Unit:

Session

Physical activity and health considerations for the

pre and post natal client

Benefits of physical activity for pre and post natal clients

Aim of the session

• To understand the benefits of physical activity for pre and post natal

clients

Learning outcomes

By the end of this session, you will be able to:

• Explain the value of physical activity for pre and post natal clients

Introduction: current research and trends

• Since 1970’s, interest in exercise during pregnancy has risen

• 2 schools of thought – liberal vs. conservative

• Seminal guidelines by ACOG in 1985

– still many unanswered questions

• Clear understanding that most types of exercise are safe for mother and baby

Task

What are 4 benefits of exercise during

pregnancy?

Keep a note of your ideas in your

portfolio.

Value of physical activity

• RCOG (2006) recommend: – maintenance of

cardiovascular fitness, muscle length and flexibility

– maintenance of a healthy weight

– improved circulation

– improved co-ordination and body awareness

– preparation for labour, and assistance in post natal recovery.

What does the research say?

• Women who exercise during pregnancy and lactation (Clapp, 2002):

– Gain less weight

– Deposit less fat

– Feel better

– Have shorter labours

– Recover more rapidly

– Are more likely to continue exercising post partum

Considerations for the fitness

professional

• Emphasise that care must be taken when exercising during pregnancy

• Clients cannot realistically expect fitness levels to improve during the course of pregnancy

• Expectant mothers should work to maintain their baseline fitness to aid pregnancy outcomes

Learning outcomes

Can you now?

• Explain the value of physical activity for pre and post natal clients

Unit:

Session

Physical activity and health considerations for the

pre and post natal client

Physiological and biomechanical changes during pregnancy

Aim of the session

• To understand the physiological and biomechanical changes that

take place during pregnancy

Learning outcomes

By the end of this session, you will be able to:

• Summarise the three trimesters

• Describe the physiological and biomechanical changes associated

with each trimester

• Explain the implications of these changes for taking part in physical

activity

Stages of pregnancy

• Pregnancy can be measured by several points of reference: – Day of last menstruation

– Ovulation

– Fertilisation

– Chemical detection

1st trimester

0-12 weeks

2nd trimester

13-26 weeks

3rd trimester

27-40 weeks

Task

Think about the changes that occur to

the circulatory and respiratory

systems.

Note down your ideas in your portfolio

Changes to the circulatory system

• Relaxation of blood vessels, leading to vascular under fill: – waves of sudden fatigue

– a racing pulse

– nausea

– pallor

– sweating

– dizziness

• Symptoms usually subside by 4th month

Heart rate changes

• During early pregnancy, exercising heart rate will be elevated at a given intensity as a result of the deficiency in blood volume and the corresponding low blood pressure.

• During mid-pregnancy increases in blood volume and blood pressure will mean that exercising heart rate will gradually decrease

• During late pregnancy, the combined effects of exercise and pregnancy expand blood volume further

Temperature and sweating

• Overheating of both mother and baby is a

common concern if the mother’s core

temperature is elevated substantially

during and immediately following exercise

• The set point for sweating also comes

down; so when core temperature does

increase they are more able to dissipate

the heat through sweating.

Changes to the respiratory system

• Pregnant women have a tendency to over breathe and sometimes feel breathless – therefore, most aspects of

respiratory function are actually improved during pregnancy

• Expanding uterus presses on and moves the diaphragm upwards reducing normal downward excursion of the diaphragm - therefore depth of breathing is increased

Task

Research the changes that occur to

the hormonal/metabolic systems

Changes to the hormonal system

• At the onset of pregnancy, relaxin begins to rise, peaking in the second trimester – it isn’t unusual for relaxin levels to

remain elevated for up to 6 months post birth

• The main effects of relaxin are to soften ligaments, cartilage and the cervix (particularly relates to the pubis symphysis and SIJ)

• Insulin resistance increases during pregnancy. This makes the pregnant woman’s pattern of energy utilisation similar to that of a mild diabetic

Weight gain

• During early to mid-pregnancy, weight gain is normally 7-11 pounds, most of which is maternal fat.

• During late pregnancy, weight gain is normally 7-11 pounds. Growth of the foetus and placenta are responsible for most weight gain at this stage.

• The additional fluid retention and blood volume expansion of pregnancy account for an additional 9-15 pounds.

