The following article will provide practical suggestions for developing and teaching prenatal group exercise or one-on-one training programs. Although exercise is safe during pregnancy, it may not be undertaken in the same way as prior to conception. The pregnant water fitness participant is drawn to the water for its soothing qualities and can benefit greatly from training in this environment.
Exercise in water can accommodate a wide range of fitness levels and abilities addressing most training needs. With respect to the physiological changes of each trimester, the woman who maintains a conditioning regime may greatly reduce the discomforts of pregnancy related to muscular strain and imbalances as well as maintain cardiorespiratory fitness.
New mothers may experience fatigue, back pain, weight gain and loss of strength due to the demands of caring for a newborn, so it is no wonder they are highly motivated to get back in shape. Water fitness becomes a natural massage and versatile piece of fitness equipment.
Realize that pre- and post-natal programs have different goals, needs and class time preferences. Programs may be creatively yet safely developed for all needs; however, planning and a good understanding of their limitations is paramount.
- Review the physiological demands on the body's energy systems as imposed by maternal exertion, specific to the water environment.
- Formulate appropriate exercise inventory for the pregnant AND postpartum woman in the water environment.
- Promote and market programs either as a separate entity or as part of a regular group exercise program.
- Show target exercises for muscular endurance to prepare for labor and delivery.
- Establish modifications for range of motion and flexibility exercises.
The following are guidelines from the American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin in February 1994, "Exercise During Pregnancy and the Postpartum Period."
Recommendations in Pregnancy and Postpartum
There is no data in humans to indicate that pregnant women should limit exercise intensity and lower target heart rates because of potential adverse effects. The following recommendations may be made for women who do not have any additional risk factors for adverse maternal or prenatal outcome:
- During pregnancy, women can continue to exercise and derive health benefits even from mild to moderate exercise routines. Regular exercise (at least three times a week) is preferable as compared to intermittent activity.
- Women should avoid exercise in the supine position after the first trimester. Such a position is associated with decreased cardiac output in most pregnant women because the remaining cardiac output will be preferentially distributed away from splanchnic beds (including the uterus) during vigorous exercise. Such regimens are best avoided during pregnancy. Prolonged periods of motionless standing should also be avoided.
- Women should be aware of the decreased oxygen available for aerobic exercise during pregnancy. They should be encouraged to modify the intensity of their exercise according to maternal symptoms. Pregnant women should stop exercising when fatigued and not exercise to exhaustion. Weight-bearing exercises may, under some circumstances, be continued at intensities similar to those prior to pregnancy. Non-weight-bearing exercises such as aquatic fitness will minimize the risk of injury and facilitate the continuation of exercise throughout pregnancy.
It is essential that any pregnant woman entering an exercise program first be assessed, be informed of potential risks pertinent to her personal medical history (especially as related to her pregnancy) AND have clearance from her medical caregiver before beginning exercise. There are some important considerations specific to pregnant exercisers, and instructors should be aware of these when designing and leading a workout.
Prenatal literally means "before birth." During the estimated 40 weeks of pregnancy, a woman's body undergoes many changes. Within weeks of conception, hormones are released that relax the ligaments throughout the body, resulting in decreased joint stability.
Blood volume increases by as much as 50 percent, which increases the amount of blood the heart has to pump with each beat. Respiratory rate increases due to greater oxygen demand and consumption. Additional pressure of the uterus on the diaphragm also increases respiratory rate and general work of breathing. Additional weight adds load to the joints and increases joint stress. The increase in surface area of the body creates more drag in the water, and changes in posture create a more forward center of gravity, presenting new challenges to balance. Increases in basal metabolic rate require extra caloric (300 calories a day) and fluid intake, especially before exercising.
