Exercise and Physical Activity During Pregnancy and Postpartum: Evidence-Based Guidelines

Foreword
References
Preface
Contents
Editors and Contributors
About the Editor
Contributors
1: Physical Activity, Exercise, and Health Promotion for the Pregnant Exerciser
	1.1	 Introduction
	1.2	 Education for Health and Lifestyle During Pregnancy
		1.2.1	 Pregnancy as an Opportunity to Promote Health
		1.2.2	 Preparing for Childbirth and Parenting
		1.2.3	 Health and Lifestyle Promotion
	1.3	 Public Health and Physical Activity During Pregnancy
		1.3.1	 Impact of Maternal Physical Activity on Chronic Disease Risk
		1.3.2	 Impact of Maternal Physical Activity on Offspring Health
	1.4	 Correlates of Physical Activity Among Pregnant Women
		1.4.1	 Identifying Physically Active Pregnant Women
		1.4.2	 Identifying Physically Inactive Women
	1.5	 Physical Activity Patterns Among Pregnant Women
	1.6	 Measuring Physical Activity, Sedentary Behavior, and Sleep Pattern
	1.7	 Further Research
	References
2: Psychological, Social and Behavioural Changes During Pregnancy: Implications for Physical Activity and Exercise
	2.1	 Psychological and Social Changes During Pregnancy
		2.1.1	 Identity
		2.1.2	 Loss of Control
		2.1.3	 Cognitive Function
		2.1.4	 Behavioural Changes
	2.2	 The Influence of Physical Activity and Exercise on Psychological Well-Being During Pregnancy
		2.2.1	 Depressive Symptoms
		2.2.2	 Anxiety Symptoms
		2.2.3	 Sleep
		2.2.4	 Summary
	2.3	 Psychosocial Barriers and Facilitators to Being Active During Pregnancy
		2.3.1	 Individual Factors
		2.3.2	 Physical Symptoms
			2.3.2.1	 Fatigue
			2.3.2.2	 Nausea
			2.3.2.3	 Discomfort, Physical Limitations and High-Risk Pregnancies
			2.3.2.4	 Lack of Time
			2.3.2.5	 Motivation
			2.3.2.6	 Attitudes and Beliefs
		2.3.3	 Social Factors
			2.3.3.1	 Social Norms
			2.3.3.2	 Healthcare Professional Advice
			2.3.3.3	 Social Support
		2.3.4	 Physical Environmental Factors
			2.3.4.1	 Transport
			2.3.4.2	 Access to Facilities
		2.3.5	 Summary
	2.4	 Behaviour Change Strategies
		2.4.1	 Systematic Reviews
		2.4.2	 Walking Interventions
		2.4.3	 Supervised Individual or Group Exercise
		2.4.4	 Information and Behavioural Counselling
		2.4.5	 Combined Interventions
		2.4.6	 Summary
	2.5	 Using Theory to Support Physical Activity in Pregnancy
		2.5.1	 The COM-B Model
	2.6	 Conclusion
	References
3: Physiological Changes During Pregnancy: Main Adaptations, Discomforts, and Implications for Physical Activity and Exercise
	3.1	 Cardiovascular Changes
		3.1.1	 Implications of Exercise During Pregnancy on the Maternal Heart
			3.1.1.1	 Maternal Cardiovascular Response to Exercise
			3.1.1.2	 Maternal Cardiovascular Adaptations to Exercise
	3.2	 Hematological Changes
	3.3	 Respiratory Changes
	3.4	 Metabolic Changes
	3.5	 Locomotor Changes
	3.6	 Microbiome Changes During Pregnancy
	References
4: Body Composition Changes During Pregnancy and Effects of Physical Exercise
	4.1	 Introduction
	4.2	 Body Composition Overview
		4.2.1	 Body Composition Levels
		4.2.2	 Fat and Adipose Tissue
