As the abdomen enlarges, it becomes impossible to comfortably assume the prone position. Exercises that are usually performed in the prone position must be modified.

Standing Push-Ups
Patient position and procedure. Standing, facing a wall, feet pointing straight forward, shoulder-width apart, and approximately an arm-length away from the wall. The palms are placed on the wall at shoulder height. Have the woman slowly bend the elbows, bringing her upper body close to the wall, maintaining a stable pelvic tilt, and keeping the heels on the floor. Her elbows should be shoulder height. She then slowly pushes with her arms, bringing the body back to the original position.

Supine Bridging
Patient position and procedure. Supine in the hook-lying position. Have the patient perform a posterior pelvic tilt and then lift her pelvis off the floor. She can do repetitive bridges, or hold the bridge position and alternately flex and extend her upper extremities to emphasize the stabilization function of the hip extensors and trunk musculature.

Quadruped Leg Raising
Patient position and procedure. On hands and knees (hands may be in fists or palms open and flat). Instruct the woman to first perform a posterior pelvic tilt, and then slowly lift one leg, extending the hip to a level no higher than the pelvis while maintaining the posterior pelvic tilt. She then slowly lowers the leg and repeats with the opposite side. The knee may remain flexed or can be straightened throughout the exercise. Monitor this exercise and discontinue if there is stress on the sacroiliac joints or ligaments. If the woman cannot stabilize the pelvis while lifting the leg, have her just slide one leg posteriorly along the floor and return.

Modified Squatting
Wall slides and supported squatting exercises are used to strengthen the hip and knee extensors for good body mechanics and also to help stretch the perineal area for flexibility during the delivery process. In addition, if the woman wishes to use squatting for labor and delivery, the muscles must be strengthened and endurance trained in advance.

• Patient position and procedure: Standing with back against a wall and her feet shoulder-width apart. Have the woman slide her back down the wall as her hips and knees flex only as far as is comfortable, then slides back up.

• Patient position and procedure: Standing with feet shoulder-width apart or wider, facing a counter, chair, or wall on which the woman can rest her hands and/or forearms for support. Have the woman slowly squat as far as is comfortable, keeping knees apart and over the feet and keeping the back straight. To protect her feet, she should wear shoes with good arch support. A woman with knee problems should perform only partial range of the squat. For optimal success with squatting during stage 2 of labor (pushing), increase the duration of the squat gradually to 60 to 90 seconds as tolerated.

Scapular Retraction
When scapular retraction exercises become difficult in the prone position, the woman should continue strengthening in the sitting or standing position.

Perineum and Adductor Flexibility
In addition to the modified squatting exercises described in the preceding text, these flexibility exercises prepare the legs and pelvis for childbirth.

Self-Stretching
• Patient position and procedure: Supine or side-lying. Instruct the patient to abduct the hips and pull the knees toward the sides of her chest and hold the position for as long as is comfortable (at least to the count of 10).

• Patient position and procedure: Sitting on a short stool with the hips abducted as far as possible and feet flat on the floor. Have her flex forward slightly at the hips (keeping the back straight), or have her gently press her knees outward with her hands for an additional stretch

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