1. EXERCISE DURING PREGNANCY Exercise during pregnancy Haleh Dadgostar Sports Medicine Specialist Rasoul e Akram Hospital

2. EXERCISE DURING PREGNANCY Outlines: 1.Physiological changes during pregnancy 2.EXERCISE PRESCRIPTION

3. EXERCISE DURING PREGNANCY  In January 2002 the American College of Obstetricians and Gynecologists (ACOG) published new recommendations and guidelines for exercise during pregnancy and the postpartum period.  It is currently recognized that habits adopted during pregnancy could affect a woman’s health for the rest of her life.  For the first time the recommendation suggests a possible role for exercise in the prevention and management of gestational diabetes. ACOG

4. EXERCISE DURING PREGNANCY The recommendations also promote exercise for sedentary women and those with medical or obstetric complications, but only after medical evaluation and clearance

5. EXERCISE DURING PREGNANCY What physiological changes happen to a woman’s body during pregnancy?

6. EXERCISE DURING PREGNANCY Increase maternal plasma volume 50%  Changes in maternal osmoregulation  Increased sodium retention by kidney Physiologic anemia of pregnancy Cardiac output increases by 30-50%  Heart rate rises 15-20 beats  Stroke volume increased by 20-30% Decreased systemic vascular resistance  Progesterone relaxes smooth muscle  21% lower than nonpregnant values PHYSIOLOGICAL CHANNGES

7. EXERCISE DURING PREGNANCY Mechanical elevation of the diaphragm  Total lung capacity decreases by 5% Progesterone causes a state of chronic hyperventilation  30-40% increase in tidal volume and minute ventilation Maternal oxygen consumption 20-40% above nonpregnant values PHYSIOLOGICAL CHANNGES

8. EXERCISE DURING PREGNANCY Increased risk of thromboembolic disease  Increased venous stasis, vessel wall injury, changes in coagulation cascade Tone and motility of the digestive system decrease do to progesterone  GERD, constipation Kidneys enlarge by about 1 cm  Increased renal vasculature, interstitial volume and urinary dead space  Glomerular filtration rate 50% increase PHYSIOLOGICAL CHANNGES

9. EXERCISE DURING PREGNANCY  Lumbar lordosis, which contributes to the very high prevalence (50%) of LBP.  Balance may be affected by changes in posture, predisposing to loss of balance and increased risk of falling. PHYSIOLOGICAL CHANGES

10. EXERCISE DURING PREGNANCY  Increased ligamentous laxity secondary to the influence of the increased levels of oestrogen and relaxin.  Theoretically, this would predispose pregnant women to increased incidence of strains and sprains PHYSIOLOGICAL CHANGES

11. EXERCISE DURING PREGNANCY Despite a lack of clear evidence that musculoskeletal injuries are increased during pregnancy, these possibilities should nevertheless be considered when prescribing exercise in pregnancy. PHYSIOLOGICAL CHANGES

12. EXERCISE DURING PREGNANCY  In some reports, physical activity has been associated with an increase in uterine contractions. The magnitude of uterine contractions reported is usually low.  physically active woman with a history of, or who is at risk of, preterm labour should be advised to reduce her activity in the second and third trimesters PHYSIOLOGICAL CHANGES

13. EXERCISE DURING PREGNANCY an increase in blood volume, heart rate, and stroke volume as well as cardiac output, and a decrease in systemic vascular By midpregnancy, cardiac outputs are 30– 50% greater than before pregnancy. Most studies show that maternal stroke volume increases by 10% by the end of the first trimester and is followed by a 20% increase in heart rate during the second and third trimesters. Mean arterial pressure decreases 5–10 mm Hg by the middle of the second trimester and then gradually increases back to prepregnancy levels. CARDIOVASCULAR ADAPTATIONS

14. EXERCISE DURING PREGNANCY After the first trimester, the supine position results in relative obstruction of venous return and therefore decreased cardiac output. For this reason, supine positions should be avoided as much as possible during rest and exercise. In addition, motionless standing is associated with a significant decrease in cardiac output, thus this position should be avoided