		4.2.3	 Fat Depots and Adipose Tissue location
	4.3	 Body Composition During Pregnancy
		4.3.1	 Pregnancy and Obesity
		4.3.2	 Pregnancy and Weight Gain
		4.3.3	 Pregnancy and Body Components
	4.4	 Body Composition Assessment in Pregnancy
		4.4.1	 Instruments and Methods
			4.4.1.1	 Laboratory Body Composition Assessment
				Four-Compartment Model
				Three-Compartment Model
				Two-Compartment Model
				Non-molecular Model Body Composition Assessment
			4.4.1.2	 Clinical Markers of Body Composition/Obesity in Pregnancy
				Body Mass Index
				Bioelectric Impedance
				Skinfold Thickness
				Body Circumferences
	4.5	 Effect of Exercise on Body Composition in Pregnancy and Postpartum
		4.5.1	 Effect of Exercise on Gestational Weight Gain and Body Composition
		4.5.2	 Recommendations of Physical Activity and Exercise During Pregnancy and Postpartum
	4.6	 Conclusion
	4.7	 Further Research
	References
5: Biomechanical Adaptations of Gait in Pregnancy: Implications for Physical Activity and Exercise
	5.1	 Introduction
	5.2	 Understanding the Biomechanical Variables
		5.2.1	 Why Gait Analysis?
		5.2.2	 Spatiotemporal and Kinematic Analysis
		5.2.3	 Kinetic Analysis and Biomechanical Loading
			5.2.3.1	 Ground Reaction Forces
			5.2.3.2	 Biomechanical Loading
			5.2.3.3	 Plantar Pressure
	5.3	 Biomechanical Gait and Balance Adaptations During Pregnancy
		5.3.1	 General Characteristics of the Biomechanical Studies with Pregnant and Postpartum Women
		5.3.2	 Spatiotemporal and Kinematic Adaptations During Pregnancy and Postpartum
			5.3.2.1	 Centre of Gravity and Balance
			5.3.2.2	 Spatial and Temporal Parameters During Gait
			5.3.2.3	 Gait and Joint Kinematics
		5.3.3	 Biomechanical Loading During Pregnancy and Postpartum
			5.3.3.1	 Ground Reaction Forces
			5.3.3.2	 Plantar Pressure
			5.3.3.3	 Joint Reaction Forces
	5.4	 Other Biomechanical Adaptations During Pregnancy
		5.4.1	 Balance and Fall Risk
		5.4.2	 Trunk Motion and Load Transportation
	5.5	 Implications for Exercise Prescription and Intervention
	5.6	 Further Research
	5.7	 Conclusion
	References
6: Specific Musculoskeletal Adaptations in Pregnancy: Pelvic Floor, Abdominal Muscles, Pelvic Girdle, and Lower Back—Implications for Physical Activity and Exercise
	6.1	 Introduction
	6.2	 The Pelvic Floor
		6.2.1	 Pelvic Floor Dysfunction and Risk Factors
		6.2.2	 Urinary Incontinence
			6.2.2.1	 Prevalence
			6.2.2.2	 Prevalence During Pregnancy
			6.2.2.3	 Prevalence After Childbirth
		6.2.3	 Etiology and Pathophysiology of Urinary Incontinence
			6.2.3.1	 Pregnancy
			6.2.3.2	 Childbirth
			6.2.3.3	 Bladder Neck and Urethral Hypermobility
			6.2.3.4	 Neural Denervation
			6.2.3.5	 Weakening of the Pelvic Floor Muscles
		6.2.4	 Levator Ani Muscle Defects
		6.2.5	 Muscle Injury Regeneration
			6.2.5.1	 Treatment Principles for Skeletal Muscle Injuries
	6.3	 Diastasis Recti Abdominis
		6.3.1	 Consequences of Diastasis Recti Abdominis
	6.4	 Pregnancy-Related Low Back Pain and Pelvic Girdle Pain
	References
		Further Reading
7: Evidence-Based and Practice-Oriented Guidelines for Exercising During Pregnancy
