DTP Blog: Dispelling Myths on Pregnancy Exercise by Ann Cowlin MA CSM CCE, director
At regular intervals, it becomes necessary to dispel two persistent myths that are often perpetuated by well-meaning care providers. Both of them were debunked long ago, in research literature that is readily available and about which I have written a great deal, including in my chapters on Women and Exercise (editions 3 & 4) and Health Promotion in Varney’s Midwifery (edition 5), in posts on the DTP website, on my Twitter feed (@anncowlin), on DTP’s Facebook page and in a textbook. The more common myth is that pregnant women should never let their pulse get over 140 beats per minute. But, more on that one at another time. That was an ACOG guess in 1985 that long ago (1994) was rescinded. The other is that pregnant women should never begin a new exercise regimen, but only modify (i.e., reduce) what they are already doing. What brings me to write this blog… read more...
In the generations since birth moved from the home to the hospital setting, it has become less and less frequent that women in developed nations see birth first hand and accept it as a natural part of life prior to their own first birth experience. The “epidemic” of fear surrounding birth may well be partly a result of this phenomenon. In a recent post published in Midwives magazine, a publication of the UK’s Royal College of Midwives, DTP director Ann Cowlin wrote a blog entitled ‘Exercise and Body Trust in Birth.’ The post addresses the confidence in one’s body that accompanies training specific exercise and how this applies to pregnant women and their preparation for birth. Here is the link to the blog post: http://community.rcm.org.uk/blogs/exercise-and-body-trust-birth
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.
Where does this come from? Trying to obliterate pain has led to increased addiction, death and other adverse side effects. A new topic has shown up in women’s health discussions: Increasing use and overdose from prescription pain killers by women, including during pregnancy.
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.
In closing…
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.
In Part 4 of our continuing series on DTP’s offspring, meet Renee Crichlow, ACSM Certified Personal Trainer from Barbados, whose REAC Fitnessbusiness includes Mum-me 2 B Fitness Series (prenatal), After Baby Fitness Series (postnatal) and 6 week Jumpstart Body Transformation Program (general female population).
See photos and read more about Renee’s business on the DTP Blog here. The adventures of one of her students is featured in a recent series of articles in Barbados Today.
Renee is a women’s fitness specialist, targeting all stages of a woman’s life cycle from adolescent, child bearing years, prenatal, postnatal to menopause. I design various exercise programmes to help women get into shape. As a trainer, friend and coach, I am committed to guiding, motivating and educating women to exceed their fitness goals and to permanently adopt healthy lifestyles. She started studying with DTP in March 2012 and completed the practicum in May 2012.
I most enjoy the good feeling associated with knowing that I am helping women to positively change their lives through exercise. I have learned that we are connected and not separate from each other. Sharing our challenges and triumphs enable each of us to grow and have a sense of belonging like a sisterhood. The baby and pregnancy stories always amaze me and I learn a lot considering I don’t have children of my own. I am also fascinated by the fact that as the pregnant mummies bellies grow, they are still moving with lots of energy and I feed off of that energy. I just love working with pregnant ladies and mothers.
I strongly recommend this book and its accompanying website by the author of the NY Times bestseller, Brain Rules. http://www.brainrules.net/.
The new text brings together much of the disparate research on fetal-infant-child brain development of the last few decades into a readable whole. At the same time, it associates these findings with effective, concrete practices and provides tips for new and expecting parents. What are some of the big, take-home messages of this text? Survival, or safety, is the primary goal of the brain. Happiness is most closely linked to having friends. Academic success is associated with self-control. And, rewarding effort produces the greatest positive feedback. There’s a lot more here and on the website. Plus the website has pages of references and a terrific quiz for parents. Links: Brain Rules for Baby: http://brainrules.net/brain-rules-for-baby. Brain Rules for Baby Quiz: http://brainrules.net/brain-rules-for-baby-parenting-quiz.
Dr. Medina starts with that notorious parental concern: How do parents raise a smart, successful, calm and happy child? He considers the job of parenting to be supporting healthy brain development – something achieved largely by living a healthy and emotionally accessible life! He has the facts to back this up. Starting with pregnancy, he provides information to demonstrate that the common early pregnancy issues of tiredness and nausea serve the fetus’ need to be left alone to follow the genetic code for producing the body’s organs and systems.