15. EXERCISE DURING PREGNANCY minute ventilation increases by almost 50%, largely as a result of increased tidal volume. This results in an increase in arterial oxygen tension to 106–108 mm Hg in the first trimester, decreasing to a mean of 101–106 mm Hg by the third trimester. There is an associated increase in oxygen uptake, and a 10– 20% increase in baseline oxygen consumption. RESPIRATORY ADAPTATIONS

16. EXERCISE DURING PREGNANCY  During pregnancy, BMR, and therefore heat production, is increased above non-pregnant levels.  The increase in body temperature during exercise is directly related to the intensity of the exercise.  During moderate intensity, aerobic exercise in thermoneutral conditions, the core temperature of nonpregnant women rises an average of 1.5°C during the first 30 minutes of exercise and then reaches a plateau if exercise is continued for an additional 30 minutes. THERMOREGULATORY CONTROL

17. EXERCISE DURING PREGNANCY  In animal studies, an increase in maternal core T >1.5°C during embryogenesis, cause major congenital malformations.  These data coupled with the results of human studies suggest that hyperthermia in excess of 39°C during the first 45–60 days of gestation may also be teratogenic in humans.  However, there have been no reports that hyperthermia associated with exercise is teratogenic in humans THERMOREGULATORY CONTROL

18. EXERCISE DURING PREGNANCY  Minimum or moderate increase in FHR by 10–30 beats/min over baseline during or after maternal exercise.  Fetal bradycardia during maternal exercise (8.9%)can only be speculated on: 1.Vagal reflex 2.Cord compression 3.Fetal head malposition FETAL RESPONSES TO MATERNAL EXERCISE

19. EXERCISE DURING PREGNANCY  Birth weight is not affected by exercise in women who have adequate energy intake. FETAL RESPONSES TO MATERNAL EXERCISE

20. EXERCISE DURING PREGNANCY EXERCISE PRESCRIPTION

21. EXERCISE DURING PREGNANCY  Maintain maternal fitness levels  Minimize risk to developing fetus  As a woman’s pregnancy changes, so must her exercise regimen  Primary concern with exercise during pregnancy is safety GOALS OF EXERCISE IN PREGNANCY

22. EXERCISE DURING PREGNANCY  Maintenance/improvement of maternal fitness  Control of excess weight gain  Improved posture and appearance  Increased energy  Improved sleep  Decreased incidence of back pain  Improved self-esteem  Decreased incidence of varicose veins  Decreased water retention  Decreased level of tension MATERNAL BENEFITS WITH EXERCISE

23. EXERCISE DURING PREGNANCY  Possible decrease in complications during labour  Shortened labour  Strengthens muscles needed for labor and delivery  More rapid postpartum recovery  Improved cardiac function  Therapeutic treatment for gestational diabetes MATERNAL BENEFITS WITH EXERCISE

24. EXERCISE DURING PREGNANCY  Exercise prescription requires knowledge of the potential risks and assessment of the physical ability to engage in various activities  The overall health, obstetric, and medical risks should be reviewed before a pregnant woman is prescribed and exercise program CLINICAL EVALUATION

25. EXERCISE DURING PREGNANCY  Avoid exercise in the supine position after the first trimester.  Pregnancy requires an additional 300 kcal/day to maintain metabolic homeostasis.  Physiologic and morphologic changes of pregnancy persist 4-6 wks postpartum. ACOG GUIDLINES

26. EXERCISE DURING PREGNANCY  Hemodynamic heart disease  Restrictive lung disease  Incompetent cervix  Multiple gestation  Persistent 2 nd or 3 rd trimester bleeding  Placenta previa after 26 wks  Premature labor during the current pregnancy  Ruptured membranes  Preeclampsia/PIH ABSOLUTE CONTRAINDICATIONS

