1. ACTIVE LIVING DURING PREGNANCY& POST PARTUM Dr. Michelle F. Mottola, Ph.D. FACSM Director, R. Samuel McLaughlin Foundation- Exercise and Pregnancy Laboratory University of Western Ontario London, Ont. N6A 3K7 Email: mmottola@uwo.ca

2. OUTLINE Historical guidelines for exercise during pregnancy PARmed-X for Pregnancy (www.csep.ca) –medical prescreening –aerobic exercise guidelines –muscle conditioning guidelines –safety considerations Promoting Active Living During Pregnancy Promoting Active Living Post partum

3. Wolfe et al. Sports Med 1989;8:273-301 MATERNAL AND FETAL WELL-BEING Optimal zone for maternal exercise prescription chronic fatigue fetal death musculo- skeletal injury prematurity fetal growth restriction altered fetal development BASELINE Threshold for maternal physical conditioning effects QUANTITY AND QUALITY OF MATERNAL EXERCISE decrease increase  metabolic and cardiopulmonary reserve promotion of normal glucose tolerance psychological benefits Maternal dose-response curve Fetal dose-response curve fetal and placental adaptations

4. IMPORTANCE OF MEDICAL PRESCREENING THRESHOLD FOR PROBLEMS??

5. Prior to 1985 Exercise Guidelines for Pregnant Women did not exist – REST!! 1985 – ACOG suggested heart rate should not go above 140 beats per minute 1994 – ACOG Ignored heart rate; Replaced with common sense guidelines HISTORICALLY: 2002 – ACOG Ignored heart rate; Replaced with exercise on all days of week!!

6. Canadian guidelines for active living during pregnancy **Joint SOGC/CSEP Clinical Practice Guideline 2003** CSEP & Health Canada (1996 Revised 2002) PARmed-X for Pregnancy (Physical activity readiness, medical prescreening & exercise prescription) - written for physician/midwife or health care professional Authors: L.A. Wolfe, Queens & M.F. Mottola, Western CSEP & Health Canada (1999) Active Living During Pregnancy Physical activity guidelines for mother & baby. Author: Angela Kochan-Vintinner (Eds. Wolfe & Mottola) www.csep.ca

8. - 4 page document - current history of pregnant women & occupation - list of contraindications to exercise - absolute, relative - Aerobic conditioning guidelines F. (frequency) 3- 4 times /week I. (intensity) target HR zones T. (time) 15 up to 30 minutes T. (type) - Muscle conditioning guidelines & precautions - Safety considerations & reasons to consult physician/midwife PARmed-X for Pregnancy

9. Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403. Objective: To investigate the impact of exercise and occupational activity on birth weight Study Design: Questionnaires were mailed at 2 weeks post partum to subjects identified from delivery room logs. Case-control design - cases were birth wts < 15 th %ile for GA - controls were > 15 th %ile; - 2 controls recruited per case Frequency???

10. Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403. Results: 853 potential subjects, 529 (62%) returned questionnaires Univariable & multivariable analyses showed: odds of giving birth to a low birth weight baby was increased for those who engaged in structured exercise  5 times per week (4.61; 1.73, 12.32) and for those who engaged in structured exercise  2 times per week (2.64; 1.29, 5.39)

11. Conclusions: Occupational activity did not impact on birth weight Structured exercise frequency during late pregnancy appears to be a determinant of birth weight Too much vs too little vs just right!! ***** 3 – 4 times per week ****** Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.

