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ExerciseandPhysicalActivityDuringPregnancy

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Thischaptershouldbecitedasfollows:

UnderreviewUpdatedue2015

Shrock,P,Glob.libr.women'smed.,
(ISSN:17562228)2008DOI10.3843/GLOWM.10098

ExerciseandPhysicalActivityDuringPregnancy
PamelaShrock,RPT,MPH,PhD
Director,PsychotherapeuticandSexualHealth,DepartmentofObstetricsandGynecology,WinthropUniversityHospital,Mineola,NewYork
INTRODUCTION
HISTORICALPERSPECTlVE
PSYCHOLOGICALANDPHYSICALBENEFITS
POSTURALCHANGES
CARDIOVASCULARANDRESPIRATORYCHANGES
MATERNALEXERCISEANDPERINATALANDFETALOUTCOME
EXERClSES
COITALACTIVITY
CONTRAINDICATEDEXERClSES
BODYMECHANICS
RESTANDRELAXATION
SPORTSACTIVITIES
REFERENCES

INTRODUCTION
Duringthechildbearingyear,fromconceptionthroughpostpartumrecovery,awoman'sbodyundergoesextensivechanges
whichfrequentlynecessitatemanyadaptations.Physicalandhormonalchangesoccurgraduallythroughoutthe9monthsof
pregnancy,andthesearereversedinamatterofweeksduringpostpartumrecovery.Skeletaltissue,muscleandconnective
tissue,bloodvolume,cardiacoutput,bodyweight,andpostureareaffected.
Asmorepregnantwomenengageindemandingoccupations,physicalactivities,andsports,theobstetriciansandmidwives
whotakecareofthemmustbecomeknowledgeableaboutthephysicalchangesofpregnancyandtheeffectsofexerciseonthe
motherandfetus.Becausepreventionisthebestapproachtohealthcare,understandingboththebodilystressesthatmay
resultfrompregnancychangesandthemeanstopreventunnecessaryproblemsenableshealthcaretobeinstitutedearlyin
pregnancyandcontinuedthroughthepostpartumperiod.

HISTORICALPERSPECTlVE
Thevalueandpossiblehazardsofphysicalexerciseandsportsactivitiesduringpregnancyhavebeendebatedforyears.1Early
observerscorrelatedanuneventfulpregnancyandeasylaborwithphysicalactivity.InExodus,Biblicalwritersobservedthat
HebrewslavewomenhadaneasiertimegivingbirththantheirsedentaryEgyptianmistresses,1andin9B.C.,Plutarchurged
Spartanwomentohardentheirbodieswithexercisetodecreasethepainofchildbearing.2
InVictoriantimes,pregnantwomenwereencouragedtoremainindoorsandkeepthemselvesconfined.3Withmorewomen
intheworkplaceinthe1930sandtheirapparenteaseofbirthing,physiciansonceagainadvocatedstrongbodymovements
forsedentarypregnantwomen.4
BasedonherworkinIndiainthe1930s,VaughaninstitutedantenatalexerciseclassesinEngland.Shewrotethatflexiblehips
andspineareconducivetoeaseoflabor,andwomenwereencouragedtosquat.3Exerciseclassestaughtbyphysiotherapists
becamepopularinGreatBritainandSweden,wheretheywerevaluedfortheireffectsonbackandabdominalmuscles.4 ,5 ,6 ,7
Duringthemid1950s,despitethelackofscientificproofofbenefits,keepfitexercisesintroducedbyobstetric
physiotherapistHelenHeardmaninBritain8wereincludedwithrelaxationandbreathingskillsinGrantlyDickRead'sbookon
painmanagementforlabor.9Infact,Heardman'sownbookdelineatedanexcellentprogramofprenatalexerciseswhichform
thebasisofthebestofmanyprenatalexerciseprogramstoday.8TheLamazemethod,popularizedintheUnitedStatesin1959
byMarjoryKarmel10andElisabethBing,11focusedonbothphysicalandpsychologicalpreparationforchildbirth.Fromthemid
1970sthroughthe1990s,theemphasisonhealthandthepublic'srenewedinvolvementinexercisecaughttheinterestofthe
pregnantpopulation.Numerousbooksonprenatalexercise,aswellasvideotapesandaudiocassettes,floodedthe
market,12,13,14,15,16,17,18 andcommunitycenters,hospitals,healthmaintenanceorganizations(HMOs),andindustriesbeganto
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offerexerciseclassesforexpectantwomen.Physiciansandmidwivesmustbeawarethatsomeofthesebookauthorsandsome
instructorsofprenatalexerciseclasseslackadequatetrainingandmaynothavesufficientknowledgeofthephysiologicchanges
ofpregnancynorofthecautionsexpectantwomenshouldfollowwhileexercising.Manyexpectantwomenenrollinregular
aerobicsclassesandtrytokeepupwiththenonpregnantparticipantsorinstructor,oftentotheirdetriment.
Beforeenrollinginapregnancyexerciseclass,itisrecommendedthattheexpectantwomanbepastherfirsttrimester,be
undermedicalsupervision,andbewarnedofanymedicalreasonthateitherprecludesherfromtakingtheclassesorwarrants
limitations.19AsoutlinedbytheAmericanCollegeofObstetricsandGynecology(ACOG),20,21theseconditionsincludeheart
disease,toxemia,rupturedmembranes,riskofprematurelabor,intrauterinegrowthretardation,poorweightgain,vaginalor
uterinebleeding,anemia,hypertension,andfetaldistress.Consultationwithhealthcareprovidersorsomedegreeofcautionis
necessaryforexpectantwomenwithrespiratoryconditionssuchasasthma20,22ororthopedicconditionssuchasbackandhip
painorjointproblems.8 ,23 ,24 ,25 Thequalificationsoftheinstructoroftheprenatalexerciseprogramshouldincludeamedical
backgroundaknowledgeofobstetrics,musclephysiology,andkinesthesiologyandexperienceworkingwithexpectant
mothers.19,22,25,26Physiciansshouldmakeinquiriesregardingthequalificationsofinstructorsbeforesigningapprovalnotesfor
theirpatientstoattendclasses.Twowaycommunicationbetweentheobstetricianandprenatalexerciseinstructorsshouldbe
institutedtoensurethesafetyofthepatient.19,20,22,24Thereisasyetnoscientificevidenceoftangibleresultsofphysical
preparationinpregnancyinthereductionofthelengthoflaborhowever,observersfeelthateffectiveabdominalexpulsive
effortsbythemothercanshortenthesecondstage.27,28Noreductioninuterineinertiaorepisiotomies(whichareperformed
routinelyintheUnitedStates)hasbeendocumented,buttherehasbeenalowerincidenceofcesareanbirthcorrelatedwith
physicalfitness.
Norelationhasbeennotedbetweenphysicalfitnessofthemotherandthenewborn'sbirthlength,headcircumference,or1
minuteApgarscore,6butrecentstudieshavefoundthatstrenuousmaternalexerciseinpregnancymaynegativelyaffectthe
mother'sweightgainandinsomecasescausesdecreasedweightinthenewborninfant.29,30

