Changing Times

In the past, pregnant athletes were expected to stop competing and postpartum athletes were expected to stay at home. But times have changed, and sports medicine staffs have found new ways to help their athletes who are expecting.

By Laura Smith

Laura Smith is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 14.9, December 2004, http://www.momentummedia.com/articles/tc/tc1409/changingtimes.htm

Itís one of the most difficult situations an athletic trainer can face, combining complex medical questions with powerful psychological issues. Itís rare, so when it hits you, chances are you wonít have a backlog of experience to draw on. Complicating matters further, your athletic department may not even have a policy you can turn to for help. The scenario? An athlete tells you that she is pregnant.

From the time an athletic trainer learns or suspects that an athlete is pregnant, a series of questions arise. How do you balance confidentiality with protecting the athleteís health and safety? What, if anything, is your role as she faces the question of whether to keep or terminate the pregnancy? Is it safe for her to continue training and competing, and if so, with what restrictions? After an athlete gives birth, what are the best rehab practices?

In this article, we tackle these questions with the expertise of several veteran athletic trainers, two team physicians, two specialists in sports gynecology, a strength and conditioning coach, and a team psychologist, all of whom have cared for pregnant athletes.

PLANNING AHEAD
Successfully handling an athleteís pregnancy starts long before the athlete shows up in the athletic trainerís office to break the news, but this is one area where athletic departments have historically failed to plan ahead, according to Lois Mattice, MS, ATC, Athletic Trainer at California State University-Sacramento. "What is the policy if someone becomes pregnant? Most institutions donít have one," she says. "Often, nobody wants to touch the subject, and the lack of clear guidelines makes it very difficult to deal with."

Jon Almquist, ATC, Specialist for the Fairfax County (Va.) Public School System, has encountered the same policy vacuum at the high school level. "There just arenít any concrete rules," he says. "Itís really left up to each institution to set a policy, and so itís critical to put one in place."

One school that has developed a formal policy on athletes and pregnancy is Wright State University. "We believed that athletes who became pregnant were either concealing their pregnancies and continuing to play, or feeling pressure to quickly opt for abortion," says Elizabeth Sorensen, PhD, Assistant Professor in the College of Nursing and Health and Faculty Athletic Representative at Wright State, who helped develop the policy with assistance from the schoolís sports medicine staff. "A policy was desperately needed to make sure this would no longer happen."

To be effective, a policy first needs to clarify the athletic departmentís philosophy on pregnant athletes. "Our policy makes it clear that we view pregnancy as a health event in an athleteís life, and that she is to be treated no differently than someone with a knee injury, a shoulder injury, or any other temporary medical condition," Sorensen says. "And it stresses that a pregnant athlete should be allowed to continue to participate whenever possible, under close medical supervision, up to and sometimes even past 14 weeks of gestation."

The Wright State policy also requires the university to assist a pregnant athlete in two very specific ways. One, it will help her obtain neutral counseling from someone outside the athletic department prior to making any decision about her course of action. Second, it will form a decision-making team to address her continued participation.

An effective policy also needs to address scholarship issues. According to NCAA rules, an athlete cannot lose his or her scholarship because of a temporary injury or medical condition, but the NCAA does not currently specify whether pregnancy falls into this category. However, if the athlete wishes to return to play, Title IX would likely protect her scholarship. And NCAA rules do allow an additional medical redshirt year for athletes who become pregnant. The Wright State policy considers pregnancy a protected condition under its scholarship rules, and counsels pregnant student-athletes against voluntarily withdrawing from their sport, since this can lead to loss of their scholarship.

Once a policy is in place, the next step is communicating it beyond the athletic administrators and sports medicine staff. Sorensen first met with all Wright State coaches. Next, she met with each female sports team and with Wright Stateís Student-Athlete Advisory Council. She also made sure that the information was included in this yearís student-athlete handbook.

In addition to having a policy, itís wise to gather a few other resources beforehand. For Jeff Konin, PhD, ATC, PT, Assistant Athletic Director for Sports Medicine at James Madison University, that means having a set of names and phone numbers for referral within armís reach. "Weíve set up a team for situations like this," Konin says. "It includes our team physician and counselors at the health center. I have those resources all arranged, so I can immediately give the athlete names and numbers."

Another resource to have on file is information regarding health insurance coverage. "Contact your student health insurance office before this ever comes up and find out exactly what is covered if a student becomes pregnant," says Sorensen. "Having that kind of practical information readily available is often the most helpful thing you can do."

