How to cater a Pilates program to the pregnant and post-pregnant patient

By Beth Puliti

It is no secret that pregnancy creates physical, hormonal and emotional changes to a woman's body. But these changes don't have to inhibit women from continuing Pilates.

If performed correctly, Pilates can help patients regain their confidence, balance their emotions and strengthen their body.

With proper guidance, pregnant and post-pregnant patients can continue their time on the mat.

Pregnant Patients

Once a woman becomes pregnant, she may experience balance issues as the center of gravity changes with the increase in fetus size, said Sherri R. Betz, PT, who serves on the Pilates Method Alliance board of directors and worked on the National Certification Exam for Pilates teachers in order to incorporate safety in Pilates training.

"Weakness can also occur, especially with water retention and anemia. Hormonal changes (increases in estrogen) stimulate relaxin, which causes laxity in the ligaments, mainly in the pelvis. The effect is decreased pelvic stability leading to lower-extremity weakness," she said.

Because of these changes, Betz suggests PTs should have their patients consult with a health care practitioner before commencing exercise, gradually increase their exercise if they were previously sedentary, avoid overheating and exercising in hot conditions and maintain adequate fluid intake to avoid dehydration.

Patients should also set aside time to exercise regularly three times per week with their maximum heart rate not exceeding 140 to 150 bpm or a limit that was set in consultation with a doctor. PTs should remind their patients not to exercise with a febrile illness and ensure that there are adequate warm-up and cool-down periods.

"It is also important that patients avoid supine positions after 20 to 28 weeks gestation. Supine positions cause uterine pressures on the inferior vena cava and aorta, which restrict blood flow to the fetus and occasionally the mother. There are not always symptoms of this problem," explained Betz.

Bilateral adductor work should be avoided as well—especially in the standing series on the reformer with light springs. This strain can cause a separation of the pubic symphysis, which usually leads to pain with standing and ambulation.

"Check for diastasis recti, which is common in two-thirds of all pregnancies," Betz advised. Allowing the stomach to bulge can cause additional weakness of the abdominal wall and further separation of the diastasis recti.

Patients should stay away from excessive weight-bearing on the hands, which can exacerbate symptoms of carpal tunnel, commonly experienced during pregnancy. Hyperextension of the lumbar spine should also be avoided.

Betz warned PTs to watch out for and stop exercise if the following symptoms occur: tachycardia (rapid heart rate), palpitations, shortness of breath, dizziness, faintness and vaginal fluid loss or bleeding.

"Pregnant patients should avoid all supine positions, inversions, over-stretching, Rollover, Corkscrew, Jackknife, Control Balance, Bicycles, Swan Dive 2 & 3, Swimming, Double Leg Kick and Rocking," she cautioned.

Although PTs need to keep many precautions in mind, Pilates can be very helpful for pregnant women. Moves that are beneficial include: standing pelvic tilts, neutral spine hip hinges, breathing work, single-leg stance work, kneeling push ups, leg pull prone modified on knees, Psoas Stretch in kneeling or sitting position, quadruped transversus abdominus facilitation, quadruped posterior tilt and Tail Wag, pelvic-floor contractions in wide-leg sitting, Mermaid, Sidelift, Spine Stretch and much more.

"Pelvic-floor relaxation exercises should be taught in the four to six weeks prior to delivery. A pelvic floor that is 'too strong' and can't relax will inhibit delivery," said Betz.

Post-Pregnant Patients

"As the fetus continues to grow in the ever-expanding uterus, movement habits and postural strategies change to accommodate the shifts taking place," said Gladys Cruz Nicholls, PT, a certified Pilates instructor and senior PT at Seton Southwest Rehab, a member of the Seton Family of Hospitals in Austin, TX. "These compensatory strategies are not forgotten after delivery."

In post-pregnant patients, postural changes can become long-term if exercises are not applied to correct asymmetries of imbalances such as increased lumbar lordosis, increased thoracic kyphosis and forward head posture, Betz explained.

Women who have recently given birth will also most likely experience pelvic-floor weakness, transversus abdominus weakness and possibly pelvic girdle instability.

"The core (diaphragm, transversus abdominis, deep multifidi and the pelvic-floor muscles) is affected by the pregnancy, labor and delivery, and if not addressed soon will later create more serious problems like low-back pain, pelvic pain, sacroiliac pain, incontinence and prolapsed pelvic organs," said Nicholls.