PSYCHOLOGICALANDPHYSICALBENEFITS
Birthisanormal,natural,physiologicprocess.Supportingthepremisethatpregnancyisastateofhealth,bothphysicaland
mentalaspectsofbodyimagemustbeconsidered.Withanincreaseinbodyweightandaprotuberantabdomen,mostwomen
feelheavy,unattractive,andcumbersometheirmovementsseemclumsy,uncoordinated,andlackinginagility.Thepregnant
woman'sbodyimagemayreachanalltimelowherposturesags,andshelosesherselfesteemandconfidence.31,32Thereisa
strongrelationbetweenphysicalandmentalhealth,andexerciseisgenerallythoughttohavetremendouspsychologicalvalue
andboostselfesteem.33 ,34 ,35
Withawellregulated,nonstrenuousexerciseprograminstitutedinthefourthmonthofpregnancythroughthepostpartum
period,apregnantwomanisabletomaintaingoodphysicalcondition,todevelopasensible,healthyapproachtoexercise,to
increasehercomfortinpregnancy,todeliberatelyprepareforpostpartumrecovery,andtosustainthenecessarymuscular
activityfortheworkofchildbirth.Feelingsofwellbeingandconfidencethatresultfromwholebodyexerciseonaregularbasis
enablehertoapproachchildbirthwithpositiveexpectations.
Physicalactivityimprovescirculation,appetite,digestion,andelimination,allofwhichareaffectedduringpregnancyandin
turnaremirroredinthepregnantwoman'smentalattitude.22,32,33Regularexerciseandnutritionarerecognizedascontributing
toahealthyandmorecomfortablepregnancy.
Selfesteemisreducedimmeasurablyafterchildbirth,whenthewomanisupsetbyherruinedfigureandadditionalfoldsof
flesh.Exerciseduringpregnancyandreinstitutedsoonafterdeliveryensuresquickerpostpartumhealingandrecuperation,
withrenewalofpositivebodyimageandselfesteem.Thesefeelingsofwellbeingandadditionalenergyallowthenewmother
tofeelthatsheisdoingsomethingforherselfandenablehertobetterfacetheresponsibilitiesofparenting.17,18,35

POSTURALCHANGES
Ashumansevolvedtoanuprightposture,severalpointsofstructuralweaknesswerecreatedinthehumanbody.Theseare
furtheraccentuatedduringpregnancypotentialproblemareasarethevertebralcolumn,theabdominalmuscles,andthepelvic
floor.
Thevertebralcolumninthenormalstatehascurvestocounteracttheforcesthatgravityexertsontheuprightposture.The
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curvesofthespineincludeaconcavityinthecervicalarea,convexityinthethoracicregion,concavityinthelumbarvertebrae,
andconvexityinthesacrum.Thelineofgravitypassesthroughthemastoidoftheskull,theshoulder,andthehipandknee
jointstojustanteriortothelateralmalleolus.Thepelvisliesatanangleof65degreestothelumbarspine,andthepelvicangle
determinestheprominenceoftheabdomenandbuttocks(Fig.1).Inthenonpregnantstate,connectivetissueisresponsiblefor
thetensilestrengthofmajorfascialstructures,ligaments,andjointsandisabletowithstandallextraphysicaleffort.
Fig.1.Posturalchangesinearlyandlatepregnancy.

Thereisevidencetosuggestthatchangesinconnectivetissueduetothehormonaleffectsofincreasedprogesteroneandrelaxin
duringpregnancyreducesupportandpermitincreasedmobilityinstructurestowhichmusclesandtendonsare
attached.17,18,24,36Examplesincludesofteningofthecervix,mobilityofthesymphysispubis,andrelaxationofthejointsofthe
pelvisandlowerback,especiallythesacroiliacjoints.Becauseofthesechangesandgreaterjointmobility,thereislessstability
ofthehipandkneejoints,whichoftencausingdiscomfortandlossofbalance.Forthesereasons,jerky,bouncingmovements,
quickturns,andjogging,whichcancauseadditionalstrainandpain,shouldbeavoided.22
Abdominalfascialoosensduetohormonaleffectsearlyinpregnancy(longbeforetheuterusislargeenoughtoaccountfor
enlargementoftheabdomen),thusallowingforgreaterstretchingoftheabdominalmuscles.Generally,thereiscontact
betweenthe2rectusabdominismusclesbelowtheumbilicusand2cmbetweenthesemusclesabovetheumbilicus.With
wideningofthelineaalbainpregnancy,adiastasiscanoccurin28%ofpregnanciesinthesecondtrimesteritsincidencepeaks
inthirdtrimesterandremainshighintheimmediatepostpartum.Thediastasisresultsinabulgeoftheabdominalwallon
increaseinintraabdominalpressureandaseparationofadistanceofmorethantwofingerwidthsbetweentherectae.18,23,27To
evaluatethiscondition,thepatientlayswithherkneesbentwhilethephysicianormidwifeplaceshisorherfingersbelowthe
xiphoidacrossthelineaalba.Thepatientraisesherheadandshouldersofftablewhilethephysicianmoveshisorherfingers
distallytodeterminehowmanyfingersfitintothespacebetweenthe2rectusabdominusmusclebellies.27Ifdiastasisis
present,thepatientisadvisedtoperformthecurlupexercisedailybytiltingthepelvisposteriorly,supportingtherectae
musclesoneithersidewithherhands,andexhalingwhileliftingherhead.22,23
Togetherwiththedownwardpulloftheglutealmuscles,theupwardpulloftheabdominalsmaintainsthecorrectalignmentof
thepelvisinrelationtothevertebralcolumn.Ifthesemusclesarewelltoned,theyadequatelysupporttheenlargeduterus
duringpregnancy.Morefrequently,thereisincreasedlumbarlordosis.
Becauseofjointchanges,somephysiciansbelievethatimpairmentofcoordinationofthelargermovementsandanincreasein
reactiontimearealsoevidentinpregnancy.Therefore,manyadviseagainstactivitiesinwhichsafetydependsonprecise
coordinationandinstantresponses,suchasskiing.19,20
Increasedbodyweightisdirectlyrelatedtoposturalchangesinthethoracicandabdominalregions.Withincreaseinweight
duringpregnancy(11.415.9kg[2535lb]normally),theabdominalmusclesarestretched,thereisprotuberanceoftheuterus
anteriorly,andthelineofgravityisshiftedforward.
Tomaintainherbalance,thewomanstandsfartherbackonherheelsandincreasesthewidthofherbase.Thisaccentuatesthe
lordosisinthelumbarspine,causingthepelvistotiltatamoreacuteangletothevertebralcolumn(seeFig.1).Structural
changes,weightredistribution,andhormonalalterationofjointstabilityputadditionalstrainonthesacroiliacandhipjoints.
Themusclesofthelowerbackareshortenedundertheincreasedworkload,resultinginfrequentbackacheandfatigue.The
extraeffortrequiredtobalancecauseshyperextensionofthekneesandweightontheinnerbordersofthefeet,resultinginthe
waddlinggaitofpregnancy,footstrain,andadditionalfatigue.35
Compensationforthisalteredbodyalignmentoccursintheupperbackandneckregion,withkyphosis,orrounding,ofthe
shouldersandforwardprotrusionofthehead.Theroundingoftheshouldersisfurthercompoundedbytheadditional0.7kg
(1.5lb)ofweightinthebreastsinpreparationforlactation.Thisresultsinshorteningofthepectoralmuscles,addedtensionin
theshoulders,andstretchingoftherhomboidmuscles,producingcomplaintsofpainintheupperbackbetweenthescapulae.
Theprotrudedpositionoftheheadfurtheraltersposturalsense,whichmustberelearned.38Headpositionalsoimpactsonthe
nervesemergingfromthecervicalspineandoftenresultsintractiononthemedianandulnarnerves,whichisexperiencedas
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numbness,tingling,andpaininthehandsandarms.36Increasedvascularityandfluidretentionmayalsocontributetothese
symptoms.24
Withtheencroachinguterusputtingpressureonthediaphragmintheseventhtoninthmonthsofpregnancy,manywomen
experienceshortnessofbreath.Thepoorposturalalignmentdescribedpreviouslyfurthercompressesthelungsfromabove,
decreasinglungcapacity.
PosturalCorrection
Poorpostureandsomeshorteningofthehipflexormusclegroupsecondarytoanteriorrotationofthepelviswithstretchingof
theabdominalmusclesmayaccountforthehighprevalenceofbackpaininpregnancy.24 ,36 ,37 ,38 ,39 Approximately50%of
womencomplainofbackacheassociatedwithpregnancy40,4110%ofactivitiesofdailylivingarelimitedbyseverelowbackpain,
and70%ofSwedishwomenusesickleavebecauseofpregnancyrelatedbackpain.Toalleviatethemagnitudeoftheproblem,
researchersdevisedaproactiveprogramofposturaleducationandsupervisedexercisebefore,during,andafterpregnancy,
withreportedresultsoflessbackpainandlowerincidenceofsickleave.42
Reeducationofthepregnantwomanandcorrectionofposturalalignmentalleviatemanyjointstrains,reducefatigue,and
assistwithwalkingandbreathingdifficulties.InformationandreeducationisincludedbychildbirtheducatorsinLamaze
childbirthpreparationclasses,28buttheseclassesusuallybegininlasttrimestertherefore,reeducationshouldbeexplainedby
thephysicianormidwifetowomenduringprenatalofficevisitsearlyinthepregnancy,beforeproblemsarise.
Realignmentisbestdoneinfrontofafulllengthmirrororwiththeaidofapartner.Bodyweightshouldbeevenlydistributed
throughthecenterofeachfootandmidwaybetweenleftandrightfeet.Kneesareslightlybenttoovercomehyperextended
knees.Abdominalmusclesaregentlycontractedandthebuttockstuckedundertocorrectthetiltofthepelvis.Thesternumis
projectedforward,whichwillstretchtheupperback,allowingtheshouldergirdletoextendcomfortablyposteriorly.Thehead
isrepositionedbyupwardstretchingoftheneckthechinistuckedinwiththetopoftheheadmaintainedparalleltothefloor
(Fig.2).
Fig.2.Realignmenttocorrectposture.

