Exercise Selection and Adaptations During Pregnancy

Abstract

There are several guidelines supporting the benefits of exercising during pregnancy. Those documents contain very general recommendations on physical activity and exercise during pregnancy, such as general guidelines for health screening and exercise prescription of aerobic exercise and strength training. They also include examples of safe physical activities during pregnancy, such as walking, running, swimming, stationary cycling, low-impact aerobics, modified yoga, and Pilates. However, those guidelines contain little information that exercise professionals could use when programming the contents of targeted exercise classes for pregnant women. This chapter addresses the steps for planning, conducting, and monitoring prenatal exercise classes and explains how to select and adapt the exercises regarding the suggested safe physical activities during pregnancy.

Appendices

Appendix 1: Exercise Positions for Pregnant Women

• 1. Standing position (Fig. 9.9):

  Fig. 9.9

  

  Standing position

  Execution: Feet apart to the width of the hips, buttocks slightly contracted, abdominal muscles activated (shortened), pelvis in neutral position, relaxed knees, straight back, shoulders lowered and retracted, head in the spine extension. The modification is standing upright with various foot settings (e.g., parallel, outside).

  Recommendations: The best position for body posture correction. Half-squats, squats, and lunges are performed from this position. Exercises for other muscle groups with equipment (e.g., dumbbells) or without may be performed. Standing position should be used in such activities, where it is impossible or contraindicated to sit or lie down (e.g., in outdoor exercises or directly after aerobics classes when the heart rate is still high).

  Contraindications and remarks: In some guidelines there is the recommendation to avoid motionless standing [122]. Carvalho et al. [123] noted that the standing position for a long time worsened low back pain in 27.2% of pregnant women in the third trimester. Although there is no clear scientific evidence, it seems that owing to the force of gravity the standing position is inappropriate for women with pubic symphysis [124].

• 2. Sitting positions (Figs. 9.10 and 9.11):

  Fig. 9.10

  

  Sitting positions on the ground

  Fig. 9.11

  

  Sitting positions: (a) on the chair; (b) on the stability ball

  Execution: Sit-downs can be done in different versions: with straight legs or bent legs and with legs in parallel or in a straddle. The back is straight, the shoulders are lowered and retracted, and the head is in the extension of the spine.

  Recommendations: Sit-downs, whether on the floor or in a chair or stability ball, are a very good alternative for women who for some reason should not do exercises in standing positions. Due to the fact that the torso is still upright, they are suitable for the posturing exercises in the upper body. They are a good starting position for exercising arm muscles, torso, and front legs, with equipment (e.g., dumbbells, exercise bands) or without, and for breathing exercises.

• 3. Vertical kneeling position (Fig. 9.12a):

  Fig. 9.12

  

  Kneeling positions: (a) vertical kneeling position; (b) kneeling sit-down position; (c) supported kneeling position

  Execution: Thighs are parallel, in natural spacing, buttocks slightly contracted, abdominal muscles activated (shortened), pelvis in neutral position, the back straight, shoulders lowered and retracted, and head in spine extension.

  Recommendations: Kneeling is a good alternative for women who for some reason should not do exercises in standing positions. It is a good position for the posturing exercises in the upper body and the starting position for muscle training of the arms and torso with equipment (e.g., dumbbells) or without.

  Contraindications and remarks: Not recommended for people with injuries or painful knees and in the case of worsening back pain in this position.

• 4. Kneeling sit-down position (Fig. 9.12b):

  Execution: Thighs are parallel, in natural spacing or apart, buttocks are resting on the feet, the back is straight, shoulders are lowered and withdrawn, and the head is in the extension of the spine.

  Recommendations: Kneeling sit-down position is a very good alternative for women who for some reason should not do exercises in standing positions, especially for those with back pain (the hip flexion reduces lumbar lordosis). Due to the fact that the torso is still upright, they are suitable for the posturing exercises in the upper body. They are a good starting position for exercising the muscles of the arms and torso with equipment (e.g., dumbbells) or without and for breathing exercises. The performance of kneeling alone is an exercise stretching the quadriceps muscles, anterior muscle group of the lower leg and foot.

  Contraindications and remarks: Not recommended for women with injuries or painful knees. Kneeling sit-downs can be problematic for women with excessively shortened and tight quadriceps and/or flexors of the foot. Change position if leg numbness occurs.

• 5. Supported kneeling position (so-called on all fours) on forearms or hands (Fig. 9.12c):

  Execution: The weight of the body rests evenly on the knees and hands; thighs and arms are arranged parallel, in natural spacing, hips over the knees, shoulders over the hands, active elbow joints, straight back, back and abdominal muscles activated, and head in the spine extension.

  Recommendations: When the abdominal and back muscles are properly activated, the position of the supported kneeling may be a good position for the exercise of the hamstrings and gluteus muscles, posterior muscles of the trunk, shoulders and neck, and also chest muscles (various versions of push-ups).

  Contraindications and remarks: Although there is no scientific evidence, taking into account the force of gravity, this position may deepen the diastasis recti abdominis (heavy uterus rests on the abdominal muscles as in a hammock, weakened abdominal tissue due to uterine pressure may be further separated). Therefore, the position in the supported kneeling should be used in moderation in asymptomatic women, and in women with confirmed separation of the rectus abdominis muscles, it seems reasonable to completely exclude this position. For a wider use of the supported kneeling for prenatal exercises, one can support the abdomen on a stability ball or big bean bags.

