Pilates Teacher

PRE & POST-NATAL P I L AT E S SPECIALIST TEACHER TRAINING PROGRAM by Carolyne Anthony

Section One - Program Goals Program Goals...... 4 1 Contraindications...... 6

Section Two - Physiology and Principles Physiology of Pregnancy and Postpartum...... 7 2 Pregnancy and Postnatal Pilates Principles...... 16

Section Three - Breathing and Relaxation Breathing...... 18 Relaxation and Visualization...... 21 3 Basic breathing exercises...... 22 Aligning the body through relaxation...... 27 TABLE OF CONTENTS TABLE

Section Four - Anatomy The Pelvis and Pelvic Floor...... 28 Abdominals...... 58 4 The gluts...... 63 Hamstrings...... 65 Hip Adductors...... 67 Shoulder Adductors and External Rotators...... 69 Back Extension and Stretches...... 71

Section Five - Posture Breakdown of Postural Changes...... 74 First Trimester...... 78 5 Second Trimester...... 81 Third Trimester...... 84 Fourth Trimester...... 86

Section Six - The Postnatal Period Listening and Watching...... 88 6 Other Changes...... 89 Overview of Early Postnatal Exercises...... 93 4 INTRO © TheCenter for Women’s Fitness1994-2011 INTRODUCTION sleep deprivation, babysitting problems an exercise routine due to lackof time, partum period.Most women tend to forego and notsomuchonexercising duringthepost been mademore onexercising duringpregnancy For many instructors and clients, emphasishas through thebirthing process itself. problems both during thepregnancy andalso opening to thechanges that are taking placeprevents Listening to andlearningfrom theindividualbodyand according to herown choiceiswhat ourprogram isabout. and to helpherlosefear andgain trust inherabilityto birth Teaching thepregnant client to relax andenjoy herpregnancy Listen to them. instincts of your clients. They are your best teachers. learn more abouttrusting your instincts andthe your pregnant orpostpartum client andhelpingyou the fears andworries that you may have aboutteaching the pregnant andpostpartum body, ofhelpingyou lose opened upyour mind to anotherway to give birth,to anotherway oflookingat When you leave this course, we at TheCenter for Women’s Fitness,hopeto have The mind,bodyANDspiritofahumanbeing. Isn’t that what Pilates isallabout? well. After all,isn’tthat what life isallabout? woman andwhat shemay experience notjust physically butemotionallyandmentally as But more thanthat itwillgive you insight into themindofpregnant andpostpartum breathing andthemany problems that may ariseduringthisperiodinawoman’s life. This program willgive you asolid foundation inanatomy andphysiology, posture and the timeandopportunity to be“postpartum” withallits realities. achieve that outcome by realigning thebody. thenew Itisalsoaboutallowing mother education inhow to give birthunderthebest possiblecircumstances andhow to help This course isnotjust abouthow to exercise duringpregnancy andpostpartum butan and respecting thehumanbodyandbirthing experience. hope that you willthenbeableto inform your client inherown journey towards trusting population and to teach your pregnant andpostpartum client more thanjust Pilates. I journey asaninstructor more informed, intuitive andtrusting of yourability to teachthis turned itinto thisbodyofwork that you are aboutto embarkon.Ihopeto make your My story isoneofanger andfrustration andshock.I took anegative experienceand change inmy life. My story isnotaboutyour average “normal”pregnancy andbirth. In 1987,Ibecame pregnant withmy first child.Suchasimple statement, suchaprofound INTRO

and all the other issues that plague new mothers everywhere. But unfortunately, while exercise during the pregnancy period is good, exercising during the post partum period is crucial.

Postpartum presents its own special needs and requirements for exercise. It is about restoring a body that has gone through a tremendous amount of change in a very little space of time. Combine that with lack of sleep, hormones bouncing all over the place and many times problems from a c section, or a diastasis recti, and you have a recipe for problems later on in life.

The sooner a client can start back, the better it will be for her body. Towards the end of the client’s pregnancy, the instructor should be advising her on gentle exercises that can be performed hours after a birth. Five minutes a day of breathing, pelvic floor work and stretching is enough to reactivate traumatized muscles and begin to realign the body. Within two weeks of a normal vaginal birth, women can be exercising gently for around half an hour.

No matter how fit a woman is going into a birth, post partum exercise programs should be based more on the type of delivery the client has had rather than on the pregnancy itself. Listening to what we call “the birth story” lets the instructor know what the clients’ body has been through and how to go about rehabilitating it. For the client, telling the story may be healing, if it was traumatic.

We understand your hesitancy going forward, so we have backed up our information with every possible source from ACOG to lay midwives and share with you our wealth of information that has taken us the past 20 years to accumulate.

For practical reasons we offer you a myriad of exercises to get you started, but we know that once you learn to let go, as your pregnant clients will, your creativity will know no bounds. You will discover, as we have, the many ways to move that bring release and strength to your clients. You will also find yourself applying this new found freedom of teaching to ALL your clients. We were born to move, our fears have got in the way.

This course is just your beginning. Please venture forth into this amazing field of work and find your own tune to sing to. I can guarantee nothing in life except that once you have been bitten by the “pregnancy bug’ you are addicted for life. - Carolyne Anthony Founder & Creative Director The Center for Women’s Fitness © The Center for Women’s Fitness 1994-2011 5 SECTION 1 TEACHING “THE DANCE OF BIRTH” First of all, what are the goals of this course? We will, with the help of the information experienced and gathered over the last 20 years, teach you the “why” behind every exercise we use in this program. We hope that once you have learned this information you will be more than comfortable designing 1 your own programs because you understand what you need to do. Our aim is always the safety and wellbeing of the pregnant and postpartum client. Every woman experiences her pregnancy and postpartum differently and the program design should reflect this. We need to fit the program to the woman and not the woman to the program.

If an exercise does not feel good to one woman, THEN DON’T USE IT. But don’t eliminate it for everyone

The exercises we have designed for pregnancy are aimed at realigning the body for successful, natural childbirth. Our bodies were made to give birth but unfortunately our unnatural lives nowadays have diminished our ability to achieve this. While some pregnancy workouts aim to keep the body strong and tight, our program works to open and release the body in time for the birth. Pilates is all about working the body according to nature. Let’s look at what nature is telling us about the pregnant body. After the birth, the exercises we have designed are aimed at realigning the body after childbirth. We look at realigning the pelvis to the spine, rehabilitating the pelvic floor, strengthening the surrounding muscle groups and stabilizing the body. We will rehabilitate the body from the birth of the baby and not so much from the pregnancy itself.

Learn to teach the client in a nonthreatening, non competitive atmosphere. Many women feel they should be working out hard. This program will give your client permission to relax and release for the birth and exercise according to their bodies’ schedule afterwards. This is done in a nurturing, calm, positive atmosphere, where women are allowed to be emotional, tired and overweight.

The relatively new Pilates principle of relaxation has been a part of the Centers’ program for the past 20 years. We incorporate relaxation, breathing and visualization techniques not just for pregnancy but also for postpartum and beyond. In fact, ALL the clients at the Center basically do the same program because it WORKS!

Correct exercise during pregnancy should include... • Breathing and releasing techniques. • Ease of movement during exercise sessions. • Preparation for labor positions. • Early postpartum recovery exercises. • Total body integration. • Attention to the “pregnancy” posture. • Acknowledgement of emotional, mental as well as physical changes. • Education on the changes taking place throughout pregnancy.

6 © The Center for Women’s Fitness 1994-2013 Correct exercise during postpartum should include... • Increasing the strength of the postpartum body gradually. • Releasing techniques for myofascial restrictions. • Deep core work. • Realignment of the pelvis to the spine. • Breathing and releasing techniques. • Understanding of the demands of new motherhood.

Some points to be aware of when designing a program for this population... 1 • Start with a good warm up. The pregnant body takes longer to “rev” up so to speak. The postpartum body is fatigued. • Avoid quick changes of movement due to the softness of the body during both pregnancy and postpartum. • Be aware of your client’s body mechanics. • Be careful of overloading spring tension too rapidly postpartum. • Intersperse the workout with rests and stretches.

This program will cover safe and beneficial exercises for a pregnant and post partum woman up to one year after the birth. A woman who has had a c section may be included with a doctor’s approval.

Contraindications for exercising during pregnancy Under NO circumstances should a pregnant women presenting with these symptoms be allowed to exercise. • Any vaginal bleeding - threatened miscarriage. • Unexplained back pain - could mean miscarriage, tearing of the placenta. • Extreme nausea - may be increased with exercise. • Marked swelling or fluid retention - may be due to an increase in blood pressure. • Pubic pain - indication of separation. • Sharp pain in abdomen or chest - a number of things-heart, uterine tearing. • Fever - never exercise with a fever whether pregnant or not. • Uterine contractions - preterm labor. • Blurred vision - indicative of blood pressure change leading to preeclampsia. • Dizziness or fainting -as above. • Decrease in fetal movement - baby maybe stressed. • Difficulty in walking - could be high sugar, pubic separation or high blood pressure. • Gush of fluid from vagina - waters may be broken. • Shortness of breath - heart trouble or anemia. • Placenta previa - the placenta grows over the cervix-exercise can cause excessive bleeding. • Multiples - three or more babies puts a strain on the pregnant heart while exercising. • History of 3 or more miscarriages - err on the side of safety. • Incompetent cervix - cervix does not stay closed. Sometimes women have a stitch put in. • Intrauterine growth retardation - baby fails to grow; uterus fails to grow at normal rate. • Pregnancy induced hypertension - bed rest is normally prescribed.

© The Center for Women’s Fitness 1994-2013 7 Contraindications for exercising during postpartum • Women may be able to resume exercising within a few days after the birth with safe, gentle movements that begin the recovery of her body. • Women who have diastasis recti may resume sessions geared towards healing this condition with a qualified instructor. • Women who have undergone a c section may resume sessions geared towards healing this condition with a doctors approval and with a qualified instructor. • All women presenting with a diastasis recti may NOT include flexion of the torso (as in One Hundreds) until the gap is healed. 1 • Overhead positions are contraindicated as long as a woman is still bleeding. This indicates that the wound has not healed and there may be a possibility of an embolism forming due to the sucking in of air through the vagina. • Vigorous or intense, prolonged exercise is not recommended as this may increase the possibility of lactic acid in the muscles which in turn may cause breast milk to taste sour. • Lateral movements of the legs are contraindicated if there is a separation of the pubic bone.

Always get a doctor’s approval from your pregnant/postpartum client before she starts. Be safe and err on the side of caution if you are unsure of how to proceed.

Some problems to watch for... • Varicose veins- legs and vulva area. • Diastasis recti. • Carpal tunnel syndrome. • Sciatica. • Swelling in hands and feet. • Round ligament pain. • Pubic pain.

8 © The Center for Women’s Fitness 1994-2013 SECTION 2 THE PHYSIOLOGY OF PREGNANCY AND POSTPARTUM Pregnancy affects changes in nearly every organ and system in the body. These changes are relatively rapid and unseen in the first trimester. Physical changes become more apparent in the second and third trimester. The changes are brought about by hormonal and uterine/fetal growth influences. We will look at some of these changes and study how they affect the way a pregnant woman should or should not exercise, and the ways in which she may be able to help herself.

While it may seem daunting to you as an instructor to teach this ever changing body, rest assured you will find it exciting and certainly never boring! Once you understand what is happening to the body during this time, it will be easier for you to design your program.

Postpartum poses its own challenges with an immediate change both physically and physiologically, within a few hours after the birth and then the less demanding changes 2 over the course of the postpartum year.

Musculo-skeletal system changes Collagen and connective tissue changes The hormone relaxin, in conjunction with progesterone, causes retention of fluid in ligaments and connective tissue and it is this that causes laxity in the joints. The main reason for this laxity is to allow for the widening of the pubic bone and the subsequent relaxing of the pelvic joints in preparation for the passage of the baby through the birth canal. The result is sometimes, though not always, a greater degree of flexibility in the mother. Many women with hypermobility report less mobility while those with little flexibility seem to be more so. This has to be taken into consideration while exercising especially if the program requires quick changes of direction (as in most aerobic classes).

During the post partum period, the effects of relaxin are apparent in the body and may stay as long as the mother is breastfeeding. Thus the body remains unstable for a while post partum and care should be taken when exercising. Every woman has a different level of relaxin and we cannot be too sure how her body will react to it. So use caution while exercising.

Some of the problems caused by this laxity in the joints during pregnancy can also be seen during a client’s monthly period due to the increase of progesterone at this time.

Teaching Tips • During pregnancy Pilates instructors need to be aware of spring tension, repetitions and weight bearing exercises on the pelvis. Stretching should be pain free. Movement should be easy and flowing with no evidence of straining. • Pilates’ equipment exercises remain a safe and stable way to exercise during pregnancy and postpartum especially if a woman is having problems with hypermobility. • When teaching this population, understand that they are still very much individuals, with different needs and capabilities and please do not rule out an exercise if one client has a problem with it.

Muscle tone changes It would make sense that if connective tissue has softened then the connection between the tendon and the muscle will also soften. This will make gaining strength during pregnancy less likely. The goal here is to maintain whatever strength the client has started with, while taking into account that towards the end of the third trimester there will be an extra surge of relaxin that will soften the body further in time for the birth. Muscle tone usually stays decreased during post partum as long as the effects of relaxin remain in the body and the mother is breast feeding. A gradual increase in spring load is recommended as lactic acid, a byproduct of an over worked, sore muscle, may alter the taste of breast milk.

Teaching Tips • Keep spring tension, weights and weight bearing exercises light during pregnancy • It will be up to the discretion of the instructor as to when to increase spring load, 2 repetitions and intensity during postpartum. In a private session this will not be too much of a problem, but careful design of a group class is imperative, with modifications or as we call them, variations. • A non breastfeeding mother will recover faster as her hormonal levels will settle quicker than a breastfeeding mother.

Some problems that may be associated with this laxity include the following: Diastasis recti - this problem occurs when the facsia surrounding the rectus abdominus muscle stretches.

Normal alignment of the rectus muscle Alignment of recti muscle when spilt

10 © The Center for Women’s Fitness 1994-2013 The rectus muscle is surrounded by fascia and when this softens due to the increase of relaxin, the muscle may lose some of its’ stability. During flexion of the torso (as in the “one hundred” or “roll up”) the uterus will exert pressure on the recti muscles which may split if they are tight. Flexion of the torso will also create a lot of pressure on the pelvic floor. Flexion of the torso in the first trimester is acceptable as long as there is NO evidence of a diastasis.

Flexion of the lumbar spine, as in pelvic tilts is safe and actually beneficial for pregnancy. Lumbar flexion will not have a detrimental effect on a diastasis. The force is lifted away from the pelvic floor and lower rectus muscles. 2

Diastasis Recti

The Pubis Symphasis may separate sideways or shear upwards and downwards

Pubis symphasis derangement The pubic bone is joined in front of the pelvis by a wad of cartilage. The bone is held together by the pubic symphasis ligament. When the ligaments soften, care should be taken not to make quick lateral changes of movement. This may be enough to cause the bones to separate. Along with separating sideways, there may also be a shearing or upward and downward slip of the bone. This shift of the pelvis may cause pain in the hips, groin and lower back if not rectified.

While abduction of the hip may be contraindicated if there is pain in this area, it does not make sense to leave out this very important muscle group for the rest of your client base.

The adductor group should be maintained to afford stability to the pelvis inferiorly, while the abductor group maintains the stability of the pelvis from a lateral perspective. Side lying hip/glut work will provide a safe environment for this to occur.

This condition may appear not only during pregnancy but may be caused by the birthing process itself. Therefore, expect to see this condition during postpartum as well.

Any movement that abducts both legs at the same time is usually contraindicated. For example - side splits on the reformer, leg circles on the reformer, and leg circles with leg springs on the cadillac.

