exercise and physical activity during pregnancy

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Print This Page This chapter should be cited as follows: Under review Update due 2015 Shrock, P, Glob. libr. women's med., (ISSN: 17562228) 2008; DOI 10.3843/GLOWM.10098 Exercise and Physical Activity During Pregnancy Pamela Shrock, RPT, MPH, PhD Director, Psychotherapeutic and Sexual Health, Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, New York INTRODUCTION HISTORICAL PERSPECTlVE PSYCHOLOGICAL AND PHYSICAL BENEFITS POSTURAL CHANGES CARDIOVASCULAR AND RESPIRATORY CHANGES MATERNAL EXERCISE AND PERINATAL AND FETAL OUTCOME EXERClSES COITAL ACTIVITY CONTRAINDICATED EXERClSES BODY MECHANICS REST AND RELAXATION SPORTS ACTIVITIES REFERENCES INTRODUCTION During the childbearing year, from conception through postpartum recovery, a woman's body undergoes extensive changes which frequently necessitate many adaptations. Physical and hormonal changes occur gradually throughout the 9 months of pregnancy, and these are reversed in a matter of weeks during postpartum recovery. Skeletal tissue, muscle and connective tissue, blood volume, cardiac output, body weight, and posture are affected. As more pregnant women engage in demanding occupations, physical activities, and sports, the obstetricians and midwives who take care of them must become knowledgeable about the physical changes of pregnancy and the effects of exercise on the mother and fetus. Because prevention is the best approach to health care, understanding both the bodily stresses that may result from pregnancy changes and the means to prevent unnecessary problems enables health care to be instituted early in pregnancy and continued through the postpartum period. HISTORICAL PERSPECTlVE The value and possible hazards of physical exercise and sports activities during pregnancy have been debated for years. 1 Early observers correlated an uneventful pregnancy and easy labor with physical activity. In Exodus, Biblical writers observed that Hebrew slave women had an easier time giving birth than their sedentary Egyptian mistresses, 1 and in 9 B.C., Plutarch urged Spartan women to harden their bodies with exercise to decrease the pain of childbearing. 2 In Victorian times, pregnant women were encouraged to remain indoors and keep themselves “confined.” 3 With more women in the workplace in the 1930s and their apparent ease of birthing, physicians once again advocated “strong body movements” for sedentary pregnant women. 4 Based on her work in India in the 1930s, Vaughan instituted antenatal exercise classes in England. She wrote that “flexible hips and spine are conducive to ease of labor,” and women were encouraged to squat. 3 Exercise classes taught by physiotherapists became popular in Great Britain and Sweden, where they were valued for their effects on back and abdominal muscles. 4, 5, 6, 7 During the mid1950s, despite the lack of scientific proof of benefits, “keep fit” exercises introduced by obstetric physiotherapist Helen Heardman in Britain 8 were included with relaxation and breathing skills in Grantly DickRead's book on pain management for labor. 9 In fact, Heardman's own book delineated an excellent program of prenatal exercises which form the basis of the best of many prenatal exercise programs today. 8 The Lamaze method, popularized in the United States in 1959 by Marjory Karmel 10 and Elisabeth Bing, 11 focused on both physical and psychological preparation for childbirth. From the mid 1970s through the 1990s, the emphasis on health and the public's renewed involvement in exercise caught the interest of the “pregnant population.” Numerous books on prenatal exercise, as well as videotapes and audio cassettes, flooded the market, 12, 13, 14, 15, 16, 17, 18 and community centers, hospitals, health maintenance organizations (HMOs), and industries began to

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Page 1: Exercise and Physical Activity During Pregnancy

5/23/2015 Exercise and Physical Activity During Pregnancy

https://www.glowm.com/section_view/heading/Exercise%20and%20Physical%20Activity%20During%20Pregnancy/item/98 1/17

Print This Page

This chapter should be cited as follows: Under review ­ Update due 2015Shrock, P, Glob. libr. women's med.,(ISSN: 1756­2228) 2008; DOI 10.3843/GLOWM.10098

Exercise and Physical Activity During Pregnancy

Pamela Shrock, RPT, MPH, PhDDirector, Psychotherapeutic and Sexual Health, Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, New York

INTRODUCTIONHISTORICAL PERSPECTlVEPSYCHOLOGICAL AND PHYSICAL BENEFITSPOSTURAL CHANGESCARDIOVASCULAR AND RESPIRATORY CHANGESMATERNAL EXERCISE AND PERINATAL AND FETAL OUTCOMEEXERClSESCOITAL ACTIVITYCONTRAINDICATED EXERClSESBODY MECHANICSREST AND RELAXATIONSPORTS ACTIVITIESREFERENCES

INTRODUCTION

During the childbearing year, from conception through postpartum recovery, a woman's body undergoes extensive changeswhich frequently necessitate many adaptations. Physical and hormonal changes occur gradually throughout the 9 months ofpregnancy, and these are reversed in a matter of weeks during postpartum recovery. Skeletal tissue, muscle and connectivetissue, blood volume, cardiac output, body weight, and posture are affected.

As more pregnant women engage in demanding occupations, physical activities, and sports, the obstetricians and midwiveswho take care of them must become knowledgeable about the physical changes of pregnancy and the effects of exercise on themother and fetus. Because prevention is the best approach to health care, understanding both the bodily stresses that mayresult from pregnancy changes and the means to prevent unnecessary problems enables health care to be instituted early inpregnancy and continued through the postpartum period.

HISTORICAL PERSPECTlVE

The value and possible hazards of physical exercise and sports activities during pregnancy have been debated for years.1 Earlyobservers correlated an uneventful pregnancy and easy labor with physical activity. In Exodus, Biblical writers observed thatHebrew slave women had an easier time giving birth than their sedentary Egyptian mistresses,1 and in 9 B.C., Plutarch urgedSpartan women to harden their bodies with exercise to decrease the pain of childbearing.2

In Victorian times, pregnant women were encouraged to remain indoors and keep themselves “confined.”3 With more womenin the workplace in the 1930s and their apparent ease of birthing, physicians once again advocated “strong body movements”for sedentary pregnant women.4

Based on her work in India in the 1930s, Vaughan instituted antenatal exercise classes in England. She wrote that “flexible hipsand spine are conducive to ease of labor,” and women were encouraged to squat.3 Exercise classes taught by physiotherapists

became popular in Great Britain and Sweden, where they were valued for their effects on back and abdominal muscles.4,5,6,7