	7.1	 Introduction
	7.2	 General Features of the Guidelines on Physical Activity in Pregnancy
	7.3	 Exercise Prescription Considering Pre-pregnancy Habits Related to Physical Activity and the Course of Pregnancy
		7.3.1	 Previously Inactive Pregnant Women
		7.3.2	 Previously Active Pregnant Women
		7.3.3	 Elite or Competitive Athletes
		7.3.4	 Pregnant Women with Obesity
		7.3.5	 Exercising in Complicated Pregnancy
		7.3.6	 Recommendations to Reduce Time Spent in Sedentary Behavior
	7.4	 Recommended Types of Exercise and Forms of Sports Activities for Pregnant women
	7.5	 Targeted Exercise Classes for Pregnant Women
		7.5.1	 Aerobic, Resistance, and Stretching Exercises
		7.5.2	 Specific Exercises for Pregnancy and in Selected Pregnancy Complaints
		7.5.3	 Exercise Positions, Structure of the Exercise Class, and Other Organizational Recommendations
	7.6	 Exercise Professionals and Obstetrics Care Providers
	7.7	 Limitations
	7.8	 Conclusions
	References
8: Exercise Testing and Prescription in Pregnancy
	8.1	 Introduction
		8.1.1	 Previous Considerations Before Start Exercising
		8.1.2	 Contraindications for Exercising While Pregnant
	8.2	 Guidelines on Exercise During Pregnancy and Useful Sources of Information
	8.3	 Health Screening of Pregnant Women Before Starting Exercise
	8.4	 Pre-exercise Evaluation with Pregnant Exercisers and Athletes
	8.5	 Exercise Testing with Pregnant Women
	8.6	 Exercise Prescription for Pregnant Women
		8.6.1	 Type and Mode of Exercise
		8.6.2	 Exercise Duration, Frequency, and Intensity
		8.6.3	 Exercise Volume
		8.6.4	 Other Forms of Physical Activity
		8.6.5	 Exercise Progression and Adaptation
		8.6.6	 Session Organization
	8.7	 Exercise Prescription in Special Conditions
		8.7.1	 Gestational Diabetes
		8.7.2	 Excess Weight and Obesity
		8.7.3	 Hypertension and Preeclampsia
		8.7.4	 Low Back Pain
		8.7.5	 Depression and Mental Disorders
	8.8	 Specific Considerations and Safety Issues Regarding Exercise During Pregnancy
		8.8.1	 Weight Gain and Caloric Intake
		8.8.2	 Hydration and Urinary Incontinence
		8.8.3	 Falls and Injury
		8.8.4	 Nausea and Dizziness
		8.8.5	 Heat, Humidity, and Environment
		8.8.6	 Sportswear and Shoes
	8.9	 Exercise Supervision and Multidisciplinary Teams
	8.10	 Further Research
	8.11	 Conclusions
	References
9: Exercise Selection and Adaptations During Pregnancy
	9.1	 Introduction
	9.2	 Planning, Conducting, and Monitoring of the Prenatal Exercise Sessions
	9.3	 The Structure of the Exercise Session for Pregnant Women
		9.3.1	 Warm-Up
		9.3.2	 Aerobic Exercise
			9.3.2.1	 Aerobics
			9.3.2.2	 Step Aerobics
			9.3.2.3	 Indoor and Outdoor Cycling
			9.3.2.4	 Walking, Jogging, or Running
			9.3.2.5	 Water Exercise and Swimming
		9.3.3	 High-Intensity Interval Training (HIIT)
		9.3.4	 Resistance, Postural, and Neuromotor Exercises
			9.3.4.1	 Resistance Exercises
			9.3.4.2	 Pilates Mat
			9.3.4.3	 Abdominals Exercises
			9.3.4.4	 Postural Exercises
			9.3.4.5	 Neuromotor Exercise
		9.3.5	 Flexibility Exercises
		9.3.6	 Pelvic Floor Muscle Exercises