CARDIOVASCULARANDRESPIRATORYCHANGES
Maternalcardiovascularchangesduringpregnancyrepresentanoverloadstatewhetherthewomanexercisesornot.Thereis
anincreaseinmaternalbloodvolumeof30%to50%(~2.25L)tomeettheneedsofsustainingthegrowingfetus.43Resting
heartratesinthenonpregnantwomanrangefrom66to72beatsperminute,risingto81to88beatsperminuteduring
pregnancy.Cardiacoutputincreases2.5timesasafunctionofraisedstrokevolumeandheartrateandresultsinpartfrom
hypertrophyoftheleftventricle.20,44,45Cardiacoutputreachesamaximumat28weeks'gestationandremainselevated
throughouttherestofthepregnancy.37Thepregnantwomen'sredbloodcelllevelincreasesby25%to30%andplasmavolume
increasesby45%,whichresultsinaphysiologicanemia.
Fromearlyinthethirdtrimester,theaddedpressureoftheenlargeduterusmayimpedeinferiorvenacavaflow,causing
posturalhypotension.Cardiacoutputmaybeenhancedifaleftorrightlateraltiltismaintainedintherecumbentposition.
Uterinepressureonthevenacavaealsocausegravitationalstasisofbloodinthelegs.ACOGGuidelinesforPhysicalActivityin
Pregnancyfirstdictatednolyingintherecumbentpositionafterthe4thmonth.2,21Later,theseguidelinesweremodifiedto
suggestplacingapillowbehindtherightbuttockwhenrecumbent.Researchhasdemonstratedthatlyingonthebackinhealthy
pregnantwomendoesnothavedeleteriouseffectsonthefetus.46
Venousbloodmustbereturnedtotheheartagainsttheforceofgravitywhenthebodyisupright.Theincreasedvolumeofthe
circulatorysystemandeffectsofprogesteroneoftencauseveinstobecomeprominentandvaricosed.Forthisreason,sitting
withlegscrossedatthekneesshouldbediscouragedduringeverydaylifebutespeciallyduringpregnancy.35
Aspregnancyprogresses,manywomenexperienceedemainthelegsandfeetwhichisunrelatedtotoxemiaormedical
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conditions.Likewise,slowedcirculationandretainedfluidresultinpatientsawakeninginthemorningwithswollenortingling
fingersandwrists.Flexion,extension,andcircularmovementsofthefeetandhandsareeasilylearnedandhelpfulforreliefof
edema.
RespiratorySystem
Owingtoa4cmupwardcompressionofthediaphragmbythegrowinguterus,thereisadecreaseintheverticaldimensionof
thethoraciccavity.Withrelaxationoftheligamentousattachments,thereisacompensatoryenlargementoftheribcage,with
resultantincreasedvitalcapacity.Restingventilationratesandtidalvolumebothincrease,causingaphysiologic
hyperventilation.Thebrain'srespiratorycenterhasareducedthresholdtobloodlevelsofcarbondioxide,causinganincrease
inrespiratoryrate.Increasedoxygenconsumptioninadvancedpregnancyandcapillaryengorgementthroughoutthe
respiratorytractcausenasalcongestion,makingnasalbreathingdifficultandfrequentlycreatingadditionalproblemswith
breathlessness,withorwithoutexercise.
EffectofExerciseontheCardiopulmonarySystem
Whenpregnantwomenexercise,cardiovascularandrespiratoryresponsenaturallyincrease.Thematernalheartrate
acceleratesfrom94to170beatsperminuteinrelationtothestrenuousnessoftheexercise.20GuidelinesfromACOGindicate
keepingheartratesbelow140beatsperminuteduringexerciseorphysicalactivityasaprecaution,eventhoughheartrateand
bloodpressurereturntopreexerciserateswithin30minutes.20,22Systolicbloodpressurerisesfrom30mmHgto40mmHg,
whereasthediastolicbloodpressurerisesonly10mmHgwithexercise.Expiratoryventilationincreasesduringexercisein
pregnancy.37Thisresultsinabeneficial18%increaseinaerobiccapacityinwomenwhodidnotexerciseduringpregnancy,
aerobiccapacitydecreased.47Severalresearcherssuggestthatthereisatrainingeffectfromparticipatinginanongoingexercise
programandthatexercisemayhelptomaintainworkefficiencyatprepregnancylevelsdespitethedemandsofthe
pregnancy.34 ,35 ,36 ,37 ,38
EffectofExerciseontheFetus
Concernsabouttheeffectsofexerciseontheuterineenvironmentandthefetushavebeenvoicedbymanyphysicians.In
particular,studiescenteredaroundtheshiftofbloodfromthesplanchnicareatotheskeletalmusclesofpregnantwomenafter
aboutofexerciseandthepossibleeffectsofthisonthefetus.33,48Fearsweredispelledbyteststhatshowedthattherewasnot
onlyrapidreversalbutacompensatoryflushback,withanincreaseinuterinebloodflowaftercessationofexercise.40
Monitoringofthefetalheartinresponsetomaternalexerciseshowedrateswithinnormallimitsandreturntobaselinewithin
30minutes.43 ,49 ,50 ,51