During the mid­1950s, despite the lack of scientific proof of benefits, “keep fit” exercises introduced by obstetricphysiotherapist Helen Heardman in Britain8 were included with relaxation and breathing skills in Grantly Dick­Read's book onpain management for labor.9 In fact, Heardman's own book delineated an excellent program of prenatal exercises which formthe basis of the best of many prenatal exercise programs today.8 The Lamaze method, popularized in the United States in 1959by Marjory Karmel10 and Elisabeth Bing,11 focused on both physical and psychological preparation for childbirth. From the mid­1970s through the 1990s, the emphasis on health and the public's renewed involvement in exercise caught the interest of the“pregnant population.” Numerous books on prenatal exercise, as well as videotapes and audio cassettes, flooded the

market,12,13,14,15,16,17,18 and community centers, hospitals, health maintenance organizations (HMOs), and industries began to

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offer exercise classes for expectant women. Physicians and midwives must be aware that some of these book authors and someinstructors of prenatal exercise classes lack adequate training and may not have sufficient knowledge of the physiologic changesof pregnancy nor of the cautions expectant women should follow while exercising. Many expectant women enroll in regularaerobics classes and try to keep up with the nonpregnant participants or instructor, often to their detriment.

Before enrolling in a pregnancy exercise class, it is recommended that the expectant woman be past her first trimester, beunder medical supervision, and be warned of any medical reason that either precludes her from taking the classes or warrants

limitations.19 As outlined by the American College of Obstetrics and Gynecology (ACOG),20,21 these conditions include heartdisease, toxemia, ruptured membranes, risk of premature labor, intrauterine growth retardation, poor weight gain, vaginal oruterine bleeding, anemia, hypertension, and fetal distress. Consultation with health care providers or some degree of caution is

necessary for expectant women with respiratory conditions such as asthma20,22 or orthopedic conditions such as back and hip

pain or joint problems.8,23,24,25 The qualifications of the instructor of the prenatal exercise program should include a medicalbackground; a knowledge of obstetrics, muscle physiology, and kinesthesiology; and experience working with expectant

mothers.19,22,25,26 Physicians should make inquiries regarding the qualifications of instructors before signing approval notes fortheir patients to attend classes. Two­way communication between the obstetrician and prenatal exercise instructors should be

instituted to ensure the safety of the patient.19,20,22,24 There is as yet no scientific evidence of tangible results of physicalpreparation in pregnancy in the reduction of the length of labor; however, observers feel that effective abdominal expulsive

efforts by the mother can shorten the second stage.27,28 No reduction in uterine inertia or episiotomies (which are performedroutinely in the United States) has been documented, but there has been a lower incidence of cesarean birth correlated withphysical fitness.

No relation has been noted between physical fitness of the mother and the newborn's birth length, head circumference, or 1­minute Apgar score,6 but recent studies have found that strenuous maternal exercise in pregnancy may negatively affect the

mother's weight gain and in some cases causes decreased weight in the newborn infant.29,30

PSYCHOLOGICAL AND PHYSICAL BENEFITS

Birth is a normal, natural, physiologic process. Supporting the premise that pregnancy is a state of health, both physical andmental aspects of body image must be considered. With an increase in body weight and a protuberant abdomen, most womenfeel heavy, unattractive, and cumbersome; their movements seem clumsy, uncoordinated, and lacking in agility. The pregnant

woman's body image may reach an all­time low; her posture sags, and she loses her self­esteem and confidence.31,32 There is astrong relation between physical and mental health, and exercise is generally thought to have tremendous psychological value

and boost self­esteem.33,34,35

With a well­regulated, nonstrenuous exercise program instituted in the fourth month of pregnancy through the postpartumperiod, a pregnant woman is able to maintain good physical condition, to develop a sensible, healthy approach to exercise, toincrease her comfort in pregnancy, to deliberately prepare for postpartum recovery, and to sustain the necessary muscularactivity for the work of childbirth. Feelings of well­being and confidence that result from whole­body exercise on a regular basisenable her to approach childbirth with positive expectations.

Physical activity improves circulation, appetite, digestion, and elimination, all of which are affected during pregnancy and in

turn are mirrored in the pregnant woman's mental attitude.22,32,33 Regular exercise and nutrition are recognized as contributingto a healthy and more comfortable pregnancy.

Self­esteem is reduced immeasurably after childbirth, when the woman is upset by her “ruined figure and additional folds offlesh.” Exercise during pregnancy and reinstituted soon after delivery ensures quicker postpartum healing and recuperation,with renewal of positive body image and self­esteem. These feelings of well­being and additional energy allow the new mother

to feel that she is doing something for herself and enable her to better face the responsibilities of parenting.17,18,35

POSTURAL CHANGES

As humans evolved to an upright posture, several points of structural weakness were created in the human body. These arefurther accentuated during pregnancy; potential problem areas are the vertebral column, the abdominal muscles, and the pelvicfloor.

The vertebral column in the normal state has curves to counteract the forces that gravity exerts on the upright posture. The

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Fig. 1. Postural changes in early and late pregnancy.

curves of the spine include a concavity in the cervical area, convexity in the thoracic region, concavity in the lumbar vertebrae,and convexity in the sacrum. The line of gravity passes through the mastoid of the skull, the shoulder, and the hip and kneejoints to just anterior to the lateral malleolus. The pelvis lies at an angle of 65 degrees to the lumbar spine, and the pelvic angledetermines the prominence of the abdomen and buttocks (Fig. 1). In the nonpregnant state, connective tissue is responsible forthe tensile strength of major fascial structures, ligaments, and joints and is able to withstand all extra physical effort.

There is evidence to suggest that changes in connective tissue due to the hormonal effects of increased progesterone and relaxinduring pregnancy reduce support and permit increased mobility in structures to which muscles and tendons are

attached.17,18,24,36 Examples include softening of the cervix, mobility of the symphysis pubis, and relaxation of the joints of thepelvis and lower back, especially the sacroiliac joints. Because of these changes and greater joint mobility, there is less stabilityof the hip and knee joints, which often causing discomfort and loss of balance. For these reasons, jerky, bouncing movements,quick turns, and jogging, which can cause additional strain and pain, should be avoided.22

Abdominal fascia loosens due to hormonal effects early in pregnancy (long before the uterus is large enough to account forenlargement of the abdomen), thus allowing for greater stretching of the abdominal muscles. Generally, there is contactbetween the 2 rectus abdominis muscles below the umbilicus and 2 cm between these muscles above the umbilicus. Withwidening of the linea alba in pregnancy, a diastasis can occur in 28% of pregnancies in the second trimester; its incidence peaksin third trimester and remains high in the immediate postpartum. The diastasis results in a bulge of the abdominal wall on

increase in intraabdominal pressure and a separation of a distance of more than two finger­widths between the rectae.18,23,27 Toevaluate this condition, the patient lays with her knees bent while the physician or midwife places his or her fingers below thexiphoid across the linea alba. The patient raises her head and shoulders off table while the physician moves his or her fingersdistally to determine how many fingers fit into the space between the 2 rectus abdominus muscle bellies.27 If diastasis ispresent, the patient is advised to perform the “curl­up” exercise daily by tilting the pelvis posteriorly, supporting the rectae

muscles on either side with her hands, and exhaling while lifting her head.22,23

Together with the downward pull of the gluteal muscles, the upward pull of the abdominals maintains the correct alignment ofthe pelvis in relation to the vertebral column. If these muscles are well toned, they adequately support the enlarged uterusduring pregnancy. More frequently, there is increased lumbar lordosis.

