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Exercise in Pregnancy (post module) - Coggle Diagram
Exercise in Pregnancy (post module)
White Hat (Facts)
Historically it was believed that pregnancy was a state of confinement and that exercise should be discouraged
This is now outdated
There are a number of physiological responses to maternal exercise in both mother and foetus that need to be considered in exercise prescription
Maternal
Max exercise capacity reached at lower level than in non-pregnancy due to increased oxygen requirements
Reduced haematocrit level but increases during exercise
Uterine contraction
Increased norepinephrine and epinephrine with activity
Increased risk of pre term labour
These increase strength & frequency of uterine contraction
Redistribution of blood flow from internal organs
Reduced cardiac reserve
Core temperature increases
IVC compression and obstruction of venous return after 16/40 (postural hypotension)
Foetal
Foetal HR
Increases 10-30bpm at onset of exercise
Bradycarddia settles within 3 mins
Returns to normal within 15-30 mins
Newborn status
Average reduction in birth weight by 310g if exercise into 3rd trimester
Helps maintain healthy weight
No change in head circumference or length
Uterine blood flow
Would need to drop by 50% to impact foetus
Doesn't occur during vigorous PA
The ACOG guidelines have changed over time to support the role of exercise in pregnancy
Exercise is safe & beneficial during pregnancy, even in previously sedentary
NO restrictions on timeframe & HR restrictions
Encourage exercise in GDM Pt's
Benefits of pregnancy
Reduced incidence of: excessive weight gain, GDM, gestational hypertensive disorder, preterm birth, caesarian, reduced birth weight
Increased incidence of vaginal delivery
Implications for HP's
Exercise now regarded as beneficial in most circumstances where previously contraindicated
For pregnant women where unsupervised exercise poses risk
Supervised and monitored in structured environment
Access to medical care available if needed
Provide individualised physical activity
Not all HP's aware that HR & time restrictions have been removed from ACOG guidelines for healthy, pregnant women
Most HP's support exercise in pregnancy
Exercise for uncomplicated pregnancy
Increased awareness of body & body image
Prepare LL's for increased weight bearing and circulatory comprimise
Deliver UL strength for demands of infant care
Awareness and control of pelvic floor, incorporate in ADL's
Learn safe body mechanics including transitions, labour & delivery positions
Maintain abdominal function and prevent or correct DRAM
Awareness of posture during & after pregnancy
Promote & maintain safe cardiovascular fitness
Prevent pregnancy related impairments
Learn relaxation skills
Learn about changes during pregnancy and birth
Prepare physically for labour, delivery and post partum activities
Education on safe post partum exercise progression
Awareness of treatment options for pelvic floor dysfunction
High risk pregnancies require additional support and supervision, however exercise remains beneficial.
No evidence to support bed rest to avoid pre-term labour and should be discouraged
Maintain low level exercise & circulation
Prevent DVT & conditioning
Need modified exercise & supervision
Remember warning signs to discontinue
Advise not to participate in vigorous exercise
Pt's on bed rest highly susceptible to DVT & deconditioning
Need medical mponitoring
Supervised modified exercise
Bed rest exercise examples
Cx AROM & chin tucks, scapula protraction/retraction, UL AROM exercises, pelvic floor exercises, isometric LL exercises, ankle pumps, foot circles
Physiotherapists have a key role in promoting exercise, its benefits and monitoring risk factors.
