Pregnancy & Exercise

 

Physical Therapy for the Prenatal and Postpartum Woman

The relationship between exercise and pregnancy has been investigated and researched extensively.

In the past 30 years there has been a tremendous increase in both the depth and breadth of research regarding the physiologic responses of the pregnant woman. Many physiologic changes occur during exercising, including changes in temperature and body carriage, effects on catecholamines, redistribution of blood flow, and changes in pulmonary function, cardiac output, and maternal renal blood flow. Different types of exercise influence the pregnant woman in different ways.

For most pregnant women, exercise is safe and healthy.

According to the American College of Obstetrics and Gynecology (ACOG) 2003, you should not participate in any exercise program if you are experiencing any of the following absolute contraindications to aerobic exercise.

 

ABSOLUTE CONTRAINDICATIONS TO AEROBIC EXERCISE DURING PREGNANCY
(You should not participate
in any exercise program)

  • Hemodynamically significant heart disease
  • Restrictive lung disease
  • Incompetent cervix
  • Multiple gestation at risk for premature labor
  • Persistent second or third trimester bleeding
  • Placenta previa after 26 weeks of gestation
  • Intra-uterine growth retardation
  • Premature labor during the current pregnancy or prior pregnancy
  • Ruptured membranes
  • Preeclamsia
  • Pregnancy induced high blood pressure (hypertension)

If you are medically cleared from any of the above absolute contraindications to participate in an active exercise program, and you are currently actively participating in a regimen, be aware of the following signs and/or symptoms during your aerobic work out. If you experience any of the following relative contraindications, stop your exercise program and consult your obstetrician for advice. Your obstetrician may refer you to physical therapy for a safe, closely monitored physical therapy program to optimize your quality of life throughout the remainder of your pregnancy.

The following relative contraindications require medical monitoring during your fitness routine. At Rehabilitex, our physical therapists will work with your obstetrician in the monitoring of your health and wellness throughout your term. We can help design an appropriate safe exercise program for you at a more therapeutic level.

 

RELATIVE CONTRAINDICATIONS TO AEROBIC EXERCISE DURING PREGNANCY
(Consult your obstetrician for a physical therapy referral)

  • Severe anemia
  • Unevaluated maternal cardiac arrhythmia
  • Chronic bronchitis
  • Poorly controlled type 1 diabetes
  • Extreme morbid obesity (BM > 33)
  • Extreme underweight (BMI < 12)
  • History of extremely sedentary lifestyle
  • Intrauterine growth restriction in current pregnancy
  • Poorly controlled hypertension
  • Orthopedic limitations
  • Poorly controlled seizure disorder
  • Poorly controlled hyperthyroidism
  • Heavy smoker

If you currently exercise and begin to experience any of the following warning signs, stop your program and consult your obstetrician and/or physical therapist.

Physical Therapy may be able to help design a more appropriate safe exercise program to meet your individual needs to eliminate or diminish the following unnecessary signs and symptoms.

 

WARNING SIGNS TO TERMINATE EXERCISE DURING PREGNANCY
(Consult your obstetrician / physical therapist team)

  • Vaginal bleeding
  • Muscular/joint pain
  • Dyspnea prior to exertion
  • Dizziness
  • Fainting
  • Shortness of breath
  • Rapid or irregular heartbeat
  • Difficulty walking
  • Insufficient weight gain
  • Headache
  • Chest pain
  • Muscle weakness
  • Calf pain or swelling (need to rule out thrombophlebitis)
  • Preterm labor / persistent contractions
  • Decreased fetal movement
  • Amniotic fluid leakage

 

Cardiovascular changes associated with pregnancy are an important consideration for pregnant women both at rest and during exercise following the first trimester (the first 12 weeks of gestation).

  • Women should avoid exercising/resting while lying on their backs, beginning in the second trimester, as much as possible. It is relatively contraindicated to exercise in the supine position because the uterus typically obstructs the vena cava (a major blood vessel), restricting blood flow and decreasing blood flow from the heart, resulting in signs and symptoms of orthostatic hypotension1,3 (dangerously low blood pressure levels causing nausea and ultimately fainting). If this should occur, roll to your side immediately upon any early symptoms such as (lightheadedness, flushed sensation, and nausea)
  • Motionless standing also is associated with significant decrease in cardiac output (blood flow), so this position should be avoided. Blood pressure may also be affected causing increased swelling in the legs and body.

