Pre and Post Natal Exercise Notes

5/26/2018 Pre and Post Natal Exercise Notes

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Fitnation Pty Ltd 2008 Pre and post natal exercise Notes 1

PRE AND POST NATAL EXERCISE


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EXERCISE DURING PREGNANCY

Pregnancy is an exciting time in a womans life and the dramatic changes that occur

during this 40 weeks presents a challenge to the fitness professional.

The major concern for the pregnant exercising woman is the safe level of exercise.

The major goal of exercising during pregnancy is to enjoy the benefits of exercise during

pregnancy and avoid the risks.

Whilst many women continue to exercise throughout the pregnancy, it is also a time

when many women cease exercising. Post natally, the time consuming demands of

caring for a new baby may prevent women from returning to a regular exercise program.

So it is crucial that we encourage adherence to exercise during pregnancy by offering

safe, effective exercise programming, taking into consideration the relative risks.

This course is designed to demonstrate:

1/ the benefits of exercise during pregnancy

2/ the risks associated with exercise during pregnancy and

3/ the implications for exercise programming and prescription

PREGNANCY

It is commonly known that pregnancy lasts for approximately nine months. There are

three trimesters in pregnancy. The first trimester refers to week 0 to 13, the second

trimester relates to weeks 14 to 28 and the third trimester relates to weeks 29 to

approximately week 42. There are different risks and implications for exercise in each

trimester and these will be discussed later.


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CAN PREGNANT FEMALES COMMENCE AN EXERCISE PROGRAM?

A previously sedentary female can take up exercise during her pregnancy. It is

recommended that exercise should not be commenced prior to the 15thweek of

pregnancy for previously sedentary females. Exercise after this stage should consist ofgradual increases in either duration or frequency. Duration should not exceed 25

minutes with a frequency of no more than 3-4 times per week.

BENEFITS OF EXERCISE DURING PREGNANCY

Fitness:

The pregnant female can maintain a certain level of fitness throughout the pregnancy so

that exercise is easier to resume after the pregnancy. Also, the labour can be a very

physically demanding experience. Cardiovascular fitness and strength can assist the

female to endure their labour with more ease.

Improved muscular tone and strength:

Hormonal changes during pregnancy effect muscular strength and tone. Exercise can

assist to maintain muscular strength. This is especially important for the protection of

joints and the prevention of injury.

Increased self esteem:

Pregnancy can be a mentally demanding time for the female. The bodily changes and

the increase in size can affect the females self esteem. Exercise can provide a way for

pregnant females to mix with the general public and feel a sense of belonging and

acceptance to a group.

Increased sense of well-being:

The pregnant female can feel she is doing the best for herself as well as the growing

foetus.


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Feeling in control of your body:

The pregnant female can feel a greater sense of control over weight gain and the other

changes that are occurring to her body.

Heightened body awareness:

By moving her body, the pregnant female can become more in tune with changes that

are occurring throughout pregnancy.

Weight control:

This is a concern for some pregnant females. Exercise can be used to control weight

gain. It is, however, important that the pregnant female gains sufficient weight

throughout pregnancy and does not become obsessed with her weight. Guidelines for

normal weight gain will be discussed later in this section.

Provide a break and relieve stress:

For some females, pregnancy can be a mentally demanding and worrying time.

Exercise can provide a mental break for these females.

Enables a quicker return to fitness after birth:

If the female feels that it wont be too difficult to regain her pre-pregnancy level of fitness

she will feel more enthusiastic to return to exercise after her pregnancy.

Promotes good posture

Poor posture is a common problem causing both lower and upper back pain in

pregnancy. Postural cues used throughout exercise programs can be related to

everyday practices.

Lessens fatigue and promotes better sleeping pattern

Improves circulation, helping to prevent/reduce fluid retention, varicose veins,

haemorrhoids


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Relieves/prevents constipation

BENEFITS OF EXERCISE POSTNATALLY

Regular exercise promotes the healing of traumatised uterine, abdominal and pelvic

muscles and hastens a return to normal muscle tone

Helps vulnerable joints associated with hormone release during pregnancy, return

to normal and prevent further weakening and strain

Regular exercise promotes positive psychological benefits, improving coping

mechanisms with stress and minimises post partum blues

CONTRA-INDICATIONS TO EXERCISE DURING PREGNANCY

There are some females who cannot exercise during pregnancy for specific medical

reasons including the following list. It is not essential that you know exactly what each of

the conditions are, but you do need to be aware that some pregnant females are

advised not to exercise throughout their pregnancy due to medical reasons. This

emphasises the importance of requesting that the pregnant female gains a medical

clearance. It would be up to the medical practitioner to discover / diagnose and inform

the client regarding the presence of any of these conditions.

