Antenatal exercise: a personal perspective Sylvia Baddeley

For most teachers, training, was a two-hour session with a physiotherapist, who taught how to teach breathing techniques for labour, pelvic tilts, knee rolling and how to improve posture throughout pregnancy.

syMa Badde~y NNEB, SCM, ADM, Lecturer on Ante and Postnatal Module, Ante and Postnatal Exercise Training Module, North Staffs Hospital Trust

Antenatal exercise sessions are offered to pregnant women in a variety of ways by different professional groups. These include midwives, physiotherapists, swimming teachers, trained and non- trained exercise instructors. Several questions have to be asked. Have these exercise sessions kept apace with the demands of fit healthy pregnant women who wish to carry on exercising throughout their pregnancy? Are there contraindications? Who should teach the women? Is the research information now available and incorporated into advantageous exercise sessions that help pregnant women cope with the massive physiological adaptation that occurs throughout pregnancy and the postpartum period? This paper presents an overview of what is currently available and attempts to establish a framework for standard setting and teacher training. This would ensure uniformity of knowledge, prevent conflicting advice and give opportunity for interprofessional liaison and development.

INTRODUCTION

The word 'complementary' is defined in the Oxford Advanced Learner's Dictionary as 'com- bining well to form a balanced whole'. Within this holistic context, exercise at any stage of life requires the balance between mental, social, physical and medical well-being.

As an educator o f the family unit, preparing families for the birth and subsequent care of their baby, I am responsible for giving advice about changes in life and how to adapt to the physiological changes that are imposed on a woman's body throughout pregnancy and the

early postnatal period. The advice given to pregnant women on exercise has changed little since the turn of the century. Berkeley (1920) stated:

'the pregnant woman should lead as quiet a life as possible. She should have plenty of fresh air and take walking exercise daily, how far she should go varying with each individual, but at any rate it should be not far enough to cause fatigue. In addition, should the opportunity occur, she may motor or take carriage exercise; whilst if she is unequal to outdoor exercise then regular exercise in some other form which will strengthen the abdominal muscles should be taken. This may be done daily as follows; having divested herself of most of her cloth- ing, she should lie on the floor, a rug inter- vening, and there with arms folded across the chest, raise herself into a sitting posture for several times in succession'.

Until the latter part of the 1980s' exercises taught in parentcraft sessions throughout the UK consisted only of pelvic tilts (very valuable but contraindicated if taught lying flat on the back), knee rolling (again taught flat on the back) to work internal and external oblique muscles which form part of the abdominal corset and ankle rotations to mobilize the ankle joint. For most teachers, training, was a two- hour session with a physiotherapist, who taught how to teach breathing techniques for labour, pelvic tilts, knee rolling and how to improve posture throughout pregnancy. The emphasis was mainly on preparation for labour, not on how to adapt to physical activity that took into account the limitations caused by the physio- logical changes of pregnancy.

The rise in interest in health-related fitness has posed questions for pregnant women and professional carers alike. Many women of child-bearing age are actively involved in con- tact sports, participate in circuit training, or attend fitness classes. They may wish to con- tinue horse riding, continue with an advanced step class, cycling or jogging. When pregnant women ask the question 'Can I continue?' or motivated pregnant non-exercisers want to start, how should professionals advise them?

MODIFICATION OF EXERCISE PROGRAMMES TO ENSURE SAFETY OF THE FETUS

In the first trimester the hormone relaxin softens ligaments and supportive soft tissue (Brooks & Fahey 1984) thereby reducing stability of joints throughout the body. This is desirable obstetri-

Complementary Therapies in Nurs/ng & M/dw/fety (1996) 2, ~ 8 �9 1996 Pearson Professional/td

