Women who exercise during pregnancy enjoy many benefits. They have more energy, less mood swings, better stress management and more restful sleep than sedentary pregnant women. James F. Clapp III, professor of reproductive biology at Case Western Reserve University in Cleveland, Ohio, has performed many studies about exercising during pregnancy and has concluded that pregnant women who exercise gain 21% less weight and have and improved attitude over sedentary women (1,2,3). He also found that women who exercised during pregnancy had shorter, easier labors (decreased by an average of 2 hours), less medical interventions (24% less cesareans and 14% reduced use of forceps), less fetal distress and a faster recovery. Clapp noted that 80% of the exercising women gave birth on or before their due date; there was also less of a need for interventions such as induced labor or epidurals in these women (3, 4). Exercise may also prevent backaches and other discomforts associated with pregnancy (5 ).
In other studies, Clapp found that the babies of women who exercised during pregnancy are leaner and have less percentage of fat, although they are larger and healthier than the babies of sedentary mothers (1,6,7, 8). More recent studies have found that moderate exercise increases placental function and growth. Maintaining vigorous exercise throughout pregnancy causes a decreased growth of the fetal fat organ and size at birth. When exercise intensity is decreased in late pregnancy, the fetal size is increased at birth as well as fetal fat. If exercise performance is increased, fetal size is decreased at birth, as well as fetal fat, producing a leaner body mass ( 9, 10, 11).
The babies’ Apgar scores (a predictor of baby’s health and survival) were generally higher in the exercising mothers (3). Women who exercise during pregnancy also tend to have more alert and calm babies, as well as smarter children (4, 8,12)!
Expectant mothers needn’t worry that exercising will hurt their baby. Clapp found that exercise doesn’t cause an increase in spontaneous abortion, premature birth, or birth defects (13). There is nothing to prove that a slight increase in body temperature causes problems. Physically fit women actually have a lower core temperature and a better ability to regulate body temperature (14). Furthermore, blood glucose levels are increased only when exercise intensity exceeded 80% of maximum; after the 23rd week, exercise produced a decrease in blood glucose, which was no longer related to exercise intensity (15) .
Although most pregnant women can and should exercise, there are times when exercise may be contraindicated. Women who have cardio-vascular disease, high blood pressure, vaginal bleeding, thyroid disease, fetal complications, diabetes, anemia, sickle cell anemia, preterm rupture of membranes, history of several miscarriages or premature labor, poor fetal growth, history of incompetent cervix, twins or abnormal presentation of fetus, or who are underweight should exercise only under careful supervision of their health care provider.
Women who habitually exercise can continue with their pre-pregnancy routine, with some modifications to allow for the physiological changes, which occur during pregnancy. Pregnant women should decrease the intensity and duration of their workouts; with pregnancy, lung capacity decreases and respiration rate increases, which can make them breathless. The changes in the cardiovascular system includes a 40% increase in blood volume and increased heart rate of 15 bpm, enabling a greater flow of nutrients and oxygen supply to the developing fetus. This shift of blood reduces the amount of oxygen and blood flow for the mom`s use during the initial phase of exercise, and can cause dizziness, therefore any exercise should have a gradual increase in effort. Too strenuous exercise may also cause pregnant women to become lightheaded and shift blood away from the uterus. Studies have concluded that the fetal heart rate is not affected when the maternal heart rate is kept under 140 to 150 beats per minute (16). When the maternal heart rate averaged 180bpm, however, indications of fetal response were frequently present.
The musculo-skeletal system undergoes extensive changes as a result of circulating hormones. Estrogen relaxes the joint capsules, allowing for more movement of the joints, including the sacroiliac and pubic joints of the pelvis. This “relaxation” of the joints is important to facilitate childbirth by opening up the pelvic outlet. More joint motion, however, can lead to sprains and strains. A pregnant woman should never push a stretch beyond the point of mild discomfort and shouldn’t hold stretches longer than 20 seconds. Stretching should be a part of every pregnant woman’s exercise program in order to keep the body flexible and help relieve general aches and pains.
There are biomechanical stressors that are placed on the spine and pelvis. As the baby grows, the center of gravity shifts and the low back increases it lordosis (known as the “Pride of Pregnancy”). A spinal evaluation by a chiropractor is important to ensure that there are no subluxations or restrictions. Gentle correction of any detected subluxations will help prevent sprains and strains from occurring and help relieve back and leg pain which may keep women from exercising during pregnancy.
Approx 30% of women will experience a separation of the rectus abdominus during pregnancy. If this does occur, abdominal exercises should cease. Even if it is not a problem, it is recommended that the abdominal muscles are supported by crossing hands over the abdominal area when doing any crunch type movements. It is not advised to do full sit-ups at any time. If a woman chooses to abdominal exercises when pregnant, the separation of abdominal muscles should be regularly checked by their health provider.