MATERNALEXERCISEANDPERINATALANDFETALOUTCOME
Studiesonmaternalexerciseandbirthoutcomeindicatethatmostfetusesareabletotoleratemoderatematernalexercise
programsthatwomencontinuethroughoutthepregnancy.48,52,53Researchinrecreationalrunners,aerobicdancers,and
nonexercisersdeterminedtheincidenceofspontaneouslossofpregnancyinall3groupscombinedwas19%(15%intheoverall
population).However,losspercentagebygroupwasrunners,17%dancers,18%andnonexercisers,25%.Exercisingdoesnot
alterpregnancyoutcomeorincreaseprobabilityofspontaneouspregnancyloss.48,50,53Studiesofenduranceexercises(i.e.
runningandaerobics)overthecourseofpregnancymonitoredexercisersevery6to8weeks.Beforetheendofthefirst
trimester,onethirdofstudysubjectsstoppedintensiveexercising,formingtwonewgroups(i.e.exercisersandnonexercisers).
Ineachgroup,9%experiencedpretermlaborbefore37weeks.Exercisersstartedlabor5daysearlierthannonexercisersand
hadlowerincidencesofobstetricalinterventions,needforlaborstimulation,episiotomy,cesareanbirth,andepidural
anesthesiaaswellasashorteractivestageoflabor.46,53,54
Decreasesinbirthweightandlessmaternalweightgainhavebeennotedinwomenwhocontinuedhighperformanceactivities
duringpregnancy.32,34Otherstudiescontradictthesefindingsoflowbirthweight,findinginsteadahigherrateoffetal
anomalies,whichcouldberelatedtohyperthermiaexperiencedduringintenseexerciseinearlypregnancy.48,55
ThermoregulatorySysteminPregnancy
Basalmetabolicrate(BMR),increasesduringpregnancy,andnecessitatesa300kcalincreaseinthepregnantwoman'scaloric
intake.Thephysiologicchangesandincreaseinadiposetissueinsulationmakespregnantwomenfeelwarmerevenatrest.51,56,57
Researchstudiesonmaternalthermoregulationsuggestthathyperthermia,specificallyinthefirsttrimester,canproduce
adverseeffectsonfetaldevelopment.45Asmaternaltemperaturesincrease,sodoesthefetaltemperature.Teratogeniceffectsof
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heatonthefetushavebeendemonstratedinanimalresearch.
Whenexercising,pregnantwomenmustberemindedtowearloosefittingclothinganddrinkfluidsbefore,during,andafter
exercise.48Womenwhoarefittendtomaintainacoolertemperaturebecauseoftheirmoreefficientcardiovascularsystem.46
AvoidinghyperthermiaisoneoftheprimaryrationalesforboththeAmericanCollegeofObstetriciansandGynecologists
(ACOG)andAmericanCollegeofSportsMedicine(ASSM)inestablishingsafetyguidelinesforprenatalexerciseintensityand
duration.

EXERClSES
Aregimenofregulatedexercises,doneslowlyanddeliberatelyandwithoutstrainortothepointoffatigue,includesallareasof
thebodyandassistswiththeposturalcorrectiondescribedpreviously.Theseexercisesimprovetoneandelasticityofslackened
orstretchedmuscles(abdominals,rhomboids,upperbackandneckmuscles)stretchshortenedmuscles(lowerbackand
pectorals)reducetensioninjointsofthepelvis,shoulders,hips,andkneessupportbreastsbystrengtheningpectoralsand
improvepostureandincreasevitalcapacityofthelungs.Althoughinmanychildbirthpreparationclassesavarietyofexercises
aretaught,13,17 ,18 ,19 ,57,58thefollowingbasicexamplescanbeeasilyexplainedbythephysicianormidwifeattheprenatalvisits.
GuidelinesforExerciseDuringPregnancy/Postpartum
1. Regularexercise(3times/week)ispreferabletointermittentactivity. 20
2. Allexercisesaredoneslowlyanddeliberately.Jerkingorbouncingmovementsthatstrainjointsshouldbeavoided.Woodenorsecurelycarpeted
surfaceswillreducebodyshockandprovidesurefooting.
3. Activitiesrequiringjumping,jarringmotionsorrapidchangeofdirectionshouldbeavoidedbecauseofjointinstability,andcompetitiveactivities
andcontactsportsshouldbediscouraged
4. Vigorousexerciseshouldbeavoidedinveryhot,humidweather(unlessinanairconditionedenvironment)andduringperiodsoffebrileillness.
5. Itisvitallyimportanttobeginanyexercisesessionwithaperiodofwarmupexercisessuchasarmcircling,shoulderandneckrotations,trunk
flexion,andgentlekneebends. 57Thisshouldbefollowedbystretchingofthevariousmusclegroupsinthearms,legs,andtrunktoprevent
damageofmusclefibersandjointstrainthesemayincludegentleyogastretches17thatarenottakentothepointofmaximumresistance. 20
6. Similarly,eachsessionendswithmuscleandjointstretches58doneslowly,withoutbouncingorjerkymovements.Coolingdownshouldbe
accompaniedbyslowandcomfortablebreathingandfollowedbyarelaxationperiod.
7. Heartrateshouldbemeasuredbeforetheexercisesessionandattimeofpeakactivity,andthetargetlevelof140beatsperminuteshouldnotbe
exceededexceptinstrongathleteswhohaveconsultedandestablishedtheirowntargetrateswiththeirphysicians.
8. Strenuousexerciseshouldnotexceed15minutesinduration,andexercisesthatemployorproducetheValsalvamaneuvershouldbeavoided.
9. Caloricintakeshouldbeadequatetomeettheextraenergyneedsofpregnancyandlactationaswellastheexerciseperformed.Liquidsshouldbe
imbibedliberallybefore,during,andafterexercisetopreventdehydration.
10. Maternalcoretemperatureshouldnotexceed38.5C. 48,54

Eachpatientprogressesatherownrate,startingbydoingeachexerciseforthreeorfourrepetitionsandslowlybuildingupto
tenrepetitions.Someexercisesincludespecificbreathingtechniquesinconjunctionwiththerequiredmovement(e.g.pelvictilt
withexhalationandreleasewithinhalationinhalationwithtwoarmstretchingtothesidestoexpandthechestandexhalation
withreturntomidline).Holdingthebreathonexertionofanyexerciseisnothelpfulcontinuousbreathingistobeencouraged.
Noexercisemustbeperformedtothepointoffatiguerestandrelaxationshouldbeinterspersedduringthesession.37,57Adding
musictotheexercisesessionenhancesenjoymentandencouragesrhythmicmovements.Atnotimeshouldthethetoes
pointed,becausethisoftenpredisposestocalfcramps.Situpsordoublelegraisesshouldnotbedoneduringpregnancynor
attempteduntilafterthe6weekpostpartumcheckup,becausetheyputtoomuchstrainontheabdominalsandencourage
diastasis.18,27,57Positionsthatincreaselumbarlordosisshouldbeavoidedtoreducepossibilityofbackache.59
Patientsusedtobediscouragedfromlyingflatonherbackforextendedperiodsoftimetominimizethepossibilityofslowing
circulationtotheuterusandpreventsupinehypotension.However,thereisnoharminlyingrecumbentforshortperiodswhile
doingexercises,20andnewestresearch46,55showsthatinhealthypregnancies,itisnotnecessaryforthepatienttoneverlieon
herbackafterthefourthmonth,asformerlyadvocatedbyACOG.21Therearesomeexercises(e.g.abdominalcurls)thatare
mosteffectivelydonewhilelyingontheback,andthepatientcanchangetoalternatepositionsaftereachset.Exercisesthat
increasecirculationinandaroundthepelvisshouldbeencouraged(e.g.pelvictilt,abdominalexercises).Standingorsidelying
positionscanbesubstitutedforexecutinghipandlegmovementsnormallyperformedwhilerecumbent.
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Timeshouldbesetasideeachdayforsomeexerciseand,wherefeasible,exerciseshouldbeincorporatedintodailyactivities.
ACOGguidelinessuggestexercising3timesperweek.1,21
BreathingExercises
Becauseofthedifficultiespregnantwomenmayhavewithrespirationduringthesecondandthirdtrimestersandthetendency
toholdthebreathduringexercising,deliberateattentiontocontinuousbreathingisencouraged.Thisensuresasteadyintakeof
oxygenaswellaspreparesthewomanfortheneedtomaintainuniformandrhythmicbreathingduringlabor.Focusedand
relaxedabdominalandlowchestbreathingskillsimproveventilationandenhancerelaxationduringpregnancy,throughlabor,
andpostpartum.11
PelvicTilt
Thepelvictiltmovement,whichisslight,strengthensandtonestheabdominalmusclesandstretchesthelowerbackmuscles.It
ismosthelpfulfordecreasingthelumbarlordosis,realigningposture,andreducinglowbackpain.
Thepatientliesonherbackwithbothkneesbentandfeetonthefloororexaminationtableabout45cm(18inches)apart.She
breathesinthroughhernose,andasshebreathesoutthroughherrelaxedmouthshepressesthesmallofherbackagainstthe
floorandnoticestheupwardtiltingmovementofherpelvisandtighteningintheabdominals.Tomakesuresheisdoingthis
exercisecorrectly,thephysiciancanplaceherorhishandunderthelumbarvertebraeandtellthepatienttopressdownonto
thehand.Thewomanholdsthispositionforacountoffourandthenslowlyreleasesassheinhalesandexhales(Fig.3).Once
mastered,thisexercisecanbedonewhilesitting,standing,oronallfours,withcarebeingtakennottoletthespinesag(Fig.4).
Whendoingthepelvictiltinthestandingposition,slightbendingofthekneeswillensurethatthemovementisperformedin
thepelvicregionanddoesnotstrainthehips.Thepelvictiltisparticularlyhelpfulforbackacheduringpregnancy,labor,and
thepostpartumperiod23,38,59andisalsousefulasanabdominaltoner.
Fig.3.Pelvictiltinthesupineposition.

