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