athletic training profession must advance through education, research, and advocacy to support perinatal athletes. This includes integrating female-specific health into curricula, ensuring sex equity in sports medicine research, and publishing professional position statements to guide clinical practice.

Because the ages of peak athletic performance and predicted peak fertility often overlap, there is an increasing prevalence of pregnant and postpartum athletes participating in high-impact activities at the highest levels, yet specific guidance for athletic trainers (ATs) on appropriate activity modifications during pregnancy and appropriate return to activity postpartum (Table 1) remains limited.^1–3 Although partaking in exercise is generally safe for most individuals during pregnancy, there are multiple risk factors and conditions while managing the care of a perinatal athlete.^3–8 Musculoskeletal injuries are common for the perinatal population, especially in the third trimester, with falls being the most frequent mechanism of injury.⁴ Recent evidence also demonstrates that postpartum individuals are at increased risk for musculoskeletal conditions, particularly in active-duty military populations for whom physical demands remain high.⁹ However, the scope and mechanisms of musculoskeletal injury specifically related to sport or physical activity in perinatal populations remain largely undefined. Exploring perinatal health in sports medicine and active populations provides a chance to develop preventive and rehabilitative health care for athletes experiencing this health condition.

Table 1.Common Definitions Related to Pregnancy¹

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New conversations about pregnant and postpartum athletes made headlines in recent years due to more new mothers competing in the Olympics. Athletes like Allyson Felix, Kim Gaucher, Alysia Montaño, and Naomi Folkard spoke to the public about their journeys of being mothers and training as Olympic athletes. Additionally, the tragic loss of Tori Bowie in the summer of 2023 to complications of pregnancy sparked renewed conversations around maternal mortality. Authors of a recent scoping review found that many postpartum athletes return to sport without adequate guidance, placing them at greater risk for injury, and highlighted the critical role that trained clinicians, including ATs, can play in creating individualized return-to-sport pathways.² Topics such as safe participation during pregnancy, return-to-play protocols, nutrition plans, common perinatal conditions, and breastfeeding concerns have begun to surface, and clinicians are recognizing a need for structured guidelines. Pregnancy is a health condition that affects every organ system, and biomechanical changes result in postural and gait changes and limitations in range of motion.^3,5,8,10,11 With appropriate evidence-based training guidelines, ATs would be able to enhance their clinical decision-making when working with pregnant and postpartum athletes. Reducing injury risk and providing optimal care while allowing these patients to continue to live active lifestyles and maintain their competitive edge is the goal. Therefore, the objectives for this article are to (1) highlight considerations and potential challenges of providing care to pregnant and postpartum patients, (2) discuss how ATs can serve an important role that is often unconsidered, (3) identify considerations for ATs as they approach the unique medical circumstances perinatal patients present, and (4) discuss ways in which the athletic training profession can improve care provided to pregnant and postpartum athletes through education, clinical practice, and research. Although the Commission on Accreditation of Athletic Training Education (CAATE) Standards serve as the criterion for professional athletic training programs, reproductive and perinatal health is only implicitly mentioned, signaling a need for more robust educational integration.¹² Because this topic is not often included in regular athletic training discussions, Table 1 provides a list of pregnancy-related definitions. According to the Board of Certification’s Practice Analysis, 8th Edition, ATs are expected to promote health literacy, optimize wellness, and implement individualized risk-reduction strategies, which are essential skills when working with pregnant and postpartum patients.¹³ These competencies reflect foundational elements of patient care that translate directly to the perinatal population. Athletic health care encompasses the services provided to a broad range of athletes, including recreational, competitive, and tactical, so this call to action can be applied to all athletes regardless of type or level of activity.

LACK OF EVIDENCE TO SUPPORT PERINATAL ATHLETES

To date, there is a dearth of available evidence regarding the epidemiology and pathophysiology of injuries sustained by perinatal athletes as well as postpartum rehabilitation and treatment. Due to the scarcity of evidence for this population, it is difficult to provide specific clinical recommendations supported by levels of evidence or grades of recommendation using established scales (eg, Strength of Recommendation Taxonomy, Centre for Evidence-Based Medicine).

