AEROBICS IN PREGNANCY.

EXPECTATIONS OF A PHYSIOTHERAPIST
BY
OBSTETRICS AND GYNAECOLOGY UNIT
PRESENTERS ARE
NDIFE IJEOMA C
ANUKAM GABRIEL C
ANEKWU MORIS E

5/28/16

OUTLINE
Introduction
Classification of exercise
Pregnancy
Facts about exercise in pregnancy
Physiology of exercise and pregnancy
Classification of exercise by age of pregnancy
Contraindication
Precautions
Benefits of exercises
References

5/28/16

INTRODUCTION
Physical activity is any bodily movement

produced by skeletal muscles that

requires energy expenditure
Exercise is any physical activity that is

planned, structured and repetitive for the

purpose of conditioning any part of the
body.
It is used to improve health, maintain
Wishiff U, July
2009

fitness and is important as a means of

5/28/16

CLASSIFICATION OF EXERCISE
Aerobic exercise is any physical activity

that uses large muscle groups and causes

your body to use more oxygen than it
would while resting.
The goal is to increase cardiorespiratory

endurance. E.g. cycling, swimming, brisk

walking, skipping rope, rowing, hiking,
playing tennis, etc.
5/28/16

Wishiff U, July
2009

CLASSIFICATION OF EXERCISE CONTD

Anaerobic exercise or strength or

resistance training is any physical activity

done without needing oxygen.
The goal is to firm, strengthen and tone

muscles as well as improve bone

strength, balance and co-ordination. E.g.
push ups, biceps curl ups using
dumbbells, weight training, sprinting etc
5/28/16

Wishiff U, July
2009

CLASSIFICATION OF EXERCISE CONTD

Flexibility exercise is any activity done

to stretch and lengthen muscles, it also

helps to improve joint flexibility.
The goal is to improve the ROM of joints

which can reduce the chance of injury

5/28/16

Wishiff U, July
2009

PREGNANCY
Pregnancy is the period from conception

to birth.
Pregnancy usually lasts 40 weeks

beginning from the ist day of the womans

last menstrual period, this period is
divided into 3 trimesters, each lasting 3
months
Ist trimester lasts from week 1 until end
of week 13
2nd trimester lasts
Wilmore
J, week 14 until end
from
7
5/28/16
2003

PREGNANCY
Ist month the embryo is about a third of

an inch long, its head and trunk plus the

beginnings of arms and legs starts to
develop.
The embryo receives nutrients and

eliminates waste through the umbilical cord

and placenta.
By the end of the ist month, the liver and

digestive system begin to develop and the

Wilmore J,
8
heart
begins to2003
beat
5/28/16

PREGNANCY
2nd month- the heart starts to pump, the

nervous system begins to develop.

1 inch or 2.5cm long
Has a complete cartilage skeleton which is

replaced by bone cells,

By month end, the arms, legs, and all of the

major organs begin to appear.

Facial features begin to form.
Wilmore J,
5/28/16
2003

PREGNANCY
3rd month the foetus has grown to 4

inch [10cm] and weighs a little more than

an ounce [28g]
The major blood vessels and the roof of
the mouth are almost completed as the
face starts to take on a more recognizably
human appearance.
Fingers and toes appear
All the major organs begins to form
The kidneys are now functional and the 4
Wilmore
chambers of the
heartJ, are complete.
10
5/28/16

2003

PREGNANCY
4th month- the foetus begins to kick and

swallow,
Weighs 4 ounce[112g]
The foetus can hear and urinate and has

established sleep wake cycles

All organs are now fully formed although they

will continue to grow for the next five months.