Because of joint changes, some physicians believe that impairment of coordination of the larger movements and an increase inreaction time are also evident in pregnancy. Therefore, many advise against activities in which safety depends on precise

coordination and instant responses, such as skiing.19,20

Increased body weight is directly related to postural changes in the thoracic and abdominal regions. With increase in weightduring pregnancy (11.4–15.9 kg [25–35 lb] normally), the abdominal muscles are stretched, there is protuberance of the uterusanteriorly, and the line of gravity is shifted forward.

To maintain her balance, the woman stands farther back on her heels and increases the width of her base. This accentuates thelordosis in the lumbar spine, causing the pelvis to tilt at a more acute angle to the vertebral column (see Fig. 1). Structuralchanges, weight redistribution, and hormonal alteration of joint stability put additional strain on the sacroiliac and hip joints.The muscles of the lower back are shortened under the increased work load, resulting in frequent backache and fatigue. Theextra effort required to balance causes hyperextension of the knees and weight on the inner borders of the feet, resulting in the“waddling” gait of pregnancy, foot strain, and additional fatigue.35

Compensation for this altered body alignment occurs in the upper back and neck region, with kyphosis, or rounding, of theshoulders and forward protrusion of the head. The rounding of the shoulders is further compounded by the additional 0.7 kg(1.5 lb) of weight in the breasts in preparation for lactation. This results in shortening of the pectoral muscles, added tension inthe shoulders, and stretching of the rhomboid muscles, producing complaints of pain in the upper back between the scapulae.The protruded position of the head further alters postural sense, which must be relearned.38 Head position also impacts on thenerves emerging from the cervical spine and often results in traction on the median and ulnar nerves, which is experienced as

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Fig. 2. Realignment to correct posture.

numbness, tingling, and pain in the hands and arms.36 Increased vascularity and fluid retention may also contribute to thesesymptoms.24

With the encroaching uterus putting pressure on the diaphragm in the seventh to ninth months of pregnancy, many womenexperience shortness of breath. The poor postural alignment described previously further compresses the lungs from above,decreasing lung capacity.

Postural Correction

Poor posture and some shortening of the hip flexor muscle group secondary to anterior rotation of the pelvis with stretching of

the abdominal muscles may account for the high prevalence of back pain in pregnancy.24,36,37,38,39 Approximately 50% of

women complain of backache associated with pregnancy40,41; 10% of activities of daily living are limited by severe low back pain,and 70% of Swedish women use sick leave because of pregnancy­related back pain. To alleviate the magnitude of the problem,researchers devised a proactive program of postural education and supervised exercise before, during, and after pregnancy,with reported results of less back pain and lower incidence of sick leave.42

Re­education of the pregnant woman and correction of postural alignment alleviate many joint strains, reduce fatigue, andassist with walking and breathing difficulties. Information and re­education is included by childbirth educators in Lamazechildbirth preparation classes,28 but these classes usually begin in last trimester; therefore, re­education should be explained bythe physician or midwife to women during prenatal office visits early in the pregnancy, before problems arise.

Realignment is best done in front of a full­length mirror or with the aid of a partner. Body weight should be evenly distributedthrough the center of each foot and midway between left and right feet. Knees are slightly bent to overcome hyperextendedknees. Abdominal muscles are gently contracted and the buttocks tucked under to correct the tilt of the pelvis. The sternum isprojected forward, which will stretch the upper back, allowing the shoulder girdle to extend comfortably posteriorly. The headis repositioned by upward stretching of the neck; the chin is tucked in with the top of the head maintained parallel to the floor(Fig. 2).

CARDIOVASCULAR AND RESPIRATORY CHANGES

Maternal cardiovascular changes during pregnancy represent an “overload” state whether the woman exercises or not. There isan increase in maternal blood volume of 30% to 50% (~2.25 L) to meet the needs of sustaining the growing fetus.43 Restingheart rates in the nonpregnant woman range from 66 to 72 beats per minute, rising to 81 to 88 beats per minute duringpregnancy. Cardiac output increases 2.5 times as a function of raised stroke volume and heart rate and results in part from

hypertrophy of the left ventricle.20,44,45 Cardiac output reaches a maximum at 28 weeks' gestation and remains elevatedthroughout the rest of the pregnancy.37 The pregnant women's red blood cell level increases by 25% to 30% and plasma volumeincreases by 45%, which results in a physiologic anemia.

From early in the third trimester, the added pressure of the enlarged uterus may impede inferior vena cava flow, causingpostural hypotension. Cardiac output may be enhanced if a left or right lateral tilt is maintained in the recumbent position.Uterine pressure on the vena cavae also cause gravitational stasis of blood in the legs. ACOG Guidelines for Physical Activity in

Pregnancy first dictated “no lying in the recumbent position after the 4th month.”2,21 Later, these guidelines were modified tosuggest placing a pillow behind the right buttock when recumbent. Research has demonstrated that lying on the back in healthypregnant women does not have deleterious effects on the fetus.46

Venous blood must be returned to the heart against the force of gravity when the body is upright. The increased volume of thecirculatory system and effects of progesterone often cause veins to become prominent and varicosed. For this reason, sittingwith legs crossed at the knees should be discouraged during everyday life but especially during pregnancy.35

As pregnancy progresses, many women experience edema in the legs and feet which is unrelated to toxemia or medical

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conditions. Likewise, slowed circulation and retained fluid result in patients awakening in the morning with swollen or tinglingfingers and wrists. Flexion, extension, and circular movements of the feet and hands are easily learned and helpful for relief ofedema.

