Pregnancy and Exercise
Introduction
In the past, any form of exercise during pregnancy was considered to be taboo and as such, pregnant women were positively encouraged to adopt a sedentary lifestyle. However, pregnancy is now more recognized as a unique time for behaviour modification and is no longer considered a condition demanding confinement and avoidance.

Before discussing the benefits of exercise in detail with any pregnant individual, it is important that we emphasise that care must be taken and, that an increase in fitness cannot really be expected. Instead, the expectant mother should be looking to maintain a baseline fitness to aid pregnancy and hopefully to get back in to training more easily after the birth.

Expectant mothers can gain the following benefits through exercise participation:

Benefits of Exercise During Pregnancy
Improved circulation	Eased recovery
Reduced swelling	Eased gastrointestinal discomforts
Reduced leg cramps	Reduced maternal weight gain
Enhanced muscular discomforts	Reduction in labour pain
Easier, shorter labours	Better self-image

Exercise Screening
Careful screening of every expectant mother wishing to exercise during pregnancy will be carried out. If there is any doubt regarding the appropriateness of exercise, the individual will be referred to the GP. In any case, the mother will receive regular check ups from the GP or midwife who will, amongst other things, monitor their blood pressure (as your personal trainer will also do) and answer any health concerns they may have.

General Principles of Exercise Prescription
Be aware of the effects of relaxin. Relaxin is a hormone released in the second trimester which softens ligaments, cartilages and the cervix, allowing these tissues to spread during delivery. This particularly relates to the pubis symphysis and the sacroiliac joint. The effects of relaxin mean that joints throughout the body are potentially vulnerable and therefore, should not be overly stresses, for example, through over-vigorous stretching.

Exercises will be given to strengthen the pelvic floor muscles. These muscles act as a hammock to cradle and support the uterus, bladder, bowels and other pelvic organs. They form a figure of eight around the urethra, vagina and anus. As the uterus grows, these muscles become overly stressed and start to sag. This can cause several potential problems not least of which is tress incontinence (National Kidney Foundation, 2002), i.e. the leaking of urine, since these muscles control the bladder.

It is commonly considered contraindicated for pregnant women to lie down in a supine position after the first trimester. It is lying still under the weight of the uterus that causes the problem because the weight of the enlarged womb compresses the inferior vena cava (Araujo, 1997). This can result in dizziness, numbness in the extremities and foetal hypoxia.

The importance of breathing out on the exertion should be emphasised to help reduce the build up of intra-abdominal pressure. Also, by exhaling on the contraction in this way, the diaphragm relaxes and moves upwards, giving more room for the foetus to shift upwards during the movement.

Bearing the above in mind there are also a number of Do's and Don'ts we should identify, which allows me to further individualise your programme.

	Do:
	Approach the exercise programme with an open mind. Focus on things other than performance, such as developing an improved sense of well-being, physical capacity and productivity.
	Make sure that the total volume of exercise is enough to enhance the sense of well being. We are all different but it appears that 20 minutes at a moderately hard RPE is the minimum for most healthy women of reproductive age (Canadian Academy of Sport Medicine, 1998).
	If it feels good, it's probably ok. This view is in keeping with the underlying principle that exercising mothers should always use common sense about what their bodies can do.
	We will always monitor and review progress.
	We should also pay attention to the little things. Adequate hydration, appropriate rest intervals, nutrition and prompt attention to any discomfort are as important as the exercise itself.
	As much attention to the process of pregnancy as to the exercise should be given. If exercise is going well but pregnancy is not running smoothly, we have a problem.

	Don't:
	Don't do anything without thinking it through.
	Don't continue if exercise produces pain (particularly abdominal or pelvic pain)
	Don't ignore fatigue. If you start to exhibit signs of noticeable tiredness, i.e. tired all the time, lacking in motivation or performance, then you are probably doing too much.
	Don't exercise in the supine position after the first trimester as this may lead to foetal hypoxia.

Aerobic Exercise Recommendations
For previous exercisers, we'll aim to maintain a level of cardiovascular fitness.
For non-exercisers, the aim will be to promote general well-being and body awareness and to promote circulation.

Warm up and cool down
Guidelines:

	We'll work on body awareness and control as the body weight and shape is constantly changing
	We'll work on gradual and slow warm up and cool down

Aerobic Exercise Recommendations
Frequency	3-5 sessions / week
Intensity	40-70% VO2 max RPE 11-13 (comfortable pace)
Time	20-30 minutes/main session
Type	predictable, aerobic physical activity, low impact (swim, cycle, walk, low impact aerobics)

Resistance Training Recommendations
For previous exercisers, we'll aim to maintain muscular strength and endurance. But we'll also aim to maintain good posture and technique
For non-exercisers the aim is to improve body awareness and learn good technique.