Need to be aware of warning signs to discontinue exercise and to seek medical in put if these occur (in all pregnancies)
Dyspnea before exertion
Chest pain
Abdominal pain
Amniotic fluid leaks
Regular painful contractions
Vaginal bleeding
Headaches
Muscle weakness impacting balance
Calf pain & swelling
Exercise program prescription for uncomplicated pregnancy
Moderate intensity exercise 30-60mins/day
Intensity: BORG scale 13-14 or talk test, HR <140bpm/ <60-80% predicted HR max
Thorough clinical evaluation prior to recommending exercise to ensure no medical contraindications
Prolonged exercise >30 mins should be performed in thermo-neutral or controlled environment. Avoid prolonged heat exposure & maintain hydration
Same principles as general population
Those previously sedentary need a greater graded increase in physcial activity and upper safe level not established
High intensity exercise safe in previously active & uncomplicated pregnancy
Safe & effective exercises include: walking, stationary cycling, aerobic exercise, dancing, resistance training, stretching, hydrotherapy, water aerobics
Continue exercise until delivery or as tolerated
Common conditions needing exercise modification
Incompetent Cervix
Cause of 20-25% of 2nd trimester stillbirths
Diagnosed by digital assessment or US
Early dilation of cervix in absence of contractions/labour causing inability to hold foetus
Potential causes: abnormality of collagen, absence of usual cervical musculature, injury to cervical musculature from previous trauma
Affects approx 1% of pregnancy to some degree
US assessment: Shortened cervix, rupture of membrane if dilates 4cm, shape of internal external OS
Usually 2nd or early 3rd trimester
Pre-eclampsia
Causes
Predisposing maternal factors: diabetes, HTN, hyperlipidaemia, obesity
Primary theory of placental cause
Malformation of placenta first trimester, symptom onset after 20/40
Placenta receives insufficient blood supply for its need
Not yet proven
Genetic susceptibility
If untreated progresses to eclampsia
Kidney damage, liver damage, clotting problems, convulsions/seizures, risk of death of mother & foetus
Risk factors
1st pregnancy, BMI>35, >1 baby being carried, aged >40yrs, HTN, kidney disease, diabetes, past history/family history of pre-eclampsia
Diagnosis: Persistent HTN >140/90 plus one or more of:
Proteinuria, persistent headaches, epigastric pain, increased liver enzyme activity, visual disturbances, high level hand/foot swelling, thrombocytopaenia
Exercise considerations
No evidence that bed rest reduces pre-eclampsia risk
Monitor warning signs to discontinue and seek medical input
Approach trending towards protective effect of physical activity during pregnancy
Encourage exercise with appropriate modifications
5-8% prevalence in 2nd half of pregnancy
Placenta Accreta Spectrum
3rd trimester bleeding common
Women prescribed moderate intensity activities to prevent bleeding
Placenta grows through uterus into other organs
Classifications
Accreta: grows deeply into and becomes attached to uterine wall, lose 3-9L post partum
Incretia: Invades more deeply into uterine wall >50%
Normal: confined to uterus
Percreta: Through uterine wall into adjacent organs most commonly bladder, significant blood loss, can't remove placenta as will affect organs
Medical management varies based off type, serios conditions requiring long term management and often surgical intervention
Exercise considerations
Exercise to maintain circulation and reduce DVT risk
Cease exercise if bleeding & monitor closely in 3rd trimester
Placenta Previa
Risk of hemorrhage in vaginal delivery
Labour & dilation causes hemorrhage
Placenta attaches lower in uterus near/across cervix
Patient requires LSCS
Post partum exercise
C-section Physio management guidelines
Reduce incisional pain with cough/movement/breastfeeding
TENS, supporting incision with hands/pillow, education re: wound care
Prevent post op vascular & GI complications
Active LL exercises, early ambulation, abdominal massage
Increase pulmonary function and reduce risk of pneumonia
Breathing instruction, huff, cough
Enhance incisional circulation & healing/prevent adhesion formation
Gentle abdominal exercise & incisional support, scar mobility & friction massage once able
Reduce post surgical discomfort from flatulence, itching etc
Positioning, massage, supportive exercises
Correct posture
Instructions re: childcare
Prevent injury & LBP
Instruction on incisional splinting and positioning for ADL's
Prevent pelvic floor dysfunction
Pelvic floor exercises, educate re: risk factors and types of dysfunction
Develop abdominal strength
Abdominal exercise progression including corrective exercises for DRAM, small abdominal crutches, supportive bracing exercises
If pain in incision need to stop
Careful in C-section patients
Follow up
Commence exercise as soon as possible
6-8/52 before recommencing vigorous exercise
Safe & controlled pace
Don't expect to begin at pre-pregnancy levels
Rectus Diastasis (DRAM)
Separation of RA along linea alba
Cause: usually increased intra-abdominal pressure
