Pregnancy

Physiological Changes During Pregnancy

• Cardiac output:– The volume of blood the heart pumps per minute

increases from about 5 liters per minute pre-pregnancy to about 9 liters per minute at 36 to 39 weeks

• Blood pressure may decrease during the first two trimesters, returns to baseline in the third trimester

• Some women may experience edema (fluid accumulation)

Physiological Changes During Pregnancy

• Nausea and vomiting typically occur during the first trimester (morning sickness)

• Center of gravity shifts which may result in balance problems

• Appetite increases

Medical Clearance

• Pregnant women need to consult with a physician before initiating an exercise program

Pregnant Women• Women who are pregnant seek out

personal training for numerous reasons:

–Self-conscious about their changing body

–Concerned about having a healthy baby

–Want to stay in shape throughout the pregnancy

–Want to be able to handle labor and delivery

Benefits of Exercise During Pregnancy

• Enhanced maternal psychological well being that may reduce the feelings of stress, anxiety, and depression often experienced during pregnancy

• Increased likelihood of adopting permanent healthy lifestyle habits

• Prevention of gestational diabetes (improving glucose tolerance)

• Improve physical discomforts, weakness, and lack of stamina

Benefits of Exercise During Pregnancy

• Improved cardiovascular and muscular fitness• Facilitated recovery from labor• Faster return to pre-pregnancy weight, strength, and

flexibility• Reduced postpartum belly• Reduced back pain during pregnancy • More energy reserve• Fewer Obstetric interventions• Shorter active phase of labor and less pain• Less weight gain

Exercise Concerns During Pregnancy

• Insufficient oxygen or energy substrates (calories) to the fetus

• Hyperthermia: –induced fetal distress or birth

abnormalities

• Increased uterine contractions

Exercise Concerns During Pregnancy

• Reduced birth weight in babies whose mothers performed high-intensity exercise (300-350 g/10-12 ounces)

• Vigorous exercise during pregnancy is associated with 5 to 15 beat per minute increase in fetal heart rate

• No documented adverse affects related to exercise-induced fetal HR

Exercise Concerns During Pregnancy

• After first trimester, supine positions results in restricted venous return of blood to the heart because of an enlarged uterus

• This position reduces cardiac output and may cause supine hypotensive syndrome

Supine Hypotensive Syndrome• Characterized by :

– Hypotension (abnormally low blood pressure) and bradycardia (abnormally slow heartbeat) when a pregnant women (especially near term) lies supine

– This syndrome is the result of compression of the aorta

Supine Hypotensive Syndrome• Exercises performed supine should be

phased out before the second trimester

• These include:– Crunch, bench press, supine exercises on a

SB, and supine stretching

• Pregnant women can do abdominal exercises in a side lying position and upper body exercises on a seated machine

Exercise Concerns During Pregnancy• Less oxygen is available for aerobic activity

because the enlarging uterus interferes with diaphragm movement.

• Avoid training at high levels of fatigue

• Due to center of gravity changes it is advisable for pregnant women to use machines for stability and support– Balance, body control, and movement mechanics

are affected– Be careful prescribing balance exercises

Exercise Concerns During Pregnancy

• Due to joint laxity in pregnancy, exercises should be performed slowly and controlled

• High risk exercises like racket sports, gymnastics, basketball, skiing, bicycling, horse-back riding, and scuba diving should be avoided

• Personal trainers should emphasize core strengthening and pelvic floor exercises to support the spine and prepare women for labor

Exercise Concerns During Pregnancy

• Avoid stretching abdominal muscles (baby is doing that for the mother) because they cause a widening of the rectus abdominis

• Avoid weighted squats

• Avoid extreme end ranges of motion

• Avoid prolonged periods of standing

Exercise Guidelines During Pregnancy• Wear comfortable exercise footwear that gives

strong ankle and arch support

• Take frequent breaks, and drink plenty of fluids to prevent overheating and dehydrating

• Avoid brisk exercise in hot, humid weather or when you have a fever

• Wear comfortable clothing that will help you to remain cool

• Wear a bra that fits well and gives lots of support to help protect your breasts

Exercise Guidelines During Pregnancy

• Running:

–If you were a runner before pregnancy, you often can keep running during pregnancy although you may have to modify your routine.