12 © The Center for Women’s Fitness 1994-2013 Elbow and Knee pain Care must be taken not to stress the joints by applying too much resistance. When using arm or leg springs, err on the side of caution and use light resistance. Long levers are more susceptible to strain. Try placing the straps around the knees or upper arms while exercising.

Cardiovascular system changes Blood volume increase Blood volume increases up to 50% by about 32 weeks’ gestation, though this may vary from woman to woman. This increase causes an increase in body fluids. Circulation during pregnancy is slower especially the returning circulation from the lower extremities to the upper extremities. This may cause the “pooling” of the fluids in the ankles (edema). Simple ankle work such as prances will help alleviate this problem.

Blood volume decrease Blood volume will return to its pre-pregnancy volume within 4 weeks postpartum. Some of this volume is lost during the delivery. 2 Teaching tips • It is important to keep the fluid levels up in a breast feeding mother. Make sure she drinks plenty of water during her session. Milk production is affected by a lack of fluid.

Cardiac output changes These changes result from the increase in blood volume. Cardiac output is the amount of blood that is pumped out of each ventricle each minute. Cardiac output and heart rate increase during pregnancy to cope with the amount of blood. The heart rate gradually increases by 10-20 beats per minute by the 20th week. Due to the increase in blood volume and heart rate the heart has to work harder at pumping sufficient blood through the ventricles. A person unused to cardiovascular activity will experience, among other things, fatigue and shortness of breath during exercise (also a sign of anemia). It is imperative to monitor all pregnant women during exercise, especially those who have not exercised in a while or not at all.

While cardiac output will stay elevated during the second and third stages of labor and stays elevated for a couple of days postpartum, it normally returns to a pre pregnant state by 3 weeks postpartum. The heart rate however, will remain elevated for up to three months post partum.

Teaching tips • ACOG guidelines state that a woman should not get her heart rate above 140 bpm while doing vigorous exercise. This number is quite low if you take into account the higher heart rate experienced by most pregnant women. Some women may have a heart rate of 220 bpm when walking up the stairs. If she then takes an aerobics class her heart rate may go through the roof, even if she feels fine. A better way to make sure the client is safe is to use the rate of perceived exertion. Ask the client how hard she feels she is working. If she says “hard” then she/you need to bring the intensity down.

© The Center for Women’s Fitness 1994-2013 13 • If your studio offers cardio workouts, please increase the length of the workout slowly postpartum, making sure it is not too intense. Watch for difficulty in breathing and rapid heart rate. This could indicate, among other things, an iron deficiency.

Blood pressure changes In general there is not a significant change in blood pressure during the pregnancy. In some cases, high blood pressure during the third trimester is indicated. (pre-eclampsia) Normally these women are advised to stop exercising. The only significant drop in blood pressure can occur when the woman is in the supine position. The weight of the uterus can compress the inferior vena cava, which may result in supine hypotension syndrome. Signs of vena cava compression are shortness of breath, dizziness and sometimes nausea. Rolling onto their side alleviates the problem. Some exercises in this program are done supine. They are limited in length of time and alternate with side lying positions. The supine exercises are included because they are felt to be beneficial to the pregnant woman.

2 During postpartum the blood pressure usually remains normal unless hemorrhaging has occurred during delivery. In this case the blood pressure will be low and this will make your postpartum client fatigued and dizzy.

Teaching tips • ACOG guidelines suggest a woman should not exercise on her back after the third month of pregnancy. It is up to you to educate your client on what may happen (supine hypotension syndrome) and the symptoms to watch for. If a client feels any of these symptoms, she will find relief from just rolling onto her side. Back lying exercises are deemed safe to perform otherwise.

Iron deficiency If a woman seems unusually fatigued and is experiencing shortness of breath during exercise and seems pale and weak, chances are she has developed anemia and should consult her physician at this time. This is a fairly common problem that can be rectified with iron supplements. The pregnant woman should be encouraged to rest as much as she can to prevent further strain on her already overtaxed body systems. Problems may occur after the birth, such as hemorrhaging, as the blood will not be able to clot.

Respiratory system Mechanical changes include a displacement of the lungs slightly upwards with the expanding uterus and a restriction of the movement of the diaphragm and an increase in the transverse diameter of the thorax. (Expanding ribcage). A pregnant woman’s intake/ outtake of air is increased during this time and her breathlessness is not always due to a restriction of the lungs and diaphragm. With the event of birth this problem rectifies itself.

During postpartum the ribcage will slowly return to normal with the help of exercise. The diaphragm will descend back into place.

14 © The Center for Women’s Fitness 1994-2013 Teaching Tips • Good breathing techniques are important for releasing tension in the thorax and facilitation of relaxation techniques. Breathing is an important part of this program. • During postpartum begin to concentrate on keeping the ribcage engaged during exercise as this will help realign the spine as well as the ribcage. It will also begin to strengthen the TA muscle.

Functional changes Basically there is little change to respiratory function during pregnancy. The expectant mother is at greater risk for respiratory diseases than when not pregnant. Also, the increase in estrogen causes the common complaint of nasal stuffiness, nosebleeds and voice change.

Basal metabolism changes There is an increase in the basal metabolic rate during pregnancy. This increase meets the increased oxygen needs of both mother and baby and maternal cardiac workload. Pregnant women should eat to appetite and consume 300 extra calories a day especially 2 if exercising.

As soon as hormone levels return to normal after the birth, the metabolism will return to a pre pregnant state. If a mother is breastfeeding she not only should eat well but must also remain well hydrated in order to produce the milk. This is very important if she is also exercising. Care should be taken not to exercise to a point of fatigue which will increase the level of lactic acid in the blood which will in turn make the mother’s milk taste slightly sour. This can lead to feeding problems in the new born. Mother’s milk is very sweet!

Teaching Tips • A majority of breastfeeding mothers will lose weight during this time. However, bear in mind that some mothers will actually gain weight. The mother may well be discouraged but try and keep her spirits up and let her know that her body is getting stronger everyday even if the weight is not coming off YET.

Hormonal changes Relaxin is primarily responsible for relaxing the pelvic joints and softening the pubis symphysis to facilitate the passage of the baby through the birth canal. Due to the instability of the joints that the hormone produces, beware of over stretching as well as quick changes of movement. Never push to a point of discomfort. All stretching should be gentle and comfortable.

The EFFECTS of relaxin are said to stay in the body for some time during the post partum period. For some women this is not the case and they are seemingly back to normal within a few days.

Teaching Tips • Constantly ask your client how she is feeling. Even if there is a slight “twinge” in the joints, you need to know. This is where her limit is.

© The Center for Women’s Fitness 1994-2013 15 Estrogen is secreted by the ovaries and adrenal cortex and these levels increase 100 fold during pregnancy. This hormone influences the growth and function of the uterus and breasts and has a role in the increase in laxity of the joints.

Following pregnancy, women experience a drastic decline in estrogen levels. Consequently, 50 to 70 percent of women experience postpartum depression within the first 10 days following delivery, and approximately 10 percent may suffer a major depression.

Progesterone causes smooth muscle relaxation and joint laxity by increasing the level of fluid in ligaments thereby causing them to become looser. It prepares the breast for lactation by stimulating breast glandular development. It also stimulates the hypothalamus to lay down extensive fat storage in the pregnant woman. At the end of the pregnancy these levels will start to drop, initiating contractions that will lead to the birth.

There is a very sudden drop in the levels of progesterone after the birth. This drop has 2 been linked to postpartum depression. Baby blues are a natural part of postpartum but watch to see if it intensifies.

Teaching Tips • Watch your client closely for signs of depression. This may manifest not just by symptoms of sadness but also by symptoms of excessive irritability, anger and anxiety. Have resources handy for such clients.

Oxcytocin is produced at the start of labor and is initiated first by the brain and then by the placenta. Oxcytocin is the hormone that causes the uterus to contract during labor and contributes to the euphoria and receptiveness to the baby that the mother feels after an unmedicated birth. It is important for cervical dilation before birth and causes contractions during the second and third stages of labor.

Oxcytocin release during breastfeeding causes mild to painful uterine contractions during the first few weeks of lactation. This also serves to assist the uterus in clotting the placental attachment point postpartum. In lactating (breastfeeding) mothers, oxytocin causes milk to be ‘let down’ into a collecting chamber, from where it can be extracted by sucking at the nipple. Sucking by the infant at the nipple stimulates neurons that make oxytocin.

Teaching Tips • For more information on this hormone, we highly recommend reading Birth Reborn by Dr Michel Odent.

Other Changes Appetite changes An exercising pregnant woman should consume an extra 300 calories per day to maintain optimal nutritional requirements. In early pregnancy, morning sickness makes it difficult for many women to eat anything. Heavy exercise is not recommended until these symptoms disappear. However, light exercise such as breathing and stretching may help alleviate some of these symptoms. There is an increase in appetite usually after

16 © The Center for Women’s Fitness 1994-2013 the first trimester. Women should eat to appetite making sure that what they eat has the best nutritional value possible. Exercising pregnant women should be encouraged to drink plenty of fluids before, during and after an exercise class. They should remain well hydrated throughout their pregnancies. Dehydration may cause mild contractions. Post partum women should follow the same rules. Breastfeeding requires a well nourished and well hydrated body. An exercising postpartum mother should also watch the intensity of the workout making sure she does not get too sore. Lactic acid build up can make breast milk taste sour.

Carpal Tunnel Syndrome Pain, tingling or burning of the palm that may extend to the elbow could indicate carpal tunnel syndrome. It may be caused by swelling of the wrists and hands which may then press on a nerve that passes through the carpal tunnel. This makes lifting weights in an exercise class difficult. Clients should be advised to either wear some support around their wrists or to eliminate any weight bearing exercises for the time being. It usually resolves after birth but may take some time.

Muscle cramps 2 Muscle cramps occur when there is evidence of dehydration. Also thought to be brought on by lack of salt/calcium in the body. Look at fluid intake and nutrition.

Sweat gland and sebaceous gland changes Increase during pregnancy causing more pronounced body odor, oily skin and sometimes acne. Takes time to subside after birth.

Obvious bodily changes Women have to learn to accept the growing body and try to release the societal stigma of being fat. There are no hard and fast rules as to weight gain, stomach size etc. Most doctors will tell a woman to gain only 28lbs. This is a hard rule to follow. Every woman is different and special in her own way. The relaxation, visualization and body awareness techniques used throughout this program help these women feel good about themselves and their babies.

During postpartum it is essential to concentrate on regaining strength and alignment rather than thinness or “buffness.”

Teaching Tips • If you have a client who is extremely obsessed with her weight gain, you may use the evidence based fact that whether she likes it or not, the body will lay down upwards of 45,000 calories worth of fat. This is nature’s way of ensuring that the postpartum mother has enough fat to live off to produce milk for her infant in times of famine.

© The Center for Women’s Fitness 1994-2013 17 How do the physiological, anatomical and physical changes affect exercise during pregnancy and postpartum? While there are certainly some concerns with exercising during pregnancy, the focus should be on what a woman CAN do as opposed to what she CAN’T. Whenever there is fear involved there is tension and we all know that working with tension is a lost cause. If you think about how hard an event labor is, you will realize just how much a pregnant woman can do. Exercising in pregnancy is about the preparation for labor and delivery. But this preparation must take into account the pace and endurance needed to get through a natural labor. Releasing the body and allowing it to do its work is essential in ensuring fewer problems during delivery.

Exercising during the postpartum period takes time and patience. Listening to a traumatized and fatigued body and taking your cues from the mother and what she is NOT saying is important in designing a program for this population.

What will help Prepare the Body? 2 PILATES PREGNANCY PRINCIPLES™

• The pelvis in the correct position A more anterior tilt is anticipated. The emphasis is on supporting the changes rather than trying to maintain neutral.

• Strength Strength comes more from the “inner” body. Finding the strength to allow the body to relax and release. To accept the loss of control over the body and to go with the flow. This kind of strength training will help throughout the early adjustments of motherhood.

• Flexibility To maintain the flexibility in the entire body by exercising with the intent of supporting the body rather than strengthening it. To be flexible in the mindset of opening and releasing rather than tightening and strengthening the body.

• Total body integration It will take every muscle working together to birth the baby. The Pilates principle of total body integration has to be one of the most important aspects of exercising during this time.

• Awareness and trust in the body Understanding what is happening to the body during this time and more importantly, allowing it to happen while supporting the changes, will increase a woman’s awareness of her strengths and flexibility, not just physically but mentally and spiritually as well.

• Breathing, Focus and the ability to relax and release The techniques that this program will teach you, will stand your client in good stead long after the baby is born and well into her life as a parent. Breathing and relaxation are the ultimate “tonics” for wellbeing.

18 © The Center for Women’s Fitness 1994-2013 What will help Recover the Body? PILATES POSTPARTUM PRINCIPLES™

• The pelvis in the correct position The pelvis will begin to realign back to a more neutral position. The lumbar spine is vulnerable at this time and will need support from the surrounding muscle groups. Binding the pelvis will aid in the realignment.

• Strength Strength has to be regained from the inside out, working with the deeper stabilizing muscles first before attempting a regular exercise program.

• Flexibility To maintain the flexibility in the entire body by exercising in a non stressful and relaxed way in order to gain the maximum benefits from Pilates exercises. • Total body integration 2 Total body integration will allow the body to regain its balance and alignment. Work- ing with flow and breathing will help achieve this.

• Awareness and trust in the body Understanding what is happening to the body during this time and more importantly, accepting the changes and trusting that you can make the postpartum body better than it ever was before.

© The Center for Women’s Fitness 1994-2013 19 SECTION 3 BREATHING AND RELAXATION This is one of the most important aspects of any pre and postnatal program. Breathing, however, seems to be the nemesis of most clients. They tend to try too hard to “get” the breathing patterns. There is nothing to get. Breathing is a normal, involuntary action that needs no learning. What we do have to learn is awareness and rhythm and depth. There is no wrong way to breathe.

What we will learn in pregnancy and postpartum is how to use the breath to:

• Activate the pelvic floor and abdominals. • Create focus. • Aid in early postpartum recovery. • Create relaxation. • Establish individual body alignment,

Learning to breathe deeply will reset the body reactors. It will change the over worked sympathetic “flight or fight” system to the parasympathetic “rest and relax” system. Breathing also acts as a “pump” for the lymph system which, on its own, does not have the ability to move waste out of the body relying on movement and breathing to help.

Deep abdominal breathing is a necessary tool for labor and delivery. Life is a great 3 teacher and we have learned from our pregnant clients both during class and during their labor and deliveries as each and every one of them turn to breathing deeply before focusing in towards their bodies and disappearing into another world.

The aim in labor is to release the thinking brain and to sink into the realms of the primal brain, allowing the body to take over and birth the baby. One of the ways to attain this is to practice deep breathing until it becomes an automatic response to calming and focusing and then delving more into the subconscious mind. We teach three different types of breathing as part of the exercise routine during pregnancy but use deep abdominal breathing exclusively during the last month of pregnancy. The exercise session in that last month consists mainly of breathing and stretching with relaxation and visualization.

There have been a number of issues in the past with the Pilates lateral ribcage breathing technique. This breath is instrumental in realigning the ribcage to the spine. However, when a woman reaches her fifth to sixth month, the uterus will lift out of the pelvic basin into the abdominal cavity. This pushes the internal organs upwards towards the chest. The ribcage then opens sideways to accommodate the expanding pregnancy. One main concern with the cue to “knit” the ribs together on the exhale causes some clients to experienced pain associated with a rigid ribcage. There are a number of exercises, coupled with breathing, that are designed to alleviate this problem.