The foetus has skin,
eyebrows
and hair.
Wilmore
J,
5/28/16
2003

11

PREGNANCY
5th month- weighs upto 1lb[454g] and

measuring 8-12 inches[20-30cm]

The foetus experiences rapid growth as

its internal organs continue to grow

The mother may feel her baby move and

hear the heartbeat with a stethoscope

5/28/16

Wilmore J,
2003

12

PREGNANCY
6th month- weighs 1-1.5lbs [454-681g]
Even though its lungs are not fully developed, a

foetus born during this month can survive with

intensive care.
The foetus is red, wrinkly and covered with fine

hair all over its body

The foetus will grow very fast during this month

as its organs continue to develop

5/28/16

Wilmore J,
2003

13

PREGNANCY
7th month- there is a better chance that

a foetus born during this month will

survive
Weighs 3lbs[1.31g]
Now the foetus can suck its thumb and

look around its watery womb with open

eyes.
14

The foetus

Wilmore J,
continues
to
2003

5/28/16

grow rapidly

PREGNANCY
8th month- growth continues but slows

down as the baby begins to take up most

of the room inside the uterus
Weighs 4-5lbs [1.8-2.3kg] and measuring

16-18inches [40-45cm]
The foetus may at this time prepare for

delivery next month by moving into the

head-down position
5/28/16

Wilmore J,
2003

15

PREGNANCY
9th month- adds 0.5lbs[227g] a week as

the due date approaches.

The foetus drops lower into the mothers

uterus and prepare for the onset of labour

which may begin anytime between 38th
and 42nd week of gestation.
Most healthy babies weigh 6-9lbs[2.7-

4kg], 20 inches long.

5/28/16

Wilmore J,
2003

16

FACTS ABOUT EXERCISE IN PREGNANCY

Regular exercise can help reduce back

pain, improve or maintain muscle tone,
reduce leg cramps, swelling and
constipation and improve sleep.
Women who exercise during
pregnancy:
1. Are less likely to experience fatigue due
to improved sleep, reduced anxiety and
neuromuscular tension
5/28/16

O'Connor D,
2005

17

FACTS ABOUT EXERCISE IN PREGNANCY

2. Have reduced weight gain and fat

deposition during pregnancy.
3. Have fewer pregnancy discomforts
4. Report a more rapid physical and
emotional recovery from delivery
5. Tend to have easier, shorter and less
complicated labors.
18

O'Connor D,
2005

5/28/16

FACTS ABOUT EXERCISE IN PREGNANCY

6. Have less need for pain relief during labor.

7. Have more stamina during labor.

8. Increase their aerobic capacity.
9. Decrease their susceptibility to illness
10. Increase their energy level.
5/28/16

O'Connor D, 2005

19

PREGNANCY
Babies of exercising mothers:
1. Have significantly lower heart rates than
babies of non-exercising mothers.
2. Are better able to cope with the stress of

birth.
3. Have a greater ability to adapt to life

outside the uterus

5/28/16
4.
Are more

O'Connor D,
healthy
2005 at birth.

20

FACTS ABOUT EXERCISE IN PREGNANCY

5. Are leaner at birth and tend to stay lean as

they grow.
6. Sleep through the night sooner.
7. Are better able to self-calm.
8. Score higher on tests of general intelligence
and oral language skills.
9. Have decreased risks of cardiovascular and
O'Connor D,
metabolic
diseases
later in life.
5/28/16
2005

21

PHYSIOLOGY OF PREGNANCY
AND EXERCISE
BY
ANUKAM GABRIEL.O (PT)

PREGNANCY INDUCED ADAPTATIONS

Musculoskeletal adaptations
Cardiovascular adaptations
Respiratory adaptations

Musculoskeletal adaptations

Anatomical

and physiological changes during

pregnancy have the potential to affect the
musculoskeletal system at rest and during
exercise.

weight-gain

significantly increase the forces

across joints by as much as 100% during
exercise.

Karzel and Friedman, 1991.

Musculoskeletal adaptations cont`d

Also, lumbar lordosis contributes to the prevalence

(50%) of low back pain in pregnant women.

This change in posture may alter balance,

increasing risk of falling.

Calguneri et al, 1982.

Musculoskeletal adaptations cont`d

increased ligamentous laxity due to the influence

of the increased levels of oestrogen and relaxin

increases the incidence of strains and sprains.

