Pregnancy Course Manual-1

P I L A T E S A N D P R E G N A N C Y

N E T W O R K

P I L A T E S

Table of Contents Acknowledgements

2

Chapter 1: Introduction

3

Course Aims and Objectives

5

Chapter 2: Overview of the Principles

7

Principle of Concentration

7

Principle of Breathing

10

Principle of Alignment

13

Principle of Centring

15

Other principles of Pilates

17

Pilates Principles & Pregnancy

19

Chapter 3: The Benefits of Exercising

20

Chapter 4: Changes that Occur during Pregnancy

23

Chapter 5: Important areas of consideration

31

Chapter 6: Pre Natal Problems & Exercise Implications

38

Chapter 7: Exercise Modifications

45

Chapter 8:

49

Guidelines

Chapter 9: Post Natal Exercise

52

Chapter 10: Pregnancy Screening

61

Exercises

63

Appendixes

98

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Acknowledgements The following people are acknowledged for their contribution towards the development of the Pilates and Pregnancy Course.

Lisa Westlake B App Sci Physio Lisa combines physiotherapy and fitness to provide exercise programs for fitness, wellness, prevention and rehabilitation. She has over 10 years experience in teaching pre and post natal exercises programs. Lisa is the developer of the Australian fitball program, has produced 6 fitball DVDs and her first book has sold over 100,000 copies. She was awarded Australian Fitness Professional of the year in 2000 and Presenter of the year in 2003. She is a popular presenter and spreads the health and fitness message through her regular Saturday talk back segment on ABC radio.

Claire Norgate, MEd Claire has spent the last 25 years studying health and wellness and is integral part of the Network Pilates training team. Claire is a qualified mid wife with a range of broad academic pursuits combined with extensive practical experience in the fitness industry in both group fitness and personal training make her an ideal educator for fitness instructors.

Zosha Piotrowski, BSpSc Zosha is an international instructor trainer and convention presenter. She is involved in developing instructors and talent in freestyle group exercise and is the key program developer for Network Pilates. Zosha is also the co-host of Pilates TV on Foxtel’s Lifestyle Channel.

Liz Dene, BHMS Liz is the former Education Program Manager for Australian Fitness Network and is actively involved in developing training courses. She has over 15 years industry experience as a trainer and group exercise instructor with expertise in fitness testing, nutrition, Pilates, pregnancy and exercise. She merges traditional fitness practices with a holistic approach to well being.

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Chapter 1 Introduction Welcome to the Network Pilates and Pregnancy course. The Network team is excited to provide you with the latest knowledge about pregnancy and Pilates, and, congratulates you on your interest in ongoing learning and development. Our goal is to help you become an exceptional Pilates instructor by providing you with the knowledge and skills necessary to teach Pilates to Pregnant women. In order to become successful at teaching Pilates to Pregnant women it is necessary to have attained competency in the Fundamental mat course objectives. Being successful will include both the ability to perform the fundamental exercises and to teach groups. Competency will be demonstrated by successfully completing both the theoretical and practical components of the Fundamental mat course. An understanding of, and an ability to apply the Fundamental objectives, is therefore needed before progressing to working with pregnant women. They are:

The objectives of the Fundamental mat: •

List the benefits of regular Pilates practice.

•

Explain the application of the Pilates Principles.

•

Demonstrate each level of the Fundamental exercises with good physical execution.

•

Classify the exercises according to their strength/stability/mobility focus.

•

Design a safe and effective class (including the warm up and cool down) that correctly acknowledges exercise selection, sequencing and repetitions.

•

Demonstrate and correctly describe lateral thoracic breathing.

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•

Give clear instructions using a variety of imagery, visual and technical commands.

•

Correct the alignment of participants with both verbal and physical feedback.

Pregnancy and Pilates Working with pregnant women can be very rewarding. It can give you the opportunity to support an exciting and infrequent event in a woman’s life. Sensible exercise during the childbearing year provides numerous physical and psychological benefits and as a fitness leader, it is our responsibility to guide our client’s, and lead our classes as safely and effectively as possible.

It is vital, however, that pre and postnatal exercise selection is the appropriate intensity and style to suit each women and does not compromise the wellbeing of the baby.

Low

impact

exercise

with

a

focus

on

movement

awareness, form, core stability, mobility and combined local and global strength is the ideal approach for prenatal exercise, thus Pilates is a perfect option for pregnant women and new mothers.

Not all Pilates exercises however, are appropriate during pregnancy, so a sound understanding of safe exercise prescription during pregnancy is required before designing prenatal and postnatal Pilates programs.

As well, because every pregnancy is different, exercises must be individualised to suit each pregnant woman. Furthermore, pregnancy is not a static process, it involves stages or trimesters that require specific modifications for each stage. Thus, a variety of options and modifications are necessary to cater safely and

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effectively for each woman according to her stage of pregnancy, health and ability. Unfortunately, some women experience certain pregnancy-associated problems. Moreover, with the average age of pregnancy increasing, more women are experiencing these heath issues. These conditions, which range from minor to serious, can further influence exercise selection.

This course aims to fine tune your skills in programming for ‘fit and well’ pregnant women and help you understand some of the limitations that can occur and their implications on exercise prescription.

Although the fitness professionals’ role is to guide pregnant women and new mums in appropriate exercise selection and technique of exercise execution fitness leaders are not trained to assess, diagnose or treat pregnancy associated problems. Therefore, any women with an undiagnosed issue must be referred to her obstetrician or treating doctor.

