Women’s Health & Fitness Programs
Many important health issues for girls and women involve matters of reproductive
health, childbearing, fertility and aging. Research informs us that an active, healthy
lifestyle provides a number of benefits throughout a woman’s life span:
reduced discomforts from pregnancy, labor, birth, recovery & menopause
reduced risk of hypertensive disorders of pregnancy and premature birth
potentially shorter active labor and reduced risk of cesarean delivery
more rapid return to joyful activities, less excess weight following birth
mother-infant interaction, leading to infant psychomotor enhancement
reduced rates of obesity, cardiovascular disease, and type 2 diabetes
reduction of some cancers, osteoporosis, falls and loss of muscle mass
improved social support, networking and stress management skills
greater belief in one’s ability to be strong and capable (self-efficacy)
As I became involved in the birthing field, one of the nurse-midwives with whom I was acquainted introduced me to Jung’s quotation: “There is no birth of consciousness without pain.” (Alternately, “There is no coming to consciousness without pain.”) It struck a deep chord in me.
When I first saw the saying, “There is no birth of consciousness without pain,” intertwined with a drawing of a woman literally giving birth, the truth of the image seemed obvious to me. It become hard-wired into my underlying assumptions about giving birth. The process itself combines intense noxious sensations with mid brain emotional input into what neural science calls pain. For years, this realization has driven what and how I teach: Being fit and educated in body/mind are the tools of enlightenment and self-empowerment.
…And This Is Now
A little while ago I came across a NY Times article “Profiting From Pain.” While the article concerns the huge increase in the legitimate opioid business – products, sales, hospitalizations, legal expenses and workplace cost – it restarted my thinking about a topic fermenting in my brain between That Was Then And This Is Now: The sense of entitlement to a pain-free existence. The idea that pain free is better than painful. And the selling of this idea for profit.
Could it be that human fear of pain is being used to generate financial profit? (the opium-is-the-opiate-of-the-masses model). Perhaps once the notion of palliative care reached a certain level of acceptance for the dying within the medical community, it began to spill over into other human conditions (the slippery-slope model). Or, perhaps we don’t want transparency at all (the denial model).
In the last few days, NPR has raised the question of whether the high cesarean birth rate is tied to the payment for procedure rather than outcome model? The recovery from cesarean is more painful than the recovery from vaginal birth, has adverse side-effects for mother and baby, and was originally designed for use only for the 15% +/- of real complications that arise in normal birth. So, how is it being sold to 35% of women in the U.S,? At one point, there was a serious discussion within the medical community that if women were afraid of the pain of birth and wanted a cesarean, a care provider should do one. No discussion of why it seems painful or how to deal with pain.
The Affordable Care Act aims to improve some of the cost issues in medical care by shifting the payment incentive away from procedures and on to outcome assessment. As a result, the cesarean rate and even such seemingly innocuous procedures as fetal monitoring are coming under scrutiny. If we truly want to do a service to the mothers-to-be in the ACA transition period and beyond, I think we must discuss the question of birth and pain.
I can think of many questions that fall under this topic…Why do we call the intense phenomenon of birth “painful”? How do our genetics, behavior, training and thought-processes affect our experience of pain? What about the health care culture – has it focused on relieving pain at the expense of what we gain from working with pain short of trauma or imminent death? How do we prepare women for working with sensation without automatically labeling it pain? Is the “empowerment” often attributed to giving birth what is learned by going through the center of the “there is no birth of consciousness without pain” experience? These questions are just a start.
Let me address the childbirth educators and pregnancy exercise instructors. This is our present challenge. In my work, I feel the necessity to make all pain management strategies understandable to my clients. I find that most of the women I see in classes must deal first with self-discovery before they can assess their commitment to the view of birth they carry in their minds. The images of birth we lay out for them to consider need to include an understanding that you cannot escape the work of birth. Being present – mindfulness – can be scary and intense but it is the medium by which our consciousness expands. Cardiovascular fitness and strength are the source of our endurance and power.
This is the time of year many of us consider where to make our charitable contributions. We have assembled a list of groups to which you might want to consider giving this year. By donating to these organizations you can help improve the lives of mothers, newborns,children and families around the world. Most will also send a card or email message to a mom in whose honor you give the gift.
UNICEF Inspired Gifts. You can choose gifts that improve education, water, health, nutrition, emergency care and other factors that affect the well-being of women and children.
The Fistula Foundation. This group exists to raise awareness of and funding for fistula treatment, prevention and educational programs worldwide. Fistula is the devastating injury cause by untreated obstructed labor.