The second half of pregnancy, he notes, is largely constituted by the development of the senses, which bring information to the brain, and – in the last months – the expansive growth of brain cells and the earliest phases of neuronal connection. He dispels the myths about commercial products aimed at improving IQ in utero, reviews findings on the adverse effects of stress, poor nutrition and a sedentary lifestyle during pregnancy, and reminds us that we are faced with certain peculiarities of human birth. Ever since we became erect, we have had to get that brain out of the pelvis before it is really ready.
Dr. Medina moves on to the relationship dynamics of the parents and/or extended family and its impact on the offspring brain. Most families experience distress when an infant arrives. Relationships are out of balance, demands increase, comfort is lessened and there are a lot of unknowns about the nature of this new being. Learning, he reminds us, takes place best when the number one brain demand is met: Safety. Situations fraught with stress and conflict are keenly sensed by infants and mitigate against a sense of safety.
Much of this discussion reinforces recent findings about the importance of vaginal birth, skin-to-skin contact and breastfeeding – chemical, mechanical and emotional needs that appear in the moments surrounding birth that, when met, set the stage for a bond of trust (safety) that enables development of higher functions. He reminds us that the best predictor of academic success is impulse control, a behavior that results partly from genetic predisposition, but is equally gleaned by observing adult behavior from the first moments of life. This sets the stage for much of the rest the book’s discussion using a Seed/Soil metaphor, akin to the traditional nature/nurture discussion – that some of what a child becomes is inborn, and some is environment.
Medina focuses on pregnancy through age 5. He notes that willing emotional responsiveness combined with appropriate demands or expectations appears to produce the most effective learning conditions in young children. Once they are in a safe state of mind/brain, infants learn quickly by watching [he cites Bandura]. Empathy and clear delineation of boundaries fall into line behind safety as features parents need to provide for healthy psychic development. Medina gives a number of examples, including one about empathizing with a child who needs a drink of water when there is none available by saying: Yes, how thirsty you must be and if I could, I would get you a big drink. I’m glad you let me know how thirsty you are so we can work on fixing that first chance we get. [NB: I have paraphrased here for the purpose of my own learning]. This sort of response feeds back the child’s experience, lets him/her know he/she is heard, supports the child’s state, but lets him/her know that the solution is still a bit off and that the parent expects the child to cooperate.
There are many topics covered with just this sort of technique…empathy and expectations. Among them is the description of positive and negative reinforcement. I find it is frequently difficult for parents to grasp the notion that if a child has a tantrum and the parent yells and screams and makes a big deal about it, that is positive reinforcement, which encourages the child to behave that way again. Whereas walking into another room and doing something else till the child is quiet – that is negative reinforcement.
I like Medina’s way of explaining it with science better than my own, which requires too much explaining about how nerve cells transmit information and how neural pathways become hardwired. His relies on more macro explanations (he is a developmental molecular biologist, so I really bow to him on this one). Basically, he tells us to praise behavior that is good and also to praise the absence of “bad” behavior, because praise for effort feels good. He also tells us to let the flow of events do the punishing. Either let a child continue to walk around in the snow with no shoes because s/he will figure out it hurts and is a terrible idea, or remove a child from the table when s/he refuse to eat because it is boring alone and s/he will figure out one can get hungry that way. The former is punishment by application; the latter is punishment by removal.
In case you are wondering what these rules might be, here they are:
The physiology of birth is complicated and still not well understood. Our subjective experiences of birth are richly textured. Personal accounts spill over with combinations of intense sensations, strong emotions, vague impressions and fine details. What is astonishing about Ina May’s Guide to Childbirth is how exquisitely she traffics in the language of an internal landscape to describe and explain this complex process. She truly captures the uniqueness and universality of birth. I am adding this book to the list of recommendations I give my clients, as well as suggesting it to other teachers.
Devoting nearly the first third of the book to positive first-hand birth stories provides a substantial grounding. Many times I found myself thinking: Yes! That woman is describing this or that essential bit of wisdom I want to impart to my clients. Let me point out one example.
On pages 24 and 25, one of narrators describes 3 slices of her experience. First, she got advice not to read or learn too much and not to make a plan because the more details she had in mind, the less likely she would get what she wanted. Too much reading would interfere with her ability to go with her body, she was told.
