From the beginning of the pregnancy the mother’s body produces a hormone called Relaxin. This hormone is responsible for loosening the ligaments in the mother’s body in preparation for the baby needing to pass through the pelvic cavity while being born. However, not only does it loosen the ligaments of the pelvic cavity but it also loosens all the ligaments in the entire body. Therefore, pregnant women often have a new found flexibility which should not be encouraged. This means that while it is wonderful for the pregnant woman to stretch and maintain flexibility, they should not work for developing more flexibility or use any new extreme ranges. If the woman does utilize these new ranges they may over stretch the ligaments which then may not be able to go back to their pre-pregnancy state once the Relaxin is not flowing through the woman’s body. This means that they would then have lax ligaments and therefore unstable joints for the rest of their life. While this may or may not translate to immediate pain or problems with the pregnancy, it could mean potential injuries and/or pain later in life.
The Relaxin also can cause instability in the pelvic structure which may lead to sciatic pain or pubic symphysis pain and/or dislocation. Sciatic pain is a shooting pain that travels from one side of the back of the pelvis down the back of the leg. The sciatic pain needs to be addressed by a trained Pilates instructor or physical therapist that can assess any muscular imbalances particular to the pelvic structure (adductor/abductors, external hip rotators/internal hip rotators, hip flexors/hip extensors, abdominal/back muscles etc.). Any imbalance then will need to be addressed with exercises specific to the imbalance. This will vary case by case based on the individuals muscular imbalance – what works for one mom may hurt another. This is one reason it is important to do Pilates before the pregnancy to address these imbalances before they cause pain. However, it is good to know that this can be alleviated and is not something pregnant women just have to live with.
The unstable pregnant pelvis should also stay away from intense leg adductor work (aka super hard inner thigh work). While the Relaxin is in the body the pubic symphysis (aka pubic bone) is open to possible dislocation/separation or throbbing pain due to too much pulling or pushing on the joint. This does not mean that mild inner thigh work is bad but stay clear of hard work there which can lead to pain in standing and walking. Pilates examples of intense leg adductor work would be things like Horseback, Side Lunges on the Chair, Magic Circle between Thighs or Ankles with heavy circle, Standing Side Splits on light springs and etc. This is particularly challenging when pregnant women become aware of weight gains in their thighs. Encourage them that there is a time afterwards when it is appropriate to work on strengthening those muscles more intensely. This dislocation can also occur doing extreme range of motions opening the legs although we have already mentioned avoiding that previously for other reasons. Instructors should also know whether or not the client is breastfeeding as the Relaxin will stay in the mother’s system while they are breastfeeding.
Contraindications During Pregnancy
The easiest contraindication to remember is that after the first trimester the pregnant client should avoid prone exercises (aka lying on the belly). When it becomes uncomfortable to lie prone then omit exercises that involve that position. Some pregnant women avoid it earlier due to increased nausea while prone or due to simply the idea of “squishing the baby.” This is fine to avoid earlier but not actually necessary until the woman is showing significantly which may vary from woman to woman. Exercises to avoid would include Swan, Breaststroke, Pulling Straps, Overhead Press, Swimming, Grasshopper, Single/Double Leg Kick and etc. Pilates exercises that involve lying prone include many extension exercises which means that if you need/want to work on extension you will need to focus on non prone exercises like Spread Eagle on the Cadillac and Down Stretch on the Reformer (only if they are strong enough for this).
While every woman consciously knows that their belly is going to expand during pregnancy, some women worry that it may not go back the way it was before or fight this inevitable truth by insisting on doing a lot of hard abdominal work. This should be avoided from the beginning of the pregnancy as it will contribute to the occurrence of a diastasis recti which will ironically cause them to keep the pregnant look after they’ve had the baby. In conjunction with the Relaxin that is softening the connective tissue, there is often times an over stretching or even a split in the linea alba which is the connective tissue that connects the two sides of the abdominals together. When this happens it is called a diastasis recti and there is a weakness in the support system for the back and the organs causing back pain and a “mummy tummy.” This occurs in one-third of all pregnancies to one degree or another but is exacerbated and/or caused by heavy abdominal work. This separation can possibly be prevented or at least minimized by working the deep layer of the transversus abdominis which supports the new weight in the midsection instead of working the muscle of flexion, the rectus abdominis. If this separation is not closed after the first baby it will continue to get larger with each subsequent baby which is why many women “show” faster in their second pregnancy. Pilates exercises that should be avoided while pregnant would include any “crunch” type exercise, the famous Hundred, the Series of 5 (Single Leg Stretch, Double Leg Stretch, Single Straight Leg Stretch, Double Straight Leg Stretch, Criss-Cross), Backstroke, Teaser, Roll Up and etc.