The Preeclampsia Foundation. This organization supports research to prevent and treat one of the most dangerous disorders of pregnancy, one that accounts for a large percentage of premature births and low birth weight infants. Having preeclampsia is also a risk factor for later heart disease for the mother.
Clean Birth. Clean Birth Kits are designed to provide birth attendants and/or expecting moms with the tools they need to ensure a clean birthing environment. The Kits ensure the WHO’s “6 Cleans”: clean hands, clean perineum, clean delivery surface, clean cord cutting implement, clean cord tying, and clean cord care.
March of Dimes. The “mother” of all charities for helping prevent and treat disorders and diseases that affect children.
This post is adapted from the 3/17/11 DTP Blog on Pregnancy Exercise Safety. For more evidence-based information on Pre/postnatal Health & Fitness, check out the DTP Blog. The Blog includes information starting prior to conception and continuing through postpartum and mom-baby fitness.
There are three sections to this post: 1) moms-to-be, 2) pregnancy fitness teachers and personal trainers and 3) some specific contraindicated and adapted exercises. All information presented is based on peer-review research and evidence collected over a 30 year period of working with this population. More information on safety can be found on this site on the page Benefits, Safety & Guidelines.
1) Safety & Exercise Guidelines for Moms-To-Be
First and foremost, be safe. Trust your body. Make sure your teacher or trainer is certified by an established organization that specializes in pre/postnatal exercise, has worked under master teachers during her preparation, and can answer or get answers to your questions.
These are the safety principles that we suggest to our participants:
get proper screening from your health care provider
do not overreach your abilities
you are responsible for your body (and its contents)
Squatting is an example of a standard pregnancy exercise used for childbirth preparation that must be adapted by each individual based on body proportions, flexibility, strength and comfort.
Don’t assume that because your teacher and some participants can do a certain movement or position that you should be able to do it just like they do. If your teacher is well trained, she will be able to help you select variations that are appropriate for your body.
When you are exercising, make sure you are getting the most from your activity. Keep these findings in mind when choosing your workout routine:
Aerobics and strength training provide the greatest health benefits, reduce the risk for some interventions in labor, help shorten labor, and reduce recovery time
Centering helps to prevent injury; relaxation and deep breathing reduce stress; and mild stretching can relieve some discomforts
Avoid fatigue and over-training; do regular exercise 3 — 5 times a week
Eat small meals many times a day (200–300 calories every 2–3 hours
Drink at least 8 cups of water every day
Avoid hot, humid places
Wear good shoes during aerobic activities
BE CAREFUL! LISTEN TO YOUR BODY!
If you experience any of the following symptoms, stop exercising and call your health care provider:
Sudden pelvic or vaginal pain
Dizziness or shortness of breath
Leaking fluid or bleeding from the vagina
Regular contractions, 4 or more per hour
Increased heartbeat while resting
Sudden abnormal decrease in fetal movement (note: it is completely normal for baby’s movements to decrease slightly during exercise)
2) Safety & Exercise Guidelines for Teachers & Trainers
A principle of practice that increases in importance for fitness professionals working with pregnant women is having the knowledge and skills to articulate the rationale and safety guidelines for every movement she asks clients to perform.
This goal requires adherence to safety as the number one priority. Here is how we delineate safety and the procedures we require of our instructors for achieving safety in practice:
First priority: safety [First, do no harm]
sometimes medical conditions preclude exercise
find an appropriate starting point for each individual
individual tolerances affect modification
general safety guidelines are physical
pregnant women also need psychological safety
Mind-Body Safety Procedures
Centering enhances movement efficiency and safety.
Always begin with centering.
Strength Training Cautions
avoid Valsalva maneuver
avoid free weights after mid pregnancy (open chain; control issue)
avoid supine after 1st trimester
avoid semi-recumbent 3rd trimester
keep in mind the common joint displacements, and nerve and blood vessel entrapment when designing specific exercises
Aerobics or Cardiovascular Conditioning Procedures
Monitor for safety
Instructional style needs to be appropriate.
Walking steps with natural gestures can be done throughout pregnancy
Vigorous steps with large gestures are more intense, appropriate as fitness increases
The ability to create movement that will be safe and work for various levels of fitness and at different points in pregnancy is one of the most critical skills for pregnancy fitness instructors.
Setting should provide physical and emotional safety
Equipment must be well-maintained
3) Contraindicated and adapted exercises
Exercises for which case studies and research have shown that there are serious medical issues include the “down dog” position, resting on the back after the 4th month, and abdominal crunches and oblique exercises. Here is more information and adaptation suggestions:
Contraindicated: “Down Dog” requires that the pelvic floor and vaginal area are quite stretched, bringing porous blood vessels at the surface of the vagina close to air. There are records of air entering the vaginal blood vessels in this position and moving to the heart as a fatal air embolism.