20 © The Center for Women’s Fitness 1994-2013 Deep abdominal breathing is such a great stress reducer as well as focusing the mind and calming the nerves. It is wonderful to see the energy change in a class when everyone begins to breathe deeply. It creates such a calm, serene atmosphere and is truly beneficial for those who have run into class after a hectic day.

The muscles and bones involved with breathing include the lungs, the diaphragm, the transversus abdominus, the posterior serratus and the intercostals (the muscles between the ribs). These muscles have attachments to the ribcage which protects the heart and lungs.

During inhalation the diaphragm contracts and pulls downward. This is mirrored by the pelvic floor diaphragm and the palate diaphragm in the roof of the mouth. It is this mirroring that allows us to stretch and release the pelvic floor muscles on an inhale. Deep breathing also allows for the opening of the throat which in turn opens the birth canal.

The (breathing) diaphragm relaxes back to its original position on an exhalation. There is a moment between an inhale and exhale where no movement of the diaphragm takes place. This is a rest space. This is the space where relaxation occurs.

The pelvic diaphragm (floor) will also return to normal. If we are to strengthen the pelvic floor, the connection should be made at the end of the exhale when all muscles are 3 back to their resting position. This will create a gentler pull on the PF muscles rather than an aggressive, sometimes violent contraction which does little to work the muscles according to their function.

The ribcage will expand sideways and forward on the inhale and return to normal on the exhalation unless there is a forced exhalation, in which case, the lower ribs will be pulled together, engaging the transversus abdominus and posterior serratus muscles. This is a wonderful way to reactivate the transversus abdominus in the early postpartum period.

During the first trimester, we will still engage the abdominals as part of the breathing exercises. These exercises are taught throughout the pregnancy with the emphasis on relaxation on the exhalation towards the end of the third trimester. These exercises will then become the early postpartum rehabilitation program.

Learning the different breaths

• Deep abdominal or belly breathing. • Lateral ribcage breathing. • Posterior ribcage breathing.

© The Center for Women’s Fitness 1994-2013 21 DEEP ABDOMINAL BREATHING Learning to find the breath • Sit on the mat. Place your hands over the lower abdominals just above the pubic bone. • Inhale into the hands through the nose. Feel the lower abdominals release into the hands. This may seem easy but for the first few tries chances are your clients will not feel their hands move. Most of them will still be breathing into the chest area. If this happens we suggest you start with the hands on the ribcage or chest and work the hands down towards the lower abdominals effectively tracing a path for the breath. It may take weeks to finally get there. • Exhale out through the mouth and feel the lower abdominals move away from the hands. Don’t try and exhale forcibly at this point. We are just trying to establish where the breath is.

The transversus abdominus is essentially a respiratory muscle which functions to press the air out of the lungs. The connection of the transversus should happen at the end of the exhale when the muscles are in their correct alignment.

Practice this until they can feel the breath being drawn down to the lower abdominals. This becomes the breath to use in labor, a rehabilitation exercise after the birth and a relaxing breath if used without the conscious muscle engagement.

Deep abdominal breathing is the precursor to relaxation and then to the visualization techniques used in class. Relaxation and visualization usually go hand in hand and is 3 a nice way to finish up a session. In order to give good relaxation, the person giving the directions needs to be relaxed as well. So as an instructor you have to learn these techniques for yourself before applying it to your clients.

22 © The Center for Women’s Fitness 1994-2013 RELAXATION TECHNIQUES Everyone can take themselves into a deeply relaxed state of mind. It just takes practice. Here are a few steps to help you on your way.

• Find a space that’s comfortable, making sure the room is warm if it’s winter and cool if it’s summer. In a studio setting, the lights can be turned down and blankets available if necessary. • Lie on your side on a mat or sit in a chair. Use some soothing music that has no vocals. Music with sounds of waves is generally excellent for pregnancy as the water sounds correspond to the amniotic fluid. • Begin by taking a few deep breaths to cleanse and focus. • Next, start taking deeper breaths, sending the breath down to the pelvic floor and lower abdominals. On the exhale allow the body to relax and release. Inhale to the deepest part of your body and exhale to relax and release. • Your body should begin to feel heavier and heavier as you continue to breathe and release. • After a while you will find your own rhythm to your breath. As you reach a calm state of mind, begin to focus in towards your mind. Don’t think. Just breathe. • Consciously begin to relax every muscle in your body starting from the top of your head to the tips of your toes. Do this in segments, head, neck, shoulders etc. • You will notice that your breath will slow down and you are calm and focused. • From this state, bring your voice up to the larynx from the lowest part of the TA. This keeps the throat open and allows for a lower tone in your voice as you talk your clients through the visualization. • Sometimes, the music tells a story and you can pace yourself along with the music. 3 Allow the client the time to assimilate the information before moving onto the next image.

VISUALIZATION From this state of deep relaxation you can begin to use imagery to achieve certain goals. You may want to send healing energy to places of pain in your body. Or you may want to release negative energy. Whatever the need is you can achieve the belief of obtaining the result from this state of consciousness.

As an instructor giving the relaxation and visualization, try and use words that are soft and nonthreatening. Above all make people feel safe. There are some who will not be able to let go and that’s just fine. Some people have issues that are beyond the scope of your teaching.

It is important to attempt all these techniques because birth is all about letting go and if the pregnant woman has the ability to release, the birth will go smoother. Tension and fear are great obstacles to living

The Center has a Relaxation and Visualization CD that is included with this course.

© The Center for Women’s Fitness 1994-2013 23 LATERAL RIBCAGE BREATHING Lateral ribcage breathing is a part of normal Pilates sessions because it truly does help realign the spine and activate the transversus abdominus. However some clients are finding that their ribcages cannot expand with their pregnancies. With this breath, the emphasis is on the inhale and not the exhale. We need to now be trying to stretch the intercostals muscles which are the muscles in between the ribs.

To learn this breath • Sit or lie on a mat. • Knees are bent and feet are flat on the floor. • Place the hands on the ribcage with finger tips touching. • Breathe sideways into the ribs trying to draw the finger tips apart. 3 • Exhale to release the muscles but not engage them.

If you inhale into a side bend it intensifies the stretch of the intercostals. There are a number of exercises throughout the workout section of this book that will address this issue.

During the post partum period you can revert back to “knitting” the ribcage as this will help activate the transversus abdominus.

24 © The Center for Women’s Fitness 1994-2013 POSTERIOR RIB CAGE BREATHING

To learn this breath • Place the hands on the posterior ribcage. • Inhale into the hands. • Exhale and pull the front of the ribcage together keeping the back wide or exhale to relax the rib cage towards the mat.

This has to be the hardest breath to master. It is beneficial in opening up the thoracic spine and increasing the capacity of the lungs. Tactile feedback using the hands or the floor is the best way to feel this breath. It is important to be able to isolate the different breathing patterns. This way you will be 3 able to choose a breath to suit your clients’ needs at any given moment.

Breathing is very much underestimated. During pregnancy and post partum it can be a wonderfully simple way to maintain the strength of the abdominals. At any stage of life, in any situation, breathing can help oxygenate, calm, focus and de stress. Learn to use it well.

The breathing sequence that follows begins every session. In the first trimester your client may lie on her back. In the second trimester, it can be done sitting, lying sideways or any other comfortable position. The exhalation can be used to release the muscles during pregnancy, and engage them during postpartum.

The supine breathing sequence becomes the early postpartum rehabilitation program. This along with the basic pelvic floor exercises that you will learn later, can be done anywhere from a few hours after the birth up until your client resumes her sessions with you.

Benefits The supine position eliminates the need to activate the surrounding muscles. Activates the pelvic floor muscles.

• Lie supine with the knees bent, feet hip width apart and place the finger tips on the sit bones. • Inhale into the finger tips using verbal cuing to indicate the breath flowing through the pelvic floor. “Breathe in between your sit bones.” • Exhale and initiate the out breath by visualizing the sit bones coming together. “Exhale and gently bring the sit bones together”. 3 • Repeat desired number of times.

Then add • Place the finger tips on the hip bones. • Inhale in between the hip bones.”Breathe in between the hip bones.” • Exhale and visualize the hip bones narrowing. “Exhale and gently bring the hip bones together.” • Repeat desired number of times.

26 © The Center for Women’s Fitness 1994-2013 Then add • Place the hands on the lower ribcage. • Inhale into the hands, expanding the ribcage, “Inhale between the hands.” • Exhale and pull the lower ribcage together. “Exhale and gently bring the ribcage together.” • Repeat desired number of times.

Then add • Place the hands on the posterior ribcage. • Inhale into the hands. • Exhale and allow the ribcage to relax towards the mat OR exhale and gently bring the front of the ribcage together, keeping the back wide. • Repeat desired number of times. 3

Then put it all together • Place the hands by the sides. • Inhale three dimensionally, down into the pelvic floor, into the lower abs, expanding the ribcage forward, back and side. • Exhale and gently pull all of the muscles and bones towards the midline. • Repeat desired number of times.

• Place the hands on the abdominals. • Inhale into the abdominals. • Exhale and allow the abdominals to relax towards the spine. • At the end of the exhale, gently pull the abdominals towards the spine to create the “flatness” of the abdominals. • Then connect the sit bones, hip bones and ribcage. • The cue becomes, “inhale, exhale, drop, connect and (do a movement).” • Repeat desired number of times.

ALIGNING THE BODY THROUGH RELAXATION 3 During pregnancy, with the ever changing body, it becomes difficult to keep to a certain “normal” alignment. Our goal here is to allow the pregnant body to “relax” into its’ own natural alignment and to not force the pregnant or postpartum client to achieve something unnatural to their bodies at this time.

We achieve this relaxed state of alignment through breathing and releasing techniques at the beginning of every session.

Relaxing the muscles loosens their hold on the bones and this may allow the bones to realign according to the individual body. There is no “perfect” alignment, especially during pregnancy and postpartum when there are daily changes to the body.

28 © The Center for Women’s Fitness 1994-2013 CUING ALIGNMENT After using the breath to create relaxation in the body begin using these cues for alignment.

In a supine position, as the body begins to relax, ask the client to “feel” the back of the head on the mat. This will position the head correctly.

Once again ask the client to loosen the neck. The release of tension may adjust the alignment of the neck.

Working down the body, ask the client to “feel” both shoulder blades on the mat.

Keep breathing and releasing in between to ensure the body is releasing.

Work your way down the body- release the back of the ribcage towards the mat. Don’t use cues that will force alignment.

“Feel” the back of the pelvis on the mat and then “feel” the soles of the feet on the mat.

Allow the client some space to relax into the alignment she has found for herself. The client will hopefully then have placed her body in HER own natural alignment.

Nine times out of ten, you will find that they have perfectly good alignment. From this point, the session should maintain a sense of relaxation to ensure that the 3 muscles are not working with tension. This will help keep the body in a good alignment.

This will also help the client take responsibility for her own body and how SHE is feeling rather than trying to accommodate your alignment cues, which may feel foreign to her changing body.

• The Pelvis and the Pelvic Floor. • Abdominals. • The gluts. • Hamstrings. • Shoulder adductors and external rotators. • Back extension and stretches.

The pregnant body is trying to open and release and it is our responsibility to support these changes rather than to try to keep the body strong and tight. Physiologically, the hormones are being produced to soften the body and it is actually almost impossible to gain strength. You can however, maintain what you have.

With this in mind, instructors are geared towards keeping sessions light, stable and flowing. There are a number of key areas that we will focus on during pregnancy to enable the client to maintain optimal fitness as well as prepare her for the event of labor and delivery.

During pregnancy, in order to stabilize a body that is trying to release, we will look to maintaining suppleness in the areas listed above.

For the postpartum period we look at the same muscle groups as during pregnancy and teach with the intention of realigning and strengthening. For the sake of a timeline, we will look at the first 12 months postpartum. If a client is consistent with her workouts she will be able to move quickly into her “normal” routine barring any complications such as a diastasis recti or a c section. 4 As Pilates’ instructors with a number of years experience, it is assumed that you know the classic repertory on Mat and Equipment. After learning the information here, you will be able to draw on your own cache of exercises once you feel confident enough.

30 © The Center for Women’s Fitness 1994-2013 THE PELVIS An overview the bony structure of the pelvis.

Sacrum

Illium

Ischial spines

Coccyx

Pubis Ischial tuberosities The pelvis consists of three bones • Hip bone - which includes the ischial tuberosities, the illium and the pubis and the ischial spines. • The sacrum. • The coccyx. 4 These bones are connected via strong ligaments that ensure the stability of the pelvis. These ligaments may have more or less movement depending on the individual. During the monthly cycle, women have an increase in the hormone progesterone which in turn may increase the amount of fluid in the tissues. This excess fluid will cause some laxity in connective tissue and ligaments. During pregnancy, progesterone plus relaxin combine to increase this laxity. Hence the pelvis may become less stable during the first few months prenatal and more unstable towards the end of the third trimester when there is an extra boost in the relaxin hormone.

The ischial spines may sometimes be too close together and may impede the birth of the baby. In such cases, a C section is indicated.

The pelvic bones are pressed apart during the birthing process and may need help realigning after the birth. The ligaments will slowly regain their ability to hold the joints together.

Sacrospinous ligament

Anterior Sacroiliac ligament

Sacrotuberous ligament Pubis Symphasis ligament

From the anterior view, we can see the winged shaped hip bones (the illium) connecting 4 at the sacrum via the sacro iliac joint (SI) at the back of the pelvis. The hip bone and SI joint are held together by the anterior sacro-iliac ligament. The laxity of this ligament may cause some SI joint discomfort during pregnancy.

Running along the top of the illium is the illiolumbar ligament connecting L4 and L5 to the illium. The laxity of this ligament may cause some instability of the pelvis to the spine and indirectly cause lower back pain.

The two hip bones join in the front at the pubis symphasis. The pubis symphasis is connected by a thick piece of cartilage. These joints are held together by the pubic ligament. This joint may become unstable to the point of creating a gap between the bones. This is a condition known as pubic symphasis derangement. The bones may either come apart laterally or “shear” up and down. This separation may occur during pregnancy or during the birthing process itself.

The ischium or sit bones are connected to the sacrum by the sacrotuberous ligament. The laxity here may also affect the SI Joint. The ischial spines are held to the sacrum via the sacrospinous ligament.

32 © The Center for Women’s Fitness 1994-2013 POSTERIOR VIEW OF PELVIC LIGAMENTS

Ilio lumbar ligament

Posterior sacroiliac ligament

Sacrotuberous ligament

Pubis Symphasis ligament Sacrospinous ligament

The same ligaments from the back of the pelvis.

We can see from these ligaments how unstable the pelvis can become especially towards the end of the pregnancy when a woman will experience a sudden increase in the 4 amount of relaxin that will soften the pelvis in time for the birth.

Superior opening

Middle

Inferior

The superior opening - also known as the pelvic inlet is the irregular shaped circle that runs along the illiopectineal line on the inside of the illium. osteriorlyP across the sacral promontory and anteriorly across the superior pubis symphasis. This is basically the top 4 of the pelvis. When the baby’s head is said to be engaged it is usually in this part of the pelvis. The illium will move further apart at this time to accommodate the baby’s head. The ischial tuberosities or sit bones will move closer together.

34 © The Center for Women’s Fitness 1994-2013 Middle

The middle opening - forms a circle midway between the superior and inferior openings. It runs posteriorly across the S3-4, the ischial spines on the sides and the pubis symphasis in the front. The pelvic diaphragm/pelvic floor muscles attach at this level.

The Pelvic Diaphragm or Levator Ani muscles are the deeper layer of the two layers of the Pelvic Floor. The muscle fibers run from back to front thus allowing for the forward 4 and backward movement of these muscles. Pelvic tilts move these muscles according to their function and are an essential exercise during pregnancy.

Illiococcygeous Puborectalis

Ischial spine

Ischiococcygeous

RELEASE Anus This layer consists of...

