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FULL-BODY FITNESS THROUGH THE TRIMESTERS

Now we are going to take a detailed look at exercising through the trimesters. Later chapters will dive deeper into the actual exercises as well as specific programs to keep you fit at every stage. This section is meant to touch on the key points to consider as well as introduce the concept of a fourth trimester, which comprises the first three months postpartum. First Trimester As mentioned, movement in the first trimester can be a struggle due to decreased energy levels and the onset of nausea. If you are finding it hard to do anything other than survive, don’t panic. It will pass. When you can, go for a walk and if that is all you can do—awesome! If your energy allows you more freedom for movement in your day, always take the time for a walk, ideally in minimal shoes (more on this later). For your strength, cardio, and release work, focus on connecting with your pelvic floor and deep core. You’ll want to do one to two minutes of core breathing on its own daily (you will learn this exercise in chapter 6) and add it to moves like the clam shell, squats, and even biceps curls to turn any exercise into a core exercise. Moves like clam shells where you’re in a side-lying position (you will learn this exercise in chapter 7) and squats are great for building strength and endurance in the glutes and legs as well as being fantastic birth preparation exercises. Having a body that is accustomed to the movements used in labor and birth before the big day arrives will ensure you are ready to not only handle the challenge but perform really well!

Second Trimester

The second trimester typically brings renewed vigor. Nausea has usually passed by now, energy levels are higher, and even though you will be showing, your belly will not really limit you in your movement. Higher repetitions, more sets, and new exercises are available to you, but still make sure you take time to relax, unwind, stretch, and release. A daily walk remains a priority as well. Add in some hills or some stairs for low-impact cardio that gets your heart rate up while respecting your pelvic floor. Exercising in the supine position (lying on your back) is typically not advised; this is due to the potential of compressing the inferior vena cava (a large vein that carries blood from the lower body back to the heart). This compression can lead to dizziness, a drop in blood pressure, and fluid retention. Some women do fine lying on their backs even late into the pregnancy, while others need to use pillows or bolsters so their head is higher than their hips for supine floor work.

Third Trimester

The third trimester is the home stretch. You have three months left to really prepare your body for labor and birth. In the first month or so, your energy should still be adequate, but in months eight and nine, you will most likely start to feel like slowing down, nesting, and starting to count down the days. Slowing down is a good thing and is essential—think of it like tapering before a big race. You have done the training and the prep work and race day is not far away. As you continue your workouts, you will naturally begin to back off the reps and the weight and opt for lighter workouts that will allow you to keep some energy in the tank for the big day. Focus on lots of release work for the pelvic floor and surrounding muscles like the glutes, inner thighs, and hamstrings. Using a stability ball pressed against a wall behind you while you hold a deep squat position can be a nice way to build endurance in your legs while also creating some space and stretch in the pelvic floor. Thinking about the most optimal birthing positions and then practicing them daily is key. Side-lying positions, supported squat positions, tall kneeling positions, and positions on all fours are considered great choices when it comes to labor and birth. In later chapters, we are going to show you exercises that mimic these positions and will help you build an amazing body for birth! Moving during early labor will help you better manage the discomfort, facilitate the passage for your baby, and allow the muscles in the core to be able to help with the process. Walking is a convenient and helpful movement, and since you will have been doing it every day of your pregnancy you will have the energy and stamina available for this in your labor. When it comes time to transition to the second stage of labor, the pushing phase, it is ideal to position yourself so that gravity can assist you. Also, you want to ensure your sacrum stays free so it can move as the baby moves. The common back-lying or lithotomy position can actually work against the birthing process because gravity is taken out of the picture. Furthermore, the bed pushing against the sacrum limits the space in the pelvis and prevents the natural movement of the sacrum as baby moves into the vaginal canal. Ideally, chose an alternative like side-lying, supported squatting, staggered standing, or all fours. The side-lying position has been shown to offer a protective element to the perineum and the pelvic floor, and it can be helpful if you have a labor that is progressing very quickly and you would like to slow things down. All-fours positions such as kneeling on the hospital bed or draping yourself over a ball are lovely supportive positions that utilize gravity and keep the sacrum free. Staggered standing with one leg elevated on a stool or chair uses gravity and keeps the sacrum free while the asymmetry in the pelvis can often help the baby navigate through the pelvis. The key is variety and movement. One position may work for a while and then you may need to switch things up and come back to the original position later. Stay fluid and trust that your movement is helping facilitate the process.