The ACOG state that pregnant women who are without obstetric or medical complications can perform a moderate level of physical activity to maintain cardiorespiratory and muscular fitness during and after pregnancy. Women who currently participate in exercise programs can continue to train throughout pregnancy (intensity and duration naturally decrease as pregnancy advances). Women who begin exercising after becoming pregnant are advised to start with a low intensity and low or non-impact activities. Duration or intensity of the exercise should not be increased before the 15th week or after the 25th week of pregnancy. Exercising three or more days per week is safer than an intermittent schedule. For women who don't have specific guidelines from their physicians, intensity should be based on maternal symptoms. Rate of perceived exertion (RPE) guidelines would be somewhat hard (6) on a 1 to 10 point scale. Heart rate guidelines from ACOG established a rate of below a maximum of 140 bpm. This was found to be too much of a blanket statement as exercise heart rate is largely dependent on resting heart rate and age-related maximum heart rate. Women were becoming mothers later in life. Additionally, heart rates in the water may be as much as 10-20 bpm lower than the same exercise intensity as land exercise because of water temperatures and the depth of the workout.
Therefore, ACOG’s recommendation that regular, low to moderate intensity at least three times per week at a comfortable self-paced level is much more realistic to all levels of female participants (athletes and beginners). The most important recommendation of ACOG guidelines is that exercises be stopped prior to fatigue and that women not exercise to exhaustion. The duration for land fitness recommends from 15 minutes for previously sedentary women to 45 minutes for fit women, and vigorous exercise should be limited to 15 to 20 minutes. In water, intermittent interval style of “SETS” alternating low to moderate CV for three to five minutes with active recovery sets of either muscular endurance, balance, function, kegels or the like will ensure women will not exhaust the muscle, overheat or get uncomfortably cold. Additionally, they will be able to comfortably complete the duration of the program and not exhaust after a 15 minute continuous cardiovascular bout.
Studies show that women who perform non-weight-bearing exercise (swimming or aquatic fitness) were able to maintain a moderate or greater intensity of exercise throughout the third trimester. Pregnant women engaging in weight-bearing modes of training on land (running, aerobics) typically stopped all exercise by the third trimester. This supports the aquatic environment as an ideal medium for exercise during pregnancy.
A woman’s ability to maintain postural integrity is greatly challenged as pregnancy progresses. The supportive role of the abdominal wall is of particular concern. As pregnancy progresses, the abdominal wall becomes thinned and stretched. Research has documented the strength/endurance improvements to the abdominal region in exercise programs that include travel through water and trunk stabilization exercises. This style of training can provide the pregnant woman with strength maintenance or needed improvements, which may not be possible in a land-based program. The entire trunk corset plays an important role in maintaining good posture and water provides an excellent medium for improving this muscular balance.
Ideally mothers would be exercising prior to conception. However, women with sedentary lifestyles should begin with short duration of low intensity and increase both duration and intensity gradually and carefully.
Never allow a pregnant women to exercise till exhaustion. Therefore pay close attention to stopping exercise prior to fatigue which in the water may sneak up quite quickly.
Acquire medical consent for each participant with specific guidelines if necessary. Screen for other current or previous injuries to the spine or other areas of the body. Observe posture for the presence of increased neck or low back extension (lordosis), forward head and shoulders, or knee hyperextension. Observe gait for signs of pain (limping) and the general ability to move (getting in and out of the pool, in and out of chairs).
Always, adhere to medical guidelines and recommendations of the physician. Teach and cue frequently neutral posture and neutral joint position. Be conscious to teach neutral wrists when holding a noodle or sculling. Avoid hip extension beyond neutral for x-country ski or skateboard (1 leg large cycling moves) movements. Screen for previous orthopedic injuries. Generally, decrease intensity and further decrease or eliminate impact from mid 2nd and 3rd trimesters. Monitor intensity throughout a program and remind ladies to self-pace at a conservatively comfortable speed. Practice breathing techniques (both exercise and diaphragmatic ) throughout the class. A mother to be will require the ability to relax and breathe, and, exert and breathe, comfortably. Encourage appropriate nutrition and hydration as exercise has higher demands for both.
A woman will need to increase caloric intake to cover the demands of the exercise and take water liberally before, during and after exercise. There is also an increased energy cost of pregnancy (at rest) of 300 calories a day. With the addition of exercise, caloric needs are even higher. With these additional metabolic costs, the pregnant woman is more susceptible to hypoglycemia.
