Training and the Delivery Room: Trese Z + Jenny T

Labor is a natural process that results in the birth of one or more infants; "normal" birth begins with the spontaneous onset of labour between 37 and 42 weeks gestation (1). Infants born prior to 37 weeks are considered premature, and those born after 42 weeks are considered postmature. 'Gestational age', a measure of fetal age/maturation, is measured in weeks from the first day of the woman's last menstrual cycle to the date of measurement (2). Although labor is a normal physiological process, it is associated with significant risks of maternal and fetal morbidities, and occurs in three stages (1):

1. Commencement of regular painful contractions to full cervical dilatation
2. Full cervical dilatation to birth of the infant
3. The interval between delivery of the infant and delivery of the placenta and membranes

In the past, it was believed that exercise during pregnancy, particularly the third trimester increased risk of preterm delivery, however, recent research suggests this is not the case. In fact, a randomized controlled trial comparing 70 women engaging in supervised moderate intensity resistance exercise between 12 and 38 weeks of gestation to 70 inactive women suggested there was no difference in gestational age between women who engaged in training and those who did not (3). A study of 131 well-conditioned recreational athletes engaging in aerobic and endurance exercise during pregnancy offered similar results, suggesting women who exercised at or above 50% of their pre-conceptional level had a lower incidence of abdominal and vaginal operative delivery, as well as a shorter period of active labor, with similar rates of pre-term labor to the inactive group (4). Although birthweight tended to be lower in the exercising group, clinical evidence of fetal distress was less frequent in these women, suggesting a beneficial effect of aerobic activity on the course and outcome of labour (4). Exercise during pregnancy has also been associated with shorter hospital stays, fewer maternal and fetal complications, and decreased health-care costs (5).

There is certainly more to be said for the benefits of prenatal exercise on labor outside of demonstrating that it does not cause preterm labour. While research in the area of prenatal exercise and labor is variable, some sources suggest women who exercise while pregnant have lower rates of cesarean delivery as well as lower rates of perceived exertion during labor (5). Additionally, research completed at the Trondheim University Hospital and several outpatient Physiotherapy clinics in Norway suggests not only that pelvic floor training during pregnancy strengthens the pelvic floor muscles, it also prevents urinary incontinence in 1 out of 6 women during pregnancy and 1 in 8 women post-pregnancy (6). In addition, it also suggests that intensive training of the pelvic floor muscles during pregnancy facilitates labour and may also prevent a prolonged second stage of labor (active pushing) in as many as 1 in 8 women (6).

Finally, the impact of prenatal exercise on stress, mood and birth outcomes cannot be overlooked. Recent research suggests that stress and negative mood during pregnancy increases the risk for both postpartum mood issues, as well as poor childbirth outcomes such as earlier birth, younger gestation age and lower birthweight (7,8). A recent study of pregnancy-specific stress and birth outcomes linked high levels of pregnancy-specific stress to pre-term delivery as well as low birthweight. In this same study, prenatal exercise and healthy eating were inversely related to pregnancy-specific stress (8). 

While all of this information is promising, the main theme running through this series has been individuality. Each woman will both engage in and respond to exercise in her own way. Please note that all exercise performed in the aforementioned studies was supervised to ensure both appropriateness as well as safety for both mum and baby. Obstetrics Nurse Trese Zannis expands on this concept based on her experience in the Sunnybrook Labour and Delivery rooms: 

“My experience in the birthing unit at SHSC has allowed me to work with women of varying backgrounds, socioeconomic statuses, and ages; providing one-to-one care in such a setting allows for the formation of a bond between the patient and myself. I have had patients that range from athletes to the women who enjoy walking in their spare time. Even though each patient comes with their own exercise background, there has been one commonality between them all: physical activity in pregnancy (when done under the supervision of a doctor and interdisciplinary team) has many benefits. My experiences with exercise in pregnancy and how it can be beneficial in the labor and delivery period are all anecdotal…I once had a patient who was a competitive runner tell me that continuing to be active in her pregnancy allowed her to cope better with the labor experience and that she had an easier time healing in the postpartum period. I have also had women who continued to do such things as: yoga, walking, and weight lifting tell me that not only was the pregnancy more manageable (with regards to less fatigue and more energy), but that they felt more prepared for the labor and delivery process because they were used to pushing their bodies in some capacity when they exercised. So while exercise posits a plethora of benefits, one should always consult their physician and interdisciplinary team of health care providers before starting or continuing an exercise regime in pregnancy.” 