Calguneri et al, 1982

Cardiovascular adaptations
Pregnancy alters maternal haemodynamics such as

increase in blood volume, heart rate, and stroke

volume as well as cardiac output, and a decrease in
systemic vascular resistance
Artal et al, 1991

By midpregnancy, cardiac outputs are 3050%

greater than before pregnancy.

Morton MJ, 1991

Cardiovascular adaptations cont`d

Maternal stroke volume s by 10% by the end of

the first trimester, followed by a 20% in heart

rate during the subsequent trimesters.

Mean arterial pressure s 510 mm Hg by the

middle of the second trimester and then gradually

increases back to prepregnancy levels.
Pivaranik, 1996

cont`d
The decreased mean arterial pressure is the result

of:
uterine vasculature
uteroplacental circulation
vascular resistance of skin & kidney.

Pivarinik, 1996.

Cardiovascular adaptations cont`d

These

changes appear to establish a circulatory reserve

to provide nutrients and oxygen to both mother and
fetus at rest and during moderate but not strenuous
physical activity.
Pivarinik, 1996

After

the first trimester, the supine position results in

relative obstruction of venous return and therefore
cardiac output.

Clark et al, 1991.

cont`d
motionless standing is associated with a significant

decrease in cardiac output.

For this reason, these positions should be avoided

as much as possible during rest and exercise.

Clark et al, 1991

Respiratory adaptations
Minute ventilation s by 50%, due to increased tidal

volume.
Prowse and Gaensler , 1965; Artal et al, 1986

Resulting in an in arterial oxygen tension to 106

108 mm Hg in the first trimester, to a mean of 101

106 mm Hg by the third trimester.
Templeton and Kelman , 1976

Respiratory adaptations cont`d

There is associated increase in oxygen uptake, and a

1020% increase in baseline oxygen consumption.

Physiological dead space during pregnancy remains

unchanged.
Sady et al, 1989

PHYSIOLOGY OF EXERCISE

Chronic exercise provides stimulus for the

systems of the body to change.

Systems will adapt according to level, intensity,

and volume.
Melzer et al, 2010

Factors that may determine responses

to exercise
Specificity of training
Metabolic differences (aerobic vs. anaerobic) in

activities
Metabolic differences within an activity
Genetic endowment
Fibre type patterns
Somatotype (Ecto,Meso,Endo)

Melzer et al, 2010

Factors that may determine

responses to exercise
Environmental factors
Fitness training status.
Time course of adaptations
Magnitude of expected changes
Mechanism of adaptations.

Gender
Mechanism of adaptation.
Age

Children vs. adults vs. older adults

Melzer et al, 2010 s

Physiologic responses and

adaptations to exercise
Neuromusculoskeletal adaptations
Cardiovascular adaptations
Respiratory adaptations
Foetal adaptations
Metabolic implications

Musculoskeletal adaptations
Short term responses includes:
Muscle fibre micro tears
Muscle soreness
Increased blood supply
Increased muscle pliability
Increased JROM.

Melzer et al, 2010

Long term adaptations

Neuromuscular adaptations
Changes occurring in activation of motor unit
Improved recruitment patterns
Improvement in neural drive
Learning how to perform the activity (facilitation)

Disinhibition/ reduction in the sensitivity of the golgi

apparatus to allow for efficient force production.

Melzer et al, 2010

Musculoskeletal adaptation cont`d

increased # of vesicles that store acetylcholine
Muscle fibre type adaptations.
Improved recruitment pattern.
Increased synchronization of motor unit firing.

Melzer et al, 2010

Musculoskeletal adaptations cont`d

Fiber transformation (IIbIIa) may also result in

increased or altered recruitment patterns.

Changes in fiber area

Melzer et al, 2010.

