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EXERCISE DURING PREGNANCY
Exercise during pregnancy
Haleh DadgostarSports Medicine SpecialistRasoul e Akram Hospital
EXERCISE DURING PREGNANCY
Outlines:
1. Physiological changes during pregnancy2. EXERCISE PRESCRIPTION
EXERCISE DURING PREGNANCY
In January 2002 the American College of Obstetricians and Gynecologists (ACOG) published new recommendations and guidelines for exercise during pregnancy and the postpartum period.
It is currently recognized that habits adopted during pregnancy could affect a woman’s health for the rest of her life.
For the first time the recommendation suggests a possible role for exercise in the prevention and management of gestational diabetes.
ACOG
EXERCISE DURING PREGNANCY
Increase maternal plasma volume 50%Changes in maternal osmoregulationIncreased sodium retention by kidney
Physiologic anemia of pregnancyCardiac output increases by 30-50%
Heart rate rises 15-20 beatsStroke volume increased by 20-30%
Decreased systemic vascular resistanceProgesterone relaxes smooth muscle21% lower than nonpregnant values
PHYSIOLOGICAL CHANNGES
EXERCISE DURING PREGNANCY
Mechanical elevation of the diaphragm Total lung capacity decreases by 5%
Progesterone causes a state of chronic hyperventilation 30-40% increase in tidal volume and minute
ventilationMaternal oxygen consumption 20-40% above
nonpregnant values
PHYSIOLOGICAL CHANNGES
EXERCISE DURING PREGNANCY
Increased risk of thromboembolic disease Increased venous stasis, vessel wall injury,
changes in coagulation cascadeTone and motility of the digestive system decrease
do to progesterone GERD, constipation
Kidneys enlarge by about 1 cm Increased renal vasculature, interstitial
volume and urinary dead space Glomerular filtration rate 50% increase
PHYSIOLOGICAL CHANNGES
EXERCISE DURING PREGNANCY
Lumbar lordosis, which contributes to the very high prevalence (50%) of LBP.
Balance may be affected by changes in posture, predisposing to loss of balance and increased risk of falling.
PHYSIOLOGICAL CHANGES
EXERCISE DURING PREGNANCY
Increased ligamentous laxity secondary to the influence of the increased levels of oestrogen and relaxin.
Theoretically, this would predispose pregnant women to increased incidence of strains and sprains
PHYSIOLOGICAL CHANGES
EXERCISE DURING PREGNANCY
Despite a lack of clear evidence that musculoskeletal injuries are increased during pregnancy, these possibilities should nevertheless be considered when prescribing exercise in pregnancy.
PHYSIOLOGICAL CHANGES
EXERCISE DURING PREGNANCY
In some reports, physical activity has been associated with an increase in uterine contractions. The magnitude of uterine contractions reported is usually low.
physically active woman with a history of, or who is at risk of, preterm labour should be advised to reduce her activity in the second and third trimesters
PHYSIOLOGICAL CHANGES
EXERCISE DURING PREGNANCY
During pregnancy, BMR, and therefore heat production, is increased above non-pregnant levels.
The increase in body temperature during exercise is directly related to the intensity of the exercise.
During moderate intensity, aerobic exercise in thermoneutral conditions, the core temperature of nonpregnant women rises an average of 1.5°C during the first 30 minutes of exercise and then reaches a plateau if exercise is continued for an additional 30 minutes.
THERMOREGULATORY CONTROL
EXERCISE DURING PREGNANCY
In animal studies, an increase in maternal core T >1.5°C during embryogenesis, cause major congenital malformations.
These data coupled with the results of human studies suggest that hyperthermia in excess of 39°C during the first 45–60 days of gestation may also be teratogenic in humans.
However, there have been no reports that hyperthermia associated with exercise is teratogenic in humans
THERMOREGULATORY CONTROL
EXERCISE DURING PREGNANCY
Minimum or moderate increase in FHR by 10–30 beats/min over baseline during or after maternal exercise.
Fetal bradycardia during maternal exercise (8.9%)can only be speculated on:
1. Vagal reflex2. Cord compression3. Fetal head malposition
FETAL RESPONSES TO MATERNALEXERCISE
EXERCISE DURING PREGNANCY
Birth weight is not affected by exercise in women who have adequate energy intake.