Course aims: •

Review the Pilates principles

•

Apply the Pilates principles to the pregnant exerciser

•

Prescribe Pilates based exercises for the fit and well pregnant woman

•

Understand the changes that occur during the childbearing year

•

Apply this knowledge to safely program the pregnant client or provide modifications to suit your pregnant class participant

•

Prescribe Pilates based exercises for the postnatal woman

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Course Objectives: At the end of this course, it is expected that each participant will be able to: •

Describe the physiological and psychological changes of pregnancy

•

Outline the stages of pregnancy

•

List the benefits of exercise during pregnancy

•

List the conditions that preclude a pregnant women from exercising

•

Describe the importance of screening and modifying exercises for the different stages of pregnancy

•

Reinforce the importance of stabilising the body in neutral alignment

•

Develop a suitable Pilates based program for a pregnant women in each trimester

•

List the specific exercise contraindications for each trimester

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Chapter 2 Overview of the Principle of Concentration: Apart from some reflexes, the central nervous system (CNS) controls all movement in the body. Although most of this control occurs at an unconscious level, we can learn healthy movement patterns and retrain inefficient patterns by

applying

our

conscious

awareness

to

control

movement. We can apply the principle of Concentration to: 1. Determine where we are statically 2. Explore how we become dynamic 3. Correct faulty alignment and muscle use 4. Create healthy movement patterns that use correct muscle sequencing. The CNS creates specific programmed neuromuscular sequences for each movement pattern we perform. The more frequently we perform a move the more ingrained the pattern becomes. The CNS is very resourceful and when needed will automatically avoid any barriers such as pain and muscle weakness. Alternative muscle use then occurs, leading to the development of a compensatory movement pattern. Because muscle movement is under our voluntary muscular control, poor patterns can be retrained and efficient movement patterns developed. Application to exercise prescription: Three distinct phases of learning occur when learning a new movement pattern or motor skill. They are the cognitive phase, the associative phase

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and the autonomous phase. We progress and circle through these phases as we move towards mastery of the skill. 1. A beginner exerciser will be in the cognitive phase. This is the stage where movement is first learnt. In the cognitive phase, the brain analyses and interprets the command. It then directs the activity, ensuring a correct starting position, movement phase and finishing position. In the cognitive stage, the movement is broken into parts and performed slowly and deliberately. In the early phase of cognitive learning, there is usually a high error rate that needs corrective feedback from an outside source. For

example,

when

learning

the

hundred the participant needs to first of all learn neutral and imprint when lying supine. After they have mastered both pelvic placement and muscle control lying supine a single bent knee lift is added. By progressing slowly, each stage is understood both mentally and physically. This will permit the learner to become able to self correct and enter the associative phase.

The pregnant woman’s body undergoes many changes, and familiar exercises often require extra concentration as the body softens in response to the hormone relaxin. 2. In the associative phase, the learner has started to get a “feel’ for the movement. There will be less errors and the learner can sometimes identify and correct their own mistakes. The movement can be performed at a quicker pace than in the cognitive phase.

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3. In the autonomous stage, there will be a level of mastery of the skill. The error rate will be significantly less. The muscles respond automatically without cognitive processing. The skill can be performed quickly and efficiently. Teaching to Pregnant groups: •

Teaching Pilates to pregnant groups requires the teacher to give information to the class clearly, specifically and in a layered manner.

•

At all levels, the instructor teaches the class the principles behind each move. This will enhance the participant’s body awareness and understanding of the move.

•

Most classes we teach will have a mix of participants, some experienced pregnant participants and some still at fundamental level. Therefore, the exercises should always be taught from easier levels and the progressions layered as able.

Giving a large amount of information can lead to sensory overload and the brain will be unable to distinguish between all the messages given. Exercise progression recommended to avoid CNS overload. •

Slow to Fast

•

Known to Unknown

•

Stable Controlled to Dynamic Functional

•

Low Force to High Force

•

Correct Execution before Increased Intensity

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The Principle of Breathing: Efficient breathing enhances energy and well-being. Lateral Thoracic (Pilates)

breathing

is

breathing

directing the air to the bottom of the lungs

whist

abdominal

maintaining

wall

activation.

slight This

technique encourages efficient oxygen exchange whilst also providing essential lumbar- pelvic- hip stability. Common breathing faults •

Fast, shallow breathing (mild hyperventilation) - anxiety

•

No or very short expiratory pause – common in asthmatics, anxiety

•

Reverse breathing

•

Upper chest breathing – common in asthmatics, emphysema

During inhalation, the diaphragm and external intercostals contract to draw in air. When breathing well (not shallow or fast) the contraction of the diaphragm can act as a stabilising mechanism of the corset. The diaphragm provides a seal over the top of the lumbar-pelvic-hip complex. During exhalation in normal quiet breathing the air is released via the elastic recoil of the lungs with the air moving from higher pressure to lower pressure. Therefore, in passive exhalation there is no need for muscular strength. In forced or active exhalation however, the abdominal muscles are used to contract and press the abdominal organs upwards. The diaphragm relaxes but the stability now comes

form

the

abdominals.

This

increases stability of the lumbar-pelvic-hip complex.

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Therefore, the stability of the lumbar pelvic hip region is produced by a combination of factors that are influenced by breathing. Breathing is a movement pattern and learning to breathe correctly can take time. Learning the movement pattern of breathing and the movement pattern of a corrective exercise together can be difficult. The SCM, scalenes, trapezius and pectoralis minor muscle group may assist inspiration especially when upper chest breathing is performed. If these muscles are over used, overactive and painful neck/shoulder muscles will often result. Application to pregnant women classes: •

Assess the groups/individuals breathing patterns

•

Be aware that pregnant women may have difficulty coordinating their breath with the movements

•

As women progress through pregnancy their ability to breathe deeply may decrease as the uterus pushes into the thoracic cavity

•

Spend time focusing on the breath in each move, reduce range of movements as breath shortens

•

Watch muscle recruitment. Stretch overactive neck and shoulder muscles

•

Mobilise the thoracic spine and ribcage using stretching and active breathing exercises

•

Teach the class to monitor their breath length

Exercises to explore Lateral Thoracic Breathing 1. Place a book or lightweight on the abdomen and upper chest (when lying supine) and middle back (when lying prone) to feel how much movement is occurring (prior to 16 weeks). 2. Sit on heels and draw a towel around lower ribcage. Hold the ends of the towel in front of your body to create resistance for the breath. Breathe in and attempt to press ribcage into towel. As you breathe out gently narrow ribcage.

