Pregnant Mamas, Make Your Exercise Count!
January 12th, 2010“Light Resistance Exercise During Pregnancy Does Not Affect Type of Delivery”.
This is the headline that came across my desk from Medscape about a study published in the American Journal of Obstetrics & Gynecology. I have to admit my first reaction was shock, then outrage. For years we perinatal fitness instructors and other proponents of exercise have been trying to stress the importance of prenatal fitness to pregnant women. Our arguments stem from research done by obstetricians and researchers such as James Clapp, III, MD and Ann Cowlin, Dance and Movement Specialist. In their decades of research, they have found that regular, moderate intensity exercise, tends to shorten labor, increase the effectiveness of pushing, reduce the need for pain medications and interventions. The aforementioned study was in direct opposition from what I know and believe to be true anecdotally from my own perinatal fitness clients. But rather than just rant, I went and read the study to see how the researchers generated their data and how they reached their conclusions.
Study Design
In this particular study Spanish researchers took healthy yet sedentary pregnant women of low to medium 
socioeconomic status in Madrid Spain and looked to see if having them do a limited amount of low intensity exercise impacted their deliveries. The women were all aged 25-35 years old with uncomplicated singleton pregnancies. The women in the study group began exercising at the beginning of the second trimester and continued for approximately 26 weeks. Their exercise regimen consisted of 8 minutes of warm up, approximately 20 minutes of toning and light resistance exercise and 8 minutes of cool down stretching performed 3 times a week. Exercise specialists monitored the exercise sessions to be sure that each lady’s heart rate remained at 80% of maximum output or less. The researchers found that, in this study, there was no difference between rates of natural deliveries, instrumented deliveries or Cesarean deliveries even when potential confounding variables were controlled. While the researchers concluded that prenatal exercise is good for both mother and baby and did not complicate pregnancy, cause preterm labor or reduce the incidence of natural delivery, it did not alter the type of delivery a woman had.
Where They Went Wrong
Not intense enough exercise
After reading the study I completely understood why the Spanish researchers saw no impact of exercise on delivery. According to their journal article, they did not have the women engage in moderate intensity activity. Clapp, Cowlin and others have all found that pregnant women reap the most benefit from prenatal exercise when they engage in low impact moderate activity exercise. Moderate intensity is defined as a rate of exertion in the range of 12-14 on a scale of 1-20 on Borg’s Rate of Perceived Exertion Scale. Exercising in the range of 12-14 enables a woman to be able to talk, but increases her cardiovascular effort contributing to endurance training.
Many exercise professionals, myself included, don’t use heart rate to monitor exercise intensity in pregnant women. The physiologic changes of pregnancy inherently make a woman’s baseline heart rate go up. The American College of Obstetricians and Gynecologists used to recommend that pregnant women not increase their heart rates above 140 beats per minute (bpm), but for many pregnant women they reached 140 bpm just walking across the room! That is why the Borg’s Scale has replaced heart rate monitoring in many clinical exercise settings.
Not Enough Exercise
In this study, the women only exercised approximately 36 minutes per session and increased their heart rates for about 20 minutes per session. To develop any sort of strength or endurance conditioning, the American College of Sports Medicine recommends 20-30 minutes of exercise at targeted intensity 3-5 times per week. A combination of brisk walking, swimming or prenatal aerobics classes with strength training using free weights (usually not more than about 5 lbs) or exercise bands or tubing to accrue the 30-45 minutes of intense activity works well. I typically warm my clients up for 10-15 minutes before and cool them down for 10-15 minutes following the work out.
Types of Exercises
The study did not indicate what types of exercises were performed, but given they used light resistance bands, I am thinking some sort of strength training. Hopefully they included some sort of cardiovascular exercise such as brisk walking, swimming or aerobic movement. The strength training should have focused on maintaining muscle tone, muscle strength (especially upper body) and providing strength and support to the skeleton. Pregnancy creates forward movement of the neck and shoulders (a round shouldered upper body posture with a “stork neck”) while also creating lordosis (sway back) in the low back. CORE strengthening will help strengthen and stabilize the spine and skeleton and reduce the risk of pain or injury to the neck, shoulders, hips and back. Pelvic floor strengthening (Kegels and other exercises) should also be incorporated into the program to help prevent the development of urinary stress incontinence, tearing and or the need for an episiotomy during delivery and organ prolapse after delivery.
My Take
Prenatal exercise stills remains controversial in some obstetric circles, yet all the data to date support the idea that regular prenatal exercise is good for both mother and baby. Amongst birth professionals there still remains controversy as to what type and how much exercise is best. I have found that even with previously sedentary mamas-to-be, if they start exercising early in their second trimester and continue until they are ready to deliver (or as close as is comfortable), they are able to increase their cardiovascular endurance and muscle strength and tone just as if they would in the non-pregnant state. This conditioning enables the ladies that I train to have less pain and discomfort, to utilize less pain medication during labor and delivery, to spontaneously go into labor rather than needing to be induced, to have shorter labors (I’m seeing about 6-8 hours) and to more effectively push. These ladies don’t need “instrumentation” during delivery and I see a lower rate of cesarean sections.
One my call my results “anecdotal” and this is correct because my clients are not organized in to controlled study groups. But if my small prenatal fitness training population is any indication, women who engage in low impact moderate intensity exercise (in the range of 12-14 on Borg’s Rate of Perceived Exertion) for 20-30 minutes 3-5 times a week, will be more likely to experience less pain and discomfort during pregnancy, shorter labors, fewer complications during labor and delivery and a shorter recovery.
