A Q U A N A T A LG U I D E L I N E SA Q U A N A T A LG U I D E L I N E S

Guidance on antenataland postnatal exercises in water

Association of Chartered Physiotherapists in Women’s Health (ACPWH)ACPWH Website www.acpwh.org.uk

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1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Benefits of aquanatal exercise . . . . . . . . . . . . . . . . . . . . . . . . 3

3 Practical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4 Safety considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Instructing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

7 Principles of teaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

8 Components of the class . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

9 Choreography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Postnatal exercise in water . . . . . . . . . . . . . . . . . . . . . . . . . 10

11 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

12 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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Published by Association of Chartered Physiotherapists in Women's Health© Copyright 2010

For review 2016

If the physiotherapist (or other person leading the class) is not a member of ACPWH shemay find it beneficial to discuss the content of the class further with an obstetric

physiotherapist. If there is no local member, inquiries may be sent to:ACPWH Administration, Fitwise Management Ltd,

Blackburn House, Redhouse Rd, Seafield, Bathgate, West Lothian EH47 7AQ01506 811077 E: info@fitwise.co.uk

or visit the ACPWH website at www.acpwh.csp.org.uk

1. IntroductionThese ACPWH guidelines are aimedprimarily towards physiotherapistsworking in women’s health. It is hopedthat they will also be of use to other healthprofessionals such as midwives, healthvisitors and aerobics teachers who wish toestablish new aquanatal classes or areinstructing for the first time. It is stronglyrecommended that new instructors attendan approved training course for aquanatalleaders (details in health magazines orwebsites). Instructors should comply withlocal Trust/Sports Centre requirementsregarding life saving qualifications. Theresponsibility for the class members in anemergency situation has to be determinedin consultation between those professionstaking part and the pool management.There should be a written protocol with anannual review.

It is assumed that professionals using theseguidelines will be teaching women in theirchildbearing year (from 3 months pregnantto 3 months after her baby is born). It would,therefore, be an advantage to use theseguidelines in conjunction with the ACPWHbooklets on safe exercise in pregnancy,following childbirth and pregnancy-relatedpelvic girdle pain (see appendix).

Aquanatal classes are very popular. Theleader of an aquanatal class needs anunderstanding both of the physiology ofpregnancy and of the teaching of safeexercise in water. Women’s healthphysiotherapists with experience in bothobstetrics and health education are anobvious choice as instructors. ACPWHrecognizes that it is essential that these

physiotherapists should share theirexpertise with other health professionals.The guidelines should ensure that classesconform to basic standards of goodpractice.

2. Benefits of aquanatal exerciseThe benefits of exercise in water are many.Water gives a sense of wellbeing andrelaxation. Pregnant women may feellighter and have greater freedom ofmovement. Since most water-basedmovement involves concentric muscleactivity, there is little or no soreness in themuscles after exercise in water. Thewomen may well notice that they havemore energy after the session and sleepbetter. There are also importantphysiological advantages, which will notbe so immediately obvious. As the womenare exercising in a supportive mediumthere is less risk of injury or the jarring ofjoints. The hydrostatic pressure of thewater may reduce lower-limb oedema andstimulate bowel function and improverespiratory function. Diuresis is increased(see 7.2). Cardiovascular fitness andmuscle tone can be increased. Abdominaltone and posture can be improved.Exercise in water during pregnancyreduces pain intensity and as well as sickleave related to back and pelvic painduring pregnancy. Buoyancy is utilized toassist or resist exercises and to supportbody weight (see 7.2).Aim for maintenance of fitness level ratherthan great improvement.Time should be allowed after the sessionfor the class to get together and to have adrink before leaving. This can be a very

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good opportunity for problems to beraised and for health education topics tobe discussed. Finally, it should not beforgotten that aquanatal classes should besociable, friendly, entertaining and fun!