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Breathing is a movement pattern and learning to breathe correctly can take time. Retrain old patterns slowly. Remember that anxiety and stress also influence breathing patterns.

____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________

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Principle of Alignment: Alignment and posture both refer to the specific position of our bones and joints. Alignment of all the joints in neutral is emphasised prior to movement. When a joint is neutral, the force created by all the components of the kinetic chain is transferred through the centre of each joint thus maintaining the joints’ integrity. This proper postural alignment provides optimal structural efficiency that in turn allows optimal functional efficiency of the kinetic chain. This means that correct or ideal posture, positions the body for efficient movement patterns in all planes of motion. When performing Pilates exercises particular attention is given to: 1. The pelvis - Neutral placement (ASIS in line with pubic bone when lying, ASIS horizontal with PSIS for males and slightly anterior for females) 2. Ribcage – The lower ribs should rest on the floor and the anterior ribcage should not “pop” when lying supine. 3. Scapulae – Shoulder blades lie smoothly against ribcage, gliding across when moving. Not winging or protracted when in neutral. 4. Head and neck – Neutral alignment, not tilted or forward placed. Application to Pregnancy: A prime focus at fundamental level is to gain an awareness of what constitutes good posture and develop stability when in neutral alignment. The participant will learn what exercises challenge them and why. We do not focus on flexibility at fundamental level because the participant with low stability may be at risk of joint injury if we develop their flexibility prior to Pilates & Pregnancy © 2007 V3 22.02.07

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developing joint stability and awareness. As well, as the pregnant woman is vulnerable to instability, stretching exercises should be given gently and only to woman who are not hypermobile in their joints. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

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The Principle of Centring: Centring is taking our awareness to the soft tissue system of our trunk and deliberately activating our stabilisers prior to movement. Effective stabilisation produces optimal alignment as we move our bodies from a static to a dynamic state. This in turn permits optimal transfer of energy through the entire kinetic chain.

Although all muscles contribute to movement and stabilisation they can be divided into those that primarily STABILISE called LOCAL MUSCLES and those whose primary task is to provide MOVEMENT called GLOBAL MUSCLES

The stabilising muscles are needed to hold a joint in neutral, leave neutral safely to provide movement, and return to neutral at the end of a movement pattern. Therefore, centring (aligning in neutral and activating stabilisers) of the lumbar-pelvic-hip corset is performed prior to any movement that is prescribed. The corset muscles (local muscles) stabilise the lumbar-pelvic-hip complex: •

Diaphragm

•

Multifidus

•

Internal Oblique

•

Transversus

•

Pelvic Floor

Abdominis

Stabilising muscles work at all joints of the body. Therefore, all the joints to be used need to be aligned and stabilising muscles activated prior to movement.

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The scapula stabilises (local muscles) include: Rhomboids

•

Rhomboids

•

Pectoralis Minor

•

Serratus Anterior

•

Lower trapezius

Serratus Anterior

Pectoralis Minor

Lower Trapezius

These four muscles work together to provide stability of the scapula. Many other muscles also attach to the scapulae. They use it as an anchor and insert in the shoulders, arms, and head/neck to provide movement. The scapula position therefore needs to be strong and stable for efficient movement patterns to occur. Application to teaching pregnant women: •

Constantly assess core stabilisation of your participants

•

Progressively teach level. Start with lower fundamental levels and progress to higher levels in stages

•

Teach your participants to self assess and to regress exercises when stabilisation is compromised

•

Assess lumbar – pelvic – hip alignment in static and dynamic state, use the warm up to assess dynamic control of pelvis

•

Assess scapula movement and control, look for winging scapula

•

Anticipate that some pregnant women may regress as their pregnancy progresses

•

If abdominals feel stretched in an exercise regress immediately

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Core Stabilisation is initially performed in a static state. Static stabilisation needs to be assessed prior to prescribing multi-joint stability exercises. Assess scapula and shoulder stability prior to loading the upper body, good stability is required before progression to intermediate levels.

All movement is initiated from the centre and the stronger the centre, the stronger the levers can be. Activate core musculature prior to any limb movement.

Other Principles of Pilates: Control - Conscious control of movement enhances body awareness and develops effective movement patterns. Movements performed without control often lead to faulty patterns of muscle recruitment. Smooth fluid movements reflect healthy movement patterns.

Precision - Movements must be performed as accurately as possible. Precision is needed for correct muscle sequencing and skeletal alignment to occur.

Isolation - Stabilising muscles often need to be trained in isolation prior to being used in a movement pattern. Proper functioning of the stabilisation muscle group is essential to prevent injury in movement patterns.