ABSOLUTE CONTRAINDICATIONS

1. Active myocardial disease

2. Congestive heart failure

3. Rheumatic heart disease

4. Thrombophlebitis

5. Recent pulmonary embolism

6. Active infectious disease

7. At risk for premature labour

8. Incomplete cervix

9. Uterine bleeding


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10. Ruptured membranes

11. Intrauterine growth retardation

12. Severe iso-immunisation

13. Severe hypertensive disease (high blood pressure)

14. Suspected foetal distress

15. Multiple miscarriages

16. No prenatal care

RELATIVE CONTRAINDICATIONS

1. Essential hypertension

2. Anaemia

3. Thyroid disease

4. Breech position in third trimester

5. Diabetes melitis

6. Multiple pregnancies

7. Extreme obesity or underweight

8. History of sedentary lifestyle

9. Placenta praevia (placenta covers opening of cervix in full or partly)

When considering the contraindications, the degree of importance depends on:

1. The intensity, type and duration of the exercise

2. Environment in which exercise is performed

3. The individual who is exercising

4. Size of exercise class

Once again, although it is not important for you to know the specifics of these

conditions, it is important for fitness instructors to be aware that for some people

exercise is not safe during pregnancy. For this reason, any female who is pregnant or

has given birth within the last eight weeks must gain medical approval prior to

commencing or resuming their exercise program. Where partial contra-indications exist


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(eg other pregnancy induced health problems), direct liaison with the individuals

medical practitioner must be conducted to gain directions for exercise prescription.

The purpose of an exercise program during pregnancy is to maintain physical fitness

and to prepare the mother for labour and delivery, not to improve athletic performance

or to participate in competitive sports. Pregnant women who have previously led

sedentary lifestyles should begin with exercise of very low intensity and advance activity

levels very gradually.

The anatomical, biomechanical and physiological changes that occur during pregnancy

create a need for specialised exercise prescription and modification. It is essential that

exercise is SAFE for both mother and baby. REALISTIC goals and expectations need to

be outlined from the beginning.

It is essential that a pre screening questionnaire be completed thoroughly before

a pre or post natal woman begins her exercise program.


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EXAMPLE OF A HEALTH AND MEDICAL FORM FOR FITNESS

PROGRAMS FOR PREGNANT FEMALES

GENERAL INFORMATION

Name: _______________________________________________________

Birth Date: ________________________________

Address: _______________________________________________________

Post Code: ________________________________

Occupation: ________________________________

Telephone:

H ________________________________

W ________________________________

Mobile ________________________________

EMERGENCY DETAILS

Spouse: ________________________________ Phone _________________

Family/ friend: ________________________________ Phone _________________

Medical Practitioner: ___________________________ Phone _________________

Obstetrician ________________________________ Phone _________________Hospital: ________________________________ Phone _________________

PREGNANCY HISTORY

Due Date: ________________________________

Is this your first pregnancy? Yes No

If no, previous pregnancy date/s __________________Type of delivery_____________

History of miscarriages? Yes No

If yes, provide details: ____________________________________________________

Previous complications during pregnancy? Yes No

If Yes, provide details:____________________________________________________

During this pregnancy have you experienced any of the following?

Marked fatigue Migraine/headache Dizziness/faintness

Foetal growth retardation Multiple births/pregnancy Premature labour/birth


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Vaginal bleeding/spotting Breech presentation Abdominal pain

Cervical stitch Heart burn/gastric reflux Knee pain

Reduced foetal movement Incompetent Cervix Pelvic joint pain

Baby smaller than expected Portion of placenta over cervix

Swelling, pain or redness in calf Incontinence (altered bladder control)

Swelling (hands, ankles, face) Preeclampsia/ pregnancy induce hypertension

Circulatory problems (varicose veins-legs, anal or vaginal)

If you have ticked any of the above, please provide details:

MEDICAL HISTORY

Have you or do you currently suffer from any of the following?

Abnormal blood pressure (high/Low) Heart disease/family historyRespiratory disease (asthma/bronchitis) Thyroid disease

Kidney disease Diabetes/family history

Chest pains/palpitations Lower back pain

Neck pain Epilepsy

Faintness/dizziness Recent viral infection

Muscular/skeletal injury Stroke

Anaemia Arthritis

Recent surgery/illness Other problems that may affect your abilityto exercise

If you have ticked any of the above, please provide details:

______________________________________________________________________

MEDICATION

Are you currently taking any medication? Yes No

Provide details: ____________________________________________________

LIFESTYLE

Do you smoke? Yes No

If yes, how many per day? _______________________________________________

Do you consume alcohol? Yes No

If yes, how many drinks per week? _______________________________________


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EXERCISE HISTORY:

Were you exercising prior to becoming pregnant? Yes No

Provide details type/frequency:

_____________________________________________________________________

Are you currently exercising? Yes No

Provide details type/frequency:

_____________________________________________________________________

What type of exercise are you interesting in?

Personal Training Small group training Walking program

What goals do you hope to achieve through exercise?

______________________________________________________________________

Note: A COMPULSORY MEDICAL CLEARANCE FROM OBSTETRICIAN IS REQUIRED

PRIOR TO COMMENCING THE PROGRAMME. LETTER IS TO ACCOMPANY

REGISTRATION FORM.

Acknowledgment and release:

I, the undersigned acknowledge that:

1. This exercise program has been specifically designed for pregnant and postnatal women by

(Quals)

2. In normal circumstances the exercises should not harm me or my baby in any way.

3. I shall inform this organisation of any medical or pregnancy related changes prior to

commencing any training session

4. This organisation will not be liable in any way for any unforseen circumstances or for any

circumstances of which I should have been aware, but failed to notify them.