• 6. Frontal plank position (Fig. 9.13):

  Fig. 9.13

  

  Frontal plank position: (a) on the forearms; (b) with legs supported on the stability ball

  Execution: The weight of the body rests evenly on the feet and hands (or forearms); the arms are parallel, in natural spacing, the shoulders over the hands, active elbow joints, straight back, trunk muscles activated, and head in spine extension.

  Recommendations: A position directed to advanced women who used it before pregnancy. It can be a good position for the exercise of the chest muscles (various versions of push-ups), hamstrings and gluteus muscles, posterior muscles of the trunk, shoulders, and neck.

  Contraindications and remarks: Although there is no scientific evidence, taking into account the force of gravity, this position may deepen the diastasis recti abdominis (heavy uterus rests on the abdominal muscles as in a hammock, weakened abdominal tissue due to uterine pressure may be further separated). Therefore, the position in the supported kneeling should be used in moderation in asymptomatic women, and in women with confirmed separation of the rectus abdominis muscles, it seems reasonable to completely exclude this position. Increasing weight of the uterus can hinder proper maintenance of the spine and abdominal contraction; therefore it is necessary to systematically evaluate the technique of exercises performed in this position.

• 7. Supine position (Fig. 9.14):

  Fig. 9.14

  

  Supine positions

  Execution: The back of the body lies on the floor, the legs can be straight or bent, and the arms along the body, sideways, or up.

  Recommendations: Excellent relaxation position, relieving the spine, good position for pelvic floor muscle exercises, breathing exercises, and visualization.

  Contraindications and remarks: Majority of guidelines on exercise in pregnancy recommended avoiding or limiting the supine position after the first trimester, or after 16 weeks of gestation, or after the fourth month of gestation (see Chap. 7; [8]). In this position, the heavy uterus presses on the inferior vena cava and decreases the uterine blood flow [74], which may result in discomfort, dizziness, or anxiety in a pregnant woman. The observation, however, shows that not all women experience a worsening of well-being in this position [125]. Therefore, the complete elimination of exercises in supine positions is not justified and should be supported by an individual assessment of the woman’s well-being. An alternative solution is to put a pillow or towel underneath one hip [126], change the position for lying on the side, or support the back to get a less horizontal body position (Fig. 9.15).

  Fig. 9.15

  

  Supine position with the support of the back

• 8. Lying on the side (Fig. 9.16):

  Fig. 9.16

  

  Lying on the side

  Execution: The weight of the body rests on one side, evenly from the legs to the shoulders, the head rests on the lower arm stretched along the torso, the trunk muscles can be relaxed, and for balance you can support the front on the palm of the upper hand and/or bend the legs in the hip joints and/or knee joints (according to the purpose of the exercise being performed).

  Recommendations: Perfect relaxation position, relieving the spine, good position for pelvic floor muscle exercises, breathing exercises, and visualization. It is a good alternative to changing positions for women who feel discomfort in lying on their backs. For longer lying, a left-sided position is more desirable [127], facilitating the free flow of venous blood to the heart. A comfortable way to change the side of lying down seems to be going through lying on the back.

  Contraindications and remarks: A frequent mistake is supporting the head on the hand of the lower arm bent in the elbow or lifting the torso through support on the forearm of the lower arm. This position unnecessarily affects one side of the neck spine.

• 9. Prone position (lying on the front):

  Due to the growing uterus, lying on the front is a very uncomfortable position for pregnant women, especially in the second and third trimester. Until more information becomes available, ACSM suggests avoiding prone position [128]. So far, however, there is no scientific evidence that the prone position is dangerous to the course of pregnancy.

  Recommendations: Before the belly protrudes, a good position for the hamstrings, gluteus muscles, and posterior muscles of the trunk, shoulders, and neck.

  Contraindications and remarks: As the pregnancy progresses, a woman may feel both physical and psychological discomfort associated with the pressure on the abdomen.

Appendix 2: Examples of Aerobics Movements for Pregnant Women

• 1. Step touch—from the basic standing position, step side to side transferring the body weight with the leading leg and putting a foot to the foot (Fig. 9.17). The movement to the side should be extensive to involve the adductors and abductors of the thigh as much as possible. When the body weight is completely transferred, the pelvic floor should be contracted. Modification of the step touch is performed in various spatial variants, e.g., double step touch, L-step, square step (step touch in a square), step touch traveling diagonally (zigzag).

  Fig. 9.17

  

  Step touch

• 2. Step out (or side to side)—standing with feet apart by a slight bent of both knees (count of 1), the weight of the body is transferred toward the movement being performed, and the other leg rests with the toes on the ground (count of 2). When the body weight is completely transferred, the pelvic floor should be contracted. The step is performed alternately in both directions. The torso is in a straight line, the foot of the stepping leg is fully attached to the ground, while the second emphasizes the movement with the toes only. Both feet are in one line (Fig. 9.18).

  Fig. 9.18

  

  Step out

• 3. Heel back. The step is performed as a step-out step, but in the last phase, the second leg is detached from the ground, bent at the knee joint to about 90°, the heel pointing toward the buttock (count of 2). When the body weight is completely transferred, the pelvic floor should be contracted. It is necessary to eliminate the forward movement of the hips in the final stage of the step that increases the lumbar lordosis (Fig. 9.19).

  Fig. 9.19

  

  Heel back

• 4. Knee up or knee lift. The knee can be raised forward (front knee up – Fig. 9.20a) or sideways (side knee up – Fig. 9.20b). The step is performed as a step-out step, but in the final stage, the second leg is detached from the ground, bent at the knee joint to about 90°, with the knee pointing forward or sideways at the thigh (count of 2). When the weight is completely transferred to the side and the knee is lifted up, the pelvic floor should be stretched. It is necessary to eliminate the forward movement of the hips in the final stage of the step that increases the lumbar lordosis. When detaching the lower limb from the ground and lifting the knee, focus on maintaining the balance of the body. In women with advanced pregnancy, it may be necessary to shorten the lift of the leg so as not to cause the abdomen to be hit from the bottom by the thigh.