Risks

The many changes of pregnancy may interfere with the ability to engage safely in some forms of physical activity. Each activity or sport should be reviewed and cleared by a professional for potential risks, such as falling or possibility of abdominal injury. These types of activities/sports activities should be avoided during pregnancy. Scuba diving and exercise at altitudes greater than 6,000 feet is contraindicated throughout pregnancy.1 Participating in exercise in altitudes greater than 6,000 feet carries various risks such as altitude sickness. If you are planning on participating in a sport at that altitude seek medical advice to familiarize yourself to the types of problems that can potentially occur.1

 

Exercising Safely During Pregnancy

Current literature is in favor of recreational and elite athletic women continuing to participate in exercise during pregnancy with close supervision by their health care provider.4 ACOG recommends all women who participate in strenuous exercise be monitored under direct medical supervision by a health care provider.

Recommended Exercise Parameters During Pregnancy

A woman's overall health, including obstetric and medical risks should be evaluated for possible medical contraindications before prescribing an exercise program. Once cleared by your OB, women can continue to derive the same associated health benefits during their pregnancy as prior to pregnancy.1,10

  • Pregnant women should participate in at least 20–30 minutes of exercise per day.
  • Begin slowly and allow your body's core temperature to adjust and warm up for the first three to five minutes of exercise.
  • Aerobics should be low impact such as swimming, walking, stationary bike.
  • Heart rate should not exceed 140–150 beats per minute, depending on your Preterm athletic conditioning status. Case studies of elite athletes have experienced > 150 beats per minute with no ill effect on the fetus (due to fetus protective physiological adaptations9 i.e., a balance is created in fetal heart rate response to exercise and exercise intensity in athletes and recreational exercising women.)6
  • Exercise, activities, or sports should be of low to moderate intensity.
  • Participation frequency should be 5-7 days a week to keep the circulation going.
  • Incorporate a cool down period with gentle stretching at the end of your work out.
  • Light weight training of 1-3 pounds, and only up to 12-15 repetitions, 2-3 times a week.
  • Do not lie on your back after the first trimester.
  • Breathe normally throughout your exercise session.
  • Drink lots of water, regardless of the weather. It is imperative to remain hydrated.

Musculoskeletal Complications 5, 8

  • Osteitis Pubis
  • Leg pain due to lower extremity edema
  • Muscular and/or joint pain (due to dehydration)
  • Joint pain due to joint laxity that increases during pregnancy
  • Nerve compression syndromes
  • Uterine contractions with moderate exercise. 
  • Low Back Pain (potential causes):
  • Hormonal changes cause ligamentous laxity, especially at the lumbo-pelvic junction.
  • Weight of the baby pressing on the pelvis and the spine. 
  • The lower back curvature may increase or decrease affecting your ideal posturing.  Shoulders begin to round and head tilts forward.

The Benefits of Exercise During Pregnancy

At Rehabilitex, our Physical Therapists can provide safe and effective guidelines (based on American College of Obstetrics and Gynecology) for those women who plan on participating in an active exercise routine during their pregnancy but are having difficulty due to pain, edema (swelling), or fatigue issues.

  • Endurance training will prepare the mom to be for the work of labor and delivery.
  • Decreases risk for complications during and following birth.
  • Decreases risk for cesarean birth.
  • Shorter labor and delivery
  • Decreases risk for neonatal complications
  • May delay or even prevent onset of gestational diabetes.
  • Exercise may be beneficial in the primary prevention of Gestational Diabetes, particularly in morbidly obese women (Body Mass Index is > 33). ACOG has endorsed exercise as a helpful adjunctive therapy for gestational diabetes mellitus when safe blood sugar levels are not achieved by diet alone.1 Women who participate in light exercise can potentially delay or even avoid insulin therapy.7

Returning To Exercise Postpartum

There are no known complications associated with resumption of exercise training following the birth of your baby. Many of the changes of pregnancy persist 4-6 weeks postpartum. Therefore, resuming physical activities/sports to the level of performance prior to pregnancy should be gradual. Check with your Obstetrician and Physical Therapist to help determine when it is medically and physically safe.

When cleared by your medical professional, the earlier you return to stress relieving physical activity after pregnancy, the better you will feel physically and emotionally.1 If you are considering breast feeding your baby, you will feel good to know that breast feeding plays an integral role in weight loss following pregnancy, especially when you progress your work outs returning to your pre-partum exercise level. Exercise does not reduce the quantity of breast milk production, nor does it compromise its nutritional value.4 In fact, Lovelady et.al found that recreational athletes who performed an average of 88 minutes per day of aerobic exercise during the 6 months of breast feeding had less body fat and produced a slightly greater quality and quantity of milk than postpartum non-exercising women.4

