 Prepared by :  Hanaa Behar  Shoroq edaliy  Khetam elkhafarna  Hadeel abo quse  Sabren salama  Wesam khatab  Somya abo omra

 The exercise in the childbearing year  The exercise needs of the disabled woman during the childbearing year that specific.  should be assessed individually,so advice and  information can be given.  Exercising during the childbearing year is not harmful to either.

 mother or baby if the pregnancy is normal and the mother healthy.  and can be positively beneficial if at a  mild to moderate level.   The aims of exercising in pregnancy  should be to maintain, or slightly improve, the woman's level of fitness.

 Provided there are no specific obstetric or medical contraindications, fit women can safely maintain the same level of fitness during pregnancy.

 Pregnant women should not undertake new, vigorous exercise, which could make them too warm, tired or breathless and regular exercisers should reduce the intensity and duration of their training as the pregnancy progresses.

 All women should be encouraged to exercise at a moderate level to derive the associated health benefits.  A moderate level is that intensity which can be maintained while able to carry on a conversation.

 The Borg Scale of Perceived Exertion or the Talk Test can be used, preferably at level 3–5.  This should be used in preference to a heart rate monitor, which is less reliable due to the pregnancy-induced increase in heart rate.

 There are benefits to exercising in the childbearing year. The benefits according to the ACPWH may include: maintenance of cardiovascular fitness, respiratory and musculoskeletal.status

maintenance of healthy weight range for mother

 improvement of body awareness, balance, coordination and posture

 improve ment in circulatio n and lowered diastolic pressure.

 an increase in both endurance and stamina

increased feelings of social and emotional well-being, when exercise is combined with social interaction.

a possible reduction in problems during labour and delivery. Labour may also be shorter and there may be fewer interventions (forceps, caesarean section)

evidence of neurological benefits to the baby and developing child

a reduction in common disorders of pregnancy

suggestion of a more rapid postnatal recovery as the woman is likely to be fitter

better glucose utilization by increasing insulin sensitivity,

suggested improved placental growth, increased fetal growth

However, further research on the benefits of exercise in pregnancy is needed and health professionals should remain up to date with current literature. Most women will fall into one of the following four types of exerciser. Using the Borg Scale of Perceived Exertion is appropriate for all women, whatever their level of fitnessor ability.

. The occasional exerciser These women may recognize the benefit of exercising when pregnant and may wish to increase the level of intensity, duration and regularity.

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. The regular exerciser Guidelines for exercise in pregnancy (ACOG 2002) suggest that the woman who exercises regularly should: discuss her exercise programme with the obstetrician, GP, physiotherapist or midwife before continuing

exercise at least three times per week for 20–30 min to improve aerobic capacity but discontinue contact or dangerous sports

self-regulate both the level of intensity and duration of exercise as the pregnancy progresses. This will help to keep core temperature below 38 °C.

always aim for low impact activity to reduce musculoskeletal stresses and wear supportive footwear

prevent dehydration by maintaining an adequate fluid intake and should avoid exercising during hot and humid weather or with pyrexia

ensure that they warm up and cool down for at least 5 minutes

not overstretch because of the hormonal effects on the ligaments

consult the relevant professional for advice on specific exercises, e.g. for the pelvic floor and abdominal muscles

avoid certain movements like low squats, cross-over steps, rapid changes of direction and ballistic exercise

avoid aortocaval compression by not exercising in the supine position (supine hypotension syndrome,

not restrict their calorific intake but aim to eat to appetite

aim to pursue a variety of exercise activities in order to avoid overtraining

not exercise to the point of fatigue nor become breathless.

The athlete These women are often the most difficult to advise as they are often highly motivated and competitive. They should follow the advice of regular exercisers. A safe level of aerobic exercise for the athlete will depend on the chosen sport and degree of fitness attained.

The athlete will inevitably need to lower the intensity and length of her training sessions and they should be aware that the same warnings and contraindications apply as for the regular exerciser.

Advisors of pregnant women athletes regarding safe exercise should remember that research into strenuous activity during pregnancy is limited, so should Endeavour to keep updated of new information.

It is best to continue with familiar activities rather than begin new types of exercise and the woman should listen to her body when exercising and stop if she feels uncomfortable, fatigued or unwe ll

 Brisk walking during which the Borg Scale/Talk Test is correctly observed is an easy and accessible method of exercising for all.