3 Practical considerations3.1 VenueAquanatal classes may be held in a publicswimming pool, sports and leisure centreor in a hospital-based hydrotherapy pool.

3.2 Pool temperatureThe temperature in the pool should bebetween 28C and 32C. Exposure to watercolder than 28C will make the womenshiver in order to maintain coretemperature. If the water is warmer than32C they may suffer from hypotension,fainting and excessive fatigue. Thehydrotherapy pool may often be heated upto 35C so additional care should be takenin this setting especially as women,especially when pregnant, react differentlyto excessive heat.

3.3 PrivacyA private session ensures a minimum ofdistraction. A good working relationshipbetween pool managers and the aquanatalleader is essential. Any problemsencountered by either party can be rapidlynotified and prompt action taken.

3.4 EquipmentUseful equipment includes woggles, floats,boards, table-tennis bats, balls, and swimcollars. Some of these are usuallyavailable from the pool. No equipmentshould be introduced to the pool withoutprior permission from the pool manager.

3.5 Food and drinks

Dehydration should be avoided and soaccess to drinks should be encouragedafter the session. If drinks are not availableat the pool, the participants should bringtheir own. Participants should be advisedto eat a light snack one hour before theclass. The time taken over drinks can beused to very good effect for healtheducation, drawing on the expertise of thecourse leaders.

3.6 Rest room/medical room

A room should be available in case ofneed. If a midwife is in attendance sheshould be responsible for the medicalneeds relating to the pregnancy of thewoman.

3.7 Cost

This should be negotiated with the poolmanager/hospital trust before theprogramme begins. Some public poolsmay offer a special price to includeadmission and a drink after the class.

4 Safety considerations4.1 Records

Records of each member of the classshould be kept carefully, including dates ofattendance, home address, telephonenumber, parity, estimated date of delivery,name and address of the GP or consultantand contact telephone number. Anyabnormality should also be noted.

4.2 Contraindications

The contraindications must be explainedto the women (as in section 5).

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4.3 Continued screeningAt every session the leaders should checkwith each participant that there has beenno change in her condition since her lastattendance.

4.4 SupervisionThe member(s) of the teaching teamshould be in attendance at all times, with alifeguard if appropriate (see 6.1). Onemember of the team should accompanythe first woman who leaves the pool, andthe other should remain at the poolsideuntil the last leaves.

4.5 Special needsThe pool attendant must be made awareof anybody who has special needs. Oneextra observer may be required if aparticipant gives any cause for concern(for example, epilepsy).

4.6 First aidThe leaders should know the location ofthe first aid box and telephone. A protocolshould be in place for occasions when aparticipant might feel unwell, and thewomen must be made aware of thisbefore they enter the pool.

4.7 Distress signalsIt should be emphasized to theparticipants that if one of them feelsunwell she should raise one arm as asignal, so that one of the leaders mayreach her quickly. The leader(s) shouldknow how to raise the alarm at thepoolside and be familiar with emergencyprocedures (see 6.1). If an emergencysituation arises the pool must always becleared immediately of class members.

4.8 Slippery surfacesThe leaders should check for slipperysurfaces, as balance may be impairedduring pregnancy. The women may wishto wear ‘slipper socks’ in the pool to avoidslipping. The pool's normal rules, forexample those forbidding running, eatingsweets or chewing gum in the pool,should be observed.4.9 TemperatureThe temperature of the pool should bechecked before the class (see 3.2).4.10 No jumping into poolThere should be no diving or jumping intothe pool.4.11 OrientationThe layout of the pool should be explainedto the women before they enter the water.4.12 Drinks after the classAfter the class a drink, either a hot drink ora fruit juice, is necessary to restore thewomen's blood-sugar level. The time takenover drinks also allows the women's bloodpressure to readjust. Allow 10 -15 minutesfor homeostasis to re-establish.