5. I give permission to staff of this organisation to contact any of the emergency contact

numbers set out above should the need arise.

6. I have read the above statement and agree to be bound by it and to release this

organisation from all claims.

Name: ________________________ Signature: ____________________ Date: ____

(Replace This organisation with organisational name)


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PROBLEMS RELATED TO EXERCISE DURING PREGNANCY

These are often related to the anatomical, physiological and biomechanical changes

that occur at different stages of pregnancy. You will need to be aware of these changes

and how they affect the clients ability to perform exercise.

MUSCULOSKELETAL CHANGES

RELAXIN

Relaxin is a hormone that is released during the first trimester of pregnancy and

remains in the body for approximately eight weeks after birth. Relaxin is at its peak at

about 12 weeks into pregnancy. The function of relaxin is to soften the structures of the

musculoskeletal system, particularly around the pelvis. The main aim of this is to aid the

birth of the baby. However, this hormone affects all structures of the musculoskeletal

system. This means that ligaments, tendons and muscles are softer and less elastic.

Sprains and dislocation, particularly related to weight bearing joints, are therefore more

common after falls and acute incidences.

Implications for Exercise: Avoid twisting and rotation exercises

Avoid ballistic stretching

Avoid deep knee bends (eg squats beyond 90 degrees)

Control stretching through normal range of movement

Avoid high impact exercise

Reduce stride length while walking

DO NOT work through pain

Keep knees glued together when changing positions

Avoid Asymmetrical exercises

Competitive sports and exercise can be more risky


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PELVIC FLOOR

This pelvic floor sling is usually weakened due to relaxin coupled with the increasedweight of the baby pushing on the pelvic area. This can cause pubic symphysis pain

that radiates into the groin, medial thigh or buttocks. It may be present during or hours

after exercise and it is aggravated by weight bearing exercises. Refer to a

physiotherapist for Diagnosis. The Pelvic floor sling also plays a major role in pelvic

organ support. If it is weakened significantly it can lead to pelvic organ prolapse and

long term incontinence. Lifting, coughing, sneezing and constipation all increase pelvic

floor stress.

Implications for Exercise:

Avoid asymmetrical weight bearing exercises

Prescribe bracing exercises for the TA and pelvic floor (kegel exercises)

Use the swissball

Brace abdominals before coughing, sneezing and lifting

Refer to a physiotherapist for diagnosis, pain relief and external support

SACROILIAC PAIN

With the postural changes that can occur as a result of a growing abdomen and the

general fatigue that pregnant females can experience, extra loading is placed through

the hip. As a result of prolonged standing, general fatigue and asymmetrically loading

through the hip (eg standing with weight going through one leg) the sacroiliac joint

which is affected by relaxin and becomes partially movable) can slip and cause pain.

This is usually a radiating pain down the buttock to the thigh.


Avoid exercises that include asymmetrically loading the hip (i.e. standing on one leg)

including standing cable leg work curls, abductions, adductions

Knee/curl/kick repeater type actions in aerobics should be avoided


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Avoid weight work involving standing think of seated or lying alternatives

BACK PAIN

LOW BACK PAIN

Once again as a result of the growing abdomen and the shift in the centre of gravity,

excessive lordosis of the lumbar spine can result (i.e. leaning back at the hip). This

places excessive strain on the structures of the lumbar spine leading to pain. The

quadriceps can also weakened as the centre of gravity passes more anteriorly to the

knee

Implications for Exercise: Place extra emphasis on postural cues such as tilting the pelvis back, keeping

shoulders square, keeping knees soft.

Encourage posterior pelvic tilt exercises through a full range of motion

Work on quadriceps strengthening (ball squats, bench squats)

Focus on posterior shoulder and scapular retractor strengthening exercises (eg:

Seated row, cable row, single arm dumbbell row)

Once again, promote seated, lying or water based exercises as alternatives

UPPER BACK

Upper back pain can be experienced particularly in the second and third trimesters of

pregnancy. This is mainly due to the fact that as the abdomen grows to accommodate

for the growing foetus the ribs need to expand. This places the costovertebral joints in

an unnatural position and can lead to upper back pain.


Encourage upper back strengthening exercises such as shoulder blade pinches or

seated rows

Encourage square shoulders as a postural cue

Stretch pectoral muscles


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Encourage the use of supportive bra.

WRISTS

The wrist joint is also affected by relaxin making it more prone to sprains and injury.


Avoid exercises that require the female client to bear her weight through her hands,

eg push ups, chin ups, tricep dips

Avoid use of heavy hand weights

DIASTASIS RECTI

This refers to a separation of the rectus abdominous muscle at the mid point (linea alba)

causing a protrusion of the anterior uteral wall. This happens to 30% of pregnant

females at around the 16th week of pregnancy. It can be felt as a long ridge (varying in

width) when the abdominals are contracted.


If you or your client notices diastasis recti cease abdominal work and seek medicaladvice. It could well be that lifting of weights and any abdominal strengthening work

may need to be ceased.

If medical clearance is giving, continue abdominal exercises working on the pelvic

floor such as bracing exercises for the transverse abdominis.

