Anthony ACE’s Guides for Fitness Professionals provide the latest research and information on the most important aspects of the fitness industry. Each title picks up where ACE’s Personal Trainer Manual and Group Fitness Instructor Manual leave off, providing the specific and safe exercise programs or group fitness classes. Pre- and Post-Natal Fitness, which covers both personal training programs and group fitness classes, discusses the physiological changes associated with pregnancy and explains how these changes influence the design and effectiveness of exercise programming for PRE- AND POST-NATAL FITNESS knowledge and skills fitness professionals need to develop effective A By Guide for this special population. This book also provides creative post-natal exercise recommendations, and will remain a valuable resource Fitness throughout your career in the fitness industry. American Council on Exercise MISSION STATEMENT The American Council on Exercise is committed to promoting active, healthy lifestyles and their positive effects on the mind, body and spirit. ACE pledges to enable all segments of society to enjoy the benefits of physical activity and protect the public against unsafe and ineffective fitness products and instruction. Professionals from the American Council www.healthylearning.com P02-012 Copyright ©2002 American Council on Exercise® (ACE®) Pre- and Post-Natal Fitness $14.95 on Exercise Lenita Anthony C H A P T E R O N E Benefits and Risks of Exercise during Pregnancy Pre- and Post-Natal A Guide for Fitness By Lenita Anthony Fitness Professionals from the American Council on Exercise First edition Copyright © 2002 American Council on Exercise (ACE) Printed in the United States of America. All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information retrieval system, is forbidden without the written permission of the American Council on Exercise. ISBN 1-58518-691-0 Library of Congress Control Number: 2001099217 Distributed by: American Council on Exercise P.O. Box 910449 San Diego, CA 92191-0449 (858) 279-8227 (858) 279-8064 (FAX) www.ACEfitness.org Managing Editor: Daniel Green Technical Editor: Cedric X. Bryant, Ph.D. Design & Production: Karen McGuire Director of Publications: Christine J. Ekeroth Associate Editor: Lisa Frantz Adlam Editorial Assistant: Jennifer Schiffer Index: Bonny McLaughlin Models: Melanie Ham and Linda Green Photography: Dennis Dal Covey Acknowledgments: Thanks to the entire American Council on Exercise staff for their support and guidance through the process of creating this manual. NOTICE The fitness industry is ever-changing. As new research and clinical experience broaden our knowledge, changes in programming and standards are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in industry standards, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources. Published by: Healthy Learning P.O. Box 1828 Monterey, CA 93942 (888) 229-5745 (831) 372-6075 (FAX) www.healthylearning.com iii iv Ann Cowlin, M.A., is assistant clinical REVIEWERS PRE- AND POST-NATAL FITNESS Sara Kooperman, J.D., owner of Sara’s City professor, Yale University School of Nursing; Workout and founder of the MANIA Fitness movement specialist, Yale University Athletic Instructor Trainer Conventions, is an AVIA Department; founder and director of Dancing athlete. Kooperman was a faculty member for Thru Pregnancy®, Inc.; author of “Women and the Kenneth Cooper Institute for Aerobic Exercise” in Varney’s Midwifery; and expert Research, a lecturer and trainer for the American consultant to the US Army Pregnancy and College of Sports Medicine, and an advisory Postpartum Fitness Program. Her textbook, board member for the Aquatic Exercise Women’s Fitness Program Development, will be Association. She has been a continuing education published by Human Kinetics in spring 2002. provider for the Association of Women’s Health Obstetric and NeoNatal Nurses (AWHONN), International Childbirth Educators Association (ICEA), AFAA, AEA, and ACE. Kooperman is a licensed attorney and veteran pregnancy exercise instructor at Northwestern Hospital in Chicago. v vi Introduction . . . . . . . . . . . . . . . . . . . . . ix CONTENTS PRE- AND POST-NATAL FITNESS Chapter Five . . . . . . . . . . . . . . . . . . . . 35 Recommendations for Pre-natal Exercise Chapter One . . . . . . . . . . . . . . . . . . . . . 