Because of these changes, a post-pregnant patient could return to Pilates at the beginner level and work up to previous intermediate or advanced levels.

PTs can work on basic deep abdominal work in neutral pelvis and spine positions to re-activate the deep abdominals, said Betz. The pelvic floor should also be focused on with a modified hundred, modified hip circles, Swan, Double-Leg Kick, Single-Leg Kick and pre-Pilates stabilization of the pelvis.

"Correct alignment of the pelvis is imperative," Betz stated. "If women strengthen an inappropriately aligned pelvis post-partum, that faulty alignment will be strengthened and stabilized."

Post-pregnant patients should avoid all inversions due to the possibility of air embolus, a rare but fatal condition where air is taken into the bloodstream through vaginal tears post-delivery. When vaginal tissues are healed after eight to 12 weeks, inversions can be safely performed.

Using visual and tactile cues to aid in teaching patients is empowering and important, said Nicholls.

She tells her patients to picture a hollow pyramid with a pelvic floor, transversus abdominis and deep multifidus stacked and supporting the torso. "This allows one to see a wide, stable base of support with relaxed posterior hip musculature that extends from the pelvic floor to the diaphragm," she explained.

C-Section Patients

"Part of the retraining of the post-natal Pilates patient is to restore organization of muscle contractions so that the entire system works in harmony and effortlessly," said Nicholls. And patients who have undergone a c-section will need careful guidance since this operation affects their abdominal muscles, causing a disruption in their load transfer into the lumbopelvic-hip area.

"Usually it is advised to avoid heavy lifting—anything heavier than the baby—for six weeks," said Betz. "As soon as the incision is comfortable and healing well, and the doctor has released her for exercise, she can begin very basic pre-Pilates and beginner-level Pilates work."

In the week following the delivery, the patient can begin pelvic-floor isometrics, transversus abdominus isometrics, diaphragmatic breathing and costal breathing, as well as progress with pre-Pilates work as tolerated.

When teaching Pilates to women after they have undergone a c-section, "PTs should evaluate the pelvic girdle for asymmetry, check the incision, check for diastasis recti, progress slowly and watch the lower abdominals very carefully for bulging," said Betz.

Patients should be encouraged to continue the abdominal and pelvic-floor contractions since those exercises will not affect the stitches and will actually help to pull the incision together.

The same Pilates moves that are beneficial for a woman who has had a c-section are beneficial for a woman who delivered vaginally. However, in the first four to six weeks following a c-section, long-lever leg lowering should be avoided as this places undue strain on the abdominals and lumbar spine, cautioned Betz.

Diabetic Patients

Gestational diabetes occurs in pregnant women who never had diabetes before, but experience high glucose levels when pregnant. This condition affects approximately four percent of all pregnant women.1

According to the American Diabetes Association, regular exercise enables a woman to use glucose without extra insulin. However, if a diabetic pregnant woman experiences high blood pressure; eye, kidney or heart problems; damage of the small or large blood vessels or nerve damage, she should speak with a diabetes team about the risks of exercise.²

"Overall, Pilates exercise in moderation is the key," said Betz. "Diet has the greatest effect on the diabetic. A small snack consumed before and after exercise is a good idea to maintain blood-glucose levels."

Diabetic patients should check their blood-glucose levels several times per day–following their diabetes team instructions. They should also record their food intake and exercise routine.

Pilates helps pregnant women from all backgrounds feel strong, confident and more prepared for labor.

"Pilates students are confident in various breathing techniques that can be applied during labor and have a strong connection to the deep abdominals and pelvic floor," said Betz.

Nicholls noted that pregnant and post-pregnant Pilates patients "will have reduced back pain, increased energy, improved mood, improved posture, increased body awareness, improved muscle tone and improved sleep."

"With a knowledgeable therapist, the patient can address problems or issues on a regular basis as their body undergoes the changes of pregnancy," said Betz. "Their recovery time is decreased and they often can't wait to get back in the studio or on the mat."

For more information about Pilates training and certification visit www.pilatesmethodalliance.org

References

1. American Diabetes Association. (2006). Gestational Diabetes. Retrieved from the World Wide Web, http://www.diabetes.org

2. American Diabetes Association. (2006). Good Prenatal Care. Retrieved from the World Wide Web, http://www.diabetes.org

Beth Puliti is editorial assistant at ADVANCE. She can be reached at epuliti@merion.com