• Ischiococcygeous muscle that attaches from the ischial spine to the coccyx • The Illiococcygeous muscle- this muscle attaches from the sacrum and coccyx and by fascia to the illium. This attachment to fascia rather than bone allows the pelvic floor to “bounce” like a trampoline when pressure is exerted on it. 4 • The Pubococcygeous – this muscle runs from both sides of the pubic bone to the sacrum and coccyx and joins with the puborectalis along the way. The pubococcygeous has a direct muscle to muscle connection with the obturator internus. The function of the obturator internus is to create both flexion and lateral rotation of the hip. Thus any movement that takes the hip into these positions will also affect the pelvic floor. If you include exercises such as footwork in a wide lateral rotation you are effectively opening and stretching the pelvic floor. In a medial rotation of the hip you will be closing the pelvic floor. • The levator ani muscles offer front to back stability to the pelvis. • The movement cue for this layer would be to “gently pull the tailbone towards the pubic bone.”

The Pelvic Diaphragm has the ability to slide forward and backward along the overlying urogenital triangle due to the layer of fascia separating the two layers. This movement of the pelvic diaphragm effectively “closes” both the anal and urethral openings, creating continence.

36 © The Center for Women’s Fitness 1994-2013 As the baby descends into the middle opening (the birth canal) it presses up against the involuntary anal sphincter muscles which will initiate the “pushing” urge which aids in the expulsion of the baby. As the baby descends into this area, the pelvic diaphragm will support its head as it turns under the pubic bone before being expelled. The baby’s’ head will also press the sacrum away from the pubic bone essentially opening the pelvic outlet.

Pelvic diaphragm

Sacrum

Hands and knees position

Baby’s head

Baby’s head 4

Back lying position

Sacrum

Pelvic diaphragm

© The Center for Women’s Fitness 1994-2013 37 The sacrum will shift backwards to open up the pelvic diameter even more. If a woman is lying down to push, the sacrum will be limited in its ability to open the pelvis and will hinder the birthing process. It is much better to give birth in an upright, hands and knees position or side lying position.

If the ischial spines are too narrow, no amount of the opening of the pelvis will accommodate the baby’s head. This is an indication for a C section. Some women may have been told that their pelvis is “too narrow” to give birth.

In an ideal world, the muscles of the pelvic floor are flexible enough to allow for this stretching of the pelvic diaphragm. Chances are though that women who have been strengthening the pelvic floor in time for the birth, have actually created a too strong a pelvic floor. This will prevent the opening of the pelvis during the birthing process and may also contribute to lower back pain as the sacrum is constantly pulled forward. This tightness in the pelvic floor may be seen in clients (whether pregnant or not) during an anterior tilt of the pelvis especially when performed in a quadruped position. To achieve a true anterior tilt, the coccyx lifts slightly towards the ceiling (pelvic diaphragm) and the ischial tuberosities will more slight apart. (uro genital triangle). If both layers of the pelvic floor are “tight” this movement of the bones is inhibited. The anterior tilt is then initiated from the lumbar spine instead.

If the pelvic floor is “tight” chances are an anterior tilt will be initiated from the lumbar spine

The sacrum remains slightly “tucked” under with a tight 4 pelvic floor

Sometimes a posture that includes excessive posterior tilting may indicate a need to release the fascia of the pelvic floor. This is discussed later.

38 © The Center for Women’s Fitness 1994-2013 The inferior opening - is bordered by the lower edge of the pubic symphasis in the front, on the sides by the ischiopubic ramus (the pelvic arch) and the ischial tuberosities (sit bones) and at the back by the coccyx. The second layer of the pelvic floor, the urogenital triangle, attaches at this point.

The more superficial layer of the pelvic floor is the urogenital triangle. This thicker stronger layer has most of its muscle fibers running from side to side rather than the front to back movement of the pelvic diaphragm.

Ischiocavernosus Uro genital diaphragm

CONTRACT RELEASE

Ischial tuberosity

Perineum

Superficial transverse Pelvic diaphragm perineal muscle This area consists of...

• A set of muscles that run diagonally along the pelvic brim -the ischiocavernosus muscles. The bulbospongiosus muscle wraps around the back of the vagina or around the back of the penis in men. These are erectile muscle fibers. When the baby’s head presses up against these muscles there is a tingling and burning sensation. • The next set of muscles run from side to side and is called the superficial transverse perineal muscle. It runs from sit bone to sit bone and holds the pelvis stable from the sides. The deep transverse perineal muscle is a broader thinner 4 muscle located deeper to the urogenital triangle, also known as the uro genital diaphragm. • The puborectalis muscle runs from the pubic bone and forms a figure of 8 before wrapping around the rectum (anus). This muscle along with the pubococcygeous muscles assists in pushing the baby out. • The pubovaginalis muscle wraps around the back of the vagina, pulling it away from the anus. • Almost all of these muscles run through the central part of the pelvic floor forming what is known as the perineum. This may also be the place to cut during an episiotomy. As you can see, cutting through this area will destroy the integrity of the pelvic floor • As the baby’s head emerges the sit bones move apart and the hip bones come closer together.

If the mother is lying on her back to push, this position will inhibit the ability of the sacrum to lift away from the pubic bone. The baby may then press against the pubic bone in order to maneuver. This may sometimes cause a separation of the pubic bone.

40 © The Center for Women’s Fitness 1994-2013 RELEASE THE PELVIC FLOOR MUSCLES

Ischial FUNCTIONS OF THE PELVIC FLOOR tuberosity The PF muscles support the lower part of the bladder, vagina and rectum and the abdominal contents. • The Illiococcygeous muscle which is a part of the pelvic diaphragm is connected to the illium via a band of fascia. This enables the pelvic diaphragm to “give” during the action of a cough or sneeze. This fascial attachment enables the pelvic floor to spring back upwards like a trampoline. If the PF muscles are weak OR tight this ability to spring back is limited and can give rise to certain problems like incontinence. The pubovaginalis muscle supports the vagina and the puborectalis muscle supports the anus, holding them in a slightly “forward” position.

They provide fecal, gas and urinary continence • The muscle fiber direction of the pelvic diaphragm runs from back to front. When these muscles contract, they pull the tailbone towards the pubic bone. This action effectively closes off both the anal and urethra sphincters ensuring continence. Bony cuing of this area during movement is very effective.

They support good sexual responses. • The uro genital triangle consists partly of erectile muscle and if this muscle is 4 healthy, it creates the possibility of greater response during love making.

They help expel the baby during the birthing process. • The puborectalis and pubococcygeous muscle work together to expel the baby.

A faster return to “normal” after the birth. • Muscles that are functioning properly through exercise, rest and good nutrition will reconnect faster than muscles that have not been looked after.

Less discomfort in the perineal area especially after stitches or due to hemorrhoids. • Performing gentle exercises as soon as possible after the birth will help heal this area. Muscle movement will bring blood to this area which will help heal it.

Stronger and quicker expulsion of the baby. • Training your muscles to open and release (including the pelvic floor) will allow for the quicker passage of the baby through the birth canal barring any other complications.

© The Center for Women’s Fitness 1994-2013 41 PROBLEMS OF A WEAK/TIGHT PELVIC FLOOR Leakage of urine during coughing, sneezing or laughing • This indicates that not only are the muscles in this area a little weak, the connective tissue may also be damaged. This can occur for a number of different reasons, childbirth being one. Some of the damage during childbirth may occur due to interference from forceps, episiotomies or vacuum births. Tight muscles will not have the ability to move correctly and may be a factor in incontinence. Poor sexual response • The inability of these muscles to respond to the stimulation from movement. Difficuty in birthing • The pelvic floor muscles should be supple enough to allow for stretching during the birthing process. Most exercise routines stress the strengthening of the pelvic floor and it is this that may cause some problems during labor and delivery.

DAMAGE TO THE PELVIC FLOOR CAN COME ABOUT THROUGH Improper body mechanics while heavy lifting • Most exertion during heavy lifting should be accompanied by an exhale. This will engage the pelvic floor and prevent undue stress on this area. Pregnancy and childbirth • Damage to this area at this time includes- episiotomies, forceps and vacuum deliveries. Long pushing stages while lying on your back prevents the pelvic floor from responding efficiently. Childbirth without interference may prevent some of these problems from occurring. Sedentary lifestyle • Lying down, sitting with your feet up- all these positions ultimately unloads the pelvic floor. Standing up loads the pelvic floor as does walking or any other daily activities. Excessive high impact sports • As with all repetitive injuries, there has to be a rest point or stretch point. Unfortunately there seems to be an imbalance in most exercise routines. Poor nutrition • None of the muscles in your body will work well if you are not eating well. 4 Kegels are the most common pelvic floor exercise used today. Women are instructed to pull these muscles up towards the cervix and then gently lower back to the starting position. They first find these muscles by stopping the flow of urine. The pelvic floor muscles, however, do not necessarily “pull up” but rather slide forward and back. When a person performs the kegel exercise they are more than likely only activating the anal and vaginal sphincter muscles, as well as the vaginal wall muscles. The anal sphincters include both the internal anal sphincter which is smooth muscle (involuntary) and the external sphincter muscles which is skeletal (voluntary). We only have control over the external sphincter muscles.

In this program there are a number of exercises like the pelvic tilt and forward kneeling stretch which will effectively both strengthen and stretch the pelvic floor. A lot of our day to day activities actually do activate our pelvic floors and we should take this into consideration when we consciously exercise this area. If we understand the function and attachments of all the pelvic floor muscles, it will make it easier for you, the instructor, to incorporate pelvic floor exercises into your daily sessions without using the cue “pull up your pelvic floor”.

42 © The Center for Women’s Fitness 1994-2013 Urethra

Vagina Pubovaginalis Pubococcygeous Illiococcygeous

Puborectalis

Ischial spine

Ischiococcygeous

Anus

The Pelvic Diaphragm or Levator Ani muscles are the deeper layer of the two layers of the Pelvic Floor. The muscle fibers run from back to front thus allowing for the forward and backward movement of these muscles. Pelvic tilts move these muscles according to their function and are an essential exercise during pregnancy.

The Pelvic Diaphragm or Levator Ani muscles

Urogenital Triangle

Bulbospongiosus

Ischiocavernosus

Uro genital diaphragm

Ischial Perineum tuberosity

Pelvic diaphragm

Puborectalis Superficial transverse perineal muscle

Pubic bone

Sit bones (ischial tuberosities)

Tail bone (coccyx)

© The Center for Women’s Fitness 1994-2013 47 To further facilitate teaching movement we use “bony” cuing. This makes it easier for the client to understand. The pelvic floor muscles are essentially attached to these bony landmarks of the pelvis. We call these the “4 points.”

• For example - to contract the pelvic diaphragm we can say “pull your tailbone to your pubic bone.” • To activate the urogenital triangle we can say “pull your sit bones together.” • To activate the whole pelvic floor we can say “pull the 4 points together.” • To release the pelvic floor, any movement that takes the sit bones away from each other and the pubic bone away from the tailbone e.g., inhaling, an anterior pelvic tilt, squatting or lateral rotation of the hip will open or stretch the pelvic floor • To close the pelvic floor any medial movement of the hip, exhaling and pulling of the four points together will strengthen this area.

The pelvic floor can be divided into...

• Anterior and posterior (front and back) This will include the muscles that attach from the pubis to the coccyx. It will also separate the PF into two triangles. • Left and Right PF This will include the transverse perineal muscles attached from both ischial tuberosities.

48 © The Center for Women’s Fitness 1994-2013 OVERVIEW OF THE PELVIS AND PELVIC FLOOR DURING THE BIRTH The pelvic bones will separate to a certain degree during the passage of the baby through the pelvis.

The sacrum will lift backwards

The illium will The illium will move apart to move apart to open the pelvis open the pelvis

The pelvic brim will The pelvic brim will move sideways move sideways

The surrounding muscle groups supporting the pelvis will slacken during the birth to allow for this opening of the pelvis. The gluts, hamstrings, hip add/abductors and abdominal muscle groups are among some of the muscles groups that will need to be supple enough to allow for this movement. If all these muscle groups have been excessively strengthened or are tight during pregnancy, they may have trouble releasing during birth and may therefore cause some problems. An exercise program should use light weights and include plenty of stretching during pregnancy.

Abdominal attachments to 4 pelvis

Hip abductor attachment to pelvis

Glut attachment to pelvis (lateral and posterior)

Hamstring attachment to Hip adductor pelvis attachment to pelvis © The Center for Women’s Fitness 1994-2013 49 After the birth of the baby, the ligaments in the pelvis will slowly begin to tighten again. Strengthening the surrounding muscle groups will help in realigning the pelvis.

Care should be taken in preventing stress to the pelvic region in early postpartum. Good body mechanics during everyday life is important during this stage. A mother should be aware of how she is carrying her child and lifting things throughout her day. There are a number of ways to help your client.

• Give her tips on maintaining her posture throughout her day. She can stand well when ever her baby is not in her arms, but also try to stay lifted when holding the baby. Body awareness is a great posture builder. • Show her how to lift properly. Breathing out on the exertion to activate the Transversus Abdominus and pelvic floor muscles. Bending her knees to save her back. • Simple everyday things have a huge impact on how the postpartum woman rehabilitates after the birth. • Simple yet effective exercises are explained in this program that every new mother can do at some point during her day. They do not take much time and they do not need any special equipment.

Once the baby has been born, the pelvis will attempt to realign. The muscles surrounding the pelvis will need special attention. Some sort of gentle binding will help support the muscles as the bones move back together.

There is a growing movement towards the traditional eastern culture of “binding” the abdominals and pelvis during the post partum period. It is beneficial to support the pelvic bones as they try to realign. If the muscles are put under too much stress trying to support this procedure, chances are they will “tighten’ or spasm in an attempt to hold the bones together.

The muscles have been stretched and traumatized and need a little support. Reconnecting the muscles of the pelvic floor, abdominals and gluteals through breathing 4 and gentle movement will be instrumental in not only regaining the strength in this area but also to begin to realign the muscles. Excessive, high impact and resistance training too early in the postpartum period will only serve to make matters worse by creating tension and fatigue in muscles that have been over taxed and traumatized.

50 © The Center for Women’s Fitness 1994-2013 RETRAINING THE PELVIC FLOOR AFTER THE BIRTH

Episiotomy Sites

During vaginal deliveries the pelvic floor is traumatized. It is stretched and sometimes torn or cut due to an episiotomy. It is extremely important to start gentle exercises as soon as possible after the birth in order to prevent future problems.

Within hours of a vaginal birth, women may start to perform the pelvic floor exercises that are activated using the breath. This will include the bony cuing of the bottom of 4 the pelvis. Use of the cues - “tailbone to pubic bone” and “sit bone to sit bone” will be instrumental in reactivating this area. “Pulling the 4 points together” is another useful cue. Use of the breath will help in reconnecting the muscles of the abdominals as well

The muscles are so stretched and fatigued that most movement will not be felt. However the muscles have memory and all we are trying to do in the first few days post partum is try and activate this memory. If left the traditional six weeks, the work of retraining these muscles becomes difficult.

• If the client has had an episiotomy, doing pelvic floor exercises will help with the pain and healing of this wound. They will serve to pull the edges of the cut together, promoting healing. • Any movement will get the circulation going which will also promote healing. • Reactivating these muscles will also take some of the pressure off the wound giving momentary comfort.

• Prolapse of the womb. • Prolapse of the bladder. • Incontinence. • Poor sexual function. • Instability in the pelvic and lumbar areas. • Poor posture.

Before beginning any kind of impact activity you need to address the pelvic floor first. This is true of everyone whether they were active before the birth or not. All women have been through the same stretching and loosening of these muscles.