Second, she describes her experience of being in a tub and how she needed a lot of reassurance because she was both scared and aware of the great power in her body. The physiological phenomena occurring in her brain and motor systems indeed would be described as these subjective states of being. She definitely perceived what was happening.
Third, she describes turning from looking at things during a contraction to listening because looking made her think, while listening allowed her to feel and be instinctive, which felt better than thinking and was not so overwhelming. Thus, she was going with her body. We see her process in this narrative.
The stories all got me thinking about whether I am telling my clients too much or too little! One of my teaching goals is to insure that clients distinguish between strategy and tactics. Example: In the case of the story above, the strategy was to go with her body. The tactics she used were to not get too much information so she did not have too many expectations and to use sound rather than vision as her way of connecting inner and outer reality.
As a teacher, I see my job as insuring that my clients who might hear this story do not think that they must use sound rather than vision in order to go with their bodies, but rather that this was a piece of the process for this woman to reach her objective. It might work, but it might not. To get this across to clients, I tell stories about births in which I have been present when opposite tactics accomplished the same strategy or where the same tactic led to different outcomes.
The multitude of stories she presents in part I allow part II – the textbook part – to come to life. Whether she is discussing stages of labor, pain or release, she calls up stories and because the reader is already receptive to the notion of examples, the illustrations help the reader grasp whatever point she is making about the process.
However, the complex physiologic sequence of birth, including its variation from woman to woman, is less well served – in part because there is still so much to be learned about how birth happens, and in part because the birth community in general (whether having had professional or academic training) is not as well versed in normal physiology as it could be.
Let me focus on two issues: One is pain/pleasure and the other is hormones/behavior. Regarding pain/pleasure, Ina May makes a lot of important points, among them that how we experience an intensely sensational experience depends to a great degree on our preparation and that different women have different pain/pleasure experiences during birth. What she doesn’t tell us, though (and I suspect because it’s not common knowledge), is that some of the factors that control how we experience sensations are beyond our control. We experience pain/pleasure through a series of sensations, mental foci and behaviors such as breathing and muscle release. These nerve impulses are forwarded throughout the brain, some sensations taking on emotional content – some terrifying and others ecstatic – depending on the neural pattern. This is the basis of both the fear/tension/pain syndrome and the orgasmic pattern. But the precise pattern is dependent on genetics, as well as environment and behavioral training.
Some individuals become aware of sensations at a very low neurological threshold; others do not. Some individuals quickly find sensation of which they are aware to be uncomfortable or emotionally intolerable; others do not. Some people need comfort measures for their discomfort soon; some later, or not at all. Tolerance of what finally becomes pain or pleasure (or just a sense of stretching or motion through space) is also variable from person to person. Thus, the point at which we start has both biological and psychosocial determinants within this already variable process. In describing the variation in how women experience pain and pleasure in labor, Ina May is great at giving us examples and identifying psychosocial or cultural variations identified in research, but not so enlightening on the biology of why and how. This may or may not matter to the reader.
The issue of hormones that govern the vicious cycle we call labor is much less well understood. We have a pretty good concept of how prostaglandins, oxytocin and endorphins are stimulated and affect the process, and Ina May describes these in accessible ways. But while adrenaline is thought to inhibit early release of oxytocin, there has been little discussion of its importance in the pushing or ejection phase (she does cite Michel Odent’s notion that adrenaline might play a part in the ejection reflex when a labor is slowing down). But, there is little recognition outside of the physiology field that what happens in transition is our energy system shifting to a sympathetic [adrenal] source to give us more power to push. That’s why contractions change, why some women have a rest period between, and why – back in the day – we used to say to a woman having difficulty culling up her resources to push that she could get mad! Going through the effort and discomfort is key to inducing the rush of beta-endorphins. We know this, in a scientific way, from research that tells us runners who listen to music (relaxing and dissociative) experience lower rates of beta-endorphins at the end of the run than runners who do not listen to music, but work through the effort and discomfort they experience (stress inducing).