-Trese Zannis R.N, Obstetrics Nurse at Sunnybrook Health Sciences Centre

Resources

1. Narayan R, Hyett J. Labor and Delivery. In: Women's Health: A Core Curriculum. Editors Jason Abbott, Lucy Bowyer, Martha Finn. Elsevier Health Sciences (2013) pp 184-201.
2. U.S. National Library of Medicine. Gestational Age. Updated 12/4/2013. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002367.htm
3. Barakat R, Stirling J R, Lucia A. Does exercise training during pregnancy affect gestational age? A randomized controlled trial. British Journal of Sports Medicine:(42) 2008 pp 674-78. 
4. Clapp J. The house of labor after endurance exercise during pregnancy. American Journal of Obstetrics and Gynecology.  1990. 163(6): 1799-1805. 
5. Effects of maternal exercise on labour and delivery. In: Physiology of Prenatal Exercise and Fetal Development. May, L.E. SpringerBriefs in Physiology. 2012 (VII). DOI: 10.1007/978-1-4614-3408-5_2
6. Salvesen K, Morkved S. Randomized controlled trial of pelvic floor muscle training during pregnancy. British Journal of Medicine. 2004 Vol 329: pp 378-380. 
7. Vieten C, Astin J. Effects of a mindfulness-based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Archives of Women's Mental Health. 2008 (11): 67-74. DOI 10.1007/s00737-008-0214-3
8. Lobel M, Cannella D L, Graham J E, DeVincent C, Schneider J & Meyer B A. Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychology. 2008. 27(5): pp 604-615. 

My Training for Two Story: Michiko .C.

Jenny had been my trainer for two years prior to my pregnancy. I had consistently trained with her one to two times per week through rigorous strength and endurance training programs. These programs progressed in levels of difficulty over time and included calisthenics, barbell and free weights activities.  My training focused primarily on core stability, explosive power and full range of movements. Jenny committed to providing me fun and challenging training programs that suited my physical and mental needs. Jenny was well aware that I had chronic heart and kidney issues and always modified my programs as per my health needs.

Once I found out that I was pregnant, I quickly informed Jenny since my training was important to me and my pregnancy was considered “high risk.” This meant that I needed close monitoring with multiple medical specialists, and a balanced lifestyle with exercise and healthy diet. Thus, my goals for training with Jenny changed abruptly to include light physical activity with minimal weight lifting so as to decrease the workload on the major organs and allow room for weight gain. At every workout session, Jenny carefully monitored my heart rate and blood pressure at the beginning, during and after every exercise and consistently monitored my perceived stress level. I learned to listen to my body - whenever I felt that my heart was racing or I was fatigued, we postponed any physical activity or decreased the level of my effort. Jenny and I were both flexible and trained only to the level that was tolerable for me. There were a lot of options for light exercise in Toronto including walking, swimming or yoga, but I preferred training at the gym with Jenny since I needed close support and guidance. With enthusiasm, I continued to train once a week with Jenny during my first trimester but only according to recommendations from my medical team. After three months, my pregnancy stressed my heart and I was medically required to completely stop exercising.

I did not train for the next six months. However, my training with Jenny was extremely helpful during labour and delivery. If I had not been mentally and physically active at the beginning of the pregnancy, I would have not been able to deliver my daughter safely and quickly. With a high risk pregnancy, C-sections are common but this method of delivery is not ideal due to blood loss and additional stress on major organs. I was warned that I may need to deliver via C-section but because of how great of a “pusher” I was with a strong core and leg power, I was able to avoid any surgical delivery methods. My husband and I were extremely pleased with how smooth the delivery process went and I am certain that this was due to my training with Jenny prior to and during my pregnancy.