FIRST RESPONSE
The days surrounding the initial discovery and disclosure of an athleteís pregnancy are often the most tense and difficult, both for the athlete and the athletic trainer. How can you help her navigate this time period, protecting her confidentiality, health, and safety?

If an athlete tells you she is pregnant, the first step is to verify her condition, according to Anita Clark, ATC, LATC, Associate Athletic Trainer at the University of Oklahoma. "We need to know for sure, so I send her to our health center for a pregnancy test," Clark says. "And I make sure that the confidentiality stays 100 percent until she has the test."

If the test confirms a pregnancy, the next step is to refer the athlete to a gynecologist without delay. "There are important steps that need to be taken immediately," says Mona Shangold, MD, Director of the Center for Womenís Health and Sports Gynecology in Philadelphia. "She needs to make a decision about keeping or terminating the pregnancy as soon as possible, so that thought process needs to start immediately. And if there is any chance at all that sheís going to keep the pregnancy, she needs to begin taking prescription folic acid right away. Any delay on that could have a negative outcome for the fetus."

The need for the athlete to decide quickly whether to keep or terminate the pregnancy must be balanced with giving her time. Clark feels itís important not to pressure the athlete. "She needs to really process the situation and talk with the important people in her life," Clark says.

During this phase, the athlete may request that the athletic trainer not inform the coach or anyone else of the situationóa request Clark says she will sometimes agree to for a short period of time. "I try as hard as I can to encourage her to tell the coach as soon as she is able to," says Clark.

Confidentiality and disclosure issues at the high school level can be more complex. Rules vary, but most schools require personnel to inform a school counselor or administrator immediately of a personal issue that affects a studentís welfareóand an athleteís pregnancy may well fall into this category.

Almquist advises against handling the situation on your own at the high school level. "Itís critical to understand the reporting structure at your school," he says. "Immediately involve another professionalóthe counselor, the school nurse, or the person you report to. And if an athlete begins to tell you something in confidence, donít promise you can keep it a secret. Make sure she knows that you may be required to tell someone."

BE CAUTIOUS WHEN COUNSELING
While an athlete is deciding whether to continue her pregnancy, what is the appropriate role of the athletic trainer in helping her through the decision? The degree to which athletic trainers discuss this issue with a pregnant athlete varies by individual, but all agree on one thing: Proceed with caution, remain neutral and supportive, and focus on your role as a health care provider.

"If the athlete wants to discuss her decision with me, Iíll ask her what she has been considering," Clark says. "I just listen and let her talk about what sheís been thinking and feeling."

Nicki Moore, PhD, Assistant Director for Athletic Psychological Services at the University of Oklahoma, stresses the importance of acknowledging your own biases. "This is a very visceral issue for many people," Moore says. "If you have a strong opinion one way or the other, thatís fineóbut understand that you may not be able to objectively help the athlete consider her options. Be aware of your own limitations and refer her to a counselor."

"An athletic trainer risks exceeding their expertise on this one," notes Konin. "Even though a trusting relationship may exist and the athlete may turn to you for advice, athletic training curriculums do not equip us to counsel athletes about crisis pregnancy. And if the pregnancy is a result of sexual assault or an incident involving alcohol, that requires a whole different level of counseling. I have no problem saying Iím out of my league and referring her to a trained counselor."

In the high school setting, Almquist believes athletic trainers should stay out of counseling pregnant athletes entirely. "Even discussing options can be dangerous," he says. "Letís say Iím an athletic trainer working with the girlsí basketball team, and an athlete tells me she is pregnant and considering an abortion. If I offer her any information about the procedure, or even acknowledge that itís an option, and her parents are adamantly against abortion, my job could be gone in a heartbeat. Stay professional and express concern, but do not express any advice or opinion one way or the other. Refer her to a counselor who is trained to handle it."

Oklahoma recently added Moore as an on-staff counselor for athletes, providing athletic trainers with a ready referral. Her training and position allow her to open a supportive, confidential dialogue with the athlete over the course of several sessions. "I focus on helping her develop a plan," she says. "I make sure she has thoughtfully considered all the options and that she is making her decision on her own behalf and not being coerced by anyone, and I help her communicate her decision to pivotal people in her life.