Avoid sit ups and oblique abdominal exercises.


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FEET

There are potential problems associated with the feet during pregnancy associated with

the effects of relaxin. In a female with high arched feet, the additional body weight may

place extra strain on the ligaments supporting the arch. It may stretch resulting in an

increased foot size and a change in biomechanics.

Implications for Exercise

Advise arch supports for females with high arched feet (refer to a podiatrist)

FLUID RETENTION / OEDEMA.

There is decreased venous return due to the effects relaxin has on blood vessels. This

can cause swelling of the feet.

Implications

Encourage water-based activity as the hydrostatic pressure of water will encourage

fluids to flow out of the system.

Avoid exercises requiring prolonged standing think of seated or floor alternatives

Encourage regular drinking of water and avoid increased salt intake

CHANGE IN BASE OF SUPPORT

The base of support changes due to the shift in centre of gravity and this often leads to

the pregnant waddle.

Implications

Strengthen the medial rotators of the hip

Avoid external hip rotation in weight bearing positions


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HORMONAL CHANGES

Catecholamines (epinephrine and non-epinephrine) are released during pregnancy to

mediate blood flow distribution. During exercise blood flow is directed to working

muscles and away from uterus


Limit aerobic exercise to fifteen minutes

Limit aerobic intensity to mild to moderately hard

Avoid prolonged, strenuous exercise

CHANGED ENDOCRINE RESPONSE

Endocrine response may change during exercise as relaxin affects veins and valves in

lower leg and affects walls of intestine. This leads to reduced peristalsis (squeezing of

the intestine to progressively move food through it), increased water resorption from

bowel, constipation, flatulence, belching, heartburn and indigestion (incompetent

stomach valves).


Dynamic calf exercises aid in blood return

Avoid prolonged standing (especially after aerobic exercise)

Pelvic floor exercises

Fibre rich diet

Encourage side lying, lean on elbow

Avoid head down positions

Small sips of fluid


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SUPINE POSITION

From the sixteenth week into pregnancy, lying in the supine position is said to place

pressure on the vena cava which effects blood flow back to the heart and therefore

around the body. Lying in the supine position can cause dizziness, blurred vision and

light-headedness.


Avoid exercise in the supine position after the 16thweek of pregnancy

Think of modifications to exercises like abdominal curls, supine stretches, supine

flies, bench press and so on.

CARDIOVASCULAR SYSTEM CHANGES

During pregnancy there is an increase in blood volume that results in an increased

cardiac output, increased stroke volume and increased resting heart rate (by

approximately 15 beats per minute).

Implications for Exercise: There is a reduced training capacity as a result of these changes. A guideline for

maximum heart rate during exercise is no more than 140 beats per minute (23 beats

in 10 seconds). This ensures that excessive demand on cardiac output and blood

supply does not result. Limit perceived rate of exertion to somewhat hard.

An increased resting heart rate means that there are smaller ranges between resting

and maximal heart rate. Therefore you need to prescribe a longer and slower warm

up

VEINS

Valves in veins are also affected by relaxin and blood vessels are less elastic. This

causes reduced peripheral resistance meaning blood flow from the extremities back to

the heart is restricted. Blood can pool in the veins causing varicose veins.


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Implications:

Use the calf muscle pump in the warm down / cool down phase of the exercise

session. This means including exercises that work the calf muscles. It is said that the

contractions of lower leg muscles will assist blood flow back to the heart. Exercises

using the calf muscle pump include walking, calf raises (preferably seated), heel

strikes, stepping, heel / toe cycling and toe press.

BLOOD

As mentioned earlier, the volume of blood increases during pregnancy. Plasma content

increases the most meaning that haemoglobin is more diluted. This results in a reduced

oxygen carrying capacity of the blood. This is of concern when considering that intense

exercise draws blood to the working muscles and away from the uterus / foetus. With a

reduced oxygen carrying capacity, reduced oxygen to the uterus can lead to foetal

distress. This increase blood volume coupled with the decreased stroke volume can

also lead to blood pooling in the periphery.


Avoid spurts of high intensity aerobic exercise (such as interval training)

Maintain moderate intensity exercise (140 bpm)

Keep the cardiovascular/aerobic component of the session to 15 minutes maximum

Encourage regular and deep breathing

Include regular rest breaks

Avoid prolonged standing exercises

Encourage dynamic rather than static stretches

Ensure you work out in an area with good ventilation and encourage loose fitting

clothing


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RESPIRATORY SYSTEM CHANGES

During pregnancy there is a decrease oxygen uptake due to haemodilution and there is

also an increased minute volume. These factors increase the respiratory systemsworkload and present a risk of hyperventilation. During the third trimester the position of

the uterus under the diaphragm also increases the work of breathing which means

pregnant women can become out of breath very easily. Pregnant women may also

achieve VO2 max at a lower level of exertion than non-pregnant women.


Avoid sudden changes in intensity in aerobic work

Encourage controlled breathing

Encourage work out at a perceived level of exertion of mild to moderately hard

ENERGY BALANCE

There is an increase in energy requirements during pregnancy due to the additional

work the body is undertaking for foetal development and tissue growth. This increase

must be met through an increase in energy intake or a decrease in energy expenditure

or both. The extra energy requirement of a pregnant female is approximately 15%. Low

maternal weight gain is a factor contributing to low birth weights, which is a risk for

babys health and well being.

