Exercise In Pregnancy

Exercise In Pregnancy

WHY EXERCISE?

For everybody, exercise can:

Increase wellness
Promote weight control
Decrease the risk of high blood pressure, heart disease and diabetes
Decrease stress and anxiety
Increase self-esteem and self-image

WHY EXERCISE IN PREGNANCY?

For you, exercise can:

Help achieve appropriate weight gain—do not exercise to lose weight during pregnancy
Decrease fatigue
Decrease discomforts of pregnancy such as nausea, back pain, swelling and bloating
Increase muscle tone, strength and endurance
Improve your posture
Improve your sleep
Prevention of low back pain, diastasis recti, and urinary incontinence
Psychological benefits -- improved mood, body image, and self-esteem, and reduction of post-partum depression
Decreased risk of blood clots, varicose veins, leg cramping, and swelling.

For your labor and delivery, exercise can:

Shorten labor
Make delivery easier
Help you cope with the pain of labor
Help you recover and get back in shape more rapidly after delivery

CHANGES IN YOUR BODY DURING PREGNANCY

Joints

Changes in hormones contribute to joint laxity (over stretching) which can result in injury. The low back is commonly affected.
Due to ligamentous laxity, the arches in the feet frequently flatten. Unlike other joints in the body that return to their normal pre-pregnancy position, the foot may not. Therefore, pregnant women should be advised to wear supportive footwear.
Avoid jumping or jarring movements which may strain your joints.

Balance

The normal weight gain of pregnancy will change your center of gravity and put more stress on your joints.
These changes increase the risk of losing your balance and falling.
Walking, swimming and riding a stationary bicycle are safe, low-risk activities.

Heart Rate

The extra weight you gain during pregnancy will cause your heart to work harder than before you were pregnant.
Exercise moderately.
If you cannot talk easily while you are exercising, you are working too hard.

Body Temperature

Pregnancy increases your body temperature and metabolic rate.
Avoid overheating by drinking plenty of water and wearing cool clothing.

EXERCISE TIPS FOR BEGINNERS:

Check with your prenatal care provider before beginning any exercise program.

Start slowly

Begin with as little as 5 minutes a day and add 5 minutes a week until you can stay active for 30 minutes a day.
Choose low-intensity activities such as gentle stretching or walking.
Water aerobic classes may be appropriate for beginners. The hydrostatic force of water produces an increase in central blood volume by pushing swelling back into the blood stream. It tends to keep maternal heart rate and blood pressure lower than with land exercises.

Exercise regularly—at least 3 times a week

This will improve your fitness
Reduced risk of injury

Warm up and cool down

Begin each exercise session with 5-10 minutes of light activity and stretching
End each exercise session with a 5-10 minute cool-down period of slow your activity and stretching.

EXERCISE TIPS FOR PROS

Do not exercise to exhaustion
Do not compete while pregnant
Moderate training intensity, activities

Women who are accustomed to aerobic exercise before pregnancy, may continue their program. She should be cautious against starting new aerobic programs or intensifying training levels.

OTHER TIPS FOR A SAFE AND HEALTHY EXERCISE PROGRAM

Pay attention to your body and use common sense.

Do not overexert yourself or exercise to exhaustion.

Be cautions when exercising in the "back lying" position after 16 weeks of pregnancy. (See Supine Hypotension, pg. 89).

Drink plenty of water to avoid overheating and dehydration.

Do not exercise in hot, humid weather or if you have a fever.

Wear cool, loose-fitting clothing

Exercise intensity should be reduced by approximately 25% during pregnancy. Light-to-moderate exercise intensity is optimal during pregnancy. Maximum maternal heart rate of 140 beats per minute for those just starting an exercise program, and a 160 beats per minute if previously exercising. You should be able to talk with ease during exercise.

Another method of determining target exercise heart rate: 220 - age x 0.60 (or 0.75).

Do not skip the cool-down portion of the exercise program! The maternal body has heat loss mechanisms, but the fetus does not.

Do not hold your breath during any exercise.

Eat a small snack and drink at least 8 ounces of fluid after exercising.