Women who exercise during pregnancy experience more weight loss after pregnancy as well as improved overall conditioning. Women may not want to eat because they may be concerned about too much weight gain. If a client has suffered from an eating disorder or has issues with body image they may try to restrict food intake to avoid the necessary weight gain. But appropriate weight gains are 2- 4 pounds for the first trimester, 10 to 11 more pounds for the second trimester and 12 to 13 more pounds for the third trimester.
Women may not want to hydrate throughout a class because of the annoyance of having to go to the washroom frequently. However, this is a small price to pay for keeping themselves and their baby properly hydrated. An instructor to should encourage drinking water throughout the program and provide drinking breaks as well as washroom breaks – so the participants will not feel that they are missing out on exercise.
There is an increased resting oxygen requirement during pregnancy and breathing may be more difficult due to the effects of the enlarged uterus on the diaphragm. In water exercise, the effect of hydrostatic pressure with immersion tends to force the fetal mass cranially. This could limit diaphragm movement and thereby limit maternal ventilation. Due to these effects, the pregnant exerciser may have decreased oxygen available for performing aerobic exercise. Therefore, emphasize the importance of exhaling on effort and breathing out to naturally take oxygen in. Additionally, gradually progress from a shallow to a deep-water depth when submerging the lungs. Focus on breathing as the lungs go submerged.
- Use RPE (0-10) to monitor exercise intensity throughout the program.
- Balance the demands placed on muscle groups to avoid overuse to the point of exhaustion and oxygen depletion.
- Teach the participant how to regulate exercise intensity according to her individual needs.
- Caution the pregnant exerciser to be aware of balance differences and adjust movements accordingly.
- During travel patterns, have the pregnant exerciser hold in a stationary position for four counts before making directional changes. This will allow inertia forces to subside.
- It may be necessary to train for muscle conditioning before aerobic conditioning.
- Special caution should be taken with respect to the round ligament. The enlarged abdomen, combined with the resulting increase of drag resistance may result in considerable strain to this area.
- Exercise design becomes crucial to avoid spasms or discomfort.
- Maintain a slightly slower pace to accommodate the increase in intensity created by greater drag resistance as pregnancy progresses.
Mechanical Changes: The increased size of the uterus and the breasts will change the center of gravity during pregnancy. This in turn may affect balance. In water consideration also has to be made for the increased surface area and the resulting increase of drag resistance. Work efficiency and intensity is affected by surface area in motion.
Safety Tips and Suggested Exercise Modifications
- Ideal pool temperature is 83-86F, 28-30C. Pool temperature should definitely not exceed 90 F, 32C. Maintaining comfortable body warmth is important to prevent nipple stimulation, which could induce labor. If the student feels chilly, have her work the legs more vigorously to generate more heat, or wear a thermal vest and aquatic tights to reduce heat loss. Even if the class is conducted in the recommended water temperature individual response will vary and should be monitored.
- Wear water shoes in the locker room and in the pool to avoid slips and falls as well as helping to maintain proper posture and tracking. Always use the ladder, ramp or stairs for pool entry and exit rather than jumping or diving in. Have students check their balance at the beginning of a class and adjust buoyancy equipment appropriately. Always bring the women back to an extended working position in the shallow end to regain their legs and provide some gravity loading before exiting the pool. Have participants exit the pool slowly and carefully using the stairs, ramp or ladder pausing as needed to regain their "gravity legs". The instructor should stand nearby to assist if necessary.
- Teach neutral spine and neutral position for all joints, reviewing spinal position frequently during exercise. Cue and help students adjust their sculling (hand movements) to acquire effective balance skills. As pregnancy advances, sculling positions for basic moves may need to change in response to a new body shape and center of buoyancy.
- Limit hip extension past neutral, because buoyancy assists the leg upwards as it moves back into extension and this may strain the broad ligament of the uterus. It is easy to hyperextend the hip and cause hyperextension at the low back, (which can also occur during scissors moves). Limit the size of movement and cue sculling to "table top" position (in front and low in the water ) using webbed gloves for extra support.
