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Physical Activity for pregnant women Maternity Teaching session Ralph Smith MBBS FFSEM MSc MRCGP DipUS(MSK) Fellow in Sport and Exercise Medicine
Physical Activity for pregnant women Maternity Teaching session
Ralph Smith
MBBS FFSEM MSc MRCGP DipUS(MSK)
Fellow in Sport and Exercise Medicine
Acknowledgements
Rate your confidence to discuss physical activity with pregnant women
3
A
1 10
Very Confident
No confidence
Rate your confidence
Discussion
A
How many times in the past two weeks have you asked patients:
» About smoking?
»Taken or requested blood tests?
»Asked about physical activity?
Images courtesy NHS Image Bank
Objectives
A
1. Become familiar with the definitions and evidence base for physical activity in general population.
2. Knowledge of the specific guidelines for pregnant women and physical activity
3. Giving brief advice in clinical practice.
Physical activity: what counts?
Sleep Sedentary Light intensity
Moderate intensity
Vigorous intensity
7 Ng SW, Popkin B (2012); Lee I-M, et al. (2012); Wen CP, Wu X (2012); WHO (2010); Ossa D & Hutton J (2002); Murray et al. (2013)
Inactivity is killing us
•Decreasing activity levels since 1960s: oAdults are over 20% less active oBy 2030 we will 35% less active
•Physical inactivity is responsible for:
o1 in 6 UK deaths oUp to 40% of many long-term
conditions oAround 30% of later life functional
limitation and falls Estimated £7.4 billion annual cost
How efficacious is health professional advice?
Permission granted from Exercise Works. Infographic designed by Toteshealth
Motivation for health behaviour can change (smoking, alcohol, diet, and physical activity)
Pregnancy – a teachable moment?
An opportunity for change:
An ideal time to adopt a healthy lifestyle with the increased motivation and frequent access to maternity care1
Less than 25 % of pregnant women meet PA guidelines2-4
Decline throughout the course of pregnancy5.
Increasing rate of obstetric and maternal complications
1. American College of Obstetricians and Gynaecolgist. Obstet Gynecol 2015;126(6):e135-42. 2. Hesketh and Evenson.Am J Prev Med 2016;51(3):e87–e89 3. Walsh JM, et al IJGO. 2011. 4. Amezcua-Prieto et al Int J Gynaecol Obstet. 2013 5. Borodulin K et al Med Sci Sports Exerc. 2008.
• HPs lack the confidence and knowledge to deliver appropriate PA advice.
• They feel under-resourced, uncertain regarding safety concerns and inadequately trained.
• Pregnant women receive inconsistent, vague and conflicting guidance.
The details behind the infographic
What are some of the barriers to physical activity for pregnant women?
Barriers to PA in pregnancy
Myths & safety fears
Timing of advice2
Fatigue, specific symptoms
& Lack of time 1
Social support1
Awareness & Empathy Person-centred strategies using behaviour
change techniques should be used to address intrapersonal & social factors1,3
1. Harrison et al. Journal of Physiotherapy 64 (2018) 24–32 2. Borodulin et al. Med Sci Sport Exerc 2008 3. Linqvist et al Sexual & Reproductive Healthcare 15 (2018) 46-53
Main physiological adaptations of the mother's body during pregnancy (HR, heart rate;VO2,
oxygen consumption).
Ruben Barakat et al. Br J Sports Med 2015;49:1377-1381
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Main effects of exercise during pregnancy on maternal and fetal well-being (BP, blood pressure;
HR, heart rate; O2, oxygen).
Ruben Barakat et al. Br J Sports Med 2015;49:1377-1381
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
• Four outcomes with definite positive effect1,2
• Directly adapted from the evidence based adult guidelines3 – most appealing to pregnant women
1. University of Oxford Physical Activity and Pregnancy Study Group. 2016. Unpublished work. University of Oxford, Oxford. 2. Rogozinska E, et al. Health Technol Assess 2017 (in press) 3. Start Active, Stay Active. Department of Health 2011.
Moore et al. (2012) PLOS Medicine
A
150 Minutes
Biggest gain in years
Those new to activity
Greatest gains are in those who go from doing nothing to doing something.
