Chapter 21Chapter 21Exercise Guidelines Exercise Guidelines

and and Recommendations Recommendations During PregnancyDuring Pregnancy

Jacalyn J. Robert-McComb, Jacalyn J. Robert-McComb, PhD, FACSMPhD, FACSM

Jessica Stovall, BSJessica Stovall, BS

Learning ObjectivesLearning ObjectivesFollowing this presentation, you should Following this presentation, you should

have an understanding of:have an understanding of: Physiological changes of pregnancy that Physiological changes of pregnancy that

may affect exercise;may affect exercise; Effects of exercise on the baby;Effects of exercise on the baby; Activities to encourage and discourage Activities to encourage and discourage

during pregnancy;during pregnancy; Guidelines for exercising while pregnantGuidelines for exercising while pregnant Postpartum exercise; andPostpartum exercise; and Contraindications to exercising while Contraindications to exercising while

pregnantpregnant

IntroductionIntroduction Mild and moderate exercise during Mild and moderate exercise during

pregnancy have very positive effects on pregnancy have very positive effects on the mother and infantthe mother and infant

Positive Effects of ExercisePositive Effects of Exercise

Reduced typical pregnancy-related Reduced typical pregnancy-related symptomssymptoms

Reduced “active stage” of laborReduced “active stage” of labor Increased sense of maternal well-beingIncreased sense of maternal well-being Decreased delivery complicationsDecreased delivery complications Reduced risk developing pregnancy Reduced risk developing pregnancy

induced hypertensioninduced hypertension Reduced bone density loss during lactationReduced bone density loss during lactation Increased birth weightIncreased birth weight Reduced risk developing gestational Reduced risk developing gestational

diabetesdiabetes

Gestational Diabetes Gestational Diabetes Mellitus (GDM)Mellitus (GDM)

Researchers found a 76% decrease in GDM Researchers found a 76% decrease in GDM risk in active women, or those who spent risk in active women, or those who spent >> 4.3 h . wk –1 engaged in recreational 4.3 h . wk –1 engaged in recreational physical activity, compared with inactive physical activity, compared with inactive women women (Dempsey, Sorensen, Williams, et al., (Dempsey, Sorensen, Williams, et al., 2004 ). 2004 ).

Perhaps one of the greatest incentives to Perhaps one of the greatest incentives to exercise moderately during pregnancy is exercise moderately during pregnancy is that children of GDM mothers are more that children of GDM mothers are more likely to have diabetes in adolescence or likely to have diabetes in adolescence or even become obese (Dempsey, Butler, even become obese (Dempsey, Butler, Williams, 2005 ).Williams, 2005 ).

Physiological Changes of Physiological Changes of PregnancyPregnancy

Musculoskeletal alterations Musculoskeletal alterations joint laxity and hypermobility can cause joint laxity and hypermobility can cause

injury during exerciseinjury during exercise Change in center of gravityChange in center of gravity

Weight of growing breasts, uterus, and Weight of growing breasts, uterus, and fetusfetus

Temperature decreases slightly after Temperature decreases slightly after exerciseexercise Helps avoid overheatingHelps avoid overheating

 

Physiological Changes of Physiological Changes of Pregnancy Cont’Pregnancy Cont’

Cardiac output (CO) Cardiac output (CO) Decreases 9% after 1Decreases 9% after 1stst trimester when trimester when

mother is in supine positionmother is in supine position Exercise should be avoided in supine Exercise should be avoided in supine

position due to vena cava compressionposition 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

Physiological Changes of Physiological Changes of Pregnancy Cont’Pregnancy Cont’

During exercise, blood diverted During exercise, blood diverted away from abdominal viscera and away from abdominal viscera and uterus to exercising musclesuterus to exercising muscles This can be a concern when there is a This can be a concern when there is a

decrease in splanchnic blood flow by 50 decrease in splanchnic blood flow by 50 percent (can cause fetal hypoxemia)percent (can cause fetal hypoxemia)

Physiological Changes of Physiological Changes of Pregnancy Cont’Pregnancy Cont’

Increased oxygen demandIncreased oxygen demand Inhibition of diaphragm because of Inhibition of diaphragm because of

enlarged uterusenlarged uterus Increase in energy demandsIncrease in energy demands

Pregnant women need to increase their Pregnant women need to increase their caloric intake by approximately 300 kcal caloric intake by approximately 300 kcal per fetus. per fetus.