"The athleteís focus for many years may have been on reaching this level of play with her sport," she continues. "Sheís also used to spending a lot of time with her team, and she may lose that. She may be dealing with issues in her own relationship. These are some of the issues that a counselor will help her work through."

COMPETING & CONDITIONING
If the athlete elects to carry the pregnancy to term, can she continue to train and compete with her team? This is needs to be decided by the athleteís obstetrician, although at schools like Wright State, the entire decision-making team weighs in. In either case, the decision should be individualized to fit the particular athlete, and a host of variables should be considered.

When obstetricians weigh the pros and cons of athletic participation for a pregnant athlete, they have little concrete medical evidence to go on. However, in recent years, evidence has prompted the medical community to loosen its guidelines regarding pregnant athletesí participation. In fact, a healthy student-athlete with a complication-free pregnancy can often continue to compete and work out alongside her team for the first three to four months of gestation.

Even in contact sports, according to Shangold, competition is safe. "During the fist trimester, the fetus is very tiny and well protected by the bones and muscles of the motherís pelvis," she says. "There really is no danger from participating, even in a contact sport, at that point."

James Clapp, MD, Professor of Reproductive Biology at Case Western Reserve University and a leading researcher on pregnancy and exercise, agrees. "A rational, conservative approach would be to allow competition until 16 to 20 weeks, but not later," he says. "After 16 to 20 weeks, sports with a risk of blunt abdominal trauma should be avoided."

Exactly when the athlete should stop competing varies with the individual and the sport. "If sheís a swimmer, thatís going to be a very different scenario than if sheís a rugby player," Sorensen says. "The plan should be highly individualized."

Whether the athlete is competing or just training with the team, there are several important considerations to take into account:

Intensity: In the 1980s, the American College of Obstetrics and Gynecology recommended that pregnant women not allow their heart rate to exceed 140 beats per minute, but that guideline is now considered obsolete. Clapp advises instead that the athlete rate her perceived exertion during exercise, and limit it to "moderately hard." She should also monitor herself for the usual signs of over-training.

Core temperature: Because high fevers in pregnant women are known to cause birth defects, obstetricians have historically advised women to avoid exercise that raised their core body temperature. While no human studies have established a concrete link between exercise-related increases in core body temperature and birth defects, animal studies do bear out a relationship. "We think itís reasonable for pregnant athletes to avoid overheating," says Jennifer Solomon, MD, Assistant Attending Physiatrist at the Hospital for Special Surgery in New York City and Team Physician at Saint Peterís College. "Donít exercise in a hot environment, wear cool clothing, and certainly stay well hydrated to help with thermo-regulation."

Cool down: "After a workout, the most dangerous time for a fetus is immediately after the exercise ends," Shangold says. "If the mother stops exercising abruptly, her heart rate falls, which leads to decreased stroke volume and cardiac output. That means a marked decrease in blood supply to the uterus. Itís absolutely critical that a pregnant woman slow down and cool down very gradually."

No supine training: Pregnant women should not do any exercises in a supine position. More research is needed, but new studies suggest that doing so may cause the enlarged uterus to press on the aorta and inferior vena cava, decreasing both venous return to the heart and blood flow to the uterus, which can result in decreased cardiac output, hypotension, and fainting.

Nutrition: Pregnant athletes who continue participating in athletics need to be careful to get enough calories for themselves, their training, and their baby, with a focus on adding carbohydrate and protein. The athlete will also need additional folic acid, calcium, and iron.

Listen to her body: After about the fourth month, the pregnant athlete will generally need to focus on low-impact, gentler workouts. "At about 18 or 20 weeks, most athletes are going to become very uncomfortable running," says Kimberly Harmon, MD, Team Physician at the University of Washington. "They should switch to a stair climber, walking, or stationary biking." Because the growing uterus shifts the athleteís center of gravity, the focus should also change to exercises that limit the risk of falling, Solomon advises.

The athleteís body is the best judge of when to back off, according to Jodi Hopkins, Strength and Conditioning Coach for the WNBA Charlotte Sting, who recently helped center Teana Miller through prenatal workouts following the 2003 season. "For the first four months, Teana worked out four or five days a week for an hour, doing 30 minutes of conditioning and 30 minutes of weight lifting," Hopkins says. "After that, it was a matter of listening very carefully to when her body told us not to push it as hard. At about four months, we went to the pool to take the weight off her body. She did pool running in place and leg kicks, and dipped down underwater to her neck to do some pec flies and side and front raises, lunges, and squats.

