Current Guidelines for Prenatal Fitness



thank you so much for waiting sorry about that my name is Catherine creme I'm an exercise physiologist and I specialize in pre and post natal fitness and I got into this field about 20 years ago just by happenstance working for the University of Wisconsin and over the last 20 years have just really fallen in love with this field as far as all of the interesting things that I've learned and all the research that has been going on that has really helped solidify how important this field is for people working in Fitness first of all who can benefit while physical therapists exercise physiologist nurses personal trainers birthing instructors doulas maternal health care providers actually anyone who comes into contact and works with pregnant and postpartum women what am I going to talk about with this webinar well there's so much information but what I want to do today is just touch on the most important factors that you need to be keeping in mind when you're thinking about working with pregnant women the physiological and biomechanical changes of pregnancy the current research the impact of exercise on maternal adaptations to pregnancy the guidelines that the Society of Obstetricians and Gynaecologists of Canada have set up contraindications and warning signs and symptoms the benefits of prenatal exercise have really been profound we've seen so much data collected over the last 20 to 25 years and from the very first groundwork studies to what we're seeing coming in actually weekly on this field have underscored the importance of women exercising during their pregnancy when they have a healthy uncomplicated pregnancy what the data has shown is a reduced maternal fat deposition and retention shorter and less complicated labor and delivery and increased ability to tolerate the biomechanical and physiological stresses of pregnancy and there's even some evidence of enhanced maternal physiological health what we're going to talk about today are four are the physiological factors of pregnancy and how exercise impacts them in metabolic the cardiovascular respiratory ventilatory and musculoskeletal first of all the metabolic there's tremendous changes that go on within the pregnant body and one of these are the metabolic rate that can increase by up to 15 to 20 percent during the span of the 40 weeks of pregnancy these hormonal shifts cause changes in how maternal metabolism is regulated and all of these changes that go on are to help the fetus get what it needs during its growth in that 40 weeks one of the things we see is the hormone slow gastrointestinal tract transit time and that allows for greater absorption of nutrients so the fetus gets all the nutrients that it needs there's an increase in fat storage during the first two time masters and that increases insulin production and sensitivity and maternal carbohydrate utilization again another way for the maternal body to be able to get enough nutrients to provide ID to its growing fetus there's also a greater rate of maternal carbohydrate utilization maternal weight gain this is something that we've seen a lot of focus on in the last 15-20 years because of the tremendous increase in obesity so one of the things that a lot of OBGYNs are looking at is how much weight is needed to have a healthy pregnancy but how much weight is too much for them to be able to get rid of it safely and Nanci waking is anywhere from 25 to 35 pounds and that can vary greatly dependent upon where she starts at at the beginning of her pregnancy if she starts out normal weight then we're seeing maybe it's somewhere on the upper end of that if she's overweight many times she doesn't need to gain that much weight to have a healthy pregnancy and if a woman is underweight she may need to gain more all of that will be something that is dependent upon within her and her healthcare provider pregnancy requires only about 300 extra calories a day so the whole adage about e eating for two really isn't true 300 calories is a small bagel so it doesn't take much to feed that that fetus and in fact a woman needs twice that after pregnancy to be able to deal with breast feeding and providing for breast milk women who exercise throughout the pregnancy gain on an average of eight pounds less than sedentary pregnant women and that's not eight pounds less of needed fat but eight pounds of excess fat and that's a huge difference because that eight pounds can really add up if she has multiple pregnancies one of the kind of landmark studies looked at maternal fat gained in exercising and control group of women and what we saw in that study is that there was a really significant difference in the amount of fat gained in women who exercised throughout their pregnancy and that is a really important term looking at throughout not just halfway through but to the very end of her pregnancy and we'll talk a little more about the importance of maintaining fitness to the end of the pregnancy as we move forward seven weeks beach unit of weight gain he is significantly less for the women who continued to exercise versus those that were in the control group and that means excess weight that she has to lose postpartum maternal thermal adaptations and these are really important in far as far as keeping the women at a lower internal core temperature because we know that increased internal core temperature can be very dangerous to a growing fetus there's a lowered sweat point so she increases sweating much earlier when she becomes hot which helps us to increase the amount of apparate of heat loss hormones increased blood vessel dilation which increases blood flow to skin there's an increase in blood volume which maintains a high flow rate to the syrup or to the surface and there's a greater body mass result in a larger area to heat now when you look at all of these factors all of these play a role in helping the body dissipate internal core heat and by increasing all of these what we really have found is that the pregnant body is much better adapted at losing core temperature increase core temperature than the non-pregnant state the effects of the exercise on maternal third allow thermal adaptations well what we find is regular exercise improves a woman's ability to reduce her core temperature because she has increased blood volume and decreased or temperature threshold so she's got a lot more blood coming to the surface and she's got vasodilation of those blood vessels so she's able to dissipate that heat and also by her lowered sweat point she's getting more sweat on the surface of that skin so the blood that's coming to the surface that is heated from the core is able to dissipate heat through radiation and three evaporative heat loss so we have just a tremendous increase in the amount of heat loss that our heat that can be dissipated in that manner one of the reasons we worry about Heat and pregnancy is because there's been some very good studies that have shown that during that first trimester when there's neural tube formation there's a real increased risk of defects that can occur when the fetus is exposed to see stress now what is in can see steep stress those are situations where the maternal body cannot get rid of that increased core temperature and those are situations like a hot tub or saunas where she is really in this very high heat environment and cannot lose heat through evaporative radiation or convection so what we always tell women is the best thing to keep in mind is just avoid those situations where we have the increased risk so avoiding hot tubs and saunas throughout pregnancy is always a good idea as far as exercise though we find that in most situations as long as she can evaporatively heat get rid of heat loss and exercise in a cool temperature that we don't see that same risk with exercise now the only time I do that caveat is if we're in a real high heat and humid environment and that's the situation again just like with a sauna or a hot tub she's not able to effectively do so paid that heat so I always tell women avoid exercise when there's high heat indexes which means there's a high temperature high humidity go into a cool environment that is controlled and make sure that she exercises earlier in the day if she is exercising outdoors or later at night ate plenty of hydration and making sure that she thinks about how she's feeling throughout that time and if she feels that she's having signs of heat exhaustion such as increased profuse sweating skin redness dizziness nausea and fatigue that she stops exercise goes into a cool environment and allows herself to dissipate that heat tips for reducing overheating again increasing the intake of cooled fluids you want to avoid high sugar drinks which can slow absorption stop activity and go to a cool environment lay down with the upper body elevated and take a cool water bath always if symptoms do not resolve within 30 minutes of rest and hydration she should seek medical attention the cardiovascular and circulatory changes are actually um I think some of the most interesting that occurs I always look at pregnancy is very much akin to running a marathon or doing the Ironman because during this short period of time there are tremendous changes that are going on within the maternal body first of all within just weeks of implantation of pregnancy hormones initiate blood vessel relaxation in reduced responsiveness now that results in a vascular under filling and you want to think a little bit about your basic physiology is that we have the heart is pumping out fluid we've got fluid and what happens with that out fluid being reduced is we have vascular under filling response to vasculature filling is hormones are released causing retention of salt in water and increasing plasma volume so the body says okay boy we're having and a lot of more relaxation of those blood vessels so we've got more area what do we need to do we need to create more fluid to fill up that area during the period of pregnancy cardiac output and blood volume increased by 40% I think I'm losing you guys you there okay back up lightheadedness fakeness nausea fatigue and rapid heart rate and increased sweating and urination can occur during this time the mechanisms causing cardiovascular system changes well changes begin within the first week of pregnancy so once that egg is implanted it's sending out hormonal signals that initiate this relaxation and reduced responsiveness of the arterial blood vessels so initially this increased vascular bed causes that under filling so we've got a lot more area and less fluid to fill it now those symptoms were going to be dizziness and lightheadedness and those are some of the first things that women notice during the first weeks of pregnancy and many times the kind of key that they know they are pregnant vascular under filling stimulates the kidneys to retain more blood to increase plasma volume so then we have this increase in blood volume and venous return to the heart so again very much like high intensity training is going on the same changes we would see heart chamber volumes increased 15 to 20 percent and stroke volume increases up to 40% by the end of pregnancy those are tremendous changes and essentially they're just like a very high end of a training state now what are the effects of maternal exercise on cardiovascular adaptations well we just are actually additive regular moderate level exercise during pregnancy has been shown to enhance the cardiovascular changes of pregnancy one study showed that plasma volumes red cell volumes and total blood volume are regularly exercising pregnant women up to 50% higher than non exercising pregnant Lin this is all really important to when you think about the fetus and making sure it is getting what it needs everything that's going on in this pregnant body is making sure that this growing fetus is going to get what it needs so when we have that increase of 30 to 50 percent in cardiac volume or output that one study observed versus control we really know that there's a tremendous additive effect that occurs during pregnancy when a woman exercises these added reserves that fit pregnant women have made beneficial for maintaining adequate blood flow to the penis when under stress there's also respiratory changes the increased levels of progesterone initiate what we call over breathing so she's improving her efficiency of oxygen uptake in carbon dioxide elimination and in essence she's gonna feel a little bit more out of breath even in the very early months of pregnancy there's a slight elevation and widening of the ribcage and that improves breathing capacity during pregnancy now these changes can cause women to feel short of breath but interestingly lung function remains at preconception levels throughout pregnancy the adaptations that occur in the respiratory system are all