A prolapsed womb or bladder has usually had some damage from the birth itself, if forceps or a C-section has been performed. The damage is usually to the ligaments holding these organs in place. While strengthening the pelvic floor may help in these cases, bladder and womb prolapse do not usually respond to exercising of the pelvic floor.

Strenuous exercise is contraindicated with these conditions. Flexion of the torso is an exercise that puts a lot of pressure on the pelvic floor and should be avoided for a while in the early postnatal period. Unloaded (for example supine exercises) pelvic floor exercises are indicated.

52 © The Center for Women’s Fitness 1994-2013 BASIC PELVIC FLOOR EXERCISES

SUPINE EXERCISES Lying supine will unload any weight bearing force on the pelvic floor and will be less tiring for your client to try and locate these muscles and exercise them especially just after the birth. This position also deactivates the gluteus maximus. The movements are small and gentle.

*These exercises may also be performed using an abdominal binder for support in the early days postpartum.

Pelvic tilts Benefits Increase mobility of this area to aid circulation Works the pelvic floor Activates the lower TA and rectus abdominus Stretches the lumbar spine

• Lie supine with the knees bent and the feet on the floor. Inhale. • Exhale and gently “pull the tailbone to the pubic bone, pubic bone to chest” • Inhale to release to an anterior pelvic tilt to “stretch” the pelvic floor. • Exhale to repeat the tilt. • The action should be of “rocking the pelvis back and forth”. There should not be 4 any tension. The movement does not incorporate the gluteus maximus.

These pelvic tilts may be done supine, sitting on a ball or in a quadruped position.

• Lie supine with the feet and knees together. Arms to the side.

• Inhale and drop both knees to one side. • Exhale, connect the 4 points and bring both knees back to center. • Repeat on the other side. 4 • Use imagery to focus on the pelvic floor bringing the knees back.

54 © The Center for Women’s Fitness 1994-2013 Single leg supine butterfly Benefits Stretches and strengthens the PF unilaterally. PF is unloaded

• Lie supine on the mat with knees and feet together.

• Inhale and allow one knee to drop to the side. • Exhale and bring the knee back to center using the imagery of the sit bone pulling together. • Visualize the pelvic floor in two parts, left and right. When one knee opens to the side think of stretching just one side of the pelvic floor. 4 • On the exhale think of pulling the knee back with the pelvic floor muscles on that side. • Repeat on the other side.

• Lie supine on the mat with soles of the feet together and knees apart. Please note that this is a vulnerable position for some people to be in. • Inhale into the PF.

• Exhale to bring both knees together. Think about using the PF muscles where they attach to the sit bones for this exercise. 4 • Try not to initiate the movement from the adductors Lying in this position allows the gluteus maximus and piriformis muscles to release so they don’t aid in the movement. • You may support the thighs as they open out to the sides.

Variation • Inhale to lower both knees out to the side. • Exhale and gently pull the four points together while keeping the knees apart. • Inhale to release.

56 © The Center for Women’s Fitness 1994-2013 MOVEMENT OF THE PELVIS

Posterior pelvic tilt (lumbar flexion)

This occurs when the iliac crest moves towards the back of the body. The ASIS (anterior superior iliac crest) is situated BEHIND the pubis symphasis. The pelvic floor muscles contract forward pulling the coccyx towards the pubic bone. This strengthens the PF muscles and prevents incontinence. A posterior pelvic tilt may also indicate a “tight” pelvic floor.

Neutral pelvic alignment

This occurs when the ASIS and the pubis symphasis are aligned vertically. This is an optimal pelvic position. The PF muscles can be worked from all points in this position.

This occurs when the iliac crest moves towards the front of the body. The pubis symphasis is behind the iliac crest. In this position the pelvic floor muscles begin to stretch as the coccyx moves away from the pubis symphasis and the sit bones move away from each other.

Lateral tilt (lateral flexion)

This occurs when one side of the pelvis is tilted up while the other side tilts down. It stretches the pelvic floor one side while the other side contracts

Rotation The pelvis will rotate as a whole, from the spine.

58 © The Center for Women’s Fitness 1994-2013 PRENATAL MAT EXERCISES FOR THE PELVIC FLOOR • Pelvic tilts on the ball. • Lateral Pelvic Tilts. • Pelvic tilts legs apart. • Hip Circles. • Pelvic Tilts on hands and knees. • Plies against the wall. • Forward kneeling stretch. • Kneeling Cat Stretch. • Adductor Stretch.

PRENATAL REFORMER EXERCISES FOR THE PELVIC FLOOR. • Roll down into pelvic tilts. • Side lying foot work-lateral rotated. • Supine footwork in lateral and medial rotation.

PRENATAL CADILLAC EXERCISES FOR THE PELVIC FLOOR • Hip Flexor and Hamstring Stretch - bar unloaded. • Cat Kneeling with the push through bar - 1 spring from above. • Breathing- trapeze and roll down bar. • Squat sequence. • Roll Down Bar Pelvic Tilts.

PRENATAL CHAIR EXERCISES FOR THE PELVIC FLOOR • Roll down into pelvic tilts. • Frog front. • Bridging from the floor.

POSTNATAL MAT EXERCISES FOR THE PELVIC FLOOR • Basic pelvic floor exercises. • Pelvic Tilts. • Bridging on the mat. 4 POSTNATAL REFORMER EXERCISES FOR THE PELVIC FLOOR • Bridging.

POSTNATAL CADILLAC EXERCISES FOR THE PELVIC FLOOR • Hip Flexor and Hamstring stretch. • Cat Kneeling with the push through bar.

POSTNATAL CHAIR EXERCISES FOR THE PELVIC FLOOR • Bridging from the floor. • Frog supine.

This muscle group includes: • The Transversus Abdominus. • The internal and external obliques. • The rectus abdominus.

Third trimester Abdominals

The most visible change in the pregnant body will be in the abdominal area. As the uterus pushes up and out of the pelvic cavity these muscles must loosen and stretch to accommodate it. This group of muscles consists of the transverses abdominus, the 4 internal and external obliques and the rectus abdominis. The transverses abdominus is the deepest muscle out of the three. It forms a corset around the body containing your internal organs. It is also considered an involuntary respiratory muscle, so it is constantly working. If this muscle is kept toned, most other problems like backaches and poor posture can be prevented. Even the simplest movement as in deep abdominal breathing can keep these muscles in shape. This muscle should not however, be strengthened to a point of “bracing’ as this will change the angle of the pelvis from anterior to a more posterior position. This in turn will change the position of the baby in utero to a less than desirable birth position.

The internal and external oblique muscles are the muscles that rotate your torso. It is these two sets of muscles, the transverse and obliques, which we concentrate on during pregnancy. The rectus abdominus can sometimes be a little too strong during pregnancy. When this muscle is tight, there is a tendency for it to split causing what is known as diastasis recti. This condition is usually attributed to having weak recti muscles but it has been the marathon runners and ice skaters and fitness instructors who have presented with this problem.

60 © The Center for Women’s Fitness 1994-2013 Pressure upwards of the uterus against the recti muscles

Pressure outwards on the pelvic floor muscles

After the first trimester of pregnancy or when a woman begins to “show” due to the uterus pulling up out of the pelvic basin, abdominal exercises that include flexion of the torso should be limited or excluded. This will include the traditional sit ups as well as Pilates exercises such as the roll up and the one hundred. This action causes the uterus to exert pressure on the recti muscles which will eventually split if they are too tight. Conversely, the recti muscles may also split if there is insufficient strength to hold their alignment. There is a delicate balancing act when it comes to this area. Flexion of the torso will also create more pressure on the pelvic floor than it needs at this time, especially towards the later stages of pregnancy.

Prevention is always better than cure. Healing diastasis after a pregnancy is time consuming and sometimes frustrating. There are plenty of good exercises that will 4 address the abdominals without using flexion.

The abdominals support the growing uterus and stabilize the pelvis which is loosening to accommodate the pregnancy. They do not help “push” the baby out. The uterus and pelvic floor work in tandem to expel the baby. Therefore it is a fallacy to think that pregnant women need strong abdominals for the pushing stage.

The stronger and tighter the abdominal muscles are, the more likely the rectus abdominus is to split. There is no disputing the fact that you need some strength in order to support the growing uterus but you can strengthen the abdominals to a point where they lose the ability to open to allow for the growth of the uterus. Overly strong abdominals may also prevent optimal positioning of the baby in utero as we will see.

Optimal strength and flexibility

Lax Abdominals

4 For a delivery to go as smoothly as possible, the baby has to be in what is known as “optimal fetal positioning”. This is when the pelvis is in a more anterior tilt to allow for a wider opening of the pelvis and a stretching of the pelvic floor. In order to support this alignment, the abdominals have to have a certain amount of suppleness to them. Gentle exercising of this area during the later stages of pregnancy with exercises such as deep abdominal breathing, may be enough to sustain this optimal position.

Lax abdominals will allow the pelvis to move into a more exaggerated anterior tilt, causing an extreme lordosis and possibly back pain. This in turn will allow the fetus to “drop” forward into the abdominal cavity and lose that optimal positioning.

Strong abdominals will create a more posterior tilt to the pelvis, which may also cause undue pain to the lumbar spine while changing the fetal position once again

Most exercise programs for pregnant women include aggressive forms of abdominal work in an effort to strengthen them for labor and delivery.

62 © The Center for Women’s Fitness 1994-2013 RETRAINING THE ABDOMINALS POSTPARTUM

Post partum abdominals

The most visible sign of change in the postpartum body will be in the abdominal area. A new mother will still look about five months pregnant a few weeks after the birth. The abdominal muscles will respond to gentle exercises like deep abdominal breathing to start to rehabilitate. Before ANY abdominal work can be resumed, the instructor MUST make sure that there 4 is no evidence of diastasis recti. Flexion and extension of the torso is contraindicated when this is present.

The transverses abdominus is the deepest muscle out of the three groups of abdominal muscles. If this muscle is gently exercised in early postpartum with even the simplest movement as in deep abdominal breathing these muscles can be coaxed back into shape

The internal and external oblique muscles together with the tranversus abdominus, compress the abdominal cavity drawing the muscles into the center, or core. This compression of the abdominal cavity will aid in closing the gap of a diastasis recti.

Gentle rehabilitation of this area begins hours after the birth with simple exercises like deep abdominal breathing and slowly including pelvic tilts and pelvic stabilizations exercises.

Abdominal binding is recommended during the postpartum period.

© The Center for Women’s Fitness 1994-2013 63 PRENATAL MAT EXERCISES THAT POSTNATAL MAT EXERCISES THAT WILL WILL MAINTAIN STRENGTH AND MAINTAIN STRENGTH AND FLEXIBILITY FLEXIBILITY IN THE ABDOMINALS IN THE ABDOMINALS • Breathing • Abdominal stabilizer on the ball • Pelvic Tilts • Oblique lifts on the Arc • Abdominal stabilizer on the ball • Oblique lifts on the ball • Spine Twist on the ball • Push Ups on the ball • Oblique lifts- on the ball • Pike on the ball • Oblique lifts- on the Arc • Single legged bridging • Stability Exercise on the mat • Bridging on the ball • Pelvic Tilts on the hands and • Abdominal roll down knees • Pendulum- bent knees • Abdominal Roll Down • Pendulum- straight legs • Deep Abdominal Breathing POSTNATAL REFORMER EXERCISES PRENATAL REFORMER EXERCISES THAT WILL MAINTAIN STRENGTH AND THAT WILL MAINTAIN STRENGTH FLEXIBILITY IN THE ABDOMINALS AND FLEXIBILITY IN THE • Side lying obliques ABDOMINALS • Side lying lateral flexion • Foot work on the short box • Bridging • Pelvic tilts • Abdominal stabilizer • Abdominal roll down with • Kneeling abdominals rotation • Kneeling Obliques • Kneeling abdominals • Abdominal roll down

PRENATAL CADILLAC EXERCISES THAT POSTNATAL CADILLAC EXERCISES WILL MAINTAIN STRENGTH AND THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE ABDOMINALS FLEXIBILITY IN THE ABDOMINALS • Cat Kneeling with the push • Cat Kneeling with the push through through bar- 1 spring from above bar • Modified Teaser • Abdominal roll down facing away • Abdominal roll down facing away from the bar 4 from the bar • Single leg abdominal roll down • Abdominal roll down facing the • Pelvic rock bar • Tower prep- pelvic tilt • Thigh Stretch with thoracic • Chest lifts extension • Chest lifts with rotation • Breathing- Roll down bar and trapeze PRENATAL CHAIR EXERCISES THAT • Short spine prep Roll down bar WILL MAINTAIN STRENGTH AND • Pelvic rock FLEXIBILITY IN THE ABDOMINALS • Kneeling roll down • Footwork • Frog front POSTNATAL CHAIR EXERCISES THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE ABDOMINALS • Pike • Oblique lifts

64 © The Center for Women’s Fitness 1994-2013 THE GLUTEALS MUSCLE GROUP

This muscle group consists of: • The gluteus minimus. • Gluteus medius. • Gluteus maximus.

During pregnancy, with the relaxation of the connective tissue and collagen, the ligaments in the pelvis will start to soften. It is not as noticeable during the first trimester, as in the second and third. Towards the end of the third trimester, there will be an extra surge of relaxin close to the birth that will allow the pelvic ligaments to become quite lax in preparation for the birth.

With this in mind we will work on the premise of trying to maintain the suppleness in the gluts to allow for the opening of the pelvis during birth and the subsequent closing after the birth. The gluts support the pelvis from a lateral and posterior position. As the pelvis begins to widen these muscles MUST have the flexibility to allow for this movement. As well as exercising for suppleness, we have to include stretches and in some cases, muscle release in order to achieve this balance.

Once the baby has been born, the pelvis begins to close. However, since relaxin may still be present in the body, the ligaments surrounding the pelvis may still be loose. This area tends to be quite weak postpartum and some clients may have difficulty with the number of repetitions they can manage.

© The Center for Women’s Fitness 1994-2013 65 PRENATAL MAT EXERCISES THAT POSTNATAL REFORMER EXERCISES WILL MAINTAIN STRENGTH AND THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE GLUTS FLEXIBILITY IN THE GLUTS • Side leg kicks on the ball • Side lying Foot Work • Side leg lifts on the ball • Side lying obliques • Clam • Feet in straps side lying • Side lying series on the Pilates • Leg lifts Arc™ • Side kicks • Side leg lifts • Bridging with extension • Side leg kicks on the Arc • Single leg bridging • Squats against the wall • Reverse Leg press • Bridging on the ball • Down Stretch modified

PRENATAL REFORMER EXERCISES POSTNATAL CADILLAC EXERCISES THAT WILL MAINTAIN STRENGTH THAT WILL MAINTAIN STRENGTH AND AND FLEXIBILITY IN THE GLUTS FLEXIBILITY IN THE GLUTS • Side lying footwork • Leg Springs- supine • Feet in straps side lying • Supine leg lift • Down Stretch modified- 2 springs • Knee lifts and lowers

PRENATAL CADILLAC EXERCISES POSTNATAL CHAIR EXERCISES THAT THAT WILL MAINTAIN STRENGTH WILL MAINTAIN STRENGTH AND AND FLEXIBILITY IN THE GLUTS FLEXIBILITY IN THE GLUTS • Piriformis stretch • Side lifts with leg • Side lying spring series • Bridging from the floor • Lunges PRENATAL CHAIR EXERCISES THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE GLUTS • Standing single leg leg pumps • Side single leg pumps 4 POSTNATAL MAT EXERCISES THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE GLUTS • Side leg kicks on the Arc • Side leg lifts on the Arc • Side leg lifts on the ball • Side leg kicks on the ball • Clam • Gluteal exercise • Bridging with pelvic tilts • Bridging on the ball

66 © The Center for Women’s Fitness 1994-2013 THE HAMSTRINGS

This muscle group consists of: • Semimembranosus. • Semitendinosus. • Biceps femoris.

