Tips for Supporting an Exercising Nursing Mom

Tips for the Fellas and Family/Friends Who Want to Help Us Help Our Babies...with our boobies... (and I promise the full staying active while nursing article is in the works! Bare with me while I do some more research for it!)

Today my husband and I celebrate 6 years of marriage. Two marathons together, countless triathlons, two Ironmans on different continents, and one amazing baby girl...

Six years later, he is still the love of my life and my Iron-partner. I wouldn't have it any other way. I love that he understands why I work so hard to be a pediatric resident, why I get up at 2:30 in the morning to pump, why Ironman is important to me. I could not ask for a better partner. But even my husband has struggled supporting me as I continue to maintain an active lifetstyle while also nursing our firstborn. It's hard, folks! It's hard for me to do it, it's for me to tell him how to help me do it, and it's hard for him to feel like he is taking an active role in feeding and caring for our daughter when...he just doesn't have boobs. In some ways, I'm sorry, guys, you will never get it. This was a really depressing realization to me when Violet was about 6 weeks old. I was totally sleep-deprived and totally exhausted and totally IN LOVE with my little girl, and part of me was so angry when I finally got it--men will just never understand what it is like to be women and mothers. But that's okay because we will never understand what it is like to be in their shoes. They'll also never have the boob-baby bond. It's not fair on either front, if that makes either side feel better. But, I will say, all of us ladies could probably get a little better at telling our men and other partners what we need from them and how they can help because of course the loving fathers and family members that they are--they totally want to. I think this article says it best. 

But a few more specific tips on helping the nursing athlete:

1. Bring me water and a snack.

Pretty much any time you do this, it will be helpful. But especially while I am nursing and especially when I come in after a run and don't have time to shower or get food or water before that wonderful child of mine needs to be on my boob.

2. Understand that I get cranky when I don't sleep but also when I don't work out.

A happy mommy is made when you watch the baby for a while so she can a) go workout, b) take a nap, or c) both!

3. Help me realize when it's important to sleep and hydrate.

Even when I feel bad because I went back to bed after feeding Violet at 4am when I finally got her back to sleep and probably could have squeezed in a pre-dawn run and given myself some happy endorphins, Curtis never makes me feel that way; he reminds me that I need sleep, too. Being women who have this notion that we can do it all (we can't; we need you, obviously, but we think we can do it all anyway), we sometimes forget that you can't just keep going forever and ever on no sleep. You need sleep to work out your mental stresses (HELLO crazy REM-sleep dreams!), to let your sore or tense muscles heal and relax, to help your body fight infection, and--here's the kicker--to make milk. Dads/partners- remind the moms in your life that they need sleep, too. And, if you're awesome like my husband, when he couldn't wake me up the other day to kiss me goodbye when he left for work and I had finally gotten Violet back to bed at 6am, he left me a cold glass of water to drink when I first woke up. BEST. IDEA. EVER...especially since the hung-over feeling of the nursing mom who is also fitting in workouts includes the need for immediate caffeine (RESIST. It just makes you more dehydrated in the long run, since most forms are diuretics.) and the worst cotton mouth imaginable.

4. Understand how hard it is for me to fit in these workouts and be supportive and tell me that the time away from my baby is time that will make me happier and healthier when I come back to him/her. 

This is something that I have to do now for my husband when he knows he has to go do his 4-hour bike ride for Ironman training but doesn't want to because he hasn't seen me or his child all week and he just wants to be with us. I hold Violet up to him and say, in my best Violet baby voice, "It's okay, Daddy. I know you want to stay, but you have to go ride so you can be my IronDAD. We can play later." And he does the same thing for me by yelling at me to go run when I am heading out the door with my shoes laced up but come back to the nursery when I hear Violet cry.

5. Love me for the mom and the athlete that I am and tell me that I am doing a great job.

My husband is amazing at this. I love him for it. Because being a mom is so hard but so awesome. It is even more awesome with a caring partner. 

And maybe it's not your husband...maybe it's your mom, your mother-in-law, someone in your family, a friend. Ladies, we need to thank all our family members who help us take care of our kids because heaven knows we aren't doing this sh*t alone. But more on that next blog.

On deck: Staying Active as a Nursing Mom

Dealing with the Postpartum Flab

There it is. I said it. We all love our babies, we love being moms (most of the time), and we love our bodies for the miraculous creations they are, BUT, what's up with the postpartum flab, and how long should you expect it to stick around? Even the happiest of moms start to wonder when they can start wearing their old clothes, especially if you're past the stage of dealing with pelvic floor issues. It's hard to remember to be thankful for your body's ability to heal and produce milk for your baby after those first couple months when the glam of motherhood wears off and the pregnancy fat lingers. Don't get bogged down, ladies. Let's talk about the flab. 