DO NOT EXERCISE IF YOU HAVE THE FOLLOW CONDITIONS

Pregnancy-induced hypertension

Pre-term ruptured membranes

Per-term labor in this or previous pregnancies

Incompetent cervix/cerclage

Persistent second or third-trimester bleeding

Intrauterine Growth Retardation (IUGR)

WARNING SIGNS – STOP EXERCISING AND CALL YOUR DOCTOR

Pain

Vaginal bleeding

Dizziness, feeling faint

Rapid heartbeat

Difficulty breathing

Chest pain

Uterine contractions

SUPINE HYPOTENSION - RELATED TO EXERCISE

Supine hypotension (also known as inferior vena cava syndrome) may develop while lying on your back. The aorta and inferior vena cava may be occluded by the increased weight and size of the uterus (usually after the fourth month of pregnancy). This occlusion causes decreased output of the heart and the following symptoms:

• Increase in maternal heart rate

• Shortness of breath

• Faintness

• Dizziness

• Nausea and vomiting

• Sweating or cold, clammy skin

• Headache

• Numbness in extremities

• Weakness

• Restlessness

Spontaneous recovery usually occurs with a change in maternal position, even if very slight. Do not suddenly stand up. Changes in position from lying to upright should be done cautiously to decrease symptoms of hypotension. Other suggestions: frequent position change, small pillow under your right hip while lying on your back, or elevating the head with several pillows. If you continue to experience supine hypotension, instead of the back lying exercises, try them while lying on your left side, or reclined sitting.

DIASTASIS RECTI:

Modifications to exercise for abdominal muscles are necessary for women with diastasis recti. In standing, the abdominal wall supports the uterus. The muscles of the abdomen must lengthen to accommodate the enlarging uterus and growing fetus. Hormonal changes and the increasing mechanical stresses placed on these structures during pregnancy may result in a painless separation of the abdominal muscles or a diastasis recti.

You should check yourself for diastasis recti before you begin this exercise program. This self-check should be repeated once a week throughout your pregnancy.

Self-Check for Diastasis Recti:

Start by lying on your back with your knees bent and feet on the floor. As you lift your head off the floor, with your fingertips, measure the width of the separation between the muscles. If you can place more than two fingers in the muscle gap, you have a diastasis recti and you need to modify the exercises.

Correction of Diastasis Recti:

Position: Back lying with knees bent and feet flat. Cross hands over the midline.

Movement Technique:

1. Inhale.

2. As you exhale,
rock your pelvis back,
flattening your lower back.

3. Tuck your chin, and slowly raise your head off the surface while pulling the belly muscle toward the midline.

4. Slowly lower the head and relax.

DO NOT try to lift shoulders off the floor.

Modification: Fold sheet lengthwise under your low back. Cross sheet over the midline, holding opposite ends in each hand. As you tuck your chin and raise your head, pull outward on the ends of the sheet. As you lower your head and relax, release the grip on the sheet.

POSTURE CHANGES DURING PREGNANCY:

Due to the growing fetus and extra weight, your back tends to be pulled forward and arched. This is usually counteracted by good stomach muscles. But the stomach muscles are also being overstretched and tend to be weakened. Therefore, the stomach muscles have difficulty holding the back in proper posture, resulting in common low back pain during pregnancy.

The upper back tends to be rounded because the low back is arched and due to the enlarging breasts. This poor posture also results in neck and upper back strain.

Postural Correction:

To correct posture during pregnancy, follow the steps below. Perform these steps simultaneously as often as you can -- at least six times per day. Try them during different daily activities such as brushing your teeth, washing the dishes, or standing in line. Maintain them while performing exercises in the standing position.

1. Elongate the neck by drawing the chin back and keeping eyes level.

2. Lift your breast bone, ribs, and head without arching your lower back, as though you are trying to be taller. Breathe normally; do not hold your breath.

3. Pull your lower abdominal muscles in by pulling your belly button towards your spine. The pelvis should be in neutral position.

4. Unlock your knees, squeeze your buttock muscles and turn your thighs slightly outward.

5. Pull "up and in" with pelvic floor muscles.

6. Shift your weight slightly so half of your weight is on your heels and half is on the balls of your feet. Slightly lift the arches of your feet without rolling on the outside of your feet.

PRENATAL EXERCISES

Exercises should be done on a firm surface. They should be performed as smoothly and rhythmically as possible. There should never be any discomfort or straining, and you should always stop before reaching a point of fatigue. Hold each exercise for a count of 5, but never hold your breath. Start with five repetitions of each exercise, and gradually increase until you are doing 20 per session.

1. Kegel Exercises:

Purpose: To strengthen the pelvic floor muscles which helps prevent urine leakage during a laugh, cough, or sneeze.

Position: Any position, sitting, standing, or lying down.

