There are several important points you should be aware of before you begin aerobic exercise: Begin your aerobic portion with a warm-up. The purpose of a warm-up is to gradually warm your muscles and joints enough to make them more flexible, reducing the likelihood of injury. Slow walking, stationary biking or marching in place for 10 minutes will help prepare your body for exercise.

Listen to your body. Moderation is the key. As you progress in your pregnancy, the type of exercise that feels comfortable may change. Modify your fitness program to fit your needs. You may find that non- weight-bearing activities, like stationary biking or swimming, cause less discomfort, especially in your third trimester. Each month of pregnancy increases the workload on your body, so an exercise level you felt comfortable with at 20 weeks (5 months) may feel much more strenuous at 30 weeks (7½ months). If you feel exhausted from your exercise, reduce the duration or intensity. You can still get health benefits from 15 minutes, three times a week. Most important, avoid overstressing your body. End your aerobic exercise with a cool-down. You can slowly reduce your level on exercise equipment or, if walking or swimming, just decrease your intensity over 5 to 10 minutes. Keep moving during your cool-down until you feel that your intensity level is below 12 on the Rating of Perceived Exertion (RPE) Scale (see Figure 1).

You should monitor the intensity of your exercise to make sure that you are not working at too high a level. A simple way to estimate intensity is the RPE Scale (see Figure 1). You should feel that your exercise level is "somewhat hard", which corresponds to 12 to 14 on the RPE Scale. If you feel out of breath and unable to talk, you are working too hard. Reduce your intensity or stop and rest. Exercising at a level over 14 on the RPE Scale may result in your body overheating, which can be dangerous for your baby. If you feel you are becoming overheated, lower your intensity.

The duration of exercise should be between 20 and 45 minutes, with a frequency of 3 to 5 days a week. The types of activity you can do include walking, swimming, biking, using a stair-climbing machine or a treadmill, or aerobic dance classes. Any moderate-level activity that can be maintained comfortably for 20 minutes will accomplish your aerobic exercise goal.

Stop exercising and contact your doctor or other health care professional if you experience any problems during or after an aerobic exercise.

Strength Training

Increased muscle strength can help your body meet the demands of pregnancy. Muscular strength is critical for maintaining proper posture, providing spine and pelvic organ support and preventing neck, shoulder and back discomfort. After delivery, a strong back and arms help protect your body from injury resulting from lifting and carrying your baby. Strength training requires proper form and frequent monitoring to avoid injury.

Following these basic points will help you develop a safe and effective weight-training program:
Avoid doing any exercises while lying on your back after your first trimester. Warm up before doing any strength exercises. Progress slowly. One set of 12 to 14 repetitions, two to three times a week, is sufficient for maintaining strength. It is important to have a rest day between strength workouts to allow your body to recover. Use any type of weight, from soup cans to lightweight dumbbells or resistance bands. Use a weight or resistance that allows you to do 12 repetitions without feeling unsteady or shaky. Don't hold your breath; exhale when lifting the weight, inhale as you lower it.

Perform the exercises without straining, using a slow, steady motion. Stop exercising and contact your doctor or other health care professional if you experience severe pain or discomfort during or after strength training.

A strength-training program should include exercises that work all major muscle groups. Following are some examples of strength-training exercises:

Biceps Curl (front of upper arm)—Stand with feet shoulder-width apart. Hold weights or resistance band in each hand with arms down at sides, palms up. Curl both arms up toward chest, with elbows bent at your side. Exhale as you lift, and inhale as you slowly lower arms down to starting position.

Triceps (back of upper arm)—In standing or sitting position, bring one arm behind your head, elbow at ear level and hand reaching back toward shoulder. Keeping elbow stationary, slowly raise weight or resistance band with bent arm into straight-arm position. Exhale as you raise arm, inhale as you return to starting position. Repeat on opposite side.

Shoulder Press (front of upper arm)—Sit or stand with feet apart, elbows bent and hands at shoulder level, palms forward. Press weights or resistance band straight up over head, exhaling as you lift. Inhale as you slowly bring arms back down to starting position.

Upper Back—Support body with same-side arm and leg on bench. Begin by raising weight or resistance band from lowered straight-arm position. Raise arm with elbow bent and pointing up until hand is at hip level. Exhale as you lift, inhale as you lower to starting position. Repeat on opposite side.

Push-Up (upper back and chest)—Position yourself on your hands and knees. Your arms should be at shoulder level with hands facing forward, elbows back. Lower your torso down toward the floor but only to the point that you are able to press yourself back up. Inhale as you lower down, exhale as you press up. If you find it difficult to press yourself back up, reduce the distance that you lower your torso down. Your back should remain straight as you perform this exercise. Start with as many as you can comfortably do, and build up.

Front Leg Raise (hip flexors and front thigh)— Start in standing position, with one hand resting on chair for balance. Extend one leg out, knee slightly bent, in front of you. Bending from the knee, slowly raise to a straight-leg position as you reach near hip level. Exhale as you extend, inhale as you return to starting position. Repeat on opposite side.

