Dispelling Myths on Pregnancy Exercise

At regular intervals, it becomes necessary to dispel two persistent myths that are often perpetuated by well-meaning care providers. Both of them were debunked long ago, in research literature that is readily available and about which I have written a great deal, including in my chapters on Women and Exercise (editions 3 & 4) and Health Promotion in Varney’s Midwifery (edition 5), in posts on the DTP website, on my Twitter feed (@anncowlin), on DTP’s Facebook page and in a textbook.

DTP_mover1_pregnantThe more common myth is that pregnant women should never let their pulse get over 140 beats per minute. But, more on that one at another time. That was an ACOG guess in 1985 that long ago (1994) was rescinded.

The other is that pregnant women should never begin a new exercise regimen, but only modify (i.e., reduce) what they are already doing. What brings me to write this blog after a blog break (to respond to our expanding pre/postnatal fitness teacher training program) is that this evening I was told the latter myth was promoted by a CNM at a recent nearby conference. A childbirth education colleague alerted me to this occurrence and also to the happy response by an unknown person in the audience, who chose to differ with the midwife, citing Dancing Thru Pregnancy® as her example!! Thank you to this responder.

Let me address – yet again – the issue of whether it is safe for pregnant women to begin an exercise regimen after they become pregnant. The caveat I offer at the outset is that doing so should be under the supervision of a knowledgeable certified pre/postnatal fitness specialist. Within the profession, the resolution of this question is generally agreed to be the Cochrane Review conducted in 2002, which found that aerobic fitness can be improved or maintained in pregnancy. Improvement requires increasing the level of aerobic challenge. More recently, researchers concluded “….pregnant women benefit from regular physical activity the same way as non pregnant subjects…” and that “…[t]he adoption or continuation of a sedentary lifestyle during pregnancy may contribute to the development of certain disorders such as hypertension, maternal and childhood obesity, gestational diabetes, dyspnoea, and pre-eclampsia.” (Melzer et al. Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes. Sports Med. 2010 Jun 1;40(6):493-507. 

Put another way, the female is not put together to be sedentary in pregnancy. It is only in recent decades that this is an option. Until the mid 20th Century, activities of daily living required physical fitness, and obesity was rare, along with sedentary behavior. In the last few decades, those who are knowledgeable about the interactions of pregnancy and exercise, and who have the experience of teaching movement to this population, have come to understand how to present activities that improve the factors that improve maternal and fetal outcomes.

Those who are extremely well-versed in the field all agree that cardiovascular (aerobic) fitness during the 6 – 12 month pre-pregnancy period may be the greatest pregnancy enhancement a woman can have. Why? Because endothelial function is greatly enhanced, oxidative stress is reduced, and vascularity is increased by aerobic fitness, and these capacities underly healthy implantation and placental development (see Research Updates 2001-2005, Winter 2005 and Winter 2004 and Update on Immune Function). Barring that, beginning early in pregnancy is helpful because placental development is still underway. Barring that, mild to moderate aerobic activity introduced by 25-30 weeks will produce cardiovascular enhancement by the time of labor. My caveat goes here, too.

All conditions mediated by inflammation are a problem in pregnancy. Physical fitness is a major preventive strategy for inflammation, and pregnancy does not stand in the way.

 

 

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Blood Pressure in Pregnancy

I was recently asked some questions regarding blood pressure during pregnancy by my colleagues at Physiquality. In preparing material, I wrote this blog, which includes very basic clinical information and explanations about this topic.

What is the normal range for blood pressure for pregnant women? What readings would fall under high blood pressure?

Blood Pressure (BP) in pregnancy is a complex topic.

First, we need to know: What are the classifications of BP?

The chart below is from the evidence-based 2014 Guidelines of the American Heart Association and the National Heart, Blood and Lung Institute of the NIH. The first number is Systolic BP or during the heart beat. The second number is Diastolic BP or between beats. These numbers are relevant for women of childbearing age.