		9.3.7	 Cool-Down
			9.3.7.1	 Birth Positions
			9.3.7.2	 Breathing Exercises
			9.3.7.3	 Visualization of Pregnancy and Birth
	9.4	 Further Research
	9.5	 Conclusion
	Appendix 1: Exercise Positions for Pregnant Women
		Standing Position (Fig. 9.9)
		Sitting Positions (Figs. 9.10 and 9.11)
		Vertical Kneeling Position (Fig. 9.12a)
		Kneeling Sit-Down Position (Fig. 9.12b)
		Supported Kneeling Position (So-Called On All Fours) On Forearms or Hands (Fig. 9.12c)
		Frontal Plank Position (Fig. 9.13)
		Supine Position (Fig. 9.14)
		Lying on the Side (Fig. 9.16)
		Prone Position (Lying on the Front)
	Appendix 2: Examples of Aerobics Movements for Pregnant Women
	Appendix 3: Examples of Basic Step Aerobics Exercises for Pregnant Women
	Appendix 4: Examples of Resistance Exercises for Pregnant Women
	Appendix 5: Examples of Abdominal Exercises for Pregnant Women Previously Inactive
		Suggestions for Exercises in the Presence of Diastasis Recti Abdominis
	Appendix 6: Examples of Posture Exercises for Pregnant Women
	Appendix 7: Examples of Balance Exercises for Pregnant Women
	Appendix 8: Examples of Flexibility Exercises for Pregnant Women
	Appendix 9: Examples of Exercises for Proper Pelvic Floor Muscle Contraction
	Appendix 10: Examples of Birth Position Exercises
	Appendix 11: Examples of Breathing Exercises for Pregnant Women
	References
10: Exercise Prescription and Adaptations in Early Postpartum
	10.1	 Introduction
	10.2	 Physical Activity and Health in the Early Postpartum, the “Fourth Trimester”
	10.3	 Physical Activity Guidelines in the Early Postpartum
	10.4	 Pre-Exercise Assessment in the Early Postpartum
	10.5	 Exercise Prescription in the Early Postpartum
	10.6	 Exercise Selection and Adaptation in the Early Postpartum
		10.6.1	 Exercises to Be Implemented in the Early Postpartum
		10.6.2	 Exercises to Be Implemented in the Early Postpartum, After Full Recovery of Pelvic Organs and Musculoskeletal Structures
		10.6.3	 Other Forms of Increasing the Volume of Physicochemical Activity or Exercise
	10.7	 Further Research
	References
11: Strengthening Competencies of Future Healthcare Professionals to Promote Physical Activity During Pregnancy
	11.1	 Introduction
	11.2	 Going Beyond Knowledge Acquisition
	11.3	 Trends and Examples of Existing Programs in Healthcare Education to Promote Physical Activity in Perinatal Care
		11.3.1	 Interprofessional and Community-Based Education: Bringing Future Healthcare Professionals and Pregnant Women Together
			11.3.1.1	 “Move Your Baby” as an Example for Interprofessional and Community-Based Education
	11.4	 Training in Behavioral Change Theory and Interventions for Pregnant Women
		11.4.1	 Continuation of Health Education Activities into Postpartum
		11.4.2	 Emphasis on Lifelong Learning and Consequences for Students’ Evaluation
	11.5	 Education in Digital Health to Encourage Physical Activity During Pregnancy
	11.6	 Future Research
	11.7	 Conclusion
	References
12: Therapeutic Exercise Regarding Musculoskeletal Health of the Pregnant Exerciser and Athlete