Musculoskeletal adaptations cont`d

Type I fibers will show some percent increase after

resistance training, but significantly more changes

after aerobic training

Mitochondrial density increases in aerobically-trained

individuals
Enzymes (creatine phosphate and myokinase)

increase due to exercise training

Melzer et al, 2010

Musculoskeletal adaptations cont`d

Neuroendocrine adaptations:

Amount of synthesis and storage

of hormones
Transport of hormones
Time needed for clearance in
tissues
Melzer et al, 2010

Musculoskeletal adaptation cont`d

Amount of hormonal degradation
Number of hormone receptors in the

tissues
Magnitude of signal sent to cell

nucleus by receptor complex

Interaction with cell nucleus
Melzer et al, 2010

Musculoskeletal adaptations cont`d

Skeletal adaptations:

bone mineral content and bone matrix s

Connective tissue adaptations:

improvement in extensibility & strength of soft

tissues

Melzer et al, 2010

CARDIOVASCULAR ADAPTATIONS
Aerobic exercise requires more energy, and,

hence, more oxygen.

How much oxygen is needed depends

primarily on the intensity at which the activity

is performed and secondarily on the duration
of the activity.
Rowell, 1986.

Cardiovascular adaptations cont`d

At the onset of short-term, light- to moderate-

intensity exercise, there is an initial increase

in cardiac output .
Cardiac output plateaus within the first 2 min

of exercise, reflecting the fact that cardiac

output is sufficient to transport the oxygen
needed to support the metabolic demands
(ATP production) of the activity.
Poliner, et al., 1980.

Cardiovascular adaptations cont`d

Cardiac output increases owing to an initial in

both stroke volume and heart rate

The in stroke volume results from an in venous

return, which, in turn, the left ventricular end

diastolic volume (LVEDV) (preload).
Poliner, et al., 1980.

Cardiovascular adaptations
cont`d
The preload stretches the myocardium and

causes it to contract more forcibly

Thus, an in the left ventricular enddiastolic

volume and a in the left ventricular end

systolic volume (LVESV) account for the in
stroke volume during light to moderate
dynamic exercice.
Poliner, et al., 1980.

Cardiovascular adaptations
cont`d
Heart rate immediately at the onset of activity as

a result of parasympathetic withdrawal.

As exercise continues, further in heart rate are

due to the action of the sympathetic nervous

system
(Rowell, 1986).

Cardiovascular adaptations
cont`d
Systolic blood pressure will rise in sympathy to

cardiac output
Rowell, 1986
Diastolic blood pressure remains relatively

constant because of peripheral vasodilation, which

facilitates blood flow to the working muscles.

Wade and Freund, 1990

Cardiovascular adaptations
cont`d
Total peripheral resistance owing to vasodilation

in the active muscles

There is an initial rapid in plasma volume due to

compensatory fluid shift.

Wade and Freund, 1990

Cardiovascular adaptations cont`d

After exercising for weeks to months,

long-term adaptive

responses, ensues:
expressed as
increase in the muscle mass of the ventricles,
permitting greater force to be exerted with each beat
of the heart.

hypertrophy of the cardiac muscle fibers,

Also, in the thickness of the posterior and septal walls

of the left ventricle can lead to a more forceful contraction

of the left ventricle, thus emptying more of the blood from
the left ventricle.

George, Wolfe,Burggraf 1991.

Cardiovascular adaptations
cont`d
Arterial blood pressure at rest, blood pressure

during sub maximal exercise, and peak blood

pressure all show a slight decline as well.

However, decreases are greater in persons with

high blood pressure.

Fagard and Tipton 1994

Cardiovascular adaptations
cont`d
For instance, resting blood pressure will on

average -3/-3 mmHg.

Also,
HR
SV

Fagard and Tipton 1994.

RESPIRATORY ADAPTATIONS
The major changes in the respiratory system

from exercise are:

An in the maximal rate of pulmonary

ventilation, which is the result of in both tidal

volume and respiratory rate
An in pulmonary diffusion at maximal rates of

work, due to in pulmonary blood flow,

particularly to the upper regions of the lung.
Lotgering et al, 1991; Sady et al,
1990

FOETAL ADAPTATIONS TO
MATERNAL EXERCISES
The main concerns of exercise in pregnancy were

focused on the fetus, and any potential maternal

benefit was thought to be offset by potential risks
to the fetus.
However, in the uncomplicated pregnancy, fetal

injuries are highly unlikely.

www.bjsportmed.com

FETAL ADAPTATIONS
CONT`D
During obstetric events, transient hypoxia could

result initially in fetal tachycardia and an in fetal

blood pressure.