FETAL RESPONSES TO MATERNALEXERCISE
EXERCISE DURING PREGNANCY
Maintenance/improvement of maternal fitness
Control of excess weight gain Improved posture and appearance Increased energy Improved sleep Decreased incidence of back pain Improved self-esteem Decreased incidence of varicose veins Decreased water retention Decreased level of tension
MATERNAL BENEFITS WITH EXERCISE
EXERCISE DURING PREGNANCY
Possible decrease in complications during labour
Shortened labour Strengthens muscles needed for labor and
delivery More rapid postpartum recovery Improved cardiac function Therapeutic treatment for gestational
diabetes
MATERNAL BENEFITS WITH EXERCISE
EXERCISE DURING PREGNANCY
Exercise prescription requires knowledge of the potential risks and assessment of the physical ability to engage in various activities
The overall health, obstetric, and medical risks should be reviewed before a pregnant woman is prescribed and exercise program
CLINICAL EVALUATION
EXERCISE DURING PREGNANCY
Avoid exercise in the supine position after the first trimester.
Pregnancy requires an additional 300 kcal/day to maintain metabolic homeostasis.
Physiologic and morphologic changes of pregnancy persist 4-6 wks postpartum.
ACOG GUIDLINES
EXERCISE DURING PREGNANCY
Hemodynamic heart disease Restrictive lung disease Incompetent cervix Multiple gestation Persistent 2nd or 3rd trimester bleeding Placenta previa after 26 wks Premature labor during the current pregnancy Ruptured membranes Preeclampsia/PIH
ABSOLUTE CONTRAINDICATIONS
EXERCISE DURING PREGNANCY
Severe anemia Unevaluated maternal cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity Extreme underweight (BMI<12) History of extremely sedentary lifestyle IUGR in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker
RELATIVE CONTRAINDICATIONS
EXERCISE DURING PREGNANCY
Women who have been exercising prior to pregnancy may continue their regular exercise regimen during pregnancy, by following the PARmed-X guidelines.
EXERCISE PRESCRIPTION PARAMETERS
EXERCISE DURING PREGNANCY
Women who did not exercise regularly prior to pregnancy should not start an exercise program until the second trimester.
It is currently recommended to exercise at a frequency of 3 times per week, progressing to a maximum of 4 to 5 times per week.
EXERCISE PRESCRIPTION PARAMETERS
EXERCISE DURING PREGNANCY
Activities to improve cardiorespiratory (aerobic exercise) and musculoskeletal (resistive exercise) status and flexibility exercises
Less strenuous but continuous aerobic exercise (i.e. brisk walking, stationary cycling, cross-country skiing and swimming) are recommended.
TYPE OF EXERCISE
EXERCISE DURING PREGNANCY
Low weights with multiple repetitions lifted through a dynamic ROM appear to be a safe and effective type of resistance exercise during pregnancy.
Evaluated on an individual basis with consideration for individual abilities
TYPE OF EXERCISE
EXERCISE DURING PREGNANCY
Low impact aerobics Walking Cycling Yoga Ball Exercise Pilates Swimming Kegel
RECOMMENDED EXERCISES
EXERCISE DURING PREGNANCY
There are several activities that pose increased risks in pregnancy such as scuba diving and exertion in the supine position and motionless standing
Avoid any exposure to hyperbaric, hyperthermic , humid or hypoxic environmental conditions.
TYPE OF EXERCISE
EXERCISE DURING PREGNANCY
Avoid aerobic activities with increased risk of blunt abdominal trauma and loss of balance (i.e. downhill skiing, horse-back riding, and gymnastics).
Avoid breath-holding during weight-training exercise.
Abdominal exercises are not recommended if diastasis recti develops
TYPE OF EXERCISE
EXERCISE DURING PREGNANCY
Activities that increase the risk of falls, such as skiing
Those that may result in excessive joint stress, such as jogging and tennis
limit repetitive isometric or heavy resistance weightlifting and any exercises that result in a large pressor effect during pregnancy
CAUTIONARY ADVICE
EXERCISE DURING PREGNANCY
In longitudinal studies of immersion exercise in pregnancy at 60% maximal oxygen consumption, it was found to be a safe activity, with advantageous effects on oedema, thermal regulation, and buoyancy, thus minimising the risk of joint injuries.
No adverse effects on the fetus have been reported to occur during water exercise in pregnancy
WATER EXERCISE
EXERCISE DURING PREGNANCY
The temperature of pool suitable for exercise in pregnancy may be slightly higher than appropriate for normal swimming, that is between 28°C and 30°C.
WATER EXERCISE
EXERCISE DURING PREGNANCY
General rhythmic activities to warm-up.
Gentle selective stretching
Aerobic activities for CVS conditioning
UL &LL strengthening ex.
Abdominal ex
Pelvic floor ex.
Posture ex
Stabilization exercise
Relaxation &breathing exercise
cool down activities
SUGGESTED SEQUENCE OF EXERCISE.
EXERCISE DURING PREGNANCY
The ACSM recommends that intensity should be 60–90% of MHR or 50–85% of either Max VO2 or HRR.
