1. Chapter 21 Exercise Guidelines and Recommendations During Pregnancy Jacalyn J. Robert-McComb, PhD, FACSM Jessica Stovall, BS

2. Learning Objectives Following this presentation, you should have an understanding of: Physiological changes of pregnancy that may affect exercise; Physiological changes of pregnancy that may affect exercise; Effects of exercise on the baby; Effects of exercise on the baby; Activities to encourage and discourage during pregnancy; Activities to encourage and discourage during pregnancy; Guidelines for exercising while pregnant Guidelines for exercising while pregnant Postpartum exercise; and Postpartum exercise; and Contraindications to exercising while pregnant Contraindications to exercising while pregnant

3. Introduction Mild and moderate exercise during pregnancy have very positive effects on the mother and infant Mild and moderate exercise during pregnancy have very positive effects on the mother and infant

4. Positive Effects of Exercise Reduced typical pregnancy-related symptoms Reduced typical pregnancy-related symptoms Reduced “active stage” of labor Reduced “active stage” of labor Increased sense of maternal well-being Increased sense of maternal well-being Decreased delivery complications Decreased delivery complications Reduced risk developing pregnancy induced hypertension Reduced risk developing pregnancy induced hypertension Reduced bone density loss during lactation Reduced bone density loss during lactation Increased birth weight Increased birth weight Reduced risk developing gestational diabetes Reduced risk developing gestational diabetes

5. Gestational Diabetes Mellitus (GDM) Researchers found a 76% decrease in GDM risk in active women, or those who spent > 4.3 h. wk –1 engaged in recreational physical activity, compared with inactive women (Dempsey, Sorensen, Williams, et al., 2004 ). Researchers found a 76% decrease in GDM risk in active women, or those who spent > 4.3 h. wk –1 engaged in recreational physical activity, compared with inactive women (Dempsey, Sorensen, Williams, et al., 2004 ). Perhaps one of the greatest incentives to exercise moderately during pregnancy is that children of GDM mothers are more likely to have diabetes in adolescence or even become obese (Dempsey, Butler, Williams, 2005 ). Perhaps one of the greatest incentives to exercise moderately during pregnancy is that children of GDM mothers are more likely to have diabetes in adolescence or even become obese (Dempsey, Butler, Williams, 2005 ).

6. Physiological Changes of Pregnancy Musculoskeletal alterations Musculoskeletal alterations joint laxity and hypermobility can cause injury during exercise joint laxity and hypermobility can cause injury during exercise Change in center of gravity Change in center of gravity Weight of growing breasts, uterus, and fetus Weight of growing breasts, uterus, and fetus Temperature decreases slightly after exercise Temperature decreases slightly after exercise Helps avoid overheating Helps avoid overheating

7. Physiological Changes of Pregnancy Cont’ Cardiac output (CO) Cardiac output (CO) Decreases 9% after 1 st trimester when mother is in supine position Decreases 9% after 1 st trimester when mother is in supine position Exercise should be avoided in supine position due to vena cava compression Exercise should be avoided in supine position due to vena cava compression Motionless standing decrease CO 18% Motionless standing decrease CO 18% Lying on side best position for CO Lying on side best position for CO

8. Physiological Changes of Pregnancy Cont’ During exercise, blood diverted away from abdominal viscera and uterus to exercising muscles During exercise, blood diverted away from abdominal viscera and uterus to exercising muscles This can be a concern when there is a decrease in splanchnic blood flow by 50 percent (can cause fetal hypoxemia) This can be a concern when there is a decrease in splanchnic blood flow by 50 percent (can cause fetal hypoxemia)

9. Physiological Changes of Pregnancy Cont’ Increased oxygen demand Increased oxygen demand Inhibition of diaphragm because of enlarged uterus Inhibition of diaphragm because of enlarged uterus Increase in energy demands Increase in energy demands Pregnant women need to increase their caloric intake by approximately 300 kcal per fetus. Pregnant women need to increase their caloric intake by approximately 300 kcal per fetus. If the pregnant woman exercises, she needs to increase her caloric intake to meet the energy cost of the activity If the pregnant woman exercises, she needs to increase her caloric intake to meet the energy cost of the activity