These three muscles all have attachments on the ischial tuberosities and help stabilize the pelvis from below and need to be strong yet supple to allow for the changes to the pelvis that will take place.

As the pelvis moves into a more anterior tilt, the hamstrings are lengthened and in doing so, may sometimes become “overstretched”. If this happens they may react by going into a stretch reflex, which is the bodys’ way of protecting itself against injury. When this occurs the hamstrings contract to prevent excessive stretching. Therefore these muscles need to be stretched regularly as part of a session.

During postpartum the hamstrings will help stabilize the pelvis from below and will aid the repositioning of the pelvis.

© The Center for Women’s Fitness 1994-2013 67 PRENATAL MAT EXERCISES THAT POSTNATAL REFORMER EXERCISES WILL MAINTAIN STRENGTH AND THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE HAMSTRINGS FLEXIBILITY IN THE HAMSTRINGS • Adductor/hamstring stretch • Bridging • Forward stretch- partner stretch • Bridging with extension • Circles partner stretch • Single leg bridging

SPECIALIST • Bend and stretch PRENATAL REFORMER EXERCISES • Hamstring curls THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE POSTNATAL CADILLAC EXERCISES HAMSTRINGS THAT WILL MAINTAIN STRENGTH AND • Roll down with knee bend FLEXIBILITY IN THE HAMSTRINGS • All footwork • Tower prep- single leg- one spring • Side lying in parallel, lateral and loaded from underneath medial rotation • Parakeet • All side lying feet in straps, parallel, lateral and medial POSTNATAL CHAIR EXERCISES THAT rotation WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE HAMSTRINGS PRENATAL CADILLAC EXERCISES THAT • Bridging with hamstring curls WILL MAINTAIN STRENGTH AND • Lunges FLEXIBILITY IN THE HAMSTRINGS • Hip hinge forward and up • Hip flexor and hamstring stretch • Squat sequence • Leg springs exercises sidekicks

PRENATAL CADILLAC EXERCISES THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE HAMSTRINGS • Knee bends • Hip flexor and hamstring stretch 4 • Hamstring curls • Lunges

POSTNATAL MAT EXERCISES THAT WILL MAINTAIN STRENGTH AND FLEXIBILITY IN THE HAMSTRINGS • Bridging on the mat • Single legged bridging • Bridging on the ball • Spine articulation • Marching • Hamstring Curl

68 © The Center for Women’s Fitness 1994-2013 THE HIP ADDUCTORS

This muscle group consists of: • Adductor minimus. • Adductor maximus. • Adductor longus. • Adductor brevis.

The adductor group has to be watched carefully. While it is essential to keep these strong to help stabilize the pelvis, this area is subject to injury that may result in a separation of the pubis symphasis.

Strengthen this area by stabilizing rather than using resistance. Pulling the legs together against resistance may actually lead to a separation of the pubic bone. To this end we have eliminated exercises such as openings and side splits on the reformer.

All double leg exercises may be done with a small ball placed between the knees whenever appropriate. This isometric contraction of the adductors is sufficient to maintain strength.

If there is no evidence of pain, then single leg work is beneficial. Most side lying leg work will aim to keep the supporting leg stable by initiating with the adductor group.

If there is any localized pain then all exercises that abduct the hips are contraindicated.

These muscles perhaps take the brunt of the opening of the pelvis and are quite weak and loose after the birth. It may take a while for the client to actually get feeling back in this area. In the early postpartum phase, stabilizing this area with a small ball may be sufficient to allow the muscles to adjust. Gradually add more resistance training for these muscles.

During postpartum, if this area has separated then care should be taken with strengthening the area. Once again, stabilizing with a small ball is preferred until normal 4 functioning has returned.

PRENATAL REFORMER EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILTY IN THE HIP ADDUCTORS • Hip opener

PRENATAL CADILLAC EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILTY IN THE HIP ADDUCTORS • Clam - Leg Spring in the center (short lever) • Side Kicks • Leg lowers and lifts

PRENATAL CHAIR EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILTY IN THE HIP ADDUCTORS • Side single leg pumps

POSTNATAL MAT EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILTY IN THE HIP ADDUCTORS • Pendulum - bent knees • Pendulum - straight legs • Side leg lifts 4 POSTNATAL REFORMER EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILTY IN THE HIP ADDUCTORS • Medial rotation on foot work

POSTNATAL CADILLAC EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILTY IN THE HIP ADDUCTORS • Basic leg springs

POSTNATAL CHAIR EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILITY IN THE HIP ADDUCTORS • Hip adduction/abduction

70 © The Center for Women’s Fitness 1994-2013 SHOULDER ADDUCTORS AND ROTATORS

This muscle group consists of: • Rhomboid major and minor. • Trapezius. • Latissimus dorsi. • Teres major and minor. • Subscapularis. • Infraspinatus.

Kyphosis may often be helped by maintaining the strength in the shoulder adductors and external rotators.

Kyphosis and lordosis occur naturally during pregnancy and if there is no undue pressure or extreme misalignment, it is quite appropriate to accept this posture.

Poor posture during the postpartum period is due to several reasons.

• Improper positioning of the baby during breastfeeding will exacerbate kyphosis. Bring the baby UP to the breast rather than stooping over towards the baby. Place the baby on a cushion to bring it up to the level of the breast. • Lack of rest/sleep will sap the new mother of strength. This is often seen in the posture. They are literally too tired to stand up straight. • Lack of good nutrition also causes fatigue and poor posture.

Strengthening the shoulder adductors and external rotators will offer relief for these weakened muscles. Stretching the chest muscles will help open up this area. 4

© The Center for Women’s Fitness 1994-2013 71 PRENATAL MAT EXERCISES THAT POSTNATAL MAT EXERCISES THAT MAINTAIN STRENGTHEN AND MAINTAIN STRENGTHEN AND FLEXIBILITY IN THE ARMS AND FLEXIBILITY IN THE ARMS AND SHOULDERS. SHOULDERS • Arms with thoracic extension • Rowing • Rowing • Single arm twist • Single arm twist • Lat Pull Down • Lat Pull Down • Rhomboids • Rhomboids • External rotator • External rotator • Side lying series on the Arc (or on the • Chest opener and shoulder ball) stretch • External rotator on the ball – light POSTNATAL REFORMER EXERCISES weights THAT MAINTAIN STRENGTHEN AND • Deltoids on the ball – light FLEXIBILITY IN THE ARMS AND weights SHOULDERS • Push Ups on the Mat • All arm exercises from the prenatal • Pushups against the wall Pilates workbook may be done postpartum PRENATAL REFORMER EXERCISES THAT MAINTAIN STRENGTHEN AND POSTNATAL CADILLAC EXERCISES FLEXIBILITY IN THE ARMS AND THAT MAINTAIN STRENGTHEN AND SHOULDERS. FLEXIBILITY IN THE ARMS AND • Side lying lat pull down SHOULDERS • Chest Expansion • Supine Arms • Rotation • Triceps • Open Arms • Arm circles • External rotation • Prone arm circles • External rotation POSTNATAL CHAIR EXERCISES THAT PRENATAL CADILLAC EXERCISES MAINTAIN STRENGTH AND FLEXIBILITY THAT MAINTAIN STRENGTH AND IN THE ARMS AND SHOULDERS 4 FLEXIBILITY IN THE ARMS AND • Chest press SHOULDERS • Triceps press • Lat pull down – both hands • Lat pull down – single/double hand

72 © The Center for Women’s Fitness 1994-2013 BACK EXTENSION

This muscle group consists of: • Erector Spinae group.

Back extension is an important part of a pregnancy, and more importantly a postpartum workout. During pregnancy this may be incorporated while the client is sitting, kneeling, or standing to accommodate the growing uterus. Back extension will be contraindicated if there is evidence of diastasis recti.

Back extension may be re introduced during postpartum if there is no evidence of diastasis recti. C sections may also have some difficulty with this so proceed slowly.

© The Center for Women’s Fitness 1994-2013 73 PRENATAL MAT EXERCISES THAT POSTNATAL REFORMER EXERCISES THAT MAINTAIN STRENGTH AND MAINTAIN STRENGTH AND FLEXIBILITY FLEXIBILITY IN THE BACK EXTENSORS IN THE BACK EXTENSORS • Back stretch • Swan on the long box • Spine roll down – partner stretch • Down Stretch modified

PRENATAL REFORMER EXERCISES POSTNATAL CADILLAC EXERCISES TO THAT MAINTAIN STRENGTH AND MAINTAIN STRENGTH AND FLEXIBILITY FLEXIBILITY IN THE BACK EXTENSORS IN THE BACK EXTENSORS • Back extension with the ball • Thigh Stretch with thoracic extension • Down Stretch modified • Prone scapula glides- with Arc • Swan – on the Arc. PRENATAL CADILLAC EXERCISES • Arms circles with back extension THAT MAINTAIN STRENGTH AND FLEXIBILITY IN THE BACK EXTENSORS POSTNATAL CHAIR EXERCISES THAT • Thigh Stretch with thoracic MAINTAIN STRENGTH IN THE BACK extension EXTENSORS • Thoracic extension and flexion • Swan • Spread eagle from the side • Swan with rotation

POSTNATAL MAT EXERCISES THAT MAINTAIN STRENGTH AND FLEXIBILITY IN THE BACK EXTENSORS • Stability exercise • Upper Back extension • Swan on the Arc • Swimming • Lower back extension 4

Along with all the strengthening exercises for pregnancy and postpartum, there has to be a balance with stretching. These may be incorporated in the middle of a session when muscles are warm enough to “give” yet not too fatigued.

We will incorporate lumbar flexion and spinal articulation into the stretch component as they are important in releasing muscles around the spine and pelvis, two areas that tend to get “tight” during pregnancy.

PRENATAL MAT STRETCHES PRENATAL CHAIR STRETCHES • Shoulder placement on the ball • Roll down • Lateral Flexion on the ball • Pelvic tilts • Pelvic Tilts on the ball • Knee bends • Lateral Pelvic Tilts on the ball • Hip flexor and hamstring stretch • Pelvic Tilts – legs apart • Calf raises • Side Lunges • Prances • Forward lunges • Achilles stretch • Spine Rotation • Chest Stretch POSTNATAL MAT STRETCH • Side stretch • Lateral Flexion • Calf stretch • Pelvic Tilts • Piriformis Stretch • Side Lunges • Lateral flexion • Spine Rotation • Spine Rotation • Forward Stretch over the ball • Neck Circles • Hip Opener POSTNATAL REFORMER STRETCHES • Lateral rotation stretch • Breathing • Thigh Stretch • Roll down into pelvic tilts • Deep squat against the ball • Roll down with knee bends • Back stretch • Spine stretch forward • Partner stretches • Piriformis stretch • Spine Twist PRENATAL REFORMER STRETCHES • Single arm shoulder stretch • Spine stretch forward • Double arm shoulder stretch • Piriformis stretch • IT band stretch • Single arm shoulder stretch • Calf 4 • Double arm shoulder stretch • IT band stretch POSTNATAL CADILLAC STRETCHES • Calf stretch • Spine stretch forward • Prances • Piriformis stretch • Lunges • Spine rotation • Mermaid • Mermaid • Chest and shoulder stretch PRENATAL CADILLAC STRETCHES • Hip Flexor and Hamstring stretch • Spine rotation • Side stretch kneeling with push • Spine stretch forward through bar • Mermaid- lateral spine flexion and rotation POSTNATAL CHAIR STRETCHES • Chest and shoulder stretch • Breathing • Side stretch kneeling with push • Roll down through bar- 1 spring • Calf raises • Prances • Achilles stretch • Lunges • Prances

Break down of postural changes during pregnancy As the uterus grows, the center of gravity shifts and pulls the pelvis forward into an anterior tilt causing a lordosis. To counter balance this, the thoracic spine will brace backwards even though the shoulders will be rotating forward with the weight of the breasts causing a kyphosis.

Third Trimester Posture 5

76 © The Center for Women’s Fitness 1994-2013 An anterior tilt is necessary to facilitate the passage of the baby through the birth canal. Women who are expecting more than one baby will also have an exaggeration of the spinal curves.

An anterior tilt may:

• Shorten the hip flexors, TFL and Piriformis muscles causing pelvic pain. Stretching these areas throughout the session is important.

• Weaken the abdominals because the angle of pull has changed. The human body is amazing in its’ ability to adapt to different situations. While it may be true that the muscles will weaken due to their “misalignment”, it becomes apparent to the instructor that the clients’ body will accommodate these changes. Adding simple non stressful abdominal activation exercises are sufficient to keep these muscles toned.

• “Stretch” the pelvic floor The pelvic floor muscles that are attached to the coccyx - the pubococcygeous and the Illiococcygeous will “open” or stretch more than in a neutral position. This is nature’s way of preparing the pelvic floor for the birth. To balance this out and to keep the integrity of this area, pelvic floor exercises have been included.

• The back extensor muscles will shorten due to the shift of the pelvis causing a lordosis. While it may seem that this is the reason many women suffer from lower back pain, it is usually because they are trying to pull the pelvis back to neutral. Allowing the pelvis to move forward while stretching and strengthening this area with simple exercises like pelvic tilts will keep your client free of symptoms.

• The shift of the pelvis will affect the range of motion of the hips. Towards the end of the pregnancy when the baby drops into the superior opening of the pelvis, the illium will move apart to make space. This will cause the ischium to move closer together. This along with the anterior tilt will change a woman’s gait. The pregnant “waddle” becomes obvious! The aim of this program is to keep as much mobility in the pelvis as possible to prevent any pain or instability in this area and to make walking easier.

• Change the curves in the thoracic and cervical spine creating a kyphosis as well as lordosis. This posture is considered normal for a pregnant body. Once again, exercises should be geared towards supporting the changes rather than trying to fix them. 5

Postpartum brings about very rapid postural changes to the body. Within the space of a few hours, the body has gone from forward gravity shifted, heavy and pressure filled to unstable, weak and traumatized. The hormone relaxin is said to still have an effect on the postpartum body for up to a year after the birth. This will also add to postpartum joint instability

Posture at this point is not solely dependent on muscular strength and stability but also on realigning the skeletal structure as well, mainly the pelvis and spine. The muscles have to be realigned and reactivated before regaining their strength. Early in the post partum period the joints may remain unstable for as long as a woman is breastfeeding. A misaligned muscle will always be a weaker muscle. 5 Fascial restrictions will also play a part in postpartum posture. The postpartum posture includes: • Weak and under activated abdominals. • Unstable lumbar spine due to the shift of pelvic alignment. • Weak back extensors due to the shift of pelvic alignment. • Significant kyphosis ( breastfeeding, holding baby). • Weakened shoulder adductors and rotators. • Unstable hamstrings due to the shift of pelvic alignment. • Weakened gluteals and hip ad/abductors due to the opening of the pelvis during the birthing process.

Realigning the body postpartum takes patience and understanding from both the instructor and client. Getting back to “normal’ after the birth of a baby can take anywhere from 6-12 months. There are a number of factors that determine the rate of healing of a postpartum woman. This includes:

• How consistent a new mother is with her exercise. • How quickly her body heals. • How long she breastfeeds for. • How much rest and good nutrition she is getting.

Posture during pregnancy and postpartum may include • Kyphosis and lordosis. • Weak shoulder adductors and rotators. • Shortened lumbar back extensors. • Weakened and misaligned abdominals. • Hyper extended hamstrings.

Exercises that may help prevent an excessive kyphosis include • Thoracic extension. • Arm and shoulder work.