focused on increasing oxygen uptake and carbon dioxide removal to and from maternal and fetal tissues rising progesterone levels cause a more frequent and deep breathing and increased carbon dioxide sensitivity so those two things together help make sure she's getting in enough oxygen to provide to her fetus and getting rid of the waste and carbon dioxide that both she and her her fetus are producing resting maternal oxygen consumption increases approximately 10 to 30 percent during pregnancy so that's a tremendous amount of increase and that's because of the greater demands from the fetus the myocardium and respiratory muscles and kidneys now how does exercise affect respiratory adaptations well it further enhances just like with the cardiovascular there's an increased level of fitness corresponding with a greater oxygen uptake exercise training improves the efficiency of oxygen and transport and utilization by increasing a viola benefit ventilation ingress count gas transfer at tissue levels and it helps to maintain peak ventilation and maximal aerobic capacity now you can see here for the musculoskeletal changes these are the most obvious changes that we can see the center of gravity moves up and out lumbar thoracic and cervical curves are exaggerated the relaxed and hormone that increases during pregnancy is specifically produced to create a laxity and joints at the pelvis to allow the baby to pass through during labor and delivery there evidence that muscle mass and strength increased during pregnancy and the changes in body shape can cause muscle and joint pain now the first point here as far as muscle mass the strength is probably due to the increased weight of the fetus and having to carry that increased weight the changes in body shape of course can cause a lot of muscle and joint pain because you're having tremendous changes in the center of gravity lumbar thoracic curves these stresses especially if women are not fit and able to deal with these stresses can really cause problems for some women during the pregnancy now one of the biggest focuses have always been on this population looking at the effect of prenatal exercise on labor and delivery and one of the seminal studies by dr. James Clapp found that women who exercise to the end of their pregnancy had a quite tremendous difference in the amount of needs for pain relief a decreased need for operative interventions as a c-section for Sep on fifty-five percent decrease in need for a pc atomy at 50 percent decrease in the need for the inducer stimulate with pitocin and also tremendous decrease in the need to intervene because of an abnormal heart rate well this all leads to all of these changes we've been talking about lead to is how does this affect the fetus and we're seeing more and more data that's really showing us how exercise during pregnancy really helps that fetus have a greater kind of reserve to deal with stresses and a lot of benefit and one of the most important things we always want to look at is there any harm to date we have no studies that show short or long-term fetal problems associated with women who continue to exercise during and non-complicated pregnancy and within normal limits and we'll talk more about what normal limits on the effect of maternal exercise in the placenta this has really been some interesting data that showed that research using ultrasound technique observed placental growth between the 16th and 14th of pregnancy and what did they find at term exercising women had a 50% more surface area of the placenta in vessels in the control and that really transforms the whole idea of how much extras how much exercise affects the amount of blood flow going to that fetus and what we're seeing what this data is the fetuses of exercising women have tremendously greater blood flow so that during times of stress when blood flow to the placenta is diminished they're still getting enough to meet their needs now one of the things we look at and some of the data is shown over the last twenty years is that an increased fetal heart rate is a normal response to sustained maternal exercise and so what we want to think about is that every time the mother exercises there's slight stresses that are being put on her and her fetus and again these are good stresses just the same sort of stress that when you're lifting weight and you are stressing that muscle to lift something a little bit harder than it's used to the muscle responds by getting stronger and we can look at this the same way with this fetus the intermittent stress is stimuli of the mother exercising and some shunting blood flow oh that's right more blood flow by more increased in toriel blood flow and a lot more blood vessels going to it there's evidence of babies of exercising moms they're able to tolerate the stresses of contraction spider can think controls and why is that again when there's contractions blood flow to the baby is reduced there's there's contraction of the blood flow but those babies still are getting far more blood flowed than babies of non exercising moms so that even during those times of stress when blood flow is diminished they're still getting plenty to meet their needs now there's also some interesting longitudinal studies that have looked at babies of exercising mothers versus controlled and these are kind of preliminary but we're really seeing some interesting statistics and those are the babies of exercising moms we're leaner at birth now in this culture that's a really important point because we know that for the most part we're born with a certain number of fat cells during the first few years of life those fat cells can increase in number and then after that we really see increase just in the size so if you're born with a greater number of fat cells than another person your ability to become more obese and more easily obese is greater because you have more fat cells to feed so if you're born leaner and again we're not talking about underweight babies we're talking about just leaner babies they're not born with an excess of amount of fat your risk of becoming obese ostensibly could be lower longitudinal studies have shown that at one year these babies did significantly better than controls and studies of mental physical performance which is another whole thing to look at outside of the physiological changes and at five years this is very interesting that shows that these babies are leaner compared to controls so again the hypotheses of being born with less fat cells and leaner carries over into the five years it'd be interesting to see what we see as these studies progress now the Society of a patrician and gynecologists of Canada published their joint clinical practice guidelines in 2003 and these guidelines are very much much like in us our ACOG guidelines essentially that they state all women without contraindications should be encouraged to participate in aerobic and strength conditioning exercises a part of them as part of a healthy at lifestyle you can get the entire guidelines by clicking or going to the the website below and it's listed here but in essence what all of the guidelines at this point are saying is that it's just be reasonable um the they've say that women who have no contraindications should set reasonable goals you don't want to try to reach peak exercise fitness levels during pregnancy avoiding activities that require greater balance and using common sense and I think that's something we're going to touch on quite a bit as we move forward about the use of common sense and thinking about what makes sense and what during pregnancy and not doing things that are outside of what is seems safe and reasonable we're going to talk now about the prenatal exercise prescription in this prescription is very much the same as you would use with any population just it's the modifications and and parameters that aren't gonna be a little bit different there's four factors we're going to look at the intensity the duration the type and frequency first of all and exercise intensity what we want to do is make sure that a woman is exercising at an intensity that feels moderate to somewhat hard for her and again every woman's going to be different these intensity levels perceptions are going to change throughout pregnancy at 10 weeks pregnancy something's gonna feel a lot easier than it did at 30 weeks or 40 weeks pregnancy so teaching you're pregnant client on how to gauge that is very important now some people will use the board scale other people just use something that's so simple to use called the talk test and what we essentially just say is we tell women when you're exercising it should be challenging enough that you're able to like really feel that you're working but not so hard that you couldn't carry on a conversation so if you're working with a client and she's on a stair stepper and she's at a level where she can't carry conversation she's gulping for air we know that's too high so we want her to feel again like she's challenged she's working hard she said somewhere on that you know four to five on the one-to-ten scale and knowing that as she moves along in pregnancy she's going to have to modify her intensity to keep herself within that level that feels safe now a lot of times we of course use heart rate as a way to measure intensity with a regular population but with pregnancy we don't do that because the cardiovascular and hormonal changes of pregnancy really alter the heart rate response so you're going to get heart rates that are all over the place and sometimes if she comes in fatigued one day her heart rates gonna be a lot higher and so we don't want her working at her normal workload because that's going to give her push her up too high into that heart rate so instead of using the heart rate again use the talk test use the borrow rating scale and have her understand that she should always work within that level it feels moderate she may be working on on a treadmill at 3:00 now miles an hour at 3% grade most of the time comes in one Dage she's had a growth spurt and that level feels like she's pushing and it's too hard she's out of breath that's the point where we modify her activity bring down that two maybe three point two miles an hour and a 2% grade see how she feels at that those modifications have to constantly be made to keep her within that level of it feels moderate always use total body monitoring during pregnancy it's not just about that heart it's not just about the lungs it's about their total body because her body's under a lot of stress she's carrying the weight of that fetus some days just the mechanical feeling of her back of her knees may be the factor that you have to work with so these are all things were going to be playing with with this exercise prescription to help make it that she can continue to exercise comfortably and safely throughout her pregnancy here just shows a little bit one of the scales is six to ten there's also the one to ten you can use either one is fine the point is is to find that point that feels moderate for them and stay within that now exercise during narration ideally I'd like to see women exercising upwards to 45 minutes to an hour each session now with pregnancy I'd rather see her exercise longer at less intensity so in this equation if it comes down to having to modify something bring down that intensity to make it for a longer period of time so she's getting the point where she can't maintain 45 minutes of exercise at her regular intensity anymore that's your cue to say okay fine we're going to bring down that intensity a little bit so that you can make that duration always decrease intensity go for duration because that is the key we want to make sure she gets that longer duration to make sure she's in that fat-burning zone now intermittent versus continued duration is also fun some women find that especially when they're around ligaments the ligaments that help support the uterus are during the growth spurt becoming more sore and painful we may need to cut down that duration to 20 minutes and she finds that at 25 minutes she's getting pain okay we're going to cut that limit down to 20 minutes and do it twice a day there's no problem with doing that again comfort and finding a way to naval her to comfortably exercise is the key exercise tight first and foremost she should find an activity that she enjoys and one that poses little risk to himself or the fetus so walking swimming cycling low-impact stationary exercise equipment classes are all great activities now there are some activities that there are contraindicated and the first two scuba diving and waterskiing our absolute contraindication meaning no one should be doing these during their pregnancy now the other ones are ones that you have to really take into consideration her level of skill what her doctor has signed on for