Although my pregnancy was considered high risk and I went through preeclampsia, my medical team allowed me to return to training with Jenny after 5 weeks postpartum mainly due to the ease of delivering my daughter. My heart and kidneys slowly recovered and I experienced little postpartum pain. However, my joints were very lax; and thus Jenny and I focused mainly on core stability and avoided heavy lifting or flexibility training.

For myself, training has always been specific and met my personal needs. This was especially true during my pregnancy and postpartum period. I find that exercising with a trainer who understands your needs is important to ensure safety during such a special time. I imagine that most pregnant women want to provide the best health for their unborn child, and to me, sufficient exercise at a suitable level is vital. I wanted to and still focus on stress relief and uplifting my mood through exercise and Jenny’s support. 

My Training for Two Story: Sabrina

1. Describe your training/exercise regime before your pregnancy:

Before getting pregnant I worked out at least 6 days a week and most often twice a day. So my day would start off with a CrossFit class early in the morning (Academy of Lions is my home base) and then either go for a run in the evening or attend one of the high intensity training Nike Training Club (NTC) classes.  Then, occasionally there were days where I did all three on the same day…yes, you can call me crazy or just addicted to physical activity! I also played in a women’s indoor soccer league but that quickly came to a stop as I knew contact sports was not going to be safe during pregnancy.

2. Any concerns you had regarding training during pregnancy:

At first, all I could think was “what if my doctor says I can’t go running anymore”?  Honestly, I was so worried about the possibility of having to stop training for medical reasons, but I have been very fortunate to have an uncomplicated pregnancy.  

Once, my doctor gave me the ‘green light’ to continue with CrossFit and running, I then started worrying about what specific exercises could be harmful to the baby or put me at risk of injury.  For example, we had such a cold, snowy and icy winter that I didn’t run outdoors very much for risk of falling, but did use an indoor track at my local community centre.

3. Why is it important to you to train during your pregnancy; what are your main goals for your training during your pregnancy:

I think my biggest worry was gaining excess weight during my pregnancy; all I could think of was gaining all the weight that took many years to shed (about 6 years ago I was 50lbs overweight) and I didn’t want to go back to that stage in my life where I was unhealthy and unhappy.  I wanted to try and enjoy this pregnancy as much as possible.

Aside from the health benefits of being physically active, training helps me stay balanced, from a mental wellness perspective.  This would be my way of dealing with the all the physical changes your body goes through during pregnancy and those wonderful hormones that alter your emotions on a daily and sometimes hourly basis.  Also, I know that this is the most important time in my life to be healthy and I’m doing it for my baby.

4. How are you training during your pregnancy, how often, how far through your pregnancy do you plan to continue:

At the moment I’m 36 weeks pregnant and still doing CrossFit classes at least 4 times a week with some modifications to exercises and of course reduced weight with all the barbell lifting.  My goal was to make it 8 months and I did…but I think I can go a couple more weeks!

Early in the pregnancy, I reduced my running to 3 times a week and wasn’t sure how long I would be able to keep up with the running or if I would sign up for any races.  I found running to be the most difficult to adapt to as I had to slow down, a lot!   As a long distance runner, I’m very focused on improving my pace, distance and finish times, but it quickly became discouraging to lace up the runners and have to run so much slower than usual!  But nevertheless, I did complete 4 races including the Nike Women’s 15k while I was 34 weeks pregnant! I have since stopped running as I noticed my form and technique as a Pose Method runner was being affected.  

As for the NTC classes, it has been a few weeks since I stopped attending. Primarily because I found that I couldn’t work out twice in one day as I once used to!   

5. How do you work with your trainer/coach/programmer and medical team to organize your training through your pregnancy? If you don't work with a trainer, where did you get the information to design your program?

When I first met with my doctor I was very clear about the intensity of my training and the various exercises I did. She did give me the ‘ok’ to keep active but of course to “listen to your body” and stop when necessary.  She was happy to hear that I would also be consulting with a trainer at the gym who knew about my exercise regimen and could provide me with tips and necessary modifications.  I was fortunate, in one way, to see my doctor and the prenatal nurse every two weeks as they were monitoring a small matter (nothing overly concerning) and they both asked about my training at each visit making sure to review list of symptoms to look out for while training (including, bleeding, leaking, shortness of breath, etc…)

I booked a few private sessions with a trainer from the gym to review some of the exercises and movements to avoid, especially during CrossFit.  Along with my program she included some core and pelvic strengthening exercises that would help with delivery and post natal recovery.