1 Benefits and Risks of Exercise during Pregnancy Exercise Intensity Exercise Duration Exercise Frequency Muscular Imbalances Abdominal and Pelvic Floor Exercise Relaxation and Stress Management The ACOG Guidelines: Clearing up the Confusion Benefits of Pre-natal Exercise Contraindications and Risk Factors High-risk Exercise Chapter Six . . . . . . . . . . . . . . . . . . . . . 47 Popular Group Exercise Modes during Pregnancy Chapter Two . . . . . . . . . . . . . . . . . . . . . 9 Physiological Changes Associated with Pregnancy Traditional Aerobics Step Training Group Indoor Cycling Yoga Aquatic Exercise Group Strength Training Cardiovascular System Respiratory System Hormonal and Metabolic Changes Musculoskeletal System Chapter Three . . . . . . . . . . . . . . . . . . . 15 Fetal Risks: “Can Exercise Harm My Baby?” Chapter Seven. . . . . . . . . . . . . . . . . . . 61 Post-natal Exercise Recovery from the Birth Process Resuming Exercise Resuming Exercise after Caesarean Delivery Breastfeeding and Exercise Mother and Baby Classes Hyperthermia Carbohydrate Utilization Supine Hypotensive Syndrome Chapter Four . . . . . . . . . . . . . . . . . . . . . . 19 Minimizing Common Maternal Conditions and Discomforts Index . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Round Ligament Pain Diastasis Recti Pubic Pain Low-back Pain Leg Cramps Carpal Tunnel Syndrome Varicose Veins References and Suggested Reading . . . . . . . . . . . . . . . 87 vii viii T INTRODUCTION PRE- AND POST-NATAL FITNESS he American Council on Exercise (ACE) is pleased to introduce Pre- and Post-Natal Fitness, a guide for fitness professionals. As the industry continues to expand, evolve, and redefine itself, the need for safe, well-designed programs and expert guidance for pregnant women and new mothers has grown as well. The intent of this book is to educate and give guidance to fitness professionals that wish to train pre- and post-natal women. It is also a valuable resource for group fitness instructors that encounter pregnant women and new mothers in their classes. As with all areas of fitness, education is a continual process. ACE recognizes this is a broad subject requiring serious study and we encourage you to use the References and Suggested Reading to further your knowledge. ix PRE- AND POST-NATAL FITNESS x CHAPTE R ON E PRE- AND POST-NATAL FITNESS Benefits A ttitudes about exercise during pregnancy have changed dramatically over the last 10 to 20 years. The stereotype of pregnancy being a time of “fragility” and “weakness” that necessitates near inactivity has long been and Risks of Exercise during discarded. This is largely due to the increasing body of scientific information regarding the safety and benefits of maternal exercise, as well as anecdotal reports by thousands of active women. In fact, cross-sectional surveys have reported that approximately 42% of pregnant women engage in regular activity (Zhang & Savitz, 1996). This is 4% higher than is reported for nonpregnant women of childbearing age. 1 Pregnancy PRE- AND POST-NATAL FITNESS outcome data on the topic at that time, the 1985 Armed with increased knowledge regarding the efficacy and safety of pre-natal exercise, most guidelines were written from a perspective of doctors are no longer reluctant to give their “first do no harm” and thus were extremely patients the “green light.” Women, in turn, are conservative. Specifically, restrictions were recognizing the many positive influences an placed on the type of exercise performed, active lifestyle can have on the pre- and post- duration, and intensity. natal periods. In fact, it is hard to walk by a However, the guidelines were soon challenged magazine rack these days that does not display at by individuals in the exercise science and fitness least one cover featuring a pregnant woman in communities, as well as by women who had form-fitting workout gear extolling the virtues of continued to exercise vigorously through their maintaining a fitness regimen. Conversely, many pregnancies with no ill effects. A number of questions and concerns remain for most research studies using human subjects were expectant women about the specific “do’s and published over the ensuing years, leading to the don’ts” of exercise during pregnancy. need for substantial revisions to the original Are the benefits of exercise during pregnancy document. In 1994, ACOG published a second really that significant? Are all types of exercise set of guidelines. The specific application of these safe for pregnant