Pregnancy: Fitness Programming Within a Continuum of Care

In this article, discussions will include health and exercise topics for the child-bearing year. Perinatal clients ask fitness professionals many questions during this time, so it is important to provide appropriate guidance within the industry’s scope of practice and know when to refer a client back to their physician. Fitness professionals working within this special population need specialized training and education beyond a basic certification. This comprehensive overview focuses on the planning for pregnancy, nutritional guidelines, special exercise considerations, fitness programming, and postpartum recovery.

Obstetricians provide perinatal care to thousands of women. In doing so, these professionals stress that while being a natural process, pregnancy is much like an athletic event. The better prepared you are mentally and physically, the easier and more tolerable the process will be. Pregnancy can be a wonderful and joyous experience. A woman’s attitude is important in how she perceives the experience to be. Taking a proactive approach to fitness, nutrition, and self-care will make each pregnancy easier, safer, and more enjoyable.

The ideal results within this childbearing year and beyond is to have a pregnancy to term without unnecessary interventions, a healthy baby, and a supportive environment that addresses the physical and emotional needs of both the mother and infant. Fitness professionals can compliment medicine by assisting clients with program specific guidelines and support.

Planning For Pregnancy

Women who are thinking about becoming pregnant should plan early and consult with their physician. All aspects of a woman’s well-being should be addressed. Topics during this visit can include, however are not limited to, diet and exercise, nutritional supplements, avoidance of certain medications and/or substance abuse, immunizations, and genetic counseling. There are many healthy babies born annually. Subject to a physician’s advice and counsel, some recommendations for a planned pregnancy that prove to be most beneficial for clients include the following:

Get into shape prior to pregnancy. Pregnancy is the hardest work a woman’s body will go through. Becoming physically fit will keep a client’s energy levels high.

Take folic acid or folate ( 400 micrograms) at least 4 weeks prior to conception and continue this throughout the pregnancy. Folic acid has been shown to reduce the risk of birth defects in a baby’s spinal cord and skull by 70%. Supplement a strict vegetarian diet with necessary vitamins and minerals, for example, B12. Without the intake of eggs or dairy products, there is a greater risk of neural tube defects (a class of birth defects affecting the brain and spinal cord. ) Manage conditions of diabetes, high blood pressure, or other circulatory problems. It becomes increasingly more difficult to try to begin to manage these conditions during pregnancy.

Special Populations

Avoid certain medications or over-the-counter therapies. From conception to about the 8th week of gestation, the baby is vulnerable to teratogens (drugs or viruses that can cause malformity). Change lifestyle to eliminate tobacco, alcohol, and/or illicit drug use. Research has associated these behaviors with miscarriage, premature and low birth weight, and birth defects. Obtain titers to ensure vaccinations are up-to-date, that is, rubella (German measles) and chickenpox. Having no immunity to these diseases can cause complications during pregnancy. Inquire about genetic counseling; regardless of a client’s health status there might be certain health problems that run throughout the families (e.g., cystic fibrosis and sickle cell anemia ). While this is no substitute for medical care, the Center for Disease Control and Prevention (CDC) and other medical societies have developed e-mail-based education programs that are offered through this Interactive Health Recorduo).

Nutritional Guidelines

Good health demands an approach to eating nutritionally that begins with pre-pregnancy, includes breast feeding, and extends to old age. Nutrition seems most appealing if taken in small, frequent meals, as this helps to stabilize blood sugar. The table below provides macronutrient levels for healthy women, pregnant women, and lactating mothers. Caloric intake will need to be adjusted based on the weight of the woman, her activity levels, and her physician’s specific recommendations. Fitness professionals can assist in helping to educate their clients about these guidelines without stepping into a licensed professional’s areas of practice.

Recommended servings for pregnancy include: whole grains, pasta, fortified cereals-six-nine, vegetables-four, fruits-two-four, milk and dairy-three , meat and beans, fish, eggs or nuts-three-four; fats oils and sweets (eat sparingly). Also include a daily intake of between 20-30 grams of fiber.