10. Effects of Exercise on the Baby Decrease risk of premature labor Decrease risk of premature labor Growth of placenta increased Growth of placenta increased Children scored higher on intelligence tests by age 5 Children scored higher on intelligence tests by age 5 Children leaner Children leaner Babies seemed to handle stress of contractions better Babies seemed to handle stress of contractions better Babies had a decrease in likeliness of getting tangled in umbilical cord Babies had a decrease in likeliness of getting tangled in umbilical cord

11. Activities to Encourage and Discourage during Pregnancy Activities Encouraged Activities Encouraged Walking Walking Stationary cycling Stationary cycling low-impact aerobics low-impact aerobics swimming swimming Activities Discouraged Contact sports hockey, wrestling, football, and soccer Sports with increase in falls horseback riding, gymnastics, skating, skiing, hang gliding, vigorous racquet sports, weight lifting, and scuba diving

12. Guidelines for Exercising while Pregnant Clearance from physician prior to beginning exercise program Clearance from physician prior to beginning exercise program

13. PAREMED-X Is one of the most often used screening tool for pregnancy Is one of the most often used screening tool for pregnancy This tool can be downloaded on the web at http://uwfitness.uwaterloo.ca/PDF/parmed- xpreg_000.pdf This tool can be downloaded on the web at http://uwfitness.uwaterloo.ca/PDF/parmed- xpreg_000.pdf Or you can use your search engine on the web using the term PAREMED-X to find this form. Or you can use your search engine on the web using the term PAREMED-X to find this form.

14. American College of Obstetricians and Gynecologists Relative and Absolute Contradictions to Aerobic Exercise During Pregnancy Relative Relative Anemia Anemia Chronic bronchitis Chronic bronchitis Extreme morbid obesity Extreme morbid obesity Extreme underweight Extreme underweight Heavy smoker Heavy smoker Orthopedic limitations Orthopedic limitations Uncontrolled hypertension Uncontrolled hypertension (See Table 21.1 in the book for a complete list) Absolute severe heart disease Restrictive lung disease Ruptured membranes Premature labor Continual 2 nd or 3 rd trimester bleeding Incompetent cervix (See Table 21.1 in the book for a complete list) Source: ACOG Committee. Opinion no. 267: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002;99:171-3 (with permission from American College of Obstetricians and Gynecologists

15. Summary of Recommendations for Aerobic Exercise During Pregnancy 30 min or more of moderate exercise a day on most days of the week, in absence of medical or obstetric complications 30 min or more of moderate exercise a day on most days of the week, in absence of medical or obstetric complications 3-5 METS; equivalent to brisk walking 3-5 METS; equivalent to brisk walking Ratings of perceived exertions useful (11-14) on the 6-20 Borg scale Ratings of perceived exertions useful (11-14) on the 6-20 Borg scale Exercise sessions longer than 45 min not well tolerated Exercise sessions longer than 45 min not well tolerated Monitor hydration and body temperature Monitor hydration and body temperature

16. Indications to Stop Exercise During Pregnancy Excessive shortness of breath Excessive shortness of breath Chest pain Chest pain Extreme fatigue Extreme fatigue Pelvic girdle pain Pelvic girdle pain Vaginal bleeding Vaginal bleeding Muscle weakness Muscle weakness Headache Headache (Note: not limited to only these listed, see Table 21.3 in the book for a complete list)

17. Strength Training during Pregnancy Strength conditioning, weight training, and stretching provides pregnant women with improved level of muscular fitness Strength conditioning, weight training, and stretching provides pregnant women with improved level of muscular fitness Help postural adjustments Help postural adjustments

