1. Exercise During Pregnancy and Postpartum
By: Erin Moore

2. Physiologic Changes with Pregnancy
Soft-tissue edema: reported by approximately 80% of women in the last 8 wks
Increased fluid retention: predispose nerve entrapment (carpel tunnel)
Ligamentous Laxity
Relaxin known to remodel pelvic connective tissue and activate collagenlytic system
Initial increase relaxin levels peak at 12 weeks and decline until the 17th week
20% increase in weight during pregnancy may increase force on a joints by as much as 100%
Hyperlordosis accentuates anterior pelvic tilt
Symphysis pubis widening begins in 10th and 12th week of pregnancy under the influence of the hormone relaxin

3. Anatomic and Physiologic Changes with Exercise during Pregnancy
About 60% of pregnant women experience LBP
Strengthen abdominal and back muscles to reduce these chances
Respiratory Changes
Decrease in pulmonary reserve: ability to exercise anaerobically is impaired, oxygen availability for strenuous exercise decreases
Aerobic training increases aerobic capacity in normal weight and overweight women
Temperature regulation
Stay well-hydrated
Wear loose fitted clothing
Avoid exercising in high heat and humidity to avoid heat stress
Decreased Arch Height
Avoid running on uneven terrain, difficult to adapt
Wear supportive shoes, consider orthotics

4. WHY Exercise During Pregnancy
Maintain physical fitness
Helps weight management
Reduces risk of gestational diabetes in obese women
Enhances psychologic well-being
Safe and desirable
150 minutes per week of moderate-intensity aerobic activity (equivalent to brisk walking)
Use talk test to prevent over exhaustion
Physical inactivity and excessive weight gain risks
Maternal obesity
Gestational Diabetes
Pregnancy complications

5. Safe and Unsafe Physical Activities
Activities to Initiate
Activities to Avoid
Walking
Swimming
Stationary Cycling
Low impact aerobics
Yoga, modified
Positions that result in decreased venous return and hypotension should be avoided as much as possible
Running/jogging, Strength training
Safe for women that participated in these exercises before pregnancy
Contact sports (ie soccer, basketball)
Activities with high risk of falling (ie off road cycling)
Hot Yoga, Hot Pilates

6. Recommended Exercise Frequency/Duration
American and Canadian Guidelines encourage women with uncomplicated pregnancies to participate in regular aerobic and resistive exercise
Treatment Frequency and Length of Session:
Previously sedentary women
Aerobic exercise 15 minutes, 3 x/ week, work up to 30 minutes 4 x/ week
Women with uncomplicated pregnancies
Moderate intensity (rate of perceived exertion: 12-14)
Resistance/flexibility training and aerobic exercise, individually or in combination
30 min/day, 4 or 5 days/week

7. Absolute Contraindication to Aerobic Exercise During Pregnancy
Hemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix of cerclage
Multiple gestation at risk of premature labor
Persistent second or third trimester bleeding
Placenta previa after 26 weeks of gestation
Premature labor during prior pregnancy
Ruptured membranes
Preeclampsia or pregnancy induced hypertension
Severe anemia

8. Relative Contraindications to Aerobic Exercise During Pregnancy
Anemia
Unevaluated maternal cardiac arrhythmia
Chronic bronchitis
Poorly controlled type 1 diabetes
Extreme morbid obesity
Extreme underweight (BMI less than 12)
History of extremely sedentary lifestyle
Intrauterine growth restriction in current pregnancy
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled seizure disorder
Poorly controlled hyperthyroidism
Heavy smoker

9. Warning Signs to Stop Exercising When Pregnant
Vaginal bleeding
Regular painful contractions
Amniotic fluid leakage
Dyspnea before exertion
Dizziness
Headache
Chest pain
Muscle weakness affected balance
Calf pain or swelling (rule out thrombophlebitis)

10. AVOID: Activities that make the pain worse
Standing on one leg
Bending and twisting to lift or carry a toddler or baby on one hip
Crossing legs
Sitting on the floor
Sitting twisted
Sitting or standing for long periods of time
Lifting heavy weights (grocery bags, vacuum cleaners)
Carrying anything in only one hand

11. During Pregnancy DO:
Be as active as possible, avoid activities that make the pain worse
Rest when possible, may need to sit down more often
Wear supportive shoes (lose arch, due to weight gain)
Keep knees together when moving in and out of the car, rolling in and out of bed
Sleep in comfortable position (with pillow between the knees)
Take stairs one at a time: upstairs leading with less painful leg, downstairs leading with more painful leg

12. Benefits of Exercise Postpartum
Improved Cardiovascular fitness
Facilitated weight loss
Increased positive mood
Decreased anxiety and depression
More energy following exercise
Decreased lactation-induced bone loss
Decreased urinary stress incontinence