Fig.4.Pelvictiltwhileonallfours.

AbdominalToners
Abdominaltonersareprogressionsofthepelvictiltexerciseandareexcellentfortoningandstrengtheningtherectus,or
straight,abdominalsandtheobliqueabdominals.Thesemusclesareusedinsecondstagepushingandforpostpartumcurlups
andwaistlinerecovery.
RECTUSORSTRAIGHTABDOMINALS.
Thepositionisthesameasforthepelvictilt.Apillowplacedundertheheadreducespressureonvenacava.Withinhalation,
thepatientrelaxes.Assheexhales,shetiltsherpelvisasinthepreviousexercise,andthenliftsherheadandslowlystretches
botharmstowardherkneesandholdsthispositionforacountoffourwhilebreathingnormallyshethenrelaxestothe
startingposition(Fig.5).Ifadiastasisisdiagnosed(i.e.iftwofingerscanbeinsertedbetweentherecti),insteadofstretching
herarmsforwardthepatientshouldbraceherabdomenbyplacingbothhandsacrossit,holdingontotheoppositesidesofthe
musclebellies.18
Fig.5.Abdominalcurlswitharmraising.
OBLIQUEABDOMINALS.
Thepositionisthesameasdescribedpreviously.Again,thepatientbeginswiththepelvictilt,butthistimesheliftsherhead
andbotharmsandstretchestowardtheleftkneeandholdsthispositionforacountoffourwhilebreathingnormallyshethen
relaxesslowlytothestartingposition.
Thepatientinhalesandexhalesafewtimes.Withthenextinhalation,sherelaxes,andonexhalationrepeatsthepelvictilt,this
timebringingbotharmstotherightknee(seeFig.5).

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Hip,Knee,andAnkle
Thestartingpositionsfortheseexercisesareeithersidelyingorstanding.Thebodyremainsrelaxedasthepatientinhales(Fig.
6A).Ifpatientislyingonherside,bothkneesarebent.Assheexhales,shebendsherkneetowardherchest(Fig.6B).While
inhaling,shestretchesherrightlegforwardbyextendingherkneeanddorsiflexingherfoot(Fig.6C).Withexhalation,she
bringsthestraightlegbacktomidline(Fig.6D),andwithinhalationbringsitbacktotheflexedstartingposition.Thisexercise
isthenrepeatedwiththeleftlegwhilekeepingtherightlegflexedafterthepatientturnstolieonoppositeside.
Fig.6.Hip,knee,andankleflexibilitydoneinsidelyingposition.

NeckandShoulderMuscles
Theexercisefortheneckandshouldermusclesisdoneinthetailorsittingposition(i.e.sittinglikeatailorwithkneesflexed)or
standing17(Fig.7).Thepatientdropsherheadforwardandgentlycirclesittotheleft,upward,totheright,andforwardinas
largeanarcaspossible.Thisisdoneslowlyanddeliberatelyandisrepeatedonalternatingsides,whilebeingcarefulnotto
placepressureonthecervicalvertebrae
Fig.7.Neckandshoulderexercises.

Theshouldersareraisedtowardtheears,pulledbackward,andslowlycircleddownandforward.Thisexerciseshouldbe
repeatedseveraltimesitcanalsobedonewiththewoman'sfingertipsonhershoulderswhileliftingandcirclingtheelbows
forward,upward,andbackward.Caremustbetakentokeepthebackstraightandtokeepthechinfrompokingforward.These
exercisesarehelpfulinreleasingtensionintheneckandshouldermusclesandshouldbefollowedbyposturalalignmentofthe
head,neck,andshoulders.
UpperBackandAbdominalSideFlexors
Withthepatientinthetailorsittingpositionorstandingwithlegsapartforbalance,thearmsarebentatthesides,andthe
fingertipsareplacedontheshoulders.Therightarmisstretchedupwardasthewomaninhales(Fig.8).Keepingthetorso
erect,thepatientstretchesherribcageandupperbackandthenslowlylowersherarmtothestartingpositionwhileexhaling.
Thisisrepeatedwiththeleftarmandthenwithbotharmsatonce.Thepatientshouldprogresstostretchingherrightarmand
bendingtotheleftwhilekeepinghertorsoinalignmentthepatientshouldthenrepeatthisexercisebystretchingherleftarm
andslowlybendingtotheright(Fig.9).Theseexercisesallowforgreatervitalcapacitybystretchingtheribcageandupper
backandstrengtheningtheabdominalsideflexorsinpreparationforpostpartumrecovery.Whenthepatient'sposture
demonstrateskyphosis,thepectoralsareusuallyshortenedthesestretchingexercisesaremostbeneficialincorrectionofthis
problem.
Fig.8.Upperbackandribcagestretch.

Fig.9.Abdominalsideflexors.

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BreastSupport
Inthesecondandthirdtrimesters,whenbreastsenlargeandincreaseinweight,aswellasduringthepostpartumperiod,
additionalsupportofthebreastsisnecessary.Strengtheningofthepectoralmuscles,whichsupportthebreasts,isachieved
throughuseofaneasyexercise.
Inthesittingposition,thepatientputsherhandstogether,asinprayer,withherelbowsflexedatshoulderlevel.Sheslowly
pressesherhandstogether(Fig.10).Thepositionisheldtoacountoffourandslowlyreleased,andtheexerciseisrepeated
severaltimes.Normal,regularbreathingshouldaccompanythisexercise.
Fig.10.Pectoraltoning.