Pregnancy results in anatomic changes that may predispose an athlete to musculoskeletal injury. The enlarging uterus shifts the woman's center of gravity up and forward, resulting in lordosis and back pain. This change in center of gravity could affect balance during activities. Increased joint laxity can cause instability, and weight gain results in an altered kinesthesia, which is critical in most sports activities. A pregnant athlete is better equipped to handle these changes compared with her sedentary counterpart due to greater muscle mass and acquired coordination.4

Musculoskeletal Complications 5, 8

  • Osteitis Pubis
  • Leg pain due to lower extremity edema
  • Muscular and/or joint pain (due to dehydration)
  • Joint pain due to joint laxity that increases during pregnancy
  • Nerve compression syndromes
  • Uterine contractions with moderate exercise.
  • Low Back Pain (potential causes):
  • Hormonal changes cause ligamentous laxity, especially at the lumbo-pelvic junction.
  • Weight of the baby pressing on the pelvis and the spine.
  • The lower back curvature may increase or decrease affecting your ideal posturing. Shoulders begin to round and head tilts forward.

Click here for more information The American Diabetes Association

Factors Influencing The Physiologic Response Of Exercise 3, 4

  • During weight bearing exercise (walking) energy expenditure includes that necessary to counteract the pull of gravity. Body weight contributes to the intensity of the exercise. The energy cost for a woman to walk a mile is increased from early to late pregnancy because body weight is increased.
  • During weight supported exercise (cycling or swimming), energy expenditure is independent of body weight. Energy expenditure for which body weight is supported is based on the amount of external work being done and the mechanical efficiency of the exerciser.
  • Exercising at sub maximal levels is beneficial. For the elite as well as the recreational athlete. Women's aerobic fitness will decline very little during pregnancy if she continues to exercise as her gestational symptoms permit. Recreational athletes tend to gain less fat than sedentary women and thus may have more metabolic active tissue available throughout pregnancy.
  • Pregnancy gestation time studies show that athletic women exhibited a higher heart rate at a given VO2, as a function of gestational age. What this means is that the athlete will perform less work as her pregnancy progresses if she does not adjust her usual exercise training heart rate upward.
  • A special case of weight supported exercise is swimming. Exercising in water, not only is body weight supported (due to buoyancy), but hydrostatic pressure also plays a significant role.

 

Physical Properties of Water Advantages

Hydrostatic Pressure

The pressure exerted by molecules of a fluid upon an immersed body. Pascal's Law = pressure is exerted equally on all surfaces of an immersed body at rest at a given depth. Pressure increases with depth and the fluid density of the water.It offsets the tendency for blood to pool in the legs, and assists in the return of blood to the heart, decreasing swelling in the legs. For example, a woman in a swimming pool in a 4 foot depth of water will have a much more significant effect from the immersion than a woman sitting in a bathtub because of the depth of the immersion. Hydrostatic force begins as soon as the immersion begins. Studies have shown a measurable change in central venous blood volume and cardiac output within a matter of seconds. The effect continues for several hours, pumping fluids. The greater the amount of edema (swelling), the greater the increase in central blood volume pumping.

  • Water immersion can and has been shown to keep woman off bed rest due to edema problems.
  • Water immersion allows increased blood flow to improve circulation. Circulation provides every muscle with nourishment. While your body is working, waste products are carried away.
  • Immersion causes an immediate increase in central blood volume leading to increased cardiac output, signaling the baroreceptors to produce an immediate drop in overall blood pressure.2
  • With immersion causes inward movement of the rib cage, upward movement of the diaphragm, and a shift of blood in the thorax from the limbs and abdomen that reduces lung volumes. Reducing total lung capacity by 5-10%. This helps to condition the muscles of inspiration and expiration as pressure is exerted on the chest wall.
  • Provides constant tactile input and assists with increasing body awareness.

Buoyancy

Archimede's Principle: When a body is completely or partially immersed in a fluid at rest, it experiences an upward thrust equal to the weight of the fluid displaced. The loss of weight of a submerged body equals the weight of the fluid displaced by the body.

  • The buoyancy of water provides physical support to the pregnant woman and her increased abdominal girth, particularly during the last several weeks of gestation. Thus, many pregnant women are able to continue to exercise throughout pregnancy rather than having to stop in the last 4-6 weeks.