I recently went to hang out with some new and old mom friends of mine, and one of them spoke with me about her concerns about losing baby weight. This is something that is often in the back of the mind for a new mother. Obviously, your child's health comes first and foremost, but part of being a good mom for your child is being a happy and healthy person. A lot of us feel better about ourselves if we can fit into our old clothes, do the athletic things we used to do, like what we see when we look in the mirror, etc. All that is fine and good, but let me remind everyone (and myself included, we all need reminders) that getting back to your old body and self is something that is a process and nothing you can do in those first months after your child is born, for most people. It's not healthy to lose all your baby weight at once because your body is restoring essential nutrients, finding fluid and hormonal balance again, and trying to prepare for the next phase of life. The transition from pregnant woman to mother doesn't happen any easier physiologically within your body than does the mental and emotional transition from pregnancy to motherhood. They both take time, so allow yourself to take that time, and try to enjoy this miraculous journey!

All that being said, after 2 to 6 months postpartum, it's okay to start thinking about changes to your diet and activity plan that can help you lose the weight you gained during pregnancy. At this point, most moms may have about 10-20 pounds left to lose, and these can be the hardest ones. Nursing mothers face the greatest challenge because we are trying to eat and drink enough to provide our baby with the proper nutrition and hydration he or she needs to grow and develop. This is so hard ladies, but it is an amazing gift you are giving your child. Whenever I feel a little bogged down about the progress I've made in physique or fitness because I feel like I have made some changes but should be further along, I just look at my baby girl and remember how amazing she is and know that if I do nothing else in this world, at least I am doing my best for her. Sometimes that works. ;-)

I'm now 11 weeks postpartum and counting, with 10 pounds left to get back to my pre-pregnancy weight but still 18 pounds shy of Ironman weight. So I'm not back either, and like I said, sometimes it's hard, and we'll go into more specifics in the upcoming blogs, but for the most part I think my advice is to try to find something each day that will give you energy and make you happy so that you can be the best mom you can be, especially on those days when you're feeling a little down, a little tired, a little flabby. 

A few general tips for getting back into your old jeans (PLEASE don't try them on for the first 3 months. Just don't. I would even venture to say don't try them on for 4 months...6-9 months if you are nursing. Just give yourself a break!) 

***Nutrtion, nutrition, nutrition. As my obstetrician told me during pregnancy when I voiced concerns about putting on weight too fast, "Just cut out the crap." Eat healthy for you, healthy for your baby if you are nursing, and forget that other stuff. Get MyFitnessPal or a similar app and log calories, if that's your thing. It's a little more complicated than limiting your calories and can be tricky if you are nursing, so we will have a separate blog on that.

***Get SLEEP whenever possible (I know, IMpossible.) Cortisol is not your friend, and it ramps up when you don't sleep and are stressed out (Oh, so, every new mom, then, right?) and helps your body store fat. The problem with this is that maybe you don't want to store fat, you know?

***Find a way to get ACTIVE...even if that's just walking or dancing with your baby!

And in the meantime, fight the flab funk with these...

The Slim Six Subtle Ways to Trick Your Brain Into Feeling Better About the Flab!

1. Take a nap! 

Always a good idea to sleep since sleep deprivation makes reasonable people unreasonable and you'll feel better about yourself and your life if you sleep, plain and simple.

2 Take a walk! 

Walk away your worries, get fresh air, get your baby outside too...but remember sunscreen for you and protective clothing for your baby ;-)

3. Call a friend.

Venting or getting a fresh positive outlook- both are super helpful! Call a friend while walking = added bonus!

4. Dance with your baby

Sometimes for me, even when I don't have anyone to watch Violet and can't really fit in a workout at home while she is napping, just holding her and singing to her while we waltz or meringue around the apartment seems like the best thing in the world. If nothing else, play music and dance while holding your baby. I think the feeling I get from it could be bottled up and sold as an antidepressant.

5. Clean.

Vacuuming with Violet!

Can't get out of the house with baby because it's raining? Feeling dreary and overwhelmed by your home's chaos and mess and want a sense of control on how just ONE thing is going? Throw that baby (don't throw your baby...you know what I mean, gently place your baby) into a carrier and vacuum the house! This is the best. At almost 3 months of age, Violet loves it, and I'm pretty sure she would've loved it a month ago during that colicky time in the evening. White noise for the baby, being close to mommy, hearing her heart beat, gentle bouncing...this is golden. And it is golden for you because it's hard to feel down or fat when you start cleaning--the productivity is something that is better than the "selfish" act of going to the gym and being away from your child (maybe you struggle with this, I often do), and you will get your heart rate up, maybe even break a sweat, and definitely burn a few calories along the way. 