In the CrossFit classes, all the coaches were aware that I was pregnant and we worked together to review the workout of the day and where I may need to make some modifications or replace exercises.

I didn’t consult with a running coach and in hind sight I probably could have benefitted from it.  I will consider it post natal to ensure that I try not to run another marathon before my body has a chance to fully recover from being pregnant and delivery.


6. Describe the importance of listening to your own body - any common signs/feelings you experienced that warned you to slow down or back off?

“Listen to your body”, was by far the most important piece of advice and the most difficult for me to follow.  I’m a firm believer that you won’t know your limits until you pass them, but things certainly change when you’re pregnant!

The most common sign to slow down or stop a certain exercise was at the slightest hint of abdominal pain (either on my side or just under my baby bump).  I could also tell when my heart rate was getting close to being too high and my breath becoming too rapid by taking the “talk test”.  So, if I was having trouble talking while doing the exercise then it was time to stop and take some deep breathes to cool down.

7. How has your training impacted your pregnancy- physically, mentally and emotionally?

Overall made my pregnancy has been fairly easy without major complications, nausea, tiredness, and other side effects that I hear many other women suffer from.  I’d like to think that my level of physical activity contributed to having fewer pregnancy discomforts and being able to maintain a healthy weight.

I guess going through pregnancy is like training for a marathon; it takes a great deal of time to condition the body and mind, it’s demanding and exhausting but all worth it in the end!

8. Do you have an important message you wish to pass on to other women who are thinking about or are concerned about training through pregnancy?

Working out during pregnancy should be just a continuation of the lifestyle you had already established and always consult your health care provider! If possible, talk to other women who were physically active during their pregnancies, to hear about their routines, successes and challenges along the way.

9. Any other information you wish to include — e.g. you can describe the experience of being asked questions/given advice from other gym goers, you can talk about your influences/role models, anything else you think is important.

At the gym, there has been such a tremendous amount of support from fellow CrossFitters and NTC friends! If you surround yourself with likeminded individuals they will keep you motivated.

I regularly got asked about what modifications I had to make to my training and occasionally people asked if my doctor knew what I was doing – I tried not look offended by their comments! I think by far, I got the most stares during my runs and races and certainly shocked quite a few people, but I tried to not let it bother me. Once again, I know my body best and what my limitations are.

I would also like to add that the general literature about physical activity for pregnant women (such as hospital or government issued pamphlets) include general guidelines, but it wasn’t the most helpful when it came to the specific training and intensity that I was used to, especially for muscle conditioning.

Of course I did some online research as well when it came to CrossFit and running and found that many women and professional athletes were able to continue to participate in their sport during pregnancy.  I was most impressed by Alysia Montano, USA track star who ran in the national championship while 8 months pregnant – that was absolutely remarkable.

Keeping an open mind - By: Paluna

When I was asked to contribute to this series I didn't think it would be hard to come up with something that I'd consider useful to readers. 

“Talk about the benefits of the yoga practice during pregnancy” was the topic requested.

I thought to myself, I'll get it done in no time. I mean,  I've been teaching for close to 10 years, done a variety of pre/post natal trainings, attended births and work with pre/post natal clients on a regular basis. Piece of cake right? 

Well it turns out, it has taken me days to complete this piece, mainly because I can't find the words to describe how rewarding this work is and how fortunate I feel to be able to share this journey with so many women. 

After hours of frustration in front of the screen I decided to let it go. I decided to stop comparing what I was writing to the other pieces I've read. I decided to stop worrying about whether the information I wanted to share was useful or not, or whether I was covering all the health and safety precautions I thought everyone would want to know about. 

On day three of me trying to finish this piece, I put the computer down, went for a walk, grabbed a green smoothie and the words “keep an open mind” came to me.  Voila!!