• Total pregnancy-related weight gain in western society is approximately 24 - 33 pounds

Task

Investigate the changes that occur to

the musculoskeletal system

Changes to the musculoskeletal system

• During pregnancy, the mother’s centre of gravity becomes greatly altered, affecting her posture and gait

• As the mother becomes increasingly lordotic (an exaggerated lumbar curve), the abdominal muscles can become strained as they stretch, and the lower back muscles become tighter, leading to soreness/pain

Abdominal muscles

• Strong abdominals are needed to support

the weight of the baby and to protect the

back, which is very vulnerable through

pregnancy

– strong abdominals will give the muscles of the

uterus some extra help during delivery

Abdominal separation

• The increased abdominal distension can often cause a splitting of the fascia (the linea alba) between the rectus abdominis muscles; this is known as diastasis recti abdominis

Pelvic floor

• During pregnancy the pelvic floor muscles

can become weakened and dysfunctional

• This can lead to urinary incontinence

(leaking of urine), pelvic organ prolapse,

haemorrhoids and other colonic-related

issues

Learning outcomes

Can you now?

• Summarise the three trimesters

• Describe the physiological and biomechanical changes associated

with each trimester

• Explain the implications of these changes for taking part in physical

activity

Unit:

Session

Physical activity and health considerations for the

pre and post natal client

Considerations for exercise participation

Aim of the session

• To understand the key considerations for pre and post natal clients

participating in physical activity

Learning outcomes

By the end of this session, you will be able to:

• List the contraindications to exercise for pre / post natal clients

• Explain the guidelines for referral

• Identify warning signs for cessation of exercise

• Explain how to respond to any warning signs during exercise

• Describe the key considerations when developing effective working

relationships

• List the types of real and perceived barriers

• Describe ways in which these barriers can be overcome

Contraindications to exercise

• There are four main contraindications that need evaluation prior to beginning or resuming exercise during pregnancy: 1. Significant physical injury

2. An acute bout of illness or chronic underlying disease

3. The onset of persistent or recurrent localised pain

4. Abnormal or heavy vaginal bleeding

ACOG guidelines

Absolute contraindications Relative contraindications

Haemodynamically significant heart disease

Restrictive lung disease

Incompetent cervix/cerclage

Multiple gestation at risk for premature labour

Persistent second or third trimester bleeding

Placenta praevia after 26 weeks gestation

Premature labour during the current pregnancy

Ruptured membranes

Pregnancy induced hypertension

Severe anaemia

Unevaluated maternal cardiac arrhythmia

Chronic bronchitis

Poorly controlled type I diabetes

Extreme morbid obesity

Extreme underweight (body mass index < 12)

History of extremely sedentary lifestyle

Intrauterine growth restriction in current pregnancy

Poorly controlled hypertension/pre-eclampsia

Orthopaedic limitations

Poorly controlled seizure disorder

Poorly controlled thyroid disease

Heavy smoker

Warning signs

• ACOG guidelines (2002) have also identified a number of warning signs to stop exercising: – Vaginal bleeding

– Dyspnoea before exertion

– Headache

– Chest pain

– Muscle weakness

– Calf pain or swelling (need to rule out thrombophlebitis)

– Preterm labour

– Decreased foetal movement

– Amniotic fluid leakage

Barriers to participation

• Fatigue/tired

• Medical complications

• Discomfort and pain

• Embarrassment

• Disapproval

Developing working relationships with

clients

• All clients are entitled to good standards of practice and care from their fitness professional – requires professional

competence; good relationships with clients and colleagues; commitment to and observance of professional ethics; and excellent communication skills.

Guidelines for referral

• When a client presents with any of the previously identified contraindications, the fitness professional must refer them to a medical professional for advice regarding further exercise

• All referrals should be discussed with the client and the client's consent obtained both to making the referral and also to disclosing information.

• Care should also be taken to ensure that: – the referral practitioner is suitably qualified

– any confidential information disclosed during the referral process will be adequately protected

Learning outcomes

Can you now?

• List the contraindications to exercise for pre / post natal clients

• Explain the guidelines for referral

• Identify warning signs for cessation of exercise

• Explain how to respond to any warning signs during exercise

• Describe the key considerations when developing effective working

relationships

• List the types of real and perceived barriers

• Describe ways in which these barriers can be overcome

Unit:

Session

Physical activity and health considerations for the

pre and post natal client

Nutritional requirements for pre and post natal clients

Aim of the session

• To know the nutritional requirements for pre and post natal clients

Learning outcomes

By the end of this session, you will be able to:

• Explain the importance of a balanced diet for pre and post natal

clients

• List sources of food which are important during the pre / post natal

period

• List the foods which should be avoided during pregnancy together

with their reasons

• Explain the importance of adequate hydration for a pre / post natal

client

Importance of a balanced diet

• A healthy pregnancy may depend as much on pre-pregnancy diet and related body composition as it does to nutrients consumed during the pregnancy

• Two important concerns are that there is an avoidance of dramatic weight loss during pregnancy; and that there is sufficient calorie intake to support breastfeeding.

