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Comprehensive Fitness Consulting, LLC

Catherine Cram, MS

Provider Disclaimer

Allied Health Education and the presenter of this webinar

do not have any financial or other associations with the manufacturers of any products or suppliers of commercial

services that may be discussed or displayed in this

presentation.

There was no commercial support for this presentation.

The views expressed in this presentation are the views and opinions of the presenter.

Participants must use discretion when using the

information contained in this presentation.

Who Can Benefit From Maternal Fitness Training?

Physical therapists

Occupational Therapists

Exercise physiologists

Nurses

Personal trainers

Birthing instructors

Doulas

Athletic trainers

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What Postpartum Fitness Information Will This Course Provide?

• Physiological and biomechanical changes of postpartum period.

• Recovery techniques for vaginal and cesarean section delivery.

• Warning signs and symptoms.

What Postpartum Fitness Information Will This Course Provide?

• Exercise prescription

• Strength and flexibility exercises

• Proper lifting techniques and ergonomics in the home

• Abdominal rehabilitation exercises

• Postpartum Exercise Program Design

Factors Influencing Increased Interest in Maternal Fitness

• Increased evidence supporting benefits of maternal exercise.

• Growth in number of women who exercise prior to and during pregnancy.

• Healthcare and fitness providers seeking

current guidelines and research on maternal fitness.

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Postpartum Benefits of Exercise

• Decreased postpartum recovery period

• Increased prengnanct fat loss

• Faster return to pre-pregnancy fitness level

• Reduced incidence of physical conditions

• Improved mood state

Postpartum Changes

Cardiovascular, circulatory, respiratory and metabolic responses of pregnancy slowly dissipate.

Ligaments remain affected by relaxin hormone up to 6 or more weeks post delivery.

COG returns to pre-pregnancy position.

• Lactation hormones are produced- daily caloric need increases to 500 kcal beyond normal needs, more if active.

• PP women may experience mood swings, depression, fatigue, musculoskeletal problems and incontinence.

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ACOG WARNING SIGNS AND SYMPTOMS

Fever of 100.2 F. or higher for 24 hours or longer

Dizziness, nausea, faintness or extreme shortness of breath

Red, warm, painful area on either breast, or excessive breast

tenderness

Inability to urinate or pain with urination

Loss of bladder control or leakage on exertion that continues 4-6 weeks

post delivery

Cesarean incision opens or has increased pain or drainage

Red, warm, tender or painful area on either leg

Severe pain

POSTNATAL:

Cesarean Section Recovery

Within hours of surgery begin the following

exercises:

-Isometric contraction of abdominal muscles with hold.

-”Hut” exercise-say the word “hut” loud and fast several times each hour.

-Cough several time every half hour.

A towel or pillow can be placed on the abdomen to provide support as she does the exercises.

Cesarean Recovery

• A c-section is a major abdominal surgery that

requires time for healing.

• Remind c-section client to avoid heavy lifting, and allow help with baby care.

• If her incision becomes red, inflamed or has a

discharge she should consult with her healthcare

provider.

• Advise client to start pelvic floor exercises.

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Scar Mobilization

Technique is effective for any scar, even one that is

old.

Can begin scar mobilization once incision is fully healed.

Start with gentle rolling of the scar horizontally and

vertically.

Pluck scar between fingers and roll and gently pull

away from underlying tissue.

Scar Mobilization

Vaginal Birth Recovery

Cold compress used for 20 minutes throughout the day can ease perineal discomfort and swelling.

Slush pack: equal parts ice and water with several tablespoons of rubbing alcohol

-Episiotomy or tear scar can be treated with scar mobilization once scar is fully healed.

-Start pelvic floor exercises and isometric abdominal

contractions.

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Postpartum Exercise

Check with healthcare provider before starting an exercise program postpartum.

Some women may feel ready for exercises within a week or two after delivery, while others who may have had complications may not be physically ready for exercise for 6-8 weeks post delivery.

Instruct client on PP warning signs and symptoms.

POSTPARTUM EXERCISE PRESCRIPTION

Intensity

Duration

Type

Frequency

Exercise Intensity

• The use of training HR to measure intensity is poor indicator of maternal exercise exertion level during the first weeks postpartum.