–Talk to your physician about whether running during pregnancy is safe for you

Posture and Pregnancy

Posture and Pregnancy• During pregnancy the weight of the baby may cause

– Lower Cross Syndrome (Anterior Pelvic Tilt)• Tightening of the hip flexors and lumbar erectors• Weakening of gluteus maximus, hamstrings, and

abdominal complex– Upper Cross Syndrome (Forward Head and

Rounded Shoulders)• Tightening of pectoralis major and minor, anterior

deltoid, and sternocleidomastoid (neck), upper trapezius, and levator scapula

• Weakening of rhomboids, serratus anterior, and lower trapezius

Posture and Pregnancy• Perform Corrective Exercises

– Stretch the tight muscles and strengthen the weak muscles

– Posterior pelvic tilts in quadruped or against the wall

– Drawing-in to engage the core complex– Chin tucks– Avoid standing in one position for long periods of

time

Recommended Exercises During Pregnancy

• KEGEL Exercises: – Strengthens the pelvic floor muscles, which

support the uterus, bladder and bowel

– Provides postural support

– As you are standing, sitting or lying down, try to contract the muscles you would use to stop urinating

– You should feel your pelvic muscles contracting

– If your abdominals or glutes tighten, you are not strengthening the pelvic floor muscles

– Hold the contraction for three seconds then relax for three seconds. Repeat 10 times

Contraindications for Exercise from International Federation of Gynecology and Obstetrics

• Pregnancy induced hypertension (high BP)

• Ruptured membranes (premature labor)• Persistent bleeding after 12 weeks• A dilated cervix ahead of schedule• HR disease or lung disease• Multiple birth pregnancy that creates a

risk of premature labor

Contraindications for Exercise from International Federation of Gynecology and Obstetrics

• A placenta that blocks the cervix after 26 weeks

• Cardiac disease• Pulmonary disease• Thyroid function abnormality• Poorly controlled type I diabetes• Seizures• Extreme obesity• Low body weight (BMI less than 12)

Contraindications for Exercise from International Federation of Gynecology and Obstetrics

• Intrauterine growth retardation• History of sedentary lifestyle• Severe anemia:

– lower than normal number of red blood cells (erythrocytes) in the blood

• Heavy smoking• Chronic bronchitis• Orthopedic limitations

Contraindications for Exercise from International Federation of Gynecology and Obstetrics

• Sudden swelling of ankles, hands, or face

• Persistent headaches, visual disturbance

• Elevation of BP that persists after exercise

• Unexplained abdominal pain

• Insufficient weight gain:– less than 2 pounds per month during last 2

trimesters

Monitoring Exercise HR During Pregnancy

• Heart rate is a poor indicator of pregnancy intensity

• A pregnant women should generally not exercise above 60% of her maximal oxygen consumption (VO2 max)

• The heart rate should not go above 140 beats per minute during exercise

• Personal Trainers can use:– Rate of Perceived Exertion (RPE) to

prescribe aerobic exercise intensity on a scale of 12-16

– Talk Test

Exercise Guidelines• Duration:

–30-60 minutes of low to moderate exercise

– The two primary concerns in relation to long durations of exercise (over 45 minutes) are energy deficit and thermoregulation

• Frequency:– Could be 7 days a week

Exercise Guidelines• Avoid exercise in the supine position

after first trimester

• Avoid contact sports

• Emphasize corrective exercises for upper and lower cross syndromes

• Avoid walking lunges (might increase connective tissue injury to the pelvic area)

• Exercise should not continue past the point of fatigue

Exercise Guidelines• Non weight bearing exercises are best like

swimming and stationary cycling

• Swimming, Walking, Elliptical Trainer, Prenatal Pilates, Prenatal yoga and Prenatal low impact aerobics are recommended

• Large increases in body temp should be avoided

• Avoid swimming in water temperatures 28-30 degrees Celsius

• Adequate hydration and appropriate clothing

Exercise After Birth• During the first three months after birth, women

are advised to observe the exercise guidelines for pregnancy

• Swimming should be avoided until any bleeding has stopped (usually about four weeks after delivery).

• Women who do strenuous exercise while breastfeeding should ensure that they have adequate rest, fluids and food intake

• A woman who has had a cesarean delivery should not exercise until her physician gives her the go-ahead (usually six weeks)

Nutrition and Pregnancy• National standards are an increase of 340

kcal/day during the second trimester and 450 kcal/day during the third trimester for a total of 2200-2800 kcal per day

• Weight gain within pregnancy is generally within the range of 25-35 pounds

• Rate of Weight Gain:

– 2-4 pounds during the first trimester

– 1 pound per week during the remainder of the pregnancy

How Much Weight Women Should Gain During Pregnancy

• Average weight gain (BMI 19.8 to 26):– 25-35 pounds

• Underweight women (BMI less than 19.8): – 28-40 pounds of weight gain

• Overweight women (BMI of 26-29): – 15-25 pounds of weight gain

• Obese women (BMI greater than 29): – 15 pounds of weight gain

• Teenage girls: – 35 to 40 pounds of weight gain

• Women carrying twins: – 35-45 pounds of weight gain

Where Does the Weight Go During Pregnancy?