NOT I. Swimming is excellent exercise if aerobic changes are induced. II. Exercising in water also raises the plasma beta endorphin levels significantly and has a beneficial effect on the respiratory cardiovascular and musculoskeletal systems.

1. serious cardiovascular, respiratory, renal or thyroid disease poorly controlled type 1 diabetes 4.risk of, or current, premature labor 5.cervical incompetence 6.history or risk of IUGR and premature labor – reduce activity after 12 weeks 7.hypertension – should be discussed with the woman's doctor 8.placenta praevia after 26 weeks' gestation – should be discussed with the woman's doctor 9.sudden swelling of ankles, hands or face 10.acute infectious disease 11.severe rhesus isoimmunization.

1.asthma 2.diabetes type 1. If insulin regimes are well controlled and exercise is moderate (Arena and Manfully 2002), discuss with diabetic consultant, GP or specialist nurse 3.history of miscarriage 4.pre-pregnancy hypertension 5.placenta praevia 6.vaginal bleeding 7.reduced fetal movement 8.anemia 9.breech presentation 10.extreme obesity 11.extreme underweight BMI<12 12.heavy smoking 13. thyroid disease

1)abdominal pain 2)leakage of amniotic fluid 3)pelvic girdle pain 4)pelvic girdle pain which may lead to difficulty in walking 5)vaginal bleeding 6)shortness of breath, dizziness, faintness, palpitations or tachycardia 7)persistent severe headache 8)calf pain 9) absence of or reduced fetal movements

For each port of the body where tension manifests itself there is a there –fold instruction *** *an order to the reciprocal muscle group to work strongly* *a command to that muscle group to stop working* *a direction to the brain to recognize the new position of ease and to remember it*

lie down comfortably on your side or sit in a chair with back and hand supported* Breathe in expanding above the waist and lower ribs then sigh out easily and continue to breathe gently keeping the movement fairly low down in the chest* The shoulders arms and hands are usually the first areas to stress so begin with these parts*

 *shoulders –pull your shoulders to wards your –feet –stop pulling –can cent rate on this new position of ease –your shoulders so begin with these parts*  *arms push your elbows slightly our from your body as though straightening the elbows – stop pushing think about this position –your arms are relaxed and comfortably supported*  *hands let them rest on your tummy or thighs or the supporting surface –open out the fingers and thumbs keeping the wrists on the support*

 Stretch the fingers and thumbs –stop moving feel the new  position –comfortable supported and relaxed*

 The teacher moves on to the remainder of the body the hips knees head and face giving clear precise instructions which can be found in full in the ACPWH leaflet*  Your body should end up in apposition of ease and as relaxed as possible breathing is at your normal resting rate relaxation can be adapted as labour

 Progresses by adopting the most comfort able position for your with easy breathing in the lower part of thechest**********

 Relaxation.breathing techniques.  encouragement to move and adopt an upright or forward leaning.posture during labor will help women to cope with discomfort and pain of contraction.

 woman in Early first stage of labour use upright position who :  Have more efficient contraction.  Have shorter labours.  are less likely to use pethidine or an epidural for pain relief.  Are less likely to have their labour accelerated artificially than women who were lying down.

 Position that help during the early stage of labour :  Sitting against a table &relaxation forwards so that shoulders.arms and head are supported.  Standing.learning backwards against the wall of the room.  Kneeling on all fours.  Kneeling on the floor & learning forwards onto chair.  Learning forwards against a partner.  Sitting astride an armless chair with arms supported on the chair back.  The birthing room may have additional aids.  Position that help during the early stage of labour :  Sitting against a table &relaxation forwards so that shoulders.arms and head are supported.  Standing.learning backwards against the wall of the room.  Kneeling on all fours.  Kneeling on the floor & learning forwards onto chair.  Learning forwards against a partner.  Sitting astride an armless chair with arms supported on the chair back.  The birthing room may have additional aids.

 When labour progresses it increase difficult to find comfortable position.  many women are content to sit back against pillows on the bed at this stage and contraction on relaxation &breathing.  When labour progresses it increase difficult to find comfortable position.  many women are content to sit back against pillows on the bed at this stage and contraction on relaxation &breathing.