4 Complementary Therapies in Nursing & Midwifery

cally, as a little more give within the joints of the pelvic girdle allows more room for manoeuvering when the baby enters the pelvic girdle, engages and settles into the delivery position (usually head down). The increase of body weight, lordosis and change in centre of gravity all produce more stress for joints around the body. Any exercise, there- fore, must take into account the increased dangers to joints, especially in the pelvic girdle and spine. There should be no impact during exercise re~mes, as this would be transmitted through the joints and the momentum of increased body mass would make it more difficult to control direction and pace of movement. 1Lelaxin also affects the stretch part of a fitness class. In non- pregnant exercisers, emphasis is laid on taking a joint beyond its normal range of movement in order to stretch the attached muscle. These manoeuvres promote flexibility around a joint and decrease the likelihood of injury during normal everyday activities and sport. The effect of relaxin can destabilize joints in the pregnant exerciser. As lig- aments have a poor blood supply it may be months before the ligament returns to its pre- stretched normal length and gives joint stability once more (Lamb 1978). Although relaxin is pro- duced by the corpus luteum (on the ovary) from just two weeks' gestation and then by the placenta from 8-10 weeks' gestation, the effects linger postnatally for 3-5 months, even though the pla- centa is delivered after the baby. Therefore, post- natal classes should be structured with the effects of relaxin in mind, i.e. they should be minimal impact with maintenance stretch techniques and emphasis on pelvic floor exercise and abdominal work adaptations.

As pregnancy progresses, increased weight (19 kg on average) enlarging girth and continu- ally changing centre of gravity changes, con- tribute to the pregnant woman's becoming more clumsy and less coordinated. The pace at which she moves and the time given to change direction are important considerations when planning an aerobic component performed to music. The American College of Obstetricians and Gynaecologist's Guidelines for Exercise During Pregnancy and Postpartum (ACOG 1991) state that maternal heartbeat should not exceed 140 beats per minute and strenuous exercise activities should not exceed 15 rain duration. Research suggests that there may he a shunt of blood away from the uterus in order to supply oxygen to larger muscle groups demanding more oxy- gen during aerobic work (e.g. the quadriceps or group of thigh muscles) (McMurray 1993). Deep flexing or extension of joints should be avoided because of connective tissue or liga- ment laxity caused by relaxin. Also all jerky movements should be avoided. No exercise should be performed in the supine position after the fourth month of pregnancy.

BENEFITS OF EXERCISE

The benefits of exercise during pregnancy have been highlighted by numerous studies. Positive effects on the cardiovascular system (Astrund & Rodahl 1979), coagulation (Williams et al 1980), plasma (Goldberg & Elliot 1985) triglycenides and mental well-being (Blumenthal et al 1982, Jonoski et al 1981) have been noted. Regular participation in exercise should have the same positive effects for both pregnant and non- pregnant women. For example, during preg- nancy, exercise may decrease the physical dis- comforts a woman experiences, resulting in decreased use of medication (Reid 1983) and a more positive view of her pregnancy (Glazer 1980). Also, exercise may improve a pregnant woman's self-esteem, thereby contributing to a more positive birth and future mother-child relationship (Lederman et al 1979, McDonald & Christakos 1963, Moore 1978, Weinberg 1978).

In order to adapt to her changing shape and to help her cope with the demands of everyday living, a comprehensive exercise programme for the pregnant woman should include instruction on postural change and the hows and whys o f achieving correct posture. Any muscle groups that will help her achieve this more successfully should be strengthened with appropriate exer- cises. For example, strengthening the different muscle groups in the legs will help her to bend her knees, not her back, when bending and lift- ing. Using the quadriceps, hamstrings, gastroc- nemius, muscle groups will place less stress on her back and pelvis. Round shoulders are com- mon in the pregnant woman, related to increase in breast size and weight and caused by changes in centre of gravity. Shoulder retractions (con- traction of the trapezius muscle between the shoulder blades) will not only help strengthen the upper back but also help to improve posture and stance. Aerobic work should be low impact, about 15 min duration, and should not raise the pulse higher than 140 beats per min. This immediately creates a problem for most fit- ness teachers as their aerobic sessions or step classes are usually longer than this. Aerobic work for the pregnant woman should be viewed as maintenance work and not be pur- sued as an attempt to increase cardiovascular fit- ness, as would normally be expected for a class aimed at the general public. This poses the question of whether a pregnant woman is safe exercising in a class that is not specifically struc- tured for her. The section of an exercise class that aims to improve muscular strength and endurance, aimed at specific muscle groups should he adapted accordingly Particular atten- tion should be placed on body position, tech-

Antenatal exercise: a personal perspective 5

nique, number o f repetitions (pregnant women tire more easily), alternatives and reducing work load as pregnancy progresses. Press-ups per- formed on the floor during the first trimester may need to be performed standing against a wall in the third trimester, or sooner if carpal tunnel syndrome (tingling and numbness in the hands and fingers) is present.

