(Adapted from Alton, Exercise guidelines for pregnancy and the ACOG Technical Bulletin 267)

Physiologic Changes During Pregnancy
 

• Progesterone, relaxin, estrogen and cortisol soften and stretch the connective tissue resulting in laxity and instability of ligaments and joints, and increasing the risk of muscoloskeletal injury
• As the uterus and breasts enlarge, the center of gravity shifts, resulting in balance problems and increasing the risk of falling and of straining the hips and back
• Blood volume expansion and increased resting cardiac output decrease the cardiac reserve during exercise
• Increased resting oxygen consumption reduces availability of oxygen during aerobic exercise
• The effects of progesterone on respiratory function combined with the u-ward displacement of the diaphragm by the enlarging uterus lower the threshold for hyperventilation
• Dehydration and hypoglycemia occur more readily
• There have been no reports that hyperthermia associated with exercise is teratogenic
   

Exercise Recommendations
 

• Regular, aerobic exercise of mild-to-moderate intensity for 30 minutes daily is preferable to intermittent activity or a sudden increase in exercise level
• Intensity should be light enough to allow conversation during exercise (there are no heart rate limitations)
• Exercise should be preceded by an extended warm-up and followed by a cool-down period and stretching.
• Ample fluid intake is important before, during and after exercise
• Carbohydrates (milk, fruit, juice, grains) should be consumed before and after exercise to prevent hypoglycemia.
• Caloric intake should be adequate to support exercise and promote optimal weight gain.
   

Exercise precautions:

Avoid vigorous exercise during hot, humid weather or while febrile, avoid use of a sauna, exercising while fatigued or to the point of exhaustion, exercises that strain the lower back, stress ligaments, injure knees, or promote separation of the symphysis pubis, avoid holding the breath or straining, avoid exercising while on the back in the third trimester

Warning signs to terminate exercise (ACOG Technical Bulletin 267):
Vaginal bleeding, dizziness, headache, chest pain, muscle weakness, calf pain or swelling (r/o blood clot), preterm labor, decreased fetal movement, amniotic fluid leakage

Exercises considered safe during pregnancy (adapted from Cont OB/Gyn 1995:5:62-90):
Bicycling (stationary balance is difficult to maintain), bowling, dancing, golf, jogging, light weight-training, low-impact aerobics, rowing, running, swimming, tennis, walking, water aerobics

Exercises not considered safe during pregnancy (adapted from Cont OB/Gyn 1995:5:62-90):
Contact sports, marathon running, diving, downhill skiing, gymnastics, heavy weight-training, high-impact aerobics, horseback riding, ice skating, mountain climbing, racquetball, rollerblading, roller-skating, scuba diving, sky diving, surfing, water skiing

Contraindications to exercise during pregnancy (adapted from ACOG Technical Bulletin No. 267):
Pregnancy-induced hypertension, severe anemia, cardiac disease, cervical incompetence or cerclage, extreme underweight, hemoglobinopathies, three or more prior miscarriages, intrauterine growth retardation, severe infection, multiple gestation at risk for preterm labor, placenta previa, polyhydramnios, preterm labor, renal disease, preterm rupture of membranes, uncontrolled seizure disorder, uncontrolled diabetes, persistent second or third trimester bleeding, poorly controlled hypertension, poorly controlled hyperthyroidism

Exercises for Pregnancy and Childbirth
(Adapted from the Women's Health Talk; Ross Pediatrics)

Kegel Pelvic Floor Strengthening Program (pdf)

What are Kegel Contractions?

Kegel pelvic floor muscle exercises help women improve stress incontinence or the involuntary loss of urine with sudden increases in their abdominal pressure (i.e. sneezing, coughing, running, or exercising). The Kegel exercise is an isometric program designed to strengthen the internal pelvic muscle called the pubococcygeus muscle (the "P.C." muscle). This muscle forms the floor of the pelvis and surrounds the urethra, vagina, and anus, thereby, providing support for all the pelvic organs. It is the muscle used to stop urination, to prevent a bowel movement, or to tighten the vagina during intercourse.

The P.C. muscle contains two types of muscle fibers called "slow-twitch" muscle fibers (70%) and "fast-twitch" muscle fibers (30%). Both muscle fiber types should be exercised so as to improve the muscle's resting tone (slow-twitch) and its rapid reflex contraction (fast-twitch) during episodes of sudden increases in intra-abdominal pressure (i.e., a cough or sneeze). The muscle can be felt by placing your fingers one to two inches inside your vagina, tightening your PC muscle, and feeling the squeeze.

Incorporate the one minute series of contractions as a regular part of your normal voiding routine for the rest of your life. You will significantly improve the strength of your pelvic floor muscles and improve your bladder control and vaginal tightness. During a sudden cough or sneeze, the pelvic floor muscles will contract reflexly, thereby stabilizing the position of the bladder neck and decreasing the accidental loss of urine. Additionally, when you feel an urge to urinate and you contract your PC muscle, there is an immediate reflex stimulation sent to the bladder to relax and thereby suppress the inconvenient sense of urinary urgency. The stronger your PC muscle, the greater the stimulation for relief of the urge sensation.

How Do You Identify the P.C. Muscle?

Sit on the toilet and begin urinating. When your bladder is nearly empty, attempt to stop the flow of urine WITHOUT contracting your abdominal, buttocks, or inner thigh muscles. This will help you identify the correct muscle. (Contraction of the P.C. muscle is performed by "drawing in" the vaginal muscles and tightening the bladder and anal sphincters as if to stop urination or defecation.) When you can successfully start and stop urinating or feel the vaginal muscle contract, you are using your P.C. muscle. If you do not succeed initially, keep trying until you have identified the correct muscle, and then do the following exercises as described below.

Performing Kegel exercises: Every time you go to the bathroom (after you finish urinating, but before you stand up) remain sitting on the toilet for one minute and perform either of the following muscle exercises (perform on alternating days):

Slow-Twitch Exercise (perform on odd numbered days): Squeeze your P.C. muscle. Hold the muscle tight for a slow count of three to ten seconds, relax, and repeat again for a total of five to ten contractions. (Remember, do not tighten your thigh, abdominal, or buttocks muscles; tighten only your P.C. muscle).

Fast-Twitch Exercise (perform on even numbered days): Quickly contract and relax your P.C. muscle ("quick flicks") 20 to 50 times, relax for five seconds, and repeat again for a total of two to four sets. You may only be able to start out with a total of 40 "quick flicks"; however, over a period of a few weeks you will be able to increase the number up to a total of 200.

After 6 - 8 weeks you will begin to notice a definite improvement. Don't quit. Remember, this is part of your voiding routine.

This should now be a regular every time you go to the bathroom, forever. It is like any isometric exercise. If you don't exercise this muscle regularly, it will become weak again and your symptoms will return. Many patients with urinary stress incontinence have cured their symptoms completely with these exercises.