	12.1	 Introduction
	12.2	 Pelvic Floor Muscle Training
		12.2.1	 Pre-Contraction
		12.2.2	 Strength Training
		12.2.3	 Evidence for Pelvic Floor Muscle Training to Prevent and Treat Urinary Incontinence during Pregnancy
		12.2.4	 Can Pelvic Floor Muscle Training Compromise Vaginal Birth?
	12.3	 Diastasis Recti Abdominis
		12.3.1	 Prevention and Treatment
	12.4	 Low Back and Pelvic Girdle Pain
		12.4.1	 Therapeutic Exercise for Pregnancy-Related Low Back and Pelvic Girdle Pain
	12.5	 Further Research
	12.6	 Conclusions
	References
13: Nutritional and Energy Requirements of the Pregnant Exerciser and Athlete
	13.1	 Introduction
	13.2	 Nutritional and Clinical Issues During Pregnancy
	13.3	 Special Groups of Pregnant Exercisers and Pregnant Athletes
		13.3.1	 Pregnant Athletes Practicing Aesthetic Sports, Weight Competing Sports, and Sports of Long Duration
		13.3.2	 Pregnant Exerciser Women Who Restrict or Prohibit Certain Dietary Practices or the Consumption of Important Sources of Energy and Nutrients
		13.3.3	 Adolescents Pregnant Exercisers
		13.3.4	 Pregnant Exerciser Women in High-Risk Categories
	13.4	 Nutritional Status of the Pregnant Exerciser and Athlete
		13.4.1	 Energy and Nutritional Requirements for the Pregnant Exerciser and Athlete
	13.5	 Diet and Physical Exercise
		13.5.1	 Daily Requirements by Activity
			13.5.1.1	 Carbohydrates
			13.5.1.2	 Proteins
			13.5.1.3	 Fat
		13.5.2	 Dietary Intake Before Physical Exercise
		13.5.3	 Dietary Intake During Physical Exercise
		13.5.4	 Dietary Intake After Physical Exercise
	13.6	 Unhealthy Habits to Avoid
		13.6.1	 Alcohol, Smoking, and Other Stimulant Substances
		13.6.2	 Lack of Sleep
	13.7	 Conclusion
	References
14: Diet Recommendations for the Pregnant Exerciser and Athlete
	14.1	 Introduction
	14.2	 Diet Quality During Pregnancy
		14.2.1	 Determinants of Dietary Quality
		14.2.2	 Dietary Sources of Nutrients
			14.2.2.1	 Protein Dietary Sources
			14.2.2.2	 Carbohydrates and Fiber Dietary Sources
			14.2.2.3	 Fat and Omega 3 Dietary Sources
			14.2.2.4	 Folate Dietary Sources
			14.2.2.5	 Vitamin C Dietary Sources
			14.2.2.6	 Vitamin D Dietary Sources
			14.2.2.7	 Calcium Dietary Sources
			14.2.2.8	 Iron Dietary Sources
			14.2.2.9	 Magnesium Dietary Sources
			14.2.2.10	 Iodine Dietary Sources
			14.2.2.11	 Zinc Dietary Sources
			14.2.2.12	 Selenium Dietary Sources
		14.2.3	 Dietary Patterns
			14.2.3.1	 Mediterranean Diet
			14.2.3.2	 Vegetarian Diets
		14.2.4	 Other Relevant Dietary Aspects
			14.2.4.1	 Hydration
			14.2.4.2	 Caffeine
			14.2.4.3	 Low- and Non-Calorie Sweeteners
	14.3	 Impact of Maternal Diet on Offspring Health
	14.4	 Food Safety for Pregnant Women
		14.4.1	 Food-Borne Infections
		14.4.2	 Dietary Contaminants Exposure
		14.4.3	 Food Supplements
	14.5	 Diet in Special Conditions
		14.5.1	 Excessive Weight Gain During Pregnancy
		14.5.2	 Gestational Diabetes
	14.6	 Practice-Oriented Dietary Guide for an Active Pregnancy
		14.6.1	 General Dietary Advice
		14.6.2	 Food Safety Advice
	References