Buttocks—Start in a standing position, with hands resting on a sturdy chair for balance. Extend one leg out behind you, knee slightly bent, and lift it up. Keep your back straight, and concentrate on working the buttock muscles. Exhale as you come up, inhale as you return slowly to starting position. Repeat on opposite side.

Inner Thigh—Stand with left hand resting on chair for balance. Extend your right leg out in front of you and swing the leg to the left, leading with your heel, in a semicircle. Slowly bring the leg back to starting position. Switch positions on chair and repeat exercise with other leg.

Outer Thigh—In same position as inner-thigh exercise, extend right leg out to the side, raising leg up slowly in a semicircle, with toe pointed toward body. Return leg slowly to starting position. Switch position on chair and repeat exercise with left leg.

Flexibility Exercises

The changes in your body's posture, weight and balance can cause muscles to feel tight and sore. Flexibility exercises help stretch muscles that are overworked and tight from exercise and daily stresses. To stretch muscles and avoid injury, keep the following points in mind: Increased levels of hormones cause ligaments to loosen, making joints more mobile. Injury can result from over-stretching, so use slow, gentle movements during your stretch. Avoid bouncing or forcing a stretch. Leg cramps are a common problem during pregnancy. If you get a muscle cramp, try to stretch the muscle in the direction opposite the cramp. Talk with your doctor if you are experiencing frequent muscle cramps. Hold each stretch at least 10 to 15 seconds (or more, if you're especially tight). It takes time for the muscle to relax. Hold the stretch; then as you feel some slack, move further into the stretch until you feel resistance, and hold. Exhale as you move into the stretch, then breathe normally as you hold.
If you feel pain or discomfort, back off or stop the stretch. It is helpful for you to do stretching exercises every day to maintain your flexibility. Avoid any exercise that requires you to lie on your back after the first trimester.
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Shoulder Circles—In a standing or sitting position, roll shoulders, in gradually bigger circles, forward then backward for 5-10 repetitions each direction.

Back of Upper Arm—Bring your arms overhead. Grasp the elbow of one arm with your opposite hand. Slowly pull the elbow behind your head until you feel resistance and hold for 10-15 seconds. Repeat on opposite side.

Chest—Place your hands on either side of an open door at shoulder level with your elbows bent. Lean forward until you feel the stretch in the chest area and hold for 20 seconds.

Groin—In a sitting position, put your feet together, grasp your feet and slowly lean forward from the hips. Hold the stretch for 10-20 seconds. You may feel this stretch in your lower back as well.

Calf—In a standing position, place your hands at shoulder level against a wall or against the back of a chair. Extend one leg straight behind you, with the other leg bent at the knee and in front of your body. Press down on your heel and hold. You may find that it increases the stretch if you press forward with your hips. Repeat on opposite side.

Front of Thigh—In a standing position, with one hand resting on a sturdy chair for balance, reach back and grasp one leg above the ankle. Gently bring your foot up toward your buttocks and hold for 15-20 seconds. Repeat on opposite side.

Back Stretches in Chair—#1: Sit with feet apart, hands resting on knees. Slowly lower your body down between your legs until you feel resistance in lower back and hips. Hold stretch for 10-15 seconds. Bring your body back into sitting position slowly, using your arms to push up. #2: Sit in chair with feet flat and slowly twist your body to one side, reaching for the back of the chair. Hold this stretch for 20 seconds. Repeat on opposite side.

Back of Thigh—In a sitting position, extend one leg out, with the other leg bent and your foot facing inward. Reach forward toward the extended foot to the point that you feel resistance. Hold for 20 seconds. Repeat on opposite side. You may use a towel placed around your extended foot with the ends grasped by your hands if you have trouble reaching your foot.

Low-Back and Hip Stretch—While in groin-stretch position, twist slowly to one side, reaching for your knee. Grasp knee and hold for 10-15 seconds. Repeat on opposite side.

Ankles—In a sitting position, extend your legs straight out in front of you. Place your arms slightly behind you, resting on your palms for balance. Slowly make small circles with your feet, gradually increasing the size of the circles for 20 seconds.

Squat—Start from a standing position, with your feet flat and shoulder- width apart. Your feet should be far enough apart to be able to drop your arms down between them as you lower into squat position. As you lower yourself down, keep your heels flat on the floor. If your heels begin to rise, widen your foot placement and squat down only to the position where the heels start to rise. You may rest your arms on your knees. Hold for 20-30 seconds. Press back up by placing your hands on your knees and pushing up with arms.

Pelvic-Floor Exercises

The muscles that make up your pelvic floor (Figure 2) play an important role during pregnancy and throughout your life in the support of the pelvic organs. These muscles are located between your legs, where they form a "floor" at the base of your pelvis, spanning in an upright curve from the pubic bones to the tailbone. Weakness in this area results in sagging and loss of support. Many of the problems associated with pregnancy that affect the pelvic area are actually the result of poor pelvic-floor strength.