  Fig. 9.20

  

  Knee up ((a) to the front; (b) to the side)

  The knee-up step can be made in repetitions, e.g., twice or four times (four knee-up repeats). Done four times it is a step changing the leading leg in choreography.

• 5. V-step (Fig. 9.21). The step is performed in the shape of the letter V, hence its name. From the basic standing position, step one foot diagonally forward, outside (count of 1); then step the second leg diagonally forward, outside to the position of feet apart (count of 2); return of the first leg to the starting position (count of 3); and return of the second leg to the starting position (count of 4).

  Fig. 9.21

  

  V-step

  The forward movement is carried naturally from the heel; the feet are directed toward the outside. When returning to the back, the feet are in a parallel position, the entire sole attached to the ground. When the feet are joining in the final stage of the step, the pelvic floor should be contracted. The center of gravity should be as far as possible at the same level, without raising it or lowering it too much. The step is performed alternately in both directions. When the movement starts from the backward direction, the step is called A step.

• 6. Mambo forward and backward (Fig. 9.22)—from the basic standing position, moving the leading leg forward with the body weight (count of 1), returning the weight of the body onto the second stationary leg (count of 2), moving the leading leg back together with the weight of the body (count of 3), and returning the weight of the body to the stationary leg (count of 4). The stationary leg is always in contact with the ground and remains in the same place; the feet are arranged in parallel with each other. The pelvic floor muscle contraction should be performed when the body weight is moved back and forth (on the counts of 1 and 3). To make the step from the second leg, it is necessary to change the leading leg.

  Fig. 9.22

  

  Mambo forward and backward

• 7. Grapevine (Fig. 9.23). From the basic standing position, step the leading leg sideways with the body weight transfer (count of 1), the crossing of the second leg at the back (count of 2), another step with the leading leg sideways with the weight transfer (count of 3), and bringing the second leg to the leading one (count of 4). The feet are directed slightly to the outside, all the time in one line. To increase the work of the abductor and adductor muscles, the feet are set far to the sides. The pelvic floor muscle contraction should be performed at the moment of crossing the legs (on the count of 2) and with joining the legs in the final step (on the count of 4). The step is performed alternately in both directions.

  Fig. 9.23

  

  Grapevine

• 8. Marching forward/backward (Fig. 9.24)—is a modification of the march. The march forward is performed on 1, 2, 3, attaching legs, the so-called tap on 4 (can be made with knee up or a kick). Return to the starting position by moving backward to 1, 2, 3, attaching legs to 4. Both legs should be loaded evenly. The pelvic floor muscle contraction should be performed at the moment of performing the tap (at count of 4).

  Fig. 9.24

  

  Marching forward/backward

  In order to increase the intensity of exercises, it is possible to perform high-impact movements. Adding jumps and hops most often takes place in the final phase of the exercise, e.g., in step touch at the moment of joining the legs (on the count of 2, Fig. 9.25). For the prevention of urinary incontinence, the woman should be advised to maintain the pelvic floor muscle contraction when jumping, and the intra-abdominal pressure is at its greatest. It is easier to maintain the pelvic floor muscle activation and the continence in movements where the thighs are together. It is likely that urine leakage may occur in movements where thighs are apart at an increase in intra-abdominal pressure, e.g., in jumping jacks. Although there is a lack of scientific research on the relationship of the frequency and intensity of stress urinary incontinence in high-impact aerobics in pregnant women, it is common sense not to recommend high-impact aerobics for those who already experience this discomfort.

  Fig. 9.25

  

  Adding high-impact elements to the aerobics movements

• 9. Examples of combinations:

  • (a) Step touch right (2 beats) + step touch left (2 beats) × 8 times [32 beats]

  • (b) Double step touch right (4 beats) + double step touch left (4 beats) × 4 times [32 beats]

  • (c) Repeat sequence (a) [32 beats]

  • (d) Repeat sequence (b) [32 beats]

  • (e) Step touch right (2 beats) + step touch left (2 beats) × 8 times [32 beats]

  • (f) Grapevine right (4 beats) + grapevine left (4 beats) × 4 times [32 beats]

  • (g) Repeat sequence (e) [32 beats]

  • (h) Repeat sequence (f) [32 beats]

  • (i) Grapevine right (4 beats) + 3 step touch left and right (12 beat) [16 beats]

  • (j) Grapevine left (4 beats) + 3 step touch right and left (12 beat) [16 beats]

  • (k) Repeat sequence (i) and (j) [32 beats]

  • (l) Repeat sequence (i) and (j) [32 beats]

  • (m) Repeat sequence (i) and (j) [32 beats]

  • (n) Grapevine right (4 beats) + step touch left and right (4 beats) + 2 V step left (8 beats) [16 beats]

  • (o) Grapevine left (4 beats) + step touch right and left (4 beats) + 2 V step right (8 beats) [16 beats]

  • (p) Repeat sequence (n) and (o) [32 beats]

  • (q) Repeat sequence (n) and (o) [32 beats]

  • (r) Repeat sequence (n) and (o) [32 beats]

  • (s) Progression: replace 2 V step for 2 mambo (or 1 mambo +1 mambo with pivot)

  • (t) Progression: replace 2 V step for 3 steps forward +1 knee lift +3 steps backward +1 leg curl