27. EXERCISE DURING PREGNANCY  Severe anemia  Unevaluated maternal cardiac arrhythmia  Chronic bronchitis  Poorly controlled type 1 diabetes  Extreme morbid obesity  Extreme underweight (BMI<12)  History of extremely sedentary lifestyle  IUGR in current pregnancy  Poorly controlled hypertension  Orthopedic limitations  Poorly controlled seizure disorder  Poorly controlled hyperthyroidism  Heavy smoker RELATIVE CONTRAINDICATIONS

28. EXERCISE DURING PREGNANCY Women who have been exercising prior to pregnancy may continue their regular exercise regimen during pregnancy, by following the PARmed-X guidelines. EXERCISE PRESCRIPTION PARAMETERS

29. EXERCISE DURING PREGNANCY

30.  Women who did not exercise regularly prior to pregnancy should not start an exercise program until the second trimester.  It is currently recommended to exercise at a frequency of 3 times per week, progressing to a maximum of 4 to 5 times per week. EXERCISE PRESCRIPTION PARAMETERS

31. EXERCISE DURING PREGNANCY  Activities to improve cardiorespiratory (aerobic exercise) and musculoskeletal (resistive exercise) status and flexibility exercises  Less strenuous but continuous aerobic exercise (i.e. brisk walking, stationary cycling, cross-country skiing and swimming) are recommended. TYPE OF EXERCISE

32. EXERCISE DURING PREGNANCY  Low weights with multiple repetitions lifted through a dynamic ROM appear to be a safe and effective type of resistance exercise during pregnancy.  Evaluated on an individual basis with consideration for individual abilities TYPE OF EXERCISE

33. EXERCISE DURING PREGNANCY  Low impact aerobics  Walking  Cycling  Yoga  Ball Exercise  Pilates  Swimming  Kegel RECOMMENDED EXERCISES

34. EXERCISE DURING PREGNANCY  There are several activities that pose increased risks in pregnancy such as scuba diving and exertion in the supine position and motionless standing  Avoid any exposure to hyperbaric, hyperthermic, humid or hypoxic environmental conditions. TYPE OF EXERCISE

35. EXERCISE DURING PREGNANCY  Avoid aerobic activities with increased risk of blunt abdominal trauma and loss of balance (i.e. downhill skiing, horse-back riding, and gymnastics).  Avoid breath-holding during weight-training exercise.  Abdominal exercises are not recommended if diastasis recti develops TYPE OF EXERCISE

36. EXERCISE DURING PREGNANCY  Activities that increase the risk of falls, such as skiing  Those that may result in excessive joint stress, such as jogging and tennis  limit repetitive isometric or heavy resistance weightlifting and any exercises that result in a large pressor effect during pregnancy CAUTIONARY ADVICE

37. EXERCISE DURING PREGNANCY  In longitudinal studies of immersion exercise in pregnancy at 60% maximal oxygen consumption, it was found to be a safe activity, with advantageous effects on oedema, thermal regulation, and buoyancy, thus minimising the risk of joint injuries.  No adverse effects on the fetus have been reported to occur during water exercise in pregnancy WATER EXERCISE

38. EXERCISE DURING PREGNANCY The temperature of pool suitable for exercise in pregnancy may be slightly higher than appropriate for normal swimming, that is between 28°C and 30°C. WATER EXERCISE

39. EXERCISE DURING PREGNANCY  General rhythmic activities to warm-up.  Gentle selective stretching  Aerobic activities for CVS conditioning  UL &LL strengthening ex.  Abdominal ex  Pelvic floor ex.  Posture ex  Stabilization exercise  Relaxation &breathing exercise  cool down activities SUGGESTED SEQUENCE OF EXERCISE.