Pregnancy & Diastasis Recti
In order to check for a diastasis recti the mother should lie on her back with her legs bent and feet on the floor. Then she should bow her head and shoulders up off the floor as if she was going to do the Hundred. While she is raised, the linea alba (mid-line) should be palpated to see if there is a vertical separation of the rectus abdominis, causing a gap of the muscles, and/or a bulge to appear. While some degree of widening may occur in all pregnancies, a one to two finger-width (two centimeter) gap is considered normal and not problematic. Sometimes the hole will close up on its own but often times simple Pilates transversus work will assist in closing it postpartum. This is ideally done immediately after the pregnancy as those tissues are the most plastic and it is easiest to heal up at that point. It is very important to make sure that postpartum women do not do abdominal work that is so difficult that they cannot maintain the transversus connection which will discourage healing of the diastasis recti. The transversus abdominis strengthening that is important both during pregnancy and postpartum can be accomplished in any Pilates exercise that is taught correctly and is appropriate to their level of strength.
Some midwives actually encourage specifically done inversions late in pregnancy to either turn a breech baby right-side down or to relieve tension on the ligaments that hold the uterus in place. This must be done in a controlled manner to avoid injury and the head must be kept tucked with the chin to the chest. On a personal note, I have used inversion both to turn a breech baby using a supported Bridge technique (Delaney’s pregnancy- 2nd) as well as using inversion to release tense ligaments using an exercise similar to Cat on the Chair without the extension (Ainsley’s pregnancy- 3rd). Pilates exercises that would be considered inversion would include Short Spine, Climb a Tree, Tower, Pull Up on the Chair, Hamstring Stretch Series on the Chair, Elephant, Pelvic Lift/Bridging, Long Spine, Airplane, Cat on the Chair, Snake/Twist, Handstand, Dolphin, Magician and etc. All inversions should always be avoided if there is an unusual amount of amniotic fluid around the baby, the abdominal tone is unusually loose (the mother has given birth before and not toned up after) or if the mother does not feel comfortable doing it. The bottom line is that pregnant women should avoid doing inversion unless they are working for one of the specific goals as mentioned above.
It may be obvious but it warrants mentioning that jumping is not suited for the pregnant woman. The jarring action can possibly cause injuries or problems as well as the possible injuries from falling while jumping. All Pilates exercises that are done on top of pieces of equipment or that require an element of balance should be done with caution to the mother and spotting during the exercise. Because of the changes occurring in the pregnant body, their balance is often unreliable. There is no exercise that is worth doing if the mother falls on her belly and has a miscarriage.
Lying Supine During Pregnancy
Around the middle of the second trimester, the baby will have grown large enough so that when the mother is lying supine, the uterine weight can collapse the mother’s veins and arteries that lie beneath the uterus. When these veins collapse there is a positional low blood pressure that may result in the mother becoming dizzy and possibly passing out. Although true Supine Hypotensive Disorder occurs in less than 10% of all pregnancies, a good, safe rule of thumb is to avoid supine exercise after the first trimester. In order to avoid SHD when exercising, pregnant women should only exercise on their back for short durations only (a few minutes at a time) and watch for feelings of dizziness. Women who experience these symptoms always feel an urgent need to either roll over or sit up, which quickly relieves symptoms . Pilates exercises that are done supine can be modified to work for a pregnant client by incorporating the Pilates Wedge or the Pilates Arc (both made by Balanced Body) under the mom while they are exercising so that they are then at an angle of about 45 degrees instead of being flat. If using the Pilates Wedge or the Pilates Arc, it should be noted that a sticky underneath is important when not on the Reformer in order to prevent the Wedge or Arc from sliding. Pilates exercises that are done supine include Footwork on the Reformer, Supine Arm Circles, Feet in Straps, Frogs Supine on the Chair and Leg Springs Series among many others. It is good to note that the “traditional” start on the Reformer includes a long stretch of supine material that while it can be done with the Wedge or Arc, it may be best to think outside the box and find warm up exercises that are more suitable to the pregnant condition. Most women never have an issue with Supine Hypotensive Disorder but from a Pilates standpoint, you don’t know if it will be a problem until it is – and that is not a good Pilates experience!
This positional low blood pressure can also occur during prolonged periods of standing while not exercising where the blood can pool in the legs which can be even more dangerous because of the risk of falling when passing out. Pilates can help prevent this with its focus on increased circulation and the many varied positions to exercise in. It is helpful to warn pregnant clients about this possibility and encourage them to change positions and to elevate their feet above their heart if they are having problems with this or excessive edema.
Pregnancy often brings unwanted water retention or edema, particularly in the extremities. While Pilates overall can help prevent and treat edema because of the focus on circulation, if a client has extreme edema other symptoms may occur such as carpal tunnel syndrome in the wrists. If carpal tunnel is a problem, it is wise to limit or eliminate the amount of exercise done with weight bearing on the hands such as in Long Stretch, Push Ups, Down Stretch and many others. Some women may be able to do some with breaks and focus on good alignment while others may need to eliminate all weight bearing on the hands altogether in order to not exacerbate the pain symptoms from the carpal tunnel.