AdductorsandHamstrings
Atonetimeitwasthoughtthatpregnantwomenshouldbecomeaccustomedtostretchingoftheadductorsandinternal
rotatorsofthethighsforaddedcomfortinexpulsion.Itwasarguedthatuseofstirrupsfordeliveryputstrainonthesemuscles
aswellasthehipandpelvicjoints,andthatwithconscientiouspracticeofsomestretchingexercises,theassociateddiscomfort
couldbedecreased.
Incorrectteachingorlearningoftheexercisecouldleadtosubluxationofthepubicsymphysisasaresultoftoovigorous
pressureonthekneesorabouncingmovement,whichinitiatesthestretchreflex,causingareboundwithfurthershortening
andprotectivesplintingofthemuscles.18Thefollowingexercisenotonlyallowsforsomestretchoftheadductorsbut,more
importantly,allowsforstretchofthetighthamstringsandlowbackextensors.17,18,57,60Thepatientsitsonthefloorwithherlegs
extendedandseparatedaswidelyascomfortableandherhandsstretchedforwardwithherarmskeptatshoulderlevel.Gently
andslowly,sheflexesforwardfromthehips,maintainingherarmsparalleltothefloorwhilestretchingthemforward,not
towardhertoes(Fig.11).Atfirstthismovementmayfeeluncomfortable,butwithpracticethediscomforteases.Nojerkingor
bouncingmovementsshouldbedone,onlystretchingforwardslowly,holdingforthecountoffour,andslowlyreleasingtothe
startingposition.57
Fig.11.Hamstringandadductorstretch.

ExercisesAidingCirculation
Asdiscussedinthesectiononcardiovascularandrespiratorychanges,pressurefromtheenlargeduterus,dependencyedema,
dilatedbloodvessels,andbloodstasiscauseswellinginthelowerextremities,fingers,andhands.Exercisestoreduceswelling
andimprovebloodcirculationdecreasepatientdiscomfortandfatigue.Toincreasecirculationinthelegsandreduceedemaof
thefeet,alternateflexionandextensionoftheanklescausespumpingactionofthecalfmusclesthatpromotestheflowofblood
(Fig.12).Theseexercisesshouldberepeatedsixtoeighttimesanddoneslowly.Pointingofthetoesandextremeplantarflexion
mayresultinlegcrampsandthereforeshouldbeavoided.Rotationoftheanklesinwidecircles,firstinonedirectionandthen
theother,isanotherexcellentexercise(seeFig.12).Theeffectsofthisexerciseoncirculationcanbeenhancedifthelegsare
supportedandraisedhigherthanthehipssothatgravityassistsinreturnbloodflow.
Fig.12.Alternateflexionandextensionofanklesandrotationofanklesinwidecircles
enhancescirculation.

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Forswollenfingersandwrists,thepatientshouldsitwithherelbowsflexedandsupportedonatableandherhandsintheair.
Alternateflexionandextensionofthefistorrotationatthewrists,withgravity'sassistance,reducesswellingandtheassociated
tinglingsensation.
Postpartum,theriskofthrombophlebitisisincreasedwhenpatientshaveundergonecesareanbirthunderregionalanesthesia
withlengthypressureonthecalfmuscles.Footandankleexercisesintherecoveryroomandearlyambulationimprove
circulationandpreventstasis.
PelvicFloor
Theimportanceofthepelvicfloor(i.e.pubococcygeusorlevatoranimuscles)hasbeensadlyneglectedbyobstetricians.These
severallayeredmuscles,bothvoluntaryandinvoluntary,formafigureeightastheyareslunginloopsaroundthevaginaland
urethralsphinctersanteriorlyandtheanusposteriorly.Theyformtheessentialsupportofthepelvicorgans,andtheirtoneand
elasticityarevitalduringeverydaylife,pregnancy,andchildbirth,especiallyduringsecondstagewhenthepelvicfloormuscles
mustbeconsciouslyreleasedtofacilitatedelivery.Thesemusclesmustthenberehabilitatedimmediatelyafterthedeliveryor
repairoftheepisiotomy,ifperformed,andconsistentlyduringthepostpartumperiodifthispelvicorgansupportistobe
maintained.
Sphinctercontrolofthebladderandrectumisavitalfunctionprovidedbythepelvicfloormuscles.Womencanbetaughtby
theirobstetricians/midwivestoreleasethesemusclesvoluntarilyduringpelvicexaminationsandduringdeliveryoftheinfant's
headsoastofacilitateitsexpulsion.Teachingtheseexercisesinprenatalexerciseclasses,childbirtheducationclasses,orany
exerciseclassesforallwomenofallagesismandatoryandcannotbeemphasizedenough.
Exerciseofthepelvicfloor,orKegel'smuscles,whenfrequentlyandconscientiouslypracticed,maintainstoneinthesemuscles,
reducesthepossibilityofurinaryincontinenceordifficultywithpostpartumurination,andhelpspreventprolapseofthe
uterus.61Anotherimportantfunctionofthepelvicfloormusclesistheiractivecontractiontoenhanceenjoymentduringcoital
activityandreflexcontractionduringorgasm.62,63
Kegelexercisesentailgainingawarenessofthemusclesofthepelvicfloorandlearninghowtoconsciouslycontractandrelease
them.Thepatientistaughttostopandstarttheflowofurinemidstreamduringurinationbyusingthesphincters,gentlyyet
firmly,severaltimesthisexercisemakesherawareoftheactionofthesemuscles.Onceawarenesshasbeengained,frequent
practiceisnecessarytomaintainmuscletonenotassociatedwithurineflow.Forthefirstweek,atleast6repetitionsshouldbe
doneslowly,maintainingthetensionforatleast5secondseachtimefollowedbyrelease.Additionalsetsofcontractionsare
addedtobuilduptoatleast5setsof6repetitionseachday.
Anothereffectiveexerciseistoimaginethatthishammockofmusclesisanelevatoronthefirstfloorthatsuccessivelyrisesina
smooth,controlled,progressivelytighterfashiontothesecond,third,fourth,andfifthfloors,holdingateachfloorandthen,
justassmoothly,releasingtensionastheelevatordescendstothefourth,third,second,andfirstfloors.22,35,57Theactof
releasingandthenpushingintothebasementpreparesthepatientforthereleaseandbulgingoftheperineumnecessaryfor
expulsion.57
Postpartumexerciseofthesemusclesshouldbeinstitutedsoonafterdelivery.Consciouseffortshouldbedirectedtothe
contractionratherthantothereleaseofthesemuscles.Theseexercisesareincludedinpreparationclassesbutcanbetaughtby
thephysicianataprenatalvisit,bythenurseinthedeliveryroom,andagainduringthepostpartumperiod.
Withearlyexercisingofthepelvicfloor,postpartumswellingisreduced,whichinturnreducesdiscomfort.Frequent
contractionofthesemusclesenhancescirculation,promoteshealingoftheepisiotomy,andstrengthensmuscletone.Incidence
andseverityofpostpartumurinaryincontinencecanbereducedbyearlyinitiationandfrequentpracticeoftheseexercises.
Aswithalltheseexercises,contractionisdoneslowlyandwithconcentratedefforttofacilitatetoningofthemusclesandto
increasepelvicorgansupportbytensingsuccessivelyharder,holdingfor5to6seconds,andreleasing.Setsofsixrepetitions
shouldbeperformed,andthenumberofsetsshouldbegraduallyincreased.Duringmusclecontraction,theedgesofthe
incisionarepulledtogetherratherthanapart,and,withthisreassurance,frequentpracticemustbeencouraged.Dailyexercise
ofthesemuscles,togetherwithpracticeofthepelvictilt,relievesthelow,achyfeelingexperiencedbymanywomenduringthe
postpartumperiod.63

