Proper self-care in pregnancy forms the foundation of a natural birth. Unfortunately, in modern time-starved obstetrics practices, few women receive counseling about the importance of proper diet and exercise unless a problem, such as gestational diabetes or excessive weight gain, has already developed. Few women are encouraged to attend childbirth preparation and the western medical viewpoint acknowledges the mind–body connections only to a limited extent, so an even smaller number of women receive any instruction in stress-reduction techniques or emotional preparation for either childbirth or parenthood. There are three hurdles to overcome in order for women to begin receiving this type of counseling in pregnancy and apply it to their pregnancy. First, as with all lifestyle modification initiatives, health care providers must begin to appreciate its value and believe it is something they can influence. Second, outpatient care structures must be modified to accommodate the time required to address these issues. Most physicians and midwives have 15 minutes or less to spend at each antenatal visit. This leaves barely enough time to perform a quick check up and address any immediate questions or concerns. Finally, women themselves must be willing to devote time to both receiving the education and committing themselves to making recommended changes in their own lifestyle. This should be a priority for all women, but for women hoping to have a natural birth, it is an essential part of making their plan a reality.

Proper Diet

Eating right, in general, seems like such a simple concept; however, the sheer volume of contradictory advice on proper diet and the numbers of individuals struggling with excess weight are a testament to just how difficult this is to achieve in our modern society. This difficulty in maintaining a healthy diet has a multifactorial etiology and pregnant women are not exempt from the problem, despite usually having a strong motivation to do what is best for their baby. Nearly 50% of women exceed their weight gain recommendations and women who start off pregnancy overweight or obese are even more likely to do so.¹ One reason for the challenge is that access to quality produce and fresh, unprocessed, whole foods is limited for many individuals on the basis of income and/or geographical location. Food preparation is also incredibly time consuming and with the majority of pregnant women working full time, as well as carrying an uneven burden of the household responsibilities, it is understandable that fast and easy is often prioritized over healthy in the hectic day-to-day schedule of most pregnant women. Furthermore, food consumption is tied to both cultural and emotional patterns that are deeply ingrained and challenging to modify even when one knows what they should be doing differently.

In regards to pregnancy specifically, there is a plethora of information regarding what one should or should not eat. Countless articles addressing diet are published in both online and print publications geared toward pregnancy. A simple Google search for books about diet in pregnancy yields over 15 separate results, which are in addition to the individual chapters that are devoted to diet in nearly every general pregnancy book. Family members and friends often take unique liberties with pregnant women in telling what they should and should not be eating. Many women, inundated with this unlimited supply of “helpful” diet advice, find themselves tuning out, skipping over the nutrition chapters in their pregnancy books, and frustrated by their inability to forego the cupcake in the cafeteria or the ice cream in the freezer. Yet, the voice that is often remarkably quiet in this steady stream of information is the woman’s own health care provider and, interestingly, most obstetricians actually receive little to no instruction on proper diet guidelines in pregnancy, which may explain their reluctance to discuss the topic. Midwifery care is more likely to include dietary counseling, but time constraints are often limiting.

However, studies have shown that health care providers are able to bring about positive changes in their patient’s diets and accomplish what all the books, magazines, and mother-in-law nagging often cannot.² These diet conversations do not have to be complicated or overwhelming for either the patient or the provider. Women should be provided with some general guidelines about choosing healthy foods, which can be summarized in four simple “rules” of pregnancy eating:

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   Maximize protein intake: A pregnant woman should eat at least 65 g. of protein daily. This means she should be eating protein at every meal and one or two protein-rich snacks, such as nuts, yogurt, or cheese.

   
   
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   Maximize vegetable and fruit intake: Women in pregnancy should eat fruit or vegetables at every meal, of varied types and colors, and incorporate produce into their snacks as well. Eating a rainbow maximizes nutritional intake. Smoothies can be an easy way to get extra fruit and vegetables, but should not be made with fruit juice or other sources of excess sugar.

   
   
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   Limit carbohydrate intake: Carbohydrates should be limited to roughly a cup per meal and should be brown versus white, whole grain versus white, starchy, and processed. True sweets and treats should be kept to a true once or twice a week treat.