5 ScreeningEach participant should be screened at herfirst class. It should be ascertained whetherthe woman can swim or has concerns aboutwater. The course leader(s) should gothrough the contraindications of exercise inwater with each woman to ensure that sheunderstands them. The women shouldappreciate the need to report any change intheir condition, since the previous class, tothe course leader(s) at the start of eachsession (see 7.4). Any problems encounteredduring the exercise class should be reported

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immediately. These symptoms includepalpitations, tachycardia, SOB, pain, ordizziness. Blood pressure should be taken ifthere is any cause for concern. In this casethe woman should be referred back to herGP/midwife. If the diastolic pressure is eitherbelow 50 mm Hg or above 80 mm Hg it isnormally inappropriate for a woman toparticipate in an aquanatal class. In the caseof hypertension the woman might bereferred from a consultant managementscheme as exercise is thought to bebeneficial. However, it is not so much theabsolute pressure levels, rather a change inthese, which may indicate the need for closermonitoring.

Contraindications include:

• heart disease• infections such as bronchitis, influenza,

ear, nose and throat, D&V and viruses• urinary or vaginal infection• some skin diseases or open wounds• active TB• continuing bleeding especially per

vaginam• incontinence - if the loss is significant

then the woman should discuss hercondition with the instructor.Note that if the woman complains of asudden onset of urinary leaking, it mightactually be loss of amniotic fluid andshould be checked

• leakage of amniotic fluid• poorly controlled diabetes or epilepsy• chlorine or bromine allergy

Screening should aim to identify contra-indications and precautions with aquanatalexercise. These include:

• Musculoskeletal dysfunction (Low backpain, Pelvic girdle pain and neck andupper back pain)

The physiotherapist or the healthprofessional teaching the class should beable to modify or suggest alternativeexercises.• Respiratory conditions• Vertigo• Nausea

Explicit approval of the consultant shouldbe obtained before accepting women intothe class if they demonstrate:• significantly high or low blood pressure

(see above)• a history of miscarriage or premature

labour• cervical suture• bleeding P.V.• low-lying placenta

Neither epilepsy nor diabetes, if wellcontrolled, need exclude a woman fromaquanatal exercise, though these womenmay prefer to have a friend or familymember with them in the pool to alert staffof any problems. All staff involved in theclass should be aware of any woman withspecial needs.Refer to ‘Good Practice in Hydrotherapy’guidelines for more information. (seeappendix).Participants should be advised not to swimimmediately before, or directly after, theirfirst class so that they can assessaccurately the benefits, or otherwise, ofthe class. Many women are surprised atthe level of fatigue they may experienceinitially.

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6. Instructing6.1 The TeamWhere possible, two qualifiedprofessionals should lead an aquanatalclass; a women’s health physiotherapistand a midwife make an ideal combination.The physiotherapist and midwife maydecide to run a ‘joint’ session where eachhas responsibility for part of theprogramme.When two or more professionals areinvolved, it is recommended that protocolsare written outlining specificresponsibilities for each healthprofessional. A qualified lifeguard shouldalways be present to be responsible for alllifesaving duties in the public pool. Localpool regulations must be observed. In thehydrotherapy pool the leader(s) shouldfollow their own local Trust policies andprocedures. The instructor should bequalified in life saving techniquesaccording to local requirements and befamiliar with safety protocols including firealarms, fire exits and emergencyprocedures (see 4.7).6.2 Number of participantsThere must be at least one leader to everyten women in a session; an ideal groupwould have two leaders and no more thanfifteen women. Check for local guidelinesand local requirements.

6.3 InsuranceA chartered physiotherapist who isteaching a class has insurance coverunder her subscription to the CSP.Midwives and other professionals shouldcheck the insurance cover provided undertheir own professional registration. A

public pool is usually well insured, but thisshould be checked. Whoever is givinginstruction is personally accountable forthe safety of the exercises.