6. Try the following mom-baby workout :-)

I thought a sample workout plan for this point and also a few more pointers might be helpful. I forgot something REALLY important last time- BODY GLIDE. I didn't forget it; I just forgot to mention its necessity in the blog post! Triathletes will understand, but just so you know, there are all kinds of parts of your body rubbing together that maybe didn't rub together before, you know? So don't forget the body glide +/- chamois butter if needed!

I came up with this short workout for mom and baby a while back when I just didn't feel like leaving Violet any earlier before my 12-hour ER shift, so running just wasn't going to happen that day. It was also the kind of shift where if I wanted to go run beforehand, I would be leaving Violet with someone else during her colicky time, and you hate to leave your baby when she's unhappy, but you also hate leaving an unhappy baby with someone else, so that's how this workout came about. The bouncing really helped her colic, and it was fun to do something together. She actually loves it more now that she is older, but we did it for the first time at 8 weeks. Obviously this isn't as good as going for a run, and it's not as good as doing weights on your own once you are up to doing heavier weights, but for 8-12 weeks postpartum, why not? 

Ideally you would add stationary bike 15-20 minutes while your baby is in his/her swing/bouncer/crib...

warm-up then
3 x 12-15 front squat with baby upright and your upper arms parallel to floor
3 x 12-15 front shoulder raise with baby in same position
3 x 12-15 bench/couch push-ups (with baby in bouncer)

3 x 12-15 floor bench press (great for tri's and chest and fun for baby too!) with baby facing away from unless you want to risk getting vomited on haha (I have tried both ways and no vomit yet! You get to see the facial expressions if the baby faces you.)
3 x 30 sec plank (if you can do a true plank for 30 seconds at this point, you are awesome!) alternatively try crunches while holding baby

you can also do them as a circuit, ideally adding an agility section like mountain climbers or high knees :-)

In honor of the slim 6, I ran 6 miles today. Didn't wear body glide on my inner thighs. Big mistake. And for those folks who think I've managed to find some kind of life balance as a new mom, let me just assure you--I haven't. I really don't know if I brushed my teeth today, but I fed my baby, and I ran 6 miles (because Violet has an amazing Nana who came over for me to do that!). That is all. And today, that's enough.

Proof of how little balance I have is shown in the fact that although I have been working on several blog posts for you guys, this is the first one I have fully finished since July 1st. A month apart! Yuck! Hopefully we can do better than that!

On Deck: 

-the nursing athlete

-pelvic floor syndrome

Postpartum TriFit Update

Long time, no see, folks! After 29 hours of labor, I reasoned that a little break was warranted, since that amounts to the time spent doing 2 Ironman races! Violet is 7 weeks old now, and I have gone for 3 runs in the last week. I honestly thought I would be running sooner than that since I ran up until 39 weeks while pregnant (just swimming and walking once post-dates…mostly out of exhaustion and this weird feeling in my pelvic floor when I was running that last time out). I kind of assumed I'd be ready to rock 'n roll by 2 weeks postpartum after a vaginal delivery, probably because I read blogs/articles about women doing Olympic tri’s 5-6 weeks postpartum; clearly, everyone is different. I didn't really think I would listen to my OB when I called to ask about exercise and they told me to hold off until my postpartum check-up. Good thing my body knew to remind me. REALITY CHECK! Just walking 4 days out from a vaginal delivery was uncomfortable. Your body makes leaps and bounds by 2 weeks postpartum, and I was even napping a little by then and getting some sleep, so I thought about running (CRAZY IDEA), then got mastitis (I don’t recommend it), then recovered, then had another setback, and this all brought me to the 6 weeks postpartum that is recommended anyway. Go figure! Maybe doctors know what they’re talking about? I won’t tell anyone if you won’t. ;)

But, seriously, folks, having a baby—it’s kind of a big deal—maybe take some time off for once! If you have a more complicated delivery like I did, your obstetrician may tell you not to exercise for the first 6 weeks postpartum. This is always the case with a C-section because it is an abdominal surgery and the abdominal wall muscles need time to heal. Unless you have had a C-section or your doctor tells you otherwise, it is actually safe to go back to light exercise as soon as leave the hospital. Those that are very athletic may have to adjust their perceptions of what light exercise is--it is actually walking, swimming, stretching, yoga, Kegels (we will be talking a lot about this in a future blog!). And then you can progress from there, depending on how you feel.