If the pregnant woman exercises, she If the pregnant woman exercises, she needs to increase her caloric intake to needs to increase her caloric intake to meet the energy cost of the activity meet the energy cost of the activity

Effects of Exercise on the Effects of Exercise on the BabyBaby

Decrease risk of premature laborDecrease risk of premature labor Growth of placenta increasedGrowth of placenta increased Children scored higher on Children scored higher on

intelligence tests by age 5intelligence tests by age 5 Children leanerChildren leaner Babies seemed to handle stress of Babies seemed to handle stress of

contractions bettercontractions better Babies had a decrease in likeliness of Babies had a decrease in likeliness of

getting tangled in umbilical cordgetting tangled in umbilical cord

Activities to Encourage and Activities to Encourage and Discourage during Discourage during

PregnancyPregnancy Activities EncouragedActivities Encouraged

WalkingWalking Stationary cyclingStationary cycling low-impact aerobicslow-impact aerobics swimmingswimming

Activities DiscouragedActivities Discouraged Contact sportsContact sports

hockey, wrestling, hockey, wrestling, football, and soccerfootball, and soccer

Sports with increase in Sports with increase in fallsfalls

horseback riding, horseback riding, gymnastics, skating, gymnastics, skating, skiing, hang gliding, skiing, hang gliding, vigorous racquet sports, vigorous racquet sports, weight lifting, and scuba weight lifting, and scuba divingdiving

Guidelines for Exercising while Guidelines for Exercising while PregnantPregnant

Clearance from physician prior to Clearance from physician prior to beginning exercise programbeginning exercise program

PAREMED-XPAREMED-X

Is one of the most often used Is one of the most often used screening tool for pregnancy screening tool for pregnancy

This tool can be downloaded on the This tool can be downloaded on the web at web at http://uwfitness.uwaterloo.ca/PDF/pahttp://uwfitness.uwaterloo.ca/PDF/parmed-xpreg_000.pdf rmed-xpreg_000.pdf

Or you can use your search engine Or you can use your search engine on the web using the term on the web using the term PAREMED-X to find this form.PAREMED-X to find this form.

American College of Obstetricians and American College of Obstetricians and Gynecologists Relative and Absolute Gynecologists Relative and Absolute Contradictions to Aerobic Exercise Contradictions to Aerobic Exercise

During PregnancyDuring Pregnancy Relative Relative

AnemiaAnemia Chronic bronchitisChronic bronchitis Extreme morbid obesityExtreme morbid obesity Extreme underweightExtreme underweight Heavy smokerHeavy smoker Orthopedic limitationsOrthopedic limitations Uncontrolled Uncontrolled

hypertensionhypertension(See Table 21.1 in the book for (See Table 21.1 in the book for

a complete list)a complete list)

AbsoluteAbsolute severe heart diseasesevere heart disease Restrictive lung diseaseRestrictive lung disease Ruptured membranesRuptured membranes Premature laborPremature labor Continual 2Continual 2ndnd or 3 or 3rdrd

trimester bleedingtrimester bleeding Incompetent cervixIncompetent cervix(See Table 21.1 in the (See Table 21.1 in the

book for a complete list) 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

Summary of Recommendations Summary of Recommendations for Aerobic Exercise During for Aerobic Exercise During

PregnancyPregnancy 30 min or more of moderate exercise 30 min or more of moderate exercise

a day on most days of the week, in a day on most days of the week, in absence of medical or obstetric absence of medical or obstetric complicationscomplications 3-5 METS; equivalent to brisk walking3-5 METS; equivalent to brisk walking Ratings of perceived exertions useful Ratings of perceived exertions useful

(11-14) on the 6-20 Borg scale(11-14) on the 6-20 Borg scale Exercise sessions longer than 45 min Exercise sessions longer than 45 min

not well toleratednot well tolerated Monitor hydration and body temperatureMonitor hydration and body temperature

Indications to Stop Exercise During Indications to Stop Exercise During PregnancyPregnancy

Excessive shortness of breathExcessive shortness of breath Chest painChest pain Extreme fatigueExtreme fatigue Pelvic girdle painPelvic girdle pain Vaginal bleedingVaginal bleeding Muscle weaknessMuscle weakness HeadacheHeadache

(Note: not limited to only these listed, see Table (Note: not limited to only these listed, see Table 21.3 in the book for a complete list)21.3 in the book for a complete list)

Strength Training during Strength Training during PregnancyPregnancy

Strength conditioning, weight Strength conditioning, weight training, and stretching provides training, and stretching provides pregnant women with improved pregnant women with improved level of muscular fitnesslevel of muscular fitness Help postural adjustmentsHelp postural adjustments

Recommendations Regarding Recommendations Regarding Resistance Training during Resistance Training during

PregnancyPregnancy Medical advice and physician recommendations Medical advice and physician recommendations

should be obtained prior to resistance training should be obtained prior to resistance training during pregnancy.during pregnancy.