- Remind students to tighten or stabilize all movements for good core posture. Avoid twisting at the waist (increases strain on the round ligament of the uterus) and flexing of the supine or supine or floating positions.
- Teach proper body mechanics such as arm and leg opposition at the beginning of each program so that the workout portion may be properly executed. Encourage proper body mechanics with activities of daily living for the baby to come such as lifting and carrying a baby, pushing the buggy or stroller, cleaning up or transferring their own bodies from place to place.
- Emphasize strengthening of the upper and lower extremities for supporting the pregnancy and the increase in body weight as well as for labor and delivery of the baby and postpartum.
- Frequently train the pelvic floor muscles with Kegel exercises. Developed by Arnold Kegal, a surgeon, this exercise strengthens the urinary opening and the outside of the vagina. The mother to be will be better able to control both the opening and the closing of the urethra, the outlet for the bladder. This is one of the first exercises that should be encouraged postpartum.
- Incorporate upper body exercises (strengthening for latissimus dorsi, rhomboids and lower trapezius to prevent rounded shoulders, chin tucks or neck retraction as well as biceps and triceps for lifting and lowering.)
- Stretching exercises should include hamstrings, iliopsoas, hip adductors, quadriceps, erector spinae, gastrocnemius and pectoral muscles. Avoid maximal stretch especially with upward assisted buoyancy movements and stop at least 20 degrees prior to pre-pregnancy end range.
- Cue frequently to avoid breath holding and practice breathing for relaxation during warm up or cool down.
- Suggest wearing a jog bra or other support to decrease bouncing and potential nipple stimulation as this can induce labor.
- Students should work at a proper water depth where they can control position, movements, balance and impact. Typically transitional (or chest to neck water depth) and deep water with a noodle is most comfortable as women will feel more weightlessness and less joint soreness. However, balance will be more challenging in these depths, so modify movements as needed. Always cue the hand positions to compliment the lower body movements.
- As pregnancy progresses traveling sideways may be modified to moving backwards. Suspended working positions will need support of a noodle or buoyant aid. Rebound moves may need to be eliminated and modified to an extended or neutral working position.
- The transition from horizontal to vertical positions may become more difficult. Eliminate these types of moves or teach coordinated arm movements that make the transitions safe and effective, allowing students extra time to complete the work. An instructor should learn how to reposition the mother (if they should fall back) to a vertical or seated position by anchoring the feet under.
- Include balance activities (the noodle is easily used).
- Intensity levels should be set by the individual according to her fitness level and comfort. The "talk test" and rate of perceived exertion (RPE) (1-10) scale should be used to monitor breathing and muscle fatigue to gauge how she feels throughout the program. Remind the mom to be that she should be conservative. She is already getting a training effect by carrying the weight of the baby around.
- Have water bottles on the side of the pool to encourage drinking water throughout a program.
- Encourage mothers to snack prior to/and after exercise to maintain proper blood sugar levels.
- Limit or avoid advanced exercise progressions of strength during pregnancy. Be very careful not to sacrifice posture, balance and mechanics of movement with the use of long levers. The properties of water increase resistance to movements naturally, and if the load is too great, the joints will absorb the stress.
- Avoid the use of buoyancy or resistive devices on the extremities because of the increased risk of poor biomechanics, poor posture and compromised balance.
- In general, keep movements small and controlled and avoid sudden changes of movement. Work basic moves slowly through the progressions, checking for neutral joint position.
Make the transition to gravity as gradual as possible by having students walk in the shallowest water possible to feel gravity before exiting the pool.
- Shortness of breath
- Leg pain
- Joint pain
- Increased Low back ache or sciatica
- Greater pain and discomfort
- Dizziness or nausea
- Vaginal bleeding
- Anemia (iron and folic acid deficiency)
- Premature contractions or menstrual-like cramps or uterine contractions (however, the water may stimulate natural contractions whether pregnant or not, especially when walking forwards. Walking backwards is one possible solution). When in doubt, seek a physician’s guidance.