 In this stage position depend on: individual choice Pain relief &obstetric factors.  If there is pain in the pelvic girdle.particularly over the symphysis pubis or sacroiliac joints then undue abduction of the hips should be avoided during labour.vaginal examination & birth the symphysis pubis joint may be protected from further disruption by limiting hip abduction and maintaining symmetry of hip positions.prone kneeling or side –lying are the optimum position for birth.  In this stage position depend on: individual choice Pain relief &obstetric factors.  If there is pain in the pelvic girdle.particularly over the symphysis pubis or sacroiliac joints then undue abduction of the hips should be avoided during labour.vaginal examination & birth the symphysis pubis joint may be protected from further disruption by limiting hip abduction and maintaining symmetry of hip positions.prone kneeling or side –lying are the optimum position for birth.

 The symphysis pubis joint may be protected from further disruption by limiting hip abduction and maintaining symmetry of hip position.  Prone kneeling or side lying are the optimum position for birth.  As the contraction starts the mother is reminded to breath in & out gently.  The symphysis pubis joint may be protected from further disruption by limiting hip abduction and maintaining symmetry of hip position.  Prone kneeling or side lying are the optimum position for birth.  As the contraction starts the mother is reminded to breath in & out gently.

 Respiration is affected by stress & adapted breathing is one of the easiest ways of assisting relaxation.  speed.slower breathing lead to deeper relaxation.  natural rhythmic breathing mustn't Be confused with specific unnatural rates of breathing its harmful to fetus &mother.  Women in labour breath very rapidly at the peak of contraction but should not encouraged it.  very Slow deep breathing cause hyperventilation  Rapid shallow breathing cause hypoventilation.  Respiration is affected by stress & adapted breathing is one of the easiest ways of assisting relaxation.  speed.slower breathing lead to deeper relaxation.  natural rhythmic breathing mustn't Be confused with specific unnatural rates of breathing its harmful to fetus &mother.  Women in labour breath very rapidly at the peak of contraction but should not encouraged it.  very Slow deep breathing cause hyperventilation  Rapid shallow breathing cause hypoventilation.

 Preventing and alleviating the early physical stresses of pregnancy and childbirth, should be taught as a priority. Common consequences of pregnancy and childbirth are the physical problems of pelvic girdle and low back pain or incontinence.

The main aim in the postnatal period is to address healthcare needs and give advice and exercises to reduce the risk of future pelvic floor dysfunction or the possibility of long-term back problems, so that the woman may recover normal function free of both pain and symptoms. Women whose pain or continence problems do not resolve with simple advice and exercises should be referred to a women's health physiotherapist

 Some 45% of all pregnant women suffer pregnancy-related pelvic girdle pain (PGP) and/or pregnancy-related low back pain (PLBP). Serious pain occurs in 25% of pregnant women and severe disability in 8% of pregnant women (Wu et al 2004).  Pelvic floor dysfunction (PFD) occurs in 52% of all pregnancy-related PGP/PLBP (Pool- Goudzwaard et al 2005).

 Pelvic floor disorders are very common and strongly associated with the female gender, ageing, pregnancy, parity and instrumental birth (MacLennan 2000). 31–47% report antenatal stress incontinence up to 34% report postnatal incontinence (Reilly et al 2002) 11.5% report faecal incontinence after a 3rd degree tear 25% report faecal incontinence after a 4th degree tear (Sangalli et al 2001).  For best compliance with the following advice and exercises, explain, demonstrate, supervise and practice at every opportunity.

 Postural awareness and care of the back  Women should be advised that the weight of her baby, her altered centre of gravity and tiredness may alter her posture and place strain on her body, putting her at risk of low back and pelvic girdle pain. Her sustained posture when standing, sitting or lying

 plus repetitive movements may influence that risk and correction may prevent or reduce pain. Back-care advice should be developed relating to comfortable positions in sitting, standing, lying, general mobility and correct lifting

For good standing posture, the centre of the head, shoulders and hips should fall in a line when viewed from the side. Standing tall, with shoulders relaxed, tummy gently drawn in and bottom tucked under, knees straight but not locked, and weight evenly distributed on both feet is advised.