women? Are there restrictions? guidelines for pre-natal exercise, as well as the Are there special needs during pregnancy that 2002 ACOG guidelines, are discussed in detail should be addressed in an exercise program? And in Chapter Five. should every pregnant woman exercise? These are Although most of the restrictions outlined in the all important questions you need to be able to 1985 ACOG guidelines became “outdated” with understand and answer. the publication of the 1994 guidelines, the use of the earlier document is still widespread among The ACOG Guidelines: Clearing up the Confusion T physicians and fitness professionals. You must understand the differences that exist between the he American College of Obstetricians and three sets of recommendations and the confusion Gynecologists (ACOG) first published surrounding them. It is likely that, in some cases, recommendations on exercise and pregnant women will have been given information pregnancy in 1985. This information was widely based on the original guidelines published in 1985 disseminated to physicians, fitness professionals, that is outdated and unnecessarily restrictive. and concerned women, who were eager to hear While we have much more research today on the long-awaited answers to their questions. Due the effects of exercise and pregnancy than we did to the limited scientific evidence and lack of in 1985, there are still areas in which the literature 2 C H A P T E R O N E Benefits and Risks of Exercise during Pregnancy is limited. For example, most of the current levels (Sternfeld et al., 1992). While even very fit research involves the effects of cardiovascular women will experience fatigue at some point exercise, with little data on the effects of strength during their pregnancy, their energy reserve and training during pregnancy. Additionally, current fatigue “threshold” remain consistently higher studies using human subjects have utilized a than in unfit women. Fit pregnant women also rather homogeneous subject group; the effects on retain a lower resting heart rate, a higher stroke a more diverse sample may impact future results volume, and higher VO2max throughout and conclusions. As a fitness professional pregnancy and during the post-partum period. • working with this population, it is important for Pregnant women who exercise have a lower you to keep an eye toward ongoing research incidence of excessive weight gain and are more developments and how this information applies to likely to stay within the range recommended pregnant exercisers. by ACOG. Exercise also helps to stabilize mood states during pregnancy. Active women Benefits of Pre-natal Exercise have been shown to experience fewer feelings of stress, anxiety, insomnia, and depression— Benefits During Pregnancy negative emotions that are commonly The potential benefits of a well-designed prenatal exercise program are numerous. Pregnant experienced during pregnancy (ACSM, 2000, 1; women who exercise can maintain or even Goodwin et al., 2000). In general, exercise increase their cardiovascular fitness, muscular appears to enhance women’s psychological well- strength, and flexibility. Research has shown that being, increase confidence in their changing women who exercise during pregnancy body image, and decrease feelings of appre- experience fewer common pre-natal discomforts hension about labor and delivery. Pregnancy is one of the critical “windows” of such as constipation, swollen extremities, leg cramps, nausea, varicose veins, insomnia, fatigue, time in the female lifespan during which positive back pain, and other orthopedic conditions (Clapp health-behavior changes are more readily & Little, 1995; Artal, 1992). Exercise can assist in accepted. During pregnancy, many women sense controlling gestational diabetes and help prevent an increased responsibility toward their personal urinary incontinence, pregnancy-induced hyper- health as they become aware of how what they do tension, diastasis recti, and deep venous impacts the health and well-being of their unborn thrombosis (Hall & Brody, 1999; Yeo et al., 2000). child. There is frequently an increased motivation Additionally, exercise can improve posture and to eat more healthfully, stop smoking, and become body mechanics, facilitate circulation, reduce more physically active. By seizing this oppor- pelvic and rectal pressure, and increase energy tunity to help pregnant women acquire an exercise 3