Suggest that your patients discuss with their physicians any guidelines or restrictions to exercise before engaging in an exercise program, either in a class or on a one-to-one basis. As always, follow your state practice act for physical therapy regarding referral, evaluation, and treatment.

Examination. Individually examine each woman before participation to screen for pre-existing musculoskeletal problems, posture, and fitness level.

Education. Educate your patients that increased uterine cramping may occur with moderate activity; this is acceptable as long as the cramping stops when the activity is completed. Teach your patient all exercise guidelines and precautions so that exercises may be carried out safely at home. Include the following:

• Do not exceed 5 minutes of supine positioning at any one time after the first trimester of pregnancy to avoid vena cava compression by the uterus. Educate your patients that compression of the vena cava also occurs with motionless standing. For supine exercise, place a small wedge or rolled towel under the right hip to lessen the effects of uterine compression on abdominal vessels and improve cardiac output. The wedge turns the patient slightly toward the left. This modification is also helpful during examination and treatment when the patient is positioned supine.

• To avoid the effects of orthostatic hypotension, instruct the woman to always rise slowly when moving from lying down or sitting to standing positions.

• Discourage breath-holding and avoid activities that tend to elicit the Valsalva maneuver because this may lead to undesirable downward forces on the uterus and pelvic floor. In addition, breath-holding causes stress to the cardiovascular system in terms of blood pressure and heart rate.

• Break frequently for fluid replenishment. The risk of dehydration during exercise is increased in pregnancy.

• Encourage complete bladder emptying before exercise. A full bladder places increased stress on an already weakened pelvic floor.

• Include appropriate warm-up and cool-down activities.

• Modify or discontinue any exercise that causes pain.

• Limit activities in which single-leg weight bearing is required, such as standing leg kicks. Besides possible loss of balance, these activities can promote sacroiliac or pubic symphysis discomfort.

Stretching/flexibility. Choose stretching exercises that are specific to a single muscle or muscle group; do not involve several groups at once. Asymmetric stretching or stretching multiple muscle groups can promote joint instability.
• Avoid ballistic movements.

• Do not allow any joint to be taken beyond its normal physiologic range.

• Use caution with hamstring and adductor stretches. Overstretching of these muscle groups can increase pelvic instability or hypermobility.

Muscle performance. Recommendations and adaptations for pelvic floor training, general strengthening, and cardiopulmonary conditioning during pregnancy and postpartum are described in the exercise section of this chapter.

Overexertion or complications. Observe participants closely for signs of overexertion or complications. The following signs are reasons to discontinue exercise and contact a physician:

• Persistent pain, especially in the chest, pelvic girdle, or low back

• Leakage of amniotic fluid

• Uterine contractions that persist beyond the exercise session

• Vaginal bleeding

• Decreased fetal movements

• Persistent shortness of breath

• Irregular heartbeat

• Tachycardia

• Dizziness/faintness

• Swelling/pain in the calf (rule out phlebitis)

• Difficulty in walking

Buy the Book that holds this excerpt: Therapeutic Exercise: Foundations and Techniques (Therapeutic Exercise: Foundations & Techniques)

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