  • (u) Intensity: adding jumps and hops, adding arm moves, increasing cadence

Appendix 3: Examples of Basic Step Aerobics Exercises for Pregnant Women

Technique considerations: Head up, shoulders down and back, chest up, abdominals lightly contracted, and buttocks gently tucked under the hips. Knees and back should never hyperextend at any time. When stepping up the body should lean from the ankles. The entire sole of the foot should contact the bench, stepping softly and quietly to avoid unnecessary high impacts. When hopping or jumping, softly contact the bench or the floor. The heel should not land over the edge of the bench to avoid Achilles tendon injury. When “touching” the bench, the toes should be used. During knee lift, leg curl, and leg abduction, avoid hyperextending the other knee and the back. When stepping down, the step should be close to the bench (no more than one shoe length away), and the heel should contact the floor. Keep a comfortable distance between the body and the bench (neither too close nor too far).

• 1. March: Walk/steps in the same place.

• 2. Basic step: Moves up and down facing the step (Fig. 9.26).

  Fig. 9.26

  

  Basic step

• 3. Step Touch: Step from side to side, on the step (Fig. 9.27).

  Fig. 9.27

  

  Step touch with step bench

• 4. Step Knee: Step from side to side, lifting your knee, each side on the step (Fig. 9.28).

  Fig. 9.28

  

  Step knee

• 5. Leg Curl: Step from side to side, kicking your heel back, each side on the step (Fig. 9.29).

  Fig. 9.29

  

  Leg curl

• 6. V Step: Move forward by stepping out wide in front of you with one leg at a time. Then step backward with one leg at a time closing the distance between your feet. Imagine you’re making a V shape on the floor with your steps (Fig. 9.30).

  Fig. 9.30

  

  V step

• 7. Tap: Tap one foot up on the step and then the other foot (Fig. 9.31).

  Fig. 9.31

  

  Tap

• 8. Mambo: The mambo involves stepping forward the step and then backward in the floor (or in the bench), repeatedly with the same foot while shifting the weight between the supporting, static foot and the moving foot (Fig. 9.32).

  Fig. 9.32

  

  Mambo

• 9. Examples of combinations:

  • (a) Front tap right and left (4 beats) × 8 times [32 beats]

  • (b) Cross tap right and left (4 beats) × 8 times [32 beats]

  • (c) Repeat sequence (a) [32 beats]

  • (d) Repeat sequence (b) [32 beats]

  • (e) Right step up and touch (4 beats) + left step up and touch (4 beats) × 4 times [32 beats]

  • (f) Repeat sequence (e) [32 beats]

  • (g) Right step up and knee lift (4 beats) + left step up and knee lift (4 beats) × 4 times [32 beats]

  • (h) Repeat sequence (g) [32 beats]

  • (i) Right step up and leg curl (4 beats) + left step up and leg curl (4 beats) × 4 times [32 beats]

  • (j) Repeat sequence (i) [32 beats]

  • (k) Right step up and knee hop (4 beats) + left step up and knee hop (4 beats) × 4 times [32 beats]

  • (l) Repeat sequence (k) [32 beats]

  • (m) Knee repeater right (8 beats) + knee repeater left (8 beats) × 2 times [32 beats]

  • (n) Repeat sequence (m) [32 beats]

  • (o) Repeat sequence (m) [32 beats]

  • (p) Repeat sequence (m) [32 beats]

  • (q) Knee repeater right (8 beats) + 2 basic steps left (8 beats) + knee repeater left (8 beats) + 2 basic steps right (8 beats) [32 beats]

  • (r) Repeat sequence (q) [32 beats]

  • (s) Knee repeater right (8 beats) + 6 basic steps left (24 beats) [32 beats]

  • (t) Knee repeater left (8 beats) + 6 basic steps right (24 beats) [32 beats]

  • (u) Knee repeater right (8 beats) + 2 basic steps left (8 beats) + 2 basic steps left over the top (8 beats) + 2 basic steps left (8 beats) [32 beats]

  • (v) Knee repeater left (8 beats) + 2 basic steps right (8 beats) + 2 basic steps right over the top (8 beats) + 2 basic steps right (8 beats) [32 beats]

  • (w) Repeat sequence (u) [32 beats]

  • (x) Repeat sequence (v) [32 beats]

  • (y) Knee repeater right (8 beats) + 2 step up knee lift left/right (8 beats) + 2 basic steps left over the top (8 beats) + 2 mambo left (8 beats) [32 beats]

  • (z) Knee repeater left (8 beats) + 2 step up knee lift right/left (8 beats) + 2 basic steps right over the top (8 beats) + 2 mambo right (8 beats) [32 beats]

  • (aa) Repeat sequence (y) [32 beats]

  • (bb) Repeat sequence (z) [32 beats]

  • (cc) Progression: replace 4 step up knee lift side-to-side for 4 step up knee lift “around the world”

  • (dd) Progression: replace 2 mambo for 1 mambo +1 mambo with pivot

  • (ee) Progression: replace knee repeater for L step forward-side +L step side-backward

  • (ff) Progression/intensity: replace step up knee lift for step knee hop

  • (gg) Intensity: adding jumps and hops, adding arm moves, increasing cadence, using different approaches to the bench

Appendix 4: Examples of Resistance Exercises for Pregnant Women

• 1. Squats—from a standing position with feet apart to the width of the hips, bend the legs in the ankles, knees, and hips lowering the center of gravity, and then return to the starting position. Throughout the exercise the soles fully touch the ground; the weight of the body rests more on the heels and the outsides of the feet. The torso remains in the neutral position, the abdominal muscles are activated, and the head is in the extension of the torso. The arms are moving forward for the balance. Returning to the starting position should be done with exhalation and simultaneous contraction of the pelvic floor muscles.