Exercises that may help prevent an excessive lordosis include • Hip flexor stretches. • Abdominal exercises especially the TA and Obliques. • Hip work. • Spine articulations and curls.

Based on all the points above, essential exercises for pregnancy and postpartum will include • Pelvic floor exercises. • Abdominal work to activate the TA and obliques and to maintain lumbar pelvic stability. • Hamstring strengthening and stretching to help stabilize the pelvis. • Hip adduction/abduction. • Arm work to include external rotation and shoulder adduction.

Additional important exercises • Thoracic extension. • Lumbar flexion and articulation of the spine. • General stretching especially hip flexor and piriformis.

The areas affected by pregnancy remain the same during the postpartum period. Those areas in pregnancy that have been overstretched and misaligned, need to be gently coaxed back into place and strengthened postpartum according to the individual client. 5 Exercising with props to support the vulnerable postpartum body is helpful. Stability balls, arcs and resistance bands are a few of the items used in this program.

Before you can begin designing sessions for your pregnant client, you need to know a little bit about what is happening to her body. Remember, everyone is different and these are some general statements.

Physical symptoms • Tiredness. • Nausea. • Sometimes vomiting may be present. • Breasts larger and more tender. • Some weight gain. • An increase in urination at this time.

Psychological symptoms • Excitement. • Fear. • Confusion.

The fetus is about 6 to 7 centimeters long, weighs a couple of ounces and looks like a miniature human being. It has some reflexes. The heartbeat can be picked up on ultrasound by six weeks.

Position of pelvic floor during the first trimester

Breakdown of first trimester fetal development. • Week one – date of last menstrual period. • Week two – ovulation and conception. • Week three and four – missed period and implantation. (Implantation may cause some spotting which may confuse some women as to whether they have a period 5 or not). • Week five – central nervous system forming. • Week six – arms and legs forming. Brain and major organs forming. • Week seven – muscles developing. Eyes forming. • Week eight – ears, bones and mouth forming. • Week nine – fetus starts to move- not felt by mother. Tooth buds appear. • Week ten – heart functions at basic level. Lungs forming. • Week eleven – head is about ½ the size of the body. • Week twelve – nose lips and chin forming. Toes and fingers formed. • Week thirteen – placenta completely formed.

80 © The Center for Women’s Fitness 1994-2013 If you look at this list, you realize how important it is to know if someone is trying to get pregnant. By six weeks the fetal brain is developing and it is at this stage that some neural tube defects may occur. Some causes for this have been linked to being overheated during vigorous exercise. Not a problem with Pilates unless you also include a cardiovascular section to your routine. Most women do not realize they are pregnant until about week eight. By then the fetus is almost fully formed.

During this trimester, the focus should be on establishing a routine that will see you through the rest of the pregnancy. Try to educate her on her pelvic floor, why you will not be working her too hard and the reason behind all of your concerns. If your client is adamant about working out hard, allow this but keep a watch on her and then give her permission to slow down when it seems like she is struggling. Never make her feel like she has done anything wrong. She really hasn’t. There is just a better way of doing this.

Back stretch over the ball 1st trimester

© The Center for Women’s Fitness 1994-2013 81 Essential exercises for the first trimester Neutral pelvic alignment Important for alignment of the pelvis to facilitate correct birth positioning of the baby and for a reference point for when the pelvis moves into a more anterior tilt.

Extension of thoracic spine To increase awareness of this area and to strengthen it in preparation for the progression of kyphosis in later pregnancy.

Flexion of lumbar spine To gain mobility in this area and to strengthen and stretch the lower transversus and the back extensors.

Transverse abdominus stabilization Strengthening and stabilization of abdominal area. Prevention of destabilization of rectus abdominus. Learning to activate this muscle with breathing exercises.

Oblique strengthening Strengthening and stabilization of abdominal area. Prevention of destabilization of rectus abdominus.

Pelvic floor toning Learning to indentify the pelvic floor and to strengthen and stretch this area.

Breathing Teach breathing as a meditative and relaxation tool and abdominal and pelvic floor strengthening exercise.

Physical symptoms • The mother usually feels better and has more energy. • For most women, morning sickness is a thing of the past. However, some women will experience nausea for the whole nine months. This is quite a strain as it is sometimes difficult to eat enough and so fatigue and lack of energy will be a factor here. • The pregnancy is more noticeable as the uterus lifts up and out of the pelvic basin into the abdominal cavity. This may cause round ligament pain. • The mother may feel the baby move at around 18-22 weeks. • Usual weight gain by the end of this trimester is between 18-25 pounds.

Psychological symptoms • The mother is more relaxed about the pregnancy and is beginning to get excited about it. There is usually a sense of well being during this time.

The fetus is around14 inches long and weighs about 1-2 pounds.

Position of the pelvic floor in the 2nd trimester

Breakdown of second trimester fetal development • Week 14 – sex is identifiable. • Week 15 – kidneys begin to function. • Week 16 – lanugo hair forming. Body is growing fast. • Week 17 – fingernails and toenails forming. Heartbeat audible. • Week 18 – heartbeat audible. Ovaries forming in females. 5 • Week 19 – mother can definitely feel the baby moving. • Week 20 – scalp hair forming. • Week 21 – skin is very thin with little or no fat. • Week 22 – eyebrows and eyelashes forming. • Week 23 – head is about 1/3 total body length. The body is covered with lanugo and vernix. Fetus can suck thumb. • Week 24 – fetus is gaining weight. The lungs are still immature. • Week 25 – gaining weight. • Week 26 – still gaining weight. • Week 27 – lungs secrete surfactant; may survive outside the womb if born now.

© The Center for Women’s Fitness 1994-2013 83 By the end of this trimester the mother looks quite pregnant. She may complain about being huge but this is nothing compared to what she will feel like at the end of the pregnancy.

At around five months the uterus will pull up out of the pelvic basin sometimes causing round ligament pain. The round ligament helps anchor the uterus to the pelvis. When the uterus expands quickly, it stretches these ligaments causing some pain. Flexing at the hips can offer some relief.

Breathing may become shallower and the rib cage will begin to expand. Use posterior and lateral ribcage breathing to stretch the intercostals muscles in preparation for further growth and upward movement of the uterus. Women in their second or more pregnancies will reach this stage quicker than first timers.

Back stretch over the ball 2nd trimester

Back stretch over the ball 2nd trimester with twins

84 © The Center for Women’s Fitness 1994-2013 Essential exercises for the second trimester Neutral/anterior pelvic alignment The pelvis may be starting to pull forward at this point. Work to sustain stability with the surrounding muscle groups. Trying to maintain neutral is a contraindication of the natural shift forward of the pelvis and lumbar spine.

Lateral flexion Add more side bending exercises to help keep the intercostals stretched to accommodate the expansion of the ribcage.

Thoracic extension Continue maintaining strength in upper body and arms. As the pelvis moves forward there will be a tendency to brace against gravity by leaning back.

Obliques and tranversus Will become more stretched at this point. Maintain with gentle exercises using breathing as a tool.

Pelvic floor Continue with the pelvic floor sequence and relevant exercises. Add more stretching of PF.

Breathing Use lateral and posterior ribcage breathing to stretch the intercostals muscles. Begin to release the body on the exhale rather than tightening. Introduce a guided relaxation.

Physical symptoms • The mother will start to get more fatigued as her weight and size increases. The baby will need more calories to lay down its store of fat at this time. Swelling in the hands, ankles and feet are likely. • Shortness of breath and faintness may be present. May have contractions known as braxton hicks.

Psychological symptoms • The mother may be getting discouraged and want the pregnancy to be over with. • Swings between excitement and fear of labor and delivery. • May have a burst of energy towards the end of this trimester known as the “nesting instinct”.

The baby just before birth is between 16- 21 inches long and weighs between 7.5-9 pounds.

Position of the pelvic floor in the 3rd trimester

Breakdown of third trimester fetal development • Week 28 – fetus is able to hiccup • Week 29 – eyes able to open, close and blink • Week 30 – fat layers forming • Week 31 – 96% of all fetuses settle into a head down position 5 • Week 32 – organs begin maturing • Week 33-35 – fetus can respond to outside stimuli • Week 36 – kidneys mature • Week 37 – fetus has firm grasp reflex • Week 38 – growth rate slowing down, fetal movement decreases • Week 39 – lungs mature, bones fully formed, lanugo hair and vernix disappearing • Week 40 – full term • Week 41 – post term • Week 42 – overdue, may be induced

86 © The Center for Women’s Fitness 1994-2013 This trimester is one of slowing down and decreasing the exercise workload. Include lots of gentle stretching and breathing.

Emphasize exercises that will stretch the pelvic floor.

Breathing at this stage is usually shallow and in the rib cage. Keep trying deep abdominal breathing, as this breath will help through labor and delivery.

Back stretch over the ball 3rd trimester

Essential exercises for third trimester Mobility of the pelvis Using pelvic tilts, hip circles, bridging to maintain the flexibility of this area.

Stability of the spine and pelvis Using gentle abdominal work with breathing.

Stretching Concentrate on inner thighs, hips and spine and pelvic floor.

Pelvic floor Stretching and releasing of this area.

Breathing Concentrate on deep abdominal breathing for calming and focusing. Breathing, relaxation and visualization is VERY important during this trimester. 5

© The Center for Women’s Fitness 1994-2013 87 FOURTH TRIMESTER 1- 12 WEEKS POSTPARTUM reestablishing a routine If a c-section was performed she has to recover from major surgery. Lack of sleep, hormonal shifts and a newborn baby compound the issues.

The mother is extremely fatigued. • If the birth was medicated, she has to recover from the side effects. • If a c-section was performed she has to recover from major surgery. • Lack of sleep, hormonal shifts and a newborn baby compound the issues.

Bleeding will be heavy in the first few days postpartum. • This flow will slowly change to brown and then to a yellowish- white or clear discharge. • If exercise is resumed too soon there may be an increase in heavy blood flow. This is an indication to slow down. • If the bleeding has not stopped or restarts after two weeks, it is time to see the health care provider. • If an episiotomy was performed, women may have trouble sitting for long. Performing pelvic floor exercises will help with this discomfort.

Laxity of the abdominals and After birth contractions • The uterus will contract back to pelvic floor contribute to the its original size in a process called instability of the pelvis. involution. • This may take anywhere from four days to several weeks. • Oxcytocin, which is responsible for the milk let down, also causes uterine contractions.

Mood swings between excitement and fear of responsibilities. 5 • May experience the “baby blues” that last about two weeks. If the mother has not recovered from this and seems to be sinking deeper into a depression, please refer her to a post partum depression counselor.

Many women have difficulty establishing breastfeeding. • The nipples may be cracked and sore. • Excessive exercise may form lactic acid which in turn may cause the breast milk to taste sour. The baby may refuse to drink this.

88 © The Center for Women’s Fitness 1994-2013 The body will slowly return to a somewhat “normal” state. • However the body will still look about five months pregnant up to four months postpartum. • Everyone is different with different recovery times.

Relaxin, a hormone that loosens collagen and connective tissue- may still have an effect on the body for several weeks after the birth.

Essential exercises for fourth trimester Neutral/anterior pelvic alignment Realignment of the pelvis to the spine with gentle exercises such as pelvic tilts.

Thoracic flexion Flexion of the torso remains contraindicated if there is evidence of diastasis recti. Otherwise gentle reestablishing of the recti muscles through myofascial release and exercise are indicated

Thoracic extension Unless there is diastasis recti, in which case thoracic extension is contraindicated, extension of the torso becomes an essential part of a postpartum workout.

Obliques and tranversus In the postpartum period, compression of the abdominals with exercises such as abdominal roll down are preferred.

Pelvic floor Rehabilitation of the pelvic floor through breathing and connecting of the muscles.

Breathing Use the breath to rehabilitate by initiating a connection on the exhale.

Listening and watching What to do with your postpartum client. • Check for a diastasis- before the start of your program, you must check to see if your client has a split in her Rectus Abdominus muscles. This will help you design a safe abdominal workout for her. This is explained in detail later on. • Ask how the birth went, even if this takes up the whole of the first session. From this information you will be able to understand what kind of rehab she will need. Also, the telling of the story helps a woman heal if the birth was traumatic in any way. For example, if she had an unscheduled C section, she may have feelings of guilt. Most likely she has been told that she should be thankful for a healthy baby but she will have her own feelings about it that need to be expressed.

Some questions to ask How long was the labor? • Long labors will leave the client quite depleted of energy and she may not be interested in resuming any kind of exercise for a while.

Was the client in bed throughout or walking around? • Lying in bed throughout the labor does help prevent some wear and tear on the pelvic floor BUT it does not help stretch it for the birth. Ideally a woman should be up and about using gravity to help bring the baby down. This in turn will help shorten the pushing stage.

How long was the pushing stage? • Long pushing stages with the woman on her back will tend to cause more damage to the pelvic floor than having her either on all fours or in a semi squatting position. Again the pressure of the baby on the PF will allow these muscles to stretch for the birth.

Did the client push in bed on her back or in a more upright position? • Lying on her back will prevent the sacrum from lifting and stretching the pelvic floor.

Was medication used? • It will take a few days for drugs to clear the system. Deep rhythmic breathing will help move lymph, which will in turn move waste products from the body.

Water birth? • Usually there is less trauma overall with a water birth

Episiotomy, Forceps or vacuum? • There is significant damage to the pelvic floor with any of these procedures.

C section? • A C section is major abdominal surgery and should not be underestimated when doing exercise.

Diastasis 6 • Is there evidence of diastasis recti?

This part of the course is written not just for the instructors who have never had children but also for some of you who have had a tough time of it but will not allow yourselves to “let go’ and heal from your trauma.

Mothers are released from hospital anywhere between two and three days after the birth and are back into the routine of caring for their family as if nothing had happened. I am not surprised by the alarming numbers of mothers who suffer from depression and exhaustion. We accept this as the “norm”. We are wrong to do so. There is no established recovery from the trauma of birth and the problems resulting from this lack of care may only become apparent in the future.

There seems to be this unspoken competition between post partum women regarding who can get back into shape the fastest. Who has lost the weight the quickest? Who is winning this race? What race? The number of women who rush back into their pre pregnancy exercise routine is frightening.

I believe that it is the lack of post partum care and support that has given rise to the epidemic of post partum depression.

Melisa Schuster - a clinical social worker, who lives in my town, specializes in post partum depression and discussed this issue at length with me. I had assumed that her interest in post partum depression was like mine -directly related to her own personal situation. On the contrary, Melisa had a wonderful experience giving birth and loves being a mother. We did both agree that it is and will always be the hardest job in the world. She is very involved with women’s issues and is also a Birthworks™ childbirth educator.

Melisa went on to express her concerns about women expecting too much from themselves and from being a mother. She warns that some new mothers have totally unrealistic expectations and that they set themselves up for failure from day one. She presents workshops dealing with the realities of becoming mothers. Melisa laughs as she describes the women who tell her that none of these problems will happen to them. These are the ones she worries about. Let’s face it; parenting is a long, hard road.

© The Center for Women’s Fitness 1994-2013 91 I have always been a little shocked by the women who have said they were not asking mothers/sisters/friends to help in the early days as they wanted to just be a family and get to know each other. This is fine, but become a family while someone else is taking care of everything. You are recovering from what amounts to running three or four marathons. Add onto to that, hormones that do not know whether they are coming or going, lack of sleep, feeding and looking after a baby whose schedule may not coincide with yours.

I truly support Melisa when she suggests the new mother stays in bed for up to ten days after the birth .You do need this time to recover, and this is when you need to have someone else take over the running of your household. You may not get along with your mother/mother-in-law but, believe me; they know what it is like and are only too glad to be helping. So relax and take advantage. Remember they love your baby as much as you do. My mother-in-law stayed with me for a year after the birth of my third daughter and while it was stressful at times, I have to admit it made life much easier for both myself and my children. I had time to spend with the older two while grandma took care of the baby.