6.4 ReferralA woman may be referred to an aquanatalclass by a hospital consultant, generalpractitioner, physiotherapist, midwife orhealth visitor, from a parentcraft class orantenatal clinic, or she may refer herself.Advertisements in GP surgeries, antenatalclasses, health clinics and leisure centresmay attract women to participate in theclass, but careful screening of everywoman is necessary to ensure her safety.

7 Principles of teaching7.1 Aims and ObjectivesThe physiotherapist who becomesinvolved in teaching exercise classesshould have a clear idea of the aims andobjectives of the class and a workingknowledge of safe exercises for thewoman in her childbearing year. Inaddition she would be well advised toparticipate in a training course foraquanatal leaders.Once the venue for the class is found andits benefits and limitations assessed theclass may start.

7.2 The PrinciplesThe principles of teaching water-basedexercise are broadly similar to those ofteaching exercise on land, for example –giving exercise safety points, frequentteaching points, clear demonstrations ofexercises, correct phrasing (music).However, it must be remembered that theexercises which are chosen and the speed

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and range of movement gained whenperforming them, are affected by basichydrotherapy principles.Note that: The depth of the startingposition will affect ability and range ofmovement (see 7.6).Other factors such as buoyancy,turbulence and streamlining will changethe effect of the exercise.Buoyancy can assist or resist movement.Using buoyancy-assisted exercise reducesweight bearing on the joints and mayallow a greater freedom and range ofmovement – floats may be used.Buoyancy-resisted exercises with orwithout floats, can be used for musclestrengthening.Turbulence is created when limbs moveagainst the resistance of the water. Thefaster the movement the more difficult itbecomes and increased strength andcontrol are needed.Streamlining can make certain exerciseseasier or more difficult. Moving the armthrough the water leading with the edge ofthe hand is easier than with the palmfacing the direction of movement. It ismore difficult still when a float is held inthe hand.Hydrostatic pressure is another positivefeature of water-based exercise as thepressure assists venous return and can beof help with moderately swollenextremities. However, diuresis will alsoincrease and pregnant women may needto leave the pool to urinate during theclass. Care must be taken leaving andentering the pool with procedures in placeto ensure safety.

7.3 Acoustics and visibilityAcoustics in swimming pools arenotoriously poor. When demonstrating anexercise, a leader should speak clearly,slowly and loudly enough for everyone tohear. The class will find it easier to followher, and she will be better placed toobserve it, if she is on the poolside ratherthan in the water. Observation by theinstructor is most important. It is obviouslymore difficult to spot poor quality ofmovement under water which is rippling.Verbal correction of exercises performedincorrectly should be followed by repeatingprecise vocal and physical demonstrationsof the exercise and then by using eyecontact with an individual if necessary.

7.4 HypermobilityExercises involving excessive hipextension should be discouraged so as toavoid an increase in lumbar lordosis,though gluteal strengthening exercises canbe taught with care. Breast stroke shouldbe avoided so as to prevent neckextension. Using a breast stroke leg actioncould exacerbate or provoke pelvic jointpain. Care should be taken with abductionand adduction against resistance as inwide side stepping exercises and lowsquats. Women should be reminded tostop and inform the class leaders if anyexercise causes discomfort. If musculo-skeletal discomfort is experienced after theclass or the next day, the instructor shouldbe informed before the next class is begun(see 5).

7.5 SpacingThe members of the class should be wellspaced in the pool.

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7.6 Depth of waterIdeally, the depth of water should be suchthat its surface is at the level of thexiphisternum. This does not compromisebalance or produce a drag on breasttissues. Very shallow water preventsexercises from being performed properlyand if the water is too deep the womenmay find movement too difficult and alsofind it hard to keep their feet on thebottom of the pool.

7.7 FatigueExcessive fatigue and undue shortness ofbreath should be avoided. The optimumlength of a session is 45-60 minutes. Someleaders may wish to include a shortrelaxation session if the temperature of thewater is warm enough (see 8).