Fetal responses are protective mechanisms

allowing the fetus to facilitate transfer of oxygen

and decrease the carbon dioxide tension across the
placenta.

www.bjsportmed.com

FETAL ADAPTATIONS
CONT`D
However, any acute alterations could result in fetal

heart rate changes, whereas chronic effects may

result in intrauterine growth restriction.

Unfortunately, there are no reports to link such

adverse events with maternal exercise alone.

www.bjsportmed.com

FETAL ADAPTATIONS
CONT`D
There is a minimum or moderate in fetal heart

rate by 1030beats/min over baseline during or

after maternal exercise.

Artal et al, 1986; Collings et al, 1983; Artal,

1990;Carpenter et al, 1988

FETAL ADAPTATIONS
CONT`D
Fetal heart rate decelerations and bradycardia

occurs with a frequency of 8.9%.

The mechanism leading to fetal bradycardia during

maternal exercise can only be speculated on

probably:
a vagal reflex.
cord compression, or
Fetal head malposition.

Artal R, 1990

FETAL ADAPTATIONS CONT`D

relationship is suggested to exists, between

strenuous physical activity, deficient diet, and the
development of intrauterine growth restriction.

Naeye and Peters, 1982; Launer et al, 1990;

McDonald et al, 1988
.

FETAL ADAPTATIONS CONT`D

Mothers whose occupation requires standing or

repetitive, strenuous, physical work have a

tendency to deliver earlier and have small for
gestational age infants.

Ahlborg and Hogstedt, 1990

METABOLIC IMPLICATIONS
Pregnancy and exercise are associated with a

higher need for energy.

In the first two trimesters, an increased intake of

150 calories per day is recommended;

Araujo, 1997

METABOLIC IMPLICATIONS CONT`D

An

increase of 300 calories per day is required in

the third trimester.

The

competing energy needs of the exercising

mother and the growing fetus raise the theoretical
concern that excessive exercise might adversely
affect fetal development.
Araujo, 1997

METABOLIC IMPLICATIONS CONT`D

Aerobic metabolism
Most of energy (50+%) needed for prolonged exercise lasting

more than about 3 min.

Krebs Cycle degrades acetyl CoA into CO2 and H+ ions and

electrons (More ATP Produced)

Electron Transport Chain receives electrons for Krebs Cycle

and used for oxidative phosphorylation and regeneration of

ATP

Araujo, 1997

METABOLIC IMPLICATIONS CONT`D

Also, free fatty acids enter the mitochondria and

undergo beta oxidation in the Krebs Cycle

All energy systems are active at a given time
Extent to which energy system is useddepends on:
Intensity
Duration

Araujo, 1997

METABOLIC IMPLICATIONS CONT`D

Maternal and Foetal Temperature Issues.
The metabolic rate during both exercise and

pregnancy, resulting in greater heat production.

Theoretically, when exercise and pregnancy are

combined, a rise in maternal core temperature could

fetal heat dissipation to the mother.

Araujo, 1997

METABOLIC IMPLICATIONS CONT`D

Animal studies have demonstrated that an increase

in core temperature can lead to midline fusion

defects of the central nervous system.