It is best for women who are not active and are thinking of getting pregnant to begin an exercise prior to conception. It’s never too late, however, even if the baby’s already on the way. Walking is one of the best exercises around! The only equipment needed are a supportive bra, a pair of walking shoes- and some fresh air. They should start off with an easy pace and gradually walk faster and farther each day, as they build up stamina.
Yoga during pregnancy is another great way to stay in shape and work muscles that will be needed during labor and the post partum period. Yoga`s benefits extend beyond the physical, bringing in breath work, focus, and the mind-body connection that are crucial for a healthy delivery. If a woman has never done yoga, it is best to go to a class tailored for pregnant women. Prenatal yoga videos and DVDs are also great to use at home if classes are unavailable. Although yoga is safe to do during pregnancy, there are poses that are contraindicated. Full inversions (head, hand, elbow and shoulder stands) should not be done in the first fourteen weeks of pregnancy as they shift the energy away from the developing fetus. Deep twists from the low back are contraindicated for all trimesters. And poses which have you lying on your stomach should be discontinued after 3-4 months. For beginners, it is often helpful to perform the warrior poses, triangle pose, and any balancing poses at the wall or using a chair for support.
The following are some great yoga poses to do during pregnancy. Remember to breathe and listen to your body. If you have any pain, stop the exercise immediately.
Ardha Titali Asan (Half Butterfly)
Sit with legs outstretched. Bend the right leg and place the right foot as far up on the left thigh as possible. The foot should stay flexed and active (Figure 1). Place the right hand on top of the bent right knee. Hold the toes of the right foot with the left hand. While breathing in, gently move the right knee up towards the chest. Breathing out, gently push the knee down and try to touch the floor. Movement of leg should be achieved by the exertion of the right arm. Repeat 10 times. Then repeat 10 times on the left side.
FIGURE 1
Benefits: Excellent practice for loosening of hip and knee joints, to enable a faster delivery.
Poorna Titali Asan (Full Butterfly)
FIGURE 2a and FIGURE 2b
Sit with legs outstretched. Bend the knees and bring the soles of the feet together, keeping the heels as close to the body as possible. Fully relax the inner thighs. Clasp the feet with both hands and rest elbows on the inner thighs. Inhale and resist the upward movement of the thighs with the elbows (Figure 2a). On the exhale, use the elbows as levers to gently press the legs down (Figure 2b).
Do not use excessive force. Repeat up to 10-20 times. Hold 30 seconds after you finish the last repetition.
Benefits: Tension from inner thigh muscles is relieved. Removes tiredness from legs.
Utkatasana (Chair pose)
FIGURE 3 and FIGURE 4
Stand erect with feet under hips, or slightly wider with toes turned out a few degrees. Place hands on your hips and inhale. Tuck the tailbone and exhale as you slowly bend the knees as if you were sitting in a chair, making sure the knees track over the toes (don`t let the knees collapse towards the middle). Straighten knees on an inhale and return to upright position. Repeat 5 times. (Figure 3) This pose may also be done by holding onto the back of a chair for support (Figure 4).
Benefits: Strengthens muscles of middle back, uterus, thighs and ankles.
Vajrasan (Thunderbolt pose)
FIGURE 5 and FIGURE 6
Kneel on the floor. Bring big toes together and separate the heels. Lower the buttocks onto the inside surface of the feet with heels touching the side of the hips. Place hands on knees, palms down. Back and head should be straight , but not tense. Hold for 30 seconds to one minute (Figure 5). Variation: Turn the toes under and sit back on the heels. Hold this variation for 30 seconds to one minute (Figure 6).
Benefits: Enhances digestive functions and can be practiced directly after meals. Relieves stomach ailments like hyperacidity often a trouble faced during pregnancy. Alters blood flow and nervous impulses in the pelvic region and strengthens pelvic muscles. Assists women in labor.
The Hindi Squat
FIGURE 7 and FIGURE 8
Begin with your hands on your hips, your feet hip distance or wider apart, with the feet turned out slightly. As you exhale, bend your knees and release your buttocks back and towards the floor. When you are all the way down, place your hands in prayer position at the center of your chest and use your elbows as levers to open up the knees and lift the chest. Work up to holding for three minutes (Figure 7). You may also squat with support, using a ball, the wall, or a chair (Figure 8).
Benefits: Increases flexibility of the lower back, hips, and calves. Strengthens the buttocks, hamstrings, and quadriceps. Tones the abdominal area. Excellent for digestion and elimination.
Balasana (Child`s pose)
Kneel on the floor. Bring big toes together and separate the knees. Lower the buttocks onto the heels and bring the forehead to the ground. Bring the arms around to the side with the palms turned upward (Figure 9). Hold for several breaths. If you cannot reach the forehead to the ground comfortably, then bring your arms in front and rest your forehead on your stacked up hands.