Protein Needs• Pregnant women require about 60 grams of

protein per day• Good sources of protein include:

– Lean meats– Poultry– Fish (Avoid eating shark, swordfish, king mackerel,

tilefish-they contain high levels of mercury)

– Dried beans– Lentils– Nuts– Eggs– Cheese

Calcium Needs• The recommended amount of calcium for women ages

19 to 50, pregnant or not, is 1,000 milligrams (mg) per day. (For teenage girls up to age 18, it is 1,300 mg daily.) That's right—the amount of calcium you need each day remains the same before, during and after pregnancy.You can get your calcium from:– Green leafy vegetables – Orange juice – Milk– Yogurt– Cheese

Iron• As maternal blood supply increases the need for iron

also increases• Essential for hemoglobin synthesis

– red, iron-based protein pigment in red blood cells that enables them to transport oxygen

• Pregnant women need 27 mg of iron per day• Good sources of iron:

– Fish, poultry, whole grain breads and cereals, green leafy vegetables, legumes, dried fruits, eggs, liver, and red meat

• Coffee and tea interfere with iron absorption

Folate(Vitamin B)• Promotes normal growth of the fetus and

placenta

• Necessary for the prevention of neural tube defects (child is born with an underdeveloped brain or no brain at all) or spina bifida (spinal cord does not completely close)

• Recommendation is 600 mcg/day

• Good sources of folate include: – Fortified cereals, lentils, peanut butter, corn,

cantaloupe, beets, asparagus, broccoli, spinach, citrus fruits, and most berries

Foods to Avoid During Pregnancy• Some infections can be picked up by pregnant women

and transferred to the developing baby via the placenta

• Examples include toxoplasmosis, listeria and salmonella

• Pregnant women are therefore advised to avoid the following foods:– Unpasteurized dairy products – Soft or blue-veined cheeses – Soft-whipped ice-cream – Raw or undercooked eggs or shellfish – Undercooked chicken – Undercooked meat products in general (deli meats)

Alcohol, Cigarettes, and Caffeine• Fetal Alcohol Syndrome:

– leading cause of mental retardation

• Small doses of alcohol may cause brain damage, delayed growth, facial and vision abnormalities

• Cigarette smoking causes low birth weight and impaired oxygen transport

• Caffeine:– Does cross the placenta and stays in the blood

stream– Extensive caffeine use may cause low birth weight– Consult physician about how much can be

consumed

Lactation• Milk production requires an additional 330 kcal/day in

the first six months and 400 kcal/day in the second six months

• Protein needs are 71 g/day or 1.1g/kg of BW per day• Advantages of Breast Feeding

– Fewer infections– Fewer allergies and intolerances– Ease of digestion– Improved cognitive development– Decreases in the risk of childhood obesity and heart

disease• Advised for women to breast feed for at least 12

months

Benefits of Breastfeeding for Mother• Promotes faster shrinking of uterus

• Reduces postpartum bleeding

• Decreases risk of ovarian and breast cancer

• Improves glucose profile in those with gestational diabetes

• Strengthens bond with infant

• Saves money not spent on formula

Gestational Diabetes• Pregnancy diabetes• If a woman gets high blood sugar when she's

pregnant, but she never had high blood sugar before, she has gestational diabetes.

• Usually diagnosed between the 24th and 28th week of pregnancy when insulin resistance usually begins

• Diagnostic Criteria:– Random blood glucose level greater than 200

mg/dL – Fasting blood glucose level greater than 126 mg/dL– Fail to clear glucose from the blood stream within

the specified time after an oral glucose tolerance test

Gestational Diabetes• The placenta supports the baby as it grows

• Hormones from the placenta help the baby develop.

• But these hormones also block the action of the mother's insulin in her body.

• Insulin resistance makes it hard for the mother's body to use insulin.

• She may need up to three times as much insulin.

Risk for Developing Gestational Diabetes

• A family history of diabetes in parents or brothers and sisters

• Gestational diabetes in a previous pregnancy • The presence of a birth defect in a previous pregnancy • Obesity• BMI greater than 29 • Older maternal age (over the age of 30) • Previous stillbirth or spontaneous miscarriage • A previous delivery of a large baby (greater than 9

pounds). • A history of pregnancy induced high blood pressure • Women of Hispanic, American Indian, or of African-

American decent.

Gestational Diabetes• Treatment:

– Special meal plans

– Exercise

– Daily blood glucose testing and insulin injections

• Usually goes away after pregnancy

• Once you've had gestational diabetes, your chances increase in that it will return in future pregnancies

Gestational Diabetes• Risk for babies born to mothers with gestational

diabetes:– Macrosomia (large, fat baby weighing 9 pounds or

more) – Shoulder dystocia (birth trauma) – Neonatal hypoglycemia (low blood sugar in the

newborn) – Prolonged newborn jaundice (yellowing of the skin,

eyes, and mouth)– Low blood calcium – Respiratory distress syndrome.

Toxoplasmosis• Can be caught from cat feces or ingesting

contaminated meat or soil

• Pregnant women should avoid handling cat litter, wear gloves when gardening and wash hands afterwards

Travel• Avoid flying after 34-36 weeks of

pregnancy • The main hazard is the risk of

developing deep vein thrombosis (DVT)–A clot in a deep vein, usually the leg

• The risk of getting a DVT is already increased by pregnancy and the individual risk could be higher for some pregnant women