Movement Technique: Contract your pelvic floor muscles as you would to stop urine flow. This muscle fatigues quickly so only do five to ten repetitions at a time. Your goal is a total of 100 repetitions per day.

2. Pelvic Tilt:

Purpose: To strength abdominals, improve posture, and decrease low back strain.

Position: Lying on your back, with your knees bent and feet on the floor. Once you are done with this exercise, do not continue to lie on your back.

Movement Technique: Flatten your back by tightening your stomach muscles. Hold for 5 seconds.

3. Diaphragmatic Breathing:

Purpose: To enhance oxygen exchange and efficient expansion of the lungs. To decrease breathlessness on minimal exertion. Since the main vein from the legs and pelvis pass through the diaphragm, its pumping action will improve blood circulation.

Position: Preferred position is sitting (but can be done in any position). Place hands on abdomen.

Movement Technique: As you breathe in, the abdomen and ribs should expand outward, as the diaphragm pushes down on the contents of the abdomen. Exhale through partially separated lips, pulling in your abdominals.

4. Cat Exercise:

Purpose: To strength abdominal muscles, improve posture, reduce back strain, and for mothers not comfortable lying on their backs or experience supine hypotensive syndrome.

Position: Hands and knees.

Movement Technique: While exhaling slowly, pulls abdomen in and push lower back up. Tuck chin down. Then slowly relax until your back is flat. Do not let your back arch.

5. Straight Curl Up (partial sit up):

Purpose: Strengthening abdominals to decrease low back strain, improve posture, and for pushing during labor.

Position: Lying on your back, with knees bent and feet flat on the floor.

Movement Technique: Perform a pelvic tilt (exercise #2) while reaching hands toward your knees. As you breathe out, lift your head and shoulders off the floor. Then slowly lower yourself back to the floor. Move slowly and do not jerk. If you have diastasis recti, be sure to modify this exercise.

6. Diagonal Curl Up:

Purpose: Same as #5.

Position: Same as #5.

Movement Technique: Perform a pelvic tilt, reach hands toward outside of knees, lift head and shoulders off the floor while rotating to one side. Do all your repetitions to one side before switching to the other side.

To increase difficulty for exercises #5 and #6:

• Cross arms over your chest.

• Or place hands behind head. Be careful not to pull with your arms. Arms should be relaxed.

7. Pelvic Swing:

Purpose: Gentle stretch for low back and abdominal, strengthen abdominals.

Position: Lying on your back, with your knees bent and feet flat on the floor.

Movement Technique: Gently lower legs to one side, aiming to touch the floor. Hold for 5-10 seconds. Return to the starting position and repeat to the other side.

8. Straight Leg Raising:

Purpose: Strengthen abdominals for posture and pushing phase of labor.

Position: Lying on your back, one leg straight and the other knee bent with foot flat on floor.

Movement Technique: Start with pelvic tilt and keep back in contact with floor as you slowly lift and then lower leg. Never try to lift both legs at once.

9. Chest Exercise:

Purpose: To strengthen muscles that support enlarging breasts.

Position:
Sitting. With arms crossed,
held at shoulder height, place hands on opposite elbows.

Movement Technique:
Push hands toward the opposite elbow,
hold for 5 seconds. Do not hold your breath.

The following exercises are stretches. These exercises are to be done slowly. Hold the stretch for 5-10 seconds. Do not hold your breath.

10. Side Bends:

Purpose: Gentle stretch for trunk.

Position:
Sitting in a chair or on the floor.
Clasp hands over head with arms straight.

Movement Technique:
Gently lean to one side, hold 5-10 seconds.
Return to starting position. Then repeat to the other side.

11. Tailor Press:

Purpose: To stretch inner thighs and ease delivery.

Position:
Sitting on the floor, with soles of feet together,
feet as close to the body as is comfortable.

Movement Technique:
With only your leg muscles, press knees down towards the floor.
Hold 5-10 seconds.

12. Calf Stretches:

Purpose: To prevent and relieve leg cramps.

Position:
Standing about two feet from wall,
place one foot in front of the other.
Be sure toes point straight ahead.
Lean forward and place elbows on the wall.

Movement Technique:
Keep heels on the floor and push hips forward. You should
feel a stretch in the calf of the leg that is farthest from the wall. Hold.

13. Upper Back Stretch:

Purpose:
Improve posture and relieve upper back strain.

Position:
Stand with head and shoulders against the wall.
Start with your hands over your head touching the wall.

