OUTLINE

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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_at_uwo.ca
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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
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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 19898273-301
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IMPORTANCE OF MEDICAL PRESCREENING THRESHOLD
FOR PROBLEMS??
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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!!
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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)
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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
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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 lt 15th ile for GA
• controls were gt 15th ile
• 2 controls recruited per case

Campbell Mottola 2001. Amer. J. Obstet.
Gynecol. 184403.
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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. 184403.
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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. 184403.
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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
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POSITION OF UTERUS AGAINST INFERIOR VENA CAVA
INFERIOR VENA CAVA
SUPINEBLOOD FLOW MAY BE RESTRICTED
STANDING NO RESTRICTION OF BLOOD FLOW
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DIASTASIS RECTI
NORMAL
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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
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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

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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
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PRESCRIPTION FOR AEROBIC ACTIVITY DURING PREGNANCY
FREQUENCY
TWO OR LESS TIMES PER WEEK
TOO LITTLE!!?
Campbell Mottola 2001. Amer. J. Obstet.
Gynecol. 184403.
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Cover page of The Economist, December 13-19th,
2003.
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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 62S105-11
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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 childs life by moms influence
  family life

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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

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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.
331147-56.
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Theory of Planned Behaviour
Social-cognitive framework
Behaviour
Downs Hausenblas 2004. J Midwifery Womens
Health 49138-44.
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• 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 49138-44.
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• 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. Womens Health Issues
13222-228.
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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.

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

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• 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)
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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!

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Rediscovering the M in MCH maternal health
promotion after childbirth
Active Living Post-partum

• 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 womens 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 womens health promotion
  in the 1st postpartum year is an essential step
  in addressing this neglect in maternal health

Walker LO, Wilging S. JOGNN 200029229-236
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Potential benefits of exercise in the postpartum
period
Regular physical activity essential to the health
of women throughout their life-span.

• Improved fitness
• Less urinary stress incontinence
• Less lactation-induced bone loss
• Less postpartum weight retention
• Improved psychosocial well-being

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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 49138-44)

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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
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Carey Quinn (2001) Can. J. Appl. Physiol.
2655-74.
Exercise Lactation Are they compatible?
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

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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
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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.
67693-701).
Adequate calcium intake (at least 1500 mg/day) is
important
(Drinkwater and Chesnut 1991. Bone Mineral
14153-160).
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 4Xs 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.
33512-518).
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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

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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.

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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.
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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.
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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.
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Aerobic conditioning

• FITT Principle
• Frequency 3 - 5 times/week
• Intensity talk test, RPE scale - moderate
• Time gt 15 minutes
• Type Activity that is comfortable

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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

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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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Post-natal Exercise Muscle Conditioning(Active
Living During Pregnancy, CSEP, 1999)

• Have baby sit on stomach while doing abdominals
• Can interact with baby while exercising obliques

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Post-natal Exercise Muscle Conditioning(Active
Living During Pregnancy, CSEP, 1999)

• Interact with baby doing hip and thigh exercises

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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

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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 post-partum??