40. EXERCISE DURING PREGNANCY  The ACSM recommends that intensity should be 60–90% of MHR or 50–85% of either Max VO2 or HRR.  The lower end of these ranges (60–70% of MHR or 50–60% of Max VO2) appears to be appropriate for most pregnant women who did not engage in regular exercise before pregnancy  The upper part of these ranges should be considered for those who wish to continue to maintain fitness during pregnancy. INTENSITY OF EXERCISE

41. EXERCISE DURING PREGNANCY Meta-analysis study of exercise and pregnancy, it was reported that, with exercise intensities of 81% of MHR, no significant adverse effects were found INTENSITY OF EXERCISE

42. EXERCISE DURING PREGNANCY  Heart rate is less reliable in pregnancy for determining exercise intensity.  The modified heart rate target zones, as outlined in the PARmed-X, are recommended for use in measuring exercise intensity in pregnant women. INTENSITY

43. EXERCISE DURING PREGNANCY GUIDING INTENSITY OF EXERCISE  Maximal heart rate AgeHeart rate range <20140-155 20-29135-150 30-39130-145 >=40 125-140  RPE (12-14)  Talk test You should be able to carry on a verbal conversation

44. EXERCISE DURING PREGNANCY  First begin with 15 minutes of continuous exercise.  The duration of exercise may be gradually increased, as pregnancy progresses, to 30 minute sessions. DURATION OF EXERCISE

45. EXERCISE DURING PREGNANCY  Accumulation of 30 minutes a day of exercise occur on most if not all days of the week  Pregnant women who have been sedentary before pregnancy should follow a gradual progression of up to 30 minutes a day FREQUENCY OF EXERCISE

46. EXERCISE DURING PREGNANCY  Sedentary women  Aerobic exercise, 65-75% max HR  Moderately perceived exertion  30 min, minimum of 3 days/wk EXERCISE PRESCRIPTION

47. EXERCISE DURING PREGNANCY  Recreational athletes and regular fitness exercisers  Aerobic exercise, 65-85% max HR  Moderate hard to hard exertion  30-60 min, 3-5 days/wk EXERCISE PRESCRIPTION

48. EXERCISE DURING PREGNANCY  Elite Athletes  Aerobic exercise, 75-85% MHR  Hard perceived exertion  60-90 minutes, 4-6 d/wk EXERCISE PRESCRIPTION

49. EXERCISE DURING PREGNANCY Activities with a high risk of falling or those with a high risk of abdominal trauma should be considered undesirable. Participation in recreational sports with a high potential for contact, such as ice hockey, soccer, and basketball, could result in serious trauma to both mother and fetus. Similarly, recreational activities with increased risk of falling, such as gymnastics, horseback riding, downhill skiing, and vigorous racquet sports, have inherent high risk of trauma in pregnant and non- pregnant women. RECREATIONAL ACTIVITIES

50. EXERCISE DURING PREGNANCY Scuba diving should be avoided throughout pregnancy because the fetus is at increased risk of decompression sickness secondary to the inability of the fetal pulmonary circulation to filter bubble formation. As for exertion at altitude, reports are available for activities at less than 2500 m (6000 feet) RECREATIONAL ACTIVITIES

51. EXERCISE DURING PREGNANCY  Ball sports  Contact sports: ultimate fighting, wrestling, football  Sports that involve bouncing, leaping, a sudden change of direction (increased joint laxity from hormones make joints susceptible to sprains)  Exercises that put you at risk for falls: rollerblading, horseback ridding, skiing  After 1st trimester avoid exercise in the supine position  Lying in the prone position  Lifting heavy free weights EXERCISES TO AVOID

52. EXERCISE DURING PREGNANCY DO NOT START EXERCISING IF  Your doctor says not to  Unusual bleeding  High blood pressure

53. EXERCISE DURING PREGNANCY  Swelling of face and hands  Severe headaches  Persistent dizziness  Chest pain or palpations  Difficulty walking because of pain  Vaginal bleeding  Excessive discharge  Fever CONTACT YOUR DOCTOR IF…