COITALACTIVITY
Formanyyears,obstetriciansrecommendedabstinencefromintercourseduringthelast6weeksofpregnancyandfor6weeks
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postpartum.Unlesssexualactivityiscontraindicatedforaspecificmedicalreason,suchastoxemia,multiplebirth,threatened
abortion,uterinebleeding,partnerwithvenerealdisease,incompetentcervix,orhabitualaborterfollowingorgasm,most
physiciansarenowmoreliberalintheirthinking,demonstratingunderstandingoftheneedsanddesiresoftheexpectant
couple.Resolutionofanxietiesandoldwives'tales,reassuranceaboutabsenceofdangers,andideasforexperimentationwith
newpositionsshouldbethefocusofthediscussionwiththepatient.
Patientswhohavelearnedtocontractthepelvicfloormusclescanusethismovementduringintercourse.Contractionofthese
musclesduringcoitusconstrictsthevaginalcanalandallowsgreatercontactwiththepenisorfingers,therebyenhancing
sexualstimulationforbothpartners.Practiceduringcoitusalsoaffordsfeedbackbythesexualpartneronthequalityand
strengthofmusclecontraction.
Whensomeformofusualsexualactivityisprohibited,itiscrucialforthephysicianormidwifetoexplaintothepatientand
herpartnerthereasonsforabstinencetoreassesstheprohibitionafteraperiodoftime,andtoencouragethemtoexplore
otherformsofsexualplay.31 ,61 ,62 ,63 Couplesshouldbeencouragedtodiscusstheirfeelingsaboutthechangeintheirsexual
behaviorsandtochooseappropriateoptionsforthemselves.Thiswillreducethefeelingsofguiltandfearonthepartofthe
womanandofsexualrejectiononthepartofherpartner.31Thereisnoconclusiveevidencethatcoitusandorgasmareharmful
tothosepregnancieswithoutpredisposingfactorssuchasbacteriuria,hypertension,placentaprevia,partner'svenerealdisease,
conditionsnecessitatingbedrest,orhabitualabortion.Inseveralstudies,coituscouldnotbeimplicatedasthecausefor
prematurelabor,ruptureofmembranes,bleeding,orinfection.63Poorresearchmethodologicfactorshindertheacceptanceof
thereportsthatintercourseisamongthefactorsthatincreasetheriskofprenatalhemorrhage.63

CONTRAINDICATEDEXERClSES
Physiciansshouldmaketheirpatientsawareofsomeexercisesthatputstrainonthepregnantbodyandfrequentlyleadto
increaseddiscomfortorproblemspostpartum.Duetothecontinuingpaucityofdefinitiveguidelinesfromresearch,
recommendationsforphysicalactivitycontinuetorelyofthepregnantwomen'sperceptionofcomfortandcommonsense.22,57,64
Thefollowingareexercisesthatrequirerestrictions.
1. Anyexercisethatincreasesthelumbarlordosisputsstrainonthesacroiliacjoints,hips,orkneesorovertaxestheabdominalmuscles.This
includessomeyogapositionsadvocatedinnumerousbooksavailableforexpectantpatientsandincludedinsomeprenatalexerciseclasses.
2. Twolegraisesfromtherecumbentpositionorfullsitupsfromtherecumbentposition(seeAbdominalToners).
3. Bridging,orliftingthebuttocksoffthefloorfromtherecumbentposition,ifitcannotbedonewithoutincreasingthelordosis.
4. Anyexercisethatencouragesbouncing,bobbing,orjerkingmovements,asfoundinmanyaerobicsorjazzerciseclassespopulartoday.Manyof
jazzboxingclassmovementsareexcellentbut,aswithactivitiesfromstepclassroutines,theyneedtobesloweddowntoensureproperbreathing
andensuremaintenanceofbalance.
5. Deepkneesquatsforwomenunaccustomedtothispositiontopreventstrainonkneeandankleligaments.Womencanbeencouragedtoslowly
bendtheirkneesfromthestandingpositiontoattainaneventualsquattingpositionwhileleaninguprightagainstawallforbalancethisexercise
isexcellentfordelivery.
6. Hyperextensionofkneesinstandingpositionputsstrainontheknees.Kneescanbeheldinagentlebend,whichwillhelpattainpelvictiltand
alleviatebackache.
7. Exercisesthatinvolvepointingthetoesandplantarflexionofthefeetcancausecalfcramps.
8. Exercisesdonepastpointoffatigue,thatcreatepain,orthatinducehyperthermiashouldnotbeperformedbythepregnantwoman.

Expectantmothersmustrespectsignalsfromtheirbodyandstopexercisingifthereispainandtorestwhenfatigued.They
musttakeextraprecautionswhenexercisingduringhotandhumidweather.Theymustmaintainwaterintake,stopfrequently
torest,eatadequatelybeforeexercise,restafterward,beawareoffetalactivity,andconsultthephysicianifuterinecontractions
becomeregular.Likewise,theymuststopexercisingiftheyexperienceshortnessofbreath,dizziness,orfaintness.

BODYMECHANICS
Ineverydayliving,manypeopledonotusegoodbodymechanicsandasaresultputstrainonmuscles,ligaments,andjoints
whileperformingdailychores.Inpregnancy,thisstrainisincreased,whethersitting,standing,orwalking(Fig.13),andthe
patientfrequentlyneedsreeducationtomaintainbodyalignmentwithoutunduestrainorpressure.

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Fig.13.Strainonmuscles,ligaments,andjointsfromperformingdaily
choresisincreasedduringpregnancy.

Thefollowingexercisescanbeeasilyshowntothepatientbyherphysician.Inparticular,thefirstonecanbedemonstratedto
thepatientwhenshecomesforherprenatalvisits.Inchangingfromsittingontheexaminingtabletoalyingposition,many
womenliestraightback,puttingseverestrainontheabdominalmusclesandjointsoftheback.Theofficenurseorphysician
cancorrectthisbytellingthepatienttobendherknees,rolltooneside,lowerherbodyusingherarms,andthenrolltoher
back(Fig.14).
Fig.14.Incorrectandcorrectwaytoliedown.

Changingfromlyingtosittingpositionsisfrequentlydoneincorrectlybyjackknifingup,whichstrainsthealreadystretched
abdominalmuscles,causesfurtherseparationoftherecti,andresultsinbackache.Thechangeshouldbemadeslowlytoavoid
dizziness.Again,thepatientbendsherknees,rollstooneside,andraisesherbodybypushinguponherhands.
Topickupobjectsfromthefloor,thepatientshouldsquatbybendingherkneeswhilekeepingherbackstraightandthenlift
theobjectbystraighteningthekneesratherthanbendingfromthewaistthismethodreducesbackstrain,tonesthemusclesof
thethighs,andaffordsbetterweightdistribution(Fig.15).Whileclimbingstairsanddoinghouseholdchores,thepatient
shoulduseherlegsasmuchaspossibleandavoidflexionoftheback.
Fig.15.Incorrectandcorrectwaytopickupobjectsfromthefloor.