The benefits o f exercise during pregnancy are now being recognized and highlighted by a number o f researchers. The mare objectives o f ante- and postnatal exercise classes should be:

�9 to increase the pregnant woman's awareness and body control and help promote correct posture

�9 to maintain and promote circulation around the body. Specific exercises relating to pregnancy, i.e., pelvic floor contractions, exercising pectorals to help support increased breast tissue should be incorporated into their exercise routines.

Attention should be paid to tailoring the intensity of exercise to different stages of ante- and postnatal work. A regular exercise pro- gramme two or three times per week, specifi- cally tailored to take into account the limita- tions o f pregnancy, helps in maintaining mobility and teaching body awareness. Minor ailments of pregnancy, i.e. varicose veins, haemorrhoids and morning sickness, are reported less by regularly exercising pregnant women. They also report improved sleep pat- terns, particularly within the third trimester.

Screening

Any pregnant woman who attends any exercise class should be screened by the teacher before participation Box 1.

Are there any problems in past pregnancies, present pregnancy or in conceiving? Are there i n j u r i e s - any joint, muscle, bone, back? Any medical problems, - - diabetes, epilepsy, heart disease, high blood pressure? Is any medication being taken?

The exercise teacher should evaluate on screening each individual who wishes to exer- cise during pregnancy. The following condi- tions may contraindicate vigorous physical activity. These are taken from the American College o f Obstetricians and Gynaecologists Guidelines (ACOG 1991) Box 2.

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�9 High blood pressure

�9 Anaemia or other blood disorders

�9 Thyroid disease

�9 Diabetes

�9 Cardiac arrhythmia or palpitations

�9 History o f precipitous labour

�9 Intrauterine growth retardation (smaller

growth than expected during

pregnancy) �9 Bleeding during pregnancy

�9 Breech presentation during the last three

months of pregnancy �9 Excessive obesity

�9 Extreme underweight

�9 History of three or more spontaneous miscarriages

�9 Ruptured membranes ('waters' broken

or draining)

�9 Premature labour

�9 Diagnosed multiple pregnancy (twins,

triplets)

�9 Incompetent cervix or neck of womb

�9 Diagnosis of placenta praevia

�9 Diagnosis of cardiac disease

Any of the following symptoms and signs should indicate the women to stop exercising and seek advice from her midwife or doctor:

�9 Pain �9 Bleeding �9 Dizziness �9 Shortness o f breath �9 Palpitations �9 Faintness �9 kapid pulse/resting �9 Back pain �9 Public pain �9 Difficulty walking

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STRUCTURE OF THE CLASS

All parts of the class should be structured specif- ically to take into account the physiological changes induced by pregnancy and the limita- tions that they impose, thus very specific train- ing in ante- and postnatal exercise should be mandatory for the exercise teacher working in this area of expertise Box 3.

6 Complementary Therapies in Nursing & Midwifery

Leisure centres and swimming pools offer water-based exercise for the pregnant woman.

ii iiiii iii iii iii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii Warm-up

�9 mobilize joints �9 pulse rate �9 short stretch

Cardiovascular work Muscle strength and endurance

�9 target specific muscle groups and exercise appropriately

Cool-down �9 stretch out exercised muscle group

Relaxation Short mobilizer

ANTENATAL EXERCISE CLASSES

Many 'traditional' parentcraft sessions are still being offered where exercises o f a very limited nature are performed on the floor, on a blanket. The exercising body is not viewed as a holistic unit, and a fragmented approach, i.e. ankle rotation and pelvic floor exercises is still taught by many midwives in health centres or hospital centres.

A number of midwives around the country have attended post basic training sessions on exercise during pregnancy, the length of courses varying from 2 to 5 days, using music as a motivator. The content and quality o f these courses vary from area to area depend- ing on the course leader's qualifications, expertise and experience in teaching people h o w to teach exercise, a very different concept f rom teaching an exercise class.

Because o f the interest in health-related fitness, a number o f midwives have obtained their Exercise to Music Teacher 's Certificate. A number o f organizations are validated by the Royal Society o f Arts, e.g. London Central Young Men's Christian Association (YMCA). Having obtained extensive knowledge and practical experience in teaching the general public exercise, this training has been fol- lowed-up by a further module on ante- and postnatal exercise with practical and theoreti- cal examination passes required to teach exercise to pregnant and postnatal women.