• Total body monitoring is important in assessment.

• RPE allows for more whole body assessment.

• Talk test is simple tool for assessing intensity level. The goal is for the client to be able to carry on a conversation without

feeling out of breath.

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Postpartum Exercise Intensity

• Avoid overloading-slow, gentle progression allows time for the body to adapt to challenges of training and motherhood.

• Training HR can be used, but close monitoring of total body response should be used as well.

EXERCISE INTENSITY

• The intensity of exercise should be at a level that feels moderate to somewhat hard (12-14 on 6-20 RPE scale or 4-5 on the 1-10 scale).

• Educate pregnant client on how to use the“talk test”togauge exercise intensity.

• Aid client in calculating her training HR zone

RATING OF PERCEIVED EXERTION (RPE) SCALE

No exertion at all 6 (sitting)

Extremely light 7 8

Very light 9 (walking slowly) 10 Light 11

12 (target zone) Somewhat hard 13

14 Hard 15 (intensity limit for pre/post)

16 Very hard 17 18

Extremely hard 19 Maximal exertion 20

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Determining Training Heart Rate

• After a PP woman has adapted to her return to exercise, she can begin to use a training HR range along with RPE or the talk test.

• Calculate a range between 60-80% of her max, depending on the type of exercise she is doing and her

preference for intensity.

Training HR Zone Calculation

1. 220-age=maximum heart rate (MHR)

2. Calculate heart rate reserve (HRR) by subtracting

resting heart rate (RHR) from MHR

3. Multiply HRR by 70-80 percent

4. Add RHR to each number to determine HR

training zone

Training HR Zone Example

1. 220-30=190 (MHR)

RHR is 70

2. 190-70=120 (HRR)

3. 120x .7=84

4. 120 x .8=96

5. Add RHR to 84 and 96

154-166 bpm target training HR range

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Training HR

Adjust level of intensity for client fitness and

postpartum recovery level.

Start at lower intensity (60%) and build duration and frequency if client is at low level of fitness.

Once target duration and frequency is reached,

build intensity.

EXERCISE DURATION

• 20-45 +minutes of aerobic exercise each session

is ideal.

• Duration and intensity should be gradually increased as fitness level improves.

• Decrease intensity before duration if RPE or HR

is over limit.

Postpartum Exercise Duration

• Start with short bouts of exercise.

• May break up exercise into several bouts during a day.

• Increase duration by several minutes each week if exercise is well tolerated.

• Baby care makes long duration exercise bouts

challenging to fit into day-encourage doing“little bits of exercise’

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EXERCISE TYPE

• Walking

• Swimming

• Cycling

• Low impact stationary exercise equipment and classes

Exercise Type

• What activities does the client enjoy or is

skilled at doing?

• What types of exercise are available to her?

• Assess risk/benefit ratio to activity.

Postpartum Exercise Type

• Innovation is key. Encourage women to think of ways they can include exercise into their daily routine.

• Use what is in the home: stairs, DVD, stationary equipment.

• Exercise type should fit into woman’s lifestyle. Be creative and show ways to do exercises throughout the day.

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Stroller Exercise

Strollers allow for exercise when childcare isn’t available. Encourage mall walking in bad weather and buddy exercise with a friend.

Exercise Frequency

Depends upon:

• Her current level of fitness.

• How her postpartum recovery is progressing.

• The type of activity and intensity.

• There should be at least one day of active rest.

• Some women are able to comfortable sustain six days a week of exercise.

EXERCISE FREQUENCY

• Depending on fitness goals, exercise frequency should be between 3-6 days a week, with greater frequency providing better benefits.

• It’s preferable to modify duration and intensity in order to maintain

frequency.

• Increase frequency, intensity and duration progressively.

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Postpartum Exercise Frequency

• It’s beneficial to work towards including some form of exercise in the daily routine.

• 5-6 days a week is ideal-consistency is key for postpartum weight loss and emotional health.

• Encourage women to look at exercise as a part of a healthy

daily routine.