Task

Use your research skills to identify some

important sources of food during

pregnancy.

Note down your findings in your portfolio

Important sources of foods

• General advice: – Ensure a good supply of

vitamins and minerals • broad spectrum of fruits and

vegetables of different colours and structures will help ensure that all nutrients are supplied

– Starchy carbohydrates to provide energy

– ‘Refined’ carbohydrates such as white bread, white rice and confectionary should be limited

• small frequent servings of the unrefined carbohydrates

Task

Research and identify the key

vitamins and minerals required during

pregnancy?

Foods to avoid

• Food sources which might contain teratogens

• Foods high in pre-formed vitamin A

• Sources of food-borne illness

• Caffeine

• Alcohol

• Oily fish

Importance of hydration

• Good hydration is extremely important for a healthy pregnancy and postpartum recovery

• During pregnancy, water is also needed for the expansion in blood volume, and insufficient intake may contribute to constipation, preterm labour, and possibly miscarriage

General advice for staying hydrated

• Drink between 8-12 glasses of water per day (more if the weather is warm or during exercise)

• Stay proactive - while thirst does signal a need for hydration, not everyone feels thirsty when they need to drink

• Avoid caffeinated and high-sugar beverages, which are actually dehydrating

• Drink smaller amounts of healthy liquids frequently, as opposed to large amounts only a couple times per day

Learning outcomes

Can you now?

• Explain the importance of a balanced diet for pre and post natal

clients

• List sources of food which are important during the pre / post natal

period

• List the foods which should be avoided during pregnancy together

with their reasons

• Explain the importance of adequate hydration for a pre / post natal

client

Unit:

Session

Design and implement exercise programmes for

the pre and post natal client

Collecting information and selecting appropriate activities

Aim of the session

• To be able to collect information and select appropriate activities

with the pre or post natal client

Learning outcomes

By the end of this session, you will be able to:

• Explain the importance of pre-activity screening

• Identify information to be collected

• Collect information about the client

• Interpret information from the screening process

• Record information in an effective manner

• Observe the legal and ethical responsibilities regarding screening,

client records and confidentiality

Importance of pre-activity screening

• Begins with initial

consultation

• Lifestyle assessment

– Questionnaires

– Interview

• Functional assessment

Identifying information to be collected

• Lifestyle

• Medical history

• Activity history

• Attitudes

• Motivating factors

• Exercise preferences

• Barriers

• Fitness assessment

Collecting information

• Reports

• Interview

• Questionnaire

• Observation

• Risk assessment

• Functional assessment

TASK: Interpreting information

Describe how the following sources of information can be interpreted to help inform exercise prescription:

• Personal goals

• Lifestyle factors

• Medical history

• Motivation

• Barriers to exercise

• Exercise preferences and current fitness

Recording information

• Fitness professionals are expected to keep records of all relevant consultations – Questionnaires (medical,

exercise, occupational, lifestyle)

– Assessment forms (physical/functional, medical, occupational health)

– Informed consent

– Recorded sessions/interviews (audio, video)

– Training log

– Referral forms and letters

Legal and ethical responsibilities

• Generally, fitness professionals should only record information based on disclosure by the client themselves, or from direct observation

• If it is necessary to record an opinion, the entry should be clear that it is an opinion and whose opinion it is

• It is essential that all fitness professionals are bound by confidentiality

Learning outcomes

Can you now?

• Explain the importance of pre-activity screening

• Identify information to be collected

• Collect information about the client

• Interpret information from the screening process

• Record information in an effective manner

• Observe the legal and ethical responsibilities regarding screening,

client records and confidentiality

Unit:

Session

Design and implement exercise programmes for

the pre and post natal client

Designing an individualised exercise programme

Aim of the session

• To be able to design an individualized, safe and effective exercise

programme for pre or post natal clients

Learning outcomes

By the end of this session, you will be able to:

• Apply the principles of FITT

• Select appropriate types of activity

• Identify alternative activities and modifications

• Describe the guidelines for stretching

• Explain the importance of pelvic floor exercises

• Explain the importance of not exercising to exhaustion

• Record the programme in an appropriate format

Considerations for exercise

• In which stage of the

pregnancy, is the client?