Clapp, 1990

Assessment and Exercise

prescription in pregnant
women

Bio-data
Name
Age
Sex
Height
Weight
Occupation
Marital status

ASSESSMENT
Palpation:
Tenderness
Temperature
Spasm
Scar (healed or unhealed)
Swelling/Oedema

72

Sagar et al, 2009

5/28/16

ASSESSMENT
Examination:

Vital signs
Abdominal girth & Symphysis Fundal
Height (SFH)
Weight
Range of Movement (ROM)

73

Sagar et al, 2009

5/28/16

ASSESSMENT
ROM
Should be within permissible range
Avoid end range pressure
Avoid ballistic movement
Note
Hypermobility (ligament laxity relaxin)
Restricted trunk movement (protruded

abdomen)
Restriction of ROM at oedematous joints

74

Sagar et al, 2009

5/28/16

ASSESSMENT
Manual muscle testing: emphasis on
Abdominal muscles
Gluteal muscles
Perineal muscles
Oedema Assessment: - girth measurement

Sagar, Naik (PT)

75

5/28/16

ASSESSMENT
Diastesis Recti Assessment: hook lying to

shoulder lift, place fingers horizontally on

the linea alba
Sacroiliac Joint dysfunction Assessment:
Fabers test
Compression & Distraction tests

Sagar, Naik (PT)

76

5/28/16

ASSESSMENT
Incontinence Assessment (Pelvic floor

muscle test)
Perinometry
Per vaginal examination with sterile
gloves
Pad test
Stress incontinence test

77

Sagar et al, 2009

5/28/16

ASSESSMENT
Exercise tolerance test
6 - minutes walk test
3 step test
Functional Assessment
Gait Assessment

78

Sagar et al, 2009

5/28/16

STATUS OF CURRENT PREGNANCY

During this pregnancy, have you experienced:

Marked fatigue
Bleeding from the vagina (spotting)?
Unexplained faintness or dizziness?
Unexplained abdominal pain?
Sudden swelling of ankles hands or
face?

Adapted from Canadian society for exercise physiology

guideline on physical and medical readiness examination
2013

STATUS OF CURRENT PREGNANCY

During this pregnancy, have you experienced:

Persistent headaches or problems with

headaches?
Swelling, pain or redness in the calf of
one leg?
Absence of fetal movement after 6th
month?
Failure to gain weight after 5th month

Adapted from Canadian society for exercise physiology

guideline on physical and medical readiness examination
2013

ACTIVITY HABITS DURING THE PAST MONTH

ANY REGULAR FITNESS/RECREATIONAL

ACTIVITIES?
INTENSITY
Heavy
Medium
Light

FREQUENCY
TIMES/DAY

TIME
MINUTES/DAY
Adapted from Canadian society for exercise physiology
guideline on physical and medical readiness examination
2013

ACTIVITY HABITS DURING THE PAST MONTH

WHAT DOES YOUR REGULAR OCCUPATION

(JOB/HOME) ACTIVITY INVOLVE?

Heavy Lifting?
Frequent walking/stair climbing?
Occasional walking (>once/hr)?
Prolonged standing?
Mainly sitting?
Normal daily activity?

Adapted from Canadian society for exercise physiology

guideline on physical and medical readiness examination
2013

Do you currently smoke tobacco?*

Do you consume alcohol?*

EXERCISING IN PREGNANCY
INTRODUCTION
The BEST time to start an exercise program is in

the second trimester.

Women who have been exercising prior to
pregnancy may continue their exercise regimens
throughout pregnancy
goals of aerobic conditioning in pregnancy
should be to maintain a good fitness level
throughout pregnancy without trying to reach
peak fitness level or train for athletic
competition

EXERCISE PRESCRIPTION
A controlled analysis of exercise prescription is

lacking, because studies in humans are limited.

Any exercise regimen should be individually
structured to the patient; her goals, physical
conditioning and general health should be
considered.
The physician should offer an explanation of
the theoretic causes of concern, balanced with
a reminder that clinical studies to date have
shown no adverse effects from moderate
exercise

EXERCISE PRESCRIPTION
Elements of exercise prescription
basic health,
recreational pursuits
competitive activities

CONSIDERATIONS FOR
EXERCISE PRESCRIPTION
The type and intensity of exercise
The duration and frequency of exercise

sessions (This is to carefully balance between

potential benefits and potential harmful effects)
Additional attention should be given to
progression in intensity over time.
Basic exercise prescription for overall health
and wellbeing