WARM-UP / COOL-DOWN

• Slow walking or slow increase of other cardio activity for 5 minutes will help prepare the body for exercise.

• Each session should end with a slow reduction in exercise

intensity to level 8-10 on the RPE scale.

STRENGTH TRAINING

• Warm up before strength training.

• Use a slow progression.

• Target major muscle groups.

• Use proper form.

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Postpartum Strength Training Guidelines

A gradual increase in weight loads as

strength increases.

Avoid having client lift a weight or

resistance that causes her to bear down

or strain.

One set of 10-12 repetitions is sufficient

for strength gains.

Focus on upper body to help prepare client for increased lifting with baby care.

Remind client to use proper form and breathing with lifts.

Strength Training Guidelines

• Start with higher reps and lower weight and progress slowly

• Monitor exercise technique carefully by mirror observation.

• Avoid maximal static lifts.

Strength Training Exercise Videos

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• Changes in postpartum body COG can cause increased muscle soreness and discomfort.

• Frequent lifting of baby and breastfeeding positioning can cause increased muscle fatigue and need for frequent stretching to alleviate muscle tension.

• The literature has not shown a correlation between decreased joint stability and production of relaxin hormone affecting postpartum joint function but you should avoid hyperextension or flexion when performing exercises.

Flexibility Training

Flexibility Exercises

Use slow gentle movements.

Use breathing to enhance stretch.

Discontinue any stretch that causes pain or discomfort.

Flexibility Exercises

• Flexibility exercise should be done daily

• Extension stretches after baby care,

feeding (to correct forward flexion)

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Flexibility Exercises Videos

Pelvic Floor Exercises

• Stress and urge incontinence

• Pregnancy and delivery may affect pelvic floor function

• Sneezing, coughing, lifting may trigger incontinence

• Incontinence is common during postpartum recovery

• Referral to physical therapy if incontinence persists after eight weeks postpartum

Pelvic Floor Exercises• Graduated contraction and hold.

• Peak contraction and longer duration hold.

• Focus on relaxation phase as it is as important in total pelvic floor strength training.

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Pelvic Floor Exercises If client has poor pelvic floor tone start with shorter

contractions and higher repetitions.

Find duration and repetition amount that client is able to sustain without PF fatigue.

Slowly increase over time duration of contraction hold.

Encourage client to form habit of doing PF exercises

several times a day during activities such as brushing teeth or other daily tasks.

Diastasis Rectus Abdominus (DRA)

• DRA is a common condition that occurs to some degree in nearly all pregnant women.

• Defined as an interrectus distance of ≥2 finger widths.

• Data hasn’t found DRA to be significantly associated with musculoskeletal pain and dysfunction.

Gluppe SL, Hilde G, Tennfjord MK, Engh ME, Bø K. Effect of a postpartum training program on the prevalence of diastasis recti

abdominis in postpartum primiparous women: a randomized controlled trial. Phys Ther. 2018;98(4):260-268.

Keshwani N, Mathur S, McLean L. Relationship between interrectus distance and symptom severity in women with diastasis recti

abdominis in the early postpartum period. Phys Ther. 2018;98(3):182-190.

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DRA

There’s scant data on what may be risk factors for developing DRA, but the following may contribute:

• Age

• Number of pregnancies

• C-section history

• Gestation weight gain

• Fetal Size

• Genetics??

Diastasis Rectus Abdominus (DRA)

DRA defined as midline separation of the rectus

muscles of great than two fingers width (approx. 3

cm) along the linea alba.

• Variability of measurement?

• Ultrasound most accurate measure.

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DRA Measurement

In supine position with knees bent have client lift

head and hold as you palpate the medial borders of

the rectus abdominis.

Measure widest separation at, above or below

umbilicus

In supine position with knees bent have client lift head and hold as you palpate the medial borders of the rectus abdominis. Measure widest separation at, above or below umbilicus

Diastasis Check Video

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DRA

More research needed to determine whether DRA has significant consequences such as:

• Low back pain

• Increased risk of PF dysfunction

• Increased risk of urinary and anal incontinence

• Pelvic organ prolapse

DRA

Need more research to better determine what type of abdominal exercise results in significant reduction of DRA.