Fourth Trimester

The fourth trimester is the recovery phase and is absolutely essential to regaining core function. The focus is on rest, recovery, and core retraining. Too many women jump immediately into training and leave out the element of retraining, only to face challenges such as lingering back pain, a tummy that won’t lie flat, and even things like incontinence and other forms of pelvic floor dysfunction. After your baby is born, regardless of whether you had a vaginal birth or a cesarean birth, you need time to recover. Ensure you have support from a doula or your family during the first few weeks so you can focus on rest and healing your postpartum body. Ice packs for your perineum are soothing for the first 24 hours (you can freeze sanitary pads or you can purchase soft gel ice packs). Following the first day, heat in the form of sitz baths multiple times a day will help. Belly wrapping is used in many cultures around the world and is slowly gaining traction in North America. Not to be confused with waist training, the gentle practice of belly wrapping provides external support to the tissues in the pelvis and abdominal wall while they heal. It is important to couple a belly wrap with restorative exercise and ensure the wrap is put on from the bottom up to take pressure off the healing pelvic floor. The pressure placed on new moms to “get their bodies back” is immense; however, it needs to be ignored. After performing one of the most incredible feats of physical and mental strength, many new moms unfortunately don’t meet their own standards and feel weak and out of shape. They are therefore vulnerable to the claims of exercise classes promoting quick results and are looking for the hardest, most intense activity that will help them feel strong again. Keep in mind, your body has just been through nine months of changes and adaptations that culminated in the birth of your baby. It is not realistic to expect your body to just bounce back to the way it was before pregnancy. The truth is, your body has changed and it will never be the same. That is not to say it can’t be better, stronger, or more functional, but it will never be the same as it was and striving to get back to what it was is futile. Instead, your focus should be on retraining your core and then gradually progressing back to more intense activities. Fitness choices such as boot camp or running are things that you may return to once your core is restored but they are not the activities to choose in an attempt to “get your body back.” The first six to eight weeks postpartum are meant for rest and recovery with gentle core restoration work added at a gradual pace. A pelvic floor physiotherapy assessment around six weeks postpartum is recommended for every woman regardless of how you gave birth. This is an overlooked aspect of women’s health that should be the standard of care and a mandatory piece of prenatal and postpartum healthcare. The traditional belief is that at six weeks postpartum women can get the green light to go back to regular activities. Currently, women take this as a thumbs up to start running or get back to the CrossFit box. The postpartum body is simply not ready for the demands of activities like running and full scale CrossFit at six weeks postpartum and may not be until around four, six, or even 12 months postpartum. Your pelvic floor physiotherapist is an essential part of your health care team and should be the one to give you the green light for a return to more intense activities. This is an escape from current norms, but as word gets out about the importance of pelvic health, more and more women are choosing to be proactive in their pregnancies and are honoring the need to recover. The hopes are that the increasing rates of incontinence and pelvic organ prolapse will start to retreat and we will see women feeling strong and confident in their postpartum bodies instead of feeling weak and broken. Training for a big event requires deliberate, intentional movement that prepares the body to perform, reduces the chances of injury, and primes the body to heal once the event is completed. Training for birth is no different. This book is increasing your knowledge about the changes that are happening and how you can best support your body through these changes and build an incredible birthing body. The next chapters will delve deeper into the core—namely, the pelvic floor, diaphragm, and abdomen—which perhaps undergoes the most significant of all the changes in pregnancy and birth.

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The Pelvic Floor: The Foundation of the Core

The pelvic floor is a part of the body that doesn’t get a lot of attention, but during pregnancy you’re likely to start thinking about it and wondering how to prepare the area for your baby’s birth. You may have heard about Kegels or been told to do them, but there is so much more you can do to prepare. This chapter will give you information you won’t believe you haven’t heard before! WHAT IS THE PELVIC FLOOR? The pelvic floor is the foundation of the Core 4, the group of deep muscles we introduced in the last chapter that are responsible for stabilizing and helping control your body’s movement. Together with the diaphragm, transversus abdominis, and multifidus, the pelvic floor has a role in breathing, creating tension in your abdominal wall, and stabilizing your spine and pelvis

The pelvic floor is a collection of muscles, nerves, tendons, blood vessels, ligaments, and connective tissue all interwoven in your pelvis. It attaches to your pubic bone (which is actually a joint but for simplicity we will say bone) in front, to your tailbone (coccyx) in back, and to your sitz bones (ischial tuberosities) on each side. It forms the base of the pelvis and has many important functions such as being responsible for sexual response and continence. It is astonishing that for a part of our body that does so much, we generally know so little about it. Unfortunately, it is not until there is a problem in the pelvis that women are given the information they should have been told before. Pelvic Floor Function As the foundation of the core, the pelvic floor helps support the pelvic organs: bladder, rectum, and your growing uterus (see figure 3.2). It also plays a role in urinary continence so you can control when you eliminate and don’t pee when you cough, run, or jump. The pelvic floor muscles also stabilize your spine and pelvis as mentioned in the previous chapter. During birth, the pelvic floor muscles must yield to allow baby to pass through the birth canal, and there is an ejection reflex that will help to push your baby out. For all this to occur, often all at once, the pelvic floor muscles must have strength, endurance, timing, coordination, and control. Kegel exercises (voluntary pelvic floor contractions followed by relaxation) can help, but they are not for everyone, because many women do them incorrectly. Kegels also reflect a limited view of the abilities of the pelvic floor.

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What Is a Pelvic Floor Physiotherapist?

Pelvic floor physiotherapy is the most underused service in women’s health, and many women don’t even know it exists until they have a problem to fi x. Pelvic fl oor physiotherapists are fi rst trained to perform general physiotherapy and then take additional training that addresses the pelvic fl oor. They perform internal (vaginal and rectal) assessments to determine the function of the muscles and position of the organs, to mobilize any scar tissue, and to teach women how to properly contract and relax their pelvic fl oor. They help balance the pelvis to ensure the pelvic muscles are aligned and able to do their job, they help release unproductive tension patterns that may interfere with labor and birth, and they help women identify the right and wrong way to engage the pelvic fl oor. Many pelvic fl oor physiotherapists have additional training to help women understand what their body needs to do when they are pushing their baby out. These therapists are also an essential part of your prenatal health care team and your postpartum recovery, and all new moms should see one around six weeks postpartum. In fact, as mentioned in the last chapter, you should rely on your pelvic fl oor physiotherapist to give you the green light to return to high-impact activities (and it will not be at six weeks postpartum!). Because it is a part of the body that is vital to so many aspects of our daily life, and also because it is a part of the body we can’t see, it is important to have a therapist who can help us access and optimize it. Kegels are in essence an isolated exercise, yet given that we are dynamic beings who move throughout the day (at least ideally), it makes sense to broaden the view of pelvic floor exercise to include movement. It’s all well and good to know how to isolate your pelvic floor muscles, but because they work in synergy with the Core 4 as the foundation to all movement, it is important to integrate the pelvic floor muscles into functional movements of daily living. Chapter 9 has been dedicated to this aim with Movement for Motherhood, which will teach you how to use your pelvic floor and Core 4 in a variety of daily movements and activities. In addition to supporting movement, the pelvic floor muscles have a role in breathing and controlling intra-abdominal pressure and therefore must work synergistically with the diaphragm, the transversus abdominis, and the multifidus, making up the Core 4 as mentioned earlier. The Core 4 form the deepest layer of the core and work together to ensure alignment, proper biomechanics, and control during activities. They are anticipatory, meaning they prepare us for movement and they also stabilize and control movement.