Current evidence on the epidemiology and pathophysiology of injuries among perinatal athletes is graded low to very low in quality due to few existing studies that include elite perinatal athletes, small sample sizes, design flaws, limited or inconsistent information on participants, no fetal data, practical challenges relating to parenthood, poor measurement reporting, a lack of research on transitioning to competition, difficulty with blinding pregnant individuals and clinicians, and overall exclusion of pregnant athletes from studies’ participant criteria.^3–8,11 Additionally, sports medicine literature is limited on guidelines after vaginal versus cesarean births, premature birth, miscarriages, fetal death, spontaneous and elective abortions, pregnant adolescents, and those pregnant with more than 1 fetus. There are even fewer studies that examine common conditions after childbirth, including infection, perineal pain, breast pain, uterine prolapse, thrombosis, gestational diabetes, cardiovascular disorders, depression, bladder and fecal incontinence, biomechanical movement dysfunction, and general fatigue.^{3,5,7,8,11,14,15} Although current training recommendations are often based on lower levels of evidence, many are nonetheless informed by expert consensus. This highlights the potential value of developing future guidelines through a formal expert panel to standardize care and provide a stronger framework for future scholarly work.

Current literature on postpartum rehabilitation progressions and treatment lacks consistent evidence. Although the physiological and biomechanical differences between females and males are well cited, studies lack training-specific guidelines for female athletes, especially the pregnant and perinatal population.^3,5,11,16 Because perinatal athletes who previously exercised regularly tend to continue with high-intensity training, ATs who work with a population of childbearing age are likely to be tasked with designing programs that progress a perinatal or postpartum athlete through rehabilitation or training.^8,17 With most athletes choosing to continue their demanding training program during childbearing years, more information is needed for clinicians to recommend and direct appropriate training.^8,16 Christopher et al established a 4-phased approach to rehabilitating a postpartum runner that considers a myriad of physical, emotional, and psychological factors when progressing an athlete back to running postpartum and can provide useful guidance to ATs caring for postpartum athletes.¹⁸ However, the recommendations do not address training during pregnancy or athletic activities beyond running, nor do Christopher et al consider elite athletes returning to competitive sport.¹⁸ There is rare evidence showing harmful effects of exercise on the pregnant athlete or fetus for the average athlete who exercised regularly before pregnancy.^8,17,19 Therefore, training programs should be carefully personalized, because each patient and each pregnancy has an individual threshold and medical history to consider, just as an a AT would design an individualized training plan for any other health condition.

Authors of future guidelines should also consider establishing characteristics that distinguish a pregnant athlete who partakes in recreational exercise from an elite or tactical pregnant athlete training for competition or as a part of a career. Current obstetrical guidelines for active pregnant athletes advocate for approximately 150 minutes of moderate aerobic exercise per week, which is significantly less in terms of duration and intensity than an elite or tactical athlete’s participation.^3,19,20 High-quality literature lacks parameters for elite or tactical perinatal athletes.^{3,5–8,16,17,19,20} Exercise recommendations should include exercise intensity, frequency, and duration; activities that should be avoided; and approval from health care professionals involved in the decision-making.

THE ROLE OF THE AT IN THE CARE OF PREGNANT AND POSTPARTUM ATHLETES

As is the case with many other health conditions, ATs thrive on interprofessional care teams, and, because pregnancy is a multisystem health condition, expertise from many different health care fields will enhance patient outcomes. The members of the interprofessional care team may include an obstetrician or midwife, a doula, a lactation consultant, a registered dietitian with education and experience working with both pregnant and athletic populations, a pelvic rehabilitation specialist, a behavioral medicine provider, a social worker, a sports medicine physician, and the AT, depending on the athlete’s individual preferences and circumstances. As the athlete progresses through their pregnancy and eventually the return-to-activity protocol postpartum, all members of the care team should collaborate closely and share equal decision-making responsibility, regardless of roles or credentials. If the dietitian has concerns about the athlete participating on a given day, that opinion should hold just as much weight as if the obstetrician were to express concerns. Because ATs often develop close and trusting relationships with their patients, the AT is uniquely positioned to facilitate communication among providers, provide education to the patient, and monitor the patient for life-threatening conditions during activity. When a pregnancy is reported or suspected, the AT should respond with compassion and a desire to help. Rapport and patient trust are critical components of patient-centered care. Research suggests that trust in the AT predicts an individual’s likelihood of disclosing a pregnancy, further emphasizing the importance of the clinician-patient relationship in these situations.²¹