FIGURE 9
Benefits: Brings circulation to the lower back and abdominals, creates space for the organs in the pelvic area, & relieves lower back tension. Relieves the pressure of painful gas.
Chakravakasana (Cat Stretch)
FIGURE 10a and FIGURE 10b
Come on to your hands and knees, with the knees under the hips. One the inhale, lengthen the spine by extending the chest forward and the hips back, keeping the spine neutral (don`t arch the lower back during pregnancy) (Figure 10a). On an exhale, round the spine, lifting the navel up towards the spine while you move your head and tailbone down (Figure 10b). Repeat several times, moving with your breath.
Benefits: Creates flexibility in the pelvis and spine; builds strength in the arms.
Chaturanga Dandasana (Push up Pose)
FIGURE 11
Come on to your hands and knees, bringing your hands in front of your shoulders a full hand space. Lean your body forward so that the shoulders come in line with the wrists. Engage your abdominal muscles and keep your tailbone tucked down and your lower back lifted, so that your buttocks don`t sag toward the ground. Inhale. Exhale and slowly band your elbows in close to your ribs (Figure 11). Inhale and push the ground away, squeezing the abdominal muscles towards the spine. Repeat 3-5 times, taking a break in Child`s Pose, as needed.
Benefits: Strengthens arms, shoulders, and abdominals.
Exercise balls are also great tools in exercising for the pregnant woman. She can put some music on and bounce around for 20 – 30 minutes with basically no impact to the spine. The ball can be used to perform supported abdominal crunches from a semi sitting position, as well as pelvic tilts (Figure 12). Lying back over the ball helps to open up the chest with support (Figure 13). Leaning against the ball during a sustained squat helps to open up the hips and pelvis. The ball can also be used during labor. This author found it helpful to bounce gently during contractions and do pelvic rolls. When the going gets tough, the laboring woman can get of her knees, rest her arms on the ball and roll.
FIGURE 12 FIGURE 13
Pregnant women may also safely exercise using stationary bicycles, swimming, water aerobics, and low impact aerobic classes specifically designed for pregnant women. Prenatal aerobic and yoga classes are wonderful because they are able to interact with other mothers to be who are going through all the same processes they are – physically, emotionally, and spiritually. Prenatal exercise videotapes can also be used if they’re unable to get to a gym or if there is inclimate weather.
The American College of Obstetrics and Gynecology (ACOG) recommends that women don’t lie on their backs or right sides after the first trimester. Their reasoning is that the weight of the baby may depress the Vena Cava and decrease the circulation to the baby. (If this is the case, why do most obstetricians place women on their backs to birth?) Other experts say that exercise may be done on the back if it is not prolonged (2 to 3 minutes). Supine exercises may also be done on a 30-degree slant board; gravity causes the baby to come out of the pelvis taking pressure off the Vena Cava. If they are exercising on their back and experience shortness of breath, nausea, tingling, numbness, or any other discomfort, they should immediately roll onto their left side.
Other selected recommendations from the ACOG include:
* Regular, mild to moderate exercise, three times per week is preferable to an irregular schedule
* Exercise capabilities decline in pregnancy, so it is important to listen to your body.
* Moderate to intense aerobic activities should be limited to periods of 15 to 20 minutes. Lower intensity activities may be conducted continuously over a longer period but should not exceed 45 minutes in total.
* Heart rate should be measured at times of peak activity and should not exceed 140 beats per minute. One way to determine whether exercise is too intense is the “talk test”: if the pregnant woman is unable to converse normally while exercising, she is overexerting herself.
* Strenuous exercise should not be performed in hot, humid weather or during illness accompanied by fever.
* Perform warm up for at least 5 to 10 minutes before exercising .
* Care should be taken to rise from the floor gradually to avoid an abrupt drop in blood pressure, and to continue some form of activity involving the legs for a brief period.
* Exercise sessions should be followed by a brief cool-down period of gradually declining activity that includes gentle stationary stretching. Stretches should not be taken to the maximum resistance.
* Choose exercises which do not require great balance because coordination and center of gravity are changed. Exercises that require jumping, jarring motions or rapid changes in direction should be avoided. These can cause damage to connective tissue.
* Avoid exercise with risk of even mild abdominal trauma.
*Maintain adequate diet. Pregnancy requires an additional 300 calories per day. Do not try to lose weight during pregnancy.
* Dress appropriately and drink lots of water; do not exercise in the heat of the day or night or if it is very humid.
* A pregnant woman`s temperature should not exceed 100.4 F while exercising. She should drink plenty of water before and after exercise to prevent dehydration and hyperthermia and take a break during exercise if more water is needed or she is tired.
* Return to pre-pregnancy routines gradually. It takes 4-6 weeks to recover and up to 10-12 after a Cesarean birth.