Respiratory System

Owing to a 4­cm upward compression of the diaphragm by the growing uterus, there is a decrease in the vertical dimension ofthe thoracic cavity. With relaxation of the ligamentous attachments, there is a compensatory enlargement of the rib cage, withresultant increased vital capacity. Resting ventilation rates and tidal volume both increase, causing a physiologichyperventilation. The brain's respiratory center has a reduced threshold to blood levels of carbon dioxide, causing an increasein respiratory rate. Increased oxygen consumption in advanced pregnancy and capillary engorgement throughout therespiratory tract cause nasal congestion, making nasal breathing difficult and frequently creating additional problems withbreathlessness, with or without exercise.

Effect of Exercise on the Cardiopulmonary System

When pregnant women exercise, cardiovascular and respiratory response naturally increase. The maternal heart rateaccelerates from 94 to 170 beats per minute in relation to the strenuousness of the exercise.20 Guidelines from ACOG indicatekeeping heart rates below 140 beats per minute during exercise or physical activity as a precaution, even though heart rate and

blood pressure return to pre­exercise rates within 30 minutes.20,22 Systolic blood pressure rises from 30 mm Hg to 40 mm Hg,whereas the diastolic blood pressure rises only 10 mm Hg with exercise. Expiratory ventilation increases during exercise inpregnancy.37 This results in a beneficial 18% increase in aerobic capacity; in women who did not exercise during pregnancy,aerobic capacity decreased.47 Several researchers suggest that there is a training effect from participating in an ongoing exerciseprogram and that exercise may help to maintain work efficiency at prepregnancy levels despite the demands of the

pregnancy.34,35,36,37,38

Effect of Exercise on the Fetus

Concerns about the effects of exercise on the uterine environment and the fetus have been voiced by many physicians. Inparticular, studies centered around the shift of blood from the splanchnic area to the skeletal muscles of pregnant women after

a bout of exercise and the possible effects of this on the fetus.33,48 Fears were dispelled by tests that showed that there was notonly rapid reversal but a compensatory “flush­back,” with an increase in uterine blood flow after cessation of exercise.40

Monitoring of the fetal heart in response to maternal exercise showed rates within normal limits and return to baseline within

30 minutes.43,49,50,51

MATERNAL EXERCISE AND PERINATAL AND FETAL OUTCOME

Studies on maternal exercise and birth outcome indicate that most fetuses are able to tolerate moderate maternal exercise

programs that women continue throughout the pregnancy.48,52,53 Research in recreational runners, aerobic dancers, andnonexercisers determined the incidence of spontaneous loss of pregnancy in all 3 groups combined was 19% (15% in the overallpopulation). However, loss percentage by group was runners, 17%; dancers, 18%; and nonexercisers, 25%. Exercising does not

alter pregnancy outcome or increase probability of spontaneous pregnancy loss.48,50,53 Studies of endurance exercises (i.e.running and aerobics) over the course of pregnancy monitored exercisers every 6 to 8 weeks. Before the end of the firsttrimester, one third of study subjects stopped intensive exercising, forming two new groups (i.e. exercisers and nonexercisers).In each group, 9% experienced preterm labor before 37 weeks. Exercisers started labor 5 days earlier than nonexercisers andhad lower incidences of obstetrical interventions, need for labor stimulation, episiotomy, cesarean birth, and epidural

anesthesia as well as a shorter active stage of labor.46,53,54

Decreases in birth weight and less maternal weight gain have been noted in women who continued high­performance activities

during pregnancy.32,34 Other studies contradict these findings of low birth weight, finding instead a higher rate of fetal

anomalies, which could be related to hyperthermia experienced during intense exercise in early pregnancy.48,55

Thermoregulatory System in Pregnancy

Basal metabolic rate (BMR), increases during pregnancy, and necessitates a 300­kcal increase in the pregnant woman's caloric

intake. The physiologic changes and increase in adipose tissue insulation makes pregnant women feel warmer even at rest.51,56,57

Research studies on maternal thermoregulation suggest that hyperthermia, specifically in the first trimester, can produceadverse effects on fetal development.45 As maternal temperatures increase, so does the fetal temperature. Teratogenic effects of

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heat on the fetus have been demonstrated in animal research.

When exercising, pregnant women must be reminded to wear loose­fitting clothing and drink fluids before, during, and afterexercise.48 Women who are fit tend to maintain a cooler temperature because of their more efficient cardiovascular system.46

Avoiding hyperthermia is one of the primary rationales for both the American College of Obstetricians and Gynecologists(ACOG) and American College of Sports Medicine (ASSM) in establishing safety guidelines for prenatal exercise intensity andduration.

EXERClSES

A regimen of regulated exercises, done slowly and deliberately and without strain or to the point of fatigue, includes all areas ofthe body and assists with the postural correction described previously. These exercises improve tone and elasticity of slackenedor stretched muscles (abdominals, rhomboids, upper back and neck muscles); stretch shortened muscles (lower back andpectorals); reduce tension in joints of the pelvis, shoulders, hips, and knees; support breasts by strengthening pectorals; andimprove posture and increase vital capacity of the lungs. Although in many childbirth preparation classes a variety of exercises

are taught,13,17,18,19,57,58 the following basic examples can be easily explained by the physician or midwife at the prenatal visits.

Guidelines for Exercise During Pregnancy/Postpartum

1. Regular exercise (3 times/week) is preferable to intermittent activity.20

2. All exercises are done slowly and deliberately. Jerking or bouncing movements that strain joints should be avoided. Wooden or securely carpetedsurfaces will reduce body shock and provide sure footing.

3. Activities requiring jumping, jarring motions or rapid change of direction should be avoided because of joint instability, and competitive activitiesand contact sports should be discouraged

4. Vigorous exercise should be avoided in very hot, humid weather (unless in an air­conditioned environment) and during periods of febrile illness.

5. It is vitally important to begin any exercise session with a period of warm­up exercises such as arm circling, shoulder and neck rotations, trunk

flexion, and gentle knee bends.57 This should be followed by stretching of the various muscle groups in the arms, legs, and trunk to prevent

damage of muscle fibers and joint strain; these may include gentle yoga stretches17 that are not taken to the point of maximum resistance.20

6. Similarly, each session ends with muscle and joint stretches58 done slowly, without bouncing or jerky movements. “Cooling down” should beaccompanied by slow and comfortable breathing and followed by a relaxation period.

7. Heart rate should be measured before the exercise session and at time of peak activity, and the target level of 140 beats per minute should not beexceeded except in strong athletes who have consulted and established their own target rates with their physicians.