Mamas on Bedrest, Don’t despair! You too have an exercise option. Bedrest Fitness is a set of exercises designed specifically for pregnant women on prescribed bed rest. The exercises are simple but effective and easily done while in bed. Do part or all of the DVD, depending on your provider’s instructions. Order your copy of Bedrest Fitness Here
I would love to hear the experiences of other birth professionals, perinatal fitness instructors and women who have exercised throughout their pregnancies. Please add your comments below and encourage other professionals and mamas to do the same!
Bed Rest is best in the first 1-2 weeks post partum.
January 5th, 2010A few months back I had a booth at a baby fair. During a lull in the participant traffic a woman strolled by and had the teeniest little bundle strapped to her chest. I asked her how old her baby was and she replied, “5 Days old.”
Her response took me aback. Okay, perhaps this is going to seem judgemental, but what could this woman have possibly needed at this baby fair, a consignment show I might add, that necessitated her bringing her 5 day old infant out amongst a throng of people? This show was at a local convention center and while it was mostly clean, it is not a place that I would have brought my newborn and most especially with the hundreds of people passing through.
But this mama’s presence brought up other questions for me. Why wasn’t she home resting after recently giving birth? How was breast feeding going? How was she feeling? Given that she was at the show, I can only surmise that she was feeling pretty well, but as a former clinician, I had to wonder what impact her early post partum sojourn was having on her recovery.
Pregnancy, labor and delivery (along with death) are very likely the most natural events in all creation. All animals experience these stages as they bear offspring and even though these are very natural events, I do believe and will state here that we need to treat the processes with respect. Obstetrics has become a very scientific, interventional discipline within medicine and we have gotten away from allowing a woman and her body to go through many of the natural processes surrounding pregnancy, labor and delivery. Sure, we are able to detect and intervene when abnormalities and/or problems arise, but we have also begun intervening when no intervention is necessary. Women are losing some of their inherent physical wisdom and as such we are seeing more and more reasons to ” intervene”.
In my opinion, this woman should not have been at this baby show. I would have rather she remained at home, resting and tending to her baby. Now I am sure that there are many out there who will vehemently oppose this view and I welcome your responses so that we can discuss the issue. But I believe for the first week, and possibly the first two weeks, new mamas should remain in bed, resting, nursing and recovering from their deliveries. Here are my reasons:
Pregnancy, labor and delivery are stressors on a woman’s body. On the scheme of things they are good stressors, but they are stressors none the less. The very process of developing an entire human being, bringing that being forth to this physical plane and then preparing to feed and nurture that being requires a lot of physical energy. For example, pregnant women are at greater risk for contracting colds and other viruses than their non-pregnant counterparts because much of the energy their bodies would normally use to fight infection is being used to help grow the baby. Their circulatory systems (heart and blood system) are temporarily stressed; their hearts are working harder circulating the increased blood fluid load which is being used to help feed and nurture the growing baby. The joints and connective tissues are stressed as they adapt to support the additional weight pregnant women must carry. All of these “stressors” miraculously take place and the body adapts to fulfill the task at hand, but once the stress is removed, it’s time to recover.
A woman’s Body needs to recover after pregnancy and delivery. I stated above that pregnancy, labor and delivery are natural processes that stress the body. So just like ordinary stress, once the stressor(s) are removed, the body needs a period of recovery during which it resets itself back to baseline. Robert Sapolsky, Ph.D, describes the effects of stress humorously and eloquently in his book “Why Zebras Don’t Get Ulcers.” Sapolsky describes how zebras in the deserts of Africa are initially in a calm (resting) state. When a predator comes along, like a cheetah, the zebras’ bodies react with the fight or flight reaction in order to prepare to defend themselves or to escape. Once the Cheetah is gone and the zebras are relaxing in safety, their bodies revert back to their normal calm states. In his book, Sapolsky uses this analogy to explain why we humans are at risk for heart attacks and ulcers-when we stay stressed, remaining in the fight or flight state even once the stressors are gone, we use up all of our resources and over time don’t have reserves from which to draw to protect ourselves when confronted with future stressors.
The same analogy can be used for new mamas who get up too soon after delivery. A woman’s body has stretched and organs have moved in order to accommodate pregnancy. Now that the baby is delivered, a time of rest is needed for a woman’s body return to baseline; for the muscles of the abdominal wall to recoil and for her uterus to migrate back down within the pelvis behind the pubic bone. This process is aided significantly by breastfeeding in the early post partum. Many women (myself included) recount that as their newborn suckled, they could feel their uterui contracting. These contractions aid in the uterine migration back into the pelvis. If a woman is up and about, the contractions will occur during nursing (if she nurses) but the abdominal muscles won’t contract and “flatten out” as much because they are also being used to hold her upright. Likewise, the uterus may or may not fully migrate back into the pelvis leaving her with a “pooch”. Activity in the early post partum has also been associated with increased lochia (post partum vaginal discharge) dizziness and lightheadedness. Time to recover can alleviate these adverse reactions.
Rest aids in breastfeeding. Finally, as if a woman’s body has not done enough, those mothers who are planning to nurse will find it easier to “get nursing going” if they aren’t moving about trying to keep order in the home and resume full activity levels. Again, breast milk production takes a lot of physical energy (about 800 extra calories daily!). If a woman is trying to run her household, care for older children, heal from pregnancy labor and delivery and breastfeed her body may not have the physical energy to meet all of its demands. At least in the first 1-2 weeks, if a woman can focus on letting her body recover; eating well, sleeping as much as she can and establishing nursing with her infant, she is more likely to be have ample milk supply for her infant and to be able to nurse for as long as she and her infant decide.
I know that many will disagree with me regarding early post partum bed rest. Post partum bed rest is not as confining nor need be as stringent as bed rest prescribed in the high risk ante partum woman. However, in those first 1-2 weeks after delivery, if a woman can give her body that time to recover and to establish nursing, both she and her infant will greatly benefit.