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Flowing Movement – Pilates movements are well coordinated without speed bumps, appreciating the dynamic state of movement without a specific beginning or end. Routine - Pilates understood the principles of frequency and progressive overload. He demanded regular practice of gradually more demanding exercises to give a training effect. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

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Pilates Principles and Pregnancy: The principles of Pilates provide a system or framework that can be used to guide movement. When the principles are applied, healthy movement patterns will be more likely. This will result in the exercises being performed safely. This is extremely important for pregnant women where the challenge of any exercise is increased. Pilates is a body-conditioning programme designed to teach efficient movement patterns and provide general well being using controlled exercises and deliberate breathing patterns. Teaching the principles of healthy movement rather than just teaching exercises is always going to give better results. Giving the pregnant exerciser more understanding of how to move their body in a safe and effective way empowers their exercising. Therefore, the more thoroughly the

principles

are

explained

when

teaching

the

movements, the more quickly the benefits will be gained. There are several variations of Pilates principles. They collectively provide a good framework for analysing and teaching movement. They incorporate an understanding of current fitness knowledge, anatomy and biomechanics.

The Principles: • Concentration

• Control

• Breathing

• Precision

• Alignment

• Integration

• Centring

• Flowing

• Isolation

movement • Routine

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Chapter 3 The Benefits of Exercising During the Child Bearing Year Pregnancy is an exciting time, involving many physical, emotional and social changes. Appropriate exercise provides many physical and psychological benefits.

Sensible exercise selection, during the childbearing year assists: •

Maintenance of general fitness and health

•

Maintenance of healthy body weight

•

Maintenance of strength during pregnancy

•

Awareness of body, posture and changes that are occurring over time

•

Progression of pregnancy

•

Mood, morale and self esteem

•

Prevention of potential problems that can be associated with pregnancy

•

Preparation for labour and early motherhood

•

Recovery after labour

•

Return to pre-pregnant weight and body shape

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Why Pilates? Pilates exercises emphasise a strong core, functional mobility, controlled breathing and postural awareness. These elements when combined with the principles of Pilates provide a helpful foundation for assessing pregnant women’s musculoskeletal status and prescribing appropriate exercises. Pilates is also an ideal exercise selection for post-natal women because it is low impact with a focus on postural alignment, core stability, movement awareness and more. Pilates provides many pre and post natal exercise requirements including: •

Low impact

•

Low intensity

•

Focus on centring

•

Postural awareness

•

Mind body awareness and connection

•

Core stability

•

Harmony of local and global conditioning

•

Mobility and flexibility

•

Extra focus on important areas such as deep abdominals, spine, and pelvic floor

•

Focus on breath

•

Relaxation

Understanding the changes, special needs and limitations during the childbearing year is needed to determine which exercises are suitable. This allows safe and effective program design.

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This course will help you understand the changes that occur during the childbearing year and enable you to apply this knowledge to safely program for your pregnant client or provide modifications to suit your pregnant class participant.

Remember every pregnancy is different so ongoing assessment and modifications are important. A recipe approach is not appropriate or safe.

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Chapter 4 Changes That Occur During Pregnancy Understanding the changes that occur as the pregnancy progresses is the key to appropriate exercise programming at any stage of the childbearing year.

Pre-Pregnancy Considerations Many women know when they are planning or hoping to become pregnant and may fall pregnant immediately or take months or even years. If a women does not become pregnant she and her partner may choose to seek assistance which may involve tests and various levels of assistance including IVF.

Sensible nutrition, exercise and rest / sleep are all important during this important time. While women generally continue their regular exercise levels in this pre pregnancy period, it is not the ideal time for excessive, high intensity programs.

The early weeks, when women often do not know they are pregnant, are important. Whilst a women may not know she is pregnant, she will probably know she ‘could be pregnant’ and should be advised to avoid high levels of exercise in the interest of maintaining the early pregnancy and healthy early organ development.

Pregnancy A human pregnancy (gestation) lasts for approximately 40 weeks, with 38 42 weeks being considered normal. Pregnancy is divided into three trimesters: •

First Trimester 1-14 weeks

•

Second Trimester 15 - 27 weeks

•

Third Trimester 28 weeks - delivery

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Even though a foetus is constantly growing, the trimesters are used to represent stages of foetal growth and maternal changes. Each trimester has unique associated exercise implications.

The “Due date” or baby’s birth date is calculated as 40 weeks from the first day of the last menstrual period. This approximate date may be modified as the pregnancy progresses. Often, an ultra sound is used to determine measurements of the baby’s bone length, abdominal circumference, head size and organ size to more accurately determine foetal age.

It is recommended that a pregnant woman visits an obstetrician, hospital pregnancy clinic, a birthing centre, midwife or GP early in their pregnancy, to have regular check ups of their general health and their baby’s development.

Special attention is given to abdominal growth (uterus), blood pressure, urine testing and weight gain. These checks are usually at 4 week intervals between conception and 28 weeks, 2 week intervals from 28 weeks to 36 weeks and weekly until the birth.

If a baby is overdue, the doctor or clinic may see the mother more frequently than once a week. If there are any special circumstances the pregnant woman is monitored more closely and may even be hospitalised in a maternity antenatal ward. Pilates & Pregnancy © 2007 V3 22.02.07

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How does a pregnant woman feel? GENERAL CHANGES DURING PREGNANCY CTABLE HANGES THAT OCCIMPLICATIONS SYSTEM CHANGE IMPLICATION Increased blood volume, cardiac Body is already CARDIOVASCULAR output and resting HR “exercising” state

RESPIRATORY

HORMONAL

WEIGHT GAIN

POSTURAL CHANGE

ABDOMINALS

in

a

Increased minute volume, and As above, oxygen uptake Increased chance of SOB in Altered shape of rib cage third trimester Decreased thoracic space during late pregnancy. Physical and psychological changes. Relaxin affects joints, blood vessels, ligaments. Forgetful, mood swings

Joint laxity increased. Increased tendency for varicose veins Gastric implications including reflux Possible decreased concentration

Increased stress on joints, Less space for other organs, Impedance to venous return, Extra stress on supporting structures

Joints require extra care Reflux may cause certain positions to be uncomfortable Increased risk of fainting with stationary standing. Lying supine is inappropriate due to decreased placental blood flow Increased weight anteriorly Lower back and posture creates changes in balance and require extra attention. posture and thus places further loading on some joints

Stretched and weakened Modify abdominal exercises followed by altered mechanics to avoid separation and Risk of separation always include appropriate deep abdominal conditioning

PELVIC FLOOR

Stretched and weakened leading to potential loss of bladder and bowel control (short and long term). EMOTIONAL AND A wide range and degree of PSYCHOLOGICAL emotional changes can exist involving mood, feelings of apprehension about labour, life change etc, body image.