8. Strenuous exercise should not exceed 15 minutes in duration, and exercises that employ or produce the Valsalva maneuver should be avoided.

9. Caloric intake should be adequate to meet the extra energy needs of pregnancy and lactation as well as the exercise performed. Liquids should beimbibed liberally before, during, and after exercise to prevent dehydration.

10. Maternal core temperature should not exceed 38.5°C.48,54

Each patient progresses at her own rate, starting by doing each exercise for three or four repetitions and slowly building up toten repetitions. Some exercises include specific breathing techniques in conjunction with the required movement (e.g. pelvic tiltwith exhalation and release with inhalation; inhalation with two­arm stretching to the sides to expand the chest and exhalationwith return to midline). Holding the breath on exertion of any exercise is not helpful; continuous breathing is to be encouraged.

No exercise must be performed to the point of fatigue; rest and relaxation should be interspersed during the session.37,57 Addingmusic to the exercise session enhances enjoyment and encourages rhythmic movements. At no time should the the toespointed, because this often predisposes to calf cramps. Sit­ups or double leg raises should not be done during pregnancy norattempted until after the 6­week postpartum checkup, because they put too much strain on the abdominals and encourage

diastasis.18,27,57 Positions that increase lumbar lor­dosis should be avoided to reduce possibility of backache.59

Patients used to be discouraged from lying flat on her back for extended periods of time to minimize the possibility of slowingcirculation to the uterus and prevent supine hypotension. However, there is no harm in lying recumbent for short periods while

doing exercises,20 and newest research46,55 shows that in healthy pregnancies, it is not necessary for the patient to “never lie onher back after the fourth month,” as formerly advocated by ACOG.21 There are some exercises (e.g. abdominal curls) that aremost effectively done while lying on the back, and the patient can change to alternate positions after each set. Exercises thatincrease circulation in and around the pelvis should be encouraged (e.g. pelvic tilt, abdominal exercises). Standing or side­lyingpositions can be substituted for executing hip and leg movements normally performed while recumbent.

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Fig. 3. Pelvic tilt in the supine position.

Fig. 4. Pelvic tilt while on all fours.

Fig. 5. Abdominal curls with arm raising.

Time should be set aside each day for some exercise and, where feasible, exercise should be incorporated into daily activities.

ACOG guidelines suggest exercising 3 times per week.1,21

Breathing Exercises

Because of the difficulties pregnant women may have with respiration during the second and third trimesters and the tendencyto hold the breath during exercising, deliberate attention to continuous breathing is encouraged. This ensures a steady intake ofoxygen as well as prepares the woman for the need to maintain uniform and rhythmic breathing during labor. Focused andrelaxed abdominal and low chest breathing skills improve ventilation and enhance relaxation during pregnancy, through labor,and postpartum.11

Pelvic Tilt

The pelvic tilt movement, which is slight, strengthens and tones the abdominal muscles and stretches the lower back muscles. Itis most helpful for decreasing the lumbar lordosis, realigning posture, and reducing low back pain.

The patient lies on her back with both knees bent and feet on the floor or examination table about 45 cm (18 inches) apart. Shebreathes in through her nose, and as she breathes out through her relaxed mouth she presses the small of her back against thefloor and notices the upward tilting movement of her pelvis and tightening in the abdominals. To make sure she is doing thisexercise correctly, the physician can place her or his hand under the lumbar vertebrae and tell the patient to press down ontothe hand. The woman holds this position for a count of four and then slowly releases as she inhales and exhales (Fig. 3). Oncemastered, this exercise can be done while sitting, standing, or on all fours, with care being taken not to let the spine sag (Fig. 4).When doing the pelvic tilt in the standing position, slight bending of the knees will ensure that the movement is performed inthe pelvic region and does not strain the hips. The pelvic tilt is particularly helpful for backache during pregnancy, labor, and

the postpartum period23,38,59 and is also useful as an abdominal toner.

Abdominal Toners

Abdominal toners are progressions of the pelvic tilt exercise and are excellent for toning and strengthening the rectus, orstraight, abdominals and the oblique abdominals. These muscles are used in second­stage pushing and for postpartum curl­upsand waistline recovery.

RECTUS OR STRAIGHT ABDOMINALS.

The position is the same as for the pelvic tilt. A pillow placed under the head reduces pressure on vena cava. With inhalation,the patient relaxes. As she exhales, she tilts her pelvis as in the previous exercise, and then lifts her head and slowly stretchesboth arms toward her knees and holds this position for a count of four while breathing normally; she then relaxes to thestarting position (Fig. 5). If a diastasis is diagnosed (i.e. if two fingers can be inserted between the recti), instead of stretchingher arms forward the patient should brace her abdomen by placing both hands across it, holding on to the opposite sides of themuscle bellies.18

OBLIQUE ABDOMINALS.

The position is the same as described previously. Again, the patient begins with the pelvic tilt, but this time she lifts her headand both arms and stretches toward the left knee and holds this position for a count of four while breathing normally; she thenrelaxes slowly to the starting position.

The patient inhales and exhales a few times. With the next inhalation, she relaxes, and on exhalation repeats the pelvic tilt, thistime bringing both arms to the right knee (see Fig. 5).

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Fig. 6. Hip, knee, and ankle flexibility done in side lying position.

Fig. 7. Neck and shoulder exercises.

Fig. 8. Upper back and rib cage stretch.

Fig. 9. Abdominal side flexors.

Hip, Knee, and Ankle

The starting positions for these exercises are either side­lying or standing. The body remains relaxed as the patient inhales (Fig.6A). If patient is lying on her side, both knees are bent. As she exhales, she bends her knee toward her chest (Fig. 6B). Whileinhaling, she stretches her right leg forward by extending her knee and dorsiflexing her foot (Fig. 6C). With exhalation, shebrings the straight leg back to midline (Fig. 6D), and with inhalation brings it back to the flexed starting position. This exerciseis then repeated with the left leg while keeping the right leg flexed after the patient turns to lie on opposite side.

Neck and Shoulder Muscles

The exercise for the neck and shoulder muscles is done in the tailor sitting position (i.e. sitting like a tailor with knees flexed) orstanding17 (Fig. 7). The patient drops her head forward and gently circles it to the left, upward, to the right, and forward in aslarge an arc as possible. This is done slowly and deliberately and is repeated on alternating sides, while being careful not toplace pressure on the cervical vertebrae

The shoulders are raised toward the ears, pulled backward, and slowly circled down and forward. This exercise should berepeated several times; it can also be done with the woman's fingertips on her shoulders while lifting and circling the elbowsforward, upward, and backward. Care must be taken to keep the back straight and to keep the chin from poking forward. Theseexercises are helpful in releasing tension in the neck and shoulder muscles and should be followed by postural alignment of thehead, neck, and shoulders.