Leisure centres and swimming pools offer water-based exercise for the pregnant woman. Aquanatal exercise was introduced in Stoke-on-Trent , U K in 1987 and has been enthusiastically used by many pregnant women , some o f w h o m are now attending in their second or third pregnancy. Many mid- wives have attended specific training events

in order to offer the aquanatal service to their pregnant clients. Water-based exercise offers many advantages to the pregnant women. The structure o f the class would be the same as land-based exercise classes, but benefits are that there is less stress on joints, and exercise is possible for individuals with limited mobil- ity. The haemodynamic changes o f preg- nancy affected by immersion may put less strain on uterine blood flow than land-based exercise and the 'resistance' factor o f water enhances the effects o f exercise. Chroic backache is often relieved as the weight o f the uterus is temporarily supported during immersion. W o m e n feel lighter and more graceful, leading to improved self-esteem.

There are inherent benefits in exercising during pregnancy by maintaining muscle tone, strength and endurance, and protecting against back pain. Positive effects are noted in the improvement o f m o o d and self-image. In the postpartum or postdelivery period, potential back pain and injury remain a sig- nificant problem for many women , as the daily care o f a young infant involves repeated bending, lifting and carrying. O f great bene- fit would be an exercise programme that incorporated back, leg and abdominal strengthening exercises as well as utilising the pelvic tilt and pelvic floor exercises.

A N A T I O N A L F R A M E W O R K

The way that antenatal and postnatal exercise programmes are introduced and offered may have far-reaching consequences that will influence the uptake or rejection o f such ser- vices. Midwives and other professionals have a unique opportunity to influence the 'Health o f the Nat ion ' . Prolonged contact with the family unit, places us in a position to influence their out look on healthy lifestyles. Improving the midwife's knowledge o f exercise during pregnancy would allow an enhanced service to be offered and enable further referral to suitably qualified trainers if needed. This should be a prime objective, not only on an individual professional basis, but it should also be encouraged to develop at a national level.

Midwives, physiotherapists and fully trained exercise to music teachers who have completed a specialist module o f training for teaching antenatal and postnatal exercise nationally, are appropriate choices. Other groups are also showing interest, such as health visitors and swimming instructors. Physiotherapists and midwives with varying levels o f expertise and practice in health

Antenatal exercise: a personal perspective 7

Motivated midwives and professionals are eagerly grasping any training initiatives.

'Combining well to form a balanced whole'

related fitness are teaching practical classes to pregnant women . Trained and untrained exercise teachers are also teaching exercise to music classes, some in partnership wi th a midwife, some not.

STANDARDIZATION OF TRAINING COURSE C O N T E N T

Courses vary in length (halfa day to 3 -5 days). I f the professional wishes to offer an antenatal or postnatal exerc ise- to-music session, land- site or water-based, there should be an agreed modular structure that incorporates knowledge on heal th-related fitness pr inci- ples structure o f a fitness class and (under- standing principles o f warm-up , cardio- vascular work , muscular strength and endurance and stretch principles and impl ica- tions). Knowledge o f h o w muscles work and o f how the body reacts during exercise is vital. Teaching the posit ion, technique, cor- rect ion points, alternatives and contraindica- tions must form a major part o f the training module . The physiological l imitations that pregnancy imposes on exercises and the impor tance o f screening are all vital ingredi- ents o f any in t roductory course encompass- ing exercise and the pregnant woman.

Motivated midwives and professionals are eagerly grasping any training initiatives. Midwifery managers want to develop these sessions for their communi ty sector or hospital bases. Trusts are aware that offering specially designed exercise classes for pregnant women may enhance uptake o f their services. The diversity o f courses and their contents can only lead to an inadequate, uncoordinated service, with varying degrees o f competencies and knowledge. The exercise world boasts some excellent training organizations (London Central Y M C A , U K at the forefront) and some training courses such as 'Fit to Perform' based in London, incorporate a 'Taster ' session on the complexities o f pregnancy and exercise that attempts to introduce the subject into their 100-hour teacher training course in order to educate exercise teachers that this is a specialist area that needs specific training.

There seems to be no defined professional who is responsible for teaching ante- and early postnatal exercise. Midwives, physio- therapists, exercise teachers, swimming teach- ers, leisure centre employees and individuals not holding a nationally recognized teaching certificate are all involved in different ways in teaching our pregnant and delivered women . Such fundamental principles o f health-related fitness are in great danger o f being c ompro - mised by our o w n lack o f a national structure.