In my experience in the past few years, women during this period are full of excitement but also fear. When it comes to physical activity, phrases such as: “you shouldn't do this or that, be careful with this or are you sure that's ok?”  are thrown around more often than not by well intentioned loved ones. However, most times without realizing the effect those words can have on a person. 

This is a period of immense physical and mental shifts. 

I strongly believe that we always know what is best for us but we sometimes get sidetracked or blinded by the “noise” outside of us. 

This is where the practice of yoga comes in.
If you decide to attend a class or hire a private teacher, hopefully you will find someone who will create an environment where you can be yourself. 

You should be allowed to share your thoughts and feelings without any judgement. 

Some women have really tough pregnancies. They should be allowed to say “I hate being pregnant” the same way other women should be allowed to express the complete opposite, because guess what, both types of pregnancy experience exist and both are valid. 

The yoga room should be a place were we connect with ourselves in any way that works for us.

My job as a teacher is not to tell women what's best for them. Information is power and by information I don't only mean what the doctor, the chiropractor or the midwife says. By information I also mean what you are feeling, what you are thinking, what you want, etc.

If I can pick one useful thing about the yoga practice is that it teaches us that the one thing we can control is our attitude. 

So once we have all the information we can possibly accumulate to take care of our body and our  health, our job is to choose our attitude. 

In pregnancy, as in life, things don't always go exactly as expected; as a yoga teacher I’m only here to help women find what they already have within them.

We work together to make this journey as meaningful and enjoyable as possible, and the only way to achieve this, is by keeping an open mind. :)

Photo by Laura Polischuik  

My Training for Two Story: by Susan L

I’ve been active my entire life. I did gymnastics and rode horses as a small child, played soccer, volleyball and ran track as an adolescent and young adult, and started dancing competitively in my 30’s.

Right up until I got pregnant, I was dancing about 10 hours per week and running an/or lifting weights 1-2 times per week. I also played soccer on the weekends.

After doing a bit of internet research and speaking to my OB and nurse, I really had no concerns about training during pregnancy except for any activities that involved contact. The only thing I stopped doing was playing soccer to avoid the risk of getting hit.  I continued dancing and running hills, mowing lawns,  and playing occasional sports such as volleyball, tennis, I even did the Warrior Dash when I was 16 weeks pregnant.

Throughout my pregnancy, I felt that I knew my body well enough to adjust my activity level as I went along based on how I was feeling. My bottom line, if anything hurt or became abnormally uncomfortable, I wouldn’t do it. My cardio fitness went first, I felt short of breath often during aerobic exercise.

By the time I got to about 6 months pregnant, I could no longer run. It was too uncomfortable and sometimes painful with the pressure of my growing belly. I could still dance and lift weights and walk, so I did as much as I could comfortably do. I walked everyday and lifted light weights a few times per week.  I never worked with a fitness professional, I just did my own thing. My main goal was to keep my weight gain to the recommended amount and keep my energy and fitness level up. I continued doing all of these things right up until the birth of my son. In fact, during the final week of my pregnancy, I was trudging through the deep snow for 2 hours per day, trying to encourage labor to start.

I had a tough labor and delivery, I truly feel that if I was not in good physical shape, my birth story would have had a different ending. My fitness level and core strength were huge factors in the birth of my son. My physical fitness gave me confidence in myself and enabled me to keep a positive attitude throughout my long and challenging labor and birth.

I attribute the speed of my post partum recovery partially to the level of fitness I maintained throughout my pregnancy.  I used the same principals for going back to training. I listened to my body and only did what felt right. Being able to exercise again was a big relief for me. I followed the general rule which is to wait until your 6 week check-up at the doctor. All went well, and I was cleared to exercise again. I began walking daily 1 week post partum, started running and dancing 6 weeks post partum and doing CrossFit classes 12 weeks post partum. I was back to my pre-pregnancy weight/size after 5 months.

Most people around me were very encouraging and positive about my activity level. Sometimes I felt like I was not cautious enough because many of my friends felt that they were putting their babies at risk if they exercised. My husband was very encouraging as well,. He supported me throughout the entire process. One of my role models is my mom, she told me to do whatever I was doing before I was pregnant. She rode her horse when she was pregnant with her 3 daughters. She’s a free spirit, to say the least.