Recently, the media has been focusing on how quickly celebrities return to their perfect stick thin figures following a pregnancy, and this has heralded an influx of new mothers in our clubs attempting to lose their pregnancy weight and return to full fitness as quickly as possible. It almost seems as though the impact of the process of pregnancy and delivery has been overlooked. How many times have you heard the phrase, “I’m pregnant, not ill!” banded around the floors of your gym while women attempt to continue with their normal lifestyles and exercise regimes as their bodies undergo significant change?
Contrary to the potential implication of the first paragraph, I am not about to tell you that we should start to view pregnancy as an illness. If pregnancy was actually a medical procedure that consisted of inserting a bag into your abdomen which was slowly filled with a heavy, unpredictable substance and was then suddenly ejected from your body nine months later, we would not expect those who had gone through such a traumatic time to begin intensely exercising within minutes of the delivery. However, society is increasingly putting pressure on women to take steps to recover their pre-pregnancy shape rapidly. Therefore, fitness professionals are seeing more and more women with excessively aggressive goals during their immediate post natal period.
We must be prepared to educate our post natal clients. We need to aid them in the development of realistic and achievable targets that moves them towards their long term goals. This requires a clear understanding of the physiological changes they experience during and after pregnancy. Any post natal exercise program must take into account the context surrounding each individual.
During pregnancy, the mother undergoes a number of physiological adaptations allowing the fetus to grow and develop safely, while maintaining maternal health.
Musculoskeletal System Changes
Bodyweight obviously increases as the uterus and fetus grow and blood volume increases in preparation for blood loss during delivery. The abdominal muscles are stretched and separated to accommodate the temporary growth of the womb. The ability of the abdominal muscles to contribute to the stability of the lumbo-pelvic-hip complex is significantly reduced. It has always been assumed that this increase in size and loss of stability combined with the change in center of gravity has caused an increased lordotic curve. In fact, studies have shown that lordosis only increases slightly, but the spine shifts posteriorly along with center of gravity. Relaxin levels within the body increase by up to 10 times at it’s peak, which causes laxity in the connective tissues. This further reduces joint stability and weakens the static supports in the lumbar spine, reducing it’s ability to withstand shear forces.
The changes during a developing pregnancy make lower back pain more likely and implications include relative flexibility and altered movement patterns.
Other Physiological Changes
As previously mentioned, blood volume increases and, alongside this, stroke volume and heart rate increases, which leads to an increase of cardiac output of between 30 and 50 percent. Metabolic demand is also increased predominantly in the second and third trimesters of pregnancy, and this creates an increase in heat production, especially during exercise where metabolic demand is even higher.
Once the baby is born, the mother is thrust into a 24-hour cycle of feeding and caring for the baby while attempting to recover and rest following a major physiological event. This can lead to extreme fatigue and a variety of emotional moods and states. The intensity of these factors are extremely relevant to both the mother’s immediate recovery and her long term return to fitness. The trainer must consider the effects of tiredness and mood swings because they are a real barrier to exercise. Strategies to reduce the negative effects of these factors should be seen as an integral part of any post natal exercise program.
Be aware that a new mother has many demands on her energy stores. Sometimes she may just need rest, and you cannot predictably timetable this event. Fluidity of programming is essential to ensure she can “take the day off” or just take the baby out for a relaxing stroll when the effects of new motherhood catch up with her. If a program is too rigid and the mother “fails” to complete her scheduled Monday exercise class because the baby has kept her up all night feeding, her motivation may decrease, and chances of program drop out increase. Such an apparent failure may also contribute to an increase in stress in what is already a very stressful time of a woman’s life.
A mother may have other goals including training for an event or increasing tone and fitness. All mothers will commonly share the goal of weight loss. Having gained between 25 and 35 pounds on average during a normal single fetus pregnancy and only lost a proportion of this during delivery, there will inevitably be a residual amount of stored fat weight that the mother will want to lose to regain her pre-pregnancy figure.