12. INCREASE IN AEROBIC EXERCISE IN 2ND TRIMESTER Week of GestationDuration Frequency (minutes/session)(session/week) 16153 17173 18193 19213-4 20234-5 21253-4 22264-5 23273-4 24284-5 25293-4 26304-5 27303-4 28304-5

13. SUPINE BLOOD FLOW MAY BE RESTRICTED STANDING NO RESTRICTION OF BLOOD FLOW POSITION OF UTERUS AGAINST INFERIOR VENA CAVA INFERIOR VENA CAVA

14. NORMAL DIASTASIS RECTI

15. CORRECT POSTURE IN STANDING POSITION Keep the neck straight and the chin held up Lift up through the chest cage Keep the shoulders back; do not round shoulders forward Be careful of (posterior pelvic tilt) Bend the knees slightly Distribute the body weight on both feet NEUTRAL PELVIC ALIGNMENT

16. Summary of Canadian Guidelines 1. Previously sedentary women with healthy pregnancies can safely start an exercise program in the second trimester 2. Women with low risk pregnancies can continue mild to moderate activity throughout 3.Mild to moderate aerobic activity within the Canadian guidelines (PARmed-X for Pregnancy) is considered safe 4. Muscle conditioning activity with necessary precautions is also considered safe

17. Adapted from Wolfe et al., 1989 MATERNAL AND FETAL WELL-BEING Optimal zone for maternal exercise prescription BASELINE QUANTITY AND QUALITY OF MATERNAL EXERCISE  metabolic & cardiopulmonary reserve promotion of normal glucose tolerance psychological benefits Maternal dose-response curve Fetal dose-response curve Threshold for maternal physical conditioning effects Fetal & Placental Adaptations Altered Fetal Development Altered Maternal Pregnancy Adaptation ? ? Sedentary lifestyle *

18. PRESCRIPTION FOR AEROBIC ACTIVITY DURING PREGNANCY FREQUENCY TWO OR LESS TIMES PER WEEK TOO LITTLE!!? Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.

19. Cover page of The Economist, December 13-19 th, 2003.

20. Among women of childbearing age, one potential pathway for obesity development is excessive pregnancy weight gain and post partum weight retention Siega-Riz et al. 2004. Nut Rev 62:S105-11 Pregnancy link to Obesity?????

21. Impact of maternal & child health on current obesity epidemic? Intervention times/promoting physical activity? before conception during pregnancy post partum early years of child’s life by mom’s influence & family life Prevention vs treatment??

22. Pregnancy is time when many women change to a healthier lifestyle improve eating habits quit smoking stop alcohol use moderate caffeine consumption think about active living Promotion of Active Living During Pregnancy

23. Stages of Change (Intentional health behaviour change – 5 stages): precontemplation (no intention) contemplation (considering a change) preparation (making small changes) action (actively engaging in change) maintenance (sustaining change over time) Bull et al. 2001. Med Sci Sports Exerc. 33:1147-56.

24. Theory of Planned Behaviour: Social-cognitive framework Behavioural Beliefs Normative Beliefs Control Beliefs Attitude Subjective Norm Perceived Behavioural Control Intention Behaviour Downs & Hausenblas 2004. J Midwifery Womens Health 49:138-44.

25. Most common behavioural advantages - exercise improves mood - increases energy and stamina Most common normative influences - family members & children - NOT PHYSICIANS!! Control beliefs obstructing exercise - physical limitations - tiredness/fatigue - time limits - weight gain Exercise behaviour decreases from pre- pregnancy to post-partum Downs & Hausenblas 2004. J Midwifery Womens Health 49:138-44.

26. Thus, with this theory, the hypothesis is that: Pregnant women will intend to engage in being active when: they evaluate exercise positively (attitude) they believe that significant others want them to participate (subjective norm) they perceive being active as under their control (perceived behavioural control) Downs & Hausenblas 2003. Women’s Health Issues 13:222-228. Results: Intention (motivation) not perceived behavioural control predicted exercise behaviour in pregnant women in second trimester Use specific exercise goals (to positively influence motivation) Strong social support networks improve exercise intention

27. Health care providers promote active living throughout the life span including pregnancy Many women are interested in maintaining or improving pre pregnancy fitness levels as they become pregnant Traditional view has been replaced with active living and healthy lifestyle habits before, during and after pregnancy. Thus it is important that:

28. OBJECTIVES : 1. To identify whether daily activity patterns established before pregnancy change during pregnancy, in terms of the type of structured and recreational activity 2.To identify factors that are associated with engaging in a structured exercise program before pregnancy 3. To identify factors that contribute to continuing a structured exercise program, or not, during the course of pregnancy. Mottola & Campbell 2003. CJAP 28(4):642-653.