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Avoid stressing pelvic floor and always include PF training

Consider the overall picture when working with pre and postnatal women. Include encouragement and support and avoid complex moves or explanations

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The Placenta: •

Supplies nutrients

•

Removes waste

•

Produces hormones to maintain pregnancy

•

Screens against harmful agents in the mothers blood

•

Implants in the wall of the uterus, ideally away from the cervix

Placenta Praevia is when the placenta implants close to, or over, the cervix. If the placenta remains over the cervix in the third trimester the baby will be delivered via caesarian section.

The First Trimester Organ development and risk of miscarriage are the main reasons for modifying exercise levels during the first trimester. Day 7

Embryo is implanted

Day 22

Spinal Cord development

Week 3

Placenta begins to develop

Week 5-6

Brain development begins.

Week 6-7

Eyes developing

Week 7-8

Muscles developing

Week 10

Skeleton formed but skull still developing

Week 11

Heart functions. Brain apparent

Week 12-13

Toes and fingers

Foetus is about 8 mm

Nerves in place and major blood vessels functioning Week13–14

Placenta issues hormones, supplying nutrients and removing waste. Baby 85 mm long.

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Main Considerations in First trimester •

Early miscarriage

•

Organ development / Core temperature

•

Fatigue

•

“Morning sickness”

•

Hormones “kicking in”

•

Constipation

•

Desire or need to keep pregnancy secret

•

May be working, dressing and exercising as though not pregnant

The Second Trimester 14 – 16 weeks

First foetal movements felt

16 – 17 weeks

Able to identify sex via ultrasound

17- 18 weeks

Audible heart beat

22 weeks

Eye almost complete, baby 27 cm long

24 weeks

Responds to sounds

28 weeks

Able to survive with significant medical intervention

Main Considerations in Second trimester •

Altered body shape as baby grows beyond pelvis

•

Forward Centre of gravity

•

Altered posture and Increased load possible back or neck pain

•

Relaxin increases joint vulnerability (NB Pelvic joints)

•

Indigestion, reflux, constipation

•

Altered mechanics of abdominals

•

Stretching of RA and Pelvic Floor

•

Risk of supine hypotension

•

Acknowledging baby and preparing nursery

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The Third Trimester Week 30

Baby about 33 cm

Week 32

Organs begin maturing

Week 36

Kidneys maturing

Week 38

Lungs maturing

The third trimester is a major time of growth for the baby. During this time the mother may experience various emotional responses from excitement

to

anxiety.

Leaving

work,

preparing for delivery and baby and planning for labour and early motherhood all may stress the expectant mother.

Main considerations in third trimester •

Fatigue

•

Further altered COG affecting posture and balance

•

Further weight gain and load on legs, back, pelvis and vascular system

•

Potential fluid retention

•

Respiratory changes

•

Possible rib splaying

•

Baby engages, decreased stress on thorax

•

Increased load on bladder, perineum and Pelvic floor

•

Pelvic joints

•

Consider risk of early labour

Other Changes to be considered: •

Core temperature

•

Posture

•

Breasts

•

Uterus

•

Pelvic floor

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•

Abdominals

•

Pelvic joints

•

Digestive system

•

Frequency of urination

•

Rib cage and thoracic joints

•

Feet

•

Fluid retention

•

Blood volume

•

Blood vessels

•

Stroke Volume and CO

•

Heart rate

•

Supine hypotension

•

Postural hypotension

The Hormones in Pregnancy: Oestrogen •

Promotes growth

•

Increases elastic properties and contractility of uterus

•

Influences breast changes

Progesterone •

Relaxes smooth muscles

•

Important in maintenance of pregnancy

Prolactin •

Promotes milk production

Oxytocin •

Stimulates uterine contractions

•

Promotes milk ejection

Adrenalin, Noradrenalin, Cortisone and Endorphins •

Heightens various body responses

•

Alters mood

•

Relieves pain

•

Can be stimulated by exercise

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Thyroid Hormones •

Essential for growth of skeleton and brain

Insulin •

Regulates blood glucose

•

Control of foetal growth

•

NB Gestational diabetes

Relaxin •

Present from 2 weeks pregnant to weeks or months after delivery

•

Relaxes ligaments and any fibrous tissues in body

•

Joints vulnerable

•

Back, pelvis and other weight-bearing joints particularly at risk

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Chapter 5 Important areas for consideration Posture and back health in pregnancy Natural spinal curvature and spinal stabilisation are challenged as the pregnancy progresses leading to a pregnant woman being vulnerable to lower back ache and other associated problems.

Altered mechanics results in: •

Shift of centre of gravity (COG) forward in second and third trimesters

•

Stretched and weakened abdominals

•

Altered mechanics of outer abdominals

•

Weakened quadriceps

•

Anterior pelvic tilt

•

Increased lumbar lordosis

•

Thoracic kyphosis

•

Cervical lordosis / Forward chin

•

Compromised posture and stability

•

Potential pain and injury

Lumbar Stabilisation Spinal and pelvic stabilisation deserve extra focus during the childbearing year as they are vital for injury prevention and assisting in post natal recovery.