• Physical therapy with Women’s Health specialist

• Transverse abdominus training

• Sahrmann series of abdominal exercises

• Pelvic floor training-PFM contractions co-contract abdominal muscles

Abdominal Exercise Videos

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DRA Guidelines

• Avoid holding breath and/or bearing down

• Treat C-section scar

• Combine ab contraction with PF contraction

• Avoid sit-ups

• Use proper body mechanics to avoid

putting pressure on midline

Postpartum Physical Therapy

Referral to a physical therapist

• Every postpartum women can benefit from a referral to a physical therapist that specializes in women’s health

• Encourage PP client to proactively request a PT referral to help manage recovery and prevent the development of a chronic condition (Including: incontinence, back pain,

pelvic pain, abdominal weakness)

• Scope of practice

Breast Feeding and Exercise

• Current research has shown that no significant difference is found in breast milk composition or volume between moderately exercising women and sedentary women.

• Breastfed babies of exercising mothers didn’t differ in growth rates when compared to breastfed babies of non-

exercising mothers.

• Breastfeeding women need at least an additional 500 kcal a day, more if exercising.

• Supportive bra with wide straps, non-elastic straps, absorbent fabric. Two sports bras for larger breasts.

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Breast Feeding Positioning

Demonstrate proper breastfeeding positions.

-Side lying on bed with baby resting on pillow and

feeding from upper breast.

-In chair: should be a comfortable chair that’s easy to get in and out of. Lumbar roll or pillow, foot rest

and baby resting on pillow or nursing ring so that

baby is supported and at breast level.

-Vary breastfeeding positions over the day.

Guidelines for Exercise Monitoring

• The most accurate method for determining whether a postpartum exercise program is appropriate is the client’s feedback.

• Ask frequently questions to assess how she is feeling during and after exercise.

• Inquire each exercise session about whether there have been any changes in her physical status, or concerns she may have about her recovery.

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Exercise Monitoring Questions

• Are you able to comfortable follow your exercise

program without discomfort or extreme fatigue?

• Is your energy level normal?

• Are you achieving your fitness goals?

Modification Points To Consider Try modifying current exercise routine by:

Reducing intensity by cutting pace, incline, or resistance until you reach a level that is well tolerated by participant.

Breaking up exercise bouts-two 20 minute cardio bouts may be better tolerated than one 40 minute during first

weeks of pp recovery.

Identifying causes for discomfort (ie: bike seat tilted too far forward, incorrect lifting techniques, need for belly support belt) and be creative in order to find options to correct discomfort.

Build your“tool box” with belly support bands, pillows, wedges, rolls, and other

aids that can be used to help keep a

postpartum client comfortable.

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Signs of Overtraining

• Elevated resting heart rate

• Frequent illness

• Unwanted weight loss

• Chronic exhaustion

• Depressed mood state

Client Self Monitoring

• Instruct client to pay close attention to their physical well-being and report any changes in status prior to exercise.

• Client should avoid exercise when ill or if they feel extreme exhaustion.

• Instruct client on warning signs and symptoms of

overtraining.

Daily Resting

Pulse

Teach clients how to monitor resting pulse each morning (helpful for determining whether body has recovered from exertion or is overstressed).

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• Avoid applying the same exercise template for each PP client.

• Be creative with exercises and practice finding ways to modify each exercise.

• View it as an interesting challenge to modify exercise to fit your client’s needs and limitations.

• Determine appropriate modifications by working with your

client and using her feedback to work as a team.

Modification Tips

Ergonomics In The Home

• Pregnant women and new mothers should look for ways to fit their

home work stations to their body by:

• Adjusting baby changing table to a height that allows user to comfortable use (usually waist height works best).

• Setting up a supportive, comfortable chair for baby feedings (use pillows to support back, step stool for feet and pillows or nursing ring

to support baby).

• Practice baby lifting techniques from crib, carrier and floor (always

bring baby to body before lifting, and use knees not back to raise up

or down).

Proper Lifting and Carrying Techniques

• Proper technique: squat or kneel in front of object, bring object to body and raise up using legs.

• It is helpful to inhale before lift, and then tighten tummy and hold as you lift and exhale.