Due to social pressures, the mother may already potentially be in a negative state as she berates herself for putting on too much weight during her pregnancy. Weight gain is normal and healthy during pregnancy. There are average or guidance levels given for weight gain. However, this challenging period of a woman’s life should not focus intently on weight management. If a little extra has been put on, it should not be seen as the end of the world. Healthy eating and exercise can reverse many of the effects, and the temporary weight gain and shape changes do not have to be a permanent physiological situation as is sometimes assumed.
There are a number of questions that need to be considered when planning an exercise program for a new mother. These include the following:
- How long has it been since the mother gave birth? Has she experienced any complications with the birth and has her medical professional cleared her to resume exercise? The American College of Obstetricians and Gynecologists (ACOG) has recommended that physical activity can be resumed as soon as "physically and medically safe." The medical professional at the mother’s post natal check up usually decides this at around six weeks (although this may be extended if there have been complications with the birth). We should not prescribe exercise for a recently pregnant lady during this time unless given specific directions from her medical professional.
- How long does the post natal period last, and when can the mother expect to return to a normal level of exercise? The length of time a woman is considered to be post natal seems to be very debatable. It is well documented that although relaxin production ceases towards the end of the pregnancy, its effects can be apparent for approximately five months post birth. This would seem to lead us to a five- to six-month period where we should be aware of any physiological differences that may still be relevant. However, clinical guidance includes time periods of three months to one year.
- Due to the stretching of the abdominals, the increase in joint laxity caused by increases in relaxin and the altered center of gravity, your potential exercise client will most likely have experienced some changes in her normal movement patterns. Research has shown that during pregnancy, there is an increased demand placed upon the hip abductors, hip extensors and ankle plantar flexors. This may result in an altered gait, which may have been established relatively early in the pregnancy, creating relative flexibilities and a reduction in the efficiency of the kinetic chain.
In the first few weeks of resuming exercise, these movement/gait issues must be addressed to give the mother a stable base from which to develop her fitness and reduce her excess weight. Exercises should include a focus on the stabilization system of the core and a return to efficient movement patterns by lengthening tight muscles and strengthening the weak. The following are recommendations for addressing these challenges:
- Utilize movement assessments to determine the individual's personal requirements.
- Focus on flexibility, core and balance exercises utilizing a stabilization approach to return the body slowly to effective function.
- Be aware of any contraindications such as hypertension, which may affect some selections of exercise or tempo. (The existence of any contraindications should lead to the exercise professional referring the client back to consult with her medical professional.)
The above physiological effects on the body can also make back pain very common. In fact, approximately 50 percent of pregnant women will suffer, and this back pain may continue for up to six months after the birth. As above, a focus on re-stabilizing the spine and core can help to minimize back pain and help the mother to get back to normal as soon as possible.
Breastfeeding and Exercise
If the mother is breastfeeding, fitness professional must consider the effects her exercise may have on the baby. Limited research has been done in this area (as with many other aspects of post natal exercise!). Research that has been done in relation to breastfeeding indicates some similarities and feasible recommendations.
- Dewey, Lovelady et al. studied 33 women who were breastfeeding and measured the volume and composition of the breast milk. This study replaced the calorific expenditure of the exercising women (approximately 400 calories per workout) by generating an increase in calorific intake. The exercise sessions were individually tailored. Aerobic exercise was prescribed at a level of 60 to 70 percent heart rate reserve. Each woman in her study exercised approximately four to five times per week. The study found that there were no adverse effects on lactation when the exercise program was started six to eight weeks postpartum, and it had a considerably positive effect on the cardiovascular fitness of the mother.