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Panjabi (1992) introduced a model of spinal stabilisation that demonstrates the connection between the passive structures of the bony system and the active components of the muscular system. •

Passive stabilising subsystem

•

Active stabilising subsystem

•

Neural stabilising sub system

This model recognizes the need for neural control of the muscular system and the potential variability of the articular

structures.

All

can

compensate, to some degree for each other.

During pregnancy, spinal stabilisation can be compromised due to: •

Altered COG

•

Increased load /stretch >> to weakening of important muscle groups

Abdominal Muscles and Pregnancy Outer abdominal muscles are stretched as the baby develops leading to: •

Abdominal weakness

•

Potential for back pain

•

Altered mechanics > curls longer effective

•

Any strain on RA is inappropriate especially after 16 weeks

•

Tendency for Rectus Diastasis (separation of RA)

Rectus Diastasis •

Separation of Rectus Abdominus (RA) at some point along the linear alba, (fibrous sheath that lies between the RA)

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•

Excessive RA work will increase the risk and amount of separation

•

Leads to decreased muscular support to spine and abdominal contents

Test for diastasis: lie in supine position, knees bent, palpate along midline whilst raising head and shoulders. Feel for gap or bulge.

Loaded supine abdominal work is also inappropriate due to risk of supine hypotension, back pain and separation. It is however, important to recruit outer abdominals to “remind them that they exist”.

Altered abdominal

mechanics means abdominal curls and similar abdominal work is not effective. Replace these with exercises that focus on posture, deep abdominals and other stabilising muscles, but beware of plank style options as they may over load the spine and lumbar or thoracic stabilisers. Ideal exercises include: •

Recruitment of deep abdominals and Pelvic floor

•

Four point kneel “Swim”

•

Four point kneel spinal flexion with emphasis on RA

•

Sitting on fitball + arm and leg movements

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The Pregnant Pelvis The pelvis is a bony basin made up of the ilium, pubic bones and the sacrum •

The pubic symphysis is the anterior joint

•

The sacroiliac joints are the posterior joints

•

These joints are relatively stable in non pregnant population

•

The developing foetus is within the pelvic rim until approx 14 weeks

Sacro-iliac joints •

Posterior joints between sacrum and ilium

•

Diarthrodial joint, synovial fluid with matching surfaces

•

Fibrocartilage on iliac surface, Hyaline cartilage on sacral surface

•

Ligamentous support , especially the Interosseos ligament

•

However this ligamentous support is compromised by relaxin

SIJ Stability •

Form Closure is created by wedge shape of joint and irregularities in joint surfaces

•

Force closure Compression generated by muscles and ligaments

•

Muscular support to SIJ provided by pelvic slings (Vleeming et al 1995)

The pelvic joints are particularly vulnerable to instability during pregnancy due to load and hormonal changes. It is essential to recognise pelvic instability and be aware that certain exercises can assist or aggravate.

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Pregnancy related pelvic pain SIJ and PS pain and instability is determined by objective and subjective assessment of symptoms, location of pain and certain tests.

Movement at these joints leads to inflammation and pain. Symptoms range from mild and intermittent to being unable to walk without aid. Severe cases report feelings of joint movement and significant pain and movement limitation.

Pain may be local or referred. Severity of symptoms and

prognosis is related to degree of asymmetry between SIJ’s.

It is important to recommend referral before continuing exercise as inappropriate programming will exacerbate the problem.

Aggravating factors •

Prolonged standing

•

Rotation

•

Unilateral weight bearing

•

Weight transfer

•

Wide stance

Examples: long walks, stairs, working in a shop, rolling over in bed, getting in and out of a car.

Exercise programming must be planned carefully to avoid causing or aggravating this relatively common problem.

The Pelvic Floor These group of muscles line the floor of the pelvis and support to its

contents,

bladder,

including

uterus

bowel,

and

the

developing baby.

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The pelvic floor muscles include: Levator Ani Coccygeus

A group of muscles forms the Levator Ani. The Pubococcygeus and the Iliococcygeus are most prominent. Other muscles supporting the perineal openings include the Puborectalis and Ischiococcygeus.

Role of the pelvic floor (PF) •

Supports the pelvic organs

•

Assists increase in IAP

•

Assists urinary and faecal continence

•

Assists spinal stabilisation

Pelvic floor integrity is compromised when the PF is weakened or stretched via •

Load on PF

•

Bounce / jolt

•

Strain

The pelvic floor must take high priority with regular inclusion of PF regimes.

Consequence of compromised PF •

Decreased support to pelvic contents

•

Incontinence: short and long term

•

Decreased role in lumbar stabilisation

Exercise considerations •

No jolt, no bounce (more than low impact)

•

No strain

•

Lumbar stability is compromised

•

Continence: Short and long term

•

Post natal return to exercise, exercise selection

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Life style considerations •

Coughing

•

Lifting

•

Toilet

•

Standing

PF Exercises: When what and how? •

Endurance and strength

•

In all positions

•

Technique

•

Long holds

•

Short lifts

•

Long hold with “pulse” at top

The Pelvic ligaments The Round ligament •

Connects the uterus to the pelvis anteriorly

•

May cramp with sudden movement

•

Felt as stabbing pain in L or R lower abdomen

The Broad ligament •

Connects the uterus to the sacrum

•

This may give a tight or dull pain in the lower back

Implications in program: •

Reassurance and treat symptomatically.