Adaptation: Use the child’s pose, with the seat down resting on the heels and the elbows on the ground, hands one on top of the other, and forehead resting on the hands. Keep the heart above the pelvis.
Contraindicated: Resting on the back during relaxation.
Adaptation: Rest in the side-lying position. About 75% prefer the left side, 25% prefer the right side.
Contraindicated: Abdominal crunches and oblique exercises can contribute to diastasis recti in some women. The transverse abdominal muscle is not always able to maintain vertical integrity at the linea alba, and thus there is tearing and/or plasticity of that central connective tissue.
Adaptation: Splinting with curl-downs, see positions below. By pressing the sides of the abdomen toward the center, women can continue to strengthen the transverse abdominals without the shearing forces that place lateral pressure on the linea alba.
Curl-downs are generally the safest and most effective abdominal strenthening exercise.
Splint by crossing arms and pulling toward center (L)
Or, splint by placing hands at sides and pressing toward center (R)
The challenges to safe motherhood vary depending where in the world you live. In some areas the challenge may be to get adequate nutrition or clean water; in other areas, it may be to prevent infection; and in still other locations it may be trying to avoid pregnancy before your body is ready or getting access to prenatal care. In the U.S., it may mean avoiding being sedentary and making poor food choices, or having to deal with the high technology environment of medical birth that can sabotage the innate physiological process of labor and birth.
Birth begins the bonding or unique love between mother and child.
The biology of birth is a complex series of cause-effect processes…baby’s brain releases chemical signals to the mother and the placenta begins to manifest the maternal immune system’s rejection of the fetus.
To help the ball get rolling, relaxation (the trophotropic response) helps promote the release of oxytocin. With the help of gravity, the head presses on the cervix, amplifying the uterine contractions. After an ultra-distance aerobic endurance test, the cervix opens enough to let the baby move into the vagina and the mother’s discomfort moves from sharp cramping into the bony structure as she transitions to the strength test of pushing. She transitions. Relaxation modulates into an ergotropic – adrenal – response to gather her power.
Pushing is an interesting term…more masculine, I think, than the one I prefer: Releasing. Releasing or letting go of the baby. It’s a catharsis. In this portion of the labor another set of important processes help the baby clear its lungs of amniotic fluid, stimulate its adrenal system and challenge its immune system, as the contractions drive the baby downward. The mother’s deep transverse abdominal muscles – if strong enough – squeeze the uterus like a tube of tooth paste, to aid this expulsion. In the meantime, the labor is helping set up the mother to fall in love and produce milk. When the baby emerges and moves onto the mother’s chest, s/he smells and tastes the mother, recognizing her mother’s flavor and setting up the potential for bonding.
Any way you slice it, there are two parts to safe motherhood. One is a safe pregnancy…healthy nutrition, physical fitness, safe water, infection prevention, support and a safe environment. The other is a safe labor. In a safe labor, there is both an environment that promotes the natural process of labor and the means necessary for medical assistance when needed. Women die at an alarming rate from pregnancy or birth-related problems. Despite some progress made in recent years, women continue to die every minute as a result of being pregnant or giving birth.
What keeps us from having a better record on motherhood is often lack of care in the developing world and too much intervention in the U.S.. They are two sides of a coin. Mothers’ experience and health needs are not on equal footing with other cultural values. In places where basic prenatal care or family planning are low priorities, at-risk women are vulnerable to the physical stresses of pregnancy and birth. In the U.S., machine-measured data is paramount, even if it produces high rates of false positives, unnecessary interventions or counterproductive procedures. We are learning that obesity and sedentary lifestyles have detrimental effects, but fewer pregnant women than their non-pregnant counterparts exercise.
Despite the money spent to support the technological model of pregnancy and birth in the U.S., there are parts of the world with lower rates of maternal deaths – especially Scandinavia, Northern Europe and parts of the Mediterranean and Middle East (Greece, the United Arab Emirates, Israel, Italy and Croatia). In fact, in the U.S., maternal deaths are on the rise.
It’s a tricky business. Clearly Western medicine has a lot to offer the developing world when there are medical concerns. On the other hand, importing the U.S. model could create more problems than it solves. Instead, the micro-solutions now being developed in many locations will be observed and evidence collected by organizations such as the White Ribbon Alliance and UNICEF.