"The athleteís body is very scientific," she continues. "Encourage her to stay in tune with its signals and sheíll know when itís time to stop doing something."

COMING BACK
After giving birth, as long as there were no complications, athletes can generally begin light exercise within a few weeks. By three or four months postpartum, most will be cleared to begin training with their team. When an athlete comes back to her sport after giving birth, the first step is thoroughly evaluating her individual situation in order to tailor a plan for her needs.

"Have an extensive talk with the athlete," Konin says. "Ask her to tell you about any after-effects sheís still experiencing. Is there lower back pain? Is she taking any medications? How is her energy level? In addition, find out as much as you can from her doctor."

When a player returns to the Charlotte Sting after giving birth, Head Athletic Trainer LaTonya Holley, ATC, LATC, performs a thorough assessment. "We evaluate her hips, shoulders, and knees to make sure everything is up to par," she says. "We pay attention to the little things, too. We evaluate her shoes and determine if she needs orthotics. We make sure that her clothing fits well and is comfortable. And as funny as it may sound, we make sure she is wearing an appropriate bra, especially if she is breast feeding."

Getting an athlete back in shape post-pregnancy generally involves helping to lower her body fat. Hopkins finds it works better to focus on body measurements rather than numbers on the scale. "We want to focus on something that more directly relates to performance, so when an athlete first comes back, I take measurements of her arms, chest, hips, waist, and legs," she says.

Avoiding scale-obsession is particularly important postpartum, Hopkins explains, because the athlete is usually feeling pressured to get back to her pre-pregnancy weight and may sabotage her training by eating too few calories. "Especially if the coach is pushing her to drop weight, she can become afraid to put anything into her mouth," Hopkins says. "If she doesnít eat enough to fuel her workouts, it will actually be harder for her to lose weight. This is a huge risk with postpartum athletes." She also strongly cautions postpartum athletes against using supplements to try to speed their weight loss.

"Weight loss is something we have to be very careful about with this population," Clark agrees. "The athlete going to need a lot of energy to care for her child, go to class, and participate in her sport. This is not the time for cutting way back on calories. Itís best to avoid focusing a lot of attention on it, and be very sensitive in how you approach it, because an eating disorder could very well be triggered during this stressful time."

Hopkins began working with Miller three months postpartum. She began with weight lifting and shooting drills, and worked up to 50 minutes of cardio, using a stair climber, treadmill, stationary bike, or elliptical trainer. She did weight training three times a week, using high reps, increasing weight gradually and focusing on flexibility and range of motion. "We also used a lot of court drills, since having the athlete actually do her sport is the best conditioning," Hopkins adds.

As the athlete works on gradual weight loss, itís important to be aware of the stress placed on muscles and joints. "When an athlete is pushing herself in workouts and sheís carrying extra weight, you tend to see a lot of little injuries," Holley says. "It can be shin splints, knee, back, or hip pain, or even stress fractures in the feet. Itís very important to prevent small injuries and to address them immediately if they do occur."

To accomplish that, Holley and Hopkins work closely together. "We emphasize to the athlete that she needs to tell us immediately if she feels that anything isnít 100 percent," Hopkins says. "As weíre working out, I ask her, ĎHow do your hips feel? How do your knees feel? How do your shins feel? I also keep a close eye on what Iím having her do. If she ran yesterday, Iíll put her in the pool or on the elliptical today. And if she has any hint of pain, Iíll send her to LaTonya so she can work with her right away." Itís also important to take into account what the athlete is doing in practices and games when planning post-pregnancy workouts, she adds.

For an athlete whoís also a new mother, being aware of changes in her life outside of athletics is equally important. "Be flexible with your workout goals and take into account whatís going on with her at home," Hopkins advises. "Lend an understanding ear, if needed. She probably has some new priorities and a lot of new responsibilities."

Although being a new mother and a student-athlete or professional athlete can be a tall order, it can also be a story with a very happy ending. "Once an athlete is responsible for someone elseís life, she almost always starts taking more control of her own life," Moore says. "That can mean working harder academically, working harder at her sport, and working harder to make a positive future for herself and her child. Having a child always results in changes in the athleteís sense of self. And with the right support, the change can definitely be for the better."



