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

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

IMPORTANCE OF MEDICAL PRESCREENING

THRESHOLD FOR PROBLEMS??

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

NORMAL DIASTASIS RECTI

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.

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

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??