Exercise in Pregnancy

Moderate intensity exercise for women with BMI <25 pre-pregnancy Light intensity exercise for women with BMI >25 pre-pregnancy

Correlate exercise to BMI

Pelvic floor lift - standing: Shift weight forward for anterior contraction; eccentric: relax; concentric: pull pelvic floor up to normal Pelvic floor lift - combined with breathing and ADI: At your dext diaphragmatic inhalation, relax the pelvic floor (elongation) With exhalation: the pelvic floor lifts and the TA contracts Pelvic floor lift - with squat: "Blow before you go" - exhale before the movement of most effort, lifting the pelvic floor (also good for lumbar instability) Pelvic floor lift - in half kneeling with resistance/ trunk rotation

Describe the pelvic floor piston technique in the following positions/combinations:

Check at the belly button, 2" above, and 2" below. Place fingers perpendicular to supine patient belly; have patient lift just their head up, and see how much your fingers sink in. Looking at fingers width and depth Anything wider than 2 finger separation is more than normal

How do you assess for postpartum diastasis recti?

Check at the belly button, 2" above, and 2" below. Place fingers perpendicular to supine patient belly; have patient lift just their head up, and see how much your fingers sink in. Looking at fingers width and depth Anything wider than 2 finger separation is more than normal

How do you measure diastasis recti?

Clamshells: make sure there is no rotation of trunk; hips stay stacked Supine hooklying bridge: activate TA 1st, then contract glutes and raise hips for bridge.

How do you strengthen gluteal muscles?

Quadruped arm/leg raise: Contract TA 1st, then lift arm and opposite leg

How do you strengthen multifidi?

NO. Underestimates HR by 10-15bpm

Is RPE a valid HR estimate for pregnant women?

Trauma - Based on MVAs and assault - wanting women to stay away from anything that could make you fall or expose you to external trauma Elevated core body temp - Based on neural tube defects from immersion in hot tub in first trimester to >103 deg F; however pregnant women are better at thermoregulation. They recommend not exercising in high heat.

Recommendations made based upon known harmful effects of other events - translated to exercise:

- Carpal tunnel syndrome - Whole body swelling due to pregnancy can increase compression on carpal tunnel Tx: night splinting, AROM, elevation - Sciatic nerve compression - Mechanical compression of fetus on sciatic nerve Tx: positional change, quadruped positioning for exercises, postural correction, sleep positioning (pillows, wedges, foam)

What are 2 kinds of nerve compression associated with pregnancy and what is the treatment?

Absolute (many are on bedrest) Hemodynamically significant heart disease Restrictive lung disease Incompetent cervix Multiple gestation at risk for premature labor Persistent bleeding in 2nd or 3rd trimester Placenta previa after 26 weeks Premature labor during current pregnancy Ruptured membranes Preeclampsia/PIH (pregnancy induced hypertension)

What are CONTRAINDICATIONS to exercise during pregnancy? Absolute

Severe anemia Maternal cardiac dysrhythmia Chronic bronchitis Poorly controlled Type I Diabetes Extreme morbid obesity Extreme underweight History of extremely sedentary lifestyle Intrauterine growth restriction Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker

What are CONTRAINDICATIONS to exercise during pregnancy? Relative

Core body temperature regulation Risk of trauma/falls Avoid supine position >5 minutes after 13 weeks Reasoning: Inferior vena cava compression resulting in supine hypotension Per MCC: Your body will tell you when something is wrong; if having them do exercises, not more than 5 min supine and only if comfortable Orthostatic hypotension Discourage Valsalva maneuver (comes in for heavy weightlifters - can limit blood flow to the fetus momentarily) Prone position in pregnancy? (becomes no longer possible at some point) Should have an apparatus in clinic to allow pregnant women to lay prone on treatment table Scuba diving disrecommended

What are PRECAUTIONS for exercise in pregnancy?

TA contraction/ draw-in: palpate your lateral belly and draw your navel towards your back Side-bridge/ side plank

What are exercises to strengthen abdominals?

Diastasis recti Diastasis pubis (hypermobility) SI-Pelvic Girdle pain (may be called PGP in literature) Postural back pain Nerve compression

What are pregnancy induced pathology, impairments that may bring someone to PT?

Neurologic compromise: pudendal and levator ani nerves Muscular impairment Episiotomy/tear Diastasis pubis (can occur during birth esp due to epidural -> lack of stretch sense and over stretching)

What are some birth injuries that can happen to pregnant women?

(childbirth preparation) Single knee to chest: supine, other leg off table Sidelying top leg in front hanging off table, top arm in opposite diagonal direction; arm and leg can be straight Child squat: ; can use elbows to push thighs more open

What are some exercises for pelvic floor/adductor lengthening?

(using overabundance of caution) Teach TA contraction Avoid prone plank beyond 20 weeks pregnancy Avoid unbraced abdominal sit-ups beyond 16 wks pregnant Avoid prone plank and unbraced abdominal crunches before 12 weeks postpartum

What are some tips to reduce risk of persistent diastasis/function loss during and after pregnancy?