The diaphragm, as shown in figure 3.3, is the largest muscle used for breathing. The diaphragm is located in the ribcage and attaches into the lumbar spine. It is a dome shape at rest and becomes flatter in shape as you breathe in. This movement forces the ribs to move out to the side. Unfortunately, many people actually use this muscle incorrectly. Each breath should be accompanied by lateral rib expansion, yet with today’s sedentary lifestyle and slouched posture many people tend to breathe up in the chest. This has a major impact on the synergy with the pelvic floor. When you breathe in, the diaphragm should contract and descend and the pelvic floor should then lengthen and descend. The transversus abdominis

should also lengthen and expand outward to allow the air to enter the body freely. When you exhale the opposite happens—the pelvic floor contracts and lifts, the transversus moves inward, and the diaphragm rises up. To help you master this synergy you will learn and practice the core breath, a fundamental exercise to practice daily in pregnancy to help minimize things like diastasis and back pain. The core breath is a key exercise for postpartum recovery as well. Pelvic Floor Dysfunction Pregnancy and birth are often blamed for many of the core challenges women face postpartum. Common struggles include incontinence, pelvic organ prolapse, pelvic pain, lower-back pain, and a tummy that simply won’t lie flat anymore. Women have a false belief that because they have had children, it is normal to have these challenges. This is not true. It is not normal—common, but not normal—and so much of what women deal with postpartum can be prevented or minimized if they are given the right information during pregnancy.

The old standard for treating pelvic floor dysfunction was for the OBGYN to dole out a standardized sheet of Kegel exercises. Science and clinical experience shows us that this is not only ineffective but can be harmful to some women. The three personalities of the pelvic floor demonstrate why certain women should not necessarily do Kegels. Most of us envision that after a baby’s ten-centimeter head comes through our vagina, the vagina will be left stretched and weak; hence, there is a need for Kegels. This is true in many cases postpartum, if the pelvic floor has been stretched and has not yet recovered its normal tone, strength, endurance, and timing. You can think of this pelvic floor as the “beach bum.” The tissue is long and lax (hypotonic) and not really working very well. Untreated, most women with this type of pelvic floor will develop incontinence, prolapse, and perhaps pain. Kegels can and should help these women, especially when used during movement. However, there is another personality of the pelvic floor we call the “gym rat.” This pelvic floor is tight (hypertonic), contracted, and can be short; therefore, it also has no power and poor timing. With this type of pelvic floor, women still have incontinence. Often, they will have pelvic pain, especially pain during intercourse. This pelvic floor has no give, and doing Kegels will worsen any dysfunction because the Kegels will be contracting an already contracted group of muscles. The third personality of the pelvic floor, “the little gymnast,” is what we should all strive for, where there is a perfect balance of tone, flexibility, and timing. This is a floor that can support a pregnancy, stretch for birth, and return to optimal Core 4 synergy. As we have discussed, our bodies are amazing at compensating. The pelvic floor muscles often come to the rescue and attempt to do the work of the abdominals that are now stretched and weakened and therefore ineffective. This most often results in pelvic floor muscles that are hypertonic and short, disrupting the synergy of the Core 4. Having Core 4 muscles that are not in sync will contribute to pelvic floor dysfunction such as urinary incontinence, pelvic organ prolapse, and pelvic pain. It is often thought that these conditions only happen to older women, but pelvic floor dysfunction can affect women at any age and any stage of life. You may have heard of your grandmother or aunt having pelvic organ prolapse, or your friends leaking pee when they exercise ever since they had kids. These issues are common but they are not normal, and in pregnancy there is a lot you can do to avoid these conditions. Your postpartum recovery is key as well. It is a time of healing, restoration, and retraining. The pelvic floor will have been through a lot, and getting started with core breathing as soon as possible postpartum will go a long way to restoring form and function and avoiding dysfunctions. Let’s take a closer look at these common dysfunctions.