So far, it’s really amazing and refreshing to be back to running. I miss my time with Violet, but it rejuvenates me so much to get my fresh-air-sunshine-sweat-endorphin-high, and then I come home to my baby girl and have so much more energy to take care of her, and I just fall in love with her all over again. Being a new mom is challenging, and it’s hard to remember the little things you need to do for yourself (like brush your teeth or eat a snack…or, in my case, go for a run) that will enable you to be a better mom and take care of your child. That being said, it will be interesting over the next several months as we roll through some of these postpartum fitness topics to see just how much fitness I am doing! I obviously want to lose more of my pregnancy weight (stay tuned), and I just miss feeling like a triathlete, to be honest. BUT, I will also be a full-time mom, full-time resident, and full-time Ironsherpa for my husband. I hadn't planned on doing very much endurance until after Curtis's race in November because we have decided to alternate who is racing so the other person can be more dedicated at home. I am, however, recently thinking that it might be longer than I thought. Violet is just so fun! And I am already missing so much time with her now that I am back at work. I mean, could you leave this face every day? 

EARLY POSTPARTUM EXERCISE TIPS:

-PUSH IT UP!

Push-ups strengthen your arms for holding your baby as he/she gets heavier and for getting rid of that pregnancy flab. There’s such a thing as mom strength and it comes from toting your baby/kid around as he or she gets bigger, and if you maximize the fun bouncing and swinging things you do, you’re golden…so pick your poison- push-ups to prepare or workouts later :)

-KEGELS!!!!

Ugh...these are super important. More on how to do them and why you should in an upcoming blog post.

-ABS

You may still have a space in your abdominal wall called diastasis recti where the muscles haven't come back together yet. Let's work on it!

Sometimes we use our Ergo in the apartment
when Violet gets very fussy...movement makes
everyone feel better, it seems! Not just adults!

-WALK!

One of my favorite things to do so far is to put Violet in a Boba wrap or Ergo carrier and just go for an adventure--leaving the apartment for an outdoor walk is an adventure when you're on maternity leave and also when you're a newborn, it turns out! This is really one of the easiest and most fun ways to get back to light exercise postpartum--go for a walk with your baby. It's great for both of you! A properly fitting stroller to accommodate a newborn without head control is also fine to use. But the great thing about carriers is that they remind the baby of being in the womb, similar to skin-to-skin time--they can hear your heartbeat and they are warm and can smell mommy! Women all over the world carry their babies on their person- see what all the fuss is about. Stroller or carrier, the best part is that both of you get fresh air. My mother-in-law swears Violet sleeps better after getting fresh air during the day. It's just healthy, folks, and a great way to fight baby blues and ward off postpartum depression.

-SUNSCREEN!

Remember a hat or covering clothing for your baby if you're taking him/her with you outside. No sunscreen for your baby until 6 months of age. This is because clothing is more protective for sun exposure anyway and new baby skin is oh so sensitive.  Sunscreen for you-- always, but especially postpartum. Any dark spots or melasma that you have from the hormones of pregnancy are only going to worsen if you go out in the sun without skin protection. So, hat- yes, glasses- yes, sunscreen everywhere- yes.

-HYDRATE/SLEEP/REPLENISH…

More on this when we talk about nutrition and exercising for the nursing mom, but even if you’re not nursing, err on the side of too much fluid intake. Another concern is sleep. It can be non-existent early on with a new baby. I know for me I felt like I adjusted to a much lower level of sleep than I was used to, especially once going back to work and coupling residency hours with mommy hours, but, remember that regardless of what you adapt to, your body will train and recover better with more sleep. If baby had a bad night, maybe skip the a.m. workout in favor of some extra shut-eye—that is, if your circadian rhythm isn’t totally caput like mine is! Last, remember to eat frequent nutritious meals to keep up energy and recovery; you have a lot of nutrient stores to replenish. You’re still anemic, whether it’s functional anemia or just a recovery anemia from childbirth, so continue taking those prenatal vitamins to pick up the slack.