RESTANDRELAXATION
Justasimportantasexercisestotoneandmaintainthebodyinoptimalcondition,istheneedforrestandrelaxationduringthe
pregnancy.17,57,60Cardiacandbasalmetabolismareaccelerated,theexpectantmother'sweighthasincreased,andfatigue
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becomesaproblem,especiallyinthelasttrimester.Patientsneedtobeencouragedtotakebreaksduringtheirdailywork,put
theirfeetup,andreplenishtheirenergybyconsciouslyreleasingmusculartensioninthebody.
Thiscanbedoneinanypositionthatiscomfortable:sitting,reclining,orlyingontheleftsidewithpillowstosupportandflex
knees.Avarietyofrestfulimagesmaybeused(gentlewaves,swayingpalms,sunnybeaches)toencouragerelaxation,orthe
patientmayimagineawarmingsensationpassingdownwardfromthetopofherheadtohertoestoinduceafeelingofcalm.
Rhythmic,restfulbreathingcanbeincludedtoencouragedeeperreleaseofstriatedmusclesandcalmingofthemind.Learning
toreleasetensionduringpregnancyhelpsthewomantoconserveherenergyandreducefatigue.Withdiligentpractice,
relaxationbecomesaskillfultoolinmeetingthedemandsofchildbirthbyenablingthewomantoremaincalm,reducefatigue,
andreducepainperceptionduringlaborandbirth.Inthepuerperium,relaxationskillprovidesaninvaluabletoolfor
counteractingthefatiguingroleofparenting,withitsdemandsofcaringforthebabywhileenduringlackofsleep.Assuch,it
shouldbeincludedineveryexercisesession,usedasameanstocooldownafterexercising,andencouragedpriortoretiringto
ensuremorerestfulsleep.

SPORTSACTIVITIES
Althoughopinionsdiffer,thescientificstudiesthathavebeenpublishedregardingtheeffectsofmaintaininginvolvementin
sportsactivitiesduringpregnancyhavebeenmostlypositive.Mostphysicianshavebeenalmostunanimousintheirbeliefthat
itisnotnecessaryforapregnantwomantolimitheractivities,providedthatshedoesnotbecomefatigued,experiencepain,or
losebalanceandhasnocontraindicationstotheactivity.Alladultsneedexercise,andfailuretoobtainexercisecanresultin
weaknessorillness.Thisisparticularlytrueforthosepregnantwomenwhoarenormallyactiveorwhoaresportsenthusiasts.
Markedrestrictionofsuchactivitiesshiftstheemphasisduringpregnancyfromthenormalphysiologicexperiencetowardone
borderingonillness.Lengthyperiodsofenforcedidlenesscanbedetrimentaltoawoman'sphysicalandmentalwellbeing
therefore,anysportorexerciseinwhichthewomanhasengagedforalongtimeispermissible,withcautionnottocontinueto
thepointoffatigueorpain.
Physiciansstronglyagreethatpregnancyisnotthetimetolearnanewsport.Anexceptionwouldbechangingfromaweight
bearingtoanonweightbearingactivity,suchasfromrunningorjoggingtoswimmingorwateraerobics.5,38,60Pregnantwomen
arealsocautionednottoindulgeincompetitivesportsoranythingthatwouldcausecontinuouspantingorfatigue.Becauseof
posturalrealignment,focusonthenewbodyimageisimportantsothatbalanceisnotimpaired.Somephysiciansbelievethat
balanceismoreprecariousinthelatterpartofthethirdtrimesterandthatwomendonotrespondasquicklyinastress
situation.
Forthisreason,physiciansadviseagainstactivitiesthatrequirequickdecisionmakingandbalance,suchasskiing,skating,
androllerblading.Crosscountryskiinghasbecomeincreasinglypopularforpregnantwomenincoldclimates,butagain,heat
restriction,pacing,adequatebreathing,andabilitytobalanceareimportant.
Walkingwithwellfitted,lowheeledshoesorsneakerswithcushionedsoles,performedwhileobservinggoodposture,isthe
exercisemostprescribedbyobstetricians.Hydrationandnutritionmustbemaintainedforextendedwalks.Additionally,
walkingshouldbeprecededandfollowedbystretching.
Swimmingisanexcellentchoiceforactivity,becausethewomanisinastateofweightlessness,withlesspressureonher
circulation.Shecanpaceherself,goingasfastorasslowasshedesireswhilemaintaininghercomfortlevelandrelaxed
breathingpattern.
Tennisisanotherpopularsportplayedbypregnantwomenwithoutilleffects,butselftolerance,heatrestrictions,ample
hydration,andnoncompetitivesettingsarekey.Curtailingtheneedtoreachfarflungballsisimperativeinadvancing
pregnancy,andavoidingsharpturnsisadvised.Playingdoublesisrecommendedoversingles.
Bicyclingisanotherformofnonweightbearingexercisethatcanbeenjoyedbythepregnantwomanifsheisaccustomedto
theactivityandcanpaceherselfandmaintainherbalance.Wearingahelmetisimperative,andknowingthelocationof
restroomsalongthewayisamust.57Iffearoffallingisaproblem,astationarybicyclecanbeused.Thisactivityisbeneficialto
thecardiovascularsystemwhilesparingthejointsandligaments.
Golfremainsafavoritewithsomepregnantwomenwhoplayregularly.Thisactivityinvolveswalkingandwellasarm
movementsandbalance.
Horsebackridinghashistoricallybeenconsidereddangerousbecauseofthebouncingmovementsandpossibilityofbeing
thrownandisnotrecommended.
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Runningandjogginghavecomeunderscrutinybothinthegeneralandthepregnantpopulation.Manyorthopedicsurgeons
decrypossibleharmtoligamentsoftheback,hips,knees,andankles.Theseareunderstrainduringpregnancybecauseof
hormonalchangesandincreasedbodyweighttherefore,pregnantwomeneventhosewhowereregularrunnersneedtobe
cautionedtorunonlyiftheyareingoodcondition,wearwellfittingandwellconditionedshoes,stretchbeforeandafter
running,neverrunonconcrete,andaboveallbeawareoftheirbodiesandstopwhentheybecomefatiguedorexperience
pain.22,26,41,58,59
Inallsportsactivities,ifawomanhaslongbeenadevotee,isproficient,ispreparedtoslowdownorstoptheactivitywhenshe
becomesfatigued,andunderstandshowpregnancychangesaffectherjointsandmuscles,sheshouldbeencouragedto
maintainherinvolvement.64Goodbodymechanicsshouldbeusedinallactivities,andgoodsenseregardingsafety,balance,
heatrestrictions,andtoleranceismandatory.
ContraindicationsforSportActivities
Womenwithconditionssuchaspreeclampsia,toxemia,placentaprevia,orheartconditions,forwhichrestisthemainmode
oftreatment,areobviouslyadvisednottoindulgeinvigorousphysicalactivity.Liberalamountsofresthavebeensaidto
improvetheprognosisofhighriskpregnanciesassociatedwiththeseconditionsorhypertension.Thereisevidence,however,
thatextendedlyinginthesupinepositionisdetrimentalduringpregnancy,becausecompressionofthevenacavalowersthe
arterialpressurethroughdecreasedvenousreturntotheheart.Asaresult,renalplasmaflowanduterinebloodfloware
decreased.However,extendedprescribedbedrestwithoutqualificationregardingpositioncouldalsohavedetrimentaleffects
onmuscletone,backpain,reducedcirculation,andemotionalstate.Tomaintaincirculationandmuscletone,thesepatients
couldbeprescribedmildbedexercisesadministeredbyaqualifiedphysicaltherapist.
Exercisestimulatesbloodflowtothemuscles,particularlytheextremities,andithasbeenspeculatedthatuterineflowmaybe
diminishedtosomedegreeduringstrenuousactivity.However,thereisnoevidencethatperiodsofmoderateexercise
compromisethefetusinanywayinanormalpregnancy.Thereissomejustificationforcurtailmentofactivityinwomenwith
incompetentcervixorwhenfrequentbleedingoccurs.Otherwise,mostphysiciansagreethatthepsychologicalbenefitsof
exerciseoutweighthesespeculativeproblems.Themainguideisforthewomantolistentoherbodysignalsandusecommon
senseandsoundjudgment.

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