29. Results: Of 529 subjects, 369 (70%) engaged in structured exercise before pregnancy By trimester 3, 258 (49%) still retained a structured exercise program By trimester 3, most popular form of exercise was walking Factors associated with quitting exercise were: having children (1.67; 1.05, 2.67) pre pregnancy BMI  25 (1.79; 1.04, 3.13) higher weight gain (1.54; 1.01, 3.45) Mottola & Campbell 2003. CJAP 28(4):642-653.

30. What do pregnant women want? Walking most popular activity Barriers to physical activity? Having children

31. Effective promotion of active living during pregnancy depends on the extent and type of physical activity performed before conception, while taking into account the needs and wants of pregnant women throughout the three trimesters of pregnancy. How do we promote physical activity during pregnancy??

32. Education Programs that include: benefits of being active during pregnancy guidelines available for exercise during pregnancy (www.csep.ca) identified barriers to being active and ways to overcome them assistance in social support (health care providers, family involvement, transportation, safety issues, facilities, subsidized community programs)

33. Perhaps community programs which facilitate and encourage walking, such as mall walking (combined with elderly), which would also overcome barriers to exercise, include child care, family walks including children May be successful in promoting active living and physical activity during pregnancy (Active Living During Pregnancy, CSEP, 1999)

34. Other ways to promote active living: Muscle conditioning activities – check out cupboard!! Increase steps taken per day – park farther away; take stairs Rake leaves; cut grass Gardening Play with kids!

35. Rediscovering the “M” in “MCH”: maternal health promotion after childbirth – The science and practice of health promotion after childbirth is less well developed except for breast feeding and family planning – Why should we promote health in the postpartum? Improve women’s health and well-being in the immediate postpartum period, Reduce the risk of developing heart disease, obesity and other lifestyle-related diseases. – Better understanding of women’s health promotion in the 1 st postpartum year is an essential step in addressing this neglect in maternal health Walker LO, Wilging S. JOGNN 2000;29:229-236 Active Living Post-partum

36. Potential benefits of exercise in the postpartum period Improved fitness Less urinary stress incontinence Less lactation-induced bone loss Less postpartum weight retention Improved psychosocial well-being Regular physical activity essential to the health of women throughout their life-span.

37. Do barriers exist ?? Women are less likely than men to participate in vigorous, regular exercise. Exercise may be further compromised by pregnancy and recovery from childbirth Children and lack of time (Downs & Hausenblas 2004. J. MidwiferyWomens Health 49:138-44)

38. To Overcome Barriers?? Importance of education and social support. Exercise education should be incorporated into pre and post natal care. Include babies & child care in programs

39. Carey & Quinn (2001) Can. J. Appl. Physiol. 26:55-74. Quicker to return to pre-pregnancy body weight More positive sense of well-being Compared to sedentary controls, exercising women more apt to be: Exercise & Lactation: Are they compatible? Mild to Moderate intensity exercise: will not cause accumulation of lactic acid in breast milk will not affect milk volume if hydration is maintained will not affect infant growth will not affect infant acceptance of post-exercise breast milk

40. Impact of Exercise on Lactation- Induced Bone Mineral Density Loss Lactation BMD Exercise BMD Regular, self-selected recreational exercise had no impact on early post-partum lactation- induced BMD loss Little & Clapp, 1998. Med. Sci. Sports Exerc. 30(6):831-836