-WATCH OUT, but enjoy the journey

My husband always makes fun of how much I fall—while walking, while running, while cycling. (I don’t fall in the pool, but probably only because it’s not possible!) I never really fell walking before pregnancy. There’s something about the increased joint laxity and the changes in your center of gravity that really throw you off! Now, postpartum, it’s time to get used to a modified body—it isn’t quite your pregnancy body after those first couple weeks of battle-scar recovery from birth and it isn’t nearly your pre-pregnancy one yet! Your body still has the increased joint laxity that it did during pregnancy when you are postpartum, so watch your footing even while walking and especially once you start running and biking. Getting the most sleep, hydration, and nutrition possible prior to and after workouts in prep and recovery will help you be alert and focused and avoid any unnecessary injuries. Your body has to re-learn your pre-pregnancy forms for running or any other exercise, so give it time to take shape and find its balance. Remember, this will be a journey back toward previous fitness.

-Swim

Probably safe earlier on than running is. Make sure your perineal tears or episiotomies have completely healed. Think about it- you wouldn't swim with an open wound, would you? For most people, I think this means wait at least 2-3 weeks.

-Bike/Run

Listen to your doc and then to your own body about when you are ready for these. I'm not too jazzed about getting on a bike anytime soon and will just settle for running now. Old-school obstetrical thinking is to wait 6 weeks to run since the uterus hasn't gone back to normal size until then. This doesn't make a lot of sense to me as an argument since I ran with a HUGE uterus and a full-term baby in it during pregnancy, but whatever. Listen to your doctor, and if you're not going to do that, at least listen to your body. To quote one of my mentors, "If it feels squishy, then maybe back off a bit." A lot of the new obstetrical thinking is to allow women to exercise after uncomplicated deliveries as soon as they are feeling up to it, within reason. Remember that you need your pelvic floor for the rest of your life and don't want to be incontinent during running or other everyday life activities, so taking 6 weeks off and spending that time with your baby really isn’t going to kill you (It didn't kill me.), especially if that’s what your body is telling you to do.

After a long winter and 6 weeks without running, I have such an endorphin high every time I go out for a run in this glorious, sunny summer we are having. It gives me so much energy to come back to my daughter, and there's no better motivation to finish strong than knowing your daughter is waiting at home for you (ok, for your boobies, but still). It'll be a while before Violet is old enough to go for runs in a stroller with her mom and dad and even longer before she's out doing her own fitness...but more on running stroller safety and fun topics coming up soon! I hope you have all missed the blog because we have some exciting posts on deck and lots of ideas and inspiration for the future! For those of you who haven’t checked the blog in 2014, you have a few posts to catch up on and keep you entertained, but some topics to look forward to in the coming months are:

For mommy:

- IT Band Syndrome
- Patellofemoral Pain Syndrome (we did this one last blog, but let me assure you it still applies postpartum, so read up!)
- Pelvic Floor Syndrome

For mommy and baby:

- Exercise & nutrition for the nursing mom
- Running stroller safety

For baby/kids: 

- Intoeing

- Neurodevelopment and sports training

So stay tuned!

Some helpful postpartum links for now:

http://www.webmd.com/parenting/baby/tc/postpartum-first-6-weeks-after-childbirth-recovery-at-home

http://www.whattoexpect.com/first-year/week-3/exercise-saddle.aspx

The extreme:

http://www.endurancecorner.com/Mimi_Winsberg/postpartum_exercise

A step-by-step slow progression:

http://www.runnersworld.com/womens-running/up-and-running?page=1

Other perspectives/blogs:

http://triathletebaby.blogspot.com/

http://www.runnersworld.com/womens-running/does-having-a-baby-really-change-everything

Patellofemoral Pain Syndrome

I thought we could take a little break from this crazy focus on perinatal fitness and do a blog on patellofemoral pain syndrome. But, just so you know, pregnant women get this too!

What is PFPS?

Patellofemoral Pain Syndrome is anterior knee pain in the area of the patella that is also referred to as “runner’s knee.” PFPS is a diagnosis of exclusion where other etiologies for knee pain should be eliminated by your physician on physical exam. For the practitioners out there, patients present with anterior knee pain involving the patella and surrounding retinaculum (see figure). They often complain of a “giving way” sensation that is actually secondary to muscle insufficiency or sudden pain. Patients may describe something known to practitioners as +theater sign—after being seated for a long period of time, patients experience frontal knee pain upon standing.

What causes this?

Patellofemoral pain syndrome is caused when the patella does not track correctly as the knee is being bent and straightened. Improper tracking leads to cartilage damage and worsening pain and inflammation. It’s very common in people who focus mainly on one sport in high volumes and is also very common in adolescent girls, likely secondary to increased Q angle that we talked about in the ACL blog. Specifically, when the knee is bent,

the 4 muscles of the quadriceps and the supporting muscles of the knee joint have to fire in balance to pull the patella in a straight line along the groove formed by the femur and tibia. In PFPS, the most common example of imbalance of muscle strength is that the lateral structures of the knee (vastus lateralis, iliotibial band, and lateral retinaculum) are tight and the vastus medialis oblique muscle on the medial (inside) of the knee is weak.