THE WAY FORWARD

In o rder to mon i to r , modera te and deve lop a modu le o f t ra ining that adequately p re - pares the professional to teach exercise safely to pregnant w o m e n , a core group o f expert ise taken f rom the exercise, m i d - wifery and phys io therapy wor ld should be responsible for taking this service forward into the year 2000. C o m p e t e n c y based cr i- teria should be deve loped wi th in a f rame- w o r k that covers core elements. Linking modules cover ing o ther aspects such as muscle strength and endurance p r o - grammes, aerobic work , wa te r -based work , wou ld be a natural progression. Standardizing course content , quality and quant i ty o f informat ion and fulfiling the s tatutory t raining requi rements o f m i d - wifery practice that demand that the m i d - wife and any o ther professional are ade- quately trained before embrac ing any new clinical skill is paramount .

' C o m b i n i n g well to form a balanced who le ' is a truism that defines not only the word ' complementa ry ' but also the profes- sional need to be competen t and cohesive. The professional bodies at the Roya l Col lege o f Midwives and within the English Nat ional Board, need to treat this p rob lem as a matter or urgency.

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FURTHER INFORMATION

For further informat ion on training courses please contact: London Central Y M C A Tra in ing and Deve lopmen t Depar tment , Great Russell Street, London, UK, who tai- lor modules o f training for different profes- sional groups. Also contact the author at The N o r t h Staffs Materni ty Hospital , Hi l ton R o a d , Harpfields, S toke -on -Tren t , Stafford- shire, U.K.

REFERENCES

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Astrund P, Rodahl K 1977 Textbook of work physiology. New York, McGraw-Hill

Berkeley C 1920 A Handbook of midwifery, 5th ed., Cassell and Company

Blumenthal J A, Williams R S, Needels T L et al 1982 Psychological changes accompanying aerobic exercise in healthy, middle aged adults. Psychosomatic Medicine 44:529-536

Brooks G A, Fahey T D 1984 Exercise physiology: human bioenergetics and its applications. John Wiley and Sons, New York

8 Complementary Therapies in Nursing & Midwifery

Glazer G 1980 Anxiety levels and concerns amongst pregnant women. Research in Nursing Health 3: 107-113

Goldberg L, Elliot D L t985 The effect of physical activity on lipid and lipoprotein levels. Medical Clinicals of North America 69:41-55

ReidJ D 1983 Effects of selected OTC medication on the unborn and newborn. Nurse Practitioner 8 (9): 43-50

Jasnoski M A, Holmes D S 198l Influence of initial aerobic fitness\aerobic training and changes in aerobic fitness on personality functioning. Journal of Psychosomatic Research 25:553-556

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Lederman R P, Lederman E, Worth B A et al 1979 Relationship of psychological factors in pregnancy to progress in labour. Nurse Research 28:94 97

McDonald R L, Christakos A C 1963 Relationships of emotional adjustment during pregnancy to obstetrical complications. American Journal of Obstetrics Gyuaecology 86:231-347

McMurray R Ge t al 1993 Recent advances in understanding maternal and fetal responses to exercise. Medicine and science in sports and exercise, p. 1309

Moore D S 1978 The body image in pregnancy. Journal of Nurse-Midwifery 22 (4): 17-27

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Williams R S, Logue E E, Lewis J G 1980 Physical conditioning augments the fibrinolytic response to venous occlusion in healthy adults. Northern England Journal of Medicine 302:987-991

R E C O M M E N D E D R E A D I N G

Baddeley S, Green S 1991 Are midwives fit to teach? Modern Midwife 1 (3): 14-15

Baddeley S 1991 Health related fitness during pregnancy. Modern Midwife 1 (3): 16-17

Baddeley S, Mowbray C 1988 YMCA guide to exercise to music, Pelham Books

Calguneri M, Bird H A 1982 Changes in joint laxity during pregnancy. Annals of the rheumatic diseases. Wright 41:126--128

Fishbein E, Phillips M 1990 How safe is exercise during pregnancy? Journal of Obstetrics, Gynaecology and Neonatal Nursing 19 (1): 45-48

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Noble E 1985 Essential exercises for the childbearing year. John Murray

Wallace A M, Dan A 1986 Aerobic exercise, maternal self esteem. Boyner, and physical discomfort during pregnancy. Journal of Nurse-Midwifery 31 (6)

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WhiteJ 1992 Exercising for two - what's safe for the active pregnant woman? The physician and sportsmedicine 20 (5)