  • Normal                        <120 mm Hg and <80 mm Hg
  • Pre-hypertensive          120-139 or 80-89
  • High BP Stage 1            140-159 or 90-95
  • High BP Stage 2            ≥ 160 or ≥ 10

Why does low BP (hypotension) occur in a healthy pregnancy?

A healthy pregnant woman with normal BP and no cardiovascular or immune system complications, will have pregnancy BP lower than her non-pregnant BP due to increased progesterone relaxing her vasculature. To create the placental and uterine blood flow, blood volume (V) expands rapidly increasing by around 40%, but stroke volume increases less, so beats per minute (pulse) may increase, systolic BP may drop 5 mm Hg and diastolic may drop 10-15 mm Hg. If V is not adequate with this relaxed vasculature, BP may drop even lower. To help maintain normal BP, women are encouraged to drink sufficient water (about 8 glasses/day) and eat enough protein (about 20-25% of daily intake) to produce a blood volume that will sustain an adequate BP. Other more severe conditions – often genetic – may also be relevant, such as postural orthostatic tachycardia syndrome.

Other causes of hypotension include lying still on the back with legs extended for long periods of time after the first trimester. The weight of the uterus impinges on the vena cava returning blood to the heart, thus reducing BP and blood flow to the uterus and placenta. Also, standing for long periods of time with a minimum of motion, as happens with teachers, cashiers, line workers and nurses in the second half of pregnancy when increasing relaxin and elastin cause further softening of vasculature. This results in difficulty returning blood from the lower limbs and reducing blood flow to the uterus and placenta.

What are hypertensive disorders of pregnancy?

According to the National High Blood Pressure Education Working Group on High Blood Pressure in Pregnancy, hypertensive disorders of pregnancy are presently classified into four categories:

  • Chronic hypertension (pre-existing)
  • Preeclampsia-eclampsia
  • Preeclampsia superimposed on chronic hypertension
  • Gestational hypertension

[The Society of Obstetricians and Gynecologists of Canada categorize these disorders as pre-existing or gestational, with the addition of preeclampsia to either category.]

Chronic hypertension is BP >140/90 prior to pregnancy or before 20 weeks. New onset of high BP after 20 weeks may indicate preeclampsia (PE), which requires further consideration. PE involves other symptoms and organs. It occurs in about 5% of all pregnancies, 10% of first pregnancies and 20-25% of women with a history of chronic hypertension. It is a serious disorder and major cause of adverse maternal and fetal outcomes, including strokes, seizures and restricted fetal growth and development.

The underlying pathogenesis of preeclampsia-ecclampsia is not yet fully understood, but is a fundamental dysfunction of the placenta leading to endothelial dysfunction and vasospasm. Possible causes include pre-existing endothelial dysfunction, metabolic dysfunction, auto-immune responses and infection. It is likely that the placenta is affected very early on, during implantation, trophoblast invasion of the uterus and opening of the spiral arteries to form the blood pool on the maternal side of the placental circulation.

Gestational hypertension is the onset of BP >140/90 after 20 weeks without other features of preeclampsia. About 1/3 of these women develop preeclampsia. Gestational hypertension is highly associated with hypertensive disorders later in life. Diabetes can also be a factor associated with hypertension.

Whenever a woman has elevated BP in pregnancy, she needs to be evaluated and have a follow up course of observation and treatment. At its most severe, a hypertensive disorder can affect all the body’s organs and systems, and can be fatal.

What can pregnant women do (diet, exercise, healthy habits) to keep their blood pressure within a normal range?

Some risk factors for hypotension or hypertensive disorders of pregnancy are inherited, others are a consequence of behavior, and many are a combination.

What can a woman do before pregnancy?

Because the events that pre-dispose a woman to hypertensive disorders may occur before she knows she is pregnant, some efforts at prevention may be helpful in the six months to a year prior to pregnancy. Preparing for the implantation period by maintaining optimal health and fitness is likely the most helpful behavior. Cardiovascular or aerobic fitness, which prevents or reduces the severity of endothelial dysfunction is highly valuable. An adequate daily nutrient intake along with sufficient water, and maintaining a BMI <25 are important factors. Women with elevated blood pressure should discuss with their care provider the balance of sodium and potassium intake, along with the total allowable amounts.