Physical Exam:

On examination, patients have tenderness to palpation on the medial and/or lateral patella, and there will be no meniscal tear signs (negative McMurray’s) or ligament instability (negative anterior drawer or Lachman test). On squat test, you will see valgus deviation of the knee, indicating weakness of the hips and quadriceps muscles. If this is a chronic problem, you may see atrophy of vastus medialis oblique on physical exam.

What can you do if you think you have PFPS:

See your doctor for a physical exam and to rule-out any serious knee pathology. Once diagnosed, treatment involves exercises to improve strength in the hips and quadriceps muscles and to increase flexibility in the quadriceps and hamstrings. It is also important to ice post-activity to help with inflammation that causes pain. NSAIDs like ibuprofen (Advil/Motrin) or naproxen (Aleve) can be taken to help reduce inflammation and pain. Relative rest from activities that worsen the pain is recommended until strength and flexibility enables the athlete to return to sport/play/recreation. BUT, you can’t just sit on the couch all day because you will experience +theater sign! ;) So, light biking or elliptical 3 x a week for 20-30 minutes to start is recommended to improve circulation and active range of motion of the knee joint, followed by some of the strengthening and flexibility exercises in the following links or prescribed by your PT or MD. Also, ask yourself, when was the last time you changed your workout/running shoes? If you’re running, you need a new pair every 300 to 500 miles or every 6-12 months. (I added the “to 12 months” part because I am the worst about this and don’t get new shoes often enough.) Orthotics may also be indicated if you are an overpronator.

My fave exercises for this:

v  Warm-up/range of motion: 20-30 minutes light stationary bicycle

v  Flexibility: IT band, quad, and hamstring stretches

v  Strength: quad sets/squeeze, bridges, planks

o   Quad sets – tighten quad muscles while you straighten the knee (can do these watching TV!)

o   Abduct knees on bridge and squeeze exercise ball to recruit abductors

o   Extending a single leg at a time on bridge and adducting leg on side plank can make these more challenging as you get stronger

v  ICE! Ice is the best exercise because you get to do it watching TV and relaxing ;) It’s also great medicine and if you do this, you might not need NSAIDs!

ENJOY FOLKS!

Elaborate exercises from Princeton: https://www.princeton.edu/uhs/pdfs/Patello-Femoral%20Pain%20Syndrome.pdf

Uptodate hand-out for patients: http://www.uptodate.com/contents/patellofemoral-pain-syndrome-the-basics?source=search_result&search=patellofemoral+syndrome&selectedTitle=2~41


Just a disclaimer: I think I am taking a maternity leave from this blog sometime soon. I am feeling really pregnant but still running up to 6 miles on days when I feel good (don't be too impressed- on other days I run maybe 2 miles, go for a walk, or just stretch and go to bed!), now starting to enter month 9. Baby will be arriving any day over the next few weeks, so it may be a while before the next post, but look forward to some great stuff on post-partum exercise circa summer 2014.

The 40-Week Training Plan: Phase III - Musculoskeletal Changes During Pregnancy

Welcome to the home stretch, ladies!

Third trimester – week 27 to week 40

The guidelines that are out there for this trimester basically go along with those for the second trimester. In addition, this trimester, the recommended extra calorie intake is an additional 450 calories per day, so make sure you are keeping a good calorie balance with expenditure to ensure you are still getting the extra calories your baby needs to grow.

The challenges of continued exercise during this trimester:

1. extra body weight = musculoskeletal pain of all kinds!

2. energy level

3. GI symptoms – return of nausea, worsening reflux, indigestion, constipation

4. frequent urination

5. Braxton Hicks contractions

6. Overheating!

7. Anxiety

Some Tips:

1. Cut back mileage if still running.

2. Short workouts are your friend! They provide you with energy without taking up too much of your free time that you should also spend resting when possible.

3. Try walking and jogging intermittently to maintain exertion without getting out of that elusive "moderate" zone.

4. Plan a run with available pit-stops for those frequent bladder issues.

5. Take up swimming or water aerobics classes if you haven't already. Weightlessness is heavenly, especially during pregnancy, and especially towards the end. It's also a good way to stay cool!

6. DRINK water, water, and more water. (Even though it makes you pee more. Dehydration is not any athlete’s friend, but it is certainly not a pregnant woman’s! And it worsens constipation, so DRINK UP!)