With the many changes in an athlete’s body and symptoms that vary day-to-day during pregnancy, the AT’s responsibility should include distinguishing between common and severe perinatal conditions and understanding when to refer the athlete to more advanced-level care.^8,11,17 With education and training in treating minor to life-threatening injuries, ATs provide a safe training environment and are prepared to intervene during emergencies. The patient’s heart rate is one of the most common and important factors that should be monitored closely in perinatal athletes.^6,7,19,20 Although heart rate may vary depending on pregnancy stage and number of fetuses being carried, ATs are educated on recognizing the exertional effort that pregnant athletes may exhibit during high-intensity training, including labored breathing and tachycardia.^3,8,11,20

The majority of hospitalizations occur in the third trimester, with falls affecting at least 25% of pregnancies.⁴ With the knowledge of gait analysis, posture corrective exercises, functional movement patterns, and faulty mechanics, the AT is uniquely qualified to monitor the patient throughout their physical adaptations during pregnancy. For ATs, several factors may contribute to clinical decision-making, depending on the patient’s medical history and predisposition to common conditions during pregnancy, and should be considered when designing a return-to-activity progression. These factors include the type of birth, complications during pregnancy or birth, compensatory biomechanical patterns, and prepregnancy training status. With appropriate education on training pregnant and postpartum athletes, ATs will become an even more valuable asset to the medical team.

COMMON CONDITIONS AND PHYSICAL CONSIDERATIONS

Pregnancy involves physiological changes that affect every organ system in the body. Common physical conditions affecting the pregnant or postpartum athlete may include musculoskeletal pain, preeclampsia, gestational diabetes, fecal or bladder incontinence, constipation, perineal tears, pelvic organ prolapse, and diastasis rectus abdominis, which affects nearly all individuals in the third trimester and persists in approximately one-third of individuals postpartum.^{3,8,11,17,22,23} However, traditional athletic training education and continuing education do not provide much guidance on how to recognize or address these conditions. For example, preeclampsia is characterized by edema, protein in the urine, and hypertension that can progress to seizures, but the diagnostic criteria vary greatly, leading to difficulties in comparisons across populations.²⁴ Preeclampsia also has implications for the developing fetus. Hypertension results in abnormal development of the placental vasculature, which leads to reduced perfusion and fetal hypoxia, so early recognition and referral to more advanced care is important.¹⁰ The most prevalent form of urinary incontinence is stress urinary incontinence, which has been reported to affect up to 20.7% of female athletes in a variety of activities, regardless of parity.^8,15,17 With early detection and proper management, therapeutic exercise may improve these conditions, restoring the patient’s overall quality of life. Along with providing careful monitoring, ATs should counsel athletes and coaches on warning signs and symptoms of common pregnancy complications that have the potential to occur during exercise.

Traditional guidelines for activity during pregnancy are set by the American College of Obstetricians and Gynecologists. These guidelines categorize pregnancy by its 3 trimesters and encourage physical activity throughout pregnancy, explaining that there is minimal risk and high benefit.¹⁹ Known benefits of routine exercise include healthy birth weight and a lower incidence of gestational diabetes mellitus, preeclampsia, premature birth, and cesarean or instrument-assisted birth.^6,19,20,25 In addition to these physical benefits, regular physical activity may also improve psychological well-being, with research linking prenatal exercise to reduced symptoms of anxiety and depression and a lower risk of postpartum depression.²⁶ For the past 20 years, literature has demonstrated that exercising is beneficial for both the patient and the fetus if the pregnancy is free of contraindications.^{5,19,20,25,27}