Other nutrition considerations include the following:

Caffeine: leads to dehydration, as it’s a natural diuretic; limit consumption or avoid all together.
Food cravings-during pregnancy there is a desire for specific foods in large quantities and while not harmful, consumption should be integrated with healthy eating.

Lactose intolerance: some women will have sensitivities to milk, substitute with lactose intolerant products or spinach, salmon, fortified juices, and sardines rich in calcium.

Listeriosis: an illness caused by bacteria. To prevent listeriosis during pregnancy, wash all fresh fruits and vegetables prior to eating, avoid unpasteurized milk or soft cheeses, raw or under-cooked meat, poultry, shellfish, and prepared meats (e.g., hot dogs or deli meats).

Mercury: it is best to stay with canned tuna, and farm-raised fish or smaller ocean fish to avoid consumption of mercury. Swordfish, king mackerel, orange roughy, halibut, and shark all have high levels resulting in harm to the baby’s brain or nervous system.

Organic nutrition:“organic” is a labeling term that denotes products are produced under the authorization of the Organic Foods Production Act; methods are used to reduce pollution from air, soil, and water, while optimizing Special Exercise Considerations health and productivity of independent communities of plants, animals, and people. This is a healthier option for mother and baby.

Phyenylketonuria (PKU): is a genetic disorder and pregnant women with this condition are unable to metabolize phenylalanine properly. Recommendations are to limit intake of all foods that contain this amino acid including meat, fish, dairy, eggs, and especially products containing artificial sweeteners (e.g., diet sodas, sugar-free chewing gum).

Pica: refers to strong urges to eat non-food items such as clay, ice, laundry starch, or cornstarch. Pica can be harmful to a pregnancy, as it affects intake of nutrients and can lead to constipation and anemia.

Plastic bottle: substitute with glass whenever possible; if using plastic the #2 Hope (high-density polyethylene) is the safest choice; look for the recycle triangle stamped on the bottom.

Supplementation: when food is not enough additional nutrients may be recommended or prescribed.

Vegetarian: need to ensure that they are getting enough of the right kind of protein in addition to taking the following supplements-iron, B 12, and Vitamin D.

Breastfeeding Benefits for Baby and Mother

Nutrition for the baby is just as important as nutrition for the mother. Breastfeeding can be beneficial by providing a ready-to-eat, easily digested, and immune-boosting source of food. Additionally, moms benefit from more efficient involution of the uterus, allowing faster recovery to their postpartum body. Studies have also shown breastfeeding lowers the incidence of breast and ovarian cancer. Alternatively, there are many formulas on the market, each specific to the infant’s nutritional demands.

Advocates of Exercise

The American College of Obstetricians and Gynecologists (ACOG) and the US Department of Health and Human Services advocate exercise for women experiencing a healthy pregnancy. Women who experience absolute and relative contraindications during pregnancy are to work directly with their physicians who in turn provide the appropriate guidance and care. Pregnant women should be given written permission to exercise, and sedentary pregnant women should not begin an exercise program in the first or third trimesters.

Women who are inactive should start slow when starting to exercise. ACOG recommends (a)to begin with as little as 5 minutes of exercise a day and add 5 minutes each week until a woman can stay active for 30 minutes a day; (b) get at least 150 minutes of moderate-intensity aerobic activity a week or try 30 minutes of aerobic exercise on most, if not all, days; (c)habitually engage in vigorous intensity aerobic activity or for those who are highly active continue physical activity during pregnancy, provided that they remain healthy and discuss with their physicians how and when activity should be adjusted over time.

Cardiovascular Changes

During pregnancy blood volume will increase from 30-50%. This places increased demands on the cardiovascular system. Some changes include increased heart rate and increased cardiac output. Specifically, heart rate goes up by 10-15 beats per minute (bpm); whereas cardiac output can increase up to 50%. In addition, pulmonary reserve is decreased because respiratory rates are elevated at rest. These additional demands on the pregnant body should be considered during any physical activity.