and says it okay for her to do and that she is skilled enough at reading her body to know when she's pushing it beyond the point of safety someone who is an excellent downhill skier may continue to exercise during her pregnancy but keep in mind if she's someone that's living at sea level and she goes out in the wintertime to somewhere that's 12 14,000 feet that could be a very dangerous situation because the hypoxia so those are things that need to be discussed with our health care provider to make sure that she is not pushing her body to a level that it's going to cause harm to her fetus now always ex asked me that come I had these questions to your client first of all what do you like doing if she doesn't like doing it she's not going to continue doing it so it needs to be something is easy for her to do an almost daily basis does it pose any risk so some classes are great but kickboxing is one that can be dangerous in fact there has been some instances of women in expectant women in kickboxing classes that have been kicked in the abdomen so if she's gonna take a class that her instructor knows she's pregnant that there's plenty of room around her so that she doesn't run the risk of being kicked or hit by another participant and make sure that it can be modified throughout her pregnancy exercise frequency now in order to derive optimal benefit for aerobic exercise if frequency should be at least three to five days a week I actually like to have women exercising up to six days a week she can do different types of activity but the more it's part of her daily schedule the more she keeps consistent with it now remember it's preferable to modify duration and intensity in order to maintain frequency so first of all we are going to drop down that intensity to maintain the duration now if she's having difficulty maintaining a frequency of five days a week or three days a week then we need to even modify more for durations so maybe we need to take down the duration in 45 minutes to 30 to make it so she can exercise three to five days a week on one of the other things we want to look at is what is our current level of fitness how is a pregnancy progressing the type of activity and intensity and always there should be one day of active rest and active rest could be a yoga day as stretching day but just a day to allow her body to recover from the exercise many pregnant women are able to sustain six days a week of exercise with these modifications as a pregnancy progresses always have a warm up and cool down the best warm-up you can do is a slow start to whatever the activity is you're going to do so if she's gonna be walking starting out with slow walking if she's gonna be jogging staring up with a slow walk then it's slow run and then into her jogging which exercise session should end with a slow reduction so that she's going down about eight from that level of 8 to 10 down lower and lower to the point where she feels that she's no longer out of breath we're short of breath strength training absolutely essential during pregnancy many women don't have really good upper-body strength and baby care requires a lot of it and we see a lot of back injury because women who are not very strong once they have their baby are lifting hundreds of times a day and tend to cause a lot of stress to that lumbar spine region one of the things we do talk about though are there's some caveats with strength training you should always avoid supine position after the first trimester and the reason for that is that there's a large vessel called the vena cava that the baby puts pressure on when you're lying flat on your back and that can cause the woman to feel light-headed so we just tell women after that first time master or make sure you're propped up in a semi-reclined position modify those positions so you never lie flat on your back especially for longer durations of time always warm up before strength training use a slow progression target major muscle groups can always use proper form and that's always a problem with pregnancy because as her center of gravity changes you really need to watch her to make sure she maintains proper form things can change it's becomes more difficult for her to lift in a certain position that's where you need to be in there constantly modifying and changing positions to maintain safety or comfort now with maternal strength training guidelines the gradual reduction in weight load may be needed as pregnancy progresses but women will amend the pregnancy core at a higher fair level of strength training do not need to change or stop their program just because the pregnant they needs again listen to how their body feels they can continue to do their strength training as long as they feel good their pregnancy is progressing normally and their physicians on board with them for doing it make sure you avoid a client lift or weight or resistance that causes her to bear down or strain she should always use her breathing exhaling with the lift and never holding her breath and very young one set of ten to twelve repetitions is sufficient for stress my things for someone who has never done strength training so if you have someone coming into your program or you're working with a one-on-one with a client if they've never known strength training they can start it during their pregnancy and they really only need to do one set about ten to twelve repetitions that see some gain strength always focus on that upper body because that's where we really need to build the strength for baby lifting the guidelines again increased repetition at lower weight loads may be needed as pregnancy progresses monitor exercise technique carefully by mirror observation or supervision and always be correcting their postural changes that may occur with advancing pregnancy and always avoid a maximal static lift flexibility training well the relaxin hormone makes people think that all women all pregnant women are very flexible to it but that's really not the case you have a lot of muscle tightening and response to the changes in center of gravity so we need to work on those tight muscles to help stretch them out and help her be more comfortable on a daily basis no I know aboard ballistic movements you want to hold those stretches for as long as you can for up to ten to fifteen seconds and again avoiding a supine position after first trimester now remember that the changes in the pregnant body can cause increased muscle soreness those postural shifts can cause her to really hold stress so certain muscles but one thing to keep in mind is the literature has not shown a correlation between decreased joint stability and production of that relaxing hormone but again we always want to use proper lifting techniques proper stretching techniques avoiding hyperextension or flexion we're performing these activities as you just can see in the picture here you want to be in a comfortable position your slow-mo gentle movements use your breathing to enhance the stress and with pregnant women always avoid pointing toes in any movement because that position can many times cause cramping of the foot discontinue any stretches that cause pain or discomfort Howick floor exercises are a very important exercise and in fact one that doesn't get included as much as it it should the concrete floor helps to provide the strength and support of the pelvic organs and also are really important during labor and delivery if a client has poor pelvic floor you want to start with shorter contractions and higher repetitions of these exercises you want to find a duration repetition amount that a client is able to sustain without pelvic floor Katti slowly increase over time duration and contraction hold and encourage clients to form a habit of doing pelvic floor exercises several times a day during activities such as brushing teeth or their daily tasks many women don't do how the floor exercises correctly they're either squeezing the thigh muscles or their buttocks and what I tell women is is that these exercise when you're doing a correct pelvic floor exercise you shouldn't see any motion these are very internal muscles and they're the same muscle group that you use to stop the flow of urine so initially I tell women that's the way you get a feel for contracting those muscles when you're urinating and you stop that flow those are the muscles that you squeeze now you shouldn't be doing that every time you're urinating because you can cause some problem with urinary retention but once you get a feel for what it's like to tighten those muscles then you know that you have the correct muscle group I have women start with a graduated contraction just like an elevator so she's contracting up up and hold hold that peak contraction and as she gets stronger she's going to bring that contraction up and hold for longer duration now focus on relaxing relaxation as well because that relaxation sensation is also very important for women during the pushing phase of labor and delivery many women when they're in that pushing phase that don't have good cover for sense and ability to contract and to relax tend to tighten those muscles so a woman that knows how to control those muscles by tightening and relaxing is better able to control those muscles during her labor and delivery guidelines for exercise monitoring and this is the most important part of any exercise program for pregnancy is the monitoring this is kind of the the icing on the cake because with good monitoring and good modifications were able to continue to keep exercise safe and effective for every woman we work with this pregnant the most accurate measure method for determining whether a pregnant exercise program is appropriate is your clients feedback and the client feedback is so imperative so every day that you're working with a pregnant client you need to talk with her and ask her how she feels how is her pregnancy progressing and has there been any problems with her pregnancy in her last visit with her healthcare provider now one of the more important questions and ones that should be just a mantra that you have with every pregnant client to be able to determine whether or not her pregnancy is still considered uncomplicated whether the exercise that you're doing is appropriate is by asking these questions are you gaining weight within your health care providers recommendations if she is not then we need to work with health care provider and the mother to make sure that we're not pushing too hard on the exercise and without her taking in enough calories is the health care provider concerned about her level of weight gain is she able to comfortably follow your exercise program without discomfort extreme exhaustion and how's her energy level now the biggest questions I always ask is the fetus growing within normal limits if not we need to reassess whether or not exercise is appropriate there may be some conditions that the fetal growth is not up to where it should be and in those instances sometimes exercise is contraindicated it's a physician concerned at all about the progression of her pregnancy and it has there been any changes in the pattern or amount of fetal movement now signs of overtraining as well need to be kept in mind if she's having an elevated resting heart rate frequent illness lack of normal weight gain or chronic exhaustion and when I talk about it elevated resting heart rate back here I have women learn to take a resting heart rate person every morning now again we're not using a training heart rate during pregnancy but resting only can give us a very good window into whether or not she's overtraining or becoming ill when she cuts to the point where she sees what her normal resting heart rate is so after a month of taking a full minute pulse every good morning she sees that her normal range is right around 65 75 beats a minute if she's been working out and she wakes up one morning takes it in it's 80 85 that's a key point to let us know that she is not really covered enough or she is maybe becoming ill and that should be a rest day and see what the next morning if it's still elevated she again needs to assess whether or not she's overtraining and she wants to be able to have that heart rate back down with her normal ranges so again keeping in mind that that morning resting heart rate can be a window to whether or not she's overwhelmed working and meeting needs to take more rest days now again we always want to ask is that fetus growing with the normal limits at each clinic visit and do the division have any concerns and has there been any changes name on a fetal movement those three questions are gonna give you a lot of information about whether or not she should be exercising whether what you're doing is working well if the fetus isn't growing normally we need to reassess exercise if there's any concerns you need to decide