INTENSITY
For moderate exercise, ratings of perceived

exertion should be 1214 (somewhat hard) on

the 620 scale.
Evidence of the efficacy of this approach is
that, when exercise is self paced, most
pregnant women will voluntarily reduce their
exercise intensity as pregnancy progresses

BORG SCALE OF EXERTION

TARGET HEART FOR THE

PREGNANT WOMEN IN
EXERCISE

Adapted from royal society of obstetrics and gynaecologists statement on exercise in

pregnancy 2006

DURATION OF EXERCISE
Two considerations before prescribing

prolonged exercise regimens for pregnant

women (in excess of 45 minutes of continuous
exercise)
Thermoregulation
Energy balance

THERMOREGULATION
The metabolic rate increases during both

exercise and pregnancy, resulting in greater

heat production.
The importance of maintaining adequate
hydration should be emphasized.
500 mL of liquid before exercising
250 mL of liquid every 30 minutes during
exercise
It is common to lose 1 to 2 litres of fluid per
hour in sweat

ENERGY BALANCE
First two trimesters an increased intake of

150 calories per day is recommended

Third trimester an increase of 300 calories
per day is required
Caloric needs with exercise are even higher

FREQUENCY OF EXERCISE
The recommendation for non-pregnant women

is that an accumulation of 30 minutes a day of

exercise occur on most if not all days of the
week. In the absence of either medical or
obstetric complications, pregnant women
could adopt the same recommendation.

American college of sports medicine and center for disease

control recommendation for pregnant women (CDC-ACSM)

PROGRESSION
Pregnant women who have been sedentary

before pregnancy should follow a gradual

progression of up to 30 minutes a day.
Women who have attained a high level of
fitness through regular exercise before
pregnancy should exercise caution in engaging
in higher levels of fitness activities during
pregnancy.
Further, women with high level of fitness should
expect overall activity and fitness levels to
decline somewhat as pregnancy progresses

ABSOLUTE
CONTRAINDICATIONS
Ruptured membranes
Preterm labour
Hypertensive disorders of pregnancy
Incompetent cervix
Growth restricted fetus
High order multiple gestation (triplets)
Placenta previa 28th week
Persistent 2nd or 3rd trimester bleeding
Uncontrolled type II diabetes, thyroid disease,

or other serious cardiovascular, respiratory or

systemic disorder

RELATIVE CONTRAINDICATIONS
Previous spontaneous abortion
Mild/moderate cardiovascular disorder
Mild/moderate respiratory disorder
Anaemia (HB< 100g/l)
Malnutrition or eating disorder
Twin pregnancy after 28th week
Other significant medical conditions

CONDITIONS REQUIRING
MEDICAL SUPERVISION WHILE
UNDERTAKING EXERCISE IN
PREGNANCY
Cardiac disease
Restrictive lung disease
Persistent bleeding in the second and third

trimesters
Pre-eclampsia or pregnancy-induced
hypertension
Preterm labour (previous/present)
Intrauterine growth restriction
cervical weakness/cerclage

CONDITIONS REQUIRING
MEDICAL SUPERVISION WHILE
UNDERTAKING EXERCISE IN
PREGNANCY
Placenta praevia after 26 weeks
Preterm prelabour rupture of membranes
Heavy smoker (more than 20 cigarettes a day)
Orthopaedic limitations
Poorly controlled hypertension
Extremely sedentary lifestyle
Unevaluated maternal cardiac arrhythmia
Chronic bronchitis

CONDITIONS REQUIRING
MEDICAL SUPERVISION WHILE
UNDERTAKING EXERCISE IN
PREGNANCY
Multiple gestation (individualised and

medically supervised)
Poorly controlled thyroid disease
Morbid obesity (body mass index greater
than 40)
Malnutrition or eating disorder
Poorly controlled diabetes mellitus
Poorly controlled seizures
Anaemia (haemoglobin less than 100 g/l).