* If weight gain is not sufficient, it is a good idea to reduce the time or strenuousness of the regimen.
* Avoid exercises where falling is likely (horseback riding, skiing, sky jumping…)
* Stop any exercise if any bleeding, vaginal water loss, sudden swelling in ankles, hands, face, redness in calf, dizziness, faintness, heart palpitations or rise in blood pressure, abdominal pain, perineal pain or persistent contractions are noted.
The following are some of the most important exercises to do during pregnancy:
Kegel Squeeze: Sit in a cross-legged position or come into a squat. Squeeze the pelvic floor muscles in a rhythmic manner with varying speeds and depths. At least 100 “Kegel`s” should be done every day. The best way to isolate these muscles and know if you are Kegel`s correctly is to stop the flow of urine midstream when on the toilet. Kegel exercises help tone the pelvic floor, prevent formation of hemorrhoids, prevent incontinence, and keep the muscles from tearing during childbirth.
Upper Body Strengthening
FIGURE 14
Stand about 2 feet from the wall and place your hands on the wall, shoulder height (Figure 14). Bend your elbows out to the side and bring your chest towards the wall, keeping your back straight. Exhale and push up, away from the wall. Upper body strengthening can also be done using rubber tubing or with very light weights (under 5 pounds). Weights should not be lifted overhead during pregnancy.
Upper body strength will be needed after the birth to hold, breast feed, and carry the baby, as well as the car seat, diaper bag, toys, etc.
Stand about 2 feet from the wall and place your hands on the wall, shoulder height (Figure 14). Bend your elbows out to the side and bring your chest towards the wall, keeping your back straight. Exhale and push up, away from the wall. Upper body strengthening can also be done using rubber tubing or with very light weights (under 5 pounds). Weights should not be lifted overhead during pregnancy.
Upper body strength will be needed after the birth to hold, breast feed, and carry the baby, as well as the car seat, diaper bag, toys, etc.
Abdominal Strengthening
FIGURE 15 FIGURE 16
Sit cross-legged on the floor, or up on a pillow; put one hand on the belly and the other on the small of the back On an inhale, expand the belly and on the exhale, bring the navel towards their spine, stopping at a point halfway between the belly button and spine – this is the starting position. From here, squeeze the navel further back towards their spine and then return to the starting position. This is one repetition. This should be repeated 100 times per day (Figure 15).
Standing crunches may also be done to strengthen the abdominals. Stand with the feet under the hips, toes pointed forward and knees slightly bent. One hand is placed on the stomach, the other on the buttocks. On an exhale, squeeze the stomach muscles while at the same time tucking in the buttocks. Inhale and release. Use a mirror to make sure the back flattens as you squeeze in the stomach (Figure 16).
Strong transverse and rectus abdominal muscles help support the lower back and prevent it from straining; they are also needed during the pushing stage of labor. Keeping the abdominal muscles strong will also help women’s stomach to return to normal after giving birth.
Lunge Stretch
FIGURE 17a and FIGURE 17b
Start on hands and knees. Bring your left foot up by your left hand by walking it forward until the knee is over the ankle. Lean forward until you feel the stretch in the front part of your right thigh. You may need to put your left hand on your left thigh to accommodate your belly. Tuck the tailbone under to increase the stretch (Figure 17a). If you are stable and would like to increase the stretch, bring both hands onto the left thigh (Figure 17b). If your hips rise when you do this, go back to the first stage. Hold for 30 seconds.
Lunges that are held stretch out a very deep muscle called the psoas muscle. When this muscle is tight it will pull on the bones in the lower back. This tension may lead to low back pain.
In general, gentle stretching keeps the muscles loose and limber, agile, and helps with pushing during delivery. Stretches should be held for 10 to 30 counts, or seconds, and you should breathe deeply in order to help relax the muscles. Never bounce or force a stretch.
All pregnant women should avoid any contact sports, scuba diving, and horseback riding, skydiving, and any exercise which requires bouncy movements, deep flexion and extension or rapid changes in direction, no matter what their fitness level. Gymnastics, high impact aerobics, weight lifting, snow and water-skiing, soccer, and long-distance running are also not recommended.
A final element of the exercise program should be relaxation and breathing! Time should be taken at the end of any exercise routine to relax and breath deeply. It will be important during delivery to let their body relax, so that the labor can progress and birthing can be facilitated. Pregnant women should put on some relaxing music, lie down on their side or in a supported position, breathe, and visualize a wonderful birth!
Christine Anderson, D.C., D.I.C.C.P., DiHom developed the pre/post-natal exercise program at the Hollywood YMCA and has been a fitness instructor for over 23 years. She has recently released the DVD entitled Dr. Christine Anderson’s Dynamic Pre Natal Yoga.
To purchase this 90 minute DVD go to http://www.customflix.com/208071 or go to the home page and click on the DVD icon in the top left corner.
References
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