•

Refer

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CHAPTER 6 Pre Natal Problems & Exercise Implications Mild, common and requiring modification Morning sickness •

Nausea and possible vomiting caused by hormonal changes

•

Sometimes but not always in the morning

•

May last first trimester or throughout pregnancy

Exercise Implication •

Has she been able to eat and drink prior to exercising?

•

If not > high risk of hypoglycaemia

•

May need to avoid or alter time of exercising

Gastric reflux, indigestion •

Relaxin effects smooth muscle and sphincter control

•

Increased abdominal pressure as baby grows

Exercise Implication Modify horizontal positions

Carpel tunnel syndrome Increased extra cellular fluid leads to pressure under the carpal tunnel, leading to constriction to the nerves and vessels passing through the carpal tunnel. This can lead to pain, altered sensation and weakness in the had and or forearm

Exercise Implication •

May be uncomfortable or unsafe to hold weights or other equipment

•

Use alternative positioning to weight-bearing through extended wrists

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Varicose Veins •

Vein walls compromised and taking extra load due to increased blood flow

•

Load further increased in later months due to increased weight and pressure from uterus and baby thus challenging standing venous return

•

Mum more vulnerable to pain and VV aggravation when standing still

•

Varicose veins can be located in the legs, anus or vulva.

Exercise Implication •

Avoid prolonged stationary standing

•

Use muscle pump

•

Consider aqua exercise

•

Support wear

•

Avoid leg crossing, tight constricting socks / clothing

•

May need to sit rather than stand

Mild Backache Low back pain during pregnancy is usually a result of increased load, compromised posture and ineffective spinal stability.

Exercise Implication •

Avoid overloading spine, keeping in mind altered inner stability and outer abdominal mechanics and increased risk of pain or injury.

•

Emphasise postural correction and awareness

•

Emphasise Spinal stabilisation and core exercises +++

•

Incorporate pelvic tilt

•

Include Back strengthening, mobility and flexibility in programming

•

Refer for assessment and management

•

Alter to suit symptoms

•

4 point kneeling exercises are ideal

•

Included gentle mobility for relief and relaxation

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Foot pain Load, extra weight and hormonal changes can challenge foot stability and lead to flattening of arches which may be uncomfortable or may be noticed as altered foot size.

Exercise Implication •

Avoid prolonged stationary standing

•

Consider foot exercises (arch, proprioception, awareness)

•

Footwear

Mild Sacroiliac or Pubic Symphysis Discomfort Slight movement at these joints can cause inflammation and discomfort. Monitor very carefully for altered levels of discomfort and modify accordingly Jolting, wide stance, weight shift L/R and single leg weight bearing may all cause or aggravate pelvic instability so be sure to monitor clients carefully and avoid all the above if even an inkling of discomfort.

Exercise Implication •

Avoid standing, low impact or wide stance

•

Avoid any single leg weight bearing

•

Replace with narrow based, even-weight bearing options

•

Modify for pelvic rotation

•

Include Piriformis stretch

•

Include centring exercises

•

Include gluteals, adductors and lat work in programming

•

Emphasis role of stabilising group ( TA, multifidus, PF and diaphragm)

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Incontinence Control of bladder and bowel can be compromised during pregnancy, especially in late stages and after delivery, due to stress and load on pelvic floor or damage to sphincters.

Exercise Implication •

Include Pelvic floor exercises in all pregnancy programming

•

Avoid jolting, jarring , prolonged standing, straining and breath holding

•

Avoid terminology such as squeeze

•

Prevent gluteals recruitment by leaning forward if necessary

•

Include rest, PF exercises

•

Full strength PF is appropriate during pregnancy

Rib Cage / Thoracic Pain Towards the latter stages of pregnancy the rib cage tends to flare to allow for the growing baby. This places pressure on the costo-vertebral joints which can cause local pain at the joint sites or referred pain which fans out around the rib cage.

Exercise Implication •

Lateral reaches may assist in alleviating discomfort

•

Rotation may aggravate or assist

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Problems requiring extra guidance / modification Past history of premature labour Hormones release by exercise can also stimulate labour so mild to moderate exercise levels are most suitable. Regular monitoring by health care provider is important and good communication regarding any symptoms is vital between instructor and participant.

Exercise Implication •

Low level intensity during third trimester

History of vaginal bleeding If a women has vaginal bleeding she must seek assessment and she should refrain from exercising. Spotting during the first trimester is not uncommon but she should wait for medical clearance if this occurs.

History of miscarriage 1 in 4 pregnancies naturally terminate. If a woman has a history of two or more miscarriages she must have medical clearance form her doctor and any symptoms must be reported. She should wait until at least 12 weeks before exercising after clearance by her obstetrician (some women will be advised not to exercise if incompetent cervix is reason for miscarriage).

Hypo / hypertension It is not uncommon for pregnant women’s BP to vary but any new BP variations, or symptoms relating to high or low blood pressure must be assessed before exercise can commence.

Exercise Implication •

Monitor for symptoms and check BP if appropriate

•

Plan program carefully to avoid excessive postural changes

•

Change positions slowly

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Diabetes If a woman has existing diabetes she will need to adjust her management when pregnant and she should seek advice from her endocrinologist or GP upon becoming pregnant. Some women develop gestational diabetes during their pregnancy. This requires thorough assessment and she will need to learn how to manage her diet and exercise program.

The woman who is still learning to manage her diabetes is at risk when she first resumes exercise, as she may not be prepared for the improved glucose uptake that can be stimulated by exercise. She should recommence exercise very gently and be prepared for hypoglycaemia by understanding the symptoms and having juice or glucose immediately available.

Exercise Implication •

Educate

•

Monitor closely

Extremely over or under weight It may be inappropriate for an extremely thin mother to exercise at all. She should be medically assessed and foetal growth monitored. Watch for signs of fatigue and maintain levels for mobility and control with minimal energy consumption.