There is an effective international midwives model adopted by JHPIEGO, the Johns Hopkins NGO working toward improved birthing outcomes. It assesses the local power structure, social connections, potential for trained birth assistants, and location of available transportation to create a network so that locals will know when a labor is in trouble and who can get the woman to the nearest hospital.
In the U.S., there are in-hospital birth centers that allow low-risk mothers the opportunity to labor and birth in a setting designed to encourage the innate processes. Women are beginning to vote with their feet…staying home for birth. Women are going abroad to give birth. At the same time, women are coming to this country to give birth, believing it is safer than where they are. There are several ways these scenes could play out.
But, I’ll wager, improving outcomes will involve compromise: Watchfulness and support in most births, plus better ways to assess danger and provide technology. No matter where you live in the world, the solution may be essentially the same.
Periodically, arguments arise in the birthing field over who controls the way we give birth. Often this happens at times when birthing women change their behavior trends, putting financial pressure on professionals working in this field. The major players in this argument are medical doctors (obstetricians), certified nurse midwives and professional home birth midwives.
Currently we are seeing women leave the traditional hospital setting for birth in larger and larger numbers…and taking their dollars with them in the process. While the question of home birth safety arises every time this control argument comes around, the question of whether it is safe to intervene in a labor that is progressing normally is a new component of the discussion. This time the argument is: The safety of home birth vs. the safety of using hospital technology to intervene in normal birth.
How Money Affects this Issue
As with all commercial ventures, controlling access to safe birth requires controlling the information in the market place. This information needs to address the perceived wants of the target audience. For a long time the main message has been: Safe birth is only available in a hospital.
The financial pressure of giving women (consumers) what they want – a normal experience of birth in a safe setting where medical help can be quickly available – has powered the birth-center industry. Free-standing and in-hospital birth centers have grown in numbers, and are largely enabled by certified nurse-midwives. Meanwhile, professional home birth midwives have increased both their credentials and practice standards, as well as their visibility.
Both of these options, birth centers and home birth, threaten the livelihood of traditional obstetrical practices. Low risk births (about 70% of births) have the potential to be normal births, requiring little or no intervention. But, giving birth in the hospital means participating in measurement procedures that intervene in the labor process.
So, to convince women they need to be in a hospital to be safe, medicine has maintained the argument that home birth or out of hospital birth is not safe. However, research does not indicate this is true. The nature of this ongoing argument is discussed in a 2002 article from Midwifery Today.
What’s New? The Counter Argument.
The physiology of normal labor is dominated by parasympathetic, meditative, gonadal energy systems. Measurement is a sympathetic, rational, adrenal energy dynamic. Only when it is time to expel the baby does the underlying energy system make a transition (transition, get it?) to an adrenal impetus for the strength activity of pushing. Immediately following normal birth, maternal physiology is again dominated by gonad-driven energy along with a rush of endorphins.
“Intervene enough and things will go awry. You can easily end up being cut and/or separated from your baby at birth.” These ideas have gone viral. With the arrival of the internet, women have found a very quick way to do what we have always done: Share information.
Thus, in my exercise program and in my childbirth preparation classes, I have more and more frequently been fielding the following question from women who want a normal birth and want to be safe: “How can I avoid interventions while I am in the hospital?”
So, I ask them what leads them to ask this question. And, they say: “I read on the internet and/or heard from my friends that interventions make birth less normal and less safe. I want to protect myself.”
Women themselves are entering the argument in a much more conscious way than in the past. Some professionals would like to keep women out of the argument. But, like with many things in our 21st century world, we have already past the point of no return. As they say, the horse has already left the barn!
Word has gotten around. More and more, as a prenatal fitness expert who strives to listen to my clients, my job has become educating and physically training women to cope with a strenuous and primitive process in a technological world.
Hopefully, we can all keep our eye on the ball here. Preventing trauma should be one key goal. Just as we have learned to hold our newborns skin to skin so they can smell and taste us, listen to our heart beat and voice, and maintain their core temperature, let us learn to comfort and nurture our new mothers, while we steel them for the rigors of birth.
If you are not yet convinced about the global need for humane care for pregnant and birthing women, google (or bing, or yahoo…) “fistula.” If you want more first world information, compare medical birth with what’s on YouTube; while these two approaches to birth are at odds in contemporary medicine, in a humane setting they are both necessary.
As for space, let me paraphrase Craig Nelson’s notion: In time, the Earth will perish. This is nothing you need to lose sleep over. It will be a long, long time before this happens. But, we need to start now to prepare. In time, the Earth will perish, and we will need to be somewhere else when that happens.
These two things will reap all the rewards that need be reaped. The enabling of safe motherhood and our movement into space are the only things that ensure human survival.