Avoiding infections or illness around the time of conception may be a factor. Hypertensive disorders are mediated by inflammation. Unfortunately, another factor may be the maternal immune response to the fetal DNA. This may also be dependent on combined maternal/paternal immune system responses.

What can a woman do once she is pregnant?

Once a woman is pregnant, maintaining optimal health and fitness continue to be important. Even if there are pre-disposing factors for disorders, she may be able to reduce the severity by staying fit, well nourished and well rested. A balanced and colorful diet, along with avoidance of alcohol, drugs and unsafe behaviors are critical.

The ability to achieve the Relaxation Response, meditation, deep breathing and hypnosis are valuable for acute BP reduction. Each of these skills is mediated by the parasympathetic nervous system response (or alpha brain rhythm) and mitigates the effects of stress on a temporary basis. Cardiovascular or aerobic fitness is effective for long-term BP reduction, as well as cardiovascular health.

Resting on the left side maximizes circulation and – if possible – finding 15 or 20 minutes to rest this way during the day is beneficial, especially if a woman’s work involves standing for long periods of time. Avoiding lying on the back or standing for long periods of time is advisable. Finding a community of support for having a healthy pregnancy can be a great asset, as well.

Pregnany & Parenting Coaching

Looking through incoming emails, tweets, fb notifications and e-newsletters that inhabit my inbox more and more, I noticed something interesting:  Lifestyle Coaches for people entering the pregnancy and parenting pathway. After some investigation, I found a plethora (many, many) web business/sites that offer services on everything from getting pregnant to getting your kid into college.

There are sites by enduring public health organizations that cover the range of conception, pregnancy, birth and early parenting issues – such sites as those by the Mayo Clinic, the March of Dimes, and WebMD – starting with how to get pregnant. You can also find business sites for these range of topics – such as The Bump and BabyCenter.

In addition, there are individualized sites that cover coaching for one or more parts of the process. Sites specialize in getting pregnant, being pregnant, giving birth, caring for a newborn, finding childcare, finding early childhood education, how to talk to toddlers, what to do with children of all ages, how to get them ready for school, how to encourage them in school and so on. Some specialize in a combination of two or more of these topics. Some started out specializing in one topic and are moving along as the owners or writers evolve in their lives.

I realize that this is an outgrowth of the “mommy bloggers.” Many computer literate women found blogging a way to deal with the life-changing event of having a child. For some, the internet became a means of making a living while staying home. Realizing that there was a large audience in this realm, the mommy entrepreneurs evolved…and, not all of them are mommies.

We are beginning to see the next generation:  pregnancy and parenting life coaches – individuals who may or may not have professional backgrounds in one of these areas, but are learning to turn their own experiences into businesses that help – or purport to help – others along this part of life’s path. Where does the impetus for this come from? Is it just that the internet makes a new business model possible? What else might be happening here?

For some time, I have thought that young persons entering parenthood these days are at a distinct disadvantage. Bearing and raising children is not easy or cheap. It requires a network of support and advice that used to be present in the extended family. But, we leave home and are much more mobile these days. We may live in Texas, but our baby’s grandparents live in Oregon or Brazil or Turkey. I asked my own exercise, childbirth education, and parenting clients about this. I found that many were in the classes precisely because they felt they had no firsthand experience or knowledge about what it was like to hold, feed or change a baby, let alone be prepared for birth and the sleep deprivation that followed. I also found mommy bloggers and entrepreneurs who found the impetus for their new work sprang from these issues in their own lives.

So, over the next series of blogs, I will be writing about some of these sites and services…both the professional organizations and the new mom entrepreneurs who have turned a difficult life transition into a way of simultaneously helping others while putting food on their tables. It looks to be an interesting journey and I hope you will follow along! I will get the next blog up in a few days, as soon as I am in the next location with internet access. My office is temporarily in the hurricane blackout zone of CT, but they promise me service soon. The first topic:  How to get pregnant!