Exercise is desirable for overweight women, but it is vital to consider excessive load on joints and pelvic floor. Monitor her closely for signs of fatigue, overheating or high blood pressure. She may also feel more awkward and unbalanced than other clients

Exercise Implication •

Exercise level may need to lower

•

Modifications for physical difficulties may be required

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Low back pain Significant low back pain my require rest or a strictly modified exercise program. Refer and liaise with a physiotherapist with interest and experience in pregnancy.

Exercise Implication •

Include stability and postural focus

•

Modify any exercise that places strain on spinal control

•

Include exercises for mobility and relief such as on a fitball

Exercise contraindications A woman should stop or avoid exercising if she feels unwell, extremely tired, dizzy, headache, or has unexplained pain or discomfort. The following conditions would contraindicate exercise: •

Pre eclampsia

•

Incompetent cervix

•

Placenta praevia

•

Ruptured membranes

•

Intra uterine growth retardation

•

Venous or pulmonary thrombosis

•

Maternal heart disease

She should stop exercising if she experiences: •

Severe headache

•

Dizziness

•

Faintness

•

Hot and sweaty

•

Nausea

•

Vomiting

•

Sudden joint pain

•

Abdominal cramps

•

New back pain

•

Bleeding

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CHAPTER 7 Exercise Modifications in Pregnancy In Relation to the Developing Baby: Maternal Trauma Extreme exercise, or blows to the abdomen, may cause placenta abruption, foetal-maternal transfusion, early rupture of membranes, preterm delivery, foetal body injury. •

Avoid falls and blunt trauma to the maternal abdomen

•

Contact sports and those with high risks of falls should be avoided

Hyperthermia The developing foetus is dependent on mother for disposal of heat. The deliberate raise of core temperature in animals has been associated with increased risk of foetal malformations. Heart rate and rate of perceived exertion are used as guidelines for controlling exercise intensity •

Guideline for avoiding raise in core temperature > 38 deg C is the basis for recommending that vigorous exercise does not exceed 15 20 minutes

•

Water exercise should be performed in the appropriate temperature and spas and saunas should be avoided. (temp for aqua 30-32deg)

•

Accommodate for hot weather or environment

•

Ensure adequate hydration

Premature labour and reduced birth weight Some studies have shown an association between strenuous exercise and reduced birth weight. Low birth weight is the single most important risk factor for poor neonatal out come. Other studies show no association between risk of low weight baby and highly intense exercise. •

Exercise at mild to moderate intensity, 3 - 4 times per week

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Twin Pregnancy Considerations Whilst exercise prescription during a twin pregnancy may follow similar guidelines it is important to recognise the increased risks and areas for special care. The Royal College of Obstericians recommend that exercise for women with a multiple pregnancy should be individualised and under medical supervision.

First Trimester •

More likely to have nausea and hyperemesis

Second Trimester •

Uterus growing faster so vena cava syndrome may occur earlier

•

Increased risk of anaemia and pre-eclampsia

Third Trimester •

Twin pregnancies at 30 weeks ( 2 x 1500 gr) = singleton at 40 weeks ( 1x 3000 gr)

•

Higher musculoskeletal and postural load

•

Vena cava syndrome increased

•

Increased risk pre-eclampsia , anaemia and preterm labour

Increased risks concerning the mother include: •

Anaemia

•

Pre-eclampsia

•

Musculoskeletal ( weight gain average 14 – 20 kg)

•

Emergency CS is more likely

Increased risk to foetuses: •

Miscarriage

•

Mortality

•

Congenital abnormalities

•

Preterm delivery

•

Growth restriction

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Exercise Modifications In Relation To Mother To Be Joint Laxity and Changes in Body Alignment Postural changes and pelvic aches and pains, created by hormonal changes and altered centre of gravity, all put the body at extra risk which exercise may exacerbate. •

Avoid high impact, jerking and jolting, extreme range of movement, and complex choreography.

•

Modify exercise technique and position changes

•

Incorporate postural cues, pelvic tilting, abdominal bracing.

Sacroiliac Joint and Pubic Symphysis •

Particularly vulnerable

•

Avoid prolonged weight bearing on one leg, Single leg activity, sudden changes in direction, wide stance movements and rotation can also aggravate

•

Incorporate centring exercises, stabilising exercises and specific stretches

Supine Hypotension and Increased Blood Pooling Lying supine may create impaired blood flow to the uterus •

Avoid supine positions after the first trimester

During later pregnancy, the uterus may impair venous return in the upright position with out the assistance of muscle pump. •

Beware of muscle conditioning in standing

•

Avoid stationary standing especially after aerobic exercise

Hypoglycaemia With the increased tendency for low blood sugar, pregnant women are more likely to feel weak or faint during exercise. A healthy carbohydrate snack an hour or so prior to exercise is recommended. Be aware of the participant who has not eaten breakfast due to morning sickness or who has been busy at work all afternoon.

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Pelvic floor Risk of short or long-term incontinence or prolapse will be increased by high stress on the pelvic floor. •

Avoid jolting the pelvic floor

•

Educate women about the importance of pelvic floor exercises

•

Incorporate pelvic floor exercises in all classes

•

Suggest PF exercises as alternatives to other inappropriate exercises

Abdominals Altered mechanics of abdominals , supine hypotension and risk of increasing rectus diastasis means abdominal exercises should be modified •

Abdominal curls are inappropriate after 16 weeks

•

Abdominal bracing is extremely beneficial throughout pregnancy

•

Bracing is preformed in various positions including sitting, standing, 4 point kneeling and side lying.

•

Women should be encouraged to “bear hug their baby” during all exercise.

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