SIDEBAR
PREGNANCY TERMINATION
Return to play following an abortion generally takes five days to one week, according to Kimberly Harmon, MD, Team Physician at the University of Washington. "Typically, an athlete will have a very early term abortion, and itís a relatively simple procedure," she says. "The after effects are primarily bleeding and cramping. As soon as the bleeding and cramping are no longer heavy, she can return to play. However, she should monitor herself for an increase in bleeding as a result of exercise. If that happens, she should back off for a few more days."

Anita Clark, ATC, LATC, Associate Athletic Trainer at the University of Oklahoma, makes sure to get information from the athleteís gynecologist. "I always find out from her doctor if there were any complications and get her recommendations for the athleteís return to play," she says.

"I also make sure to refer the athlete to our counselor," Clark continues. "The procedure may be over quickly, and physically, she may not look any different. But she may experience emotions afterward that she isnít anticipating."

Nicki Moore, PhD, Assistant Director for Athletic Psychological Services at the University of Oklahoma, agrees. "Itís important to be alert to the athleteís mood," she says. "Notice if sheís isolating herself, losing weight, or showing signs of depression or anxiety. Check in with the athlete to make sure she has access to the support she needs, including counseling.

"Sometimes," Moore continues, "the athlete will seem fine right after the abortion, but issues will come up for her later. Significant periods can be at the time when she would have given birth and one year after the date when she had the abortion. Be aware of those times, because she may need some additional support."



SIDEBAR
THE COACH FACTOR
NCAA rules allow an additional medical redshirt year for athletes who become pregnant, and Title IX offers them protection from discrimination. But those safeguards can be meaningless if a coach communicates that he or she may not want the athlete to come back. In most cases, the coachís attitude toward an athleteís pregnancy is one of the biggest factors in her decision whether or not to continue with her sport.

Thatís why, when Wright State University instituted a new policy on athlete pregnancy this year, the medical teamís first meeting was with coaches. "I told them about the new policy, which stresses that a pregnancy is to be treated no differently from any other temporary medical condition," says Elizabeth Sorensen, PhD, Assistant Professor in the College of Nursing and Health and Faculty Athletic Representative at Wright State.

Communicating with coaches about the issue before it comes up is key, agrees Carol Tracy, JD, Executive Director of the Philadelphia-based Womenís Law Project. Tracy represented Tara Brady, a basketball player who sued Sacred Heart University over its handling of her pregnancy. Brady alleged that her coach refused to speak to her except through a third party following her return. The suit ultimately was settled out of court with undisclosed terms.

"If the coach has a negative attitude about the athleteís pregnancy, it has a profound effect on the student," Tracy says. "Athletic trainers can help educate coaches about the issue by making sure they understand that their behavior can become an issue of discrimination. The number of male athletes who become fathers is staggering, but they donít face negative stereotypes and treatment from the coach or risk losing their spot on the team. A student-athlete who experiences this kind of treatment has a very legitimate legal claim."

Athletic trainers can also help ease the initial communication process between coach and athlete. Most believe itís the athleteís responsibility to inform her coach of her pregnancy, but there are ways to help her through that conversation and pave the way to a positive outcome.

"What often keeps coach and athlete from communicating effectively is the athleteís fear of the disappointment or anger she assumes the coach will express," says Nicki Moore, PhD, Assistant Director for Athletic Psychological Services at the University of Oklahoma. "Before she goes and talks with the coach, do some role playing with her. Tell her, ĎIím going to be your coach and you practice what youíre going to say.í Or tell her, ĎIím going to be you and you be the coachí and allow her to voice the worst things she imagines the coach saying.

"The coach-athlete relationship can almost be a parent-child relationship," Moore continues. "So before she talks to the coach, help her embrace her status as a young adult and not as a child. Remind the athlete that she has spent a lot of time reaching the decision to carry the pregnancy to term, so help her voice the message that, ĎI have thought this through and I am handling this situation as responsibly as I can, and Iíd like to ask for your support.í That can result in a much better exchange that sets the stage for a more supportive, or at least accepting, reaction."



BOX
POLICY TALKS
The NCAA is considering adopting the Wright State policy on athletes and pregnancy as a model for all its member institutions. The NCAAís Committee on Womenís Athletics reviewed the policy in June and forwarded it to the Committee on Competitive Safeguards and Medical Aspects of Sports, which will consider it in December. For more on the policy, visit: www.ncaa.org/news/2004/20040412/awide/4108n14.html.