- Toxemia – pregnancy induced high blood pressure (condition may appear in six to seven percent of all pregnancies)
- Weight loss
Recommendations After Abnormal Response
- For any of the above abnormal responses, send the participant directly to her health care provider for proper diagnosis and medical recommendations.
- For contractions or cramps: if the student is in the first or second trimester, stop exercise and send back to OB/GYN or physician. If the student is in her third trimester, decrease intensity and re-assess with OB/GYN or physician's approval. Natural currents of water’s resistance may falsely stimulate contractions.
- For spinal pain, check for neutral spine and check methods used by the student to maintain balance during exercise performance. Correct or modify to improve effectiveness.
- Stress that all participants should exercise at their own pace. (RPE 5-7)
- Students may have their blood pressure checked before, during and after a program if the instructor is trained in blood pressure checks. A computerized blood pressure machine is a necessary investment if you are working with high risk or new to exercise expectant mothers.
Exercise should be postponed and the client referred back to their health care provider if any of the following occurs:
- Persistent severe headache and/or visual disturbances
- Swelling, pain and redness in the calf of one leg
- Increased heart rate or higher than predicted training level (factoring in water heart rates)
- High blood pressure persisting after exercise
- Excessive fatigue, palpitations or chest pain
- Unexplained abdominal pain, pubic pain or absence of fetal movement
- Joint or spinal symptoms persist or intensify
- Persistent menstrual cramps or uterine pain
- Progressive abnormal decrease in functional abilities
- The student’s water breaks (rupture of membranes)
- Any bloody or abnormal vaginal discharge
- Sudden swelling of ankles, hands or face
Sports Training (Prenatal)
Many women wish to continue their sports and athletics because they are female athletes and have enjoyed fitness and sport all of their lives. There are a lot of misconceptions and out of date guidelines. Most people (incorrectly) believe that exercising during pregnancy increases the incidence of miscarriage. A normal rate of miscarriage is somewhere between 15 to 20 percent. Clapp et al. researched that the incidence of miscarriage was consistently 16 to 17 percent for both exercisers and non exercisers. Continuing exercise throughout early pregnancy does not increase the incidence of miscarriage or birth defects.
Therefore, utilize sports specific training as tolerated (i.e., speed play, intervals, agility and cardio/muscular endurance work). Ask about previous and current fitness levels (how many times the client exercises each week, how long and how often).
Exercise Do's AND Don'ts
Do go at a pace that feels good.
- Don’t push yourself beyond your pre-pregnancy fitness level.
- Monitor and regulate intensity based on self-paced exercise.
- Do work on upper and lower body endurance.
- Don’t overdo flexibility.
- Do work on posture and technique.
- Don’t over do flexion of the spine and abdominal work.
- Do work in neutral, extended, suspended with a noodle.
- Don’t do bobbing or rebounding moves.
- Do work controlled with appropriate water speed.
- Don’t do ballistic movements, sudden directional changes or twisting on joint.
Exercise Implications (Review)
- Strengthen the upper back (trapezius, rhomboids, latissimus dorsi, triceps,) to relieve kyphosis (round shoulders).
- Strengthen abdominals and entire trunk corset. Do lots of body checks.
- Strengthen the hamstrings, quadriceps, and adductors to help support the knee structures and increase strength to carry the baby and mother around pre and postpartum.
- Strengthen the pelvic floor to support the weight of the uterus and prepare for supportive functioning postpartum. Teach the kegal movement during a class so they may practice after a class and postpartum.
- Stretch the pectorals, hip flexors, and lower back to prevent low back discomfort using 20 degrees less than normal range of motion.
Other considerations for water:
- Avoid cold water below 83 degrees F and/or cool airflow that may elicit nipple erection.
- Wear supportive swimwear and breast support to protect the enlarging breasts as well as prevent against nipple chaffing or stimulation.
- The effect of hydrostatic pressure during immersion has been shown to reduce edema and is proportional to the depth of water.