Urinary Incontinence By definition, incontinence is any unwanted loss of urine at any time and of any amount. You may hear women say that it is normal to leak after having kids, but the truth is it is not normal. There are two main types of incontinence: stress urinary incontinence (SUI) and urge urinary incontinence (UUI). SUI occurs when there is an increase in intra-abdominal pressure that is too great for the sphincters and pelvic floor to manage. Small amounts of urine leak out with exertion such as laughing, coughing, sneezing, and running. UUI typically involves a sudden, often uncontrollable, need to find a bathroom. It can be the result of nerve damage or scar tissue, or it can even be behavioral. It is also possible to have both types; this is called mixed incontinence. During pregnancy the need to urinate can increase under the effects of hormones and the pressure on the bladder as baby grows. It is also common to experience some form of incontinence as well. Studies show that if you experience incontinence in your pregnancy, there is a 70 percent chance that you will continue to live with it postpartum as well (Rocha, Brandao, Melo, Torres, Mota, and Costa 2017). Pelvic Organ Prolapse Pelvic organ prolapse is the descent of the pelvic organs (bladder, uterus, or rectum) into the vaginal canal. A cystocele occurs when the bladder bulges into the vaginal wall (also called an anterior wall prolapse). A uterine prolapse occurs when the uterus starts to descend into the vagina. A rectocele is when the rectum bulges into the vagina (also called a posterior wall prolapse). There are varying degrees of prolapse ranging from grade 1, which is very mild, to grade 4, which most often requires surgery. An important thing to note about prolapse is that the degree of descent doesn’t necessarily correlate with the symptoms. Some women may have a small prolapse and be very symptomatic, while others will have a more advanced prolapse yet have no symptoms at all. Some common signs of prolapse may be lower-back pain, a sense of heaviness in the pelvis, a tugging or pulling sensation, a feeling like something is falling out, pain with intercourse, inability to insert a tampon, or inability to keep a tampon in. These are just a few of the symptoms, and they are felt to different degrees by different women. Like we said, some may feel symptoms when they have an early stage prolapse while others feel nothing at all and only notice the prolapse once there is a bulge at the entrance to the vagina. Pelvic organ prolapse is not life threatening, but it is life altering. Especially for active women, it can be a very unpleasant reality. Also note that prolapse can take years to develop and, because not everyone feels the early signs and symptoms, it is important to seek out a pelvic floor physiotherapist as part of your health care team in pregnancy and for the rest of your life. If you do not have access to a qualified pelvic floor physiotherapist and you suspect you have a prolapse, accessing resources online like the Association for Pelvic Organ Prolapse Support (APOPS) and asking your OBGYN to do a POP-Q (a special test to measure the grade of prolapse) can help you make informed choices about your health care. Posture, alignment, proper body mechanics, Core 4 synergy, preparing your body for birth, recovering optimally, and delaying the return to high-impact activities will all play a role in preventing or minimizing the descent of the pelvic organs. Pelvic Pain Pelvic pain is another dysfunction often brushed off as just another pregnancy ailment. However, just because you are pregnant does not mean you need to suffer. Things like lower-back pain, sacroiliac joint pain, pubic symphysis diastasis (pain in the front of your pelvis at the pubic joint), and dyspareunia (pain during sex) can all be treated and often cured during pregnancy or postpartum. Often the problem is as simple as the pelvic floor muscles being hypertonic (too tight), or hypotonic (too lax). Other problems include compensatory strategies coming into play, such as referred pain from other muscles like the hip adductors, or uneven rotational forces on the pelvic bones. Once again, posture, alignment, and synergy in the Core 4 play important roles in prevention and treatment of pelvic floor dysfunctions during pregnancy.

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TYPES OF TRAINING

Fitness has several elements, and each affects different systems of your body. There is muscular strength and endurance, cardiovascular endurance, flexibility, muscle release and relaxation and functional movement to improve activities of daily living. No element alone is sufficient for fitness; all play important roles in your overall health and well-being. Depending on your goal, the activities you choose as part of your training program will be reflective of what you are training for. Someone training for a marathon, for example, will need to build up her cardiovascular endurance. That doesn’t mean she’ll work on only that element. The other elements play key roles as well, and each workout will have aspects of all of them, with the major focus being on cardiovascular endurance. The goal of a successful pregnancy and birth is not a set amount of time or distance as it is with a marathon. As an event, labor and birth is not a consistent environment: each woman’s experience is different, as is each pregnancy and birth. Your training in pregnancy should cover all elements of fitness to help you build a body that is strong yet supple and able to go the distance.

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Muscular Strength and Endurance

Early on in pregnancy is a great time to really focus on building and maintaining a strong core. The core is made up of the pelvic floor, the diaphragm (the muscle that controls breathing), the multifidus (deep spinal muscles), and the transversus abdominis muscles (the deepest abdominal muscles). These four key components make up what is called the “Core 4,” and they need to work synergistically to support the body in movement. As the pregnancy progresses, many changes affect the Core 4 as it responds to an ever-increasing load. The pelvic floor has additional weight to adjust to, the abdominals undergo an ever-increasing stretch, the center of gravity shifts, and the muscles in the back face additional strain. Building a strong and functional Core 4 early on in pregnancy can help minimize the shifts in gravity, the strain on the back, and the stretch of the abdominals and ensure the pelvic floor is well-positioned to handle the increasing weight of the baby. The next chapter will present more detail about the Core 4. Body alignment and posture are key to enabling the core to respond to the demands of pregnancy. Breath work such as the core breath (you will learn more about how the core breath relates to the abdominals in chapter 4 and a step-by-step exercise in chapter 6) is a daily essential that will train the core functionally in preparation for birth. The core breath is also the first exercise you will do after your baby is born to optimize your recovery and kick-start your core retraining. Starting core breathing in pregnancy takes advantage of creating muscle memory so that when you use it to restore and retrain postpartum, your body already knows what to do and you will recover more efficiently and quickly. Applying the core breath to dynamic movement is a fantastic birth prep workout too! This will be covered in depth in the exercise section in chapter 6. While strengthening the core is essential, so too is building endurance of both body and mind. Birth is often compared to a marathon, but it makes more sense to compare it to three or four back to back marathons or an Ironman! Marathons last between two to eight hours, but most labors are much longer than that—sometimes an entire day or even two.

