Pre and Post Natal Exercise Notes

PRE AND POST NATAL EXERCISE
Fitnation Pty Ltd 2008 Pre and post natal exercise Notes
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.
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 15th week of pregnancy for previously sedentary females. Exercise after this stage should consist of gradual 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.
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
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
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
(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.
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 Hospital: ________________________________ Phone ________________________________ Phone
PREGNANCY HISTORY Due Date: ________________________________ Yes Yes No No Yes No
Is this your first pregnancy? History of miscarriages?
If no, previous pregnancy date/s __________________Type of delivery_____________ If yes, provide details: ____________________________________________________ Previous complications during pregnancy? If Yes, provide details:____________________________________________________ During this pregnancy have you experienced any of the following? Marked fatigue Foetal growth retardation Migraine/headache Multiple births/pregnancy Dizziness/faintness Premature labour/birth
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Vaginal bleeding/spotting Cervical stitch Reduced foetal movement Baby smaller than expected
Breech presentation Heart burn/gastric reflux Incompetent Cervix
Abdominal pain Knee pain Pelvic joint pain
Portion of placenta over cervix Incontinence (altered bladder control) Preeclampsia/ pregnancy induce hypertension
Swelling, pain or redness in calf Swelling (hands, ankles, face)
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) Respiratory disease (asthma/bronchitis) Kidney disease Chest pains/palpitations Neck pain Faintness/dizziness Muscular/skeletal injury Anaemia Recent surgery/illness Heart disease/family history Thyroid disease Diabetes/family history Lower back pain Epilepsy Recent viral infection Stroke Arthritis Other problems that may affect your ability to exercise If you have ticked any of the above, please provide details: ______________________________________________________________________ MEDICATION Are you currently taking any medication? Provide details: LIFESTYLE Do you smoke? If yes, how many per day? Do you consume alcohol? If yes, how many drinks per week? Yes Yes No No Yes No
____________________________________________________
_______________________________________________ _______________________________________
EXERCISE HISTORY: Were you exercising prior to becoming pregnant? Provide details type/frequency: _____________________________________________________________________ Are you currently exercising? 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: ____ Yes No Yes No
(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 increased weight 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. Implications for Exercise: 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. Implications for Exercise: 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. Implications for Exercise: 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.
Implications for Exercise: If you or your client notices diastasis recti cease abdominal work and seek medical advice. 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 Implications for Exercise:
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). Implications for Exercise: 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. Implications for Exercise: Avoid exercise in the supine position after the 16th week 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.
Fitnation Pty Ltd 2008 Pre and post natal exercise Notes 17
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.
Implications for Exercise: 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 systems workload 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. Implications for Exercise: 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 Placenta Uterus and amniotic fluid Mothers extra blood and fluid Breasts Extra fat stores 3.5kg 0.7kg 1.8kg 2.0kg 1.5kg 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.
Implications for Exercise: 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 8-40 Trimesters involved First, second, third Possible Problems 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 0-22 Second and third First and second Aortocaval Syndrome Spontaneous abortion dehydration increases 22-40 0-40 Second and third First, second and third Premature labour Inadequate diet accelerated starvation
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SUMMARY FOETAL RISKS

Week 0-12 0-40 Trimester Involved First First, second and third Possible Problems Heat stress (congenital malformations) Impaired uterine/umbilical blood flow (foetal hypoxia, foetal distress, intrauterine 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 exercise 5. 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 16th week 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 OF GUIDELINES FOR EXERCISE DURING PREGNANCY AND POST PARTUM (Based on Australian College of Gynaecologists Guidelines)
The guidelines are based on the unique and physiological conditions that exist during 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.
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 of pregnancy, 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 been undertaken 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 tucked under, 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 16th week 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 16th week 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
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 Upper Back Purpose Promotion of correct posture Example Shoulder shrugs, scapula pinches, seated row
Lower Back
Promotion of correct posture
Pelvic tilts (against wall, on all fours, sitting) Pelvic rocks Swiss ball exercises
Abdomen
Promotion of good posture, prevention of low back pain, strengthen muscles of labour
Abdominal tightening exercises, mediball / swiss ball exercises, oblique curls (whilst lying on the side or from the swiss ball)
Pelvic Floor
Promotion of bladder control, prevention of incontinence
Kegel exercises squeeze the muscles of the pelvic floor and hold for ten seconds. Repeat three times regularly 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.
Upper body
Improved muscular support of breasts
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) and PREMATURE 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.
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 16th week 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 back during 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.
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 times throughout 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.
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Pre and Post Natal Exercise Notes

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Pre and Post Natal Exercise Notes

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PRE AND POST NATAL EXERCISE

EXERCISE DURING PREGNANCY

BENEFITS OF EXERCISE DURING PREGNANCY

Feeling in control of your body:

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

BENEFITS OF EXERCISE POSTNATALLY

CONTRA-INDICATIONS TO EXERCISE DURING PREGNANCY

PREGNANCY HISTORY Due Date: ________________________________ Yes Yes No No Yes No

Is this your first pregnancy? History of miscarriages?

Breech presentation Heart burn/gastric reflux Incompetent Cervix

Abdominal pain Knee pain Pelvic joint pain

Swelling, pain or redness in calf Swelling (hands, ankles, face)

(Replace This organisation with organisational name)

PROBLEMS RELATED TO EXERCISE DURING PREGNANCY

Avoid weight work involving standing think of seated or lying alternatives

Encourage the use of supportive bra.

CHANGE IN BASE OF SUPPORT

CHANGED ENDOCRINE RESPONSE

CARDIOVASCULAR SYSTEM CHANGES

RESPIRATORY SYSTEM CHANGES

CORE TEMPERATURE CHANGES

Create a cool environment (eg use fans)

SUMMARY - MOTHER RISKS

SUMMARY FOETAL RISKS

CONTRAINDICATIONS TO EXERCISE POSTNATALLY

PREGNANCY AND POSTPARTUM

The important components of exercise during pregnancy include the following:

MODIFICATIONS OF EXERCISE DURING PREGNANCY

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

POSTNATAL EXERCISE GUIDELINES

Promotion of correct posture

Promotion of bladder control, prevention of incontinence

Improved muscular support of breasts

Shoulder shrugs Pectoral Stretches Scapula pinches Seated row

Buttocks, lower limbs

Facilitation of weight bearing, prevention of varicose veins

EXAMPLE OF CLASS FORMAT

Stretch out the calves, hamstrings, quadriceps and back

SITTING AND RELAXATION EXERCISES:

PELVIC FLOOR EXERCISES

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