• Use a front baby carrier and limit side carry position.

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Proper Lifting Techniques Review

Think and plan before moving by removing objects

that impede your movement.

Get as close to baby as possible, contract abdominals and pelvic floor as you grasp and lift.

Maintain a stable foot position, and bend from hips

not back-keep back straight.

Postpartum Fitness Program Development

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Maternal Class Instructor Qualifications

Fitness or health related degree with

fitness trainer certification.

Establish professional scope by

reminding client that each woman and

each pregnancy is unique, and your

training, education and experience

enable you to create a safe and effective

prenatal fitness program.

Experience and training in prenatal

fitness. Continuing education courses

in maternal exercise training.

Instructor’s personal experience with

pregnancy should not be used as a

reference point for clients. Use

evidence based information and

guidelines when developing exercise

programs for clients.

Instructor Guidelines for Postpartum Exercise Class

• Each participant must provide a signed release to exercise from her healthcare provider.

• It is helpful to have each participant fill out a health history prior to starting class.

• Signed consent/waiver from participant.

• Develop policies and procedures for management of emergencies.

Consent to Exercise

• Prior to working with any client require that she

provides a signed consent that she is cleared for

exercise by her healthcare provider.

• Take a health history prior to starting exercise to

gain information on her health status and exercise

history.

• Note any physical limitations that may require modified exercise techniques.

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Policies and Procedures

Have a plan of action in case of an emergency

• Have client healthcare and family contact number.

• If client presents with physical problem, discontinue exercise and contact her healthcare provider.

• Do not allow client to drive self. Call ambulance, or if less serious have family member come to pick her up.

• Follow up with client and determine whether it is safe for her to continue exercise by asking for clearance from healthcare provider.

Exercise Program Development

Postpartum women who were exercising during pregnancy:

May continue with her current exercise routine as long as she feels comfortable.

There are no set weight lifting limit guidelines- use client

feedback to determine when modifications may be needed.

Advise athletes of the importance of staying within RPE limits and remind them that it will take time for her body to recover after her pregnancy, labor and delivery.

Program DevelopmentPostpartum women who were sedentary during pregnancy:

• More focus is needed with sedentary client to help her become aware of her body’s signals.

• Work with client on aiding her in understanding RPE scale, and help reassure her that it is safe for her to exercise.

• Ask her for frequent feedback and assist her in learning how to self modify exercise.

• You may increase her exercise and weight training load with gentle

progression and as tolerated.

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Class Outline

Class duration

1 hour is ideal.

(warm up, at least 30 minutes of

cardio and strength and stretching

portion).

Class Frequency

3-4 days a week.

May have to modify to fit facility

limitations.

Cardio activities

(Are cardio machines such as

treadmills, stationary bikes, rowing

machines, elliptical machines or

pool available, or is aerobic dance

or walking an option).

Determine strength training

methods and flexibility aids (balls,

resistance bands, wedges, mats,

weights).

Cardiovascular Portion

• Prior to starting cardio have participant do 5 minutes of warm up (can be slow walking, or slow low increase of intensity on any machine).

• 30-40 minutes of cardiovascular exercise.

• Can be broken up into two sections with strength training between.

• Have participant record RPE and heart rate for each exercise

bout.

• Monitor participants using“talk test” and modify routines as needed when RPE is too high or low.

• At each class monitor participant exercise response and record.

• Pay close attention to any changes in participant response

to exercise and encourage feedback.

• Operate within your scope of practice.

• Encourage proper referral and aid participant in follow

through if needed.

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Facility Requirements

• Temperature controlled.

• Clean, well ventilated.

• Restrooms easily accessible.

• Water fountain or drinking water source available.

• Mats, balls, and other

fitness equipment and storage.

Facility Requirements

• Onsite childcare if possible.

• Outdoor stroller exercise classes are a good option in fair weather environments.

Exercise Class Goals

• Provide a well-rounded fitness program in a safe environment.

• Aid participant in setting realistic fitness goals.

• Teach participant how to self-monitor exercise intensity and modifications techniques.

• Establish and environment that fosters support, motivation

and positive social interaction between class participants.