54. EXERCISE DURING PREGNANCY  Avoid exercising while lying down, especially in late pregnancy.  Limit flat on the back exercise time to 2‐3 minutes, and do these exercises before aerobic or cardiovascular training exercises. SAFETY GUIDELINES

55. EXERCISE DURING PREGNANCY  Avoid sudden changes of position or level.  Cool down to prevent pooling of blood in the extremities.  Rest daily in the side‐lying position to maximize blood flow during the second and third trimesters SAFETY GUIDELINES

56. EXERCISE DURING PREGNANCY  Do warm up for 5-10 minutes and cool down with static stretches and limbering exercises.  Do not maximum stretch.  Wear support bras and arch supports during exercise.  Avoid hot tubs, steam rooms, saunas or spas during pregnancy SAFETY GUIDELINES

57. EXERCISE DURING PREGNANCY Women who have been previously active may continue their exercise during the first trimester to a maximum of 30-40 minutes at a frequency of 3-4 x week as Tolerated Current literature supports moderate intensity exercise of 2-4 x a week in a pregnant woman without adverse effect on fetal birth weight. Studies confirm that guidelines are necessary for maternal exercise because there is still some controversy regarding the threshold for exercise and fetal stress RECOMMENDATIONS FOR EXERCISE DURING LOW RISK PREGNANCY

58. EXERCISE DURING PREGNANCY  Regular activity (3x/wk) is preferable to intermittent activity  Competitive activity is discouraged  Vigorous exercise should not be performed in hot, humid weather or during times of febrile illness  Maternal core temp should not exceed 38 degrees.  Liquids should be taken liberally to prevent dehydration ACOG GUIDELINES 2002

59. EXERCISE DURING PREGNANCY ACOG GUIDELINES  Ballistic movements should be avoided.  Deep flexion or extension of joints should be avoided because of connective tissue laxity

60. EXERCISE DURING PREGNANCY  Maternal heart rate should not exceed 140 beats per minute.  Strenuous activity should not exceed 15 minutes duration.  Exercises that employ the Valsalva maneuver should be avoided. ACOG GUIDELINES

61. EXERCISE DURING PREGNANCY  Modify intensity of exercise according to maternal symptoms.  Stop exercising when fatigued and not exercise to exhaustion ACOG GUIDELINES

62. EXERCISE DURING PREGNANCY  Vaginal bleeding  Dyspnea prior to exertion  Dizziness  Headache  Chest pain  Muscle weakness  Calf pain or swelling  Preterm labor  Decreased fetal movement  Amniotic fluid leakage WARNING SIGN

63. EXERCISE DURING PREGNANCY

64.  Sit on a pillow on the floor with legs crossed  Lean forward or back  Don’t slump shoulders  Stretch legs occasionally  Make it a way of life TAILOR SITTING (GROIN STRETCH)

65. EXERCISE DURING PREGNANCY  Strengthens quads  Use furniture or support from a partner to assist balance  10 reps/4 per day and every time you pick up something  Avoid bending over from the waist SQUATTING

66. EXERCISE DURING PREGNANCY  Arch your back up and down  Brief, frequent exercises each day  Start with sets of 20 x 4, build to 80 x 2  Especially before bedtime  Takes pressure off structures in low back and pelvis PELVIC TILTS AND ROCKING

67. EXERCISE DURING PREGNANCY CalfCalf HamstringHamstring QuadricepsQuadriceps PectoralisPectoralis PiriformisPiriformis Iliotibial bandIliotibial band Abdominal, groinAbdominal, groin STRETCHES

68. Backache during pregnancy is common because of the pressure of the fetus and the laxity of supporting structures. BACK ACHE

69. EXERCISE DURING PREGNANCY  Exercise  Posture  Straight neck, chin tuck, lift ribs, rolls shoulders back, contract lower abdominal muscles, tuck buttocks under  Ergonomics  Tailor sit or use lumbar roll in chairs  Place a foot on a stool for prolonged standing PREVENTING BACK ACHE