Implications:

Encourage the eating of snacks prior to and after exercise

Control exercise frequency, intensity and duration (aim for moderate level all round).

Maximum of 4 sessions per week

Advise carbohydrate rich snack 1 hour prior to exercise


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As a guideline, the mother should increase her body weight by approximately 20-25%

during pregnancy. So, for a 60kg female she should put on 12kg of weight during

pregnancy at approximately 1-2kg per month.

This will account for the following:

Baby 3.5kg

Placenta 0.7kg

Uterus and amniotic fluid 1.8kg

Mothers extra blood and fluid 2.0kg

Breasts 1.5kg

Extra fat stores 2.5kg (this only accounts for 20% of weight gain)

CORE TEMPERATURE CHANGES

Due to the additional work the body is undertaking in the growth and development of the

uterus and the foetus core body temperature rises. The foetus cannot dissipate heat

independently. It relies on the mother to do so. As the mothers core body temperature

is already raised any further rises in core body temperature can reduce her capacity to

dissipate heat. Increases in core body temperature over 38 degrees Celsius

(approximately one degree warmer than normal) in the first trimester have been linked

to birth defects and malformations.


Avoid exercising on hot or humid days

Avoid spas, hot baths and saunas

Drink cold water before, at regular intervals during and after exercise

Keep cardiovascular work to 15 minutes max

Indoor pool temperature should not exceed 28 degrees (effects her ability to

dissipate heat)

Include regular rest breaks

Encourage cool, light, loose fitting clothing


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Create a cool environment (eg use fans)

SUMMARY - MOTHER RISKS

Weeks Trimesters involved Possible Problems

8-40 First, second, third Relaxin: Laxity of joints and ligaments

musculoskeletal injuries

24-40 Second and third Oedema nerve compression syndrome

eg carpal tunnel syndrome

4-40 First, second and third Cardio-vascular changes supine

hypotension, arrhythmia, palpitations

16-40 Second and third Aortocaval Syndrome

0-22 First and second Spontaneous abortion dehydration

increases

22-40 Second and third Premature labour

0-40 First, second and third Inadequate diet accelerated starvation


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SUMMARY FOETAL RISKS

Week Trimester Involved Possible Problems

0-12 First Heat stress (congenital malformations)

0-40 First, second and third Impaired uterine/umbilical blood flow

(foetal hypoxia, foetal distress, intra-

uterine growth retardation)

24-34 Second and third Premature labour


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SIGNS INDICATING THAT AN EXERCISE SESSION SHOULD BE CEASED

IMMEDITALEY

Vaginal bleeding or fluid loss Uterine contractions

Deep back or pubic pain

Lower abdominal pain or cramping

Difficulty in walking

Headache, dizziness, faintness

Palpitations or unusually slow heart beat

Unusual breathlessness

Sudden swelling in hands, feet, ankles or face

Feeling extremely fatigued or hot

Noticeable change in babys movements (noted by mother)

CONTRAINDICATIONS TO EXERCISE POSTNATALLY

1. Fatigue and exhaustion the new mother may have no energy left after caring for

the needs of the new baby who may be waking through the night. The adjustment to

the new lifestyle will take time.

2. Unhealed perineum the perineum can be torn during child birth. In some cases

stitches may be present to aid the healing process.

3. Vaginal bleeding(lasts 4 - 6 weeks normally) making exercise difficult in terms of

clothing and comfort

4. Anaemia low iron levels can lead to fatigue and a reduced capacity to perform

exercise5. Infective condition / mastitis(inflammation and infection of breast ducts)


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POSTNATAL EXERCISE CONSIDERATIONS

Factors to consider in continuing with exercise after the birth of the baby will depend on:

Type of birth vaginal, caesarean (caesarean births lead to a longer recovery period

and guidelines must be sought from the medical practitioners involved regarding

exercise)

Health complications during/after birth

Six week postnatal check and clearance this must be gained prior to exercise

continuing

Demands of motherhood irritability, tired include relaxation, stress relief and

shorter, less intense workouts (including at home options)

Hormonal postnatal depression (poor sleeping patterns, world collapsing around

her, resentment towards baby/husband, more common in career woman)

Urinary incontinence high impact exercise such as running and aerobics may be

out of the question for women experiencing incontinence. This highlights the

importance of continual pelvic floor strengthening exercises throughout pregnancy

Persistent lower back problems the back may take a while to recover from the

stress and strain it has been placed under. This can effect the type of exercises to

be prescribed postnatally (refer to back pain section of Exercise for Rehabilitation

notes.