7.8 HypothermiaIn order to avoid hypothermia thereshould be no prolonged standing in or outof the pool. The women should be advisednot to get the tops of their heads wet, asthis increases the loss of body heat.Towels can be left at the pool side andwarm showers must be available.

7.9 Alternative exercisesIt should be stressed to the women thatthey need not do any exercise with whichthey are unhappy or uncomfortable. Theinstructor should be prepared to offer analternative.

7.10 ClothingThe leader should wear comfortable, coolclothing as she is likely to become veryhot. Flat, non slip shoes should be worn tocomply with pool regulations. Clothessuch as shorts and t-shirt allow the

participants to see the correct bodyalignment of the demonstrator.The participants should wear a bathingcostume or bikini and t-shirt.

8 Essential componentsIt is suggested that every class shouldincorporate the following components:

1 Posture check, possibly before enteringthe pool, with tips on maintaining itcorrectly in the water. Continue withposture checks throughout the class

2 Warm-up in the water3 Aerobic exercises4 Breathing awareness5 Strengthening and endurance of

relevant muscle-groups6 Co-ordination activities7 Stretch. Stretches should involve all

muscle groups used in section 58 Relaxation (optional). If the participants

are warm enough in the water this canbe an enjoyable way to end the class

9 Posture check on transferring fromwater to dry land

10 Pelvic-floor muscle exercises. Thesecan be taught in the water but, if not,then an ideal alternative time is duringthe coffee break. This also allows anopportunity for the women to talk,either to each other or with theinstructor, about any problems theymay have (see section 2)

9 Choreography9.1 Exercise to MusicA degree of skill and practice is requiredto match the pace of teaching exercises toparticipants in water rather than on land

particularly when the teacher is standingon the edge. Often insufficient time isallowed for the women to perform theexercise against resistance and turbulencewhile maintaining balance and goodposture. This can result in inaccuracies ofmovement as well as reduced benefit fromthe exercises.

Generally the beat of the music needsto be slower than for a land-based classto allow for the effects of waterresistance. The instructor needs toperform the exercises slowly anddeliberately. Whilst music can add anelement of fun and provides a focus,classes can be held successfullywithout the aid of music.

9.2 MusicIf a cassette or CD player is connected to

the mains, a circuit breaker must be used.A battery-operated machine is, of course,safer. Check with the pool manager thatthe pool has a Phonographic PerformanceLicence (PPL) to cover playing ofcommercially recorded music. If not youwill have to purchase your own licence.There are many sources of pre-recordedmusic available for purchase.

10. Post natal exerciseExercise in water classes may be taughtto the postnatal woman. Theinformation above is mostly relevantapart from the following points;

• Sometimes the class may be taughtwith a mix of antenatal and postnatalwomen. Sometimes the class may besuitable for mother and baby. If thebaby is being introduced to the pool

then current regulations must beobserved. If the mother alone isexercising, then she should beadvised to make arrangements forher child as many leisure centres donot provide crèche facilities forchildren under two years of age. Theleisure centre facilities should bedetermined prior to advertising theclass. Some venues allow babies tobe brought in car seats or similarand placed on pool surrounds underadult supervision. Toddlers shouldnot be permitted into the pool area.The instructor needs to be flexiblewith the type of exercises taught andable to offer a greater range ofprogressions and alternatives.

• It is not necessary to have a midwifeor second health professional inattendance for postnatal onlyclasses.

• The physiological benefits ofexercise are the same as for anyother non-pregnant woman but withthe emphasis being on regainingrather than maintaining the level offitness. Another advantage of beingin a postnatal class is that theinstructor can correct the effects ofpregnancy such as poor posture orweak abdominal muscles andstructure the class to focus on themost relevant muscles to retrain.Emphasis should be on regainingabdominal stability and musclebalance.