70. EXERCISE DURING PREGNANCY  PHYSICAL: muscles  MENTAL: thoughts and concentration  EMOTIONAL: feelings  It’s a learned response – practice it  Use it as a time to communicate with your unborn baby RELAXATION

71. EXERCISE DURING PREGNANCY  Improves tone in pelvic floor muscles  Poor tone may cause: – Incontinence – Discomfort – More labor pain – Torn tissues – Uterine prolapse KEGEL EXERCISE

72. EXERCISE DURING PREGNANCY KEGEL EXERCISE Beginners: quick squeezes, 2 x 5 mins or 30 per day Intermediate: hold for 10 secs x 50 per day Advanced: elevators Exhale as you begin each contraction 10-20 secs 5-7 secs Elevate

73. EXERCISE DURING PREGNANCY  To find the pelvic floor muscles, imagine that you are trying to stop yourself passing wind and at the same time trying to stop your flow of urine in mid-stream. You should feel a ‘squeeze and lift’.  It is important to do this Without tightening your buttocks Without holding your breath Without squeezing your legs together PELVIC FLOOR EXERCISES

74. EXERCISE DURING PREGNANCY Try and lift for as long as you can (up to 10 seconds). You should feel a ‘letting go’ sensation when you relax these muscles. Give yourself a few seconds break then repeat this 10 times. Then try 10 fast, hard squeezes, with 2-3 seconds rest in between. Repeat 10 short and 10 long contractions 5- 6 times a day PELVIC FLOOR EXERCISES

75. EXERCISE DURING PREGNANCY How to Do the Kegel Exercise 1. Try to tighten the muscles a small amount at a time,.like an elevator going up to the tenth floor.. Then release very slowly one.floor. At a time. 2. Try to tighten the muscles from front to back. Include the anus (rectum) PELVIC FLOOR EXERCISES

76. EXERCISE DURING PREGNANCY  Practice while you sit, stand, walk, drive or watch TV  Three times each day  Five repetitions  Work up to 20 to 30 each time PELVIC FLOOR EXERCISES

77. EXERCISE DURING PREGNANCY KNEE PRESS  The knee press will strengthen your inner thighs,stretch your lower back and improve your circulation  Work up to doing 10 repetitions each day

78. EXERCISE DURING PREGNANCY Leg Raise 1. Lie on your back with feet flat on the floor. 2. Bring one knee up to your chest as close as you can. 3. Raise your leg in the air. 4. Bend your knee and return your foot to the floor. 5. Do the same exercise with your other leg. ABDOMINAL STRENGTHENERS

79. EXERCISE DURING PREGNANCY ABDOMINAL STRENGTHENERS Knee Reach 1. Lie on your back with feet flat on the floor. 2. Lift your head and at the same time move one knee towards your nose. 3. Do the same thing with your other leg.

80. EXERCISE DURING PREGNANCY Get on your hands and knees with arms straight. 2. Tighten your tummy muscles and tuck you hips under. Your back will hunch a little. 3. Relax. 4. Do this slowly and evenly THE PELVIC ROCK

81. EXERCISE DURING PREGNANCY ABDOMINAL EXERCISES

82. EXERCISE DURING PREGNANCY Position Two 1. Stand with your back against a wall. 2. Tighten your tummy muscles and tuck in your buttocks so the small of your back is flat against the wall. 3. If you put your hands on your hip bones, you should feel your hips rock. THE PELVIC ROCK

83. EXERCISE DURING PREGNANCY

84. FULL BODY STRETCH This exercise helps you warm up by stretching your whole body.

85. EXERCISE DURING PREGNANCY NECK STRETCH

86. EXERCISE DURING PREGNANCY FULL BODY TWIST This exercise will stretch your waist, upper body and neck. It helps to keep your spine or backbone more flexible

87. EXERCISE DURING PREGNANCY Strengthening of External Rotators Corner Press Out

88. EXERCISE DURING PREGNANCY

89. THANKS FOR YOUR KIND ATTENTION