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Regular exercise is essential for maintaining one's health and fitness and is equally important for pregnant women. Research shows that exercise is beneficial to pregnant women for an array of reasons.

Like everything else in life, it's all about balance. During pregnancy, postural changes occur and it is important to counteract these changes to avoid musculoskeletal dysfunction and injury. It is suggested that expectant mothers gain an average of 25 to 35 pounds during pregnancy.¹This weight gain is distributed throughout the body with excess stress placed on the feet and lower back.

Most notably, the center of gravity shifts forward due to the growing fetus and breasts and the base of support increases. Pregnant women demonstrate an increased lumbar lordosis, which shortens the spinal extensors as well as the hip flexors whereas the abdominal muscles lengthen.

The lengthened abdominal muscles cause the gastrocnemius and soleus muscles to work overtime in order to maintain balance while fighting the ever-changing center of gravity. A forward head with rounded shoulders posture becomes evident and there is a backward shift of the thoracic spine.¹Expectant mothers will be aware of such postural changes by the third trimester, or possibly sooner, and these changes will affect their balance. Exercise is the best way to maintain one's balance and to reduce possible injury during pregnancy.

Fitness programs should focus on safety and avoidance of falls. Orthopedic problems are common obstetric complaints, and it is imperative that PTs are aware of these postural changes so they can help patients find balance and avoid dysfunction during pregnancy.

An expectant mother should exercise in order to:

• Reduce weight gain during pregnancy and obtain more rapid weight loss after pregnancy;

• Improve mood and sleep patterns;

• Decrease risk of urinary incontinence due to pelvic floor muscle weakness and dysfunction;

• Relieve or prevent low-back pain;

• Potentially prevent gestational diabetes;

• Increase her rate of postpartum recovery;

• Strengthen muscles in preparation for labor and to support joint laxity;

• Increase flexibility;

• Increase or maintain aerobic endurance;

• Decrease muscle tension that helps promote relaxation;

• Increase understanding of how posture is affected by pregnancy;

• Promote feelings of well-being and a positive self-image;

• Obtain an invaluable support system through exercise classes.

Growing Bellies, Changing Bodies
Cardiovascular changes that occur in pregnant women also affect how a woman feels at rest and during exercise. These changes include increases in blood volume, cardiac output and resting heart rate.

As a result of such changes, pregnant women experience shortness of breath, sometimes with minimal exertion. Pregnant women should always monitor their symptoms during exercise or exertion.

In addition, expectant mothers should avoid the supine position after the first trimester to avoid obstruction of venous return, which decreases cardiac output and results in orthostatic hypotension. Motionless standing can also decrease cardiac output and should be avoided.

The American College of Obstetricians and Gynecologists (ACOG) recommend 30 minutes of moderate exercise a day for healthy pregnant women.²As a guideline, being able to talk during exercise is a good gauge of exercise intensity.

Women should exercise within their comfort zone and stop with any pain, dizziness, faintness, excessive fatigue, vaginal bleeding or unusual symptoms. Women should not exercise to the point of exhaustion.

It is also important for this population to drink sufficient fluids before, during and after exercise to avoid dehydration because in pregnancy there is an increase in metabolism, which increases body temperature. Proper nutrition is also imperative and due to this increased metabolism, pregnant women should consume an extra 300 calories per day.¹

Precautions
Many activities, despite their benefits, have risks and pregnant women should consider taking some precautions. For example, hormonal production causes increased ligament and joint laxity, which can lead to dysfunction and injury. Therefore, high-impact activities, such as jumping, bouncing and contact sports should be avoided. Some women prefer to wear a brace or an external support around their waist during exercise for comfort and stability.

Diastasis recti can occur during pregnancy, usually toward the third trimester. There is no need to panic if this occurs but extra precautions should be taken. In this condition, the rectus abdominus muscle is separated vertically at the linea alba due to increased tension at the abdominal wall.

Assessment of this condition can be performed by a PT or as a self-test by the patient. The test is performed in the supine position and the PT or patient places four fingers at the umbilicus horizontally.

The expectant mother is then asked to raise her head and shoulders to the inferior scapular angle while the width of the gap is noted at the fingers. The test is also performed two inches above the umbilicus and two inches below due to differing abdominal muscle integrity.¹If the gap between the left and right rectus abdominus is 2.5 or more fingers, the diastasis recti is large enough to warrant some precautions with movements and exercise. No treatment is necessary while the woman is still pregnant.

• Movements that strain the abdominals should be avoided and these include:

• Rising straight up from a supine position and twisting at the same time;

• Lifting and carrying heavy objects;

• Stretching the rectus abdominus with certain postures or positions;

• Exercising where the abdominal wall bulges out on exertion.

Women who were active prior to pregnancy can continue to be active throughout pregnancy. However, women who were not active prior to pregnancy should speak with their doctor about implementing a safe exercise program.

Contraindications to Exercise
Exercise is contraindicated for some medical conditions. These include any risk for preterm labor, persistent second or third trimester bleeding, and premature rupture of membranes to name a few.²There are other conditions where exercise is contraindicated in pregnancy and expectant mothers should consult their physician or a health care provider to learn more. In addition, pregnant women with hypertension or other medical conditions should receive advice from their doctor about when and how to exercise.

On the Move
There is an abundance of exercise options available to pregnant women. Low-impact activities are highly recommended, such as swimming or walking. Participation in a walking program is convenient as it can be integrated readily into daily schedules. A vast array of classes may also be available in the community ranging from prenatal yoga and Pilates classes to low-impact aerobic or toning classes. Again, pregnant women should consult their doctor prior to beginning any exercise program.

Through Newborn Connections at California Pacific Medical Center in San Francisco, CA, we offer a progressive 60-minute exercise class that is led by PTs with advanced training in obstetrics, musculoskeletal issues and women's health. The class consists of a gentle warm-up, followed by low-impact aerobics. After cool-down, strengthening exercises with free-weights or resistive bands are performed as well as stretching and flexibility exercises.

"I have felt more energy doing these exercises," stated Jessica Sterling, a participant in the class who is 39 weeks pregnant. Another participant, Irina Kaploun, is 25 weeks pregnant and shared, "It makes me feel good that I am able to do something active while pregnant."

Throughout the class, pelvic floor exercises are performed using Kegels, which isolate the pelvic floor. In addition, expectant mothers use resistive bands attached to exercise balls while doing various movements in a standing position to provoke concentric adductor and gluteus medius strengthening with a focus on tightening the transversus abdominus muscles. This is a more functional approach, which engages the pelvic floor using an overflow technique from these muscles. The PTs also provide the participants with education in proper body mechanics and help bring awareness to the postural changes occurring throughout pregnancy.

Barring any contraindications, pregnant women can benefit greatly from most forms of exercise. As PTs, it is our job to consider the overall health of the patient and recommend the best and safest exercise program for an expectant mother and her unborn child.

References
1. Herman, H. (2003). Pregnancy and Postpartum Clinical Highlights. Course notes. Las Vegas, NV.

2. ACOG Committee Opinion No. 267. (2002). Exercise During Pregnancy and the Postpartum Period, (99)1.

Amy Wilusz is a physical therapist at California Pacific Medical Center Outpatient Physical Medicine and Rehabilitation and Newborn Connections in San Francisco, CA.