Inter-rectus distance >2cm, linea alba tissue extension & abdominal wall bulging
Recommend early abdominal strengthening to reduce inter-rectus distance
Management
Lack of consensus on variables for physio management
Suggested benefit from studies for abdominal crunch exercises, deep core stability exercises
Consider physio for persisting DRAM
Components to include: core strengthening aerobic activity, postural training manual therapy, education & training on appropriate mobility and lifting techniques
Usually resolves without treatment
General guidelines
Resuming exercise or starting new routines is important, build up gradually post partum
Resume exercise gradually after pregnancy as soon as medically safe
Can be within days
Pelvic floor exercises in immediate post partum
Post partum is opportune time for care providers to recommend & refine healthy lifestyle
Patients with medical interventions in vaginal deliveries
Graded progression with appropriate clearances
Post C-section
Rest & allow wound healing
Graded reintroduction as wound & tissues heal
Exercise & breastfeeding
Regular aerobic physical activity in lactating mothers improves maternal cardiovascular fitness
May wish to feed or express prior to avoid discomfort
No affect on milk production, composition or infant growth
Red Hat (Feelings)
I feel I should look for further opportunities to learn and develop skills in Womens Health, within scope as a rural generalist clinician to support community needs
Developing stronger relationships with key local stakeholders and highlighting commitment to ongoing learning can serve to break down community barriers
Completing this module makes me feel more confident in my ability to provide services locally, as I recognise my own skill set is adequate to support exercise in pregnancy
Presence of high risk pregnancies and lack of understanding regarding recommendations on exercise in pregnancy can cause feelings of stress and anxiety for consumers
Providing appropriate education and support can reduce feelings of stress and anxiety
Pregnancy is often a time for reflection, increased health service engagement and positive health behaviour change.
Green Hat (Creativity)
Facilities in my current employment are suitable for supervised exercise during pregnancy, providing an opportunity to grow service and meet community needs
Opportunities exist to better coordinate shared care and alternative models of care including Telehealth for supervised exercise, screening of at-risk patients, and providing advice and education locally
My increased knowledge means I am more competent and confident in delivering clinical services in this area, addressing local service gaps.
Structure of current employer, Bowen Hospital, with a multidisciplinary nursing, medical and allied health team provides opportunities for increased collaboration to better manage complicated pregnancies locally.
Yellow Hat (Benefits)
Exercise in pregnancy has been shown to increase incidence of vaginal delivery
Exercise during pregnancy reduces: excessive weight gain, gestational diabetes, gestational hypertensive disorders, pre-term birth, caesarean birth and birth weight
Benefits of exercise are seen in high risk pregnancies and conditions which were previously contraindicated
Benefits can occur pre-natal, post-natal and during delivery
Support to increase understanding, adress misconceptions and promote exercise can support healthy lifestyle changes that carry over post partum
Upskilling in this area provides an opportunity to improve my clinical skills and therefore the services available in my community
This works to improve gender equity in health care access
Blue Hat (Overview)
Exercise is safe and beneficial during pregnancy
Exercise modification is required in a number of common conditions to maintain safety to mother and child
A number of pregnancy related physiological mechanisms have implications for maternal exercise during pregnancy
Exercise and activity be completed at any level from mod-vigorous through to bed exercises
Historical views of exercise in pregnancy related to state of confinement are now outdated
Most health professionals now understand that exercise is beneficial however further upskilling is required to understand updated guidelines and activity modification for specific conditions
Black Hat (Difficulties)
Anatomical and physiological changes during pregnancy can impact exercise tolerance
Evolution in guidelines over times means some health professionals and consumers have outdated beliefs regarding exercise in pregnancy
At risk pregnancies require additional supervision and consideration in exercise prescription
Recommendations for exercise in thermoneutral environment can be difficult to maintain locally, due to climate and lack of appropriate exercise facilities.
Lack of specialist Womens Health services locally has impacted access to best practice care in the past
Thorough clinical evaluation should be conducted before recommending exercise program to ensure no medical reason to avoid physical activity