Looking after a baby takes every ounce of energy you have. It is constant and is physically exhausting. In childbirth education classes, really what they should prepare women for is the long haul after the birth.

Women are very well looked after during their pregnancy compared to the postpartum period. Where are the post partum doctor visits or the books on recovery or even the post partum exercise class? It seems as though they have been swallowed up by a black hole. Post partum women are severely neglected and this is really the time to be looking after them. Their exercise sessions become their sanctuary, so be prepared. Make time to listen to their concerns. Educate yourself on the signs of depression.

92 © The Center for Women’s Fitness 1994-2013 My own postpartum story is one of depression and panic. I was alone in a foreign country and scared to death. I went from being a very active dancer, fitness instructor and just plain old socialite to being completely alone a few weeks after my baby was born. My mother was half a world away and my husband traveled most of the week. My sister in law very kindly arrived from England to help me for several weeks but she had left her own young daughter at home with her mother and needed to get back. My dancer friends were far too busy to help and since I was a newcomer to the country, I had yet to make very many friends. I made the mistake of staying home long after it was necessary for my health. It became a habit that was hard to break. After a while the mere thought of leaving my house was overwhelming and I would break out in a sweat just thinking about it.

Things went from bad to worse and I sunk into a depression that lasted fourteen months. At that time, I thought every mother felt like this and that it was “normal”. Every time I saw a pregnant woman, I wanted to run up to her and tell her not to do it, that it was hell.

Because I had been too scared to exercise while I was pregnant, getting back into shape afterwards was difficult. I made the mistake of trying to exercise at the level I had left off at when I got pregnant. I had no understanding of my body and what it needed.

I did come out of the depression by myself and exercise certainly played a big part in my recovery. According to Melisa Schuster it is sometimes just a case of chemistry that can be put right with medication or a combination of counseling, nutrition and exercise. Not all of her clients are candidates for medication and she stresses that everyone is different and responds to different methods. I believe that I should have been on something and that it would have made such a difference to being a new mother. It was only when I began talking about it that the people around me mentioned they had been very worried about me. How I wished they had taken the initiative to convince me to seek help. I know it must have been hard for them too. I felt like I had missed a whole year of my daughter’s life. I have always felt guilty about this.

When I talked to Melisa though, she reassured me that relationships can and do heal. I think I have a very good relationship with my eldest daughter now.

I wouldn’t wish post partum depression on anyone and I encourage you to watch for the signs in your clients. Some mild depression is normal after the birth as your hormones start to settle. However, if they begin to feel worse after about two weeks, please have resources on hand to refer them to. New motherhood is a highly stressful, life changing event.

As a passionate exerciser I do have to say that exercise can greatly help alleviate feelings of depression. I keep a close watch on the post partum ladies in my classes and encourage them to keep coming to class even if they don’t feel like exercising. Just getting them out and in the company of other women going through the same thing, is therapy enough. They always end up exercising, too! 6

© The Center for Women’s Fitness 1994-2013 93 We need to give women permission to be post partum and have them understand that it is a journey into another way of life that needs time to adjust to. Some women have a great transition and move forward naturally, but for some, it takes more time to adjust, especially if this life is totally different from the one they left behind.

Most importantly for new mothers is to be acknowledged. Yes, they are very thankful for the healthy baby but they are dealing with a huge change in life and sometimes they are frustrated and resentful. These are normal feelings that should not be brushed aside and dismissed. The issues they have with their bodies are also real and need to be dealt with.

However, when it comes to exercise, especially as a postpartum exerciser, many programs do not take into consideration that the postpartum body is different from the pre pregnancy one and while it is different, it is by no means worse. If we all changed our mindset about how we should look as young girls, young women and then new mothers, older mothers and finally the grandest achievement of all-GRANDmothers, we would see that each stage of our lives is to be experienced in the present and to accept the body changes that come with it. So often I hear people trying to “get back into shape” after their babies. What shape would that be? You now have a body that has just done something AMAZING! Treat it with the respect and love it deserves and understand that recovering the body after birth is about restoring, strengthening and nurturing.

Exercise need not be intense and overwhelming to be beneficial. Just after the birth, many women can begin a program of restoration using deep breathing and simple movements of their bodies. The exercises should be simple enough to perform anywhere and at any time. Rehabilitation of the pelvic floor, realignment of the pelvis to the spine and general stretching and releasing are all truly beneficial and will work wonders even though they are gentle.

I believe in the Asian tradition of binding the abdominals of the postpartum woman and even encourage them to perform their gentle exercises while using the binder. The binder technically holds both the ribcage and pelvis stable allowing the overstrained surrounding muscles to realign without undue stress. Nutrition and rest are equally important to help restore the body.

Beyond calming and relaxing the new mother, deep abdominal breathing will also act as a pump for the lymph system and will help remove excess hormones and fluid from the body. Deep abdominal breathing also activates the deepest abdominal muscle the tranversus abdominus as well as the pelvic floor and helps to strengthen these muscles.

All in all postpartum should be a period of quiet gentle nurturing of both the mother and child, filled with respect and awe for the miracle that has just happened.

94 © The Center for Women’s Fitness 1994-2013 OVERVIEW OF EARLY POSTNATAL EXERCISES For the sake of an exercise routine, we can separate the progress of a postpartum woman week by week.

*All these exercises are appropriate for Diastasis recti and C sections.

Very roughly we can divide the weeks up as follows.

WEEK 1-2 Within hours of the birth, a woman may resume doing exercises to help rehabilitate the pelvic floor. Deep abdominal breathing will reactivate her abdominals and pelvic tilts will realign her pelvis to her spine. Any kind of stretching is highly recommended as it will create “space” in the body and will promote the release of tension.

The building of an early postpartum exercise program becomes easy if you have had the client throughout her pregnancy. You have already trained her in the following exercises which have built muscle memory and in doing so; she now has the ability to perform these exercises alone at home. She understands how they should feel and what to do.

For a normal vaginal delivery without any complications, six weeks is the estimated time that your clients will begin to come back for sessions. You may then start them on the other exercises in this program.

Supine breathing exercise sequence This particular exercise need not only be done in the supine position but can also be done sitting feeding the baby, in a quadruped position or even standing.

• Lie supine with the knees bent feet hip width apart and place finger tips on the sit bones. • Inhale into the finger tips using verbal cuing to indicate the breath flowing through the pelvic floor. “Breathe in between your sit bones”. • Exhale and initiate the out breath by visualizing the sit bones coming together. “Exhale and gently bring the sit bones together”. • Place the finger tips on the hip bones. • Inhale in between the hip bones.”Breathe in between the hip bones.” 6 • Exhale and visualize the hip bones narrowing. “Exhale and gently bring the hip bones together”.

© The Center for Women’s Fitness 1994-2013 95 • Place the hands on the lower ribcage. • Inhale into the hands, expanding the ribcage, “Inhale between the hands”. • Exhale and pull the lower ribcage together. “Exhale and gently bring the ribcage together.” • Place the hands on the posterior ribcage. • Inhale into the hands. • Exhale and allow the ribcage to relax towards the mat OR exhale and gently bring the front of the ribcage together, keeping the back wide.

Then put it all together. • Place the hands by the sides • Inhale three dimensionally, down into the pelvic floor, into the lower abs, expanding the ribcage forward, back and side. • Exhale and gently pull all of the muscles and bones towards the midline.

Pelvic tilts

• Lie supine with the knees bent and the feet on the floor. • Inhale. • Exhale and connect all the muscles from the breathing sequence adding the cue “tailbone to pubic bone, pubic bone to chest” to initiate the pelvic tilt. The gluts and hamstrings are not activated at this point. It is more of a “rocking” movement 6 of the pelvis. • Inhale to release to neutral.

• Lie supine with the feet and knees together. Arms to the side. • Inhale and drop both knees to one side. • Exhale, connect the 4 points and bring both knees back to center. • Repeat on the other side. • Use imagery to focus on the pelvic floor bringing the knees back. • This exercise will also stretch the lumbar spine.

• Lie supine on the mat with knees and feet together. • Inhale and allow one knee to drop to the side. • Exhale and bring the knee back to center using the imagery of the sit bone pulling together. • Visualize the pelvic floor in two parts, left and right. When one knee opens to the side think of stretching just one side of the pelvic floor. • On the exhale think of pulling the knee back with the pelvic floor muscles on that side. • Repeat on the other side.

• Lie supine on the mat with soles of the feet together and knees apart. Please note that this is a vulnerable position for some people to be in. • Inhale into the PF. • Exhale to bring both knees together. Think about using the PF muscles where they attach to the sit bones for this exercise. • Try not to initiate the movement from the adductors Lying in this position allows the gluteus maximus and piriformis muscles to release so they don’t aid in the movement. • You may support the thighs as they open out to the sides. • This exercise will also stretch the adductors.

Variation • Inhale to lower both knees out to the side. • Exhale and gently pull the four points together while keeping the knees apart. • Inhale to release.

Adding to • The breathing sequence. • Basic pelvic floor exercises.

Simple pelvic stabilization exercises. Pelvic and spine stabilization

• Lie supine with the knees bent and feet on the floor. • Arms are by the sides. • Inhale to prepare. • Exhale use the cue “drop, connect and lift” one foot off the mat. • Inhale to lower. • Exhale to lift the other foot off the mat. 6

• The breathing sequence. • Basic pelvic floor exercises. • Pelvic and spine stabilization.

Add on • Bridging may be introduced at this time as long as there is no bleeding.

Bridging on the mat

• Lie supine with the knees bent, arms at the sides. • Inhale. • Exhale and roll up the spine. • Inhale at the top. • Exhale to roll down. 6

• From a bridge position, inhale and release the gluts and feel the spine lengthen. • Exhale and squeeze the gluts into a posterior pelvic tilt. • Inhale to release.

A COMPLETE EARLY POSTPARTUM ROUTINE WILL THEN INCLUDE • Breathing sequence. • Pelvic Floor sequence. • Pelvic tilts. • Pelvic Stabilization. • Bridging. • Bridging with pelvic tilts. Giving the early postpartum woman just a few exercises will not overwhelm her and she is then more likely to do them. These exercises do not take much time or effort but really do make a difference.

We also suggest the use of a “binding” garment while performing the exercises above. This will support the bones as they begin to move back into place and allow the muscles to realign without strain.

6 Please now refer to the workbooks for the practical sessions.

102 © The Center for Women’s Fitness 1994-2013 RECOMMENDED READING Frye, Anne “Holistic Midwifery” Labrys Press Portland 1998 Kisner, Carolyn “Therapeutic Exercise F.A. Davis Company Philadelphia 2002 Carriere, Beate “The Pelvic Floor” Thieme Stuttgart 2006 Carriere, Beate “The Swiss Ball” Springer 1998 Manne, Joy “ Conscious Breathing” 2004 Balaskas, Janet “ Preparing for Birth with Yoga HarperCollins 1994 Balaskas Janet, New Active Birth Harvard Common Press; 1992 Odent,Michel Birth and Breastfeeding: Rediscovering the Needs of Women During Pregnancy and Childbirth Rudolph Steiner Pr; 2008 Odent,Michel Birth Reborn Birth Works, Incorporated 1994 Gaskin, Ina May, Spiritual Midwifery Book Publishing Company 2002 Calais Germain, Blandine The Female Pelvis Anatomy & Exercises Eastland Press 2003 Calais Germain, Blandine The Anatomy of Breathing Eastland Press 2006 Murphy, Magnus MD, Pelvic Health and Childbirth Prometheus Books; 2003 Northrup, Christiane MD, Women’s Bodies Women’s Wisdom. The Wisdom of Menopause Anthony, Carolyne The Pilates Way to Birth. The Center for Women’s Fitness, 2007 RECOMMENDED WEBSITES www.thecenterforwomensfitness.com www.pilatesanytime.com www.midwiferytoday.com www.childbirthgraphics.com www.michelodent.com www.bellefit.com

Carolyne Anthony Carolyne Anthony has been in the Dance, Fitness and Pilates world for over 30 years. She trained as a professional dancer in London, England in the late 1970’s. She obtained her teaching diploma in 1982 and went on to dance professionally in Europe, Asia and Africa. She remains a member of the Royal Academy of Dancing and an Associate of The Imperial Society of Teacher of Dance. Carolyne was introduced to Pilates in 1983, at the prompting of her Models Jazz instructor. She found Alan Herdman and continued to learn from him until she left for the USA. It wasn’t until 2001 that she realized there were Mindy Catron certification programs for Pilates and she promptly signed up for them. She has studied Polestar, PhysicalMind, CoreGrace and Basi Faculty Member (Pregnant model) techniques. On her to do list is to certify with the PMA. Carolyne Mindy danced professionally for many years on Broadway and National is now on the faculty of Balanced Body University. Tours and found her way from there to her second career teaching Pilates and GYROTONIC®. She earned her STOTT® Pilates certification In the 80’s as a newcomer to the USA her focus turned to fitness from Pilates on Fifth in New York City and went on to teach at that as the aerobics boom began to hit. Carolyne certified with AFAA studio for a few years until moving to Maplewood, NJ where she now and the AEA as a group fitness instructor and went on to study the works as a freelance instructor. She was only weeks into her own PACE (people with arthritis can exercise) program. She put all this pregnancy in 2005 when she found Carolyne’s course. It was an amazing knowledge to good use as an instructor with the New England weekend that had a huge impact on her own pregnancy and the birth of Health and Racquet Clubs. her daughter and an even greater impact on the way she teaches. She feels very honored to be chosen by Carolyne to teach this important While living in Connecticut, Carolyne also joined the faculty of the work and hopes to inspire others the way Carolyne first inspired her. Hartford Conservatory of Music and Dance, teaching ballet, jazz and pedagogy to the diploma students. She danced with the New www.spiritus-nj.com England Dance Theater and helped found and became the Artistic Director of the Enfield Civic Ballet Company. It was during this time that she became pregnant with her first child. Erin Wetzel Carolyne was dismayed to learn that no matter how many Faculty Member (Postnatal model) certifications or diplomas she had acquired, nothing had given her any information on how to exercise during her pregnancy. Being too Erin’s love for movement began with her training as an actor. At the scared to do what she was doing, Carolyne opted to stop moving University of Michigan she studied Movement and Voice and learned during the pregnancy. Finding herself with an unrecognizable body different modalities such as Alexander Technique, Tai Chi, Pilates, after the birth of her daughter, she busied herself with designing and Laban movement theory. After her first pregnancy, Erin revisited an exercise program that was both safe and beneficial for pregnant Pilates, and fell in love again. She has focused her Pilates career on women. Her goal was to prepare the body for the birth, not just to working with both pre and post natal women, and actors in vocal be fit. Through the course of her next two pregnancies, Carolyne training and movement. refined her skills and knowledge and today you have the highly successful Pre and Post natal Pilates Specialist programs. Erin is the owner of Core Arts Pilates in Jackson, MI, and looks forward to continuing to explore the body in motion, and to help others find Carolyne works from a holistic point of view, seeing the body as an their own potential for movement. amazing instrument that needs the correct attention in order to work properly. Her efforts to make this possible for her clients has www.coreartspilates.com led her to study for her Masters in Natural Health, become certified as a Birth Doula and to learn other healing modalities . Currently Carolyne is a level two Reiki practitioner, Level 1 Myofascial release practitioner (John Barnes approach) and an Esoteric Healer. Her love of dance is evident in the way she instructs her movement classes whether Pilates or fitness.

Today The Center for Women’s Fitness has 12 host studios around the world, 10 faculty members and more than 300 certified teachers Credits teaching the method. The Center continues to expand. Photographer, Kimberley Lennox Photographer, Steve Kuzma Graphic Design, Anthony Kapp

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