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EXERCISE PRESCRIPTION

FORMULA FOR SAFE EXERCISE DURING PREGNANCY

Avoid high impact exercise Avoid twisting movements

Monitor heart rates (140Bpm and below)

Exercise three times per week

Consider exercise intensity moderate

Exercise duration 15 minutes and under for cardiovascular activity

Encourage regular cold fluid intake

Discourage exercise in hot/humid weather Encourage frequent rest breaks

Discourage supine exercises after the 16thweek

Encourage seated exercises

Remember to encourage postural cues

Encourage regular deep breathing

Avoid increases of more than one degree Celsius in core body temperature

Encourage regular food intake


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SUMMARY OFGUIDELINES FOR EXERCISE DURING PREGNANCY AND POSTPARTUM(Based on Australian College of Gynaecologists Guidelines)

The guidelines are based on the unique and physiological conditions that existduring pregnancy and the postpartum period. They outline general criteria for

safety to provide direction to clients in the development of exercise programs.

PREGNANCY AND POSTPARTUM

1. Doctors consent must be obtained to participate in exercise program

2. Regular exercise (at least 3 times per week) is preferable to intermittent activity.

Alternate routine with low impact aerobics, cycling, swimming, walking and

strengthening.

3. Exercise should not be performed in hot, humid weather or during a period of febrile

illness. Saunas and steam baths to be avoided.

4. Ballistic movements (jerky motions and complex choreography) should be avoided.

Exercise should be done on a wooden floor or a tightly carpeted surface to reduce

shock and provide a sure footing. Avoid exercise that may involve loss of balance

(stepping) especially in last trimester.5. Deep flexion or extension of joints should be avoided because of connective tissue

laxity. Activities that require jumping, jarring motions or rapid changes in directions

should be avoided because of joint instability.

6. Warm up and cool down periods need to be longer than normal. Vigorous exercise

should be preceded by a 5 minute period of muscle warm up. Slow walking or

stationary cycling with low resistance can accomplish this.

7. Do not stop exercise suddenly or stand in one position for a prolonged period of

time. This will result in blood pooling in legs, low blood pressure and possible

fainting. Vigorous exercise should be followed by a period of gradually declining

activity that includes gentle stationary stretching. Because connective tissue laxity

increases the risk of joint injury, stretches should not be taken to the point of

maximum resistance.


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8. Heart rate should be measured at times of peak activity. Target heart rates and

limits established in consultation with her physician should not be exceeded.

9. Care should be taken to gradually rise from the floor to avoid orthostatic

hypotension. Some form of activity involving the legs should be continued for a brief

period.

10. Liquids should be taken liberally before and after exercise to prevent dehydration. If

necessary, activity should be interrupted to replenish fluids.

11. Women who have led sedentary lifestyles should begin with physical activity of very

low intensity and advance activity levels very gradually.

12. Activity should be stopped and physician consulted if any unusual symptoms appear

(bleeding, faintness, dizziness, shortness of breath, hearth palpitations).

13. Postural awareness essential at all times. Ensure back in good alignment and

knees slightly bent (shock absorbers).


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PREGNANCY ONLY

1. Maternal heart rate should not exceed 140 beats per minutes during exercise or a

perceived level of exertion of mild to moderately hard. Client should be able to talk

while exercising. Encourage client to LISTEN TO HER BODY and work at her own

pace, not to compete with instructor or other class members.

2. Strenuous activities should not exceed 15 minutes in duration.

3. No exercise should be performed in the supine position after the fourth month of

gestation is completed.

4. Exercises that employ the Valsalva manoeuvre should be avoided (holding breath).

Encourage exhaling on effort and inhaling in a relaxed manner.

5. Caloric intake should be adequate to meet not only the extra energy needs ofpregnancy, but also of the exercise performed. Client not to exercise on an empty

stomach. Complex carbohydrate snack e.g. banana to be eaten one hour prior to

exercising.

6. Maternal core temperature should not exceed 380C. Ensure intensity of exercise not

too high and that adequate hydration is maintained before, during and after exercise.

Client to dress in cool, comfortable, non-restrictive clothing with supportive bra and

good athletic shoes.

7. Avoid contact, collision or very competitive type sports.

8. Modify intensity of exercise according to clients level of fitness and stage of

pregnancy. Avoid exercise to exhaustion or fatigue.


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The important components of exercise during pregnancy include the following:

1. Aerobic fitness assists in coping with demands on body pre and postnatally

2. Strength training compensates for joint instability, muscle imbalances and

altered posture

3. Flexibility training essential for good posture, preparation for birth and injury

prevention

4. Rest/Relaxation and recovery (between workouts)

5. Healthy, nutritious diet sufficient to sustain babys growth and exercise

requirements

Exercise will help to maintain fitness, strength and endurance, making the physical

demands more manageable and pregnancy more comfortable. The pregnant woman

will enter labour better equipped with confidence and stamina and postnatally her

recovery will be easier and more rapid.

EXERCISE FREQUENCY

So far a lot has been said about exercise intensity and duration. Studies have also beenundertaken to ascertain safe frequency levels for exercise. One such study measured

the birth weights of babies born to mothers who exercised approximately 6 times per

week throughout pregnancy and those who were born to mothers exercising

approximately 3 times per week throughout exercise. Babies born to mothers exercising

six times per week were 10% lighter than those whose mothers exercised less

frequently. Low birth weights have been identified as the greatest risk to health of the

baby after birth. For this reason, the recommended frequency of exercise is no more

than 3-4 times per week.