A strong mind and body that have the mental and physical stamina to endure the challenge is vital. Increased sets and repetitions in your workouts is one way to prepare. Daily practice of birth positions and using visualization are two others. Just as an athlete would visualize the event, you should envision your labor and birth and help pattern your brain to be ready for the big day. In chapter 6, we will discuss visualization. Chapters 7, and 8, will go into detail about exercises, sets, and reps. Cardiovascular Endurance Cardiovascular training is another fitness component that needs to be considered when training for birth. Interval training most closely resembles the demands of birth itself, and it should play a role in your pregnancy cardio training. Low-impact activities that will elevate the heart rate are the best choices because they will improve cardiovascular fitness while protecting the pelvic floor from additional strain. If you are a runner or if you participate in activities with a lot of jumping or in other impact activities, you may wish to adjust your training to find low-or no-impact exercises. While running and jumping are perfectly safe, they do place the already compromised core under additional strain that is perhaps not optimal. Changes in the center of gravity and hormonal influences that increase mobility and instability of the pelvis are reasons to seek out alternatives to running and jumping in pregnancy. Activities like walking (especially hill walking), swimming, and elliptical training are great choices. Spinning and cycling may be options as well, but pay attention to your pelvic alignment, your body temperature (you don’t want to overheat), and your rate of perceived exertion. Stretch and Release Work An often overlooked aspect of training is stretch and release work. Flexible, supple muscles are better able to release and yield as they need to during birth. Tight (also called hypertonic), overused muscles will restrict the space in the pelvis, resist the need to release, and be more likely to become injured during birth. As with any muscle in the body, the balance between strength and length is important. Stretch and release work that targets the muscles in the pelvic floor, the adductors, the glutes, and the hip flexors is a great way to optimize the pelvis in pregnancy and ensure it can respond to the needs of labor in a positive way. We will cover this in more detail in chapter 3. Functional Movement for Motherhood As a mom caring for babies and children, you will move your body in ways that you may rarely or never have done before. The most common movements for motherhood are squatting, lifting, carrying, pushing, pulling, rotating, bending, and balancing. Daily life will include lifting and carrying your baby, lifting and carrying a car seat (with and without your baby), bending and lifting your baby out of the crib, and rotating in the car to check on your child in the car seat. You will bend and squat and lift doing the many loads of laundry that are required—you will be busy! Ideally, you will start doing these moves after the first few weeks of recovery because rest is critical. You should not be doing loads of laundry or carrying your baby in a car seat right after your baby is born. Delegate those tasks to your doula or family so you can focus on resting and healing and then gradually start to bring movement into your day. Remember, there is movement and there is exercise. As a busy mom, you will be getting a lot of movement. Women who are concerned that they are too busy to make it to the gym for their workouts or do any exercise at home should not discount that their busy lives are full of movement. Besides, the early weeks postpartum are meant for rest, healing, and recovery. Restorative exercises (such as those you will learn in chapter 14) and gradual daily motherhood movements are all you need to worry about, and learning them while still pregnant will make the recovery and core restoration much easier!

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Abdominal Changes

As we have mentioned, the abdominal wall is one part of the body that undergoes a lot of change and contributes to the shifting center of gravity. This can in turn start to affect the alignment of the pelvis and cause the body to utilize compensatory strategies to find and maintain stability. With the pull of the growing abdomen, the tendency is for the top of the pelvis to start to tip anteriorly (forward), resulting in a more significant curve in the lumbar spine (the low back). As pregnancy progresses, the natural reaction to the heaviness in front and the pelvis tipping forward is to lean back and press the entire pelvis forward. Over time, this can result in a loss of the lumbar curve (the gentle curve in the low back) and a non-optimal curve higher in the spine. It can also contribute to a tight posterior pelvic floor, and glutes that no longer work as they should. This is not at all what we presented as optimal alignment with the ribs over the pelvis and the pelvis over the ankles. See figure 1.2 for an example of an abnormal curve. Many women are not aware of the subtle alignment shifts and think it is normal to have aches and pains in pregnancy. With the right body awareness, education, and daily movement, pregnancy can be comfortable and alignment can be maintained close to normal even with the shifts in the center of gravity. The key is to move with awareness, release tension around the pelvis, and ensure that you work on the glutes throughout pregnancy. This will allow the baby to grow “in” the body rather than “out in front,” so there will be less change in the center of gravity and less strain on the abdominal wall. In pregnancy, the abdomen goes from being relatively flat to being convex with obvious stretching of the muscles and connective tissue, namely the linea alba. The stretching of the linea alba contributes to the condition diastasis recti (introduced briefly earlier in this chapter but covered in more detail in chapter 4). While diastasis recti is a normal response to pregnancy, it is worth taking steps to minimize it so that the abdominal wall has a better opportunity to return to optimal function postpartum. Studies have shown that over 50 percent of women with diastasis recti have some form of pelvic floor dysfunction such as incontinence or prolapse (Spitznagle, Leong, and Van Dillen 2007). The rectus muscles attach to the pubic symphysis (the pubic joint or pubic bone as most people call it), so it only makes sense that if the muscles have stretched or moved out of their normal anatomical position, the pelvis may be affected.

When the pelvic floor and the muscles around the pelvis, such as the psoas, have normal tone, there is space for the baby to be “in” the pelvis. When the pelvic floor and the psoas muscles have too much tone or are tight and holding tension, it can mean less space in the pelvis. In turn, the abdomen will expand farther out in front, creating more strain on the linea alba. This increases the chances of the recti muscles moving farther away from the midline and presents a greater challenge for the connective tissue to regain its normal tension, which stabilizes the core. When talking about changes in the abdomen, we need to address the psychological and emotional sides too. While the first signs of the baby bump can be exciting, as the pregnancy progresses and the belly gets bigger and bigger, thoughts turn to “how am I going to get my abs back?” It can be unsettling, especially if you have been quite fit, to gain weight and watch your body change. The exercises in this book, along with the awareness about body alignment that you will put into practice, are all designed to optimize your body and ensure your abs will return to optimal form and function so you will have confidence in your postpartum body and your journey into motherhood.