18. Recommendations Regarding Resistance Training during Pregnancy Medical advice and physician recommendations should be obtained prior to resistance training during pregnancy. Medical advice and physician recommendations should be obtained prior to resistance training during pregnancy. Resistance training for all pregnant women may not be appropriate. If women have any of the contraindications to aerobic exercise as proposed by American College of Obstetrics and Gynecology they should not participate in resistance training. Resistance training for all pregnant women may not be appropriate. If women have any of the contraindications to aerobic exercise as proposed by American College of Obstetrics and Gynecology they should not participate in resistance training. Women who have never participated in resistance training should not initiate one during pregnancy. Women who have never participated in resistance training should not initiate one during pregnancy.

19. Recommendations Cont’d Women should be encouraged to breathe normally during resistance training, breath holding reduces oxygen delivery to the placenta Women should be encouraged to breathe normally during resistance training, breath holding reduces oxygen delivery to the placenta Heavy resistance should be avoided since it may expose the joints, connective tissue, and skeletal structures of an expectant woman to excessive forces. An exercise set consisting of at least 12-15 repetitions without undue fatigue is recommended. Heavy resistance should be avoided since it may expose the joints, connective tissue, and skeletal structures of an expectant woman to excessive forces. An exercise set consisting of at least 12-15 repetitions without undue fatigue is recommended. As training occurs, overload initially by increasing number of repetitions and, subsequently, by increasing resistance. As training occurs, overload initially by increasing number of repetitions and, subsequently, by increasing resistance. Resistance training on machines if preferred to free-weights because machines can be more easily controlled and require less skill. Resistance training on machines if preferred to free-weights because machines can be more easily controlled and require less skill. Source: Byrant C, Peterson J, Graves J. Muscular strength and endurance. In: Roitman J, ed. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 3rd ed. Philadelphia: Williams and Wilkins, 1998:448-455.

20. Royal college of Obstetricians and Gynecologists Key Points for Exercise During Pregnancy Women should be encouraged to participate in aerobic and strength-conditioning exercise as part of a healthy lifestyle during pregnancy. Women should be encouraged to participate in aerobic and strength-conditioning exercise as part of a healthy lifestyle during pregnancy. Reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level throughout pregnancy without trying to reach peak fitness level or train for athletic competition Reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level throughout pregnancy without trying to reach peak fitness level or train for athletic competition

21. Royal college of Obstetricians and Gynecologists Key Points for Exercise During Pregnancy Cont’ Women should choose activities that will minimize the risk of loss of balance and fetal trauma Women should choose activities that will minimize the risk of loss of balance and fetal trauma Women should be advised that adverse pregnancy or neonatal outcomes are not increased for exercising women Women should be advised that adverse pregnancy or neonatal outcomes are not increased for exercising women Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence

22. Royal college of Obstetricians and Gynecologists Key Points for Exercise During Pregnancy Cont’ Women should be advised that moderate exercise during lactation does not affect the quantity or composition of breast milk or impact fetal growth Women should be advised that moderate exercise during lactation does not affect the quantity or composition of breast milk or impact fetal growth Source: Royal College of Obstetrics and Gynecologists. Exercise in pregnancy. RCOG Statement No. 4 – January 2006; 1-6.

23. Postpartum Exercise Benefits Benefits Increased vitality Increased vitality Better overall mood and reduction in anxiety Better overall mood and reduction in anxiety

24. Conclusion Pregnant mothers: Pregnant mothers: Should obtain a clearance from their physician prior to beginning exercise program. Should obtain a clearance from their physician prior to beginning exercise program. Must be aware of their imitations and exercise within these limitations Must be aware of their imitations and exercise within these limitations Educated appropriately for certain exercise Educated appropriately for certain exercise If exercise is performed properly, exercise is very beneficial to both mother and baby during pregnancy and the post partum period. If exercise is performed properly, exercise is very beneficial to both mother and baby during pregnancy and the post partum period.