Upper Back and Abdominal Side Flexors

With the patient in the tailor sitting position or standing with legs apart for balance, the arms are bent at the sides, and thefingertips are placed on the shoulders. The right arm is stretched upward as the woman inhales (Fig. 8). Keeping the torsoerect, the patient stretches her rib cage and upper back and then slowly lowers her arm to the starting position while exhaling.This is repeated with the left arm and then with both arms at once. The patient should progress to stretching her right arm andbending to the left while keeping her torso in alignment; the patient should then repeat this exercise by stretching her left armand slowly bending to the right (Fig. 9). These exercises allow for greater vital capacity by stretching the rib cage and upperback and strengthening the abdominal side flexors in preparation for postpartum recovery. When the patient's posturedemonstrates kyphosis, the pectorals are usually shortened; these stretching exercises are most beneficial in correction of thisproblem.

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Fig. 10. Pectoral toning.

Fig. 11. Hamstring and adductor stretch.

Fig. 12. Alternate flexion and extension of ankles and rotation of ankles in wide circlesenhances circulation.

Breast Support

In the second and third trimesters, when breasts enlarge and increase in weight, as well as during the postpartum period,additional support of the breasts is necessary. Strengthening of the pectoral muscles, which support the breasts, is achievedthrough use of an easy exercise.

In the sitting position, the patient puts her hands together, as in prayer, with her elbows flexed at shoulder level. She slowlypresses her hands together (Fig. 10). The position is held to a count of four and slowly released, and the exercise is repeatedseveral times. Normal, regular breathing should accompany this exercise.

Adductors and Hamstrings

At one time it was thought that pregnant women should become accustomed to stretching of the adductors and internalrotators of the thighs for added comfort in expulsion. It was argued that use of stirrups for delivery put strain on these musclesas well as the hip and pelvic joints, and that with conscientious practice of some stretching exercises, the associated discomfortcould be decreased.

Incorrect teaching or learning of the exercise could lead to subluxation of the pubic symphysis as a result of too­vigorouspressure on the knees or a bouncing movement, which initiates the stretch reflex, causing a rebound with further shorteningand protective splinting of the muscles.18 The following exercise not only allows for some stretch of the adductors but, more

importantly, allows for stretch of the tight hamstrings and low back extensors.17,18,57,60 The patient sits on the floor with her legsextended and separated as widely as comfortable and her hands stretched forward with her arms kept at shoulder level. Gentlyand slowly, she flexes forward from the hips, maintaining her arms parallel to the floor while stretching them forward, nottoward her toes (Fig. 11).At first this movement may feel uncomfortable, but with practice the discomfort eases. No jerking orbouncing movements should be done, only stretching forward slowly, holding for the count of four, and slowly releasing to thestarting position.57

Exercises Aiding Circulation

As discussed in the section on cardiovascular and respiratory changes, pressure from the enlarged uterus, dependency edema,dilated blood vessels, and blood stasis cause swelling in the lower extremities, fingers, and hands. Exercises to reduce swellingand improve blood circulation decrease patient discomfort and fatigue. To increase circulation in the legs and reduce edema ofthe feet, alternate flexion and extension of the ankles causes pumping action of the calf muscles that promotes the flow of blood(Fig. 12). These exercises should be repeated six to eight times and done slowly. Pointing of the toes and extreme plantar flexionmay result in leg cramps and therefore should be avoided. Rotation of the ankles in wide circles, first in one direction and thenthe other, is another excellent exercise (see Fig. 12). The effects of this exercise on circulation can be enhanced if the legs aresupported and raised higher than the hips so that gravity assists in return blood flow.

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For swollen fingers and wrists, the patient should sit with her elbows flexed and supported on a table and her hands in the air.Alternate flexion and extension of the fist or rotation at the wrists, with gravity's assistance, reduces swelling and the associatedtingling sensation.

Postpartum, the risk of thrombophlebitis is increased when patients have undergone cesarean birth under regional anesthesiawith lengthy pressure on the calf muscles. Foot and ankle exercises in the recovery room and early ambulation improvecirculation and prevent stasis.

Pelvic Floor

The importance of the pelvic floor (i.e. pubococcygeus or levator ani muscles) has been sadly neglected by obstetricians. Theseseveral­layered muscles, both voluntary and involuntary, form a figure­eight as they are slung in loops around the vaginal andurethral sphincters anteriorly and the anus posteriorly. They form the essential support of the pelvic organs, and their tone andelasticity are vital during everyday life, pregnancy, and childbirth, especially during second stage when the pelvic floor musclesmust be consciously released to facilitate delivery. These muscles must then be rehabilitated immediately after the delivery orrepair of the episiotomy, if performed, and consistently during the postpartum period if this pelvic organ support is to bemaintained.

Sphincter control of the bladder and rectum is a vital function provided by the pelvic floor muscles. Women can be taught bytheir obstetricians/midwives to release these muscles voluntarily during pelvic examinations and during delivery of the infant'shead so as to facilitate its expulsion. Teaching these exercises in prenatal exercise classes, childbirth education classes, or anyexercise classes for all women of all ages is mandatory and cannot be emphasized enough.

Exercise of the pelvic floor, or Kegel's muscles, when frequently and conscientiously practiced, maintains tone in these muscles,reduces the possibility of urinary incontinence or difficulty with postpartum urination, and helps prevent prolapse of theuterus.61 Another important function of the pelvic floor muscles is their active contraction to enhance enjoyment during coital

activity and reflex contraction during orgasm.62,63

Kegel exercises entail gaining awareness of the muscles of the pelvic floor and learning how to consciously contract and releasethem. The patient is taught to stop and start the flow of urine midstream during urination by using the sphincters, gently yetfirmly, several times; this exercise makes her aware of the action of these muscles. Once awareness has been gained, frequentpractice is necessary to maintain muscle tone not associated with urine flow. For the first week, at least 6 repetitions should bedone slowly, maintaining the tension for at least 5 seconds each time followed by release. Additional sets of contractions areadded to build up to at least 5 sets of 6 repetitions each day.