Movement Technique:
Slowly lower your hands against the wall
until your hands are by your shoulders. Hold.

14. Flat-Footed Squat:

Purpose:
To stretch legs and practice optional delivery position.

Position:
Standing with feet a shoulder's with apart.

Movement Technique:
Slow bend your knees, keeping your heels on the floor,
until you are in a full squat. Hold up to 5 minutes at a time.

REFERENCES:

ACOG Technical Bulletin (189) February, 1994. Exercise during pregnancy and the postpartum period.

ACOG Patient Education, May, 1998.Exercise during pregnancy.

Hall, Carrie and Brody, Lori Then, 1999. Therapeutic Exercise: Moving Toward Function, pp 213-230.

POSTNATAL EXERCISES

Post-Partum Exercise Guidelines:

1. Gradually return to exercise but exercise regularly (three times per week). The process of reversal to the pre-pregnant state is thought to take six to eight weeks (although the anatomic effects of hormones may persist as long as 12 weeks).

2. Correct anemia before engaging in moderately strenuous activities. Stop exercising if vaginal bleeding increases or bright red blood appears.

3. Avoid moderately strenuous activities if excessive vaginal bleeding occurs or soreness of an episiotomy persists.

4. Avoid exercises that raise the hips and pelvis about the chest, such as bridging, knee-chest positions, and inverted postures, until post-partum bleeding has stopped completely. These positions put the body at risk for a rare but fatal air embolism through the vagina.

5. Avoid jerky movements, extreme stretching, and heavy weight lifting for 12 weeks or longer if joint laxity persists.

6. Use the same precautions as in pregnancy to prevent musculoskeletal injury, for approximately 12 weeks.

7. Provide good support to the breasts during exercise, especially if nursing. Nursing mothers should feed the infant before exercising to avoid discomfort.

8. Target heart rates and limits should be established in consultation with a physician and may be based on fitness level during and before pregnancy.

9. Be sure to check for diastasis recti (three days after delivery) before starting abdominal strengthening exercises. (See page 89.)

10. Progress to the next phase of exercises as you are comfortable.

Vaginal Delivery:

Phase I:

1. Kegel Exercises -- may be started within the first 24 hours after delivery.

Purpose: Essential in restoring pelvic muscle tone, reducing edema, facilitating circulation, and relieving pain, especially if an episiotomy has been performed or the perineum was torn. Strengthening the pelvic floor muscles enhance normal bladder and sexual function.

Hint: Mother should also contract or "brace" the pelvic floor muscles before coughing, sneezing, laughing, or lifting the infant.

2. Pelvic Tilt

3. Diaphragmatic Breathing

4. Upper Back Stretch

5. Postural Correction

Phase II:

6. Pelvic Swing

7. Straight Leg Raising

Phase III:

8. Straight Curl Up -- Be sure to check for diastasis recti. If greater than a 2-finger separation is present, do correction of diastasis recti instead.

9. Diagonal Curl Up

Cesarean Recovery (C-Section):

Exercises may begin within 24 hours after delivery, but should be based on the patient's comfort level.

Phase I:

1. Huffing

Purpose: A breathing exercise to keep lungs clear of mucus. Coughing may be painful. Huffing is easier to do, more effective, and much less painful.

Movement Technique: Quick, forceful outward breaths while pulling the abdominal muscles up and in. It is rather like saying "ha" but briskly and with a force from the abdominal muscles.

2. Diaphragmatic Breathing

3. Kegel Exercises: Beneficial because the pelvic floor has undergone dramatic changes during the pregnancy, or there may have been a lengthy and unproductive trial of pushing.

4. Ankle Pumps

Purpose: Improve circulation and prevent leg blood clots.

Position: Lying or sitting.

Movement Technique: Bend the ankle as far as you can by pulling your toes up toward you and then pointing your toes. Repeat ten times every hour.

5. Upper Back Stretch

6. Postural Correction

Phase II:

7. Pelvic Tilt

Phase III:

8. Bridge and Twist

Purpose: Assist in alleviating discomfort from decreased intestinal mobility, including gas.

Position: Lying on your back, knees bent and feet on the floor.

Movement Technique: Lift hips several inches off the floor. Maintain this elevated position as you twist your hips to the right, and then to the left.

** Do not do this exercise until post-partum bleeding has completely stopped.

9. When comfortable, start lying on your stomach. Placing a pillow under your hips may help for comfort.