 The pregnant woman should choose a comfortable chair, which supports both her back and thighs. She should sit well back and if necessary place a small cushion or folded towel behind the lumbar spine for additional comfort. Equal weight should be placed on each of her buttocks to prevent strain on the pelvic ligaments. The seat height should allow the feet to rest on the floor, or a small footstool or cushion may be placed under the feet to raise them slightly

 Her workstation should be at the correct height such that she does not need to bend forwards. If relaxing in an easy chair, the head can be supported and the legs elevated slightly on a stool. Legs should not be crossed.

 Sleep is a very valuable commodity during pregnancy and health professionals can advise and help women to find a comfortable position. Lying flat  on the back should be discouraged because of the risk of supine hypotension due to pressure from the gravid uterus on the inferior vena cava. However, if she wakes having been lying on her back she should be advised to lie on her side for a few moments before rising slowly. lying

 Women should be encouraged to make sure their seating and workstation is suitable, particularly if sitting for any length of time . Regular changes of task and alteration of positions is beneficial  IF the woman's work involves constant standing she should ensure she sits at regular break times and be very careful

if her work involves lifting or great physical effort. Many workplaces offer pregnancy risk assessments to employees

 Lifting heavy or awkward objects should be avoided during pregnancy  Twisting or bending while lifting is a particularly high-risk activity. If lifting is unavoidable , the thigh muscles, not those of the back, should take the strain.

The abdominal and pelvic floor muscles should be drawn in for support and protection of the back and pelvis before bending the knees, holding the object or toddler close to the body, then lifting with the back straight (Fig. 16.9). Toddlers should not be carried on one hip, or, at least, advise to alternate the hip. A rucksack carried on the back is much better for the back than a heavy shopping bag.

 There is evidence that pelvic floor muscle training used during a first pregnancy reduces the prevalence of urinary incontinence at 3 months following birth).  The recommendation for preventive use of physical therapies is that pelvic floor muscle training should be offered to women in their first pregnancy as a preventive strategy for urinary incontinence

1.Sit, stand or lie down on your side. Imagine that you are trying to stop yourself passing wind and at the same time trying to stop the flow of urine 2.The feeling should be of squeeze and lift, closing and drawing up the back and front passages 3.Hold for as long as possible, up to 10 s, breathing normally, and then relax 4.Repeat up to 10 times

 The muscles should also be able to react to and maintain continence during sudden rises in intra-abdominal pressure as during a sneeze, cough or laugh; practicing a few short, fast squeezes will help maintain this control Try to draw up the pelvic floor muscle gently when lifting.

 Try to practice this set of up to 10, 10-s squeezes at least 3 times a day This regime will help to build up, or maintain the endurance in the pelvic floor muscle during pregnancy You should feel that your low tummy support muscle is working at the same time; this is good

 Abdominal exercises to the aponeurosis, rectus sheath and lineal alba, it may help to limit DRAM. The mother should adopt a pain-free position, with good The deepest layer of muscles within the abdominal corset, TrA is important in postural control, controlling the neutral spine position and giving support to the weight of the growing baby. By its attachment postural alignment. Sitting, standing, side-lying or four-point kneeling are good positions but she should avoid lying on her back after 16 weeks of pregnancy, because of the risk of supine hypotension. Figure illustrates the transverses exercise, and Boxes 16.3 and 16.4 proved instructions for pelvic tilting and the TrA exercise.

 Instruction in pelvic tiltingPlace your hands on your abdomenGently tighten your tummy muscles and buttocks and allow the back of your waist to slump backwards. Your pubic bone rocks up towards you. Breathe normally and hold the tilt for 5–10 sRelax and allow your back to hollowRepeat a few times. This is pelvic tiltingThe mid-way position is the neutral spine position and is safest for your backPracticing the abdominal exercise is best done in the neutral spine position.

 Instructions for the TrA exercisePlace your hands on lower part of abdomenTake a gentle breathAs you breathe out, gently draw in and lift the lower tummy away from your hand, this time not allowing your back to moveKeeping the tummy in, continue to breathe normally a few timesFeel the muscle working under your hand as it supports the weight of your babyRelaxRepeat up to 10 times, trying to hold each lift for 10 s, but don't hold your breathRepeat this set 6–8 times a dayTry in different positions, and try to use this muscle during activity requiring effort.