To track the development of the fetus, gestation is divided into trimesters, with each trimester lasting approximately 12 weeks.²⁴ Athletic trainers and other providers can also use these trimesters to track physiological changes in the athlete and make appropriate training modifications to accommodate those changes. Aerobic exercise 3 to 4 days each week, up to daily, for 30- to 60-minute sessions at a time, is encouraged during the first trimester and up to birth.^19,20 Those who regularly performed high-intensity aerobic activity before pregnancy are encouraged to continue the same activities through pregnancy and postpartum, with appropriate medical clearance and monitoring.^19,20 At 14 weeks and beyond, it is recommended to avoid contact sports, such as lacrosse and martial arts; activities with a high risk of falling, such as equestrian sports and skiing; training in a supine position, such as bench press and backstroke in swimming; exercises that increase intra-abdominal pressure, such as gymnastics and scuba diving; and holding breath underwater for long periods.^19,20 Exercises such as walking, running, stretching, stationary cycling, dancing, aerobics or water aerobics, and resistance training with body weight, bands, or free weights are all safe and beneficial throughout each pregnancy phase.^6,19,20,25 Modifications are recommended as biomechanical and physiological changes place new stresses on the body that require adaptation.^4,8,19 Even with research demonstrating positive outcomes from physical activity, pregnant elite athletes are often hesitant to participate due to uncertainty of proper precautions and how to correctly modify activities.^28,29 The role of the AT is to understand necessary precautions and to intervene if signs and symptoms of emergent conditions present.

POSTPARTUM RETURN-TO-ACTIVITY CONSIDERATIONS

Safety precautions should be continued as the athlete enters postpartum. Though the patient is no longer pregnant, many of the physical symptoms experienced in the third trimester may persist into the postpartum period. The effects of pregnancy can extend well beyond the first year after childbirth, particularly in athletes who continue to lactate, as hormonal fluctuations associated with breastfeeding may influence musculoskeletal recovery and readiness to return to sport.^{3,5,6,8,11,18,19,33} Musculoskeletal changes will continue and must be monitored during the first 6 months postpartum as connective tissue and muscle tissue recover and repair after childbirth.^4–8,11,19

Immediate recovery from childbirth may involve monitoring wound healing, including cesarean or episiotomy incisions and perineal tearing.⁶ Continued interdisciplinary care is recommended to assess the patient’s physical and mental status, pelvic health concerns, nutritional needs, breastfeeding concerns, and patient goals as they pertain to physical progression and athletic performance, and return to activity should be gradual and individualized after a period of relative rest.^7,32 High-intensity training and exercises involving jumping or running may lead to injury if done before adequate healing of the pelvic floor, abdominal muscles, or associated wounds. Generally, return to high-impact activity is not recommended before 6 weeks postpartum for a vaginal birth or 8 weeks for a cesarean birth, although these timelines may vary depending on the individual’s healing, symptoms, and medical guidance.⁷ Komatsu et al found significant variability in the time for resolution of pain and functional recovery between vaginal and cesarean birth.³⁴ Median time for pain-free functional recovery was 19 days after vaginal birth and 27 days after cesarean birth, so type of birth should be considered during an athlete’s recovery.³⁴ Although the interprofessional health care team continues to monitor health assessments, the patient may begin progressing their weight training and cardiovascular training. Setbacks are probable in this rehabilitation phase, so educating the patient and coaching staff on recovery expectations is essential. Once the patient returns to unrestricted activity and competition, a routine maintenance program for injury prevention and regular physical, functional, and mental health screenings may be established to support long-term health, enhance performance, and reduce the risk of reinjury. The AT should continue to work with a comprehensive interprofessional health care team for appropriate activity progressions and continuity of care.