7. Listen to  your body and take care of your mental health, whether that means exercise or rest ;)

                                                                                                                                          

How's it going?

32 weeks, 2 days, first senior 24-hour call in the NICU. Last
year at this time I was getting up at 4:30am to run pre-shift.
Now I just got up for a strength workout. And baby was
happy with the extra sleep! :-P

32 weeks, 2 days, and counting… Just two weeks ago, I thought I had gone for my last run, thanks to some lovely pain in my right hip. I took a week off and did a LOT of pool time, and it helped my back and my SAD (seasonal affective disorder, see this old blog post regarding SAD), but I was still waking up every night with AWFUL joint pain in my hip (also in my ankles and knees, but the hip was much worse). Then last week when the snow had finally melted a bit, I decided it would be a shame not to try for one more run to see how things were going. So I went. It was short and slow, but it was okay. So I am gradually back into running but not making myself any promises about how long I will keep hitting the pavement as this pregnancy progresses and as my prenatal body feels more and more foreign and estranged from my triathlete one…and also now that I’m doing 24-hr calls every 4^th night in the neonatal ICU.

So here it is folks—the fun of the third trimester! Just 5 weeks in, I have to say, I’ll take GERD and indigestion over joint pains any day! I tried to compare my joint pain while running this pregnant to the pain I experienced running the marathon portion of an Ironman after wrecking my bike. I will just say that it’s a different kind of pain now, and I don’t get a medal for continuing to train through this, which makes my motivation to run a bit different. It’s not that I need a medal to run through pain, but I do want to do what’s best for my baby and for my health so I can be a good mom later, and I’m training for a different kind of race these days ;)

Here are just some of the symptoms that women experience secondary to the musculoskeletal changes during pregnancy:

1. Back pain
2. Joint pains
3. Muscle strains
4. Nerve pain

Back pain –

Most back pain during pregnancy is due to mechanical factors resulting from altered posture, muscle weakness, joint laxity, and/or vertebral facet joint irritation. Fluid retention within connective tissue can also contribute to the pain. Yay. I haven’t tried one of those pregnancy sleeping pillows yet, but there is a method to the madness, folks. A pillow to support the weight of the uterus and a pillow between the legs relieves much of the pressure on the back, and as always, lay on your side to provide the best blood flow to the baby and to decrease risk of IVC syndrome as we talked about in the 2^nd trimester blog post.

What you can do about it (ACOG recommendations to prevent back pain):

● Wear low-heeled (but not flat) shoes with good arch support.

● Get help when lifting heavy objects.

● Place a board between the mattress and box spring if your bed is too soft.

● Squat down, bend knees and keep the back straight when lifting.

● Sit in chairs with good back support, or use a small pillow to provide support.

● Sleep on the side with pillows between the knees for support.

● Apply heat, cold, or massage to the painful area.

Pain in joints – pelvis, hips, knees, ankles, shoulders, you name it!

30 weeks... a day I thought was my last run
during pregnancy, but it wasn't :)

While relaxin is to blame for pelvic girdle pain (pain in the 3 joints of the pelvis including sacroiliac joints—it’s ok, it helps your pelvis open more to deliver your baby!), laxity in other joints during pregnancy is actually thought to be due to elevated estradiol and progresterone levels, not relaxin. Along with increased joint laxity, the force across some joints is increased up to two-fold during pregnancy. Yowza. As a person with 2 prior knee surgeries and osteoarthritis from the age of 22, I have to say that I really didn’t expect my knee to make it this long. It’s starting to hurt in the exact spot that used to during college ball, and I know it’s the weight gain and the extra force, coupled with the fact that I haven’t been very dedicated to strength training during pregnancy, so you guys and cyberland as my witness, I am going to have a goal to be more dedicated to strength training these last 8 weeks and see how the joint pain does. It’s partly because of how much strength I feel like I’ve lost in my legs and partly after hearing my new-mom-friends speak about how traumatic labor and delivery was for them because they just felt like their whole bodies were sore for days after labor. I’m sure a lot of that is all the adrenaline and hormones that it takes to push a baby out, but I feel like I owe it to myself to find the time for some strength training to do what little I can for a better delivery for this baby girl. As it goes now, I wake up at night with pain in different joints. Maybe it’s time to finally buy one of those pregnancy pillows? But somehow I feel like it wouldn’t work proportion-wise for a 6’2” woman! Whatever you choose, remember that moderate exercise, light stretching, Tylenol, icing, changes in position throughout the day if you have a stationary job, and time off your feet if you have an active job are all things that are recommended for joint pains during pregnancy.