Frequency 3-4 days per week Time >15 min up to 30 min at a time for 120 minutes per week of exercise (150 min including warm-up and cool down periods) Intensity Determined by HR Based on age, pre-pregnancy BMI

What are the 2014 ACSM Guidelines on exercise in pregnancy (for average women)? (frequency, time, intensity)

Cardiorespiratory Fitness Decreased Low back pain Reduced depression Control of weight gain Glucose control (helps prevent /control gestational diabetes) Preparation for labor

What are the benefits of exercise during pregnancy?

Pre-pregnancy BMI <25 (moderate intensity exercise) LOW fitness level: 128-144 bpm ACTIVE fitness level: 130-145 bpm FIT fitness level: 140-156 bpm Pre-pregnancy BMI >=25 (low intensity exercise) HR 101-120

What are the exercise HR targets for pregnange aged 30-39 per the 2014 ACSM guidelines on pregnancy?

Based on 2002 CPG: used expert opinion in the face of paucity of quality research. No research looking at high intensity exercise in pregnant women, so cannot include in guidelines. Problems with research in pregnant women (IRB does not want controlled trials in pregnant women; fear of danger to fetus)

What are the issues associated with guidelines for exercise in pregnancy?

↑O2 uptake ↑HR (15-20bpm higher resting HR) ↑stroke volume ↑cardiac output (50% higher) ↑tidal volume ↑Joint laxity associated with hormonal changes (Relaxin). Allows passage of baby through birth canal. Weight gain ↑'s forces through joints Shifting weight distribution Affects balance/coordination, though most women adapt well

What are the physiologic changes in pregnancy?

Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements."

What did the the ACOG committee opinion December 2015 update say about how safe and beneficial exercise is in pregnant women? "

Medical clearance required; typically 4-6 weeks for vaginal delivery 8-10 weeks for cesarean section delivery Gradual return to pre-pregnancy fitness levels due to deconditioning associated with postpartum period Adequate hydration critical for breastfeeding supply issues Light to moderate exercise does not interfere with breastfeeding supply

What does return to exercise look like in the postpartum period?

Pain in the SI/pelvic girdle region that is often attributable to joint laxity or hypermobility

What is SI/pubic symphysis/pelvic girdle pain in pregnancy?

teach TA contraction Strengthen obliques (avoid unbraced abdominal crunches until after 12 weeks postpartum)

What is an intervention for diastasis recti?

When pregnant, there is normal linea alba separation for growth of the fetus, esp at the level of the umbilicus. This becomes an issue residually after pregnancy, as it may not return to the prior state. Incidence: postpartum 36-62% Some diastasis is normal during and up to 12 weeks postpartum. 80-90% of women return to normal by 12 weeks. If it persists over time, will lead to weaker abdominal wall, low back pain, postural implications, and lower level of performance in fitness. Unfortunately, it is unknown what leads to persistence. Possibly core/abdominal exercises too soon after pregnancy may cause

What is diastasis recti?

Shift in the center of mass anteriorly results in posterior lean, forward head and rounded shoulders

What is postural back pain in pregnancy?

Tx focuses on core stabilization exercise (not rectus abdominis) and external stabilizing devices such as an SI belt during pregnancy

What is the treatment for SI/pubic symphysis/pelvic girdle pain?

Postural correction/exercise Core stabilization exercise

What is the treatment for postural back pain in pregnancy?

Eliminated the 140bpm HR limit

What item was eliminated in the 1995 update?

Abdominals (TA and obliques, not rectus) Multifidi Gluteal muscles Pelvic Floor Combining pelvic floor with exercise other exercises and functional movement patterns Lengthening for childbirth preparation

What kind of core stabilization exercises are important for pregnant or postpartum women?

Persistent diastasis recti Incontinence (impaired pelvic floor muscles after birth) Pelvic floor muscle tears Diastasis pubis Posture reeducation (breastfeeding, carrying the baby)

What kind of issues may warrant postpartum rehabilitation?

Typically provoked with SLS (putting on pants, running) or asymmetric loading of the pelvis (lunge)

What movements typically provoke SI/pubic symphysis/pelvic girdle pain?

summarized common conditions, illnesses and complaints that interfere with strenuous exercise and competition, during pregnancy and after childbirth. provides recommendations for exercise training during pregnancy and after childbirth for high-level regular exercises and elite athletes identified major gaps in literature that limit confidence with which recommendations can be made Per MCC: Most of the literature is incidental findings; IRB does not like to allow controlled trials with pregnant women. More research is needed

What was the content of the 2016 IOC Expert Meeting Consensus Statement on exercise and pregnancy in recreational and elite athletes?

HR should not exceed 140 bpm Strenuous activities should not exceed 15 minutes No exercises that employ a Valsalva maneuver Maternal core temperature should not exceed 100.4 degrees Deep flexion or extension of joints should be avoided Ballistic movements should be avoided Competitive activities should be discouraged

What were the restrictive 1985 American Congress of Obstetricians and Gynecologists (ACOG) guidelines on exercise in pregnancy that were used until 1995?