Your amazing body is going through some pretty significant changes and will continue to do so as your pregnancy progresses. Developing an awareness of the changes, why they are happening, and how you can best support your body through those changes will go a long way toward optimizing your birth and your recovery. From hormonal to biomechanical changes and more, you will experience an incredible process as you grow and ready yourself to birth your baby. In the next chapter, we will look at exercise and movement in pregnancy while keeping all these changes in mind.

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Get Fit for Birth

To truly be fit for birth, you need to move in ways that prepare you for the big day. That doesn’t mean just exercising, but increasing your movement in general. We live in a world where we can and often choose to outsource much of our movement. While this might seem like a great idea, our bodies—especially when pregnant—really like to move! Instead, we use automatic doors, escalators, and moving sidewalks, and we drive almost daily, usually to an office where we sit most of the day. Because of this, we perform very little natural movement and ultimately rely on our one-hour exercise classes to convince ourselves that we are fit. But what are we fit for? Birth is an active and dynamic process. The popular media has done a good job of portraying birth as something you do lying on your back, but birthing a baby is not something to be “taken lying down.” The more upright and mobile you are, the easier your baby will move into and out of your pelvis. Movements and fitness activities that take into account the changes happening in pregnancy, that mimic labor, and that blend strength and release work are the best choices to help you stay fit in pregnancy and get fit for birth. Labor, birth, and motherhood offer many physical and emotional challenges, so when you move and exercise in ways that prepare you for those challenges, well, they become a bit less challenging. Be deliberate in your daily activities and find ways to sit less and move more; choose exercise that helps prepare your body for the big day and for your new role as a mother. Motherhood requires you to move in ways that you may not be accustomed to: carrying uneven, heavy loads (car seats and laundry baskets); bending and lifting (placing baby in car seats and cribs); twisting and rotating (calming a fussy baby in the car); and sometimes carrying laundry in one arm while carrying and calming a fussy baby with the other! Let’s delve deeper and look at best practices for preparing the body for birth and motherhood.

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THE PRINCIPLE OF SPECIFICITY

The principle of specificity is nothing new in the fitness realm but it is remarkable that, until recently, the principle has not been applied to pregnancy and birth. It has been understood that staying active during pregnancy is beneficial and being fit can improve the birth process and speed postpartum recovery. Unfortunately, research leading to recommendations for specific training for the event of childbirth has been overlooked. As an active woman who is now pregnant, you appreciate the need to stay fit and you most likely have a strong desire to return to your prepregnancy fitness level once your baby is born. You may have begun your search for safe exercises or information about intensity levels, but do you really know how to train for the demands of birth? Fitness and movement play an undeniably important role in childbirth. It stands to reason that training the pregnant body using movements that mimic labor and birth could contribute to better births and recoveries for many women. Childbirth is a physically demanding event that requires a balance between effort and surrender. It requires endurance, strength, flexibility, and a mind–body connection that ensures that the body responds appropriately, meaning it can soften, let go of tension, and allow labor and birth to unfold. Therefore, training the entire body is essential, and the elements of training, recovery, and retraining are key just as they are for any other physical event you may have trained for in the past. In recent years, the trend in sports and fitness is to make workouts and training increasingly more intense. This type of challenging workout is attractive to many pregnant women, especially to new moms who feel out of shape after being pregnant and just want to feel like themselves again. While birth is a very physically demanding event, we need to concentrate on specificity. What does the body need to do in labor and birth and what movements and exercises will train the body for the big day? The key is not to reach for 1-rep max goals or to set speed or distance goals but rather to move in ways that challenge the body now and work to prepare the body for labor and birth. Box jumps are not required in birth; nor are medicine ball slams or mountain climbers. While those exercises can certainly build up strength and endurance, are they actually preparing the body for birth? It’s understandable if you are an avid CrossFitter and can’t imagine not participating in your daily workout, but perhaps with the information in this book you may choose to modify your current workout regimen and set a goal to be back at it after your baby is born and when your core has been retrained and restored. Fitness training should be specific to the demands of birth and specific to the needs of each trimester, including the fourth trimester—the recovery period. Your training will vary through the trimesters to ensure your body is ready for what lies ahead. Early on, the focus is on your core.

When you reach the second trimester, strength and endurance using both cardiovascular training and muscular training are key components. Then, in the third trimester, both strength and endurance training continue, but the intensity is dialed back and more attention is paid to release work, stretching, and visualization as well as learning functional movements for motherhood. The exercises in this book will help you prepare your body for motherhood with movements like deadlifts, squats, and one-arm carries—moves you will be doing many times every day. Finally, the priority of the fourth trimester is healing, recovering, retraining, and restoring using many of the exercises you perfected in pregnancy. Let’s face it, as a new mom you won’t want to have to learn a new exercise program on top of learning to how breastfeed, care for a new baby, and do it all on very little sleep. As you might already know, all workouts, training regimens, and exercise programs include a recovery component. Rest is an essential element of training, yet new moms often do too much too soon and make poor decisions regarding their return to exercise. They fail to take the time to recover from birth and to gradually retrain their body. They jump right back into what they were doing before they were pregnant and give no thought at all to the changes the body underwent in pregnancy or the fact that birth leaves the body in a somewhat injured state that needs time to heal (much longer than six weeks). A researcher at Salford University in England interviewed women at different stages of postpartum and found that it can take a full year to recover from childbirth (Wray 2011). By six weeks postpartum, initial tissue healing will be well under way, and the uterus will usually have returned to its non-pregnant state. But it will take your whole body much longer to achieve full recovery.