Leg Cramps and Muscle Strains

Daily exercise to improve circulation and stretching is recommended to prevent leg cramps, but you may get some anyway. Try hot showers, ice massage, and increased hydration to help. For muscle strains, we all know that we’ve had them before, but your body is changing and your technique and form change so much during pregnancy that you are using muscles in different ways. A significant increase in the anterior tilt of the pelvis occurs, causing more use of hip extensor, abductor, and ankle plantar flexor muscles. Stance and gait widen to maintain the movement of the trunk. And I must be doing the weirdest stride ever because I feel it in my hip flexors! Go figure! What all this means is that you may feel some muscles pulling in weird ways, and if something goes too far, remember the kind of race you are running these days- a race for two, not an individual endurance or speed race, and take time for rest and recovery. Ice and foam-rolling for myofascial release and decreased inflammation are your friends because anti-inflammatory drugs are off the market during pregnancy. NSAIDs like ibuprofen are particularly dangerous for baby kidneys, so avoid these. Tylenol is considered safe for pain during pregnancy, but let’s be honest, folks, Tylenol does not work that well for musculoskeletal pain and inflammation, and some studies now link Tylenol use in pregnancy to Autism. (What isn’t linked with Autism these days? Tylenol is still a class B drug, so obstetricians are fine with you taking it for pain during pregnancy if you want to!)

Nerve pain

Numbness and tingling secondary to nerve impingement can be a worrisome and not fun part of trying to stay active during pregnancy. Some people experience carpal tunnel syndrome (fluid retention during pregnancy can cause compression of the median nerve as it enters the carpal tunnel of the wrist) and De Quervain’s tenosynovitis (similar pathophysiology but this one is the thumb). Others have issues with sciatica (inflammation and/or compression of the sciatic nerve, usually manifested as low back and buttock pain that radiates down the leg and can causes numbness and tingling in your leg/foot) because of baby’s position or because of the adjustments the body makes to accommodate the increased weight and laxity in the pelvis. For the medical folks out there, it’s important to assess all patients with back pain for any neurological sequelae. Nerve root irritation can be assessed by muscle tenderness at various levels: S1 (calf muscles), L5 (extensor hallucis muscles, which affect the toe-walking test), L4 (quadriceps and anterior tibialis, which affect heel-walking with foot dorsiflexion). Also MDs, check for significant muscle weakness, sensory impairment, or deep tendon reflex changes that can suggest radiculopathy.

Where are we going from here?

One of my worries used to be that I would be post-dates and would not go into labor no matter how much activity I did. They tell women who are near their due dates to start walking every day to initiate labor, so my thought was, what do women do to initiate labor when they have already been running during pregnancy? :-\ I thought I'd need to do some crazy LSD's (long-slow-distance runs, not the psychotropic drug for those of you thinking I'm insane) at 39 weeks to get the baby out. But, I’m not as worried about this now, mostly because I’m really not certain how much longer I’ll keep going with this. I feel so much better if I get activity, but it is getting harder and harder to do work activities and household chores these days. In short, I am 8 months pregnant...and I'm a resident. Extra sleep might make me change my thoughts on staying active, but sometimes sleep is just more important now. I know, super annoying!  At any rate, each time I do head out for a run, when I feel too slow or my running clothes don't fit or I wonder if I am totally destroying my stride and picking up bad habits, I just think that it could be my last chance to run before the baby comes...and about how special it is to share the intimacy and stream-of-consciousness thoughts of my running with her...and I let all my anxieties about the stupid stuff from the day and the worries about tomorrow fade. Yes, I am getting a little awkward these days, but, I’m here, my baby is still growing and active, and after admitting ex-28-weekers, I can only say that I’m just so glad she’s still going along for the ride and staying in the incubator for now!

Interesting tid-bits and references:

Ponnapula P, Boberg JS. Lower extremity changes experienced during pregnancy. J Foot Ankle Surg. 2010 Sept-Oct;49(5):452-8.

Riberiro et al. Static and dynamic biomechanical adaptations of the lower limbs and gait pattern changes during pregnancy. Womens Health. 2013 Jan;9(1):99-108.

Thein-Nissenbaum JM et al. Low back and hip pain in a postpartum runner: applying ultrasound imaging and running analysis. J Orthop Sports Phys Ther. 2012 Jul;42(7):615-24.

Myths & Facts on Exercise During Pregnancy

Another running pregnant blog

Next up: Patellofemoral Pain Syndrome!