• How experienced is the

client and what are her

exercise capabilities?

Task

Outline some general ‘do’s’ and

‘don’ts’ when it comes to exercise

prescription for pregnant clients.

Task

Outline some general guidelines for

warming up and cooling down.

Applying the principles of FITT

• It is unrealistic to formulate generic exercise recommendations that can be applied across the board for all pregnant women

– Individual differences in health status, physical fitness, and previous exercise experience

• National guidelines may provide a good starting point for prescription

Guidelines for aerobic activity

Guidelines for muscular conditioning

TASK: additional considerations

How does pregnancy affect the following, and what exercise modifications can you make:

• Body position

• Joint laxity

• Abdominal muscles

• Posture

• Resistance training

Importance of pelvic floor exercises

• The pelvic floor performs an important function in urinary and faecal control, as well as support of the pelvic organs (avoiding prolapse). – Awareness and control of these

muscles may be helpful in order for a woman to relax them during labour

– Usually at around the fifth month of pregnancy, there is an increase in pressure around the pelvic area as the uterus grows. Urinary incontinence may become a common problem

Guidelines for flexibility training

Task

Produce a hand-out for your pregnant

client that summarises exercise

guidelines for each trimester, across

aerobic training, muscular

conditioning, and flexibility.

Importance of not exercising to

exhaustion

• May result in symptoms similar to overtraining syndrome

• These include fatigue (acute and chronic), pain, loss of motivation, susceptibility to injury and common infections, and decreased exercise performance

• If symptoms of overtraining appear, the most sensible solution would be to modify either the exercise programme or other lifestyle variables that produce the fatigue

Recording programmes

• Exercise professionals are expected to keep records of all client training programmes, in addition to relevant consultations and assessments – key to an effective service, and

can help in monitoring and improvement of a service delivery

• All information written on programme cards should be clear and precise, and recorded in an appropriate format

Task: programme design

Using the sample programme card

provided, design an exercise

programme for trimesters 1, 2 and 3.

Learning outcomes

Can you now?

• Apply the principles of FITT

• Select appropriate types of activity

• Identify alternative activities and modifications

• Describe the guidelines for stretching

• Explain the importance of pelvic floor exercises

• Explain the importance of not exercising to exhaustion

• Record the programme in an appropriate format

Unit:

Session

Design and implement exercise programmes for

the pre and post natal client

Identifying and managing specific risks for the pre and post natal client

Aim of the session

• To be able to identify and manage specific risks to the pre or post

natal client when participating in physical activity

Learning outcomes

By the end of this session, you will be able to:

• Identify any specific risks for the pre or post natal client

• Describe ways to manage the identified risks

Introduction

• Many experts warn that the risks of exercise may cause premature labour, abortion, or congenital deformities.

• However, there are no reports documenting that regular exercise per se, increases the occurrence of maternal or foetal injury in a healthy woman with a normal pregnancy.

• Nevertheless, each woman must be informed of the potential risks of exercise, and warned of any associated problems so that an educated decision can be made regarding exercise

Occupational risks

• Risks associated with physically

demanding jobs should always be

considered by the fitness professional.

• For example, experts warn against

engaging in persistent heavy workloads

that include strenuous lifting, long hours of

standing, or exposure to loud noise or

vigorous vibrations

Foetal hypoxemia

• Exercise may cause decreased utero-placental blood flow, which may lead to foetal hypoxemia and/or hypoglycaemia.

• During sustained exercise, there is decreased splanchnic blood flow; however, the trained pregnant woman's placenta will have an expanded blood volume and oxygen extracting capability, thereby providing adequate foetal nutrition

• Problems of foetal distress due to hypoxia are usually rare and have been shown to occur only in women who were unfit and engaged in episodic, intensive exercise during pregnancy

Hyperthermia

• The greatest threat of foetal defects

caused by high temperature occurs during

the first trimester. Intensive exercise,

particularly in hot, humid conditions

• However, adaptive mechanisms during

pregnancy will result in improved heat-

dissipation, which is enhanced further with

exercise training.

