Prenatal Aquatics

Due to physiological changes and the growing baby, extra strain is placed on many areas of the body during pregnancy, and the aquatic environment can be physically more comfortable and mentally soothing than other forms of exercise for pregnant women. Swimming and aqua exercise may also be recommended by a healthcare provider as a way of staying active and healthy. By encouraging moms-to-be to think more about their movement quality and by performing specific strengthening and postural work, fitness professionals may be able to help alleviate discomfort as well as encourage better health and posture.

Before you start, it is important to make sure you have the appropriate qualifications to enable you to plan, teach and evaluate an aquatic exercise session. However, if you are regularly teaching prenatal participants or you are planning to deliver a specific “aqua-natal” class, then consider a specific exercise and pregnancy qualification. There are a number of contraindications to exercise in pregnancy, issued by the American Congress of Obstetricians and Gynecologists (ACOG), all of which should be checked prior to starting any exercise program.

Absolute contraindications to aerobic exercise during pregnancy (ACOG):

• Hemodynamically significant heart disease
• Restrictive lung disease
• Incompetent cervix/cerclage
• Multiple gestation at risk for premature labor
• Persistent second or third trimester bleeding
• Placenta previa after 26 weeks gestation
• Premature labor during the current pregnancy
• Ruptured membranes
• Pregnancy-induced hypertension

Relative contraindications to aerobic exercise during pregnancy (ACOG):

• Severe anemia
• Unevaluated maternal cardiac arrhythmia
• Chronic bronchitis
• Poorly controlled type I diabetes
• Extreme morbid obesity
• Extremely underweight (BMI <12)
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in current pregnancy
• Poorly controlled hypertension/pre-eclampsia
• Orthopedic limitations
• Poorly-controlled seizure disorder
• Poorly-controlled thyroid disease
• Heavy smoker

Perceived Risks and Real Benefits

Naturally, mom-to-be may be concerned about exercising and the potential risks to her pregnancy and her baby. However, research now suggests that exercise, particularly exercise in water, is safe and may be beneficial in pregnancy.

Perceived Risk #1: There may be a belief that exercising while pregnant, with increased body weight, an altered center of gravity and unstable joints, could lead to joint and/or muscle damage. Indeed, there may already be some discomfort (e.g., back pain, leg cramps and pelvic girdle pain).

Real Benefit #1: The buoyancy of the water actually cushions and relieves the stress on weight-bearing joints, making movements more comfortable. The resistance of the water supports limbs and slows down movement, therefore preventing extreme range of movement and possible injury. Recent studies have shown a reduction in back pain and general discomfort of pregnancy in women participating in aquatic exercise.^2,3

Perceived Risk #2: There may be concern that exercise could lead to redistribution of blood flow away from the uterus and therefore a lack of oxygen to the baby.

Real Benefit #2: Blood volume actually increases in pregnancy, and this helps to maintain blood supply to the uterus and baby during exercise at normal levels. In addition, during aquatic exercise, because the pressure of water around mom-to-be pushes fluid from her tissues into her blood vessels, blood volume is further increased. This may increase blood flow to the uterus and baby.^4,5

Perceived Risk #3: There may be a worry that the baby will become stressed as mom-to-be becomes more active and her heart rate increases.

Real Benefit #3: Research has shown that there is no significant increase in the baby’s heart rate during maternal exercise in water.⁵ Also, aquatic exercise can reduce stress in the mother and lead to a healthier pregnancy.⁶

Achieving the Benefits

There are some simple ways of adapting an aqua session to enhance the health benefits to mother and baby. Make your warm up more gradual and a bit longer so your pregnant participants have more opportunity to maintain good posture, technique and balance. Just remember to keep them moving so they don’t get cold in the water!

Consider prioritizing specific muscle groups/areas of the body within your main workout section in order to improve functional ability and support any joints that are uncomfortable or swollen. There are lots of exercises you could incorporate that could be useful in childcare activities (e.g., pushing arms forward against the water while walking forwards could replicate the action of pushing a buggy. Add a float in each hand or a noodle for extra resistance). This will also help to improve abdominal strength and support a painful back. A few more examples might include:

Standing at the pool wall with one foot on a “noodle” and pushing the noodle up and down with the foot will help to maintain strength in the legs for lifting and carrying the baby. “Wall press ups” at the pool wall will help to maintain strength in the chest muscles and support the weight of larger, heavier breasts.

Performing “breaststroke” arms (arms fully underwater, palms facing back) will not only target the weakened and stretched upper back muscles but will also help to open out the chest, giving moms-to-be room to breathe more deeply.

Try to avoid twisting movements of the torso and excessive abdominal work, as these muscles are already being weakened and stretched by the expanding uterus. Focus on core stability and good posture while performing all other activities in the session. At the end of your session, the cool down needs to be more gradual too, so that blood flow and heart rate can adjust comfortably. Again, try to do this without letting participants get cold. Use large (but comfortable) traveling movements to keep the client moving and maintain warmth.

The pace of the session may need to be slightly slower in order to accommodate changes in center of gravity and balance. Allow time to transition between exercises too if balance is affected (e.g., after traveling forwards, do something on the spot before traveling back). Offer support for stretches and activities that require balance for the same reason. This could mean using the side of the pool or a float to hold on to. Using a partner may not be a good idea, especially if you are training more than one pregnant women and they are both off balance!

Take care with the range of movement of your activities in order to help keep clients with lax joints (especially in the pelvic area) safe and comfortable (e.g., if you are performing side steps, allow participants to step only as wide as any discomfort in the pubic area or pelvis will allow).

Finally, remember to continually screen your clients and gain feedback from them to ensure they are comfortable and be alert for any warning signs (see list below). Ultimately, the type of exercise anyone chooses is individual.

Warning signs to terminate exercise while pregnant

• Vaginal bleeding
• Dyspnea before exertion
• Dizziness
• Headache
• Chest pain
• Muscle weakness
• Calf pain or swelling
• Preterm labor
• Decreased fetal movement
• Amniotic fluid leakage

Pregnant women may be encouraged to try aquatic exercise as it will feel more comfortable, and they should be able to continue well into their pregnancy. They can also be reassured of the benefits of water for their mind, body and baby.

References

¹ACOG Committee Opinion, No. 267. (2002). Exercise During Pregnancy and the Postpartum Period. Obstetrics and Gynecology. 99: 171-173.

²Kihlstrand, M., Stenman, B., Nilsson, S., et al. (1999). Water Gymnastics Reduced the Intensity of Back/Low Back Pain in Pregnant Women. Acta Obstetricia Gynecologica Scandinavica. 78:180-185.

³Smith, S. & Michel Y. (2006). A Pilot Study on the Effects of Aquatic Exercise and the Discomforts of Pregnancy. Journal of Obstetric Gynaecological and Neonatal Nursing. 35: 315-323.'

⁴Katz V.L. (1996). Water Exercise in Pregnancy. Seminars in Perinatology. 20:285-291.

⁵Katz V.L. (2003). Exercise in Water During Pregnancy. Clinical Obstetrics and Gynecology. 46:432-441.

⁶Parker K.M. & Smith S.A. (2003). Aquatic Aerobic Exercise as a Means of Stress Reduction During Pregnancy. 12:6-17.