41. (Ritchie et al. 1998. Am. J. Clin. Nutr. 67:693-701). Lumbar bone recovered after resumption of menses, regardless of breast feeding status in active women Adequate calcium intake (at least 1500 mg/day) is important Other studies: (Drinkwater and Chesnut 1991. Bone & Mineral 14:153-160). Weight loss in overweight breastfeeding women? Restricted diet: 500 kcal less per day, no less than 1800 kcal/day 25% daily energy from fat; 20% from protein; 55% carbohydrate Exercise program: 4X’s per wk, moderate program Wt loss of 0.5 kg/wk did not affect Vitamin B-6 status (Lovelady et al. 2001. Med. Sci. Sports Exerc. 33:512-518).

42. Summary of Preliminary Data Post-partum women who exercised during pregnancy can maintain their fitness levels at 2 months post delivery At 2 months post-partum, active women have lower resting blood pressure than active non- pregnant control women Major activity is walking up to 60 minutes with/without stroller by 2 months post-partum Most appear to have no problem with breast feeding by 2 months post-partum

43. Guidelines exist for exercise during pregnancy, but relatively little attention has been given to exercise in the postpartum period, and specific guidelines for exercise in the postpartum period are essentially nonexistent. Guidelines??

44. General guidelines\Evidence Based Do not start moderate exercise until after 1st physician checkup Can take baby for walk if no complications Stretching, pelvic floor strengthening, relaxation & breathing exercises are OK Do not rush getting back into shape Do not overly fatigue Maintain proper nutrition & hydration Rest intervals may be helpful to avoid fatigue Can exercise in supine position When to return?? Mottola 2002. Current Sports Med. Reports pp. 362-368.

45. It is safe to participate in exercise following an uncomplicated vaginal delivery. Women should use fatigue as their guide to participation in exercise activities following delivery. Walking, stretching, and pelvic floor exercises are safe to perform in the immediate postpartum period. Abdominal exercises should be done with caution in this period to avoid injury to the lower back. Exercise in the postpartum period can facilitate postpartum weight loss. Women who exercise in the postpartum period are less likely to retain their pregnancy weight gain. Mottola 2002. Current Sports Med. Reports pp. 362-368. General guidelines\Evidence Based

46. Breast feeding guidelines Exercise after feed baby or pump Wear support bra NOT sports bra!! Mild to moderate exercise is OK Avoid strenuous activity Ensure adequate hydration before, during and after activity Ensure adequate caloric intake to support both exercise and lactation Mottola 2002. Current Sports Med. Reports pp. 362-368.

47. Aerobic conditioning FITT Principle – Frequency: 3 - 5 times/week – Intensity: talk test, RPE scale - moderate – Time: > 15 minutes – Type: Activity that is comfortable

48. Muscle conditioning Avoid fatigue Avoid holding breath during exercise Use baby as resistance - carefully Incorporate baby into routine where possible Stop any exercise that is painful Can exercise in supine position

50. Post-natal Exercise Muscle Conditioning (Active Living During Pregnancy, CSEP, 1999) Using baby for post-natal activities Using baby as resistance tool (carefully!!) Have fun interacting with baby when doing push- ups

51. Have baby sit on stomach while doing abdominals Can interact with baby while exercising obliques Post-natal Exercise Muscle Conditioning (Active Living During Pregnancy, CSEP, 1999)

52. Interact with baby doing hip and thigh exercises Post-natal Exercise Muscle Conditioning (Active Living During Pregnancy, CSEP, 1999)

53. Influence on early post-natal life Infants who were fed breast milk or who were breast fed longer had lower risk of overweight in adolescence Parental feeding patterns Parental activity patterns Obese mother – obese child Maternal influence as care-giver

54. If maternal-child interaction is a significant initiating factor in the obesity epidemic, will the prevention of excessive weight gain in mother during pregnancy and subsequently less weight retention post-partum lead to lower rates of obesity in successive generations? Active living during pregnancy & post-partum??