Another effective exercise is to imagine that this hammock of muscles is an elevator on the first floor that successively rises in asmooth, controlled, progressively tighter fashion to the second, third, fourth, and fifth floors, holding at each floor and then,

just as smoothly, releasing tension as the elevator descends to the fourth, third, second, and first floors.22,35,57 The act ofreleasing and then “pushing into the basement” prepares the patient for the release and bulging of the perineum necessary forexpulsion.57

Postpartum exercise of these muscles should be instituted soon after delivery. Conscious effort should be directed to thecontraction rather than to the release of these muscles. These exercises are included in preparation classes but can be taught bythe physician at a prenatal visit, by the nurse in the delivery room, and again during the postpartum period.

With early exercising of the pelvic floor, postpartum swelling is reduced, which in turn reduces discomfort. Frequentcontraction of these muscles enhances circulation, promotes healing of the episiotomy, and strengthens muscle tone. Incidenceand severity of postpartum urinary incontinence can be reduced by early initiation and frequent practice of these exercises.

As with all these exercises, contraction is done slowly and with concentrated effort to facilitate toning of the muscles and toincrease pelvic organ support by tensing successively harder, holding for 5 to 6 seconds, and releasing. Sets of six repetitionsshould be performed, and the number of sets should be gradually increased. During muscle contraction, the edges of theincision are pulled together rather than apart, and, with this reassurance, frequent practice must be encouraged. Daily exerciseof these muscles, together with practice of the pelvic tilt, relieves the low, achy feeling experienced by many women during thepostpartum period.63

COITAL ACTIVITY

For many years, obstetricians recommended abstinence from intercourse during the last 6 weeks of pregnancy and for 6 weeks

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postpartum. Unless sexual activity is contraindicated for a specific medical reason, such as toxemia, multiple birth, threatenedabortion, uterine bleeding, partner with venereal disease, incompetent cervix, or habitual aborter following orgasm, mostphysicians are now more liberal in their thinking, demonstrating understanding of the needs and desires of the expectantcouple. Resolution of anxieties and “old wives' tales,” reassurance about absence of dangers, and ideas for experimentation withnew positions should be the focus of the discussion with the patient.

Patients who have learned to contract the pelvic floor muscles can use this movement during intercourse. Contraction of thesemuscles during coitus constricts the vaginal canal and allows greater contact with the penis or fingers, thereby enhancingsexual stimulation for both partners. Practice during coitus also affords feedback by the sexual partner on the quality andstrength of muscle contraction.

When some form of “usual” sexual activity is prohibited, it is crucial for the physician or midwife to explain to the patient andher partner the reasons for abstinence; to reassess the prohibition after a period of time, and to encourage them to explore

other forms of sexual play.31,61,62,63 Couples should be encouraged to discuss their feelings about the change in their sexualbehaviors and to choose appropriate options for themselves. This will reduce the feelings of guilt and fear on the part of thewoman and of sexual rejection on the part of her partner.31 There is no conclusive evidence that coitus and orgasm are harmfulto those pregnancies without predisposing factors such as bacteriuria, hypertension, placenta previa, partner's venereal disease,conditions necessitating bed rest, or habitual abortion. In several studies, coitus could not be implicated as the cause forpremature labor, rupture of membranes, bleeding, or infection.63 Poor research methodologic factors hinder the acceptance ofthe reports that intercourse is among the factors that increase the risk of prenatal hemorrhage.63

CONTRAINDICATED EXERClSES

Physicians should make their patients aware of some exercises that put strain on the pregnant body and frequently lead toincreased discomfort or problems post partum. Due to the continuing paucity of definitive guidelines from research,

recommendations for physical activity continue to rely of the pregnant women's perception of comfort and common sense.22,57,64

The following are exercises that require restrictions.

1. Any exercise that increases the lumbar lordosis; puts strain on the sacroiliac joints, hips, or knees; or overtaxes the abdominal muscles. Thisincludes some yoga positions advocated in numerous books available for expectant patients and included in some prenatal exercise classes.

2. Two­leg raises from the recumbent position or full sit­ups from the recumbent position (see Abdominal Toners).

3. Bridging, or lifting the buttocks off the floor from the recumbent position, if it cannot be done without increasing the lordosis.

4. Any exercise that encourages bouncing, bobbing, or jerking movements, as found in many aerobics or jazzercise classes popular today. Many ofjazz­boxing class movements are excellent but, as with activities from step class routines, they need to be slowed down to ensure proper breathingand ensure maintenance of balance.

5. Deep knee squats for women unaccustomed to this position to prevent strain on knee and ankle ligaments. Women can be encouraged to slowlybend theirknees from the standing position to attain an eventual squatting position while leaning upright against a wall for balance; this exerciseis excellent for delivery.

6. Hyperextension of knees in standing position puts strain on the knees. Knees can be held in a gentle bend, which will help attain pelvic tilt andalleviate backache.

7. Exercises that involve pointing the toes and plantar flexion of the feet can cause calf cramps.

8. Exercises done past point of fatigue, that create pain, or that induce hyperthermia should not be performed by the pregnant woman.

Expectant mothers must respect signals from their body and stop exercising if there is pain and to rest when fatigued. Theymust take extra precautions when exercising during hot and humid weather. They must maintain water intake, stop frequentlyto rest, eat adequately before exercise, rest afterward, be aware of fetal activity, and consult the physician if uterine contractionsbecome regular. Likewise, they must stop exercising if they experience shortness of breath, dizziness, or faintness.

BODY MECHANICS

In everyday living, many people do not use good body mechanics and as a result put strain on muscles, ligaments, and jointswhile performing daily chores. In pregnancy, this strain is increased, whether sitting, standing, or walking (Fig. 13), and thepatient frequently needs re­education to maintain body alignment without undue strain or pressure.

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Fig. 13. Strain on muscles, ligaments, and joints from performing dailychores is increased during pregnancy.

Fig. 14. Incorrect and correct way to lie down.

Fig. 15. Incorrect and correct way to pick up objects from the floor.

The following exercises can be easily shown to the patient by her physician. In particular, the first one can be demonstrated tothe patient when she comes for her prenatal visits. In changing from sitting on the examining table to a lying position, manywomen lie straight back, putting severe strain on the abdominal muscles and joints of the back. The office nurse or physiciancan correct this by telling the patient to bend her knees, roll to one side, lower her body using her arms, and then roll to herback (Fig. 14).

Changing from lying to sitting positions is frequently done incorrectly by “jackknifing up,” which strains the already stretchedabdominal muscles, causes further separation of the recti, and results in backache. The change should be made slowly to avoiddizziness. Again, the patient bends her knees, rolls to one side, and raises her body by pushing up on her hands.