13. Weight Retention Postpartum
Mother’s with normal weight prior to pregnancy and those who gained the recommend weight are less likely to require intervention postpartum
Mother’s with additional weight gain in the postpartum period
More susceptible to long term weight gain
More likely to have related disease:
Obesity
Heart disease
Diabetes
Decrease postpartum weight retention
Increased physical activity helps to
Maintain lean body mass
Enhance fat loss
Improve aerobic fitness
Weight loss of more than 1.5 kg is not recommend for lactating women

14. WHY Strengthen the Pelvic Floor Muscles
Urinary stress incontinence
30-60% of pregnant women
15 % of postpartum women have it 3 months after delivery
Pelvic floor trauma
Due to vaginal delivery
Intervention
Strengthen pelvic floor muscles
Pelvic training program: perform 8-12 maximum pelvic floor muscle contractions twice a day (3x per week)
Hold the max contraction for 6-8 seconds, adding 3- 4 fast contractions at the end of each maximal contraction

15. Looking after your baby
Change diapers at waist height
Do not lift baby too often
Carry baby in front of you, don’t carry baby on one hip
Kneel at the bath side rather than bending over
Keep your baby close to you when moving them in and out of the car seat
If you have to carry baby in car seat hold it in front of you, not on one hip
Don’t lift baby out of high shopping trolleys
Do pelvic floor muscle exercises daily

16. The Effect of Core and Lower Extremity Strengthening on Pregnancy-
The Effect of Core and Lower Extremity Strengthening on Pregnancy- Related Low Back and Pelvic Girdle Pain: Systematic Review
Biomechanical stresses:
Change in pelvic and spinal alignment, joint laxity, and weight gain
Muscle weaknesses:
Weakness at the proximal hip, abdominal and lumbosacral regions may contribute to impaired core stability thus, altered alignment, decreased ability to withstand stress, and disruption of normal gait pattern
PPGP (Pregnancy Pelvic Girdle Pain) : pain of musculoskeletal origin between the levels of the posterior iliac crests and gluteal folds involving the anterior and/or posterior aspects of the pelvis that may radiate into the posterior thigh
Interventions:
Activity modification, exercise, joint and soft tissue mobilization, aquatics, acupuncture, bracing, positioning
Muscle Strengthening:
local stabilizers, specifically the TA more effective to reduce the laxity of the lumbopelvic and sacroiliac joints than global stabilizers alone

17. Intervention: Land Versus Aquatic Exercise
Physiological and Psychologic benefits
Decreased joint compressive forces
Improved edema management
Increased blood volume and cardiac output
Improved control of weight gain
Decreased back pain
Reduced postpartum depression
Muscle relaxation

18. Intervention: Exercise
Pelvic Floor Core Exercise
First find comfortable spinal position, tilt the pelvis forward and backward until you find a neutral spinal position that is comfortable for your back
Contract Pelvic floor: Hold in gas
Contract Transverse Abdominus: Pull belly button to spine
Purpose: Strengthen the pelvic floor, which helps to stabilize SI joint laxity

19. Intervention: Exercise
Quadruped Pelvic Tilts
Obtain the quadruped position with spine in neutral position.
Extend the lumbar spine, performing an anterior pelvic tilt to end range.
Next flex the spine, performing a posterior pelvic tilt to end range.
Then return to neutral spine position. Continue in a controlled manner
Purpose: Facilitate and maintain a neutral hip position

20. Intervention: Exercise
Clamshell
Get into the side lying position with the hips stacked on top of each other
Contract the muscles you would use to prevent a bowel movement
Continue to contract the muscles as you rotate the top leg toward the ceiling (make sure feet stay together)
Purpose: Improve hip strength and stabilize spine

21. Intervention: Exercise
Diaphragmatic Breathing
Sit with back straight
Place one hand on chest and one on bell. Breath in through the nose slowly and deeply. The hand on your belly should be the one that is moving.
Breath out through your mouth
Perform this exercise slowly
Purpose: Facilitate deep core muscle activation, relaxation technique

22. Resources
Borg-Stein J, D. S. (2015). Musculoskeletal Aspects of Pregnancy. American Journal of Physical Medicine & Rehabilitation,
Lillios, S. (2012). The Effects of Core and Lower Extremity Strengthening on Pregnancy-Related Low Back and Pelvic Girdle Pain: A Systematic Review. Journal of Womenʼs Health Physical Therapy
Mottola, M. (2002). Exercise in the Postpartum Period: Practical Applications. Current Sports Medicine Reports
Opinion, C. (2015). Physical Activity and Exercise During Pregnancy and the Postpartum Period. The American College of Obstetricians and Gynecologists, 1-8.

23. Questions?