Hormonal stress

• Exercise is known to cause surges in certain hormones such as the catecholamines and prolactin, which may cause premature increases in uterine contractility. – For women accustomed to exercise, this results in a

reduction of these responses

• Furthermore, studies have not shown a correlation between vigorous exercise and early spontaneous abortion or premature onset of labour – However, women with a history of multiple

miscarriage should be cautious and have all exercise programmes approved by their GP

Foetal growth

• Exercise may also result in decreased

birth size and body weight, especially in

those who maintain vigorous activity

throughout their pregnancy.

– These infants tend to be leaner, but no less

healthy than those born to sedentary mothers

Trauma

• Blunt or penetrating trauma to the abdomen could result in foetal damage, and is more likely to occur later in pregnancy, when the foetus is anterior to the pelvis and less protected.

• Women involved in contact sports may be at higher risk, and should be warned that they may become more prone to falls, due to balance alterations

High risk contact sports

High risk contact sports for pregnant women

Ice and field hockey

Gymnastics

Boxing

Horseback riding

Wrestling

Ice and in-line skating

Football

Alpine and water skiing

Hang gliding

Rugby

Board and body surfing

Competitive basketball

Vigorous racquet sports

Power lifting

Scuba diving

Rock climbing

High-altitude activities

Strains and sprains

• Pregnant women need to be particularly careful with ballistic exercise, since it may increase the risk of orthopaedic problems, such as soft tissue injuries. – This is due to hormonal changes including the

increase in relaxin and progesterone, which may cause increased laxity

• If a pregnant woman experiences considerable posterior pelvic pain or pubic symphysis pain aggravated by exercise, they should immediately be referred back to their GP

Hypoglycaemia

• During pregnancy, hypoglycaemia can occur as a result of low-intensity, long-distance exercise, becoming more of a problem as pregnancy progresses.

• In addition, pregnant women utilize carbohydrates more readily during exercise, compared to non-pregnant women.

• If a pregnant client feels dizzy, faint, or tired during the late stages of an exercise session, or during the recovery phase, blood glucose should be checked

Learning outcomes

Can you now?

• Identify any specific risks for the pre or post natal client

• Describe ways to manage the identified risks

Unit:

Session

Design and implement exercise programmes for

the pre and post natal client

Post-natal exercise considerations

Aim of the session

• To understand the considerations for post-natal exercise prescription

Learning outcomes

By the end of this session, you will be able to:

• Describe the considerations and benefits of post natal exercise

• Describe post natal concerns for exercise

Considerations for exercise

• The first question usually asked at this point is “when can I resume exercising?” – dependent upon the events of labour

and the 6 week ‘all clear’ by the client’s GP

• However it is normal that transversus abdominis (TA) and pelvic floor (PF) exercises can be performed immediately post labour

• Current guidelines (ACOG, 2003; RCOG, 2006) recommend that women should avoid all physical stress for two weeks (i.e. ‘don’t carry anything heavier than the baby’) and not resume full daily activities for a minimum of six weeks after delivery

Benefits of post natal exercise

• Improved posture

• Increased local muscular endurance

• Increased stamina

• Increased energy

• Increased metabolic rate

• Increased weight loss, improved body image

• Increased self-confidence

• Reduced anxiety

Reduced joint stability

• Rising levels of relaxin produced during pregnancy increase the elasticity of ligaments and cartilage leading to instability of joints, particularly the sacroiliac joint and the pubis symphysis.

• Exactly how long relaxin stays in the body is still subject to debate

• The mother is the best judge and will know when she no longer ‘feels loose’

Exercise implications

• Maintenance stretching is strongly recommended, and stretching to increase flexibility should be avoided for 16-20 weeks

• When resistance training, include muscular endurance work and avoiding working to failure

• Avoid high impact activities for the first few months

Weak abdominals

• It may take six weeks for muscles to fully recover or even longer if they were weak before pregnancy.

• Gentle abdominal exercises in the early post-natal period will be vital in encouraging this process (e.g. tummy tightening, pelvic tilting) – however, guidance and advice

should be sought if there is abdominal separation

Breast-feeding

• Both breast-feeding and exercise are big fluid drains potentially leading to dehydration.

• To avoid dehydration, water intake around breast-feeding and exercise must be a priority – Use of a good supporting (sport)

bra is essential during exercise

– Avoid prone lying during the early post-natal period

– Consider vigorous arm/upper body work to promote milk flow

Learning outcomes

Can you now?

• Describe the considerations and benefits of post natal exercise

• Describe post natal concerns for exercise