Pregnancy Pathway, Outcome – Mom & Baby Health Status

This 2/1/2010 entry seems to draw attention consistently, so we decided it was worth re-posting it. The discussion concerns determinants of the health outcome for mom & baby in the Pregnancy Pathway. It reviews the pathway, and then continues to the last stage of the Pathway, the health outcome. Here’s the whole graphic:

So, the big question is: How can we predict the health outcome of mom and baby, given all the variables of preconception, conception, pregnancy, labor and birth?

Well, there are some things for which we can predict or estimate risk/benefit ratios, and there are some for which we cannot. Let’s start by going over the major things that are not very predictable. At the moment, genetics is pretty much unpredictable. Down the road…maybe…but for now, not so much. Some IVF labs claim they can slightly slightly increase the odds for one sex or the other.

Post-conception, chorionic villi sampling and amniocentesis are methods by which the genetic make-up of the fetus can be identified. These are done mainly to give parents a choice about continuing a pregnancy if there is a question about genetically transmitted disorders or conditions, such as Down Syndrome. But, for now, the best way to manipulate the genetic odds of health outcome for your offspring is to mate with someone who is healthy and has health-prone genes!

Once you are pregnant, it is clear that prenatal health care, exercise, healthy nutrition, stress management and adequate sleep play significant roles in increasing the potential for a healthy outcome for mother AND baby. In fact, not only short term, but also long term healthy outcomes are linked to these factors. These are factors within our control.

Risk factors – most of which are within in our control – that can adversely affect outcomes include environmental toxins, risky behaviors (unsafe sex, drinking, smoking or drugs), poor nutrition, sedentary behavior, stress and isolation (lack of social support). These risks, as well as the benefits, are all discussed in the previous posts.

At this point, it is important to note that there is a lot that goes into making a healthy pregnancy, birth and outcome that is within the control of the mother, providing she has family and/or social support to take good care of herself.

The labor process and birth mode can also affect health outcome, but in general the effect is short-lived. For moms who have received regular care and are in excellent health, the occurrence of a truly devastating birth outcome for mother and/or baby is extremely rare. The exception may be mental or emotional turmoil that can accompany a difficult, unexpected and uncomfortable situation, such as an unplanned cesarean birth.

 

Group exercise programs are a source of social support.

Three interesting research outcomes point to the importance of exercise groups. One is that exercise can help prevent some disorders of pregnancy, such as preeclampsia or gestational diabetes. Second is that the health benefits of exercising during pregnancy and the postpartum period are beneficial for both short and long term for mother and infant. Disorders of pregnancy are risk factors for future cardiovascular disease and metabolic disorders. Third is that exercise is most likely to occur when there is good social support.

Moving together is a “muscle bonding” experience that helps bind moms-to-be and new moms into a community of support. Within the group, moms can get help with tips for healthy eating and living, along with the support of others who know what she is experiencing. There are a lot of ways to get adequate exercise. When you are pregnant or a new mom, an exercise group can be one critical path to health and well-being.

Reflecting on Mother’s Day

Mothers make people.

Be sure to thank your mom!

It is a stunning thought that with our bodies women are able to make new people.

It is a big responsibility.

We want to give words of encouragement to all moms-to-be and new moms who take care of themselves and their little ones through healthy living!

Bless you all for all you do! For every mom who takes care of herself prior to, during and after pregnancy, the load is reduced for the March of Dimes and the White Ribbon Alliance for Safe Motherhood.

If you have questions about how to live healthy for your baby, here are some ways to get those questions answered…

• Post a question to us via Comments.

• Check our Blog archives for Pregnancy Pathway topics that can help you have a healthy pregnancy and postpartum experience, including pre-conception health, conception, exercise, nutrition, avoiding toxins, birth preparation, recovery, and other healthy behavior topics.

• Visit our website www.dancingthrupregnancy.com for tips on exercise and nutrition and for updates on current research.

If you want to help others who may not be as fortunate as you, here is another organization you can help: www.thediaperbank.org that provides diapers for those who cannot afford them.

Thanks for reading, and pass on our location. Thanks!

Pregnancy Pathway, Conception – Review & Small Rant!