whether or not her physician feels she should continue exercise safely and if there's changes in fetal movement after and this usually is after about the second trimester that she's feeling this fetal movement then again she needs to stop exercising and see your healthcare provider I'm going to just cut through this client self monitoring you can't see inside your clients body and know how she's feeling so her feedback to you is vitally important always instruct the client to pay close attention to their physical well-being and report any changes clients should avoid exercise when ill or they feel extreme exhaustion and a client instruct client and warning signs and symptoms of overtraining as I talked about that daily resting pulse is very important on giving a window to how her body is responding to exercise and whether or not she's overtraining or at that point becoming ill remember each week of pregnancy presents with new physical challenges so your ability to provide modifications as you move through pregnancy is vitally important view the exercise prescription as a make a basic template so you're going to be modifying that that intensity duration frequency and type throughout the pregnancy to keep that woman comfortable and able to continue to exercise always attempt modifying an exercise before you eliminate it and the most important factor remember is that each woman's pregnancy will present with her own unique needs and challenges always reduce intensity cutting pace incline or resistance until you reach a level that is well tolerated think about breaking up exercise bouts 20 minutes two times instead of 40 minutes at one bout if she's having difficulty maintaining that 40 minutes and identify causes for discomforts look at the bike seat if she's having problems with her pelvis being painful change the tilt incorrect lifting techniques can cause pain so belly's support may be needed if she's walking after a certain point of pregnancy and her on ligament hurts you need to be creative in order to find options to correct discomfort always remember avoiding supine ab exercise and you want to provide modifications by semi recumbent position using pillows using a wall or wedge to lift her body up if she ever becomes lightheaded or dizzy when doing exercises even in the modified position have a rollover onto her left side to re-establish blood flow and low mass your exercise class goals should be deliberate provide a well-rounded fitness routine in a safe environment a participant in setting realistic fitness goals teach participants how to self monitor and establish an environment that fosters support motivation and a positive social interaction in in conclusion once you walk away from this saying first of all I understand how that prenatal exercise is really a vital point part of a healthy pregnancy it's safe and beneficial for almost all pregnant women who have an uncomplicated pregnancy pregnant women should be encouraged to continue or even start a fitness program for exercise during her pregnancy and she should be provided with modification techniques that allow her to continue to exercise to the end of her pregnancy for more information please feel free to contact me at my website or at my email address that's listed below this is just a touching on all of the topics that we work with to build a safe and effective exercise program but I think you'll find that that working with this population is such a joy and it's a challenge in a way that really makes you think about all the skills that you have and use them to really be creative with this popular and helping them have the best and most healthy pregnancy that they can have and now I'm going to send it back to Melissa for questions alright so we had a few questions pop up I will do my best to read them off and hopefully we can get an answer if not as I mentioned catherine has provided her email address so some people can send them through over there um the first question is from Julie and she is asking is it always best to refer to a pelvic floor physiotherapist for an assessment and not be prescribing pelvic floor strengthening exercises as a personal trainer many women tend to have an overactive pelvic floor muscle which will create long-term holding patterns and dysfunction I treat many individuals for pelvic floor conditions and teaching them to activate the muscles in a rigid way is not always that useful for many people nor is it functional please consider this part of your presentation that's a really great point and my short answer and that is anytime anyone can get a referral to a physiotherapist that is phenomenal and I try to have every pregnant woman I work with get that referral but that being said you don't want to not provide pelvic floor exercise information to the general pregnant population you're working with because to not do so and give them this information is to not really help them with providing that strength training for the pelvic floor that's very important and that's a little bit what I talked about with a lot of women holding it and tightening it the pelvic floor it can be a problem for some women but in the vast majority just teaching them basic pelvic floor contraction and relaxation exercises is so beneficial and we really don't see a downside to doing that but again any time you can get a referral to a physiotherapist to any pregnant women I think is so important awesome thing you know um how do you feel about pregnant women engaging in kettlebell classes again this is one of those things you have to look at each woman's level of ability whether she was doing the kettlebells before she was pregnant and already has that strength build-up whether she's working with someone one-on-one who can watch modify and help her control her movements in a way that are safe those are all factors that have to be brought into consideration before you would have a woman take part in a class like that okay I'm are there any other pelvic floor exercises other than kegels to do or teach well kegels are in pelvic floor exercises they call them kegels but they're penny interchangeable are kind of the gold standard for that but there are other ones that a physiotherapist can work with that require a bit more one-on-one monitoring so I would say at this level um the regular Kegel exercises the two different basic core exercises of both the short flick contractions where you contract and relax contract and relax and then the greater stair step three of slowly lifting strengthening holding holding holding and then dropping down relaxation are the two that we have people start with I'm is there any way to prepare for a c-section there there actually is and I think that's an excellent question the best way to prepare for a c-section is being as fit as possible because recovery and being able to back quickly after Donaldson trying on conditioning and as far as the belly building back that muscle control all is vitally important and that's another situation where I would highly recommend that she work with a physiotherapist on abdominal strengthening postpartum to help her bring back those muscles that were cut but being fit having good muscle strength is going to help her very much in her recovery and we see women who are fit during her pregnancy that have had a c-sections seem to have less of a problem during her recovery because she has a better base a better strength a better cardiovascular fitness okay don't sorry I lost my place would you be able to touch on Prevention's for diocese no diastasis recti also are there any dangers of low squats during pregnancy two very good questions again things I would have loved if touched on if we had a lot more time there's been a lot of talk about a diastasis recti and during pregnancy one of the things I want to say first and foremost is every single pregnant woman is going to have a diastasis recti and what that simply is is the thinning and widening of the connective tissue between the rectus abdominus sheet of muscles of two sides of that the reason for that is to allow the baby room to grow this is not a hernia which hernia would be more of a cutting or an opening of that area this is a thinning and widening of the connective tissue now the degree of that width can be dependent on a lot of factors and first and foremost it's your own body biomechanics if you're very short you're going to have the baby push up further you don't have as much height to allow that that growth so you're going to have probably a greater widening of that area now what people have looked at is is there a greater risk of injury low back injury because of that loss of support of the recti muscles and we haven't really seen a lot of data to show that to be the case but that doesn't mean we don't want to think about avoiding exercises that put a lot of intra-abdominal pressure on that Linea Alba that that's thin connective tissue so I really do not like to see any kind of supine sit-ups during pregnancy or postpartum there's a wonderful group of exercises called Hartmann rehabilitative exercises that I actually have I can provide for anyone that's interested if you want to email me they're progressive exercises that slowly work on the transverse muscle group so we don't put the pressure on that Linea Alba and it really is a great exercise group to do postpartum to bring back that area and then the second question was the deep squats if a woman's been doing squatting during or before her pregnancy and she can comfortably continue with them without knee strained back strain well then she can continue with that but for most women as she gets further along in her pregnancy it's very helpful for her to have a chair or something that stationary and stable to help pull her up after that deep squat because it's very difficult with the weight of the baby and the change in the biomechanics of the body to lift up without putting strain on the knee alright so we'll do one more quick question and then we are at one o'clock so we will have to end there I know there are a few unanswered questions um so Katherine has provided her email address um Katherine you're being asked it can you just pop the slide up with your email address on it again so some people can copy it down just because we are missing out on a few questions um and then you guys can shoot Katherine an email if you have any further questions or want to talk a little bit more if we didn't quite get to yours and so the last question that we will go on here oh sorry I'm with a client with multiple pregnancy twins does the blood flow increase that much more and what about calorie intake I love these questions they're really great and people are really thinking and first of all it's a great question and there's a lot of controversy about exercise with multiples but more and more they're finding that we're not immediately putting a woman on bed rest and that we do encourage them to keep exercising there's not a two-fold increase of everything but there is an even greater increase in all of the cardiovascular respiratory metabolic changes that are going to occur when you have two babies that you're providing for so I feel that exercise is still as important but we have to be much more careful about whether or not she's gaining normally working very closely with her healthcare provider to make sure that we're not over stressing her body so it requires a lot more monitoring and modifications and I'm sorry what was the second part of that I the calorie count as well so his calorie count and blood flow for twins we're twins I would say this is gonna look you're gonna have to look a lot again on where is she at as far as when she starts a pregnancy if she's normal weight we're gonna look at her weight gain and weight gain is gonna really tell us how many calories are needed most doctors have her eat probably close to maybe double that but if she's gaining too much weight they may bring it back down if she's not gaining enough you might pop it up so these are just guidelines but looking at how her weight gain is progressing during a pregnancy it's gonna tell you a lot about how many calories she needs so all we was watching that if she's not gaining enough again we need to increase that if she's gaining too much your healthcare provider may say she needs to drop down that amount perfect so I think that concludes everybody um so again we will be replacing sorry placing a recording of this webinar up on your campus pro interactive account takes about a week or so so check in with us next week um if you have any questions directly for Katherine her email address is up on the screen if you want to copy it down quickly if you missed copying it down or you have any other further questions please contact info at kf8 procom thank you guys so much for spending your lunch hour with us and thank you