The lower end of these ranges (60–70% of MHR or 50–60% of Max VO2) appears to be appropriate for most pregnant women who did not engage in regular exercise before pregnancy
The upper part of these ranges should be considered for those who wish to continue to maintain fitness during pregnancy.
INTENSITY OF EXERCISE
EXERCISE DURING PREGNANCY
Meta-analysis study of exercise and pregnancy, it was reported that, with exercise intensities of 81% of MHR, no significant adverse effects were found
INTENSITY OF EXERCISE
EXERCISE DURING PREGNANCY
Heart rate is less reliable in pregnancy for determining exercise intensity.
The modified heart rate target zones, as
outlined in the PARmed-X, are recommended for use in measuring exercise intensity in pregnant women.
INTENSITY
EXERCISE DURING PREGNANCY
GUIDING INTENSITY OF EXERCISE Maximal heart rate
Age Heart rate range<20 140-15520-29 135-15030-39 130-145
>=40 125-140
RPE (12-14)
Talk testYou should be able to carry on a verbal conversation
EXERCISE DURING PREGNANCY
First begin with 15 minutes of continuous exercise.
The duration of exercise may be gradually increased, as pregnancy progresses, to 30 minute sessions.
DURATION OF EXERCISE
EXERCISE DURING PREGNANCY
Accumulation of 30 minutes a day of exercise occur on most if not all days of the week
Pregnant women who have been sedentary before pregnancy should follow a gradual progression of up to 30 minutes a day
FREQUENCY OF EXERCISE
EXERCISE DURING PREGNANCY
Sedentary women Aerobic exercise, 65-75% max
HR
Moderately perceived exertion
30 min, minimum of 3 days/wk
EXERCISE PRESCRIPTION
EXERCISE DURING PREGNANCY
Recreational athletes and regular fitness exercisers
Aerobic exercise, 65-85% max HR
Moderate hard to hard exertion
30-60 min, 3-5 days/wk
EXERCISE PRESCRIPTION
EXERCISE DURING PREGNANCY
Elite Athletes Aerobic exercise, 75-85% MHR
Hard perceived exertion
60-90 minutes, 4-6 d/wk
EXERCISE PRESCRIPTION
EXERCISE DURING PREGNANCY
DO NOT START EXERCISING IF
Your doctor says not to
Unusual bleeding
High blood pressure
EXERCISE DURING PREGNANCY
Swelling of face and hands Severe headaches Persistent dizziness Chest pain or palpations Difficulty walking because of pain Vaginal bleeding Excessive discharge Fever
CONTACT YOUR DOCTOR IF…
EXERCISE DURING PREGNANCY
Avoid exercising while lying down, especially in late pregnancy.
Limit flat on the back exercise time to 2 3 ‐minutes, and do these exercises before aerobic or cardiovascular training exercises.
SAFETY GUIDELINES
EXERCISE DURING PREGNANCY
Avoid sudden changes of position or level.
Cool down to prevent pooling of blood in the extremities.
Rest daily in the side lying ‐position to maximize blood flow during the second and third trimesters
SAFETY GUIDELINES
EXERCISE DURING PREGNANCY
Do warm up for 5-10 minutes and cool down with static stretches and limbering exercises.
Do not maximum stretch.
Wear support bras and arch supports during exercise.
Avoid hot tubs, steam rooms, saunas or spas during pregnancy
SAFETY GUIDELINES
EXERCISE DURING PREGNANCY
Regular activity (3x/wk) is preferable to intermittent activity
Competitive activity is discouraged Vigorous exercise should not be performed in
hot, humid weather or during times of febrile illness
Maternal core temp should not exceed 38 degrees.
Liquids should be taken liberally to prevent dehydration
ACOG GUIDELINES 2002
EXERCISE DURING PREGNANCY
ACOG GUIDELINES
Ballistic movements should be avoided. Deep flexion or extension of joints should be
avoided because of connective tissue laxity
EXERCISE DURING PREGNANCY
Maternal heart rate should not exceed 140 beats per minute.
Strenuous activity should not exceed 15 minutes duration.
Exercises that employ the Valsalva maneuver should be avoided.
ACOG GUIDELINES
EXERCISE DURING PREGNANCY
Modify intensity of exercise according to maternal symptoms.