REVIEW: Evidence is clear – pre-pregnancy maternal health status, including physical fitness, healthy nutrition and an uncompromised immune system affect the health and well-being of both mother and offspring, in both short and long term.

This is the message summary from our first two areas of discussion:  Preconditions and Conception – the green and sand colored sections on the chart below.

pregnancy_pathway

COMING ATTRACTIONS: We are about to move on to the blue section – Pregnancy!!  So, bookmark this Blog for future reference!

Also, you can subscribe to this Blog by clicking on Blog Info in the upper right corner and then clicking on Subscribe in the drop down menu.

But, yes, you guessed it, first we have a small rant!

SMALL RANT: When we note that fitness, nutrition and a healthy immune system play significant roles in the outcome of pregnancy and the future health of mother and child, we are appealing to young people of childbearing age to be careful about your bodies. The alliance of egg and sperm shapes the world. With 6.5 Billion egg/sperm combinations (yes, people) presently living on earth, our resources are stretched. With time, either we get more picky about doing this, or the 3rd rock from the sun (remember that show?) is cooked.

Humorous incursion: In case you need further enlightenment on this whole area, there is a great website that will help you out. Be prepared to be amused and amazed!

The Truth about Eggs and Sperm

Hopefully, this gets you in the right mood and keeps you smiling. After all, once you actually are pregnant, we have more serious matters to discuss.

Pregnancy Pathway, Preconditions – Genetics

Please refer to February 5 entry for complete graphic. The Precondition we will discuss today is Genetics.

bubblus_preconditions_-_genetics

There are genetic factors totally outside your control that determine things as simple as your offspring’s hair or eye color, how the earlobe attaches to the side of the head and whether or not s/he can roll the tongue. More complex things, such as a predisposition to types of cancers, bleeding disorders or various other diseases, also have a genetic basis.

Because the male contributes the sex of the offspring, once conception happens, the sex off the fetus is determined — at least genetically. But, it turns out not everything genetic is set in stone. In utero, hormone exposures may affect how male and female characteristics develop, so that some girls will be very girlie, some will be tomboys, and some may be gay. A similar effect will influence how boys develop.

Genetic, environmental and behavioral preconditions can be  intertwined. Environmental factors can alter genes, causing them to express proteins that would otherwise be dormant. Likewise, our behavior affects some of our genes. If we have a family propensity for heart disease, but we eat a healthy diet, exercise and avoid risky behaviors, we alter the impact of our genetic code.

Keep in mind that some things will be completely determined by genes. It is not reasonable to hope, for example, that our offspring will be 6’5″ if both parents are short (or vice versa). If the mother has “thrifty genes” — that is, genes that make it easy for her to gain weight — she may well do so during pregnancy, even if she follows a reasonably healthy lifestyle. If the immune systems of both parents have some similarities, it may affect the maternal immune response to the implanting trophoblast cells, thus affecting the placenta and, indeed, the entire pregnancy.

So, how do we advise people who are thinking of pregnancy to prepare themselves for a healthy pregnancy genetically? Surely, to determine all the potential genetic possibilities is not feasible or affordable at this point. Maybe in another century! But, we can know some factors:  Is there sickle cell anemia in both families? Is there a Mediterranean type of sickle cell disorder? What about clotting factors or differences in Rh? What about diseases or disorders that are not common, like ALS? These are things that potential parents may want to discuss.

Like so much of life, we can’t know everything. There are no guarantees. There is a lot to be learned still about human genes and how they work.

This blog has at its heart the notion that physical activity has tremendous benefits for mother and offspring…and for partners, too. How does the genetic component affect this? First, preconception fitness lowers some risk factors for mothers and babies. Second, each mother’s genes will make it easier or more difficult for her to enjoy or benefit from the activity of exercise. We appreciate this and encourage young moms-to-be to find something enjoyable that you like doing and find people or situations that support you in being active now before you become pregnant.

If you need assistance or advice, please go to http://www.dancingthrupregnancy.com (use the BlogRoll)

Find Ask the Expert under the Consumer menu. Let us know how we can help!