	We'll work on body awareness and control as the body weight and shape is constantly changing
	We'll work on gradual and slow warm up and cool down

Considerations:

	Relaxin loosens joints, making the sacroiliac and pubis symphysis joints particularly vulnerable
	Blood pressure may gradually, and normally, increase during pregnancy

Resistance Training Exercise Recommendations
Frequency	2-3 x / week
Intensity	form failure - 15 - 20 repetitions
Time	1-2 sets per exercise, 8-10 exercises
Type	all major muscle groups, include abdominal and pelvic floor (circuit format)

Additional resistance training guidelines:

	All work should be performed from a stable base.
	Allow time to change starting positions.
	Correct technique and posture is vital, and will be encouraged throughout. This will be easier with higher repetitions.
	Minimise isometric work.
	Breath holding should be avoided particularly during exertion.
	Avoid lifting weights above the head and using weights that strain the lower back muscles.
	Remember that prone lying is not advisable after the first trimester and lying on the back can cause problems with reduced venous return and dizziness. The position for floor work and resistance training must be considered.
	Think about improving posture by strengthening abdominal, upper back (retractors) and the gluteals muscles.
	Abdominal work can be performed from a box position.
	In the 2nd and 3rd trimester, the abdominals can be adequately exercised by pelvic tilting.
	Weights can continue into the third trimester although certain machines may become more difficult as the baby increases in size.
	Due to possible pubis symphysis instability, avoid inner and outer thigh machines from second trimester and instead work theses muscles in a side-lying position on the floor.
	Ballistic exercises, such as lunges, should also be avoided, although bodyweight squats will be acceptable for many.

Flexibility Recommendations
Frequency	minimum of 2-3 x /week
Intensity	to a position of mild discomfort
Time	8-10 seconds
Type	controlled dynamic for warm up. All major muscle groups used in the sessions and hypertonic muscles (no PNF or developmental)

Flexibility guidelines:

	Mobility exercises to lubricate joints within their normal range of movement.
	Don't excessively flex joints and any static stretching should be maintenance-based (i.e. don't stretch to extreme ranges and no developmental work).
	Any stretching should be done from a stable base (could use a wall, chair or partner). Avoid placing uneven pressure on the pelvis, i.e. standing on one leg (quadriceps stretch will need support).
	Rise and change direction slowly to avoid dizziness. You'll be thought how to get down to the floor and back up again.

Post-natal Exercise Recommendations
The post-natal period is often a difficult time in terms of maintaining the commitment to exercise. Getting to know the baby and how to care for the baby is a rewarding experience but it takes a lot more time. The danger is that the women will leave herself no personal time in which to exercise. As fitness professionals, it is vital that we make women fully aware of the many benefits of post-natal exercise. A thorough understanding of any potential risks should support this.

The ACOG (1994) recommended that women should avoid all physical stress for two weeks (i.e. 'don't carry anything heavier than the baby') and not resume full daily activities for a minimum of six weeks after delivery. It is also advised that those who delivered by Caesarean section should not exercise for 12 weeks after delivery to allow proper healing time.

It is important, after birth, that the mother is cleared by a doctor before embarking on an exercise programme.

Benefits of post-natal exercise:

	Improve posture
	Increased local muscular endurance
	Increased stamina
	Increased energy
	Increased metabolic rate
	Increased weight loss, improved body image
	Increased self-confidence
	Reduced anxiety

Post-natal concerns:

Injury from reduced joint stability

It has already been noted that the rising levels of relaxin produced during pregnancy increases the elasticity of the ligaments and cartilage leading to instability of joints, particularly the sacroiliac joint and the pubis symphysis.

Exactly how long relaxin stays in the body is up for debate and will vary between mothers. Five months if often quoted although estimates vary from three months up to a year. In reality, the hormone can be present for as long as the mother is breast-feeding, which may be up to two years. The mother is the best judge and will know when she no longer 'feels loose'.

Exercise implications:

	Maintenance stretching is strongly recommended and stretching to increase flexibility should be avoided for 16-20 weeks
	When resistance training, adopt muscular endurance work and avoiding working to failure
	Avoid high impact activities for the first few months

Injury from weak abdominals

It may take six weeks for muscles to fully recover or even longer if they were weak before pregnancy. Gentle abdominal exercises in the early post-natal period will be vital in encouraging this process. Tummy-tightening, pelvic tilting and lying and kneeling abdominal raises can be commenced immediately after the baby is born.

It should be noted that pelvic floor exercises are still important after Caesarean delivery. Although, the pelvic floor has not been through the same degree of stretching and trauma of a vaginal delivery, relaxin has still increased its elasticity and it has still had to support the growing baby for nine months.

Breast-feeding

A point of caution here is that both breast-feeding and exercise are big fluid drains so to avoid dehydration, water intake around breast-feeding and exercise must be a priority. Other noteworthy points relating to breast-feeding and exercise are:

	A good supporting (sport) bra is essential during exercise to prevent over stretching of breast tissue.
	Prone lying is inappropriate for early post-natal mothers.
	Vigorous arm work may actually promote milk flow. Mothers should be aware of this to prevent any embarrassment.

Pelvic floor exercises:
It is important that women is made aware that these must be performed daily for the rest of her life and that she will not get the full benefits for about 6-8 weeks.

To tighten the pelvic floor muscles, start by pulling in round the back passage, front passage and the vagina. Lift a little and then stop - imagine lifting and lowering a drawbridge.

	Pelvic floor exercise can be performed in any position.
	Start by contracting the pelvic floor muscles by lifting and holding for up to 10 seconds and gradually release. Begin with 5 sets of 10 repetitions per day, gradually working up to 10 repetitions per day.
	Try not to contract the abdominals, buttocks or thigh muscles.
	Keep breathing throughout.
	Quality is better than quantity.