WARNING SIGNS TO TERMINATE EXERCISE

Excessive shortness of breath
Chest pain or palpitations
Presyncope or dizziness
Painful uterine contractions or preterm labour
Leakage of amniotic fluid
Vaginal bleeding
Excessive fatigue

WARNING SIGNS TO TERMINATE EXERCISE

Abdominal pain, particularly in back or pubic

area
Pelvic girdle pain
Reduced fetal movement
Dyspnoea before exertion
Headache
Muscle weakness
Calf pain or swelling

FIRST TRIMESTER

103

5/28/16

FIRST TRIMESTER
Yoga and relaxation techniques
Weight training
Stretching
Kegels
Walking

(Juhl et al, 2010; Ruchat et al, 2012;

Yeo, 2010
104

5/28/16

FIRST TRIMESTER
Dancing
Stationary bicycle ergometry
Brisk walking
Jogging
Swimming
Sex

105

(Beddoe et al, 2009; Babbar et al, 2012; Balogh, 2005;

OConnor et al, 2011)

5/28/16

SECOND TRIMESTER
Yoga
Deep breathing exercise
Stationary bicycle ergometry (recumbent if

needed)
Dancing

Harper, 2012
106

5/28/16

SECOND TRIMESTER
Walking
Stair climbing
Jogging
Swimming
Sex

Harper, 2012
107

5/28/16

THIRD TRIMESTER
Yoga
Deep breathing exercises
Walking
Stair climbing
Dancing
Stationary ergometry (recumbent)

Harper, 2012
108

5/28/16

REFERENCES
1. ACOG Committee. Opinion no. 267: exercise during

2.
3.

4.

5.

pregnancy and thepostpartum period. Obstet Gynecol

2002;99:1713.
Blair SN, Kohl HW, Gordon NF. How much physical activity is
good for health? Annu Rev Publ Health 1992;13:99126.
Blair SN. Physical activity, fitness, and coronary heart
disease. In: C Bouchard, RJ Shephard, T Stephens, eds.
Physical activity, fitness, and health: international
proceedings and consensus statement. Champaign,
IL:Human Kinetics, 1994:591608.
Pate RR, Pratt M, Blair SN, et al. A recommendation from the
Centers for Disease Control and Prevention and the
American College of Sports Medicine. JAMA 1995;273:4027
Karzel RP, Friedman MJ. Orthopedic injuries in pregnancy. In:
Artal R, Wiswell RA, Drinkwater BL, eds. Exercise in
pregnancy. 2nd ed. Baltimore: Williams and Wilkins,1991.

REFERENCES
6. Artal R, Platt LD, Sperling M, et al. Exercise in

pregnancy. I. Maternal cardiovascular and metabolic

response in normal pregnancy. Am J Obstet Gynecol
1981;140:1237.
7. Veille J-C, Hohimer RA, Burry K, et al. The effect of
exercise on uterine activity in the last eight weeks of
pregnancy. Am J Obstet Gynecol 1985;151:72730.
8. Grisso JA, Main DM, Chiu G, et al. Effects of physical
activity and life style factors on uterine contraction
frequency. Am J Perinatol 1992;9:48992.
9. Hale RW, Milne L. The elite athlete and exercise in
pregnancy. Semin Perinatol 1996;20:27784.
10. NRC (National Research Council).Recommended
dietary allowances. 10th ed. Washington, DC: National
Academy of Sciences, 1989.

REFERENCES
11. O'Connor D, Crowe M, Spinks W (2005) Effects of

static stretching on leg capacity during cycling.

Turin 46(1) 52-56.
12. Wilmore J, Knuttgen H. (2003) Aerobic exercise
and Endurance improving fitness for health
benefits. The physician and sports medicine.
31(5):45.
13. Wishiff U, Ellingsen O, Kemi OJ, (July 2009), High
intensity interval Training to maximize cardiac
benefits of exercise training. Exercise and sports
sciences reviews 37(3) 139-146.
14. Clapp JF III. Exercise in pregnancy: A brief clinical
review. Fetal Med Rev 1990; 2: 89-101