again to Katherine for coming on board for this webinar today we hope to talk to you guys all soon thanks so much for the University of Wisconsin and over the last 20 years have just really fallen in love with this field as far as all of the interesting things that I've learned and all the research that has been going on that has really helped solidify how important this field is for people working in Fitness first of all who can benefit while physical therapists exercise physiologist nurses personal trained birthing instructors doulas maternal health care providers actually anyone who comes into contact and works with pregnant and postpartum women what am I going to talk about with this webinar well there's so much information but what I want to do today is just touch on the most important factors that you need to be keeping in mind when you're thinking about working with pregnant women the physiological and biomechanics is of pregnancy the current research the impact of exercise of maternal adaptations to pregnancy the guidelines that the Society of Obstetricians and Gynaecologists of Canada have set up contraindications and warning signs and symptoms the benefits of prenatal exercise have really been profound we've seen so much data collected over the last 20 to 25 years and from the very first groundwork studies to what we're seeing coming in actually weekly on this field have underscored the importance of women exercising during their pregnancy when they have a healthy uncomplicated pregnancy what the data has shown is a reduced maternal fat deposition and retention shorter and less complicated labor and delivery and increased ability to tolerate the biomechanical and physiological stresses of pregnancy and there's even some evidence of enhanced maternal physiological health what we're going to talk about today are four are the physiological factors of pregnancy and how exercise impacts them the metabolic the cardiovascular respiratory ventilatory and musculoskeletal first of all the metabolic changes there's tremendous changes that go on within the pregnant body and one of these are the metabolic rate that can increase by up to 15 to 20 percent during the span of the 40 weeks of pregnancy these hormonal shifts cause changes in how maternal metabolism is regulated and all of these changes that go on are to help the fetus get what it needs during its growth in that 40 weeks one of the things we see is the hormone slow gastrointestinal tract transit time and that allows for greater absorption of nutrients so the fetus gets all the nutrients that it needs there's an Creason fat storage during the first two time masters and that increases insulin production in sensitivity and maternal carbohydrate utilization again another way for the maternal body to be able to get enough nutrients to provide ID to its growing fetus there's also a greater rate of maternal carbohydrate utilization maternal weight gain this is something that we've seen a lot of focus on in the last 15-20 years because of the tremendous increase in obesity so one of the things that a lot of OBGYNs are looking at is how much weight is needed to have a healthy pregnancy but how much weight is too much for them to be able to get rid of it safely and and seed waking is anywhere from 25 to 35 pounds and that can vary greatly dependent upon where she starts at at the beginning of her pregnancy if she starts out normal weight then we're seeing maybe it's somewhere on the upper end of that if she's overweight many times she doesn't need to gain that much weight to have a healthy pregnancy and if the woman is underweight she may need to gain more all of that will be something that is dependent upon within her and her healthcare provider pregnancy requires only about 300 extra calories a day so the whole adage about e eating for two really isn't true 300 calories is a small bagel so it doesn't take much to feed that that fetus and in fact a woman needs twice that after pregnancy to be able to deal with breast feeding and providing for breast milk women who exercise throughout the pregnancy gain on an average of 8 pounds less than sedentary pregnant women and that's not eight pounds less of needed fat but eight pounds of excess fat and that's a huge difference because that eight pounds can really add up if she has multiple pregnancies one of the kind of landmark studies looked at maternal fat gained in exercising and control group of women and what we saw in that study is that there was a really significant difference in the amount of fat gained in women who exercised throughout their pregnancy and that is a really important term looking at throughout not just the halfway through but to the very end of her pregnancy and we'll talk a little more about the importance of maintaining fitness to the end of the pregnancy as we move forward seven weeks beach unit of weight gain he is significantly less for the women who continued to exercise versus those that were in the control group and that means excess weight that she has to lose postpartum maternal thermal adaptations and these are really important in far as far as keeping the women at a lower internal core temperature because we know that increased internal core temperature can be very dangerous to a growing fetus there's a lowered sweat point so she increases sweating much earlier when she becomes hot which helps us to increase the amount of apparate of heat loss hormones increased blood vessel dilation which increases blood flow to skin there's an increase in blood volume which maintains a high flow rate to the syrup to the surface and there's a greater body mass result in a larger area to heat now when you look at all of these factors all of these play a role in helping the body dissipate internal core heat and by increasing all of these what we really have found is that the pregnant body is much better adapted at losing core temperature increased core temperature than the non-pregnant state the effects of the exercise on maternal third allow thermal adaptations well what we find is regular exercise improves a woman's ability to reduce her core temperature because she has increased blood volume and decreased or temperature threshold so she's got a lot more blood coming to the surface and she's got vasodilation of those blood vessels so she's able to dissipate that heat and also by her lowered sweat point she's getting more sweat on the surface of that skin so the blood that's coming to the surface that is heated from the core is able to dissipate heat through radiation and three evaporative heat loss so we have just a tremendous increase in the amount of heat loss that our heat that can be dissipated in that manner one of the reasons we worry about Heat and pregnancy is because there's been some very good studies that have shown that during that first trimester when there's neural tube formation there's a real increased risk of defects that can occur when the fetus is exposed in he's dress now what is in can see steep stress those are situations where the maternal body cannot get rid of that increased core temperature and those are situations like a hot tub or saunas where she is really in this very high heat environment and cannot lose heat through evaporative radiation or convection so what we always tell women is the best thing to keep in mind is just avoid those situations where we have the increased risk so avoiding hot tubs and saunas throughout pregnancy is always a good idea as far as exercise though we find that in most situations as long as she can evaporatively heat get rid of heat loss and exercise in a cool temperature that we don't see that same risk with exercise now the only time I do a caveat is if we're in a real high heat and humid environment and that's the situation again just like with a sauna or hot tubs she's not able to effectively do so paid that heat so I always tell women avoid exercise when there's high heat indexes which means there's a high temperature high humidity go into a cool environment that is controlled and make sure that she upper exercises earlier in the day if she is exercising outdoors or later at night ate plenty of hydration and making sure that she thinks about how she's feeling throughout that time and if she feels that she's having signs of heat exhaustion such a increased profuse sweating skin redness dizziness nausea and fatigue that she stops exercise goes into a cool environment and allows herself to dissipate that heat tips for reducing overheating again increasing the intake of cool fluids you want to avoid high sugar drinks which can slow absorption stop activity and go to a cool environment lay down with the upper body elevated and take a cool water bath always if symptoms do not resolve within 30 minutes of rest and hydration she should seek medical attention the cardiovascular and circulatory changes are actually I think some of the most interesting that occurs I always look at pregnancy is very much akin to running a marathon or doing the Ironman because during this short period of time there are tremendous changes that are going on within the maternal body first of all within just weeks of implantation of pregnancy hormones initiate blood vessel relaxation and reduced responsiveness now that results in a vascular under filling and you want to think a little bit about your basic physiology is that we have the heart is pumping out fluid we've got fluid and what happens with that out fluid being reduced is we have vascular under filling response to vasculature filling it's hormones are released causing retention of salt in water and increasing plasma volume so the body says okay boy we're having and a lot of more relaxation of those blood vessels so we've got more area what do we need to do we need to create more fluid to fill up that area during the period of pregnancy cardiac output and blood volume increased by 40% I think I'm losing you guys you there okay back up lightheadedness faintness nausea fatigue and rapid heart rate and increased sweating and urination can occur during this time the mechanism is causing cardiovascular system changes well changes begin within the first week of pregnancy so once that egg is implanted it's sending out hormonal signals that initiate this relaxation and reduced responsiveness of the arterial blood vessels so initially this increased vascular bed causes that under filling so we've got a lot more area and less fluid to fill it now those symptoms were going to be dizziness and lightheadedness and those are some of the first things that women notice during the first weeks of pregnancy and many times the kind of key that they know they are pregnant vascular under filling stimulates the kidneys to retain more blood to increase plasma volume so then we have this increase in blood volume and venous return to the heart so again very much like high-intensity training is going on the same changes we would see heart chamber volumes increased 15 to 20 percent and stroke volume increases up to 40 percent by the end of pregnancy those are tremendous changes and essentially they're just like a very high end of a training State now what are the effects of maternal exercise on cardiovascular adaptations well we just are actually additive regular moderate level exercise during pregnancy has been shown to enhance the cardiovascular changes of pregnancy one study showed that plasma volumes red cell volumes and total blood volume are regularly exercising pregnant women up to 50% higher than non exercising pregnant man this is all really important to when you think about the fetus and making sure it is getting what it needs everything that's going on in this pregnant body is making sure that this growing fetus is going to get what it needs so when we have that increase of 30 to 50 percent in cardiac volume or output that one study observed versus control we really know that there's a tremendous additive effect that occurs during pregnancy when a woman exercises these added reserves that fit pregnant women have made beneficial for maintaining adequate blood flow to the penis when under stress there's also respiratory changes the increased levels of progesterone initiate what we call over breathing so she's improving her efficiency of oxygen uptake in carbon dioxide elimination and in essence she's gonna feel a little bit more out of breath even in the very early months of pregnancy there's a slight elevation in widening of the rib cage and that improves breathing capacity during pregnancy now these changes can cause women to feel short of breath but interestingly lung function remains at preconception levels throughout pregnancy the adaptations that occur in the respiratory system are all focused on increasing oxygen uptake and carbon dioxide removal to and from maternal and fetal tissues rising progesterone levels cause a more frequent