Exercise During Pregnancy and Postpartum By: Erin Moore

Physiologic Changes with Pregnancy Soft-tissue edema: reported by approximately 80% of women in the last 8 wks Increased fluid retention: predispose nerve entrapment (carpel tunnel) Ligamentous Laxity Relaxin known to remodel pelvic connective tissue and activate collagenlytic system Initial increase relaxin levels peak at 12 weeks and decline until the 17th week 20% increase in weight during pregnancy may increase force on a joints by as much as 100% Hyperlordosis accentuates anterior pelvic tilt Symphysis pubis widening begins in 10th and 12th week of pregnancy under the influence of the hormone relaxin

Anatomic and Physiologic Changes with Exercise during Pregnancy About 60% of pregnant women experience LBP Strengthen abdominal and back muscles to reduce these chances Respiratory Changes Decrease in pulmonary reserve: ability to exercise anaerobically is impaired, oxygen availability for strenuous exercise decreases Aerobic training increases aerobic capacity in normal weight and overweight women Temperature regulation Stay well-hydrated Wear loose fitted clothing Avoid exercising in high heat and humidity to avoid heat stress Decreased Arch Height Avoid running on uneven terrain, difficult to adapt Wear supportive shoes, consider orthotics

WHY Exercise During Pregnancy Maintain physical fitness Helps weight management Reduces risk of gestational diabetes in obese women Enhances psychologic well-being Safe and desirable 150 minutes per week of moderate-intensity aerobic activity (equivalent to brisk walking) Use talk test to prevent over exhaustion Physical inactivity and excessive weight gain risks Maternal obesity Gestational Diabetes Pregnancy complications

Safe and Unsafe Physical Activities Activities to Initiate Activities to Avoid Walking Swimming Stationary Cycling Low impact aerobics Yoga, modified Positions that result in decreased venous return and hypotension should be avoided as much as possible Running/jogging, Strength training Safe for women that participated in these exercises before pregnancy Contact sports (ie soccer, basketball) Activities with high risk of falling (ie off road cycling) Hot Yoga, Hot Pilates

Recommended Exercise Frequency/Duration American and Canadian Guidelines encourage women with uncomplicated pregnancies to participate in regular aerobic and resistive exercise Treatment Frequency and Length of Session: Previously sedentary women Aerobic exercise 15 minutes, 3 x/ week, work up to 30 minutes 4 x/ week Women with uncomplicated pregnancies Moderate intensity (rate of perceived exertion: 12-14) Resistance/flexibility training and aerobic exercise, individually or in combination 30 min/day, 4 or 5 days/week

Absolute Contraindication to Aerobic Exercise During Pregnancy Hemodynamically significant heart disease Restrictive lung disease Incompetent cervix of cerclage Multiple gestation at risk of premature labor Persistent second or third trimester bleeding Placenta previa after 26 weeks of gestation Premature labor during prior pregnancy Ruptured membranes Preeclampsia or pregnancy induced hypertension Severe anemia

Relative Contraindications to Aerobic Exercise During Pregnancy Anemia Unevaluated maternal cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity Extreme underweight (BMI less than 12) History of extremely sedentary lifestyle Intrauterine growth restriction in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker

Warning Signs to Stop Exercising When Pregnant Vaginal bleeding Regular painful contractions Amniotic fluid leakage Dyspnea before exertion Dizziness Headache Chest pain Muscle weakness affected balance Calf pain or swelling (rule out thrombophlebitis)

AVOID: Activities that make the pain worse Standing on one leg Bending and twisting to lift or carry a toddler or baby on one hip Crossing legs Sitting on the floor Sitting twisted Sitting or standing for long periods of time Lifting heavy weights (grocery bags, vacuum cleaners) Carrying anything in only one hand

During Pregnancy DO: Be as active as possible, avoid activities that make the pain worse Rest when possible, may need to sit down more often Wear supportive shoes (lose arch, due to weight gain) Keep knees together when moving in and out of the car, rolling in and out of bed Sleep in comfortable position (with pillow between the knees) Take stairs one at a time: upstairs leading with less painful leg, downstairs leading with more painful leg

Benefits of Exercise Postpartum Improved Cardiovascular fitness Facilitated weight loss Increased positive mood Decreased anxiety and depression More energy following exercise Decreased lactation-induced bone loss Decreased urinary stress incontinence