One of the things that makes Ina May’s book so valuable, in my mind, is the discussion near the end about midwifery, statistical support for natural birth and enumeration of the risks associated with surgical birth that are often glossed over when a family experiences dystocia. There are many elements within the birthing community striving to create an accessible spectrum of choices for birth. Let’s face it, birthing at home for low risk women, seamless transport alternatives, birthing centers attached to medical facilities, and readily available medical options when emergencies arise, would be a wonderful future. Birth attendants with universal acceptance, variable but rigorous training, and delineated scopes of practice would be ideal. Whether we get there remains to be seen, but I am glad Ina May exists, has her track record and is being listened to in this effort.
I have long wanted to write this post. Recently two articles appeared in the NY Times prompting me to move forward. One article dealt with how it is that ongoing vigorous exercise produces brain enhancements. The second article dealt with how running creates its “high” and explained why the resulting addiction is an evolutionary benefit for human survival.
Every day in Africa a gazelle wakes up.
It knows it must run faster than the fastest lion or it will be killed.
Every morning a lion wakes up.
It knows that it must outrun the slowest gazelle or it will starve to death.
It doesn’t matter whether you are a lion or a gazelle.
When the sun comes up, you better be running.
Abe Gubegna
Ethiopia, circa 1974
The pregnant mom who exercises vigorously and regularly — the one who runs or swims or does aerobic dancing — is not the one at risk, or whose infant is at risk, of a lack of tolerance for the rigors of labor or for lifestyle health problems. It is the sedentary or low activity mother and her offspring who are at risk. I have written at length on this reality in my chapter on Women and Exercise in Varney’s Midwifery.
This realization has plagued me for ages, and the two articles in the Times convinced me to make this statement, explain why it is true and exhort women of childbearing age to become aerobic animals.
In the contemporary world, we are not as active as previous generations. Few women exercise to the extent required to develop the capacity to withstand the rigors of birth. It is little wonder that so often health care providers hear that women are afraid to exercise, and childbirth educators hear that pregnant moms are afraid of birth and don’t have confidence in their ability to do it. There are solutions for these issues…
The biggest bang for the buck is aerobics. This gets almost everything that helps you in labor. It increases endurance, strength and range of motion. It improves breathing capacity (you get more oxygen + less fatigue). It reduces your need to tap your cardiac reserve (your body works hard in labor but not to the degree it must if you are not fit). Plus, regular participation in a good cardio or aerobic workout gives you the mental toughness and confidence you need to know that your body is capable of the work and the recovery — what we call body trust. Fit Pregnancy has discussed the myths surrounding how hard a pregnant woman can work out.
Learning useful positions and movements is extremely helpful. Be sure that your workout also includes strength and coordination movements — such things as squatting, core movements for pelvis and spine, and other motions that aid your progress in labor. Being upright and moving are keys to a healthy labor. These require strength and coordination.
Mental focus and being present teach you to work with your body. Activities such as relaxation training, yoga, pilates for pregnancy and dance help you develop the mental skills (mindfulness and deep breathing) that accompany your movement. Learn to recognize your body’s signals so you know when it’s time to push.
A truly effective use of your time is a one hour class a couple times a week that combines all these elements. We have known this for decades. The evidence is clear that it works. Keep moving…right into labor and birth!
So let’s get on with the topic of How to Get Pregnant, starting with why do we need to know this?
In the past few decades, the average age for a first pregnancy in the U.S. has moved from the mid twenties into the mid thirties. In the same time period, the facts of conception — sperm enters egg released in mid cycle, then zygote implants in the uterus, along with how sex allows this to happen and how to prevent it — seems to have disappeared from middle and high school health classes. If that weren’t enough, as women have become more and more essential in the work force, the cost of having children as well as starting later, have driven down the birth rate. Similar conditions exist in most developed nations, although teen pregnancy rates are lower everywhere else.
The birthing population has bifurcated — we see older women (over 35) and teens as the major groups having children. On the one hand we have been working to reduce teen pregnancy while helping older and older women become first time moms. To a certain extent, they need the same information; its just that with teens we use this information to prevent pregnancy and with older women we use information to help them increase their odds of getting pregnant.