Resistance training for all pregnant women may Resistance training for all pregnant women may not be appropriate. If women have any of the not be appropriate. If women have any of the contraindications to aerobic exercise as contraindications to aerobic exercise as proposed by American College of Obstetrics and proposed by American College of Obstetrics and Gynecology they should not participate in Gynecology they should not participate in resistance training.resistance training.

Women who have never participated in Women who have never participated in resistance training should not initiate one during resistance training should not initiate one during pregnancy.pregnancy.

Recommendations Cont’dRecommendations Cont’d

Women should be encouraged to breathe normally Women should be encouraged to breathe normally during resistance training, breath holding reduces during resistance training, breath holding reduces oxygen delivery to the placentaoxygen delivery to the placenta

Heavy resistance should be avoided since it may expose Heavy resistance should be avoided since it may expose the joints, connective tissue, and skeletal structures of the joints, connective tissue, and skeletal structures of an expectant woman to excessive forces. An exercise set an expectant woman to excessive forces. An exercise set consisting of at least 12-15 repetitions without undue consisting of at least 12-15 repetitions without undue fatigue is recommended.fatigue is recommended.

As training occurs, overload initially by increasing As training occurs, overload initially by increasing number of repetitions and, subsequently, by increasing number of repetitions and, subsequently, by increasing resistance.resistance.

Resistance training on machines if preferred to free-Resistance training on machines if preferred to free-weights because machines can be more easily controlled weights because machines can be more easily controlled and require less skill.and require less skill.

Source: Byrant C, Peterson J, Graves J. Muscular strength and endurance. In: Source: Byrant C, Peterson J, Graves J. Muscular strength and endurance. In: Roitman J, Roitman J,

ed. ACSM’s Resource Manual for Guidelines for Exercise Testing and ed. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 3rd Prescription, 3rd

ed. Philadelphia: Williams and Wilkins, 1998:448-455.ed. Philadelphia: Williams and Wilkins, 1998:448-455.

Royal college of Obstetricians and Royal college of Obstetricians and Gynecologists Key Points for Gynecologists Key Points for Exercise During PregnancyExercise During Pregnancy

Women should be encouraged to Women should be encouraged to participate in aerobic and strength-participate in aerobic and strength-conditioning exercise as part of a conditioning exercise as part of a healthy lifestyle during pregnancy.healthy lifestyle during pregnancy.

Reasonable goals of aerobic conditioning Reasonable goals of aerobic conditioning in pregnancy should be to maintain a in pregnancy should be to maintain a good fitness level throughout pregnancy good fitness level throughout pregnancy without trying to reach peak fitness level without trying to reach peak fitness level or train for athletic competitionor train for athletic competition

Royal college of Obstetricians and Royal college of Obstetricians and Gynecologists Key Points for Exercise Gynecologists Key Points for Exercise

During Pregnancy Cont’During Pregnancy Cont’ Women should choose activities that Women should choose activities that

will minimize the risk of loss of will minimize the risk of loss of balance and fetal traumabalance and fetal trauma

Women should be advised that adverse Women should be advised that adverse pregnancy or neonatal outcomes are pregnancy or neonatal outcomes are not increased for exercising womennot increased for exercising women

Initiation of pelvic floor exercises in Initiation of pelvic floor exercises in the immediate postpartum period may the immediate postpartum period may reduce the risk of future urinary reduce the risk of future urinary incontinenceincontinence

Royal college of Obstetricians and Royal college of Obstetricians and Gynecologists Key Points for Exercise Gynecologists Key Points for Exercise

During Pregnancy Cont’During Pregnancy Cont’

Women should be advised that Women should be advised that moderate exercise during lactation moderate exercise during lactation does not affect the quantity or does not affect the quantity or composition of breast milk or impact composition of breast milk or impact fetal growthfetal growth

Source: Royal College of Obstetrics and Gynecologists. Exercise in Source: Royal College of Obstetrics and Gynecologists. Exercise in pregnancy. RCOG Statement No. 4 – January 2006; 1-6.pregnancy. RCOG Statement No. 4 – January 2006; 1-6.

Postpartum ExercisePostpartum Exercise

BenefitsBenefits Increased vitalityIncreased vitality Better overall mood and reduction in Better overall mood and reduction in

anxietyanxiety

ConclusionConclusion

Pregnant mothers: Pregnant mothers: Should obtain a clearance from their Should obtain a clearance from their

physician prior to beginning exercise physician prior to beginning exercise program.program.

Must be aware of their imitations and Must be aware of their imitations and exercise within these limitationsexercise within these limitations

Educated appropriately for certain exerciseEducated appropriately for certain exercise If exercise is performed properly, If exercise is performed properly,

exercise is very beneficial to both exercise is very beneficial to both mother and baby during pregnancy and mother and baby during pregnancy and the post partum period.the post partum period.