  Working muscles: muscles of the lower extremities.

  Difficulty options: the intensity of the exercise can be adjusted by the range of movement; the simplest version is a quarter-squat, intermediate half-squat, and advanced full squat. For a balance exercise, you can add the raising of the bent leg to the front. Squats can be performed with a load, such as dumbbells in the hands or barbells on the shoulders. Arm work can be attached to squats, for example, elbow flexion to activate biceps brachii (Fig. 9.33).

  Fig. 9.33

  

  Quarter-squat with elbow flexion

• 2. So-called sumo squats – squats performed in the straddle, feet directed outward.

  Working muscles: as above and additionally thigh adductor muscles are more engaged.

• 3. Backward, forward, or sideways lunges – from a standing position, a large step backward, forward, or sideways, lowering the center of gravity, and then return to the starting position. The torso remains in the neutral position, the abdominal muscles are activated, and the head is in the extension of the torso. The arms are moving forward for the balance. Returning to the starting position should be done with exhalation and simultaneous contraction of the pelvic floor.

  Working muscles: in backward and forward lunges mainly flexors and extensors of the lower extremities, in sideways lunges additionally work the hip abductor and adductor muscles.

  Difficulty options: the intensity of the exercise can be adjusted by the range of deflection in the joints of the legs, the smaller the deflection the easier the exercise option. For a balance exercise after backward or forward lunges, you can add the raise of the bent leg forward, with sideways lunges—raising a straight leg to the side. Lunges can be done with a load, such as dumbbells in the hands or barbell on the shoulders. Arm exercise can be added to lunges, for example, the raising of arms to the front or side (activation of the shoulder muscles, Fig. 9.34).

  Fig. 9.34

  

  Lunges with different arm moves

  Exercises in high positions (various options of squats and lunges) are good functional exercises, preparing the body of a pregnant woman to move with the growing belly. Due to the fact that they engage several large muscle groups, they are more intensive compared to exercises performed in low positions (sitting, kneeling, or lying). Nevertheless, in the case of worsening back pains, it is recommended to replace them with exercises performed while sitting, kneeling, or lying down.

• 4. French press—from a sitting position with legs resting against the ground for stabilization, perform the elbow extension (Fig. 9.35).

  Fig. 9.35

  

  French press

  Main working muscles: triceps brachii.

  Difficulty options: the exercise can be done single-handed or with two-handed weight, e.g., a dumbbell or exercise band.

• 5. Modified unilateral behind the neck press (Fig. 9.36)—from sitting position on a stability ball, with legs resting against the ground for stabilization, shoulders lowered, arms bent in the elbow joints, straighten arm in the elbow joint upward.

  Fig. 9.36

  

  Modified unilateral behind the neck press

  Main working muscles: triceps brachii, shoulder, and upper back muscles.

  Difficulty options: exercise can be done with both hands with a load, such as a dumbbell.

• 6. Pelvic bridging (Fig. 9.37)—from lying on the back, knees flexed, feet on the ground, lift hips together with hip joint extension, while feet, shoulders, and head maintain contact with the ground. It is recommended to contract pelvic floor muscle together with lifting the hips.

  Fig. 9.37

  

  Pelvic bridging

  Main working muscles: hip extensor muscles.

  Difficulty options: the intensity and difficulty of the exercise can be increased by putting feet on a platform or a stability ball or by performing the exercise on one leg.

• 7. Outer thigh lift (Fig. 9.38)—from lying on the side, hip and knee of the lower leg flexed to stabilize the body, lift (abduct) the upper leg.

  Fig. 9.38

  

  Outer thigh lift

  Main working muscles: thigh abductors.

  Difficulty options: the intensity of the exercise can be adjusted by increasing the time of the abductor muscle contraction by keeping the upper leg up or by putting the body on the stability ball (which activates the core muscles).

• 8. Inner thigh lift (Fig. 9.39)—lying on the side, hip and knee of the upper leg flexed to about 90°, placed in front of the body, lift (adduct) the lower leg. It is recommended to contract the pelvic floor muscle together with the leg lift.

  Fig. 9.39

  

  Inner thigh lift

  Main working muscles: thigh adductors.

  Difficulty options: the intensity of the exercise can be adjusted by increasing the time of the adductor muscle contraction by keeping the lower leg up.

• 9. Squeezing the ball with your knees and hands (Fig. 9.40)—from the seated position, knees flexed, feet on the ground, stability ball in the front between the thighs, hands on the upper part of the ball. At exhalation there is simultaneous pressure of thighs and hands on the ball, with exhalation—relaxation. It is recommended to contract abdominal and pelvic floor muscles together with the activation of the thigh and chest muscles.

  Fig. 9.40

  

  Squeezing the ball with your knees and hands

  Main working muscles: thigh adductors, chest muscles, optionally abdominal and pelvic floor muscles.

  Difficulty options: the intensity of the exercise can be adjusted by increasing the time to maintain muscle contraction (squeezing the ball).

• 10. Sideways push-ups (Fig. 9.41)—in the position of lying on the side, hips and knees flexed to stabilize the body. The hand of the lower arm covers the abdomen, the hand of the upper arm on the ground at the chest level. Straighten the upper arm.

  Fig. 9.41

  

  Sideways push-ups

  Main working muscles: triceps brachii, unilateral trunk muscles.

  Difficulty options: advanced exercise, toward the end of pregnancy, it may be necessary to shorten the extension movement in the elbow joint (incomplete extension).

