Blog 4 – What exercise advice should fitness professionals give to pregnant and postpartum women?

Yesterday (at the time of writing), I met with the Fitness Trainers and Exercise Instructors of Matti’s Studio in Jerusalem about what they should know about working with pregnant women and new mothers. I was invited by the owner who wanted her staff to give consistent advice to pregnant clients who were turning to them to have their fitness needs met. My hope is that more (in my fantasy world, I would say ‘all’) health clubs see this population as a source for future clientele. Professionalism and inspiring trust are excellent marketing tools and great ways to retain members.

As we didn’t have much time, we didn’t talk much about the numerous benefits of exercising during pregnancy. There’s loads of that on the internet (including this recent study that shows that exercising during pregnancy helps in fetal brain development): http://www.sciencedaily.com/releases/2013/11/131110204330.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Ftop_news%2Ftop_health+%28ScienceDaily%3A+Top+News+–+Top+Health%29 . I emphasized that it’s essential for a pregnant woman to get her doctor’s approval to exercise, even if she is continuing the same exercise routine that she has been doing for a long time. The problem with this is that, in Israel, many doctors don’t know that there are evidence-based, published guidelines about exercising during pregnancy, let alone what these guidelines say. Note that, in keeping with the Center for Disease Control’s recommendation for exercise for the general population, the most reputable guidelines for exercising pregnant women, those of the American Council of Obstetricians and Gynecologists (ACOG) say, “In the absence of either medical or obstetric complications, 30 minutes or more of moderate exercise a day on most, if not all, days of the week is recommended for pregnant women.”  (http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Exercise%20During%20Pregnancy%20and%20the%20Postpartum%20Period.aspx ).  (These recommendations were ratified by ACOG in 2011 with no substantive changes). The Canadian guidelines go one step further and state that  “Women and their care providers should consider the risks of not participating in exercise activities during pregnancy”. (http://www.csep.ca/cmfiles/publications/scholarly/Joint_SOGC_CSEP_Guidelines.pdf ). That’s a far cry from the old recommendations that pregnant women MAY continue to do what they did before, and that they should limit the length of the most intense part their exercise session to 15 minutes and the intensity to a maximum of 140 beats per minute (those recommendations were discarded in 1994!). I hope that pregnant women who want to exercise will share these guidelines with their doctors and midwives who can then base their advice to pregnant women on current research.

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Of course, the most important consideration for a pregnant woman exercising is to maintain a favorable environment in the uterus.  Her exercise prescription should take into consideration what she was accustomed to doing before she became pregnant, how familiar she is with her new exercise prescription and how she feels when she does it (this will differ depending on the progression of the pregnancy and her energy level at that time). It is essential that the exercise prescription avoids any risk of injury, falling and abdominal trauma. What does ‘familiarity’ mean? While a woman with a normal pregnancy who hasn’t exercised before can begin a low impact aerobics program increasing exercise duration, frequency and intensity gradually, she should not be advised to join a spinning class! The intensity of her workout should be guided by the Rate of Perceived Exertion scale and the ‘talk test’ – she should be able to say a complete sentence at peak intensity.

The big controversy in prenatal exercise has been, for many years, exercising while lying on the back after the 16th week of pregnancy. Many instructors advise their clients that if they feel ok in this position, then a small amount of exercise on the back shouldn’t be a problem. I’m not sure what aspect of the sentence, “After the first trimester of pregnancy, avoid doing any exercises on your back” (ACOG 2011 recommendations) leaves room for interpretation. Even the current guidelines of the ACSM (American College of Sports Medicine) that previously had stated that a small amount of supine exercise may be ok, now state, “Exercising in the supine or prone positions should be avoided after the first trimester”.  That pretty much nixes a Pilates class after the 16th week, unless it is a class specifically for pregnant women, with modifications of positions. I wish more doctors encouraged their pregnant clients to exercise, but ignoring published guidelines is not a great way to inspire a doctor’s trust in a health facility or instructor.

While we talked about the usual issues of the importance of strengthening the upper back and stretching the iliopsoas muscles, I wanted to focus on the pelvic floor and the abdominal muscles. The big news flash is that we no longer recommend that pregnant women do 100 kegels a day! This will only lead to shortened pelvic floor muscles, not something a woman in labor will appreciate as she’s birthing her baby. The goal is now strength while keeping the length of the muscles, with exercises such as squats that work the gluteals (done with correct alignment). As so many pregnant women suffer from urinary stress incontinence (peeing every time they cough or laugh or sneeze), helping them develop awareness and the ability to contract the muscles before these stress triggers is a functional way of helping them with this potentially embarrassing situation.

So back to my all-time favorite subject – separated abdominal muscles. Many researchers have found that more than half of all pregnant women have abdominal muscle separation, classified as a width of 2.5 fingers or more at the largest point of separation, usually around the level of the navel. Can fitness professionals prevent this from happening during pregnancy and, if so, how? They can’t exercise on their backs after the 16th week and most pregnant women will place increased stress on the abdominal muscles when they are in the ‘all-fours’ position, so the critical issue of alignment needs to be the focus. While most fitness professionals follow the general caution that pregnant women should not exercise in this position, (planks, cat stretch, etc.), exercising in this position should be individually prescribed, based on the woman’s ability to engage the abdominal muscles against gravity.

A very effective exercise, reinforcing the concept of correct alignment, is done in the standing position. Have the woman stand with her back to a wall, with her heels, butt and head touching the wall, but with her shoulder blades drawn forward away from the wall by crossing her arms in front of her at shoulder height. On an exhalation, as she slides her ribs down, her shoulder blades will flatten against the wall. The flaring out of the ribs is often a cause of abdominal muscle separation that can easily be rectified with correct alignment.

When a new mom comes to exercise after giving birth, it is essential that her abdominal muscles be evaluated for separation, so that she can be safely guided to do the most effective exercises for her individual situation, otherwise a separation can be increased with incorrect exercise prescription. I would like to think that fitness professionals who work with pregnant women and new mothers share the same oath as physicians, “First – do no harm”.

While we talked about additional challenges and solutions for exercising pregnant women and new moms, the main emphasis of my talk was teaching correct alignment. It’s as easy as sitting upright on a strength training machine in the weight room, forward on the seat (not leaning against the back of the chair), with a small ball or yoga block between the knees to align the body and engage the core, which is so critical for pregnant women and new moms.

So thank you, Matti, for your professionalism in advancing your trainers’ knowledge about working with this population and for developing a policy of consistence. It is just too confusing for the public and doesn’t inspire confidence when different trainers offer conflicting advice. I hope more health clubs follow this example.

 

Bio:

Rachelle Oseran (BA) became a Lamaze Certified Childbirth Educator in 1984 through the UCLA School of Nursing and has prepared more than 3000 couples for normal birth over the past 29 years. She is also a Birth Doula, certified by DONA International, a Fitness Professional certified by ACE (the American Council on Exercise), specializing in Prenatal and Postnatal Fitness and a Certified Yoga and Pilates Instructor. She lectures in Israel and internationally on Prenatal and Postnatal Exercise.

Rachelle teaches a Lamaze-Accredited Childbirth Educator training course. She also co-founded and co-directed Great Shape/YMCA, the group exercise department of the Jerusalem International YMCA for 23 years.

Rachelle was recently inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to the field of childbirth education. She lives in Jerusalem, Israel, with her husband and 3 sons.

For more information, visit her website at www.childbirtheducation.co.il ,  e-mail her at rachelleoseran@gmail.com  or contact her on +972-52-2342909.

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