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.
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 nontrained 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
syMaBadde~y NNEB, SCM,ADM, Lecturer on Ante and Postnatal Module, Ante and Postnatal Exercise Training Module, North StaffsHospital Trust
The word 'complementary' is defined in the Oxford Advanced Learner's Dictionary as 'combining 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
Complementary Therapiesin Nurs/ng& M/dw/fety(1996) 2, ~ 8
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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 clothing, she should lie on the floor, a rug intervening, 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 twohour 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 physiological changes of pregnancy. The rise in interest in health-related fitness has posed questions for pregnant women and professional carers alike. Many women o f child-bearing age are actively involved in contact sports, participate in circuit training, or attend fitness classes. They may wish to continue 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-
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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, therefore, 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 ligaments have a poor blood supply it may be months before the ligament returns to its prestretched normal length and gives joint stability once more (Lamb 1978). Although relaxin is produced 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 placenta is delivered after the baby. Therefore, postnatal 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 continually changing centre of gravity changes, contribute 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 Guidelinesfor Exercise During Pregnancy and Postpartum ( A C O G 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 oxygen during aerobic work (e.g. the quadriceps or group o f thigh muscles) (McMurray 1993). Deep flexing or extension o f joints should be avoided because of connective tissue or ligament laxity caused by relaxin. Also all jerky movements should be avoided. N o 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 nonpregnant women. For example, during pregnancy, exercise may decrease the physical discomforts a woman experiences, resulting in decreased use of medication (Reid 1983) and a more positive view o f 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 exercises. For example, strengthening the different muscle groups in the legs will help her to bend her knees, not her back, when bending and lifting. Using the quadriceps, hamstrings, gastrocnemius, muscle groups will place less stress on her back and pelvis. R o u n d shoulders are common in the pregnant woman, related to increase in breast size and weight and caused by changes in centre of gravity. Shoulder retractions (contraction 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 fitness 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 pursued as an attempt to increase cardiovascular fitness, 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 structured 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 attention should be placed on body position, tech-
Antenatal exercise: a personal perspective
nique, number o f repetitions (pregnant women tire more easily), alternatives and reducing work load as pregnancy progresses. Press-ups performed 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:
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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.
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Attention should be paid to tailoring the intensity of exercise to different stages of anteand postnatal work. A regular exercise programme two or three times per week, specifically tailored to take into account the limitations 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 patterns, 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?
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High blood pressure Anaemia or other blood disorders Thyroid disease Diabetes Cardiac arrhythmia or palpitations History o f precipitous labour Intrauterine growth retardation (smaller growth than expected during pregnancy) Bleeding during pregnancy Breech presentation during the last three months of pregnancy Excessive obesity Extreme underweight History of three or more spontaneous miscarriages Ruptured membranes ('waters' broken or draining) Premature labour Diagnosed multiple pregnancy (twins, triplets) Incompetent cervix or neck o f womb Diagnosis of placenta praevia 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 9 9 9 9 9 9 9 9 9
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Pain Bleeding Dizziness Shortness o f breath Palpitations Faintness kapid pulse/resting Back pain Public pain Difficulty walking
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STRUCTURE OF THE CLASS The exercise teacher should evaluate on screening each individual who wishes to exercise during pregnancy. The following conditions may contraindicate vigorous physical activity. These are taken from the American College o f Obstetricians and Gynaecologists Guidelines (ACOG 1991) Box 2.
All parts of the class should be structured specifically to take into account the physiological changes induced by pregnancy and the limitations that they impose, thus very specific training 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 in order to offer the aquanatal service to their pregnant clients. Water-based exercise offers many advantages to the pregnant w o m e n . T h e 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 mobility. T h e haemodynamic changes o f pregnancy 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 significant problem for many w o m e n , as the daily care o f a y o u n g infant involves repeated bending, lifting and carrying. O f great benefit w o u l d be an exercise programme that incorporated back, leg and abdominal strengthening exercises as well as utilising the pelvic tilt and pelvic floor exercises.
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiiiii iii iii 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
Leisure centres and swimming pools offer water-based exercise for the pregnant woman.
A N T E N A T A L 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. T h e content and quality o f these courses vary from area to area depending on the course leader's qualifications, expertise and experience in teaching people h o w to teach exercise, a very different concept from teaching an exercise class. Because o f the interest in health-related fitness, a n u m b e r o f midwives have obtained their Exercise to Music Teacher's Certificate. A n u m b e r o f organizations are validated by the Royal Society o f Arts, e.g. London Central Y o u n g Men's Christian Association (YMCA). Having obtained extensive knowledge and practical experience in teaching the general public exercise, this training has been followed-up by a further module on ante- and postnatal exercise with practical and theoretical examination passes required to teach exercise to pregnant and postnatal w o m e n . 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 w o m e n , some o f w h o m are n o w attending in their second or third pregnancy. M a n y midwives have attended specific training events
A NATIONAL FRAMEWORK 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 services. Midwives and other professionals have a unique opportunity to influence the 'Health o f the Nation'. Prolonged contact with the family unit, places us in a position to influence their outlook on healthy lifestyles. Improving the midwife's knowledge o f exercise during pregnancy w o u l d 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 w h o have completed a specialist module o f training for teaching antenatal and postnatal exercise nationally, are appropriate choices. O t h e r 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
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 w o m e n . Trained and untrained exercise teachers are also teaching exercise to music classes, some in partnership with a midwife, some not.