ACOG recommends that pregnant women exercise at a moderate intensity of 12-14 “somewhat hard” using the Borg rating of perceived exertion (RPE) 6-20 scale. So, if pregnant women are able to talk normally while exercising, the heart rate is at an acceptable level. Because of these changes, it is recommended to avoid prolonged standing or crossing of the legs.

Studies show that women who voluntarily continue weight-bearing exercise during pregnancy maintain their long-term fitness to exercise over time at a higher level, gain less weight (3.4 vs. 9.9 kg), deposit less fat (2.2 vs. 6.7 kg), and have increased fitness levels than those who stop.

Hormonal and anatomical changes.

During pregnancy there is an increased secretion of various hormones to include relaxin, estrogen, progesterone, and elastin. Elastin and relaxin causes connective tissues and joints to soften, thus increasing the risk for potential injuries. Some changes women will experience include an expanding rib cage, pelvic instability, and an increased shoe size.

With the enlarging weight of the uterus and breast, special attention should be paid to strengthening and stretching exercises to minimize stress to the spine. This includes exercises to stretch the chest and strengthen the upper back (trapezius, rhomboids) while maintaining strong abdominals and gluteal muscles to help prevent added strain to the low back. To help minimize stress during pregnancy, women should maintain a neutral pelvic position by performing an isometric contraction of the abdominals and erector spinae muscles simultaneously. Stretching these muscles often, wearing supportive shoes, and elevating the legs during rest will provide additional comfort.

Pelvic floor muscles. These puboccygeal muscles are located in the perineum floor, attached to the pubic bone in front and coccyx in back, providing a base of support for the pelvic organs (e.g., uterus, bladder, and bowel), as well as forces incurred by straining, coughing, and more. ln addition, they provide sphincter control (i.e., a ring like muscle that normally maintains constriction of a body passage or that relaxes as required by normal physiological functioning) for perineal openings (e.g., urethra, vagina, and rectum).

Maintaining the health of these muscles is essential for pregnancy and a lifetime, as women will have increased tonicity and support for their pelvic organs. Encourage 50 to 100 repetitions of kegel exercises throughout the day. These can be performed in any position, and are best identified as those muscles that contract to stop the flow of urine. Clients should contract these muscles and return to a neutral pelvic floor between repetitions.

As women lie supine after 20 weeks of gestation, many begin to feel uncomfortable, faint, or nauseous. Therefore, exercising in this position should be avoided. Should women experience this, they need to roll to one side until the condition improves.

Carpal tunnel syndrome is a condition resulting from pressure on the median nerve where it passes into the hand via a gap under a ligament at the front of the wrist. This is typically caused by edema in the wrists and women experience tingling and/or numbness in their hands. It may be uncomfortable for pregnant women to put any pressure or rely on support from their hands. Therefore, weight-bearing exercises using the hands will need to be modified.

Round ligament syndrome refers to pain or discomfort caused by stretching of the round ligaments on the sides of the uterus from a fetal growth spurt. Bringing the legs up toward the abdomen often relieves this discomfort.

Leg cramps: During pregnancy up to 30% of women can experience a sharp, painful cramp or “charley horse” in the calf, foot, or both-especially at night. Causes for these cramps include dehydration, electrolyte imbalance, metabolic, vascular, and neurologic disorders. Stretching the legs before going to bed can help relieve cramps. Other recommendations are to drink plenty of water, wear supportive stockings, and rest when tired. To increase blood flow, clients should lie on their left side and flex their feet gently to improve circulation. When exercising, have clients keep feet flexed and encourage them to minimize the amount of time sitting with their legs crossed.