• Full screening is necessary althoughsome different questions need to beraised such as when was the baby

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born, have you had a six week GPcheck, did you have a caesareandelivery, how do you feel today, areyou breastfeeding? If the mother haspelvic girdle pain, is still bleeding oris excessively fatigued she should beadvised not to participate.

• The components of the class willneed to be adapted to reflect theneeds of the participants.

• The drink session also allows achance for the mothers to talk anddebrief their experiences with thehealth professional available ifneeded for advice. Thephysiotherapist may be able toidentify, advise or refer for treatmentto the appropriate health professional,those with problems relating to beinga new mother. These may includecontinence, musculoskeletal,psychosexual problems andsuspected postnatal depression. Oncethe new mother has completed heraquanatal course, the instructor iswell placed to advise her on the typesof exercise to pursue next. She is in akey position to encourage the motherand her new baby to exercise for life.

11. Further readingBaum G (1998) Aquarobics: The TrainingManual WB SaundersCirullo J (1997) Aquatic exercise for theobstetric and gynecologic patient, in Ruoti,Morris, Cole (eds) Aquatic RehabilitationLippincottEvans GM (1997) Aquanatal exercise, inCampion MR (ed) Hydrotherapy: Principlesand Practice Butterworth Heinemann

Granath AB, Hellgren MS, GunnarssonRK (2006) Water aerobics reduces sickleave due to low back pain duringpregnancy - Journal of Obstetric,Gynecologic, & Neonatal NursingJul;35(4):465-471Halksworth G (1994) AquanatalExercises Books for Midwives PressHarrison JA (1991) Teaching AquafitSunderland PolytechnicKatz VL, McMurray RG, Cefalo RC (1991)Aquatic exercise during pregnancy, inMittelmark RA, Wiswell RA, DrinkwaterBL Exercise in Pregnancy Williams &WilkinsKatz J (1995) Water fitness during yourpregnancy Human Kinetics USAKihlstrand M, Stenman B, Nilsson S,Axelsson O (1999) Water-gymnasticsreduced the intensity of back/lowbackpain in pregnant women ActaObstetricia et GynecologicaScandinavica 78(3):180ˆ5Pennick VE, Young G (2007)Interventions for preventing andtreating pelvic and back pain inpregnancy Cochrane Database ofSystematic Reviews 2007, Issue 2.Art.No.:CD001139. DOI:10.1002/14651858.CD001139.pub2Rattenberry W et al. (2009) NHSEvidence - women's health AnnualEvidence Update on Antenatal andPregnancy Care, Nuffield Departmentof Obstetrics and Gynaecology,University of OxfordSkinner AT, Thompson AM (eds) (1983)Duffield's Exercise in Water BailliereTindall

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Vleminckz M (1988) Pregnancy andrecovery: the aquatic approach, inMcKenna J (ed) Obstetrics andGynaecology Churchill LivingstoneWaller B, Lambeck J and Daly D (2009)Therapeutic aquatic exercise in thetreatment of low back pain: a systematicreview Clinical Rehabilitation 23(1), 3-14.

12. AppendixHydrotherapy is:“ A therapy programme utilizing theproperties of water, designed by a suitablyqualified Physiotherapist specifically for anindividual to improve function, carried outby appropriately trained personnel, ideallyin a purpose built and suitably heatedhydrotherapy pool” (HACP 2005) nowknown as ATACP.Physiotherapists providing hydrotherapysessions should have knowledge andtraining in line with the standards set bythe CSP as specified in the followingdocuments:Quality Assurance Standards 2012 CSPGood Practice in Hydrotherapy 2007 CSPwww.csp.org.uk

BookletsFit and Safe (Mothers and mothers-to-be)Fit and safe (Health professionals)Pregnancy-related Pelvic Girdle Pain(Heath professionals)Pregnancy-related Pelvic Girdle Pain(Mothers and mother-to-be)Fit for PregnancyFit for the FutureThese and other booklets available via theACPWH website www.acpwh.csp.org.uk

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