Weight Retention Postpartum Mother’s with normal weight prior to pregnancy and those who gained the recommend weight are less likely to require intervention postpartum Mother’s with additional weight gain in the postpartum period More susceptible to long term weight gain More likely to have related disease: Obesity Heart disease Diabetes Decrease postpartum weight retention Increased physical activity helps to Maintain lean body mass Enhance fat loss Improve aerobic fitness Weight loss of more than 1.5 kg is not recommend for lactating women

WHY Strengthen the Pelvic Floor Muscles Urinary stress incontinence 30-60% of pregnant women 15 % of postpartum women have it 3 months after delivery Pelvic floor trauma Due to vaginal delivery Intervention Strengthen pelvic floor muscles Pelvic training program: perform 8-12 maximum pelvic floor muscle contractions twice a day (3x per week) Hold the max contraction for 6-8 seconds, adding 3- 4 fast contractions at the end of each maximal contraction

Looking after your baby Change diapers at waist height Do not lift baby too often Carry baby in front of you, don’t carry baby on one hip Kneel at the bath side rather than bending over Keep your baby close to you when moving them in and out of the car seat If you have to carry baby in car seat hold it in front of you, not on one hip Don’t lift baby out of high shopping trolleys Do pelvic floor muscle exercises daily

The Effect of Core and Lower Extremity Strengthening on Pregnancy- The Effect of Core and Lower Extremity Strengthening on Pregnancy- Related Low Back and Pelvic Girdle Pain: Systematic Review Biomechanical stresses: Change in pelvic and spinal alignment, joint laxity, and weight gain Muscle weaknesses: Weakness at the proximal hip, abdominal and lumbosacral regions may contribute to impaired core stability thus, altered alignment, decreased ability to withstand stress, and disruption of normal gait pattern PPGP (Pregnancy Pelvic Girdle Pain) : pain of musculoskeletal origin between the levels of the posterior iliac crests and gluteal folds involving the anterior and/or posterior aspects of the pelvis that may radiate into the posterior thigh Interventions: Activity modification, exercise, joint and soft tissue mobilization, aquatics, acupuncture, bracing, positioning Muscle Strengthening: local stabilizers, specifically the TA more effective to reduce the laxity of the lumbopelvic and sacroiliac joints than global stabilizers alone

Intervention: Land Versus Aquatic Exercise Physiological and Psychologic benefits Decreased joint compressive forces Improved edema management Increased blood volume and cardiac output Improved control of weight gain Decreased back pain Reduced postpartum depression Muscle relaxation

Intervention: Exercise Pelvic Floor Core Exercise First find comfortable spinal position, tilt the pelvis forward and backward until you find a neutral spinal position that is comfortable for your back Contract Pelvic floor: Hold in gas Contract Transverse Abdominus: Pull belly button to spine Purpose: Strengthen the pelvic floor, which helps to stabilize SI joint laxity

Intervention: Exercise Quadruped Pelvic Tilts Obtain the quadruped position with spine in neutral position. Extend the lumbar spine, performing an anterior pelvic tilt to end range. Next flex the spine, performing a posterior pelvic tilt to end range. Then return to neutral spine position. Continue in a controlled manner Purpose: Facilitate and maintain a neutral hip position

Intervention: Exercise Clamshell Get into the side lying position with the hips stacked on top of each other Contract the muscles you would use to prevent a bowel movement Continue to contract the muscles as you rotate the top leg toward the ceiling (make sure feet stay together) Purpose: Improve hip strength and stabilize spine

Intervention: Exercise Diaphragmatic Breathing Sit with back straight Place one hand on chest and one on bell. Breath in through the nose slowly and deeply. The hand on your belly should be the one that is moving. Breath out through your mouth Perform this exercise slowly Purpose: Facilitate deep core muscle activation, relaxation technique

Resources Borg-Stein J, D. S. (2015). Musculoskeletal Aspects of Pregnancy. American Journal of Physical Medicine & Rehabilitation, 180-192. Lillios, S. (2012). The Effects of Core and Lower Extremity Strengthening on Pregnancy-Related Low Back and Pelvic Girdle Pain: A Systematic Review. Journal of Womenʼs Health Physical Therapy. 116-124. Mottola, M. (2002). Exercise in the Postpartum Period: Practical Applications. Current Sports Medicine Reports. 362-368 Opinion, C. (2015). Physical Activity and Exercise During Pregnancy and the Postpartum Period. The American College of Obstetricians and Gynecologists, 1-8.

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