and deep breathing and increased carbon dioxide sensitivity so those two things together help make sure she's getting in enough oxygen to provide to her fetus and getting rid of the waste and carbon dioxide that both she and her her fetus are producing resting maternal oxygen consumption increases approximately 10 to 30 percent of pregnancy so that's a tremendous amount of increase and that's because of the greater demands from the fetus the myocardium and respiratory muscles and kidneys now how does exercise affect respiratory adaptations well it further enhances just like that the cardiovascular there's an increased level of fitness corresponding with greater oxygen uptake exercise training improves the efficiency of oxygen and transport and utilization by increasing a viola benefit ventilation ingress count gas transfer at tissue levels and it helps to maintain peak ventilation and maximal aerobic capacity now you can see here for the musculoskeletal changes these they're the most obvious changes that we can see the center of gravity moves up and out lumbar thoracic and cervical curves are exaggerated the relaxed and hormone that increases during pregnancy is specifically produced to create a laxity and joints at the pelvis to allow the baby to pass through during labor and delivery there's evidence that muscle mass and strength increased during pregnancy and the changes in body shape can cause muscle and joint pain now the first point here as far as muscle mass and strength is probably due to the increased weight of the fetus and having to carry that increased weight the changes in body shape of course can cause a lot of muscle and joint pain because you're having tremendous changes in the center of gravity lumbar thoracic curves these stresses especially if women are not fit and able to deal with these stresses can really cause problems for some women during the pregnancy now one of the biggest focuses have always been on this population looking at the effect of prenatal exercise on labor and delivery and one of the seminal studies by dr. James clap found that women who exercise to the end of their pregnancy had a quite tremendous difference in the amount of needs for pain relief a decreased need for operative interventions as a c-section for Sep a fifty five percent decrease in need for a PC a t'me a fifty percent decrease in the need for the inducer stimulate with the Tosun and also tremendous decrease the need to intervene because of an abnormal heart rate well this all leads to all of these changes we've been talking about lead to is how does this affect the fetus and we're seeing more and more data that's really showing us how exercise during pregnancy really helps that fetus have a greater kind of reserve to deal with stresses and a lot of benefit and one of the most important things we always want to look at is there any harm it's a date we have no studies that show short or long-term fetal problems associated with women who continue to exercise during an uncomplicated pregnancy and within normal limits and we'll talk more about what normal limits on the effect of maternal exercise in the placenta this has really been some interesting data that showed that research used the ultrasound technique observed potential growth between the 16th and 14th of pregnancy and what did they find at term exercising women had a 50% more surface area of the placenta in vessels in the control and that really transforms the whole idea of how much extras how much exercise affects the amount of blood flow going to that fetus and what we're seeing what this data is the fetuses of exercising women have tremendously greater blood flow so that during times of stress when blood flow to the placenta is diminished they're still gaining enough to meet their needs now one of the things we look at and some of the data is shown over the last 20 years is that an increased fetal heart rate is a normal response to sustained maternal exercise and so what we want to think about is that every time the mother exercises there's slight stresses that are being put on her and her fetus and again these are good stresses just the same sort of stress that when you're lifting weight and you are stressing that muscle to lift something a little bit harder than it's used to the muscle responds by getting stronger and we can look at this the same way with this fetus the intermittent stress the stimuli of the mother exercising and some shunting blood flow Oh tits right more blood flow by more increased entry Oh blood flow and a lot more blood vessels going to it there's evidence of babies of exercising moms they're able to tolerate the stresses of contraction spider can think controls and why is that again when there's contractions blood flow to the baby is reduced there's there's contraction of the blood flow but those babies still are getting far more blood flow than babies of non exercising moms so that even during those times of stress when blood flow is diminished they're still getting plenty to meet their needs now there's also some interesting longitudinal studies that have looked at babies of exercising mothers versus controlled and these are kind of preliminary but we're really seeing some interesting statistics and those are the babies of exercising moms we're leaner at birth now in this culture that's a really important point because we know that for the most part we're born with a certain number of fat cells during the first few years of life those fat cells can increase in number and then after that we really see increase just in the size so if you're born with a greater number of fat cells than another person your ability to become more obese and more easily obese is greater because you have more fat cells to feed so if you're born leaner and again we're not talking about underweight babies we're talking about just leaner babies they're not born with an excess of amount of fat your risk of becoming obese ostensibly could be lower longitudinal studies have shown that at one year these babies did significantly better than controls and studies of mental physical performance which is another whole thing to look at outside of the physiological changes and at five years this is very interesting that shows that these babies are leaner compared to controls so again the hypotheses of being born with less fat cells and leaner carries over into the five years it'd be interesting to see what we see as these studies progress now the Society of a nutritionist and gynecologists of Canada published their joint clinical practice guidelines in 2003 and these guidelines are very much much like in u.s. our ACOG guidelines essentially that they state all women without contraindications should be encouraged to participate in aerobic and strength conditioning exercises a part of them as part of a healthy at lifestyle you can get the entire guidelines by clicking or going to the the website below and it's listed here but in essence what all of the guidelines at this point are saying is that it's just be reasonable um the they say that women who have no contraindications should set reasonable goals you don't want to try to reach peak exercise fitness levels during pregnancy avoiding activities that require greater balance and using common sense and I think that's something we're going to touch on quite a bit as we move forward about the use of common sense and thinking about what makes sense and what during pregnancy and not doing things that are outside of what is seems safe and reasonable we're going to talk now about the prenatal exercise prescription and this prescription is very much the same as you would use with any population just it's the modifications and and parameters that are going to be a little bit different there's four factors we're going to look at the intensity the duration the type and frequency first of all and exercise intensity what we want to do is make sure that a woman is exercising at an intensity that feels moderate to somewhat hard for her and again every woman's going to be different these intensity levels perceptions are going to change throughout pregnancy at 10 weeks pregnancy something's going to feel a lot easier than it did at 30 weeks or 40 weeks pregnancy so teaching you're pregnant client on how to gauge that is very important now some people will use the board scale other people just use something that's so simple to use called the talk test and what we essentially just say is we tell women when you're exercising it should be challenging enough that you're able to like really feel that you're working but not so hard that you couldn't carry on a conversation so if you're working with a client and she's a stair stepper and she's at a level where she can't carry on conversation she's gulping for air we know that's too high so we want her to feel again like she's challenged she's working hard she said somewhere on that you know four to five on the one-to-ten scale and knowing that as she moves along in pregnancy she's gonna have to modify her intensity to keep herself within that level that feels safe now a lot of times we of course use heart rate as a way to measure intensity with a regular population but with pregnancy we don't do that because the cardiovascular and hormonal changes of pregnancy really alter the heart rate response so you're going to get heart rates that are all over the place and sometimes if she comes in fatigued one day her heart rates gonna be a lot higher and so we don't want her working at her normal workload because that's gonna give her push her up too high into that heart rate so instead of using the heart rate again use the talk test use the borrow rating scale and have her understand that she should always work within that level it feels moderate she may be working on a treadmill at 3:00 now miles an hour at 3% grade most of the time comes in one day she's had a growth spurt and that level feels like she's pushing and it's too hard she's out of breath that's the point where we modify her activity bring down that to may be 3.2 miles an hour at a 2% grade see how she feels at that those modifications have to constantly be in made to keep her within that level that feels moderate always use total body monitoring during pregnancy it's not just about that heart it's not just about the lungs it's about their total body because her body's under a lot of stress she's carrying the weight of that fetus some days just the mechanical feeling of her back of her knees may be the factor that you have to work with so these are all things were going to be playing with with this exercise prescription to help make it that she can continue to exercise comfortably and safely throughout her pregnancy here just shows a little bit one of the scales is six to ten there's also the one to ten you can use either one is fine the point is is to find that point that feels moderate for them and stay within that now exercise during narration ideally I'd like to see women exercising upwards to 45 minutes to an hour each session now with pregnancy I'd rather see her exercise longer at less intensity so in this equation if it comes down to having to modify something bring down that intensity to make it for a longer period of time so she's getting the point where she can't maintain 45 minutes of exercise at her regular intensity anymore that's your cue to say okay fine we're going to bring down that intensity a little bit so that you can make that duration always decrease intensity go for duration because that is the key we want to make sure she gets that longer duration to make sure she's in that fat-burning zone now intermittent versus continued duration is also fun some women find that especially when they're around ligaments the ligaments that help support the uterus are during the growth spurt becoming more sore and painful we may need to cut down that duration to 20 minutes and she finds that at 25 minutes she's getting pain okay we're going to cut that limit down to 20 minutes and do it twice a day there's no problem with doing that again comfort and finding a way to naval her to comfortably exercise is the key exercise tight first and foremost she should find an activity that she enjoys and one that poses little risk to himself or the fetus so walking swimming cycling low-impact stationary exercise equipment classes are all great activities now there are some activities that there are contraindicated and the first two scuba diving and waterskiing our absolute contraindication meaning no one should be doing these during their pregnancy now the other ones are ones that you have to really take into consideration her level of skill what her doctor has signed on for and says it'll pay for her to do and that she is skilled enough at reading her body to know when she's pushing it beyond the point of safety someone who was an