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HORMONAL CHANGES

It is no secret that hormones play significant roles in conception, pregnancy, labor, and the postpartum body. In this section, we will look at the main hormones that affect the pregnant body most profoundly. We have not listed all the hormones, because we are focusing on those that contribute most to the changes. Human Chorionic Gonadotropin (HCG) This hormone is secreted in your urine and is used by home pregnancy tests to determine if you are pregnant. The role of HCG is to tell your body that there is a life form in your womb and that your body needs to get ready to nurture it. HCG also tells the ovaries to stop maturing an egg every month. The level of HCG rises consistently until it reaches a peak around the end of the first trimester, which typically coincides with an end to the nausea as well. While the cause of morning sickness has never been determined with 100 percent agreement, many health professionals believe it is HCG. This hormone is also responsible for increasing the blood supply to the pelvis, which can make the signal to empty the bladder increase in frequency. Exercise can be a challenge in the early weeks and months of pregnancy because of the nausea. Gentle walks, release work (such as stretching and yoga), and light weight training, as tolerated, are all great options to choose until you are feeling better. Some women find fresh air and movement can help ease the symptoms while others simply can’t make it far from the bathroom. Nausea is the most common reason women may need to stick close to a toilet, but if it is the increase in bladder signals that keeps you close to the bathroom, recognize that it is not always because your bladder is full. A bladder should signal to empty every two-and-a-half to four hours. In pregnancy, whether because of hormones or because of reduced space and more pressure on the bladder, the signal to empty may come more often. This can in turn train the bladder to continue to signal before it is completely full even after you are no longer pregnant. Once your baby is born, ensure you work to retrain your bladder so it knows it is not okay to want to empty every 45 to 60 minutes. We will talk more about this in chapter 3.

Progesterone Progesterone Progesterone keeps the uterus muscle relaxed by inhibiting it from contracting. Progesterone also plays a role in the immune system by helping the body tolerate foreign DNA (the fetus). Early on, progesterone is produced by the corpus luteum in the ovary. By the second trimester, it switches to being produced by the placenta. Progesterone contributes to relaxation of the blood vessels throughout the body, which can contribute to lower-thannormal blood pressure. Because it also relaxes all smooth muscles such as the intestines, the passage of food through the intestines can slow down and contribute to constipation. Constipation is an unpleasant side effect of progesterone. It is uncomfortable and can lead to straining, which can be damaging to the pelvic floor (the group of muscles at the base of the pelvis). The pelvic floor will undergo a lot of strain during childbirth, so you don’t want to experience additional strain on a daily basis due to constipation. Be sure you stay well hydrated and eat high-fiber foods (both soluble and insoluble fiber) to help make your bowel movements easy to pass. Exercise and movement can also help with constipation, so aim to get out for a daily walk. Walking is also beneficial for the pelvic floor and of course for mental well-being. Emotional stress and the decrease in blood pressure may cause tiredness, so pay attention to how you are feeling. During pregnancy, the general feeling of exhaustion, as well as a feeling of breathlessness brought on by what used to be a very easy task, can be attributed to progesterone. Progesterone makes your body extra sensitive to carbon dioxide in your blood and actually causes you to breathe more deeply so that the oxygen demands for you and baby are met. The early influence of progesterone can often make the first trimester a big challenge physically, mentally, and emotionally. For active women, feeling sick, tired, and constipated all the time is a struggle, and many women just want it to be over so they can feel like themselves again.

Take Action Managing the hormonal roller coaster and the mood swings in pregnancy can be challenging. Prenatal massage can work wonders at reducing stress hormones (cortisol and norepinephrine) and increasing serotonin and dopamine levels (the “feel good” hormones). We all have varying levels of these even when we are not pregnant, but pregnancy worries can contribute to higher levels of the stress hormones. When added to the other hormonal fl uctuations, many women feel like they are just not quite themselves. Prenatal massage not only feels good physically but also can help you feel good emotionally as well. It helps stabilize hormone levels and may even help reduce the likelihood of depression (Field, Figueiredo, Hernandez-Reif, Diego, Dees, and Ascencio 2008).

Estrogen Estrogen Estrogen production occurs only in the ovaries in early pregnancy and then switches to the placenta by the second trimester. Estrogen levels rise slowly and consistently throughout pregnancy until estrogen starts to be produced more quickly as the end of the pregnancy approaches. The role of estrogen is to help stimulate hormone production in the fetus’s adrenal gland, stimulate growth of the fetus’s adrenal gland, and prepare and enhance your uterus so it can respond to oxytocin when the time comes to birth your baby. Elevated estrogen levels may not only prompt nausea but also may increase your appetite. During the second trimester, estrogen plays a major role in the milk duct development that enlarges the breasts. As the breasts become larger in pregnancy, posture and alignment change. The pelvis may start to tip anteriorly, the shoulders start to round, and you may start to lean back to counteract the shifting center of gravity. Ensure you have a well-fitting maternity bra and make a point to check your posture several times throughout the day. Try to do lots of stretching and release work to open the chest, lengthen the hamstrings, and stretch the hips.

Relaxin

Relaxin is a hormone produced by the ovaries and the placenta that is responsible for relaxing the ligaments in the pelvis as well as softening and lengthening the cervix. Relaxin is often blamed for the aches and pains commonly associated with pregnancy. You may feel less stable in all joints, most markedly in the pelvis. Relaxin is at its highest in the first trimester and at delivery. It is not known exactly how long relaxin levels stay elevated in the body after the baby is born, but it is typically present from four to nine months postpartum.

The linea alba (LA), which means “white line,” is another area of the body that is sensitive to the increase in relaxin. The LA is the connective tissue that holds the two straps of the rectus abdominis (the “6-pack” muscles) in place. As the uterus grows, the LA must expand to accommodate the growing baby, which causes the two straps of the rectus abdominis to move away from the midline of the body. This is termed diastasis rectus abdominis. You may also see it written as diastasis recti or simply DRA. Recent research has determined that 100 percent of women will get this abdominal separation by the 35th week of pregnancy. More on this can be found in chapter 4. Movement, especially movement with awareness, is essential during pregnancy. With the knowledge that your pelvis is less stable and your abs are shifting out of their ideal alignment, you can make more appropriate exercise choices that safeguard and build up your body rather than put it at increased risk for injury.