Stop exercising when fatigued and not exercise to exhaustion
ACOG GUIDELINES
EXERCISE DURING PREGNANCY
Vaginal bleedingDyspnea prior to exertionDizzinessHeadacheChest painMuscle weaknessCalf pain or swellingPreterm laborDecreased fetal movementAmniotic fluid leakage
WARNING SIGN
EXERCISE DURING PREGNANCY
Sit on a pillow on the floor with legs crossed
Lean forward or back
Don’t slump shoulders
Stretch legs occasionally
Make it a way of life
TAILOR SITTING (GROIN STRETCH)
EXERCISE DURING PREGNANCY
Strengthens quads Use furniture or support
from a partner to assist balance
10 reps/4 per day and every time you pick up something
Avoid bending over from the waist
SQUATTING
EXERCISE DURING PREGNANCY
Arch your back up and down
Brief, frequent exercises each day
Start with sets of 20 x 4, build to 80 x 2
Especially before bedtime
Takes pressure off structures in low back and pelvis
PELVIC TILTS AND ROCKING
EXERCISE DURING PREGNANCY
Calf
Hamstring
Quadriceps
Pectoralis
Piriformis
Iliotibial band
Abdominal, groin
STRETCHES
EXERCISE DURING PREGNANCY
• Backache during pregnancy is common because of the pressure of the fetus and the laxity of supporting structures.
BACK ACHE
EXERCISE DURING PREGNANCY
Exercise Posture
Straight neck, chin tuck, lift ribs, rolls shoulders back, contract lower abdominal muscles, tuck buttocks under
Ergonomics Tailor sit or use lumbar roll in chairs Place a foot on a stool for prolonged standing
PREVENTING BACK ACHE
EXERCISE DURING PREGNANCY
PHYSICAL: muscles
MENTAL: thoughts and concentration
EMOTIONAL: feelings
It’s a learned response – practice it
Use it as a time to communicate with your unborn baby
RELAXATION
EXERCISE DURING PREGNANCY
Improves tone in pelvic floor muscles
Poor tone may cause:– Incontinence– Discomfort– More labor pain– Torn tissues– Uterine prolapse
KEGEL EXERCISE
EXERCISE DURING PREGNANCY
KEGEL EXERCISE
Beginners: quick squeezes, 2 x 5 mins or 30 per day
Intermediate: hold for 10 secs x 50 per day
Advanced: elevators
Exhale as you begin each contraction
EXERCISE DURING PREGNANCY
To find the pelvic floor muscles, imagine that you are trying to stop yourself passing wind and at the same time trying to stop your flow of urine in mid-stream. You should feel a ‘squeeze and lift’.
It is important to do this • Without tightening your buttocks • Without holding your breath • Without squeezing your legs together
PELVIC FLOOR EXERCISES
EXERCISE DURING PREGNANCY
Try and lift for as long as you can (up to 10 seconds). You should feel a ‘letting go’ sensation when you relax these muscles. Give yourself a few seconds break then repeat this 10 times.
Then try 10 fast, hard squeezes, with 2-3 seconds rest in between.
Repeat 10 short and 10 long contractions 5-6 times a day
PELVIC FLOOR EXERCISES
EXERCISE DURING PREGNANCY
How to Do the Kegel Exercise1. Try to tighten the muscles a small amount at
a time, .like an elevator going up to the tenth floor.. Then release very slowly one .floor. At a time.
2. Try to tighten the muscles from front to back. Include the anus (rectum)
PELVIC FLOOR EXERCISES
EXERCISE DURING PREGNANCY
Practice while you sit, stand, walk, drive or watch TV
Three times each day Five repetitions Work up to 20 to 30
each time
PELVIC FLOOR EXERCISES
EXERCISE DURING PREGNANCY
KNEE PRESS
The knee press will strengthen your inner thighs,stretch your lower back and improve your circulation
Work up to doing 10 repetitions each day
EXERCISE DURING PREGNANCY
Leg Raise1. Lie on your back with feet flat
on the floor.2. Bring one knee up to your chest
as close as you can.3. Raise your leg in the air.4. Bend your knee and return your
foot to the floor.5. Do the same exercise with your
other leg.
ABDOMINAL STRENGTHENERS
EXERCISE DURING PREGNANCY
ABDOMINAL STRENGTHENERS
Knee Reach1. Lie on your back with feet flat on the floor.2. Lift your head and at the same time move one
knee towards your nose.3. Do the same thing with your other leg.
EXERCISE DURING PREGNANCY
Get on your hands and knees with arms straight.
2. Tighten your tummy muscles and tuck you hips under. Your back will hunch a little.
3. Relax.4. Do this slowly and evenly
THE PELVIC ROCK
EXERCISE DURING PREGNANCY
Position Two1. Stand with your back against
a wall.2. Tighten your tummy
muscles and tuck in your buttocks so the small of your back is flat against the wall.
3. If you put your hands on your hip bones, you should feel your hips rock.
THE PELVIC ROCK
EXERCISE DURING PREGNANCY
FULL BODY STRETCH
This exercise helps you warm up by stretching your whole body.
EXERCISE DURING PREGNANCY
FULL BODY TWIST
This exercise will stretch your waist, upper body and neck. It helps to keep your spine or backbone more flexible