   
   
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   Maximize water intake: Water should be the beverage of choice and pregnant women should have at least 2 L of water per day, with increased amounts during exercise or heat exposure. Fruit juices or sodas should be considered sweets and treats, not a daily beverage.

Women should be provided with these guidelines at their first pregnancy appointment, but informed that the first trimester is a grace period when it comes to proper eating, as most women have some degree of nausea and food aversions, which make following these guidelines challenging. The most important thing in regards to diet in the first trimester is simply staying hydrated and keeping something down, which for most women is simple carbohydrates. However, once the second trimester arrives and nausea and vomiting of pregnancy is resolving, these recommendations should be revisited and the mother reminded that second trimester is the time to begin focusing on a healthy diet. At each following visit, she should be questioned about what she is eating in a typical day and suggestions for improvement should be made.

Women should also be counseled about typical weight gain expectations and goals for pregnancy, in respect to their pre-pregnancy weight. Excessive weight gain in pregnancy is associated with an increased risk of gestational diabetes, hypertension and preeclampsia, induction, longer labors, and cesarean delivery.³ Weight gain should be reviewed at each visit. Generally, women should not expect to gain a significant amount of weight in the first half of the pregnancy and weight gain should be limited to approximately one pound per week for the second half of the pregnancy. If a woman is exceeding or not meeting these recommendations, a more thorough assessment of her diet should be performed with a food diary and reviewed at the next visit. Consult with a dietician may also be considered. Research, while mixed, has indicated that dietary counseling, in and of itself, helps reduce the incidence of excessive weight gain in pregnancy.⁴ However, stronger evidence exists supporting the combination of both diet and exercise in preventing women from gaining too much weight in pregnancy.^5,6

Exercise

Like eating a proper diet, exercising in pregnancy is something most women know they should do, but many women find it difficult to accomplish. Barriers to exercise in pregnancy are numerous. Often, despite recommendations to exercise, women are afraid that it will harm their baby or they may be told by friends or family members that it is not safe. Even some doctors still give the outdated advice that women should not exercise in the first trimester and should avoid it altogether if they did not exercise prior to pregnancy. Other women simply fall out of the habit during the first trimester, when nausea and fatigue may prevent them for exercising, and never put it back into their routine. For women who did not regularly exercise prior to pregnancy, time constraints and lack of motivation are common barriers that continue to contribute to a sedentary lifestyle. Pregnancy is also a challenging time to begin an exercise regimen, as women are frequently more fatigued, with a greater amount of musculoskeletal discomfort.

However, despite these hurdles, providers should actively encourage their patients, especially those desiring a natural birth, to exercise and inquire about exercise during their routine prenatal visits. The safety of exercise in pregnancy has been well established in medical literature, for both women who were active prior to pregnancy and those that were not. Some common concerns about exercise are that it may lead to premature birth, cause fetal growth restriction, contribute to maternal hyperthermia, or result in episodes of fetal hypoxia. These concerns have been specifically examined and no association with either premature delivery or premature growth restriction has been demonstrated, except in small studies of women who maintained vigorous exercise throughout their pregnancies without appropriate accommodating caloric intake.⁷ Exercise in high temperatures is not recommended; however, studies have not demonstrated increased maternal temperatures even in these conditions nor fetal anomalies as a result. The only concerns regarding exercise in healthy pregnancies that are documented in the research are an increased risk of falls and abdominal trauma, maternal sprains and strains, and maternal hypoglycemia. Pregnant women should make modifications in their exercise routine to minimize these risks; however, these concerns should not prevent women from exercising.⁸

Contraindications to exercise are few, but include⁹:

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  Severe cardiovascular, respiratory, or systemic disease

  
  
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  Uncontrolled hypertension or diabetes

  
  
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  Placenta previa

  
  
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  Ruptured membranes or premature labor

  
  
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  Persistent bleeding after first trimester

  
  
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  Incompetent cervix

  
  
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  Preeclampsia

  
  
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  Higher order multiple gestations

  
  
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  Poor fetal growth

On the other hand, there are numerous benefits of exercise in pregnancy^9–11:

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  Maintenance and improvement in physical fitness, which aids in both stamina during labor and delivery and improved maternal condition after pregnancy

  
  
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  Decreased rates of cesarean delivery and operative vaginal delivery

  
  
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  Decreased risk of gestational diabetes

  
  
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  Decreased incidence of preeclampsia and hypertension

These benefits have a particular relevance for women who wish to minimize technological interventions during their labor and delivery, as exercise reduces their likelihood of developing conditions that considerably restrict their ability to have an unmedicated birth.