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BODY CHANGES

The influence of hormones contributes to many of the changes your body is going through; however, other systems in the body are undergoing change as well. Just like your baby grows and develops each day, so do you! Pregnancy is a constant state of change and adaptation that culminates in the birth of your baby. Let’s look at some of the other changes that are happening in your body and some ways to help adjust.

Cardiovascular System Changes

Your pregnant body must work harder to circulate oxygen and blood around your body. Your heart rate will fluctuate with the changes you encounter in each trimester. Early on, your resting heart rate will increase by about 10 to 20 beats per minute. This means that your exercising heart rate will also be higher. This increase is caused by hormonal changes, including those that cause vasodilation (widening of the blood vessels). As a result of this widening, the blood pressure drops so your pregnant body must work harder to circulate oxygen and blood throughout a larger surface area. Over time, your body will adapt and your exercising heart rate may return to closer to what it was before you were pregnant. During pregnancy, monitoring your exertion level by how fast your heart is beating is not as reliable. The talk test and the rate of perceived exertion (RPE) are better for determining a suitable intensity level for exercise. The RPE is a scale to help you determine the intensity of your exercise (see table 1.1). Mentally, feeling winded can be a challenge for many women, especially those who considered themselves fit before pregnancy. Many women say they suddenly feel out of shape, which can be discouraging to those who felt they were at their peak of physical fitness before getting pregnant.

Around the midpoint of pregnancy, when progesterone relaxes the walls of the blood vessels and contributes to lowering the blood pressure, some women may feel faint if they stand too long or if they get up too quickly. Pregnancy and birth are very physical events, and looking at them as though they are another event to train for can help bring a more positive outlook. We’ll discuss this training and heart rate monitoring in chapter 2. Respiratory System Changes Early on in pregnancy, hormonal changes typically contribute to feelings of breathlessness. Even though you are actually getting more oxygen into your system, it sure doesn’t feel like it! As the pregnancy progresses and the uterus moves up out of the pelvis, the space into which the diaphragm descends when you inhale decreases, which can make it difficult to take a deep breath. The pressure of the uterus on the diaphragm increases the work required for breathing, because it is harder for the diaphragm to contract and descend on the inhalation. Therefore, more effort and energy are required to bring in the same amount of air. This can mean less oxygen is available for aerobic exercise. Making sure you stand and move frequently throughout the day will help offset these effects, as will stretching and muscle release work for the side body and obliques. When tension is held in the rib cage or the obliques, it can restrict the expansion of the ribs and descent of the diaphragm needed

during inhalation. Even later in pregnancy, when the uterus is starting to limit the contraction of the diaphragm, having freedom in the obliques can help you bring in more air. Skeletal Alignment Changes It is no surprise that the growth of the abdomen in pregnancy causes shifts in the center of gravity. When not pregnant, your weight should be more over your heels, meaning your pelvis should be over your ankles and your ribs should be over your pelvis. As the belly grows, there is a greater mass out front that can start to alter your center of gravity, but ideally, you should still be able to keep your pelvis over your ankles. Unfortunately, our modern- day lifestyle, with increased sitting and lack of walking and squatting, means our backsides typically don’t have the mass to counterbalance the growing belly. The result is compensations in the form of tight hamstrings, the pelvis migrating forward in front of the ankles, flat gluteal muscles that don’t work like they should, and pelvic floor muscles that are short and tight. The exercise sections will cover key release work and movements that will help ensure your backside can counterbalance the front to keep you in optimal alignment. The proper movement and release work can enable your body to better carry the weight of your baby with less strain on the ligaments, making the experience more comfortable while also encouraging optimal fetal positioning (see figure 1.1). In ideal alignment, there would be a plumb line that would run in a straight line from the ears through the shoulders, hips, knees and ankles. There are apps that allow you to use your photo and apply a plumb line to see how well or not aligned you are. For a quick glimpse, you can use a strap or a card with a weight on the end, like the buckle on the end of a yoga strap, and hold it close to your pelvis with the weighted end hanging at your ankles. Simply hold the strap where your greater trochanter bulges on the outside of your thigh at your hip and allow the weight of the buckle end to point out where you are holding your weight. Ideally, the buckle will be beside the ankle, but for those whose weight is more forward, the buckle will hang closer to the center or front part of the foot. This allows you to see where your pelvis is in relation to your ankles and can provide some good insight into how you hold your body in space. The growth of the breasts is another pull on the frame that can contribute to the body finding different strategies for balance and control. As the breasts grow, the heaviness can encourage rounding of the shoulders. Rather than accepting this change as being caused by the enlarged breasts, we should look at addressing tightness in the chest and weakness in the upper back—issues that can be easily tackled throughout pregnancy—to mitigate the alterations to alignment.

The feet often give us clues to changes up above. Some women claim that their feet grow in pregnancy. What may really be happening is that weakness in the lateral hip rotators cause the thighs to rotate internally, which in turn can cause the arches to lower. It may also be that hormonal

changes contribute to the ligamentous arch in the foot softening, especially when the center of gravity pulls the weight of the body more to the forefoot (in front of the ankle). This can create the illusion of the foot being longer. Choosing exercise and movements that work on the lateral rotators of the hip will help, as will spending more time “barefoot and pregnant” so that the muscles in the foot work as they should rather than being restricted by the shoes you wear.

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