• 11. Modified side plank (Fig. 9.42)—in lying on the side position, in the position of lying on the side, hips and knees flexed to stabilize the body, the forearm of the lower arm is a support for the trunk. Lift the hips laterally. It is recommended to contract pelvic floor muscles together with the hips lift.

  Fig. 9.42

  

  Modified side plank

  Main working muscles: unilateral trunk muscles, hips abductors.

• 12. Difficulty options: advanced exercise, toward the end of pregnancy, additional support of the torso on the upper hand may be necessary.

Appendix 5: Examples of Abdominal Exercises for Pregnant Women

• 1. Breathing abdominally, air pushing the belly forward, increasing the waist circumference (inhale through the nose, exhale through the mouth). Exercise can be performed in any position.

• 2. Sit on the ball, arms crossed on the chest, tilt the trunk back while rotating the pelvis forward and performing a full exhalation, return.

• 3. Sit on the ball, arms along the torso, bend the trunk to the right, return, and change the side. You can add a load in your hands (e.g., dumbbells, kettlebells).

• 4. Sit on the ball, arms to the side. Twist the trunk to the right, return to the starting position, change sides.

• 5. Sit on the ball, circular movements on the pelvis.

• 6. Sit on the ball, alternating the lift of the bent leg. A more difficult option of this exercise is the alternate lift of the bent leg from the semi-squat position, with the back resting against the wall (the ball may be under the back).

• 7. Sitting down with legs bent on the floor, hands are holding the back of the thigh. Tilting of the trunk back, back to the starting position. Exercise recommended for beginners. A more difficult version of this exercise is to keep your hands crossed on the chest. The more the trunk tilts back, the greater the activation of the abdominal muscles.

• 8. Sitting down with bent legs, torso twists. A more difficult version of the exercise is the twist of the torso with simultaneous tilting back. The more the torso tilts back, the greater the activation of the abdominal muscles.

• 9. A kneeling sit, a “cat’s back” or emphasizing the thoracic and lumbar part of the spine, activating the abdominal muscles. In women with no diastasis recti abdominis, the exercise can be performed in the position of a supported kneeling (see Appendix 1).

• 10. Lying back, legs bent. Arms along the torso. Pelvic lift, return to starting position.

• 11. Lying on the side. Side-lying trunk lifts.

9.1.1 Suggestions for Exercises in the Presence of Diastasis Recti Abdominis

The following exercises are recommended for both pregnant and postpartum women with the separation of abdominal muscles.

• 12. Sit on the ball, back straight, arms along the torso. Raise the right knee, or gently bend the lower limb in the hip joint. Lower, change sides. It is important that the back remains in the same position during the exercise.

• 13. Standing, back based on the wall (alternatively using a stability ball). Perform elongation of the spine with the simultaneous activation of the abdominal muscles. Try to make sure that your entire back is leaning against the wall. Make a slight flexion in the knee joints while trying to keep the spine straight.

• 14. Sit cross-legged or sit on the ball, hands on the abdomen. Inhale through the nose, abdomen forward. Exhaling with the mouth, direct the navel toward the spine. Imagine that you hug the baby with the outer part of the abdomen (exercise combined with visualization, activating the transversus abdominis muscles).

• 15. Straddle sit with legs bent. The ball in the front is held with the inner side of the thighs and palms, simultaneous pressure with the legs and hands on the ball with the exhalation and conscious abdominal contraction.

Appendix 6: Examples of Posture Exercises for Pregnant Women

• 1. In a standing position balancing from the front to the back of the foot and back looking for the moment when the weight of the body rests exactly in the middle of the foot. Exercise can be done with eyes closed.

• 2. Exercise as above balancing on both sides of the body.

• 3. In standing position, the head, shoulders, buttocks, and feet are touching the wall; the task is to touch the wall with the largest part of the back.

• 4. In standing, sitting, or kneeling position, keeping your hands on the belly, conscious activation of the abdominal muscles by making a loud grunt or an energetic exhalation through the mouth. The back and head remain in an unchanging vertical position.

• 5. Maintaining the correct posture in march and/or aerobic movements.

• 6. In sitting position consciously “opening” the chest, making the maximum inhale, pushing out the chest, and pulling the shoulders back.

• 7. In the standing, sitting, or kneeling position, performing the elongation of the spine, independently checking the position of the head, shoulders, and shoulder blades and activation of the abdominal muscles.

• 8. In supine position, arms to the side, shoulder blades touching the floor, the task is to touch the floor with the largest part of the back. Note: for some women this position may be uncomfortable. The alternative is to practice this exercise in standing back to the wall.

Appendix 7: Examples of Balance Exercises for Pregnant Women

• 1. In a standing position, maintaining correct posture, checking the elongation of the spine; the position of the head, shoulders, and shoulder blades; and activation of the abdominal muscles (Fig. 9.43).

  Fig. 9.43

  

  Examples of balance exercises

• 2. Difficulty can be increased by adding arm moves, by increasing the time of the exercise, or by performing the exercises with eyes closed.

• 3. Difficulty can be decreased by performing the exercises with support (wall, chair, etc.).

Appendix 8: Examples of Flexibility Exercises for Pregnant Women

• 1. Hip flexor stretch—from the kneeling position, the stability ball held on the side for balance, forward step, shifting the weight of the body on the forward leg with the maximum movement of the hips down and forward. Exercise is performed alternately, first on one and then on the other side (Fig. 9.44).

  Fig. 9.44

  

  Hip flexor stretch

• 2. Inner thigh (thigh adductors) stretch with both legs bent—from the sitting position with the soles of the feet together, moving the knees maximally downward. Optionally, one can gently press the inner parts of the thighs with a smooth motion (Fig. 9.45).