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Postpartum Depression

• Postpartum Depression is a common condition after pregnancy and occurs in approximately 15% of new mothers with a higher rate for women living in poverty and for teenaged mothers.

• Symptoms can appear during pregnancy and through the

first year postpartum.

• The degree of severity varies from mild to severe.

• Important to identify women who are at risk and provide support with appropriate treatment.

Symptoms of PP Depression

• Feelings of anger or irritability

• Lack of interest in baby or mothering

• Changes in appetite and sleep

• Feelings of sadness, guilt, shame or hopelessness

• Loss of interest in things that used to provide

pleasure

• Thoughts of harming self or baby

• Crying or lack of any emotion

Risk Factors for PP Depression

• History of a personal or family member depression, anxiety or PP depression

• Premenstrual dysphoric disorder

• Lack of support with baby care

• Financial or partner stress

• Pregnancy and/or PP complications

• Major recent life event

• Multiples

• Infant in NICU

• Health issues such as diabetes, thyroid imbalance

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Edinburgh Postnatal Depression Scale

• The EPDS is a useful tool for helping PP women and their healthcare provider identify their risk for PP depression

• The scale isn’t a clinical assessment and should be used to help a woman identify her risk and promote the referral

to a mental health provider

• 10 questions scale. Women who score above a 13 are likely to be suffering from some degree of depression

Edinburgh Scale Example

In the past 7 days:

1. I have been able to laugh and see the funny side of things

__As much as I always could

__Not quite so much now

__ Definitely not so much now

__Not at all

2. I have looked forward with enjoyment to things

__As much as I ever did

__Rather less than I used to

__Definitely less than I used to

__Hardly at all

Edinburgh Scale Print Out

https://www.fresno.ucsf.edu/pediatrics/dow

nloads/edinburghscale.pdf

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Postpartum Support Organizations

https://www.postpartum.netPPSO provides direct peer support to

families, train professionals, and provide a bridge to connect them.

Postpartum Support Organizations

https:/ / www.postpartum.net

Case Study #1

A woman who is two weeks postpartum would like

to start with an exercise program. She had a

vaginal delivery and is recovering normally.

She is still experiencing a bright red vaginal

discharge, especially when she’s up and moving.What exercise routine would you suggest she start

at this point?

Case Study #1

A bright red vaginal discharge is a sign that a PP woman’s body is sufficiently healed enough for her to begin an exercise program. Advise her to allow more time for her body to recover and don’t start exercising until her discharge has resolved.

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A breast feeding PP woman is having problems

with back and shoulder muscle discomfort following

baby feeding and with baby care.

What would you recommend she do to help her

reduce her muscular discomfort?

Case Study #2

Case Study #2-Show breastfeeding positions that are more comfortable: Side lying on

bed with a pillow and baby resting on top.

-In chair-use pillow to bring baby to breast or nursing ring, have a foot rest and lumbar support.

-Provide stretches that improve posture after forward flexion-wall and door stretch, ball extension.

-Check that diapering station is at correct height and supplies are within easy reach without excessive twisting.

-Review proper lifting techniques.

-Suggest a front carrier for baby and avoid side hip carry.

Case Study #3

A woman who is eight weeks postpartum and has

been exercising the past two weeks would like to

include abdominal strengthening exercises in her routine. She has poor abdominal strength and a

wide diastasis recti (>3 fingers).

What exercises would be appropriate for her to start

to help improve her abdominal strength?

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Case Study #3

Sahrmann exercises

-Focus on basic breath and levels one and two.

-Side leg drop

-Isometric drawing in (add pelvic floor contraction as she becomes stronger)

Postpartum exercise helps new mothers recover physically and emotionally faster, and aids in return to pre-pregnancy weight.

Empower pregnant and postpartum women with guidelines and information so they can feel confident that their fitness routine is safe.

Conclusion

New Mom Discussing First Weeks PP Video

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TRIP Database

http://www.tripdatabase.com/

The TRIP Database is a clinical search tool designed to allow health professionals to rapidly identify the highest quality clinical evidence for clinical practice.

Questions?

ppfconsultingllc@gmail.com