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EXERCISE DURING PREGNANCY

Exercise during pregnancy

Haleh DadgostarSports Medicine SpecialistRasoul e Akram Hospital


Outlines:

1. Physiological changes during pregnancy2. EXERCISE PRESCRIPTION


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


What physiological changes happen to a woman’s body during pregnancy?


Increase maternal plasma volume 50%Changes in maternal osmoregulationIncreased sodium retention by kidney

Physiologic anemia of pregnancyCardiac output increases by 30-50%

Heart rate rises 15-20 beatsStroke volume increased by 20-30%

Decreased systemic vascular resistanceProgesterone relaxes smooth muscle21% lower than nonpregnant values

PHYSIOLOGICAL CHANNGES


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

ventilationMaternal oxygen consumption 20-40% above

nonpregnant values



Increased risk of thromboembolic disease Increased venous stasis, vessel wall injury,

changes in coagulation cascadeTone 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



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


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



Despite a lack of clear evidence that musculoskeletal injuries are increased during pregnancy, these possibilities should nevertheless be considered when prescribing exercise in 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



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


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


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 reflex2. Cord compression3. Fetal head malposition

FETAL RESPONSES TO MATERNALEXERCISE


Birth weight is not affected by exercise in women who have adequate energy intake.

FETAL RESPONSES TO MATERNALEXERCISE


EXERCISE PRESCRIPTION


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


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


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


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


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

ABSOLUTE CONTRAINDICATIONS


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


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


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


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


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


Low impact aerobics Walking Cycling Yoga Ball Exercise Pilates Swimming Kegel

RECOMMENDED EXERCISES


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


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


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


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


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


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.


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


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


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


GUIDING INTENSITY OF EXERCISE Maximal heart rate

Age Heart rate range<20 140-15520-29 135-15030-39 130-145

>=40 125-140

RPE (12-14)

Talk testYou should be able to carry on a verbal conversation


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


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


Sedentary women Aerobic exercise, 65-75% max

HR

Moderately perceived exertion

30 min, minimum of 3 days/wk



Recreational athletes and regular fitness exercisers

Aerobic exercise, 65-85% max HR

Moderate hard to hard exertion

30-60 min, 3-5 days/wk



Elite Athletes Aerobic exercise, 75-85% MHR

Hard perceived exertion

60-90 minutes, 4-6 d/wk



DO NOT START EXERCISING IF

Your doctor says not to

Unusual bleeding

High blood pressure


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…


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


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


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


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


ACOG GUIDELINES

Ballistic movements should be avoided. Deep flexion or extension of joints should be

avoided because of connective tissue laxity


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


Modify intensity of exercise according to maternal symptoms.

Stop exercising when fatigued and not exercise to exhaustion

ACOG GUIDELINES


Vaginal bleedingDyspnea prior to exertionDizzinessHeadacheChest painMuscle weaknessCalf pain or swellingPreterm laborDecreased fetal movementAmniotic fluid leakage

WARNING SIGN


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)


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


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


Calf

Hamstring

Quadriceps

Pectoralis

Piriformis

Iliotibial band

Abdominal, groin

STRETCHES


• Backache during pregnancy is common because of the pressure of the fetus and the laxity of supporting structures.

BACK ACHE


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


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


Improves tone in pelvic floor muscles

Poor tone may cause:– Incontinence– Discomfort– More labor pain– Torn tissues– Uterine prolapse

KEGEL EXERCISE


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


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


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



How to Do the Kegel Exercise1. 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)



Practice while you sit, stand, walk, drive or watch TV

Three times each day Five repetitions Work up to 20 to 30

each time



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


Leg Raise1. 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


ABDOMINAL STRENGTHENERS

Knee Reach1. 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.


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


ABDOMINAL EXERCISES


Position Two1. 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


FULL BODY STRETCH

This exercise helps you warm up by stretching your whole body.


NECK STRETCH


FULL BODY TWIST

This exercise will stretch your waist, upper body and neck. It helps to keep your spine or backbone more flexible


Strengthening of External Rotators

Corner Press Out


THANKS FOR YOUR KIND ATTENTION

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