To pick up objects from the floor, the patient should squat by bending her knees while keeping her back straight and then liftthe object by straightening the knees rather than bending from the waist; this method reduces back strain, tones the muscles ofthe thighs, and affords better weight distribution (Fig. 15). While climbing stairs and doing household chores, the patientshould use her legs as much as possible and avoid flexion of the back.

REST AND RELAXATION

Just as important as exercises to tone and maintain the body in optimal condition, is the need for rest and relaxation during the

pregnancy.17,57,60 Cardiac and basal metabolism are accelerated, the expectant mother's weight has increased, and fatigue

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becomes a problem, especially in the last trimester. Patients need to be encouraged to take breaks during their daily work, puttheir feet up, and replenish their energy by consciously releasing muscular tension in the body.

This can be done in any position that is comfortable: sitting, reclining, or lying on the left side with pillows to support and flexknees. A variety of restful images may be used (gentle waves, swaying palms, sunny beaches) to encourage relaxation, or thepatient may imagine a warming sensation passing downward from the top of her head to her toes to induce a feeling of calm.Rhythmic, restful breathing can be included to encourage deeper release of striated muscles and calming of the mind. Learningto release tension during pregnancy helps the woman to conserve her energy and reduce fatigue. With diligent practice,relaxation becomes a skillful tool in meeting the demands of childbirth by enabling the woman to remain calm, reduce fatigue,and reduce pain perception during labor and birth. In the puerperium, relaxation skill provides an invaluable tool forcounteracting the fatiguing role of parenting, with its demands of caring for the baby while enduring lack of sleep. As such, itshould be included in every exercise session, used as a means to cool down after exercising, and encouraged prior to retiring toensure more restful sleep.

SPORTS ACTIVITIES

Although opinions differ, the scientific studies that have been published regarding the effects of maintaining involvement insports activities during pregnancy have been mostly positive. Most physicians have been almost unanimous in their belief thatit is not necessary for a pregnant woman to limit her activities, provided that she does not become fatigued, experience pain, orlose balance and has no contraindications to the activity. All adults need exercise, and failure to obtain exercise can result inweakness or illness. This is particularly true for those pregnant women who are normally active or who are sports enthusiasts.Marked restriction of such activities shifts the emphasis during pregnancy from the normal physiologic experience toward onebordering on illness. Lengthy periods of enforced idleness can be detrimental to a woman's physical and mental well­being;therefore, any sport or exercise in which the woman has engaged for a long time is permissible, with caution not to continue tothe point of fatigue or pain.

Physicians strongly agree that pregnancy is not the time to learn a new sport. An exception would be changing from a weight­

bearing to a non­weight­bearing activity, such as from running or jogging to swimming or water aerobics.5,38,60 Pregnant womenare also cautioned not to indulge in competitive sports or anything that would cause continuous panting or fatigue. Because ofpostural realignment, focus on the new body image is important so that balance is not impaired. Some physicians believe thatbalance is more precarious in the latter part of the third trimester and that women do not respond as quickly in a stresssituation.

For this reason, physicians advise against activities that require quick decision­making and balance, such as skiing, skating,and rollerblading. Cross­country skiing has become increasingly popular for pregnant women in cold climates, but again, heatrestriction, pacing, adequate breathing, and ability to balance are important.

Walking with well­fitted, low­heeled shoes or sneakers with cushioned soles, performed while observing good posture, is theexercise most prescribed by obstetricians. Hydration and nutrition must be maintained for extended walks. Additionally,walking should be preceded and followed by stretching.

Swimming is an excellent choice for activity, because the woman is in a state of weightlessness, with less pressure on hercirculation. She can pace herself, going as fast or as slow as she desires while maintaining her comfort level and relaxedbreathing pattern.

Tennis is another popular sport played by pregnant women without ill effects, but self­tolerance, heat restrictions, amplehydration, and noncompetitive settings are key. Curtailing the need to reach far­flung balls is imperative in advancingpregnancy, and avoiding sharp turns is advised. Playing doubles is recommended over singles.

Bicycling is another form of non­weight­bearing exercise that can be enjoyed by the pregnant woman if she is accustomed tothe activity and can pace herself and maintain her balance. Wearing a helmet is imperative, and knowing the location ofrestrooms along the way is a must.57 If fear of falling is a problem, a stationary bicycle can be used. This activity is beneficial tothe cardiovascular system while sparing the joints and ligaments.

Golf remains a favorite with some pregnant women who play regularly. This activity involves walking and well as armmovements and balance.

Horseback riding has historically been considered dangerous because of the bouncing movements and possibility of beingthrown and is not recommended.

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Running and jogging have come under scrutiny both in the general and the pregnant population. Many orthopedic surgeonsdecry possible harm to ligaments of the back, hips, knees, and ankles. These are under strain during pregnancy because ofhormonal changes and increased body weight; therefore, pregnant women—even those who were regular runners—need to becautioned to run only if they are in good condition, wear well­fitting and well­conditioned shoes, stretch before and afterrunning, never run on concrete, and above all be aware of their bodies and stop when they become fatigued or experience

pain.22,26,41,58,59

In all sports activities, if a woman has long been a devotee, is proficient, is prepared to slow down or stop the activity when shebecomes fatigued, and understands how pregnancy changes affect her joints and muscles, she should be encouraged tomaintain her involvement.64 Good body mechanics should be used in all activities, and good sense regarding safety, balance,heat restrictions, and tolerance is mandatory.

Contraindications for Sport Activities

Women with conditions such as pre­eclampsia, toxemia, placenta previa, or heart conditions, for which rest is the main modeof treatment, are obviously advised not to indulge in vigorous physical activity. Liberal amounts of rest have been said toimprove the prognosis of high­risk pregnancies associated with these conditions or hypertension. There is evidence, however,that extended lying in the supine position is detrimental during pregnancy, because compression of the vena cava lowers thearterial pressure through decreased venous return to the heart. As a result, renal plasma flow and uterine blood flow aredecreased. However, extended prescribed bed rest without qualification regarding position could also have detrimental effectson muscle tone, back pain, reduced circulation, and emotional state. To maintain circulation and muscle tone, these patientscould be prescribed mild bed exercises administered by a qualified physical therapist.

Exercise stimulates blood flow to the muscles, particularly the extremities, and it has been speculated that uterine flow may bediminished to some degree during strenuous activity. However, there is no evidence that periods of moderate exercisecompromise the fetus in any way in a normal pregnancy. There is some justification for curtailment of activity in women withincompetent cervix or when frequent bleeding occurs. Otherwise, most physicians agree that the psychological benefits ofexercise outweigh these speculative problems. The main guide is for the woman to “listen” to her body signals and use commonsense and sound judgment.

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