ACTIVE LIVING DURING PREGNANCY& POST PARTUM Dr. Michelle F. Mottola, Ph.D. FA Director, R. Samuel McLaughlin Foundation Exercise and Pregnancy Laboratory University of Western Ontario London, Ont. N6A 3K7 Email: [email protected]
Jan 02, 2016
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: [email protected]
OUTLINEOUTLINE
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 PregnancyPromoting Active Living Post partum
Wolfe et al. Sports Med 1989;8:273-301
MATERNAL AND FETAL WELL-BEING
Optimal zone for maternalexercise prescription
• chronic fatigue
fetal death
• musculo- skeletal injury
• prematurity• fetal growth restriction
• altered fetal development
BASELINE
Threshold for maternalphysical conditioning effects
QUANTITY AND QUALITY OF MATERNAL EXERCISE
decrease
increase
•metabolic and cardiopulmonary reserve• promotion of normal glucose tolerance• psychological benefits
Maternal dose-response curveFetal dose-response curve
• fetal and placentaladaptations
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!!
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, medicalprescreening & exercise prescription)- written for physician/midwife or health care
professionalAuthors: 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
- 4 page document- current history of pregnant women & occupation- list of contraindications to exercise
- absolute, relative- Aerobic conditioning guidelines
F. (frequency) 3- 4 times /weekI. (intensity) target HR zonesT. (time) 15 up to 30 minutesT. (type)
- Muscle conditioning guidelines & precautions- Safety considerations & reasons to consult
physician/midwife
PARmed-X for Pregnancy
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 < 15th %ile for GA- controls were > 15th %ile; - 2 controls recruited per case
Frequency???
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)
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.
INCREASE IN AEROBIC EXERCISE IN 2ND TRIMESTER
Week of Gestation Duration Frequency(minutes/session) (session/week)
16 15 317 17 318 19 319 21 3-420 23 4-521 25 3-422 26 4-523 27 3-424 28 4-525 29 3-426 30 4-527 30 3-428 30 4-5
SUPINEBLOOD FLOW MAY BE RESTRICTED
STANDINGNO RESTRICTION OF BLOOD FLOW
POSITION OF UTERUS AGAINST INFERIOR VENA CAVA
INFERIOR VENA CAVA
CORRECT POSTURE IN STANDING POSITION
Keep the neck straight and the chin held upLift 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 PELVICALIGNMENT
Summary of Canadian GuidelinesSummary 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
Adapted from Wolfe et al., 1989
MATERNAL AND FETAL WELL-BEING
Optimal zone for maternalexercise prescription
BASELINE
QUANTITY AND QUALITY OF MATERNAL EXERCISE
• metabolic & cardiopulmonary reserve• promotion of normal glucose tolerance• psychological benefits
Maternal dose-response curveFetal dose-response curve
Threshold for maternalphysical conditioning effects
Fetal & Placental
Adaptations
•Altered Fetal Development
Altered Maternal
Pregnancy Adaptation
?
?
Sedentary lifestyle
*
PRESCRIPTION FOR AEROBIC ACTIVITY DURING PREGNANCY
FREQUENCY
TWO OR LESS TIMES PER WEEK
TOO LITTLE!!?
Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.
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?????
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??
• 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
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.
Theory of Planned Behaviour:
Social-cognitive framework
Behavioural Beliefs
Normative Beliefs
ControlBeliefs
Attitude
SubjectiveNorm
PerceivedBehaviouralControl
Intention Behaviour
Downs & Hausenblas 2004. J Midwifery Womens Health 49:138-44.
Most common behavioural advantages- exercise improves mood- increases energy and staminaMost 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.
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
• 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:
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.
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.
What do pregnant women want?
Walking most popular activity
Barriers to physical activity?
Having children
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??
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)
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)(Active Living During Pregnancy, CSEP, 1999)
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!
Rediscovering the “M” in “MCH”: Rediscovering the “M” in “MCH”: maternal health promotion after childbirthmaternal 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 1st 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
Potential benefits of exercise in Potential benefits of exercise in the postpartum periodthe postpartum period
Improved fitnessLess urinary stress incontinenceLess lactation-induced bone lossLess postpartum weight retentionImproved psychosocial well-being
Regular physical activity essential to the health of women throughout their
life-span.
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)
To Overcome Barriers??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
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
Impact of Exercise on Lactation-Impact of Exercise on Lactation-Induced Bone Mineral Density LossInduced 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
(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).
Summary of Preliminary DataSummary 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
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??Guidelines??
General guidelines\Evidence BasedGeneral 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.
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 BasedGeneral guidelines\Evidence Based
Breast feeding guidelinesBreast feeding guidelinesExercise after feed baby or pumpWear support bra NOT sports bra!!Mild to moderate exercise is OKAvoid strenuous activityEnsure adequate hydration before,
during and after activityEnsure adequate caloric intake to
support both exercise and lactationMottola 2002. Current Sports Med. Reports pp. 362-368.
Aerobic conditioningAerobic conditioning
FITT Principle– Frequency: 3 - 5 times/week– Intensity: talk test, RPE scale -
moderate– Time: > 15 minutes– Type: Activity that is comfortable
Muscle conditioningMuscle conditioning
Avoid fatigueAvoid holding breath during
exerciseUse baby as resistance - carefullyIncorporate baby into routine where
possibleStop any exercise that is painfulCan exercise in supine position
Post-natal Exercise Muscle ConditioningPost-natal Exercise Muscle Conditioning(Active Living During Pregnancy, CSEP, 1999)(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
Have baby sit on stomach while doing abdominals
Can interact with baby while exercising obliques
Post-natal Exercise Muscle ConditioningPost-natal Exercise Muscle Conditioning(Active Living During Pregnancy, CSEP, 1999)(Active Living During Pregnancy, CSEP, 1999)
Interact with baby doing hip and thigh exercises
Post-natal Exercise Muscle ConditioningPost-natal Exercise Muscle Conditioning(Active Living During Pregnancy, CSEP, 1999)(Active Living During Pregnancy, CSEP, 1999)
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
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 & Active living during pregnancy & post-partum??post-partum??