S T A N D A R D I Z A T I O N OF T R A I N I N G COURSE C O N T E N T Courses vary in length (halfa day to 3 - 5 days). If the professional wishes to offer an antenatal or postnatal exercise-to-music session, landsite or water-based, there should be an agreed m o d u l a r structure that incorporates k n o w l e d g e on health-related fitness principles structure o f a fitness class and (understanding principles o f w a r m - u p , cardiovascular w o r k , muscular strength and endurance and stretch principles and implications). K n o w l e d g e o f h o w muscles w o r k and o f h o w the b o d y reacts during exercise is vital. T e a c h i n g the position, technique, correction points, alternatives and contraindications must form a m a j o r part o f the training module. T h e physiological limitations that pregnancy imposes on exercises and the importance o f screening are all vital ingredients o f any i n t r o d u c t o r y course encompassing exercise and the pregnant w o m a n . Motivated midwives and professionals are eagerly grasping any training initiatives. Midwifery managers want to develop these sessions for their c o m m u n i t y sector or hospital bases. Trusts are aware that offering specially designed exercise classes for pregnant w o m e n may enhance uptake o f their services. T h e diversity o f courses and their contents can only lead to an inadequate, uncoordinated service, with varying degrees o f competencies and knowledge. T h e 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. T h e r e seems to be no defined professional w h o is responsible for teaching ante- and early postnatal exercise. Midwives, physiotherapists, exercise teachers, s w i m m i n g teachers, leisure centre employees and individuals not holding a nationally recognized teaching certificate are all involved in different ways in teaching our pregnant and delivered w o m e n . Such fundamental principles o f health-related fitness are in great danger o f being c o m p r o mised by o u r o w n lack o f a national structure.
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THE WAY FORWARD In o r d e r to m o n i t o r , m o d e r a t e and d e v e l o p a m o d u l e o f training that adequately p r e pares the professional to teach exercise safely to pregnant w o m e n , a core g r o u p o f expertise taken from the exercise, m i d wifery and p h y s i o t h e r a p y w o r l d should be responsible for taking this service f o r w a r d into the year 2000. C o m p e t e n c y based criteria should be d e v e l o p e d w i t h i n a f r a m e w o r k that covers core elements. Linking m o d u l e s c o v e r i n g o t h e r aspects such as muscle strength and e n d u r a n c e programmes, aerobic w o r k , w a t e r - b a s e d w o r k , would be a natural progression. Standardizing course c o n t e n t , quality and quantity o f i n f o r m a t i o n and fulfiling the statutory training r e q u i r e m e n t s o f m i d wifery practice that d e m a n d that the m i d wife and any o t h e r professional are a d e quately trained before e m b r a c i n g any n e w clinical skill is p a r a m o u n t . ' C o m b i n i n g well to form a balanced w h o l e ' is a truism that defines not only the w o r d ' c o m p l e m e n t a r y ' but also the professional need to be c o m p e t e n t and cohesive. T h e professional bodies at the R o y a l College o f M i d w i v e s and within the English National Board, need to treat this p r o b l e m as a matter or urgency.
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FURTHER I N F O R M A T I O N For further information on training courses please contact: L o n d o n Central Y M C A T r a i n i n g and D e v e l o p m e n t D e p a r t m e n t , Great Russell Street, L o n d o n , U K , w h o tailor modules o f training for different professional groups. Also contact the author at T h e N o r t h Staffs Maternity Hospital, H i l t o n R o a d , Harpfields, S t o k e - o n - T r e n t , Staffordshire, U.K.
REFERENCES
ACOG 1991 Guidelines. Mittlemark, Wisewell and Drinkwater, 2nd ed. Exercise in pregnancy. Williams & Wilkins, p. 313 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 O T C 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 Lamb D R 1978 Physiology of exercise: responses and adaptations. MacMillan, New York 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 G e 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 WeinbergJ S 1878 Body image disturbance as a factor in the crisis situation of pregnancy. J O G N Nurse 7 (2): 18-20 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
RECOMMENDED
READING
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 H o w safe is exercise during pregnancy? Journal of Obstetrics, Gynaecology and Neonatal Nursing 19 (1): 45-48 Knutten H G 1974 Physiological response to pregnancy at Kendall, rest and during exercise. Journal of Applied Physiology 35-5 Lotgering F K, Longo L D 1885 Maternal and fetal responses to exercise Gilbert, during pregnancy. Physiological reviews. The American Physiological Society 65 (1) Mittlemark R, Wisewell R, Drinkwater B 1991 Exercise in pregnancy. 2nd ed. Baltimore. Williams & Wilkins 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) Whiteford B, Polden M 1988 Postnatal exercises. Century Publishing WhiteJ 1992 Exercising for two - what's safe for the active pregnant woman? The physician and sportsmedicine 20 (5)