excellent downhill skier may continue to exercise during her pregnancy but keep in mind if she's someone that's living at sea level and she goes out in the winter time to somewhere that's twelve fourteen thousand feet that could be a very dangerous situation because the hypoxia so those are things that need to be discussed with our health care provider to make sure that she is not pushing her body to a level that it's going to cause harm to her fetus now always ask ask me that come I had these questions to your client first of all what do you like doing if she doesn't like doing it she's not going to continue doing it so it needs to be something that's easy for her to do an almost daily basis does it pose any risk so some classes are great but kickboxing is one that can be dangerous in fact there has been some instances of women and expectant women in kicks by boxing classes that have been kicked in the abdomen so if she's gonna take a class that her instructor knows she's pregnant that there's plenty of room around her so that she doesn't run the risk of being kicked or hit by another participant and make sure that it can be modified throughout her pregnancy exercise frequency now in order to derive optimal benefit from aerobic exercise if frequency should be at least three to five days a week I actually like to have women exercising up to six days a week she can do different types of activity but the more it's part of her daily schedule the more she keeps consistent with it now remember it's preferable to modify duration and intensity in order to maintain frequency so first of all we are going to drop down that intensity to maintain the duration now if she's having difficulty maintaining a frequency of five days a week or two days a week then we need to either modify more per duration so maybe we need to take down the duration in 45 minutes to 30 to make it so she can exercise three to five days a week on one of the other things we want to look at is what is the current level of fitness how is the pregnancy progressing the type of activity and intensity and always there should be one day of active rest and active rest could be a yoga day as stretching day but just a day to allow her body to recover from the exercise many pregnant women are able to sustain six days a week of exercise with these modifications as a pregnancy progresses always have a warm up and cool down the best warm-up you can do is a slow start to whatever the activity is you're going to do so if she's gonna be walking starting out with slow walking if she's gonna be jogging stirring up with a slow walk then it's slow run and then into her jogging which exercise session should end with a slow reduction so that she's going down to about eight from that level of eight to ten down lower and lower to the point where she feels that she's no longer out of breath for a shorter bath strength training absolutely essential during pregnancy many women don't have really good upper body strength and baby care requires a lot of it and we see a lot of back injury because women who are not very strong once they have their baby are lifting hundreds of times a day and tend to cause a lot of stress to that lumbar spine region one of the things we do talk about though are there's some caveats with strength training you should always avoid supine position after the first trimester and the reason for that is that there's a large vessel called the vena cava that the baby puts pressure on when you're lying flat on your back and that can cause the woman to feel light-headed so we just tell women after that first time an Esther or make sure you're propped up in a semi-reclined position modify those positions so you never lie flat on your back especially for longer durations of time always warm up before strength training use a slow progression target major muscle groups and always use proper form and that's always a problem with pregnancy because as her center of gravity changes you really need to watch her to make sure she maintains proper form things can change it becomes more difficult for her to lift in a certain position that's where you need to be in they're constantly modifying and changing positions to maintain safety or comfort now with material strength training guidelines the gradual reduction in weight load may be needed as pregnancy progresses but women will amend the pregnancy core at a higher level of strength training do not need to change or stop their program but just because the pregnant they need to again listen to how their body feels and they can continue to do their strength training as long as they feel good their pregnancy is progressing normally and their physicians on board with them for doing it make sure you avoid a client lift or weight or resistance that causes her to bear down or strain she should always use her breathing exhaling with the lift and never holding her breath and very down one set of ten to twelve repetitions is sufficient for stroke night games for someone who has never done strength training so if you have someone coming into your program or you're working with a one-on-one with a client if they've never known strength training they can start it during their pregnancy and they really only need to do one set about ten to twelve repetitions that see some gain of the strength always focus on that upper body because that's where we really need to build the strength for baby lifting the guidelines again increased repetition at lower weight loads may be needed as pregnancy progresses monitor exercise technique carefully by mirror observation or supervision and always be correcting the postural changes that may occur with advancing pregnancy and always avoid a maximal static lift flexibility training well the relaxant hormone makes people think that all women all pregnant women are very flexible but that's really not the case you have a lot of muscle tightening and response to the changes in center of gravity so we need to work on those tight muscles to help stretch them out and help her be more comfortable on a daily basis no I know aboard ballistic movements you want to hold those stretches for as long as you can for up to 10 to 15 seconds and again avoiding a supine position after first trimester now remember that the changes in the pregnant body can cause increased muscle soreness those postural shifts can cause her to really hold stress so certain muscles but one thing to keep in mind is the literature has not shown a correlation between decreased joint stability and production of that relaxing hormone but again we always want to use proper lifting techniques proper stretching techniques avoiding hyperextension or flexion move performing these activities as you just can see in the picture here you want to be in a comfortable position use slow-mo gentle movements use your breathing to enhance the stress and with pregnant women always avoid pointing toes in any movement because that position can many times cause cramping of the foot discontinue any stretches that cause pain or discomfort pelvic floor exercises are a very very important exercise and in fact one that doesn't get included as much as it it should the concrete floor helps to provide the strength and support of the pelvic organs and also are really important during labor and delivery if a client has poor pelvic floor you want to start with shorter contractions and higher repetitions of these exercises you want to find a duration repetition amount that a client is able to sustain without pelvic floor fatigue slowly increase over time duration and contraction hold and encourage clients to form a habit of doing pellit four exercises several times a day during activities such as brushing teeth are their daily tasks many women don't do how the floor exercises correctly they're either squeezing the thigh muscles or the buttocks and what I tell women is is that these exercise when you're doing a correct pelvic floor exercise you shouldn't see any movement these are very internal muscles and they're the same muscle group that you use to stop the flow of urine so initially I tell that's the way you get a feel for contracting those muscles when you're urinating and you stop that flow those are the muscles that you squeeze now you shouldn't be doing that every time you're urinating because you can cause some problem with urinary retention but once you get a feel for what it's like to tighten those muscles then you know that you have the correct muscle group I have women start with a graduated contraction just like an elevator so she's contracting up up and hold hold that peak contraction and as she gets stronger she's going to bring that contraction up and hold for longer duration now focus on real action relaxation as well because that relaxation sensation is also very important for women during the pushing phase of labor and delivery many women when they're in that pushing phase that don't have good cover for sense and the ability to contract and to relax tend to tighten those muscles so a woman that knows how to control those muscles by tightening and relaxing but is better able to control those muscles during her labor and delivery guidelines for exercise monitoring and this is the most important part of any exercise program for pregnancy is the monitoring this is kind of the icing on the cake because with good monitoring and good modifications we're able to continue to keep exercise safe and effective for every women we work with this pregnant the most accurate method for determining whether a pregnant exercise program is appropriate is your client's feedback and the client feedback is so imperative so every day that you're working with a pregnant client you need to talk with her and after how she feels how is her pregnancy progressing and has there been any problems with her pregnancy and her last visit with her healthcare provider now one of the more important questions and ones that should be just a mantra that you have with every pregnant client to be able to determine whether or not her pregnancy is still considered uncomplicated whether the exercise that you're doing is appropriate is by asking questions are you gaining weight within your health care providers recommendations if she is not then we need to work with health care provider and the mother to make sure that we're not pushing too hard on the exercise and without her taking in enough calories is the health care provider concerned about her level of weight gain is she able to comfortably follow your exercise program without discomfort extreme exhaustion and how's her energy level now the biggest questions I always ask is the fetus growing within normal limits if not we need to reassess whether or not exercise is appropriate there may be some conditions that the fetal growth is not up to where it should be and in those instances sometimes exercise is contraindicated it's a physician concerned at all about the progression of her pregnancy and there has there been any changes in the pattern or amount of fetal movement now signs of overtraining as well need to be kept in mind if she's having an elevated resting heart rate frequent illness lack of normal weight gain or chronic exhaustion and when I talk about it elevated resting heart rate back here I have women learn to take a resting heart rate person every morning now again we're not using a training heart rate during pregnancy but resting on anyway can give us a very good window into whether or not she's overtraining or becoming ill when she cuts to the point where she sees what her normal resting heart rate is so after a month of taking a full minute pulse every good morning she sees that her normal range is right around 65 75 beats a minute if she's been working out and she wakes up one morning takes it in it's 80 85 that's a key point to let us know that she is not only covered enough or she is maybe becoming ill and that should be a rest day and see what the next morning if it's still elevated she again needs to assess whether or not she is overtraining and she wants to be able to have that heart rate back down what her normal range is so again keeping in mind that that morning resting heart rate can be a window to whether or not she's overwhelmed working and to take more rest days now again we always want to ask is that fetus growing with the normal limits at each clinic visit and the position have any concerns and has there been any changes name on a fetal movement those three questions are going to give you a lot of information about whether or not she should be exercising whether what you're doing is working well if the fetus isn't growing normally we need to reassess exercise if there's any concerns you need to decide whether or not her physician feels she should do you exercise safely and if there's changes in fetal movement after and this usually is