What grips and maneuvers are safe during pregnancy?

Safe Grips and Maneuvers During Pregnancy

Vagal maneuvers including Valsalva maneuver, carotid sinus massage, and the diving reflex (ice-cold towel to face) are safe and recommended during pregnancy for acute treatment of supraventricular tachycardia, and the Valsalva maneuver during labor is well tolerated. 1

Therapeutic Vagal Maneuvers (For Arrhythmia Management)

First-Line Interventions for SVT

• Valsalva maneuver is the most effective vagal technique and should be performed with the patient in supine position 1

  • The patient raises intrathoracic pressure by bearing down against a closed glottis for 10-30 seconds, equivalent to at least 30-40 mmHg 1
  • This is more successful than carotid sinus massage in terminating tachycardia 1

• Carotid sinus massage can be performed after confirming absence of bruit by auscultation 1

  • Apply steady pressure over the right or left carotid sinus for 5-10 seconds 1
  • Switching between Valsalva and carotid massage achieves an overall success rate of 27.7% 1

• Diving reflex maneuver involves applying an ice-cold, wet towel to the face 1

  • Facial immersion in water at 10°C (50°F) has proven effective in laboratory settings 1

Important Safety Note

• Never apply pressure to the eyeball - this practice is potentially dangerous and has been abandoned 1

Valsalva Maneuver During Labor and Delivery

Safety During Delivery

• Valsalva maneuver during labor is well tolerated in pregnant women with cardiovascular disease, including cardiomyopathies 1
• Adverse outcomes during delivery are low (3-4%) and similar between vaginal delivery and cesarean section 1
• Vaginal delivery should be preferred over cesarean section, which should be reserved only for obstetric reasons or emergency cardiac/maternal health reasons 1

Modifications for Exercise

• Women who experience light-headedness with excessive Valsalva maneuver (straining while holding one's breath) when exercising should avoid the breath-hold 1
• This applies specifically to resistance training contexts, not therapeutic vagal maneuvers 1

Physical Activity Maneuvers and Positions

Safe Exercise Practices

• Warm-up and cool-down periods should be included in any physical activity regimen 1
• Ligaments become relaxed during pregnancy due to increasing hormone levels, which may impact range of movement and increase injury risk 1

Positions to Avoid During Resistance Training

• Avoid supine position for extended periods during resistance exercises as pregnancy progresses 2
• This is due to potential compression of the inferior vena cava, which can reduce venous return 2

Safe Resistance Training Modifications

• Resistance training is safe and beneficial during pregnancy when appropriately modified 2, 3
• Avoid ballistic movements, exercises that rely heavily on balance, and movements with risk of abdominal trauma 2
• A combination of aerobic and resistance training activities demonstrates greater improvements in pregnancy outcomes than aerobic activity alone 1

When to Stop Any Maneuver or Activity

Absolute Warning Signs

Stop immediately and seek medical attention if experiencing: 1, 4

• Persistent excessive shortness of breath that does not resolve on rest
• Severe chest pain
• Regular and painful uterine contractions
• Vaginal bleeding
• Persistent loss of fluid from the vagina (ruptured membranes)
• Persistent dizziness or faintness that does not resolve on rest

Clinical Context and Pitfalls

The evidence strongly supports that properly performed vagal maneuvers are safe therapeutic interventions during pregnancy 1. The key distinction is between therapeutic vagal maneuvers (performed acutely for arrhythmia management under medical supervision) and Valsalva during exercise (which may need modification based on individual tolerance) 1. The 2024 AHA/ACC guidelines specifically confirm that Valsalva during labor is well tolerated even in high-risk cardiac patients 1, which provides reassurance for its safety in normal pregnancy contexts.