Diastasis recti: The rectus abdominis covers the front surface of the abdomen stretching from the crest of pubis to the xiphoid process. Holding these two muscles together is a fibrous tissue called the linea alba. As the uterus enlarges, the muscles will stretch to a point, however, to prevent the muscles from over stretching the linea alba splits. This is not painful to the mother: however, as women exercise they notice a change in this area of their abdomen and will have questions. As the head, neck, and shoulders lift up, the abdominal muscles tense and a gap will be apparent. By placing a hand on the abdomen below the navel with the fingers pointing towards the feet, a gap can be felt. If the gap is one finger or less, this is considered normal. However, if the gap is two fingers wide oblique work should be omitted, and if the gap is three fingers or more eliminate curl-ups and head raises. Performing pelvic tilts and bracing the abdominals will help to support the transverse abdominis (i.e., muscle that wraps around the torso from front to back and from the ribs to the pelvis) and stretch the low back without any further tearing.

Hydration and heat: Pregnant women should take time to drink before, during, and after exercise. It is important to stay hydrated. With weight gain, women increase in mass producing a rise in core temperature. While this would be a concern during exercise, pregnancy actually produces partial acclimation which causes sweating to occur sooner and lowers the core temperature. Women should avoid saunas, steam rooms, and whirlpools. Core temperature should not exceed 38° C or 101° F, whether experiencing a fever or not. The most vulnerable time during development is from the 23 to 28 days of gestation, when the neural tube is forming.

Fitness Programming

When a pregnant woman has been cleared for exercise, an appropriate fitness program should be designed so that it includes the special considerations mentioned above, any guidelines the physician has given, and a client’s goals. It is recommended that a client new to exercise begin her exercise program after the first 12 weeks of gestation. About 15% of recognized pregnancies will end in a miscarriage with more than 80% of miscarriages occurring within the first 3 months of pregnancy (first trimester) depending on maternal age and parity. Miscarriage has been associated with chromosomal defects in about a half or two thirds of cases. While there is no conclusive evidence to support the notion that exercise causes miscarriage, the loss of a baby can be a traumatic experience, and as such, this recommendation is given to fitness professionals.

For current clients that become pregnant, it too will be necessary for them to consult with and receive clearance from their physician on the appropriate intensity and duration of a program. Pregnancy is not a time where tremendous fitness adaptations will occur.

Provided below are popular fitness modalities with recommended exercise suggestions for pregnant women to exercise safely. With some of these exercise modes, high-risk moves have been listed with suggested modifications. For movements of daily living as well as exercise, transitioning from one position to the next will assist in blood flow and comfort. From a standing position, kneel to one knee, lower the other knee and sit to the side, walk down to a side-lying or quadraped position, and reverse the movement to stand.

Group Exercise Formats

Aqua. For participation in water classes, pregnant women experience a center of gravity change and significant reduction of pressure to the low back. Other benefits include buoyancy, blood pressure stabilization, and-through movement-the alleviation of swelling. Water pressure against the body in motion creates a hydrostatic effect, causing body fluids to move effortlessly upward and a massage effect to reduce swelling. Participants should perform movements with proper posture, hydrate often, and have a snack available. Encourage clients to wear water shoes during exercise as well as into the locker room to avoid slipping; progress slowly when exiting the pool, transition to gravity as gradually as possible. Recommended depth of the water is between the sternum (70% of body weight lifted) and navel (50% of body weight lifted); water temperature should be 83-86° F (28-30° C) and avoid temperatures that exceed 90° F (32° C).

Dance-exercise classes. There are multiple variations of dance-exercise classes being taught from high-/low-impact aerobics to rhythmic jazz, ballroom, ballet, Latin, and so many more. Progression and speed of movement should be appropriate for the pregnant exerciser. Modifications can and should include tempo, choreography, change of direction, and the elimination of jumping or hopping.

Indoor cycling. Many women enjoy this modality as it provides support to the joints. Recommendations include a proper set-up of the cycle with handlebars raised at least one notch higher than the norm. This will decrease the possibilities of discomfort from the knees being too close to the abdomen. Participants are encouraged to wear a pregnancy support belt, perform endurance and recovery rides, and change the intensity as often as needed.

Pilates. This method incorporates certain principles of movement that allow women the opportunity to bring balance into their pregnancy: (a) physically, (b) emotionally, and (c)physiologically. Some physical benefits include increased strength and flexibility with better coordination; emotionally women feel more in control and at peace; physiologically women experience improvements in biometric measures. Pilates uses both mat and equipment methods.