- Carey, Quinn and Goodwin performed a test on the composition of breast milk when new mothers exercised at different intensities. They only tested nine post partum women, and therefore this evidence is only indicative. Their research consisted of three treadmill "oxygen uptake" assessments, the first to a level of 100 percent VO2max and the second and third to 75 and 50 percent, respectively. They found that the maximal exercise session significantly increased the milk lactic acid content for over 90 minutes after the workout, whereas the lower intensity workouts showed no increase in lactic acid.
- Gregory et al researched the effect of exercise on levels of the major immunoglobulin in human secretions (IgA). They performed a maximal graded treadmill tests, testing the composition of the milk at 10, 30 and 60 minutes following the exercise. After exhaustive exercise at 10 and 30 minutes, there were significantly lower levels of IgA in the milk than when at rest, although the levels had returned to normal by 60 minutes post workout.
With the results of the above research and various anecdotal stories of babies refusing milk immediately after a workout, it would seem sensible to encourage a breastfeeding mother to feed her baby just before a workout. This will create enough time to recover the quality of the breast milk following the exercise. This advice makes perfect physical sense because, the longer it is since the mother has fed her baby, the more engorged her breasts could be, leading to an uncomfortable, even painful workout.
It is going to be difficult enough for the new mother to adapt to the demands of her new addition, so the best formula for success is to discuss and agree some short term SMART (Specific, Measurable, Achievable, Realistic and Timely) goals based on her specific exercise targets.
Of primary importance to most post natal clients will be the reduction of fat weight over the first six months. This has been shown to be important from a long term health perspective. There have been a number of clinical studies that have shown a link between postpartum weight retention and long term obesity. Rooney et al. undertook a 10-year study to look at this possible association. They found that women who did not lose their pregnancy weight within the first six months postpartum had gained approximately 17 pounds 10 years later, whereas those who did lose their baby weight had only gained approximately five pounds. Obviously, such weight loss has to be done safely, effectively and realistically, allowing extra time if necessary. If a client has up to 25 pounds to lose following a pregnancy, then it should be achievable, within safe limits, within a six-month period.
Finally, motivation has to be taken into consideration for the new mother. Goals must be short term and SMART as well as enjoyable for the client in order to ensure adherence. Consider structuring group exercise and maybe walks or workouts with other mothers to address research that suggests women with young children find it difficult to stick to an exercise program. By making workout time fun and relaxing, it is possible to raise energy levels and give the ladies time out from being moms, increasing the likelihood that they will view exercise as a benefit to them personally.
Application of Research
The following guidance and observations have also been identified from the published scientific research.
- Build in contingency plans for when an aerobic or gym session is either not achievable or beneficial. Make these alternative plans fun and enjoyable, thereby encouraging the client to adhere to her program even when not 100 percent motivated.
- Prior to completion of any workouts, ensure the client has completed her post natal check up, has been cleared for exercise and has no contraindications to any of the exercises selected (if in doubt, refer to a medical professional).
- Due to the changes in posture and muscle balance experienced during pregnancy, it is advisable to focus on the stabilization of the core and hips as well as creating improved flexibility in tight muscle groups prior to moving onto a more dynamic routine.
- Special consideration should be given to the separation of the abdominals. Exercise selection should focus on working the transversus abdominis until this separation has been reduced to minimal levels.
- Be aware that some effects of pregnancy can still be having an impact up to one year postpartum. Make sure progressions are slow and manageable, with focus on achieving perfect technique at each stage of training.
- For breastfeeding mothers, suggest that it will be beneficial to feed their baby before a workout and to keep workouts moderate to light, unless explicitly specified by a medical professional.
There is not an abundance of research in relation to post natal exercise and its benefits. However, what has been published can be utilized to ensure we offer our clients the most safe and effective workouts possible. This article includes the application of research findings to the challenges faced by fitness professionals as more women want to return to working out soon after giving birth. The main thing to consider is how this research applies to your client and her personal circumstances. It is always advisable to open a channel of communication between you and the medical profession to further ensure you are helping the new mother achieve her goals and enhance her lifestyle in a safe and appropriate manner.
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