Current recommendations are for pregnant women to exercise at least three times weekly, for a minimum of 30 consecutive minutes. Many women confuse being active during the day with adequate exercise; however, this does not have the same benefit as true, dedicated exercise in which the woman has consistent, maintained physical exertion. Women should also be encouraged to vary their exercise, incorporating cardiovascular exercise with light strengthening routines, as well as activities that help open and strengthen the pelvic floor, such as yoga and pilates. Yoga, specifically, has been shown to reduce pain during labor, shorten the total duration of labor, and improve quality of life and interpersonal relationships during pregnancy.¹²

Specific physical activities that are suitable in pregnancy include:

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  Walking, running, and jogging

  
  
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  Swimming

  
  
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  Stationary cycling

  
  
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  Yoga and pilates, modified for pregnancy

  
  
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  Aerobics

  
  
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  Strength training, modified for pregnancy

However, there are certain activities that should be avoided in pregnancy including:

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  Activities with a high risk of falling or trauma: skiing, surfing, horseback riding, ice skating, or off-road cycling

  
  
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  High impact or contact sports

  
  
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  Scuba diving

  
  
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  Sky diving

However, despite the clear benefits and specific recommendations from the American College of Obstetrician and Gynecologists about exercise in pregnancy, only 52% of obstetricians routinely discuss exercise and among those that do, a large portion do not counsel their patients in accordance with current guidelines. For example, despite evidence to the contrary, many obstetricians advise women not to exceed a certain heart rate, recommend reducing exercise load in the third trimester, and do not recommend sedentary women initiate exercise in pregnancy.¹³ Reeducation of health care providers is an important component of women receiving the appropriate information regarding prenatal physical activity. For health care providers looking for guidance in how to encourage their pregnant patients to incorporate exercise into their routines, methods for encouraging lifestyle modification have been studied and can be applied to their practice. A tool which has demonstrated efficacy in smoking cessation, the five A’s, has also shown to be beneficial in weight reduction and exercise promotion.^14,15 The five A’s stand for ask, advise, assess, assist, and arrange. Doctors and midwives should ask about exercise at each visit, make recommendations regarding the information the patient reports, assess progress by both monitoring weight gain and reviewing food diaries, assist patients who are having challenges by exploring their individual barriers to change and suggesting solutions, and arrange specialist care with dieticians or physical therapists if indicated.

Women, for their part, must be willing to listen to their care providers and make exercise a priority. Many sedentary women are able to make a long list of why they cannot exercise; however, the truth is there are very few people who cannot exercise. It is usually simply a question of what is taking precedence in their lives. When women schedule exercise into their week and consider it a commitment that they are unable to break, they are more likely to be consistent with an exercise routine. Women should also know that exercise does not have to occur in the gym. This may be especially helpful for women that have other young children at home or work long hours. A dance party in the living room can be great exercise. Starting the day off with a yoga stretching routine is an easy modification that only requires waking 15 minutes earlier. Light hand weights and simple squats are strengthening activities that can be done while watching an evening television show. Women should be looking for all the ways they can incorporate physical activity into their day, rather than focusing on all the things that are keeping them from getting to a gym.

Stress Reduction and Mental Preparation for Birth

In addition to proper nutrition and physical activity, the emotional well-being of the mother should also be cared for in the antenatal period as part of a holistic model of care and preparation for an unmedicated delivery. While pregnancy is a happy and exciting time for most women, it also represents a major life-changing event, which is stress producing. Up to 12% of women experience depression at some point in pregnancy and one in five pregnant women meet diagnostic criteria for an anxiety disorder.^16–18 Women experiencing mood disorders in pregnancy may be more likely to desire natural birth options, as they may have a stronger desire to maintain control over their birth process than women who are not experiencing anxiety.