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The need for change
Female participation and professionalisation within sport is growing, leading to greater investment, competition and publicity. Despite this, there is a lack of female-specific research and frameworks to guide organisations in supporting and optimising female athlete performance,1 particularly during the transition into motherhood. Recent developments in sporting regulations allow greater flexibility in team selections to support perinatal athletes who are pregnant or on maternity leave.2 However, provisions to assist these athletes returning to their sport are lacking and there is a need for greater recognition of perinatal health considerations, for example, pelvic health. Multidisciplinary teams managing athletes often include sports medicine clinicians (particularly physiotherapists and physicians), surgeons, physiologists and coaches.3 In the context of the perinatal athlete, we argue that it is crucial that specialist pelvic health physiotherapists, midwives and obstetric and gynaecological consultants are included in the multidisciplinary team supporting their return-to-sport. In this editorial we will outline considerations that are necessary for supporting athletes during and after pregnancy. In doing so we aim to provide a framework to guide multidisciplinary teams managing perinatal athletes and their return-to-sport postpartum.
Perinatal considerations
Several anthropometric and physiological factors have been argued to explain sex differences in performance and injury,1 yet sex-comparisons do not allow perinatal considerations to be explored. For example, female breasts lack intrinsic support and fluctuate in size during the perinatal period, which may exacerbate painful exercise-induced breast motion.4 5 Additionally, performance and exercise participation may be affected by pelvic floor dysfunction, such as urinary incontinence and pelvic organ prolapse.4 6 7 While pelvic floor dysfunction is not specific to women, women appear to have a greater predisposition for such dysfunction, partly due to having a larger pelvic outlet and greater surface area that requires support from the pelvic floor.8 9 Moreover, the additional pelvic outlet (vagina) in women increases the risk for structural support deficits at the base of the pelvis8 and this risk increases further during pregnancy and childbirth. Despite the acknowledged impact of pelvic floor dysfunction on sporting performance and quality of life,10 these reports are often overlooked in return-to-sport frameworks.
Return-to-sport frameworks traditionally focus on managing musculoskeletal injuries, psychological readiness and risk of re-injury3 with no consideration given to managing postpartum return-to-sport, conceivably because the focus has been on male rather than female athletes. Furthermore, female athletes entering motherhood during their athletic career is a relatively new occurrence. For these athletes and their multidisciplinary teams, the perinatal period provides challenges due to the complex changes to bodily systems.5 6 It is recommended that the following factors are considered within a whole-systems, biopsychosocial approach to perinatal athlete support: childbirth-related trauma (such as abdominal wall dysfunction, pelvic floor dysfunction or post-traumatic stress), menstrual health, breast health, energy balance, psychological well-being, fear of movement and sleep.5 6 Additionally, athletes should be supported in their choice to breastfeed, with consideration given to the physiological impact and practicalities surrounding breastfeeding with training and competition.5
Unlike musculoskeletal injury return-to-sport, pregnancy and childbirth offer athletes and their multidisciplinary teams a unique opportunity to plan ahead for the impending physical and psychological changes.9 This opportunity for forward planning calls for the development of athlete driven services to formulate proactive rather than reactive approaches to athlete care. Enhancing perinatal athlete care via a proactive approach could optimise athletic performance and enable women to continue sporting careers beyond the transition into motherhood, safeguarding their sporting longevity. Conceivably, it may also address the disparity that exists in recognising female-specific considerations, such as pregnancy and childbirth, within athlete care by providing equitable service provision to female athletes.
The 6 Rs framework: a phased, whole-systems, biopsychosocial approach
We propose the 6 Rs framework to guide multidisciplinary teams in preparing, returning and optimising perinatal athletes for their sport (table 1 and infographic in online supplemental file 1). The 6 Rs framework encourages practitioners to reframe perinatal athlete evaluation within a whole-systems, biopsychosocial model of care.5 It also supports a criterion-based approach3 to facilitate return to performance via individualised, evidence-informed, systematic and planned phases. Implementing this framework requires the safety of the mother and baby to be the overarching consideration and consultation with a multidisciplinary team, including the primary obstetric healthcare provider, is recommended. This ensures that all aspects of perinatal athlete performance are considered, including appropriate and individualised timescales for tissue healing and postpartum recovery. Further resources and wider reading relevant to each phase can be found in online supplemental file 2. The suggested timescales for the 6 Rs, shown in table 1, will serve as a guide for multidisciplinary teams supporting perinatal athletes to apply and modify as necessary. Return-to-sport postpartum should not be rushed, and athletes may move back and forward between phases depending on their individual rehabilitation needs.
Supplemental material
Supplemental material
Conclusion
The 6 Rs framework builds on existing return-to-sport models by using a proactive rather than reactive approach to perinatal athlete management. By understanding individualised, perinatal considerations, sporting organisations can educate and support athletes in preparation for the expected whole-systems, biopsychosocial changes during and after pregnancy. This will subsequently optimise their return-to-sport postpartum. It will also enable the sporting success and longevity of the female athlete to be safeguarded beyond motherhood.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank Ms Molly McCarthy-Ryan for her critical comments on earlier versions of the manuscript.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @ABSPhysio, @IzzyMoorePhD, @emma_physiomum, @SportsMedNI, @RosCooke1
Correction notice This article has been corrected since it published Online First. Reference 5 has been updated.
Contributors GMD and RC conceptualised and devised the scope of the editorial. GMD, ISM and RC drafted the initial manuscript. GMD, ISM, EB, AR and RC all made substantial contributions to the revision of the manuscript prior to submission. AR produced the infographic based on the presented editorial. All authors consented to the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests ISM is an Associate Editor for British Journal of Sports Medicine.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.