Learn about our Aquatic Physical Therapy Program

 

Prenatal Women & Water Exercise

  • The body is in a state of weightlessness or near weightlessness.The water acts as a cushion for the mom to be.
  • Water exercise can ease problems such as painful varicose veins, swollen hands and feet & leg cramps which are common during pregnancy.
  • It is a very comfortable way for these individuals to gain strength in the pelvic floor, spinal, and abdominal muscles.
  • Increased strength will better support the added weight of the uterus and baby, thus reducing strain in the back and allow you to carry the baby easier and more comfortably.
  • Aquatic programming is the most comfortable, safest, and healthiest form of exercise for pregnant women, by lessening gravities downward pull on the body, reducing stress on the joints and tissues, and has a cooling affect which is important during pregnancy when a women's core temperature is higher than normal.
  • Hydrostatic pressure and buoyancy prevent the heart rate from elevating as much as it would on land without overdoing.
  • Water provides resistance in all directions and lends itself to smoother control of movements, reduces heavy, clumsy, painful feeling and promotes good self-image.
  • Immersion in water helps prevent and reduce edema/swelling that occurs with pregnant women and can keep them off bed rest. >Water pressure experienced by the body pushes fluid into the bloodstream and then out as a waste product.
  • Due to the real physiologic effect of immersion to induce diuresis, patients should shower before entering the pool to take care of "clearance" ahead of time.

Incorporating professional advice from a Physical Therapy specialist is very beneficial when a specifically designed program is indicated.

Our therapists at Rehabilitex are ready to help you manage symptoms and maintain a healthy level of fitness during and following your pregnancy.

When a woman is pregnant, posture, center of gravity, and body size all change. These changes may be accompanied by new aches and pains that pregnant women may not necessarily have to suffer from. Our Physical Therapists can work with you in analyzing your problems/complaints to determine if these complaints are manageable through physical therapy intervention. Here at REHABILITEX, we can teach you how to manage these types of symptoms during your pregnancy and into the Post–Partum period.

HOW?

  • Our physical therapists will complete an evaluation to determine what movements/positions that may be causing the discomfort.
  • You as a client will learn how to maintain more comfortable postures for the day time, as well as while sleeping. Everyone is different, so we teach you how to adjust daily posture modifications and even sleep positions to meet your individual needs.
  • Some woman may need an orthopedic support for the low back and abdomen. This belt can help relieve the strain on muscles that are stretched by the increasing size of the baby and uterus.
  • The arches of the feet may fall and require education on foot wear options and/or shoe inserts to increase shock absorption.
  • If land exercise options are not comfortable, AQUATICS is a great adjunct to your physical therapy intervention.
  • Post-Partum problems are often posture induced and can be remedied by training of posture, body mechanics, and ergonomic counseling.

If you are planning to become pregnant, yet want to remain active, a physical therapy consulation may be very beneficial. Your body may easily adapt to the few changes that occur during and/or following your pregnancy. It is common to experience new aches and pains while adapting to the changes in your exercise habits and lifestyle. Physical Therapy can be used to your advantage. Your training program may simply need to become more moderate than you are used to. We can teach you how to modify your exercise program and even learn how to monitor your own heart rate so that you can continue to enjoy the advantages of fitness during pregnancy without those warning signs and relative contraindications discussed prior.

We are here to help you learn how to manage your pregnancy and exercise needs.

Together we can deliver wonderful things!

 

References

  1. (Committee Opinion No. 267) Washington, DC. ACOG January 2002, committee Opinion No. 267. Exercises During Pregnancy and the Postpartum Period. Clin Obstet Gynecol, vol 46(2) June 2003 pp496-499
  2. Katz, Vern L MD. Exercise in Water During Pregnancy. Clin Obstet Gynecol, vol 46(2) June 2003 pp432-441
  3. O'Toole, Mary L PhD. Physiologic Aspects of Exercise in Pregnancy. Clin Obstet Gynecol, vol 46(2) June 2003 pp379-389
  4. Pivarnik, James M Phd. Perkins, Candace D BS. Athletes and Exercise, Clin Obstet Gynecol, vol 46 (2) June 2003 pp403-414
  5. Schauberger, CW, MD. Rooney, Brenda L PhD. Obstetrics: Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels. Am J Obstet Gynec, vol.174(2) February 1996 pp667-671
  6. DeCree Carl. Safety guidelines for exercise during pregnancy (correspondence). Lancet, vol 351(9119). June 1998 pp1889-1890
  7. Garcia-Patterson, Apolonia MD, Martin E RN. Evaluation of light exercise in the treatment of gestational diabetes. Diabetes Care, vol. 24 (11). November 2001 pp2006-2007
  8. Durak E, Jovanovic-Peterson L, Peterson ChM: Comparative evaluation of uterine response to exercise on five aerobic machines. Am J Obstet Gynecol 162:754-756, 1990
  9. Clapp, James F III MD, Stepanchak, William RMUS. Portal vein blood flow — effects of pregnancy, gravity, and exercise. Am J Obstet Gynec, Vol 183(1). July 2000 pp167-172

 

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