after about the second trimester but she's feeling this fetal movement then again she needs to stop exercising and see your healthcare provider I'm gonna just cut through this client self monitoring you can't see inside your clients body and know how she's feeling so her feedback to you is it's vitally important always instruct the client to pay close attention to their physical well-being and report any changes clients should avoid exercise when ill or they feel extreme exhaustion and a client and struck client and warning signs and symptoms of overtraining as I talked about that daily resting pulse is very important on giving a window to how her body is responding to exercise and whether or not she's overtraining or at that point becoming ill remember each week of pregnancy presents with new physical challenges so your ability to provide modifications as you move through pregnancy is vitally important view the exercise prescription as a beta basic template so you're going to be modifying that that intensity duration frequency and type throughout the pregnancy to keep that woman comfortable and able to continue to exercise always attempt modifying an exercise before you eliminate it the most important factor remember is that each woman's pregnancy will present with her own unique needs and challenges always reduce intensity by cutting pace incline or resistance until you reach a level that is well tolerated think about breaking up exercise bouts 20 minutes two times instead of 40 minutes at if she's having difficulty maintaining at 40 minutes and identify causes for discomforts look at the bike seat if she's having problems with her pelvis being painful change the tilt incorrect lifting techniques can cause pain so belly's support may be needed if she's walking after a certain point of pregnancy and her on ligament hurts you need to be creative in order to find options to correct discomfort always remember avoiding supine ab exercise and you want to provide modifications by semi recumbent position using pillows using a wall or wedge to lift her body up if she ever becomes light-headed or dizzy when doing exercises even in the modified position how to roll over onto her left side to re-establish blood flow and mass your exercise class goals should be to provide a well-rounded fitness routine in a safe environment a participant in setting realistic fitness goals teach participants how to self monitor and establish an environment that fosters support motivation and a positive social interaction in in conclusion once you walk away from this saying first of all I understand how that prenatal exercise is really a vital point part of a healthy pregnancy it's safe and beneficial for almost all pregnant women who have a non complicated pregnancy pregnant women should be encouraged to continue or even start a fitness program for exercise during her pregnancy and she should be provided with modification techniques that allow her to continue to exercise to the end of her pregnancy for more information please feel free to contact me at my website or at my email address that's listed below this is just a touching on all of the topics that we work with to build a safe and effective exercise program but I think you'll find that that working with this population is such a joy and it's a challenge in a way that really makes you think about all the skills that you have and use them to really be creative with this population and helping them have the best and most healthy pregnancy that they can have and now I'm send it back to Melissa for questions all right so we had a few questions pop up I will do my best to read them off and hopefully we can get an answer if not as I mentioned Katherine has provided her email address so some people can send them through over there um the first question is from Julie and she is asking is it always best to refer to a pelvic floor physiotherapist for an assessment and not be prescribing pelvic floor strengthening exercises as a personal trainer many women tend to have an overactive pelvic floor muscle which will create long-term holding patterns and dysfunction I treat many individuals for pelvic floor conditions and teaching them to activate the muscles in a rigid way is not always that useful for many people nor is it functional please consider this part of your presentation that's a really great point and my short answer and that is any time anyone can get a referral to a physiotherapist that is phenomenal and I try to have every pregnant woman I work with get that referral but that being said you don't want to not provide pelvic floor exercise information to the general pregnant population you're working with because to not do so and give them this information is to not really help them with providing that strength training for the pelvic floor that's very important and that's a little bit what I talked about with lot of women holding it and tightening it the pelvic floor it can be a problem for some women but in the vast majority just teaching them basic pelvic floor contraction and relaxation exercises is so beneficial and we really don't see a downside to doing that but again any time you can get a referral to a physiotherapist to any pregnant women I think is so important awesome thing u-um how do you feel about pregnant women engaging in kettlebell classes again this is one of those things you have to look at each woman's level of ability whether she was doing the kettlebells before she was pregnant and already has that strength build-up whether she's working with someone one-on-one who can watch modify and help her control her movements in a way that are safe those are all factors that have to be brought into consideration before you would have a woman take part in a class like that okay I'm are there any other pelvic floor exercises other than kegels to do or teach well kegels are in pelvic floor exercises they call them kegels but they're kind of interchangeable are kind of the gold standard for that but there are other ones that a physiotherapist can work with that require a bit more one-on-one monitoring so I would say at this level on the regular Kegel exercises the two different basic core exercises of both the short flick contractions where you contract and relax contracting relax and then the greater stair sub-tree of slowly lifting strengthening holding holding holding and then dropping down relaxation are the two that we have people start with I'm is there any way to prepare for a c-section there there actually is and I think that's an excellent question the best way to prepare for a c-section is being as fit as possible because recovery and being able to build back quickly after Thomason trying conditioning and as far as the belly building back that muscle control all is vitally important and that's another situation where I would highly recommend that she work with a physiotherapist on abdominal strengthening postpartum to help her bring back those muscles that were cut but being fit having good muscle strength is going to help her very much in her recovery and we see women who are fit during her pregnancy that have had a c-section seem to have less of a problem during her recovery because she has a better base a better strength a better cardiovascular fitness okay um well sorry I lost my place would you be able to touch on Prevention's for diastasis no diastasis recti also are there any dangers of low squats during pregnancy two very good questions again things I would have loved if touched on if we had a lot more time there's been a lot of talk about a diastasis recti and during pregnancy one of the things I wanted to say first and foremost is every single pregnant woman is going to have a diastasis recti and what that simply is is the thinning and widening of the connective tissue between the rectus abdominus sheet of muscles the two sides of that the reason for that is to allow the baby room to grow this is not hernia which a hernia would be more of a cutting or an opening of that area this is a thinning and widening of the connective tissue now the degree of that width can be dependent on a lot of factors and first and foremost it's your own body biomechanics if you're very short you're going to have the baby push up further you don't have as much height to allow that that growth so you're going to have probably a greater widening of that area now what people have looked at is is there a greater risk of injury low back injury because of that loss of support of the recti muscles and we haven't really seen a lot of data to show that to be the case but that doesn't mean we don't want to think about avoiding exercises that put a lot of intra-abdominal pressure on that Linea Alba that that's thin connective tissue so I really do not like to see any kind of supine sit-ups during pregnancy or postpartum there's a wonderful group of exercises called Hartmann rehabilitative exercises that I actually have I can provide for anyone that's interested if you want to email me they're progressive exercises that slowly work on the transverse muscle group so we don't put the pressure on that Linea Alba and it really is a great exercise group to do postpartum to bring back that area and then the second question was the deep squats if a woman's been doing squatting during or before her pregnancy and she can comfortably continue with them without knee strained back strain well then she can continue with that but for most women as she gets further along in her pregnancy it's very helpful for her to have a chair or something that stationary and stable to help pull her up after that deep squat because it's very difficult with the weight of the baby and the change in the biomechanics of the body to lift up without putting strain on the knee alright so we'll do one more quick question and then we are at one o'clock so we will have to end there I know there are a few unanswered questions so Katherine has provided her email address um Katherine you're being asked it can you just pop the slide up with your email address on it again so some people can copy it down just because we are missing out on a few questions um and then you guys can shoot Katherine an email if you have any further questions or want to talk a little bit more if we didn't quite get to yours and so the last question that we will go on here um sorry I'm with a client with multiple pregnancy twins does the blood flow increase that much more and what about calorie intake I love these questions they're really great and people are really thinking and first of all it's a great question and there's a lot of controversy about exercise with multiples but more and more they're finding that we're not immediately putting a woman on bed rest and that we do encourage them to keep exercising there's not a two-fold increase of everything but there is an even greater increase in all of the cardiovascular respiratory metabolic changes that are going to occur when you have two babies that you're providing for so I feel that exercise is still as important but we have to be much more careful about whether or not she's gaining normally working very closely with her healthcare provider to make sure that we're not over stressing her body so it requires a lot more monitoring and modifications and I'm sorry what was the second part of that I the calorie count as well so his calorie count and blood flow for twins we're twins I would say this is gonna look you're gonna have to look a lot again on where is she at as far as when she starts a pregnancy if she's normal weight we're gonna look at her weight gain and weight gain is gonna really tell us how many calories are needed most doctors have her eat probably close to maybe double that but if she's gaining too much weight they may bring it back down if she's not gaining enough you might pop it up so these are just guidelines but looking at how her weight gain is progressing during a pregnancy it's gonna tell you a lot about how many calories she needs so all we was watching that if she's not gaining enough again we need to increase that if she's gaining too much or healthcare provider may say she needs to drop down that amount perfect so I think that concludes everybody um so again we will be replacing sorry placing a recording of this webinar up on your campus borough interactive account takes about a week or so so check in with us next week um if you have any questions directly for Katherine her email address is up on the screen if you want to copy it down quickly if you missed copying it down or you have any other further questions please contact info at kf8 procom thank you guys so much for spending your lunch hour with us and thank you again to Katherine for coming on board for this webinar today we hope to talk to you guys all soon thanks so much

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