- Non-weight bearing exercise is favored over weight-bearing exercise because of the exercisers' ability to maintain higher intensity, moderate duration training throughout the pregnancy. Shallow water exercise is weight bearing, but is considerably less than land exercise.
Because the mother to be is gaining weight and her belly and breasts are enlarging, it is most comfortable and safe to utilize transitional and deep water depths.
Transitional depth falls between shallow and deep water depths. This is the area where the participant’s feet can touch the bottom of the pool...Although it is a more difficult depth to control, it is an excellent depth for warm ups. Be careful not to JUMP nor bounce in this depth. Ideally, stand tall in extended working position and utilize easy patterns such as side knee lifts, marches and walking patterns. Remind the exerciser to push the feet down against buoyancy and resist the urge to lift the legs or knees higher. Help them to get used to the change from gravity to buoyancy and maintaining an upright posture by using sculling or stabilizing arm movements.
Training in transitional level requires a different technique to that of shallow water training. The depth of the water creates a slower pace than a shallow water work. Traveling backward usually doesn't work because buoyancy is too difficult to overcome and works against speed development, but it the mother to be uses her hands to assist and balance the movement – it may be an excellent way to attain neutral spine and take the excess stress off the low back. Therefore, travel requires cuing the hands and making sure that the participant steps through the toe ball heel to ensure getting the heels down.
Deep water training is defined between neck and shoulder depth with feet off the bottom of the pool. The center of balance is at the chest because the lungs act like life preservers. This makes balance more of a challenge. In water, the center of buoyancy is the lungs. On land, it must be balanced with the center of gravity (pelvic area for women or the chest area for men). Buoyancy is additionally enhanced as lungs are submerged. It will make you float upwards even more, so take time to adapt to this change.
Deep water training requires equipment to provide a balance between work and rest (so muscles do not fatigue prior to breathing). It is recommended to utilize equipment such as adjustable six pack belt or ideally noodles, which may be easily adjusted to balance posture and balance.
Some people in the past have attempted deep water training without any buoyancy assistance, but typically, they spend so much time sculling and trying to keep their head above the water – and they sacrifice posture and functional range of motion and technique.
Decide prior to the class (dependent on the woman’s phase of pregnancy) where the noodle should be placed.
- In front of the body to balance the floating buttocks
- A straddle to support comfort and easy cardio positions
- At the back to balance the growing belly
Each class and exercise may need to use difference noodle positions to gain the most benefit. Therefore, review with the women in transitional depth prior to going to the deep the benefits and technique of changing positions. Note that noodles are NOT a legal life saving device, so if a woman is not comfortable or skilled in the deep, she may easily stay in the transitional depth and just perform deep water techniques.
Creating Purpose When Designing a Program
Aquatic exercise is an effective approach for training pre- and post-partum fitness. Self paced exercise may greatly help to diminish pain, increase strength and range of motion and improve a woman’s ability to perform activities of daily living. Think differently about the water environment and the application of land-based exercise science and knowledge and always evaluate for your exercise design for purposeful, effective and functional exercise opportunities. Help mothers and mothers-to-be enjoy an uplifting and social activity. It may be the most uplifting gift of the day!!
- American College of Obstetricians and Gynecologists. (2000). Getting in Shape after a Baby is Born. (Brochure) Washington, D.C. www.acog.com
- American College of Obstetricians and Gynecologists. (1995). Planning for Pregnancy, Brith, and Beyond (2 nd Edition). Washington, D.C. www.acog.com
- American College of Obstetricians and Gynecologists. (1994). ACOG Technical Bulletin, NO. 189, Washington, D.C. www.acog.com
- Callaway, C. & Anthony, L. (2000). Exercise and Pregnancy. Group Fitness Instructor Manual. San Diego, Calif. American Council on Exercise. (pp. 248-280).
- Griffin, D. and Twynham, J. (2000). WaterART™ Fundamentals Instructor Training Program, Body Check Inc. Toronto
- Mothers and More . (2000).