Pelvic floor muscle training prescribed by a physical therapist with advanced training in pelvic health (eg, a board-certified women’s health clinical specialist) or an occupational therapist with similar advanced training may be beneficial for all athletes participating in impact activities and is recommended for athletes who suffer from pelvic floor dysfunction or urinary or fecal incontinence after pregnancy.^{3,5–7,11,22,35} These conditions are not normal but are common for postpartum patients.^3,5–7,35 Patients who experience episiotomy scarring or perineal tears due to birth also often experience pelvic floor dysfunction.⁵ Although pelvic floor strengthening is commonly emphasized in postpartum recovery, it is important to recognize that some individuals may present with pelvic floor dysfunction such as hypotonicity, hypertonicity, or coordination impairments, all of which require individualized assessment and treatment approaches by a trained specialist.^5–7,15,35 Pelvic floor muscle training postpartum can improve the patient’s quality of life and reduce complications or delays in returning to sports participation.^5–7,15

Lactating individuals have increased caloric needs to support milk production, and when these needs are not met, they may be at elevated risk for relative energy deficiency in sport. Inadequate energy intake during this period can impair hormonal function, hinder recovery, and compromise both athletic performance and lactation.³⁶ Athletic trainers should consider these nutritional demands when advising postpartum athletes and collaborate with dietitians or other providers to ensure adequate nutritional support during the postpartum period. In smaller-sample-size studies, the majority of athletes who continued to breastfeed while returning to high-impact exercise did not experience adverse health effects, nor did they notice an effect on lactation production or ability to breastfeed.⁷ However, monitoring calcium and vitamin D intake may be beneficial during the lactation period to maintain adequate bone density.³

Recent literature shows the most commonly reported postpartum symptom is low back and pelvic pain, affecting nearly half of studied athletes.^4–7,11 Neck pain and shoulder pain are also frequently reported, with urinary incontinence affecting most postpartum individuals.¹¹ Urinary incontinence can be problematic for several months to years after birth and affects a higher percentage of individuals after the birth of their first child compared with nulliparous athletes.^6,11,15 With weight training or sports that require increases in intra-abdominal pressure, such as gymnastics, ATs may collaborate with pelvic rehabilitation specialists and intervene to improve physical function. By slowly increasing the load, the AT can monitor the demands placed on the core and pelvic floor, which were stressed by pregnancy.^6,11,15 Standards for this phase are needed in the athletic training profession, as they would help guide the athlete as they return to an active lifestyle without compromising their health. Table 2 offers general guidelines for a phased approach to activity postpartum. These guidelines should be adapted to fit individual situations and circumstances. A team-based health care approach should be maintained, and all members of the health care team should be in agreement with the athlete’s progression.

Table 2.Athletic Participation Considerations After Full-Term Birth

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Sundgot-Borgen et al found that athletes felt their training levels were the same or had improved since parenthood, but athletes reported not being satisfied with the postpartum training guidance they had received.³ Athletic trainers are qualified to recognize potential risks during athletic activity, have the knowledge and skills to intervene in emergencies and musculoskeletal injuries, and are capable of properly progressing an athlete to a level of activity consistent with prepregnancy. Athletic trainers are uniquely positioned to support perinatal athletes, offering clinical expertise and trusted guidance in situations in which medical advice may be limited or unsatisfactory.²¹ Their presence fills a critical gap in care, making them an invaluable asset to this population.

CALL TO ACTION FOR THE ATHLETIC TRAINING PROFESSION

Table 3 provides specific calls to action for each facet of the athletic training profession. As health care providers with a specialty in athletic health care, ATs are uniquely equipped to provide expertise and guidance for pregnant and postpartum athletes.

Table 3.Recommended Actions for Athletic Training Professionals

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CONCLUSIONS

At the professional organization level, advocacy for education, awareness, and resources are needed to improve perinatal health monitoring and patient outcomes. The athletic training profession is equipped to mobilize, develop, and use a position statement that addresses care for perinatal athletes. While awareness to improve perinatal care and resources across health care organizations grows, the everyday life experiences of perinatal athletes continue to be marginalized. There is much to be considered in being an advocate, promoting safety, and practicing ethically for perinatal athletes. Only through understanding perinatal athletes’ needs and implementing progressive education and resources can this issue be resolved.