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ACTIVE LIVING DURING PREGNANCY& POST PARTUM

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. OUTLINE.

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ACTIVE LIVING DURING PREGNANCY& POST PARTUM

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

  4. IMPORTANCE OF MEDICAL PRESCREENING THRESHOLD FOR PROBLEMS??

  5. HISTORICALLY: 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 2002 – ACOG Ignored heart rate; Replaced with exercise on all days of week!!

  6. www.csep.ca 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)

  7. PARmed-X for Pregnancy - 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

  8. Frequency??? 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 Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.

  9. 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) Campbell & Mottola 2001. Amer. J. Obstet. Gynecol. 184:403.

  10. 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.

  11. INCREASE IN AEROBIC EXERCISE IN 2ND TRIMESTER Week of Gestation Duration Frequency (minutes/session) (session/week) 16 15 3 17 17 3 18 19 3 19 21 3-4 20 23 4-5 21 25 3-4 22 26 4-5 23 27 3-4 24 28 4-5 25 29 3-4 26 30 4-5 27 30 3-4 28 30 4-5

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

  13. DIASTASIS RECTI NORMAL

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

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

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

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

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

  19. Pregnancy link to Obesity????? 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

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

  21. Promotion of Active Living During Pregnancy • 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

  22. 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.

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

  24. 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.

  25. 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) • 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 Downs & Hausenblas 2003. Women’s Health Issues 13:222-228.

  26. Thus it is important that: • 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.

  27. OBJECTIVES: • To identify whether daily activity patterns established before pregnancy change during pregnancy, in terms of the type of structured and recreational activity • To identify factors that are associated with engaging in a structured exercise program before pregnancy • 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.

  28. 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.

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

  30. How do we promote physical activity during pregnancy?? 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.

  31. 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)

  32. 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)

  33. 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!

  34. Active Living Post-partum 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 1st postpartum year is an essential step in addressing this neglect in maternal health Walker LO, Wilging S. JOGNN 2000;29:229-236

  35. Regular physical activity essential to the health of women throughout their • life-span. 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

  36. 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)

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

  38. Exercise & Lactation: Are they compatible? Carey & Quinn (2001) Can. J. Appl. Physiol. 26:55-74. Compared to sedentary controls, exercising women more apt to be: • Quicker to return to pre-pregnancy body weight • More positive sense of well-being 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

  39. Exercise Lactation BMD BMD Impact of Exercise on Lactation-Induced Bone Mineral Density Loss • 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

  40. Other studies: Lumbar bone recovered after resumption of menses, regardless of breast feeding status in active women (Ritchie et al. 1998. Am. J. Clin. Nutr. 67:693-701). Adequate calcium intake (at least 1500 mg/day) is important (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).

  41. 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

  42. Guidelines?? • 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.

  43. General guidelines\Evidence Based When to return?? • 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 Mottola 2002. Current Sports Med. Reports pp. 362-368.

  44. General guidelines\Evidence Based • 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.

  45. 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.

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

  47. 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

  48. 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

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