Vigorous activity not recommended
Every activity counts & give them
permission
Start gradually
Target population
Those already active:
Encourage, maintain but adapt activities
E.g. replacing contact sports with non- contact sport or an appropriate exercise class
• UK guidelines applicable to pregnant women
• This is in keeping with other
worldwide recommendations1,2
• Moderate intensity
150 minutes of moderate activity each week
1. Amercian College of Obstetricians and Gynaecolgist. Obstet Gynecol 2015;126(6):e135-42. 2. Evenson et al. Am J Lifestyle Med. 2014 March/April; 8(2): 102–121
Muscle strengthening activities
• Evidence to suggest improvements in muscle strength1
• No adverse health effects during pregnancy2
• Same benefits all adults receive
• There is an absence of evidence regarding strenuous strength training for pregnant women2
1. O'Connor PJ et alJ Phys Act Health 2011;8(3):309-20
2. Bø K et al Br J Sports Med 2016;50(10):571-89.
Vigorous Activity:
• Adjust their activity as their pregnancy progresses to those they find most suitable and comfortable
• Not recommended within this infographic because there was insufficient evidence from the systematic review of reviews
• Excellent IOC consensus statements published in BJSM
Type?
Remember: the aim of keeping fit, not to reach peak fitness
Build Activity in your daily routine Active transport, Home, Leisure
Brisk walk, jogging, swimming, cycling, dance, strength exercises
Encourage antenatal classes: Social and prioritise time
No adverse maternal or infant outcomes for healthy women
resulting from moderate intensity physical activity during pregnancy
•
Listen & Adapt with the physiological changes
Physical Activity Discontinued
Breathlessness before or following minimal exertion, headaches, dizziness, chest pain, muscle weakness affecting balance & calf pain or swelling. Women may also be advised to reduce/stop physical activity following pregnancy complications such as vaginal bleeding, regular painful contractions or amniotic fluid leakage.
Activities not recommended
1.Cakmak B et al. J Matern Fetal Neonatal Med 2016;29:1623–5. 2. Vladutiu CJ et al. J Phys Act Health 2010;7:761–9. 3. Bø K et al Br J Sports Med 2016;50(10):571-89 4. ACOG 2015
Increased risk of trauma/high risk of falling Postural Balance affected after first trimester X2-3times likely to injury by falling 1,2
Those with physiological risk factors
Scuba diving, sky diving/ vigorous exercise above 6000ft3
Those involve lying in supine position after the 1st trimester4
Other Messages…
Those with obstetric or medical complications
01 Cool, comfortable and hydrated
02 Warm up and cool down
03
Give them permission!
Discussing Physical activity
34
35
No minutes
Keep active important for your health
Sign post to leaflet
1-3 minutes
-Ask about PA levels -Give them
permission & tell them Benefits
-Sign post to leaflet
More minutes
Assess & Brief advice 3-5
minutes
Patient Encounter: booking
Green 59.1% (3757)
Amber 28.1% (1785)
Red 12.8% (814)
Reported Physical Activity levels categories
6356
women
9M
Patient Encounter: Booking
1 in 8 women were very inactive
Less than 2/3 of
women met the
recommended PA
levels
Women with a BMI
>30kg/m2 were
associated with lower
self reported activity
levels
1 in 8 women were
very inactive
Less than 2/3 of
women met the
recommended
PA levels
Women with a BMI
>30kg/m2 were associated
with lower self reported
activity levels
Green 60.5% (1692)
Amber 26.4% (738)
Red
12.8% (359)
Reported Physical Activity levels categories all for women
Environment changes
Promotional film
Posters and waiting areas
Environment changes
Promotional film
Posters & waiting areas
Patient leaflets & local catalogues
Brief advice performed by staff/Clinical
champion & Leaflet given
Assessment of PA levels
Clinical champion input: Motivation interviewing
intervention & PPAQ assessment
Telephone follow up and/or review in
next appt
Further support required
Referral pathway
Motivational Interviewing Training Module:
The course is free limited availability. Online for 1 hour per week for 8 weeks, and an additional 1-2 hours clinical practice per week Starts 4 February 2019
Keep spreading the word….
@Activepregnancy
@Movingmedicine
Make every contact count for physical advice