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MODIFICATIONS OF EXERCISE DURING PREGNANCY

1. AEROBIC EXERCISE

Maximum heart rate = 140 beats per min. Aerobic benefits can be maintained or

achieved using 60-75% target heart rate zones

Mild to moderate exertion (monitor response) you can use the perceived rate of

exertion scales or the talk test to monitor this

Talk test ensure client not short of breath, able to talk comfortably

Duration of cardiorespiratory component = 15 minutes (increased heart rates for

extended periods may result in overheating, decreased maternal blood glucose,

decreased blood flow to uterus)

To prevent risks associated with exercise intensity

maintain adequate hydration before, during and after exercise

longer warm up and cool down periods

exercise in well ventilated environment

client to wear cool, comfortable clothing

carbohydrate rich snack about one hour prior to exercise program

stop exercise immediately if danger signs occur

3-4 sessions/week, alternate days

Avoid complex choreography

Avoid sudden changes in direction

Pelvic joint dysfunction avoid large steps, stepping type exercise

Emphasise postural awareness i.e. shoulders down and back, buttocks tuckedunder, abdominals drawn in and knees slightly flexed (soft)

Emphasise regular, not intermittent exercise (3-4 times per week)


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2. STRENGTH TRAINING

Emphasise core stabilisation / bracing exercises

Target muscle groups (upper body, back extensors, abdominals, gluteals,quadriceps, pelvic floor)

Avoid prolonged standing

Use light weights (10 - 15 reps; 2 - 3 sets)

slow, controlled movements

limit overhead movements

avoid straining

avoid Valsalva manoeuvre (holding breath)

brace abdominals and pelvic floor first

Use machines in preference to free weights (require less skill and more easily

controlled)

Isolate one muscle group at a time

Avoid deep squatting

Pelvic joint pain avoid unilateral leg exercises (keep knees glued together)

avoid unilateral weight bearing exercises

Allow adequate recovery between sets

Avoid supine position after 16thweek of pregnancy

Pelvic Floor Exercises ALWAYS MANDATORY!

FLEXIBILITY TRAINING

Do not over stretch already lax joints

Avoid bouncing at end of range

Slow, gradual stretching (hold 20 - 30 seconds)

Avoid supine position after 16thweek of pregnancy

Change positions slowly

Encourage controlled breathing (breath out into stretch)


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3. RELAXATION

Balance physical with psychological

Inward focus, get in touch with body Increase breathing awareness (labour preparation)

Improves quality of sleep/rest, minimising fatigue

Stress relief

Appropriate background music

Types of Exercise Recommended for Pregnancy

Low Impact Aerobics (simple choreography) utilising exercise ball

Walking

Stationary cycling

Swimming (avoid breastroke) pool temperature 29 310C

Non-competitive or collision type sports

POSTNATAL EXERCISE GUIDELINES

A gradual recovery is essential for a smooth transition to motherhood. With the focus

on wellbeing rather than increased aerobic fitness and weight loss. The hormonal and

physical changes of pregnancy will readjust after the first 6 - 8 weeks. It may take up to

9 months for the stretched muscles to return to shape. Lactation requires adequate rest

and good nourishment.

Guidelines

1. Obtain clearance from doctor to resume exercise

2. LISTEN TO BODY and do not expect too much too soon

3. Avoid exercise if still bleeding, experiencing pain or discomfort

(episiotomy/Caesarean section

4. Rest if fatigued


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5. Caesarean section minimal exercise prior to 6 week check up

avoid sit-ups/obliques until 12 weeks (lift only head)

core stability and pelvic tilting exercises

6. Pelvic Floor Exercise mandatory

7. Postural correction/education/back care advice essential

8. Good warm up and cool down

9. Maintain adequate hydration

10. Encourage wearing well supporting bra

11. Encourage good, healthy, nutritious habits

12. Exercise regularly, rather than intermittently

13. Target specific muscle groups (abdominals, pelvic floor, gluteals, abductors, upper

body, back extensors)

14. Core stability exercises important

15. Check for abdominal diastasis core stability exercises

pelvic tilting

pelvic floor exercises

avoid crunches/obliques

16. Relaxin still present in body up to 12 weeks postnatally, therefore muscles, joints

and ligaments till susceptible to injury. AVOID OVERLOAD, OVERSTRETCH,

EXCESSIVE EXERCISE. Avoid jarring, ballistic, jumping type activities (may also

lead to/aggravate incontinence)

17. Begin aerobic activity with low impact type exercise i.e. cycling, swimming, low

impact aerobics. Gradually increase workout duration and intensity as fitness level

improves


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EXAMPLES OF STRENGTH EXERCISES FOR PREGNANT FEMALES

Body Part Purpose Example

Upper Back

Lower Back

Abdomen

Pelvic Floor

Upper body

Promotion of correct

posture

Promotion of correct

posture

Promotion of good

posture, prevention of

low back pain,

strengthen muscles of

labour

Promotion of bladder

control, prevention of

incontinence

Improved muscular

support of breasts

Shoulder shrugs, scapula pinches,

seated row

Pelvic tilts (against wall, on all fours,

sitting)

Pelvic rocks

Swiss ball exercises

Abdominal tightening exercises,

mediball / swiss ball exercises,

oblique curls (whilst lying on the side

or from the swiss ball)

Kegel exercises squeeze the

muscles of the pelvic floor and hold for

ten seconds. Repeat three timesregularly throughout the day. To teach

a beginner this exercise, ask them to

try and stop the flow of urine the next

time that they go to the bathroom.