Pelvic-floor exercises are simple to perform but require that you first correctly identify the location of the muscles. They form a figure eight around the perineal body by surrounding the urethra, vagina and anus (Figure 3). You can feel the movement of the muscles by placing your fingertips on the perineal body and coughing. You should feel a downward push as you cough. You can feel how your pelvic-floor muscles work by stopping your flow of urine.

Exercises for the pelvic floor, originally developed by Dr. A. H. Kegel, a US gynecologist, are very important. Strong pelvic floor muscles will help support the growing weight of the uterus and baby and will return more quickly to their pre-pregnancy tone after delivery.

Exercise #1. Contract your pelvic-floor muscles and hold for 10 seconds.

Exercise #2. Slowly contract and release, contracting your pelvic-floor muscles progressively tighter to a count of five and slowly relaxing to a count of five. (A slow count is counting "one thousand one, one thousand two, one thousand three . . .")

• If you find it difficult to hold for 10 seconds, begin with 3 to 5 seconds. Slowly build up the time as you become stronger.
• Try to start with five or more repetitions of each exercise, two to three times a day, building to 10 to 15 repetitions, 5 to 10 times a day. If your pelvic-floor muscles tire quickly, do fewer repetitions each time, but increase the frequency throughout the day.
• Don't tense your abdomen, buttocks and thighs when doing these exercises. Lie, sit or stand with your legs slightly apart so you can isolate the correct area.
• No one will be able to tell that you are doing these exercises, so do them anywhere. Establish certain times of the day (before you get out of bed each morning) or activities (driving to work, brushing your teeth) as your "cue" to do your exercises.
• Prevention of pelvic-floor problems is certainly better than treatment. Adding these exercises into your daily routine during and after pregnancy will help avoid problems that may come with age.

If you are having any pelvic-floor problems, such as urinary incontinence, or have trouble locating this muscle group, talk to your doctor or other health care professional.

Abdominal Strength Exercises

The abdominal muscles consist of three different groups that work together to support the spine and pelvic organs. Sometimes during pregnancy, a separation of the vertical muscles along the front of the abdomen can occur as they spread apart to make room for your growing baby (a condition known as diastasis recti). A separation is not dangerous to the baby, but it does affect muscle function and abdominal support.

Before doing any abdominal exercises, use the self-check for separation (described and illustrated below). If you have a separation of more than two fingers' width, check with your doctor or other health care professional before doing any abdominal exercises. Have him or her help you check for diastasis, and continue to use the self-check to monitor any increase in separation during your pregnancy.

If you are experiencing any problems during or after pelvic floor exercises, contact your doctor or other health care professional.

If you develop any discomfort when performing abdominal exercises, or notice a separation more than the width of two fingers, stop the exercises and consult your doctor.

Treat your abdominal muscles with care. Rising from a lying position, lifting heavy objects or any other activity that increases pressure on the abdominal wall can widen a separation of the recti muscles. To lessen the strain, first roll onto your side and then push up with your arms when rising from a lying position. Also, remember not to hold your breath or bear down during any exercise or activity.

Self-Check for Separation

Here's how to measure the amount of separation in the recti muscles:

1. Lie on your back. Bend your knees with your feet flat on the floor. Relax and take a couple of gentle breaths.
2. Exhale and rise to a partial sit-up (see drawing).
3. At the area of your navel, place your fingers horizontally in the soft gap between the recti muscles that run through the center of the abdomen. You may see a bulge in the gap area when you do the sit-up.
4. Press your fingers down into the gap to measure the width of the separation.
5. If you have more than a two-finger separation, check with your doctor or other health care professional before doing any abdominal exercises.

CAUTION: With a separation of more than two fingers, don't do sit-ups or exercises that make you hold your breath or bear down holding your breath.

Posture

The increase in abdominal and breast size and the loosening of ligaments and joints during pregnancy cause changes in posture. Your center of gravity shifts, creating problems with balance and increasing tightness in back muscles. You can reduce some of the discomfort resulting from these changes by maintaining proper posture.

Sitting causes the greatest stress on your low-back area. Using proper posture when sitting will help prevent low-back soreness. If you sit for long periods each day, take time every hour to stretch. If possible, get up from your chair and walk around for a few minutes. These tips will help you ease low-back strain: to help support your lower back, position a towel or small pillow in the small of your back. Your feet should be flat on the floor. If your feet don't reach the floor, prop a book or box under them so your thighs are level (horizontal) with the floor. Do the back stretches in a chair, described in the flexibility section, throughout the day, and whenever you feel stiff from sitting. Never lift by bending from the waist; this puts pressure on the low back and could cause injury. When lifting an object, bend your knees to pick it up and hold it close to your body when rising. Avoid lifting overhead or twisting your torso while holding heavy objects.

If you do become injured, contact your doctor immediately. Ice and rest are the usual remedies, but in some cases, physical therapy is helpful in treating the injury and learning proper body mechanics to prevent further injury.