Understanding the menstrual cycle, ovulation, charting temperature — all the basic techniques of using the “natural” method of birth control — have become the first steps of the how-to-get-pregnant coaches. Beyond this, a number of sites have their own essential lists to help women be healthy and ready. Sites such as gettingpregnant.com, pregnancy.org/getting-pregnant, and storknet.com/cubbies/preconception/ provide additional information. Many suggestions — things to avoid eating, what proteins are needed for ovulation, how to reduce stress, what to do if there are sperm problems, how to find IVF clinics, donors and surrogates — are addressed.
How effective are these suggestions? Well, research tells us they are somewhat effective. None of the sites I contacted answered my query about how they measure or assess consumer outcomes when following their suggestions.
An interesting article in the NY Times 9/1/2011, entitled Are You as Fertile as You Look? openened with this sentence: “FORTY may be the new 30, but try telling that to your ovaries.” The reality is that being under 35 is still the best predictor of how difficult it may be for you to become pregnant. As the article makes clear, looking 30 and being 30 are not the same thing. Even healthy living does not prevent the loss of good eggs.
So, what conclusions can we draw? First, even if you come from a “fertile family,” it may behoove you to have your children in your late 20s or early 30s. Second, if you are putting off having children beyond that time, ask yourself what extremes you are willing to go to to have your own biological offspring. And, third, consider adoption. Frankly, it would be wonderful if adoption were easier, but in the drive to conceive at later and later ages we see the hand of biology and understand why adoption is not easy: Our own offspring — our own DNA out there in the world — is a heady motivation.
If you are on the pathway of becoming pregnant, being under 35 is the best ally you have. If not, maybe some of the suggestions on the web will work for you. Whatever you decide, all the best.
One parting comment: Regular moderate exercise — while it helps you stay young and healthy — will not prevent your eggs from being popped out every month. It will help you have a healthy pregnancy if you conceive, so stay with it!
Sometimes it is fun to look back at the long road to the present! Recently, I was interviewed by our local online media outlet (the Branford CT Patch) and was really thrilled with the resulting story. It focused on the 30 year road of DTP and I thought you might find it interesting.
Here is the link to the story and the subtitle:
What started as a “fledgling experiment” has become one Branford woman’s life work.
Thank you for taking a look!
Still looking for new ways to develop core strength & coordination for new moms…start with the posture on the left (inhale) and move to the one on the right (exhale). Keep the transverse abdominal sucked in. Repeat.…
Recently, while talking with some moms in our postpartum exercise class, DTP’s Mom-Baby Fitness™ program, I realized it has been a while since I have addressed the notion of what we call “the 3rd body.” This stems from the idea that before you are pregnant, you live in your 1st body; then, while pregnant, you live in your 2nd body. After giving birth, many women feel their options are to try to get their first body back or live in what they are left with after birth. We suggest another way: create your 3rd body.
We discovered this 3rd body in working with women to gain the fitness necessary to have a healthy recovery and enjoy motherhood. What we found was that women were often becoming more fit than they had been before pregnancy, with less body fat and more muscle, yet their clothes did not fit the same. Sometimes the flaring of the ribs and/or hip bones made for a larger waist – despite less fat!
Many clients also feel a new, deeper sense of their core developed. In fact, over time they realized they actually liked this body better in some ways! After all, they came into the world with the pre-pregnancy body, but this body they actually created out of the profound experience of the physical self that pregnancy and birth provide. It extended the empowerment of birth into motherhood.
Extending this metaphor even further, of course, leads to the 4th and 5th bodies, if you have another child. Eventually, there are more bodies as women go through perimenopause, menopause, post menopause, and what I like to call the phenomenal wisdom stage. Each body represents a new opportunity to become someone strong and profound.
I figure I am to body #8 now, and in each stage I have found something incredible that I could not have at other stages. Long ago I gave up looking for my past bodies. Each one has been brilliant in some way, but in the end it had to be left behind if I was to enjoy life’s path to the fullest.
Living in the moment does require knowing where you are in time, space and energy. So, discard your past bodies with delight and move on. Use your energy to create yourself in the present.
It’s a process and you won’t fully live in your next body until you own the toll of the last one. A postpartum mom may experience hair loss, bigger feet, a mal-aligned spine, constant thirst if she is breastfeeding, exhaustion and a jelly belly. But, all these things will pass with time, if you eat right and exercise regularly. Oh, and you can bring the baby, who will have a blast meeting other babies!!