  Fig. 9.45

  

  Hip flexor stretch with both legs bent

• 3. Inner thigh (thigh adductors) stretch with one leg bent—from the position of sitting with straight legs, bending of one leg and its maximum move outward. A hand on the same side of the body can hold the leg and support the movement (Fig. 9.46).

  Fig. 9.46

  

  Inner thigh stretch with one leg bent

• 4. Trunk muscle stretch in kneeling position—from the kneeling position, the trunk flexion with the maximum extension of the arms forward. Optionally, the exercise can be performed with a roller or a ball (Fig. 9.47).

  Fig. 9.47

  

  Trunk muscle stretch

• 5. Back muscle stretch in sitting position—from the sitting position with legs slightly bent, in a slight stride, the maximum rounding of the back with the chin pulled toward the sternum (stretching of the upper back muscles and posterior neck muscles). When the trunk flexion is deepened, the stretching of the lower part of the back muscles also intensifies. When performing this exercise in a sitting position with straight legs, the hamstrings will also be stretched (Fig. 9.48).

  Fig. 9.48

  

  Back muscle stretch in sitting position

• 6. Chest muscle stretch—from the supine position, the roller under the chest, the arms to the side, the bulge of the chest up. Optionally, the exercise can be performed on a stability ball. Due to the lack of data on the potential impact of stretching exercises on the intensification of abdominal muscle separation, it is recommended to limit the stretching movement at abdominal level in this exercise (Fig. 9.49).

  Fig. 9.49

  

  Chest muscle stretch

• 7. Trunk muscle and thigh abductors stretch in lying back position—from the supine position, one-sided flexion in the hip and knee joints and then performing internal rotation trying to put the inner part of the knee on the floor. Throughout the exercise, both shoulders should be in contact with the floor. This is a very good position for strengthening the diaphragm by abdominal breathing (Fig. 9.50).

  Fig. 9.50

  

  Trunk muscle and thigh abductors stretch

Appendix 9: Examples of Exercises for Proper Pelvic Floor Muscle Contraction

• 1. It is best to perform the exercises lying on one’s back with bent knees and feet resting on the floor (alternatively lying sideways or sitting with your back leaning against the wall or stability ball).

• 2. Contract pelvic floor muscles for 3–5 s, as if you were trying to stop a flow of urine or squeeze a tampon. Then relax these muscles. Try recognizing the difference between contracting and relaxing these areas.

• 3. Put your hands on your abdomen and contract abdominal muscles for 3–5 s as if you wanted to grunt or cough. Then relax those muscles. Try feeling the difference between contracting and relaxing abdominal muscles.

• 4. Put your hands on your buttocks and contract gluteal muscles for 3–5 s, lifting slightly your hips off the floor. Then relax those muscles. Try feeling the difference between contracting and relaxing gluteal muscles.

• 5. Put your hands on the inner parts of thighs, and contract thigh adductor muscles for 3–5 s pushing one knee into the other. Then relax those muscles. Try feeling the difference between contracting and relaxing the thigh adductor muscles.

• 6. Breathe deeply in and out relaxing all the above muscles.

• 7. Try keeping the abdominal, gluteal, and thigh muscles relaxed, and once again contract the pelvic floor muscles for 3–5 s, as if you tried stopping urine flow or squeezing a tampon.

Appendix 10: Examples of Birth Position Exercises

• 1. Standing birth position—the pregnant woman is standing with feet apart; hands are based on thighs. In this position, the woman can perform any movements of the pelvis, circular, forward, and backward. Another version of this position is a standing position leaning against the wall or hanging on ladders.

  Recommendations and remarks: The position is proposed between a series of exercises strengthening the muscles of the legs in high positions, i.e., squats, half-squats, and lunges. Recommended for beginners as an alternative to squatting position (Fig. 9.51).

  Fig. 9.51

  

  Standing birth position

• 2. Squatting position (Fig. 9.52)—typical for the primitive human during the physiological, instinctive push. It provides the most effective biomechanics during the pushing. A full squat should be made, feet pointing outward, while bending the torso. The abdomen, buttocks, and pelvic floor muscles should be maximally relaxed. Thighs can touch the stomach and chest, compressing the ribs and making the diaphragm’s work easier, thus shortening the pushing phase. The inclination of the body forward along with the weight transfer on hands based on the floor ensures correct positioning of the pelvis and the coccyx bone, increasing the space of the birth canal. In addition, laying the body close to the ground responds to the instinctive need of the woman. The position allows the woman to give birth to a child on her own.

  Fig. 9.52

  

  Squatting position

  Recommendations and remarks: The position is proposed between a series of exercises strengthening the muscles of the legs in high positions, i.e., squats, half-squats, and lunges. Performing the above position requires strong leg muscles, as well as stretching of the anterior and inner thigh and shank muscles. As most Western adults find it difficult to squat with heels down, compromises are often made such as putting a support under the elevated heels or another person supporting the squatter. For beginners it is recommended to start from a standing delivery position (Fig. 9.51), gradually increasing the flexion in the joints of lower extremities.

• 3. Sitting birth position (Fig. 9.53)—the pregnant woman is sitting with her legs apart, knees are bent, her hands can hold her thighs or lower legs, and her torso is slightly bent forward.

  Fig. 9.53

  

  Sitting birth position

  Recommendations and remarks: The position is proposed between a series of exercises strengthening the abdominal muscles from the sitting position.