Step. For participation in step aerobics, the heigh l of a client’s platform should be no greater than 6 inches, reducing to 4 during the last trimester. At any time a client cannot see her feet, participation should be continued by performing movements on the floor without the step. The music speed should be of a tempo in which full range of motion can be demonstrated, that is, 118-122 bpm. Movements that require tremendous pelvic stability or pressure to the perineum floor should be avoided.

Yoga. This practice of over 5,000 years emphasizes the “union of the mind and body,” something pregnant women can recall during labor and delivery. Benefits include increased fitness levels, flexibility and tonicity of the pelvic floor, increased circulation, and control of the breath during exertion and relaxation. Clients should maintain proper body alignment and avoid any exercise that is uncomfortable. Movements should be performed slowly and with control.

Weight or resistance training. With pregnant women, the recommendation is to use equipment which provides the most support to the body. Weight machines keep the body in proper alignment while isolating the primary muscle group for endurance conditioning. As clients workout on machines, fitness professionals should ensure that no joints hyperextend, by using foot pedals to bring forward the arms of equipment. This will alleviate any risk of potential injury due to the laxity of connective tissue.

Other options are to use hand weights or resistance tubes. If there is allergic reaction to latex, use tubing with nylon handles. Light weights of 1-3 pounds and the strength of a resistance tube should be used appropriately for the various muscle groups. Caution is given to wrapping tubing around the hands as this will increase blood pressure. Ankle weighted boots or wraps should only be used to strengthen the legs during a workout. Make sure clients are exhaling on their effort as they perform lifts. The recommendation is to perform higher repetitions with lighter weight, that is, 12-15 per set.

Flexibility and relaxation techniques. Stretching at the end of a workout should be for at least 10 minutes in duration. Repeat stretches two to four times per muscle group and hold for 15-30 seconds. Ideally, it is best to stretch daily. Relaxation techniques can include meditation, guided imagery, and massage. Incorporate these techniques as appropriate.

Other fitness activities. Participation in golf and tennis are activities many pregnant women continue as long as they are comfortable. Running can be modified to include longer duration walking programs. Cardiovascular activities that provide non-impact or low-impact options include swimming and the use of a stationary cycle, elliptical, or treadmill. For clients that need a connection to other pregnant women and newborns, there are community fitness programs (e.g., Baby Boot Camp, Stroller Fit, YMCA You and Me Baby).

Activities that are too strenuous or create an unstable platform for the pregnant exerciser should be avoided. Some of these include kickboxing, horseback riding, water or snow skiing, core board, trampoline, and skating (ice or roller).

Postpartum recovery. A physician’s medical clearance is important for returning to exercise after child birth. For most women this is 4-8 weeks postpartum depending upon the birth process. However, kegel exercises can be performed shortly after delivery to assist in rehabilitating pelvic floor muscles and increasing blood flow to the area. Hormonal changes continue, so ensure that joints and connective tissues are protected from injury. It will be important to focus on muscle symmetry and posture to strengthen weak muscles and stretch those that are tight. New moms will want to focus on their core, especially the abdomen. For women wanting to increase their tone or those that might have experienced diastasis recti, they might benefit from the well-researched Tupler Technique. Cardio-vascular exercise should start slow and gradually progress once the client’s energy level increases. Stretching and relaxation techniques will help with muscle tension and common discomforts. Along with exercise, rest, proper nutrition, and adjusting to parenthood are all factors to be considered.

The miracle of life and delivering a healthy baby begins with a physician’s involvement and support in the planning for pregnancy, nutritional guidelines, special exercise considerations, fitness programming, and postpartum recovery. A fitness professional can assist women by helping to develop/carry out sate and effective fitness programs before, during, and after pregnancy. This can help to improve a women’s mood, self-esteem, and adjustments to physical changes. Fitness professionals should be sure to provide a continuum of care by referring to a client’s physician when appropriate or other professionals as questions arise beyond the industry’s scope of practice.

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