This will teach them the sensation of

contracting the correct muscles.

Shoulder shrugs

Pectoral Stretches

Scapula pinches

Seated row


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Buttocks,

lower limbs

Facilitation of weight

bearing, prevention of

varicose veins

Seated leg curls and extensions, calf

raises (seated), leg work from the side

lying position

RECORDS TO BE KEPT:

Personal details (name, age, occupation, emergency contact nos)

Pregnancy history

Instructor recommendations

Medical history

Attendance recording

Exercise history/lifestyle

Clients signature/consent with waiver clause

Modifications/precautions

ALWAYS KEEP EMERGENCY CONTACT NUMBERS AT HAND

The most dangerous complications are OVERHEATING (first Trimester) andPREMATURE LABOUR (last trimester)


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EXAMPLE OF CLASS FORMAT

WARM UP AND STRETCHING

The warm up should be gentle and gradual. The focus should be on preparing the body

for activities to come. Movements should be fluid, low impact and easy to follow. The

following exercises should be included in the warm up:

Shoulder rolls

Shoulder girdle mobilisations arms forward and back opening out scapula and

pinching back.

Pelvic tilting forward and back in a controlled manner

Pelvic circling

Isolated abdominal movements

Ankle circles

Stretch out the calves, hamstrings, quadriceps and back

CARDIOVASCULAR COMPONENT:

This should include low impact movements with gradual changes. Any change in

direction should include a stabiliser movement such as squats or heel strikes to the

front. Keep the choreography simple, smooth and controlled. Avoid bouncing, jarring,

ballistic type exercises and keep any side stepping narrow.

The cardiovascular section can be performed on the swiss ball or on the floor.

Remember the duration should be no longer than 15 minutes and the intensity should

be moderate.

The use of a step is controversial especially as the pregnancy advances. The pregnant

females centre of gravity and balance is affected making falls more probable. Using a

step further increases the chance of falls.


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The cool down should include walking on the spot or around the room to prevent blood

from pooling in the lower extremities. Slower, smaller movements should be performed

for 5 minutes to slowly cool the body down.

STRENGTH COMPONENT

Many strengthening exercises can be performed whilst sitting on a swiss ball, which is

preferable to standing for prolonged periods of time. Use very light weights or

therabands. It is best to start with two handed movements before progressing to single

arm movements.

Exercises to include:

Abdominal bracing (Throughout)

Bicep curls double arms, single arms, single arms with opposite leg lifting,

progress to same leg lifting

Rowing (pinching scapula together)

Lateral raises

Flies

Upright rowing

Tricep extensions

ABDOMINALS:

The best form of exercise for the abdominals is the use of a swiss ball. Normal sit ups

from the supine position are not recommended after the 16thweek of pregnancy and

when you think about it, they only work the rectus abdominis anyway. It is preferred that

the transverse muscles are worked as a priority in an effort to strengthen the backduring pregnancy.

Sit on the ball and brace the stomach. A good teaching cue for pregnant females is to

tell them to hug your baby into your spine. Sitting on the ball lift one leg off the ball and

hold (start by asking them to place their hands on the ball and then try without holding).

Add curl backs and side waist work as illustrated in the pages to follow.


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General cues for core stability:

Keep the back upright

Keep weight equally distributed on buttocks

Draw in abdomen below the belly button

Keep hips level

GLUTEALS AND HAMSTRINGS:

Resting your scapula on the ball with knees bent (bridging position) and lift legs

in an alternating fashion.

Use the swiss ball to perform squats against the wall

Abductor work from a side lying position can also be performed to work the

gluteal area

KNEELING EXERCISES:

Kneeling on all fours abdominal bracing with progressions

Spinal mobility stretching exercises

Shoulder strengthening exercises

SITTING AND RELAXATION EXERCISES:

Sitting on the ball or on the floor perform:

Spinal rotations

Side stretching

Hamstring stretch

Hip flexor stretch

Chest

Arms Neck


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PELVIC FLOOR EXERCISES

Pelvic floor exercises are crucial for pregnant females. They can be performed from a

standing, sitting, kneeling or lying position and should be repeated several timesthroughout the day every day.

Sitting on the swiss ball with legs apart can be a good way to teach pelvic floor

exercises. Teach females to contract their pelvic floor muscles (almost as if they were

preventing urinal flow) and hold the contraction for ten seconds. Repeat ten times.

Complete fast contractions (contract/relax/contract) to train fast twitch fibres as well.

A more advanced exercise is to ask clients to contract their pelvic floor muscles by

imagining the pelvic floor is an elevator contract to the first floor and hold, then

contract to the second floor and hold, then contract to the third floor, hold, then relax to

the bottom floor. Repeat three times.

It is important to remind clients to maintain normal breathing whilst performing these

exercises. Encourage your clients to complete these exercises at every opportunity

whist waiting in cues, talking on the phone or making dinner.

Pre and Post Natal Exercise Notes

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