  An option of this position can be performed sitting on the ball with legs apart, her hands resting on her thighs, her torso leaning slightly forward, and her feet on the floor. One can add circular movement of the hips. The position is proposed between a series of exercises strengthening the various muscle groups made from the sitting position on the ball. The elasticity of the ball supports the rhythm of the up-down movement of the hips and facilitates relaxing of the pelvic muscles. Both sitting positions are a good alternative for women who for some reason cannot execute the standing or squatting positions.

• 4. Horizontal kneeling or so-called child position (Fig. 9.54)—the pregnant woman is in the sit-on kneeling position (sitting on the heels), the torso maximally bent, arms forward, and the forehead can be based on the hands.

  Fig. 9.54

  

  Horizontal kneeling

  Recommendations and remarks: The position is proposed between a series of exercises strengthening various muscle groups from the position of kneeling or kneeling sit-down. It is a very good position for relaxation and exercise stretching the muscles of the back, buttocks, chest, and arms.

• 5. “All fours” position (Fig. 9.55)—kneeling supported on the straightened arms, thighs in a slight straddle, and the coccyx high up. Birthing in this position requires the help of a third party.

  Fig. 9.55

  

  “All fours” position

  Recommendations and remarks: The position relieves the spine. Proposed between series of exercises strengthening different muscle groups from the position of kneeling or kneeling sit-down. It is not recommended for women with a diagnosed diastasis recti abdominis.

• 6. Knee-elbow position (Fig. 9.56)—it is a variation of a kneeling position, with the upper body resting on bent forearms. Thanks to this, it is possible to lift the pelvis higher up. Birthing in this position requires the help of a third party.

  Fig. 9.56

  

  Knee-elbow position

  Recommendations and remarks: The position relieves the spine. Proposed between series of exercises strengthening various muscle groups from the position of kneeling or kneeling sit-down. It is not recommended for women with a diagnosed diastasis recti abdominis. One should be cautious about using it for women with a tendency to a headache (blood flows to the head with gravity).

• 7. Side lying with open legs (Fig. 9.57)—lying sideways, upper leg bent, moved apart, knee pointing up, the hand of the upper arm grabs the leg below the knee and pulls it toward the chest. Birthing in this position requires the help of a third party.

  Fig. 9.57

  

  Side lying with open legs

  Recommendations and remarks: The position relieves the spine. Proposed between a series of strengthening exercises performed from the position lying sideways. During labor, it is recommended to lie on the left side to ensure the proper flow of venous blood to the heart. However, during the exercise classes, to ensure the bilateral balance of muscular work, one should change the sides of the exercises of this position.

• 8. Side lying curled up or so-called fetal position (Fig. 9.58)—lying sideways, body curled up, legs bent and drawn toward the chest. Birthing in this position requires the help of a third party.

  Fig. 9.58

  

  Side-lying curled up

  Recommendations and remarks: As for the side lying with open legs position (see step 7).

Appendix 11: Examples of Breathing Exercises for Pregnant Women

• 1. Abdominal (belly or “diaphragmatic”) breathing—the abdominal cavity expands during inhalation and decreases during exhalation. During the exercise, take a deep breath, directing the air to the abdomen, and then perform a calm maximum exhalation. In this exercise the diaphragm maximally drops into the abdomen, creating more space for optimal oxygen intake. This way of breathing improves blood flow to the abdominal region and helps to relax abdominal muscles. It also calms the nervous system and that is why it is recommended for relaxation, also during labor.

• 2. Chest breathing—in this exercise women should focus on working the rib cage during breathing. At the time of inhalation, the chest should clearly increase in volume, rising up, forward, and sideways. Abdominal muscles should be activated throughout the entire duration of the exercise. A good position to perform this exercise is standing, requiring constant activation of the abdominal muscles to maintain the correct posture. They can be performed on a walk or during other exercises involving large muscle groups, e.g., during squats. Chest breathing is useful especially in the last weeks of pregnancy, when a large uterus makes it difficult to lower the diaphragm.

• 3. “Three-dimensional breathing”—both above exercises can be supported by an additional sensory stimulus. While breathing, the woman puts her hands in the front and on the side of the abdomen or chest and then on the back. With each breath, the hands should float slightly, with the exhalation slightly falling.

• 4. Breath visualization—the effectiveness of the breath can be increased by visualization. For example, you can imagine your abdominal cavity or lungs as a large vase, which when you inhale fills with water and is emptied during exhalation. In another exercise, a woman can imagine that during the breath her child performs inhalation and exhalation together with her. Such exercises are to increase the awareness of breathing.

• 5. Diaphragm exercises in trunk lateral flexion and rotations. Exercise for strengthening the diaphragm is deep abdominal breathing. It is difficult to breathe this way when the trunk is laterally inclined or twisted, which changes the biomechanical conditions for diaphragm operation.

• 6. Breathing exercises preparing for delivery. Painful uterine contractions during delivery disturb the respiratory rhythm and may lead an inexperienced woman to hold her breath. The task of the pregnancy exercise session is to prepare the woman’s body for a quick and shallow breath, which can help her to overcome the pain of childbirth. The breathing resembles the panting or blowing out of a candle or feather flame, hence the name pant breathing or feather blowing. Acceleration and shallowness of breath impede gas exchange and may cause hyperventilation in a beginner. Therefore, this exercise should start from 15–20 s gradually extending to 60–90 s. Respiratory delivery exercises are good to perform in delivery positions, including visualization of labor and delivery pain. Each breathing sequence can be ended with a long, deep inhale through the nose followed by a long, deep exhale through the mouth, recommended for pushing. The exercise of the pushing itself is not recommended during pregnancy.